What is the treatment for a lost voice?

Treatment of Lost Voice (Dysphonia/Aphonia)

For lost voice persisting beyond 4 weeks or with concerning features, laryngoscopy is mandatory before initiating treatment; voice therapy is the primary treatment for most causes amenable to conservative management, while antibiotics, steroids, and reflux medications should NOT be routinely prescribed without laryngeal visualization. 1

Initial Assessment and Red Flags

Perform a focused history and physical examination to identify factors requiring expedited laryngeal evaluation 1:

• Recent surgical procedures involving head, neck, or chest 1
• Recent endotracheal intubation 1
• Concomitant neck mass 1
• Respiratory distress or stridor 1
• History of tobacco abuse 1
• Professional voice user status 1

Assess voice quality characteristics 1:

• Breathy voice suggests vocal fold paralysis or incomplete closure 1
• Strained voice with pitch breaks suggests spasmodic dysphonia 1
• Complete aphonia may indicate functional disorder or severe structural pathology 1

Diagnostic Algorithm

Laryngoscopy is required when: 1

• Dysphonia fails to resolve or improve within 4 weeks 1
• Serious underlying cause is suspected (regardless of duration) 1
• Before prescribing voice therapy 1

Do NOT obtain CT or MRI prior to laryngeal visualization 1

Treatment Based on Etiology

For Functional Voice Disorders (Psychogenic Aphonia)

Make a positive diagnosis based on internal inconsistency—symptoms resolve during spontaneous conversation, automatic utterances, or when attention is diverted 2

Immediate intervention strategies: 1, 2

• Reduce excessive musculoskeletal tension through circumlaryngeal massage and manual laryngeal repositioning 1
• Slow speech down or elongate sounds rather than building tension—explain this as "resetting the system" 2
• Use dual tasking while speaking as distraction from dysfluent patterns 2
• Employ nonsense words or syllable repetitions to demonstrate potential for normal function 2
• Redirect patient focus from speech mechanics to conversational content 2

Most patients (82%) recover voice during the first day of vocal exercises using facilitating techniques including relaxation, respiration exercises, gargling, chewing, pushing, inhalation phonation, and masking 3

Address comorbid psychological conditions: 2

• Treat depression first or concurrently with SSRIs or low-dose amitriptyline 2
• Refer to mental health professionals for structured CBT or acceptance and commitment therapy 2
• Evaluate psychosocial stressors including relationship conflicts, workplace stress, and trauma history 2

For Structural Laryngeal Lesions

Voice therapy is first-line for patients with dysphonia from causes amenable to therapy 1, 4

Surgical intervention is indicated for: 1, 4

• Suspected malignancy 1, 4
• Symptomatic benign vocal fold lesions (polyps, cysts, nodules) that do not respond to conservative management 1, 4
• Glottic insufficiency requiring medialization 1, 4

Botulinum toxin injections should be offered for dysphonia caused by spasmodic dysphonia and other laryngeal dystonias 1, 4

What NOT to Do

Strong recommendations AGAINST: 1

• Do NOT routinely prescribe antibiotics to treat dysphonia 1
• Do NOT prescribe antireflux medications based on symptoms alone without laryngeal visualization 1
• Do NOT routinely prescribe corticosteroids prior to laryngeal visualization 1
• Do NOT obtain CT/MRI before visualizing the larynx 1

Critical Pitfalls to Avoid

Do not focus exclusively on voice symptoms while ignoring depression or anxiety—this leads to treatment failure and relapse in functional disorders 2

Do not assume functional disorder is a diagnosis of exclusion—make a positive diagnosis based on internal inconsistency and demonstrate positive clinical signs to the patient 2

Do not delay laryngoscopy beyond 4 weeks—delayed diagnosis of laryngeal cancer leads to higher disease stages and worse prognosis 4

Do not provide communication aids that perpetuate avoidance patterns in functional disorders—encourage direct communication without technological supports 2

Patient Education and Follow-up

Inform patients about control and preventive measures 1, 4

Document resolution, improvement, or worsening of symptoms after treatment or observation 1, 4

Prepare patients for possibility of relapse with emphasis on self-management using techniques learned during therapy 1

Even after lengthy periods of aphonia, complete recovery of voice function is possible in nearly all cases with appropriate intervention 5