What is the best course of treatment for a patient who has completely lost their voice?

Management of Complete Voice Loss (Aphonia)

For a patient with complete voice loss, perform laryngoscopy immediately if red flags are present (recent surgery, intubation, neck mass, respiratory distress, tobacco use, or professional voice user), or within 4 weeks if symptoms persist without improvement, then initiate voice therapy as the primary treatment once laryngeal pathology is identified. 1, 2

Immediate Assessment and Red Flags

Do not prescribe antibiotics, corticosteroids, or antireflux medications before visualizing the larynx. 1, 3

Assess for factors requiring urgent laryngoscopy: 1

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

If any red flags are present, perform laryngoscopy immediately rather than waiting. 1

Diagnostic Laryngoscopy

Laryngoscopy must be performed before prescribing voice therapy, with results documented and communicated to the speech-language pathologist. 2

• If dysphonia persists beyond 4 weeks without improvement, perform laryngoscopy or refer to a clinician who can. 1
• Do not obtain CT or MRI prior to laryngeal visualization for patients with a primary voice complaint. 1, 3
• Laryngoscopy will reveal whether vocal folds are structurally normal (suggesting functional aphonia) or show paralysis, lesions, or other pathology. 1

Primary Treatment: Voice Therapy

Voice therapy is the first-line treatment for aphonia amenable to behavioral intervention, delivered by certified speech-language pathologists. 2

Direct Symptomatic Techniques

The following techniques can restore voice, often during the first therapy session: 1, 2, 4

• Attention redirection: Bubble blowing with vocalization, amplification devices, or electroglottography biofeedback 2
• Automatic speech tasks: Counting, reciting days of the week, or singing familiar songs to bypass conscious vocal control 2
• Postural maneuvers: Phonating while bending forward or looking at the ceiling 2
• Laryngeal manipulation: Circumlaryngeal massage during phonation to reposition and relax the larynx (requires patient consent before neck contact) 2
• Inhalation phonation: Having the patient phonate while inhaling 4
• Gargling, chewing, or pushing exercises during phonation 4

Resolution Timeline

• 82% of patients with functional aphonia recover voice during the first day of vocal exercises. 4
• Voice therapy typically involves 1-2 sessions weekly for 4-8 weeks. 2
• Resolution or reduced severity often occurs during small talk, spontaneous discussion, or when attention is diverted—this inconsistency is a hallmark of functional aphonia. 1

Condition-Specific Management

Functional (Psychogenic) Aphonia

Combined direct voice techniques with psychological counseling are essential, as outcomes improve when patients understand psychosocial connections. 2

• Total or partial loss of voice despite normal vocal fold structure and function on laryngoscopy is diagnostic. 1
• Often preceded by psychological trauma, stressors, or difficult life events. 1, 5
• Help patients notice and challenge catastrophic thinking (e.g., "If my voice isn't perfect, I'm a failure"). 1
• Address fear-avoidance behaviors and hypervigilance to throat sensations. 1
• Refer to mental health professionals if extreme distress or psychiatric symptoms emerge during treatment. 1

Vocal Fold Paralysis (Post-Surgical or Idiopathic)

If laryngoscopy reveals unilateral vocal fold paralysis: 1

• Voice therapy helps patients compensate for altered laryngeal physiology and can be used alone or combined with procedures. 1, 2
• Injection laryngoplasty (temporary, typically months) restores vocal fold position and bulk. 1
• Framework procedures or reinnervation (permanent) restore vocal fold position, often performed in operating room. 1
• Laryngeal nerves may take over a year to completely heal and may never fully recover. 1

Muscle Tension Dysphonia

• Voice therapy is highly effective as primary treatment, targeting abnormal muscle patterns without anatomic laryngeal changes. 2
• Look for supraglottic compression, tender extralaryngeal muscles, and struggle behaviors (overmouthing, eye blinking, facial contortions, excessive neck/shoulder tension). 1, 6

What NOT to Do

Strong recommendations against: 1, 3

• Do not routinely prescribe antibiotics for dysphonia—this is a strong recommendation against. 1, 3
• Do not prescribe antireflux medications based on symptoms alone without laryngeal visualization. 1
• Do not routinely prescribe corticosteroids prior to laryngoscopy. 1, 3
• Do not obtain imaging (CT/MRI) before visualizing the larynx. 1, 3

Common Pitfalls

• Do not assume all aphonia is viral or infectious—functional aphonia can present identically and requires voice therapy, not antibiotics. 3, 5
• Do not delay laryngoscopy beyond 4 weeks in persistent cases, as delay significantly affects outcomes. 1, 5
• Children under 2 years may not participate effectively in voice therapy; family education becomes the primary intervention. 2
• Professional voice users may require more urgent evaluation due to occupational impact, even with recent symptom onset. 1, 3

Finding Qualified Providers

Certified and licensed speech-language pathologists are the appropriate professionals to deliver voice therapy and can be located through ASHA's ProFind search engine or by contacting ASHA's Action Center. 2