Voice disorders, explained

Also called carcinoma larynx or throat cancer, it is the disease where the laryngeal tissue gives rise to cancer-causing (malignant) cells forming a tumour. The tumour commonly originates from the thin flat cells (squamous cells) in the inner lining of the larynx, therefore it is referred to as squamous cell carcinoma. Other types, such as adenocarcinoma, can also affect the larynx.

The larynx is a hollow organ made of cartilage and muscles, situated behind the tongue in the throat. It connects to the windpipe (trachea) below, humidifies inspired air, and contains the vocal cords that produce speech — hence its name, the voice box. Laryngeal cancer often obliterates the cavity of the larynx and affects vocal cord function.

Based on the position of the vocal cords, the larynx is divided into three parts:

• Supraglottis — above the vocal cords
• Glottis — containing the vocal cords
• Subglottis — below the vocal cords

Laryngeal cancer is divided into the same three categories. Cancer of the glottis is the most frequent, followed by supraglottic tumours. Subglottic cancers are the least common.

Risk factors include both extrinsic and intrinsic factors:

• Smoking and other forms of tobacco use (typically more than 8–10 years)
• Long-term heavy alcohol consumption
• HPV (human papillomavirus) infection
• Long-term acid reflux (laryngopharyngeal reflux)
• Exposure to heavy metal paints, asbestos or radiation
• Older age (over 55 years), male sex, and family history

Typically, a 60-year-old man who is a habitual smoker and/or tobacco user is most likely to have throat cancer.

Symptoms vary with the part of the larynx involved. Glottic cancers being most common, the voice is affected in about 60–70% of cases. Patients usually present with two or more of the following:

• Voice change or hoarseness (or inability to speak) lasting more than 2 weeks
• A swelling or lump in the neck felt from outside
• Difficulty or pain while chewing or swallowing
• Constant ear pain that does not go away
• Slight difficulty in breathing
• Coughing up blood on more than one occasion
• Weight loss with or without loss of appetite

On examination the doctor may find a palpable neck lump, enlarged lymph nodes, or generalised paleness. Indirect laryngoscopy may or may not show a tumour; further diagnostic tests are then advised.

Depending on symptoms, signs and risk factors, a referral to an ENT specialist is often recommended. Common procedures include:

• Imaging — chest X-ray, CT scan and MRI
• Endoscopy — a thin flexible scope passed through the nose or into the larynx in the outpatient clinic
• Biopsy — a small piece of tissue taken under endoscopic guidance and studied under the microscope
• Fine needle aspiration — sampling an external lump with a needle in the outpatient setting

The “stage” of cancer describes extent and spread; the “grade” relates to severity or prognosis. Clinicians use the TNM system; for patients, stages are often simplified with a number system.

Treatment aims to remove the tumour and prevent recurrence while keeping laryngeal function as intact as possible. Choice depends on tumour location, stage and grade, and the patient’s general health.

Major modalities are surgery and radiotherapy. Radiotherapy or chemotherapy may be given before surgery to shrink the tumour. In more advanced cases where surgery is not possible, chemoradiation may slow growth.

Supportive measures after medical advice can include dietary support, speech therapy, lifestyle modification, exercise, a balanced diet, and — critically — quitting smoking. These are palliative aids, not replacements for medical treatment.

Success rates for stage I and II disease are quite good, approaching 90% five-year survival; outlook for more advanced cases is more guarded. Where the larynx is removed entirely, newer aids such as a voice prosthetic valve can help restore near-normal speech.

Throat cancer is largely preventable and highly treatable if diagnosed early. Quitting smoking drastically reduces risk; avoiding risk factors and adopting a healthier lifestyle go a long way toward prevention.

Laryngitis means inflammation of the larynx (voice box). Swelling and irritation around the vocal cords cause pain and hoarseness. The larynx is a hollow muscular organ in the throat at the start of the windpipe; it assists breathing, produces and modulates voice, and helps prevent food or foreign bodies entering the windpipe.

Acute laryngitis lasts less than 3 weeks. Symptoms develop suddenly; it often heals with voice rest and fluids, and mostly affects children under 10 years.

Chronic laryngitis develops gradually and lasts more than 3 weeks. It is more common in older people and is seen with cigarette smoking, infections such as tuberculosis, respiratory allergies — and most commonly with acid reflux.

Acute laryngitis (often in children and young adults) is commonly infectious — viral (rhinovirus, influenza) most often, sometimes bacterial after a viral illness, rarely fungal. Non-infectious causes include vocal misuse (yelling or shouting), chemical fumes or pollutants, and trauma from intubation or procedures.

Chronic laryngitis is most often due to acid reflux (GERD). Other causes include long-term vocal misuse (singers, public speakers), cigarette smoke, chronic inhaler use, allergies or uncommon autoimmune disease, and long-term infections such as tuberculosis.

Risk rises with sore throat / upper respiratory infections, heavy voice use (singers, teachers, speakers), reflux disease, and smoking or toxic fume exposure.

Only infectious acute laryngitis is contagious. It can spread by breathing infectious droplets from coughing or sneezing, by direct salivary contact, or via contaminated objects such as towels or spoons. Non-infectious laryngitis is not communicable.

The classical symptom in all forms is hoarseness of voice, usually with pain or discomfort in the throat. Other symptoms include dry cough, sore throat, difficulty swallowing, increased saliva, and fever in infectious cases.

Seek urgent care for red-flag signs: difficulty breathing or shortness of breath (especially in children or the elderly); stridor (noisy high-pitched breathing in small children); high fever above 103℉ or fever that will not settle; trouble swallowing or excessive drooling in children.

Diagnosis is usually clinical, with neck lymph-node assessment and indirect laryngoscopy (mirror and light) to inspect redness and vocal-cord swelling. Acute cases rarely need further tests; biopsy may be considered in unexplained chronic laryngitis.

Acute laryngitis is mostly self-limited and resolves in 2–3 weeks. Home care includes voice rest, steam inhalation, warm fluids, and a softer diet when swallowing is hard. Antibiotics are reserved for confirmed bacterial infection after culture; steroids for rapid recovery should generally be avoided unless advised.

For chronic laryngitis, identify and treat the root cause before medication.

Do: rest the voice and body; drink warm liquids; salt gargles or lozenges; breathe moist air / use a humidifier; cover coughs and sneezes.

Don’t: speak or whisper forcefully; use drying decongestants; eat solids when swallowing is difficult; over-exert during recovery.

LPR is a condition where acid from the stomach reaches the voice box (larynx) through the food pipe, causing pain and hoarseness. It occurs in the setting of GERD, but many people do not have heartburn or regurgitation — so LPR is sometimes called “silent reflux,” which can make it harder to diagnose.

The oesophagus has muscular sphincters at each end that normally allow food only toward the stomach. If either or both malfunction, stomach contents can travel up into the throat. The larynx is easily affected because it sits close to the opening of the oesophagus.

LPR is lifestyle-related and more common in older people. Risk rises with eating late at night or lying down soon after meals, tight clothing that increases stomach pressure, stress and anxiety, and being overweight with limited activity.

• Hoarseness with difficulty speaking (dysphonia)
• Dry chronic cough, worse when sleeping or lying down
• Frequent need to clear the throat
• Feeling of a lump in the throat
• Mild throat pain
• Difficulty swallowing
• Sensation of something sticky in the throat
• Difficulty breathing (rare)

In children (uncommon), symptoms may differ — such as recurring tonsillitis and sore throat.

Diagnosis is usually based on symptoms and examination of the larynx (indirect laryngoscopy). In LPR, vocal cords may show redness and swelling with more small capillaries and increased mucus. Extensive testing is not ordinarily needed; imaging may rule out other disease. In obscure cases, throat pH testing, barium swallow, or endoscopy may be used.

Untreated LPR can lead to chronic cough and sore throat, masses or granuloma in the voice box, swelling or nodules on the vocal cords, and aggravation of asthma or bronchitis. Some researchers suggest a possible role in laryngeal cancer, though evidence is limited.

LPR is managed with lifestyle change plus acid-regulating medication after medical advice. Proton pump inhibitors (for example omeprazole, pantoprazole, rabeprazole) are preferred; antacids and other regulators may also be used as directed. Raise the head of the bed when sleeping, and avoid frequent throat clearing.

LPR is fairly benign when a healthy lifestyle reverses it, but it should not be ignored — once complications set in, quality of life can decline.

Vocal cord nodules are painless “callus”-like bumps that develop on the vocal cords (usually both), giving rise to gradually increasing raspiness. People in voice-heavy professions — singing, teaching, public speaking — often overuse the voice without proper care. Anyone with yelling, whispering or excessive talking can develop them. Soft nodules may resolve with voice rest; repeated damage can create hard, fibrous nodules that stiffen the cords.

Typical features: both cords involved; usually in the anterior one-third of the cord; evidence of abusive vocal behaviour in almost all cases.

Voice may progress from a slight rasp to profound hoarseness. Early on there is a husky tone with loss of higher pitch; later, onset delay, voice breaks at certain pitches, and a breathy weak quality — most noticeable with a quiet voice.

A history of excessive voice use, with or without throat pain, and without sore throat or breathing difficulty, points toward nodules. Doctors also ask about frequent throat clearing, long cough, and increased whispering — these also traumatise the folds. Definite diagnosis is by endoscopic visualisation (nasal endoscopy) of the larynx and vocal cords.

Voice therapy is first-line. Complete resolution is often achievable without surgery; treated conservatively, nodules are less likely to recur. Therapy includes voice rest, warm saline gargles, quieter lower-pitched speaking, quitting smoking, avoiding cough/throat clearing, and plenty of fluids.

Surgery (phonomicrosurgery) is reserved for hard nodules, failed therapy, or time-critical professional needs. If careless voice use continues after surgery, nodules will recur.

After surgery: voice rest, control reflux, avoid alcohol, speech therapy, and avoid coughing/throat clearing. Discuss possible effects (tongue numbness, throat pain/swelling, dental injury, rare permanent hoarseness) with your surgeon.

• Use your voice in moderation and rest it, especially if you use it professionally
• Avoid smoking and alcohol
• Avoid allergens that trigger sneezing and coughing
• Eat healthy foods; drink plenty of water and warm fluids; limit fatty foods

• Don’t try to out-talk noise in restaurants, gatherings, planes, buses or arenas (Lombard effect)
• Don’t yell, cheer or scream over background noise
• Don’t lecture a large audience without a microphone
• Don’t clear your throat continually or cough unnecessarily
• Don’t do prolonged loud, aggressive talking, laughing or crying
• Don’t start voice with a harsh glottal attack; don’t yell, scream, whisper, or speak outside a comfortable pitch
• Don’t speak in a low monotone that becomes gravelly (glottal fry)
• Don’t squeeze out words without enough breath, or raise shoulders/tense the neck while breathing
• Don’t clench teeth or hold the jaw tense
• Don’t eat just before performing (allow ~3 hours); avoid excess caffeine, chocolate, milk, nuts, popcorn, smoking and alcohol before performance
• Don’t skip warm-ups or cool-downs; don’t “over-sing” if you are hoarse afterward
• Don’t use the voice extensively with a cold, laryngitis, or painful swallowing
• Don’t ignore prolonged hoarseness, pain, fullness, heartburn or allergies
• Don’t expose the voice to pollution, cigarette smoke or chemical fumes
• Don’t use aspirin-like medication casually — it can predispose to vocal fold haemorrhage

• Drink plenty of water (at least 6–8 glasses a day) and keep humidity healthy
• Eat a healthy diet; take a sip of water or silent cough instead of clearing the throat
• Build in voice-rest periods, especially when ill or tired
• Whistle, clap or use a bell to attract attention in noisy places
• Maintain good posture; keep the jaw passive; release neck tension gently
• Use abdominal breathing and speak softly at a comfortable pitch, pausing for breath
• Warm up before speaking or singing; cool down afterward
• Project with breath and posture; face the listener; use a microphone for public speaking
• Notice early fatigue (hoarseness, dry throat, tension, poor projection)
• See a doctor for throat discomfort or hoarseness lasting more than 3–4 days
• Treat allergies and infections promptly; avoid self-medication

Puberphonia (mutational falsetto) is the inappropriate persistence of a higher-pitched prepubertal voice well beyond puberty. In the majority of cases the larynx is anatomically and physiologically normal.

It occurs in both males and females, but is more common — and more noticeable — in men. During puberty the larynx enlarges, vocal folds thicken and lengthen, and pitch falls (about one octave in males; a few semitones in females). Persistence of a high-pitched adult voice is therefore more striking in men.

Most often the larynx is normal and the cause is psychological — emotional stress or self-consciousness after an early voice break. It is rarely due to immaturity of the larynx or vocal cords.

The voice remains high-pitched, weak, breathy, monotonous and feminine in quality — immature and inadequately assertive. Pitch may drop suddenly with coughing or laughing.

ENT specialists and speech-language pathologists perform a complete voice assessment, examine the voice box, and consider social and emotional impact before referring for voice therapy.

Voice is identity; untreated disorders can lead to inferiority feelings or depression. There is no age bar for treatment, but delay can make the condition resistant to therapy — seek evaluation as soon as the problem is noticed.

Direct voice therapy (vocal exercises with an SLP) usually produces rapid improvement; continue until the new voice is stable. Follow-up or psychological counselling is rarely needed.

Indirect therapy creates a supportive environment — counselling and voice-care education.

Surgery is considered when therapy fails (often after delay or denial). Relaxation thyroplasty is a simple, effective operation through a small neck crease under local anaesthesia; it lowers pitch by relaxing and shortening the vocal folds.