Hoarseness-Voice Disorders

VIDEOLARYNGOSTROBOSCOPY

videostroboskop

It is the detailed examination of vocal cords and laryngeal structures. During phonation, fundamental frequency of CVs is transmitted to the system with laryngeal microphones. The cycle’s every phase can be examined in milliseconds when the xenon light source on the stroboscope sends light beams, which have the same frequency with the fundamental frequency, on vocal cords.
Obtained images can be recorded in the system, and information can be given to patient as well as to the clinician.
Evaluated patient group;
Having examined by an ear nose throat physician and having pre-diagnosis;

  •  The patients who have complaints about hoarseness and need their CVs to be examined in detail.
  • The patients with CV paralysis who need their laryngeal structures to be examined in detail, are evaluated by our unit.

 

 

VOCAL ANALYSIS

sesanalizator

It is the examination of 22 different vocal characteristics with computerized voice analyzer at voice laboratory. Fundamental frequency of voice, Jitter and all its frequency related features, shimmer and all amplitude features of voice, air leakage in voice, voice volume, voice intensity, and tremor features are examined by our unit in all aspects.
The patient is asked to create an ‘a’ phonation in stable frequency and volume within the estimated time period. This voice is recorded in computer and put into analysis.
At out unit, we perform acoustic and aerodynamic vocal analysis before the vocal therapy session, and give feedback about new developments.

Evaluated patient group;
Having examined by an ear nose throat physician and having pre-diagnosis;

  • It can be applied on patients who have complaints about hoarseness.
  • Vocal analysis is performed at the beginning of vocal therapy sessions.

VOCAL THERAPY
It is the rehabilitation program performed in order to recover or preserve vocal health. In our unit, at least 5 vocal sessions are applied, although the duration of treatment can vary according to the type, features, and level of pathology. This treatment is also supported by home programs.
The patient group to be treated;
Having examined by an ear nose throat physician and having pre-diagnosis;

  • CV nodule
  • Functional hoarseness,
  • Postoperative vocal rehabilitation (CV cyst, polyp, granuloma, CV sulcus errors etc.)
  • Patients with CV paralysis orpatients who undergo postoperative CV medialisation,
  • Vocal artists
  • For protective purposes, people who need to use their voice frequently are also treated by our unit.

FLUENCY DISORDER AND ITS REHABILITATION 
Treatments for recovering speaking fluency are preformed at out unit. For full efficacy of this treatment, the patient should be literate and below 20 years of age.
In addition to computerized treatment programs for influent patients, the most widely established and productive techniques are performed at out unit.

On Vocal Diseases and Hoarseness 
There are several causes for hoarseness. Most of them do not generate serious health issues, and they usually heal in short time. Acute laryngitis is the most common cause for hoarseness. Acute laryngitis emerges during having cold and other upper respiratory tract inflammations, yelling and straining voice too much. Voice retreats to its original state within 1 week or 2 weeks.
More long-termed hoarseness disorders are usually caused by using voice excessively and forcefully. This type of voice use habits produces small swellings referred to as nodule that causes hoarseness. Nodules are usually seen with people who need to use their voices for long time periods and for professional purposes, but with a faulty technique (e.g. singers, teachers politicians). Nodules, which emerge due to excessively forceful vibrations of vocal cords, do not fade away automatically unless habits of vocal training and vocal use are corrected. During acute laryngitis followed by excessive yelling, there might be slight bleedings inside the vocal cord. If voice is not rested at this stage, bleeding may transform into unilateral vocal cord swellings referred to as polyps and trigger continuous hoarseness.
One of the common causes of hoarseness in adults is the irritation of vocal cords due to rising level of gastric acids from the alimentary canal to the laryngeal due to the weakness of a muscle located at the point where the alimentary canal and the stomach intersect. This is called laryngopharyngeal reflux. Hoarseness is more common during mornings and lessens during day. Sticking in the throat, a sense of having something stuck in the throat, and habits of clearing the throat are common symptoms of hoarseness. Most of the patients who experience hoarseness due to reflux do not usually have complaints about their stomachs.
Smoking is another factor that causes hoarseness. Since smoking is an important risk factor behind the development of laryngeal and throat cancers, smoking people with non-healing hoarseness should consult an ear-nose-throat diseases specialist for examination.
More uncommon causes of hoarseness include allergy, goiter, and nervous system diseases. Many people may experience slight levels of hoarseness due to ageing.
WHAT IS HOARSENESS? 
Hoarseness expresses abnormal changes of voice. When hoarseness occurs, voice may be heard whispery, rough, cracked, or strained. There may be alteration in vocal tonality and volume. Vocal changes are usually connected to disorders related to the vocal cord. The vocal cord is located inside the laryngeal. They vibrate while speaking, and thus the first phase of voice production happens. The rate of this vibration varies between 200 and 300/sec for females, and 100 and 150/sec for males. Vocal cords expand while breathing.
WHAT SHOULD I BE CAREFUL ABOUT?

To prevent hoarseness or make it quickly disappear, there are some proscriptions that the patient might want to follow, such as:
– Not smoking and not consuming alcohol (Avoiding smoking is more important)
– Using voice in the correct tonality without making it lower or higher in a frequent manner.
– Avoiding speaking for a long time
– Speaking with diaphragm without exhausting the laryngeal muscles.
– Drinking water a lot.
– Avoiding throat clearing movements
– For patients who have acid leakage in their stomachs, avoiding tea, coffee, coke, and alcohol in evenings, avoiding eating until fully stuffed, avoiding sleeping directly after eating, and sleeping on a high pillow.
– Having appropriate humidity and temperature inside the place you live.

With whom hoarseness is more common? What is the rate of having hoarseness?

All human beings definitely experience hoarseness several times during their lifetime. Hoarseness may be seen with babies as well as with 80 years old elderlies, it may last for few hours, or it may continue for a lifetime. There are limited researches on the rate of having hoarseness and they are inaccurate since many vocal disorders are treated with pastilles bought from pharmacies. Although we do not have credible data on the rate of hoarseness, we know which diseases are more common. Various researches show that diseases occurring due to incorrect usage of voice such as nodules-polyps-edema, and those related to smoking such as chronic laryngitis-leukoplakia-cancer are the most common vocal diseases. These types of diseases are followed by vocal cord paralysis and psychogenic-functional vocal disorders. The rate of having these diseases varies according to age and type. However, generally, vocal disorders are usually seen with people around 25 to 65 ages.
What are the causes of hoarseness?

Hoarseness can be examined under two main categories: One is the acute (sudden) hoarseness, and the other is chronic (continuing) hoarseness.
Acute hoarseness usually occurs due to regional inflammations in the laryngeal (for instance acute laryngitis). The factors behind are usually viruses, excessive and incorrect voice use, and smoking. Chronic hoarseness may be caused by functional reasons without having vocal cord polyps, bad laryngeal diseases, neurologic disorders, chronic irritation due to smoking, acid leakage of the stomach, or any other pathologic case. Another categorization of hoarseness is made on the basis of presence or absence of an organic pathology. In this case, we can divide hoarseness in to two parts as organic hoarseness and functional hoarseness.
Causes of Organic Hoarseness
A- Infectious Inflammatory:
– Acute Viral Laryngitis
– Bacterial tracheid / laryngitis
– Laryngotracheobronchitis
B- Non-Infectious Inflammatory:
– Laryngopharyngeal reflux
– Smoking irritation
– Chronic coughing
C- Trauma (trauma reaching to the laryngeal from outside)
D- Tumors:
– Benevolent tumors (cysts, vocal cord polyps, papilloma, chondroma, lipoma, hemangioma, neurofibroma)
– Malignant tumors (cancers)
E- Systemic:
– Hormonal disorders (hypothyroidism, virilization)

– Diseases (rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, Wegener’s granulomatosis, tuberculosis, syphilis, amyloidosis, pemphigus)
F- Neurologic:
– Central lesions (hemorrhage, head trauma, multiple sclerosis, neural tumors, Guillain Barre Syndrome)

– Peripheral lesions (tumors, surgery, particularly thyroid and cardiovascular surgery, cardiac and neuromuscular diseases; aortic aneurysm, myasthenia gravis, spastic dysphonia)
Causes of Functional Hoarseness
A-Psychogenic Dysphonia (hysterical aphonia)
B-Habitual Dysphonia
C-Ventricular dysphonia

Functional hoarseness means the hoarseness in the laryngeal without an organic pathology.  Functional hoarseness may emerge in relation to emotional condition or personal characteristics of patients. It is seen in variety of ways. Among them, psychogenic dysphonia occurs because of psychic reasons or delusive reasons. There is not any organic cause. This case, which is usually seen with women, typically emerges after an acute psychic trauma. The patient complains about sudden hearing loss. The ability to speak through whispering is generally preserved. Examination of the laryngeal is normal. Coughing sound is entirely normal. Treatment aims to improve the patient’s psychic condition. The patient should be informed that his/her hoarseness is psychological and not related to any disease.

As opposed to psychogenic dysphonia, habitual dysphonia does not emerge suddenly and it is caused by personal characteristics and habits instead of a psychic trauma. It has hyperkinetic and hypokinetic subtypes. In hyperkinetic type, extreme contractions happen during examination. While speaking, enlargement in neck veins and contractions in neck muscles can be observed. Behavioral and vocal trainings should be included in the treatment. Patient’s motivation is critical for success of the treatment. In hypokinetic type, movements of the laryngeal become insufficient for speaking. It is usually seen with bashful and shy people with immature personalities. In this case, voice is low and weak. During laryngeal examination, it is observed that vocal cords are not closing entirely. Vocal training and psychotherapy are applied during the treatment. However, success chance is slimmer compared to hyperkinetic dysphonia.

Ventricular dysphonia is the formation of voice with the vibration of fake vocal cords instead of the real vocal cords. It usually emerges due to inadequate performance of vocal cords caused by a vocal cord paralysis, light therapy, or psychogenic reasons. Treatment is performed with speaking therapy. In some cases, fake vocal cords may be removed by excision with laser for the purposes of treatment.
Acute Viral Laryngitis

It usually follows an acute infection in the nose, in paranasal sinuses, or in pharynx. It spreads through droplets and its usual initiators are adeno virus and influenza virus. Climate changes, diminishingof body resistance, physical or psychological stress may trigger the disease. Main complaints are hoarseness and pain and discomfort in the laryngeal. Coughing may sometimes be included in these complaints as well. Voice does not entirely fade away, but there remains a coarse voice. During the examination, it is observed that vocal cords lose their whiteness and get swollen. A supportive treatment, which includes voice recovery, steam inhalation, and prohibition of cold, smoking, and alcohol, is carried on. Discovery of dark or purulent mucus indicates a bacterial infection, which requires a more aggressive treatment. In this case, the treatment should be supplemented with antibiotics and mucolytic agents. With this treatment, acute laryngitis can be healed within several days.

Chronic Laryngitis 

Identifying the main cause for chronic laryngitis is usually difficult. The reason for irritation might be smoking, purulent sinusitis or other respiratory tract infections, industrial gas and smokes, laryngopharyngeal reflux, incorrect voice usage, and respiration through mouth. Alcohol consumption paves the way for edema in vocal cords and bleeding. Patients complain about hoarseness and mild coughing. While these complaints may start stealthily, they may turn out be continuous as a result of an upper respiratory traction infection. During the examination, it is observed that vocal cords lose their whiteness and turn into pink or red colors. If laryngeal mucosa is smooth and regular,biopsy should not be performed, but the patient should be closely watched. In this case, complete healing can be achieved with voice recovery, prohibition of smoking and alcohol, and appropriate medical treatment. However, biopsy must be performed if there are white spots belonging to leukoplakia or keratosis on the vocal cord. A treatment protocol should be organized in accordance with biopsy results.
Vocal Cord Nodule

Nodules are benevolent swellings emerging at the loose ends of the vocal cords after a trauma. These are also called “singer’s nodule”. They are usually located on the front 1/3 and the back 2/3 conjunction spots. This spot is the region where vocal cord vibrates the most. Excessive and incorrect use of voice may cause trauma. Patients with nodules are usually aggressive and nervous. Hoarseness is their only complaint. In its early phase, the nodule is observed as soft and red swellings on the loose edges of both vocal cords. During the treatment, incorrect use of voice that may generate the nodule should be prevented; diseases such as sinusitis and laryngopharyngeal reflux that may engender the nodule should be researched; and proper medical treatment should be applied when these diseases are identified.
Surgical treatment can be performed in case of keratosis, which follows the trauma referred to as fibrotic or hard nodule. Surgery should be classical cold microlaryngeal operation, and laser should not be utilized. However, vocal therapy must definitely be applied before and after the surgery. Childhood vocal cord nodules do not require surgical operation; instead, vocal therapy should be performed.


Vocal Cord Polyp

These are the benevolent tumors of the vocal cords. They are frequently seen with males and smokers. Chronic trauma and incorrect voice use play important roles in the emergence of the disease. Factors such as alcohol consumption and smoking also affect on polyp formation.  Initial symptoms of polyps are hoarseness and respiration problems. Unilateral polyps produce different vibrations and hence generating a cracked voice. Microlaryngeal surgery is the preferred treatment method for polyps. In surgery, in addition to classic cold surgery, excision with laser can also be performed.
Reinke’s Edema (Polypoid Degeneration)

It is characterized with fluid collection in Reinke’s space under mucosa in the vocal cords. Causes of Reinke’s Edema include allergy, infections, and especially local irritants. Smoking and chronic sinusitis are known to be quite effective on the development of Reinke’s Edema. In recent years, it is showed that acid leakage from the stomach (laryngopharyngeal reflux) is also a factor behind Reinke’s Edema.
Since the volume of the vocal cords increases due to the fluid inside the Reinke’s space, vibration rate of the vocal cords in a second (frequency) decreases and voice becomes deeper. As smoking became more common among women in recent years, this disease can often be seen with women as well.
In addition to hoarseness and deepening of voice, there are also other symptoms such as dry coughing and a sense of foreign substance in the throat. During the examination, increased volume and reddening of the vocal cords can be observed. Sometimes, edema reaches excessive levels so that Polypoid degeneration occurs. First microlaryngeal surgery and then vocal therapy should be performed during the treatment. The factors effective in etiology and particularly cigarettes should be kept away from the living environment.

What are the findings derived from vocal cord paralyses? 

1- One-sided vocal cord paralysis: The vocal cord tends to be slightly off the middle line towards the sides. Voice is usually normal if the vocal cord is on the middle line. However, if it remains in the outer side, it can compensate soon, but some minor voice alterations persist. Yet, if there is significant distant between vocal cords, then a serious hoarseness may emerge.
2- Two-sided vocal cord paralysis: If vocal cords are located on the middle line, or very close to it, they can generate very accurate sounds. However, a substantial problem with breathing occurs. It requires immediate intervention.
3- Paralysis of the nerve that sustains the laryngeal’s senses: When paralysis is one-sided, fluids may flow into the lungs in the beginning, but the body compensates this situation quickly. Sensorial nerve also changes the tension of the vocal cord. In the case of this nerve branch’s paralysis, a sense of pressure in the throat, an urge for clearing the throat, and minor hoarseness develop.  If there is paralysis in this sensorial nerve’s branch, which moves both muscles, the patient states that his/her speaking voice is usually normal, but his/her voice alters when singing. In the case of two-sided sensorial nerve paralyses, getting foods and liquids into the lungs becomes unavoidable.