Understanding Voice Problems
The History:

  • Correct medical diagnosis in all fields often hinges on asking the right questions, and listening carefully to the answers.  This process is known as “taking a history”, and is usually the first step of the initial office visit encounter.  The history may be taken directly by the physician or by a nurse or medical assistant, who then relates the history to the physician. 

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  • Medical care for voice problems utilizes a  comprehensive history that recognizes that there is more to the voice than simply the vocal folds.  Virtually any body system may be responsible for voice complaints.

  • Problems outside the larynx often cause voice dysfunction in people whose vocal folds appear fairly normal, and these issues need to be relayed to the physician and/or medical staff at the time of the history.  Regardless of whether or not the patient feels that portions of his or her medical or surgical history, including the use of medications, herbal remedies, or vitamin supplements are relevant to the voice problem, it is extremely important that the voice doctor and the voice team are aware of everything that currently affects or has in the past affected the function of the entire body.

What questions help to understand the voice problem?

Describe your hoarseness?
  • Most people with voice problems complain of “hoarseness” or “laryngitis”.  A more accurate description of the problem often is helpful in identifying the cause.

   Hoarseness can be described as raspiness, which is a coarse, scratchy sound of the
voice.  It is commonly by abnormalities on the vibratory margin of the vocal fold. 
These may include swelling, roughness from inflammation, growths, scarring, or
anything that interferes with vocal fold vibration. 

  Breathiness is caused by lesions (abnormalities) that keep the vocal folds form
closing completely, including paresis (partial weakness), paralysis (complete
weakness), cricoarytenoid joint injury or arthritis, vocal fold masses, scarring, or
atrophy of the vocal fold tissues.  These abnormalities permit air escape when the
vocal folds are supposed to be tightly closed.  We hear this air leak as breathiness. 

  Fatigue of the voice is the inability to continue to phonate for extended periods
without change in vocal quality.  The voice may fatigue by becoming hoarse, losing
range, changing timbre, breaking into different registers, or by other uncontrolled
behavior.  These problems are especially apparent in actors and singers.  A well
trained singer should be able to sing for several hours without developing vocal
fatigue.  Fatigue often is caused by misuse of abdominal and neck musculature, or
overuse (singing or speaking to loudly or too long).  Vocal fatigue also may be a sign
of general tiredness, sleep apnea, thyroid abnormalities, myasthenia gravis, or other
serious illnesses. 

  Volume disturbance may present as inability to speak or sing loudly or softly.  Each
     voice has its own dynamic range.  Most volume problems are secondary to intrinsic
limitations of the voice or technical errors in voice production, although hormonal
changes, aging, and neurological diseases are other causes.  Superior laryngeal nerve
paresis will impair the ability to speak loudly.  This is a frequently unrecognized
consequence of viral infection of the laryngeal nerves, and may be precipitated by an
upper respiratory tract infection. 

  Prolonged warmup time, especially in the morning, is most often caused by reflux
laryngitis, a condition in which stomach acid refluxes up the esophagus and into the
throat, where it caused a chemical burn. 

  Tickling or choking during speech or singing is often associated with inflammation
in the larynx, sometimes related to reflux or allergy.  

  Pain while vocalizing can indicate laryngeal nerve instability or paresis, vocal fold
lesions, laryngeal joint arthritis, infection, or acid reflux irritation; but it is much
more commonly caused by excessive muscular activity in the larynx and/or neck. 

What is your voice training and how do you use your voice professionally?
  • The amount of voice use and training also affects the voice. 

  • Extensive untrained speaking under adverse environmental circumstances is a common cause of voice problems.  Such conditions occur, for example, among stock traders who speak over excessive trading room noise, teachers in large or noisy classrooms, sales people who talk in noisy rooms, restaurant personnel who are required to talk over the background noise of the kitchen and restaurant , and people who speak over the telephone in noisy offices.

  • Vocal problems can be aggravated by habits that impair the mechanics of voice production, such as sitting with poor posture and bending the neck to hold a telephone against one shoulder.  Subconscious efforts to overcome these impediments often produce enough voice abuse to cause vocal fatigue, hoarseness, and even nodules (callous-like growths, usually on both vocal folds).  Recognizing and eliminating the causal factors usually results in disappearance of the nodules and improved voice.

Do you smoke, use drugs/medications, or have any specific environmental exposures?

  • Exposure to environmental irritants is a well-recognized cause of voice dysfunction.  Smoke (both primary and second-hand), dehydration, pollution, and allergens may produce hoarseness, frequent throat clearing, and vocal fatigue. 

  • The deleterious effects of tobacco smoke upon the vocal folds have been known for many years.  Smoke from marijuana and illicit drugs is even more toxic than cigarette smoke and causes more severe injury to the larynx than what is typically seen with tobacco smoke.  Smoking not only causes chronic irritation, but can result in alterations in the vocal fold epithelium (the cells lining the vocal fold). 

  • The use of various medications and supplements may affect the voice, too, and it is extremely important for the laryngologist to know all of the prescription and over-the-counter medications that are being taken as well as any herbal remedies, vitamins, supplements, or throat sprays that are being used, even if not on a daily basis. 

What is your normal diet?

  • Some foods also may contribute to voice complaints in people with “normal” vocal folds.  Milk products are particularly troublesome to some people.  Milk contains casein, which increases and thickens mucosal secretions.  Acidic food such as tomatoes, lemons, grapefruit, and oranges aggravate reflux disease, as do caffeine, fried foods, fatty foods, dairy products, and alcohol.  Additionally, alcohol can impair one’s ability to control the voice, predisposing to vocal injury

Do you have other medical problems?

  • Disturbances in the respiratory (breathing), cardiovascular (heart and blood vessels), gastrointestinal (stomach and intestines), endocrine (both sex and other hormones), neurological, musculoskeletal, and psychological systems may contribute to voice complaints. 

  • Because voice function relies on complex brain and nervous system interactions, even slight neurological dysfunction may cause voice abnormalities.  Additionally, voice impairment is sometimes the first symptom of serious neurological diseases such as myasthenia gravis, multiple sclerosis, Lou Gherig’s disease (also known as amyotrophic lateral sclerosis or ALS), and Parkinson’s disease.

Have you had a bodily injury?

  • Proper posture is important to optimal function of the abdomen, back, and chest, which help to control the breath in talking and singing .  Injuries that involve these or the other support structures (i.e. hips, knees, ankles, neck, and head) can contribute to voice problems. 

Do you have gastrointestinal (GI) problems?

  • Gastrointestinal disorders commonly cause voice complaints, and, it is important for the treating physician to be aware of a history of such problems even if that history is remote.

Do you have asthma or other problems breathing?

  • Respiratory problems are especially problematic to singers, other voice professionals, and wind instrumentalists, but they may cause voice problems in anyone.  Appropriate breath support is essential to healthy voice production. 

Do you have hormonal problems?

  • Endocrine (hormone-related) problems may include thyroid abnormalities, diabetes (elevated blood sugar), other abnormalities in glucose (sugar) metabolism, pituitary (the primary endocrine gland) abnormalities, abnormalities in sex hormone levels, and abnormalities in cortisol (a natural steroid made by the body to help it manage and heal form stress and bodily injury) levels.  A dysfunction in any of these hormone systems can have marked vocal effects. 

  • Mild hypothyroidism (low thyroid hormone levels often associated with goiter) typically causes a muffled sound, slight loss of range, and vocal sluggishness.  Similar findings may be seen in pregnancy, during use of oral contraceptives (in about 5% of women), for a few days prior to menses, and at the time of ovulation. 

  • Premenstrual loss of vocal efficiency, endurance, and range is also accompanied by a propensity for vocal fold hemorrhage, which may alter the voice permanently.

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