What is Functional Voice Disorders?
Our voice is important for human interaction and communication. Losing it partially or completely can greatly affect our quality of life and safety. It can also greatly impact professionals who rely on their voice for work, like singers, teachers, lawyers, actors, and media personalities. But really, most people would find it hard to manage if they had major issues with their speech.
Our voice is created when air from our lungs passes over the vocal folds (like two flaps in your throat) and causes them to vibrate. This process involves the diaphragm (a muscle that helps us breathe), the throat, and the movement of our tongue, cheeks, and lips. To keep your voice healthy, it’s recommended to avoid things that can strain your vocal folds, such as shouting or screaming for too long or too loudly. Voice issues can arise due to physical problems like nodules (small, hard lumps), scars, dislocation of cartilage, and nerve injuries. If voice quality is affected and there are no physical or neurological factors to blame, a functional voice disorder may be suspected.
Voice disorders are generally categorized into the following types:
- Structural organic voice disorders: These are caused by physical changes in the throat, like swelling, vocal nodules, or presbylarynx (aging-related changes in the throat).
- Neurogenic organic voice disorders: These include issues like vocal tremors, spasmodic dysphonia (involuntary movements of the vocal folds), paralysis of the vocal folds, etc. These are related to problems with the nerves supplying the larynx (voice box).
- Functional voice disorders (FVD): These are caused by improper use of the voice box and diaphragm, even when there is no physical or neurological problem. These can adversely affect social and professional life.
Unfortunately, there is no consensus on how to best evaluate voice disorders, as there haven’t been many thorough studies looking at the best assessment or examination techniques for FVD. The most common FVDs include vocal fatigue, muscle tension dysphonia (voice hoarseness due to muscle tightness), diplophonia (the production of two separate sounds at once), and ventricular phonation (abnormal voice creation due to the stiffness of the true vocal folds). All of these disorders commonly present with a hoarse voice.
What Causes Functional Voice Disorders?
Constantly straining your voice or using it incorrectly can increase your chances of developing throat disorders such as nodules (colloquially known as “singer’s nodes”) and hematomas. These are physical changes in your larynx or voice box that can be seen during an examination by a doctor. Misusing your voice and certain mental health conditions can also lead to what are known as functional voice disorders (FVDs).
FVDs are usually easier for doctors to recognize than other disorders that have physical and mental source because they can check the structure and function of the larynx using a mirror or a flexible fiber optic endoscope, a device that allows them to see inside your throat. This helps them rule out disorders that are strictly physical. Whether physical or functional, these voice disorders can affect various aspects of your voice like its quality, pitch, and volume, all of which can be very troubling for patients.
Functional voice disorders are often caused by:
* Phonotrauma, which is a result of misusing, overstraining and overusing the voice. Examples include yelling, screaming, constant throat-clearing, and talking loudly.
* Psychogenic aphonia and dysphonia, which are usually seen in patients with underlying mental health issues such as anxiety, depression, and conversion disorder. The latter can be associated with symptoms that resemble serious neurological disorders like blindness and paralysis.
Risk Factors and Frequency for Functional Voice Disorders
Voice disorders affect an estimated 20 million people, which is about 0.98% of the United States population. Misuse or overuse of the voice, known as ‘vocal abuse’, is the most common cause in both adults and children. Teachers, in particular, are at an increased risk.
- A study from 2008 involving 905 teachers in Spain found that 57% of them suffered from voice disorders. The most common was vocal strain, affecting 18%.
- In another study, it was found that teachers were at a greater risk of voice disorders than nursing staff. The study showed that 11.6% of teachers had voice disorders, compared to 7.5% in the non-teaching population.
- Additionally, more teachers reported both current and past symptoms of voice disorders compared to those not in the teaching profession.
These studies highlight the significantly higher risk of voice disorders among those in the teaching profession as opposed to other professions.
Signs and Symptoms of Functional Voice Disorders
To diagnose voice disorders, doctors will ask about how often symptoms occur, how long they last, and how severe they are, including what makes them better or worse. They will also consider environmental factors that might impact the patient’s voice, such as dry air, drinking alcohol, smoking, and exposure to dust or chemicals. It’s also important for the doctor to understand the patient’s usual voice use and needs so a personalized treatment plan can be developed. A patient’s past and present medical conditions, previous surgeries, mental health, any trauma history, and medications can provide additional important information.
The doctor will also perform a physical examination, which includes a general assessment of the head and neck, touching the voice box (larynx) and windpipe (trachea), and using a special video tool to watch how the vocal cords move when the patient speaks.
Testing for Functional Voice Disorders
Conducting a comprehensive evaluation of your throat (specifically the larynx) and your voice is crucial to creating an effective voice therapy plan. We practice a three-step process for patients experiencing voice issues:
1. Understanding your medical history
2. Thorough physical examination
3. Additional tests
In the history-taking stage, we gather any relevant medical, surgical, psychological or traumatic information that may guide diagnosis and treatment. We then evaluate your voice – taking note of any issues you might encounter in everyday life, professionally or personally, because of your voice problem. We listen to the pitch, volume and overall quality of your voice to pinpoint the issue. This helps us to properly comprehend the root of the problem and find the best solution.
Next, we complete an ear, nose, and throat examination. We assess the quality, loudness and range of your voice, and check functions like how clear your nose is, the operation of your pharynx (the part of the throat behind the mouth and nasal cavity), and the efficiency of your velopharynx (the part that connects the nose to the mouth). Depending on your condition, we might suggest further tests like pulmonary function studies, especially if you struggle with breath control during speech, or a hearing evaluation, as hearing difficulties can affect your perception of your own voice and therefore the way you talk.
The most vital step in diagnosing voice difficulty is called laryngoscopy. This process involves studying the larynx, or voice box, through several different methods, such as mirror laryngoscopy, flexible fiberoptic laryngoscopy, distal chip laryngoscopy, digital transoral laryngoscopy, and stroboscopy. Out of these, stroboscopy provides the most information, as it studies the wave pattern of your vocal cords.
Because functional voice disorders can vary greatly in nature, we also evaluate for signs of psychogenic and muscle tension problems. These are often treated by speech-language pathologists (SLPs) with a combination of voice therapy, counseling, and potentially, psychotherapy.
It’s important to note that functional voice disorders can exhibit differently in different people. They can come across as dysphonia (difficulty in speaking), stuttering, or prosodic abnormalities (alterations in pitch, volume, rhythm of speech) and can sometimes resemble organic disorders, which makes diagnosis challenging. That’s why a thorough examination, accurate diagnosis, and suitable treatment are vital. Differentiating functional or psychogenic disorders and behavioral movement disorders from observable speech and voice disturbances can be challenging, as many behavioral and neurological conditions can mimic symptoms of organic voice conditions.
Treatment Options for Functional Voice Disorders
The first step in treating Functional Voice Disorders (FVD) is finding out the correct diagnosis. The treatment method used may be different based on what has caused the problem, what type of FVD it is, and how severe it is. Many times, understanding what’s causing the issue and changing related behaviors can provide relief.
There are three main ways to treat FVD:
1. Medical Treatment
2. Surgery
3. Voice Therapy
Voice therapy is performed by professionals called speech-language pathologists. They use a method that looks at the whole problem, aiming to manage the areas of breathing, voice production, and resonance (the vibration in your vocal tract when you speak) all together. This approach focuses on managing these areas rather than just addressing the symptoms of the voice problems.
Various techniques are used in voice therapy, like auditory masking, the accent method, conversation training therapy, Lax Vox speech therapy, expiratory muscle strength training, phonation resistance training, chant speech, and confidential voice. Speech-language pathologists use different techniques based on the type of voice disorder and the underlying cause itself.
The treatment might involve certain posture correction, relaxation techniques, keeping yourself hydrated, vocal functioning exercises, counseling, education about the condition, and changing behaviors that affect voice production.
In some cases, vocal fold nodules (small, noncancerous growths on the vocal cords) can be successfully treated with voice therapy alone. However, for other types of vocal cord problems such as laryngeal webs, polyps, contact ulcers, and papilloma, surgery might be needed. Identifying the cause of the voice problem is key to successful treatment.
Voice therapy is the standard treatment to help many people in the United States who suffer from voice disorders. However, current treatments are not always effective due to various reasons such as incorrect diagnosis, the patient not following the treatment, or the severity of the voice disorder.
What else can Functional Voice Disorders be?
If a person is experiencing dysphonia, which is a change or difficulty in voicing, there could be a range of causes. The possible causes might include:
- Somatoform disorder: a mental health condition where a person has physical symptoms with no identifiable physical cause
- Conversion disorder: a mental condition where a person has blindness, paralysis, or other nervous system symptoms that can’t be explained by medical evaluation
- Abuse: physical, sexual, or emotional maltreatment
- Anxiety disorder: a mental health condition characterized by feelings of worry, anxiety, or fear
- Depression: a mood disorder that causes a persistent feeling of sadness and loss of interest
- Munchausen syndrome: a mental disorder in which a person repeatedly and deliberately acts as if they are sick when they are not really ill
- Malingering: the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives
- Allergic and environmental asthma: a chronic respiratory disorder in which the airways become inflamed and narrowed when exposed to certain triggers
- Anaphylaxis: a severe, potentially life-threatening allergic reaction
- Bilateral vocal fold paralysis: a condition where both sides of the vocal cords are unable to move
- Exercise-induced asthma: a narrowing of the airways in the lungs that is triggered by physical activity
- Foreign body obstruction: a blockage of the airway by an object, restricting breathing
- Laryngeal abnormalities like tumor, polyps, or cyst: they are growths that occur in the larynx, or voice box
What to expect with Functional Voice Disorders
Several factors can indicate a good outcome for a patient, including the sudden start of symptoms, no pre-existing serious health conditions, the ability to remove the cause (especially if it’s a stressful event), being a young male, and generally being in good health. On the other hand, some factors may suggest a worse outcome, such as personality disorders, the patient’s negative view of their health, linked motor symptoms, and seizures that occur due to psychological factors rather than a physical condition.
To improve the patient’s condition, it’s very important to correctly define the issue through a comprehensive examination and thoughtful reasoning. The treatment has to align with the root cause of the problem; help from voice therapy, for example, won’t have much benefit for a patient if the issue is a throat mass that needs to be surgically removed. The best chances of reducing symptoms and helping the patient increase their quality of life typically comes from a multidisciplinary approach, usually involving an ear, nose, and throat specialist (known medically as an otorhinolaryngologist) or a laryngologist trained in a fellowship program, and speech-language pathologist (SLP).
Possible Complications When Diagnosed with Functional Voice Disorders
The main problems related to functional voice disorders (FVD) are tied to difficulties in communication and the loneliness that can come from ineffective speaking. When talking becomes a challenge or leads to poor communication, it can lead to feelings of frustration, low self-esteem, and even anxiety or depression. In cases where the FVD is psychological, prolonged FVD can make related mental health problems worse, which can amplify the effects of the FVD.
Common Challenges:
- Communication barriers
- Social isolation
- Difficulty in speaking
- Ineffective communication
- Frustration
- Low self-esteem
- Anxiety
- Depression
- Exacerbation of FVD in the long-term
- Worsening of underlying mental health conditions
Preventing Functional Voice Disorders
The main treatment for voice disorders that aren’t caused by physical changes, is voice therapy, which is customized based on how the patient is affected and their likely recovery. A major challenge is that it can be hard for patients to stick to the regular check-ups and long-term self-care required by this treatment. But, results are better when problems that might stop a patient from following the treatment plan are recognized and tackled, often by using questionnaires that focus on the patient’s experience.
Also, if a patient better understands their diagnosis and what’s causing the condition, they’re likely to be more motivated. This understanding helps them see what’s creating the problem, which can contribute to a better outcome.
