speech therapy exercises for spasmodic dysphonia

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Overview  |  Understanding the Disorder  |  Symptoms  |  Diagnosis  | Treatment

Spasmodic Dysphonia (SD) A voice disorder resulting from involuntary movements (spasms) of the voice box muscles.

Dystonia A nervous system problem that causes involuntary movement; dystonia is not a psychological problem; SD is a type of dystonia

Adductor SD (Ad-SD) Spasms in muscles that close vocal folds, which interrupt speech and cause strained or strangled voice breaks

Abductor SD (Ab-SD) Spasms in muscles that open vocal folds, which interrupt speech and cause breathy or soundless voice breaks

How is SD treated? No Cure for SD, but Treatment Options Improve Symptoms

• Although there is no cure for SD, in most cases treatment can improve symptoms.
• However, treatment that improves voice symptoms does not affect the course of the disorder. In other words, if a person elects not to be treated, the SD will not become worse.

Patient Self-Help Strategies Some people with SD find ways to improve their voice on their own. These can include chewing something while talking, speaking while laughing, and speaking in falsetto or in a “cartoon-character” voice.

A trick to the brain: It is thought that maneuvers like these take advantage of the task-specific nature of SD to “fool” the brain into thinking that the person is using the larynx for something other than connected speech. However, over time these strategies generally become less effective.

Botulinum Toxin Injection – Main Therapy for SD Laryngeal injections of botulinum toxin are the main therapy for SD. Botulinum toxin is a naturally occurring substance that weakens muscle by blocking the release of acetylcholine from nerve endings. Acetylcholine is a substance that triggers muscle contraction.

Effects Are Temporary The effects of botulinum toxin are temporary, lasting about three months, and dose-dependent, so that the muscle weakness is proportional to the amount of toxin used. Research has found that there is a “plateau effect” at higher doses of botulinum toxin; however, at the typical low doses used for the treatment of SD, there is a consistent dose-dependent response.

 Different Types of Botulinum Toxin Of the eight types of botulinum toxin that exist, two are available for use in humans – botulinum toxin, type A and botulinum toxin, type B.

• Botulinum toxin, type A: Has been used to improve voice symptoms of patients with SD in the United States since 1984. In this period, it has been shown to be safe, it improves voice symptoms of SD, and it is recognized as such by the American Academy of Otolaryngology–Head & Neck Surgery.
• Botulinum toxin, type B: Is now available for unrestricted use. It may be used in those people for whom type A no longer has any effect.

How Botulinum Toxin Treatment Works for SD The principle behind botulinum toxin treatment of SD is to weaken the muscles that are hyperactive or involved in the involuntary movements or spasms. The muscles that undergo spasms are therefore the ones injected – weakening them will minimize the effects of the spasms on voice.

How Botulinum Toxin Treatment Is Performed

• Injections Through the Skin
• Botulinum toxin is usually injected through the skin of the neck into the appropriate spots with the aid of electromyography (EMG).
• The procedure is performed in a physician’s office. Afterwards, the patient may usually go on with the normal activities of the day.
• The discomfort associated with the injection commonly disappears after a day or two.
• More rarely, botulinum toxin may be injected through the mouth under a general or local anesthetic.

(For more information, see LEMG .)

Low Dose in the Beginning

• The physician can arrive at the correct amount only through experience with each individual case and feedback from the patient. For this reason, a record of the dose and its effect is usually kept.
• Because there is no means of correcting botulinum toxin muscle weakening before it runs its course, most physicians prefer to begin with a low dose and add toxin as necessary.

Staggered Injections for Ab-SD to Avoid Breathing Difficulty

• In Ab-SD, the toxin is directed at weakening the muscles that open the vocal folds. Inadequate parting of the vocal folds could result in breathing difficulty, so injections are often staggered, with one vocal fold injected one or two weeks after the first.
• Sometimes, a treating physician may prefer to treat just one side per three-month “cycle” to minimize these effects.

Adjusting Dose and Frequency of Injections

• Often, the dose of botulinum toxin can be adjusted to minimize unwanted effects in both types of SD.
• In the case of Ad-SD, for instance, decreasing the dose can usually shorten the duration of the breathiness, but the overall length of benefit may be decreased. Obviously, each person prefers to be injected as infrequently as possible, but each has a different tolerance for the breathy voice period following the injection. People for whom voice is crucial, like lawyers or schoolteachers, may opt for smaller doses at more frequent intervals.

Determining Side to Inject – One-Sided or Both Sides?

• Currently there are no standard rules for injecting botulinum toxin to one or both sides.

Two-Sided Injections for Ad-SD

• Most commonly, injections to both sides are done for Ad-SD. This is based on the notion that the disorder is bilateral and symmetric. However, in certain patients a unilateral injection may be preferable to minimize side effects.

Usually One-Sided for Ab-SD

• Injections for Ab-SD are typically either on one side only or on one side with a large dose and the other side a small dose. The patient will then return approximately three weeks later for a repeat injection, depending upon the response to the first injection.

Measuring Treatment Success

• Because the aim of SD treatment is to relieve symptoms rather than cure the condition, the patient’s self-rating of speech and voice is probably the best measure of its effectiveness.

 Common Observations on Treatment Response

What does it feel like to have a botulinum toxin injection?

Done Through the Neck

• Most botulinum toxin injections are done through the skin of the neck using EMG guidance. The otolaryngologist may or may not inject the skin overlying the voice box with a small amount of numbing medicine. (For more information, see LEMG.)

Injection for Ad-SD

• For the injection procedure, patients are placed in a completely reclining or semi-reclining position, and a very thin needle is then passed through the skin overlying the voice box into the voice box muscle responsible for moving the vocal folds to the midline (adductor muscles).
• Once the needle has been verified by LEMG to be in the targeted muscle, the botulinum toxin is injected. The patient will experience a small amount of discomfort from the needle going through the skin and must try not to swallow during the procedure.
• The patient will often hear the EMG activity, which sounds like television static, and should not be startled by this sound.

Injection for Ab-SD

• The muscle to be injected is localized by LEMG.
• The needle is then passed through the skin of the neck, in a similar fashion as for Ad-SD except that the voice box is slightly rotated to allow the EMG needle to find the appropriate muscle (posterior cricoarytenoid muscle) on the posterior part of the larynx.

(For more information, see LEMG and Anatomy & Physiology of Voice Production .)

What to Expect After Injections

Typical Pattern Observed in SD patients

Basis of pattern not understood but probably related to process of nerve recovery after weakness from botulinum toxin, type A injections

Key Information

A Note on Aftereffects of Injection

• In Ad-SD, because the muscles that bring the vocal folds together are initially “over-weakened,” injection is normally followed by a period of breathy, whispery voice and sometimes coughing when drinking liquids. This may last for up to two weeks. Most otolaryngologists aim to adjust the botuli

What dose of botulinum toxin should I receive?

• There is no standard botulinum toxin dose. The dose and injection sites for each patient with SD must be customized according to the severity of the condition, the patient’s voice demands and response to botulinum toxin.

What are the common complications of SD treatment?

• There may be some complications with botulinum toxin, type A injections, or none at all. The risk of complications is best discussed with your otolaryngologist.

Complications observed after botulinum toxin, type A injections for SD are described below.

Difficulty Swallowing

• Difficulty swallowing is probably the most common side effect of botulinum toxin injections. Since the larynx (voice box) lies next to the entrance of the esophagus, and since laryngeal muscles are small and located fairly deep within the neck, toxin may inadvertently reach the esophageal or pharyngeal muscles. Weakening of these muscles, when added to the weakening of the vocal folds that results from treatment, can result in altered or impaired swallowing.
• More an inconvenience than a danger: Some temporary change in swallowing is reported by up to 17 percent of patients. In the vast majority of cases, this is more of an inconvenience than a danger. However, it is possible to impair swallowing more severely, and even theoretically cause a lung infection from food entering the trachea (windpipe). Because the effect of botulinum toxin is temporary, it is usually necessary only to exercise caution while eating or drinking until the situation returns to normal. This is usually a matter of days or weeks, although in very rare cases the problem may persist for the entire three months that the toxin has effect.
• Usually observed after the first injection, thereafter not so often: Difficulty with swallowing (especially liquids) following botulinum toxin injection is often most noticeable with the first injection and may decrease with subsequent injections.
• Although always a possibility when a needle is passed through the skin, there have been no reported cases of infection as a result of botulinum toxin injection performed in a physician’s office with normal attention to cleanliness and sterile technique.

Minor Bleeding

• Minor bleeding and bruising at the injection site may occur, especially in those patients who take aspirin or blood thinners. Serious bleeding has not been reported.

Side Effects

• Overall experience with botulinum toxin injections reveals that the treatment remains effective over time and seems to have no important side effects for the patient. It is best for patients to consult their physicians about possible side effects.
• Muscles treated with botulinum toxin have been shown to decrease in size, but in the larynx this is not noticeable. This decrease in size appears to reverse once treatment is discontinued.

The safety of botulinum toxin in pregnancy and during breast feeding has not been established. Thus injection should not be administered in these situations.

Muscle-Specific Side Effects

• Side effects are specific to whether the injected muscle is an adductor or abductor muscle.

In Ad-SD, adductor-specific side effects include:

• Soft, breathy voice
• Difficulty drinking liquids
• Both of these side effects occur because the treated vocal folds are unable to come together completely.

In Ab-SD, abductor-specific side effects include:

•  Some breathing restriction (since the treated vocal fold is not able to move aside fully)

How to Minimize Side Effects

• Side effects can be minimized and sometimes even eliminated by altering dose or injection pattern. Feedback information from the patient’s experience with the previous injection is essential in making the necessary adjustments. Therefore, each new injection should be preceded by a discussion between the patient and the physician about the effects of the previous injection.

How long will botulinum toxin type A injections be effective?

Developing Tolerance – Loss of Drug Effect

• Loss of drug effect, or resistance, to botulinum toxin can occur after many treatments.
•  Higher doses and more frequent treatments increase the likelihood that a person will become resistant.
• Resistance is rare among people with SD since the dose used is very small.

Resistance to botulinum toxin is not well understood, but it has been found to occur when the body forms antibodies (the body’s defense mechanism) to the botulinum toxin or associated substances, thereby neutralizing their effectiveness. The body forms antibodies to any foreign substance introduced to it, including the botulinum toxin (which originates from one type of bacteria). Resistance to botulinum toxin can be tested by injecting botulinum toxin into the muscle in the forehead and observing the muscle’s response.

Surgical Treatment – A Second-Choice Treatment

• Surgery for SD, like surgery for all dystonias, is a second-choice treatment – recommended for patients in whom botulinum toxin treatment is for one reason or another impossible, ineffective, or poorly tolerated. Unfortunately a disappointingly large number of patients have had a recurrence of symptoms months to years following surgery.

Aim of Surgery to Weaken Muscles That Go Into Spasms

• The goal of surgery for SD is the same as for botulinum toxin treatment: to weaken the muscles that spasm.

Types of Surgical Interventions for SD

Cutting Recurrent Laryngeal Nerve (RLN)

• Surgeons initially cut or crush the nerve to the vocal fold, called the recurrent laryngeal nerve.
• Despite encouraging initial results, about two-thirds of patients develop symptoms of SD again within three years.
• Furthermore, although the SD symptoms return, the paralysis that results from the cutting of the RLN remains – a condition that has its own drawbacks.

(For more information, see Vocal Fold Paresis/Paralysis. )

Cutting Superior Laryngeal Nerve (SLN) and Manipulating the Larynx to Reduce Effect of Spasms on Voice

• Surgeons have also tried cutting the secondary nerve to the larynx, known as the superior laryngeal nerve, and manipulating the larynx so the vocal folds lie farther apart (lateralization thyroplasty) or are under less tension (anterior commissure release). None of these techniques have resulted in satisfactory long-term control of symptoms.

Cutting Both Nerve and Muscle: Thyroarytenoid (TA) Neuromyomectomy

• One surgical procedure being done in Japan involves removing some of the thyroarytenoid muscle (the muscle within the vocal fold) and nerve innervating it. This surgery is called a TA neuromyomectomy.
• The results of this procedure have been very favorable. However, the long-term success of this surgical procedure in other countries has yet to be demonstrated.

(For more information, see Anatomy & Physiology of Voice Production. )

Selective Denervation-Reinnervation – Cutting the Nerve That Causes Spasms and Replacing It With Normal Nerve

• Currently, a procedure known as selective laryngeal adductor denervation-reinnervation is being carefully studied. In this operation, nerves to two of the muscles that close the vocal folds (adductors) are cut (denervation) and replaced (reinnervated) with nerves from muscles that are normal (not involved in the dystonia, i.e., no spasms). Initial results, as in other surgical approaches, have been promising.
• Long-term results are not yet well known.

Non-Treatment Not Harmful

• Available treatments for all forms of SD are able only to improve or minimize symptoms. Opting not to be treated has no effect on the underlying central nervous system disorder. Patients should only continue with treatment if they feel it is beneficial.

Other Treatments

Voice Therapy

• Voice therapy by itself has not been useful in controlling the symptoms of SD. However, voice therapy can help control the side effects of treatment and help the patient manage the anxiety that often worsens the symptoms of SD.

Voice therapy may be helpful following botulinum toxin treatment by helping the person:

• Eliminate the body’s poor compensation behaviors
• Adjust to the changes in the voice from treatment
• Maximize the beneficial effects of the botulinum toxin treatment

Psychological/Psychiatric Treatment

• SD is an organic disorder of the central nervous system. As a result, psychological/psychiatric treatment is not an effective primary treatment.
• However, any chronic condition can be emotionally and psychologically draining. SD is especially so because it affects the voice. A mental health professional may help SD patients better handle the stresses associated with SD.

Oral Medication Treatment

• Many medications that act on the central nervous system may be beneficial in dystonia. Unfortunately, at doses that relieve symptoms, significant side effects–like sedation and memory loss – are common.
• In most cases of SD, oral medication is not used at all or is used only as an auxiliary therapy. A neurologist specializing in movement disorders is usually the most appropriate person to consult regarding medication. For this reason, many otolaryngologists who specialize in SD recommend evaluation by such a specialist at some point.

SD Can Be Frustrating

• SD is a frustrating, chronic condition for which no cure is currently known. However, it is only rarely associated with other diseases. In most cases, treatment can substantially improve symptoms, often resulting in a near-normal voice.

Open Patient-Physician Communication Important

• Because, in the end the affected person is the best judge of his or her voice function, honest and open communication between the doctor and patient is essential in getting the most out of treatment and overcoming the disorder.

Further Information Is Available

Patient Associations and Support Groups

• National Spasmodic Dysphonia Association
• Dystonia Medical Research Foundation
• National Institutes for Deafness and Communication Disorders page on SD

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What is Spasmodic Dysphonia?

Spasmodic dysphonia is a challenging and often misunderstood voice disorder that affects the vocal cords. Characterized by involuntary spasms that disrupt vocal cord movements, this

condition can significantly impact a person’s ability to speak and communicate effectively.

In this article, we’ll explore the various aspects of spasmodic dysphonia, including its types,

causes, symptoms, and the range of treatment options available.

Understanding the Types of Spasmodic Dysphonia

Exploring the causes of spasmodic dysphonia, recognizing the spasmodic dysphonia symptoms, spasmodic dysphonia treatment, getting started with spasmodic dysphonia treatment.

Spasmodic dysphonia is a voice disorder characterized by involuntary spasms of the vocal

cords, which disrupt normal voice production.

Spasmodic dysphonia is primarily classified into three main types, each affecting voice

production in distinct ways and presenting unique challenges for diagnosis and management:

● Adductor Spasmodic Dysphonia

● Abductor Spasmodic Dysphonia

● Mixed Spasmodic Dysphonia

Adductor Spasmodic Dysphonia (ADSD)

The most common type of spasmodic dysphonia, Adductor Spasmodic Dysphonia, occurs when the vocal cords close too tightly and often. This excessive closure interrupts the normal vibration of the vocal cords necessary for voice production. As a result, individuals with ADSD typically experience choppy or jerky speech. Their voices can abruptly cut out or break, making their speech difficult to understand. This type of spasmodic dysphonia can be particularly straining as it often requires significant effort to speak.

Abductor Spasmodic Dysphonia (ABSD)

In contrast to ADSD, Abductor Spasmodic Dysphonia involves the vocal cords opening too

widely. In ABSD, the vocal cords fail to close properly, which leads to prolonged pauses in

speech and breathy or whispery sounds, as the voice tends to fade or even disappear

mid-conversation. This type can be especially challenging to manage because the voice's

unpredictability makes consistent communication difficult.

Mixed Spasmodic Dysphonia

The least common and most complex type is Mixed Spasmodic Dysphonia, which features

elements of both adductor and abductor types. Individuals with this form experience symptoms of both excessive closure and inadequate closure of the vocal cords, leading to a voice that can unpredictably break into a whisper or cut out entirely. Mixed Spasmodic Dysphonia is particularly difficult to diagnose and treat because the symptoms can vary widely, often mimicking other voice disorders, and may change over time.

Understanding these types is crucial for developing effective treatment strategies, as each type may respond differently to various therapies.

The underlying causes of spasmodic dysphonia remain not fully understood, but research

suggests a combination of neurological, genetic, and environmental factors play a role in its

development.

At its core, spasmodic dysphonia is believed to stem from dysfunction within the basal ganglia, a group of structures in the brain that are crucial for regulating voluntary motor movements and coordination. This dysfunction can lead to the misfiring of nerve signals that control the muscles of the vocal cords, resulting in the spasmodic symptoms characteristic of the disorder.

Genetics also appear to contribute to the risk of developing spasmodic dysphonia. Some

studies have found that the disorder can run in families, suggesting a possible hereditary

component. Environmental and emotional factors are also implicated in triggering or

exacerbating the symptoms of spasmodic dysphonia. Stress, for instance, is often reported by patients to worsen their symptoms.

While the exact mechanisms behind spasmodic dysphonia are complex and not entirely clear, it appears to result from an interplay of multiple unavoidable factors. Because of this, the most important measure you can take is staying educated and seeking early intervention at the first symptoms to mitigate its consequences.

Take Control of Your Voice: Explore Effective Spasmodic Dysphonia Treatments Today!

The symptoms of spasmodic dysphonia will vary from case to case, but there are still a few

symptoms you can keep an eye out for. If you recognize any of the following signs, it’s important to consult a speech-language pathologist as soon as possible:

● Voice Breaks: Sudden interruptions in speech, characteristic by the type of adductor.

● Strain and Struggle While Speaking: Individuals with spasmodic dysphonia often

experience difficulty speaking, which can be physically tiring and frustrating.

● Variability in Voice Quality: The voice may sound different from day to day or even

within the same day, often worsening with use and improving with rest.

● Breathy or Whispery Voice: Common in abductor type, where the voice can sound

weak and breathy.

While they can be difficult to recognize, it’s important to keep an eye out for each sign. Early

detection is crucial as it allows you to seek treatment before the condition worsens.

While there is no cure for spasmodic dysphonia, several effective treatments can help manage its symptoms and significantly improve communication. The choice of treatment often depends on the specific type of spasmodic dysphonia, its severity, and individual needs and preferences.

The most common treatment methods include:

● Botox injections

● Voice therapy

● Thyroplasty

● SLAD-R Surgery

Botulinum toxin injections

Botulinum toxin (Botox) injections are the primary treatment for spasmodic dysphonia. Botox is a neurotoxin that temporarily paralyzes muscles, reducing spasms when injected directly into the vocal cords. This treatment helps to stabilize the voice and make it less interrupted.

Botox is particularly effective for Adductor Spasmodic Dysphonia, where the vocal cords close too tightly, and also useful in cases of Abductor Spasmodic Dysphonia, to control the duration and frequency of vocal cord openings. The effects of Botox typically last for several months, necessitating periodic retreatment.

Voice Therapy

Voice therapy involves sessions with a speech-language pathologist who helps patients learn

exercises and techniques to improve vocal control and efficiency. This treatment can maximize voice function by teaching strategies to manage symptoms of spasmodic dysphonia, such as better breath support and voice projection. It may also involve relaxation techniques to reduce the overall effort of speaking.

Voice therapy is recommended for all types of spasmodic dysphonia and is especially beneficial for milder cases or for patients seeking non-invasive treatment options. It can also complement other treatments like Botox injections to enhance their effectiveness.

Thyroplasty

Thyroplasty is a surgical procedure that adjusts the position or tension of the vocal cords by

inserting an implant into the voice box. This operation helps stabilize the voice by physically

modifying the vocal cords to reduce spasms and improve sound production.

Thyroplasty is typically considered for patients with severe spasmodic dysphonia who have not responded well to Botox or for whom Botox's effectiveness has waned. As a more permanent solution compared to Botox, it offers lasting benefits but also carries the inherent risks of surgery.

Selective laryngeal adductor denervation-reinervation (SLAD-R) is a complex surgical option

aimed at permanently reducing spasms by reinnervating the muscles responsible for vocal cord closure. The procedure involves severing the nerves originally innervating the affected muscles and connecting them to different nerves that normally do not trigger spasms.

SLAD-R is usually reserved for severe cases of Adductor Spasmodic Dysphonia where less

invasive treatments have failed. Although it offers a more durable solution, the surgical outcome and recovery can vary, presenting a consideration of risks and benefits.

Treatment for spasmodic dysphonia typically involves a comprehensive evaluation to confirm

the diagnosis and determine the form and severity of the disorder. A treatment plan is then

tailored to the individual’s specific symptoms, lifestyle, and personal preferences.

To get started with your treatment, get in touch with an experienced speech-language

pathologist today. At Better Speech, a licensed specialist in spasmodic dysphonia is just one

click away. Our team specializes in diagnosing and treating a variety of speech and language disorders. Reach out to our skilled Speech-Language Pathologists for guidance on managing and improving communication skills. At Better Speech, we offer online speech therapy services convenient for you and tailored to your child's individual needs. Our services are affordable and effective - get Better Speech  now.

Frequently Asked Questions

What is the prognosis for someone with spasmodic dysphonia.

The prognosis for someone with spasmodic dysphonia varies widely based on the type, severity, and response to treatment. While spasmodic dysphonia is generally considered a chronic condition, many individuals find their symptoms can be effectively managed with ongoing treatment. Regular Botox injections, voice therapy, or surgical interventions can help maintain a more stable voice. Early diagnosis and personalized treatment plans are key to improving outcomes.

Can spasmodic dysphonia go away on its own?

How is spasmodic dysphonia diagnosed, are there any lifestyle changes to help spasmodic dysphonia, can children develop spasmodic dysphonia.

About the Author

Aycen Zambuto

I’m a seasoned educator in speech therapy with over six years of experience helping people navigate challenges in communication. Throughout this time, I’ve found joy in guiding individuals through a variety of therapeutic journeys, from toddlers with apraxia to seniors with dysphonia.

I’m passionate about demystifying this complex world of speech therapy and helping readers around the globe achieve clear and effective communication. When I’m not writing about speech, you’ll often find me reading, traveling or spending time with friends and family.

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Voice Disorders

View All Portal Topics

The scope of this page focuses on voice disorders of organic, functional, and psychogenic origin(s).

See the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

For information on gender-affirming voice services, see ASHA’s Practice Portal page on Gender Affirming Voice and Communication .

A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone et al., 2010; Lee et al., 2004). A voice disorder is present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not perceive it as different or deviant (American Speech-Language-Hearing Association [ASHA], 1993; Colton & Casper, 2011; Stemple et al., 2010; Verdolini & Ramig, 2001).

For the purposes of this document, voice disorders are categorized as follows:

• alterations in vocal fold tissues (e.g., edema or vocal nodules) and/or
• structural changes in the larynx due to aging.
• vocal tremor,
• spasmodic dysphonia, or
• vocal fold paralysis.
• vocal fatigue,
• muscle tension dysphonia or aphonia,
• diplophonia, or
• ventricular phonation.

Voice quality can also be affected when psychological stressors lead to habitual, maladaptive aphonia or dysphonia. The resulting voice disorders are referred to as psychogenic voice disorders or psychogenic conversion aphonia/dysphonia (Stemple et al., 2010). These voice disorders are rare. Speech-language pathologists (SLPs) may refer individuals suspected of having a psychogenic voice disorder to other appropriate professionals (e.g., psychologist and/or psychiatrist) for diagnosis and may collaborate in subsequent behavioral treatment.

The complementary relationships among these organic, functional, and psychogenic influences ensure that many voice disorders will have contributions from more than one etiologic factor (Stemple et al., 2014; Verdolini et al., 2006). For example, vocal fold nodules may result from behavioral voice misuse (functional etiology). However, the voice misuse results in repeated trauma to the vocal folds, which may then lead to structural (organic) changes to the vocal fold tissue.

SLPs may also be involved in the assessment and treatment of disorders that affect the laryngeal mechanism (i.e., the aerodigestive tract) and that are not classified as voice disorders, such as the following:

• Paradoxical vocal fold movement (PVFM)—a condition in which there is intermittent adduction of the vocal folds that interferes with breathing. When this is suspected, SLPs may be consulted to help identify abnormal laryngeal and respiratory function and to teach various techniques (e.g., vocal exercises, relaxation techniques, quick-release breathing techniques, and proper breath management) to improve laryngeal and respiratory control (Mathers-Schmidt, 2001; Patel et al., 2015; Traister et al., 2016).
• Exercise-induced laryngeal obstruction (EILO)—EILO is most often diagnosed in adolescence and is typically due to obstruction at the laryngeal level due to inappropriate glottic closure or adduction/collapse of supraglottic structures (Maat et al., 2011). EILO may go by other names such as supraglottic airway obstruction during exercise (Murry & Milstein, 2016).

For further information, see ASHA’s Practice Portal page on Aerodigestive Disorders .

Incidence and Prevalence

Incidence of voice disorders refers to the number of new cases identified in a specific time period.

Prevalence refers to the number of individuals who are living with voice disorders in a given time period.

Estimates of incidence and prevalence vary due to a number of factors, including etiology, age, gender, and occupation.

In the pediatric population, the reported prevalence of a voice disorder has ranged from 1.4% to 6.0% (Black et al., 2015; Carding et al., 2006). Longer stays in the neonatal intensive care unit and prolonged intubation (more than 28 days) were associated with more severe dysphonia in premature infants (Hseu et al., 2018). An estimated range of 41%–73% of children were identified with vocal nodules, indicating vocal nodules as a predominant cause of pediatric dysphonia (Martins et al., 2015); however, there can be a variety of causes other than vocal fold nodules that result in dysphonia in the pediatric population. Rates indicated no statistically significant differences across race in preschool-aged children (Duff et al., 2004).

Approximately one out of 13 adults in the United States will experience a voice problem annually, but only a relative minority seek treatment (10%; Bhattacharyya, 2014). The rate of young adults (aged 24–34 years) with voice disorders was estimated to be 6%, with no significant difference across age groups, race/ethnicity, or education levels (Bainbridge et al., 2017). Prevalence was reported to be higher in adults aged 60 years and older, with estimates ranging from 4.8% to 29.1% in population-based studies (de Araújo Pernambuco et al., 2014).

Among adults (between 19 and 60 years of age) with a voice disorder, the most frequent diagnoses included functional dysphonia (20.5%), acid laryngitis (12.5%), and vocal polyps (12%; Martins et al., 2015).

Of individuals over the age of 60 years who had been evaluated for vocal problems, voice disorders were most commonly associated with presbyphonia (changes associated with aging voice), reflux/inflammation, functional dysphonia, vocal fold paralysis/paresis, and Reinke’s edema (Martins et al., 2015). Laryngeal cancer diagnoses were reported to have peaked in adults between 75 and 79 years of age and decreased thereafter (Roy et al., 2016).

Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth and/or gender identity. Voice disorders were reported to be significantly more prevalent in male children than in female children (Carding et al., 2006; Martins et al., 2015). In adulthood, however, prevalence was higher in female adults than in male adults, with a reported ratio of 1.5:1.0 (Martins et al., 2015; Roy et al., 2005).

Although female adults more frequently received diagnoses of dysphonia with no specific cause noted, male adults were more frequently diagnosed with chronic laryngitis (Cohen et al., 2012). Also, after the age of 40 years, male adults had higher prevalence rates of laryngeal cancer than female adults (Cohen et al., 2012).

Teachers were estimated to be two to three times more likely than the general population to develop a voice disorder (Martins et al., 2014). Certain factors, such as number of classes per week, noise generated outside of the school setting, and volume of voice while lecturing, were indicated to increase the risk of teachers developing a voice disorder (Byeon, 2019).

The mean prevalence of voice disorders was estimated to be 46% among singers (Pestana et al., 2017). The most prevalent laryngeal pathologies and voice disorder symptoms reported in singers included, but were not limited to, Reinke’s edema, polyps, gastroesophageal reflux disease, laryngeal pain, and hoarseness; however, risk of developing laryngeal pathologies or vocal cord symptoms may vary based on differences in singing style and genre (Kwok & Eslick, 2019).

According to a claims-based study, almost 30% of dysphonia claims were individuals in the service industry. Those in the service industry were estimated to be 2.6 times more likely to develop benign laryngeal growth and individuals in the manufacturing industry were estimated to be 1.4 times more likely to develop malignant laryngeal growth compared to the general population (Benninger et al., 2017).

Signs and Symptoms

The term dysphonia encompasses the auditory-perceptual symptoms of voice disorders. Dysphonia is characterized by altered vocal quality, pitch, loudness, or vocal effort.

Perceptual signs and symptoms of dysphonia include

• rough vocal quality (raspy, audible aperiodicity in sound);
• breathy vocal quality (audible air escape in the sound signal or bursts of breathiness);
• strained vocal quality (increased effort; tense or harsh);
• strangled vocal quality (as if talking with breath held);
• abnormal pitch (too high, too low, pitch breaks, decreased pitch range);
• abnormal loudness/volume (too high, too low, decreased range, unsteady volume);
• abnormal resonance (hypernasal, hyponasal, cul-de-sac resonance);
• aphonia (loss of voice);
• phonation breaks;
• asthenia (weak voice);
• gurgly/wet-sounding voice;
• pulsed voice (fry register, audible creaks or pulses in sound);
• shrill voice (high, piercing sound, as if stifling a scream); and
• tremorous voice (shaky voice; rhythmic pitch and loudness undulations).

Other signs and symptoms include

• increased vocal effort associated with speaking,
• decreased vocal endurance or onset of fatigue with prolonged voice use,
• variable vocal quality throughout the day or during speaking,
• running out of breath quickly,
• frequent coughing or throat clearing (may worsen with increased voice use), and
• excessive throat or laryngeal tension/pain/tenderness.

Signs and symptoms can occur in isolation or in combination. As treatment progresses, some may dissipate, and others may emerge as compensatory strategies are eliminated.

Auditory-perceptual quality of voice in individuals with voice disorders can vary depending on the type and severity of the disorder, the size and site of the lesion (if present), and the individual’s compensatory responses. The severity of the voice disorder cannot always be determined by auditory-perceptual voice quality alone. Therefore, further instrumental assessment may be indicated to determine the severity and/or etiology of a voice disorder.

Normal voice production depends on power and airflow supplied by

• the respiratory system;
• laryngeal muscle activation;
• balance, coordination, and stamina of respiration, phonation, and resonation subsystems; and
• oral cavity, and
• nasal cavity.

A disturbance in one of these subsystems or in the physiological balance among the systems may lead to or contribute to a voice disorder. Disruptions can be due to organic, functional, and/or psychogenic causes.

Organic causes include the following:

• vocal nodules, cysts, or polyps
• glottal stenosis
• recurrent respiratory papilloma
• sarcopenia (muscle atrophy associated with aging)
• arthritis of the cricoarytenoid or cricothyroid,
• laryngitis, or
• laryngopharyngeal reflux
• intubation trauma
• chemical exposure
• external trauma
• recurrent laryngeal nerve paralysis
• adductor/abductor spasmodic dysphonia
• Parkinson’s disease
• multiple sclerosis
• pseudobulbar palsy

Functional causes include the following:

• phonotrauma such as
• excessive throat clearing/coughing
• speaking in too high or too low pitch
• muscle tension dysphonia
• ventricular phonation
• vocal fatigue due to

Psychogenic causes include the following:

• chronic stress disorders
• conversion reaction such as
• conversion aphonia
• conversion dysphonia

Making modifications to pitch without the guidance of a skilled service provider is not recommended and may result in vocal misuse. However, voice services may be provided to assist with appropriate pitch modifications.

Recognizing associations among these factors, along with patient history, may help in identifying the possible causes of the voice disorder. Even when an obvious cause is identified and treated, the voice problem may persist. For example, an upper respiratory infection could be the cause of the dysphonia, but poor or inefficient compensatory techniques may cause dysphonia to persist, even when the infection has been successfully treated.

Roles and Responsibilities

SLPs play a central role in the assessment, diagnosis, and treatment of voice disorders. The professional roles and activities in speech-language pathology include the following:

• prevention and advocacy
• administration

SLPs are trained to evaluate voice use and function to determine the cause of reported symptoms and select treatment methods for improving voice production.

Appropriate roles for SLPs include the following:

• Provide prevention information to individuals and groups known to be at risk for voice disorders, as well as to individuals working with those at risk.
• Conduct a comprehensive voice assessment, including clinical and instrumental evaluation.
• Identify normal and abnormal vocal function, describe perceptual qualities of voice, and assess vocal habits.
• Diagnose a voice disorder.
• Refer individuals to other professionals as needed to obtain a medical diagnosis (e.g., unilateral vocal fold immobility as the cause of dysphonia).
• Refer individuals to other health care professionals when medical/surgical or psychological evaluation and treatment are indicated and facilitate patient access to comprehensive services.
• Make decisions about management of voice disorders and develop culturally responsive treatment plans.
• Provide treatment, document progress, and determine appropriate dismissal criteria.
• Counsel patients and provide education aimed at preventing further complications from voice disorders.
• Serve as an integral member of a collaborative team (see ASHA’s resources on  collaboration and teaming  and  interprofessional education/interprofessional practice [IPE/IPP] ) that includes professionals such as
• otolaryngologists/laryngologists,
• pulmonologists,
• allergists,
• gastroenterologists,
• neurologists,
• endocrinologists,
• mental health professionals, and
• vocal coaches or voice teachers.
• Consult with other professionals, family members, and caregivers to facilitate program development and to provide
• supervision,
• evaluation, and/or
• expert testimony (as appropriate).
• Remain informed of research related to voice disorders and help advance the knowledge base related to the nature and treatment of voice disorders.
• Advocate for individuals with voice disorders at the local, state, and national levels.

As indicated in the ASHA  Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

See the Assessment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening may be conducted if a voice disorder is suspected. It may be triggered by concerns from individuals, parents, teachers, or health care providers. When deviations from normal voice are detected during screening, further evaluation is warranted.

Screening includes evaluation of vocal characteristics related to

• respiration;
• resonance; and
• pitch range, and

Clinicians may use a formal screening tool (Lee et al., 2004) or obtain data using informal tasks. Standardized self-report questionnaires can be included for a more thorough screening (e.g., Deary et al., 2003; Hogikyan & Sethuraman, 1999; Jacobson et al., 1997).

Comprehensive Assessment

All patients/clients with voice disorders should be examined by a physician, preferably in a discipline appropriate to the presenting complaint. The physician’s examination may occur before or after the voice evaluation by the SLP. Consultation with an otolaryngologist can be important, particularly in the case that an SLP does not have access to instrumentation for evaluation. Assessment and treatment of voice disorders may require use of appropriate personal protective equipment .

A comprehensive assessment is conducted for individuals suspected of having a voice disorder, using both standardized and nonstandardized measures (see ASHA’s resource on assessment tools, techniques, and data sources ). For a review of clinical voice assessments, see Roy et al. (2013).

Diagnostic therapy may be performed as part of the comprehensive assessment to help in making a diagnosis and to determine if the individual is stimulable to voice therapy efforts.

Comprehensive assessment is conducted to identify and describe

• impairments in body structure and function , including underlying strengths and weaknesses in speech sound production and verbal/nonverbal communication;
• comorbid deficits such as other health conditions and medications that can affect voice;
• limitations in activity and participation , including functional status in communication and interpersonal interactions;
• contextual (environmental and personal) factors that affect communication and life participation; and
• quality of life related to communication impairment and functional limitations.

See ASHA’s resource titled person-centered focus on function: voice [PDF] for an example of assessment data.

Comprehensive Assessment for Voice Disorders: Typical Components

Case history.

• the individual’s description of the voice problem, including onset and variability of symptoms
• medical status and history, including surgeries, chronic disorders, and medications
• previous voice treatment
• daily habits related to vocal hygiene

Self-Assessment

• the individual’s self-perception of voice/vocal quality
• emotions and self-image and
• the ability to communicate effectively in everyday activities as well as in social and work settings (e.g., Hogikyan & Sethuraman, 1999; Jacobson et al., 1997; Ma & Yiu, 2001)

Oral-Peripheral Examination

• assessment of structural or motor-based deficits that may affect communication and voice, including oral musculature, strength, speed, and range of motion
• assessment (during rest and purposeful speech tasks) of symmetry and movement of structures of the face, oral cavity, head, neck, and respiratory system
• testing of mechano-sensation of face and oral cavity
• testing of chemo-sensation (i.e., taste and smell)
• assessment of laryngeal sensations (dryness, tickling, burning, pain, etc.) and palpation of extrinsic laryngeal musculature, as indicated

Assessment of Respiration

• respiratory pattern (abdominal, thoracic, clavicular)
• coordination of respiration with phonation (breath-holding patterns, habitual use of residual air, length of breath groups)
• maximum phonation time (Dejonckere, 2010; Speyer et al., 2010)
• s/z ratio to assess for glottal insufficiency, which may be indicative of laryngeal pathology (Eckel & Boone, 1981; Stemple et al., 2010)

Auditory-Perceptual Assessment

This subjective assessment is based on the clinical impressions of the SLP during production of sustained vowels, sentences, and running speech.

Voice Quality

• roughness —irregularity in voicing source
• breathiness —audible air escape in voice
• strain —perception of excessive vocal effort
• pitch —perceptual correlate of fundamental frequency
• loudness —perceptual correlate of sound intensity
• overall severity —global, integrated impression of voice deviance
• additional perceptual features
• diplophonia
• pitch instability
• wet/gurgly quality

The perceptual features above are defined in ASHA’s Consensus Auditory-Perceptual Evaluation of Voice ( CAPE-V ; ASHA, n.d., 2002; Kempster et al., 2009).

See ASHA’s Practice Portal page on Resonance Disorders .

• Assess resonance quality, such as
• hypernasal, or
• cul-de-sac.
• If abnormal, assess stimulability for normal resonance.
• If normal, evaluate the focus of resonance, such as
• pharyngeal/laryngeal, or
• voice onset/offset characteristics, such as
• delayed voice onset and
• quality of voice at onset
• ability to sustain voicing for appropriate phrasing during speech
• ability to demonstrate a strong and consistent rate of vocal fold valving during diadochokinesis

Rate of Speech

Rate of speech may be indirectly impacted by voice disorders. For instance, a patient with a voice disorder may deliberately slow rate of speech to compensate for a voice disorder and increase intelligibility. For reasons such as these, an SLP may consider assessment of rate of speech (e.g., via diadochokinetic rate assessment).

Instrumental Assessment

Physicians are the only professionals qualified and licensed to render medical diagnoses related to the identification of laryngeal pathology as it affects voice. Imaging should be viewed and interpreted by an otolaryngologist with training in this procedure when it is used for medical diagnostic purposes. 

Laryngeal Imaging

Measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy). Please see ASHA’s resource on Vocal Tract Visualization and Imaging for more information.

Acoustic Assessment

Objective measures of vocal function related to vocal loudness, pitch, and quality (Patel et al., 2018).

• Vocal amplitude
• habitual sound pressure level (SPL) in decibels (dB)—typical sound level of voice during connected speech
• minimum and maximum vocal SPL (dB)—softest and loudest sustainable phonation
• Vocal frequency
• mean vocal F0 in hertz (Hz)—average of the estimates of the F0 for acoustic signal recorded during connected speech
• vocal F0 standard deviation (Hz)—standard deviation of the estimates of the F0 for acoustic signal recorded during connected speech
• minimum and maximum vocal F0 (Hz)— F0 values for the lowest and highest pitched sustainable phonations
• Vocal signal quality
• vocal cepstral peak prominence (dB)—relative amplitude of the peak in the cepstrum that represents the dominant harmonic of the vocal acoustic signal (sustained vowels and connected speech samples)

Aerodynamic Assessment

Measures (using noninvasive procedures) of glottal aerodynamic parameters required for phonation.

• Glottal airflow
• average glottal airflow rate (L/sec or mL/sec)—estimated from oral airflow rate during vowel production
• Subglottal air pressure
• average subglottal air pressure (centimeters of water [cmH 2 O] or kilopascals [kPa])—estimated for intraoral air pressure produced during repetition of stop consonants in syllable strings
• Mean vocal SPL and F0 —extracted from simultaneously recorded acoustic signal; facilitates interpretation of airflow and air pressure measurements

SLPs should be aware of potential sources of error or impediments to recording quality during aerodynamic assessment. Sources of error may contribute to inaccurate data. These error sources include

• a microphone,
• a preamplifier,
• analog-to-digital conversion (i.e., digital interface), and
• consistent distance of sound source (voice) to microphone;
• acoustic qualities of room; and
• ambient noise (Patel et al., 2018; Švec & Granqvist, 2018).

Pediatric Voice Assessment Considerations

Although many of the same voice disorders may exist among children and adults, the following conditions tend to be unique to the pediatric population (Sapienza & Ruddy, 2009):

• This is the most common cause of infant inspiratory stridor.
• inspiratory stridor,
• immature laryngeal cartilage,
• floppy epiglottis, and/or
• foreshortened aryepiglottic folds.
• This occurs more frequently in the pediatric population during the 4th to 10th week of gestation.
• This may cause airway blockage.
• This may be acquired due to laryngeal trauma.
• Dyspnea and inspiratory stridor are associated symptoms.
• Type I—Interarytenoid deficit above the true vocal folds.
• Type II—The cricoid lamina is involved; the cleft extends below the true vocal folds.
• Type III—A total cricoid cleft that extends through the cricoid cartilage and may extend into the cervical trachea.
• Type IV—A cleft that extends into the posterior thoracic trachea wall and may extend to the carina.
• Puberphonia —a functional voice disorder that may occur to male adolescents following a voice change during puberty that results in maintaining a high-pitched voice

Further information regarding laryngomalacia and laryngeal cleft may be found in ASHA’s Practice Portal page on Aerodigestive Disorders .

See the Treatment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving. The ASHA Practice Portal page on Head and Neck Cancer addresses intervention aimed at acquisition of alaryngeal speech sufficient to allow for functional oral communication.

Intervention is designed to

• establish appropriate vocal hygiene routines/practices;
• capitalize on strengths and address weaknesses related to underlying structures and functions that affect voice production;
• improve self-awareness of voice quality and kinesthetic factors (e.g., tension);
• facilitate the individual’s activities and life participation by assisting the person in acquiring new communication skills and strategies;
• modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation; and
• provide appropriate accommodations and other supports as well as training in how to use them.

Voice use within different settings should be considered when determining vocal needs and establishing goals. For example, vocal needs within the workplace may be different from those within the community (e.g., home and social settings).

Collaborating With Other Professionals

SLPs often team with otolaryngologists/laryngologists and other medical professionals (e.g., pulmonologists, gastroenterologists, neurologists, allergists, endocrinologists, and occupational medicine physicians) and, if appropriate, develop treatment plans to support the medical plan and to optimize outcomes. Collaboration with otolaryngologists/laryngologists is especially important to rule in or rule out underlying pathologies. SLPs can only diagnose functional abnormalities, and only otolaryngologists can diagnose organic pathologies (e.g., nodules, polyps, tumors).

Some individuals develop voice disorders in the absence of structural pathology (e.g., functional aphonia, muscle tension dysphonia, and mutational/functional falsetto) and may benefit from psychological counseling in addition to what can be provided by the SLP. Counseling, direct manipulation of the voice, and use of interview questions can be used to probe possible factors contributing to the voice problem. SLPs refer the individual to the appropriate health care professional(s) to address issues outside the SLP’s scope of practice (ASHA, 2016).

See ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice (IPE/IPP) .

Treatment Approaches

Approaches can be direct or indirect, and SLPs often incorporate aspects of more than one therapeutic approach in developing a treatment plan.

Direct Approaches

Direct approaches focus on manipulating the voice-producing mechanisms (phonation, respiration, and musculoskeletal function) to modify vocal behaviors and establish healthy voice production (Colton & Casper, 2011; Stemple, 2000).

Indirect Approaches

Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs (Roy et al., 2001; Thomas & Stemple, 2007). Indirect approaches include the following two components:

• Patient education —discussing normal physiology of voice production and the impact of voice disorders on function; providing information about the impact of vocal misuse and strategies for maintaining vocal health (vocal hygiene).
• Counseling —identifying and implementing strategies such as stress management to modify psychosocial factors that negatively affect vocal health (Van Stan et al., 2015).

Therapeutic Plan

A therapeutic plan typically involves at least one direct approach and one or more indirect approaches based on the patient’s condition and goals. Some clinicians concentrate on directly modifying the specific symptoms of the inappropriate voice, whereas others take a more holistic approach, with the goal of balancing the physiologic subsystems of voice production—respiration, phonation, and resonance.

Clinicians may begin by

• identifying behaviors that are contributing to the voice problems, including unhealthy vocal hygiene practices such as
• talking loudly over noise,
• throat clearing, and
• poor hydration.
• implementing practices to reduce vocally traumatic behaviors (e.g., voice conservation) and healthy vocal hygiene practices such as
• drinking plenty of water and
• talking at a moderate volume.

Use of personal protective equipment (PPE) (i.e., face mask) can potentially cause increased strain on voice and perception of vocal effort (Ribeiro et al., 2020). Please see ASHA's Aerosol Generating Procedures and the Resources section below for further information.

Pediatric Voice Treatment Considerations

There may be differences between treating voice disorders in adults and pediatrics due to differences in anatomy, etiology, and developmental level. According to Braden (2018), anatomical differences between pediatric and adult voice include the following:

• laryngeal size
• size of the vocal tract
• Pediatric vocal folds are shorter than adult vocal folds.
• Pediatric vocal folds lack the five-layer structure until adolescence.
• Infant vocal folds are monolayer.
• Infant vocal folds have hyaluronic acid distributed evenly (concentrated in adults).
• Infant vocal folds have more fibroblasts than adults in the lamina propria.
• The newborn larynx is located at approximately C4.
• The adult larynx is located at approximately C6-C7.

As a child’s phonatory structures grow and develop, the respective speaking pitch decreases (decreased frequency of vocal tract formants and fundamental frequency). There is a rapid decrease in mean fundamental frequency in the first 3 years, with another significant change at puberty (McAllister & Sjölander, 2013). Abnormal voice changes may be monitored during adolescence as they may be indicative of a functional voice disorder such as puberphonia. Stridor should also be closely monitored in the pediatric population as it could potentially indicate a compromised airway (Theis, 2010).

Many treatment approaches used for adult populations may be considered for the pediatric population, although adaptations may be needed to meet each child’s developmental level (Braden, 2018). Comorbid developmental disorders such as expressive or receptive language deficits may further complicate treatment of voice in the pediatric population. Some children may not have an internal concept of normal versus abnormal voicing (Hooper, 2004) and, therefore, may have difficulty addressing dysfunction.

Another consideration is potential difficulties that may occur in obtaining treatment in the school-based setting. Challenges may include

• difficulty obtaining referrals to ENT/voice specialists,
• delays in scheduling pediatrician and/or ENT visits,
• difficulty accessing imaging and medical records,
• insurance coverage or payment for MD visits, and
• barriers in eligibility criteria and determining adverse effects on educational performance.

Please see Childes et al. (2017) for further consideration of barriers and challenges.

Treatment Options

The following subsections offer brief descriptions of general and specific treatments for individuals with voice disorders. They are organized under two categories: physiologic voice therapy (i.e., those treatments that directly modify the physiology of the vocal mechanism) and symptomatic voice therapy (i.e., those treatments aimed at modifying deviant vocal symptoms or perceptual voice components using a variety of facilitating techniques). The inclusion of any specific treatment approach does not imply endorsement by ASHA. For more information about treatment approaches and their use with various voice disorders, see Stemple et al. (2010).

Treatment selection depends on the type and severity of the disorder and the communication needs of the individual. Clinicians incorporate functional daily voice needs into goals that reflect inclusion and participation in home, work, and social communities. Linguistic features in some languages may influence the need for specific aspects of voice treatment, such as influences of tonal languages on resonance. In addition, consideration of individuals’ needs, such as gender and/or gender expression or use of regional accents, is an important aspect of goal development.

Physiologic Voice Therapy

Physiologic voice therapy programs strive to balance the three subsystems of voice production (respiration, phonation, and resonance) as opposed to working directly on isolated voice symptoms. Most physiologic approaches may be used with a variety of disorders that result in hyper- and hypofunctional vocal patterns. Below are some of the physiologic voice therapy programs, arranged in alphabetical order.

Accent Method

The accent method is designed to increase pulmonary output, improve glottic efficiency, reduce excessive muscular tension, and normalize the vibratory pattern during phonation. During therapy, the clinician may do one or more of the following tasks (Kotby et al., 1993; Malki et al., 2008):

• facilitate abdominal breathing by initially placing the patient in a recumbent position;
• use rhythmic vocal play with models of accented phonation patterns, which the patient then imitates; and/or
• transfer rhythms to articulated speech, initially being given a model and eventually progressing through reading, monologues, and conversational speech.

Conversation Training Therapy (CTT)

CTT focuses exclusively on voice awareness and production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. Grounded in the tenets of motor learning, CTT strives to guide patients in achieving balanced phonation through clinician reinforcement, imitation and modeling in conversational speech. CTT incorporates six interchangeable components (Gartner-Schmidt et al., 2016; Gillespie et al., 2019), as follows:

• clear speech
• auditory and kinesthetic awareness
• negative practice/labeling
• embedding basic training gestures into speech
• prosody, projection, and pauses
• rapport building

Expiratory Muscle Strength Training (EMST)

EMST improves respiratory strength during phonation. Increase in maximum expiratory pressure can be trained with specific calibrated exercises over time, thus improving the relationship between respiration, phonation, and resonance. EMST uses an external device to mechanically overload the expiratory muscles. The device has a one-way, spring-loaded valve that blocks the flow of air until the targeted expiratory pressure is produced. The device can be calibrated to increase or decrease physiologic load on the targeted muscles (Pitts et al., 2009).

Lee Silverman Voice Treatment (LSVT)

LSVT (Ramig et al., 1994) is an intensive treatment developed for patients with Parkinson’s disease. It is designed to maximize phonatory and respiratory function using a set of simple tasks. Individuals are instructed to produce a loud voice with maximum effort and to monitor the loudness of their voices while speaking. The effort that is involved generates improved respiratory support, laryngeal muscle activity, articulation, and even facial expression and animation. Using a sound-level meter, visual biofeedback may be provided to demonstrate the effort necessary to increase loudness. LSVT is provided by clinicians who are trained and certified in the administration of this technique.

Five basic principles are followed in LSVT, as follows:

• Individuals should “think loud.”
• Speech effort must be high.
• Treatment must be intensive.
• Patients must recalibrate their loudness level.
• Improvements are quantified over time.

Manual Circumlaryngeal Techniques

Manual circumlaryngeal techniques are intended to reduce musculoskeletal tension and hyperfunction by re-posturing the larynx during phonation. There are three main manual laryngeal re-posturing techniques, as follows:

• Push-back maneuver—place forefinger on the thyroid cartilage and push back to change the shape of the glottis.
• Pull-down maneuver—place thumb and forefinger in the thyrohyoid space and pull the larynx downward.
• Medial compression and downward traction—place thumb and forefinger in the thyrohyoid space and apply medial compression.

Applying these maneuvers during vocalization allows the individual to hear resulting changes in voice quality (Andrews, 2006; Roy et al., 1997). Care is taken when employing these techniques, as some patients report discomfort.

Phonation Resistance Training Exercises (PhoRTE)

PhoRTE (Ziegler & Hapner, 2013) was adapted from LSVT and consists of four exercises, as follows:

• producing /a/ with loud maximum sustained phonation
• producing /a/ with loud ascending and descending pitch glides over the entire pitch range
• producing functional phrases using a loud and high (pitched) voice
• producing the same functional phrases using a loud and low (pitched) voice

Individuals are reminded to maintain a “strong” voice throughout these treatment exercises. PhoRTE has a less intensive intervention schedule than LSVT. PhoRTE also differs in that it combines both loudness and pitch when producing phrases (i.e., loud and low pitch, loud and high pitch). Use of PhoRTE has been studied in adults with presbyphonia (aging voice) as a way to improve vocal outcomes (e.g., decrease phonatory effort) and increase voice-related quality of life (Ziegler et al., 2014).

Resonant Voice Therapy

Resonant voice therapy uses a continuum of oral sensations and easy phonation, building from basic speech gestures through conversational speech. Resonant voice is defined as voice production involving oral vibratory sensations, usually on the anterior alveolar ridge or lips or higher in the face in the context of easy phonation. The goal of resonant voice therapy is to achieve the strongest, “cleanest” possible voice with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2010). The program incorporates humming and both voiced and voiceless productions that are shaped into phrase and conversational productions (Verdolini, 1998, 2000).

Stretch and Flow Phonation

Stretch and flow phonation —also known as Casper-Stone Flow Phonation —is a physiological technique used to treat functional dysphonia or aphonia (Stone & Casteel, 1982). It focuses on airflow management and is used for individuals with breath-holding tendencies. Individuals are instructed to focus on a steady outflow of air during exhalation. Various biofeedback methods are used, including placing a piece of tissue in front of the mouth or holding one’s hand in front of the mouth to monitor airflow. Voicing is introduced once the individual masters continuous airflow during exhalation. As such, this technique produces a breathy voice quality and a slowed speaking rate. Eventually, this voice quality is carried into trials with spoken words and phrases, and the breathiness is gradually reduced.

Flow phonation (Gartner-Schmidt, 2008, 2010) is a hierarchical therapy program designed to facilitate increased airflow, ease of phonation, and forward oral resonance. It was modified from stretch and flow phonation by eliminating the “stretch” component, which reduced the rate of speech in the original therapy.

Vocal Function Exercises (VFEs)

VFEs are a series of systematic voice manipulations designed to facilitate return to healthy voice function. VFEs work to strengthen and coordinate laryngeal musculature and improve efficiency of the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation (Stemple, 1984). Sounds used in training are specific, and correct production is encouraged. VFEs consist of four exercises—warm-up, stretching, contracting, and power exercises. Exercises are completed twice a day (morning and evening) in sets of two. Maximum phonation time goals are set on the basis of individual lung capacity and an airflow rate of 80 mL/sec. Individuals are advised to use a soft, engaged tone and are trained to use a semi-occluded vocal tract (SOVT) without tension during voice productions.

Symptomatic Voice Therapy

Symptomatic voice therapy focuses on the modification of vocal symptoms or perceptual voice components. Symptomatic voice therapy assumes voice improvement through direct symptom modification using a variety of voice facilitating techniques (Boone et al., 2010) that are either direct or indirect. Symptoms to be addressed may include

• pitch that is too high or too low,
• voice that is too soft or too loud,
• breathy phonation,
• hard glottal attacks, or
• glottal fry.

Amplification

Amplification devices such as microphones can be used to increase voice loudness in any situation that requires increased volume (e.g., when speaking to large groups or during conversation when the individual’s voice is weak). As such, voice amplification can function as a supportive tool or as a means of augmentative communication. It can help prevent vocal hyperfunction that may be a result of talking at increased volume or for extended periods of time.

Auditory Masking

Auditory masking is used in cases of functional aphonia/dysphonia and often results in changed or normal phonation. Individuals are instructed to talk or read passages aloud while wearing headphones with masking noise input. Using a loud noise background, the individual often produces voice at increased volume (Lombard effect) that can be recorded and used later in treatment as a comparison (e.g., Adams & Lang, 1992; Brumm & Zollinger, 2011).

Biofeedback

Biofeedback is the concept that self-control of physiologic functions is possible given external monitoring of internal bodily state. Biofeedback may be kinesthetic, auditory, or visual and is intended to provide clear and reliable information in response to alterations in voice production. Thus, patients may make real-time adjustments regarding vocal pitch, loudness, quality, and effort. Ideally, biofeedback helps increase awareness of physical sensations with respect to respiration, body position, and vibratory sensation. This awareness may help individuals understand physiological processes when generating voice.

Chant Speech

Chant speech uses a rhythmic, prosodic pattern as a template for spoken utterances. It is used in therapy to help reduce phonatory effort that results in vocal fatigue and decreased phonatory capabilities. Chant speech requires pitch fluctuations and coordination of respiratory, phonatory, and resonance subsystems. Speakers habituate to these more efficient vocal patterns. The increased lung pressure required for these tasks may also decrease reliance on laryngeal resistance and reduce fatigue (e.g., McCabe & Titze, 2002).

Confidential Voice

Confidential voice is designed to reduce laryngeal tension/hyperfunction and increase airflow (Casper, 2000). The individual begins with an easy and breathy vocal quality and builds to normal voicing without decreasing airflow. This technique is intended to address excessive vocal tension and to facilitate relaxation in the muscles of the larynx.

Inhalation Phonation

Inhalation phonation is used to facilitate true vocal vibration in the presence of habitual ventricular fold phonation, functional aphonia, and/or muscle tension dysphonia. Individuals produce a high-pitched voice on inhalation. Upon inhalation voicing, the true vocal folds are in a stretched position, suddenly adducted, and in vibration. Upon exhalation, patients try to achieve a nearly matched voice. This approach eases the way to gaining true vocal fold vibration.

The patient is instructed in the technique of sitting with upright posture and with the shoulders in a low, relaxed position to facilitate voice production with less effort. Collaboration with a physical therapist or an occupational therapist may be necessary with some patients.

In cases of vocal hyperfunction, a variety of relaxation techniques may be useful as a tool to reduce both whole-body and laryngeal area tension. The goal of these techniques is to reduce effortful phonation. Frequently used techniques include progressive muscle relaxation (slowly tensing and then relaxing successive muscle groups), visualization (forming mental images of a peaceful, calming place or situation), and deep breathing exercises.

Semi-Occluded Vocal Tract (SOVT) Exercises

SOVT exercises involve narrowing at any supraglottic point along the vocal tract in order to maximize interaction between vocal fold vibration (sound production) and the vocal tract (the sound filter) and to produce resonant voice.

Cup bubble , also known as Lax Vox , is an aerodynamic building task aimed at improving the ability to sustain phonation while speaking. It is done by having a patient blow air initially into a cup of water without voice. Voicing can be added for subsequent trials, and in time, pitch can be altered across and within trials. Eventually, the cup is removed during voicing, and the phonation continues. These exercises are thought to widen the vocal tract during phonation and reduce tension in the vocal folds. Biofeedback increases the individual’s awareness of their healthy voice production (e.g., Denizoglu & Sihvo, 2010; Simberg & Laine, 2007).

Straw phonation is one of the most frequently used methods to create semi-occlusion in the vocal tract (Titze, 2006). Narrowing the vocal tract increases air pressure above the vocal folds, keeping them slightly separated during phonation and reducing the impact collision force. To accomplish this, the individual semi-occludes the vocal tract by phonating through a straw or tube. Resistance can be manipulated by varying the length and diameter of the straw or immersing the opposite end of the straw in water. Individuals practice sustaining vowels, performing pitch glides, humming songs, and transitioning to the intonation and stress patterns of speech. Eventually, use of the straw is reduced and eliminated.

Lip trills can be used to create semi-occlusion at the level of the lips. This technique involves a smooth movement of air through the oral cavity and over the lips, causing a vibration (lip buzz), similar to blowing bubbles underwater. Often, the trills are paired with phonation and pitch changes. The focus is to improve breath support and produce voicing without tension.

Twang Therapy

Twang therapy is used for individuals with hypophonic voice. It involves the narrowing of the aryepiglottic sphincter using a “twang” voice to create a high-intensity voice quality while maintaining low vocal effort (Lombard & Steinhauer, 2007). The desired outcome is decreasing phonatory effort and increasing vocal efficiency.

This facilitating technique uses the natural functions of yawning and sighing to overcome symptoms of vocal hyperfunction (e.g., elevated larynx and vocal constriction). The technique is intended to lower the position of the larynx and subsequently widen the supraglottal space in order to produce a more relaxed voice and encourage a more natural pitch.

Treatment Considerations: Telepractice and Telecommuting

SLPs should take appropriate measures whether services are being delivered in-person or through telepractice. Teletherapy may not provide as reliable sound quality as in-person. Therefore, additional equipment (e.g., microphones) can enhance vocal quality while reducing vocal strain. Additionally, SLPs should take into consideration whether or not the patient is telecommuting for their profession, as there is some emerging research regarding effects of telecommunications on voice (Tracy et al., 2020).

Please see ASHA’s Practice Portal page on Telepractice and ASHA’s Telepractice Evidence Map .

Treatment Considerations: Rehabilitation of Professional Voice

Additional training/education may be necessary to provide professional voice rehabilitation. Clients who use their voice professionally (e.g., singers, voice actors) may have different needs than the usual client with a voice disorder and may seek services from multiple disciplines, including:

• an otolaryngologist
• a singing teacher
• a voice and speech trainer

Service Delivery

Refer to the Service Delivery section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for individuals with voice disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may affect treatment outcomes.

• Format —the structure of the treatment session (e.g., group vs. individual; direct and/or consultative).
• Provider —the person offering the treatment (e.g., SLP, trained volunteer, caregiver).
• Dosage —the frequency, intensity, and duration of service. Clinicians consider the unique needs of each patient and the nature of the voice disorder in determining appropriate dosage for therapy. Some voice therapy programs will have specific dosage parameters. See De Bodt et al. (2015) for a summary of international practices regarding temporal variables (dosage and frequency) in voice therapy.
• Timing —when intervention is conducted relative to the diagnosis.
• Setting —location of treatment (e.g., home, community-based, work).

ASHA Resources

• Aerosol Generating Procedures
• ASHA CAPE-V Form
• ASHA Code of Ethics
• ASHA Scope of Practice in Speech-Language Pathology
• Consumer Resource Related to Voice Disorders
• Cultural Responsiveness
• Definitions of Communication Disorders and Variations
• Gender Affirming Voice and Communication
• Graduate Curriculum on Voice and Voice Disorders [PDF] (Developed by ASHA Special Interest Group 3: Voice and Voice Disorders)
• Multicultural Issues in the Treatment of Voice Disorders
• Preferred Practice Patterns for the Profession of Speech-Language Pathology
• States with Specific Instrumental Assessment Requirements
• Using Masks for In-Person Service Delivery During COVID-19 Pandemic: What to Consider
• Vocal Tract Visualization and Imaging 

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Otolaryngology–Head and Neck Surgery: Clinical Practice Guidelines
• The National Center for Voice and Speech
• National Institute on Deafness and Other Communication Disorders
• National Spasmodic Dysphonia Association
• RCSLT: New Long COVID Guidance and Patient Handbook
• Speech-Language & Audiology Canada: Covid-19 changes the way many people use their voices
• The Voice Foundation
• World Voice Day

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About This Content

Acknowledgements.

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Voice Disorders page:

• Julie M. Barkmeier-Kraemer, PhD, CCC-SLP
• Jennifer N. Craig, MS, CCC-SLP
• Archie B. Harmon, PhD, CCC-SLP
• Robert E. Hillman, PhD, CCC-SLP
• Barbara Jacobson, PhD, CCC-SLP
• Rita R. Patel, PhD, CCC-SLP
• Bari Hoffman Ruddy, PhD, CCC-SLP
• Joseph C. Stemple, PhD, CCC-SLP
• Yumi A. Sumida, MS, MFA, CCC-SLP
• Kristine Tanner, PhD, CCC-SLP
• Shannon M. Theis, PhD, CCC-SLP
• Miriam R. van Mersbergen, PhD, CCC-SLP
• Laura Purcell Verdun, MA, CCC-SLP

In addition, ASHA thanks the members of the ASHA-Special Interest Division 3: Working Group on Voice and Voice Disorders, whose work was foundational to the development of this content. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members.

ASHA also thanks the American Academy of Otolaryngology-HNS Speech, Voice and Swallowing Committee members and ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee members whose work was foundational to the development of this content.

The members of the AAO-HNS Speech, Voice and Swallowing Committee included Robert Sataloff, Jonathan Aviv, Mary Beaver, Alison Behrman (ASHA representative), Mark Courey, Glendon Gardner, Norman Hogikyan, Christy Ludlow (ASHA representative), Roger Nuss, Clark Rosen, Mark Shikowitz, Robert Stachler, Lee Akst, and Susan Sedory Holzer (staff liaison).

The members of the ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee included Leslie Glaze (coordinator), Bernice Klaben, Lori Lombard, Mary Sandage (associate coordinator), Susan Thibeault, and Michelle Ferketic (ex officio). Celia Hooper, vice president for professional practices (2003–2005), served as monitoring vice president for ASHA.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Voice Disorders. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/ .

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Muscle Tension Dysphonia

Voice strain.

Muscle tension dysphonia, or voice strain caused by muscle tightness, can occur even when there is no damage to your vocal cords (also known as vocal folds). It’s often overlooked and left untreated. The Duke voice care team of laryngologists -- ear, nose, and throat (ENT) doctors with advanced training in voice disorders -- and highly trained speech pathologists diagnose your condition and help you learn to use your voice more comfortably in order to speak or sing without strain.

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About Muscle Tension Dysphonia

If your voice is tired, your throat feels tight, or it hurts to talk, you may have muscle tension dysphonia, or voice strain caused by muscle tightness. This common voice problem can occur even if your vocal cords are normal but the muscles in your throat are working inefficiently. You may not be using your breath to effectively energize your voice, or your throat muscles may be too tight when you speak. Muscle tension dysphonia can make your voice sound strained or hoarse and can make it uncomfortable to talk. It is common to experience muscle tension dysphonia along with another voice problem.

Muscle tension dysphonia can happen when you’ve been sick and developed a vocal cord injury, such as laryngitis or swelling of the vocal cords. Because of that injury, you may start relying on other muscles in your throat to speak. Even when your vocal cords have healed after the illness is over, you can get stuck in a pattern of relying on these muscles. 

Other factors that may contribute to muscle tension dysphonia include excessive talking without breaks, screaming, talking loudly in noisy environments, or habitually speaking at a pitch that is too high or too low for you.

Duke Health offers locations throughout the Triangle. Find one near you.

Tests and Treatments for Muscle Tension Dysphonia

Comprehensive voice evaluation.

We will examine your head, neck, and larynx (voice box) as part of a comprehensive voice evaluation. We also assess your voice use patterns -- how much and how loudly you speak or sing -- and what your voice sounds like. Your laryngologist will evaluate the role of any medical conditions that can cause voice changes, such as surgeries or recent illnesses.

Videolaryngostroboscopy

This detailed visual exam helps us evaluate how your vocal cords vibrate while you speak or sing. A tiny camera attached to a small tube called an endoscope is inserted through your nose and allows us to see your vocal cords and larynx (voice box). A flashing strobe light simulates slow motion video images of your vocal cords. The exam takes about a minute. Your nose may be sprayed with topical anesthetic for your comfort. 

The exam allows your team to look for lesions, stiffness, paralysis , irregular movements, muscle strain, or incomplete closure of the vocal cords. After the exam, your team will review the images with you to determine an accurate diagnosis and treatment plan.

Videolaryngostroboscopy is the best test for reaching an accurate diagnosis and determining the best treatment for your voice.

Voice Therapy

Voice therapy helps you learn to relax your throat muscles, use your breath to power your voice efficiently, and use good oral resonance (how air flows through your mouth and nose when you speak). You’ll work with a speech pathologist who will guide you through vocal exercises to improve breathing, reduce throat strain, and find your optimal pitch and volume for strong, healthy speaking. The goal is to teach you to speak with minimal vocal effort.

Laryngeal Massage and Myofascial Release

If appropriate, you may receive targeted manual therapy performed by a speech pathologist. This may involve gentle stretching or massage in areas of the head, neck, and torso where muscle tension is present. People often experience dramatic relief of throat strain and discomfort after these treatments. You may also learn stretches and self-massage techniques for daily use to reduce strain and support relaxed, healthy voice use.

Why Choose Duke

Expert Diagnosis Often with muscle tension dysphonia, the vocal cords may appear normal, and only detailed examination using videolaryngostroboscopy can identify minor muscle inefficiencies. This test is typically only available at ear, nose, and throat clinics like Duke's that specialize in voice disorders.

Skilled Voice Therapists We are one of only a few dedicated voice care centers in the Southeast providing expert voice therapy , the treatment of choice for muscle tension dysphonia. Our team of speech pathologists has advanced training in voice problems and years of experience in providing relief for this condition.

Specialty Care for Singers and Professional Voice Performers If you are one of the many singers affected by muscle tension dysphonia, you’ll benefit from the expertise of our clinical singing voice specialists .

Coordinated Care If you have other medical conditions that may contribute to your voice strain -- such as allergies , asthma , or acid reflux -- we will work with your other providers throughout Duke Health to ensure you receive the best care from an integrated team. 

Active Research to Advance Care Our ongoing research into how voice problems affect how we feel about ourselves gives us insight into treating the whole range of voice disorders, including muscle tension dysphonia.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 10 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

• Brain & Nervous System

Spasmodic Dysphonia: Causes, Symptoms, and Treatment

Spasmodic dysphonia (or laryngeal dystonia) is a rare voice disorder that is thought to happen when your brain sends abnormal signals to your vocal folds. It only affects about 1 in 100,000 people. With this condition, the muscles in your larynx (or voice box) have spasms – or tighten up – when you use your voice. While it can happen in children or much older people, it usually shows up in middle-aged people. Both men and women can have SD, but women are affected more.

What Are the Symptoms of Spasmodic Dysphonia?

With this disorder, your voice may sound:

• Whispered or breathy

People with spasmodic dysphonia sometimes describe their voices as sounding “off” or “not right.”

Your symptoms will usually happen gradually over your first and second year of having the disorder. Then, they’ll stop progressing and stay the way they are.

While your voice may sound different when you speak, your larynx often acts normally when you do other things. You may not notice symptoms when you:

What Causes Spasmodic Dysphonia?

Experts don’t fully understand what causes spasmodic dysphonia. They’re looking into how it’s related to an issue in your brain, specifically in the area called the basal ganglia. They’re also studying possible genetic links.

The muscle spasms in your larynx are sudden and cause your vocal cords to move in strange ways. This causes your voice to sound different. The spasms will start and stop as you use your voice. There might be a link between more spasms and higher stress.

How Is Spasmodic Dysphonia Diagnosed?

Spasmodic dysphonia can be tough to diagnose because your larynx looks normal on MRI and CT scans. The symptoms can also be very similar to other conditions.

To get a proper diagnosis, you’ll likely need a few experts on your health care team. These include a:

• Neurologist.  This doctor focuses on the brain and nervous system.
• Speech-language pathologist.  This expert specializes in voice, language, and speech disorders.
• Otolaryngologist (ENT). This specialist looks at your ears, nose, throat, head, and neck. A type of otolaryngologist, called a laryngologist, usually needs to also confirm your SD diagnosis.

Your care team will listen to your voice to get a better idea of your symptoms. 

An otolaryngologist may also do a test on you called a videostroboscopy. This looks at your larynx and listens to your voice. The doctor will put a small tube through your nose into the back of your throat. The tube is lit and will show them your larynx and vocal cords and how they move when you use your voice.

They may use imaging tests like an MRI to check for issues in your brain. But this isn’t usually done.

What’s the Treatment for Spasmodic Dysphonia?

While there’s no cure for this disorder, there are treatments you can use to lessen the symptoms:

Botox (botulinum toxin) shots.  A specialist can inject a small amount of this toxin into your vocal folds to relax the muscles. Every treatment usually lasts a few months.

Myofascial release.  This treatment puts pressure on the outside of your throat and stretches your muscles to ease symptoms.

Anti-anxiety medications. Oral (taken by mouth) medications for anxiety can help ease stress, which can make your symptoms worse.

Selective laryngeal adductor denervation-reinnervation (SLAD-R). This is a surgery that cuts specific nerves that you use while you speak. Then, it reconnects them in a different way. This process might break the nerve path from your brain to your vocal cords.

Thyroplasty.  There are two types of this procedure for spasmodic dysphonia. One splits your vocal folds to stop your larynx from closing too tightly. The other places your vocal folds closer together to stop them from opening too much.

Voice therapy.  Your speech-language pathologist can teach you ways to change how you talk. This may help lessen the effects of SD.

How Can You Prevent Spasmodic Dysphonia?

There is no way to prevent spasmodic dysphonia. In some conditions, you can avoid or begin certain habits that might affect the condition. But with this disorder, there are no risk factors or lifestyle behaviors that will lower your chances of getting it.

What’s the Outlook With Spasmodic Dysphonia?

Spasmodic dysphonia is a condition that’ll last your whole life. While you can treat it to calm its symptoms, they’ll eventually come back.

To learn how to live a high-quality life with this disorder, you can try a few things:

Voice devices.  These tools can help you use your voice more effectively with spasmodic dysphonia. They may make your voice louder in person or over the phone or use computer software and smartphone apps to translate text into speech.

Support groups.  You can find local groups for people with spasmodic dysphonia. These can help you connect with others and learn new tips and tricks from people who have similar issues with their voices.

Self-care.  If you’re sleepy or stressed with this condition, it can make your symptoms worse. Make sure that you take care of yourself, ease anxiety, and get good rest.

Help from loved ones. Don’t let spasmodic dysphonia stop you from spending time with friends and family. Ask them for support and understanding. They can also be a great outlet to express your feelings about the disorder.

Counseling.  A trained expert can be a great resource to help you cope with the symptoms of this disorder. They can help you learn how to function better in social and career settings.

Experts are still learning more about the disorder so that they can find other causes, ways to diagnose it, and new treatments.

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How Speech Language Pathologists Treat Spasmodic Dysphonia

When you encounter someone who speaks with a strangled, hoarse, or breathy-sounding voice you may assume they’re simply getting over a bad cold.

“I’m sorry, I’m not sick­—it’s just my voice,” college student Mia* got used to saying when she entered the University of Minnesota as a freshman.

Mia suffers from Spasmodic Dysphonia (SD), a voice disorder in which the vocal folds don’t move the way they should when speaking. At a minimum, this disorder affects around 50,000 people in North America, but experts suspect the number is higher. It’s possible that some cases continue to go unresolved for many years before an accurate diagnosis is made.

As a speech-language pathologist , you will be called in to help patients with SD through voice therapy . You will usually be one of a team of professionals working together to help improve the ability of individuals like Mia to communicate on the job and at home.

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Spasmodic Dysphonia Presents Challenges When it Comes to Getting the Diagnosis Right

Unfortunately many individuals have to work through a wrong diagnosis before stumbling on the right one.

Blogger Eric Y shares that his ENT initially treated him surgically for a deviated septum and acid reflux, with no change in symptoms. After some internet research and a long trip from Honolulu to Chicago for an evaluation Eric officially had his diagnosis: Spasmodic Dysphonia.

Because there isn’t a straightforward test for SD, it is believed to be one of the most misdiagnosed conditions in the speech world. Usually it takes a team of professionals focusing on their area of expertise to arrive at a diagnosis. A preferred team will look something like this:

• Speech-Language Pathologist : evaluates voice production and quality
• Otolaryngologist (ENT) : evaluates the vocal cords and how they move
• Neurologist : checks for signs of dystonia or other neurological conditions

Unclear Origins and a Debate

If you’re looking for definitive answers for what caused a patient’s SD, you’re probably out of luck. Based on available evidence, most experts think that it’s a brain problem: the nervous system regulator in the basal ganglia starts producing inaccurate signals, impacting the timing and intensity of how the muscles contract and relax.

Many patients, like Mia, note that the change happened after a specific event. For Mia, it was surgery to remove a benign tumor. Others point to head trauma, infections, illness, or stressful events as the triggering incident.

Members of the medical community disagree on whether or not these events can induce the kind of brain changes that result in SD, although ongoing research may bring about clarity in the coming years. While understanding origins might improve future treatment, the good news is that current treatments can be surprisingly effective.

Spasmodic Dysphonia Treatment

As mentioned before, SD evaluation and treatment requires a team approach. It is highly unusual for speech therapy alone to provide adequate support.

• The most common treatment at this time is Botox injections in the vocal cords, combined with voice therapy.
• Speech Therapy. Focused therapy is given before and after Botox injections, which happen 3-4 times a year. Your work will generally focus on helping the patient to control their breath and manage tongue placement to speak more efficiently.
• Selective laryngeal adduction denervation and reinnervation(SLAD/R) surgery involves clipping away the laryngeal nerve and then reattaching the related muscles to a nerve that isn’t associated with the patient’s SD. Most patients see significant improvement 6-12 months after the surgery, and most will never need the Botox treatments again once they have healed from the surgery. Roughly 80% of patients are satisfied with the results, however some patients’ voices are permanently altered.

Advising Patients on Options When Their Careers Are Impacted

Although there are no clear statistics anecdotally there appears to be a large number of individuals with SD who work in careers that put high demands on their voices. Whether they are in radio, education, members of the clergy, or just find themselves on the phone much of the day, this voice illness can dramatically affect their careers.

As a speech-language pathologist part of your role will be to help individuals with SD manage their symptoms and find ways to decrease voice strain while on the job. Sometimes standard SD treatment is enough to keep an individual in their current job, but if not you may want to discuss some other possible approaches with your patient. These could include:

• Ask the employer for a grace period: some people respond very well to treatment and after a series of months can return to their previous tasks with little difficulty.
• Ask the employer to adjust job responsibilities so they can focus on less vocally straining tasks.
• As the employer, if they will accept the use of a voice amplifier.
• Explore some workarounds so that more vocally demanding tasks happen during optimum times within the Botox treatment schedule.
• Ask for a transfer within the company to a position that doesn’t require a high level of vocal energy.

Assistive Technologies

Initially your patient may resist assistive technologies, but using products that reduce strain on their voices can actually improve their overall quality of life. Whether it’s making themselves heard and understood with less frustration or reducing talk time so they can save their voices for when really needed, these assistive technologies are worth considering.

• Voice Amplifiers: Voice amplifiers like this one can help your patient project their voice without as much vocal strain. They can choose from a variety of microphone options including handheld, headset, and collar microphones.
• Text-to-Speech Apps: These apps allow your patient to make phones calls and communicate in real-time with individuals using text-to-speech technologies. The individual will simply type what they want to say, and the app converts the text to speech so the person on the other end can hear them.
• Operator Assisted Speech: These services are similar to the text-to-speech apps, but instead of a computer generated voice an operator plays the middle-man. So your patient types and the operator speaks out their message. These can vary from state to state, but most systems are similar to this one offered in North Carolina.

Specializing in the Treatment of Spasmodic Dysphonia

You won’t find any industry certifications specific to Spasmodic Dysphonia, but because it is a neurological disorder you may want to consider pursuing board certification from the Academy of Neurologic Communication Disorders and Sciences (ANCDS) .

In order to be eligible for this certification, you’ll need to fulfill the following requirements:

• Be a fully certified CCC-SLP
• Have five years of clinical experience with neurologic communication disorders
• Submit your CV or resume with three letters of recommendation from health care professionals familiar with your skills
• Complete the Board Certification Candidacy Application and pay applicable fees

The certification process involves submitting two case studies, giving an oral presentation, and taking part in a discussion following your presentation. The reviewers will then give you a “Pass” or notify you that your work “Does not meet standards.”

Additional Ways to Specialize Your Focus

In working with spasmodic dysphonia you’ll find yourself drawing on methods from various speech-language methods you may want to get additional training in something called Expiratory Muscle Strength Training (EMST) . This method uses a specially calibrated device combined with specific exercises to increase respiratory strength of the patient. The company that created a commonly used device for this training offers periodic workshops for professionals.

You can also improve your ability to treat SD by attending workshops or webinars on voice therapy subjects. Some of the places you can find these trainings include:

• National Spasmodic Dysphonia Association : Periodic workshops and conferences; join the newsletter list for information as the events portion of the website doesn’t always have the earliest posting for these events.
• Mayo Clinic School of Continuous Professional Development : Offers conferences and online workshops.
• University of Wisconsin Voice and Swallow Clinics Lecture Series : Online lectures available to ASHA members for CEU’s.
• The Voice Foundation : Annual symposium and various conferences and events. Many SLP’s specializing in voice issues are members of this foundation.
• Northern Speech Services : Online workshops on speech related topics for CEU’s.
• National Center for Speech and Voice : Summer intensives on Vocology.
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Voice Exercises for Spasmodic Dysphonia – Your Path to Improved Vocal Health

Are you or someone you know grappling with the challenges of Spasmodic Dysphonia (SD)? In this post, we'll delve into how voice exercises for Spasmodic Dysphonia, when combined with a proper Neuro-Rehabilitation protocol, can be the key to easing symptoms, enhancing your quality of life and lead you to recovery from this condition.

Example of improvement produced by following Dr. Farias’ Recovery program for Spasmodic Dysphonia:

Before following Dr. Farias’ Neuro-Rehabilitation protocol:

After following Dr. Farias’ Neuro-Rehabilitation protocol:

What is the difference between Dr. Farias’ Neuro-Rehabilitation protocol for SD and traditional voice therapy for SD?

In the realm of Spasmodic Dysphonia (SD) (also know as Laryngeal Dystonia) treatment has been traditionally focused on muscle-targeted approaches through conventional voice therapy. However, the results did not achieve the expected outcomes. It’s essential to understand that SD is not solely a muscular issue; It is a neurological condition. SD involves a complex interplay of neurological factors. This is where Dr. Farias’ groundbreaking neuroplasticity-based neuro-rehabilitation for SD comes into play. This innovative approach aims to rehabilitate the underperforming neural networks at the core of this condition, addressing both vocal and non-vocal symptoms comprehensively. Through a series of progressive exercises, this method works to retune neural function and normalise the intricate processes involved in speech production. The results have been nothing short of unprecedented, offering new hope and tangible improvements for those living with SD.

Understanding Voice rehabilitation for Spasmodic Dysphonia

Voice exercises for Spasmodic Dysphonia (SD) are a vital component of managing this challenging voice disorder. These exercises are designed to address the specific vocal challenges associated with SD and help individuals regain control over their voice. Whether you have abductor or adductor SD, voice exercises can be tailored to your unique needs. They focus on improving vocal function, reducing vocal strain, and enhancing vocal control, all of which contribute to an increased quality of life. Through regular practice and guidance these exercises can be an effective tool in minimising SD symptoms and improving your overall vocal health.

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Join the complete online recovery program for dystonia patients.

Strategies for Abductor SD

For those facing abductor SD, you are guided in transitioning voiceless sounds to voiced ones and articulating sounds for easier speaking. These techniques empower you to regain control over your voice.

Strategies for Adductor SD

In the case of Adductor SD, you will use strategies to produce a smoother airflow, reducing tension and strain during speaking, leading to more comfortable and effective communication.

Key Benefits of Dr. Farias Dystonia Recovery Program

• Reduced vocal strain
• Improved vocal function
• Enhanced vocal control
• Increased quality of life

Dr. Farias’ Spasmodic Dysphonia Recovery Program

Dr. Farias has developed a comprehensive set of exercises that have aided many in improving voice quality and reducing spasm frequency and severity. These exercises encompass:

• Breathing exercises
• Vocal warm-up exercises
• Voice resonance exercises
• Articulation exercises
• Fluency exercises
• Non voice related brain training, which involves: eye tracking exercises , sensory stimulation exercises, relaxation, meditation, music and sound therapy, all design to improve your brain, auditory and vocal function

Dr. Farias’ Spasmodic Dysphonia Recovery Program is a valuable asset for individuals with SD.

Don’t let SD hold you back – take action, embrace voice exercises, and embark on your journey to improved vocal health today.

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Spasmodic Dysphonia

Anatomy of the condition.

Dystonia is a neurological disorder which causes involuntary muscle movements. Spasmodic dysphonia is a form of dystonia. It produces involuntary spasms of the vocal folds, causing disordered speech.

There are two typical forms of spasmodic dysphonia:

• Adductor type is the most common form of spasmodic dysphonia. Abrupt, involuntary contraction of the muscles that bring the vocal folds together cause this type. It causes closure of the vocal folds. This causes broken, strained speech and a tight quality to the voice.
• Abductor type is the less common form of spasmodic dysphonia. It happens when involuntary contractions in the muscles that open the vocal folds let air escape suddenly. This causes breathy, whispery voice breaks.

There are other, less common, forms of spasmodic dysphonia. These include a combination of the two types.

Causes or Contributing Factors

Spasmodic dysphonia (SD) has no known cause. Many physicians believe a neurological disorder causes SD. Abnormal functioning of the basal ganglia structure in the brain would be to blame. Onset occurs without warning or explanation. Spasmodic dysphonia is more prevalent in women and among people between ages 40 and 50.

A halting, interrupted voice pattern is the key symptom for the adductor variety of SD. With the abductor type of SD, the voice has breathy voice breaks. When patients with SD try to control spasms, we often hear a tight or constricted sounding voice. Symptoms may improve or worsen, depending on the time of day.

The condition is hard to diagnose and is frequently misdiagnosed. the disease often mimics other conditions or speech patterns. appropriate diagnosis requires a thorough examination by an experienced team of voice specialists..

There is not a definitive test for the condition. Diagnosis depends on a combination of symptoms and evaluation by the clinical voice team.

Non-Operative Treatments

Botox offers one of the most effective treatments for spasmodic dysphonia. the drug softens and weakens vocal muscles, diminishing spasms. this treatment also reduces voice wispiness from the abductor form of the disease..

The results of Botox may vary, but the drug normally takes effect 24-48 hours after the injections. First, the voice becomes soft and breathy for a period of several days to two weeks. Then the voice should get stronger and stronger, with fewer spasms. The duration of the effect varies. Most patients see relief for three to four months before needing the next injection.

Because Botox weakens vocal muscles, an initial side effect may be difficulty swallowing. Our speech pathologists can usually train the patient in alternative swallowing techniques.

Voice relaxation techniques and other speech therapies may help reduce symptoms.

Operative Treatments

In some instances, we may recommend surgery. selective laryngeal adductor denervation reinnervation is a new surgical option. our surgeon divides the nerves to the muscles, which brings the vocal folds together. alternate neural tissue is then used to lessen the symptoms of spasmodic dysphonia., related care at emory.

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Hearing the sound of a voice just like yours can be a powerful experience. Take a listen to other voices.

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Join us for the 2024 Symposium in Tampa, FL on Saturday, May 4, 2024.

2023 RESEARCH HIGHLIGHTS

Read the highlights from the 2023 Research Program including new grants!

Cannabinoid Use in the Treatment of Laryngeal Dystonia and Vocal Tremor: A Pilot Investigation

Read a summary about a study on the use of cannabinoids as a treatment for spasmodic dysphonia, a form of laryngeal dystonia.

Clinical Trial Looks at Effectiveness of New Neurotoxin, DAXXIFY, for Spasmodic Dysphonia

New clinical trial evaluates the safety of DAXXIFY and compares the treatment response to botulinum toxin A in patients with adductor spasmodic dysphonia.

RECENT WEBINARS PRESENTED BY DYSPHONIA INTERNATIONAL

“In 2010, I was asked by the organization to be involved with the Dystonia Advocacy Network. I went to Washington, DC, to present an award to the Congressman from my district. This was the best thing that ever happened to me. I had not done any public speaking since my symptoms of SD began, but now, here I was speaking to legislators about a topic so important to me. While there is no cure, research can help improve treatment options and help fund future research. It was this organization that has helped me improve my self-esteem and feel great again. Assuring that the NSDA, now Dysphonia International, can continue to help others is so important to me and that’s why I give.

CONNECT WITH OTHERS

I understand.   Those two powerful words can bring relief, comfort, and affirmation to your experience. We can connect you with people who have walked in your shoes. Whether it is through Support Group, Area Contact Leaders, on-line support, local meetings, or symposiums, know the challenges of living with a voice disorder.

PROFILES OF STRENGTH: STORIES OF REAL PEOPLE

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