Voice disorders

Introduction to voice and speech production

Humans actively produce speech through a coordinated process (respiratory, resonatory, phonatory, articulatory systems) involving multiple body parts, starting with the lungs generating airflow to vibrate vocal folds in the larynx, creating a glottal source. This raw, buzzy-voiced sound, driven by air pressure and the Bernoulli effect, forms the foundation of voice production.

Next, the vocal tract—comprising the throat, mouth, and nasal passages—amplifies and resonates this sound, enhancing voice timbre. The tongue, lips, and soft palate articulate the sound into recognisable vowels and consonants. Additionally, paralinguistic features like speech rhythm, rate, intonation, and vocal tone convey mood, personality (prosody), and social cues unconsciously.

The vocal folds’ fundamental frequency (e.g., 110 Hz for men, 300 Hz for children) determines pitch, while amplitude controls loudness. Precise vocal fold movements and mucosal wave regularity ensure clear voice quality, with irregularities causing hoarseness or breathiness. This intricate sensorimotor system, analogous to a trombone shaping sound, highlights challenges in diagnosing speech disorders. Understanding these mechanisms supports effective speech therapy and vocal health, ensuring communication.

Table: List of Voice disorders

S. No.	Voice Disorders
1.	Ventricular Dysphonia
2.	Puberphonia.
3.	Functional dysphonia
4.	Spasmodic dysphonia
5.	Presbylaryngis
6.	Stuttering (Stammering)
7.	Tourette Syndrome
8.	Phonasthenia
9.	Hyponasality and Hypernasality
10.	Laryngeal Myoclonus

1. Ventricular Dysphonia

Ventricular dysphonia (VD), also known as dysphonia plica ventricularis,  occurs when the voice is produced by the vibration of false vocal folds rather than the vibration of the true vocal folds. It more commonly occurs due to severe muscle tension or sometimes due to dysfunctioning true vocal fold, leading to compensatory overfunctioning of the false vocal folds. The greater mass of the false vocal folds slows down the vibration, hence lowering the pitch of the voice. Therefore, unlike true folds, false folds create a rough, low-pitched, unpleasant hoarse voice, sometimes with breaks or diplophonia.

Causes

It can be compensatory or non-compensatory.

• Compensatory VD arises when true vocal fold function fails due to resection, paralysis, fixation, surgical excision or tumours, forcing the false vocal folds to compensate for the phonatory functions of true vocal cords.
• Non-compensatory VD is seen in habitual, psycho-emotional, or idiopathic cases and occurs in a normal larynx. Here voice begins normally but soon becomes rough when false cords usurp the function of true cords.

Diagnosis

Indirect laryngoscopy or laryngeal videostroboscopy shows false fold movement, often obscuring true folds during phonation. In psychogenic cases, false fold approximation may be seen.

Treatment

• Compensatory VD, linked to laryngeal disorders, proves challenging but may improve with voice therapy.
• Non-compensatory cases, especially psychogenic, respond well to voice therapy and psychological counselling. Moreover, treatments like botulinum toxin injections or surgery address severe cases.

 

2. Puberphonia.

The fundamental frequency of an adult male voice ranges from 85 to 180 Hz, while that of an adult female ranges from 165 to 255 Hz. During puberty, adolescent males typically experience a deepening of the voice due to a rapid elongation of the vocal cords up to 60%, which occurs as the Adam’s apple (thyroid cartilage) enlarges. Females, however, do not undergo this change. When a high-pitched voice persists beyond puberty in males without any structural or organic cause, we refer to the condition as puberphonia. It causes effortful speech, fatigue, or discomfort, impacting vocal health and confidence.

Aetiology

Multiple factors can lead to puberphonia. Emotional stress, psychogenic influences, and delayed development of secondary sexual characteristics commonly contribute to the condition. In some individuals, hypogonadism leads to reduced testosterone levels, which may prevent proper voice maturation and the appearance of male secondary sexual traits. However, in many cases, the exact cause remains unknown.

Diagnosis

• To diagnose puberphonia, clinicians perform the Gutzmann pressure test. They apply backwards and downward pressure on the thyroid cartilage while the patient phonates. This manoeuvre relaxes the vocal cords, often causing the voice to shift to a lower, more masculine pitch. A positive test supports a diagnosis of puberphonia.
• The laryngeal assessment via indirect laryngoscopy or videostroboscopy reveals thin vocal folds with minimal mucosal waves. Acoustic analysis shows a female-range speaking fundamental frequency.

Management

• Speech therapyis the mainstay of management of puberphonia and yields excellent results when patients actively engage. The patient pressing on his larynx learns to produce a low tone voice and then trains himself to produce syllables, words and numbers
• In resistant cases, botulinum toxin injectionsinto the cricothyroid muscles relax the cricothyroid muscles, or Ishiki type 3 thyroplasty, shortens the vocal cords to lower the pitch. This helps in the reduction of pitch of the voice by reducing the tension of the vocal cords.

 

3. Functional dysphonia

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4. Spasmodic dysphonia

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5. Presbylaryngis: Understanding the Ageing Voice

Presbylaryngis refers to structural changes in the larynx due to ageing, often leading to presbyphonia—the clinical manifestation of age-related vocal changes. In males, the pitch of the voice typically increases after 50, while in females, it decreases.

Presbylaryngis results from age-related vocal cord atrophy, ossification of laryngeal cartilage, joint (cricothyroid and cricoarytenoid) stiffness, and loss of muscle mass, especially type I fibres. Additionally, reduced hyaluronic acid and increased collagen deposition cause stiffening and bowing of the vocal folds, leading to a gap between the vocal cords during phonation. Consequently, elderly patients may experience a breathy, weak, or high-pitched voice, vocal fatigue, and communication difficulty.

Diagnosis. It typically involves laryngoscopy and stroboscopy to evaluate vocal fold closure.

Treatment. Although complete restoration of youthful vocal tone is not feasible, therapy can significantly improve vocal quality, endurance, and patient confidence.

1. Voice therapy.It remains the first-line treatment, aiming to strengthen laryngeal muscles and enhance vocal control.
2. Fat injection.In cases with a significant vocal fold gap, injection augmentation using fat or other materials improves glottic closure.
3. Bilateral medialization thyroplasty.When injections fail, bilateral medialization thyroplasty may offer a more permanent solution.

 

6. Stuttering (Stammering): Causes, Symptoms, and Best Treatment Approaches
Stuttering is a neurological speech fluency disorder where the smooth coordination between the muscles responsible for breathing, voice production (phonation), and articulation are disrupted. It can affect both children and adults.

Clinical Features of Stuttering

• Primary Symptoms. Repetition of initial sounds (e.g., “c-c-cat”), Prolonged pronunciation of certain syllables, Blocking where the speaker knows what they want to say but cannot begin, Hesitation or silence before speaking.
• Secondary Physical Symptoms. Involuntary eye blinking, Facial twitching or grimacing, Neck or head jerking. These secondary symptoms often arise as coping mechanisms.
• Triggers That Worsen Stuttering. Speech fluency often deteriorates under stress, such as Public speaking, Formal interviews, Emotional discussions, and High-stakes communication settings. These situations increase performance anxiety, exacerbating speech disruption.
• When Fluency Improves Temporarily. Interestingly, fluency may temporarily improve in certain situations such as Emotional arousal, walking or engaging in motor activities, singing or using a metronome, shouting or loud speech, or using a foreign accent. These adaptations help by bypassing usual speech patterns and creating rhythmic speech cues.

Risk Factors for Stuttering. Certain developmental and environmental factors play a role in the onset and persistence of stuttering. Key risk factors include:

• Parental Overcorrection. Repeated reprimanding of a child’s speech between 2–4 years can convert normal developmental dysfluency into chronic stammering.
• High Anxiety and Perfectionism. Children with anxious temperaments are more vulnerable.
• Genetic Predisposition. A family history of stuttering increases risk.

Treatment Options for Stuttering

• Preventive Strategies. Avoid correcting or punishing speech efforts. Create a calm, encouraging environment for the child. Use positive reinforcement to boost confidence in communication.
• Speech Therapy. This is the mainstay of treatment. It includes breath control techniques, Real-time fluency monitoring, Pitch and rate modulation. Speech therapy is most effective when initiated early and maintained consistently.
• Cognitive Behavioural Therapy (Psychotherapy). It is helpful in reducing social anxiety, addressing fear of speaking, improving self-image. Especially beneficial in adolescents and adults who have developed emotional barriers.
• Technological Aids. Devices such as SpeechEasy use Delayed Auditory Feedback (DAF), Frequency-Altered Feedback (FAF). These tools alter the perception of one’s voice, promoting smoother speech in around 50% of users.
• Pharmacological Options. In selected adult cases, botulinum toxin (Botox) injections (1 unit or less) to the laryngeal muscles may improve fluency by reducing muscle tension.

 

7. Tourette Syndrome

Tourette Syndrome is a type of tic disorder involving both motor tics (involving body movement e.g., blinking, shrugging) and vocal tics (involving sounds you make, e.g., throat clearing, inappropriate coughing, hooting or barking). These symptoms often begin between ages 5 and 10 and can significantly affect quality of life, academic performance, and social interactions.

Unlike many degenerative diseases, Tourette Syndrome does not worsen over time. In fact, symptoms often improve during late adolescence or early adulthood. However, in some cases, tics may persist into adulthood. Tics may be worsened by stress or excitement, fatigue, environmental cues like sounds or touch. They tend to reduce during deep sleep but may persist at a reduced frequency during light sleep. Vocal tics can lead to chronic vocal abuse, potentially resulting in vocal cord nodules or polypoid changes.

Many individuals with TS also experience associated Neurobehavioral Disorders like ADHD (Attention-Deficit Hyperactivity Disorder), OCD (Obsessive-Compulsive Disorder), Learning disabilities, Anxiety and sleep disorders. These conditions often create more functional impairment than tics alone.

Treatment Options for Tourette Syndrome. There is no permanent cure, but many treatment strategies can reduce symptoms:

Medications

• • Dopamine blockers (e.g., haloperidol, pimozide)
  • Alpha-2 agonists (e.g., clonidine, guanfacine)
  • Stimulants (e.g., methylphenidate for coexisting ADHD)
  • SSRIs for managing OCD or anxiety.
  • Botulinum toxin. Local injections of botulinum toxin to manage rapid facial tics and dystonic tics such as refractory loud barking sounds.

Behavioral Therapies

• • CBIT (Cognitive Behavioral Intervention for Tics)
  • Habit reversal training
  • Supportive psychotherapy

 

8. Phonasthenia: Vocal Fatigue Explained

Phonasthenia refers to voice weakness due to fatigue of phonatory muscles, particularly the thyroarytenoid and interarytenoid muscles. This condition typically results from voice misuse, overuse, or chronic laryngitis.

Common Symptoms

• Voice tires easily during speaking
• Reduced vocal stamina
• Hoarseness after prolonged talking

Laryngoscopic Features. Phonasthenia is diagnosed using indirect laryngoscopy, which shows:

• Elliptical glottic gap → Thyroarytenoid weakness
• Triangular posterior glottic gap → Interarytenoid weakness
• Keyhole glottic configuration → Involvement of both muscles

Treatment Strategy

• Strict voice rest during periods of vocal strain
• Vocal hygiene education, including hydration and avoiding shouting
• Speech therapy may be required in chronic cases

 

9. Hyponasality and Hypernasality: Nasal Resonance Disorders

Nasal resonance plays a critical role in articulation. Any disruption in airflow through the nasal cavity can lead to resonance disorders such as hyponasality and hypernasality.

Hyponasality (Rhinolalia Clausa)

Hyponasality is a reduction or absence of nasal resonance, especially during pronunciation of nasal consonants like m, n, ng. It typically results from obstruction of the nasal cavity or nasopharynx.

Common Causes

• Nasal polyps
• Nasal tumors
• Adenoid hypertrophy
• Allergic rhinitis
• Common cold

Hypernasality (Rhinolalia Aperta)

Hypernasality occurs when non-nasal sounds acquire nasal resonance, due to incompetent closure between the nasopharynx and oropharynx or abnormal communication between the oral and nasal cavities.

Common Causes

• Cleft soft palate
• Velopharyngeal insufficiency
• Submucous cleft palate
• Oronasal fistula
• Post-adenoidectomy changes
• Paralysis of soft palate

 

10. Laryngeal Myoclonus: Rhythmic Vocal Jerks

Myoclonus is a neurological disorder involving sudden, brief, involuntary muscle jerks. When it affects the larynx, speech and breathing may become irregular.

Key Features of Laryngeal Myoclonus

• Broken speech pattern
• Ventilatory dysfunction
• Rhythmic adduction and abduction of vocal cords
• Coordination with palatal and diaphragmatic movements

These features distinguish it from other neurological causes of dysphonia.

Treatment Options

• Medications like clonazepam or carbamazepine are usually ineffective
• Botulinum toxin injection into the thyroarytenoid muscles can reduce involuntary contractions

Oculopalatal Myoclonus: A Rare Variant

In some cases, myoclonus extends to the soft palate, larynx, diaphragm, and facial muscles, leading to oculopalatal myoclonus. Symptoms include:

• • Palatal jerks
  • Vocal tremors
  • Diaphragmatic spasms
  • Clicking tinnitus due to rhythmic tensor veli palatini contractions

 

———— End of the chapter ————

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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