Can abusing the voice create problems?

Voice abuse through technical dysfunction is an extremely common source of hoarseness, vocal weakness, pain and other complaints. In some cases, voice abuse can even create structural problems such as vocal nodules, cysts and polyps. Now that the components of voice function are better understood, techniques have been developed to rehabilitate and train the voice in speech and singing. Such voice therapy improves breathing and abdominal support, decreases excess muscle activity in the larynx and neck, optimizes the mechanics of transglottal (through the vocal fold area) airflow and maximizes the contributions of resonance cavities. It also teaches vocal hygiene, including techniques to eliminate voice strain and abuse, maintain hydration and mucosal function, mitigate the effects of smoke and other environmental irritants and optimize vocal and general health. A voice therapy team includes an otolaryngologist (ear, nose and throat doctor) specializing in voice, a speech-language pathologist specially trained in voice, a singing voice specialist with training in vocal injury and dysfunction, and when needed, an arts-medicine psychologist, psychiatrist, pulmonologist, neurologist, exercise physiologist, or other specialist. Progress is monitored not only by listening to the patient and observing the disappearance of laryngeal pathology when it is present, but also by quantitative measurement parameters in the clinical voice laboratory. However, in some cases there are structural problems in the larynx that are correctable only with surgery.


What are cysts?

Submucosal cysts of the vocal folds are usually also traumatic lesions that produce blockage of a mucous gland duct, although they may also occur for other reasons and may even be present at birth. They often cause contact swelling on the opposite vocal fold and are usually initially misdiagnosed as nodules. Often, they can be differentiated from nodules by strobovideolaryngoscopy when the mass is obviously fluid-filled. They may also be suspected when the nodule (contact swelling) on the other vocal fold resolves with voice therapy but the mass on one vocal fold persists. Cysts may also be found on one side (figure to right) (occasionally both sides) when surgery is performed for apparent nodules that have not resolved with voice therapy. The surgery should be performed superficially and with minimal trauma, as discussed later.


What are polyps?

Many other structural lesions may appear on the vocal folds. Of course, not all respond to nonsurgical therapy. Polyps are usually unilateral (or one side) masses, and they often have a prominent feeding blood vessel coursing along the superior surface of the vocal fold and entering the base of the polyp (below). The pathogenesis of polyps cannot be proven in many cases, but the lesion is thought to be traumatic in many patients. At least some polyps start as vocal hemorrhages. In some cases, even sizable polyps resolve with relative voice rest and a few weeks of low-dose corticosteroid therapy. However, many require surgical removal. If polyps are not treated, they may produce contact injury on the contralateral (opposite) vocal fold. Voice therapy should be used to assure good relative voice rest and prevention of abusive behavior before and after surgery. When surgery is performed, care must be taken not to damage the leading edge of the vocal fold, especially if a laser is used.

Intraoperative photo shows the right posthemorrhagic polyp. Note the prominent vessel overlying the polyp and the dilated vessels bilaterally on the superior surface and on or near the vibratory margins. Also note that indentation on the left vocal fold is from contact trauma. From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.

Intraoperative photo shows the right posthemorrhagic polyp. Note the prominent vessel overlying the polyp and the dilated vessels bilaterally on the superior surface and on or near the vibratory margins. Also note that indentation on the left vocal fold is from contact trauma. From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.

Typical appearance of vocal nodules. From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.

Typical appearance of vocal nodules. From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.

What are vocal nodules?

Small, callous-like bumps on the vocal folds called nodules are caused by voice abuse (above). Occasionally, laryngoscopy reveals asymptomatic vocal nodules that do not appear to interfere with voice production; in such cases, the nodules need not be treated. Some famous and successful singers have had untreated vocal nodules throughout their entire careers. However, in most cases nodules are associated with hoarseness, breathiness, loss of range, and vocal fatigue. They may be due to abuse of the voice during either speaking or singing. Voice therapy always should be tried as the initial therapeutic modality and will cure the vast majority of patients even if the nodules look firm and have been present for many months or years. Even in those who eventually need surgical excision of the nodules, preoperative voice therapy is essential to prevent recurrence.

Caution must be exercised in diagnosing small nodules in patients who have been speaking or singing actively. In many people, bilateral, symmetrical soft swellings at the junction of the anterior and middle thirds of the vocal folds develop after heavy voice use. No evidence suggests that people with such "physiologic swelling" are predisposed to development of vocal nodules. At present, the condition is generally considered to be within normal limits. The physiologic swelling usually disappears with 24 to 48 hours of rest from heavy voice use.


Reach right vocal fold cyst and left reactive mass in abduction (open)(a) and aduction (closed)(b). From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.

Reach right vocal fold cyst and left reactive mass in abduction (open)(a) and aduction (closed)(b). From Sataloff, R.T., Hawkshaw, M.J., Sataloff, J.B., DeFatta, R.A., and Eller, R.L. Atlas of Laryngoscopy, Third Edition. San Diego, California: Plural Publishing, Inc.; 2012.


What happens if a blood vessel in a vocal fold ruptures?

Vocal fold hemorrhage, the result of a ruptured blood vessel, is a potential vocal disaster. Hemorrhages resolve spontaneously in most cases, with restoration of normal voice. However, in some instances, the hematoma (collection of blood under the vocal fold mucosa) organizes and fibroses, resulting in the formation of a mass and/or scar. This alters the vibratory function of the vocal fold and can result in permanent hoarseness. In specially selected cases, it may be best to avoid this problem through surgical incision and drainage of the hematoma. In all cases, vocal fold hemorrhage should be managed with absolute voice rest until the hemorrhage has resolved and normal vascular and mucosal integrity have been restored. This often takes six weeks, and sometimes longer. Recurrent vocal fold hemorrhages are usually due to weakness in a specific blood vessel. They may require surgical cauterization of the blood vessel using a laser.