Description. Cysts in vocal folds are similar to cysts other places in the body. They are essentially fluid-filled sacs surrounded by a layer of “skin”. Often, a single cyst forms at the middle of one vocal fold, where impact stress is greatest. The other vocal fold usually develops a “reactive swelling” caused by the cyst from other similar-appearing lesions such as nodules and polyps by regular clinical examination, the final diagnosis can be made only if the cyst is surgically removed and inspected under a microscope.

Causes. No one really knows the exact causes of vocal fold cysts. Because they often form at the middle of the vocal fold, where impacts stress is the greatest during voicing, most people think that voice use does play some role in their development.

Treatment. Cysts do not go away with voice therapy alone. However, voice therapy is usually the first treatment approach, for two reasons. First, the cyst may be surrounded by swelling, and the opposite fold usually has swelling as well; voice therapy should be effective for reducing the swelling, and thus improving symptoms. Second, the results from voice therapy can help to make the diagnosis: if a lesion goes away with therapy, then it probably wasn’t a cyst. If it doesn’t go away, then it might be a cyst, and surgery may be appropriate.
 

Description. Hemorrhaging within the vocal folds involves bleeding into the tissue. Small vessel ruptures can cause tiny, visible capillaries sometimes called “varices” (varix, singular) or “capillary ectasias”. Larger bleeds involved a broader perfusion of blood into the tissue.

Causes. One cause of hemorrhage in the vocal folds is extremely loud voice use, for example, screaming. Sometimes visible blood vessels feed into vocal fold lesions and help to maintain them. This occurs sometimes with polyps and often with cancerous tumors.

Treatment.  It depends on the cause. If the bleed is new and extensive, the treatment of choice is usually complete voice rest for several days or even for few weeks. More commonly patients are advised to avoid blood thinners including aspirin and alcohol when possible. If prominent vessels persist, or if they are due to benign or cancerous lesions, surgery may be undertaken to both remove the lesions and cauterize the vessels.
 

Description. Sulcus literally means “groove”. In the most general sense, a vocal fold sulcus is a groove that forms in the vocal fold tissue. Many clinicians use the term “sulcus vocalis” to refer to any type of groove in the vocal folds. Other clinicians distinguish between different types of grooves and “sulci” (plural of “sulcus”). A “physiologic sulcus” is a shallow groove running from the front to the back of the vocal fold, which is seen in many people and may not cause trouble for the voice at all. “Sulcus vergeture” is a somewhat deeper groove, and may produce voice symptoms. True “sulcus vocalis” is a deep pit in the vocal fold tissue, which goes all the way to the muscle, and can severely impair voice. Common complaints of sulci are voice weakness, fatigue, and a “reedy” or “veiled” sound.

Causes. There is debate about cause of the vocal fold sulci. In some cases, they may result from a cyst that has ruptured. In other cases, they may be present from birth.

Treatment. Although voice therapy may help to improve some of the symptoms of sulcus, usually therapy does not make the symptoms go away entirely. In such cases, surgery may be use.
 

Description. Bowed vocal folds are literally folds that look like two bows joined at the front and back. The back and front of the vocal folds may come together, but the middle part stays open. Typical symptoms are weak voice and vocal fatigue.

Causes. The most common cause of bowing is “presbylarynx”, which literally means “old larynx”. However, bowing can also occur in young persons. In many cases, bowing  at any age comes from a subtle lack of “nerve” input to the vocal folds. The result is a lack of closure in the middle part of the vocal fold, and over time, also a loss of muscle bulk in the vocal folds adding to difficult with closure. There is also speculation that bowing might be cause by muscular over-use, especially if seen in young adults.

Treatment. Almost always, the first line of treatment for bowing is voice therapy. Therapy can be used to exercise the vocal folds and to bulk them up to get the best vocal fold closure possible during voicing. Therapy can also help to reduce the over-activity of other muscles that often occurs as a compensation for poorly closing vocal folds. In extreme cases of bowing or with persons too cognitively impaired to successfully use behavioral methods, one or both vocal folds may injected with material to add bulk.  SEE POWER POINT  -  CLICK FOR HANDOUT
 

Description. Granulomas are comprised of grainy tissue that builds up in the larynx, usually at the back of the vocal folds near the cartilage called the “vocal process”. Sometimes, a granuloma is seen on one vocal process, and a ulcerated pit is seen on the other vocal process where the granuloma hits up against it. This combination is referred to as a classic “cup and saucer” appearance.

Causes. Many granulomas are clearly caused by the reflux of stomach acids onto the back of the vocal folds. Otherwise, granulomas can be caused by the insertion of airway tubes during surgery, the prolonged use of airway tubes after surgery and some disease states such as tuberculosis and HIV+. There is that some evidence that low pitch and overactivity of the back part of the larynx may also contribute to granulomas in some cases.

Treatment. Gastric reflux treatment is almost always part of the treatment program for granulomas, even if a person is not known for certain to have reflux. This treatment usually involves a combination of medication and dietary regulations. If the lesions are very large or do not respond to medication, then the treatment may proceed with either microsurgery or voice therapy, or both. Because granulomas often recur, the treatment program is usually comprehensive in order to address several of the factors known to increase the risk of recurrence (ongoing reflux treatment an change of voice use patterns).  SEE POWER POINT

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Description. Muscle tension dysphonia, also called MTD, is a condition in which one or more laryngeal muscle sets are overactive, causing voice fatigue and discomfort. Sometimes MTD accompanies another organic condition, although often it occurs on its own. A typical finding with MTD is that the vocal folds do not come together during voice production, especially in the back by the vocal process. Although incomplete posterior closure is a common finding for many females, in MTD the findings is exaggerated. Sometimes the false vocal folds are also overactive during voice production.

Causes. The cause of MTD is over-activity in some laryngeal muscles, and perhaps underactivity in other muscles causing muscular imbalances. Generally, the over-activity is assumed to be non-organic and can be changed with voice therapy.

Treatment. Voice therapy is the treatment of choice for MTD. A variety of approaches may be used. Laryngeal massage is one approach that may be particularly effective.  CLICK FOR HANDOUT
 

Description. Vocal fatigue is a frequent descriptor for a well-known set of symptoms, including deteriorated vocal quality, decreased endurance loss of frequency and intensity control, and complaints of effortful, unstable, or ineffective voice production.

Causes. The etiology is vocal abuse and misuse.

Treatment. Using physiologic voice therapy has proved promising and effective. This therapy includes voice therapy programs that have been devised to directly alter or modify  the physiology of the voice mechanism. Clinically, patients with complaints of vocal fatigue will exhibit vocal folds that appear normal under indirect laryngoscopy. Symptoms of the disorder include dryness on the mouth or throat. Perceptually, there is shortness of breath; and effortful phonation.  CLICK FOR HANDOUT

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Description. The essential component of vocal abuse are prolonged, effortful, and maladaptive vocal behaviors, usually based perceptually, on excessively loud or aggressive voice production, sharp glottal attack (voice onset), inappropriate technique for voice or singing, and aggressive laryngeal vegetative maneuvers, including throat clearing, coughing, or grunting. Vocal abuse or misuse often result from poor or ineffective training in vocal technique, including insufficient respiratory support, excessive laryngeal tension during phonation, and failure to achieve proper oral resonant focus. Across time, the effect of these poor vocal behaviors, whether, produced knowingly or unknowingly, can cause traumatic injury to the vocal fold cover, sometimes to the extent that benign lesions will form.

Causes. The etiology is hyperfunction of the laryngeal mechanism.

Treatment. The best treatment is to identify and eliminate the vocal behavior that created the voice disorder. In many cases, a brief period of voice therapy is helpful so that the individual can learn good vocal techniques such as proper breath support for speech or eliminating forceful voicing. - CLICK FOR HANDOUT

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Description. Puberphonia occurs when acoustic changes of maturation do not occur. Physiologically, this is caused by persistent hyperfunction of the cricothyroid muscles with a pronounced elevation of the entire larynx. Typically mild dysphonias characterized by high pitch, low intensity, cul-de-sac nasality, and breathiness. The condition is most commonly seen in males who continue to use a high pitch in speech. Occasionally, puberphonic voice is encountered also in females who use a high-pitched “little girl” voice.

Causes. The causes have not been systematically studied. It is assumed that either “learning” or psychological causes contribute to the problem.

Treatment. Voice therapy is the treatment of choice, usually appropriate pitch and resonance can be triggered in the first o second therapy session but subsequent therapy is needed to familiarize and stabilize the “new” voice as the patients own.
 

Description. Patients who elect to proceed with gender reassignment do not present as voice disorders per se. These patients need to alter voice production so that listeners will perceive the speaking voice as appropriate for desired gender.

Causes. Transgender voice problems are caused by anatomical differences between male and female voice production systems, and a mismatch between biological capabilities and social propensities. Additionally, cultural factors tend to influence voice inflection and language in gender-specific ways.

Treatment.  These patients can benefit from behavioral therapy, medical and surgical interventions. Treatment are targeted specifically for the define need posed by the patients gender transition (usually pitch, quality, and prosody). Medical interventions sometimes involve hormone treatments in conjunction with other aspects of transgender management.  SEE POWER POINT

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