Voice Disorders

Who Gets Voice Disorders and Why?

A voice disorder may prevent a professional singer from performing or a business person from effectively managing his or her affairs, or it may prohibit simple, daily, verbal communication between elderly spouses. A person’s vocal quality may influence the type of work that person does, and conversely, the type of work a person does may influence the importance of avoiding voice difficulties and the degree of professional impairment that may result from a voice problem. Voice disorders are ubiquitous, and many have severe social, psychological, professional, and economic consequences.
 

The Prevalence of Voice Disorders

In the United States, voice disorders affect approximately 25 million people, and yet there are less than 80,000 patient visits annually to a voice specialist. For this population, voice disorders are not just a mere annoyance. And, the professional and economic impacts of voice disorders will continue to increase as the United States’ economy continues to shift from manufacturing to a service and information base. As a result, by 2010, the portion of the population that relies on its voice for their profession will grow five times faster than those who do not need their voices for their work. Approximately 1%-2% of the American population has a voice disorder and the prevalence of voice disorders is higher than other well-known diseases as compared below:

Relative Prevalence of Well-Known Diseases

Additionally, as many as 30%-50% of the American population has reflux disease, a condition caused by the backflow of stomach contents into the esophagus and/or throat. Reflux is one of the most commonly under-diagnosed and under-treated causes of voice problems; and, it is an important focus of contemporary laryngology. Until relatively recently, many voice disorder patients went untreated, but today, with advances in diagnosis and treatment, that has changed.
 

Levels of Vocal Usage

The success of treating patients with voice disorders depends to a great extent upon accurate diagnosis and identification of the vocal needs of each patient within the context of the patient’s professional and social needs and obligations. The same voice disorder may have profoundly different impact on two different patients depending on their professions. There are four levels of vocal usage, based upon a hierarchy of vocal use, performance, and need:

The Levels of Voice Use

Level I: Elite Vocal Performer
A person for whom even a slight aberration of voice may have dreadful consequences. Most singers and actors are in this group; the opera singer is the quintessential level I performer.

Level II: The Professional Voice User
A person for whom a moderate vocal problem might prevent adequate job performance. This group includes most broadcasters, actors, clergy, teachers, etc.

Level III: Non-Vocal Professional
A person for whom a severe vocal problem would prevent adequate job performance. This group includes lawyers, physicians, businessmen, business women, etc.

Level IV: Non-Vocal Non-Professional
A person for whom vocal quality is not a prerequisite for adequate job performance. This group includes many clerks, laborers, and so forth. Although persons in this group may suffer very significant social liability from a voice disorder, they are not prevented from doing their work.

Professional vocalists, especially singers, are the first to seek medical attention if something happens that adversely affects the voice. When a voice disorder strikes a well-known vocalist, it may prevent an adequate performance or even force cancellation of performances. Obviously, concert promoters, support staff, and the public are adversely impacted. Thus, a voice problem can have profoundly adverse financial and professional implications for the singer’s career, and may damage the singer’s reputation as well.

Most commonly, the voice problems of vocal performers are acute “emergencies” caused by upper respiratory infection such as a cold, reflux; or they may be environmental or stress-related.

Other professional voice users (levels II and III) may suffer similar emergencies; however, more commonly, the voice problems in these groups are chronic. For non-vocal non-professionals, the type of voice problems may be similar, but level IV patients usually do not seek medical attention until the problem is chronic. However, any level patient may be just as severely affected from a social and a psychological point of view as any other patient.

The Multiple Causes of Voice Disorders
 

In most cases, voice disorders are multifactorial (that is they have more than one cause.) It’s almost as though several things need to go wrong before voice decompensation occurs; see “vocal decompensation.”  The most common problems that affect the voice and larynx are

• laryngopharyngeal reflux (the backflow stomach contents into the throat) that may be completely silent occurring without heartburn or digestive symptoms

• vocal fold weakness (partial paralysis or the effects of aging or “Bell’s palsy of the throat”)

• voice misuse abuse and overuse syndromes

Lesions (growths) occurring on the vocal folds may result from vocal fold weakness, laryngopharyngeal reflux, and/or vocal fold bowing (weakness paresis). The table below shows the results of a study done on 200 voice disorder patients by Dr. Jamie Koufman, Director of the Voice Institute of New York.

It can be seen that approximately 70% of patients have laryngopharyngeal reflux and 50% have vocal weakness or some other neurological problem that affects the voice while 1 out of 5 (20%) have a vocal fold growth of some kind, and 90% have abnormal laryngeal biomechanics (meaning they are having to use compensatory mechanisms such as extra work, to achieve vocal fold closure. The table below shows the distribution.
 

Results of the Voice Disorders Etiology (causes) Study

The Voice Institute of New York prides itself on providing precision diagnostics. These include videostroboscopy, laryngeal electromyography, acoustical measurement, and reflux testing. Once accurately diagnosed, most voice disorders can be corrected.