Experts Discuss How to Approach Challenging Dysphonia Cases

A panel of voice experts delved into a type of case that many otolaryngologists may find difficult to diagnose: dysphonia without lesions or problems with vocal fold motion. The discussion mainly touched on scarring, muscle tension dysphonia, and essential tremor.

Clark Rosen, MD, moderator of the session and director of the University of Pittsburgh Voice Center, said that these cases are often vexing to some general otolaryngologists. “When we see people with dysphonia, and they’re clearly dysphonic, but you look at the larynx and there’s no obvious lesion [and] no obvious motion impairment, the question is, why are they dysphonic?” he said. “In talking to my general otolaryngology colleagues, it would be this group of patients they struggle with the most.”

The differential diagnosis for dysphonia without a vocal fold lesion or motion impairment includes primary muscle tension dysphonia, vocal fold atrophy, secondary muscle tension dysphonia associated with glottal incompetence, essential tremor of the vocal tract, spasmodic dysphonia, vocal fold scar or sulcus vocalis, inflammation, and a functional or psychogenic cause.

Case 1: Hoarseness after Cough

Panelists discussed the case of a 64-year-old woman who, for four months, experienced hoarseness that started with a bad cough. She had no past voice problems, but had prior tobacco use and chronic obstructive pulmonary disease (COPD). She had a Voice Handicap Index-10 (VHI-10) of 32.

The panelists offered some tips on their initial evaluation.

Norman Hogikyan, MD, professor of otolaryngology at the University of Michigan in Ann Arbor, said he would take a long listen to her voice before using an endoscope. “I think too often people will jump to drop in the scope to try to understand what’s going on. … I’d like to interrogate her vocal capabilities a little bit more [and] listen to some non-voice laryngeal tasks. I’d like to listen to her doing a sustained voice task, and I’d also like to assess her range.

Mark Courey, MD, director of the Grabscheid Voice and Swallowing Center at Mount Sinai in New York City, agreed. “I would try to have her talk a little bit longer and get some sustained phonation,” he said. “And I would also be palpating her neck when I was doing this to see what was going on with her neck muscles.”

Michael Johns III, MD, director of the University of Southern California Voice Center in Los Angeles, emphasized the value of an “up-close evaluation” on endoscopy. “We can gain a lot of information from a very detailed, high quality anatomic examination.”

The panelists eventually agreed, after seeing stroboscopy footage that showed decreased mucosal wave on one side and lateral-to-medial blood vessels, that the problem seemed to be scarring.

In scarring cases, Dr. Hogikyan said, “history often guides you because there’s an antecedent event, unfortunately, often iatrogenic.” He added, “This is an example of a diagnosis where stroboscopy really shines.” It allows you to see vibratory capacity of the vocal fold mucosa, and scarring usually causes mucosal stiffness, he said.

Dr. Johns noted the importance of looking for patients who may have experienced an acute laryngeal event and then continue to use and put a lot of strain on their voices. “Patients have a tendency to push through upper respiratory tract infections and acute laryngitis,” he said. “And unfortunately, based on how we’re built, we have no pain feedback in that type of illness. And yet with increased effort we can generate sound. … I can just continue using my voice, and I can strip and scar the lamina propria. It’s an awareness issue.”

Dr. Courey suggested getting patients to use both high and soft phonation on stroboscopy. “I think that, oftentimes, people think about getting stroboscopy only at modal pitch and intensity, and I think with these patients you bring out subtle vibratory abnormalities better with ranges of pitch.”

Case 2: Muscle Tension Dysphonia

Another case involved a 55-year-old woman with what the panelists described as a “laryngologic full house” for a year: globus, swallowing problems, voice problems, and shortness of breath. She reported that she had been hit on the head with a board at work. The panel agreed with Dr. Johns that the “strained, pressed quality” to the woman’s voice strongly suggested muscle tension dysphonia.

Discussing this problem with patients can be difficult, panelists said. They agreed that it is best to avoid the word “psychogenic” and instead describe the issue as “functional.”

Dr. Hogikyan said his approach is to tell patients, “It’s a good type of problem to have. Your voice structures themselves are healthy, but your body’s using them in an abnormal way. Another way to think about that would be posture. I can have good posture; I can have bad posture. If I have bad posture long enough, it becomes habitual. And your voice box is in a bad posture. And what we’re going to do is to try to get your body out of the abnormal posture.”

I think too often people will jump to drop in the scope to try to understand what’s going on. … I’d like to interrogate [the patient’s] vocal capabilities a little bit more [and] listen to some non-voice laryngeal tasks. —Norman Hogikyan, MD

He said this approach “takes burden off of the patient” and doesn’t imply they’re doing anything knowingly to alter their voice.

Dr. Johns added, “It’s important to make sure the patient knows that they have a diagnosis. Because otherwise if they aren’t very clear that they have a diagnosis, then they’re going to leave the office and they’re going to go home and say, ‘They found nothing wrong,’” and probably won’t do what they need to do to get better.

Dr. Courey said it is important to describe the root of the problem. “Learning how to use your vocal folds efficiently,” he said, “you have to recognize the cause of how the inefficiency started.”

In cases when essential tremor is possible, panelists said, prolonged phonation, laryngoscopy at glottic and non-glottic sites, and a good family history are important tools. “Patients are exceptionally good at masking tremor during free-running speech,” Dr. Johns said. “You really need to push these patients for prolonged phonation. You’ll hear tremor, and patients who even have subtle tremor will stop phonating when they start hearing the tremor. You really have to push them.”

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Thomas R. Collins is a freelance medical writer based in Florida.