Disorders of voice | speech

• Functional precipitator
  • Mucosal disorders
  • Muscular disorders
  • Nonorganic disorders
• Structural precipitator
  • Trauma
  • Inflammation
  • Neurologic
  • Tumor
  • Congenital
  • Endocrine

Take a look at the list to the left, but first indulge me for a few moments as I present my arguments for this categorization. No grouping of diseases seems to be entirely discrete. There is admittedly overlap and uncertainty about some diseases. There will probably be times when you will find this rigid stratification of disease not acceptable to your needs. Additionally, this classification is of voice disorders as opposed to speech disorders.

The first level of classification

The first level of classification I would like to make is by causes of laryngeal disease. I will assert this is a beneficial grouping as treatment generally depends on the cause of the disease.

Functional precipitator

For example, the subcategories of a Functional precipitator of disordered voice usage are caused primarily by an excessive use type of behavior. These behavioral diseases are a group of illness where the behavioral process occurs first (the excessive use) and then an anatomic change (e.g. swelling) may follow. To me, this implies that the behavioral process must be corrected first. If it is not and the anatomic abnormality is corrected first, the problem will likely recur. At a minimum, a change in behavior (reduction of excessive use) should stop progression of the injury and potentially may even correct the injury. If the behavioral problem is corrected and the anatomic problem is so chronic that it does not resolve, then surgical intervention may be indicated.

An analogy might be: if a worker quits digging ditches, the callouses on their hands go away. If they shave their callouses off each week but continue to work, they keep coming back.

Structural precipitator

Non-behavioral disorders (a Structural precipitator) are often best treated first with medical or surgical intervention. Get rid of the problem and the vocal symptoms go away.

An analogy might be: remove the pebble inside your shoe and you will quit limping. All the therapy in the world will not make the limp better and may even be unnecessary.

There is a time and place for both surgery and therapy.

The second level of classification

The diseases caused primarily by a Functional precipitator fall into three subcategories. Vocal behavior that is extreme in volume or in quantity of use could be termed the Vocal Overdoer syndrome. This typically leads to, or places, the patient at risk for mucosal disorders. Repeated mucosal trauma leads to a surface injury such as polyps, nodules, cysts, etc.

Muscle disorders which are non-neurologic in etiology would include the Vocal Underdoer syndrome where, over time, they may come to lack muscle bulk and may have trouble with bowing. Muscle injury or lack of use causes a relative lack of volume in the vocal fold since the foundation of the vocal cord is the vocalis muscle.

Maladaptive behaviors lead to Non-Organic disorders. That is a behavior that places the vocal folds in such a position as to generate a non-normal type of sound - lovely at the Comedy Club but not too functional for day to day use. Indeed, any funny sound that you can make, if you persisted in using that sound for all your communicative needs could be considered a non-organic type of voice disorder.

Non-behavioral laryngeal disorders could have the following subcategories: Trauma, Inflammation, Neurologic, Tumor, Congenital, Endocrine and Swallowing.

I can hear your arguments already. Smoking causes cancer so it could be in the behavioral category and cysts are congenital so behavior does not effect their formation at all. Perhaps, but ignoring those and any other arguments you may have (but only for the moment), I will proceed.

The remaining diseases are primarily structural and result from non-behavioral causes. They will usually require medical or surgical intervention for treatment. This is not meant to exclude behavioral modifications as stopping smoking may certainly play a role in the recurrence or lack of recurrence of laryngeal carcinoma.

Functional precipitator

Disordered voice usage (a change in vocal behavior or function leads to a voice problem and a subsequent change in anatomy)

Mucosal

• Nodule
• Polyp
• Cyst
• Sulcus
• Granuloma
• Capillary ectasia
• Hemorrhage
• Smoker’s polyp
• Leukoplakia

Muscular

• Bowing
• Muscle tension dysphonia
• Voice fatigue syndrome
• Deconditioning

Nonorganic

• Habituated aphonia
• Habituated hoarseness
• Habituated cough
• Mimicked spasmodic dysphonia
• Mimicked asthma
• Inappropriate falsetto (puberophonia)

Structural precipitator

Structural changes lead to changes in vocal function

Trauma

• Trauma - external
• Skeletal - cartilage fracture
• Trauma - internal - intubation
• Ligamentous - arytenoid dislocation
• Mucosal injury

Inflammation

• Hyoiddynia
• Acid Reflux (GERD)
• Infectious
• Granulomatous
• Post radiation changes

Neurologic

• Paralysis
  • Complete
    • Denervation and atrophy
    • Synkinesis and bulk
  • Partial
• Spasmodic dysphonia
  • ABductor
  • ADductor
  • Mixed
  • Tonic variant
  • Respiratory
• Tremor
• Other CNS (ALS, myasthenia)

Tumor

• Benign
• Saccular cyst
• Papilloma
• Leukoplakia
• Erythroplasia
• Malignant
• Squamous Cell Carcinoma
• Other tumors

Congenital

• Cysts
• Sulci

Endocrine

• Postmenopausal