Dysphonia is a general term that refers to voice quality of hoarseness. It is the reason for 1% of all visits to the primary care medical professional.
Hoarseness is not a disease but a symptom. It is associated with many laryngeal diagnoses.
Dysphonia is a broad term. Voice can be classified as dysphonic with any changes to pitch, loudness, quality or variability. Although hoarseness and dysphonia are commonly used interchangeably, they are not the same. A monotone voice is not hoarse but ,by definition, is dysphonic.
The prevalence of dysphonia in adults under the age of 65 is 6.6%.
Dysphonia is more common in females than males. This is attributed to the anatomical differences of the vocal mechanism.
However, in childhood, dysphonia is more common in males. This is not attributed to anatomic differences prior to puberty, but louder use of the larynx and inappropriate strain by boys over girls at the same age.
The most common laryngeal diagnosis among children is vocal cord nodules which is associated with damaging vocal cord strain.
In the older population, the incidence is between 4-30%. This is attributed to a wide range of etiologies. This can range from polyps to vocal cord paralysis.
Voice disorders can be divided into two categories: organic causes and functional causes.
Functional dysphonia refers to hoarseness resulting from vocal cord overuse or psychogenic causes.
- Psychogenic
- Vocal cord misuse
- Idiopathic
Organic Causes can be divided into structural or neurogenic. Structural dysphonia refers to something that impairs the function of the vocal cords. Neurogenic refers to a central nervous system or peripheral nervous system impairment.
- Neoplasm either premalignant or squamous cell carcinoma
- Trauma- prior surgery, damage during intubation, thermal injuries, blunt trauma
- Endocrine causes such as thyroid or gonadal disorders
- Amyloidosis
- Smoking chronically
- Viral laryngitis
- Gastroesophageal reflux
- Medicines such as inhaled steroids
The most common cause of hoarseness is laryngitis (acute 43% Chronic 10%) and functional dysphonia (30%) in all reported cases. Less common are vocal cord polyps and neurologic causes. Treatment depends on the etiology.
Neoplastic/ structural is a class due to abnormal growths on the vocal cords that restrict function. These lesions include both benign and malignant lesions.
Inflammatory is a class that causes inflammatory changes in the vocal cord tissue. Allergies, infections, reflux, trauma, smoking and singers’ nodules due to abuse are all etiologies.
Neuromuscular is a class that causes disturbances in the neuromuscular control of laryngeal function. Multiple sclerosis, Parkinsonism, Myasthenia and nerve injury due to strokes are just a few that cause neuromuscular dysfunction.
Systemic diseases can also affect the vocal cords and cause dysphonia. These include hypothyroidism, amyloidosis and sarcoidosis.
Psychological stresses can also impair vocal cord function causing dysphonia.
Anatomy
The larynx is composed of muscle and soft moist tissue. The larynx is at the top of the trachea. The laryngeal cords known as the voice box, is at the top of the trachea. As air moves into this area, the vocal cords vibrate creating sound. If this area is inflamed or has developmental abnormalities such as growths, the cords will not approximate, a voice disorder originates.
Diagnosis
History and physical exam are always the primary starting point for the etiology of the disorder. A mirror can be put in the mouth to view the movement of the cords.
Flexible laryngoscope has replaced the rigid scope. This flexible tube with a lighted tip and camera is commonly used to view the anatomy.
A video stroboscope is used to obtain slow motion views of the vocal cord movement during speech.
For neurologic etiologies electromyography measures the electrical currents in the muscles in the laryngeal area.
Sound analysis can be done by computer and measures any unusual sound created by the vocal cords.
Treatment
Depending on the diagnosis, the primary treatment is vocal cord rest. Voice therapy with speech pathologists can be consulted in more refractory cases.
Treatment of allergies if that is deemed the etiology.
Stopping smoking is mandatory.
Medicines for conditions such as reflux diseases. Injections are sometimes given into the vocal cords to reduce the inflammation. The common injections are steroids.
Surgery to remove growths on the cords. Lasers are commonly used to excise non-cancerous tumors. Potassium titanyl phosphate laser treatment stops the blood supply to the growths and allows removal with less trauma to the cord tissues.
For spastic dysphonia, modulators such as botulinum toxin are injected to stop the spasms.
If the vocal cord is paralyzed, injections are placed to approximate the vocal cords. This can be fat or collagen. Implants have also been used.
Despite the common use of the above techniques and injectables, the results are not consistent. Tissue regenerative products have gained interest and scientific studies have proven the efficacy both in animal and human models.
The first reported use of tissue products was in 2009 by Hirano et al. This was in an animal model. Then in 2016, the first case of vocal cord injection of tissue products was reported with excellent outcomes. Fibroblast growth factor was isolated and injected in 100 patients in 2021 by Hirano et al. These patients had multiple pathological causes of dysphonia that included scarring, atrophy and sulcus related pathologies. He reported positive effects of intracordal injections resulting in improved voice with no severe adverse effects.
Platelet Rich Plasma is a blood derived concentrate of autologous growth factors, cytokines and bioactive proteins. PRP could be used as an alternative to commercial growth factors for cell therapies and could potentiate stem cell proliferation, migration and differentiation. PRP has an appeal over other growth factors owing to its availability and fewer regulatory hurdles. PRP is widely used in cosmetic, dental, orthopedic, dermatological, wound healing and other treatments in medicine. However, long term results in the use of PRP for dysphonia were unavailable until recently.
Study
Laryngoscope Investig Otolaryngol 2023 Sept 5;8(5):1304-1311 PMID 37899871
Bhatt et al first reported the use of PRP for the treatment of vocal cord scarring and reported improvement. Murry et al showed PRP improvement is voice quality short term. Johns et al, in a safety and efficacy study, reported PRP is a safe modality with minor morbidity.
In a study published in 2023, 158 PRP injections were administered to 63 patients. Thirty-four had unilateral or bilateral vocal cord scars, 17 has unilateral or bilateral sulcus lesions, five had mature vocal cord nodules, four had atrophy and three had combinations of these pathologies. All patients had previously failed standard therapies or surgery. For all patients, it had been greater than 6 months after the last intervention and had stabilized from their treatments. The treatments included voice therapy, steroid injections, laser surgery, augmentation laryngoplasty and micro flap techniques.
All patients received three monthly injections of PRP. All procedures were done by laryngoscopy to insure proper placement. All patients tolerated the injections and most reported transient soreness. Few reported excessive cough and throat clearing lasting only 24 hours post injection.
The results showed both short- and long-term improvements after 1-3 monthly intervals of injections. The short- and long-term improvements appear to be more pronounced in patients with mild to moderate dysphonia than those with severe dysphonia. This study defined the short term as three months and the long term as 12 months post treatment.
Conclusion of this study was platelet rich plasma is an alternative treatment for patients with mild to moderate dysphonia due to vocal cord scarring, sulcus and atrophy.
- Efficacy of Platelet Rich Plasma in Benign Vocal Fold Lesions: A Systematic Review and Meta-Analysis
Eur Arch Otorhinolaryngol 2024 Jan;281(1):13-21 PMID 37709923
Objective: To evaluate the efficacy of platelet rich plasma in benign vocal fold lesions.
Conclusion: Platelet Rich Plasma is effective in reducing VHI scores, Jitter and Shimmer percentages and NHR values. This effect is more evident after following up, especially 3 months or more.
J Voice 2024 Mar 8:S0892-1997(24)00033-X PMID 38461100. Ahead of Print
Objective: Mature vocal fold nodules and fibrous phono-traumatic lesions that have failed standard voice therapy can be challenging. This study reports the short term (3 months) voice results after PRP injection in 11 subjects with recalcitrant, bilateral phono-traumatic lesions that have failed voice therapy.
Conclusion: Short term improvements were found in 9 of the 11 subjects. PRP injections into the vocal folds may be a new treatment for nonsurgical intervention in patients with recalcitrant, bilateral photo-traumatic lesions.
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RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
