Functional Voice Disorders

Author Credentials 

Amanda Hu, MD
Clinical Associate Professor, Laryngologist
Department of Surgery, Division of Otolaryngology – Head & Neck Surgery
University of British Columbia
2775 Laurel Street, 4th Floor
Vancouver, Canada
V5Z 1M9
Email: Amanda.cm.hu@gmail.com

Module Summary

A functional voice disorder is the result of vocal misuse or abuse of an anatomically and physiological intact vocal apparatus. When the voice is disproportionately poor compared to laryngeal findings, then a functional voice disorder should be suspected. Six different types of functional voice disorders are described in the literature: Type 1, hysterical aphonia/dysphonia; type 2, habituated hoarseness; type 3, falsetto voice, type 4, vocal abuse; type 5, postoperative dysphonia; and type 6 relapsing aphonia. Functional voice disorders may lead to secondary laryngeal pathology, like vocal fold nodules. Voice therapy is the main treatment. A multidisciplinary team with a speech therapist, psychiatrist/psychologist, and/or neurologist is beneficial

Module Learning Objectives 
  1. Define the term “functional voice disorder” as a voice disorder that is the result of misuse or abuse of the anatomically and physiologically intact vocal apparatus.
  2. Describe the typical patient with a functional voice disorder.
  3. Discuss different methods to evaluate a patient for a functional voice disorder.
  4. List the four basic patterns of muscle tension dysphonia seen on transnasal fiberoptic laryngoscopy.
  5. Recognize that voice therapy is the main treatment for functional voice disorder.
  6. Appreciate the advantages of a multidisciplinary team, with a speech language pathology, psychologist/psychiatrist, and neurologist.
  7. List the five (now six) different types of functional voice disorders.

Anatomy

Learning Objectives 

The larynx is anatomically and physiologically normal

References 
  1. Koufman JA, Blalock PD. Classification and approach to patients with functional voice disorders. Ann Otol Rhinol Laryngol. 1982 Jul-Aug;91(4 Pt 1):372-7.

Pathogenesis

Learning Objectives 
  1. A functional voice disorder is the result of vocal misuse or abuse of an anatomically and physiological intact vocal apparatus
  2. A discrete precipitating event may be present, like an acute episode of viral laryngitis, vocal fold surgery, an event associated with “secondary gain”, conversion disorder, psychological/psychiatric condition
  3. more modern term for functional voice disorder is muscle tension dysphonia
References 
  1. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.

Incidence

Learning Objectives 
  1. Functional voice disorders are common. Functional voice disorders account for 40% of patients presenting to a multidisciplinary voice center.
  2. Functional voice disorders are more common in females than males
  3. Professional voice users are at risk for muscle tension dysphonia
  4. Continued cigarette smoking is correlated with a relatively poor outcome in functional voice disorders
References 
  1. Koufman JA, Isaacson G. The spectrum of vocal dysfunction. Otolaryngol Clin North Am. 1991;24(5):985-8
  2. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.

Patient Evaluation

Learning Objectives 
  1. When the voice is disproportionately poor compared to laryngeal findings, then a functional voice disorder should be suspected
  2. Five areas of evaluation include: 1. history, 2. laryngoscopic examination, 3. perceptual-acoustic assessment, 4. voice related palpable musculoskeletal features, and 5. psychological evaluation
References 
  1. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.
  2. Morrison MD; Nichol H; Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope. 1986; 96(1):1-8

Measurement of Functional Status

Learning Objectives 
  1. Self-reported quality of life indices like the Voice Handicap Index 10 can be used to measure functional status
  2. Auditory-perceptual assessment of voice can be measured with clinical tools like the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)
  3. The role of the voice laboratory (objective voice analysis) is limited by the fact that the vocal characteristics are not unique to functional voice disorders
References 
  1. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.
  2. The American Speech-Language-Hearing Association (2002-20006). Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) ASHA Special Interest Division 3, Voice and Voice Disorders. Accessed on May 15, 2018.
  3. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and Validation of the Voice Handicap Index- 10. Laryngoscope. 2004;114(9):1549-1556.

Imaging

Learning Objectives 
  1. Laryngeal examination with: mirror examination, transnasal fiberoptic laryngoscopy, videostroboscopy
  2. There are four basic patterns of muscle tension dysphonia seen on transnasal fiberoptic laryngoscopy:
    1. Type 1: Laryngeal isometric, in which the posterior glottal chink is open
    2. Type 2: False vocal cord closure
    3. Type 3: Partial AP contraction of the larynx
    4. Type 4: Complete sphincterlike closure of the larynx (arytenoid to petiole contraction)
References 
  1. Koufman JA. Approach to the patient with a voice disorder. Otolaryngol Clin North Am. 1991; 24(5):989-98.

Treatment

Learning Objectives 
  1. Voice therapy with a speech language pathologist is the main treatment. One large study reported that voice therapy was effective in 69% of patients. Patient motivation and compliance with speech therapy were main predictors of successful treatment.
  2. Multidisciplinary approach with a speech therapist, psychologist/psychiatrist, and neurologist is beneficial.
References 
  1. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.
  2. Koufman JA. Approach to the patient with a voice disorder. Otolaryngol Clin North Am. 1991;24(5):989-98
  3. Morrison MD; Nichol H; Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope. 1986;96(1):1-8
  4. Andrea M, Dias Ó, Andrea M, Figueira ML. Functional Voice Disorders: The Importance of the Psychologist in Clinical Voice Assessment. J Voice. 2017 Jul;31(4):507.e13-507.e22.

Rehabilitation

Learning Objectives 

Voice therapy with a speech language pathologist (see treatment section)

Staging

Learning Objectives 

Fives types of functional dysphonia were classically described:
Type 1, hysterical aphonia/dysphonia; type 2, habituated hoarseness; type 3, falsetto voice, type 4, vocal abuse; and type 5, postoperative dysphonia
A sixth type was later added: relapsing aphonia

References 
  1. Koufman JA, Blalock PD. Classification and approach to patients with functional voice disorders. Ann Otol Rhinol Laryngol. 1982 Jul-Aug;91(4 Pt 1):372-7.
  2. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.

Case Studies

  1. 21 year old woman presented with a sudden onset of loss of voice after an upper respiratory tract infection. Her mother had recently passed away from breast cancer and she had taken a year off college to care for her mother. Upon examination, she was aphonic. Videostroboscopy was unremarkable with an intact cough and swallow. She was treated with voice therapy and referred to a psychologist. Her voice made a full recovery.
  2. 27 year old female teacher presented with a gradual onset of hoarseness over the school year. She had a rowdy class that caused her a lot of stress. She was raising her voice to discipline her students. She was also a smoker. Upon examination, she had a harsh quality to her voice. Videostroboscopy showed muscle tension dysphonia and vocal fold nodules. She was treated with voice therapy. She was prescribed voice amplification and started using a microphone to teacher. She rested her voice over the summer and returned to teaching in September with a healthier voice.

Complications

Learning Objectives 

Functional dysphonia with prolonged aberrant vocal usage may lead to development of secondary pathological lesions of the larynx, like vocal nodules, polyps, or granulomas.

References 
  1. Koufman JA, Blalock PD. Classification and approach to patients with functional voice disorders. Ann Otol Rhinol Laryngol. 1982 Jul-Aug;91(4 Pt 1):372-7.

Review

Review Questions 
  1. Define the term “functional voice disorder”
  2. Describe typical characteristics of a patient with a functional voice disorder
  3. Discuss five areas of evaluation for a patient with a functional voice disorder
  4. List the four basic patterns of muscle tension dysphonia seen on transnasal fiberoptic laryngoscopy
  5. What is the main treatment for functional voice disorder?
  6. List the five or six different types of functional voice disorders
References 
  1. Koufman JA, Blalock PD. Classification and approach to patients with functional voice disorders. Ann Otol Rhinol Laryngol. 1982 Jul-Aug;91(4 Pt 1):372-7.
  2. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991 Oct;24(5):1059-73.
  3. Koufman JA, Isaacson G. The spectrum of vocal dysfunction. Otolaryngol Clin North Am.1991; 24(5):985-8.
  4. Morrison MD, Nichol H, Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope.1986; 96(1):1-8.
  5. The American Speech-Language-Hearing Association (2002-20006). Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) ASHA Special Interest Division 3, Voice and Voice Disorders. Accessed on May 15, 2018. 
  6. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and Validation of the Voice Handicap Index- 10. Laryngoscope. 114(9):1549-1556.
  7. Koufman JA. Approach to the patient with a voice disorder. Otolaryngol Clin North Am. 1991;24(5):989-98.
  8. Andrea M, Dias Ó, Andrea M, Figueira ML. Functional Voice Disorders: The Importance of the Psychologist in Clinical Voice Assessment. J Voice. 2016 Nov 18. pii: S0892-1997(16)30276-4. 
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