Dr David Vokes: Voice Disorders, Dysphonia, Hoarseness and Conditions Treated

Phonation is the medical term for the production of the voice by the larynx (voicebox). Dysphonia is the medical term for disordered voicing or an abnormal voice. Most people describe their voice change using terms such as hoarseness, huskiness or raspiness. There are many varied vocal symptoms that people may experience, including:

  • A rough or raspy voice
  • A breathy or airy voice
  • A weak or quiet voice
  • A tight, strained or strangled voice
  • Effortful voicing
  • Poor vocal projection
  • Vocal fatigue
  • Voice or pitch breaks
  • Difficulty singing
  • Limited vocal range
  • Pain with voicing (odynophonia)

Dysphonia is important because of the significant impact it has on a person’s quality of life, their ability to interact with others, their ability to work, and because it may be the first sign of a serious underlying medical condition, such as a cancer of the throat, or even a chest problem.

Dysphonia is a common symptom in the general population and its prevalence does vary according to the vocal demands of each person. People who use their voice a great deal more than average for their occupation -such as teachers, singers, musicians, actors, the clergy, lawyers, doctors, salespeople and customer service representatives – are at increased risk of developing a voice disorder. Teachers are the occupational group most often diagnosed with a voice disorder. The prevalence of voice disorders in the general population is 6% in non-teachers, but 11% in teachers.  The prevalence of a voice disorder occurring at any time in a person’s lifetime is approximately 30% for non-teachers and 60% for teachers.

Any voice change that lasts for more than 3 weeks should be investigated with an examination of the larynx (voice box).

David is a Voice Specialist, expert in the diagnosis and treatment of voice disorders using the most current diagnostic technology such as videostroboscopy.

Videostroboscopy (or stroboscopy) is a specialised examination of the vocal folds using an endoscope placed through the nose or mouth to examine the larynx (voice box) with a strobe light. This special light source allows assessment of the vibration of the vocal folds. The video examination is recorded for detailed review and for patient education. The video examinations are stored for future reference to follow a patient’s progress.

David uses high definition Olympus videoendoscopes with a stroboscope in his consultation rooms in Remuera to assess the function of the vocal folds in detail, and has extensive experience in the interpretation of this examination.

For more information about specific voice disorders please click on a link below:

Care of the Singing Voice

Singing well requires a combination of optimal vocal technique and optimal physical health (both of the larynx and the rest of the body). As such, singers have specific needs when caring for their voice. Specialists looking after singing must consider a singer’s musical genre, their vocal style, their vocal workload, their singing training, and their general health.

There are a many varied vocal symptoms that singers may experience, and it is important to understand what a singer’s specific vocal concerns are. These symptoms may include:

  • A rough or raspy voice
  • A breathy or airy voice
  • A weak or quiet voice
  • A tight, strained or strangled voice
  • Effortful voicing
  • Poor vocal projection
  • Vocal fatigue
  • Voice or pitch breaks
  • Limited vocal range
  • Pain with voicing or singing

Dr Vokes is an expert in evaluating the structure and function of the larynx to ensure that a singer can perform at their desired level. He believes in an interdisciplinary approach to the care of the singer, working closely with vocal coaches, singing teachers, voice therapists and other medical specialists.

All videostroboscopic examinations of the larynx are recorded, and a copy of each examination is provided so that a singer has their own record of the examination for all members of the voice care team to consult at any time.

Transgender Voice Care

Transgender voice care, also referred to as gender affirming voice care, is available to help people when the sound of their voice does is not consistent with their gender identity. Transgender voice care starts with voice therapy and may include laryngeal surgery as well.

The initial stage of transgender voice care is usually led by a speech language therapists who specializes in voice therapy. For many people voice therapy is the only treatment required to help them achieve their vocal goals. However, for some people, it can be difficult to achieve their vocal goals, or they may be able to achieve their vocal goals but it is too effortful to maintain their goals, and so surgery to alter the pitch of the voice may be recommended to help improve the voice quality.

Depending on the desired outcome of the surgery, this surgery is called Vocal Feminization Surgery or Vocal Masculinization Surgery.

David is a Voice Surgeon experienced in Transgender Voice Care who works closely with Speech Language Therapy colleagues to help people achieve their vocal goals.

Vocal Fold Nodules

Vocal fold nodules, cysts and polyps are all benign (non-cancerous) vocal fold lesions that may occur as a result of injury to the vocal folds from prolonged and/or excessive voice use. The medical term for this is phonotrauma, and so these lesions are often referred to as phonotraumatic lesions. Each type of lesion is different, and requires specific treatment tailored to the individual. Treatment may be non-surgical – voice therapy – and/or surgical – excision or removal of the lesion(s).

Vocal Fold Nodules

Vocal fold nodules are swellings on both vocal folds due to prolonged and/or excessive voice use. These swellings are benign and are like blisters. Typically, the nodules occur at the midpoint of each vocal fold.  These swellings may get bigger and firmer with prolonged and/or repeated voice overuse. Similar to blisters, the swellings often disappear or reduce in size when the area is no longer irritated

What causes VF nodules?

VF nodules are common in people who have a high vocal load, such as teachers and singers, but can happen to anyone.

How do VF nodules affect my voice?

Voice is produced when the VFs come together and vibrate as air (that is breathed out by the lungs) passes between the VFs. VF nodules prevent the VFs from coming together completely. This results in a breathy and/or rough sounding voice that gets worse with prolonged voice use.

How are VF nodules treated?

Voice therapy is usually the first treatment offered. Voice therapy is a behavioural approach that helps you to use your voice in a safe and healthy way.  With voice therapy the swellings usually subside gradually. Voice therapy involves recommendations in looking after your voice and discussing techniques that are suited for your lifestyle and work. Surgery is an option if voice therapy is unsuccessful.

Vocal Fold Cysts

Vocal fold nodules, cysts and polyps are all benign (non-cancerous) vocal fold lesions that may occur as a result of injury to the vocal folds from prolonged and/or excessive voice use. The medical term for this is phonotrauma, and so these lesions are often referred to as phonotraumatic lesions. Each type of lesion is different, and requires specific treatment tailored to the individual. Treatment may be non-surgical – voice therapy – and/or surgical – excision or removal of the lesion(s).

Vocal Fold Cyst

A vocal fold cyst is a fluid-filled sac that develops just under the lining of the vocal fold and is buried within the vocal fold. It usually develops in only one vocal fold. 

What causes a vocal fold cyst?

The main cause of a vocal fold cyst is prolonged and/or excessive voice use. For example, talking loudly or shouting, talking for long periods of time, and/or severe coughing.  Vocal fold cysts may affect anyone – however they are more common in people who use their voice a great deal, such as teachers and singers.

How does a vocal fold cyst affect my voice?

Voice is produced when the vocal folds come together and vibrate as air (that is breathed out from the lungs) passes between the vocal folds. A vocal fold cyst prevents the vocal folds from coming together completely. This results in a voice that is hoarse. Your voice may sound rough, breathy or weak. A vocal fold cyst may also cause a sensation that there is something stuck in your throat that you cannot clear.

How is a vocal fold cyst treated?

A vocal fold cyst is usually treated with surgery. This operation is called a microlaryngoscopy where the vocal fold cyst is removed via the mouth and is carried out under general anaesthetic. A vocal fold cyst sometimes disappears without surgical treatment, although this is uncommon. A voice therapist (Speech-Language Therapist) will see you before and after surgery to give you advice on how to care for your voice and optimize the surgical outcome.

Does a vocal fold cyst come back after treatment?

Surgery to remove a vocal fold cyst is successful in most cases. Recurrence (or return) of a cyst is uncommon. Voice therapy reduces the likelihood of a new cyst developing.

Vocal Fold Polyps

Vocal fold nodules, cysts and polyps are all benign (non-cancerous) vocal fold lesions that may occur as a result of injury to the vocal folds from prolonged and/or excessive voice use. The medical term for this is phonotrauma, and so these lesions are often referred to as phonotraumatic lesions. Each type of lesion is different, and requires specific treatment tailored to the individual. Treatment may be non-surgical – voice therapy – and/or surgical – excision or removal of the lesion(s).

Vocal Fold Polyp

A vocal fold polyp is a solid mass that develops from just under the lining of the vocal fold and then protrudes from the lining of the vocal fold. It usually occurs in only one vocal fold. 

What causes a vocal fold polyp?

The main cause of a vocal fold polyp is prolonged and/or excessive voice use. For example, talking loudly or shouting, talking for long periods of time, and/or severe coughing. A vocal fold polyp may also arise from a single episode of voice overuse. A vocal fold polyp may affect anyone – however they are more common in people who use their voice a great deal, such as teachers and singers.

What does a vocal fold polyp do to my voice?

Voice is produced when the vocal folds come together and vibrate as air (that is breathed out from the lungs) passes between the vocal folds. A vocal fold polyp prevents the VFs from coming together completely. This results in a voice that sounds hoarse and gets worse with prolonged use. A vocal fold polyp may result in a feeling that there is something “stuck” in your throat that you cannot clear.

How is a vocal fold polyp treated?

A vocal fold polyp is usually treated with surgery. This operation is called a microlaryngoscopy where the vocal fold polyp is removed via the mouth and is carried out under general anaesthetic. A vocal fold polyp can sometimes disappear without surgical treatment, although this is uncommon. A voice therapist (Speech-Language Therapist) will see you before and after surgery to give you advice on how to care for your voice and optimize the surgical outcome.

Will I always have a vocal fold polyp?

Surgery to remove a vocal fold polyp is successful in most cases. Recurrence (or return) of a vocal fold polyp is uncommon. Voice therapy reduces the likelihood of a new vocal fold polyp developing.

Vocal Fold Paralysis (Unilateral)

Unilateral vocal fold paralysis is a condition in which one of the vocal folds does not move (also referred to as an immobile vocal fold). The vocal folds close when you voice or swallow. Paralysis of one vocal fold usually results in poor and/or incomplete closure of the vocal folds.

What causes Vocal Fold Paralysis?

The most common causes of unilateral vocal fold paralysis is injury to the recurrent laryngeal nerve (the nerve that controls movement of the vocal fold) from surgical procedures (such as thyroidectomy, cervical spinal surgery, cardiac surgery, lung surgery) or from intubation; viral inflammation of the nerve, referred to as a viral neuropathy; compression of the nerve by masses adjacent to the nerve; and neurological conditions.

How could Vocal Fold Paralysis affect me?

If you have one vocal fold that does not move you may experience vocal symptoms such as breathiness and/or weakness/quietness of the voice, fatigue of the voice with prolonged talking, and poor projection of the voice. Often people with paralysis of one vocal fold have difficulty swallowing, such as coughing or choking when swallowing (especially liquids).  Your neck and/or throat may also feel tired and may ache.

How is Vocal Fold Paralysis treated?

Vocal fold paralysis is treated by a Laryngologist (ENT Surgeon) and a Voice Therapist (Speech-Language Therapist). The Voice Therapist will teach you vocal techniques and will help you to optimise your voicing to improve how your voice sounds and feels. Surgery to augment the vocal fold is often necessary to improve closure of the vocal folds. Vocal fold augmentation is achieved either by injecting an absorbable filler for temporary augmentation, or by inserting permanent implants into the vocal fold.

Vocal Fold Paresis

Vocal fold paresis is a condition in which one or both of the vocal fold(s) is/are weak. The vocal folds close when you voice or swallow. Weakness of tone or both of the vocal fold(s) results in weaker closure of the vocal folds.

What causes Vocal Fold Paresis?

Common causes are injury to the nerve(s) to the vocal folds from surgical procedures (such as thyroidectomy, cervical spinal surgery, cardiac surgery, lung surgery) or from intubation; viral inflammation of the nerve(s), referred to as a viral neuropathy; compression of the nerve(s) by masses adjacent to the nerve(s); and neurological conditions.

How could Vocal Fold Paresis affect me?

If you have a weak vocal fold (or if both are weak) you may experience vocal symptoms such as fatigue of the voice with prolonged talking, reduced projection of the voice, quietness of the voice or an inability to sing. Occasionally people with weakness of the vocal fold(s) may have difficulty swallowing, such as coughing or choking when swallowing (especially liquids).  Your neck and/or throat may also feel tired and may ache.

How is Vocal Fold Paresis treated?

Vocal fold paresis is treated by a Laryngologist (ENT Surgeon) and a Voice Therapist (Speech-Language Therapist). The Voice Therapist will teach you vocal techniques and will help you to optimise your voicing to improve how your voice sounds and feels. Surgery to augment the vocal fold(s) may be recommended to improve closure of the vocal folds. Vocal fold augmentation is achieved either by injecting an absorbable filler for temporary augmentation, or by inserting permanent implants into the vocal fold(s).

Vocal Fold Atrophy

What is VF Atrophy?

Vocal fold (VF) atrophy is a condition in which the VF(s) lose their bulk and become thin. VF atrophy is also known as VF bowing. The VFs close when you voice or swallow. Atrophy of the VF(s) results in weaker closure of the VFs.

What causes VF Atrophy?

Common causes are thinning secondary to ageing, or secondary to medications, such as steroid inhalers for asthma.

How could VF Atrophy affect me?

If you have thin VF(s) you may experience vocal symptoms such as fatigue of the voice with prolonged talking, reduced projection of the voice, quietness of the voice or an inability to sing. Occasionally people with thinning of the VF(s) may have difficulty swallowing, such as coughing or choking when swallowing (especially liquids).  Your neck and/or throat may also feel tired and may ache.

How is VF Atrophy treated?

VF atrophy is treated by a Laryngologist (ENT Surgeon) and a Voice Therapist (Speech-Language Therapist). The Voice Therapist will teach you vocal techniques and will help you to optimise your voicing to improve how your voice sounds and feels. Surgery to augment the VF(s) may be recommended to improve closure of the VFs. VF augmentation is achieved either by injecting an absorbable filler for temporary augmentation, or by inserting permanent implants into the VF(s).  

Laryngeal papillomatosis

What is Laryngeal Papillomatosis?

Laryngeal papillomatosis is a condition in which there are single or multiple lumps or masses on the vocal fold(s), and often in the other parts of the larynx, caused by a viral infection. These masses, called papillomata, are essentially warts that grow on the lining of the larynx.

Laryngeal papillomatosis is often referred to as Recurrent Respiratory Papillomatosis (RRP), because these masses may occur anywhere in the airway, from the nose to the lungs. The larynx is the part of the airway most commonly affected.

This is a rare condition and it has become even less common in recent years since the introduction of vaccines that are protective against HPV infection, such as Gardasil.

What causes Laryngeal papillomatosis?

Laryngeal papillomatosis is caused by infection of the larynx with one of two subtypes of the Human papilloma virus (HPV): subtypes 6 (most commonly) and 11.

How could Laryngeal papillomatosis affect me?

The most common problem that develops as a result of Laryngeal papillomatosis is an abnormal voice. In children the papillomata may cause other symptoms such as shortness of breath, noisy breathing and difficulty swallowing.

How is Laryngeal papillomatosis treated?

At this time, Laryngeal papillomatosis cannot be cured. The goal of treatment is to improve the voice (and to improve breathing and swallowing if they are affected.)

Surgery is the main treatment. The aim of surgery is to reduce the burden of papillomata on the vocal folds (and in other parts of the larynx). The most commonly surgical technique used to reduce the papilloma burden is the laser, and the most commonly used lasers (such as the TruBlue Laser) target the blood vessels in the papillomata. Medications are sometimes used in addition to surgery to enhance the effects of surgery. The most commonly used medication with activity against papillomata is Bevacizumab (also known as Avastin), which is usually injected into the larynx. For severe cases of Laryngeal papillomatosis Bevacizumab may be injected into the blood stream to avoid surgical procedures. Vaccination with the Gardasil vaccine may also boost the immune system’s response to Laryngeal papillomatosis and should be considered for every person with Laryngeal papillomatosis, whatever their age. 

Reinke’s Oedema

Reinke’s oedema is a collection of gelatinous fluid in Reinke’s space. This space is just under the surface of the vocal fold in the larynx (voice box). 

What causes Reinke’s Oedema?

The most common cause of Reinke’s oedema is smoking. Other causes include voice overuse, reflux, hormonal changes and thyroid disease. Reinke’s oedema does not go away on its own and will likely reoccur if smoking is not stopped.

How does Reinke’s Oedema affect my voice?

Voice is produced when the vocal folds come together and vibrate as air (that is breathed out from the lungs) passes between the vocal folds.  The oedema in the superficial layer of the vocal folds causes swelling and this prevents the vocal folds from coming together smoothly. This results in a voice that is deep in pitch and has a rough quality. The deep pitch to the voice is very noticeable in women.

How is Reinke’s Oedema treated?

The cause of the oedema needs to be corrected before specific treatment is indicated. This means stopping smoking and treating any reflux or hormonal conditions. Specific treatment includes voice therapy and surgery. The oedema can be removed surgically in a procedure called a microlaryngoscopy and this is carried out under general anaesthetic. Voice therapy will take place before and/or any surgery to give you advice on how to care for your voice.

Does Reinke’s Oedema come back after treatment?

Preventing the recurrence of Reinke’s oedema depends on correcting the underlying causes, effective voice therapy and successful initial surgery.

Laryngeal Cancer

A diverse group of cancers may affect the larynx (voice box), however more than 90% of laryngeal cancers are squamous cell carcinomas, which arise from the lining of the larynx.  Fortunately, laryngeal cancer is an uncommon cancer in New Zealand, because the prevalence of smoking has decreased in recent decades. Alcohol is the other major risk factor for laryngeal cancer.

The most common symptoms of laryngeal cancer include abnormal or difficult voicing (dysphonia), restriction of breathing leading to stridor (noisy breathing) and/or shortness of breath, and difficulty swallowing. Less common symptoms include a lump in the neck and ear pain.

Laryngeal cancer affecting the vocal cords (or glottis) is the most common type of laryngeal cancer in New Zealand, and is often detected early, as voice change occurs early in the course of this illness. If diagnosed and treated at an early stage, the prognosis for people with laryngeal cancer is excellent.

Treatment involves either surgery or radiation therapy alone for early stage laryngeal cancer, or a combination of these treatments for advanced laryngeal cancer.  The treatments may have an adverse impact on voice quality, swallowing, and breathing.  In recent decades, major efforts have been made to develop treatments to preserve the structure and function of the larynx using minimally invasive laryngeal surgery, radiotherapy, and chemoradiotherapy.

Voice Evaluation

Voice disorders can have a huge impact on the quality of your life. Communication with your family and friends may be difficult. Your livelihood may be jeopardised if you rely on your voice for your work. Your voice change may be the first sign of a serious underlying medical condition.

If you have any voice change that lasts for more than 3 weeks, you should be evaluated with an examination of your voice box.

The evaluation of a voice disorder begins with a thorough history to explore the concerns that a person has about their voice, and to discover their lifestyle and their vocal demands. A full understanding of a person’s medical history is also important. The voice is examined firstly by listening to the voice (perceptual evaluation) and then by visualizing the vocal cords (or vocal folds) within the larynx (voice box). Videostroboscopy (or stroboscopy) is the specialised examination of the vocal folds using an endoscope placed through the nose or mouth to examine the larynx (voice box) and the vocal folds with both a normal light and a strobe light. The strobe light source allows detailed assessment of the vibration and closure of the vocal folds. The examination is recorded and then reviewed by David with the person undergoing the examination to enhance their understanding of both the diagnosis and the treatment of their condition. These video examinations are archived to follow a person’s progress. David uses high-definition Olympus videoendoscopes and stroboscopy in his office in Remuera to assess the function of the vocal folds in detail and has extensive experience in the interpretation of this examination.
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