Vocal Cord Disorders

What Is It?

The vocal cords are two bands of elastic muscle tissue. They are located side by side in the voice box (larynx) just above the windpipe (trachea). Like other tissues in the body, vocal cords can be strained and damaged. Vocal cords are also subject to infections, tumors and trauma. 

When you are silent, the cords remain open. They create an airway through which you breathe.  

When you speak, the air you exhale from your lungs is forced through the closed vocal cords. This causes them to vibrate. They vibrate faster for higher-pitched sounds, slower for lower-pitched sounds. 

Strained vocal cords generally aren't noticed until the problem becomes severe. People who use their voices for a living or who shout or scream frequently are at particular risk. People who work in noisy environments that require shouting to communicate are also at risk.  

Common vocal cord disorders include:  

• Vocal cord nodules. These are small, hard, callus-like growths caused by vocal abuse. They occur in pairs, with one nodule on each vocal cord at the site of greatest irritation. They sometimes are called singer's, screamer's or teacher's nodules. 
• Vocal cord polyps. Polyps are small, soft growths that usually appear alone on a vocal cord. They are caused most often by vocal abuse or long-term exposure to irritants, such as chemical fumes or cigarette smoke.  
• Contact ulcers. This is a less common disorder. Contact ulcers are erosions and sores on the vocal cords. They tend to occur in people who consistently use great force when beginning to speak, instead of gradually increasing force and loudness. For example, contact ulcers may affect people who work as public speakers.  Ulcers also can be caused by gastroesophageal reflux disease (GERD), or heartburn. Reflux is when acidic stomach contents flow back up the esophagus and irritate the larynx.  
• Laryngitis. This is a swelling of the vocal cords caused by inflammation or infection. Swollen vocal cords vibrate differently than usual, changing the typical sound of your voice. You can lose your voice if the inflammation is so severe that you can't make a sound.  

Laryngitis can be caused by:

• Vocal abuse
• Allergies
• Viral infection
• Reflux of stomach acids
• Exposure to irritating substances, such as cigarette smoke or too much alcohol

• Vocal cord tumors. Tumors can be cancerous or noncancerous. Noncancerous tumors can be caused by a virus. Or they may be unusual growths of body tissue that cause voice problems. Cancerous tumors are most likely to occur in smokers and people who drink too much alcohol. Cancerous tumors are life threatening if not caught and treated early.  
• Vocal cord paresis and vocal cord paralysis. Vocal cord paresis occurs when one or both vocal cords don't open and close properly, changing voice quality. When one or both vocal cords don't move at all, this is called vocal cord paralysis. If both vocal cords are paralyzed and remain in the closed position, breathing can be difficult. 

Vocal cord paresis and paralysis can have several causes, including:

• • Surgical trauma, most often from thyroid surgery, but also from any neck or chest surgery
  • Head or neck trauma
  • Trauma during birth
  • A neurological disease (such as Parkinson's disease or multiple sclerosis)
  • Stroke
  • A tumor
  • A viral infection
  • Some debilitating diseases, such as myasthenia gravis

Paresis also can result from weakened vocal cord muscles. Vocal cord muscles can be weakened temporarily as a side effect of inhaled corticosteroid medicine sprays. They may also weaken after extended treatment with an artificial respirator (ventilator) in a hospital. 

Symptoms

Symptoms can vary, depending on the vocal cord disorder.

• Vocal cord nodules
  • Hoarseness
  • Low-pitched voice
  • Breathy voice
  • Singers may notice a loss of vocal range.
• Vocal cord polyps
  • Hoarseness
  • Low-pitched voice
  • Breathy voice
• Contact ulcers
  • Some throat pain while talking
  • Possible hoarseness
  • A voice that tires easily
• Laryngitis
  • A change in the sound of the voice, from hoarseness to croaking or complete loss of voice
  • If due to an infection:
    • Fever
    • Throat pain
    • Malaise
    • A feeling of having to clear your throat
• Vocal cord tumors
  • Hoarseness
  • With large tumors, possibly trouble breathing or swallowing
• Vocal cord paresis
  • Changes in the voice:
    • Hoarse
    • Breathy
    • Change of pitch
    • Unable to get louder
  • Discomfort from the strain of trying to move paralyzed cords
  • Possible breathing difficulties

Diagnosis

Your doctor will ask about your medical history. The doctor will listen to the quality of your voice and then inspect your vocal cords. This is usually done by holding a small mirror at the back of your mouth. To get a better view, the doctor may use a small, flexible lighted tube with a camera at the end. The tube is inserted through the nose to the larynx. 

You will need to make certain sounds so your doctor can see your vocal cords in action. The examination may be videotaped so your doctor can analyze it later. This is all that is needed to diagnose most cases of laryngitis, vocal cord nodules and polyps. 

In some cases, your doctor may recommend an acoustic analysis. This is a series of tests that measure the quality of your voice, including its pitch stability, range and intensity. Often, these tests are used when vocal cords are paralyzed or if a growth must be removed surgically. Using the test results, doctors and voice therapists can judge the amount of improvement after treatment.  

Cancer of the larynx can look similar to a noncancerous growth or a contact ulcer. If an abnormality is found on the vocal cords, your doctor may do a biopsy. A biopsy involves removing a tiny sample of the affected vocal cord tissue so it can be examined in a laboratory.  

Additional tests, such as a computed tomography (CT) scan or MRI, may be required in some cases.  

Expected Duration

• Vocal cord nodules – If you don't do anything to change your vocal cord abuse, nodules can last a lifetime. They can even come back after they are surgically removed. With proper voice training with a certified therapist, nodules can disappear within six to 12 weeks.  
• Vocal cord polyps – With rest, some vocal cord polyps will go away on their own within a few weeks. Most, however, have to be removed surgically.  
• Contact ulcers – It can take a long time for contact ulcers to heal. Some doctors recommend resting your voice for a minimum of six weeks. If the ulcers are caused by acid reflux, the reflux problem must be treated to keep your vocal cords healthy.  
• Laryngitis – Laryngitis caused by a viral infection usually goes away within one to three weeks. Laryngitis from vocal abuse usually goes away on its own in a few days with voice rest.  
• Vocal cord tumors – Noncancerous tumors generally do not go away. They must be removed surgically. Cancerous tumors must be treated immediately to prevent the cancer from spreading. Untreated cancer of the larynx leads to death.  
• Vocal cord paresis or paralysis – In some cases, the voice returns on its own within a year. If not, the condition is likely to be permanent. Surgery may be done to try to improve speech. 

Prevention

To help prevent disorders caused by vocal abuse (including laryngitis, vocal cord nodes and polyps, and contact ulcers), you need to learn how to talk without straining your vocal cords. A voice therapist can teach you how to do this. Look for a licensed and certified speech-language pathologist who specializes in voice. 

To prevent disorders related to acid reflux (including contact ulcers and laryngitis), see your doctor to treat the reflux. Medications can help to control stomach acid. Lifestyle changes also help some people. Changes include:  

• Eating smaller meals to avoid overfilling the stomach  
• Not eating or snacking three to four hours before sleeping to make sure all food is well digested before you lie flat 
• Raising the head of your bed a few inches to keep your head and upper chest higher than your stomach 
• Avoiding alcohol, caffeine, fatty foods, chocolate and peppermint, which may trigger heartburn 

To help prevent vocal cord disorders caused by irritation (including laryngitis and vocal cord polyps), avoid smoking, drinking or inhaling chemical irritants. To help prevent vocal cord cancer, quit smoking and limit your consumption of alcoholic beverages.  

If you use an inhaled corticosteroid medicine to treat asthma or other lung disease, you may be able to prevent vocal cord muscle weakness. Use a spacer device that catches large medicine droplets too heavy to be carried deep into your lung airways. These large droplets can otherwise settle in your throat and trachea, where they can cause side effects. 

If you have viral laryngitis, cover your mouth when coughing and wash your hands often to prevent others from getting your infection. 

Treatment

For vocal cord disorders resulting from vocal abuse, there are two main treatments:  

• For short-term relief, rest your voice. Speak or make sounds only when absolutely necessary. Try not to talk or whisper at all for a couple of days.  
• For long-term relief, voice therapy. Learn the proper way to speak to avoid straining your vocal cords. 

If rest and therapy don't resolve the disorder, other treatments are available. They are based on the type of disorder:

• Vocal cord nodules may require surgical removal.  
• Most vocal cord polyps require surgical removal.  
• A contact ulcer may require surgical removal if it does not go away on its own after a minimum of six weeks of voice rest. You also may need voice therapy and treatment for acid reflux.  
• Laryngitis caused by a virus needs rest and fluids. Antibiotics are not helpful to treat viral infections but may be recommended if a bacterial infection is suspected.  
• Vocal cord tumors require surgical removal if they are noncancerous. They generally will not return.  

Treating cancerous tumors depends on the extent of the cancer. In the early stages, radiation, chemotherapy, surgery to remove a portion of the larynx or a combination of treatments may be needed. Some voice will remain after these procedures.  

In later stages of cancer, the entire larynx, including the vocal cords, must be removed (laryngectomy). You will need to learn a new speech method, using a special valve inserted surgically between the trachea and the esophagus. This allows air to be sent up the esophagus, creating enough vibrations for understandable speech.  

• People with vocal cord paresis or paralysis may be able to learn how to speak in different ways through voice therapy.  

If improvement is not satisfactory, surgery may be recommended to change the position of the affected vocal cord. Surgery can also add bulk by injecting the vocal cord with collagen, body fat or some other substance.  

These types of procedures are recommended more often when one of the vocal cords is paralyzed. Both techniques bring the paralyzed cord closer to the cord that is not paralyzed. This allows the cords to vibrate enough to make sounds.  

For people with two paralyzed vocal cords, the goal of treatment is to improve breathing. The most common procedure is a tracheotomy. This procedure creates a hole in the neck below the level of the vocal cords. A breathing tube is placed into the hole.  

• Vocal cord muscle weakness due to inhaled corticosteroids may require a change in medicines. That is, if using a spacer device does not prevent symptoms.  

When To Call a Professional

See your doctor if you:

• Lose your voice for more than a few days
• Are hoarse for more than two weeks
• Have hoarseness accompanied by:
  • Difficulty swallowing
  • A lump in the throat
  • Unexplained pain
  • Coughing up blood

Prognosis

• Vocal cord nodules. Nodules can come back if vocal abuse continues. This is true whether they disappear with voice rest and voice therapy or are surgically removed.
• Vocal cord polyps. Polyps may be removed successfully with surgery. But they can return if you don't have voice therapy and don't stop inhaling irritating substances.
• Contact ulcers. With rest, treatment of reflux and retraining the voice, most contact ulcers go away without complications in weeks or months.
• Laryngitis. Most cases of laryngitis go away within a few days to a few weeks, depending on their cause.
• Vocal cord tumors. Noncancerous tumors usually do not return after they are surgically removed. You usually regain your normal voice.

Cancerous tumors can be very serious. The earlier they are detected and treated, the better the likelihood of survival and cure. Your voice may change dramatically, depending upon the extent of the cancer and the type of treatment.

• Vocal cord paresis. Many instances of vocal cord weakness improve over time. This may take many months.
• Vocal cord paralysis. Some cases go away within a year on their own. But many people require surgery to restore their voice, and many need voice therapy. With proper treatment, most people with one-sided vocal cord paralysis will regain good voice quality and control. People with two-sided vocal cord paralysis must relearn how to use their voices after they have had surgery to assist their breathing.

Additional Info

National Institute on Deafness and Other Communication Disorders
National Institutes of Health
https://www.nidcd.nih.gov/