Frequently asked questions:

What is hoarseness?
What are the causes of hoarseness?
How is hoarseness evaluated?
When should I see a otolaryngologist or laryngologist for hoarseness?
How is hoarseness treated?
How can voice disorders be prevented?
What are symptoms of swallowing disorders?
How does swallowing normally occur?
How are swallowing disorders diagnosed?
How are swallowing disorders treated?

Dr. Feinberg in the Media

Dr. Feinberg discusses Aging and Voice Problems


Dr. Feinberg discusses Swollen Glands


Dr. Feinberg discusses Swallowing Disorders



Dr. Feinberg on Swallowing Disorders
Dr. Feinberg on Laryngitis



What is hoarseness?  back to top

Hoarseness is a change in the vocal quality. A hoarse voice can be described as strained, rough, breathy, raspy, or froggy, gravelly, strangled, squeaky, or irregular. Hoarseness can also describe an alteration of the pitch of the voice, either too high or too low, or alterations in the loudness of the voice. Because the voice is produced by vibration of the vocal cords and resonance in the throat, nose, and face, hoarseness results from disorders affecting these structures.

The voice is created by bringing the vocal cords together (vocal cord adduction) and by forceful exhalation of air. This results in vibration of the vocal cords, creating sound energy. The sound energy is shaped into the human voice by the airway above the vocal cords (the vocal tract.) Problems involving the vocal tract can also cause disorders of resonance (nasal sounding voice, muffled voice, articulation disorders, shaky or tremulous voice.)

Symptoms of hoarseness include:

  • Vocal fatigue
  • Delayed voice initiation
  • Froggy voice
  • Unreliable or irregular voice
  • Gravelly voice
  • Low or high pitch voice
  • Breathy or airy voice
  • Voice Breaks
  • Cough or throat clearing
  • Increased vocal effort
  • Loss of upper register when speaking or singing

What are the causes of hoarseness?  back to top

A variety of disorders of the vocal cords result in hoarseness. These include:

Acute laryngitis: Swelling or inflammation of the vocal cords can occur due to infections caused by bacteria, viruses, or fungi. Acute laryngitis lasts for less than 4 weeks and is usually self-limited. The swollen and inflamed vocal cords are unable to vibrate normally, leading to vocal strain, hoarseness, and sometimes complete loss of the voice (aphonia).

Chronic laryngitis: Swelling or inflammation of the vocal cords can extend beyond a 4 week period, leading to prolonged periods of hoarseness. The surface of the vocal cord can become thickened, and the blood vessels under the surface of the vocal cord can become engorged. Overuse or misuse of the voice usually accompanies chronic laryngitis, and so can non-cancerous vocal cord growths including vocal nodules, polyps, granulomas, and cysts.

Aging of the voice (presbyphonia): Changes in the voice occur during the course of our lifetimes. During childhood and adolescence dramatic changes occur in the larynx, as the structure of the vocal cords mature. During development, the location of the larynx descends from high in the neck in a newborn to the lower neck by adulthood. By the late teen years, the larynx achieves maturity.

Later in life, the vocal cords begin to change, with loss of bulk (atrophy) of the vocal muscles and stiffening of the vocal cord cover. The laryngeal cartilages calcify and stiffen. There is loss of mucus glands with drying of the larynx. In addition, the respiratory mechanism changes as the rib cartilages calcify and lose compliance. Finally, there can be tremor resulting from the loss of fine coordination of the vocal cord muscles. The cumulative changes with aging vary from person to person, and are generally referred to as presbyphonia (aging of the voice).

Characteristic changes with aging include:

  • Higher pitch in men
  • Lower pitch in women
  • Decreased projection of the voice
  • Decreased vocal stamina
  • Shakiness or tremor of the voice
  • Increased difficulty with communication, amplified by hearing loss in one’s peers

Aging of the voice relates less to chronological age and more to physiologic age. Hoarseness in the elderly is often unrelated to aging, and needs to be investigated similar to in younger patients.

Benign vocal cord growths: Overuse of the voice over a short or long period of time can result in abnormal growths on the vocal cords.

  • Vocal nodules are calluses on the edge of both vocal cords just beneath the surface. They generally occur at the mid-portion of the vocal cord, and are symmetric on both sides. They occur primarily in vocal overdoers – people who overuse their voice. These include singers, teachers, attorneys, cheerleaders, and extroverts.
  • Vocal cord polyps also occur in the middle of the vocal cord, but unlike vocal nodules they are usually centered on only one of the vocal cords. There can be a reactive nodule or depression (vocal cord sulcus) on the other vocal cord due to trauma from the polyp. Vocal cord polyps result from trauma to the blood vessels beneath the surface of the vocal cord, and they can vary in size and appearance.
  • Vocal cord cysts are non-cancerous growths filled with skin or with mucous, occurring under the surface of the vocal cord. They can be present from birth (congenital vocal cord cyst) or acquired. Acquired cysts occur due to overuse of the vocal cords (phonotrauma) or due to obstruction of mucus glands on the undersurface of the vocal cord.

Laryngeal Papilloma: Papillomatosis is a disorder affecting children and adults exposed to certain strains of the human papilloma virus. Growths can occur throughout the larynx, as well as in the nose, trachea, and lungs. The growths can lead to hoarseness and obstruction of the airway. The growths tend to recur after excision. Rarely papilloma can undergo cancerous changes over time. Prevention is difficult, although human papilloma virus vaccines administered to children and adolescents prior to exposure may decrease the number of children and adults affected over time.

Acid reflux: Gastroesophageal reflux (GERD) and laryngopharyngeal reflux (LPR) are disorders caused by exposure of the esophageal and laryngeal tissues to acid produced in the stomach. Symptoms include heartburn, regurgitation, throat burning, throat pain, throat clearing, chronic cough, sensation of a lump in the throat, difficulty swallowing, and hoarseness. The tissues of the larynx and throat are more sensitive to stomach acid than the esophagus (swallowing tube) so one can have damage to the larynx without damage to the esophagus.

Medications and the Voice: Prescription, over-the-counter, and herbal supplements can affect the voice. For patients suffering from voice disorders, the benefits of a medication must be weighed against the risk of dysphonia (hoarseness).

Medications affect the voice through different mechanisms. These include:

  • Drying of the mucus membranes: Adequate mucus is necessary for a healthy voice. If the mucus becomes dry or overly thick the voice can become hoarse.
    • Examples include:
      • Antidepressants
      • Muscle relaxants
      • Diuretics (water pills)
      • Antihypertensives (blood pressure medications)
      • Antihistamines (allergy medications)
  • Medications causing fluid retention, or swelling of the vocal cords
    • Examples include:
      • Estrogen replacement therapy
      • Oral contraceptives (birth control pills)
      • Inadequate thyroid hormone replacement
  • Medications increasing the risk of bleeding (vocal hemorrhage – see below)
    • Examples include:
      • Anticoagulants (blood thinners)
      • Herbal medications (for example, vitamin E, Garlic, Ginkgo biloba)
  • Medications increasing laryngeal sensitivity and causing cough or throat clearing
    • Examples include:
      • Angiotensin-converting-enzyme inhibitors
  • Medications causing fungal infection
    • Examples include:
      • Inhaled corticosteroids (asthma medications)
      • Antiobiotics

Vocal hemorrhage: Rupture of blood vessels just beneath the surface of the vocal cord can occur in response to loud yelling, cheering, singing, or forcefully coughing. This can lead to sudden bleeding within the vocal cord and loss of the voice. Vocal hemorrhage is considered a vocal emergency requiring voice rest until resolution occurs. The presence of blood in the vocal cord can lead to inflammation, scar formation, vocal cord polyp formation, and risk of persistent hoarseness.

Vocal cord cancer (glottic cancer, laryngeal cancer, voice box cancer, laryngeal carcinoma) is usually but not always associated with smoking. Cancerous growths can occur on, above, or below the vocal cords. For cancers of the vocal cords the first symptom is typically hoarseness. Additional symptoms can include difficulty swallowing, throat or ear pain, shortness of breath, and a neck mass. There are many types of cancers that can affect the larynx, but by far the majority is squamous cell carcinoma. There are approximately 12,000 new cases of vocal cord cancer diagnosed each year in the United States.

Precancerous vocal cord disorders: Prior to becoming vocal cord cancer, the epithelium of the vocal cord (i.e. skin) undergoes a sequence of precancerous changes. These changes are referred to as vocal cord dysplasia, vocal cord keratosis, vocal cord leukoplakia, or vocal cord erythroplasia. Depending on the degree of severity, precancerous changes of the vocal cords are considered mild, moderate, or severe. Severe dysplasia is also referred to as carcinoma-in-situ.

Smoking: Smoking is a common cause of hoarseness, and smoke causes inflammation and irritation to the vocal cords and larynx. In addition to causing cancer and precancerous disorders of the vocal cords, smoking can lead to swelling of the vocal cords, polyp formation, and a deep and rough vocal quality. Because of the higher risk of developing laryngeal cancer, smokers should be evaluated without delay for hoarseness.

Neurologic diseases: A large number of neurologic disorders can affect the vocal cords and cause hoarseness. These include stroke, Parkinson’s disease, myasthenia gravis, multiple sclerosis, ALS and other motor neuron disorders, and spasmodic dysphonia (laryngeal dystonia).

Spasmodic dysphonia: Spasmodic dysphonia is a neurologic voice disorder, resulting in vocal cord spasm. Abnormal muscular contractions affect the muscles that close (adduct) or open (abduct) the vocal cords, causing the voice to have a strained, strangled, or breathy quality. Spasmodic dysphonia causes intermittent excessive closing of the vocal cords during vowel sounds (adductor spasmodic dysphonia) or intermittent excessive opening during voiceless consonants (abductor spasmodic dysphonia). Adductor spasmodic dysphonia results in a strained and strangled voice, while abductor spasmodic dysphonia results in a breathy voice. Mixed spasmodic dysphonia has characteristics of both types (adductor and abductor).

Vocal cord paralysis can affect one or both vocal cords, resulting in a breathy and weak voice. Vocal cord paralysis can result from surgery, intubation, cancer in the neck and chest, trauma, viral infections, and a variety of other causes.

Voice misuse: there are efficient and inefficient ways of using the voice. Excessive tension in the neck, laryngeal, abdominal, and throat muscles can lead to hoarseness and inefficient voice production. Poor breathing techniques can lead to discomfort with phonation, vocal fatigue, and an increased risk of developing benign vocal cord lesions (vocal cord polyp or vocal nodules). Some disorders of vocal misuse are associated with stress or psychiatric illness.

How is Hoarseness Evaluated?  back to top

Hoarseness of short duration (associated with a respiratory infection, common cold, or flu) may be evaluated by a primary care physician specializing in internal medicine, family practice, or pediatrics. When hoarseness persists beyond several weeks, it is best evaluated by an otolaryngologist (ear, nose and throat specialist) or laryngologist (an ear, nose and throat specialist that focuses primarily on voice disorders). A voice care team consists of an otolaryngologist or laryngologist, speech and language pathologist, and singing or acting voice specialists. A voice center is a facility that offers specialized equipment for recording the voice, imaging the vocal cords, and treating patients with voice disorders.

During an evaluation, the following information is gathered:

Medical History: The first step in the evaluation of hoarseness is to obtain a thorough history. Important information includes the duration of hoarseness, quality of the voice, timing of hoarseness, associated symptoms including difficulty swallowing, pain with speaking or swallowing, and alleviating factors. Additional important information includes occupation, vocal demands, current or former history of smoking, alcohol intake, dietary history, and medications.

Physical Examination: Evaluation of hoarseness includes a thorough examination or the ears, nose, throat, and neck. Critical to the evaluation of hoarseness is laryngoscopy. This can be performed in a number of ways.

  • Mirror laryngoscopy (indirect laryngoscopy) – The physician uses a dental mirror to view the vocal folds. This is sometimes limited by factors such as a large tongue or the gag reflux.
  • Flexible laryngoscopy – a flexible narrow tube is passed through the nostril and into the throat, and the vocal folds are visualized. The laryngoscope can be coupled with a video camera to record the exam. Flexible laryngoscopy allows visualization of the vocal cords during speech or singing, and allows assessment of the nasal cavities, nasopharynx (back of the nose), oropharynx, larynx, and hypopharynx (lower throat).
  • Rigid laryngoscopy – a rigid laryngoscope is a metal rod with an angled camera on the tip, which is placed into the mouth. The angled camera allows the vocal cords to be visualized, and provides a magnified image. The laryngoscope can be coupled with a video camera to record the examination.
  • Laryngeal video-stroboscopy – a flashing light is used to illuminate the vocal cords and is synchronized with the frequency at which the vocal cords vibrate. This provides a virtual slow motion image of the vocal cords vibrating. Both flexible laryngoscopes and rigid laryngoscopes can be coupled with a strobe light, and typically the examination is recorded on a computer or in older systems on a video tape. Subtle abnormalities can be diagnosed with videostroboscopy that are not evident to the naked eye.
  • High speed imaging – a special camera is used to record the rapid vibration of the vocal folds, providing a real-time image of the vocal cord vibration not visible to the naked eye. At the present time, most high speed cameras are used in research rather than in the clinical setting, but may become more widely utilized in the future. Certain vocal cord pathologies are not well visualized with stroboscopy, but can be evaluated with high speed imaging.
  • Voice evaluation – a variety of tools are available to measure the voice, including perceptual voice measures, computerized voice analysis software, and specialized equipment to measure airflow through the vocal cords. Detection of vocal irregularities can help in the diagnosis and treatment of voice disorders, as well as to monitor progress with vocal cord surgery or voice therapy.

When Should I see an Otolaryngologist or Laryngologist for Hoarseness?    back to top

You should see an otolaryngologist or laryngologist if:

  • Hoarseness persists beyond 3 weeks
  • You are a smoker with hoarseness
  • You have associated difficulty swallowing
  • You feel a lump in your throat
  • You experience pain when swallowing or speaking
  • You are coughing or spitting up blood
  • You are a singer or professional voice user
  • Hoarseness is associated with difficulty breathing or shortness of breath

How is hoarseness treated?  back to top

The treatment of hoarseness varies depending on the cause. Treatments for voice disorders include:

  • Voice rest and behavioral modification
  • Speech therapy
  • Hydration
  • Acid reflux management
  • Management of associated medical disorders
  • Medications and modification of existing medications
  • Surgery

The treatment of selected voice disorders are listed below:

  • Benign Vocal Cord Lesions:
    • Vocal Nodules: Vocal nodules are calluses that form in the middle of the vocal cords, bilaterally. They are caused by overuse or misuse of the vocal cords. Sufferers include vocal overdoers (extroverts, singers, cheerleaders, teachers, salespeople, etc.) Treatment options include voice therapy to eliminate vocal trauma leading to nodule formation, voice rest, and surgery. Voice therapy is an integral part of the treatment for nodules, and can be curative as a standalone treatment. It is also used to prevent recurrence after surgery. Vocal nodules are highly treatable.
    • Vocal Cord Polyps: Vocal cord polyps also result from vocal fold overuse and misuse. Polyps also occur in the middle of the vocal cord, usually unilaterally but occasionally bilaterally. Polyps vary in size and consistency. Very small polyps may resolve with voice therapy, but most polyps require microsurgical excision. Over time, polyps can cause damage to the opposite vocal cord either in the form of a reactive nodule or as a depression (sulcus).
    • Vocal Cord Cysts: Vocal cord cysts are encapsulated (contained within a sac) collections of mucus or skin deep to the surface of the vocal cord. The can be acquired or congenital (the patient is born with the cyst). The presence of a cyst impairs the normal vibration of the vocal cord and leads to hoarseness. Treatment consists of microsurgical excision. Cyst excision is a technically challenging operation and is best performed by a skilled and experienced voice surgeon. Recurrence can occur if the cyst is not removed completely. Depending on the location and size of the cyst, there may be some residual hoarseness present after excision. Preoperative laryngeal videostroboscopy is helpful in predicting the postoperative vocal outcome.
    • Laryngeal papilloma:Laryngeal papilloma is caused by the human papilloma virus. Growths can occur on, above, and below the vocal cords. Growths on the vocal cords lead to hoarseness by preventing normal closure and vibration of the vocal cords

Treatment for laryngeal papilloma consists of phonomicrosurgery, removing the growths while preserving the normal surrounding vocal cord tissues. Surgery can be facilitated with angiolytic lasers (pulsed KTP laser, pulsed dye laser) or surgical shaving devices (microdebriders). Some surgeons prefer to use a carbon dioxide laser. Following surgery, it is common to experience recurrence of disease in the larynx, and many patients require surgery every several months.

Pulsed angiolytic lasers allow office-based excision of laryngeal papilloma without sedation. Office-based treatment eliminates the need for repeated general anesthetics for patients with frequent recurrence of disease. This treatment is offered at specialized centers around the country, including the Hoag Voice and Swallowing Center in Newport Beach, California.

A number of adjuvant treatments are used to minimize recurrence of laryngeal papilloma. These include intralesional injection of cidofovir, Avastin, mumps vaccine, and oral medications including indole-3-carbinol and artemisinin. Small reports exist describing the efficacy of these medications.

While laryngeal papilloma is a benign disorder, in rare cases papilloma can lead to pre-cancerous and cancerous changes of the larynx. In addition, certain strains of the human papilloma virus cause oropharyngeal (tonsil, tongue base) cancer, although these strains differ from those that cause papilloma.

  • Cancerous and precancerous vocal cord growths
    • Laryngeal dysplasia: laryngeal cancer is preceded by precancerous changes of the vocal cords and laryngeal tissues. Precancerous changes cause hoarseness of varying severity depending on the extent and location of dysplasia. The normal epithelium (skin) of the vocal cord is transparent. When the skin loses its transparency it can take on a white appearance, sometimes referred to as keratosis or leukoplakia. In other cases, the skin can appear red, commonly referred to as erythroplasia. Diagnosis is confirmed with biopsy, as it is difficult to visually differentiate early glottic cancer (vocal cord cancer) from dysplasia.

Treatment of laryngeal dysplasia is primarily surgical. A variety of lasers can be used to facilitate excision. The pulsed angiolytic lasers (pulsed KTP, pulsed dye) lasers are particularly helpful and can be used either in the operating room or in the office setting to treat dysplasia of the vocal cords. The key to treatment is preservation of the soft portions (superficial lamina propria) of the vocal cord beneath the epithelium (skin). The precancerous lesions frequently recur and can require regular treatments to prevent progression to laryngeal cancer. For patients with frequent recurrence unsedated office-based laser surgery provides a significant convenience over repeated general anesthetics.

    • Laryngeal cancer: treatment of laryngeal cancer varies depending on the stage of the cancer (determined by the size, location, and extent of disease within the neck), age of the patient, comorbidities, and other factors. In general, the goal of treatment is cure of cancer while preserving the primary functions of the larynx (voice, swallowing, and breathing). Options include surgery, radiation, chemotherapy, and combinations of the three treatments.

Early laryngeal cancer: Surgical treatment is preferred over radiation therapy in most cases of early laryngeal cancer (T1 and T2). Depending on the extent of disease, similar voice preservation and cure rates can be achieved with either surgery or radiation.

Surgery has several advantages over radiation therapy in the treatment of early laryngeal cancer. Surgery preserves the normal tissue integrity within the larynx while radiation leads to scarring, atrophy, loss of mucus glands, and can lead to secondary cancers many years after treatment. In addition, radiation therapy can lead to early or delayed onset dysphagia (difficulty swallowing) which is very challenging to treat. In most cases, radiation therapy is a one-time treatment, meaning that recurrence of cancer will require surgical treatment. Surgery in a previously irradiated field is challenging, and outcomes are poor. The duration of treatment is much shorter for surgery, and the recovery is much faster. Finally, the cost of surgery is considerably less than radiation therapy.

In some patients with early glottic cancer radiation therapy is preferable over surgery. These include poor surgical candidates with comorbidities that preclude anesthesia. In addition, when cancerous changes occur diffusely throughout the larynx radiation therapy can lead to better tissue preservation compared with surgery.

Advanced stage laryngeal cancer: Advanced stage tumors of the larynx (T3) can be treated with surgery, radiation therapy, and chemotherapy. Radiation with or without chemotherapy can be used for “organ preservation”, although many patients require laryngectomy for treatment failure. In addition, the risk of lifelong voice and swallowing disability after radiation with or without chemotherapy is very high.

The most advanced cancers of the larynx (T4) invade through the laryngeal cartilages and are not well controlled with radiation therapy and chemotherapy alone. Treatment often requires a combination of surgery and radiotherapy.

  • Neurologic disorders
    • Vocal Cord Paralysis – Paralysis occurs due to dysfunction or injury of the recurrent laryngeal nerve, the nerve primarily responsible for vocal cord movement. This can happen unilaterally or bilaterally (one or both nerves and vocal cords are affected). Partial paralysis is referred to as paresis.
    • Symptoms of unilateral vocal cord paralysis include:
      • Hoarseness
      • Breathiness
      • Effortful phonation
      • Air wasting (excessive air pressure is required to produce a normal conversational voice
      • Diplophonia (sounds like 2 sounds being produced at once – caused by differential tension between the normal and paralyzed vocal cord)
      • Difficulty swallowing – typically manifests as coughing with liquids, saliva, and food. Food and mucus can stick in the throat.
    • Symptoms of bilateral vocal cord paralysis include:
      • Airway problems – shortness of breath with exertion, noisy breathing (stridor), or weak cough
      • Normal to breathy voice (the voice can vary considerably depending on the position of the paralyzed vocal cords)
      • Difficulty swallowing – typically manifests as coughing with liquids, saliva, and food. Food can mucus can stick in the throat
    • Injury to the recurrent laryngeal nerve can occur from multiple mechanisms. These include:
      • Stretching or transection of the nerve during surgery in the skullbase, neck, or chest
      • Trauma to the neck or chest
      • Intubation (breathing tube placement) during surgery or intensive care unit stay
      • Cancer invading the recurrent laryngeal nerve or vagus nerve in the skullbase, neck, or chest
      • Nerve stretching from an aortic aneurysm
      • Viral infections involving the nerve

Vocal cord paralysis can occur at any age, from childhood to the adulthood. Treatment varies based on the duration of the paralysis, the voice and swallowing disability of the patient, age and comorbidities of the patient, mechanism of the paralysis, configuration of the larynx and paralyzed vocal cord, and surgeon and patient preference.

  • Options for unilateral vocal cord paralysis include:
    • Injection laryngoplasty – a variety of materials are available to augment (fatten) the paralyzed vocal cord, allowing the non-paralyzed vocal cord to more easily meet the paralyzed cord. Most of these materials are temporary, and last from weeks to 2 years in duration. Commonly used medialization materials include Radiesse voice, Restylane, Collagen, Juvederm, fat, Cymetra. In the past Teflon was commonly used.
    • Medialization laryngoplasty (thyroplasty) – an implant is used to medialize (push toward the midline) the paralyzed vocal cord. This is a permanent procedure, allowing the non-paralyzed vocal cord to more easily compensate for the paralyzed vocal cord. Gore-Tex, silastic, or pre-made implants are commonly used. Medialization can be combined with surgery to reposition the arytenoid (the cartilage behind the vocal cord). Arytenoid adduction and adduction arytenopexy are two types of surgery for arytenoid repositioning.
    • Laryngeal reinnervation – the recurrent laryngeal nerve can be connected to a different nerve (typically the ansa cervicalis nerve) and sewed together using microvascular techniques. Over months to a year the new nerve connection develops and provides improved tone to the paralzed vocal cord. This technique does not result in purposeful motion of the paralyzed vocal cord.
    • Voice therapy – In some cases voice therapy can be helpful, usually as an adjunct the other techniques, to provide improved vocal efficiency in patients suffering from vocal cord paralyisis.
  • Spasmodic dysphonia: As mentioned above, spasmodic dysphonia is a neurologic voice disorder resulting in involuntary vocal cord spasm. Treatment for spasmodic dysphonia is designed to lessen the symptoms of vocal spasm and improve the quality of the person’s voice. Therapies are symptomatic, but not curative of the underlying neurologic disorder
    • Botox injection: Botulinum toxin is an effective treatment in the management of spasmodic dysphonia. Botox is injected into the vocal muscles using special equipment to guide the injection into the appropriate muscle (laryngeal electromyography, or laryngeal EMG). The effect of injection starts within 24-72 hours of the procedure and lasts an average of 3 months. The procedure requires no sedation and causes minimal discomfort, and can be repeated as needed when the effect subsides. Both abductor and adduction spasmodic dysphonia are treated with Botox.

Side effects include transient weakness of the voice and occasionally mild difficulty swallowing with liquids. These symptoms usually resolve within 2 weeks of the procedure.

  • Surgery: A number of surgeries have been described in an attempt to manage spasmodic dysphonia. At the present time, there are a couple of reasonable surgical options for spasmodic dysphonia. One is selective adductor denervation and reinnervation (SLAD/R) surgery. This surgery involves cutting a branch of the recurrent laryngeal nerve that supplies innervation to the adductor (closing muscles) of the larynx. This nerve is then connected to a branch of the ansa cervicalis nerve, which normally supplies innervation to the anterior neck muscles. The vocal cords maintain their ability to open, and over the next months to a year after surgery the vocal cords gain strength but do not regain motion with closing. If successful, the voice loses its spasticity and retains adequate strength.

Patients have variable breathiness after surgery, which can be mild to severe. In some patients recurrence of spasms can occur, and may require Botox injections. Difficulty swallowing can persist after surgery. Due to potential irreversible side effects, I consider this surgery to be a second-line treatment for spasmodic dysphonia, for patients that have failed Botox treatment or that are unwilling to undergo repeated injection procedures

Another surgical option is the Isshiki type 2 thyroplasty. This surgery involves splitting the thyroid cartilage and separating the vocal cords slightly. The procedure is performed with the patient awake so the voice can be monitored, and is reversible if he results are not favorable. There are small reports describing the efficacy of this procedure, although it has not become popular in the United States.

  • Oral Medications: Oral medications provide little relief in the symptoms of spasmodic dysphonia, but can be used if other forms of dystonia are also present. Medications used in the treatment of dystonia include anticholinergics, benzodiazepines, and baclofen.
  • Voice therapy: Voice therapy is of limited benefit in the treatment of patients with spasmodic dysphonia. Benefits of voice therapy include reducing compensatory hyperfunctional vocal behaviors that have arisen due to spasmodic dysphonia. Voice therapy is not curative of spasmodic dysphonia, but can be useful as an adjunctive treatment.
  • For more information about spasmodic dysphonia, please visit:

How can voice disorders be prevented?  back to top

  • Smoking cessation – smoke causes irritation to the vocal cords, leading to swelling and polyp formation, in addition to causing vocal cord cancer
  • Avoidance of secondhand smoke
  • Adequate hydration
    • Intake of eight 8-ounce glasses of water per day
    • Avoidance of dehydrating agents such as alcohol or caffeine
    • Home humidification in dry climates
  • Dietary precautions
    • Avoidance of spicy or acidic foods
    • Avoidance of fatty foods and dairy products, which can thicken the mucus
  • Vocal hygiene
    • Use good breathe support when speaking or singing. Take a deep breath before beginning to speak, and take frequent breaths when speaking
    • Avoidance of using the voice too long or too loudly – Do not scream or yell
    • Warm up the voice before heavy use
    • Use amplification when in situations where voice projection is necessary
    • Avoid speaking or singing when the voice is injured or hoarse

What are the symptoms of swallowing disorders?  back to top

Swallowing disorders are characterized by difficulty in the transfer of food or liquid from the mouth into the stomach. Symptoms of difficulty swallowing, or dysphagia, include:

  • Drooling
  • Coughing or choking with meals
  • Food or pills sticking in the throat or chest
  • Regurgitation of food or liquid
  • A sensation of a lump in the throat
  • Aspiration pneumonia
  • Pain or discomfort in the lower throat or chest
  • Emesis when swallowing
  • Weight loss
  • Voice changes with meals

How does swallowing normally occur?  back to top

Swallowing is conceptually divided into several stages:

  • Oral phase – Food is chewed and mixed with saliva and passed into the throat. This phase of swallowing depends on the ability to seal the lips, the presence of dentition to chew the food, and saliva to moisten the food bolus.
  • Oropharyngeal phase – The palate and uvula seal the top of the throat preventing food or liquid from passing into the nose. The muscles in the pharynx including the base of the tongue squeeze and push the bolus into the lower throat.
  • Pharyngoesophageal phase – the larynx elevates, the epiglottis seals the top of the larynx, and the vocal cords close. The bolus is passed from the back of the tongue into the lower throat (pyriform sinuses) and into the upper esophagus. The upper esophageal sphincter transiently relaxes allowing the food to pass into the stomach.
  • Esophageal phase – the esophagus squeezes, passing the bolus into the stomach. This is referred to as peristalsis. Primary peristalsis describes the initial wave of muscular contraction, and secondary contraction clears any residue from within the esophagus. This stage of swallowing is involuntary.

How are swallowing disorders diagnosed?  back to top

Depending on the type of symptoms you are experiencing your doctor will recommend specific diagnostic tests. These may include:

  • Laryngoscopy: A flexible or rigid laryngeal camera is used to assess the function of the pharynx and larynx, and to visualize the presence of secretions in the lower throat or airway.
  • Barium esophagram: The patient swallows different consistencies of liquid barium and an x-ray is taken of the neck, mouth and chest.  Abnormalities of the digestive tract and swallowing mechanism are identified.

This test is used to diagnose masses, obstructions, pouches, or narrowing along the swallowing tube, to evaluate the clearance of food from the esophagus. In addition, the test helps to diagnose a hiatal hernia or acid reflux.

  • Modified barium esophagram (MBS): The patient is given varying consistencies of solids and liquids mixed with barium, and an x-ray is taken of the mouth, neck, and chest.  The swallowing mechanism is evaluated. This is primarily used to assess the safety of the swallow and to rule out aspiration or penetration of food or liquid material into the airway. A modified barium swallow can also be used to diagnose masses, obstructions, pouches, or narrowing in the lower throat and esophagus.
  • Esophageal manometry: A thin catheter is placed into the esophagus and measure the pressure at specific locations throughout the esophagus as the patient swallows.

This test is used to diagnose disorders of esophageal motility.

  • Flexible endoscopic evaluation of swallowing (FEES): A flexible laryngoscope is passed through the nose and into the throat.    The swallowing mechanism is then assessed by administering the patient varying consistencies of liquids, purees, and solid foods mixed with green food coloring. The examination is recorded and the swallowing mechanism is evaluated.

This test is used to detect aspiration of foods or liquids, laryngeal and pharyngeal function, and to assess compensatory strategies during the swallow.

  • Flexible endoscopic evaluation of swallowing with sensory testing (FEESST): This is similar to FEES, but in addition assesses the sensory function of the larynx. A special machine generates calibrated pulses of air, which are applied to the lower throat. This test estimates the airway protective capacity and assists in determining the likelihood of aspiration.
  • Esophageal pH Testing: This is a test measuring acidity in the esophagus and pharynx over an extended period of time. The test can be administered in several ways, but in general a sensor is placed into the esophagus or pharynx and measures events of acid reflux over time and correlates these events with the patient’s position and symptoms. A positive test result confirms the presence of acid reflux and can help direct treatment. The test can be combined with the measurement of impedance.
  • Esophagoscopy: A flexible endoscope is inserted through the mouth or nose, and passes into the esophagus and stomach, allowing inspection of the lining of the upper digestive tract but requiring no sedation.  Biopsies and other procedures may be performed as needed. When performed through the nose, the test is referred to as transnasal esophagoscopy (TNE), and allows the procedure to be done without sedation. When the exam is performed through the mouth it requires sedation.

How are swallowing disorders treated?  back to top

  • Diet: Disorders related to acid reflux can be treated with dietary modification. Strategies include:
    • Eating a bland diet with smaller, more frequent meals. This includes avoidance of spicy foods, acidic foods (vinegar, citrus, onion, garlic), fatty foods (fried foods, dairy products), and foods known to trigger reflux (chocolate, mint, etc).
    • Avoiding medications that cause acid reflux (aspirin, nitrates, vitamin C, etc).
    • Eliminating tobacco, alcohol and caffeine.
    • Reducing weight and stress.
    • Avoiding food within three hours of bedtime.
    • Elevating the head of the bed at night.

For patients suffering from aspiration, a modified diet may be utilized altering the consistency of food or liquids.

  • Medications: Many swallowing disorders can be treated with medication. Drugs that decrease the amount of acid produced by the stomach, muscle relaxants, and antacids are some of the medical options. In addition, Botulinum toxin (Botox) is sometimes used to weaken the upper or lower esophageal sphincter in patients with upper esophageal sphincter dysfunction or spasm.
  • Swallowing therapy: For patients suffering from stroke, choking, aspiration, or pneumonia, specialized therapy is administered by speech and language pathologists. Treatment serves to strengthen and improve the coordination of the muscles involved in the swallowing process, and to provide compensatory strategies to improve the swallowing safety and efficiency. Swallowing therapy can be combined with neuromuscular electrical stimulation, a type of device that uses electrical current to stimulate targeted muscles in the neck and throat.
  • Surgery: A number of swallowing disorders can be treated surgically.

If a narrowing exists in the throat or esophagus, the area may be stretched or dilated. In cases of muscle spasm (upper esophageal sphincter spasm, achalasia), the muscle may be released surgically. These dilatation and myotomy procedures can be combined with chemical weakening of muscles using Botox.

Other disorders such as Zenker’s diverticulum are treated with surgery. A Zenker’s diverticulum is an acquired pouch in the lower throat just above the esophagus that accumulates food and secretions. Depending on the size of the diverticulum and other factors, the surgery can be achieved endoscopically (diverticulotomy) or through the neck (diverticulectomy).

In some instances, acid reflux results from the presence of an anatomic weakness at the lower esophageal sphincter. This is called a hiatal hernia. In patients with hiatal hernia, surgical repair is possible and is called Nissen fundoplication. This can be performed laparoscopically through small incisions.

For patients suffering from chronic aspiration, procedures to protect the airway include gastrostomy tube placement, laryngeal diversion procedures, and tracheotomy.

Disclaimer: The information provided on this website is for general educational purposes only. It is not intended to be used as a substitute for medical advice. Any concerns or questions you have about your health or the health of your family should be discussed with your physician. Please note that medical information is constantly changing. Therefore some information may be out of date.

Special thanks to the American Academy of Otolaryngology-Head and Neck Surgery, American Speech-Language-Hearing Association, National Spasmotic Dysphonia Association, Recurrent Respiratory Papillomatosis Foundation for these resource links.

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