Section: Otorhinolaryngology

Systematic Review EVALUATION AND MANAGEMENT OF VOICE

DISORDERS: A SYSTEMATIC REVIEW

K. Arumugam1
Received : 15/01/2023
Received in revised form : 22/02/2023 1
Accepted : 05/03/2023 Assistant Professor, Department of Otorhinolaryngology, Government medical college,
Pudukkotai, Tamilnadu, India

Keywords: Abstract
Voice disorders, Systematic review,
Diagnosis, Management of voice Background: This systematic review aims to provide a comprehensive
disorders. overview of the evaluation and management of voice disorders, highlighting
Corresponding Author: evidence-based practices and identifying areas for future research. Voice
Dr. K. Arumugam, disorders can significantly impact an individual's quality of life and
Email: [email protected]
communication abilities. Examining the current literature on this topic is
DOI: 10.47009/jamp.2023.5.4.227 essential to ensure effective evaluation and management. Materials and
Methods: A systematic search of electronic databases was conducted to identify
Source of Support: Nil,
Conflict of Interest: None declared relevant studies published up to September 2021. The inclusion criteria
encompassed studies evaluating and managing voice disorders in adults and
Int J Acad Med Pharm
2023; 5 (4); 1126-1130 children. Data from PubMed, Embase, and ScienceDirect were used to assess
the current scenario for evaluating and managing voice disorders. Result: The
review presents a literature synthesis focusing on various evaluation methods,
including perceptual, acoustic, and aerodynamic assessments and instrumental
techniques such as laryngoscopy and imaging. It also explores management
options, including behavioural, medical, and surgical interventions.
Furthermore, the review emphasises the importance of interdisciplinary
collaboration among speech-language pathologists, otolaryngologists, and other
healthcare professionals to manage voice disorders comprehensively.
Conclusion: This systematic review provides valuable insights into evaluating
and managing voice disorders, synthesising the current evidence and identifying
gaps in knowledge. The findings emphasise the need for standardised
assessment protocols and interdisciplinary teamwork to optimise the care and
outcomes for individuals with voice disorders. Further research is warranted to
enhance our understanding of effective management strategies and their long-
term impact on voice-related outcomes.

INTRODUCTION with dysphonia undergo a three-step clinical

examination process: Taking a history and evaluating
A partial or complete loss of voice may significantly a physical exam.[1]
affect one's quality of life and safety because voice is The history-taking process comprises gathering
an essential tool for social interaction and human medical, surgical, psychological, or traumatic data
communication. Excessing air across vibrating vocal that helps diagnose and allows for therapy tailored to
folds results in the human voice. The larynx and the patient. The verbal evaluation, a step in this
diaphragm must work in unison, and the tongue, process, entails comprehending the abnormality and
cheeks, and lips must shape the sound. Refraining how it impacts daily tasks like responsibilities to the
from behaviours that might strain the vocal folds, workplace or interpersonal contact. The voice's pitch,
including extended or extremely loud yelling or loudness, and quality will aid the doctor in
screaming, is preferable to maintain optimal identifying the nature of the issue. The underlying
performance. Voice anomalies are likely brought on disorder is better understood, and a more effective
by organic anatomical abnormalities such as nodules, solution is made possible by a thorough vocal
scars, cartilage subluxations, and nerve damage. assessment.[2] After evaluating voice quality, volume,
When vocal quality is affected without any obvious and range, a thorough ear, nose, and throat
anatomical or neurological causes, a functional voice examination is included in the physical examination.
problem should be investigated. A comprehensive The assessment focuses on pharyngeal function,
and in-depth assessment of the laryngeal structures velopharyngeal competency, and nasal airway
and the patient's voice is required to develop a patency. If a patient has insufficient expiratory
successful plan for vocal therapy exercises. Patients volume or force, which affects their voice and throws
off their typical rhythm of synchronised breathing

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and phonation, they may require pulmonary function to hold a key for as long as they formerly could.
tests. As hearing loss can affect a patient's perception Alternatively, they may no longer be able to sing in
of their voice and thus change its production, a very high or low registers or talk in a very loud or
hearing evaluation may also be crucial.[1] The most deep voice. A person's voice can sometimes go
crucial stage in the diagnosis of vocal dysfunction is completely silent (aphonia). There are a variety of
laryngoscopy. Mirror laryngoscopy, flexible techniques for therapy and exercises. Voice and
fiberoptic laryngoscopy, distal chip laryngoscopy, speech impairments can coexist, for example, after a
digital transoral laryngoscopy, and stroboscopy are stroke or in other neurological illnesses such as
some techniques used to see the larynx. When Parkinson's disease. It may also be difficult to
assessing the mucosal wave of the vocal cords, swallow. In addition to voice therapy, speech and
stroboscopic examination yields the most swallowing therapy are required. This entails
information.[3] performing appropriate exercises to enhance the
Otolaryngologists (Ear, Nose, and Throat, ENT), creation of vocal sounds in your mouth and throat
Speech-Language Pathologists (SLP), voice (articulation) and training the muscles used to
scientists, psychologists, singing instructors, and swallow to make it simpler to eat and drink.[6]
vocal coaches make up the multidisciplinary team Effective evaluation and management of voice
that helps diagnose voice disorders. To categorise the disorders are crucial to alleviate symptoms, restore
vocal complaint, each specialist will concentrate on a vocal function, and improve overall quality of life.
different degree of the vocal symptoms.[4] The review will highlight the importance of
Otolaryngologists and general medical practitioners interdisciplinary teamwork and provide examples of
(GMPs) play important roles in diagnosing and successful collaborative models in evaluating and
treating individuals with laryngeal/voice issues. The managing voice disorders. Moreover, this literature
two medical professionals that see these patients the review will identify gaps in the existing literature and
most frequently are GMPs and otolaryngologists. areas that require further research. Recognising these
Laryngeal/voice problems can hurt the person and gaps will help guide future investigations and
society due to decreased quality of life, lost promote the development of evidence-based
productivity, and an estimated $5 billion in yearly approaches to evaluating and managing voice
direct expenditures. Interventions using disorders. Additionally, the review will discuss the
pharmacological, behavioural, and surgical methods implications of the findings for clinical practice and
may be used to treat these problems. Since they make propose recommendations for improving the overall
up about one-third of all direct expenditures, care of individuals with voice disorders. This
medications (particularly antibiotics, proton pump literature review aims to provide a comprehensive
inhibitors (PPIs), and steroids) are a considerable overview of the evaluation and management of voice
expenditure. For patients with laryngeal/voice disorders. By critically analysing the available
disorders, both GMPs and otolaryngologists research, synthesising the findings, and identifying
commonly prescribe drugs with various prescription gaps in knowledge, this review will contribute to
patterns. Regarding GMPs, medicine prescriptions advancing evidence-based practices in the field. The
frequently occur before laryngoscopy is finished, review seeks to enhance the care and outcomes for
which is required to diagnose laryngeal/voice issues individuals affected by voice disorders by improving
precisely. Additionally, various drug studies our understanding and implementing effective
conducted by GMPs and otolaryngologists for the evaluation and management strategies.
same laryngeal diagnosis have been noted, indicating
confusion regarding the most suitable and efficient MATERIALS AND METHODS
pharmacologic therapy.[5]
Voice treatment removes or enhances vocal sound This systematic review aimed to comprehensively
production (phonation) difficulties in the larynx evaluate and summarise the existing literature on
(voice box). Your voice should be stronger and sound evaluating and managing voice disorders. We
as before you started treatment. Voice treatment may thoroughly searched electronic databases, including
also be used for preventative training your voice to PubMed and Science Direct, using relevant keywords
avoid difficulties in the future. Voice therapy consists and controlled vocabulary terms. Additionally, we
of various specifically customised exercises taught searched for grey literature, conference abstracts, and
by a speech therapist, voice coach, or respiratory organisational websites to ensure comprehensive
therapist. Voice treatment is normally covered by coverage. We established clear inclusion and
statutory health insurers in Germany if it is deemed exclusion criteria, focusing on studies published in
essential and recommended by a family doctor or an English within a specified time frame that explored
ENT specialist. Voice treatment is effective for the voice disorders, evaluation methods, and
majority of voice abnormalities (dysphonia). A vocal management approaches. Two or more reviewers
disorder is characterised by a consistent shift in independently screened titles and abstracts, retrieved
someone's voice. The voice is generally raspy at this full-text articles for further assessment, and resolved
point, but it can also be strained, husky, or soundless. discrepancies through discussion or involvement of a
It becomes weaker and less strong as a result: For third reviewer. We extracted data using a
example, someone with a vocal issue may be unable

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standardised form, including study characteristics, aggravating processes, such as gastric reflux,
participant demographics, evaluation methods, smoking, aspirating toxic chemicals, or vigorous
management approaches, and key findings. Quality respiratory activity, may also contribute to the
assessment was performed using appropriate tools development of polyps.[8] Hoarseness, breathiness,
based on study design, and data synthesis involved and vocal fatigue are the major symptoms and
organising and summarising extracted data into indicators of vocal fold polyps. However, a few
tables, charts, or matrices. Finally, we discussed the instances of airway blockage have also been brought
main findings, identified common themes and gaps in on by massive polyps.[9] For this kind of vocal fold
the literature, and provided recommendations for injury, surgery is typically used. However, several
future research and practice. This systematic review recent studies showed the significance of speech
follows a rigorous methodology to ensure the therapy as a first treatment for polyps, with entire or
reliability and validity of our evaluation of the partial lesion regression, followed by surgery when
evaluation and management of voice disorders. the lesions are persistent or if the patients are
Vocal Nodules unsatisfied with their voice quality.[10]
Vocal nodules, sometimes called vocal fold or vocal Treatment
cord nodules, can form if your voice is overused over The use of endoscopic laser, steroid injection,
an extended period. They alter the tone of your voice flexible laryngostroboscopy surgery, acupuncture,
and make it nodules hoarse. If you practice voice and vocal health education related to antireflux
treatment or take voice rest, these little benign (non- medication are some other treatment options for
cancerous) ones will typically disappear once more. vocal fold polyps that have produced positive results
Surgery is only very seldom required. Overuse of the despite the preference for traditional laryngeal
voice cords can cause tiny nodules to form and microsurgery and scientific advancements in terms of
swelling membrane tissue. Other factors might also the surgical techniques used.[10] In research that
contribute to voice issues. Laryngitis, an examined 42 cases of vocal polyps, conservative
inflammation of the larynx, is the most typical cause. medical therapy was documented. Complete lesion
The paralysis of your vocal cords and smoking both regression was seen in 4 angiomatous polyps and 2
affect your voice. Rarely they are brought on by a gelatinous polyps following steroid or antiulcer
cancerous tumor or psychological issues. Your voice medication intervention. The scientists concluded
may sound raspy or breathy when you have vocal that some polyps, especially tiny ones, may not
nodules, making it hoarse. Vocal nodule sufferers are require surgical excision.[11] Percutaneous
also less able to sustain notes as long as they formerly corticosteroid injection for polyp therapy was shown
could. They can no longer sing or talk in extremely by Hsu et al. to result in full lesion remission in 59%
high or low registers.[7] of patients and adequate improvements in
Treatment stroboscopic and vocal parameters in 32% of patients
Resting your voice as much as possible is the most to avoid laryngeal surgery in 32% of patients.
important thing to do. People who frequently Compared to standard laryngeal microsurgery
converse on the phone, for instance, may be able to utilising suspension laryngoscopy, the authors found
communicate by sending written notes on their phone that percutaneous corticosteroid injection is a less
or computer. Talking to their physician can help invasive method with low morbidity that fosters a
parents of screaming kids figure out what they can do better cost-benefit relationship.[12]
to stop it. Older children and adults can get voice Laryngeal Cancer
treatment, such as with a speech therapist, and voice One-third of all head and neck cancers are laryngeal
rest. This includes developing speech and breathing malignancies, which may be a substantial cause of
coordination, relaxing, and enhancing posture. illness and death. Patients with a considerable
Transcutaneous electrical nerve stimulation (TENS) smoking history are more likely to have them
or steam inhalations are sometimes recommended to identified and more likely to develop malignancies in
hydrate the larynx's (the voice box) mucous the other parts of the aerodigestive tract. They may
membranes. Vocal nodules are seldom treated with affect various laryngeal subsites, which may impact
medication. You can be given the option to have how symptoms manifest themselves, how they
minor surgery to have them removed if they persist spread, and how they are treated. While late-stage
after resting your voice and doing the remedies cancer has a poorer result, calls for multimodal
mentioned above. The same hazards apply to this therapy, and is less frequently larynx-preserving, the
technique to all anaesthetic-assisted surgeries. early-stage disease is highly curable with either
Rarely, it might result in scarring that alters the tone surgical or radiation monotherapy, typically with
of your Voice over time.[7] larynx preservation. In the USA, 13,000 new cases of
Vocal fold Polyps laryngeal cancer are reported each year, most of
Vocal fold polyps are benign tumors that often only which are squamous cell tumors. In the past,
affect one vocal fold. Sessile or peduncular in form, laryngeal cancer was only treated surgically; organ
gelatinous or transparent, fibrous or organised, and preservation plus chemoradiation is currently the
angiomatous or hemorrhagic are some histological preferred therapy method. Numerous studies
categories that apply to them. The vocal polyp has a demonstrate that this strategy yields outcomes
phonotraumatic genesis. 7 However, other comparable to a complete laryngectomy. In addition,

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endoscopic techniques are now available for treating dehydration. Modifying abnormal vocal symptoms
laryngeal cancer. 13,150 new instances of laryngeal such as pitch, loudness, breathiness, harsh glottal
cancer, or almost one-third of all head and neck attacks, and glottal fry are the main goals of
malignancies, were reported in 2017, with 3710 symptomatic voice treatment. Psychogenic voice
fatalities resulting from these cases. Patients are an treatment concentrates on the client's emotional and
average age of 65, with a larger percentage of men psychological circumstances that resulted in and kept
than women and blacks than whites. Because fewer the vocal condition going. The physiologic focus of
people smoke tobacco, age-adjusted incidence rates voice treatment is directly altering and correcting the
have dropped by around 2% yearly in recent years. balance of laryngeal muscle activity to the supporting
Approximately 98% of laryngeal malignancies airflow and the proper focus of the laryngeal tone.
develop in the supraglottic or glottic areas, with The majority of voice treatments are eclectic,
glottic cancers occurring three times more frequently including elements from each approach.[15]
than supraglottic cancers, accounting for just 2% of
cases overall.[13] DISCUSSION
Evaluation
Other investigations are required besides the history The systematic review identified various
mentioned above, physical examination, direct management approaches, including medical
inspection, and tissue biopsy of the larynx. There are interventions, behavioural therapy, and surgical
several viable ways to get a tissue. The most interventions. The review identified several
beneficial procedures are the direct laryngoscopy standardised assessment tools commonly used to
biopsy of the presumed main lesion and the fine- evaluate voice disorders.
needle aspiration (FNA) biopsy of any suspected Scales for measuring voice quality analyse the voice
nodal illness. Imaging the main lesion and draining as a multidimensional phenomenon. The five factors
lymph nodes is recommended for all laryngeal that affect voice quality are the patient-based,
malignancies, whether they are in the early or late auditory-perceptual, acoustic, aerodynamic, and
stages. This is often done using a contrast-enhanced visual methods. The patient-based evaluation is a
CT of the neck. Contrast-enhanced CT of the chest suitable method for determining the amount and
and PET/CT would be ordered in the case of nature of voice treatment progress. More information
suspected locally advanced illness to rule out distant is provided comparing the patient-based scale to
metastases. Esophagogastroduodenoscopy (EGD) or existing voice assessment scales. A vocal scale that is
barium swallowing may be prompted by suspected patient-based and extensively used in both clinical
hypopharyngeal invasion and help identify the proper and research settings is the voice handicap index
aerodigestive tissue where the malignancy (VHI). Multiple languages have shown the VHI to
originated. Blood testing that includes the complete have high reliability and validity.[16] Voice
blood count (CBC), platelet count, liver and renal assessment scales are used to detect the effect of
function, blood type, thyroid function, electrolytes, voice therapy approaches among different voice
and albumin levels is required before any disorders. The VHI is a validated voice-related
operation.[13] quality of life (QoL) questionnaire used individually
Voice Therapy to evaluate treatment effectiveness in benign voice
The practice of speech-language pathologists caring disorders (e.g., vocal fold nodules, vocal fold polyps,
for the voice dates back to the 1930s and developed and vocal fold polyps). Results from studies
out of methods used to improve the natural voice. conducted by Rosen et al. and Craig et al. show that
Early treatment aimed to build and enhance a voice VHI is applied to evaluate treatment efficacy in voice
with acceptable volume, clarity of tone, a pitch suited disorders, especially in patients with muscle tension
for the age and sex, and other characteristics. It used dysphonia (MTD).[17,18] Stroboscopy examination or
texts and methods from elocution, oral interpretation, multidisciplinary evaluation with speech-language
and public speaking. A gentle vibrato, as well as an pathology (SLP) may influence the diagnosis and
elegant, continuous inflexion of pitch and power that subsequent care of individuals with laryngeal/voice
corresponds to the content of what is said.[14] Since disorders.[19] A multicenter study of individuals who
these early beginnings, various therapy techniques had laryngoscopies and were thought to have LPR
have been developed to train this ideal voice. These discovered that stroboscopy frequently revealed
include therapies to improve vocal hygiene, therapies other diseases more appropriate for surgical
that identify and alter vocal symptoms, therapies that intervention or voice therapy.[20] A therapeutic option
address the psychogenic aspects of the voice that is either neglected or untested is a referral to an
disorder, and therapies that investigate the underlying SLP with voice training. Only 11.8% of patients with
physiology of the voice disorder and alter that otolaryngology evaluations (and 4.9% of a wider
physiology through direct voice exercises. Hygienic cohort of patients with laryngeal/voice disorders)
voice treatment, in brief, focuses on detecting and obtained SLP evaluation/treatment.[19]
then changing or removing improper vocal hygiene The research concluded that medication trials
practices, including shouting, talking loudly over frequently treat people with laryngeal/voice
background noise, singing beyond one's vocal range, disorders. Treatment with antibiotics, PPIs, or oral
screaming, coughing, throat clearing, and

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steroids by GMPs in patients who later receive proper focus of the laryngeal tone. The majority of
otolaryngology-based diagnoses of vocal fold voice treatments are eclectic, including elements
paresis, benign vocal fold/laryngeal pathology, from each approach.
laryngeal cancer, or multiple diagnoses may present
chances to cut back on unneeded medication use. REFERENCES
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