Dysphonia: Epidemiology, Diagnosis and Risk Factors at Tertiary Health Care Center

Abstract

The physical, mental, financial, social and emotional constraints encountered by an individual having voice disorder can be easily anticipated as communication is the utmost need in day to day life and some professions. To study the clinical epidemiology of voice disorders in surrounding population and identify the risk factors. It also intended to make people aware of vocal hygiene programme. This observational, prospective, cross sectional study was conducted in Chirayu medical college and hospital, Bhopal from September 2016 to August 2017. All the patients were subjected to diagnostic flexible video laryngoscopy and stroboscopy and in some patients Chest X-ray PA view, USG Neck, Computerized tomography and Magnetic resonance imaging were advised for the confirmation. Amongst 45 patients who formed this study group, male preponderance was seen with male to female ratio of 2.2:1. Laryngeal malignancy (13 cases) was the commonest pathology, followed by vocal polyp (7 cases) and vocal cord palsy (6 cases). Rare cases of tubercular laryngitis and hemorrhage were also diagnosed. The largest group of patients belonged to labor/farming occupation suggesting the rural referral to this tertiary care center followed by housewives.

Introduction

Communication is the most important thing in day to day life, professionally, socially and personally. Voice not only helps in communication but also unveils emotions. Hence the physical, mental, financial, social and emotional constraints encountered by an individual having voice disorder can be easily anticipated. Some professionals like singers, teachers, lawyers, clergyman etc. are highly exposed to the risk of voice-related disorders. Increasing awareness about healthy behavior with the voice in their occupations will help in improving their quality of work and in minimizing any permanent impairments and/or disability. Good vocal hygiene can prevent and treat some pathologies, and voice therapy is a cornerstone of management in some cases of hoarseness [1], we also emphasized to increase awareness about vocal hygiene. This would not only improve their quality work but also minimize permanent impairments and/or disability.

Larynx because if its anatomical position has always challenge the otolaryngologists when it comes to clinical examination. Traditionally indirect laryngoscopic mirror examination and direct laryngoscopy with rigid Jackson’s laryngoscope were used for diagnosis. But the advent of flexible laryngoscope, Hopkins telescope and stroboscope has revolutionized the diagnostic dilemma. 70 degree Hopkins telescope routinely used for nasal endoscopic surgeries proved to be the most useful diagnostic tool. It is less time consuming, quick, easy in inexperience hands like residents, cheap and also useful in uncooperative patients.

Objectives

To study the clinical epidemiology of voice disorders in surrounding population and create awareness about vocal hygiene programme.

Materials and Methods

This present Observational, Prospective, Cross sectional study was conducted in Chirayu medical college and hospital, Bhopal from September 2016 to August 2017 after the approval from institutional ethical committee. The patients visiting ENT OPD with complains of change in voice were included in study. Patients having voice disorders not related to larynx like nasal & nasopharyngeal pathology, oral & oropharyngeal lesions and speech disorders due to central nervous system lesions were excluded from this study. The patient was subjected to thorough and complete history taking and clinical examination. All the patients were subjected to diagnostic flexible video laryngoscopy and stroboscopy, if needed patients were advised chest x-ray PA view, USG neck, computerized tomography and magnetic resonance imaging for the confirmation.

Observations

During this period of 1 year, 45 patients attended ENT OPD with the history change in voice. Amongst these, 31 patients were males and 14 females. Male preponderance was seen with male to female ratio being 2.2: 1. The age group of the patients ranged from 14 to 78 years. The median age for male was 50 and female was 45 and The mean age was 39 years. Not a single female patient was found in 7th and 8th decade. The largest number of patients were seen in 5th and 6th decade i.e. 10 patients (22.2%) in each decade, followed by fourth and eighth decade.

The pathologies of these patients were categorized according to Rosen’s classification [2] into four major categories of voice disorders are identified based on pathophysiology and auditory-perceptual and visual-perceptual observations. These four categories include functional, organic, neuromuscular and systemic causes.

The commonest symptom with which patient presented was change in voice. 23 patients (51.11%) presented with the duration up to 3 months, whereas 14 patients (31.11%) presented with history up to 6 months. Remaining 8 patients had complained up to 1 year (Table 1).

Table 1.

The following table showing Rosen’s classification, diagnosis and no. of cases

Rosen’s classification	Diagnosis	Number of cases	Percentage
Functional voice disorder	Muscle tension dysphonia	0	0
	Mutational falsetto	2	4.4
	Plica ventricularis	2	4.4
Neuromuscular control abnormality	Vocal cord palsy	6	13.3
	Spasmodic dysphonia	0	0
Organic voice disorder	Vocal nodules	4	8.8
	Vocal polyp	7	15.6
	Tubercular laryngitis	2	4.4
	Chronic laryngitis	3	6.6
	Haemorrhage	2	4.4
	Reinke’s edema	1	2.2
	Laryngeal malignancy	13	28.8
Systemic	Reflux laryngitis	3	6.6
Total		45	100

The largest group of the patients belonged to the labor/farming occupation (36%) followed by housewives (31%), private job/businessman (13.3%), students (8.7%), singer (6.6%) and teachers (4.4%).

Vocal professionals were categorized according to classification by Koufman and Isaacson [3]. Level I or the elite vocal performers (singers)—3 (6.6%), Level II or the professional voice users (businessmen)—6(13.3%), Level III or nonvocal professionals (teachers)—2 (4.4%), Level IV or nonvocal nonprofessionals (laborer, housewives, students)—34 (75.7%). In males, largest group was of laborer/farmer (54.10%). All females were housewives. 25 patients had positive history of tobacco consumption in the form of tobacco chewing and smoking. All 13 patients diagnosed with laryngeal malignancy were smokers. 4 females, 4 males and 3 students had history of vocal abuse. 4 patients were professional voice users. 3 patients were diagnosed to have LPR (Laryngopharyngeal Reflux).

Discussion

Voice plays an important role in day to day communication in personal and professional life. Hence impact of change in voice on one’s life can be anticipated. Speech abnormality can be categorized as dysphasia, dysarthria and dysphonia. Dysphasia generally implies to upper motor neuron pathologies, mainly at the level of Broca’s area whereas dysarthria is concerned with the pathologies of articulating organs and dysphonia at the laryngeal level.

Voice disorder or dysphonia may be defined as a voice quality which has one or more of the following features [2]

1. Is inaudible

2. There is age and gender discordance with speaker

3. Is incapable of fulfilling linguistic and paralinguistic features

4. Is easily fatigable and is associated with pain and discomfort with phonation.

In 2019, V Lyberg-Åhlander [4], in his study found the overall prevalence of voice disorders to be 16.9%. Amongst these, 15.5% patients having voice problems up to small extent and 1.4% to a great extent. Ying -Ta Lai et al. [5] found the prevalence to be 3.6% in Taiwan in 2014.

The causes of hoarseness are determined after obtaining a detailed medical history of the circumstances preceding the onset of hoarseness and performing a thorough physical examination. The latter may include visualization of the vocal cords, possibly using indirect laryngoscopy, flexible nasolaryngoscopy or strobo video laryngoscopy. In the absence of an upper respiratory tract infection, any patient with hoarseness persisting for more than 2 weeks requires a complete evaluation.

The male to female ratio was found to be 2.2:1 in our study, similar finding was observed in study of H Kumar et al. [6] and Banjara et al. [7] whereas, V Lyberg and Ying-Ta Lai et al. observed female was more prone to voice disorders. Majority of the patients were seen in fifth and sixth decade (22%) each, followed by fourth (15.5%) and seventh (13.3%) decade. though similar trend was noticed by Banjara et al. Ying-Ta Lai et al. found it common between 20 and 39 years of age group on the contrary V Lyberg-Åhlander found it common in ages more than 65 years.

The pathologies of these patients were categorized according to Rosen’s classification [2]. According to Rosen’s classification, four major categories of voice disorders are identified based on pathophysiology and auditory-perceptual and visual-perceptual observations. These four categories include functional, organic, neuromuscular and systemic causes. The commonest pathology noticed in present study was carcinoma larynx 28.88% succeeded by vocal polyps 15.55% and neurological lesions 13.33%. In our study 2 cases were diagnosed 4.44% of tubercular laryngitis. Banjara et al. (2011) mentioned functional lesions 16.33% to be most common etiology followed by vocal nodule 11.95%, vocal palsy 11.16%, cancer 9.56% and chronic laryngitis 9.56%.

The commonest symptom with which patient presented was change in voice 100%. Hansa et al. and K S Sindhu et al. a reported the hoarseness, as major complaint in 95.61% and 98% respectively. The other associated symptoms were fatigability of voice, cough, dysphagia, neck swelling, foreign body sensation, dyspnea. 23 patients (51.11%) presented with the duration up to 3 months, whereas 14 patients (31.11%) presented with history up to 6 months. Remaining 8 patients (17.77%) had complained up to 1 year.

Koufman and Isaacson [3] evolved a classification of vocal professionals based on their voice use and risk. Level I (elite vocal performers): Included sophisticated voice users like the singers and actors, where even a slight vocal difficulty causes serious consequences to them and their careers. Level II (professional voice users): For whom moderate vocal difficulty would hamper adequate job performance. Clergymen, lecturers, teachers, politicians, public speakers, and telephone operators would classify in this level of voice users. Level III (nonvocal professionals): It includes teachers and lawyers. They can perform their jobs with slight or moderate voice problems; only severe dysphonia endangers adequate job performance. Level IV (nonvocal/nonprofessionals): which include labourers, homemakers and clerk. These are the persons who are not impeded from doing their work when they experience any kind of dysphonia.

Banjara et al. found that1.59% elite vocal performers, 3.59% professional voice users, 9.56% nonvocal professionals and 85.26% nonvocal/nonprofessionals. These findings were in conformity with ours that majority of patients belonged to Level IV or nonprofessionals [3]. V Lyberg-Åhlander reported highest prevalence of voice problem in teaching and service occupations.

In our study 25 patients had history of tobacco chewing and smoking out of which 13 had laryngeal malignancy which explains the correlation of tobacco consumption and malignancy. Our study shows vocal abuse and laryngopharyngeal reflux as an etiology to cause laryngeal pathologies. Ying-Ta Lai et al. concluded infectious etiology as the leading cause of dysphonia.

Vocal polyp and vocal nodules were surgically treated with microlaryngeal surgery. Carcinoma of larynx was treated with surgery, radiotherapy and chemotherapy according to staging and histopathological type. All the patients with dysphonia were subjected to speech therapy and thought about the vocal hygiene to prevent the recurrence. With the exception of professional voice users or individuals who have experienced a voice problem, many consider voice production as a relatively abstract construct and are unaware of their inherent vocal capability. According to Mara Belau, Gisele Oliveira [8] a comprehensive vocal hygiene program often includes: education regarding the vocal mechanism; identification and reduction of phonotraumatic behaviors and high-risk vocal situations; conservation of voice or vocal rest, controlling the amount of talking, monitoring vocal pitch and intensity; local lubrication and systemic hydration; optimal dietary considerations; controlling laryngopharyngeal reflux, gastroesophageal reflux and allergies; and minimizing the influence of medications, environmental factors, and lifestyle choices on voice. This program may be employed as a preventive tool to avoid voice problems or as a method to treat voice problems. Regardless, the components of vocal hygiene are relatively standard, but evolving. Vocal hygiene as a therapeutic tool is considered a patient-centered behavioral treatment which includes modification of vocal habits and the implementation of principles to facilitate improved vocal health,voice, and the body mechanisms that produce voice, are meant to last a lifetime. But the vocal mechanism cannot tolerate excessive wear and tear. There are good habits—things you can do to take care of your voice. Vocal abuse plays an important role in causing vocal pathologies like vocal polyp and vocal nodules. According to Rosen CA, Anderson D, Murry T [1] good vocal hygiene can prevent and treat some pathologies, and voice therapy is a cornerstone of management in some cases of hoarseness. Pasa et al. [9] in their study emphasized the effectiveness of vocal hygiene training and vocal exercises in preventing voice disorders in teachers. Hence awareness of vocal hygiene programme can effectively prevent voice disorders in some professionals like singers, teachers, lawyers, clergyman etc. who are highly exposed to the risk of voice-related disorders.

After the confirmation of diagnosis, patients with organic lesions like vocal polyp, cysts, and nodules were subjected to microlaryngeal surgery. Laryngeal cancer patients were appropriately treated with surgery, radiotherapy and chemotherapy. Most of the patients were referred to speech therapy and educated about vocal hygiene. Majority of patients showed satisfactory improvement to suffice their need. Medical therapy was advised to the patients of reflux laryngitis, acute and chronic laryngitis, tubercular laryngitis.

Summary and Conclusions

Voice has very important role, not only for the purpose of communication but also in unveiling the emotions. Hence the role of voice and the impact of voice disorders on one’s life can easily be foreseen. The present study conducted, highlighted that the voice disorders if timely diagnosed and treated can improve one’s quality of life. The flexible laryngoscopy and stroboscopy are today’s necessity in early diagnosis and timely management. The speech therapy and awareness for vocal hygiene is the mainstay of treatment strategy. Amongst 45 patients who formed this study group, male preponderance was seen with male to female ratio of 2.2:1. Laryngeal malignancy (13 cases) was the most common pathology, followed by vocal polyp (7 cases) and vocal cord palsy (6 cases). Rare cases of tubercular laryngitis and hemorrhage were also diagnosed. The largest group of patients belonged to labor/ farming occupation suggesting the rural referral to this tertiary care center followed by housewives. 11 patients had history of vocal abuse.

Author Contribution

AC: Chief investigator, RM: Co-investigator, GC: Co- investigator.

Funding

None.

Availability of Data and Material

CMCH, Bhopal.

Declarations

Conflict of interest

None.

Consent to Participate

Consent taken.

Ethical Consideration

There are no ethical conflict related to this study.

Consent for Publication

Consent taken.