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You Have a Voice: Causes & Treatments of Dysphonia
Spasmodic dysphonia, a focal form of dystonia, is a neurological voice disorder that involves "spasms" of the vocal cords causing interruptions of speech and affecting the voice quality. Dr. Craig Berzofsky discusses the causes and treatments of dysphonia.
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Learn more about Dr. Craig Berzofsky
Craig Berzofsky, MD, MHS
Dr. Craig Berzofsky is a board-certified Otolaryngologist and fellowship-trained Laryngologist, specializing in treating voice, airway and swallowing disorders. After graduating from Emory University in Atlanta, Georgia, Dr. Berzofsky received a Masters in Health Sciences in Biochemistry and Molecular Biology from The Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.Learn more about Dr. Craig Berzofsky
Transcription:
You Have a Voice: Causes & Treatments of Dysphonia
Melanie Cole, MS (Host): Maybe you’ve heard someone whose voice sounds tight, broken, whispery, or otherwise not quite right. It might be a condition known as spasmodic dysphonia. Here to tell us about that today is Dr. Craig Berzofsky. He's board certified otolaryngologist and fellowship trained laryngologist specializing in treating voice, airway, and swallowing disorders at St. Luke’s Cornwall Hospital. Dr. Berzofsky, give us a little lesson on the anatomy of the voice to begin with. How do we make sounds? How does it even work?
Craig Berzofsky, M.D., MHS (Guest): So, in order to make sounds, we use our vocal cords. Our vocal cords are housed inside the neck right behind the cartilage that we can all feel when you touch the front of your neck. The vocal cords open and they close in order to produce voice. Vocal cords close together and then air from your lungs come up and as they put your vocal cords apart, the vocal cords start to vibrate. With that vibration, you produce the sound. Then the sound actually gets modified through your throat and actually in through your mouth. That’s what gives us our words and our sentences and our syllables. That’s how we are able to produce a nice, good voice.
Host: So what kind of things can go wrong with the vocal cords? Tell us a little bit about spasmodic dysphonia. What is it?
Dr. Berzofsky: So, anything can go wrong with the vocal cords just like any other muscle that we have in the body. You can get inflammation of the vocal cords. You can get lesions of the vocal cords. You can get cancer of the vocal cords. Anytime you have any neurological problems you can get trouble moving the vocal cords. So, anything like that can cause anything from weak voice to changing the pitch of the voice. So anytime you have disruption, you can get changes that we all determine hoarseness of the voice.
Spasmodic dysphonia is a very specific dysfunction of the voice. It is actually a neurological dysfunction that is described as a dystonia or spasming of the vocal cords. With spasmodic dysphonia, the vocal cords either spasm closed, and people get a very choppy voice, or they can actually spasm open and people get a very breathy voice that’s very difficult to hear.
Host: Is this a common disorder, Dr. Berzofsky? Is it something that effects people in certain professions? Like I speak for a living. Or because it’s a neurological disorder, are there certain risk factors?
Dr. Berzofsky: It is not a common disorder. It’s actually pretty rare for people to have the problem. Although a lot of people do have spasmodic dysphonia and have had it for so long that they actually think it is their normal voice and don’t seek help. I think the typical statistics is about 4 in 100,000 people that actually get the disease. So, it’s actually pretty rare to see. When it does effect people, it’s usually between the ages of 30 and 50. It’s more common in women than in men, but it is not something that we see commonly.
The people that are more effected by this problem are people who do use their voice for a living, but most people do find it difficult to communicate if they have very tight spasms. So many people are seeking treatment even if their voice is not used much during the day.
Host: So, are there specific symptoms that somebody would notice? Tightness in the throat or, as you said, hoarse voice. Are there other red flags that would send them to see a laryngologist in the first place?
Dr. Berzofsky: As far as spasmodic dysphonia, usually the voice is their main concern. It is a neurological dystonia and people can get other dystonia’s with it as the same time. So, a lot of patients will get what we call blepharospasm, which is actually twitching of the eyelids. Some people actually get other special spasms. So, their lips can quiver, or they have quivering of their eyebrow. Then some people actually get spasms in their neck muscles. So, their neck is always tilted to one side and is very tight and has difficult moving. Those patients are usually presenting a lot earlier and sooner because they have other issues that are causing those problems. A lot of patients come referred from neurologists because they usually see the neurologist for the other spasms and then they get sent to us to deal with the voice spasm.
Host: Tell us how it’s diagnosed. What’s involved in diagnosing vocal disorders as a general rule?
Dr. Berzofsky: Diagnosing vocal disorders is usually a multi-specialty diagnosis arm. Most people are seeing the ENT doctor and sometimes the laryngologist like myself first. The first thing we do when we assess these patients is actually listening to their voice and to assess what the dysfunction is. Do they have a spasming voice? A weak voice? Does the pitch sound difference? Is it a woman that has a very deep pitch that sounds almost like a male voice? So, we’re getting a sense on that aspect.
The next part is actually visualizing the vocal cords. In order to do that, we have cameras in the office that provide us high definition resolution of the vocal cords themselves. The cameras either go through the mouth or through the nose and this allows us to look at the vocal cords while they're being used. So, with the camera in place, patients are speaking to us, singing to us, and we’re looking at how the vocal cords vibrate back and forth and whether they're spasming or not. After this, a lot of patients are then assessed by a speech therapist or a voice therapist, and they can actually help us diagnose a lot of functional issues with the voice if the vocal cords themselves seem to be in normal condition.
Host: Doctor, if somebody is diagnosed with spasmodic dysphonia or dysphonia in general, what are some of the treatment options available?
Dr. Berzofsky: So, if someone has dysphonia that is due to some sort of lesion or tumor, those patients usually are managed with a surgical treatment option. If patients do have more inflammatory lesions like vocal cord nodules or sometimes patients have inflammation, those patients undergo more voice therapy to help treat their underlying voice by decreasing the tension with which they speak. Neurological disorders are managed with a combination of treatment. It all depends on how severe the dysfunction is.
The one interesting thing about spasmodic dysphonia in and of itself is it is not treated very well with voice therapy. With voice therapy, sometimes we can get people to talk at a lower pitch, so they don’t use the strength of their vocal cords and that decreases spasms, but it doesn’t work very well. The mainstay of treatment for spasmodic dysphonia is actually Botox injections into the vocal cords themselves. The injections are done in the office with a guidance from an EMG needle. The needle is a very small needle placed through the skin. Once it’s in the muscles, we inject a very small amount of Botox into the vocal cords. Most people do very well with this type of treatment. The Botox is a temporary treatment. It lasts about three to four months, and patients come back about every three to four months for repeat injections.
Host: That’s so cool doctor. So how long… You said they come back every three to four months. How long do they have to do that?
Dr. Berzofsky: This is a disease that lasts a very long time. Most people it’s for the rest of their life. So many of these people come back for the rest of their life about every three to four months for their injections. Some people do modify how often they come because it can be a little disturbing for the lifestyle if you have to go every three to four months. So, some patients come with they need their voice more than others. So, they come around the holiday time because they want to communicate with family and friends more often. Other times when they're not socializing as much, they can skip their injection.
Host: Give us some of your best advice for good vocal cord health in the first place. You mentioned vocal cord therapy. What does that look like?
Dr. Berzofsky: So, in general for vocal cord health, the best things we talk to people about are using your voice in what we call confidential voice. So, when you're actually talking to someone you should talk to them directly and not screaming across a room trying to get people’s attention. If you're out in public in a restaurant, sitting closed to people that way you're not having to push your voice to scream over other people’s conversations. The other things we like to tell people to do are increase your hydration. So, drinking enough fluids. Not speaking with dry vocal cords. That helps with the voice as well.
Other things we have people do for their voice. Reflux can disturb the voice at times. So, having people use better habits when it comes to eating. If they do need to see a doctor for management of reflux, we do recommend that they see a doctor for that as well. That helps actually keep people’s voice in good working condition. Another thing we have people is when they do have some troubles with their voice is the best treatment actually usually is not to whisper. Just use your voice normally and not try and push your voice during those periods of time. Then we recommend if you have hoarseness and it lasts over about a month, you should be seeing some sort of doctor to take a look at the vocal cords to assess what the problem is.
Host: As a last question doctor, are there some things that we can do? Like does honey help? You mentioned not to whisper and not to scream, but are there other things like can spicy food hurt? Or does alcohol? Can any of these things hurt our vocal cords?
Dr. Berzofsky: Yeah. So, anything that can increase the amount of reflux we have or increase any acid that gets into the throat can definitely affect our vocal cords and cause lots of inflammation. As far as other foods that are bad for us, coffee, tea, anything with caffeine, fake sugars. Those all can affect the vocal cords as well. Anything that reduces acid that comes up. So, some people use Tums or Zantac or things like that. That definitely can help the vocal cords if reflux is a cause. Things that can help improve the vocal cords, some people do use honey. This more acts as a lubricant and just keeps the vocal cords in a good working shape. Some people use a lot of… There’s a lot of homeopathic remedies that people use. Just more misting and keeping the vocal cords moist and not dehydrated and that helps them a lot as well.
Host: Great information. Thank you so much Dr. Berzofsky for coming on today and sharing your expertise and explaining about spasmodic dysphonia and vocal cord disorders and what we can really do to keep a good healthy vocal cords and voice. Thank you again. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That’s stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much tuning in.
You Have a Voice: Causes & Treatments of Dysphonia
Melanie Cole, MS (Host): Maybe you’ve heard someone whose voice sounds tight, broken, whispery, or otherwise not quite right. It might be a condition known as spasmodic dysphonia. Here to tell us about that today is Dr. Craig Berzofsky. He's board certified otolaryngologist and fellowship trained laryngologist specializing in treating voice, airway, and swallowing disorders at St. Luke’s Cornwall Hospital. Dr. Berzofsky, give us a little lesson on the anatomy of the voice to begin with. How do we make sounds? How does it even work?
Craig Berzofsky, M.D., MHS (Guest): So, in order to make sounds, we use our vocal cords. Our vocal cords are housed inside the neck right behind the cartilage that we can all feel when you touch the front of your neck. The vocal cords open and they close in order to produce voice. Vocal cords close together and then air from your lungs come up and as they put your vocal cords apart, the vocal cords start to vibrate. With that vibration, you produce the sound. Then the sound actually gets modified through your throat and actually in through your mouth. That’s what gives us our words and our sentences and our syllables. That’s how we are able to produce a nice, good voice.
Host: So what kind of things can go wrong with the vocal cords? Tell us a little bit about spasmodic dysphonia. What is it?
Dr. Berzofsky: So, anything can go wrong with the vocal cords just like any other muscle that we have in the body. You can get inflammation of the vocal cords. You can get lesions of the vocal cords. You can get cancer of the vocal cords. Anytime you have any neurological problems you can get trouble moving the vocal cords. So, anything like that can cause anything from weak voice to changing the pitch of the voice. So anytime you have disruption, you can get changes that we all determine hoarseness of the voice.
Spasmodic dysphonia is a very specific dysfunction of the voice. It is actually a neurological dysfunction that is described as a dystonia or spasming of the vocal cords. With spasmodic dysphonia, the vocal cords either spasm closed, and people get a very choppy voice, or they can actually spasm open and people get a very breathy voice that’s very difficult to hear.
Host: Is this a common disorder, Dr. Berzofsky? Is it something that effects people in certain professions? Like I speak for a living. Or because it’s a neurological disorder, are there certain risk factors?
Dr. Berzofsky: It is not a common disorder. It’s actually pretty rare for people to have the problem. Although a lot of people do have spasmodic dysphonia and have had it for so long that they actually think it is their normal voice and don’t seek help. I think the typical statistics is about 4 in 100,000 people that actually get the disease. So, it’s actually pretty rare to see. When it does effect people, it’s usually between the ages of 30 and 50. It’s more common in women than in men, but it is not something that we see commonly.
The people that are more effected by this problem are people who do use their voice for a living, but most people do find it difficult to communicate if they have very tight spasms. So many people are seeking treatment even if their voice is not used much during the day.
Host: So, are there specific symptoms that somebody would notice? Tightness in the throat or, as you said, hoarse voice. Are there other red flags that would send them to see a laryngologist in the first place?
Dr. Berzofsky: As far as spasmodic dysphonia, usually the voice is their main concern. It is a neurological dystonia and people can get other dystonia’s with it as the same time. So, a lot of patients will get what we call blepharospasm, which is actually twitching of the eyelids. Some people actually get other special spasms. So, their lips can quiver, or they have quivering of their eyebrow. Then some people actually get spasms in their neck muscles. So, their neck is always tilted to one side and is very tight and has difficult moving. Those patients are usually presenting a lot earlier and sooner because they have other issues that are causing those problems. A lot of patients come referred from neurologists because they usually see the neurologist for the other spasms and then they get sent to us to deal with the voice spasm.
Host: Tell us how it’s diagnosed. What’s involved in diagnosing vocal disorders as a general rule?
Dr. Berzofsky: Diagnosing vocal disorders is usually a multi-specialty diagnosis arm. Most people are seeing the ENT doctor and sometimes the laryngologist like myself first. The first thing we do when we assess these patients is actually listening to their voice and to assess what the dysfunction is. Do they have a spasming voice? A weak voice? Does the pitch sound difference? Is it a woman that has a very deep pitch that sounds almost like a male voice? So, we’re getting a sense on that aspect.
The next part is actually visualizing the vocal cords. In order to do that, we have cameras in the office that provide us high definition resolution of the vocal cords themselves. The cameras either go through the mouth or through the nose and this allows us to look at the vocal cords while they're being used. So, with the camera in place, patients are speaking to us, singing to us, and we’re looking at how the vocal cords vibrate back and forth and whether they're spasming or not. After this, a lot of patients are then assessed by a speech therapist or a voice therapist, and they can actually help us diagnose a lot of functional issues with the voice if the vocal cords themselves seem to be in normal condition.
Host: Doctor, if somebody is diagnosed with spasmodic dysphonia or dysphonia in general, what are some of the treatment options available?
Dr. Berzofsky: So, if someone has dysphonia that is due to some sort of lesion or tumor, those patients usually are managed with a surgical treatment option. If patients do have more inflammatory lesions like vocal cord nodules or sometimes patients have inflammation, those patients undergo more voice therapy to help treat their underlying voice by decreasing the tension with which they speak. Neurological disorders are managed with a combination of treatment. It all depends on how severe the dysfunction is.
The one interesting thing about spasmodic dysphonia in and of itself is it is not treated very well with voice therapy. With voice therapy, sometimes we can get people to talk at a lower pitch, so they don’t use the strength of their vocal cords and that decreases spasms, but it doesn’t work very well. The mainstay of treatment for spasmodic dysphonia is actually Botox injections into the vocal cords themselves. The injections are done in the office with a guidance from an EMG needle. The needle is a very small needle placed through the skin. Once it’s in the muscles, we inject a very small amount of Botox into the vocal cords. Most people do very well with this type of treatment. The Botox is a temporary treatment. It lasts about three to four months, and patients come back about every three to four months for repeat injections.
Host: That’s so cool doctor. So how long… You said they come back every three to four months. How long do they have to do that?
Dr. Berzofsky: This is a disease that lasts a very long time. Most people it’s for the rest of their life. So many of these people come back for the rest of their life about every three to four months for their injections. Some people do modify how often they come because it can be a little disturbing for the lifestyle if you have to go every three to four months. So, some patients come with they need their voice more than others. So, they come around the holiday time because they want to communicate with family and friends more often. Other times when they're not socializing as much, they can skip their injection.
Host: Give us some of your best advice for good vocal cord health in the first place. You mentioned vocal cord therapy. What does that look like?
Dr. Berzofsky: So, in general for vocal cord health, the best things we talk to people about are using your voice in what we call confidential voice. So, when you're actually talking to someone you should talk to them directly and not screaming across a room trying to get people’s attention. If you're out in public in a restaurant, sitting closed to people that way you're not having to push your voice to scream over other people’s conversations. The other things we like to tell people to do are increase your hydration. So, drinking enough fluids. Not speaking with dry vocal cords. That helps with the voice as well.
Other things we have people do for their voice. Reflux can disturb the voice at times. So, having people use better habits when it comes to eating. If they do need to see a doctor for management of reflux, we do recommend that they see a doctor for that as well. That helps actually keep people’s voice in good working condition. Another thing we have people is when they do have some troubles with their voice is the best treatment actually usually is not to whisper. Just use your voice normally and not try and push your voice during those periods of time. Then we recommend if you have hoarseness and it lasts over about a month, you should be seeing some sort of doctor to take a look at the vocal cords to assess what the problem is.
Host: As a last question doctor, are there some things that we can do? Like does honey help? You mentioned not to whisper and not to scream, but are there other things like can spicy food hurt? Or does alcohol? Can any of these things hurt our vocal cords?
Dr. Berzofsky: Yeah. So, anything that can increase the amount of reflux we have or increase any acid that gets into the throat can definitely affect our vocal cords and cause lots of inflammation. As far as other foods that are bad for us, coffee, tea, anything with caffeine, fake sugars. Those all can affect the vocal cords as well. Anything that reduces acid that comes up. So, some people use Tums or Zantac or things like that. That definitely can help the vocal cords if reflux is a cause. Things that can help improve the vocal cords, some people do use honey. This more acts as a lubricant and just keeps the vocal cords in a good working shape. Some people use a lot of… There’s a lot of homeopathic remedies that people use. Just more misting and keeping the vocal cords moist and not dehydrated and that helps them a lot as well.
Host: Great information. Thank you so much Dr. Berzofsky for coming on today and sharing your expertise and explaining about spasmodic dysphonia and vocal cord disorders and what we can really do to keep a good healthy vocal cords and voice. Thank you again. This is Doc Talk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That’s stlukescornwallhospital.org. I’m Melanie Cole. Thanks so much tuning in.