Aphonia is the complete or near-complete loss of the ability to produce speech sounds, despite intact language comprehension and cognitive ability. It differs from dysphonia, which refers to partial impairment or hoarseness. Aphonia may result from organic laryngeal pathology, neurologic injury, psychogenic causes, or excessive strain of the vocal apparatus.

Pathophysiology

Aphonia arises when the mechanism of voice production is disrupted at one or more levels:

• Laryngeal dysfunction: Structural lesions (nodules, polyps, edema, tumors) or inflammatory processes impede vibration of the vocal cords.

• Neurologic injury: Damage to the recurrent or superior laryngeal nerves (branches of the vagus nerve) or brainstem nuclei can paralyze the vocal cords.

• Psychogenic causes: Conversion disorder or severe emotional stress can inhibit voluntary phonation despite normal laryngeal anatomy and nerve function.

• Muscle tension/spasm: Excessive contraction of intrinsic laryngeal muscles prevents appropriate cord adduction and vibration.

Etiology and Associated Features

Clinical Examination

1. History: Onset, duration, precipitating factors (voice overuse, surgery, trauma, emotional stress), associated symptoms (pain, cough, stridor, dysphagia).

2. Voice assessment: Ask the patient to speak, cough, and clear the throat — preserved cough with absent voice suggests psychogenic cause.

3. Oropharyngeal and laryngeal inspection: Look for swelling, erythema, foreign bodies.

4. Flexible or indirect laryngoscopy: Gold standard to visualize cord movement, lesions, or edema.

5. Neurologic exam: Assess cranial nerves IX, X, XI, XII for evidence of central or peripheral nerve damage.

Diagnostic approach

• Laryngoscopy to assess cord mobility, structural lesions, or inflammation.

• Imaging (neck/chest CT or MRI) for nerve compression or tumors.

• Electromyography (EMG) in suspected neuropathic paralysis.

• Consider psychiatric evaluation if organic causes are excluded and history suggests stress or trauma.

Management

Patient counseling

• Avoid excessive talking, shouting, or whispering during recovery.

• Maintain good hydration and avoid irritants (smoking, alcohol, dust).

• Emphasize early evaluation for persistent or progressive voice loss (>2 weeks).

• Reassure patients with psychogenic aphonia that prognosis is excellent with therapy.

Special considerations

• Children: Commonly due to acute laryngitis, croup, or vocal cord nodules; rarely psychogenic.

• Older adults: Persistent aphonia should raise suspicion for laryngeal malignancy or neurologic disease.

• Post-surgical patients: Monitor voice changes after thyroid, neck, or thoracic surgery — early referral to ENT can prevent long-term disability.

Key points

• Aphonia is the loss of voice resulting from organic, neurologic, or psychogenic causes.

• Thorough history, laryngoscopic evaluation, and attention to airway symptoms are crucial.

• Most cases resolve with appropriate treatment, but persistent aphonia requires exclusion of malignancy or nerve injury.

References

1. Sulica L, Behrman A. Management of voice disorders. In: Flint PW, Haughey BH, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Philadelphia: Elsevier; 2021.

2. Morrison MD, Rammage LA. Muscle tension dysphonia. J Voice. 1993;7(1):118-126.

3. Boone DR, McFarlane SC, Von Berg SL, Zraick RI. The Voice and Voice Therapy. 9th ed. Boston: Pearson; 2013.

4. Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2018;158(1_suppl):S1-S42.