Dysphonia refers to hoarseness, weakness, or difficulty in producing voice sounds. It encompasses any abnormality in vocal quality, pitch, loudness, or vocal effort. Dysphonia may be organic, neurologic, or functional in origin.

• Organic causes: Disorders of the larynx, vocal cords, or laryngeal nerves.

• Functional causes: Vocal overuse, muscle tension, or psychogenic factors.

• Neurologic causes: Central or peripheral nervous system disorders affecting vocal cord innervation, e.g., Parkinson’s disease.

• Physiologic/normal variant: Pubertal voice changes (dysphonia puberum).

Pathophysiology

• Laryngeal pathology: Inflammation, nodules, polyps, tumors, or trauma can alter vocal fold vibration.

• Neural dysfunction: Lesions of the recurrent laryngeal nerve or vagus nerve reduce vocal cord mobility. Central lesions affecting corticobulbar pathways may also impair phonation.

• Muscle tension dysphonia: Excessive contraction of laryngeal muscles leads to abnormal voice production.

• Neurodegenerative disease: Parkinson’s disease or ALS may cause hypophonia due to impaired motor control of vocal cords.

Examination Technique

Inspection and Palpation:

• Examine the neck and laryngeal area for swelling, asymmetry, or masses.

• Palpate the larynx during phonation for tenderness or abnormal movement.

Voice Assessment:

• Ask the patient to sustain vowels (“ah,” “ee”) and assess pitch, loudness, and quality.

• Note breathiness, hoarseness, tremor, strain, or pitch breaks.

• Assess ability to speak in normal conversation and during maximum phonation.

Specialized Evaluation:

• Laryngoscopy (indirect or fiberoptic) to visualize vocal cord structure and movement.

• Acoustic analysis or voice spectrography for objective assessment of pitch, intensity, and quality.

Clinical Features

Differential Diagnosis

Limitations

• Assessment may be subjective; subtle changes require specialized evaluation.

• Voice quality is influenced by patient effort, fatigue, and environment.

• Requires differentiation between organic, neurologic, and functional causes.

Patient counseling

• Explain that dysphonia is a symptom, not a disease, and may reflect a wide range of underlying conditions.

• Emphasize voice rest, hydration, and avoidance of irritants (smoking, excessive shouting).

• Discuss referral to ENT specialists or speech-language pathologists for persistent or progressive dysphonia.

• Early evaluation is important to exclude serious causes such as laryngeal tumors or neurologic disorders.

Conclusion

Dysphonia is a common clinical sign indicating abnormal vocal production. Etiologies range from transient inflammation to structural, neurologic, or functional disorders. Careful assessment, including visualization and acoustic analysis, allows for accurate diagnosis, timely management, and preservation of vocal function.

References

1. Rubin JS, Sataloff RT, Korovin GS. Diagnosis and Treatment of Voice Disorders. 4th ed. New York: Springer; 2020.

2. Stachler RJ, et al. Clinical Practice Guideline: Hoarseness (Dysphonia). Otolaryngol Head Neck Surg. 2018;158(1_suppl):S1–S42.

3. Bhattacharyya N. The prevalence of voice problems among adults in the United States. Laryngoscope. 2014;124(3):875–879.

4. Ropper AH, Samuels MA, Klein JP. Adams and Victor’s Principles of Neurology. 11th ed. New York: McGraw-Hill; 2021.