Aphonia

Aphonia is the inability to speak or loss of voice through disease of or damage to the larynx or mouth. Aphonia means the patient has no voice at all. Aphonia may take several different forms. You may have a partial loss of your voice and it may sound hoarse. Or, you may have complete loss of your voice and it may sound like a whisper. Loss of voice can come on slowly or quickly depending on the cause.

Functional aphonia

Functional aphonia is a condition of acute voice loss ¹. There are two types of functional aphonia − habitual aphonia and psychogenic aphonia − which may be a presentation of a specific underlying psychiatric ailment ². Habitual aphonia can be caused by any factor and may continue after the etiological basis disappears. Patients continue to be aphonic because of lack of secondary gain of impaired voice or because of lack of appropriate proprioceptive feedback from vocal fold contact during the aphonia. This lack of proprioceptive feedback perpetuates the condition ³. It is a rather rare disorder with a prevalence of 0.4% ⁴. Functional aphonia appears about eight times more frequently in females than in males. When the patient tries to phonate, the vocal folds approximate, but remain open. The patient whispers only either entirely without sound or with short insertions of extremely high-pitched phonations, which sound breathy or strained ⁵.

Although no definite cause is known for functional aphonia, it may occur because of a severe emotional disturbance or severe stress. In addition, it is mentioned that patients with recurrent aphonia exhibit a significantly higher level of anxiety and significantly more respect for social norms and codes of propriety. Their coping is also characterized by a higher escape tendency. Patients with recurring aphonia also report a significantly higher number of problems in their private lives ⁶.

The criterion for functional aphonia that has been reported by a number of clinicians and reiterated is that phonations of a nonverbal type, such as coughing, throat clearing, and crying, usually remain intact, whereas all voluntary speech trials are characterized by a whispering voice ⁷. These nonverbal phonations are of value to the clinician diagnostically as well as clinically. The ability of the patient to produce an audible cough is considered one of the most significant signs diagnosing the functional nature of the disorder ⁸.

Diagnosis of functional aphonia is usually confirmed on the basis of the patients’ history of sudden voice loss. In addition, there is discrepancy between the normal aspect of the larynx on one hand and severe dysphonia with reduced adduction of the vocal folds during phonation and complete closure during coughing on the other ⁹. Acute laryngitis, acute vocal abuse (trauma), postoperative status (such as after extensive extirpation of the vocal fold mucosa), and sudden psychogenic stress were common predisposing factors ³. It is recommended, although not essential, to attempt voice restoration at the first session of therapy ¹⁰.

Functional aphonia treatment

Behavior re-adjustment voice therapy may be used to stabilize the regained voice. Therapy should be started immediately and it is mostly focused on correcting symptoms. Prompt therapy is very important to avoid a supposed serious risk that the aphonia will become permanent if the patient gets used to it. The ‘immediate’ initiation of therapeutic intervention using voice therapy is thought to be very important because as aphonia continues the disorder is likely to become more and more fixed ¹¹. Different methods have been suggested and used by many authors for the management of functional aphonia. Old methods such as surprising the patient with brutal force methods such as the ‘Muck ball’ method and sudden obstruction of the laryngeal inlet until suffocation leading to a reflex cry have been used. Others have mentioned methods including the application of an electromagnet to the tongue, grasping the tongue and larynx with both hands, irritation by dripping water, blowing powder into the larynx, or by brushing the mucosa with cocaine ¹². Over time, the techniques have become more sophisticated with phoniatrics therapy using the general idea of shaping the nonphonatory function of the vocal folds such as coughing for regaining the lost voice ¹³.

Aphonia causes

Aphonia is usually due to problems with the voice box (called the larynx). However, there can be other causes, including:

• Conditions that affect the vocal cords or airway. This may involve injury, swelling, or disease, such as:
  • Laryngitis —caused by a viral, bacterial, or fungal infection
  • Vocal abuse—yelling or talking excessively
  • Exposure to airborne irritants, such as smoke or air pollution
  • Acid reflux from gastroesophageal reflux disease (GERD)
  • Thickening of the vocal chords
  • Nodules or polyps on the vocal chords
  • Muscle tension dysphonia
  • Damage to the nerves that affect how the larynx functions
  • Laryngeal or thyroid cancer
  • Removal of larynx
  • Breathing problems that affect the ability to speak
  • Neurological disorders such as myasthenia gravis , multiple sclerosis , Parkinson’s disease , and amyotrophic lateral sclerosis
• Psychological conditions such as hysterical aphonia or psychogenic aphonia

Risk factors for developing aphonia

Factors that may increase your chance of developing aphonia include:

• Overusing your voice such as speaking until you are hoarse
• Behaviors that abuse your vocal chords, such as smoking , which also puts you at a higher risk for cancer of the larynx
• Having surgery on or around the larynx.

Aphonia prevention

To help reduce your chance of aphonia:

• If you smoke, talk to your doctor about ways to quit .
• If you drink, limit your intake.
• Limit your exposure to fumes and toxins.
• Avoid talking a lot or yelling.
• Avoid whispering.
• Learn vocal techniques from a voice therapist if you have to speak a lot for your job.
• Get treatment for conditions that may cause loss of voice.

Aphonia symptoms

Aphonia symptoms may include:

• Inability to speak or inability to speak above a whisper
• Hoarseness
• Spasm of vocal cords
• Throat pain
• Difficulty swallowing—food or fluids may go into the lungs

Aphonia diagnosis

You will be asked about your symptoms and medical history. A physical exam will be done.

The cause of your symptoms may not be obvious. You may be referred to an ear, nose, and throat doctor. This doctor may use an instrument called a laryngoscope to examine your vocal cords. Other tests may also be done to evaluate your voice function.

If your doctor is concerned that there may be a neurological or psychological cause, you may be referred to other specialists.

Aphonia treatment

Aphonia treatment involves treating the underlying cause.

You can take the following steps to help ease laryngitis:

• Rest your voice.
• Avoid smoking.
• Stay hydrated.
• Use a cool mist humidifier.
• Take over-the-counter pain relievers, such as acetaminophen and ibuprofen.

Other treatments depend on the specific cause, such as:

• Participating in voice therapy if your loss of voice is due to voice overuse
• Taking medication to control acid reflux
• Having surgery to remove growths.

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