The other type of nonorganic dysphonia or nonorganic hoarseness presents in many different ways. A nonorganic hoarseness can mimic any organic voice disorder. Some of my colleagues term all of these disorders muscle tension dysphonia though not all nonorganic dysphonias involve tension. Nonorganic hoarseness can also be caused by excessive relaxation of the vocal cord muscles.
While the problem in nonorganicity is in the brain, and not in the vocal cords, an alternative term “psychogenic hoarseness” carries with it pejorative meaning, at least in the mind of the typical American patient. Using the term psychogenic dysphonia can make resolution of the problem more difficult. Additionally, the American health insurance system often separates mental health care from “medical” care and will not pay for “psychogenic” disorders. Unfortunately, this pays for the physician not to diagnose a psychiatric condition.
With these caveats in mind, let’s explore nonorganic voice disorders.
Andrew’s Story
Andrew Smith first lost his voice three years ago. He is a professor and teaches at a community college. The first time he lost his voice, it was gone completely for a week; then he was hoarse for a few months. He saw an ENT physician who told him that his larynx was red and inflamed and placed him on a reflux medication — a strong proton pump inhibitor. This treatment helped “a little bit.” However, when his voice returned, it was never as strong as it used to be.
The next school year he used a microphone to teach in class because his voice never completely recovered. Still, it was difficult for his students to hear him by the end of the day. By the end of each week, his voice was a whisper. He improved during the summer. Then, the following fall, his microphone was not available and on the second day of teaching class, he lost his voice again, completely. He continued to teach by assigning projects rather than speaking about them. He cannot yell, primarily because it causes pain in his neck. A second ENT noted an ulcer on his vocal cords, treating him with antibiotics, steroids, and an anti-reflux medication, ultimately for over six months and for most of that time he was on double doses. He altered his diet and his lifestyle to “avoid acid reflux” and he acknowledges there was perhaps slight improvement. He later tried a naturopathic approach without improvement.
As I try to reconstruct his story, his initial voice loss could fit the story of a person who develops a viral nerve injury. This acute laryngitis should have improved and not persisted. He is not an innately talkative person, so nodules are rather unlikely. One of the commonalities of nonorganic disorders is that they don’t quite fit any specific organic illness set of symptoms. They come close, but there are discrepancies, so I begin to consider nonorganic hoarseness as a diagnosis.
The likely driving force behind a nonorganic hoarseness is that there is likely some secondary gain — obvious or not. The secondary gain may range from increased attention from family or friends, to relief from some obligation, to financial gain. Most times, the onset of the gain is initially inadvertent.
The Examination
When I examine Andrew’s vocal cords with the endoscope, they appear completely normal in structure. The visible functional abnormality is the vocal cords being held apart during phonation, though I could see them close together at various other times during the exam. Since they can close completely some of the time, I know they are not weak or paralyzed. I can feel with my fingers on his neck that he is pulling his larynx up very high and tight when speaking and also contracting the muscle under his chin very tightly. I find no red color out of the ordinary for mucosa. I find no ulcer. The only reason for air leak is the vocal cords being held apart during attempted voice production.
Now the story fits a pattern. Andrew likely had an initial organic illness, quite possibly acute viral laryngitis. With swollen vocal cords, in order to speak at all, Andrew had to hold the vocal cords slightly apart. However, as the swelling resolved and if, during the initial illness, Andrew was relieved from some burden — perhaps related to his teaching — then as the vocal cords returned to their normal size, the vocal cords tended to stay apart and his voice just tended to remain poorly functional. Holding the vocal cords apart now lets air leak out — a husky hoarseness.
One illness, viral laryngitis, was transmuted into muscle tension within the larynx, which holds the vocal cords apart whenever making a sound. It also explains the variety of symptoms within his illness. Sometimes he can only whisper, sometimes there is pain in his neck if he speaks louder than a whisper, sometimes his voice just “cracks,” sometimes his voice returns completely to normal. He seems to “maybe get better” on anti-reflux medication or other treatments. Both his hoarseness and his improvement are inconsistent.
Treatment as Retraining
During my examination of Andrew, before the endoscopy, I record him performing a number of vocal tasks. I ask him to sing low notes and high notes. I ask him to shout, to cough, to clear his throat, and to hum. Even though he is whispering to me at the beginning of the exam, on some of these vocal tasks a normal voice inadvertently comes out. During the endoscopy, I aim to reproduce these sounds which come out normally so I can film the position of the vocal cords.
At the end of endoscopy, I have a recording of both abnormal voice production and normal voice production, which aids me in diagnosis, but this is also the beginning of treatment. I review the video with Andrew and his spouse, who is present during the exam. I explain why sound comes out normally sometimes and why at other times, when the vocal cords are apart, sound is poor. Together we begin to practice the production of normal and abnormal voice. I explain how the pain comes from excessive muscle tension in his neck when speaking.
I am very successful in dealing with nonorganic hoarseness since the potential for complete return of normal voice is essentially 100 percent. Surgical voice problems do not have that rate of improvement since there is often some trade-off involved with surgeries.
I persuade Andrew to buy in to his own ability to cure his voice. Andrew is re-learning to use his voice and by the end of the appointment we both have the visual and audible evidence that it is possible for him to restore his voice with practice. Part of the treatment is having family present, so that when Andrew leaves he will have some support that his voice is recoverable. The family will have heard his normal voice. I write letters to all of Andrew’s other physicians to be sure every person treating Andrew is on the same page. Otherwise, it is often easier for a patient to remain hoarse and on a pill than to confront the issues and put in the effort to produce a normal voice.
His wife chimes in: “Does that mean we can lower the head of the bed now? Can we eat chocolate again? Can we eat Indian food? Can we have coffee in the morning again?” Not only can Andrew resume his normal speaking pattern, his family can resume a normal life. I encourage Andrew to stop taking reflux medication, which is doing nothing for his voice; it may well have side effects and even without side effects it gives him a crutch to lean on, preventing recovery.
Andrew’s secondary gain is subtle and not obvious to me. It has not been necessary for me to identify and correct the initiating problem. Just giving Andrew a face-saving means of vocal restoration is often sufficient. I usually ask patients to return in a month, encouraging them to continue the practice we started in the office of switching between a normal and an abnormal voice — essentially giving the patient control over their voice again.
Many times when I see patients again, they cannot even make their “old, tight voice” anymore. They will report to me that suddenly one day their voice was normal again and now it is difficult to produce the tight voice without a great deal of effort and pain.
La Belle Indifférence
A resolution for nonorganic hoarseness can be made much more difficult when there is money, an outstanding workman’s compensation, or a legal battle involved. Especially difficult are cases where the patient will receive more money if they remain ill than if they recover. Until that financial carrot is removed, voice recovery is very difficult.
Another observation I suspect the patient cannot make in himself, but the examiner may observe, is an inappropriate smile which the examiner can elicit: la belle indifférence — the beautiful indifference. During the interview I often offer sympathy for a patient with a comment such as, “This vocal problem must be really getting you down.” The nonorganic patient responds with a “Yes, it is really terrible!” accompanied with a rather bright smile on his face, the seeming opposite of the weariness one would expect with a drawn out, never-ending, hopeless type of illness. An individual with a nonorganic illness is beautifully indifferent to his problem.
What You Learned
- Nonorganic dysphonia can mimic any organic voice disorder — the key to diagnosis is finding symptoms that don’t quite fit any single organic pattern.
- The term “psychogenic” is avoided because it is pejorative and may make treatment more difficult; it also creates complications with insurance systems.
- Secondary gain — relief from obligation, attention, financial benefit — is usually the driving force and typically begins inadvertently.
- Diagnosis depends on finding vocal tasks (coughing, humming, yelling) during which a normal voice inadvertently emerges; these same moments become the opening moves of treatment.
- Showing the patient their own normal voice production on video, with family present, is itself the beginning of recovery. Prognosis for complete return is essentially 100 percent.
- Resolution is far harder when financial incentives — litigation, workers’ compensation — are tied to remaining ill.
- La belle indifférence: an incongruously bright affect in a patient describing a devastating illness is a clinical sign worth noting.