Types of Voice Disorders

I find it helpful to think of voice disorders falling into two broad categories: behavioral causes and structural causes. This categorization is based upon the perceived cause of the hoarseness — and ultimately it helps in directing the type of treatment.

Two Categories, One Framework

I find it helpful to think of voice disorders falling into two broad categories:

• Behavioral causes
• Structural causes

This categorization is based upon the perceived cause of the hoarseness and ultimately it helps in directing the type of treatment for the problem.

Behavioral Voice Disorders

Behavioral voice disorders arise from how the voice is used. The vocal behavior or pattern of use causes the change in sound. Broadly, overuse, underuse and inappropriate use cause the vocal impairment. An example would be the person who talks so much that the voice becomes hoarse directly from the talking. The overuse causes a swelling to arise in the middle of the vocal cord. The swelling allows air to leak around it, causing a husky hoarseness. The swelling also creates a stiff portion and increases the mass, impairing vocal cord vibration.

The essential characteristic of a behavioral disorder is that vocal behavior is the primary cause. Change the behavior, and the disorder resolves — or at minimum, the driving force behind it is removed. This makes behavioral disorders fundamentally different from structural ones in their approach to treatment.

Structural Voice Disorders

A structural hoarseness problem is one in which the vocal cord structure changes as the primary event. For example, a smoker, over many years of exposing his vocal cords to tobacco ingredients and heat, may develop a cancer. While smoking is a behavior, it is not a vocal behavior. This cancerous growth or bump on the vocal cords has nothing to do with how much or little the person makes the vocal cords vibrate. As the bump actually grows, it changes the weight and stiffness on one vocal cord and causes perhaps both an air leak around the bump (huskiness) as well as two separate pitches from the two unequally weighted sides of the larynx.

Structural disorders encompass infections, congenital disorders, neurolaryngological conditions, tumors, mucous gland disorders, trauma, and unusual disorders — each with a primary structural change that explains the altered sound.

The categorization of behavioral versus structural is not about blame — it is about directing treatment. Treating a structural problem with voice therapy alone, or treating a behavioral problem with surgery alone, will fail. The framework ensures the right tool is applied to the right problem.

Where to Go Next

The chapters that follow explore each category in depth. Behavioral Hoarseness covers the full range of overuse, underuse, and inappropriate use disorders — from nodules and polyps through muscle tension dysphonia, nonorganic dysphonia, and cricopharyngeal spasm. Structural Hoarseness covers infections, congenital variants, neurolaryngology, tumors, mucous gland disorders, trauma, unusual disorders, and their combinations.

The three-part laryngeal examination — history, vocal capabilities testing, and visual endoscopy — leads directly to this behavioral versus structural categorization. The history identifies the pattern of use and onset; the vocal capabilities testing reveals what sound the larynx cannot make; and the endoscopy reveals the structural correlate. Together, they make the categorization — and the treatment direction — clear.

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