Introduction
The voice is a distinctive feature of each person, even reflecting our emotional state. It is part of our personality and how others identify us, in addition to being the tool through which we communicate.
Moreover, the voice is one of our work instruments, as we often need to use it for hours every day—especially professionals whose work depends on their voice, such as singers, actors, teachers, and others.
Even if we don’t use our voice professionally, voice problems can have a significant functional, physical, and sometimes emotional impact.
When should I see a specialist for a voice problem?
Voice problems are extremely common. In general, they are referred to as dysphonia.
Most people have experienced some episode of dysphonia at some point in their life, often due to an acute cold or vocal overexertion.
Beyond these temporary cases, voice problems can appear suddenly or develop gradually, starting with signs of vocal strain, fatigue, or neck tension, eventually leading to changes in the voice—from subtle to very noticeable. When dysphonia is recurrent and/or progressive, it can cause significant functional limitations in daily life.
Any persistent dysphonia, or one that does not improve after two weeks, should be assessed by an otolaryngologist.
How are voice problems classified?
There are three types of dysphonia:
- Organic: Associated with an anatomical lesion of the vocal cords.
- Congenital:
- Epidermoid cyst
- Vocal sulci
- Vergeture
- Microsynechiae
- Acquired:
- Traumatic: Traffic accidents, prior intubations
- Inflammatory: Laryngitis, laryngopharyngeal reflux
- Neoplastic
- Neurological
- Post-surgical
- Congenital:
- Functional: Cases in which there is a recurrent and progressive alteration of the voice without an anatomical lesion in the vocal cords—although such a lesion may develop over time. These are caused by misuse of the voice or vocal overexertion.
- Organic-functional: Organic lesions of the vocal apparatus caused by sustained poor vocal habits. According to the European Laryngological Society (ELS), these are also called exudative lesions of Reinke’s space:
- Vocal nodules
- Serous pseudocyst
- Fusiform edema
- Polyps
- Reinke’s edema
- Submucosal cyst
- Vocal cord hemorrhage
- Arytenoid granuloma
What does a voice study involve?
At Altiorem Clinic, we begin with an interview or anamnesis to learn about the characteristics of your voice problem—its frequency, whether it’s worse in the morning or evening, its relationship with vocal effort, etc. Other relevant information includes your profession, professional or amateur singing use, digestive symptoms, smoking habits, and any medical or surgical history.
We then carry out a comprehensive assessment:
- Patient subjective assessment
At Altiorem, we use the Voice Handicap Index (VHI) questionnaires, developed by Jacobson et al. and later validated by the Laryngology, Voice, Phoniatrics, and Swallowing Committee of the Spanish Society of Otolaryngology (SEORL).
This questionnaire provides insight into how vocal pathology affects the patient’s quality of life in functional, physical, and emotional aspects. It is also useful for comparing results before and after treatment.
- Perceptual or psychoacoustic evaluation
This is the specialist’s subjective evaluation of the voice.
Using the GRABS scale (Grade, Rough, Asthenic, Breathy, Strain), we assess the overall degree of dysphonia and the specific qualities of roughness, weakness, breathiness, and tension. - Aerodynamic assessment
Phonation occurs when the expiratory pulmonary airflow travels through the respiratory tract and reaches the vocal cords. The interaction between this airflow and the resistance of the vocal cords produces vibration, which, together with resonance in the upper aerodigestive tract— oropharynx, oral cavity, and paranasal sinuses—creates the voice.
Aerodynamic evaluation measures phonorespiratory efficiency, i.e., the relationship between lung function and laryngeal function.
The patient is instructed to sustain phonation after a forced inhalation for as long as possible, repeating the exercise with the vowels “a”/“e” and the consonant /s/.
- Laryngostroboscopic examination
Fibroscopy is a common ENT examination.
For voice problems, we focus on the phonatory apparatus, aiming for the highest possible magnification and definition. This may involve using a flexible nasal endoscope or a rigid 70º telelaryngoscope through the oral cavity, depending on the case.
Stroboscopic light is essential for this procedure. By emitting flashes of light, it creates an optical illusion that transforms the high-frequency, periodic motion of the vocal cords—imperceptible to the naked eye—into a slow-motion view. This allows us to see the free edge of the vocal cords and identify lesions affecting their movement and closure during phonation, which can cause dysphonia.
We assess glottic closure, periodicity of vocal cycles, symmetry of the vocal cords, and the presence, absence, and characteristics of the mucosal wave.
5. Acoustic analysis and spectrogram
Acoustic analysis evaluates the sound characteristics of the voice.
It measures parameters such as fundamental frequency (pitch), mean intensity, perturbation parameters of pitch and intensity (jitter and shimmer), and glottal noise.
The spectrogram is a graphic representation of the acoustic wave produced during phonation.
How is my voice problem treated?
After the voice study, we reach the most specific diagnosis possible, identifying and classifying the type of dysphonia.
Depending on various factors, treatment may involve medication, rehabilitation (speech therapy), or surgery.
Often, these approaches are combined—for example, anti-inflammatory treatment followed by speech therapy and then phonosurgery; or conversely, surgery followed by rehabilitation.
Your voice specialist at Altiorem will explain in detail your case and the most appropriate treatment options.
Should I repeat this study?
One of the main advantages of a voice study is that it allows for a more accurate diagnosis, which is crucial for determining the right treatment and prognosis.
It is also the best way to measure treatment effectiveness objectively, both before and after intervention. Therefore, we recommend performing the study at both stages.