Aphonia: functional, organic, psychogenic, true aphonia

The loss of the ability to produce a voice is called "aphonia". A person speaks only in a whisper, without the hoarseness or wheezing characteristic of dysphonic disorders. All patients with aphonia should be carefully examined. Treatment measures are carried out depending on the causes of the disorder. Competent and timely treatment allows you to quickly restore your voice without losing or distorting the tonality.

Epidemiology

Voice disorders often become a reason for seeking medical help: about 0.25% of all outpatients and more than 3% of all otolaryngological patients seek medical help with complaints of such disorders. In addition, many cases of aphonia are recurrent pathologies (more than 10%). According to clinical observations, aphonia, regardless of its origin, is closely associated with a stress factor, mental disorder (most often with anxiety-depressive disorders).

According to various statistics, the prevalence of phoniatric diseases is estimated at 3-9%, and throughout life, aphonia to one degree or another occurs in 15-28% of people.

Voice loss is more common in women than in men. The prevalence among pediatric patients is from 3 to 45%, and among elderly people aged 70-80 years – up to 35%. However, no clear dependence of aphonia development on age has been found.

Over the past decade, doctors have noted a sharp increase in the number of patients with functional disorders of the vocal apparatus. According to experts, this is due to increased stress on the nervous system and the human psyche. Laryngeal pathologies that complicate speech communication negatively affect performance and increase the risks of professional unsuitability.

Causes aphonies

The causes of aphonia can be different, for example:

• Inflammatory processes affecting the larynx (acute or chronic laryngitis, laryngotracheitis). The inflammatory reaction leads to the appearance of edema, which suppresses the function of the vocal cords.
• Chemical intoxications cause tissue damage and swelling similar to a post-inflammatory allergic reaction.
• Tumor processes in the larynx such as fibrosis or papillomatosis, as well as laryngeal cancer, as well as perilaryngeal oncology - for example, tumors of the trachea or esophagus.
• Traumatic injuries to the larynx and vocal folds – in particular, injuries from foreign objects, or as a result of surgical or resuscitation procedures (example: tracheotomy and intubation). [ 1 ]
• Peripheral paralysis, damage to the recurrent nerve during surgery for tumor processes or thyroid dysfunction.
• Central paralysis, typical of strokes, traumatic brain injuries, cancer, microbial infections, and intoxications. [ 2 ]
• Myopathies and other muscle disorders affecting the vocal cords.
• Hysterically conditioned laryngeal paralysis caused by states of hypo- or hypertonia in neuroses, psychoses, hysteria, neurasthenia.
• Excessive strain on the vocal cords, lack of treatment for dysphonia.
• Occupational hazards: toxic smoke, steam and gas exposure.
• Psychogenic factors: severe fright, nervous stress, a conflict situation accompanied by strong emotional shock, as well as other conditions that contribute to the release of a large amount of adrenaline into the blood with an expansion of the excitation zone in the cerebral cortex.

Experts say that the immediate cause of aphonia is the lack or insufficient closure of the vocal cords. This disorder is provoked by functional or organic factors.

Risk factors

Provoking factors that can lead to the development of aphonia may include:

• weakness, instability of the nervous system, tendency to painfully experience stress, quarrels, and insults;
• forced frequent changes in vocal activity (from loud speech and shouting to complete prolonged silence);
• frequent laryngitis, tonsillitis;
• long-term use of anabolic steroids;
• working in conditions of constant noise, or staying in smoky, hot workshops, dusty rooms with poor ventilation;
• work that involves regular exposure to the outdoors (including during the cold season);
• childhood and old age;
• bad habits (mostly smoking and drinking alcohol);
• diseases of the digestive tract or thyroid gland;
• congenital defects in the development of the larynx.

Pathogenesis

The vocal mechanism combines all the organs that participate in the creation and reproduction of sounds. One of these organs is the larynx. The air flow from the lungs exits through the glottis, formed by the vocal folds adjoining each other. The basic vocal characteristics are determined by the degree of air pressure, the vibration frequency of the elastic ligaments, and the magnitude of their opening. The tonality, timbre, and volume of the voice depend on these indicators.

Voice formation is completely controlled in the cerebral cortex and the central nervous system. Frequent psychogenic triggers for the development of aphonia are associated with this. The oropharyngeal mechanism and paranasal sinuses also play a role in the formation of vocal sound, but they have virtually no effect on the development of aphonia.

Since the voice is a sound vibration at a certain frequency, which is the result of vibrations of the vocal cords under the influence of the air flow, then if they are not sufficiently closed, the sound is not formed, since there is no resonance. To put it simply, the essence of aphonia is the non-adjacent vocal cords. In general, aphonia is divided into several varieties, depending on the cause of the disorder.

The absence of resonance is largely associated with the state of muscle tone. This determines such types of pathology as hypotonic and hypertonic aphonia.

The functional type of aphonia is considered reversible, although in some patients this disorder entails organic changes in the larynx. For example, prolonged hypotonia or psychogenic type of aphonia entail the development of atrophic laryngitis with the formation of a groove of the elastic ligament. Along with this, false fold phonation is formed, leading to hypertrophy of the vestibular folds.

Symptoms aphonies

In case of functional aphonia (not organic), the patient has a loud sounding cough, which indicates the presence of the voice-forming function. Instability, instability of painful changes in the larynx area is typical: the formed edema, redness, compaction of the vocal cords and their incomplete closure are always temporary, transient.

In case of organic origin of the disorder, the symptoms are stable, and the otolaryngologist notes the same clinical picture during each examination. In addition, almost all aphonias are characterized by sensitivity disorders: patients note a feeling of dry mucous membranes, a feeling of pressure or a foreign object in the throat, sometimes pain. In all cases, there is general neurotic symptoms:

• increased irritability;
• mood swings;
• sleep disorders;
• suspiciousness;
• negative thoughts, pessimistic attitude.

Functional aphonia most often makes itself known as a consequence of acute laryngitis in patients prone to neuroses. In such a situation, the loss of the ability to speak out loud is quite stable, despite the fact that local painful signs of laryngitis are no longer present.

In some patients, the functional type of aphonia develops suddenly, abruptly, under the influence of strong emotions, fear, or stress.

Functional pathologies are characterized by both general neurological and local signs. General neurological symptoms include:

• anxiety, gloomy mood, worries;
• depression, various kinds of fears and pessimism;
• irritability, irascibility, mood instability;
• worsening sleep, apathy.

Local symptoms include sensory and secretory disturbances.

The true form of pathology is observed against the background of laryngeal disorders, in which there is poor closure or insufficient vibration of the vocal cords, which is the result of inflammatory diseases, tumor or cicatricial processes. In addition, aphonia can be one of the first symptoms of croup in diphtheria.

Aphonia in children

Disorders of the voice function in children are closely connected with the development of the whole organism, with the formation of the nervous and endocrine systems, respiratory and articulatory apparatus. Central organic voice disorders can be provoked by paralysis or paresis of the vocal cords. Often such disorders are typical for patients with cerebral palsy.

Peripheral organic disorders are most often caused by various inflammatory processes, as well as the following pathologies:

• laryngitis;
• traumatic injuries, including burns of the larynx;
• peripheral paralysis and paresis;
• neoplasms in the larynx;
• postoperative cicatricial changes, laryngeal stenosis.

Other causes include: severe fright, shock, stress, excessive psycho-emotional and vocal loads. In addition, aphonia often occurs against the background of respiratory pathologies - especially if the child did not adhere to a gentle vocal regime during treatment.

In case of organic disorders, children are prescribed general and local drug therapy. A common and necessary method is also working with a psychologist and speech therapist. Such classes should be conducted as early as possible, which will allow achieving the most positive result and preventing the fixation of voice disorders and the development of neurotic reactions. [ 3 ]

The main treatment measures for the correction of aphonia in childhood:

• work with a psychotherapist and speech therapist;
• breathing exercises;
• articulation gymnastics;
• phonopedic exercises;
• massages (including the so-called “speech therapy” massage).

Stages

Voice formation occurs in stages:

• Stage 1 – air accumulates in the lungs and is released through the laryngeal cavity with exhalation.
• Stage II – during the process of passing through the glottis, air provokes vibrational oscillations of the vocal cords: the voice is formed.
• Stage III – the formed sound spreads to the area of the palate, tongue, teeth and lips: speech is formed.

Any disturbance in this mechanism of voice reproduction entails a change in the voice and, in particular, the development of aphonia.

Forms

Since many causes and mechanisms of aphonia are known, doctors identify the disease according to the following varieties:

• Functional aphonia is a consequence of reflex mechanical disorders, excessive tension of the vocal folds (loud singing, screaming, squealing). Psychogenic aphonia, the causes of which are psychoemotional or stress overstrain, also belongs to the category of functional voice dysfunctions. Most often, this form of the disease is diagnosed in female patients and children. Hysterical aphonia, in which the voice is lost, has approximately the same development mechanism, but the person is quite capable of coughing loudly or laughing. The hysterical type of dysfunction develops as a result of the impact of a powerful nerve impulse on the department responsible for phonation processes. [ 4 ]
• True aphonia (also known as laryngeal aphonia) develops when the larynx is affected by all sorts of infectious diseases. In particular, this may be aphonia with laryngitis or diphtheria croup. Among other causes of the true form of pathology, one can name muscular laryngeal paralysis, which occurs as a result of cerebrovascular accidents or craniocerebral trauma. A less common cause is considered to be tumor processes that prevent adequate closure and vibration of the folds.
• Aphonia of central origin refers to functional variants of the disorder. The disorder occurs suddenly, as a reaction to psychological trauma in people prone to hysteria. Non-closure of the vocal cords during diagnostics reveals variability, which is one of the signs of the psychogenic origin of the pathology. This type of aphonia can exist for a long period of time, but even after the restoration of the vocal function, relapses are not excluded.

There are also central aphonias of organic origin, the causes of which are brain disorders, cerebral palsy, and dysarthria.

• Spastic aphonia is caused by muscle spasm in the larynx. As a result of spastic contraction, the gap between the elastic ligaments narrows, making vibrational oscillations impossible. The spastic variant is characterized by laryngeal pain and difficulty swallowing.

Complications and consequences

Some types of aphonia – for example, those associated with impaired innervation of the laryngeal region, or with a malignant tumor of the larynx – can lead to a complete loss of vocal function.

If the voice is lost due to infectious and inflammatory pathologies of the ENT organs, or as a result of stressful situations, then in such cases there is every chance for its restoration, provided that the underlying disease is treated in a timely and competent manner.

The occurrence of aphonia in childhood is especially dangerous. If such a disorder is persistent and continues for a long time, it can negatively affect the child's speech and cognitive development, complicating social and everyday communication. In adult patients, aphonia causes difficulties in performing professional duties.

Psychogenic aphonia is especially prone to consolidation and further persistent existence. This entails the development of a chronic voice disorder, with regular and frequent exacerbations. Such patients often experience a decrease in emotional background, negativism and pessimism are noted: patients refuse to believe in the success of treatment, depressive states develop.

Diagnostics aphonies

Diagnostic examination of a patient with aphonia begins with a survey, during which the doctor finds out the most likely causes, triggers for the disorder, as well as associated problems. For example, the doctor will definitely specify the presence of pain in the throat, larynx, a feeling of irritation, burning, general weakness, etc.

The doctor needs to carefully examine the patient's head and neck, palpate possible formations in the neck, tongue, and oral cavity. The larynx and surrounding structures require special attention: the examination is carried out using indirect laryngoscopy, a mirror, and a light source.

An alternative method may be fiber-optic laryngoscopy, which allows for a full examination of the larynx and observation of the vocal cords. If pathological neoplasms are detected, direct laryngoscopy is performed with the possibility of taking samples of biomaterial for biopsy.

Additional instrumental diagnostics may include computed tomography, nuclear magnetic resonance imaging of the head and neck, as well as endoscopy and chest X-ray.

The quality of laryngeal function can be determined more clearly using laryngostroboscopy, and laryngeal electromyography helps to determine what triggered the development of aphonia: deterioration of innervation or muscle pathologies. [ 5 ]

Laboratory tests do not have specific deviations, so the following are usually prescribed:

• clinical blood test with a detailed leukocyte formula to detect symptoms of allergic or infectious-inflammatory processes in the body;
• a pharyngeal swab to identify the pathogen if an infectious process with damage to the larynx is suspected;
• study of hormone levels in the blood (TSH, thyroxine, triiodothyronine – to assess the likelihood of endocrine pathology).

Differential diagnosis

Differentiation of diseases is carried out jointly with an otolaryngologist, psychologist and psychiatrist. Radiography of the larynx and trachea, laryngoscopy, tracheoscopy, laryngostroboscopy, endofibrolaryngoscopy are mandatory, acoustic voice examination, electromyography and glottography are carried out, and the function of external respiration is assessed.

The indicated studies allow to quickly differentiate between dysphonia and aphonia:

• Hypotonic dysphonia in microlaryngoscopy is characterized by incomplete closure of the glottis during phonation. The configuration of the slit may be different - like an elongated oval, line or triangle.
• The atrophic form is characterized by thinning of the vocal fold borders according to the sulcal type and atrophy of the vocal folds. During microlaryngostroboscopy, a predominant weakening of the phonatory oscillations of the vocal folds of small and medium amplitude, with a uniform frequency, is determined. The displacement of the mucous tissue along the border of the vocal fold is noticeably expressed. Acoustic examination reveals a shortening of the duration of maximum phonation to approximately 11 seconds. Phonatory oscillations are not noted, or there is frequency and amplitude asynchrony. One of the typical signs: incomplete closure of the glottis.
• Hypertonic dysphonia is manifested by an increased vascular pattern, hyperemia of the mucous tissue, and closure of the vocal cords during phonation. Microlaryngostroboscopy reveals an extended closure phase, low-amplitude oscillations with a slight displacement of the mucous edges. With hypertonicity, granulomas, nodular elements, hemorrhages, and chronic laryngitis are often determined. The vestibular folds are hypertrophied.
• Mutational dysphonia does not always give a laryngoscopic picture. Increased vascular pattern of the vocal folds, ovality of the slit during phonation or triangularity in the posterior laryngeal region are possible.
• The abductor type of spasmodic dysphonia is manifested by symptoms of hyperfunction: closure of the vocal folds, false fold phonation, tremor of the folds, and increased vascular pattern.

First of all, it is necessary to differentiate aphonia from bilateral laryngeal paralysis and dysphonia. Dysphonia denotes a disorder of the vocal function, manifested by hoarseness, huskiness, and voice changes. With a complete loss of vocal sound and transition to a whisper, they speak of aphonia.

Treatment aphonies

Treatment tactics for aphonia depend on the underlying cause of the disorder.

The true form of pathology requires removal of the tumor, excision of scar tissue, etc. At the same time, it is necessary to provide vocal rest. Physiotherapy is indicated.

The paralytic form is difficult to treat, or cannot be treated at all, unless the cause of the problem is eradicated (esophageal tumor, aortic aneurysm, inflammatory reaction, etc.).

The spastic and functional form of the disease requires general strengthening therapy against the background of taking sedatives. Psychotherapist sessions, breathing and phonopedic exercises are also recommended.

The functional form may require long-term treatment: everything depends on the depth of the neurosis and the general condition of the patient. Regular work with a psychotherapist is necessary. Drug therapy involves taking tranquilizers against the background of physiotherapy procedures. [ 6 ]

If aphonia developed against the background of a viral infection or a cold, then medications corresponding to these diseases are prescribed. If after recovery from ARVI or flu the voice does not recover, then additional diagnostics are prescribed.

If the cause of aphonia is thyroid dysfunction, then a consultation with an endocrinologist with further normalization of the hormonal balance will be required.

When loss of voice and prolonged dry cough are combined, the doctor prescribes bronchodilators to eliminate the sore throat and dryness. After eliminating such problems, the vocal function usually returns to normal.

Swelling of the throat that accompanies aphonia is eliminated by taking antiallergic (antihistamine) drugs.

Patients with the psychogenic form of the disease are recommended psychoanalytic consultations and suggestotherapy. Autogenic training has a good effect, and in advanced cases, hypnotherapy helps. Many patients require correction of other disorders that could provoke loss of voice. A positive attitude and instilling faith in the patient in the success of the treatment play a major role.

Cases of aphonia in childhood, which could be caused by foreign objects entering the throat or larynx, require urgent measures. After removing such an object, the doctor must carefully examine the patient to exclude damage to the mucous tissues. [ 7 ]

Medicines

Medicines are prescribed as part of complex therapy, with the obligatory condition of observing a gentle regimen for the larynx. The following medications can be used:

• Tincture of ginseng, magnolia vine, and other stimulants and vitamins help eliminate hypotonic aphonia, improve microcirculation and restore the ability to speak.
  • Take 20 drops of lemongrass tincture three times a day 15 minutes before meals for two weeks. The drug is contraindicated for children under 12 years of age. May cause allergies.
  • Ginseng tincture is taken in the first half of the day, 20 drops half an hour before meals, twice a day for a month. During the treatment, increased excitability, sleep disturbances, headaches, and increased heart rate may be observed.
• Psychotropic drugs, tranquilizers, neuroleptics, antidepressants and antispasmodic drugs can eliminate hyperkinetic aphonia.
  • Adaptol is a tranquilizer drug that is taken 500 mg twice a day. The duration of treatment is determined individually. Possible side effects: decreased blood pressure, dizziness, weakness.
  • Tranquilizer - taken orally at 0.5-1 mg 2-3 times a day, with a possible increase in dosage. Duration of treatment is 2 weeks, with gradual withdrawal of the drug. Contraindications for use: children under 18 years old, closed-angle glaucoma.
• Spasms are eliminated with the help of γ-aminobutyric acid and Aminolone preparations.
  • Aminolone is prescribed in individual dosages. Treatment can last for several weeks. Possible side effects: nausea, instability of blood pressure, digestive disorders, sleep disorders.
• Vitamin and homeopathic preparations help speed up recovery and quickly restore lost function.
  • Homeovox is a homeopathic multi-component remedy that is taken orally between meals, 2 tablets every hour (on the first day), then 2 tablets five times a day. The duration of treatment is one week. Allergic reactions to the drug are possible.
• Antiviral drugs and immunomodulators may be prescribed for acute respiratory viral infections and flu. Antibiotics and sulfanilamide drugs are indicated for inflammatory bacterial diseases.

Physiotherapy treatment

Physiotherapy is prescribed to patients with aphonia according to individual indications, since not only the features of the pathology are taken into account, but also its causes and stage, age and other factors. The treatment is almost always perceived positively, there are no side effects.

The main methods used are:

• Inductothermy involves the use of a high-frequency alternating magnetic field. The procedure causes vasodilation in the area of impact, accelerates blood circulation, stops the inflammatory reaction, and resolves infiltrates. At the same time, muscle tone and excitability of nerve receptors are reduced, which causes spasmolytic, analgesic, and sedative effects.
• UHF therapy is based on the influence of ultra-high-frequency electromagnetic field. UHF has an anti-inflammatory spasmolytic effect, reduces tissue swelling, activates cell proliferation, and relieves pain. Indications for the procedure include tonsillitis, laryngitis, neuritis, acute and chronic inflammatory processes of the ENT organs.
• Magnetotherapy is based on the effect of an alternating low-frequency magnetic field on a specific area of the body. The procedure provides an analgesic, antispasmodic, anti-inflammatory and anti-edematous effect, normalizes the tone of blood and lymphatic vessels, improves the functioning of the autonomic and endocrine systems, and also helps improve the patient's psycho-emotional state.
• Ultrasound therapy has a chemical-physical, mechanical and slight thermal effect. Ultrasound waves have a strong analgesic, anti-inflammatory, antispasmodic, antihistamine effect, improve tissue trophism.

The most common physiotherapeutic method for treating aphonia is electrical stimulation. This procedure involves the use of pulsed currents that change the functional state of the muscles and nerves. Thanks to electrical stimulation, it is possible to maintain the contractile properties of the muscles, increase blood circulation, optimize tissue metabolism, and prevent the development of atrophic processes. The procedure is especially indicated if aphonia develops against the background of paresis of the laryngeal muscles.

Auxiliary methods of influence may include:

• hydrotherapy, balneotherapy;
• massage of the neck and shoulder area;
• acupuncture;
• electrosleep.

Herbal treatment

In order to restore vocal function in case of aphonia, you can additionally use effective herbal remedies:

• Take half a glass of anise seed, boil for about 15 minutes in 200 ml of water. After cooling, filter the decoction, add 1 tbsp. honey and the same amount of cognac. This remedy is taken 10-15 minutes after meals three times a day.
• A decoction of marshmallow flowers (can be replaced with pharmacy syrup) is mixed with honey and drunk 1-2 tablespoons three times a day, swallowing little by little.
• Drink a warm decoction of zucchini or cucumber with honey. This helps to soften the throat area and speed up recovery.
• Take 100 g of leeks, chop and boil in 500 ml of boiling water for 15 minutes. Filter and take a couple of sips several times a day.
• Pour 1 tbsp of thyme herb with 200 ml of boiling water, keep under the lid for 10 minutes, filter, add honey and lemon juice. Drink throughout the day instead of tea.
• Drink an infusion of boiling water and tangerine peel several times a day.
• Boil ½ teaspoon of cloves in 500 ml of water for 10 minutes. Add honey and lemon juice. Take warm, a few sips shortly before bed.

In addition to such treatment for aphonia, it is necessary to follow several more rules:

• give up bad habits (smoking and drinking alcohol);
• regularly moisturize the throat area;
• avoid spicy seasonings, too hot or too cold dishes;
• avoid straining your vocal cords (you shouldn’t even speak in a whisper for long);
• monitor the state of the nervous system, pay attention to the quality of digestive processes and the functioning of the thyroid gland.

Surgical treatment

Surgical assistance is required only in case of persistent aphonia caused by hypotonia: implantation surgery or thyroplasty is indicated, which are performed to enhance the adduction of the vocal folds.

False fold phonation with hypertrophied vestibular folds requires surgical removal of hypertrophic areas. After surgery, anti-inflammatory drugs are prescribed, phonopedics and stimulating therapy are connected, aimed at improving the tone of the true vocal folds.

Laryngoplasty, thyroplasty, tracheostomy - these interventions are indicated for patients with persistent aphonia that does not respond to medication. To restore voice function, the surgeon excises scars and removes tumors.

Prevention

Prevention of aphonia and other similar dysfunctions consists of a number of important points. Firstly, it is necessary to understand that a temporary disruption of voice reproduction, which occurred as a result of laryngitis, overfatigue, intoxication, can pass without a trace only when the reproduction apparatus is provided with rest and the maximum gentle regime without any vocal load. If this is not done, then aphonia will become more stable, secondary mental problems will be added.

Temporary loss of voice due to stress, severe fear is often associated with disorders of other body functions. Most often, after a certain time, the person's condition stabilizes, the voice and speech are restored. However, it is important to know that such recovery usually occurs with some delay, because the impaired functions of other organs and systems must first normalize. Doctors advise: do not rush. It is better to temporarily protect the speech apparatus and consciously give the body the opportunity to "come to its senses" on its own.

In general, prevention should consist of strengthening the nervous system and preventing neuroses. And prevention of voice dysfunctions (including those of an organic nature) is aimed at preventing possible causes of this disorder.

Forecast

The voice is one of the most important components of speech function. It is not only the ability to communicate: the voice determines individuality and self-expression. Therefore, it is not surprising that aphonia is often caused by mental pathology, psychotraumatic factors.

Disorders of vocal functions can have different outcomes, depending on the causes, mechanism of development and neglect of the disorder. If the disorder exists for a long time, then the person's communication skills suffer and deteriorate. And without treatment, not only is the ability to work lost: the voice may not be restored at all. To prevent this from happening, it is necessary to visit a doctor as soon as possible, already at the first signs of a problem.

Functional dysfunction has a favorable prognosis for most patients. For the true and paralytic forms of the disease, the prognosis can be favorable only if the underlying pathology is cured. Aphonia caused by an inflammatory process in the vast majority of cases is cured on its own after the inflammation is relieved.