Functional dysphonia. Causes. Symptoms. Diagnostics. Treatment
Functional dysphonia is a violation of the voice function, characterized by incomplete closure of the vocal cords in the absence of pathological changes in the larynx; is observed in neurotic states.
Fostasthenia, aphonia (functional aphonia), hypotonic dysphonia, (hypokinetic, hypofunctional dysphonia), hypertonic dysphonia (hyperkinetic, hyperfunctional dysphonia), hypo-hypertonic dysphonia (vestibular folding, false voice).
The disease is diagnosed in 40% of patients with a disorder of the voice function. Persistent hypotonic dysphonies account for 80% of the structure of functional disorders of voice formation.
Screening of voice disorders is carried out by assessing the voice by ear, its correspondence to the sex and age of the patient. Changing the height, timbre, strength and working range of the voice, its rapid fatigue, the disruption of phonetic breathing, intelligibility and fluency of speech testifies to the disease of the vocal apparatus,
Depending on the type of voice and the nature of the clamping of the vocal folds, one distinguishes: aphonia; hypo-, hyper- and hypo-hypertonic dysphonia. According to the etiopathogenetic factor, mutational, psychogenic and spastic diafonia are isolated.
Causes of functional dysphonia
The main etiological factors in the development of functional disorders of the voice are constitutional, anatomical, innate features of the vocal apparatus, voice overload, psychotraumatic factors, previously transferred respiratory tract diseases, asthenic syndrome of any etiology. Hypotensive disorders can also form against a background of prolonged silence, as well as after surgical interventions on the larynx with atrophy of the vocal folds. Anxious and depressive disorders are the cause of the development of functional dysphonia in 29.4% and in spastic dysphonia in 7.1% of cases. In 52% of patients with functional dysphonia, hormonal disorders are diagnosed, more often the thyroid gland. Other causes are neurological diseases, such as Parkinson's disease and myasthenia gravis, traumatic brain injury, cerebrovascular accident, etc.
Pathogenesis of functional dysphonia
Functional dysphonia is a manifestation of the violation of processes at different levels of conditioned reflex relationships. With the passage of time, they acquire the character of the pathology of the peripheral part of the vocal apparatus, the larynx.
Functional changes are reversible, but in some cases can lead to organic changes in the larynx. For example, long-term hypotonic dysphonia or psychogenic aphonia leads to the development of atrophic laryngitis with the formation of the groove of the vocal fold. Simultaneously, a false-lining phonation is formed, which causes hypertrophy of the vestibular folds. Hyperkinetic dysphonia is the cause of the formation of persistent violations of microcirculation of the vocal folds and the appearance of granulomas, ulcers, polyps, nodules and other pathologies of the larynx. In elderly patients, the development of functional disorders of the voice function is due to age-related changes in the larynx and the body as a whole; they are characterized by hypotonic dysphonia.
The mechanism of the development of the disease during the mutation of the voice is associated with the discoordination of the transition from the falsetto mechanism of voice formation to the thoracic mechanism. During the mutation period, a change in the frequency of the fundamental tone associated with an increase in the larynx occurs. In boys, the height of the voice decreases by an octave, the vocal folds are extended by 10 mm and thicken. In girls, the height of the voice decreases by 3-4 semitones, and the length of the vocal folds changes by 4 mm. Normally, the mutation is completed within 3-6 months. The causes of pathological mutation can be hormonal disorders and psychoemotional factors.
The pathogenesis of the development of spasmodic dysphonia has not yet been fully studied. The disease is attributed to the focal forms of muscular dystonia along with such a nosology as spastic torticollis, writing spasm, etc.
Symptoms of functional dysphonia
The clinical picture of functional dysphonia is caused by a violation of the voice function of one degree or another.
Hypotone dysphonia is a violation of the voice function, caused by a decrease in the tone of the vocal folds and other muscles involved in the formation of halos. There is a rapid fatigue of the voice, aspirated hoarseness.
Hypertensive dysphonia is a violation of the voice function due to increased tone of the vocal folds. The phonation is carried out with the tension of the muscles of the neck, the voice is sharp, hoarseness pronounced.
Hyper-hypertonic dysphonia (vestibular-folding voice) is a violation of the voice function due to a decrease in the tone of the vocal folds with the formation of phonation at the level of the vestibular folds with the subsequent development of their hypertrophy.
Afoniya - the lack of sonority of the voice while maintaining a whispered speech.
Psychogenic dysphonia or aphonia is a disorder of the voice function, the leading etiological factor of which is considered psychogenic.
Mutational dysphonia is a voice disorder that occurs during a mutation.
Spastic dysphonia is a violation of the voice, characterized by tense-compressed intermittent phonation, trembling, hoarseness, violation of intelligibility of speech. There are abductor and adductor forms. During the speech there is a twitching of the diaphragm. Diagnose the violation of articulation, changes in the psycho-emotional sphere. Clinical neurological examination reveals an organic pathology in the form of dystonic syndromes (such as writing and blepharospasm, torticollis, etc.).
Diagnosis of functional dysphonia
Functional dysphonia is characterized by a prolonged disorder of the vocal function - several weeks, months and even years. Its instability, deterioration of a voice after a load, on a background of deterioration of the general condition, after the transferred viral infections is marked.
Great importance for the diagnosis of voice disorders, especially functional nature, has a subjective voice evaluation, which can be supplemented with stress tests (for example, reading aloud for 40 minutes), as well as psychological testing to identify somatoform disorders. During listening to the speech, attention is paid to the tonality, strength, working dynamic range, timbre, features of the voice attack, diction, the nature of the flash breath, the work of the articulatory apparatus, the condition of the neck muscles and the posture of the subject.
For differential diagnosis of voice disorders, laryngo- micro-laryngo-, micro-laryngostrosis, vibeolaryngostrosis, endofibrolaringo-, tracheoscopy, acoustic voice analysis, timing of maximum phonation, spectral computer voice analysis, external respiration function evaluation, gloto- and electromyography, laryngeal x-ray tomography and trachea, CT of larynx.
With hypotonic dysphonia, a microlaringoscopic examination reveals incomplete closure of the glottis during phonation. Its shape can be different - in the form of an elongated oval, a linear slit or a triangle in the back third of the vocal folds. Atrophic shape is characterized by thinning of the margin of the voice fold in the form of a groove, atrophy of the vocal folds. Mikrolaringostroboscopic research allows to reveal the predominance of weakened lantern oscillations of vocal folds of small or medium amplitude, uniform in frequency. Displacement of the mucous membrane along the edge of the vocal fold is determined quite clearly. Acoustic examination reveals a decrease in the time of maximum phonation on average to 11 seconds, a decrease in the voice intensity in women to 67 dB, in men to 73 dB. At an atrophic form, the lantern oscillations are absent or asynchronous in frequency and amplitude, for all patients the incomplete closure of the glottis is characteristic. The displacement of the mucous membrane along the free edge is not determined. With aphonia, the absence of the closure of the vocal folds during laryngoscopy is noted.
Laryngoscopic picture with hypertonic dysphonia is characterized by an increase in the vascular pattern, the mucous membrane is often hyperemic, with phonation overlapping vocal folds. Gradually, a false voice is formed. With microlaringostroboscopy, lengthening of the clamping phase, oscillations of small amplitude with a slight displacement of the mucosa along the edge are characteristic. Gynertonus dysphonia often leads to the development of granulomas, nodules, hemorrhages of the vocal folds, chronic laryngitis. For a long period of time, a false voice is formed. Develops hypertrophy of the vestibular folds. In some cases, the vocal folds are not visible, and during phonation the vestibular closure is visualized.
With mutational dysphonia, the larynoscopic picture can be normal; sometimes there is an increase in the vascular pattern of the vocal folds, an oval cleft in phonation, or a triangular one in the posterior larynx (the "mutational triangle").
In the abductor form of spasmodic dysphonia, the microlaringoscopic picture is characterized by signs of hyperfunctional dysphonia: recollection of vocal folds, false-phonetic phonation and trembling of the vocal folds, strengthening of the vascular pattern. With an adductor form, the vocal folds do not close under the phonation, forming a gap throughout the entire length.
Differential diagnosis is necessary in case of aphonia with bilateral paralysis of the larynx, when the patient has a voiced cough. It is possible to carry out the test with mute. With the loss of auditory control over the voice, its full restoration is possible.
Indications for consultation of other specialists
In the process of diagnosis and treatment of disorders of the voice function requires a multidisciplinary approach involving the rehabilitation of a neurologist, endocrinologist, psychiatrist and phonopaedist.
Treatment of functional dysphonia
The approach to the treatment of functional dysphonia should be complex. It is necessary to influence on etiopathogenetic factors: treatment of general-somatic diseases, somatomorphic disorders, sanation of foci of chronic infection.
Objectives of treatment
Formation of correct skills of steady phonation, increase of endurance of the vocal apparatus.
Indications for hospitalization
Hospitalization is indicated when surgical treatment is necessary.
The most effective method of treating functional disorders of voice functions is phonopedy. Articulatory and respiratory gymnastics, Actively apply acupuncture, psycho-and physiotherapy, massage of the collar zone. Of the physiotherapy methods for hypotonic dysphonia, it is recommended to use electrical stimulation of the larynx muscles with diadynamic currents, amplipulse, electrophoresis on the larynx with neostigmine methylsulfate. Mutational dysphonia does not require special therapy, except for the treatment of concomitant diseases, rational psychotherapy and phonopedy.
Drug therapy for hypotonic dysphonia includes stimulants (eleutherococcus spiny rhizomes and roots, B vitamins, neostigmine methyl sulfate 10-15 mg orally 2 times a day for 2 weeks, and improving microcirculation of vocal folds preparations.
In hypotypertensive dysphonia and false-fonctional phonation, general and local anti-inflammatory therapy of hypertrophic laryngitis is performed.
Treatment of spastic dysphonia is carried out together with neurologists. Apply GABA-ergic drugs, blockade of the larynx muscles, massage of the neck muscles and phonophoresis.
With pronounced stable hypotonic dysphonia, implant surgery or tyroplasty is indicated, the purpose of which is to enhance the adduction of vocal folds. When pseudosecladic phonation with hypertrophy of the vestibular folds, surgical treatment consists in removing hypertrophied sections of the vestibular folds. In the postoperative period, in addition to anti-inflammatory therapy, conduct phonopedia and stimulating treatment aimed at increasing the tone of true vocal folds.
In some cases, it is necessary to continue the phonopedia within a few months. In the treatment of persons with voice speech professions, especially vocalists, long-term follow-up with correction of the voice load is required.
It should be reminded to the patient that the change in voice is a symptom of the disease of the vocal apparatus, requiring the use of an otorhinolaryngologist for the diagnosis of a vocal disorder; failure to follow the doctor's recommendations, including voice hygiene, can lead to the formation of organic pathology of the larynx.
With functional dysphonia, the duration of disability is individual, an average of 14-21 days.
More often favorable. A persistent violation of the voice function, a prolonged nature of the flow leads to a deterioration in patient communication. Functional voice disorders in the absence of proper therapy reduce the ability of practically healthy people to work, create a threat of working capacity.
Prophylaxis of the disorder of the voice function consists, first and foremost, in observing the hygiene of the voice, the formation of the correct skills of phonation, the setting of the speech and singing voice, especially in the persons of the voice-speech professions. Of great importance are the timely diagnosis and treatment of general diseases, leading to the development of dysphonia.