Voice and Resonance Disorders 73Diseases affecting the cerebellum can result in ataxic dysphonia, but usually do not cause
changes in the vocal cords that can be observed on visual inspection, as noted previously, because
the cerebellum regulates and coordinates fine motor movements, pitch, and loudness, and voice
quality changes may be heard. Extrapyramidal dysphonias may be quick or slow. According to
Aronson (1990), quick, jerky, irregular, and unpredictable laryngeal movements can be caused
by damage to the basal ganglia. These unwanted movements result in sudden forced inspiration
or expiration, excess volume variations, and voice quality changes. Dystonia and athetosis are
slower forms of hyperkinesia and result in pitch, loudness, phrasing, and voice quality disorders.
(Prolonged use of medi cation can cause tardive dyskinesia and resulting dysphonia.) Parkinson’s
disease, resulting from damage to the extrapyramidal system and a reduction in the neurotrans-
mitter dopamine, causes hypokinetic dysarthria with slow, unwanted laryngeal movements.
Patients with Parkinson’s disease often have laryngeal tremor, reduced volume, and monopitch.
Upper (pseudobulbar) and lower (bulbar) motor neuron damage can result in spastic and f laccid
vocal cord functioning, respectively. Typically, spastic dysphonia results in a harsh voice, with
restricted pitch and loudness, and f laccid dysphonia results in a breathy voice quality. Voice thera-
py for these diseases depends on the type of dysfunction and may include behavioral management,
counseling, and instruction to reduce unwanted movements; improving the strength and tone of
muscles; and exercises to improve loudness, voice quality, and pitch modulation.
Voice Disorders Related to Vocal Strain and Abuse
Vocal nodules, polyps, and contact ulcers are the primary voice disorders related to vocal
strain and abuse. The list of vocally abusive be hav iors is long and includes talking too loudly and
too much, speaking at a suboptimal pitch, hard glottal attacks, frequent and abusive throat clear-
ing, abusive singing, and others. Exposure to irritating chemical fumes, acid ref lux, the use of
cigarettes and other tobacco products, and excessive use of alcohol also can be vocally abusive. As
discussed at the beginning of this chapter, the vocal cords vibrate very rapidly, and even a small
amount of vocally abusive be hav ior can result in vocal nodules, polyps, and contact ulcers. These
growths usually occur on the vocal cord opposite the dominant hand and at the juncture of the
anterior and middle commissures of the vocal pro cess, the point of maximal contact force during
most phonation. “Voice prob lems lead not only to deviant vocal structures and qualities, but also
to functional and emotional impacts on the individual” (Ma & Yiu, 2012, p. 259).
Vocal nodules, benign tumors about the size of a peppercorn, can occur on either or both vocal
cords. They are more common in women and are sometimes called teachers’, preachers’, and sing-
ers’ nodes. Female teachers tend to have voice prob lems more frequently than male teachers (Smith,
Kirchner, Taylor, Hoffman, & Lemke, 1998), and teaching effectiveness is linked directly to the
use of the voice (Schmidt, Andrews, & McCutcheon, 1998). A vocal polyp is a f luid- filled blister
that may be sessile (broad based) or pedunculated (hanging down from a stem). Some physicians
consider vocal polyps and prenodules to be precancerous. A contact ulcer is an abrasion of the
vocal cords. It is more common in men than in women, and the ulceration may be granulated. A
granuloma is a firm, per sis tent, inf lammatory lesion (Dirckx, 2001).
The goal of treating voice disorders resulting from vocal strain and abuse is to eliminate or
minimize the vocally abusive habits. For patients with gaps between their habitual and optimal
pitch, be hav ior modification, instruction, and counseling can be used to help them use their
optimal pitch habitually. These methods can also be used to reduce the frequency and severity of
hard glottal attacks, abusive throat clearing, and loud, excessive speaking. For singers, instruction
and training by professional coaches may be required. Ending the patient’s exposure to irritating
chemicals and providing medical management of acid ref lux also may be warranted, particularly
for those with contact ulcers. It is desirable, but often difficult, to have patients stop using tobacco
products and alcohol. Teaching the patient to speak with more relaxed laryngeal muscles also helps
to reduce vocal fold contact pressure (Tanner, 1991, 2003c). According to Ma and Yiu (2012), acu-
punc ture is an effective treatment for phonotrauma.