There are many different causes of hoarseness resulting in a change in the voice. Some of the most common causes include non-cancerous (benign) vocal cord growths and swelling, also known as phonotraumatic lesions. Lesions appear as lumps or bumps on the vocal cords or vocal folds. To understand how they affect the voice and how they can be treated, we need to first look at how sound is created by the voice box when we speak or sing.
Sounds are initiated from the voice box by coordinating multiple muscles in the body, not just the vocal cords. First, our lungs generate a flow of air up through our windpipe as we breathe out. As the air flows through the voice box between the vocal cords, it causes the vocal cords to vibrate, like the flapping of a sail or strumming a pair of guitar strings, to create sound. That initial sound is then modified as it travels through the throat and shaped into words by moving the tongue and lips.
Our vocal cords normally vibrate between 100 to 200 times per second when we speak. When those vibrations are multiplied over the course of a day, we may generate millions of vibrations per day. Phonotrauma is the trauma or stress placed on the vocal cords when we use our voices beyond what our bodies can typically handle. This may occur with vocal overuse, yelling, coughing, vocal use during an upper respiratory infection, or clearing our throat repeatedly.
This high degree of stress on the vocal cords can cause problems, such as swelling or inflammation of the vocal cords, which may be reflected in the quality of our voice the next day. Permanent damage does not typically occur from a single incident. However, repeated injury to your vocal cords can lead to the development of various benign phonotraumatic vocal fold lesions. Continued injury can even lead to scar tissue, which is a difficult problem to treat and may cause permanent hoarseness.
Benign phonotraumatic lesions are generally grouped according to their causes and appearance and include nodules, polyps, and cysts. Scars or a crease on the vocal fold, called sulcus, are extreme examples of what can occur from phonotrauma.
Nodules—These are bumps or calluses that form usually on both vocal cords. They tend to form slowly in response to the day-to-day phonotrauma that builds up over months to years, like the calluses on the bottom of a marathon runner’s feet.
Polyps—These can be caused by a small blood vessel that has popped and is bleeding beneath the surface of the vocal cord and later turns into a blood blister or hemorrhagic polyp. Other times they form from longer periods of stress on the vocal cords like nodules. Most occur only on one vocal cord but can involve both sides.
Cysts—These form under the surface of the vocal cord. Phonotrauma can cause inflammation that blocks the glands that create mucus in the voice box or can cause small tears in the vocal cord allowing skin debris to become trapped. Trapped fluid/mucus or skin debris turns into a cyst that will not drain.
Vocal hygiene—You can take better care of your vocal cords and limit potential problems by:
Voice therapy—Voice therapy is usually prescribed by your ENT (ear, nose, and throat) specialist, or otolaryngologist, and performed by a speech language therapist. Voice therapy consists of physical therapy for the muscles and tissues within the voice box, or larynx, and training you how to correctly use those muscles. Voice therapy teaches you different ways to decrease the impact on your vocal folds when using your voice and how to use your voice more safely and effectively. Some types of phonotraumatic lesions can resolve completely or significantly just with vocal hygiene and voice therapy. A full course of voice therapy varies depending on the severity of the lesion and how long it has been there. Even if surgery is recommended, voice therapy is a very important part of the overall treatment plan and may be most helpful when done both before and after surgery.
Surgery—Surgery for phonotraumatic lesions is sometimes called phonosurgery. This type of surgery is performed by an ENT specialist who is trained to use a microscope or telescope with microscopic instruments to operate on the vocal folds, which are typically only about two centimeters long. The surgery is conducted through the mouth with no incisions on the outside of the neck. This type of surgery may also sometimes involve the use of a laser to treat the lesion. In some cases, a laser procedure treatment can be done in the office by placing a laser fiber through a flexible camera. After the surgery, you usually would be on voice rest (i.e., no talking, whispering, coughing, or clearing the throat) for anywhere between three to seven days depending on your situation.
Phonotrauma and phonotraumatic lesions are quite common but often left undiagnosed. Voice rest and improved vocal hygiene alone can help let your body heal but may not completely resolve voice symptoms. In more chronic cases, voice therapy is typically done prior to a surgical procedure to improve underlying vocal behaviors and increase the chance of full recovery. Finally, if surgery or other procedures (such as laser treatment) are needed, most patients recover and improve or regain their voices. The recovery process varies based on underlying factors of the phonotrauma and careful transition back to normal voice use may take several weeks to months. It is important to work with your ENT specialist, speech therapist, or both to achieve the best possible voice outcome.