VOICE DISORDERS AND PHONOSURGERY I1 0030-6665/00 $15.00 +.OO
NOMENCLATURE OF VOICE DISORDERS AND VOCAL PATHOLOGY Clark A. Rosen, MD, and Thomas Murry, PhD This article provides a framework for describing voice disorders and vocal pathology. The terminology used is intended to improve commu- nication among voice care professionals. A comprehensive dictionary of terms relating to voice disorders remains to be developed, in conjunction with improvements in measurements and development of standards. Currently there is no standardized nomenclature regarding voice dis- orders and pathologic conditions of the vocal folds. During a scientific presentation, it is common for a still photograph or video recording of a vocal fold lesion to be shown diagnosed as one type of lesion, only to hear immediate controversy among audience members on the correct name for the pathologic entity. This problem diminishes voice care profession- als ability to communicate clinical and scientific information effectively. This lack of precision also leads to confusion in communication among patients, voice scientists, and voice care professionals. This problem in communication pervades the clinical and the scientific realm and poses a major barrier to advancing the understanding of pathologic vocal condi- tions and their subsequent treatment. The lack of a common nomenclature also makes it difficult to evaluate, compare, and process results reported in clinical and voice science publications and presentations. Cooperation among institutions is limited by the lack of common nomenclature. For example, how could a multicenter trial regarding vocal nodules be con- ducted when there are no accepted diagnostic criteria of vocal nodules? The lack of consensus about nomenclature has occurred partly be- cause of the rapid advancement of knowledge and interest in voice dis- From the Department of OtoIaryngoIogy-Head and Neck Surgery, University of Pittsburgh School of Medicine (CAR, TM); and the University of Pittsburgh Voice Center (CAR), Pittsburgh, Pennsylvania OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA VOLUME 33 * NUMBER 5 - OCTOBER 2000 1035 1036 ROSEN&MURRY orders. Also, voice clinicians use different diagnostic techniques and come from different specialties and training. Thus, multiple nomenclature sys- tems have evolved, none with adequate definitions or classification of pathophysiology. The multidisciplinary nature of voice science and care is often heralded as providing a unique advantage for the study and treat- ment of voice disorders. Nonetheless, it has produced a quagmire of no- menclature which is at best confusing and at worst may lead to incorrect or unnecessary treatments or procedures. A number of classification proposals have been advanced, but these have been limited to specific types of voice disorders such as muscle- tension dysphonia.8,10 Traditional texts have also tried to classify voice disorders as functional or organic, or as disorders resulting from vocal fold closure or the lack of vocal fold closure. These descriptive categories lack reference to pathophysiologic conditions or the presence or absence of a lesion. A more comprehensive classification system would (1) be un- derstood by members of all disciplines involved in voice disorders (sci- entists, physicians, speech pathologists, singing teachers, vocal patholo- gists); (2) account for the presence or absence of a lesion; (3) be consistently used among voice-care professionals; and (4) be objective. The nomencla- ture system should not require extensive diagnostic equipment and should have a direct impact on treatment and outcomes for voice disor- ders. No such global classification system exists at present. Although the following classifications are not meant to be all-encompassing, the goal is to provide a framework for identifying voice disorders and pathologic conditions of the vocal folds. The proposed classification and nomenclature system is based on vi- sual and auditory perceptual evaluation, including laryngeal examina- tion, of the voice-disordered patient. It is also based on the treatments for the variety of problems encountered and is anatomically and physiolog- ically grounded when possible. This classification can be modified and expanded as new knowledge and understanding of voice disorders be- comes available. This system divides all voice disorders into four major categories: nonorganic voice disorders, organic voice problems, move- ment disorders (neuromusmlar control abnormalities), and systemic dis- eases that affect the voice-production system. NONORGANIC VOICE DISORDERS Nonorganic (functional) voice disorders have a common finding of dysphonia associated with normal vocal fold morphology and normal vocal fold motion (as seen on examinations engaging a variety of phon- atory vocal tasks). Disorders that fit into this category include muscle- tension dysphonia, functional dysphonia, conversion dysphonia, and psy- chogenic dysphonia. The concept that vocal fold adduction in conjunction with simultaneous subglottic airflow results in vocal fold vibration and subsequent sound production is generally well accepted. Nonorganic voice problems are predominantly caused by abnormal kinesiology and biomechanics of the larynx in general and of the vocal folds specifically. NOMENCLAW OF VOICE DISORDERS AND VOCAL PATHOLOGY 1037 Other disorders, however, may involve the proper control and coordina- tion of subglottic airflow with vocal position. These disorders have a va- riety of origins, ranging from psychologic to idiopathic, but a common element is dysphonia associated with normal vocal fold anatomy and mo- tion. In nonorganic voice disorders, the overriding problem is the coordi- nation of respiratory effort and vocal fold position or tension. How laryn- geal and vocal fold coordination is controlled, adjusted, and maintained is not well understood. Difficulties in the classification of these voice dis- orders stem from the poor understanding of laryngeal control, feedback, and kinesiology. These voice disorders have traditionally been identified with psychogenic events. Recently, Morrison10 and Koufman8 have de- scribed and classified inappropriate laryngeal postures based primarily on laryngeal activity observed during phonation by flexible, transnasal laryngoscopy.8,*0 The authors propose that the voice disorders in persons with normal morphology and normal vocal fold motion be called functional voice dis- orders, with several subcategories. This classification seems reasonable be- cause the overall anatomy and physiology are thought to be normal, but the ability to use the vocal mechanism for normal voice production is not functional (Fig. 11. Muscle-Tension Dysphonia Patients with dysphonia, not aphonia, and normal vocal fold mor- phology and movement can further be classified as having a form of mus- cle-tension dysphonia (MTD).I0 Additional classification can be based on the specific abnormal laryngeal postures found using a standard exami- nation protocol. The authors suggest that classification be based on the predominate laryngeal posture during connected speech as seen during Functional Dysphonia PRIMARY MTD MTA A P yschogenic Figure 1. Nonorganic voice disorders. MTD =muscle tension dysphonia; MTA =muscle tension aphonia; AP =anterior-posterior supraglottic constriction; FVF =false vocal fold hyperadduction; URI = upper respiratory infection. 1038 ROSEN & MURRY flexible, transnasal l aryngo~copy.~~~~~ Laryngeal posturing associated with MTD can be divided based on the activity of the supraglottis during con- nected speech as supraglottic constriction in the anterior-posterior (AP) dimension (AP squeeze) or in the axial plane from excessive false vocal fold (FVF) hyperadduction during speech. Muscle-tension dysphonia should also be categorized as primary or secondary based on whether organic pathologic conditions contribute to trigger the MTD behavior. If glottal incompetence caused by vocal fold paralysis or vocal fold lesions is present, MTD laryngeal behavior is often present. This is secondary MTD, because it is clearly related to the coex- isting glottal incompetence. Patients with a nonorganic voice disorder associated with minimal or no sound production are classified as having muscle-tension aphonia, signifying that there is minimal or no sound production despite normal vocal fold motion and laryngeal anatomy. Psychogenic Voice Disorders Psychogenic voice disorders involve an abnormal relationship be- tween psyche (personality) and voice. Clearly, there is a relationship be- tween voice and personality, and a pathologic condition in one can affect the other. The voice serves many capacities. It is a mechanism for emo- tional outlet such as a laugh, a cry, or a scream. It is a mechanism for involving and enticing other people, as in arousal, and it is a crucial means of communication, a way to interact with others. For a significant number of people, problems of personality lead to dysfunctional voice use. In these cases, counseling with a psychologist or psychiatrist is effective in ad- dressing the problem. Voice problems of psychogenic nature are problems that are so intertwined with psychologic issues that often even teaching good vocal technique (voice therapy) will not resolve the problem. The patient often reverts to misuse or traumatic use of the larynx as a way of working out personality issues. This condition is often seen in young chil- dren who are excessively loud, crying, and screaming. It is also seen in people who are under significant pressures to perform vocally, for ex- ample, teachers, lecturers, and singers. The treatment for such patients is combined therapy which may include voice, psychologic, and pharma- cologic therapies. Conversion Dysphonia In conversion disorders, some symptom is transferred from the men- tal to the physical realm. These disorders are not fully understood. A conversion disorder becomes evident when someone with a personality disorder finds life to be so difficult that the person escapes by substituting some type of tangible disability (e.g., voice loss) in place of the psychologic problem. The symptom provides a focus of attention and distracts an ex- aminer from the psychologic situation. The substitute symptom is also NOMENCLATURE OF VOICE DISORDERS AND VOCAL PATHOLOGY 1039 more acceptable than the primary disorder. In a conversion disorder, some gain is usually obtained by the person with the problem, and the patient may even temporarily recover only to convert a voice disorder to some other disorder (e.g., to headaches or hand numbness).1o A treatment pro- gram involving counseling, voice therapy, and with supportive care by the family physician and mental health professional is important in the treatment of these disorders. ORGANIC VOICE DISORDERS Organic voice disorders involve actual pathologic changes to the lar- ynx in general and to the vocal folds in specific. Organic voice disorders include vocal nodules, vocal fold cysts, vocal fold polyps, Reinkes edema, vocal fold granuloma, leukoplakia, carcinoma of the vocal fold, and am- yloidosis and sarcoidosis of the larynx. All these disorders involve a physical abnormality of the larynx. The pathologic occurrence is usually in the lamina propria of the vocal fold (vocal fold scarring, vocal fold hemorrhage, vocal fold polyp). Organic Voice Disorders Leu koplakia Hyperkeratosis Carcinoma-in-situ Carcinoma Diffuse Focal 1. Epithelium II. Lesions of the lamina propria Reinkes edema Nodules Polyp Scar Reactive lesion cyst Subepithelial Deep Varices Ectasias 111. Arytenoid Vocal fold granuloma Infection Laryngeal or glottal web Stenosis Vascular IV. Other 1040 ROSEN&MURRY A further classification for voice disorders caused by anatomic ab- normalities can be based on the layered structure of the vocal folds, as described by Hirano.6 The vocal fold can be divided into the epithelium, the lamina propria, and muscle. The authors propose that organic voice disorders be classified as diseases of the epithelium, of the lamina propria, and of the arytenoid cartilage (see box). Voice disorders caused by epithelial abnormalities are usually diag- nosed by histopathologic means or by visual features. Diseases within this category include leukoplakia, keratosis, and malignancy of the squamous epithelium. Classification systems exist for premalignant conditions and malignancies of the vocal folds.' The problems of dysplasia, leukoplakia, and keratosis of the vocal fold are presently poorly understood, and di- agnosis is usually based on a combination of histologic and gross presen- tation features. Classification of malignancy is based on the histology lo- cation, and size of the lesion. Voice disorders associated with abnormalities of the lamina propria are probably the most controversial of all. Most of these entities are focal lesions of the vocal fold, except for Reinke's edema, which can be char- acterized as a diffuse pathologic problem of Reinke's space of the vocal fold. Vocal Nodules Classification of vocal nodules, vocal fold polyps, and vocal fold cysts is difficult, because they all involve pathologic changes of the superficial lamina propria. Vocal nodules are superficial lesions of the lamina propria of the vocal fold (see Color Plate). The pathologic condition is thought to occur at the basement membrane zone and the superficial layer of the lamina pr0pria.3-~Vocal fold polyps and cysts are also benign pathologic entities of the vocal folds that tend to occur at a slightly deeper plane of the lamina propria and usually require combined treatment with voice therapy and phonomicrosurgery. Vocal nodules are typically character- ized as bilateral, midmembranous vocal fold lesions of the basement membrane zone and the superficial layer of the lamina propria. This voice disorder usually responds to nonsurgical treatment methods (see the ar- ticles by Casper and Muny and by Carroll elsewhere in this issue). Lar- yngovideostroboscopic (LVS) examination of vocal nodules reveals an abnormal, hourglass-shaped glottal closure pattern but no or minimal reducfion in the mu- cosal wave amplitude, especially when compared with a vocal fold cyst or p01yp.'~ Vocal Fold Cyst and Vocal Fold Polyp A vocal fold polyp or vocal fold cyst also involves a focal abnormality of the superficial portion of the lamina propria (see Color Plate). These lesions, however, are thought to be either slightly deeper within the lam- ina propria or to consist of different histopathologic changes that are per- manent unless surgically removed. These lesions are usually unilateral, but a reactive lesion is often found on the contralateral vocal fold imme- diately across from the cyst or polyp (see Color Plate). NOMENCLATURE OF VOICE DISORDERS AND VOCAL PATHOLOGY 1041 The reactive lesion is thought to be more responsive to nonsurgical therapy and anatomically more superficial, based on clinical and LVS find- i ng~. ~ Scarring of the vocal fold fits into this category. The etiology, patho- physiology, and treatment of vocal fold scar are discussed in detail else- where (see the article on vocal fold scar by Rosen elsewhere in this issue). Vocal fold cysts can be further classified by their location within the lam- ina propria, superficial or deep. The most common location for vocal fold cysts is within the superficial portion of the lamina propria. These lesions can be called subepithelial vocal fold cysts. The focal nature of the lesion is usually evident on LVS examination. These lesions affect both the shape of the vocalfold free edge and the features of vocal fold vibration seen on LVS e~aminati0n.I~ Deeper vocal fold cysts are found on or involve the vocal fold ligament. These lesions cause minimal or no change in the shape of the vocal fold free edge but usually severely impair the vibratory behavior of the vocal fold. Vascular lesions of the membranous vocal fold have been recently classified by their appearan~e.~,~ These lesions are often associated with other pathologic vocal fold conditions (nodules, scarring, polyps, cysts, and so forth) or can occur as isolated lesions. Reinkes Edema Reinkes edema is a condition also known as polypoid degeneration, in which a chronic accumulation of gelatinous, mucoid material develops in Reinkes space. This condition is usually associated with gastroesoph- ageal reflux disease (GERD), tobacco use, and vocal abuse.2O The treatment addresses the causative factors for the development of Reinkes edema. The mainstay of treatment of Reinkes edema is treatment for GERD, voice therapy, and phonomicrosurgery.20 Vocal Fold Granuloma Vocal fold granuloma is the most common pathologic condition re- lated to the arytenoid cartilage. Vocal fold granuloma is the result of a perichondritis of the arytenoid cartilage in which granulation tissue is deposited and develops at the vocal process of the arytenoid cartilage? The origin is often related to endotracheal tube intubation or is unknown. Idiopathic vocal fold granuloma is often thought to be related to vocal abuse and laryngopharyngeal reflux disease. MOVEMENT DISORDERS OF THE LARYNX Laryngeal movement disorders (neuromuscular control abnormali- ties) involve abnormal movement of the larynx and are usually caused by abnormalities in muscular control. Common disorders within this cate- 1042 ROSEN 81 MURRY gory are unilateral vocal fold paralysis, vocal fold paresis, paradoxical vocal fold motion disorder, bilateral vocal fold paralysis, spasmodic dys- phonia (abductor, adductor, and mixed), and essential tremor of the lar- ynx. Treatment for these different voice disorders is varied. It is best to use descriptive categories for diseases in this category. Voice disorders caused by problems of decreased, increased, or absent vocal fold motion fall into this classification. The problems underlying these voice disorders are either neurologic or muscular in nature. The gross laryngeal muscles and the general innervation sources of the larynx are well understood, but knowledge about specific innervation patterns, muscle subunits, muscle types, and neuromuscular control are poorly un- derstood. 16,17 Vocal Fold Paralysis and Pathologic Conditions of the Cricoarytenoid Joint Dysphonia caused by unilateral vocal fold immobility is probably the best understood and most often studied voice disorder. This category en- compasses patients with a unilateral vocal fold paralysis or a pathologic condition of the cricoarytenoid joint. The latter is usually further catego- rized as originating either from arytenoid dislocation or from cricoaryte- noid joint fixation. Vocal fold immobility may be categorized by the po- sition of the immobile vocal fold, that is, median, paramedian, or lateral. Other important descriptors of an immobile vocal fold include vocal -fold length, tension, and bulk. The position, length, tension, and bulk of an immobile vocal fold often determine the severity of dysphonia and the treatment methods. (See the article on vocal fold injection by Rosen else- where in this issue, and see the articles on paralytic dysphonia by Zeitels and Woo in Otolaryngologic Clinics of North America 33:803-839,2000.) Vocal Fold Paresis or Atrophy An important but poorly understood and described voice disorder is dysphonia related to decreased vocal fold motion, strength, or bulk. This condition is often called vocal fold paresis or vocal fold atrophy. To con- fuse the situation further, the term vocal fold bowing is often used as a diagnosis when it is, in fact, strictly a descriptor. Laryngeal electromy- ography has been used to evaluate these voice disorders, but its use at present is not standardized, and many of its applications are controver- ~i al .~,'~,'~ The authors suggest that vocal fold paresis be used to describe a vocal fold that has demonstrable adductory-abductory motion (not mo- tion caused by the Bernoulli's effect during airflow through the glottis) but in which the motion is not entirely normal in speed, strength, or range of motion. In contrast, vocal fold atrophy should be used to describe an observed decreased bulk of the vocal fold from a variety of reasons (id- iopathic, aging, history of denervation, and so forth). The best method of assessing vocal fold bulk is looking for a drop-off of the membranous vocal fold at the junction of the vocal process and the membranous vocal fold NOMENCLATURE OF VOICE DISORDERS AND VOCAL PATHOLOGY 1043 during adduction (see Color Plate). Looking at the depth of the laryngeal ventricle can also help assess vocal fold atrophy. Patients with vocal fold atrophy often have a deepening of the laryngeal ventricle with an appar- ent loss of muscle bulk in the lateral aspect of the vocal fold. In contrast with vocal fold paresis and atrophy, vocal fold bowing is a descriptive term of vocal fold posture during phonation. Careful exami- nation will show no loss of physical size of the vocal fold (in width or ventricular depth), but only a bowed posture of the vocal fold during attempted phonation. Vocal fold bowing is seen most often in patients with muscle-tension aphonia. The authors propose that the term vocal fold bowing be used only in conjunction with MTD or muscle-tension aphonia voice disorders and not for vocal fold paralysis, paresis, or atrophy. Other Laryngeal Movement Disorders The category of movement disorders of the larynx also includes paradoxical vocal fold motion disorder, spasmodic dysphonia (SD), and essential tremor of the larynx. Each of these disorders is characterized primarily by aberrant movements of the vocal folds or larynx. In para- doxical vocal fold motion disorder, the primary movement disruption occurs during respiration, most often during inhalation. There may also be vocal fold adduction movement during exhalation. The movement is characterized by complete or partial adduction of the true vocal folds dur- ing respiration. Voice quality may be normal or dysphonic. Flexible en- doscopy during quiet breathing will reveal this condition, which can be further substantiated during flow-volume loop spirometry te~ti ng.'~,'~ These patients often present with cough, globus, a sensation of throat tightness, or stridor. Spasmodic dysphonia is a neurogenic disorder of the vocal folds char- acterized by random spasmodic abductory or adductory movements dur- ing phonation. With adductor movement, the abnormal voice quality is perceived as strained, rough, or hoarse. In abductor SD, the voice contains breathy segments and is often described as breathy. Current treatment is with botulinum toxin with adjunctive voice therapy in some cases." (See the article by Gibbs and Blitzer in Otoluryngologic Clinics of North Americu 33:879-894, 2000.) Tremor is a regular movement of the vocal folds superimposed on the basic vocal fold adductor-abductory motion. Tremor can be present during rest or seen only with muscle activation (phonation). As with other neurogenic voice disorders, flexible endoscopy during a variety of vocal tasks provides the best method for diagnosi~.'~,'~ SYSTEMIC DISEASES OF THE VOCAL PRODUCTION TRACT Often systemic diseases have adverse effects on the function of the vocal production tracts and result in a voice change. These diseases in- 1044 ROSEN & MURRY clude reflux laryngitis, which is a manifestation of GERD, infections of the larynx, and many neurologic diseases (e.g., Parkinsons disease). (See the articles by Ulualp and Toohill and Woodson in Otolaryngologic CIinics of North America 33:785-801, 895-903, 2000.) SUMMARY Many dysphonias are caused by multiple disorders (e.g., vocal fold paralysis with contralateral vocal fold atrophy, vocal fold polyp with a contralateral reactive lesion, bilateral vocal fold atrophy and a vocal fold granuloma, secondary MTD with vocal nodules). The classification scheme proposed in this article allows multiple, synchronous, and often directly related diagnoses. A comprehensive nomenclature for describing voice disorders re- mains to be developed. This article broadly categorizes voice disorders according to the presence or absence of pathologic conditions, normal or abnormal function, or the presence or absence of aberrant motion of the vocal folds. Within each of these broad categories, physiology, pathologic conditions, and neurophysiology remain to be classified with appropriate nomenclature. With closer attention to nomenclature, more uniform com- munication in journals, texts, and conferences will lead to improved di- agnosis and appropriate treatment. References 1. American J oint Committee of Cancer: AJCC Cancer Staging Manual, ed 5. Philadelphia, Lippincott Raven, 1997, pp 41-43 2. Benjamin B, Roche J : Vocal granuloma, including sclerosis of the arytenoid cartilage: Radiographic findings. 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Min YB, Finnegan EM, Hoffman HT, et al: A preliminary study of the prognostic role of electromyography in laryngeal paralysis. Otolaryngol Head Neck Surg 111:770-775, 1994 10. Morrison MD, Rammage LA: Muscle misuse voice disorders: Description and classifi- cation. Acta Otolaryngol (Stockh) 113:428-434, 1993 11. Murry T, Woodson GE: Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy. J Voice 9:460-465,1995 pp 13-27 NOMENCLATURE OF VOICE DISORDERS AND VOCAL PATHOLOGY 1045 12. Nunez RA, Rosen CA, Murry T: Dynamic voice evaluation using flexible laryngoscopy. Emedicine: Otolaryngology and Facial Plastics, 2000. Available at: http//www. emedicine.com. Accessed March 1, 2000. 13. Postma GN, Courey MS, Ossoff RH: Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol107472-476,1998 14. Rosen CA, Murry T: Dynamic Assessment Using Flexible Endoscopy [videotape]. San Diego, Singular Publishing, 1997 15. Rosen CA, Murry T, Lombard L: Acoustic AE dynamic of bilateral vocal fold lesions. Annals of Otolaryngology, in press 16. Sanders I, Rai S, Han Y, et al: Human vocalis contains distinct superior and inferior subcompartments: Possible candidates for the two masses of vocal fold vibration. Ann Otol Rhinol Laryngol 107826-833, 1998 17. Sanders I, Wu BL, Mu L, et al: The innervation of the human larynx. Arch Otolaryngol Head Neck Surg 119:934-939,1993 18. Woo P: Laryngeal electromyography is a cost-effective clinically useful tool in the eval- uation of vocal fold function. Arch Otolaryngol Head Neck Surg 124:472-475,1998 19. Yin SS, Qiu WW, Stucker FJ: Major patterns of laryngeal electromyography and their clinical application. Laryngoscope 107126-136, 1997 20. Zeitels SM, Bunting GW, Hillman RE, et al: Reinke's edema: Phonatory mechanisms and management strategies. Ann Otol Rhinol Laryngol 106:533-543, 1997 Address reprint requests to Clark A. Rosen, MD Eye and Ear Institute, Suite 500 200 Lothrop Street Pittsburgh, PA 15213 e-mail crosen8vms.cis.pitt.edu