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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.
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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

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