Aphonia: functional, organic, psychogenic, true

The loss of the ability to utter a voice is called aphonia. At the same time, a person speaks only in a whisper, without hoarseness, wheezing, characteristic of dysphonic disorders. All patients with aphonia should be monitored carefully. Therapeutic measures are carried out, depending on the causes of the violation. Competent and timely treatment allows you to quickly return your voice without losing or distorting the tone. 

Epidemiology

Voice disorders are often the reason for seeking medical help: about 0.25% of all outpatients and more than 3% of all otolaryngological patients go to doctors with complaints of such disorders. In addition, many cases of aphonia are related to recurrent pathologies (more than 10%). According to clinical observations, aphonia, regardless of origin, is closely associated with a stress factor, mental disorder (most often - with anxiety-depressive disorders).

According to various statistics, the prevalence of phoniatric diseases is estimated at 3-9%, and throughout life, aphonia to one degree or another occurs in 15-28% of people.

Loss of voice is more common in women than in men. Distribution among pediatric patients - from 3 to 45%, and in elderly people 70-80 years old - up to 35%. Nevertheless, no unambiguous dependence of the development of aphonia on age was found.

Over the past decade, doctors have noted a sharp increase in the number of patients with functional disorders of the vocal apparatus. This is due, according to experts, an increase in the load on the nervous system and human psyche. Laryngeal pathologies that complicate verbal communication negatively affect performance and increase the risks of professional unfitness.

Causes of the aphonia

The reasons for the appearance of aphonia are different, for example:

• Inflammatory processes affecting the larynx (acute or chronic laryngitis, laryngotracheitis). The inflammatory response results in edema, which suppresses the function of the vocal cords.
• Chemical intoxication causes tissue damage and edema as a post-inflammatory allergic reaction.
• Tumor processes in the larynx region of the type of fibrosis or papillomatosis, as well as laryngeal cancer, as well as peri-laryngeal oncology - for example, tumors of the trachea or esophagus.
• Traumatic injuries to the laryngeal region and vocal folds - in particular, trauma from the ingress of foreign objects, or as a result of surgical or resuscitation manipulations (example: tracheotomy and intubation). [1]
• Peripheral paralysis, damage to the recurrent nerve during surgery for tumor processes or thyroid dysfunction.
• Central paralysis, characteristic of strokes, craniocerebral trauma, cancer, microbial infections, intoxication. [2]
• Myopathies and other muscle disorders affecting the vocal cords.
• Hysterically conditioned laryngeal paralysis caused by states of hypo or hypertonicity in neuroses, psychosis, hysteria, neurasthenia.
• Excessive tension of the vocal cords, lack of treatment for dysphonia.
• Occupational hazards: toxic smoke, steam and gas exposure.
• Psychogenic factors: severe fright, nervous stress, a conflict situation accompanied by a strong emotional shock, as well as other conditions that contribute to the release of a large volume of adrenaline into the bloodstream with an expansion of the excitation zone in the cerebral cortex.

Experts call the immediate cause of aphonia the absent or insufficient closure of the vocal cords. Such a violation is provoked by functional or organic factors.

Risk factors

The provoking factors that can lead to the development of aphonia can be:

• weakness, lability of the nervous system, a tendency to painfully experience stress, quarrels, resentments;
• forced frequent drops in vocal activity (from loud speech and screaming to complete prolonged silence);
• frequent laryngitis, tonsillitis;
• long-term use of anabolic steroids;
• work in conditions of constant noise, or stay in smoky hot workshops, dusty rooms with poor ventilation;
• work associated with regular stay on the street (including during the cold season);
• children and old age;
• bad habits (mostly smoking and drinking alcohol);
• diseases of the digestive tract or thyroid gland;
• congenital defects in the development of the larynx.

Pathogenesis

The vocal mechanism combines all the organs that are involved in the creation and reproduction of sounds. One of these organs is the larynx. Through the glottis, formed by adjoining vocal folds, air flows from the lungs. In this case, the basic vocal characteristics are determined by the degree of air pressure, the vibrational frequency of the elastic ligaments, as well as the size of their opening. The tonality, timbre and loudness of the voice depend on these indicators.

Voice production is fully controlled in the cerebral cortex and central nervous system. It is with this that the frequent psychogenic triggering factors of the development of aphonia are associated. The oronosopharyngeal mechanism and the paranasal sinuses also play a role in the formation of vocal sound, but they practically do not affect the appearance of aphonia.

Since the voice is a sound vibration at a certain frequency, which is the result of vibrations of the vocal cords under the influence of the air flow, when they are insufficiently closed, no sound is formed, since there is no resonance. Simply put, the essence of aphonia lies in the non-adherence of the vocal cords to each other. In general, aphonia is divided into several types, depending on the cause of the disorder.

The lack of resonance is largely due to the state of muscle tone. This determines such types of pathology as hypotonic and hypertonic aphonia.

The functional type of aphonia is considered reversible, although in some patients this disorder entails organic changes in the larynx. For example, prolonged hypotonia or psychogenic type of aphonia leads to the development of atrophic laryngitis with the formation of an elastic ligament groove. Along with this, false-fold phonation is formed, leading to hypertrophy of the vestibular folds. 

Symptoms of the aphonia

With functional aphonia (not organic), the patient has a bright-sounding cough, which indicates the presence of a voice-forming function. Instability, instability of painful changes in the larynx region is typical: the formed edema, redness, induration of the vocal cords and their incomplete closure are always temporary, transient.

With an organic origin of the disorder, the symptoms are stable, and the otolaryngologist notes the same clinical picture during each examination. In addition, almost all aphonias are characterized by sensitivity disorders: patients note a feeling of dryness of the mucous membranes, a feeling of pressure or a foreign object in the throat, and sometimes pain.  In all cases, there is a general neurotic symptomatology:

• increased irritability;
• mood swings;
• sleep disorders;
• suspiciousness;
• negative thoughts, pessimistic mood.

Functional aphonia most often makes itself felt as a consequence of acute laryngitis in patients prone to neuroses. In such a situation, the loss of the ability to speak aloud is quite stable, despite the fact that the local painful signs of laryngitis are already absent.

In some patients, the functional type of aphonia develops at one moment, abruptly, under the influence of strong emotion, fear, stress.

For functional pathologies, both general neurological and local signs are characteristic. General neurological symptoms include:

• anxiety, gloomy mood, feelings;
• oppression, all sorts of fears and pessimism;
• irritability, irascibility, instability of mood;
• sleep deterioration, apathy.

Local signs are sensory and secretory disorders.

The true form of pathology is noted against the background of laryngeal disorders, in which there is poor closure or insufficient vibration of the vocal cords, which is the result of inflammatory diseases, tumor or cicatricial processes. In addition, aphonia can be one of the first symptoms of croup in diphtheria.

Aphonia in children

Violations of the voice function in children are closely related to the development of the whole organism, with the formation of the nervous and endocrine systems, the respiratory and articulatory apparatus. Central organic vocal disorders can be triggered by paralysis or paresis of the vocal cords. Often, such disorders are typical for patients with cerebral palsy.

Peripheral organic disorders are more often caused by various inflammatory processes, as well as by such pathologies:

• laryngitis;
• traumatic lesions, including burns of the larynx;
• peripheral paralysis and paresis;
• neoplasms in the larynx;
• postoperative cicatricial changes, laryngeal stenosis.

Among other reasons: severe fright, shock, stress, excessive psycho-emotional and vocal stress. In addition, aphonia often occurs against the background of respiratory pathologies - especially if during the treatment the child did not adhere to a sparing voice mode.

With organic disorders, children are prescribed general and local drug therapy. A common and necessary method is also working with a psychologist and speech therapist. Such classes should be carried out as early as possible, which will allow to achieve the most positive result and prevent the fixation of voice disorders and the development of neurotic reactions. [3]

The main therapeutic measures for the correction of aphonia in childhood:

• work with a psychotherapist and speech therapist;
• breathing exercises;
• articulatory gymnastics;
• phonopedic exercises;
• massages (including the so-called "speech therapy" massage).

Stages

The formation of the voice occurs in stages:

• I Art. - air accumulates in the lungs and is exhaled through the laryngeal cavity.
• II Art. - in the process of passing the glottis, the air provokes vibrational vibrations of the vocal cords: a voice is formed.
• III Art. - the formed sound extends to the area of the palate, tongue, teeth and lips: speech is formed.

Any violation in this mechanism of vocal reproduction entails a change in voice and, in particular, the development of aphonia.

Forms

Since many causes and mechanisms of the appearance of aphonia are known, doctors identify the disease according to the following types:

• Functional aphonia is a consequence of reflex mechanical disorders, excessive tension of the vocal folds (loud singing, screaming, screeching). The category of functional voice dysfunctions also includes psychogenic aphonia, the causes of which are psychoemotional or stressful overstrain. Most often, this form of the disease is diagnosed in female patients and in children. Hysterical aphonia has approximately the same developmental mechanism, in which the voice is lost, but a person is quite capable of coughing or laughing loudly. The hysterical type of dysfunction develops as a result of the impact of a powerful nerve impulse on the department responsible for phonation processes. [4]
• True aphonia (aka laryngeal) develops when the larynx is affected by all kinds of infectious diseases. In particular, it can be aphonia with laryngitis or diphtheria croup. Among other reasons for the true form of pathology can be called muscular laryngeal paralysis, which occurs as a result of disorders of cerebral circulation or traumatic brain injury. A less common cause is tumor processes that prevent adequate closure and oscillation of the folds.
• Aphonia of central origin refers to the functional variants of the disorder. The disorder occurs suddenly, in the form of a reaction to psychological trauma in people with a tendency to hysteria. Non-closure of the vocal cords during diagnosis reveals variability, which is one of the signs of the psychogenic origin of pathology. This type of aphonia can exist for a long period of time, but even after the restoration of voice function, relapses are not excluded.

There are also central aphonia of organic origin, the causes of which are cerebral palsy, cerebral palsy, dysarthria.

• Spasmodic aphonia is caused by muscle spasm in the larynx. As a result of spastic contraction, the gap located between the elastic ligaments narrows, which makes vibration vibrations impossible. The spastic variant is characterized by laryngeal pain, difficulty in swallowing. 

Complications and consequences

Some types of aphonia - for example, those associated with impaired innervation of the laryngeal region, or with a malignant tumor of the larynx - can lead to a complete loss of voice function.

If the voice is lost due to infectious and inflammatory pathologies of the ENT organs, or as a result of stressful situations, then in such cases there is every chance for its restoration, provided that the underlying disease is treated promptly and competently.

The appearance of aphonia in childhood is especially dangerous. If such a violation is persistent and lasts a long time, then this can negatively affect the child's speech and cognitive development, complicate social and everyday communication. In adult patients, aphonia causes difficulties in performing professional duties.

Psychogenic aphonia is especially prone to consolidation and further stable existence. This entails the development of a chronic voice disorder, with regular and frequent exacerbations. In such patients, the emotional background often decreases, negativism and pessimism are noted: patients refuse to believe in the success of treatment, depressive states develop.

Diagnostics of the aphonia

Diagnostic examination of a patient with aphonia begins with a survey, during which the doctor finds out the most likely causes, triggering factors for the onset of the disorder, as well as related problems. For example, the doctor must clarify the presence of a sore throat, larynx, perspiration, burning sensation, general weakness, etc.

The doctor needs to carefully examine the patient's head and neck, to feel for possible formations in the neck, tongue, and oral cavity. The area of the larynx and surrounding structures require special attention: the examination is carried out using indirect laryngoscopy, using a mirror and a light source.

An alternative method can be fiber-optic laryngoscopy, which allows you to fully examine the larynx and observe the work of the vocal cords. If pathological neoplasms are found, then direct laryngoscopy is performed with the possibility of taking biomaterial samples for biopsy.

Additional instrumental diagnostics may include computed tomography, nuclear magnetic resonance imaging of the head and neck, as well as endoscopy and chest x-ray.

It is possible to more clearly determine the quality of laryngeal function with the help of laryngostroboscopy, and laryngeal electromyography helps to determine what triggered the development of aphonia: deterioration of innervation or muscle pathologies. [5]

Laboratory tests do not have specific abnormalities, so they usually prescribe:

• a clinical blood test with an expanded leukocyte formula to detect symptoms of allergic or infectious-inflammatory processes in the body;
• throat swab to identify the pathogen if an infectious process with a laryngeal lesion is suspected;
• a study of the content of hormones in the blood (TSH, thyroxine, triiodothyronine - to assess the likelihood of endocrine pathology).

Differential diagnosis

Disease differentiation is carried out in conjunction with an otolaryngologist, psychologist and psychiatrist. Be sure to perform an X-ray of the larynx and trachea, laryngoscopy, tracheoscopy, laryngostroboscopy, endofibrolaryngoscopy, conduct an acoustic voice study, electromyography and glossography, evaluate the function of external respiration.

These studies allow you to quickly distinguish between dysphonia and aphonia:

• For hypotonic dysphonia with microlaryngoscopy, incomplete closure of the glottis during phonation is characteristic. The slit configuration can be different - like an oblong oval, line or triangle.
• The atrophic form is characterized by a thinning of the borders of the vocal fold in a furrow type and atrophy of the vocal folds. In the course of microlaryngostroboscopy, the predominant attenuation of the phonatoric vibrations of the vocal folds of small and medium amplitude, with a uniform frequency, is determined. The displacement of the mucous tissue along the border of the vocal fold is noticeably expressed. An acoustic study reveals a shortening of the duration of maximum phonation to about 11 seconds. No phonatory oscillations are observed, or there is frequency and amplitude asynchrony. One of the typical signs: incomplete closure of the glottis.
• Hypertensive dysphonia is manifested by an increased vascular pattern, hyperemia of the mucous tissue, and interconnection of the vocal cords during phonation. During microlaryngostroboscopy, an elongated closure phase, low-amplitude oscillations with a slight displacement of the edges of the mucosa are found. With hypertonia, granulomas, nodular elements, hemorrhages, and chronic laryngitis are often determined. The vestibular folds are hypertrophied.
• Mutational dysphonia does not always give a laryngoscopic picture. Possible enhanced vascular pattern of the vocal folds, ovality of the cleft during phonation, or triangularity in the posterior laryngeal region.
• The abductor type of spastic dysphonia is manifested by symptoms of hyperfunction: crossing of the vocal folds, pseudofold phonation, trembling of folds, increased vascular pattern.

First of all, differentiation of aphonia with bilateral laryngeal palsy and dysphonia is required. Dysphonia denotes a disorder of vocal function, manifested by hoarseness, hoarseness, and voice changes. With a complete loss of vocal sound and the transition to a whisper, they speak of aphonia.

Treatment of the aphonia

Therapeutic tactics for aphonia depend on the root cause of the disorder.

The true form of pathology requires the removal of tumor neoplasms, excision of scar tissue, etc. At the same time, it is necessary to provide vocal rest. Physiotherapy is indicated.

The paralytic form is difficult to treat, or it is not treated at all, if the cause of the problem is not eradicated (esophageal tumor, aortic aneurysm, inflammatory reaction, etc.).

The spastic and functional form of the disease requires general strengthening therapy while taking sedatives. Classes with a psychotherapist, breathing and phonopedic exercises are also recommended.

The functional form may require long-term treatment: it all depends on the depth of the neurosis and the general condition of the patient. Regular work with a psychotherapist is required. Drug therapy involves taking tranquilizers against the background of physiotherapy procedures. [6]

If aphonia has developed against the background of a viral infection or a cold, then drugs are prescribed that correspond to these diseases. If, after recovering from acute respiratory viral infections or flu, the voice is not restored, then additional diagnostics are prescribed.

If the cause of aphonia is thyroid dysfunction, then an endocrinologist's consultation will be required with further normalization of the hormonal balance.

With a combination of voice loss and a lingering dry cough, the doctor prescribes bronchodilators that eliminate perspiration, dry throat. After such problems are corrected, the voice function usually returns to normal. 

The concomitant aphonia swelling of the throat is eliminated by taking antiallergic (antihistamines) drugs.

Patients with a psychogenic form of the disease are shown psychoanalytic consultations, suggestion therapy. Autogenic training has a good effect, and hypnotherapy helps in advanced cases. Many patients require correction of other disorders that could provoke a loss of voice. An important role is played by a positive attitude and instilling faith in the patient in the success of the treatment.

Urgent measures require cases of aphonia in childhood, which could be triggered by foreign objects entering the throat or larynx region. After removing such an object, the doctor must carefully examine the patient to exclude damage to the mucous tissues. [7], 

Medicines

Medicines are prescribed as part of complex therapy, with a prerequisite for compliance with a gentle regimen for the larynx. The use of such medicines is possible:

• Tincture of ginseng, lemongrass, as well as other stimulants and vitamins help to eliminate hypotonic aphonia, improve microcirculation and restore the ability to speak.
  • Lemongrass tincture is taken 20 drops three times a day 15 minutes before meals, for two weeks. The drug is contraindicated in children under 12 years of age. May cause allergies.
  • Ginseng tincture is taken in the first half of the day, 20 drops half an hour before meals, twice a day for a month. In the course of treatment, there may be increased excitability, sleep disturbance, headache, and increased heart rate.
• Psychotropic drugs, tranquilizers, neuroleptics, antidepressants and antispasmodic drugs can eliminate hyperkinetic aphonia.
  • Adaptol is a tranquilizer drug that is taken 500 mg twice a day. The duration of treatment is determined individually. Possible side effects: decreased blood pressure, dizziness, weakness.
  • Tranquezipam is taken orally at 0.5-1 mg 2-3 times a day, with a possible increase in dosage. The duration of treatment is 2 weeks, with a gradual withdrawal of the drug. Contraindications for use: children under 18 years of age, angle-closure glaucoma.
• Spasms are eliminated with γ-aminobutyric acid and Aminalon preparations.
  • Aminalon is prescribed in individual dosages. The treatment can take several weeks. Possible side effects: nausea, instability of blood pressure, digestive disorders, sleep disturbances.
• Vitamin and homeopathic medicines can speed up recovery and quickly restore the lost function.
  • Homeovox is a homeopathic multicomponent remedy that is taken orally between meals, 2 tablets every hour (on the 1st day), then 2 tablets five times a day. The duration of treatment is one week. Allergic reactions to the drug are possible.
• With ARVI and influenza, antiviral drugs, immunomodulators can be prescribed. For inflammatory bacterial diseases, antibiotics, sulfa drugs are indicated.

Physiotherapy treatment

Physiotherapy is prescribed for patients with aphonia according to individual indications, since not only the peculiarities of the course of the pathology are taken into account, but also its causes and stage, age and other factors. Treatment is almost always perceived positively, there are no side effects.

The main methods used are considered to be:

• Inductothermy involves the use of a high-frequency alternating magnetic field. The procedure causes vasodilation in the area of exposure, acceleration of blood circulation, arrest of the inflammatory reaction, resorption of infiltrates. At the same time, the tone of the muscles and the excitability of nerve receptors decrease, which causes an antispasmodic, analgesic and sedative effect.
• UHF therapy is based on the influence of an ultra-high frequency electromagnetic field. UHF has an anti-inflammatory antispasmodic effect, reduces tissue edema, activates cell proliferation, and relieves pain. Among the indications for the procedure are tonsillitis, laryngitis, neuritis, acute and chronic inflammatory processes of the ENT organs.
• Magnetotherapy is based on the effect of an alternating low-frequency magnetic field on a specific area of the body. The procedure provides an analgesic, antispasmodic, anti-inflammatory and anti-edema effect, normalizes the tone of blood and lymphatic vessels, improves the functioning of the autonomic and endocrine systems, and also helps to improve the psycho-emotional state of the patient.
• Ultrasound therapy has a chemical-physical, mechanical and low thermal effect. Ultrasonic waves have a strong analgesic, anti-inflammatory, antispasmodic, antihistamine effect, improve tissue trophism.

The most common physiotherapy method for treating aphonia is electrical stimulation. This procedure involves the use of impulse currents that change the functional state of the muscles and nerves. Thanks to electrical stimulation, it is possible to maintain the contractile properties of the muscles, increase blood circulation, optimize tissue metabolism, and prevent the development of atrophic processes. The procedure is especially indicated if aphonia develops against the background of paresis of the laryngeal muscles.

Auxiliary methods of influence can be:

• hydrotherapy, balneotherapy;
• massage of the neck and collar zone;
• acupuncture;
• electrosleep.

Herbal treatment

In order to restore the voice function with aphonia, you can additionally use effective herbal remedies:

• Take half a glass of aniseed, boil for about 15 minutes in 200 ml of water. After cooling, the broth is filtered, add 1 tbsp. L. Honey and the same amount of cognac. This remedy is taken 10-15 minutes after meals three times a day.
• A decoction of marshmallow flowers (can be replaced with pharmacy syrup) is mixed with honey and drunk in 1-2 tbsp. L. Three times a day, swallowing a little.
• They drink a warm broth of zucchini or cucumber with honey. This will soften the throat area and speed up recovery.
• Take 100 g of leeks, chop and boil in 500 ml of boiling water for 15 minutes. Filter and take a couple of sips several times a day.
• Pour 1 tbsp. L. Thyme herbs 200 ml of boiling water, kept under the lid for 10 minutes, filtered, honey and lemon juice are added. Drink during the day instead of tea.
• Drink infusion of boiling water and tangerine peel, several times a day.
• Boil in 500 ml of water for 10 minutes ½ tsp. Carnations. Add honey and lemon juice. It is taken warm in a few sips shortly before bedtime.

In addition to such treatment for aphonia, several more rules must be observed:

• give up bad habits (smoking and drinking alcohol);
• regularly moisturize the pharyngeal area;
• give up spicy seasonings, too hot or too cold dishes;
• avoid tension of the vocal cords (even in a whisper, one should not speak for a long time);
• monitor the state of the nervous system, pay attention to the quality of digestive processes and the work of the thyroid gland.

Surgery

Surgical assistance is required only with persistent aphonia provoked by hypotension: implantation surgery or thyroplasty is indicated, which are performed to enhance the adduction of the vocal folds.

False-fold phonation with hypertrophied vestibular folds requires prompt removal of areas of hypertrophy. After the operation, anti-inflammatory drugs are prescribed, phonopedics and stimulating therapy are used to improve the tone of the true vocal folds.

Laryngoplasty, thyroplasty, tracheostomy - these interventions are indicated for patients with persistent aphonia, which does not lend itself to medical correction. To restore the voice function, the surgeon performs scars excision, removes tumor neoplasms.

Prevention

Prevention of aphonia and other similar dysfunctions consists of a number of important points. Firstly, it is necessary to understand that a temporary impairment of vocal reproduction, which occurred as a result of laryngitis, overwork, intoxication, can disappear without a trace only when rest and the maximum sparing mode are provided for the reproductive apparatus without any vocal load. If this is not done, then the aphonia will become more stable, and secondary mental problems will be added.

Temporary loss of voice against the background of stress, severe fright is often associated with violations of other body functions. Most often, after a certain time, the person's condition stabilizes, the voice and speech are restored. However, you need to know that such recovery usually occurs with some delay, because first the impaired functions of other organs and systems must be normalized. Doctors advise: do not rush. It is better to temporarily save the speech apparatus and deliberately give the body the opportunity to "come to its senses" on its own.

In general, prevention should consist of strengthening the nervous system and preventing neuroses. And the prevention of voice dysfunctions (including those of an organic nature) is aimed at preventing possible causes of this violation.

Forecast

Voice is one of the most important components of speech function. It is not only the ability to communicate: the voice determines individuality and self-expression. Therefore, it is not surprising that aphonia is often caused by mental pathology, traumatic factors.

Violations of vocal functions can have different outcomes, depending on the causes, mechanism of development and neglect of the disorder. If the disorder persists for a long time, then the person's communication skills suffer and deteriorate. And in the absence of treatment, not only the ability to work is lost: the voice may not be restored at all. To prevent this from happening, it is necessary to visit a doctor as early as possible, already at the first sign of a problem.

Functional dysfunction has a favorable prognosis for most patients. For the true and paralytic form of the disease, the prognosis can be favorable only if the underlying pathology is cured. Aphonia caused by the inflammatory process, in the overwhelming majority of cases, heals on its own after stopping the inflammation.