The scope of this page focuses on voice disorders of organic, functional, and psychogenic origin(s).
See the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
For information on gender-affirming voice services, see ASHA’s Practice Portal page on Voice and Communication Services for Transgender and Gender Diverse Populations.
A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone et al., 2010; Lee et al., 2004). A voice disorder is present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not perceive it as different or deviant (American Speech-Language-Hearing Association [ASHA], 1993; Colton & Casper, 2011; Stemple et al., 2010; Verdolini & Ramig, 2001).
For the purposes of this document, voice disorders are categorized as follows:
Voice quality can also be affected when psychological stressors lead to habitual, maladaptive aphonia or dysphonia. The resulting voice disorders are referred to as psychogenic voice disorders or psychogenic conversion aphonia/dysphonia (Stemple et al., 2010). These voice disorders are rare. Speech-language pathologists (SLPs) may refer individuals suspected of having a psychogenic voice disorder to other appropriate professionals (e.g., psychologist and/or psychiatrist) for diagnosis and may collaborate in subsequent behavioral treatment.
The complementary relationships among these organic, functional, and psychogenic influences ensure that many voice disorders will have contributions from more than one etiologic factor (Stemple et al., 2014; Verdolini et al., 2006). For example, vocal fold nodules may result from behavioral voice misuse (functional etiology). However, the voice misuse results in repeated trauma to the vocal folds, which may then lead to structural (organic) changes to the vocal fold tissue.
SLPs may also be involved in the assessment and treatment of disorders that affect the laryngeal mechanism (i.e., the aerodigestive tract) and that are not classified as voice disorders, such as the following:
For further information, see ASHA’s Practice Portal page on Aerodigestive Disorders.
Incidence of voice disorders refers to the number of new cases identified in a specific time period.
Prevalence refers to the number of individuals who are living with voice disorders in a given time period.
Estimates of incidence and prevalence vary due to a number of factors, including etiology, age, gender, and occupation.
In the pediatric population, the reported prevalence of a voice disorder has ranged from 1.4% to 6.0% (Black et al., 2015; Carding et al., 2006). Longer stays in the neonatal intensive care unit and prolonged intubation (more than 28 days) were associated with more severe dysphonia in premature infants (Hseu et al., 2018). An estimated range of 41%–73% of children were identified with vocal nodules, indicating vocal nodules as a predominant cause of pediatric dysphonia (Martins et al., 2015); however, there can be a variety of causes other than vocal fold nodules that result in dysphonia in the pediatric population. Rates indicated no statistically significant differences across race in preschool-aged children (Duff et al., 2004).
Approximately one out of 13 adults in the United States will experience a voice problem annually, but only a relative minority seek treatment (10%; Bhattacharyya, 2014). The rate of young adults (aged 24–34 years) with voice disorders was estimated to be 6%, with no significant difference across age groups, race/ethnicity, or education levels (Bainbridge et al., 2017). Prevalence was reported to be higher in adults aged 60 years and older, with estimates ranging from 4.8% to 29.1% in population-based studies (de Araújo Pernambuco et al., 2014).
Among adults (between 19 and 60 years of age) with a voice disorder, the most frequent diagnoses included functional dysphonia (20.5%), acid laryngitis (12.5%), and vocal polyps (12%; Martins et al., 2015).
Of individuals over the age of 60 years who had been evaluated for vocal problems, voice disorders were most commonly associated with presbyphonia (changes associated with aging voice), reflux/inflammation, functional dysphonia, vocal fold paralysis/paresis, and Reinke’s edema (Martins et al., 2015). Laryngeal cancer diagnoses were reported to have peaked in adults between 75 and 79 years of age and decreased thereafter (Roy et al., 2016).
Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth and/or gender identity. Voice disorders were reported to be significantly more prevalent in male children than in female children (Carding et al., 2006; Martins et al., 2015). In adulthood, however, prevalence was higher in female adults than in male adults, with a reported ratio of 1.5:1.0 (Martins et al., 2015; Roy et al., 2005).
Although female adults more frequently received diagnoses of dysphonia with no specific cause noted, male adults were more frequently diagnosed with chronic laryngitis (Cohen et al., 2012). Also, after the age of 40 years, male adults had higher prevalence rates of laryngeal cancer than female adults (Cohen et al., 2012).
Teachers were estimated to be two to three times more likely than the general population to develop a voice disorder (Martins et al., 2014). Certain factors, such as number of classes per week, noise generated outside of the school setting, and volume of voice while lecturing, were indicated to increase the risk of teachers developing a voice disorder (Byeon, 2019).
The mean prevalence of voice disorders was estimated to be 46% among singers (Pestana et al., 2017). The most prevalent laryngeal pathologies and voice disorder symptoms reported in singers included, but were not limited to, Reinke’s edema, polyps, gastroesophageal reflux disease, laryngeal pain, and hoarseness; however, risk of developing laryngeal pathologies or vocal cord symptoms may vary based on differences in singing style and genre (Kwok & Eslick, 2019).
According to a claims-based study, almost 30% of dysphonia claims were individuals in the service industry. Those in the service industry were estimated to be 2.6 times more likely to develop benign laryngeal growth and individuals in the manufacturing industry were estimated to be 1.4 times more likely to develop malignant laryngeal growth compared to the general population (Benninger et al., 2017).
The term dysphonia encompasses the auditory-perceptual symptoms of voice disorders. Dysphonia is characterized by altered vocal quality, pitch, loudness, or vocal effort.
Perceptual signs and symptoms of dysphonia include
Other signs and symptoms include
Signs and symptoms can occur in isolation or in combination. As treatment progresses, some may dissipate, and others may emerge as compensatory strategies are eliminated.
Auditory-perceptual quality of voice in individuals with voice disorders can vary depending on the type and severity of the disorder, the size and site of the lesion (if present), and the individual’s compensatory responses. The severity of the voice disorder cannot always be determined by auditory-perceptual voice quality alone. Therefore, further instrumental assessment may be indicated to determine the severity and/or etiology of a voice disorder.
Normal voice production depends on power and airflow supplied by
A disturbance in one of these subsystems or in the physiological balance among the systems may lead to or contribute to a voice disorder. Disruptions can be due to organic, functional, and/or psychogenic causes.
Organic causes include the following:
Functional causes include the following:
Psychogenic causes include the following:
Making modifications to pitch without the guidance of a skilled service provider is not recommended and may result in vocal misuse. However, voice services may be provided to assist with appropriate pitch modifications.
Recognizing associations among these factors, along with patient history, may help in identifying the possible causes of the voice disorder. Even when an obvious cause is identified and treated, the voice problem may persist. For example, an upper respiratory infection could be the cause of the dysphonia, but poor or inefficient compensatory techniques may cause dysphonia to persist, even when the infection has been successfully treated.
SLPs play a central role in the assessment, diagnosis, and treatment of voice disorders. The professional roles and activities in speech-language pathology include the following:
SLPs are trained to evaluate voice use and function to determine the cause of reported symptoms and select treatment methods for improving voice production.
Appropriate roles for SLPs include the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
See the Assessment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Screening may be conducted if a voice disorder is suspected. It may be triggered by concerns from individuals, parents, teachers, or health care providers. When deviations from normal voice are detected during screening, further evaluation is warranted.
Screening includes evaluation of vocal characteristics related to
Clinicians may use a formal screening tool (Lee et al., 2004) or obtain data using informal tasks. Standardized self-report questionnaires can be included for a more thorough screening (e.g., Deary et al., 2003; Hogikyan & Sethuraman, 1999; Jacobson et al., 1997).
All patients/clients with voice disorders should be examined by a physician, preferably in a discipline appropriate to the presenting complaint. The physician’s examination may occur before or after the voice evaluation by the SLP. Consultation with an otolaryngologist can be important, particularly in the case that an SLP does not have access to instrumentation for evaluation. Assessment and treatment of voice disorders may require use of appropriate personal protective equipment.
A comprehensive assessment is conducted for individuals suspected of having a voice disorder, using both standardized and nonstandardized measures (see ASHA’s resource on assessment tools, techniques, and data sources). For a review of clinical voice assessments, see Roy et al. (2013).
Diagnostic therapy may be performed as part of the comprehensive assessment to help in making a diagnosis and to determine if the individual is stimulable to voice therapy efforts.
Comprehensive assessment is conducted to identify and describe
See ASHA’s resource titled person-centered focus on function: voice [PDF] for an example of assessment data.
This subjective assessment is based on the clinical impressions of the SLP during production of sustained vowels, sentences, and running speech.
The perceptual features above are defined in ASHA’s Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V; ASHA, n.d., 2002; Kempster et al., 2009).
See ASHA’s Practice Portal page on Resonance Disorders.
Rate of speech may be indirectly impacted by voice disorders. For instance, a patient with a voice disorder may deliberately slow rate of speech to compensate for a voice disorder and increase intelligibility. For reasons such as these, an SLP may consider assessment of rate of speech (e.g., via diadochokinetic rate assessment).
Physicians are the only professionals qualified and licensed to render medical diagnoses related to the identification of laryngeal pathology as it affects voice. Imaging should be viewed and interpreted by an otolaryngologist with training in this procedure when it is used for medical diagnostic purposes.
Measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy). Please see ASHA’s resource on Vocal Tract Visualization and Imaging for more information.
Objective measures of vocal function related to vocal loudness, pitch, and quality (Patel et al., 2018).
Measures (using noninvasive procedures) of glottal aerodynamic parameters required for phonation.
SLPs should be aware of potential sources of error or impediments to recording quality during aerodynamic assessment. Sources of error may contribute to inaccurate data. These error sources include
Although many of the same voice disorders may exist among children and adults, the following conditions tend to be unique to the pediatric population (Sapienza & Ruddy, 2009):
Further information regarding laryngomalacia and laryngeal cleft may be found in ASHA’s Practice Portal page on Aerodigestive Disorders.
See the Treatment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving. The ASHA Practice Portal page on Head and Neck Cancer addresses intervention aimed at acquisition of alaryngeal speech sufficient to allow for functional oral communication.
Intervention is designed to
Voice use within different settings should be considered when determining vocal needs and establishing goals. For example, vocal needs within the workplace may be different from those within the community (e.g., home and social settings).
SLPs often team with otolaryngologists/laryngologists and other medical professionals (e.g., pulmonologists, gastroenterologists, neurologists, allergists, endocrinologists, and occupational medicine physicians) and, if appropriate, develop treatment plans to support the medical plan and to optimize outcomes. Collaboration with otolaryngologists/laryngologists is especially important to rule in or rule out underlying pathologies. SLPs can only diagnose functional abnormalities, and only otolaryngologists can diagnose organic pathologies (e.g., nodules, polyps, tumors).
Some individuals develop voice disorders in the absence of structural pathology (e.g., functional aphonia, muscle tension dysphonia, and mutational/functional falsetto) and may benefit from psychological counseling in addition to what can be provided by the SLP. Counseling, direct manipulation of the voice, and use of interview questions can be used to probe possible factors contributing to the voice problem. SLPs refer the individual to the appropriate health care professional(s) to address issues outside the SLP’s scope of practice (ASHA, 2016b).
See ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice (IPE/IPP).
Approaches can be direct or indirect, and SLPs often incorporate aspects of more than one therapeutic approach in developing a treatment plan.
Direct approaches focus on manipulating the voice-producing mechanisms (phonation, respiration, and musculoskeletal function) to modify vocal behaviors and establish healthy voice production (Colton & Casper, 2011; Stemple, 2000).
Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs (Roy et al., 2001; Thomas & Stemple, 2007). Indirect approaches include the following two components:
A therapeutic plan typically involves at least one direct approach and one or more indirect approaches based on the patient’s condition and goals. Some clinicians concentrate on directly modifying the specific symptoms of the inappropriate voice, whereas others take a more holistic approach, with the goal of balancing the physiologic subsystems of voice production—respiration, phonation, and resonance.
Clinicians may begin by
Use of personal protective equipment (PPE) (i.e., face mask) can potentially cause increased strain on voice and perception of vocal effort (Ribeiro et al., 2020). Please see ASHA guidance to SLPs regarding aerosol generating procedures and the Resources section below for further information.
There may be differences between treating voice disorders in adults and pediatrics due to differences in anatomy, etiology, and developmental level. According to Braden (2018), anatomical differences between pediatric and adult voice include the following:
As a child’s phonatory structures grow and develop, the respective speaking pitch decreases (decreased frequency of vocal tract formants and fundamental frequency). There is a rapid decrease in mean fundamental frequency in the first 3 years, with another significant change at puberty (McAllister & Sjölander, 2013). Abnormal voice changes may be monitored during adolescence as they may be indicative of a functional voice disorder such as puberphonia. Stridor should also be closely monitored in the pediatric population as it could potentially indicate a compromised airway (Theis, 2010).
Many treatment approaches used for adult populations may be considered for the pediatric population, although adaptations may be needed to meet each child’s developmental level (Braden, 2018). Comorbid developmental disorders such as expressive or receptive language deficits may further complicate treatment of voice in the pediatric population. Some children may not have an internal concept of normal versus abnormal voicing (Hooper, 2004) and, therefore, may have difficulty addressing dysfunction.
Another consideration is potential difficulties that may occur in obtaining treatment in the school-based setting. Challenges may include
Please see Childes et al. (2017) for further consideration of barriers and challenges.
The following subsections offer brief descriptions of general and specific treatments for individuals with voice disorders. They are organized under two categories: physiologic voice therapy (i.e., those treatments that directly modify the physiology of the vocal mechanism) and symptomatic voice therapy (i.e., those treatments aimed at modifying deviant vocal symptoms or perceptual voice components using a variety of facilitating techniques). The inclusion of any specific treatment approach does not imply endorsement by ASHA. For more information about treatment approaches and their use with various voice disorders, see Stemple et al. (2010).
Treatment selection depends on the type and severity of the disorder and the communication needs of the individual. Clinicians incorporate functional daily voice needs into goals that reflect inclusion and participation in home, work, and social communities. Linguistic features in some languages may influence the need for specific aspects of voice treatment, such as influences of tonal languages on resonance. In addition, consideration of individuals’ needs, such as gender and/or gender expression or use of regional accents, is an important aspect of goal development.
Physiologic voice therapy programs strive to balance the three subsystems of voice production (respiration, phonation, and resonance) as opposed to working directly on isolated voice symptoms. Most physiologic approaches may be used with a variety of disorders that result in hyper- and hypofunctional vocal patterns. Below are some of the physiologic voice therapy programs, arranged in alphabetical order.
The accent method is designed to increase pulmonary output, improve glottic efficiency, reduce excessive muscular tension, and normalize the vibratory pattern during phonation. During therapy, the clinician may do one or more of the following tasks (Kotby et al., 1993; Malki et al., 2008):
CTT focuses exclusively on voice awareness and production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. Grounded in the tenets of motor learning, CTT strives to guide patients in achieving balanced phonation through clinician reinforcement, imitation and modeling in conversational speech. CTT incorporates six interchangeable components (Gartner-Schmidt et al., 2016; Gillespie et al., 2019), as follows:
EMST improves respiratory strength during phonation. Increase in maximum expiratory pressure can be trained with specific calibrated exercises over time, thus improving the relationship between respiration, phonation, and resonance. EMST uses an external device to mechanically overload the expiratory muscles. The device has a one-way, spring-loaded valve that blocks the flow of air until the targeted expiratory pressure is produced. The device can be calibrated to increase or decrease physiologic load on the targeted muscles (Pitts et al., 2009).
LSVT (Ramig et al., 1994) is an intensive treatment developed for patients with Parkinson’s disease. It is designed to maximize phonatory and respiratory function using a set of simple tasks. Individuals are instructed to produce a loud voice with maximum effort and to monitor the loudness of their voices while speaking. The effort that is involved generates improved respiratory support, laryngeal muscle activity, articulation, and even facial expression and animation. Using a sound-level meter, visual biofeedback may be provided to demonstrate the effort necessary to increase loudness. LSVT is provided by clinicians who are trained and certified in the administration of this technique.
Five basic principles are followed in LSVT, as follows:
Manual circumlaryngeal techniques are intended to reduce musculoskeletal tension and hyperfunction by re-posturing the larynx during phonation. There are three main manual laryngeal re-posturing techniques, as follows:
Applying these maneuvers during vocalization allows the individual to hear resulting changes in voice quality (Andrews, 2006; Roy et al., 1997). Care is taken when employing these techniques, as some patients report discomfort.
PhoRTE (Ziegler & Hapner, 2013) was adapted from LSVT and consists of four exercises, as follows:
Individuals are reminded to maintain a “strong” voice throughout these treatment exercises. PhoRTE has a less intensive intervention schedule than LSVT. PhoRTE also differs in that it combines both loudness and pitch when producing phrases (i.e., loud and low pitch, loud and high pitch). Use of PhoRTE has been studied in adults with presbyphonia (aging voice) as a way to improve vocal outcomes (e.g., decrease phonatory effort) and increase voice-related quality of life (Ziegler et al., 2014).
Resonant voice therapy uses a continuum of oral sensations and easy phonation, building from basic speech gestures through conversational speech. Resonant voice is defined as voice production involving oral vibratory sensations, usually on the anterior alveolar ridge or lips or higher in the face in the context of easy phonation. The goal of resonant voice therapy is to achieve the strongest, “cleanest” possible voice with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2010). The program incorporates humming and both voiced and voiceless productions that are shaped into phrase and conversational productions (Verdolini, 1998, 2000).
Stretch and flow phonation—also known as Casper-Stone Flow Phonation—is a physiological technique used to treat functional dysphonia or aphonia (Stone & Casteel, 1982). It focuses on airflow management and is used for individuals with breath-holding tendencies. Individuals are instructed to focus on a steady outflow of air during exhalation. Various biofeedback methods are used, including placing a piece of tissue in front of the mouth or holding one’s hand in front of the mouth to monitor airflow. Voicing is introduced once the individual masters continuous airflow during exhalation. As such, this technique produces a breathy voice quality and a slowed speaking rate. Eventually, this voice quality is carried into trials with spoken words and phrases, and the breathiness is gradually reduced.
Flow phonation (Gartner-Schmidt, 2008, 2010) is a hierarchical therapy program designed to facilitate increased airflow, ease of phonation, and forward oral resonance. It was modified from stretch and flow phonation by eliminating the “stretch” component, which reduced the rate of speech in the original therapy.
VFEs are a series of systematic voice manipulations designed to facilitate return to healthy voice function. VFEs work to strengthen and coordinate laryngeal musculature and improve efficiency of the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation (Stemple, 1984). Sounds used in training are specific, and correct production is encouraged. VFEs consist of four exercises—warm-up, stretching, contracting, and power exercises. Exercises are completed twice a day (morning and evening) in sets of two. Maximum phonation time goals are set on the basis of individual lung capacity and an airflow rate of 80 mL/sec. Individuals are advised to use a soft, engaged tone and are trained to use a semi-occluded vocal tract (SOVT) without tension during voice productions.
Symptomatic voice therapy focuses on the modification of vocal symptoms or perceptual voice components. Symptomatic voice therapy assumes voice improvement through direct symptom modification using a variety of voice facilitating techniques (Boone et al., 2010) that are either direct or indirect. Symptoms to be addressed may include
Amplification devices such as microphones can be used to increase voice loudness in any situation that requires increased volume (e.g., when speaking to large groups or during conversation when the individual’s voice is weak). As such, voice amplification can function as a supportive tool or as a means of augmentative communication. It can help prevent vocal hyperfunction that may be a result of talking at increased volume or for extended periods of time.
Auditory masking is used in cases of functional aphonia/dysphonia and often results in changed or normal phonation. Individuals are instructed to talk or read passages aloud while wearing headphones with masking noise input. Using a loud noise background, the individual often produces voice at increased volume (Lombard effect) that can be recorded and used later in treatment as a comparison (e.g., Adams & Lang, 1992; Brumm & Zollinger, 2011).
Biofeedback is the concept that self-control of physiologic functions is possible given external monitoring of internal bodily state. Biofeedback may be kinesthetic, auditory, or visual and is intended to provide clear and reliable information in response to alterations in voice production. Thus, patients may make real-time adjustments regarding vocal pitch, loudness, quality, and effort. Ideally, biofeedback helps increase awareness of physical sensations with respect to respiration, body position, and vibratory sensation. This awareness may help individuals understand physiological processes when generating voice.
Chant speech uses a rhythmic, prosodic pattern as a template for spoken utterances. It is used in therapy to help reduce phonatory effort that results in vocal fatigue and decreased phonatory capabilities. Chant speech requires pitch fluctuations and coordination of respiratory, phonatory, and resonance subsystems. Speakers habituate to these more efficient vocal patterns. The increased lung pressure required for these tasks may also decrease reliance on laryngeal resistance and reduce fatigue (e.g., McCabe & Titze, 2002).
Confidential voice is designed to reduce laryngeal tension/hyperfunction and increase airflow (Casper, 2000). The individual begins with an easy and breathy vocal quality and builds to normal voicing without decreasing airflow. This technique is intended to address excessive vocal tension and to facilitate relaxation in the muscles of the larynx.
Inhalation phonation is used to facilitate true vocal vibration in the presence of habitual ventricular fold phonation, functional aphonia, and/or muscle tension dysphonia. Individuals produce a high-pitched voice on inhalation. Upon inhalation voicing, the true vocal folds are in a stretched position, suddenly adducted, and in vibration. Upon exhalation, patients try to achieve a nearly matched voice. This approach eases the way to gaining true vocal fold vibration.
The patient is instructed in the technique of sitting with upright posture and with the shoulders in a low, relaxed position to facilitate voice production with less effort. Collaboration with a physical therapist or an occupational therapist may be necessary with some patients.
In cases of vocal hyperfunction, a variety of relaxation techniques may be useful as a tool to reduce both whole-body and laryngeal area tension. The goal of these techniques is to reduce effortful phonation. Frequently used techniques include progressive muscle relaxation (slowly tensing and then relaxing successive muscle groups), visualization (forming mental images of a peaceful, calming place or situation), and deep breathing exercises.
SOVT exercises involve narrowing at any supraglottic point along the vocal tract in order to maximize interaction between vocal fold vibration (sound production) and the vocal tract (the sound filter) and to produce resonant voice.
Cup bubble, also known as Lax Vox, is an aerodynamic building task aimed at improving the ability to sustain phonation while speaking. It is done by having a patient blow air initially into a cup of water without voice. Voicing can be added for subsequent trials, and in time, pitch can be altered across and within trials. Eventually, the cup is removed during voicing, and the phonation continues. These exercises are thought to widen the vocal tract during phonation and reduce tension in the vocal folds. Biofeedback increases the individual’s awareness of their healthy voice production (e.g., Denizoglu & Sihvo, 2010; Simberg & Laine, 2007).
Straw phonation is one of the most frequently used methods to create semi-occlusion in the vocal tract (Titze, 2006). Narrowing the vocal tract increases air pressure above the vocal folds, keeping them slightly separated during phonation and reducing the impact collision force. To accomplish this, the individual semi-occludes the vocal tract by phonating through a straw or tube. Resistance can be manipulated by varying the length and diameter of the straw or immersing the opposite end of the straw in water. Individuals practice sustaining vowels, performing pitch glides, humming songs, and transitioning to the intonation and stress patterns of speech. Eventually, use of the straw is reduced and eliminated.
Lip trills can be used to create semi-occlusion at the level of the lips. This technique involves a smooth movement of air through the oral cavity and over the lips, causing a vibration (lip buzz), similar to blowing bubbles underwater. Often, the trills are paired with phonation and pitch changes. The focus is to improve breath support and produce voicing without tension.
Twang therapy is used for individuals with hypophonic voice. It involves the narrowing of the aryepiglottic sphincter using a “twang” voice to create a high-intensity voice quality while maintaining low vocal effort (Lombard & Steinhauer, 2007). The desired outcome is decreasing phonatory effort and increasing vocal efficiency.
This facilitating technique uses the natural functions of yawning and sighing to overcome symptoms of vocal hyperfunction (e.g., elevated larynx and vocal constriction). The technique is intended to lower the position of the larynx and subsequently widen the supraglottal space in order to produce a more relaxed voice and encourage a more natural pitch.
SLPs should take appropriate measures whether services are being delivered in-person or through telepractice. Teletherapy may not provide as reliable sound quality as in-person. Therefore, additional equipment (e.g., microphones) can enhance vocal quality while reducing vocal strain. Additionally, SLPs should take into consideration whether or not the patient is telecommuting for their profession, as there is some emerging research regarding effects of telecommunications on voice (Tracy et al., 2020).
Additional training/education may be necessary to provide professional voice rehabilitation. Clients who use their voice professionally (e.g., singers, voice actors) may have different needs than the usual client with a voice disorder and may seek services from multiple disciplines, including:
Refer to the Service Delivery section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for individuals with voice disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may affect treatment outcomes.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
Adams, S. G., & Lang, A. E. (1992). Can the Lombard effect be used to improve low voice intensity in Parkinson’s disease? International Journal of Language & Communication Disorders, 27(2), 121–127. https://doi.org/10.3109/13682829209012034
American Speech-Language-Hearing Association. (n.d.). ASHA Cape-V Form. https://www.asha.org/Form/CAPE-V/
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations [Relevant paper]. https://www.asha.org/policy/RP1993-00208/
American Speech-Language-Hearing Association. (2002). Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) form. https://www2.asha.org/Form/CAPE-V/
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. https://www.asha.org/policy/et2016-00342/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. http://www.asha.org/policy/SP2016-00343/
Andrews, M. L. (2006). Manual of voice treatment: Pediatrics through geriatrics (3rd ed.). Thomson Delmar Learning.
Aronson, A. E., & Bless, D. M. (2009). Clinical voice disorders (4th ed.). Thieme.
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Black, L. I., Vahratian, A., & Hoffman, H. J. (2015). Communication disorders and use of intervention services among children aged 3–17 years: United States, 2012 (NCHS Data Brief, No. 205). National Center for Health Statistics.
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Braden, M. (2018). Advances in pediatric voice therapy. Perspectives of the ASHA Special Interest Groups, 3(3), 68–76. https://doi.org/10.1044/2018_PERS-SIG3-2018-0005
Brumm, H., & Zollinger, S. A. (2011). The evolution of the Lombard effect: 100 years of psychoacoustic research. Behaviour, 148(11–13), 1173–1198. https://doi.org/10.1163/000579511X605759
Byeon, H. (2019). The risk factors related to voice disorder in teachers: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 16(19), 3675. https://doi.org/10.3390/ijerph16193675
Carding, P. N., Roulstone, S., Northstone, K., & ALSPAC Study Team. (2006). The prevalence of childhood dysphonia: A cross-sectional study. Journal of Voice, 20(4), 623–630. https://doi.org/10.1016/j.jvoice.2005.07.004
Casper, J. (2000). Confidential voice. In J. C. Stemple (Ed.), Voice therapy: Clinical studies (pp. 128–139). Singular.
Childes, J., Acker, A., & Collins, D. (2017). Multiple perspectives on the barriers to identification and management of pediatric voice disorders. Perspectives of the ASHA Special Interest Groups, 2(3), 49–56. https://doi.org/10.1044/persp2.SIG3.49
Cohen, S. M., Kim, J., Roy, N., Asche, C., & Courey, M. (2012). Prevalence and causes of dysphonia in a large treatment-seeking population. The Laryngoscope, 122(2), 343–348. https://doi.org/10.1002/lary.22426
Colton, R. H., Casper, J. K., & Leonard, R. (2011). Understanding voice problems: A physiological perspective for diagnosis and treatment (4th ed.). Lippincott Williams & Wilkins.
de Araújo Pernambuco, L., Espelt, A., Balata, P. M. M., & de Lima, K. C. (2014). Prevalence of voice disorders in the elderly: A systematic review of population-based studies. European Archives of Oto-Rhino-Laryngology, 272(10), 2601–2609. https://doi.org/10.1007/s00405-014-3252-7
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Voice Disorders page:
In addition, ASHA thanks the American Academy of Otolaryngology-HNS Speech, Voice and Swallowing Committee members and ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee members whose work was foundational to the development of this content.
The members of the AAO-HNS Speech, Voice and Swallowing Committee included Robert Sataloff, Jonathan Aviv, Mary Beaver, Alison Behrman (ASHA representative), Mark Courey, Glendon Gardner, Norman Hogikyan, Christy Ludlow (ASHA representative), Roger Nuss, Clark Rosen, Mark Shikowitz, Robert Stachler, Lee Akst, and Susan Sedory Holzer (staff liaison).
The members of the ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee included Leslie Glaze (coordinator), Bernice Klaben, Lori Lombard, Mary Sandage (associate coordinator), Susan Thibeault, and Michelle Ferketic (ex officio). Celia Hooper, vice president for professional practices (2003–2005), served as monitoring vice president for ASHA.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Voice Disorders. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/.