The recent horror movie, Us by Jordan Peele unwittingly brought to the spotlight a certain voice disorder known as spasmodic dysphonia. In the film, a terrifying character named Red, played by actress Lupita Nyong’o, speaks with an unusual (and deliberately freakish) tone of voice, which she later explains in interviews was inspired by spasmodic dysphonia. While Nyong’o’s inadvertent association of a vocal disability with a horror film character has received a lot of backlash, it has also helped to increase public awareness of a debilitating condition which costs the US billions of dollars in lost productivity every year.

What is Dysphonia?
Dysphonia is a form of impaired voice production. It can manifest as an alteration to voice quality (such as breaks in the voice, sounding strained, strangled, or breathy), voice pitch (high or low), volume, or requiring an increased effort to produce vocal sounds, ultimately making it difficult to communicate and affecting the person’s quality of life.

What Dysphona Sounds Like

Traditionally, dysphonias are categorized into either organic causes, which are factors not directly related to the use of the voice, such as gastroesophageal reflux or Parkinson’s disease, or functional dysphonias, arising from misuse of the voice, poor vocal techniques, or vocal muscle imbalance. In recent times, the term ‘muscle tension dysphonia’ has been preferred over the original ‘functional dysphonia’. In the US, dysphonia has been estimated at a rate between 3 to 9% in the general population.

The specific condition portrayed by the character Red in the film Us, spasmodic dysphonia, is a type of organic dysphonia. Spasms of the laryngeal muscles during speech disrupt the normal sounds, often reducing the voice to a strained whisper. An estimated 50 000 people in North America are affected by this condition with onset typically at mid-age and a gender bias towards women.

Voice hoarseness describes one of the symptoms of dysphonia and change in voice quality. On its own, hoarseness is quite common, usually as a result of an upper respiratory tract infection or voice overuse. Inflammation of the larynx (voice box), acid reflux, smoking or exposure to second-hand smoke, and head/neck cancer can also cause hoarseness and dysphonia.

Young children, particularly boys between 8 and 14 years of age, are found to be at greater risk of hoarseness (possibly from playing cowboys and pirates), as are the elderly (possibly from playing very enthusiastic games of bingo). Unsurprisingly, those working in industries with high vocal demands also experience a higher rate of hoarseness, such as singers, call center operators, and sports coaches. Hoarseness in school teachers alone costs the US about $2.5 billion dollars every year from work absenteeism, likely from trying to reign in those 8 to 14-year-old cowboys and pirates.

What Causes Dysphonia?
At a basic level, a disruption in any of the components of voice production, including laryngeal muscle movement and the airflow through these muscles, can cause dysphonia. Organic causes of dysphonia were briefly discussed above and can include structural problems such as vocal fold abnormalities or trauma of the larynx, or may arise from an underlying neurological condition such as multiple sclerosis or paralysis of the laryngeal nerve. In the case of spasmodic dysphonia, while the exact cause is not well understood, dysfunction in the basal ganglia of the brain controlling certain muscle movement is thought to play a role. Functional dysphonia can be caused by yelling such as a very loud “yee-haw!” or “shiver me timbers!”, or excessive throat clearing, both behaviors causing what is known as phonotrauma. Interestingly, psychological and personality characteristics have also been associated with functional dysphonia with many patients suffering this condition being described as “introverted, stress reactive, alienated, and unhappy”. Organic dysphonia was not associated with any consistent psychological traits.

Diagnosis and Treatment of Dysphonia
Amendments to the clinical guidelines in 2018 by the American Academy of Otolaryngology & Head and Neck Surgery when investigating voice hoarseness encourages a laryngoscopy to examine the larynx after 4 weeks of persistent hoarseness. Previously, the guidelines allowed up to 3 months before recommending laryngoscopy in the absence of any obvious, significant concerns such as potentially cancerous lesions around the head and neck. CT and MRI imaging is not recommended without having performed laryngoscopy first as this may result in unnecessary radiation exposure but in the absence of a conclusive diagnosis from laryngoscopy alone, imaging may be required.

The diagnostic team investigating dysphonia may comprise of an ear, nose, and throat (ENT) specialist, neurologist, and speech pathologist. Identifying the type and underlying cause of the dysphonia, whether organic or functional, is paramount to successful treatment. In many cases, basic hoarseness can be treated by resting the voice and avoiding irritants such as tobacco smoke or spicy foods, but some patients may require vocal therapy to identify areas of improvement to vocal hygiene and to modify how the voice is used to prevent future hoarseness. Botox injections into the problematic muscle to reduce laryngeal spasming has been found to be successful in treating spasmodic dysphonia and is approved by the American Academy of Otolaryngology & Head and Neck Surgery though considered to be an off-label use by the FDA. Other treatments include the use of medications or surgery, depending on the underlying cause.

Vocal problems affect approximately 28 million American workers daily to varying degrees. Though many cases may be attributed to simple voice overuse when demanding someone walk the plank or when playing a horror movie character, for the thousands suffering true dysphonia, hoarseness and voice disorders can have real implications for work and social life. If you believe you have a persistent vocal disorder, help is available from your local ENT specialist.