Voice Disorders

A voice disorder is an altered voice quality, pitch, loudness or effort, or a voice that no longer meets your daily needs: hoarse, breathy, strained, weak or lost.⁠^1,2 Voice therapy with a speech-language pathologist is the main treatment for many voice disorders, after a doctor examines the vocal folds (see speech therapy for adults).⁠^2,3 Hoarseness that has not improved within 4 weeks needs that exam.⁠²

What is a voice disorder?

A voice disorder occurs when the quality, pitch or loudness of the voice differs from what is expected, or is inappropriate, for a person’s age, gender, cultural background or location, or when the voice no longer meets the person’s daily needs, even if other people hear nothing wrong.⁠¹ The voice comes from the vocal folds, two bands of muscle tissue in the larynx (voice box) that vibrate as air from the lungs passes between them; the throat, nose and mouth shape the sound.⁠⁴

Clinicians call the symptom dysphonia: an altered voice quality, pitch, loudness or vocal effort that impairs communication or quality of life. Aphonia is the loss of the voice.⁠^1,2 Hoarseness is the everyday word for it: a voice that is weak, breathy, scratchy or husky, or that has changed in pitch or quality.⁠¹³ Speech-language pathologists (SLPs) play a central role in assessing and treating voice disorders, and a doctor examines the larynx.⁠¹ Speech therapy explains what SLPs do.

How common are voice disorders?

Very common, and few people get them checked:⁠⁵

• In a year: an estimated 17.9 million US adults, 7.6%, report a voice problem in the past 12 months, and about 9.4 million (4.0%) a problem that lasted a week or longer.⁠¹⁴
• Who gets care: about 1 in 13 adults has a voice problem each year, but only about 10% of them see a health professional for it.⁠^1,5
• Over a lifetime: hoarseness affects nearly one third of people at some point.⁠²
• At work: adults with a voice problem reported 7.4 lost workdays in the past year, against 3.4 for those without one.⁠⁵

Who is most at risk of a voice disorder?

• Women: in a national survey, 9.3% of women and 5.9% of men reported a voice problem, and ASHA reports a ratio of 1.5 to 1 in adults.⁠^1,5
• Teachers: two to three times more likely than the general population to develop a voice disorder; in a telephone survey of 2,531 people in Iowa and Utah, 11.0% of teachers and 6.2% of others had a current voice problem.⁠^1,15
• Singers and other heavy voice users: the mean prevalence of voice disorders in singers was estimated at 46%, and NIDCD counts doctors, lawyers, nurses, sales people and public speakers among those who make great demands on their voices.⁠^1,4
• Older adults: estimates for people 60 and older range from 4.8% to 29.1%.⁠¹
• People who smoke: smoke irritates the vocal folds, and cancer of the vocal folds is seen most often in people who smoke.⁠⁴

In the teacher survey, being a woman, being aged 40 to 59, having 16 or more years of education and having a family history of voice disorders were also linked to having had a voice disorder.⁠¹⁵

What causes voice disorders?

Anything that makes it harder for the vocal folds to vibrate can cause a voice problem, and many voice disorders have more than one cause.⁠^1,16 The most common cause of hoarseness is a cold or throat infection, which most often goes away on its own within 2 weeks.⁠¹³ The causes NIDCD, ASHA and MedlinePlus list:

• Infection and inflammation: colds and other upper respiratory infections, laryngitis, allergies, and inflammation from acid reflux (GERD) or laryngopharyngeal reflux. In a national survey, infectious laryngitis was the most common diagnosis mentioned, in 17.8% of cases, and reflux was mentioned in 8.0%.⁠^1,4,5,13
• Voice misuse and overuse (phonotrauma): yelling, screaming, excessive throat clearing or coughing, and speaking at too high or too low a pitch; over time, shouting or singing can cause swelling or growths such as nodules.⁠^1,13
• Growths on the vocal folds: nodules and polyps, cysts, swelling (edema), and laryngeal papillomatosis, growths caused by HPV.⁠^1,4
• Muscle tension dysphonia: inefficient use of the voice when the larynx itself is normal, and the most common functional voice disorder.⁠^1,17
• Nerve and brain conditions: vocal fold paralysis, spasmodic dysphonia, vocal tremor, Parkinson’s disease, multiple sclerosis, ALS and stroke.⁠^1,18,19
• Injury and surgery: irritation from a breathing tube or bronchoscopy, injury to the head, neck or chest, and damage to the nerves and muscles around the larynx from trauma or surgery, including thyroid surgery.⁠^13,18,20
• Smoking and drinking: heavy smoking or drinking, particularly together, and breathing in irritating substances.⁠¹³
• Cancer: of the larynx or throat, and thyroid or lung cancer.⁠^4,13
• Aging: structural changes in the larynx and loss of muscle with age (presbyphonia).⁠¹
• An underactive thyroid gland.⁠¹³
• Stress: rarely, psychological stress leads to a habitual loss of voice or dysphonia (psychogenic voice disorders); NIDCD also lists psychological trauma.⁠^1,4

Even when an obvious cause is found and treated, the voice problem can persist: a cold may start it, and inefficient ways of compensating can keep the hoarseness going after the infection has cleared.⁠¹ Among adults aged 19 to 60 with a voice disorder, the most frequent diagnoses in one series were functional dysphonia (20.5%), acid laryngitis (12.5%) and vocal polyps (12%).⁠¹

What are the types of voice disorders?

ASHA groups voice disorders by where they come from:⁠¹

The types often combine. Nodules can start with voice misuse, a functional cause, and the repeated trauma then changes the tissue of the vocal folds, an organic one.⁠¹ SLPs also assess and treat problems of the larynx that are not classed as voice disorders, such as paradoxical vocal fold movement.⁠¹

What are the signs and symptoms of a voice disorder?

A voice disorder can show in how the voice sounds, how it feels to use it, or both. The signs ASHA lists, alone or in combination:⁠¹

• a rough, raspy voice, or a breathy one with audible air escaping;⁠¹
• a strained voice that takes more effort, or a strangled one, as if talking while holding the breath;⁠¹
• pitch that is too high or too low, breaks in pitch or a smaller pitch range, and loudness that is too high, too low or unsteady;⁠¹
• a weak voice, breaks in the voice, or loss of voice (aphonia);⁠¹
• a shaky voice, with rhythmic changes in pitch and loudness;⁠¹
• more effort to speak, a voice that tires with long use or varies through the day, and running out of breath quickly;⁠¹
• frequent coughing or throat clearing, and tension, pain or tenderness in the throat.⁠¹

How a voice sounds does not always show how severe the problem is, which is why an instrumental examination may be needed to judge the severity or the cause.⁠¹

How do you know if your voice is not healthy?

NIDCD suggests six questions. A yes to any of them may mean a voice problem, and its advice is to see a doctor to find the cause:⁠⁴

• Has your voice become hoarse or raspy?
• Have you lost the ability to hit some high notes when singing?
• Does your voice suddenly sound deeper?
• Does your throat often feel raw, achy or strained?
• Has it become an effort to talk?
• Do you find yourself repeatedly clearing your throat?

When should you see a doctor about hoarseness?

Most hoarseness from a cold or throat infection clears on its own within 2 weeks.⁠¹³ The consumer advice is to see a provider when hoarseness in an adult has lasted more than 2 to 3 weeks.⁠^13,16 The hoarseness guideline for clinicians calls for laryngoscopy, an examination of the larynx, when hoarseness has not cleared or improved within 4 weeks, or at any time if a serious cause is suspected.⁠²

Which signs mean you should be seen sooner?

The guideline’s strong recommendation is to look first for the factors that call for a faster examination of the larynx. With the consumer warning signs, see a doctor promptly for hoarseness with any of these:⁠^2,13

• trouble breathing, noisy breathing or stridor, or trouble swallowing;⁠^2,13,18
• recent surgery on the head, neck or chest, or a recent breathing tube;⁠²
• a lump in the neck;⁠²
• a history of smoking;⁠²
• using your voice for your work;⁠²
• other possible signs of cancer of the larynx: a feeling of a lump in the throat, a cough or sore throat that does not go away, unexplained weight loss, or ear pain that lasts a long time.⁠²¹

After thyroid surgery, the AAO-HNS guideline on thyroid surgery recommends that a change in voice be checked by examining how the vocal folds move (see voice changes after thyroid surgery).⁠²⁰

Is sudden trouble speaking an emergency?

Yes: sudden trouble speaking is a warning sign of a stroke.⁠²²

Paralysis of both vocal folds is rare, but it usually causes serious problems with breathing and can be life threatening.⁠¹⁸

How is a voice disorder diagnosed?

With a history, an examination of the larynx and, usually, a voice evaluation by an SLP. The doctor examines the throat, neck and mouth, and asks how much of the voice is lost, when the hoarseness started, whether it comes and goes or is getting worse, about voice overuse, fumes, allergies, throat surgery, smoking and alcohol, and about other symptoms such as fever, cough, trouble swallowing, weight loss or fatigue.⁠¹³ Tests can include laryngoscopy, a throat culture, an X-ray or CT scan of the neck, and blood tests.⁠¹³ The guideline advises against a CT or MRI for a voice complaint before the larynx itself has been examined.⁠²

Who examines and treats voice disorders?

An otolaryngologist, the ear, nose and throat doctor (ENT), is the doctor best placed to diagnose a voice disorder, and may refer you to an SLP, who helps you improve the way you use your voice.⁠⁴ ASHA’s guidance is that everyone with a voice disorder should be examined by a physician, before or after the SLP’s voice evaluation: SLPs can diagnose only functional problems, and only otolaryngologists can diagnose organic ones, such as nodules, polyps and tumors.⁠¹

Other specialists join when needed. SLPs work with otolaryngologists or laryngologists and with lung, allergy, digestive, nerve and hormone specialists, mental health professionals, and vocal coaches or voice teachers.⁠¹ Spasmodic dysphonia is usually diagnosed by a team of an otolaryngologist, an SLP and a neurologist.⁠⁸

What is laryngoscopy, and what is stroboscopy?

Laryngoscopy is a look at the vocal folds through an endoscope, a thin tube with a light, passed through the mouth or nose.⁠^16,18 Stroboscopy adds a flashing light that lets the team watch the vocal folds move: ASHA describes videoendoscopy as measuring structure and gross function, and videostroboscopy as measuring how the vocal folds vibrate during voicing.⁠^1,16 When imaging is used for a medical diagnosis, an otolaryngologist trained in it should view and interpret it.⁠¹ Under the hoarseness guideline, laryngoscopy may be done at any time, should be done when hoarseness has not improved within 4 weeks or a serious cause is suspected, and should be done before voice therapy is prescribed, with the results shared with the SLP.⁠²

What happens in a voice evaluation with a speech-language pathologist?

The SLP’s comprehensive assessment typically covers:⁠¹

• Case history: your description of the problem, when it started and how it varies, your medical history, surgeries and medicines, earlier voice treatment, and daily habits that affect the voice.⁠¹
• Self-assessment: how you see your voice and how the problem affects your emotions, your self-image and your communication at home, at work and socially, often with a standardized questionnaire such as the Voice Handicap Index.⁠^1,9
• An oral and physical exam: the face, mouth, head and neck, sensations in the larynx, and gentle palpation of the muscles around it.⁠¹
• Breathing: your breathing pattern, how breath and voice are coordinated, and how long you can sustain a vowel (maximum phonation time).⁠¹
• Listening: ratings of roughness, breathiness, strain, pitch, loudness and overall severity on sustained vowels, sentences and running speech, using ASHA’s Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).⁠¹
• Acoustic and airflow measures: recordings that measure loudness, pitch and voice quality, and noninvasive measures of the airflow and air pressure used to make voice.⁠¹
• Trial therapy: techniques tried during the evaluation, to help with the diagnosis and to see whether the voice responds.⁠¹

How are voice disorders treated?

By the cause. Most voice problems can be reversed by treating the underlying cause, or with behavioral and surgical treatments.⁠⁴ The American Academy of Otolaryngology–Head and Neck Surgery Foundation’s guideline on hoarseness, updated in 2018, sets out what clinicians should and should not do:⁠²

Do antibiotics, steroids or reflux medicines help hoarseness?

Not as routine treatments. A Cochrane review of three trials with 351 adults found that antibiotics do not appear to work for acute laryngitis on objective measures, and that their modest benefits on some symptoms may not outweigh their cost, side effects and effect on antibiotic resistance; the evidence was of very low quality.⁠⁷ The guideline makes a strong recommendation against routine antibiotics for hoarseness, and recommends against routine corticosteroids before the larynx has been examined.⁠²

Reflux medicine has a place when reflux is the cause: MedlinePlus advises medicine to reduce stomach acid if hoarseness is due to GERD, while the guideline advises against prescribing it for hoarseness alone, on symptoms only, without looking at the larynx first.⁠^2,13 Decongestants, and some cold and allergy medicines, can dry out the vocal folds; ask your doctor which medicines are safest for you.⁠^4,13

When is surgery needed for a voice disorder?

When the cause calls for it: the guideline lists suspected cancer, benign growths that have not responded to conservative treatment, and vocal folds that do not close fully.⁠² For nodules and polyps, surgery is usually done only when they are large or long-standing; for vocal fold paralysis, doctors often wait at least a year, because some voices recover on their own; and for spasmodic dysphonia, surgery is used when more conventional measures have failed.⁠^8,16,18 Voice therapy often comes first, and after surgery for paralysis, more voice therapy fine-tunes the voice.⁠^18,23

What is voice therapy?

Voice therapy is treatment with an SLP to improve how the voice is produced and how breathing and the larynx work together.⁠¹ It combines direct approaches, which work on breathing, voicing and muscle tension to build healthy voice production, with indirect ones, which change the habits, surroundings and stresses around voice use: education about how the voice works and how to look after it (vocal hygiene), and counseling, such as stress management.⁠¹ A treatment plan typically includes at least one direct approach and one or more indirect ones, chosen for your condition and goals.⁠¹

Therapy often starts by finding what strains the voice, such as shouting, talking loudly over noise, coughing, throat clearing and not drinking enough water, and by building healthier habits, such as drinking plenty of water and talking at a moderate volume.⁠¹ Goals are set around the voice you need, which may differ at work, at home and socially, and the SLP helps you become aware of how your voice sounds and feels, including tension.⁠¹

Which voice therapy exercises do SLPs use?

ASHA describes many named approaches, without endorsing any. The main ones, and what research has tested:⁠¹

Other techniques ASHA describes include the accent method, conversation training therapy, expiratory muscle strength training, confidential voice, chant speech, yawn-sigh, twang therapy, inhalation phonation, biofeedback, relaxation and posture, and auditory masking, which often brings back a changed or normal voice in functional voice loss.⁠¹ ASHA advises against changing your pitch without a skilled clinician’s guidance, because it can lead to voice misuse.⁠¹

Does voice therapy work?

For many voice disorders, yes. Behavioral voice therapy guided by an SLP is recommended as the main treatment for many kinds of voice disorders, and a systematic review of 15 randomized trials found that it generally leads to significant improvements in voice outcomes; the authors note that how meaningful the gains were in daily life was rarely discussed.⁠³

For functional dysphonia, a voice disorder without a structural cause, a Cochrane review of six randomized trials found evidence that comprehensive voice therapy, combining direct and indirect elements, works, with similar effects in patients and in teachers. Indirect therapy on its own did not work in one study, publication bias may have influenced the results, and in one study the benefit lasted at least 14 weeks.⁠^1,6

A 2020 network meta-analysis of 13 randomized trials compared nine therapies on the Voice Handicap Index: stretch-and-flow phonation, resonant voice therapy, the Comprehensive Voice Rehabilitation Program and vocal function exercises all improved scores, and stretch-and-flow phonation did best.⁠²⁶ For muscle tension dysphonia, behavioral voice therapy is the front-line treatment.⁠¹⁷

Does vocal hygiene advice work on its own?

Not on the trial evidence. In 58 teachers randomized to vocal hygiene, vocal function exercises or no treatment for 6 weeks, only the group who kept up the exercises reported less voice handicap.⁠⁹ In 44 teachers, only the group given a voice amplifier improved significantly; the vocal hygiene group showed no significant improvement on any measure, though both treated groups did better than no treatment on some.⁠¹⁰ A Cochrane review of two small, poor-quality trials in teachers and student teachers found no evidence that voice training prevents voice problems.⁠³⁰ Vocal hygiene belongs in therapy as one part, beside direct work on the voice.⁠^1,6

Can voice therapy help an aging voice?

Early trials suggest it can. In people over 60 evaluated for voice problems, the most common findings were presbyphonia (the aging voice), reflux or inflammation, functional dysphonia, vocal fold paralysis or weakness, and Reinke’s edema.⁠¹ PhoRTE, adapted from LSVT, uses four loud exercises: a sustained loud vowel, loud pitch glides, and everyday phrases said loud and high, then loud and low.⁠¹ In a preliminary randomized trial of 16 older adults with presbyphonia, both PhoRTE and vocal function exercises improved voice-related quality of life over 4 weeks, only PhoRTE reduced the effort of speaking, and the untreated group did not change.⁠²⁹ A systematic review found vocal function exercises effective in aging voices as well.⁠²⁴

Why does home practice matter?

Because the trials link results to doing the work. In the teacher trial of vocal function exercises, the benefit was in the group that adhered to the exercise regimen, and the authors of the three-treatment trial discuss uneven compliance and dropout between groups.⁠^9,25 Vocal function exercises are practiced twice a day, and teachers given amplifiers reported better compliance than those given hygiene advice.⁠^1,10

What happens in voice therapy, session by session?

On Medicare, a course of outpatient voice therapy runs like this:

How long does voice therapy take?

It depends on the disorder and the program, and some programs set their own dose.⁠¹ Across 93 published studies and 47 textbooks, voice therapy averaged 9.25 weeks and about 11 sessions, most often of 30 or 60 minutes, once or twice a week, for a little over 8 hours with the therapist in all; North American patients had more sessions (12.5) over a shorter time (7.6 weeks).⁠³⁴ Named programs set their own schedules:

• Vocal function exercises: twice a day, morning and evening, in sets of two.⁠¹
• The teacher trials of vocal function exercises, vocal hygiene, amplification and resonant voice therapy: 6 weeks.⁠^9,10,25
• PhoRTE: a 4-week program in the trial above.⁠²⁹
• LSVT LOUD: 16 one-hour sessions, 4 days a week for 4 weeks; in the UK PD COMM trial, four 50-minute sessions a week for four weeks.⁠^28,35
• Therapy for chronic cough, in the two trials a Cochrane review found: four sessions, weekly or over two months.⁠³⁶

Ask the SLP how many sessions they expect for your diagnosis, and how much home practice the plan needs.

What are vocal nodules and polyps?

Vocal fold nodules and polyps are growths on the vocal folds. Nodules are benign, noncancerous growths, often compared to calluses: when the voice is used the wrong way the folds swell, the swollen spots harden over time, and nodules can grow larger and stiffer if the misuse continues.⁠¹⁶ They form on both vocal folds and typically cause hoarseness, discomfort and an unstable voice when speaking or singing.⁠³⁷ Polyps, compared to blisters, can be on one or both folds, are usually bigger than nodules, and are also called polypoid degeneration or Reinke’s edema.⁠¹⁶

Most of the time, voice misuse or overuse causes nodules, through coaching, cheerleading, talking loudly or singing, for example. Polyps can follow long-term misuse or a single episode, such as yelling at a concert, and long-term smoking, thyroid problems and reflux may also cause them.⁠¹⁶ The signs of both include a rough, scratchy or harsh voice, breathiness, hoarseness, a feeling of a lump in the throat, less ability to change pitch, neck pain, pain shooting from ear to ear, and tiredness of the voice and body.⁠¹⁶

Can vocal nodules go away without surgery?

Treatment usually starts without surgery, and depends on the cause, the size of the growths and the problems they cause. Medical causes such as reflux, allergies or thyroid problems need treating before the nodules or polyps can go away, and voice therapy with an SLP teaches vocal hygiene, how to stop misusing the voice and how to get enough breath to talk; surgery is usually done only when the growths are large or have been there a long time.⁠¹⁶ The hoarseness guideline likewise reserves surgery for benign growths that do not respond to conservative management.⁠² A Cochrane review found no randomized trial comparing surgery with non-surgical treatment for nodules, and calls for such trials.⁠³⁷

What is muscle tension dysphonia?

Muscle tension dysphonia is a voice disorder from inefficient use of the voice when the larynx itself is structurally normal; it is the most common functional voice disorder.⁠^1,17 Behavioral voice therapy is the front-line treatment, and manual therapy around the larynx may be part of it.⁠¹⁷

Techniques aimed at excess tension include manual circumlaryngeal techniques, relaxation, posture, confidential voice, yawn-sigh, inhalation phonation and semi-occluded vocal tract exercises.⁠¹ In a meta-analysis of 6 studies, manual circumlaryngeal therapy improved acoustic measures of voice quality in muscle tension dysphonia; its effect on pitch could not be confirmed, and the authors call for more high-quality randomized trials.⁠¹⁷

What is functional or psychogenic voice loss?

Some people lose their voice, or speak with a strained one, without any structural problem in the larynx: functional aphonia and muscle tension dysphonia are examples, and they may benefit from psychological counseling as well as voice therapy.⁠¹ Rarely, psychological stress leads to a habitual loss of voice or dysphonia; SLPs may refer someone with a suspected psychogenic voice disorder to a psychologist or psychiatrist for diagnosis, and work with them on treatment.⁠¹ Auditory masking, talking or reading aloud while hearing loud noise through headphones, often brings back a changed or normal voice in functional voice loss, and inhalation phonation can help bring back true vocal fold vibration.⁠¹

What is vocal fold paralysis?

Vocal fold paralysis, also called vocal cord paralysis, is a voice disorder in which one or both vocal folds do not open or close properly. Paralysis of one fold is common; paralysis of both is rare and can be life threatening.⁠¹⁸ A fold that stays open leaves the airway and lungs unprotected, so food or liquid can enter the windpipe and lungs.⁠¹⁸

It comes from damage to the nerve that controls the vocal folds: injury to the head, neck or chest, lung or thyroid cancer, tumors of the skull base, neck or chest, infections such as Lyme disease, surgery, and neurological conditions such as multiple sclerosis, Parkinson’s disease and stroke; in many cases the cause is unknown.⁠^18,23

The signs are a hoarse or breathy voice, a voice that cannot get loud, lasts only a short time or has lost pitch and loudness, shortness of breath or noisy breathing, and choking or coughing when eating, a sign of swallowing trouble (dysphagia); food or liquid that reaches the lungs can cause pneumonia.⁠^18,23 An otolaryngologist diagnoses it, listening to the voice and looking at the vocal folds with an endoscope; some also use laryngeal electromyography, which measures the electrical impulses of the nerves in the larynx.⁠¹⁸

How is vocal fold paralysis treated?

The most common treatments are voice therapy and surgery. Some voices recover naturally during the first year after diagnosis, which is why doctors often delay surgery for at least a year and refer you to an SLP for voice therapy meanwhile: exercises to strengthen the vocal folds or improve breath control, and ways of using the voice differently, such as speaking more slowly or opening the mouth wider.⁠¹⁸ When one fold is paralyzed, a doctor may want you to try voice therapy before surgery, and it may be the only treatment you need.⁠²³

The most common operations move the paralyzed fold toward the middle, with an implant or stitches, or make it larger with an injection, so the other fold can meet it; they usually give a stronger voice, and more voice therapy follows to fine-tune it.⁠^18,23 Close to a quarter of people who have an implant placed need another operation to reposition it, and a Cochrane review found no randomized trials comparing the materials used for injection.⁠^18,38 When both folds are paralyzed, a tracheotomy, a breathing tube placed through an opening in the front of the neck, may be needed, and an SLP teaches how to use the voice and care for the tube.⁠^18,23

What about voice changes after thyroid surgery?

Thyroid surgery can injure the nerves of the larynx: about 1 in 10 patients have a temporary nerve injury, and up to 1 in 25 have longer-lasting voice problems.⁠²⁰ The AAO-HNS guideline on voice outcomes after thyroid surgery recommends that the surgeon identify the recurrent laryngeal nerve during the operation, that any change in voice be documented between 2 weeks and 2 months afterward, that vocal fold movement be examined when the voice has changed, with referral to an otolaryngologist if it is abnormal, and that patients with a voice change be counseled on options for voice rehabilitation.⁠²⁰

What is spasmodic dysphonia?

Spasmodic dysphonia, also called laryngeal dystonia, is a rare, lifelong disorder in which the muscles inside the vocal folds spasm, interrupting their vibration. It causes voice breaks and a tight, strained or breathy voice, from a break every few sentences to, in severe cases, a spasm on every word.⁠⁸ The voice usually sounds normal when laughing, crying or whispering, and stress often makes the spasms worse; it most often begins between ages 30 and 50, and affects more women than men.⁠^8,14

It is thought to come from abnormal function in the basal ganglia, a part of the brain that helps coordinate movement; it can run in families and may occur with dystonia elsewhere in the body.⁠⁸ There is no simple test, and because its symptoms resemble other voice disorders, diagnosis usually involves an otolaryngologist, who views the vocal folds through a thin lighted tube passed through the nose, an SLP and a neurologist.⁠^8,39

Does Botox work for spasmodic dysphonia?

It is the most common treatment, and the hoarseness guideline recommends offering it.⁠^2,8 Very small amounts of botulinum toxin are injected into the affected muscles of the larynx, weakening them; the voice generally improves for three to four months, then symptoms slowly return and the injection is repeated.⁠⁸ It works better for adductor than for abductor spasmodic dysphonia and does not help everyone; early side effects, a temporarily weak, breathy voice and some trouble swallowing, usually ease within days to weeks.⁠⁸

In a placebo-controlled trial of 24 patients in Japan, the injection reduced voice breaks in adductor spasmodic dysphonia, with improvement lasting 12 weeks; breathy hoarseness (77.3%) and aspiration when drinking (40.9%) were common but mild, and resolved within 4 weeks. Allergan supplied the drug and placebo.⁠⁴⁰ A Cochrane review from 2004 found only one eligible trial, too few for firm conclusions.⁠⁴¹

Voice therapy may reduce symptoms in mild cases and can work alongside injections to reduce strain; counseling helps some people accept and live with the condition; voice amplifiers and text-to-speech apps help some people communicate; and surgery is an option when more conventional measures have failed. No study has yet compared the treatments to find a single best one.⁠⁸ In a phase IIb trial of 106 patients, sodium oxybate, a drug approved in the US for narcolepsy, improved symptoms only in those whose voice improves with alcohol, and its effect faded by 300 minutes after a dose.⁠⁴²

Why is my voice shaky?

A shaky, trembling voice has several causes. Vocal tremor is a neurological voice disorder in its own right, and some people with spasmodic dysphonia have it as well.⁠^1,8 Tremor, a neurological condition of shaking or trembling movements, can affect the vocal cords, and a shaky voice is one of its common symptoms: essential tremor, one of the most common movement disorders, can affect the voice, and dystonic tremor can affect the vocal cords.⁠⁴³ Stress, strong emotion and tiredness can trigger tremor, and some medicines, too much caffeine and an overactive thyroid can cause it or make it worse.⁠⁴³ A doctor diagnoses tremor with a physical and neurological exam that includes speech, and working with a speech therapist is among the approaches that may help.⁠⁴³

How do Parkinson’s disease and other neurological conditions affect the voice?

Conditions of the brain and nerves can weaken or disrupt the voice. In Parkinson’s disease, a quieter voice is among the first and most pervasive speech changes, and speech problems generally do not respond to medicines or brain surgery alone; as many as 89% of people with Parkinson’s develop a speech disorder.⁠³⁵ In ALS, dysarthria brings slow, effortful, slurred speech, with a breathy or hoarse voice.⁠¹⁹ Multiple sclerosis, stroke and pseudobulbar palsy are among the other neurological causes ASHA lists, and stroke, MS and Parkinson’s can all cause vocal fold paralysis.⁠^1,18

What is LSVT LOUD, and does it help the Parkinson’s voice?

LSVT LOUD is an intensive program developed for Parkinson’s disease: people learn to produce a loud voice with maximum effort and to monitor their own loudness, following principles such as “think loud”, and it is given by clinicians trained and certified in it.⁠¹ The standard course is 16 one-hour sessions, 4 days a week for 4 weeks, with daily homework.⁠³⁵

In the PD COMM trial in the UK, 388 people with Parkinson’s and dysarthria were randomized to LSVT LOUD, usual NHS speech therapy or none. At three months, those given LSVT LOUD reported less voice handicap than both other groups, with the benefit over no therapy lasting 12 months; NHS therapy, given at a much lower intensity, did no better than none.⁠²⁸ Vocal strain was the most common side effect, mostly minor and temporary, and there were no serious adverse events.⁠²⁸ In an earlier US trial of 64 people, LSVT LOUD increased loudness at 1 and 7 months more than articulation therapy or no treatment; that trial was funded in part by LSVT Global, Inc., for which several of its authors have worked or consulted.⁠³⁵

LSVT LOUD can be given face to face or remotely, and treatment may need repeating if the effect wears off or as the disease progresses.⁠²⁸ Medicare covers therapy that maintains function or slows decline, not only therapy that restores it.⁠⁴⁴

How do people speak after a laryngectomy?

Hoarseness or another voice change can be a sign of cancer of the larynx, together with trouble swallowing, a feeling of a lump in the throat or neck, a cough or sore throat that does not go away, shortness of breath, unexplained weight loss, or ear pain that lasts a long time. Risk factors include smoking or chewing tobacco, drinking alcohol, acid reflux and HPV.⁠²¹ Cancer is a rare cause of hoarseness, but a serious one when hoarseness does not go away in a few weeks.⁠¹³

Treatment can include surgery, radiation, chemotherapy, targeted drugs and immunotherapy. Radiation and chemotherapy can leave a hoarse voice and swallowing trouble (dysphagia), and not every operation removes the larynx; SLPs help with speech and swallowing before, during and after treatment.⁠²¹

After a total laryngectomy, the surgeon creates a breathing opening in the neck, a stoma, and the voice has to be replaced. Right after surgery, people communicate with paper and pen, a dry-erase board, a picture board, or a phone or tablet; as they heal, the SLP helps them choose among three main options:⁠^21,45

Writing, gestures and AAC devices remain options, and ASHA lists laryngectomy among the surgeries after which AAC can help.⁠^45,46 SLPs weigh vision, thinking skills and dexterity, healing, family support and access to equipment and follow-up care in helping each person choose.⁠⁴⁵

What other throat problems does a speech-language pathologist treat?

Can speech therapy help a chronic cough?

It can be part of the treatment. A chronic cough in an adult is one that lasts more than 8 weeks; it can make the voice rough or hoarse, and its most common causes are acid reflux, allergies or sinus problems that drip mucus down the throat, and asthma.⁠⁴⁷ An SLP works with the doctors to help you understand what triggers the cough, learn ways to reduce coughing and keep the vocal cords healthy.⁠⁴⁷ A Cochrane review found two trials with 162 adults with unexplained chronic cough: a combined physiotherapy and speech therapy program improved quality of life and cough frequency, but the difference from healthy lifestyle advice lasted only up to four weeks, and the evidence is too limited for firm conclusions.⁠³⁶

What is paradoxical vocal fold movement?

Paradoxical vocal fold movement is a condition in which the vocal folds come together intermittently in a way that interferes with breathing. It is not classed as a voice disorder, but SLPs help identify it and teach techniques, such as vocal exercises, relaxation, quick-release breathing and breath management, to improve control of the larynx and breathing.⁠¹ A related condition, exercise-induced laryngeal obstruction, is most often diagnosed in adolescence.⁠¹

What is gender-affirming voice therapy?

Some people work with an SLP to make their voice and other aspects of their communication fit their gender or gender expression. The SLP assesses pitch, intonation, voice quality, resonance and other aspects of communication, and the goals follow what the client wants their own voice to be.⁠⁴⁸ Changing the voice without proper guidance can lead to voice misuse and to disorders such as muscle tension dysphonia and nodules, and hormone therapy alone gives variable results and does not change intonation, loudness or other features of how a voice is perceived, so SLPs adapt techniques used for other voice problems.⁠⁴⁸ Coverage varies by payer and plan, and a diagnosis of gender dysphoria is often needed for insurance coverage but does not guarantee it.⁠⁴⁸

How can teachers, singers and other professional voice users protect their voice?

People who use their voice for work make great demands on it, which puts them at risk of voice problems: singers, teachers, doctors, lawyers, nurses, sales people and public speakers among them.⁠⁴ Teachers are estimated to be two to three times more likely than the general population to develop a voice disorder, with risk tied to the number of classes a week, noise from outside the school and how loudly they lecture; people in the service industry were estimated to be 2.6 times more likely to develop a benign growth on the larynx.⁠¹

For teachers, amplification has been tested in two randomized trials. In both, a portable voice amplifier used for 6 weeks significantly reduced self-rated voice handicap, and in the second, teachers rated it higher for overall improvement, clarity and ease than resonance therapy or breathing-muscle training; resonance therapy also worked.⁠^10,25 NIDCD suggests a lightweight microphone and amplifier-speaker in classrooms, exhibit areas and exercise rooms.⁠⁴

Singers and voice actors may need more than standard voice therapy and may see several professionals: an otolaryngologist, an SLP, a singing teacher, and a voice and speech trainer.⁠¹ Professional voice use is one of the reasons the hoarseness guideline gives for a faster examination of the larynx.⁠² At work, the Job Accommodation Network lists voice amplification, including for the telephone, and a flexible schedule and job restructuring for a weak voice.⁠⁴⁹ Face masks can add vocal strain and the sense of effort, and SLPs consider whether someone telecommutes for their work.⁠¹

How do you take care of your voice?

NIDCD’s healthy-voice habits:⁠⁴

• Stay hydrated: drink plenty of water, especially when exercising, and balance caffeine or alcohol with plenty of water.⁠⁴
• Rest the voice: take vocal naps through the day, rest it when you are sick, and avoid speaking or singing when it is hoarse or tired.⁠⁴
• Humidify: use a humidifier at home, especially in winter or a dry climate; 30% humidity is recommended.⁠⁴
• Watch drying medicines: avoid or limit medicines that dry the vocal folds, including some cold and allergy medicines, and ask your doctor which are safest for you.⁠⁴
• Do not smoke, and avoid secondhand smoke.⁠⁴
• Avoid the extremes: screaming and whispering both stress the voice, as does talking too loudly or too softly.⁠⁴
• Use your breath, and a microphone: support the voice with deep breaths rather than the throat alone, and use a microphone where it fits.⁠⁴
• Mind your setting: avoid talking in noisy places, and avoid cradling the phone between head and shoulder.⁠⁴
• Everyday health: avoid mouthwash or gargles with alcohol or irritating chemicals, wash your hands often to prevent colds and flu, get enough rest and regular exercise, and talk to your doctor about persistent heartburn.⁠⁴

What helps while your voice is hoarse?

MedlinePlus’s home care: talk only when you need to until the hoarseness goes away, drink plenty of fluids (gargling does not help), add moisture to the air with a vaporizer, avoid whispering, shouting, crying and singing, avoid decongestants, and cut down on or stop smoking at least until the hoarseness goes; vocal rest and time may improve it.⁠¹³

Habit advice is not proven to prevent voice disorders: a Cochrane review found no evidence that voice training, including voice-care education, prevents voice problems in people at risk.⁠³⁰ If hoarseness lasts, see a doctor, and consider voice therapy with an SLP experienced in voice problems.⁠^4,13

Does Medicare or insurance cover voice therapy?

Yes, when it is medically necessary. Medicare Part B covers medically necessary outpatient speech-language pathology, including therapy to maintain function or slow decline; you pay 20% of the Medicare-approved amount after the deductible, and a doctor, nurse practitioner, clinical nurse specialist or physician assistant certifies the need.⁠¹¹ Medicare covers it in each setting:

Medicare has no cap on outpatient therapy, but once physical therapy and speech-language pathology together pass $2,480 in a year (the 2026 amount), each claim must confirm that the therapy is medically necessary, and claims past $3,000 can be picked for review.⁠⁵¹

Improvement is not required. Medicare covers skilled therapy to maintain function or to prevent or slow decline, not only to restore it, provided the other coverage rules are met; coverage turns on the need for skilled care, not on the potential to improve.⁠⁴⁴ That matters in lifelong conditions such as spasmodic dysphonia.⁠⁸ Speech-generating devices are covered separately, as durable medical equipment, for a severe speech impairment.⁠⁵²

Medicaid, Marketplace plans and the VA. For adults, speech, hearing and language services are an optional Medicaid benefit, so coverage depends on your state; home health is a mandatory benefit.⁠⁵³ Every Marketplace plan covers rehabilitative and habilitative services and devices, though the specific services vary with each state’s requirements.⁠⁵⁴ For veterans, audiology and speech pathology are standard medical benefits for every enrolled veteran.⁠⁵⁵ With any private plan, ask about visit limits, whether a referral is needed, and whether the SLP is in network.

Voice disorder vs speech or language disorder: what is the difference?

A voice disorder affects the sound made in the larynx; speech and language disorders affect how sounds are shaped into words, and how language is used and understood:⁠^1,14,19

Other adult speech, swallowing and communication problems have their own causes and treatment: dysphagia, cognitive-communication disorders, stuttering in adults, and the changes in speech, swallowing and communication that come with ALS and dementia.

What are the common myths about hoarseness?

• Myth: whispering rests the voice. Whispering is an extreme of the vocal range, like screaming, and both can stress the voice; MedlinePlus lists whispering among the actions that strain the vocal cords.⁠^4,13
• Myth: antibiotics clear up hoarseness. They do not appear to work for acute laryngitis on objective measures, and the guideline strongly recommends against routine antibiotics.⁠^2,7
• Myth: a smoker’s hoarse voice is nothing to worry about. A history of tobacco use is a reason for a faster look at the larynx, and cancer of the vocal folds is seen most often in people who smoke.⁠^2,4
• Myth: hoarseness is reflux, so reflux pills fix it. The guideline recommends against reflux medicine for hoarseness alone, on symptoms only, without first examining the larynx.⁠²
• Myth: gargling soothes a hoarse voice. Gargling does not help; drinking plenty of fluids keeps the airways moist.⁠¹³
• Myth: nodules always need surgery. Surgery is usually done only when nodules are large or long-standing; treating causes such as reflux or allergies, and voice therapy, come first.⁠¹⁶
• Myth: a scan is the first test. The guideline advises against a CT or MRI for a voice complaint before the larynx itself has been examined.⁠²

How do you find a voice therapist near you?

Start with a doctor who can examine your larynx, usually an otolaryngologist (ENT), then a licensed speech-language pathologist experienced in treating voice problems; the hoarseness guideline asks the doctor to share the laryngoscopy findings with the SLP before voice therapy starts.⁠^2,4 ASHA’s specialty certification boards cover AAC, child language, fluency and swallowing, not voice, and specialty certification is not required to practice in any area.⁠⁵⁶

The DrSensory speech therapy directory lists practices by state and city. On a city page, set Care for to Adults, then ask the practice about its experience with voice disorders, and whether it works with an ENT or laryngologist, when you call.

Every SLP needs a state license. ASHA’s Certificate of Clinical Competence (CCC-SLP) is a national credential whose holders have met standards that typically go beyond state licensure, and anyone can check an SLP’s certification on ASHA’s site.⁠^57,58

What should you ask a voice therapist before you book?

• How many adults with my voice problem have you treated?
• Do you work with an ENT or laryngologist, and can you see my laryngoscopy or stroboscopy results?
• Which approaches do you use for my diagnosis, and how much home practice does it take?
• How many sessions do you expect, and how do we measure progress?
• For Parkinson’s disease: are you trained and certified in LSVT LOUD?
• Do you offer telehealth, and do you take Medicare or my plan?

Can voice therapy be done online?

For many people, yes. A 2025 systematic review of six studies found that, despite small and varied studies, the evidence supports voice therapy by telehealth for selected patients, especially for programs that need no hands-on contact, such as LSVT LOUD, and that hybrid in-person and remote plans are an option.⁠⁵⁹ Sound quality is the catch: teletherapy may not carry the voice as reliably as an in-person session, so a good microphone helps.⁠¹

ASHA’s standard is that telepractice be of equal quality to in-person care, with your right to ask for in-person sessions at any time; Medicare covers speech therapy by telehealth from home through December 31, 2027.⁠^12,60 If leaving home is hard, Medicare home health covers speech therapy at home for people who are homebound.⁠⁵⁰ Online speech therapy and in-home therapy explain both.

Sources

1. American Speech-Language-Hearing Association. Voice Disorders (Practice Portal). “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”; “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”. Types: organic, “physiological voice disorders that result from alterations in respiratory, laryngeal, or vocal tract mechanisms”, either structural, “organic voice disorders that result from physical changes in the vocal mechanism” (such as nodules, edema and “structural changes in the larynx due to aging”), or neurogenic, “organic voice disorders that result from problems with the central or peripheral nervous system innervation to the larynx that affect functioning of the vocal mechanism” (vocal tremor, spasmodic dysphonia, vocal fold paralysis); functional, “voice disorders that result from inefficient use of the vocal mechanism when the physical structure is normal” (vocal fatigue, “muscle tension dysphonia or aphonia”); and psychogenic, when “psychological stressors lead to habitual, maladaptive aphonia or dysphonia”: “These voice disorders are rare”, and 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”. “many voice disorders will have contributions from more than one etiologic factor”: “vocal fold nodules may result from behavioral voice misuse (functional etiology)”, and “the voice misuse results in repeated trauma to the vocal folds, which may then lead to structural (organic) changes to the vocal fold tissue”. Not classified as voice disorders: paradoxical vocal fold movement, “a condition in which there is intermittent adduction of the vocal folds that interferes with breathing”, for which SLPs teach “vocal exercises, relaxation techniques, quick-release breathing techniques, and proper breath management”; “EILO is most often diagnosed in adolescence”. How common: “In the pediatric population, the reported prevalence of a voice disorder has ranged from 1.4% to 6.0%”, with vocal nodules “a predominant cause of pediatric dysphonia”; “Approximately one out of 13 adults in the United States will experience a voice problem annually, but only a relative minority seek treatment”; “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”; among adults aged 19 to 60, “the most frequent diagnoses included functional dysphonia (20.5%), acid laryngitis (12.5%), and vocal polyps” (12%); over 60, “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”; in adults, “prevalence was higher in female adults than in male adults, with a reported ratio of 1.5:1.0”. “Teachers were estimated to be two to three times more likely than the general population to develop a voice disorder”, with risk tied to the “number of classes per week, noise generated outside of the school setting, and volume of voice while lecturing”; “The mean prevalence of voice disorders was estimated to be 46% among singers”; “Those in the service industry were estimated to be 2.6 times more likely to develop benign laryngeal growth”. Signs: “Dysphonia is characterized by altered vocal quality, pitch, loudness, or vocal effort”; “rough vocal quality (raspy, audible aperiodicity in sound)”; “breathy vocal quality (audible air escape in the sound signal or bursts of breathiness)”; “strained vocal quality (increased effort; tense or harsh)”; “strangled vocal quality (as if talking with breath held)”; “abnormal pitch (too high, too low, pitch breaks, decreased pitch range)”; “abnormal loudness/volume (too high, too low, decreased range, unsteady volume)”; “aphonia (loss of voice)”; phonation breaks; asthenia (weak voice); “tremorous voice (shaky voice; rhythmic pitch and loudness undulations)”; “increased vocal effort associated with speaking”; “decreased vocal endurance or onset of fatigue with prolonged voice use”; “variable vocal quality throughout the day or during speaking”; “running out of breath quickly”; “frequent coughing or throat clearing (may worsen with increased voice use)”; “excessive throat or laryngeal tension/pain/tenderness”; “The severity of the voice disorder cannot always be determined by auditory-perceptual voice quality alone”. Causes: “vocal nodules, cysts, or polyps”, edema, recurrent respiratory papilloma, “sarcopenia (muscle atrophy associated with aging)”; inflammation from “laryngitis, or laryngopharyngeal reflux”; intubation trauma; neurologic causes including recurrent laryngeal nerve paralysis, “adductor/abductor spasmodic dysphonia”, Parkinson’s disease, multiple sclerosis and pseudobulbar palsy; phonotrauma such as yelling, screaming, “excessive throat clearing/coughing” and “speaking in too high or too low pitch”; muscle tension dysphonia; vocal fatigue; psychogenic causes including “chronic stress disorders”, anxiety, depression and conversion aphonia or dysphonia. “Making modifications to pitch without the guidance of a skilled service provider is not recommended and may result in vocal misuse”. “Even when an obvious cause is identified and treated, the voice problem may persist”: “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”, on a team with “otolaryngologists/laryngologists, pulmonologists, allergists, gastroenterologists, neurologists, endocrinologists, mental health professionals, and vocal coaches or voice teachers”. Assessment: “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”; “Standardized self-report questionnaires can be included for a more thorough screening”; “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”. Typical components: “the individual’s description of the voice problem, including onset and variability of symptoms”, “medical status and history, including surgeries, chronic disorders, and medications”, “previous voice treatment” and “daily habits related to vocal hygiene”; “the individual’s self-perception of voice/vocal quality” and its effect on “emotions and self-image” and communication; an oral-peripheral examination, including “palpation of extrinsic laryngeal musculature”; respiration, including “maximum phonation time”; an auditory-perceptual assessment, “based on the clinical impressions of the SLP during production of sustained vowels, sentences, and running speech”, rating roughness, breathiness, strain, pitch, loudness and overall severity as “defined in ASHA’s Consensus Auditory-Perceptual Evaluation of Voice”. “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”; laryngeal imaging: “Measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy)”; acoustic assessment: “Objective measures of vocal function related to vocal loudness, pitch, and quality”; aerodynamic assessment: “Measures (using noninvasive procedures) of glottal aerodynamic parameters required for phonation”. Treatment: “Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving”; it aims to “improve self-awareness of voice quality and kinesthetic factors (e.g., tension)”; “Voice use within different settings should be considered when determining vocal needs and establishing goals”; “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”. “Direct approaches focus on manipulating the voice-producing mechanisms (phonation, respiration, and musculoskeletal function) to modify vocal behaviors and establish healthy voice production”; “Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs”: patient education, “providing information about the impact of vocal misuse and strategies for maintaining vocal health (vocal hygiene)”, and counseling, “identifying and implementing strategies such as stress management to modify psychosocial factors that negatively affect vocal health”. “A therapeutic plan typically involves at least one direct approach and one or more indirect approaches based on the patient’s condition and goals”; clinicians may begin by identifying habits such as “shouting, talking loudly over noise, coughing, throat clearing, and poor hydration” and building others such as “drinking plenty of water and talking at a moderate volume”. “Use of personal protective equipment (PPE) (i.e., face mask) can potentially cause increased strain on voice and perception of vocal effort”. Named approaches (“The inclusion of any specific treatment approach does not imply endorsement by ASHA”): the accent method; conversation training therapy; expiratory muscle strength training; LSVT, “an intensive treatment developed for patients with Parkinson’s disease”, in which “Individuals are instructed to produce a loud voice with maximum effort and to monitor the loudness of their voices while speaking” and which “is provided by clinicians who are trained and certified in the administration of this technique”; manual circumlaryngeal techniques, “intended to reduce musculoskeletal tension and hyperfunction by re-posturing the larynx during phonation” (“Care is taken when employing these techniques, as some patients report discomfort”); PhoRTE, which “was adapted from LSVT and consists of four exercises”, “producing /a/ with loud maximum sustained phonation”, “producing /a/ with loud ascending and descending pitch glides over the entire pitch range” and functional phrases in “a loud and high (pitched) voice” and “a loud and low (pitched) voice” (“PhoRTE has a less intensive intervention schedule than LSVT”); resonant voice therapy (“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 program incorporates humming and both voiced and voiceless productions that are shaped into phrase and conversational productions”); stretch and flow phonation, “a physiological technique used to treat functional dysphonia or aphonia” that “focuses on airflow management and is used for individuals with breath-holding tendencies”; vocal function exercises (“VFEs work to strengthen and coordinate laryngeal musculature”; “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”); amplification (“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, “used in cases of functional aphonia/dysphonia and often results in changed or normal phonation”, in which “Individuals are instructed to talk or read passages aloud while wearing headphones with masking noise input”; biofeedback; chant speech; confidential voice, “designed to reduce laryngeal tension/hyperfunction and increase airflow”, in which “The individual begins with an easy and breathy vocal quality and builds to normal voicing without decreasing airflow”; inhalation phonation, “used to facilitate true vocal vibration in the presence of habitual ventricular fold phonation, functional aphonia, and/or muscle tension dysphonia”; posture; relaxation; semi-occluded vocal tract exercises, among them cup bubble, straw phonation (“the individual semi-occludes the vocal tract by phonating through a straw or tube”; “Eventually, use of the straw is reduced and eliminated”; narrowing the vocal tract reduces “the impact collision force”) and lip trills; twang therapy; and yawn-sigh. “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”; SLPs consider “whether or not the patient is telecommuting for their profession”. “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”: an otolaryngologist, an SLP, a singing teacher, and a voice and speech trainer. Dosage: “Clinicians consider the unique needs of each patient and the nature of the voice disorder in determining appropriate dosage for therapy. Some voice therapy programs will have specific dosage parameters”. Checked October 7, 2026.
2. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. Clinical practice guideline: hoarseness (dysphonia) (update). Otolaryngology–Head and Neck Surgery. 2018;158(1 Suppl):S1–S42. doi:10.1177/0194599817751030 (PMID 29494321). The American Academy of Otolaryngology–Head and Neck Surgery Foundation’s guideline on “dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life”; “Dysphonia affects nearly one-third of the population at some point in its life”. Strong recommendations: assess for factors calling for expedited laryngeal evaluation, among them “recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user”; “Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy”. Recommendations: “Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected”; “Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP)”; surgery for “suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency”; “Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia”; “Clinicians should inform patients with dysphonia about control/preventive measures”; “Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation”. Strong recommendation against: “Clinicians should not routinely prescribe antibiotics to treat dysphonia”. Recommendations against: “Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx”; “Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx”; “Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx”. Option: “Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia”.
3. Desjardins M, Halstead L, Cooke M, Bonilha HS. A systematic review of voice therapy: what “effectiveness” really implies. Journal of Voice. 2017;31(3):392.e13–392.e32. doi:10.1016/j.jvoice.2016.10.002 (PMID 27863745). “Behavioral voice therapy guided by a speech-language pathologist is recommended as the main treatment approach for many kinds of voice disorders”. “Only randomized controlled trials were included in the review”: “Fifteen papers met the inclusion criteria, covering five categories of voice disorders (functional, Parkinson induced, GERD induced, presbyphonia, unilateral vocal fold paresis) and seven specific behavioral voice therapy approaches”; “Statistically significant improvements were found postintervention on at least one outcome variable in all but one study. Clinical significance of the results was rarely discussed”; “Behavioral voice therapy generally leads to significant improvements in voice outcomes, but further research considering clinical meaningfulness of the results are needed”.
4. National Institute on Deafness and Other Communication Disorders. Taking Care of Your Voice (last updated June 11, 2025). “The sound of your voice is produced by vibration of the vocal folds, which are two bands of smooth muscle tissue that are positioned opposite each other in the larynx”; “The vibrations produce sound waves that travel through the throat, nose, and mouth, which act as resonating cavities to modulate the sound”. “Singers, teachers, doctors, lawyers, nurses, sales people, and public speakers are among those who make great demands on their voices. This puts them at risk for developing voice problems”. Signs: “Has your voice become hoarse or raspy?” “Have you lost your ability to hit some high notes when singing?” “Does your voice suddenly sound deeper?” “Does your throat often feel raw, achy, or strained?” “Has it become an effort to talk?” “Do you find yourself repeatedly clearing your throat?” “If you think you have a voice problem, consult a doctor to determine the underlying cause”; “A doctor who specializes in diseases or disorders of the ears, nose, and throat, and who can best diagnose a voice disorder, is an otolaryngologist”; “Your otolaryngologist may refer you to a speech-language pathologist. A speech-language pathologist can help you improve the way you use your voice”. Causes include “Upper respiratory infections”, “Inflammation caused by gastroesophageal reflux (sometimes called acid reflux, heartburn, or GERD)”, “Vocal misuse and overuse”, “Growths on the vocal folds, such as vocal nodules or laryngeal papillomatosis”, “Cancer of the larynx”, neurological diseases “such as spasmodic dysphonia or vocal fold paralysis” and psychological trauma; research continues on “laryngeal papillomatosis caused by HPV (human papillomavirus)”. “Most voice problems can be reversed by treating the underlying cause or through a range of behavioral and surgical treatments”. Healthy habits: “Drink plenty of water, especially when exercising”; “If you drink caffeinated beverages or alcohol, balance your intake with plenty of water”; “Take vocal naps—rest your voice throughout the day”; “Use a humidifier in your home. This is especially important in winter or in dry climates. Thirty percent humidity is recommended”; “Avoid or limit use of medications that may dry out the vocal folds, including some common cold and allergy medications. If you have voice problems, ask your doctor which medications would be safest for you to use”; “Don’t smoke, and avoid second-hand smoke. Smoke irritates the vocal folds. Also, cancer of the vocal folds is seen most often in individuals who smoke”; “Wash your hands often to prevent getting a cold or the flu”; “Get enough rest. Physical fatigue has a negative effect on voice”; exercise regularly; “If you have persistent heartburn or GERD, talk to your doctor about diet changes or medications that can help reduce flare-ups”; “Avoid mouthwash or gargles that contain alcohol or irritating chemicals”; “Try not to overuse your voice. Avoid speaking or singing when your voice is hoarse or tired”; “Rest your voice when you are sick”; “Avoid using the extremes of your vocal range, such as screaming or whispering. Talking too loudly and too softly can both stress your voice”; “Support your voice with deep breaths from the chest, and don’t rely on your throat alone”; “Avoid cradling the phone when talking”; “Consider using a microphone when appropriate. In relatively static environments such as exhibit areas, classrooms, or exercise rooms, a lightweight microphone and an amplifier-speaker system can be of great help”; “Avoid talking in noisy places. Trying to talk above noise causes strain on the voice”; “Consider voice therapy. A speech-language pathologist who is experienced in treating voice problems can teach you how to use your voice in a healthy way”. Checked October 7, 2026.
5. Bhattacharyya N. The prevalence of voice problems among adults in the United States. Laryngoscope. 2014;124(10):2359–2362. doi:10.1002/lary.24740 (PMID 24782443). “The 2012 National Health Interview Survey was analyzed”: an estimated 17.9 million adults reported a voice problem; “Overall, 10.0% ± 0.1% saw a healthcare professional for their voice problem”; “Females were more likely than males to report a voice problem (9.3% ± 0.3% vs. 5.9% ± 0.3%”; “Infectious laryngitis was the most common diagnosis mentioned (685,000 ± 86,000 cases, 17.8% ± 2.0%)”; “Gastroesophageal reflux disease was mentioned in 308,000 ± 54,000 cases (8.0% ± 1.4%)”; “Respondents with a voice problem reported 7.4 ± 0.9 lost workdays in the past year versus 3.4 ± 0.1 lost workdays for those without”. “Voice problems affect one in 13 adults annually. A relative minority seek healthcare for their voice problem, even though the self-reported subjective impact of the voice problem is significant”.
6. Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. Cochrane Database of Systematic Reviews. 2007;(3):CD006373. doi:10.1002/14651858.CD006373.pub2 (PMID 17636842). “We identified six randomised controlled trials including a total of 163 participants in intervention groups and 141 controls. One trial was high quality”. “No studies were found evaluating direct voice therapy on its own. One study did not show indirect voice therapy on its own to be effective when compared to no intervention”; in one study “the remedial effect remains significant for at least 14 weeks”; “There is also limited evidence from one study that the number of symptoms may remain lower for a year”; “Publication bias may have influenced the results”. “Evidence is available for the effectiveness of comprehensive voice therapy comprising both direct and indirect therapy elements. Effects are similar in patients and in teachers and student teachers screened for voice problems”; “Larger and methodologically better studies are needed”.
7. Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database of Systematic Reviews. 2015;(5):CD004783. doi:10.1002/14651858.CD004783.pub5 (PMID 26002823). “We included three RCTs (351 participants) that had moderate to high risk of bias”; “The quality of the evidence was very low for all outcomes”. “Antibiotics do not appear to be effective in treating acute laryngitis when assessing objective outcomes”, and “these modest benefits from antibiotics may not outweigh their cost, adverse effects or negative consequences for antibiotic resistance patterns”.
8. National Institute on Deafness and Other Communication Disorders. Spasmodic Dysphonia (last updated June 18, 2020). Spasmodic dysphonia, or laryngeal dystonia, “is a disorder affecting the voice muscles in the larynx, also called the voice box”; “In spasmodic dysphonia, the muscles inside the vocal folds spasm (make sudden, involuntary movements), interfering with vocal fold vibrations”; it “may occur along with other forms of dystonia that cause repeated spasms in other parts of the body”. “Spasmodic dysphonia causes voice breaks during speaking and can make the voice sound tight, strained, or breathy. In some people, the breaks occur once every few sentences. In more severe cases, spasms may occur on every word”; “Some people with spasmodic dysphonia may also have vocal tremor—a shaking of the larynx and vocal folds that causes the voice to tremble”. “Spasmodic dysphonia is a chronic condition that continues throughout a person’s life”; “Spasmodic dysphonia is a rare disorder. It can affect anyone, but the first signs occur most often in people between the ages of 30 and 50. It affects more women than men”. Types: “Adductor spasmodic dysphonia is the most common form of spasmodic dysphonia”, in which “spasms cause the vocal folds to slam together and stiffen”; the voice “may sound strained and strangled”; “The person’s speech may be choppy, with words cut off or difficult to start because of muscle spasms”; “The spasms are usually absent—and the voice sounds normal—while laughing, crying, or whispering. Stress often makes the muscle spasms more severe”. “Abductor spasmodic dysphonia is less common”: “spasms cause the vocal folds to remain open”, and “As a result, the voice often sounds weak and breathy”. Mixed spasmodic dysphonia, “a combination of the above two types, is very rare”. “Spasmodic dysphonia is thought to be caused by abnormal functioning in an area of the brain called the basal ganglia. The basal ganglia help coordinate the movements of muscles throughout the body”; “In some cases, spasmodic dysphonia may run in families”. “Diagnosis of spasmodic dysphonia can be difficult because the symptoms are often similar to those of other voice disorders. Diagnosis usually follows examination by a team”: an otolaryngologist, who will “pass a small lighted tube through the nose and into the back of the throat”, a speech-language pathologist and a neurologist, who “will evaluate for signs in the brain of dystonia and other movement disorders”. “There is currently no cure for spasmodic dysphonia, but treatment can help reduce its symptoms. The most common treatment is the injection of very small amounts of botulinum toxin directly into the affected muscles of the larynx”; “The toxin weakens muscles by blocking the nerve impulse to the muscle”; “Botulinum toxin injections generally improve the voice for three to four months, after which voice symptoms slowly return. Reinjections are needed to maintain a good speaking voice. Initial side effects include a temporarily weak, breathy voice and occasional swallowing problems, but these usually improve after a few days to a few weeks. Botulinum toxin injections are more effective with adductor spasmodic dysphonia than with abductor spasmodic dysphonia. They do not help in every case”. “Behavioral therapy (voice therapy) may reduce symptoms in mild cases. Voice therapy may work along with botulinum toxin injections to reduce voice strain. Some people may also benefit from psychological counseling to help them accept and live with their voice problems”; “Some devices can help amplify a person’s voice, whether in person or over the phone. Computer software and tablet or smartphone apps can be used to translate text into synthetic speech”; “When more conventional measures have failed, surgery may be performed on the larynx”; “To date, there are no comparative studies pointing to a single, best treatment”. Checked October 7, 2026.
9. Roy N, Gray SD, Simon M, Dove H, Corbin-Lewis K, Stemple JC. An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. Journal of Speech, Language, and Hearing Research. 2001;44(2):286–296. doi:10.1044/1092-4388(2001/023) (PMID 11324651). “58 voice-disordered teachers were randomly assigned to 1 of 3 groups: vocal hygiene (VH, n = 20), vocal function exercises (VFE, n = 19), and a nontreatment control group (CON, n = 19)”. They completed “the Voice Handicap Index (VHI)-an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders” before and after “a 6-week treatment phase”. “Only the group who adhered to the VFE regimen reported a significant reduction in mean VHI scores”, and compared with vocal hygiene “the exercise group reported more overall voice improvement”; “the VFE should be considered as a useful alternative or adjunct to vocal hygiene programs in the treatment of voice problems in teachers”.
10. Roy N, Weinrich B, Gray SD, Tanner K, Toledo SW, Dove H, et al. Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study. Journal of Speech, Language, and Hearing Research. 2002;45(4):625–638. doi:10.1044/1092-4388(2002/050) (PMID 12199394). “Forty-four voice-disordered teachers were randomly assigned to one of three groups: voice amplification using the ChatterVox portable amplifier (VA, n = 15), vocal hygiene (VH, n = 15), and a nontreatment control group (n = 14)”, “Before and after a 6-week treatment phase”. “only the amplification group experienced significant reductions on mean VHI scores”; “no significant improvements were observed within the VH group on any of the dependent measures”; “compared to the control group, both treatment groups (i.e., VA and VH) experienced significantly more improvement on specific outcomes measures”, and “there were no significant differences between the VA and VH groups to indicate superiority of one treatment over another”; the amplification group reported “greater compliance with the treatment program”. “These findings clearly support the clinical utility of voice amplification as an alternative for the treatment of voice problems in teachers”.
11. Centers for Medicare & Medicaid Services. Speech-language pathology services (Medicare.gov). Part B covers “medically necessary outpatient speech-language pathology services”, which “provide evaluation and treatment to regain and strengthen speech and language skills. This includes cognitive and swallowing skills, or therapy to improve or maintain current function or slow decline”; “Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify you need this care”; after the Part B deductible you pay 20% of the Medicare-approved amount; “There’s no limit on how much Medicare pays for your medically necessary outpatient speech-language pathology services in one calendar year.” Checked October 7, 2026.
12. Centers for Medicare & Medicaid Services. Telehealth (Medicare.gov). “Through December 31, 2027, Medicare covers telehealth services that you can get from anywhere in the U.S., including your home”; the examples listed include speech therapy, cognitive assessments and “Caregiver training services”; after the Part B deductible you pay 20% of the Medicare-approved amount, and “For most telehealth services, you’ll pay the same amount that you would if you got the services in person”; Medicare Advantage plans “may offer more telehealth benefits than the basic coverage in Original Medicare.” Checked October 7, 2026.
13. MedlinePlus, National Library of Medicine. Hoarseness (Medical Encyclopedia; reviewed October 28, 2024). “Hoarseness refers to difficulty making sounds when trying to speak. Vocal sounds may be weak, breathy, scratchy, or husky, and the pitch or quality of the voice may change”; “Hoarseness is most often caused by a problem with the vocal cords”; “The most common cause of hoarseness is a cold or throat infection, which most often goes away on its own within 2 weeks”; “A rare but serious cause of hoarseness that does not go away in a few weeks is cancer of the voice box”. Causes include acid reflux (GERD), allergies, “Breathing in irritating substances”, “Cancer of the throat or larynx”, chronic coughing, “Colds or upper respiratory infections”, “Heavy smoking or drinking, particularly together” and “Overuse or abuse of the voice (as in shouting or singing), which, over time, may cause swelling or growths on the vocal cords called vocal cord nodules”; less common causes include “Injury or irritation from a breathing tube or bronchoscopy”, “Damage to the nerves and muscles around the voice box (from trauma or surgery)”, “Thyroid or lung cancer”, “Underactive thyroid gland” and “Immobility of one or both vocal cords”. Home care: “Vocal rest and time may improve hoarseness. Hoarseness that continues for more than 4 weeks should be checked by a health care provider”; “Talk only when you need to until hoarseness goes away”; “Drink plenty of fluids to help keep your airways moist. (Gargling does not help.)”; “Use a vaporizer to add moisture to the air you breathe”; “Avoid actions that strain the vocal cords such as whispering, shouting, crying, and singing”; “Take medicines to reduce stomach acid if hoarseness is due to GERD”; “Do not use decongestants which can dry out the vocal cords”; “If you smoke, cut down, or stop at least until hoarseness goes away”. Contact a provider if “You have trouble breathing or swallowing” or “Hoarseness has lasted for more than 1 week in a child, or 2 to 3 weeks in an adult”. “The provider will examine your throat, neck, and mouth and ask you some questions about your symptoms and medical history”, among them how much of the voice is lost, when it started, whether it comes and goes, voice overuse, fumes, allergies, throat surgery, smoking and alcohol, and other symptoms such as “fever, cough, sore throat, difficulty swallowing, weight loss, or fatigue”; tests can include laryngoscopy, a throat culture, “X-rays of the neck or CT scan” and blood tests. Checked October 7, 2026.
14. National Institute on Deafness and Other Communication Disorders. Quick Statistics About Voice, Speech, Language (last updated July 8, 2025). “An estimated 17.9 million U.S. adults ages 18 or older, or 7.6%, report having had a problem with their voice in the past 12 months”; “Approximately 9.4 million (4.0%) adults report having a problem using their voice that lasted 1 week or longer during the last 12 months”. “Spasmodic dysphonia, a voice disorder caused by involuntary movements of one or more muscles of the larynx (voice box), can affect anyone. The first signs of this disorder are found most often in people ages 30-50. More women than men appear to be affected”. “Anyone can acquire aphasia (a loss of the ability to use or understand language)”. Checked October 7, 2026.
15. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. Journal of Speech, Language, and Hearing Research. 2004;47(2):281–293. doi:10.1044/1092-4388(2004/023) (PMID 15157130). “2,531 randomly selected participants from Iowa and Utah (1,243 teachers and 1,288 nonteachers) were interviewed by telephone”; “The prevalence of reporting a current voice problem was significantly greater in teachers compared with nonteachers (11.0% vs. 6.2%)”; “being a teacher, being a woman, being between 40 and 59 years of age, having 16 or more years of education, and having a family history of voice disorders were each positively associated with having experienced a voice disorder in the past”; “These results support the notion that teaching is a high-risk occupation for voice disorders”.
16. Communication Health Support Association (the consumer affiliate of the American Speech-Language-Hearing Association). Vocal Fold Nodules and Polyps. “Vocal fold nodules and polyps are growths on your vocal folds. Some people consider a nodule to be like a callus and a polyp to be like a blister”; “Anything that makes it harder for the vocal folds to vibrate can cause a voice problem”. Nodules “are benign growths that form on the vocal folds. They are not cancerous. When you use your voice the wrong way, your vocal folds may swell. Over time, the swollen spots can get harder, like a callus. These nodules can get larger and stiffer if vocal misuse continues”. Polyps “can be on one or both of the vocal folds”; “Most polyps are bigger than nodules. You may hear them called polypoid degeneration or Reinke’s edema”. Signs include a rough, scratchy or harsh voice, breathiness, hoarseness, a feeling of a lump in the throat, “less ability to change your pitch”, neck pain, “shooting pain from ear to ear” and “voice and body tiredness”. “Most of the time, vocal abuse or misuse causes nodules. Long-term vocal abuse can cause polyps, too. But polyps may happen after just one instance of vocal abuse, like yelling at a concert. Smoking cigarettes for a long time, thyroid problems, and reflux may also cause polyps”; vocal abuse can come from “overusing your voice (for example coaching, cheerleading, or talking loudly)” and singing. “You should see a doctor if your voice has been hoarse for more than 2 to 3 weeks”; the team looks at the vocal folds “by putting a long tube, called an endoscope, in your mouth or through your nose and into your throat. A flashing light, called a stroboscope, lets the team watch your vocal folds move”. “Treatment depends on what caused the nodules or polyps, how big they are, and what problems they are causing”; surgery “is usually done only when they are large or have been there for a long time”; “You need to treat any medical causes of your voice problem, such as reflux, allergies, or thyroid problems, before the nodules or polyps will go away”; “The SLP can teach you how to take care of your voice, called vocal hygiene”; “Treatment may also help you change how your voice sounds or teach you how to get enough breath to talk”. Checked October 7, 2026.
17. Barsties v. Latoszek B, Watts CR, Hetjens S. The efficacy of the manual circumlaryngeal therapy for muscle tension dysphonia: a systematic review and meta-analysis. Laryngoscope. 2024;134(1):18–26. doi:10.1002/lary.30850 (PMID 37366280). “Muscle tension dysphonia (MTD) is the most common functional voice disorder. Behavioral voice therapy is the front-line treatment for MTD, and laryngeal manual therapy may be a part of this treatment”. “We identified 6 eligible studies from 30 studies”; “The efficacy of MCT for MTD was confirmed in most clinical studies by assessing jitter, shimmer, and harmonics-to-noise ratio related to voice quality. The effects of MCT on the fundamental frequency changes could not be verified”; “Further contributions of high-quality randomized control trials are needed”.
18. National Institute on Deafness and Other Communication Disorders. Vocal Fold Paralysis (last updated March 6, 2017). “Vocal fold paralysis (also known as vocal cord paralysis) is a voice disorder that occurs when one or both of the vocal folds don’t open or close properly. Single vocal fold paralysis is a common disorder. Paralysis of both vocal folds is rare and can be life threatening”; “the paralyzed fold or folds may remain open, leaving the air passages and lungs unprotected”; “You could have difficulty swallowing or food or liquids could accidentally enter the trachea and lungs, causing serious health problems”. “Vocal fold paralysis may be caused by injury to the head, neck, or chest; lung or thyroid cancer; tumors of the skull base, neck, or chest; or infection (for example, Lyme disease). People with certain neurologic conditions such as multiple sclerosis or Parkinson’s disease, or who have sustained a stroke, may experience vocal fold paralysis. In many cases, however, the cause is unknown”. Symptoms include “changes in the voice, such as hoarseness or a breathy voice; difficulties with breathing, such as shortness of breath or noisy breathing; and swallowing problems, such as choking or coughing when you eat”; “Changes in voice quality, such as loss of volume or pitch, also may occur. Damage to both vocal folds, although rare, usually causes serious problems with breathing”. “Vocal fold paralysis is usually diagnosed by an otolaryngologist”, who will “look directly into the throat at the vocal folds” with an endoscope; “Some doctors also use a procedure called laryngeal electromyography, which measures the electrical impulses of the nerves in the larynx”. “The most common treatments for vocal fold paralysis are voice therapy and surgery. Some people’s voices will naturally recover sometime during the first year after diagnosis, which is why doctors often delay surgery for at least a year”; meanwhile voice therapy “may involve exercises to strengthen the vocal folds or improve breath control while speaking”, or using the voice differently, “by speaking more slowly or opening your mouth wider when you speak”. “The most common procedures change the position of the vocal fold. These may involve inserting a structural implant or stitches to reposition the laryngeal cartilage and bring the vocal folds closer together. These procedures usually result in a stronger voice. Surgery is followed by additional voice therapy to help fine-tune the voice”. “When both vocal folds are paralyzed, a tracheotomy may be required to help breathing”, an incision in the front of the neck with a breathing tube; “therapy with a speech-language pathologist helps you learn how to use the voice and how to properly care for the breathing tube”. Of medialization laryngoplasty, a structural implant: “close to a quarter of the people who receive this treatment must return for repositioning surgery to fine-tune the placement of the implant”. Checked October 7, 2026.
19. The ALS Association. FYI: Suggestions and information about speech changes & augmentative alternative communication (AAC) (fact sheet, June 10, 2020). “This causes dysarthria – the term used to describe slow, effortful, slurred speech, and breathy or hoarse voice.” “Speaking may make you tired, especially later in the day.” “Therapeutic oral exercises designed to strengthen muscles for people with other forms of dysarthria have not been demonstrated to improve speech for people with ALS”; “Oral motor exercises are not recommended for speech changes resulting from ALS”. Advice includes to “begin Message and Voice Banking so that your own voice can be used in a speech generating device (SGD) or text-to-speech (TTS) app if ever required”; to teach partners “to repeat back any part of a sentence that they DID understand”; “Alert your partner if you are shifting topics and name the new topic.” “a removable, palatal lift appliance” for a nasal quality; “For those with very weak or no arm movement, alternative access equipment can enable a person to operate an SGD or tablet with head, foot or eye movement.” “Low-tech communication systems, like paper communication boards, are an essential backup to your high-tech speech generating device.” “A speech therapist will have other strategies to help with challenges like phone communication, emergency alerting systems for times when you are home alone, and tools for signaling to others within the home if you have a need.” Checked October 7, 2026.
20. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngology–Head and Neck Surgery. 2013;148(6 Suppl):S1–S37. doi:10.1177/0194599813487301 (PMID 23733893). American Academy of Otolaryngology–Head and Neck Surgery, for “adult patients aged 18 years or older after thyroid surgery”. “About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25”. A strong recommendation that “the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery”; recommendations to “educate the patient about the potential impact of thyroid surgery on voice”, to “document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery”, to “examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery”, to “refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery” and to “counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation”.
21. Communication Health Support Association (the consumer affiliate of the American Speech-Language-Hearing Association). Laryngeal Cancer. Signs may include “hoarseness or voice changes”, problems swallowing, “feeling like you have a lump in your throat or neck”, “sore throat or cough that won’t go away”, “shortness of breath”, “unexplained weight loss” and “ear pain that lasts a long time”; risk factors include “smoking or using chewing tobacco”, drinking alcohol, “acid reflux (GERD)” and “contact with human papillomavirus (HPV)”. Treatment may include surgery, radiation, chemotherapy, targeted drug therapy and immunotherapy; “Radiation and chemotherapy can cause changes such as” a hoarse voice and trouble swallowing; “Doctors use different types of surgeries to treat laryngeal cancer. Not all of them involve removing your larynx”; with a laryngectomy, “your surgeon will create a breathing hole in your neck, called a stoma”. “SLPs play an important role before, during, and after cancer treatment to help with any speech or swallowing problems you may have”. “Right after surgery, you will not be able to talk”; options then include paper and pen, “a dry-erase board”, “a picture board” and “technology such as phones or tablets to type messages or to generate electronic speech”; later, “There are three main options”. The electrolarynx: “This small electronic device creates vibrations to help you speak. You place it against your neck or put a small tube in your mouth. Many people start with this method because it’s easy to learn”. Tracheoesophageal puncture: “Your doctor can create a small hole between your breathing tube and esophagus, either during your cancer surgery or later. There is a one-way valve in this hole”. Esophageal speech: “You take air into your mouth and trap it in your esophagus”, “Then you push the air back up—similar to a controlled burp”; “Learning this method takes practice and works better for some people than others”. Checked October 7, 2026.
22. Centers for Disease Control and Prevention. Signs and symptoms of stroke (May 19, 2026). Signs include “Sudden confusion, trouble speaking, or difficulty understanding speech”; “Call 9-1-1 right away if you or someone else has any of these symptoms”; in the B.E. F.A.S.T. test for speech, “Ask the person to repeat a simple phrase. Is the speech slurred or strange?”; “The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms”; “Note the time when any symptoms first appear”; “Do not drive to the hospital or let someone else drive you”; a TIA “is a sign of a serious condition that will not go away without medical help”, so “tell a health care team about the symptoms right away.” Checked October 7, 2026.
23. Communication Health Support Association (the consumer affiliate of the American Speech-Language-Hearing Association). Vocal Fold Paralysis. “In vocal fold paralysis, one or both vocal folds cannot move. It can also cause breathing and swallowing problems”; with unilateral paralysis, “One vocal fold does not move. It is more common than bilateral paralysis”. Signs include “Being unable to speak loudly”, “Being able to produce voice for a very short time”, hoarseness, a breathy voice, “Limited pitch and loudness”, “Choking or coughing while eating” and “Possible pneumonia if food and liquid get into the lungs”. “Nerve damage causes vocal fold paralysis. The vagus nerve runs from the brainstem to the larynx. This nerve controls vocal fold movement. Anything that damages this nerve can cause paralysis, including head and neck injuries, tumors, disease, surgery, or stroke”. Treatment: “You might have surgery to bring one or both vocal folds closer to the middle”; “You might also have something injected into the fold to make it larger. This procedure allows the other fold to move closer to it and may help your voice”; “Voice therapy can also help unilateral paralysis”; “Your doctor may want you to try voice therapy before surgery or other medical treatments. It may be the only treatment that you need”. Checked October 7, 2026.
24. Angadi V, Croake D, Stemple J. Effects of vocal function exercises: a systematic review. Journal of Voice. 2019;33(1):124.e13–124.e34. doi:10.1016/j.jvoice.2017.08.031 (PMID 29108674). “Twenty-one articles were included for the final appraisal”; “All studies demonstrated positive effects of VFEs as demonstrated by effect sizes across selected voice parameters”; “None of the included studies reported adverse voice outcomes as a result of VFEs”; “Outcome studies demonstrate that VFEs are efficacious in enhancing vocal function in individuals with normal and disordered voices, presbylaryngeus, and professional voice users”; “The available research suggests moderate to strong evidence to support the use of VFEs for a variety of voice disorders”. A co-author, J. Stemple, is the developer ASHA credits for the exercises.
25. Roy N, Weinrich B, Gray SD, Tanner K, Stemple JC, Sapienza CM. Three treatments for teachers with voice disorders: a randomized clinical trial. Journal of Speech, Language, and Hearing Research. 2003;46(3):670–688. doi:10.1044/1092-4388(2003/053) (PMID 14696994). “Sixty-four teachers with voice disorders were randomly assigned to 1 of 3 treatment groups: voice amplification using the ChatterVox portable amplifier (VA; n = 25), resonance therapy (RT; n = 19), and respiratory muscle training (RMT; n = 20)”, for 6 weeks; “only the VA and RT groups reported significant reductions in mean VHI scores and in voice severity self-ratings following treatment”; “teachers in the VA group reported significantly more overall voice improvement, greater vocal clarity, and greater ease of speaking and singing voice following treatment”; the results “provide new evidence to support RT as an effective treatment alternative for voice problems in teachers”. “The results are discussed in the context of uneven levels of self-reported compliance and disparate dropout rates among the treatment groups”.
26. Barsties v. Latoszek B, Watts CR, Neumann K. The effectiveness of voice therapy on voice-related handicap: a network meta-analysis. Clinical Otolaryngology. 2020;45(5):796–804. doi:10.1111/coa.13596 (PMID 32534474). “We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions”; “The primary outcome variable was VHI-30 with a score from 0 to 120”. “Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy”, and “no medical, pharmacological or instrumental (eg voice amplification) treatments were considered”. “The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP)”; “SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment” (stretch-and-flow phonation, resonant voice therapy, the Comprehensive Voice Rehabilitation Program and vocal function exercises); “Further contributions of high-quality intervention studies are needed”.
27. Pozzali I, Pizzorni N, Ruggeri A, Schindler A, Dal Farra F. Effectiveness of semi-occluded vocal tract exercises (SOVTEs) in patients with dysphonia: a systematic review and meta-analysis. Journal of Voice. 2024;38(1):245.e17–245.e35. doi:10.1016/j.jvoice.2021.06.009 (PMID 34284924). “eight articles were included”; “None of the study was completely judged at low RoB”; “The quality of evidence resulted very low for each analysis”; “voice therapy based on SOVTEs is not to consider significantly superior if compared to other treatments, even if a favorable trend was detected”; “Further high-quality RCTs on specific SOVTEs are recommended”.
28. Sackley CM, Rick C, Brady MC, Woolley R, Burton C, Patel S, et al. Lee Silverman voice treatment versus NHS speech and language therapy versus control for dysarthria in people with Parkinson’s disease (PD COMM): pragmatic, UK based, multicentre, three arm, parallel group, unblinded, randomised controlled trial. BMJ. 2024;386:e078341. doi:10.1136/bmj-2023-078341 (PMID 38986549). “388 people with Parkinson’s disease and dysarthria”: “130 to Lee Silverman voice treatment (LSVT LOUD), 129 to NHS speech and language therapy, and 129 to no speech and language therapy.” “LSVT LOUD consisted of four, face-to-face or remote, 50 min sessions each week delivered over four weeks. Home based practice activities were set for up to 5-10 mins daily on treatment days and 15 mins twice daily on non-treatment days”; “Only speech and language therapists or therapist assistants trained in LSVT LOUD could deliver the intervention.” At three months, LSVT LOUD users “reported lower voice handicap index scores” than those with no therapy “(−8.0 points (99% confidence interval −13.3 to −2.6); P<0.001)”, and “Patients in the LSVT LOUD group also reported lower voice handicap index scores than did those randomised to NHS speech and language therapy”; “No evidence suggests a difference in voice handicap index scores between NHS speech and language therapy and no speech and language therapy”. “A robust signal shows that, after three months, LSVT LOUD is effective compared with no SLT for the reduction of dysarthria related to Parkinson’s disease, which persists throughout the 12 months from starting treatment.” NHS therapy was given at lower intensity (“404 mins (234); five sessions” against a median of 16 LSVT LOUD sessions): “NHS therapy was delivered at a much lower intensity and did not show benefit over control. Therefore, these results should not be interpreted as evidence of no beneficial effect for all NHS SLT theoretical approaches, across all dosages.” “93 adverse events (predominately vocal strain) were reported in the LSVT LOUD group, 46 in the NHS speech and language therapy group”; “No serious adverse events were recorded”; “The higher rate of vocal strain with LSVT LOUD treatment was mostly a minor, transient issue at an acceptable rate in relation to the level of benefit”. “Dysarthric symptoms vary in their response to increased dopaminergic medication and can become worse with subthalamic stimulation surgery”; “re-intervention might still be required should the treatment effect wear off or as their Parkinson’s disease progresses and their dysarthria deteriorates”. Limits: “Differences in access to therapy and intervention format could not be concealed from participants, making trial blinding unfeasible”; “most participants were in the early stages of Parkinson’s disease with mild speech impairment”; the trial closed early during COVID-19. Funded by the NIHR; “LSVT LOUD training was provided by LSVT Global. The funder and LSVT Global had no role in the PD COMM trial design, data collection, data analysis, data interpretation, or writing of the report.”
29. Ziegler A, Verdolini Abbott K, Johns M, Klein A, Hapner ER. Preliminary data on two voice therapy interventions in the treatment of presbyphonia. Laryngoscope. 2014;124(8):1869–1876. doi:10.1002/lary.24548 (PMID 24375313). “Presbyphonia is common among elderly individuals, yet few studies have evaluated behavioral treatment approaches for presbyphonia”. “Preliminary data from 16 elderly participants with presbyphonia randomly assigned to VFE, PhoRTE, or a no-treatment control group (CTL) were analyzed”, “Before and after a 4-week intervention period”: “Preliminary data revealed VFE and PhoRTE groups demonstrated a significant improvement in V-RQOL scores. However, only PhoRTE demonstrated a significant reduction in PPE” (perceived phonatory effort); “The CTL group did not demonstrate significant changes”.
30. Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for preventing voice disorders in adults. Cochrane Database of Systematic Reviews. 2007;(4):CD006372. doi:10.1002/14651858.CD006372.pub2 (PMID 17943906). “We identified two randomised controlled trials including a total of 53 participants in intervention groups and 43 controls. One study was conducted with teachers and the other with student teachers. Both trials were poor quality”. “We found no evidence that either direct or indirect voice training or the two combined are effective in improving self-reported vocal functioning when compared to no intervention. The current practice of giving training to at-risk populations for preventing the development of voice disorders is therefore not supported by definitive evidence of effectiveness”.
31. Code of Federal Regulations, 42 CFR §410.61, Plan of treatment requirements for outpatient rehabilitation services. “The plan is established before treatment is begun by one of the following”, among them “A speech-language pathologist who furnishes the speech-language pathology services”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.” Text as published in the eCFR. Checked October 7, 2026.
32. Code of Federal Regulations, 42 CFR §424.24(c), Outpatient physical therapy, occupational therapy, and speech-language pathology services. When an SLP establishes the plan, “the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case”; “Recertification is required at least every 90 days”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.” Text as published in the eCFR. Checked October 7, 2026.
33. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15: Covered medical and other health services (Rev. 13889, issued July 30, 2026), section 220.3. “The progress report provides justification for the medical necessity of treatment”; “The minimum progress report period shall be at least once every 10 treatment days.” Checked October 7, 2026.
34. De Bodt M, Patteeuw T, Versele A. Temporal variables in voice therapy. Journal of Voice. 2015;29(5):611–617. doi:10.1016/j.jvoice.2014.12.001 (PMID 25795350). A review of the literature from 1975 to 2013, “resulting in 93 qualified publications”, with “data reported in scientific textbooks (47 publications)”: “voice therapy lasts an average of 9.25 weeks distributed over 10.87 sessions of mostly 30 (36.36%) or 60 minutes (27.27%) and occurs once (34.55%) or twice (28.18%) per week. The total amount of time that a voice therapist spends face-to-face with the patient is 8.17 hours on average”; “For North American patients, more sessions (12.52) are reported over a shorter period (7.62 weeks), resulting in more face-to-face time (12.15 hours) between therapist and patient”. “The potential impact of diagnosis, clinical practices, prescription habits, health insurance rules, patient compliance, and study design on the representativeness of the data is discussed”.
35. Ramig L, Halpern A, Spielman J, Fox C, Freeman K. Speech treatment in Parkinson’s disease: randomized controlled trial (RCT). Movement Disorders. 2018;33(11):1777–1791. doi:10.1002/mds.27460 (PMID 30264896). “As many as 89% of people with Parkinson’s disease (PD) develop speech disorders”; “Reductions in vocal loudness are among the first and most pervasive changes in speech”, and “speech disorders in PD are generally unresponsive to pharmacological or neurosurgical interventions alone”. 64 people with Parkinson’s were randomized to LSVT LOUD, LSVT ARTIC (articulation) or no treatment. Dose: “Individual treatment session of 1 hour, 4 consecutive days per week over a 4-week period”; daily exercises include holding a vowel “in a good-quality, loud voice, for as long as possible” and “Participant reads 10 self-generated phrases he/she says daily in functional living”; “Tasks increase in length of utterance and difficulty across weeks, progressing from words to phrases to sentences to reading to conversation”; homework “10 minutes, performed once per day” on treatment days and “15 minutes, performed twice per day” on other days, plus a carryover assignment: “Participant is to use the louder voice practiced in exercises in a real-world communication situation”. “At 1 and 7 months, SPL between-group comparisons showed greater improvements for LSVT LOUD (n = 22) than LSVT ARTIC (n = 20; P < 0.05) and UNTXPD (n = 22; P < 0.05)”; “Only LSVT LOUD maintained CETI-M improvements at 7 months.” Funded by “National Institutes of Health-National Institute of Deafness and Other Communication Disorders (NIH-NIDCD) R01 DC01150 and LSVT Global, Inc.”; after the study, “Ramig, Halpern, and Fox have had employment roles with LSVT Global, and Spielman and Freeman have been paid consultants.”
36. Slinger C, Mehdi SB, Milan SJ, Dodd S, Matthews J, Vyas A, et al. Speech and language therapy for management of chronic cough. Cochrane Database of Systematic Reviews. 2019;(7):CD013067. doi:10.1002/14651858.CD013067.pub2 (PMID 31335963). “We found two studies involving 162 adults that met our inclusion criteria”, all with unexplained chronic cough; “The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months”; “The control interventions were healthy lifestyle advice in both studies”. The gains in quality of life and cough frequency with “a physiotherapy and speech and language therapy intervention (PSALTI)” “were statistically significant but short-lived, with the between-group difference lasting up to four weeks only”; “Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough”.
37. Pedersen M, McGlashan J. Surgical versus non-surgical interventions for vocal cord nodules. Cochrane Database of Systematic Reviews. 2012;(6):CD001934. doi:10.1002/14651858.CD001934.pub2 (PMID 22696326). “Vocal cord nodules are bilateral, benign, callous-like growths of the mid-portion of the membranous vocal folds”; “They characteristically produce hoarseness, discomfort and an unstable voice when speaking or singing”. “No studies fulfilled the inclusion criteria”; “There is a need for high-quality randomised controlled trials to evaluate the effectiveness of surgical and non-surgical treatment of vocal cord nodules”.
38. Lakhani R, Fishman JM, Bleach N, Costello D, Birchall M. Alternative injectable materials for vocal fold medialisation in unilateral vocal fold paralysis. Cochrane Database of Systematic Reviews. 2012;(10):CD009239. doi:10.1002/14651858.CD009239.pub2 (PMID 23076955). Background: “Speech and language therapy forms the initial mainstay of management in cases of UVFP, since up to 60% of cases will resolve spontaneously”, and “If vocal fold paralysis persists surgery, in the form of injection medialisation, has been shown to be an effective intervention”. “We identified no RCTs which met the inclusion criteria for this review”; “There is currently insufficient high-quality evidence for, or against, specific injectable materials for patients with UVFP”.
39. Communication Health Support Association (the consumer affiliate of the American Speech-Language-Hearing Association). Spasmodic Dysphonia. “Spasmodic dysphonia (SD) is a long-term, or chronic, voice disorder”; “Your voice may sound jerky, shaky, hoarse, or tight. You may have times when you cannot make any sounds at all. You may also have times when your voice sounds normal”; “Being tired or stressed may make your voice worse. You may find that your voice problems go away when you sing or laugh”. “There is no simple test for spasmodic dysphonia”; testing is best done by a team of an SLP, an otolaryngologist and a neurologist. “There is no cure for SD”; “Botox makes the muscles in your larynx weaker and may lead to a smoother voice”; “Voice therapy with an SLP may help you produce a better voice”; “You may want to work with a career counselor if your voice causes problems at work”. Checked October 7, 2026.
40. Hyodo M, Nagao A, Asano K, Sakaguchi M, Mizoguchi K, Omori K, et al. Botulinum toxin injection into the intrinsic laryngeal muscles to treat spasmodic dysphonia: a multicenter, placebo-controlled, randomized, double-blinded, parallel-group comparison/open-label clinical trial. European Journal of Neurology. 2021;28(5):1548–1556. doi:10.1111/ene.14714 (PMID 33393175). “Twenty-four patients (22 with adductor SD and two with abductor SD) were enrolled”, in a trial run to obtain approval in Japan; in adductor SD, voice breaks fell with botulinum toxin and not with placebo, and “The improvement persisted for 12 weeks following BT injections”; “Adverse events included breathy hoarseness (77.3%) and aspiration when drinking (40.9%) but were mild and resolved in 4 weeks”; “Botulinum toxin injection was safe and efficacious for the treatment of SD”. “Allergan supported the clinical trial by providing the investigational drug and placebo”.
41. Watts CC, Whurr R, Nye C. Botulinum toxin injections for the treatment of spasmodic dysphonia. Cochrane Database of Systematic Reviews. 2004;(3):CD004327. doi:10.1002/14651858.CD004327.pub2 (PMID 15266530). Background: “The use of botulinum toxin for the treatment of spasmodic dysphonia is currently the treatment of choice for management of this neurological voice disorder”. “Only one study in the literature met the inclusion criteria”; “The evidence from randomized controlled trials does not allow firm conclusions to be drawn about the effectiveness of botulinum toxin for all types of spasmodic dysphonia”.
42. Simonyan K, O’Flynn LC, Hamzehei Sichani A, Frucht SJ, Rumbach AF, Sharma N, et al. Efficacy and safety of sodium oxybate in isolated focal laryngeal dystonia: a phase IIb double-blind placebo-controlled cross-over randomized clinical trial. Annals of Neurology. 2025;97(2):329–343. doi:10.1002/ana.27121 (PMID 39565101). 106 patients with laryngeal dystonia, some of whose symptoms ease with alcohol (EtOH+) and some not: “Sodium oxybate showed clinically meaningful improvement of symptoms in EtOH+ LD patients, with acceptable tolerability”; “Drug efficacy waned by 300 minutes after intake without a rebound”. The drug is “approved by the United States (US) Food and Drug Administration (FDA) (schedule III)” “to treat cataplexy and excessive daytime sleepiness in patients with narcolepsy”. Funded by the NIDCD; “We thank Jazz Pharmaceuticals for the in-kind supply of sodium oxybate and matching placebo through a research grant”.
43. National Institute of Neurological Disorders and Stroke. Tremor. “Tremor is a neurological condition that includes shaking or trembling movements in one or more parts of the body, most commonly affecting a person’s hands. It can also happen in the arms, legs, head, vocal cords, and torso”; common symptoms include a shaky voice. “Some tremor can be triggered by stress or strong emotion, being physically tired, or being in certain postures or making specific movements”. “Essential tremor (previously also called benign essential tremor or familial tremor) is one of the most common movement disorders”; “It also may affect a person’s head, voice, or lower limbs”. Dystonic tremor most commonly affects “the neck (cervical dystonia), vocal cords (laryngeal dystonia), or arms/legs (limb dystonia)”. “Several drugs can cause tremors, including certain asthma medicines, corticosteroids, chemotherapy, and drugs used for certain psychiatric and neurological disorders”; “Excessive caffeine may cause temporary tremor or make an existing tremor worse”; “An overactive thyroid can cause tremors”. To diagnose it, “They will perform a neurological exam and test muscle tone and strength, reflexes, balance, and speech”; “Working with a physical, speech, and occupational therapist may help control tremor and adapt to daily challenges caused by the tremor”. Checked October 7, 2026.
44. Centers for Medicare & Medicaid Services. Jimmo settlement. The Jimmo Settlement Agreement (January 2013) “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)”; coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Checked October 7, 2026.
45. American Speech-Language-Hearing Association. Communication After Total Laryngectomy (Practice Portal, Head and Neck Cancer). “Several communication methods are available to people who have had total laryngectomies. These include writing, gesture, low- and high-tech augmentative and alternative communication (AAC) devices, and alaryngeal speech”; SLPs consider “visual, cognitive, and fine motor skills/manual dexterity”, healing, “family/care partner support” and “access to equipment and follow-up care (e.g., geography, cost, transportation)”. Electrolarynx: “a handheld, battery-operated or pneumatic device that creates an external vibratory source for voicing”, most often “placed flush to the skin on the side of the neck, under the chin, or on the cheek”; “An electrolarynx with an intraoral tube can be trialed within 1–3 days of surgery”; “The tone produced for voicing with an electrolarynx has an electronic quality”; “Most individuals are candidates for the use of electrolarynxes after laryngectomy”; “Some people use these devices as their only method of communication, whereas others use them as a backup to other methods”; “Electrolarynx use requires good manual dexterity”. Esophageal speech: “air is taken into the mouth, brought down into the esophagus, and returned back from the esophagus to generate sound for speech”; it “allows hands-free communication independent of additional devices”; “Esophageal speech has a sound quality that is harsh, low in intensity/volume and pitch, and sometimes wet”; “There is no surgery required to use esophageal speech, and there are no expenses for equipment”; “Esophageal speech requires an extended learning period, and many people have trouble acquiring use at a functional conversational level”. Tracheoesophageal speech: a surgical puncture “forms a fistula tract between the trachea and the esophagus that is fitted with a voice prosthesis”; “When an individual occludes the stoma, exhaled tracheal air passes through the prosthesis via a one-way valve into the esophagus”; “The one-way valve allows air exchange for speech production while preventing aspiration of food and liquid”; “Surgeons may perform the TEP as a primary procedure during laryngectomy surgery or later as a secondary procedure”; “Indwelling prostheses last longer and need less maintenance than non-indwelling prostheses, but the non-indwelling types offer greater independence and are less expensive”; “Utterance length, phrasing, volume, and intelligibility are generally closer to laryngeal speech than other forms of alaryngeal communication due to the pulmonary air supply powering TEP speech”; candidacy includes “the motivation to communicate and participate in the daily maintenance of the TEP” and the risk of “the need for more frequent voice prosthesis replacement”. Checked October 7, 2026.
46. American Speech-Language-Hearing Association. Augmentative and alternative communication (Practice Portal). Unaided forms “do not require an external tool” (gestures, signs, facial expressions); aided forms “require some form of external tool, either electronic or nonelectronic”; “Examples of acquired disabilities that may benefit from AAC include cerebrovascular accidents (i.e., stroke); traumatic or acquired brain injuries; neurodegenerative diseases, such as ALS, supranuclear palsy, primary progressive aphasia, and apraxia; disability following surgeries (e.g., glossectomy, laryngectomy)”; “There are no prerequisites for AAC intervention”; “AAC use may help improve natural speech when used in a multimodal approach”; “selections can be made via eye gaze, head pointing, or scanning methods”, and direct selection can use a joystick, eye gaze, a head mouse or “brain–computer interface technology”; with voice banking “an individual can record a large inventory of speech, which is then used to create a synthetic voice that approximates their natural voice”, and “Voice banking should be completed when a communicator’s energy and skills are sufficient to generate clear speech”; with message banking “an individual can use their own voice or a proxy voice to digitally record and store messages, which may include words, phrases, sentences, and sounds using natural voice, inflection, and intonation”; “Medicare may not cover AAC devices in all settings (e.g., skilled nursing facilities, hospice).” Checked October 7, 2026.
47. Communication Health Support Association (the consumer affiliate of the American Speech-Language-Hearing Association). Chronic Cough. “Chronic cough is one that lasts more than 4 weeks in children and more than 8 weeks in adults”; “If you are dealing with a cough this long, you should consult a doctor”. Symptoms include “a rough or hoarse voice from coughing” and “coughing frequently throughout the day”. The most common causes: “acid reflux (stomach acid that rises into the throat)”, “allergies or sinus problems that cause mucus to drip down the back of your throat” and “asthma or other breathing problems”. “Your SLP is an important member of the team”; SLP treatment focuses on “helping you understand chronic cough and what might trigger your cough”, “teaching you ways to help reduce coughing” and “teaching you ways to keep your vocal cords healthy”. Checked October 7, 2026.
48. American Speech-Language-Hearing Association. Gender Affirming Voice and Communication (Practice Portal). “People may seek gender affirmation services to make their voice and/or other aspects of their communication congruent with their gender and/or gender expression”; “The SLP assesses a variety of aspects of verbal and nonverbal communication, such as vocal pitch, intonation, voice quality, resonance”, fluency and articulation; “Focus on the client’s self-determined goals, what they feel fits them, and what best represents their authentic voice”. “Modifying voice without proper guidance can encourage maladaptive patterns of voice misuse, leading to phonatory trauma and voice disorders such as muscle tension dysphonia and vocal nodules”. Hormone therapy: “the extent, rate, and experience of using hormone therapy alone are quite variable and not always satisfactory”; “Hormone treatment does not result in changes to other aspects of voice (e.g., intonation, volume, and nonverbal communication) that may influence how gender is perceived by others”. “Clinicians might incorporate aspects of intervention strategies traditionally used with functional voice and resonance disorders but modify the strategies to meet the client’s goals”. “Coverage varies by payer and plan for services related to gender affirmation”; “A medical diagnosis of gender dysphoria is often necessary to receive insurance coverage for gender affirming care services but does not guarantee it”. “Telepractice can be a viable way to provide services if it fits with the client’s lifestyle and if they have access to the appropriate equipment”. Checked October 7, 2026.
49. Job Accommodation Network (US Department of Labor, Office of Disability Employment Policy). Speech-language impairment. “The ADA does not contain a definitive list of medical conditions that constitute disabilities”; a person with a disability “has a physical or mental impairment that substantially limits one or more” major life activities, has a record of one, or is regarded as having one. Accommodation ideas: for no speech or unintelligible speech, an “Augmentative and Alternative Communication (AAC) Device”, “Communicate Another Way” and “Speech Generating Communication Devices with Telephone Access”, with job restructuring for unintelligible speech; for weak speech, a flexible schedule, job restructuring, voice amplification and “Outgoing Voice Amplification - Telephone”. Checked October 7, 2026.
50. Centers for Medicare & Medicaid Services. Home health services (Medicare.gov). Home health care helps you “maintain your current condition or level of function, or slow your rate of decline”; covered services include “speech-language pathology services (if you meet certain conditions)”; you must need part-time or intermittent skilled services and be homebound: “Leaving your home isn’t recommended because of your condition or you have trouble leaving your home without help” and “You’re normally unable to leave your home and leaving takes a lot of effort”; “You can still get home health care if you attend adult day care”; a provider “must see you in person and confirm you need home health care”; “You pay nothing for covered home health services.” Checked October 7, 2026.
51. Centers for Medicare & Medicaid Services. Therapy services. The Bipartisan Budget Act of 2018 repealed the outpatient therapy caps and “preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record”; “For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined”; “the MR threshold is $3,000 for PT and SLP services”, and “not all claims exceeding the MR threshold amount are subject to review.” Checked October 7, 2026.
52. Centers for Medicare & Medicaid Services. National coverage determination: speech generating devices (50.1). “Speech generating devices are considered to fall within the durable medical equipment (DME) benefit category”; “They are covered for patients who suffer from a severe speech impairment and have a medical condition that warrants the use of a device”; covered forms include “software that allows a computer or other electronic device to generate audible/verbal speech”; “Computers and tablets are generally not considered DME because they are useful in the absence of an illness or injury”; “Internet or phone services or any modification to a patient’s home to allow use of the speech generating device are not covered by Medicare.” Checked October 7, 2026.
53. Medicaid.gov (Centers for Medicare & Medicaid Services). Mandatory & optional Medicaid benefits. “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process”; mandatory benefits include home health services and nursing facility services; optional benefits include “Speech, hearing and language disorder services.” Checked October 7, 2026.
54. HealthCare.gov (Centers for Medicare & Medicaid Services). What Marketplace health insurance plans cover. “All plans offered in the Marketplace cover these 10 essential health benefits”, among them “Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)”; “Specific services covered in each broad benefit category can vary based on your state’s requirements.” Checked October 7, 2026.
55. Veterans Health Administration. VHA Directive 1170.02(1): VHA audiology and speech pathology services (December 9, 2020; amended July 19, 2022). The directive covers “disorders of hearing, tinnitus, balance, speech, language, voice, fluency, cognitive and swallowing”; “Audiology and speech pathology services are standard medical benefits available to all enrolled Veterans.” Checked October 7, 2026.
56. American Speech-Language-Hearing Association. ASHA clinical specialty certification. A Board Certified Specialist (BCS) has demonstrated advanced knowledge and skills in an area; “Specialty certification is not required to practice in any area within the Audiology or Speech-Language Pathology Scopes of Practice”; “Specialty certification is currently available through” five boards: the “American Audiology Board of Intraoperative Monitoring”, the “American Board of Augmentative and Alternative Communication”, the “American Board of Child Language and Language Disorders”, the “American Board of Fluency and Fluency Disorders” and the “American Board of Swallowing and Swallowing Disorders.” Checked October 7, 2026.
57. American Speech-Language-Hearing Association. Information about ASHA certification. The CCC is “a nationally recognized professional credential that represents a level of excellence in the field”; holders “have voluntarily met rigorous academic and professional standards, typically going beyond the minimum requirements for state licensure.” Checked October 7, 2026.
58. American Speech-Language-Hearing Association. Audiology and speech-language pathology certification. ASHA’s public tool lets anyone “Verify the status of an individual’s Certificate of Clinical Competence in Audiology (CCC-A) or Speech-Language Pathology (CCC-SLP).” Checked October 7, 2026.
59. Franz L, Da Canal A, Spinato G, Baracca G, Lucchini E, de Filippis C, et al. Tele-voice therapy. Application of the tele-medicine paradigm to speech therapy for dysphonia: a systematic review. American Journal of Otolaryngology. 2025;46(3):104626. doi:10.1016/j.amjoto.2025.104626 (PMID 40267705). “only 6 articles were included”; “Despite their methodological heterogeneity and small sample size, the available studies seem to support tele-speech therapy as an effective tool for selected dysphonia patients”; “remote therapy may be proposed to overcome logistical issues, potentially increasing patients’ adherence, especially in case of rehabilitation programs requiring no direct contact or manipulation (e.g. Lee Silverman Voice Treatment for Parkinson’s disease)”; “hybrid in-person and remote approaches may be proposed as flexible solutions”; “large-scale prospective controlled studies are required”.
60. American Speech-Language-Hearing Association. Telepractice (Practice Portal). “Use of telepractice should be of equal quality to in-person services”; informed consent includes “the client’s right to request in-person services at any time”; “Clinicians should verify state licensure/certification requirements in the state from which the clinician provides services as well as the state in which the client receives services prior to initiating services.” Checked October 7, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your individual situation.