Dysphonia is altered voice production characterized by changes in voice quality (hoarseness, roughness, breathiness, strain), pitch (too high/low/restricted range), loudness (too soft/loud), or vocal effort, affecting communication and quality of life. Affects 1/3 of population at some point with point prevalence of 6-10%, higher in occupational voice users (teachers 50%, singers, lawyers, salespeople, broadcasters). Acute dysphonia (<3 weeks) usually viral laryngitis; chronic (>3 weeks) requires laryngoscopy to evaluate.
Classification by etiology: Organic causes include benign vocal fold lesions (nodules from chronic vocal abuse 'singer's nodules', polyps from acute trauma/microhemorrhage, cysts congenital or retention, Reinke's edema from smoking/reflux, vocal fold scarring), neurogenic (unilateral vocal fold paralysis from recurrent laryngeal nerve injury thyroid surgery/cardiothoracic/idiopathic, bilateral paralysis as airway emergency, spasmodic dysphonia adductor/abductor focal dystonia, vocal tremor, presbylaryngeus from atrophy), structural (laryngeal trauma, web/synechiae, sulcus vocalis, papillomatosis), inflammatory (laryngopharyngeal reflux, allergic, autoimmune, infectious), and malignant (squamous cell carcinoma especially with smoking history). Functional causes include muscle tension dysphonia (primary or compensatory), psychogenic (conversion aphonia, factitious), and ventricular dysphonia. Inhaled corticosteroid use causes dysphonia in 5-50% of asthma/COPD patients.
Evaluation: history (onset, duration, course, voice use, smoking, reflux, surgery, neurological), perceptual voice assessment (GRBAS scale: grade, roughness, breathiness, asthenia, strain; CAPE-V), laryngoscopy (flexible/rigid, mandatory if dysphonia >3 weeks per AAO-HNS guidelines), stroboscopy (assesses mucosal wave, vibratory pattern, glottic closure), acoustic analysis (jitter, shimmer, harmonics-to-noise ratio, fundamental frequency), aerodynamic (maximum phonation time, mean airflow), Voice Handicap Index (VHI-10) for impact assessment. Imaging (CT/MRI) for vocal fold paralysis to evaluate recurrent laryngeal nerve along course. Treatment is multidisciplinary: voice therapy with speech-language pathologist (resonant voice therapy, vocal function exercises, Lee Silverman Voice Treatment LSVT for Parkinson's, semi-occluded vocal tract exercises) is first-line for muscle tension dysphonia, nodules, presbyphonia. Microlaryngeal surgery for polyps, cysts, scar (cold steel or laser, microflap technique preserving lamina propria). Injection laryngoplasty (calcium hydroxylapatite, hyaluronic acid, autologous fat) for vocal fold paralysis or atrophy, often as initial intervention. Medialization thyroplasty (type I, Isshiki) and arytenoid adduction for permanent paralysis. Botulinum toxin injection for spasmodic dysphonia (3-month intervals). LPR treatment with PPI and lifestyle modification. Smoking cessation. Allergies, autoimmune disease management. Cancer treatment per oncology. Voice rest after surgery. Singing voice specialist for performers.