[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [ENT](https://durgical.com/en/ent/) › [Throat and neck: approach to complaints](https://durgical.com/en/ent/areas/throat/) › Voice and speech disorders: muscle tension, spasmodic dysphonia, puberphonia and voice care

# Voice and speech disorders: muscle tension, spasmodic dysphonia, puberphonia and voice care

- Topic

Many voice problems come from how the voice is used, not from a lesion; they are treated with voice therapy once the larynx has been seen.

Updated Nov 12, 2026

**See it in 3D:** [Vocal folds](https://durgical.com/en/anatomy/vocal-fold/) · [Thyroarytenoid](https://durgical.com/en/anatomy/musculus-thyreoarytenoideus/) · [Lateral cricoarytenoid](https://durgical.com/en/anatomy/lateral-cricoarytenoid-muscle/) · [Posterior cricoarytenoid](https://durgical.com/en/anatomy/musculus-cricoarytenoideus-posterior/) · [Recurrent laryngeal nerves](https://durgical.com/en/anatomy/recurrent-laryngeal-nerve/) · [Soft palate](https://durgical.com/en/anatomy/soft-palate/)

## Key points

- Three groups: structural (nodules, polyps, Reinke oedema), neurogenic (paralysis, spasmodic dysphonia, tremor) and functional (muscle tension, psychogenic, puberphonia).
- Always see the vocal folds before voice therapy; dysphonia lasting more than 4 weeks needs laryngoscopy.
- Adductor spasmodic dysphonia: strained, strangled voice with breaks that improves when laughing or whispering; treated with botulinum toxin injections every 3 to 4 months.
- Psychogenic aphonia: whispers but coughs with a normal sound, because the folds close fully on coughing.
- Puberphonia (mutational falsetto): a boy keeps a high-pitched child voice after puberty with a normal larynx; voice therapy works.
- Open nasal voice (hypernasality): cleft palate or palatal weakness; closed nasal voice (hyponasality): adenoids or nasal blockage.

## What it is

Voice disorders are grouped by cause. Structural (organic) disorders are lesions you can see: nodules, polyps, cysts, oedema or an ageing larynx. Neurogenic disorders come from the nerves or brain: vocal fold paralysis, spasmodic dysphonia (laryngeal dystonia), tremor, Parkinson disease or myasthenia. Functional disorders come from using the larynx badly with a normal structure: muscle tension dysphonia, psychogenic aphonia and puberphonia. The rule for every one of them is the same: look at the larynx before starting voice therapy, because a cancer can sound like a functional problem. Speech disorders are different from voice disorders: they affect articulation or resonance (for example the nasal voice of a cleft palate or the blocked-nose voice of large adenoids). Teachers, singers and call-centre staff are the classic patients.

## Key facts

- Drink water through the day and balance caffeine or alcohol with more water; use humidified air in dry places.
- Avoid smoking and second-hand smoke; treat reflux.
- Rest the voice when ill or hoarse; schedule short vocal rests in a long working day.
- Avoid shouting, whispering and talking over background noise; use a microphone in classrooms.
- Support the voice with breath rather than straining the throat; seek voice therapy with a speech-language therapist when problems recur.

## Structure

- Structural: nodules (both sides, voice overuse), polyps (usually one side), cysts, Reinke oedema (smokers), sulcus, scar, presbylarynx (thin, bowed folds in old age).
- Neurogenic: unilateral vocal fold paralysis (breathy voice, weak cough), spasmodic dysphonia (adductor, abductor or mixed), essential tremor, Parkinson disease (soft, monotonous voice), myasthenia gravis (voice tires with use).
- Functional: primary muscle tension dysphonia, secondary muscle tension (compensating for a lesion), psychogenic (conversion) aphonia or dysphonia, puberphonia, ventricular (false fold) phonation.
- Speech (not voice) disorders: dysarthria (motor speech from neurological disease), rhinolalia aperta (hypernasality) and rhinolalia clausa (hyponasality).

## In clinical practice

- Muscle tension dysphonia: rough, strained or effortful voice, neck tension, throat pain after talking; the larynx sits high and the supraglottis squeezes on laryngoscopy, with no lesion.
- Spasmodic dysphonia usually starts at 30 to 50 years, more in women; it is a neurological dystonia, sometimes with dystonia elsewhere or voice tremor.
- Abductor spasmodic dysphonia gives a breathy voice with breathy breaks; it responds less well to botulinum toxin.
- Psychogenic aphonia often starts suddenly after stress; the folds move normally for breathing and coughing.
- Puberphonia: high, weak or breaking voice in a teenage boy whose larynx has grown; pressing the thyroid cartilage backwards (Gutzmann test) brings out a lower voice.
- Voice users at risk: teachers, singers, salespeople, call-centre workers, coaches; voice care is part of prevention.

## Next step / Initial management

- First workup: duration, voice use, tobacco, reflux, neurological symptoms and medication; refer to ENT for laryngoscopy (ideally with stroboscopy) if dysphonia lasts more than 4 weeks.
- Refer as a priority (within two weeks) smokers, drinkers and patients with a neck lump, dysphagia, pain or haemoptysis; refer the same day for stridor.
- Functional dysphonia, nodules, puberphonia and psychogenic aphonia: voice therapy with a speech-language therapist after laryngoscopy; psychological support when stress or anxiety drives it.
- Suspected spasmodic dysphonia or tremor: routine referral to ENT and neurology; botulinum toxin injections into the laryngeal muscles are the main treatment.
- Breathy voice after neck or chest surgery: early ENT referral to assess vocal fold paralysis.
- Puberphonia: also check pubertal development; refer to endocrinology if it is delayed.

## Test yourself

Think of the answer, then tap the question to see it.

## A 42-year-old woman has a strained, strangled voice with breaks on vowels, which improves when she laughs or whispers. Laryngoscopy shows no lesion. What is the diagnosis and treatment?

Adductor spasmodic dysphonia (laryngeal dystonia); botulinum toxin injections into the laryngeal muscles, repeated every 3 to 4 months, with voice therapy as support.

## A young woman suddenly whispers after a family conflict, but her cough sounds normal. What is the likely diagnosis?

Psychogenic (functional) aphonia: the folds close normally on coughing. Confirm with laryngoscopy and treat with voice therapy and psychological support.

## A 17-year-old boy with normal puberty still has a high-pitched, breaking voice. What is it and how is it treated?

Puberphonia (mutational falsetto); voice therapy with a speech-language therapist, which usually brings down the pitch quickly.

## A child has a hyponasal voice, mouth breathing and snoring. What type of speech change is this and the likely cause?

Rhinolalia clausa (hyponasality), usually from enlarged adenoids or nasal obstruction.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/voice-and-speech-disorders-muscle-tension-spasmodic-dysphonia-puberphonia-and-vo/)

## Elsewhere in DurgiPedia

- [Cranial nerve examination](https://durgical.com/en/clinical-exam/cranial-nerve-examination/)
- [Voice sounds: bronchophony, egophony and whispered pectoriloquy](https://durgical.com/en/clinical-exam/voice-sounds-bronchophony-egophony-and-whispered-pectoriloquy/)

## Connections

## See it in 3D 6

The structures of Durgical's 3D anatomy where it is found.

- [Vocal folds](https://durgical.com/en/anatomy/vocal-fold/)
- [Thyroarytenoid](https://durgical.com/en/anatomy/musculus-thyreoarytenoideus/)
- [Lateral cricoarytenoid](https://durgical.com/en/anatomy/lateral-cricoarytenoid-muscle/)
- [Posterior cricoarytenoid](https://durgical.com/en/anatomy/musculus-cricoarytenoideus-posterior/)
- [Recurrent laryngeal nerves](https://durgical.com/en/anatomy/recurrent-laryngeal-nerve/)
- [Soft palate](https://durgical.com/en/anatomy/soft-palate/)

## Related 5

- [Voice and swallowing: how the larynx and pharynx work](https://durgical.com/en/ent/voice-and-swallowing-how-the-larynx-and-pharynx-work/)
- [Approach to hoarseness](https://durgical.com/en/ent/approach-to-hoarseness/)
- [Mirror and flexible laryngoscopy](https://durgical.com/en/ent/mirror-and-flexible-laryngoscopy/)
- [Laryngitis and other laryngeal inflammation: acute, chronic, TB, perichondritis and congenital webs](https://durgical.com/en/ent/laryngitis-and-other-laryngeal-inflammation-acute-chronic-tb-perichondritis-and/)
- [Larynx: cartilages, glottis and laryngeal nerves](https://durgical.com/en/ent/larynx-cartilages-glottis-and-laryngeal-nerves/)

## Related conditions 8

- [Vocal fold nodules, polyps and laryngitis](https://durgical.com/en/conditions/vocal-fold-nodules-polyps-and-laryngitis/)
- [Vocal fold paralysis (recurrent laryngeal nerve injury)](https://durgical.com/en/conditions/vocal-fold-paralysis/)
- [Laryngopharyngeal reflux](https://durgical.com/en/conditions/laryngopharyngeal-reflux/)
- [Parkinson disease](https://durgical.com/en/conditions/parkinson-disease/)
- [Essential tremor](https://durgical.com/en/conditions/essential-tremor/)
- [Myasthenia gravis](https://durgical.com/en/conditions/myasthenia-gravis/)
- [Cleft lip and palate](https://durgical.com/en/conditions/cleft-lip-and-palate/)
- [Adenoid hypertrophy](https://durgical.com/en/conditions/adenoid-hypertrophy/)

## In Pharmacology 1

- [Botulinum toxin type A](https://durgical.com/en/pharmacology/botulinum-toxin-type-a/)

[← All of ENT](https://durgical.com/en/ent/)

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Functional Voice Disorders](https://www.ncbi.nlm.nih.gov/books/NBK563182/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Dysphonia](https://www.ncbi.nlm.nih.gov/books/NBK565881/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Laryngeal Botulinum Toxin Injection](https://www.ncbi.nlm.nih.gov/books/NBK567733/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Unilateral Vocal Fold Paralysis](https://www.ncbi.nlm.nih.gov/books/NBK519060/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Spasmodic Dysphonia](https://www.nidcd.nih.gov/health/spasmodic-dysphonia) (National Institute on Deafness and Other Communication Disorders (NIDCD), NIH, 2020); [Taking Care of Your Voice](https://www.nidcd.nih.gov/health/taking-care-your-voice) (National Institute on Deafness and Other Communication Disorders (NIDCD), NIH, 2025).

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/ent/voice-and-speech-disorders-muscle-tension-spasmodic-dysphonia-puberphonia-and-vo/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/voice-and-speech-disorders-muscle-tension-spasmodic-dysphonia-puberphonia-and-vo/