Functional dysphonia is a change in your voice, with hoarseness, tiredness or effort when speaking, that happens without serious damage to the vocal cords. The muscles of the voice box and neck are working with too much tension. It is very common in people who use their voice a lot, and it is mainly treated with voice therapy.

What is functional dysphonia?

Dysphonia means “an altered voice”: rougher, weaker, higher or lower than normal, or that tires easily. It is functional when the problem lies in how the voice is used, not in a significant lesion of the vocal cords.

It is also called muscle tension dysphonia, and it is the most common functional voice problem. In functional aphonia, the voice disappears altogether, although coughing or laughing still produces sound.

What are the symptoms?

A hoarse or rough voice that gets worse through the day.
Vocal fatigue: talking is hard work and your voice cracks or fails by the evening.
Effort when speaking, as if you have to push the voice out.
Tension or pain in the throat or neck.
A feeling of a lump in the throat and a need to clear it.

It often improves with rest or on holiday and gets worse with work.

Why does it happen?

Usually several things happen at the same time:

Heavy or incorrect voice use: teachers, call-centre staff, singers, or always talking in noisy places or by shouting.
Stress and muscle tension in the neck and shoulders.
An infection (for example, after a cold) after which you keep pushing the voice.
Reflux and dryness can contribute but are rarely the only cause.
Smoking irritates the vocal cords.

How is it diagnosed?

History: when it began, how you use your voice, what makes it better or worse.
Flexible nasendoscopy: a thin tube passed through the nose shows the vocal cords. It is essential to rule out nodules, polyps, paralysis or other lesions, and before starting voice therapy.
Neck examination: we look for muscle tension.
Assessment by a speech and language therapist, who looks at how you breathe, speak and project your voice.

Blood tests, CT or MRI are not usually needed before the larynx has been seen.

How is it treated?

Voice therapy with a speech and language therapist

This is the main treatment. It consists of sessions with a therapist to learn to breathe better, relax your neck and use your voice without straining. It includes exercises to do at home. Most people improve with it. We refer you to a speech and language therapist once your larynx has been examined.

Voice care

Daily habits are part of the treatment. We explain them in vocal hygiene: how to look after your voice.

Treat contributing factors

If there are signs of reflux, allergy or dryness, we treat them. Stopping smoking helps.

What usually does not help

Antibiotics: they do not work unless there is a bacterial infection.
Steroids and reflux medicines for hoarseness alone, before the larynx has been seen: guidelines recommend not giving them.
Total voice rest for a long time: it can increase tension.

Advice

Do not strain your voice, shout or talk over loud noise.
Take breaks if you talk a lot, and sip water through the day.
Do not smoke or breathe in smoke.
Avoid throat clearing: swallow or take a sip of water instead.
Look after your neck and shoulders: stretch and relax during the day.
Go to your therapy sessions and practise at home.

When should I seek urgent help?

Call 112 (in Spain) or your local emergency number, or go to A&E, if you have:

Difficulty breathing or a high-pitched noise when you breathe.
Trouble swallowing even saliva.
Blood when you cough.

Book an appointment soon if:

Hoarseness lasts more than 4 weeks.
You smoke, drink alcohol often or are over 45.
You notice a lump in the neck, pain on swallowing or ear pain that lasts.
The hoarseness began after surgery or after a breathing tube.
Your job depends on your voice.

Frequently asked questions

Is it serious? Usually not. Even so, hoarseness lasting more than 4 weeks should always be checked with a camera.

Will it go away? In most cases it improves a lot with voice therapy and changes in habits. If you strain your voice again, it can come back.

Why do I have it if I do not have nodules? Because the problem is the tension with which you use your voice, not a lesion. Nasendoscopy confirms this.

Can I keep working? Usually yes, adapting how you use your voice. We explain how in clinic, and your therapist shows you how to do it.

Is it caused by reflux? It may contribute but is usually not the only cause. We do not give reflux medicine without first looking at the larynx.

Is it psychological? Not necessarily. Stress tightens muscles, but the cause is physical: how the voice is used.

References

For general information only. It does not replace a medical consultation and cannot be used for diagnosis. In an emergency in Spain, call 112.

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