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Journal of" Voice

Vol. 3, No. 4, pp 337-341


1989 Raven Press, Ltd., New York
A Study on the Mechanism of Functional Dysphoni a
Shilin Yang and Liancai Mu
Liaoning Research Center of Logopedics and Phoniatrics, 3rd Hospital Affiliated to China Medical University,
Shenyang, People's Republic of China
Summary: A total of 333 patients with a diagnosis of functional dysphonia were
studied by both laryngeal electromyography (EMG) and spectral analysis.
EMG and acoustic analysis revealed that some patients with so-called func-
tional dysphonia diagnosed by physical examination alone in fact suffered from
a variable degree of laryngeal nerve paralysis. Laryngeal EMG plays an im-
portant role in determining whether patients with a diagnosis of functional
dysphonia have organic disease of the laryngeal nerves. Key Words: Functional
dysphonia--Vocal cord paresis--Laryngeal electromyography.
Functional dysphoni as have been described ex-
tensively in the literature and classified into many
forms by previ ous authors (1-5). It is generally ac-
cept ed that functional dysphoni a usually occurs in
peopl e who are emotionally unstable. On the ot her
hand, the dysphoni as can cause secondary organic
abnormalities such as vocal cord nodules or polyps.
Generally speaking, incomplete closure of the vocal
cords is the most striking finding on l aryngoscopy.
Although the functional dysphonias have been di-
vided into many forms, t hey are usually classified
into four t ypes, i. e. , hyperfunctional, hypofunc-
tional, plicae ventricularis, and habitual dyspho-
nias. It is generally accept ed that these four t ypes of
dysphoni a are functional without organic disease of
the larynx.
MATERIALS AND METHODS
Subjects
.Subjects were 333 patients with a diagnosis of
functional dysphoni a, 211 males and 122 females,
ranging from 14 to 78 years of age.
The subjects were divided into four groups.
Groups 1 included t hose with inadequate cl osure
of the glottis (fusiform glottic chink or a small tri-
This work was presented at the Beijing International Sympo-
sium on Otolaryngology, Beijing, October 25-30, 1988.
Address correspondence and reprint requests to Dr. Liancai
Mu, Department of Otolaryngology, 3rd Hospital Affiliated to
China Medical University, Shenyang, Liaoning, P.R. of China.
angular chink bet ween the t wo cords from the an-
terior commi ssure to t he post eri or commi ssure) or
inadequate cl osure of the glottis with hypert rophy
or hyperadduct i on of the ventricular folds (Figs.
1--4).
Group 2 includes t hose with simple hypert rophy
or hyper adduct i on of vent ri cul ar fol ds (Figs. 5
and 6).
Group 3 includes t hose with inadequate cl osure
of the glottis or hypert rophy of the vent ri cul ar fold
associates with vocal nodule, pol yp, or edema of
the vocal cords (Figs. 7-9).
Group 4 includes t hose with functional dysphoni a
without positive findings in the larynx (Fig. 10).
Methods
Initially, the vocal cords were examined by indi-
rect l aryngoscopy. Next , the voi ce of the patient
was analyzed with a Bruel & Kj aer 2031 Nar r ow
Band Spect rum Anal yser in order to eval uat e pho-
nat ory function. Finally, one DI SA four-channel
el ect romyograph provi ded simultaneous monitoring
and recording of spont aneous muscl e act i vi t y from
the cri cot hyroi d (CT), t hyr oar yt enoi d (TA), and
post eri or cr i coar yt enoi d (PCA) muscl es of bot h
sides. Recordi ngs of el ect romyography wer e pro-
duced utilizing monopol ar concentric needl e elec-
trodes. An external approach was al ways used for
inserting the el ect rodes. In addition, st r oboscopy
was used in some cases of each group.
337
338 S. YANG AND L. MU
FIGS. 1-4. Typical glottic shapes seen during indirect laryngoscopy in patients with dysphonia. Fig. 1. Fusiform chink. Fig. 2. Posterior
small triangular chink. Fig. 3. Large triangular chink. Fig. 4. Inadequate closure of the glottis with hypertrophic or hyperadducted
ventricular folds.
RESULTS
The dysphonias of the 333 patients were classi-
fied into four types: hyperfunctional, hypofunc-
tional, habitual, and plicae ventricularis.
Hyperfunctional dysphonia
This term indicates excessive use of all of the
laryngeal muscles. During phonation, excessive
tension of the vocal cords is usually seen. In
marked cases, the voice sounds rough and heavy.
The respiratory muscles also show evidence of ex-
cess activity and the neck veins are frequently dis-
tended because of straining. On laryngoscopy, the
main laryngoscopic feature of increased laryngeal
muscle tension is an open posterior glottic chink
between the arytenoid cartilages. In some cases,
the vocal cords are usually red and thickened and
the ventricular folds are hypertrophic. Stroboscopy
revealed that fluctuation of the mucosa of the vocal
cords is reduced.
In this group, three of five only had a small tri-
angular chink in the posterior one-third of the glot-
tis, and one had a small triangular chink with a hy-
FIGS. 5, 6. Typical glottic shapes seen during indirect laryngos-
copy in patients with dysphonia plicae ventricularis. Fig. 5. Hy-
pertrophy of the ventricular fold. Fig. 6. Hyperadduction of the
ventricular fold.
pertrophic ventricular fold; another had normal vo-
cal cords (Figs. 11-13).
Spectral analysis of these subjects' voices re-
vealed that the vocal cord function was decreased.
The voice spectrum showed that the noise compo-
nent increased.
Hypofunctional dysphonia
Hypofunctional dysphonia is characterized by
hypotonia of the muscles of the vocal cord. It usu-
ally occurs in people who are emotionally unstable.
The voice is weak and muffled and air escape can be
heard. Incomplete closure of the vocal cords is the
most striking finding on laryngoscopy. On strobos--
copy, active vibration of the mucosa of the vocal
cords was observed in some cases of this group.
This is the largest group in this study. There were
146 patients with this form of dysphonia. In this
group, 93 cases had a large triangular chink between
the two cords from the anterior commissure to the
posterior commissure, 18 cases had a large triangu-
lar chink with hypertrophy or hyperadduction of the
ventricular folds, 33 cases had fusiform chink be-
tween the two cords, and 2 cases had a fusiform
chink with hyperadduction of the ventricular folds
(Figs. 14-17).
The voice spectrum showed that the noise com-
ponent obviously increased, indicating that these
patients had reduced phonatory function.
Habitual dysphonia
The habitual dysphonias are primary functional
disorders that are usually caused by incorrect use of
the voice and often by emotional disorders. The
dysphonia can cause secondary organic abnormali-
ties such as vocal cord nodules or polyps. How-
ever, most cases in this group had hoarseness with-
out positive findings in the larynx.
There were 117 patients with this form of dyspho-
Journal of Voice, Vol. 3, No. 4, 1989
MECHANI SM OF FUNCTI ONAL D YSPHONIA 339
i
" " '~ 11
FIGS. 7-9. Typical glottic shapes seen in group 3. Fig. 7. Inadequate closure of t he glottis with vocal
nodule. Fig. 8. Inadequate closure of the glottis with polypus of the vocal cord. Fig. 9. Hypert rophy
of the ventricular fold with a vocal nodule.
nia. Ninety-nine cases of the 117 had reduced pho-
natory function. A spectrum of the voice showed
that the vocal range became narrow, and the pho-
nation time was short. The others, however, had
normal phonatory function.
Dysphonia plicae ventricularis
Dysphonia ventricularis arises when the ventric-
ular folds play an active part in phonation. The ven-
tricular folds were not designed for phonation, so
that they produce a rough unmodulated sound. Dur-
ing phonation, the ventricular folds often close first,
and in long-standing cases may be hypertrophic. In
some cases, it was difficult to see the true vocal
cords during laryngoscopy.
Sixty-five patients with hypertrophy or hyperad-
FIG. 10. The normal glottic
shape on phonation.
FIGS. 11-13. Hyperfunctional dysphonia with variable glottic
shapes. Fig. 11. Small triangular chink. Fig. 12. Small triangular
chink with a hypertrophic ventricular fold. Fig. 13. Normal vocal
cords.
duction of the ventricular folds and with normal
true vocal cords were included in this group (Figs.
18 and 19).
Among the 65 patients, there were 17 cases with
normal vocal range, and 48 cases with reduced vo-
cal range, as the voice spectrum showed.
Laryngeal EMG findings and diagnostic criteria
are as follows: (a) Prolonged duration of the poten-
tials, electrical silence, or fibrillation potentials
FI GS. 14-17. Hypofunctional dysphonia with variable glottic
shapes. Fig. 14. Large triangular chink. Fig. 15. Large triangular
chink with hypertrophy or hyperadduction of the ventricular
folds. Fig. 16. Fusiform chink. Fig. 17. Fusiform chink with hy-
peradducted ventricular folds.
FIGS. 18, 19. The glottic shapes seen in the patients with the
dysphonia plicae ventricularis. Fig. 18. Hypert rophy of the ven-
tricular fold. Fig. 19. Hyperadduction of the ventricular folds.
Journal of Voice, Vol. 3, No. 4, 1989
340 S. YANG AND L. MU
TABLE 1. Some EMG findings and diagnosis in the patients with variable forms of dysphonias
Mean pot ent i al Dur at i on
(ms)
CT TA PCA
Pat i ent Age Clinical EMG
no. Sex (years) diagnosis L R L R L R diagnosis
39 Femal e 32 Hypo- FD 6.3 6.5 5.6 5.3 12.1 8.1 BCPP of RLN, SLN
21% 25% 64% 55% 168% 32%
76 Male 20 Hyper - FD 5.3 5.3 3.9 4.9 6.2 6.3 BPP of RLN
1% 1% 14% 23% 38% 40%
5 Femal e 26 Hypo- FD 6.8 6.0 4.4 5.5 6.6 6.7 LCPP and RRLN PP
26% 13% 22% 62% 56% 52%
91 Male 55 DPV 5.4 5.3 4.7 3.5 5.9 5.3 LRLN PP
1 % - - 3 4 % 1 % 31% 18%
97 Femal e 20 Hypo- FD 5.0 5.1 3.9 3.4 4.9 4.7 Nor mal EMG
- 3 % - 1 % 14% - - 11% 6%
37 Male 47 Hypo- FD Silence 3.6 3.6 4.7 4.7 BSLN CP
2% 2% 4% 4%
135 Male 18 Hypo- FD 4.7 5.4 3.8 F. P. 4.3 6.1 LSLN PP, RRLN PP
- 9 % 4 % 1 2 % - 2 % 34%
Prol onged pot ent i al durat i on means t hat over 20% of pot ent i al s measur ed have prol onged durat i on.
L, left; R, right; Hypo-FD, hypofunct i onal dysphoni a; Hyper-FD, hypeffuct i onal dysphoni a; DPV, dysphoni a plicae vent ri cul ari s;
BCPP, bi l at eral combi ned partial paralysis; BPP, bilateral partial paralysis; LCPP, left combi ned partial paral ysi s; PP, part i al paralysis;
BSLN CP, bi l at eral SLN compl et e paralysis.
from unilateral or bilateral CT, TA, PCA, or CT,
either of the TA and PCA, indicates that the patient
has a combined recurrent laryngeal nerve (RLN)
and the superior laryngeal nerve (SLN) partial or
complete paralysis. (b) If the above EMG findings
are found in unilateral or bilateral TA and PCA, or
in either of them, a diagnosis of partial or complete
RLN paralysis can be made. (c) Prolonged potential
duration or electrical silence or fibrillation poten-
tials from unilateral or bilateral CT muscles, indi-
cates that unilateral or bilateral SLNs have been
paralyzed partially or completely.
Some EMG findings as diagnostic evidence of la-
ryngeal nerve paralysis are shown in Table 1.
EMG findings of the 333 patients with dysphonias
are summarized in Table 2.
DISCUSSION
Functional dysphonias are common voice disor-
ders in clinical practice. Our classification is based
TABLE 2. EMG changes and diagnosis of the four forms of the dysphonias
Int ri nsi c laryngeal muscl es
Clinical diagnosis
Hyper-FD Hypo- FD HD DPV Tot al EMG diagnosis
BTA, PCA; ei t her of TA, PCA 3
BCT, TA, PCA; ei t her of TA, PCA 0
LTA, PCA; ei t her of TA, PCA 0
RTA, PCA; ei t her of TA, PCA 1
LCT, TA, PCA; RTA, PCA; ei t her of RTA, PCA 0
BCT 0
LCT, RTA, PCA; ei t her of RTA, PCA 0
LCT, TA, PCA; ei t her of TA, PCA 0
RCT, TA, PCA; LTA, PCA 0
LCT, TA, PCA; RCT 0
RCT; LTA, PCA 0
LCT 0
Nor mal EMG of CT, TA 0
PCA on bot h sides
Hyper t hyr oi di sm 0
Congest i on of vocal cords 0
1
5 Total
89 65 37 194 BPP of RLN
8 8 2 18 BCPP
9 12 7 28 LRLN, PP
16 19 11 47 RRLN PP
3 3 3 9 LCPP and RRLN PP
4 1 2 7 BSLN CP or PP
2 0 0 2 LSLN, RRLN PP
2 2 1 5 LCPP
0 4 0 4 RCPP; LRLN PP
0 1 0 1 LCPP; RSLN PP
0 1 0 1 RSLN, PP; LRLN PP
0 0 0 1 LSLN PP
6 1 1 8 FD
1 0 0 1 FD
6 1 1 6 FD
0 0 0 1 FD (vocal overuse)
146 117 65 333
FD, funct i onal dysphoni a; HD, habi t ual dysphoni a. The ot her abbr evi at i ons are t he same as t hose in Tabl e 1.
Journal of Voice, Vol. 3, No. 4, 1989
MECHANI SM OF FUNCTI ONAL D YSPHONI A 341
on 333 patients with dysphonias and on previous
classifications in the literature. The results of this
study showed that 16 cases (4.8%) of the 333 were
truly functional with normal EMG of the intrinsic
laryngeal muscl es, while the ot her 317 cases
(95.2%) were organic with varying degrees of laryn-
geal nerve paresis. The etiology of 232 cases
(69.9%) of the 333 remains unknown. We agree with
Dedo' s opinion (6) that the cases whose cause is
unknown may be caused by a virus. Clinically, par-
tial paralysis of the laryngeal nerves can not be
identified with routine examinations without laryn-
geal electromyography. Some of the so-called func-
tional dysphonias are in fact due to laryngeal nerve
paresis.
CONCLUSIONS
The results of the present study indicate that neu-
rogenic lesions in laryngeal muscles are frequent in
dysphonia diagnosed as functional from routine ex-
aminations.
The present study emphasizes the diagnostic
value of electromyographic examination in cases
suffering from dysphonia of unknown origin.
Acknowledgment: We thank Mrs. Zhao Yuhong for her
help in editing and typing the manuscript, Mrs. Li) Shu-
qing for technical assistance, and Mr. Fan Yu for the
photography. This study was supported in part by re-
search grant No. 3860762 from the National Natural Sci-
ence Funds.
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2. Morrison MD, Nichol H, Rammage LA. Diagnostic criteria
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3. Koufman JA, Blalock PD. Classification and approach to
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4. Zhang N. Conci se vocal disorders. Beijing: Peopl e' s Pub-
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Journal of Voice, Vol. 3, No. 4, 1989