Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

Psychological correlates of functional dysphonia:An investigation using the Minnesota multiphasic personality inventory

Abnormal psychological factors have been implicated in the development of functional dysphonia (FD). This investigation describes the personality and psychological characteristics of 25 female subjects who had received the diagnosis of FD. In all subjects symptoms were resolved after voice therapy. While vocally asymptomatic, these remitted subjects with FD completed the Minnesota Multiphasic Personality Inventory (MMPI), an objective personality questionnaire. When compared with a medical outpatient control group, the results showed that subjects with FD scored significantly higher on 7 of 10 clinical scales, suggesting an elevated degree of emotional maladjustment. A stepwise logistic discriminant analysis identified 2 clinical scales that provided valuable discriminatory power between the two groups. Scale I (Hs-hypochondriasis), which measures the number and type of reported somatic complaints, and scale 7 (Pt-psychasthenia), a measure of diffuse anxiety, discriminated the groups with 88% sensitivity and 89% specificity. The results suggested that in spite of symptom improvement after voice therapy, the subjects with FD continued to exhibit poor levels of adaptive functioning, which may represent trait-like vulnerability. The clinical implications of these results for voice practitioners are discussed.     

Objective Voice Quality Analysis Before and After Onset of Unilateral Vocal Fold Paralysis

This study was designed to investigate objective voice quality measurements in unilateral vocal fold paralysis (UVFP) by eliminating intersubject variability. To our knowledge this is the first report objectively analyzing paralytic dysphonia as compared to the same voice before onset of UVFP. The voices of two male subjects were prospectively recorded before and after the onset of iatrogenic UVFP (thoracic surgery).The following acoustic measurements of the vowel /a/ were performed using the CSL and MDVP (Kay Elemetrics): jitter, shimmer, harmonics-to-noise ratio, cepstral peak prominence, the relative energy levels of the first harmonic, the first formant and the third formant, the spectral slope in the low-frequency zone (0-1 kHz and 0-2 kHz), and the relative level of energy above 6 kHz. Distribution of spectral energy was analyzed from a long-term average spectrum of 40 seconds of text. Laryngeal aerodynamic measurements were obtained for one patient before and after onset of paralysis using the Aerophone II (Kay Elemetrics). Pitch and amplitude perturbation increased secondary to UVFP, while the harmonics-to-noise ratio and the cepstral peak prominence decreased. A relative increase in the mid-frequency and high-frequency ranges and a decrease in the low-frequency spectral slope were observed. Mean airflow rate and intraoral pressure increased, and glottal resistance and vocal efficiency decreased secondary to UVFP. The findings of this self-paired study confirm some but not all the results of previous studies. Measures involving the fundamental and the formants did not corroborate previous findings. Further investigation with vocal tract modeling is warranted.     

The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign masses

Hard or abrupt glottal attack (HGA) is one of the vocal behaviors often associated with benign lesion of the vocal folds. This study was designed to determine whether the frequency of HGA was different in hyperfunctional voice patients with and without vocal fold masses. One hundred and forty-seven subjects were studied. All subjects received a complete otolaryngological evaluation including strobovideolaryngoscopy, objective voice measures, and evaluation by a speech-language pathologist. Thirty-two patients were diagnosed with muscle tension dysphonia (19 male, 13 female) without vocal fold masses. Fifty-seven patients were diagnosed with unilateral vocal fold masses (29 male, 28 female), most of which were cysts. Fifty-eight patients were diagnosed with bilateral vocal fold masses (13 male, 45 female). Of the 45 females with bilateral vocal fold masses. 26 had a vocal cyst and reactive nodule and 19 had bilateral vocal fold nodules. The control group was balanced and matched based on sex and on percentage of singers and nonsingers. It consisted of 49 subjects with no vocal fold pathology (20 male, 29 female). The group was composed of professional speakers, singers, and nonprofessional speakers. All voice disordered groups demonstrated higher frequencies of HGA than the control group. Differences were found between the male and female subjects in this study. No differences were found between the various disorders. Differences were also found between the subgroups of bilateral masses, where the bilateral nodules group presented a higher frequency of HGA than the cyst and contralateral reactive nodule.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy     

The Relationship Between Perceptual Evaluation and Objective Multiparametric Evaluation of Dysphonia Severity

SUMMARY: The purpose of this study was to investigate the usefulness of the Dysphonia Severity Index (DSI) as an objective multiparametric measurement in assessing dysphonia. The DSI was compared with the score on Grade of the GRBAS scale. Investigated was also whether the DSI is related to severity of dysphonia, which was represented by different diagnosis groups. Furthermore, it was investigated whether the DSI can differentiate between a group of patients and a control group. A total of 294 patients with different voice pathologies were included. A control group consisted of 118 volunteers without any voice complaints. The voices of all participants were perceptually evaluated on Grade, and the DSI was measured. The groups of patients with voice complaints have a lower DSI and higher scores on Grade than the control group. The DSI was significantly lower when the score on Grade was higher. The DSI discriminates between patients with nonorganic voice disorders, vocal fold mass lesions, and vocal fold paresis/paralysis. To determine whether the DSI discriminates between patients and controls, the sensitivity and specificity for different DSI cutoff points were calculated. With a DSI cutoff of 3.0, maximum sensitivity (0.72) and specificity (0.75) were found. We conclude that the DSI is a useful instrument to objectively measure the severity of dysphonia.     

Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) is associated with changes in acoustic and aerodynamic voice measurements and can have a significant impact on a patient's quality of life. Few objective data regarding the efficacy of voice therapy for UVFP exist. The aim of this study was to retrospectively analyze voice modifications in a group of patients with UVFP before and after voice therapy. Forty patients with UVFP of different etiology were included in the study. Each subject had voice therapy with an experienced speech/language pathologist twice a week; the mean number of sessions was 12.6. A multidimensional assessment protocol was used; it included videoendoscopy, the maximum phonation time (MPT), the GIRBAS scale, spectrograms and a perturbation analysis, and the Voice Handicap Index (VHI). Pre- and posttreatment data were compared by means of the Wilcoxon and Student's t tests. A complete glottal closure was seen in 8 patients before voice therapy and in 14 afterward. Mean MPT increased significantly. In the perceptual assessment, the difference was significant for five out of six parameters. A significant improvement was found on spectrographic analysis; as for perturbation analysis, the differences in jitter, shimmer, and noise-to-harmonic ratio values were significant. VHI values showed a clear and significant improvement. A significant improvement of voice quality and quality of life after voice therapy is an often reached and reasonable goal in patients with UVFP.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Assessing outcomes for dysphonic patients

This study was designed to evaluate a disease-specific outcome measure for patients with selected voice disorders and to relate this instrument to a standardized quality of life measurement. In addition, the study attempts to document the degree of handicap for dysphonia patients globally, between different vocal pathologies, and in comparison to other chronic diseases. In this prospective, observational study, 260 adult patients evaluated for alterations of voice completed a general quality of life measure (the Medical Outcomes Trust Short Form 36-Item[SF-36]) and a voice-specific instrument (Voice Handicap Index [VHI]) pretreatment.

The highest correlation was between the social functioning score of the SF-36and the total score of the VHI and the physical, emotional, and functional subscales (p < 0.001) of the VHI. Significant correlation was also obtained for the SF-36 domains mental health (p < 0.01), general health (p < 0.01), and role functioning emotional (p < 0.017) with the three VHI domains and the total VHI score. Patients had significantly lower scores than the general U.S. population in five of the eight domains of SF-36. Patients with vocal fold paralysis had the highest level of pretreatment disability as measured on both the VHI and SF-36 among voice patients. The patients with dysphonia had a lower level of physical functioning than the patients with chronic sinusitis (p < 0.01), reflecting a greater handicap. In addition, the dysphonia group had lower levels of social functioning than the angina (p < 0.01) and sciatica (p < 0.01) groups and a lower score for mental health than the angina group (p < 0.01).

The SF-36 correlates with the VHI in the domains of social functioning,mental health, and role functioning emotional. The baseline handicap for voice disorders represents a significant disability even in comparison to conditions such as angina pectoris, sciatica, and chronic sinusitis.     

Poor Voice Quality in Future Elite Vocal Performers and Professional Voice Users

The voice quality of 86 occupational voice users, i.e., students of a high school for audiovisual communication, was assessed by means of a multidimensional test battery containing: the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, dysphonia severity index (DSI), and voice handicap index (VHI). In a questionnaire on daily habits the prevalence of smoking, eating habits, and vocal abuse were recorded. A comparison of the voice characteristics of the future occupational voice users with a control group revealed significant differences. The results of the VHI and the DSI of these students revealed significantly worse scores than the score of a control group characterized by no vocal complaints. Moreover, the questionnaire on daily habits showed that the future elite vocal performers and professional voice users take less precautions for the care of their voices. These findings support the importance of a good balanced vocal coaching.     

Japanese version of voice handicap index for subjective evaluation of voice disorder

Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient's perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient's disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient's psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.     

Vocal Problems Among Teachers: Evaluation of a Preventive Voice Program

Vocal education programs for teachers may prevent the emergence of vocal disorders; however, only a few studies have tried to evaluate the effectiveness of these preventive programs, particularly in the long term. Two hundred and sixty-four subjects, mostly kindergarten and primary school female teachers, participated in a course on voice care, including a theoretical seminar (120 minutes) and a short voice group therapy (180 minutes, small groups of 20 subjects). For 3 months, they had to either attend the vocal ergonomics norms and, as psychological reinforcement, they had to make out a daily report of vocal abuse, or to follow the given exercises for a more efficient vocal technique, reporting on whether the time scheduled was respected or not. The effectiveness of the course was assessed in a group of 21 female teachers through a randomized controlled study. Evaluation comprehended stroboscopy, perceptual and electro-acoustical voice analysis, Voice Handicap Index, and a course benefit questionnaire. A group of 20 teachers matched for age, working years, hoarseness grade, and vocal demand served as a control group. At 3 months evaluation, participants demonstrated amelioration in the global dysphonia rates (P=0.0003), jitter (P=0.0001), shimmer (P=0.0001), MPT (P=0.0001), and VHI (P=0.0001). Twelve months after the course, the positive effects remained, although they were slightly reduced. In conclusion, a course inclusive of two lectures, a short group voice therapy, home-controlled voice exercises, and hygiene, represents a feasible and cost-effective primary prevention of voice disorders in a homogeneous and well-motivated population of teachers.     

Symptomatology of adductor spasmodic dysphonia: A physiologic model

Vocal symptomatology of adductor spasmodic dysphonia (SD) is reviewed critically from historical, epidemiologic, and clinical perspectives. A model of symptomatology of this disorder based on a large patient population, and clinical and physiologic observations is advanced. The model incorporates crucial symptomatic and asymptomatic phonatory and nonphonatory physiologic parameters of laryngeal behavior in these patients. These parameters include vocal fold contact area, vocal fold collision force, glottic compression, and subglottic air pressure. Inappropriate efferent discharges from brain-stem basal ganglia are hypothesized as causing overadduction of the vocal folds in phonation, generating the basic and fundamental vocal symptom of adductor SD—strained, strangled, overpressured voice quality. Cortical loops are implicated as accountable for compensatory vocal behavior, not as the primary site of the disorder. Symptom occurrence, variability, magnitude, effects, and failure of treatment approaches, as well as recurrence of symptoms after ablative or invasive procedures, are explained by this model. The model also predicts that symptomatology of adductor spasmodic dysphonia is unique to this disorder and that symptoms are phonotopically organized. The minimal diagnostic battery based on the model is presented, and it is shown how this battery aids in the differential diagnosis of adductor SD and other phonatory disorders that closely mimic the vocal symptoms of adductor spasmodic dysphonia, including tremor.     

Behavioral Characteristics of Children With Vocal Fold Nodules

Vocal fold nodules (VNs) in children are benign, bilateral lesions occurring on the mid-membranous vocal folds. Repetitive phonotraumatic behavior leading to chronic vocal fold injury and repair is frequently cited as the primary etiology; however, specific behavioral characteristics may predispose some children toward intense and potentially phonotraumatic voice use, thereby contributing secondarily to VN formation. The purpose of this case-control study was to determine whether children with VNs possess unique behavioral characteristics that may predispose them to VN development. Parents of 26 children with VNs (20 boys, 6 girls, mean age=7.2 years, SD=2.5 years), and 29 vocally normal, medical controls (22 boys, 7 girls, mean age=6.7 years, SD=2.4), completed the Childhood Behavior Checklist (CBCL/4-18, Achenbach, 1991), a standardized parent-rating scale with strong psychometric properties. No significant between-group differences were detected on any of the behavior problem syndrome scales. Group differences approached significance for the individual items "screams a lot" and "teases a lot" (VN group > Controls). The VN group scored significantly higher than the controls on the "Social Scale," a compilation of positive ratings of the child's social activity, frequency of contacts with friends, behavior with others, and behavior by themselves. Observed outcomes were consistent with previous characterizations of children with VN as "outgoing" or "extroverted" but were not consistent with other claims that this population may be at risk for "aggressive," "attentional," or "impulsive" behavior problems.     

Vocal Evaluation in Teachers With or Without Symptoms

The aim of this study was to perform voice evaluation in teachers with and without vocal symptoms, identifying etiologic factors of dysphonia, voice symptoms, vocal qualities, and laryngeal lesions. Eighty teachers were divided into two groups: GI (without or sporadic symptoms, 40) and GII (with frequent vocal symptoms, 40). They answered a specific questionnaire, and were subject to a perceptual vocal assessment (maximum phonation time, glottal attack, resonance, coordination of breathing and voicing, pitch, and loudness), GIRBAS scale, and to videolaryngoscopy. Females were predominant in both groups, and the age range was from 36 to 50 years. Elementary teachers predominated, working in classes with 31-40 students. Voice symptoms and alterations in the perceptual vocal analysis and in the GIRBAS scale were more frequent in GII. In 46 teachers (GI-16; GII-30), videolaryngoscopy exams were abnormal with the vocal nodules being the most frequent lesions. These results indicate that a teacher's voice is compromised, and requires more attention including control of environmental factors and associated diseases, preventive vocal hygiene, periodic laryngeal examinations, and access to adequate specialist treatment.     

Psychogenic spasmodic dysphonia: A case study with expert opinions

Spasmodic (spastic) dysphonia (SD) is considered by some to be a neurologic syndrome and by others a symptom complex of multiple etiologies, neurologic and psychogenic. A case of a 26-year-old female psychiatric nurse with psychogenic SD (PSD) is presented. The dysphonia was alleviated within one session of voice therapy. Psychogenic etiology was established by the author, based on three diagnostic criteria—symptom incongruity, symptom reversibility, and symptom psychogenicity. Seven nationally recognized voice experts listened to audio-recorded samples of the patient's pre- and posttherapy voice during conversational speech. The experts agreed that the dysphonia was psychogenic and characterized it as staccato-like speech, effortful phonation, and interrupted flow of speech; six characterized it with intermittent voice arrests (voice stoppages); five with hoarse-harsh voice; and four with waxing and waning, strained-strangled phonation. These are often described as salient features of SD. Nevertheless, the experts disagreed among themselves as to whether the dysphonia was characteristic of SD and should be labeled as such. The author argues that as long as the voice characteristics and pathophysiologic findings that constitute SD are not well delineated, and as long as the diagnosis of SD is based on symptoms alone, patients with psychogenic or poorly understood voice disorders are likely to be misdiagnosed with organic (neurologic) SD and thus subjected to undue medical treatment. The author also argues that the debate over the etiology of SD can be resolved if SD is considered a neurologic syndrome, PSD a nonorganic phonatory disorder that mimics the syndrome, and if the voice symptoms and pathophysiologic characteristics of SD are well defined and agreed on.     

Correlation of VHI-10 to Voice Laboratory Measurements Across Five Common Voice Disorders

ObjectiveTo correlate change in Voice Handicap Index (VHI)-10 scores with corresponding voice laboratory measures across five voice disorders.Study DesignRetrospective study.MethodsOne hundred fifty patients aged >18 years with primary diagnosis of vocal fold lesions, primary muscle tension dysphonia-1, atrophy, unilateral vocal fold paralysis (UVFP), and scar. For each group, participants with the largest change in VHI-10 between two periods (T_A and T_B) were selected. The dates of the VHI-10 values were linked to corresponding acoustic/aerodynamic and audio-perceptual measures. Change in voice laboratory values were analyzed for correlation with each other and with VHI-10.ResultsVHI-10 scores were greater for patients with UVFP than other disorders. The only disorder-specific correlation between voice laboratory measure and VHI-10 was average phonatory airflow in speech for patients with UVFP. Average airflow in repeated phonemes was strongly correlated with average airflow in speech (r = 0.75). Acoustic measures did not significantly change between time points.ConclusionsThe lack of correlations between the VHI-10 change scores and voice laboratory measures may be due to differing constructs of each measure; namely, handicap versus physiological function. Presuming corroboration between these measures may be faulty. Average airflow in speech may be the most ecologically valid measure for patients with UVFP. Although aerodynamic measures changed between the time points, acoustic measures did not. Correlations to VHI-10 and change between time points may be found with other acoustic measures.     

The impact of preventive voice care programs for training teachers: A longitudinal study

The teaching profession puts vocal health at a higher risk than other professions, causing what is referred to as "occupational dysphonia." There is a need for primary prevention of "occupational dysphonia" among the teaching profession, where good vocal health is promoted before a problem occurs. To investigate the primary prevention of occupational dysphonia among teachers, this study uses a sample population of 55 training teachers, in the postgraduate certificate of education (PGCE) course at the University of Ulster, Northern Ireland, who were randomly assigned to three training groups: control, indirect, and direct. The vocal performance of the three groups was measured at two points over the year of the PGCE course: first before any teaching or training began, and again after the first teaching practice. The training for the indirect and direct groups was provided before the teaching practices. Acoustic and self-perceptual measurements were used to assess the multidimensional outcomes. The results demonstrate interesting trends, that although not found to be significant, are approaching significance. Their voices will be reevaluated at a third point of measurement. The acoustic measurement reflects deterioration from time 1 to time 2 for the control group, improvement for the direct group, and no change for the indirect group, indicating that the training has proved beneficial. The self-rating scores vary in agreement with the acoustic results, presenting interesting findings. The findings of this study will be of benefit to teachers, their educators, voice therapists, health promoters, and human resource personnel.     

Autologous fat implantation for vocal fold scar: A preliminary report

New insights into the anatomy and physiology of phonation, along with technological advances in voice assessment and quantification, have led to dramatic improvements in medical voice care. Techniques to prevent vocal fold scar have been among the most important, especially scarring and hoarseness associated with voice surgery. Nevertheless, dysphonia due to vocal fold scar is still encountered all too frequently. Although it is not generally possible to restore such injured voices to normal, patients with scar-induced dysphonia can usually be helped. Voice improvement is optimized through a team approach. Treatment may include sophisticated voice therapy and vocal fold surgery. Although experience with collagen injection has been encouraging in selected cases (particularly in those involving limited areas of vocal fold scar), there is no consistently successful surgical technique. Attempts to treat massive vocal fold scar, such as may be seen following vocal fold stripping, have been particularly unsuccessful. This paper reports preliminary experience with the implantation of autologous fat into the vibratory margin of the vocal fold of patients with severe, extensive scarring. Using this technique, it appears possible to recreate a mucosal wave and improve voice quality. Additional research is needed.     

A report on alterations to the speaking and singing voices of four women following hormonal therapy with virilizing agents

Four women aged between 27 and 58 years sought otolaryngological examination due to significant alterations to their voices, the primary concerns being hoarseness in vocal quality, lowering of habitual pitch, difficulty projecting their speaking voices, and loss of control over their singing voices. Otolaryngological examination with a mirror or flexible laryngoscope revealed no apparent abnormality of vocal fold structure or function, and the women were referred for speech pathology with diagnoses of functional dysphonia. Objective acoustic measures using the Kay Visipitch indicated significant lowering of the mean fundamental frequency for each woman, and perceptual analysis of the patients' voices during quiet speaking, projected voice use, and comprehensive singing activities revealed a constellation of features typically noted in the pubescent male. The original diagnoses of a functional dysphonia were queried, prompting further exploration of each woman's medical history, revealing in each case onset of vocal symptoms shortly after commencing treatment for conditions with medications containing virilizing agents (eg, Danocrine (danazol), Deca-Durabolin (nandrolene decanoate), and testosterone). Although some of the vocal symptoms decreased in severity with the influences from 6 months voice therapy and after withdrawal from the drugs, a number of symptoms remained permanent, suggesting each subject had suffered significant alterations in vocal physiology, including muscle tissue changes, muscle coordination dysfunction, and propioceptive dysfunction. This retrospective study is presented in order to illustrate that it was both the projected speaking voice and the singing voice that proved so highly sensitive to the virilization effects. The implications for future prospective research studies and responsible clinical practice are discussed.