Although Adult Voice Disorders are outlined here, Speech Therapy Enterprises LLC services both the Child, Adult and Geriatric Populations regarding Voice Disorders:
ADULTS: Voice Guidelines for Referral to Speech-Language Pathologists (SLPs)

REFERRAL:Adult Voice Referral Guidelines, Page 1 of 2 by ASHA

Most Common Etiologies:
• Structural
– Head and neck cancer
– Laryngitis
– Vocal nodules
• Movement
– Hyperfunctional hoarseness or aphonia
– Parkinson’s disease
– Vocal fold paralysis

Related Terms:
Aphonia, aspiration, breathy, diplophonia, dysarthria, esophageal speech, hoarseness, hyperkinetic, intonation, intubation, loudness, monotone, nasality, pitch, pitch breaks, reflux, resonance, silent aspiration, stridor, structural deviations, tracheostomy, velar, velopharyngeal incompetence, vocal abuse, vocal fry, vocalization, vocal quality, voice prosthesis

Potential Consequences:
• With neurogenic origin, risk for illness and/or death due to aspiration, malnutrition, or dehydration
• With structural origin, risk for illness and/or death due to aspiration or breathing obstruction
• Reduced ability to communicate after episode of vocal overuse or through the course of the day
• Isolation from family members and social contacts; at risk for depression and reduced self-confidence
• Disruption of ability to fulfill educational and/or vocational roles including potential loss of employment
• Risk for personal injury due to difficulty communicating about a dangerous situation or calling for help
Behaviors1 That Should Trigger an SLP Referral
Vocal quality
• breathy and/or hoarse voice often accompanied by reduced loudness and/or intermittent loss of voice due to overuse of voice from:
– frequent yelling, screaming, or arguing
– singing in vocally abusive manner
– vocalizing excessively
– routinely talking over noise
– overuse in environment with laryngeal irritants (e.g., excessive dust or cigarette smoke with chronic allergies, sinusitis, or episodes of upper respiratory infections)
• voice has too little or too much nasality; may exhibit nasal regurgitation of foods or liquids
• sounds harsh, strangled, and/or strident, often unpleasant for the listener
• tremulous, jerky vocal quality of emotional or unknown etiology

• complete loss of voice due to structural, physiological, or emotional etiology
• partial loss or intermittent loss of voice due to:
– overuse of voice
– intubation trauma
– stress and/or laryngeal tension
– difficulty using vocal mechanism effectively and consistently
– reduced vocal control/endurance
– voice prosthesis
– esophageal speech
• voice is too soft/weak secondary to:
– problems with vocal quality
– poor respiratory support/control for speech
– poor head, neck, and/or body posture for speech
– overcompensating for other more vocally taxing activities
• voice is excessively loud due to:
– routinely speaking over loud environmental noise
– hearing loss
– forcing the voice in the presence of vocal fold pathology such as growths or edema

• too high or low for age, sex, or physical size
• monotone, often accompanied by reduced loudness, hearing loss, or emotional difficulty
• vocal inefficiencies with pitch breaks as symptom of:
– vocal quality difficulties
– diplophonia (production of two pitches simultaneously)

Neurologically based voice difficulties
• excessively breathy and/or hoarse quality often accompanied by reduced speech intelligibility and/or swallowing problems; may have weak cough and wet, gurgly voice after eating, which indicates increased risk for aspiration
• tremulous, jerky vocal quality
• voice is too soft and/or intermittent loss of voice; may exhibit poor respiratory control for speech and/or body posture for speech
• hyperkinetic condition with variable rate and flow of speech, as well as excessive loudness