Voice Disorders: Etiology and Diagnosis *Regina Helena Garcia Martins, †Henrique Abrantes do Amaral, *Elaine Lara Mendes Tavares, ‡Maira Garcia Martins, *Tatiana Maria Gonçalves, and *Norimar Hernandes Dias, *,†,‡Botucatu, São Paulo, Brazil Summary: Objectives. Voice disorders affect adults and children and have different causes in different age groups. The aim of the study is to present the etiology and diagnosis dysphonia in a large population of patients with this voice disorder.for dysphonia of a large population of dysphonic patients. Methods. We evaluated 2019 patients with dysphonia who attended the Voice Disease ambulatories of a university hospital. Parameters assessed were age, gender, profession, associated symptoms, smoking, and videolaryngoscopy diagnoses. Results. Of the 2019 patients with dysphonia who were included in this study, 786 were male (38.93%) and 1233 were female (61.07). The age groups were as follows: 1–6 years (n = 100); 7–12 years (n = 187); 13–18 years (n = 92); 19–39 years (n = 494); 41–60 years (n = 811); and >60 years (n = 335). Symptoms associated with dysphonia were vocal overuse (n = 677), gastroesophageal symptoms (n = 535), and nasosinusal symptoms (n = 497). The predomi- nant professions of the patients were domestic workers, students, and teachers. Smoking was reported by 13.6% patients. With regard to the etiology of dysphonia, in children (1–18 years old), nodules (n = 225; 59.3%), cysts (n = 39; 10.3%), and acute laryngitis (n = 26; 6.8%) prevailed. In adults (19–60 years old), functional dysphonia (n = 268; 20.5%), acid laryngitis (n = 164; 12.5%), and vocal polyps (n = 156; 12%) predominated. In patients older than 60 years, presbyphonia (n = 89; 26.5%), functional dysphonia (n = 59; 17.6%), and Reinke’s edema (n = 48; 14%) predominated. Conclusions. In this population of 2019 patients with dysphonia, adults and women were predominant. Dysphonia had different etiologies in the age groups studied. Nodules and cysts were predominant in children, functional dys- phonia and reflux in adults, and presbyphonia and Reinke’s edema in the elderly. Key Words: Dysphonia–Voice disorders–Etiology–Epidemiology–Hoarseness. INTRODUCTION About 10% of the general population presents with voice dis- orders, and among voice professionals, the proportion reaches 50%.1–3 Children and adults are equally affected; however, the causes are different according to the age groups. In early childhood, a frequent cause of dysphonia is acute viral laryngitis. The infection may progress to the trachea affecting the tracheobronchial tree. The manifestations are usually self- limited and rarely progress into bacterial laryngotracheal bronchitis.4 In children older than 4 years, vocal nodules pre- dominate among the causes for dysphonia. These lesions are phonotraumatic, directly related to vocal overuse. The peak in- cidence is between 5 and 10 years, mostly in boys, receding after adolescence.4–7 The treatment of choice is voice therapy.8 The second cause of dysphonia in childhood is vocal cyst. Cysts are classified as epidermal or mucosal. Epidermal cysts are con- genital and may be attached to the vocal ligament, worsening voicing even more. The intensity of voice involvement is related to the size of the cyst, requiring, in many cases, surgical removal.9,10 Laryngeal papillomatosis is also frequent in children and ac- companied by progressive dysphonia and respiratory discomfort.11 Verrucous lesions implant in the vocal cords and may involve also the supraglottic or the subglottic region and the trachea. Lesions of laryngeal papillomatosis are always recurring and they need repeated surgical removal. Adjuvant treatment with intralesional cidofovir has proved efficient; however, most authors report their experience with the drug in adults.12 A recent sys- tematic review that evaluated the benefits of cidofovir in the treatment of laryngeal papillomatosis included 15 randomized studies in adults and only four in children and found no differ- ence between the drug and placebo.13 Therefore, the benefits of cidofovir remain questionable. Among adults, the causes of dysphonia are many, including— besides the ones previously mentioned—laryngeal trauma (mechanical, thermal, or chemical trauma); inflammations or in- fections (due to smoking, virus, bacteria, or reflux laryngitis); leukoplakia, endocrine, rheumatic, or neoplastic causes (benign or malignant); neurological, psychological, or emotional causes; and medication. Cancer of the vocal folds is an important cause of dysphonia in patients who smoke; videolaryngoscopy is man- datory in all smoking patients with vocal symptoms for longer than 15 days. This topic deserves a special article and will not be discussed in this paper. Other important causes of dyspho- nia in adults include papilloma, cysts, hemangioma, sulcus, vocal polyps, and Reinke’s edema.14–17 Even though the literature presents many publications with epidemiologic data on dysphonia, few studies analyze large popu- lations of adults, children, and elderly patients with this voice disorder. Additionally, rare diagnoses such as vocal sulcus and mucosal bridges have little mention in studies of children with voice disorders, and have been diagnosed more often. Thus, the purpose of this study is to analyze the causes and epidemio- Accepted for publication September 29, 2015. From the *Ophthalmology, Otorhinolaryngology, Head and Neck Surgery Department, Botucatu Medical School, UNESP—Universidade Estadual Paulista; †Botucatu Medical School, UNESP—Universidade Estadual Paulista, Botucatu, São Paulo, Brazil; and the ‡De- partment of Otorhinolaryngology, São Paulo State University. Address correspondence and reprint requests to Regina Helena Garcia Martins. Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Botucatu Medical School/UNESP, Distrito de Rubião Jr, CEP 18618-970, Botucatu, São Paulo, Brazil. E-mail address: rmartins@fmb.unesp.br Journal of Voice, Vol. 30, No. 6, pp. 761.e1–761.e9 0892-1997 © 2016 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2015.09.017 mailto:rmartins@fmb.unesp.br logical data of a large population of adults and children with voice disease. METHODS To analyze the etiology and diagnosis of dysphonia, this study included patients with voice disease who sought treatment in the ambulatory of the Botucatu Medical School between 2004 and 2014. Patients were included in the study in the chrono- logical order of arrival at the ambulatory for voice disorders. All patients underwent videolaryngostroboscopy to confirm the diagnosis of dysphonia with a rigid telescope 70°, 8 mm (AZAP, Germany), or nasofibroscopy (3.5 mm in diameter, Olympus, Japan) and videostroboscopy(Atmos Inc., Germany). Patients diagnosed with acid laryngitis or psychogenic dysphonia were submitted to multidisciplinary assessment, including measure- ment of pH levels and examination by a gastroenterologist and a psychologist. The diagnosis of presbyphonia was established in patients aged more than 60 years who showed the following having vocal symp- toms: vocal fatigue, decreased vocal range, and low and breathy voice. The videolaryngoscopy of these patients did not identi- fy organic laryngeal lesions, but showed atrophy of the vocal folds, prominence of vocal apophysis, bowed vocal folds, and vocal tremor. All patients included in this study were evaluated by a speech pathologist. The following parameters were analyzed: age, gender, pro- fession, associated symptoms (vocal overuse, gastroesophageal symptoms, and nasosinusal symptoms), smoking, and laryn- geal diagnoses. The project was approved by the Ethics in Research Committee of the Botucatu Medical School. This study included only patients with predominant symp- toms of dysphonia who were treated in the Voice Disease ambulatory. Only one laryngeal diagnosis was considered per patient (the most relevant); the patients with uncertain diagno- ses were excluded, as well as patients with laryngeal cancer, and those treated in other sites such as the emergency department or wards. Some patients had their diagnoses confirmed during microsurgery. The results were presented in tables and charts and submit- ted for statistical analyses. The chi-square test was used to compare the parameters studied, using the 5% level of significance. RESULTS Age group and gender Of the 2343 medical records initially selected, 324 were ex- cluded because they were incomplete. Thus, 2019 patients were included in the study, of which 786 were male (38.93%) and 1233 were female (61.07%), distributed in age groups as shown in Table 1. Children aged between 1 and 18 years corresponded to 18% of the population, with a predominance of boys. Of the cases, 64% were adults aged 19–60 years (472 men and 833 women), and 16% were 60 year olds or older. Smoking Only 275 patients (13.62%) reported smoking, and 35 (1.70%) had stopped smoking. All of them are adults. Associated symptoms The associated symptoms were vocal overuse (n = 677; 33.53%), gastroesophageal symptoms (n = 535; 26.5%), and nasosinusal symptoms (n = 497; 24.61%). Profession Among the professions, domestic employees, students, and teach- ers were the most prominent (Table 2). Laryngeal diagnoses The laryngeal diagnoses are presented in Table 3 and Figures 1–6, where they appear by age group and gender. In 379 children, with ages ranging from 1 to 18 years (19%) (Figures 1–3), vocal nodules predominated, being diagnosed in 225 patients (59%), followed by vocal cysts (n = 39; 10.3%), and acute laryngitis (n = 26; 6.8%). There were 1305 adult patients aged between 19 and 60 years (64.6%) (Table 3; Figures 4–6), and among them the main laryngeal diagnoses were functional dysphonia (n = 268; TABLE 1. Age and Gender Age (Years) Gender Total N (%) Male N Female N 1–6 62 38 100 (4.96) 7–12 112 75 187 (9.26) 13–18 39 53 92 (4.55) 19–39 194 300 494 (24.47) 41–60 278 533 811 (40.16) >60 101 234 335 (16.60) Total 786 (38.93) 1233 (61.07) 2019 (100.00) Note: P < 0.0001. TABLE 2. Profession Profession N (%) Domestic worker 577 (28.57) Student 351 (17.38) Teacher 295 (14.61) Retired 289 (14.31) Sales person 192 (9.50) Vendor 93 (4.60) Singer 49 (2.43) Nurse 18 (0.90) Bank worker 17 (0.84) Secretary 16 (0.80) Preacher 14 (0.70) Telemarketing operator 10 (0.50) Others 98 (4.86) Note: P < 0.0001. 761.e2 Journal of Voice, Vol. 30, No. 6, 2016 20.5%), acid laryngitis (n = 164; 12.5%), and vocal polyps (n = 156; 12%). In the population older than 60 years (n = 335; 16%), presbyphonia (n = 89; 26.5%), functional dysphonia (n = 59; 17.6%), and Reinke’s edema (n = 48; 14%) predominated. DISCUSSION This study included only dysphonic patients and confirmed the predominance of adults between the ages of 20 and 60 years (64%), and females (61%); however, in children between the ages TABLE 3. Laryngeal Diagnoses in the Total Population in Both Genders Laryngeal Diagnosis Male Female N (%) P Value Functional/normal 153 193 346 (17.13) 0.03 Vocal nodules 147 199 346 (17.13) 0.005 Acid laryngitis 80 121 201 (9.96) 0.004 Reinke’s edema 53 134 187 (9.26) <0.0001 Polyp 79 101 180 (8.91) 0.1 Cyst 47 72 119 (5.90) 0.02 Paralysis 34 76 110 (5.45) <0.0001 Presbyphonia 21 68 89 (4.40) <0.0001 Vocal sulcus 19 53 72 (3.56) <0.0001 Leukoplakia 54 9 63 (3.12) <0.0001 Acute laryngitis 28 32 60 (2.98) 0.6 Psychogenic 2 49 51 (2.53) <0.0001 Granuloma 19 28 47 (2.32) 0.19 Papillomatosis 10 20 30 (1.48) 0.07 Microvascular lesion 12 15 27 (1.34) 0.56 Vocal bridge 7 19 26 (1.29) 0.02 Nonspecific chronic laryngitis 8 16 24 (1.19) 0.1 Microweb 8 12 20 (1.00) 0.37 Dystonia 3 12 15 (0.75) 0.02 Laryngeal hemangioma 2 2 4 (0.20) 1 Laryngeal lymphangioma 0 1 1 (0.05) 0.31 Myasthenia 0 1 1 (0.05) 0.31 Total 786 1233 2019 (100.00) <0.00001 Note: P = men × female. FIGURE 1. Laryngeal diagnosis of children aged between 1 and 6 years. Regina Helena Garcia Martins et al Voice Disorders: Etiology and Diagnosis 761.e3 of 1 and 12 years, boys predominated, corroborating the find- ings of other authors.1,4,9,15–18 The predominance of voice disorders among women has been reported by several authors, and the causes include the female glottic configuration, favoring glottic bowing, the vocal self-perception, the hormonal influence on vocal qualities, and the asymmetric concentration of hyaluronic acid in the lamina propria of the female larynx.19 Analyzing the many professions, we found a large percent- age of patients doing domestic work or studying. However, in putting together all the activities that require a high vocal demand (teacher, salesperson, vendor, singer, preacher, telemarketing op- erator, etc.), we verified that domestic employees and students accounted for more than 30% of the patients, confirming the strong relation between dysphonia and professions with a high FIGURE 2. Laryngeal diagnosis of children aged between 7 and 12 years. FIGURE 3. Laryngeal diagnosis of children aged between 13 and 18 years. 761.e4 Journal of Voice, Vol. 30, No. 6, 2016 vocal demand. It is worth highlighting that dysphonia was men- tioned by 33% of the patients included in this study. Vocal damage produced by voice abuse may be clearly identified in teachers; 50–80% of this group of patients had dysphonia at some point of their careers.18 Assunção et al.20 evaluated the question- naires answered by 649 teachers and found that 32% of them presented vocal symptoms, with a predominance of women. The authors underscored, among the main risk factors, long working hours, constant need for increasing voice intensity, excessive noise in the classes, smoking habits, air conditioning, and inhaled FIGURE 4. Laryngeal diagnosis of patients aged between 19 and 40 years. FIGURE 5. Laryngeal diagnosis of patients aged between 41 and 60 years. Regina Helena Garcia Martins et al Voice Disorders: Etiology and Diagnosis 761.e5 pollutants (dust and chalk powder), as also emphasized by other authors.21–24 The studies comparing the incidence of voice dis- orders in teachers with that in other professions clearly demonstrate the high incidence of dysphonia in teaching pro- fessionals and its relationship to excessive phonatory demands. Akinbode et al.23 evaluated 341 teachers and 155 professionals of other areas and found a prevalence of dysphonia in 42% of teachers against 18% in nonteachers. Similar results were re- ported by other authors such as Roy et al.1 (57.7% versus 28.8%), Angellilo et al.3 (51.4% versus 25.9%), and Van Houtte et al.24 (51.2% versus 27.4%). Among nonteachers, a prevalence of dysphonia between 3% and 9% is estimated.4,15,21 Higher rates are reported in children, between 6% and 23%.9,10,25,26 A smaller percentage was found by Bhattacharyya15 in a populational study that identified 1.4% children with vocal disorders, the main diagnoses being laryn- gitis and allergies. Functional dysphonia, vocal nodules, and laryngopharyn- geal reflux were the most frequent diagnoses in the present study, adding, respectively, to 17%, 17%, and 10%. Functional voice disorders are the most frequent causes of dysphonia in many epi- demiological studies. Those are vocal disorders occurring in the absence of laryngeal organic lesions that explain the symp- toms, as in conversion aphonia, psychogenic dysphonia, and hyper- and hypodysfunctional dysphonia.27 In this study, among the laryngeal lesions, vocal nodules pre- dominated in children. They affected 41% of the children younger than 6 years, with the incidence peaking to 73% between the ages of 7 and 12 years and decreasing to 51% between the ages of 13 and 18 years. Such values are close to those pre- sented by Moreti et al.,27 who diagnosed 62.6% vocal nodules in a population of 99 children between 7 and 15 years of age. Tavares et al.26 identified functional dysphonia in 44% and vocal nodules in 31% of 259 children with dysphonia during laryngoscopies. The higher incidence of vocal nodules in boys was evident in our study until the age of 12 years; from 12 years on, vocal nodules were more prevalent in girls and adult women, validat- ing the findings of other authors.7–10,26,28,29 Smillie et al.29 evaluated 154 school-age children and diagnosed vocal nodules in 52%, which were most predominant in boys. Martins et al.5 diag- nosed 57% of vocal nodules and 15% of vocal cysts in 304 children between 4 and 18 years of age submitted to videolaryngoscopy, most of them boys (64%). Vocal overuse and high-intensity voicing with effort, which are common in children and teachers, contribute to the patho- physiology of vocal nodules. In such conditions, the adduction of the vocal folds has a intense impact, causing trauma. Con- sequently, edema, microvascular injuries, and mucosal thickness appear. The point of strongest collision of the vocal folds is in the medium third; the local mucosa will suffer histological changes such as edema, and thickening of the epithelium and the basal membrane, resulting in nodule formation.6,30 After ad- olescence, with laryngeal growth, especially in males, because of the action of sex hormones, vocal nodules tend to regress and reabsorb slowly and naturally.6,30 This favorable outcome happens mainly in boys, in which laryngeal changes are more evident. For this reason, nodules surgery in children is not the treat- ment of choice, but rather vocal therapy.31 The satisfactory results of vocal therapy in 29 children (14 boys and 15 girls) ranging in age from 5 to 12 years with the diagnosis of hyperfunc- tional dysphonia or vocal nodules, presented by Mackiewicz- Nartowicz et al.,32 confirms the benefits of such treatment, as well as other authors’ findings.33,34 Acid laryngitis was the third most frequent laryngeal diag- nosis in this study (10%). Gastroesophageal symptoms are often FIGURE 6. Laryngeal diagnosis of patients over 60 years old. 761.e6 Journal of Voice, Vol. 30, No. 6, 2016 associated with vocal symptoms, especially laryngopharyngeal reflux, heightening the interest of researchers in the topic. For some authors, the gastric juice acts as a potent chemical irri- tant for the laryngeal mucosa, resulting in inflammation, mucosal thickening, pachydermia, polyps, and even leukoplakia.35–39 Other researchers believe that the importance attributed to reflux has been overestimated because laryngeal lesions are caused by many factors and deserve more rigorous investigation.40 In this study, for the videolaryngoscopy diagnosis of acid laryngitis, the symp- toms of gastroesophageal reflux were considered, as well as the classic endoscopic findings, such as edema, pachydermia, mucosal thickening, and granulomas in the posterior glottic commis- sure. Acid laryngitis was diagnosed in 10% of the patients, and confirmed by pHmetry, although a larger number of patients re- ported gastroesophageal reflux (26.5%). Nasosinusal symptoms are also frequent in patients with dys- phonia and were reported by 24% of the patients in our study. Nasal secretions and constant cough result in inflammation and mucosal thickening, favoring dysphonia.15,16,41 Other laryngeal diagnoses often present were Reinke’s edema (9.2%), polyps (8.9%), and vocal cysts (6%). Reinke’s edema appears almost exclusively in chronic smokers older than 40 years, as already found by other authors and in this study.42–45 It occurs mostly in women, causing the voice to become hoarse and vir- ilized. In this study, Reinke’s edema was the third most common cause of dysphonia in patients older than 60 years. Leukopla- kia is also frequent in smokers, but in this study, this diagnosis might have been underestimated because oncologic patients, in whom leukoplakia is more often diagnosed, were excluded. Assunção et al.20 evaluated 197 patients with dysphonia and found organic causes in 85% of the cases, mainly vocal nodules (24.4%), Reinke’s edema (23.4%), vocal polyps (13.7%), contact ulcer (8.6%), unspecific chronic laryngitis (6.1%), vocal fold paral- ysis (5.6%), vocal cyst (2.5%), vocal sulcus (1%), and trauma (2%). Polyps and vocal cysts are lesions related to vocal overuse, frequently found in children and voice professionals. Polyps are seen usually in adult patients. The origin of vocal polyps in- volves a number of factors, including allergies, vocal overuse, gastroesophageal reflux, inhaled pollutants, and smoking.42,43 Cysts may be congenital, from the implantation of epidermal embry- onic tissue, or mucous, which originates from the obstruction of the draining duct of a mucosal gland.43,46,47 Vocal cysts are present in almost every age group; in this study, they were more frequent between 7 and 12 years of age. Vocal cords paralysis was diagnosed in this study in 5.4% of the cases, in adults as well as in children. Unilateral paralysis is more frequent, mostly due to iatrogenic injury to the recur- rent laryngeal nerve during intrathoracic surgical procedures, in children as well as in adults.48–50 Jabbour et al.50 analyzed ret- rospectively the causes of vocal cord paralysis in 404 children and found that unilateral paralysis was most frequent, especial- ly on the left (66.8%), followed by bilateral paralysis (25.3%). The most common causes were iatrogenic injury from heart surgery (68.8%), idiopathic causes (21%), and neurological causes (7.4%). López Sousa et al.51 presented a series of 12 neonates who were operated for ductus arteriosus, and observed that three of the cases progressed to vocal folds paralysis and dysphonia. Other causes of unilateral vocal fold paralysis include nerve com- pression by tumors or vessels in its cervical or intrathoracic portion. In bilateral paralysis, the compression of the vagal nerve by expanding processes of the central nervous system predominates.48–53 In this study, no child with bilateral paraly- sis was included because in such cases—due to the median or paramedian position of both vocal folds—respiratory symp- toms predominate, justifying the exclusion of children with bilateral paralysis. This study had a high number of patients with the diagnoses of vocal folds paralysis and older than 40 years because it is routine in our service to perform pre and post-operative laryn- goscopy and vocal analysis in all patients submitted for thyroid or parathyroid surgery. This practice differentiates paralysis caused by tumor compression from iatrogenic paralysis. It also allows us to follow the recovery of the vocal cords mobility. In a study that included 400 patients with vocal cord paralysis, Reiter et al.53 found iatrogenic causes in two thirds of the cases, thyroidec- tomy being the main cause for bilateral paresis in adults. This study included a relatively large population of patients older than 60 years (16.5%), which justifies the 89 diagnoses of presbyphonia. We have reported a growing number of elderly patients who seek ambulatories because of vocal problems, and a greater interest in this patient population in vocal therapy. Yamauchi et al.54 reported a 7% increase per year in the number of elderly patients with vocal disorders in the ambulatories for voice disorders. The above-mentioned authors analyzed 1157 pa- tients with vocal disorder and observed that 37% were older than 65 years, of which 11% had vocal folds atrophy. Some studies have published the effectiveness of the interventions for presbyphonia such as voice therapy, neuromuscular electrical stim- ulation, and surgery. Such interventions may mitigate the symptoms related to aging voice.55 Minimal lesions of the vocal folds such as sulcus, mucosal bridges, microwebs, and microvascular lesions added to 7% of the laryngeal diagnosis of this present study. Vocal sulcus was the most prevalent lesion, being diagnosed early in a 3-year- old child. Such lesions may drastically compromise the voice, especially the sulcus vergeture because it is adherent to the vocal ligament, therefore compromising the muco-ondulatory movement.56 Less frequent laryngeal diagnoses were acute laryngitis (2.9%), psychogenic dysphonia (2.5%), vocal folds granulomas (2.3%), and laryngeal papillomatosis (1.4%). Acute laryngitis is often diagnosed in children, and the main etiology is viral. In viral infections of the upper airways, the inflammatory process extends to the mucosa of the vocal folds that present edema and hyper- emia, hence hoarseness.52 Psychogenic dysphonia, although less frequent, was also an important diagnosis in this study because it was diagnosed early in one of the adolescents. When diagnosed in children or ado- lescents, psychogenic dysphonia usually reflects severe emotional problems connected to sexual abuse or death of a family member. According to Misono et al.,57 symptoms of depression and anxiety may be present in one third of dysphonic patients, especially Regina Helena Garcia Martins et al Voice Disorders: Etiology and Diagnosis 761.e7 women. Therefore, psychogenic dysphonia deserves psycho- logical attention and treatment. Laryngeal granulomas were diagnosed only in adult patients in this study, probably because we excluded children with glottic stenosis and stridor, which often present associated granulo- mas. Granulomas may be secondary to laryngopharyngeal reflux, phonotrauma, granulomatous laryngitis, or traumatic intubation.58,59 Finally, we mention laryngeal papillomatosis, which ac- counted for 1.48% of the laryngeal diagnoses in this study. Laryngeal papillomatosis is the most important benign laryn- geal neoplasm, and the earlier it appears, the more it recidivates. Laryngeal lesions in adults are fewer and more localized. The subtypes of papillomavirus 6 and 11 are the most frequent and are rarely associated with neoplasm, different from subtypes 16 and 18, which coexist with laryngeal cancer in many cases.11 CONCLUSIONS In this study, which included 2019 dysphonic patients, there was a predominance of adults and women. There were different eti- ologies of dysphonia in the age groups studied, with nodules and cysts predominating in children, functional dysphonia and reflux in adults, and presbyphonia in the elderly. REFERENCES 1. Roy N, Merrill RM, Thibeault S, et al. 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Regina Helena Garcia Martins et al Voice Disorders: Etiology and Diagnosis 761.e9 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0235 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0240 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0240 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0245 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0245 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0250 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0250 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0255 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0255 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0255 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0260 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0260 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0265 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0265 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0270 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0270 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0275 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0275 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0275 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0280 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0280 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0280 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0285 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0285 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0285 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0290 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0290 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0295 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0295 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0300 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0300 http://refhub.elsevier.com/S0892-1997(15)00217-9/sr0300 Voice Disorders: Etiology and Diagnosis Introduction Methods Results Age group and gender Smoking Associated symptoms Profession Laryngeal diagnoses Discussion Conclusions References