This is very important to set the focused direction to achieve the targeted goal. When it comes to the question of patient care, professionals must be cautious and vigilant regarding the assessment of the patient’s complaint and problem that made them consult their provider. A detailed history of the patient’s voice concerns will help the clinician to diagnose a patient’s vocal problem and the cause behind it. Furthermore, it will help the clinician to understand the pathophysiology of the vocal complaints.

Assessment of functional voice disorders comprises taking the history of the patient’s vocal symptoms, medical history, the use of medications, occupation, any recent psychiatric or psychosocial stressors, emotional setback, laryngeal exposure to irritants like smoking, alcohol, occupational irritants, and misuse or abuse of voice.

A systematic and thorough evaluation of vocal mechanism and the patient’s voice problem is important from a therapy point of view, so an effective strategy for vocal function exercises can be planned accordingly. Functional dysphonia is a voice disorder having no organic lesion in the phonatory mechanism. Clinical evaluation for dysphonic patients is carried out in three steps.

1. History Taking
2. Physical Evaluation
3. Examination

The history-taking pertains to ascertaining medical, surgical, or accidental information essential to make a diagnosis and tailoring treatment to the patient.

The purpose of the vocal evaluation is to understand the anomaly (any change of voice affecting daily life needs like professional commitments, and unpleasantness for listeners due to roughness and hoarseness) of the voice production. The equality of voice, pitch, volume, and loudness will help the clinician to rule out the type of problem. Detailed vocal evaluation means a better understanding of the voice function leading to appropriate intervention.[15]

Physical examination includes (during patient’s interview) a complete ear, nose, and throat examination after assessment of voice quality, loudness, and range of ease is done. The purpose of the assessment is to focus on nasal airway patency, pharyngeal function, and velopharyngeal competency to rule out the nature of the voice disorder. Some patients may need pulmonary analysis as they exhibit diminished breath support causing an alteration in the laryngeal mechanism, so the normal pattern of synchronized respiration and phonation is compromised. Evaluation of hearing ability is also important as hearing loss can influence the voice sound.

Laryngeal visualization or examination of the larynx for the internal structure is the most important step for the diagnosis of laryngeal disease. There are many ways of vocal fold and larynx examination, which include mirror laryngoscopy, flexible fiberoptic laryngoscopy, distal chip laryngoscopy, digital transoral laryngoscopy, and stroboscopy. Stroboscopy is considered to be the best method to evaluate a mass or any irregularity of vocal folds.[16][17]

Due to the heterogeneity of functional voice disorders, an overview also includes psychogenic disorders and muscle tension voice disorders as subgroups based on observation. Clinical profiles of psychogenic voice disorders and muscle tension voice disorders are treated by speech-language pathologists who use symptomatic behavioral voice therapy along with models of counseling and psychotherapy.[18]

Presentation of functional voice disorders can occur in many forms (dysphonia, stuttering, or prosodic abnormalities) and may mimic organic disorders, so diagnosis can be difficult. A thorough examination, correct diagnosis, and proper treatment can be very efficient. Functional or psychogenic disorders and behavioral movement disorders can be hard to identify due to their speech and voice disturbances. This is because many behavioral, neurological conditions can mimic symptoms of organic voice conditions. That is why clinicians find it challenging to make a diagnosis out of fear of being incorrect.[1]

The first step in any treatment is the right diagnosis, so is the case with voice disorders. Multiple factors can be involved in the treatment depending on the cause, type, and severity of the disorder. Most problems can be managed by just knowing about the cause and by avoiding it.

There are mainly three treatments which include:

1. Medical treatment
2. Surgical treatment
3. Voice therapy

Speech-language pathologists use a holistic approach striving for the balance for respiration, phonation, and resonance instead of directly addressing the symptoms of voice problems. Multiple rehabilitative strategies like auditory masking, Accent method, conversation training therapy (CTT), Lax Vox speech therapy, expiratory muscle strength training, phonation resistance training exercise, chant speech, and confidential voice are used treat and manage FVDs. Multiple facilitative techniques are used by SLPs to restore the patient’s normal voice depending on the type of voice disorder while also trying to know the underline reasons.[19] Correct positioning, relaxation, hydration, vocal functioning exercises, counseling, patient education, and behavioral modification are part of the management. 

In some cases, vocal fold nodules are successfully treated with voice therapy alone. In contrast, in other cases, there are certain types of lesions (laryngeal web, polyps, contact ulcers, and laryngeal papilloma) that need surgical management. In any case, the identification of the cause is the key to a successful treatment. Voice therapy is the standard-of-care for many of the nearly 140 million people in the United States who suffer from voice disorders. Yet, patients claim that current therapies are ineffective at meeting their voice needs.

The following is the differential diagnosis of FVDs:[20][21]

• Somatoform disorder
• Conversion disorder
• Abuse
• Anxiety disorder
• Depression
• Munchausen syndrome
• Malingering
• Allergic and environmental Asthma
• Anaphylaxis
• Asthma
• Bilateral vocal fold paralysis
• Exercise-induced asthma
• Foreign body obstruction
• Laryngeal abnormalities (eg, neoplasm, polyps, cyst)

Prognostic factors can be grouped into good and poor prognostic factors. Good prognostic factors include acute onset of symptoms, absence of underlying organic pathology, elimination of the identifiable stress, male gender, young age, and good general health status. Poor prognostic factors include personality disorder, poor perception of their own well being, motor symptoms, and psychogenic nonepileptic seizures.

For effective treatment and intervention, based on medical experience, it is essential to reach the closest possibilities relevant to the patient’s problems of concern. Direct speech therapeutic strategies might not benefit the patient who needs surgical treatment initially. A multidisciplinary approach (for the better diagnosis leading to good prognosis) for a patient who needs a voice prosthesis will help both otolaryngologist and a speech-language pathologist to make an interventional plan.[22]

Patients may get upset and agitated when asked to repeat what they are saying, again and again. Vocal activity may be restricted as an avoidance strategy, resulting in social communication being compromised. Difficulty with communication may result in low self-esteem, anxiety, and depression. Poor compliance towards treatment can cause complications in long-term management resulting in poor patient outcomes. If a functional voice disorder is secondary to an underlying identifiable psychological stress, poor communication can result in the worsening of the associated psychiatric condition.[23]

The mainstay of treatment of functional voice disorders is vocal rehabilitation, which is tailored according to patient presentation and prognosis. However, follow-ups and compliance have been an issue, as this is a long term treatment strategy. Patient outcomes can be improved by identifying multiple factors that affect patient compliance. A multifactorial diagnosis should be made initially to exclude neurological and psychiatric disorders. The elimination of organic causes and increased patient insight increases a patient's understanding of their condition and compliance. Assessment questionnaires can be provided to patients, so patient problems can be addressed and managed from a patient perspective.[24]

The role of the multidisciplinary team in terms of delivering health care to the patient is essential to provide optimal outcomes in the treatment. It is important to have good interprofessional communication between the health care team. At the same time, it is pertinent to communicate clearly with the caregiver and the patient to improve health care outcomes.

Research has proved that working together reduces the number of medical errors and improves patient safety. An interprofessional team that provides a holistic and integrated approach regarding patient care can help in achieving the best possible outcomes of treatment. Patients with voice disorders may require a team consisting of an otolaryngologist, psychologist, psychiatrist, speech-language pathologist, and other health professionals. This multidisciplinary collaboration plays a vital role in achieving long-term patient-centered care to improve individual health outcomes and can enhance the chances of a patient’s quick recovery.[25]