iatrogenic, for example. depending on the diagnosis and severity of the voice problem, and depending on the category that the voice disorder falls into, there are various treatment methods that can be suggested to the patient. the professional has to keep in mind there is not one universal treatment, but rather the clinical approach must find what the optimal effective course of action for that particular patient is. there are three main type of treatments: medical treatments, voice therapy and surgical treatments. when necessary, certain voice disorders use a combination of treatment approaches. a medical treatment involves the use of botulinum toxin (botox) or anti-reflux medicines, for example. botox is a key treatment for voice disorders such as spasmodic dysphonia. voice therapy is mainly used with patients who have an underlying cause of voice misuse or abuse. laryngologists also recommend this type of treatment to patients who have an organic voice disorder - such as vocal fold nodules, cysts or polyps as well as to treat functional dysphonia. certain surgical treatments can be implemented as well - phono microsurgery (removal of vocal fold lesions performed with a microscope), laryngeal framework surgery (the manipulation of the voice box), as well as injection augmentation (injection of substance to vocal folds to improve closure). surgical treatments may be recommended for patients having an organic dysphonia. a combination of both an indirect treatment method (an approach used to change external factors affecting the vocal folds) and a direct treatment method (an approach used where the mechanisms functioning during the use of the vocal folds, such as phonation or respiration, are the main focus) may be used to treat dysphonia. direct therapies direct therapies address the physical aspects of vocal production. techniques work to either modify vocal fold contact, manage breathing patterns, and/or change the tension at level of the larynx. notable techniques include, but are not limited to, the yawn-sigh method, optimal pitch, laryngeal manipulation, humming, the accent method, and the lee silverman voice treatment. an example of a direct therapy is circumlaryngeal manual therapy, which has been used to reduce tension and massage hyoid-laryngeal muscles. this area is often tense from chronic elevation of the larynx. pressure is applied to these areas as the patient hums or sustains a vowel. traditional voice therapy is often used to treat muscular tension dysphonia. indirect therapies indirect therapies take into account external factors that may influence vocal production. this incorporates maintenance of vocal hygiene practices, as well as the prevention of harmful vocal behaviours. vocal hygiene includes adequate hydration of the vocal folds, monitoring the amount of voice use and rest, avoidance of vocal abuse (e.g., shouting, clearing of the throat), and taking into consideration lifestyle choices that may affect vocal health (e.g., smoking, sleeping habits). vocal warm-ups and cool-downs may be employed to improve muscle tension and decrease risk of injury before strenuous vocal activities. it should be taken into account that vocal hygiene practices alone are minimally effective in treating dysphonia, and thus should be paired with other therapies. medication and surgery medical and surgical treatments have been recommended to treat organic dysphonias. an effective treatment for spasmodic dysphonia (hoarseness resulting from periodic breaks in phonation due to hyperadduction of the vocal folds) is botulinum toxin injection. the toxin acts by blocking acetylcholine release at the thyro-arytenoid muscle. although the use of botulinum toxin injections is considered relatively safe, patients' responses to treatment differ in the initial stages; some have reported experiencing swallowing problems and breathy voice quality as a side-effect to the injections. breathiness may last for a longer period of time for males than females. surgeries involve myoectomies of the laryngeal muscles to reduce voice breaks, and laryngoplasties, in which laryngeal cartilage is altered to reduce tension. epidemiology dysphonia is a general term for voice impairment that is sometimes used synonymously with the perceptual voice quality of hoarseness. it is the reason for 1% of all visits to primary care providers. the lifetime risk of hoarse voice complaints among primary care patients is 30%. since hoarseness is a general symptom, it is associated with a number of laryngeal diagnoses. there is an interplay of sex and age differences associated with dysphonia. the point prevalence of dysphonia in adults under the age of 65 is 6.6%. dysphonia is more common in adult females than males, possibly due to sex-related anatomical differences of the vocal mechanism. in childhood, however, dysphonia is more often found in boys than girls. as there are no anatomical differences in larynges of boys and girls prior to puberty, it has been proposed that the higher rate of voice impairment found in boys arises from louder social activities, personality factors, or more frequent inappropriate vocal use. the most common laryngeal diagnosis among children is vocal fold nodules, a condition known to be associated with vocally damaging behaviours. however, a causal relationship has not yet been definitively proven. the overall prevalence of dysphonia in children ranges from 3.9% - 23.4%, most commonly affecting children between the ages of 8 - 14. among the elderly, dysphonia is associated with both naturally occurring anatomical and physiological changes as well as higher rates of pathological conditions. the point prevalence of dysphonia among the elderly is 29%. findings regarding the prevalence of geriatric dysphonia in the general population are very variable, ranging from 4 - 29.1%. this variability is likely due to different methodology used in obtaining information from participants. the most common laryngeal diagnoses among the elderly are polyps, laryngopharyngeal reflux, muscle tension dysphonia, vocal fold paresis or paralysis, vocal fold mass, glottic insufficiency, malignant lesions, and neurologic conditions affecting the larynx.