The major etiologic factors of<unk> s have been organized into the following categories: Mechanical issues Mechanical issues resulting in<unk> s are related to physical trauma at the level of the vocal folds. Trauma occurs when adductive forces are excessive, meaning that a person's vocal folds are closing abruptly and forcefully while speaking or engaging in other non-vocal behaviors (such as throat-clearing and coughing). In addition, the presence of the<unk>  makes it impossible for the vocal folds to come to a complete closure in adduction. This causes the person to use more force when speaking in an attempt to close the vocal folds completely, which in turn creates more trauma to the vocal folds. Glottal insufficiency (when the vocal folds cannot close completely, often due to vocal fold paralysis) can also be an underlying cause of<unk> s.<unk>  trauma can occur when a person frequently speaks at a pitch that is lower than their modal voice, especially in vocally-demanding professions like acting, teaching and singing. Research suggests that men are more commonly affected than women. Inflammatory issues Inflammatory issues associated with<unk>  include gastroesophageal reflux, allergy or infection. There is some disagreement among researchers as to whether inflammatory issues are a direct cause. Some researchers identify reflux and infection as indirect causes due to aggressive coughing that usually occurs as a result. Intubation For patients in need of tracheal intubation to receive oral drugs, an oversized tube, excessive movement of the tube, or infection can lead to<unk> s, but this is rare. Psychosocial factors People with certain personality traits and vocal patterns may be more susceptible to the development of<unk> s. Tenseness, high-stress, aggressiveness and impulsiveness are personality traits associated with<unk> .
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