John Murphy, M.D., MPH, DPH, President COVID-19 Long-haul Foundation

Abstract

Long COVID—also called post-COVID-19 condition or post-acute sequelae of SARS-CoV-2 infection (PASC)—is a multisystem disorder that commonly produces persistent neurological, respiratory, autonomic, and cognitive symptoms months after the acute infection. Speech-language pathology (SLP) professionals have become essential in identifying and managing an array of communication and swallowing disorders that arise in the context of long COVID, including dysphonia, dysphagia, and cognitive-communication disorders. This article synthesizes current evidence about prevalence, putative mechanisms, clinical manifestations, diagnostic approaches, and treatment options relevant to SLP practice, highlighting where evidence is robust and where critical gaps remain. The discussion draws on consensus definitions, observational cohorts, systematic reviews, professional guidance, and emerging clinical practice guidelines to propose a pragmatic, evidence-informed approach to assessment and intervention for long-COVID-related communication disorders. World Health Organization+2Nature+2

Introduction

Since 2020, millions of people worldwide have recovered from acute SARS-CoV-2 infection only to experience new or persistent symptoms—often debilitating—weeks to months later. The World Health Organization (WHO) clinical case definition of post-COVID-19 condition generally identifies symptoms beginning within 3 months of acute infection and persisting at least 2 months, with typical features including fatigue, shortness of breath, and cognitive dysfunction; this working definition has framed epidemiologic and clinical investigations. World Health Organization

Communication and swallowing impairments—ranging from voice changes to cognitive-linguistic slowing to overt oropharyngeal dysphagia—are frequently reported by patients with long COVID and present unique diagnostic and therapeutic challenges for SLPs. These disorders may arise from multiple, potentially overlapping mechanisms: direct viral neurotropism, immune-mediated injury, microvascular dysfunction, deconditioning after critical illness (including intubation), medication effects, and persistent inflammatory or autonomic dysregulation. The heterogeneity of presentations demands multidisciplinary assessment and individualized rehabilitation plans informed by evolving evidence. Nature+1

Epidemiology of Speech- and Swallowing-related Sequelae

Estimates of the prevalence of voice and swallowing problems after COVID-19 vary by population and methodology. Reports from outpatient cohorts and systematic reviews have found dysphonia in roughly ~10–30% of people during acute infection, with a smaller but significant fraction continuing to report persistent voice complaints months later; dysphagia appears less common overall but is concentrated in hospitalized and ICU populations, particularly those who required prolonged intubation. Large cohort and systematic reviews suggest that cognitive-communication complaints (such as word-finding difficulty and “brain-fog”-related verbal slowing) are among the more frequently reported long-term cognitive symptoms, affecting a substantial minority of sufferers. PMC+2MDPI+2

A patient-led international survey (early and foundational in the literature) documented multisystem symptom burdens and substantial functional impairment up to seven months after infection, underscoring the scale and heterogeneity of persistent symptoms that include speech and language complaints. Population-level studies and systematic reviews also estimate that at least 10% of SARS-CoV-2 infections lead to some form of long-term sequelae, though the exact fraction varies with variant, vaccination status, and cohort selection. PubMed+1

Etiology and Pathophysiologic Mechanisms Relevant to SLP

Long-COVID communication and swallowing disorders are likely multifactorial. The main mechanistic hypotheses with bearing on speech pathology practice are:

1. Direct neural injury and neuroinflammation. SARS-CoV-2 can be associated with central and peripheral nervous system effects—neuroinflammation, small-vessel endothelial injury, and dysregulated immune responses—that plausibly impair cortical and subcortical networks critical for language, motor speech planning, and sensorimotor integration. Objective cognitive deficits in memory, attention, and verbal working memory have been documented in cohort studies. Nature+2Frontiers+2
2. Laryngeal injury and neuropathy. Viral infection, reflex cough, and intubation-related trauma can affect the larynx. Vocal fold immobility/paralysis, laryngeal hyperresponsiveness, and maladaptive laryngeal behaviors have been described as causes of persistent dysphonia after COVID-19. Reflux and chronic cough—common in PCC—may further contribute to laryngeal irritation and compensatory voice patterns. PMC+1
3. Deconditioning and ICU-acquired weakness. In hospitalized cohorts, prolonged mechanical ventilation and critical illness polyneuropathy/myopathy lead to respiratory muscle weakness, impaired breath support for phonation, and swallowing dysfunction. Oropharyngeal dysphagia after intubation is well documented in critical care literature and is a major driver of aspiration risk in these patients. PMC+1
4. Autonomic and interoceptive dysregulation. Dysautonomia—orthostatic intolerance, POTS-like syndromes, and altered respiratory control—can affect voice and speech production indirectly through breath-control instability and fatigue, and directly via central network dysfunction. Nature
5. Neurovascular and microthrombotic effects. Microvascular changes and thrombotic events (including stroke in some patients) may produce focal deficits in language or motor planning regions; while less common than diffuse processes, these events necessitate prompt neurologic assessment when focal speech deficits are present. The Lancet

Together, these mechanisms explain why patients present with a mixture of peripheral (laryngeal, bulbar), central (cognitive-linguistic, motor speech), and systemic (fatigue, autonomic) contributions to communication and swallowing impairment.

Clinical Phenotypes and Observations

Dysphonia and Voice Disorders

Clinical presentations include breathy or hoarse voice, reduced vocal endurance, pitch instability, and vocal fatigue. Laryngeal examination in cohorts has found a mixture of structural (edema, granuloma), neurogenic (vocal fold paresis), and functional (muscle tension dysphonia, laryngeal hypersensitivity) substrates. Acoustic analyses and patient-reported outcome measures indicate that while many patients recover voice function spontaneously over months, a notable subset has persistent impairment requiring voice therapy or, rarely, surgical intervention. Professional bodies recommend laryngological assessment and targeted voice therapy in persistent cases. PMC+2MDPI+2

Dysphagia and Swallowing Disorders

Oropharyngeal dysphagia occurs particularly among patients with severe acute COVID-19—those intubated, tracheostomized, or with prolonged ICU stays—but also appears in some nonhospitalized patients, perhaps related to neuromuscular weakness or cranial neuropathies. Instrumental assessments (videofluoroscopic swallow study, FEES) commonly identify delayed swallow initiation, reduced laryngeal elevation, and aspiration risk especially in those with critical illness. Swallow rehabilitation, diet modification, and strategies to reduce aspiration risk are core SLP interventions. PMC+1

Cognitive-Communication Disorders

Patients frequently report word-finding difficulty, conversational inefficiency, slowed verbal fluency, and problems with discourse coherence—symptoms collectively described in patient communities as “brain fog.” Objective cognitive testing in multiple cohorts has shown deficits in attention, executive function, and verbal working memory that correlate with subjective language complaints. These impairments alter pragmatic skills (turn taking, topic maintenance) and increase the cognitive load of communication. Cognitive-communication therapy (including metacognitive strategies, pacing, and memory supports) is therefore central to rehabilitation. Frontiers+1

Cough, Laryngeal Hyperresponsiveness, and Speech

Chronic cough and laryngeal sensory neuropathy are commonly reported in long COVID and may provoke compensatory hyperfunctional voice behaviors. Management often blends voice therapy with cough-management strategies (behavioral cough suppression, neuromodulatory approaches) and referral to ENT when structural pathology is suspected. SAC+1

Diagnostic Approach (Role of the SLP)

A comprehensive, staged assessment is advised:

1. History and symptom inventories. Detailed timeline of acute illness, intubation/tracheostomy history, vaccination status, viral variant if known, and multipronged symptom review (fatigue, breathlessness, cognitive symptoms) are essential. Use standardized SLP outcome measures for voice, swallowing, and communication (e.g., VHI, EAT-10, BSE/MBSS results where available). ASHA Publications+1
2. Perceptual and instrumental voice assessment. Laryngoscopic examination (flexible or rigid) and acoustic analysis clarify structural vs. functional etiologies. Where resources permit, stroboscopy can identify subtle vibratory abnormalities. PMC
3. Swallowing evaluation. Bedside screening followed by instrumental evaluation (videofluoroscopy/FEES) when aspiration is suspected—especially for previously intubated patients or those with cough during eating. PMC+1
4. Cognitive and language testing. Screening for attention, working memory, processing speed, and language function (standard neuropsychological tests and discourse analyses) to quantify cognitive-communication impairment and plan therapy. Frontiers+1
5. Multidisciplinary evaluation. Given overlapping etiologies, collaboration with ENT, neurology, pulmonology, cardiology (for dysautonomia), and rehabilitation medicine optimizes diagnosis and management. Professional guidance documents recommend integrated care pathways for PCC patients. RCSLT+1

Treatment and Rehabilitation Strategies

Principles

Treatment must be individualized, pragmatic, and paced to account for fatigue and post-exertional symptom exacerbation (PESE). Interventions should target the specific substrate(s) identified: structural laryngeal injury, neuromuscular weakness, maladaptive behavior, or central cognitive limitations.

Voice Interventions

• Behavioral voice therapy (vocal hygiene, breath support training, resonant voice, semi-occluded vocal tract exercises) is first-line for functional and many organic dysphonias.
• Laryngologic interventions (injection augmentation, medialization) are reserved for persistent structural or neurogenic lesions.
• Neuromodulatory strategies (addressing laryngeal hypersensitivity and chronic cough) and reflux management when indicated.
  Data show many patients respond to targeted voice therapy over weeks to months, though some cases are refractory and require combined surgical and behavioral approaches. PMC+1

Swallowing Rehabilitation

• Compensatory strategies (postural changes, texture modification) to reduce aspiration risk while therapy proceeds.
• Therapeutic exercises (laryngeal elevation maneuvers, effortful swallow, respiratory-swallow coordination) to restore motor function.
• Neuromuscular electrical stimulation (NMES) and other adjuncts have mixed evidence; their use should be individualized and follow guideline recommendations. Intensive rehabilitation tends to yield better functional outcomes in ICU-associated dysphagia but must respect fatigue limits. PMC+1

Cognitive-Communication Therapy

• Restorative training for attention, processing speed, and working memory (computerized or therapist-led).
• Compensatory strategies (external memory aids, structured notes, conversational scaffolding).
• Metacognitive and pacing approaches to reduce cognitive load during communication and to manage PESE. Observational studies and early intervention trials suggest benefit for quality of life and return-to-work outcomes. Frontiers+1

Fatigue and PESE Management

Therapies must be balanced with symptom stabilization strategies: pacing, activity modification, and graded return-to-activity programs adapted for cognitive and communication tasks. Coordinated care with physiatry and occupational therapy is important. Nature

Pharmacologic and Neuromodulatory Options

There are no specific medications proven to reverse long COVID. Symptom-directed pharmacologic management (neuropathic pain agents for laryngeal sensory neuropathy, proton-pump inhibitors for reflux, and medications for dysautonomia) can augment SLP treatment. Experimental neuromodulatory approaches are under study but not yet standard. Nature

Prognosis

Prognosis is heterogeneous. Many patients experience gradual improvement over months; others have persistent deficits lasting a year or longer. Predictors of poorer recovery include severity of the acute illness, need for ICU care or prolonged intubation, preexisting neurologic disease, and older age. However, even patients with mild initial infection can develop persistent cognitive and communication impairments. Longitudinal studies indicate some degree of recovery over time for many, but a significant minority remains functionally impaired at one year and beyond. Nature+1

System-level Considerations and Clinical Pathways

Professional organizations (national associations of SLPs/SLTs, ENT societies, and rehabilitation bodies) recommend structured care pathways for long COVID that include early screening, prioritized instrumental assessment for at-risk patients, and multidisciplinary rehabilitation teams. Access to services is a major barrier: many health systems are still building capacity to manage the volume and complexity of PCC patients. Telepractice has been widely adopted for both assessment and therapy and can increase access if implemented with careful attention to patient fatigue and digital equity. RCSLT+1

Research Gaps and Priorities

Key unresolved questions include:

• The precise biological mechanisms that produce chronic cognitive-linguistic dysfunction and whether specific biomarkers can predict SLP-relevant outcomes.
• Randomized controlled trials testing specific SLP interventions (e.g., voice therapy protocols, swallowing exercise regimens, cognitive-communication rehabilitation) and their timing and dosing.
• Longitudinal natural-history studies stratified by variant, vaccination status, age, and comorbidity to define prognosis more accurately.
• The role of novel therapeutics targeting immune dysregulation and whether they influence communicative outcomes.
  Filling these gaps will require coordinated multicenter studies and integration of patient-reported outcomes with objective functional measures. Nature+1

Practical Recommendations for Clinicians

1. Screen all patients with suspected long COVID for communication and swallowing complaints.
2. Use a stepped approach: bedside screening → instrumental assessment if indicated → targeted therapy.
3. Individualize rehabilitative plans and pace therapy to account for fatigue/PESE.
4. Coordinate care with ENT, neurology, rehabilitation medicine, cardiology (for dysautonomia), and mental health supports.
5. Document outcomes with standardized measures and contribute data to registries to accelerate learning. PMC+1

Conclusion

Long COVID has created a persistent clinical demand for speech-language pathology services. Dysphonia, dysphagia, and cognitive-communication disorders are common and can be disabling; the etiologic picture is multifactorial, and management requires individualized, multidisciplinary care that balances active rehabilitation with symptom stabilization. Although many uncertainties remain, emerging guidance and accumulating observational studies provide a framework for pragmatic, evidence-informed practice. Priorities for the field include rigorous trials of SLP interventions, mechanistic studies linking biomarker and imaging findings to clinical phenotypes, and system-level planning to expand access to specialized rehabilitation services for the growing population of people living with long COVID. Nature+1

---

References & Footnotes

Below are the citations keyed to the numbered footnotes in the text above. Each entry includes an identifier linking to the web.run search result I used for that source so you can inspect the primary material quickly.

1. WHO. A clinical case definition of post COVID-19 condition by a Delphi consensus (6 Oct 2021). World Health Organization
2. Davis HE, Assaf GS, McCorkell L, et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine / medRxiv (2021). PubMed+1
3. National review: Davis, H.E. et al., Long COVID: major findings, mechanisms and recommendations. Nature Reviews Microbiology (2023). Nature
4. Greenhalgh T. Long COVID: a clinical update. The Lancet (2024). The Lancet
5. Gölaç H., Vocal outcomes after COVID-19 infection: acoustic voice analysis. (PMC article; 2022). PMC
6. Jeleniewska J., Objective and Subjective Voice Outcomes in Post-COVID (MDPI). MDPI
7. Seo JW., Updated Clinical Practice Guidelines for the Diagnosis and Management of Dysphagia (2024). PMC
8. Doll EJ., COVID-19 and Speech-Language Pathology Clinical (ASHA practice guide, 2021). ASHA Publications
9. Royal College of Speech and Language Therapists (RCSLT) Long COVID guidance. RCSLT
10. Speech-Language & Audiology Canada position statement (2024). SAC
11. Guo P., COVCOG 2: Cognitive and Memory Deficits in Long COVID. Frontiers (2022). Frontiers
12. Espinar-Herranz K., Memory, Emotion, and Quality of Life in Patients with Long COVID (2023). PMC
13. Takács J., Cognitive Slowing, Dysfunction in Verbal Working Memory in PCC (MDPI, 2025). MDPI
14. Post-COVID Dysphonia: recent studies / PMC (2025). PMC
15. Swallowing Evaluation in Post-COVID Patients (PMC, 2025). PMC
16. Systematic reviews on dysphonia and COVID (Elsevier, Wiley reviews 2024–2025). www.elsevier.com+1
17. ResearchGate / systematic review and meta-analysis of COVID-related dysphonia (2023–2025 analyses). ResearchGate
18. Silva AS., Long COVID: persistent impacts and challenges for speech… SciELO / Codas (2025). SciELO
19. Fuzzy cognitive mapping / decision support for post-COVID SLP management (MDPI, 2024). MDPI
20. JAMA Network Open: Definition of Post–COVID-19 Condition Among Published Research Studies (Chaichana U. et al., 2023). JAMA Network
21. Early deep-phenotype mapping of long COVID (Deer RR. et al., 2021). ScienceDirect
22. Practical ASHA/ENT guidance on outpatient practice changes after COVID (2022 perspectives). ASHA Publications
23. Lancet Infectious Diseases: Soriano JB. et al., A clinical case definition of post-COVID-19 condition by a Delphi consensus (2022). The Lancet
24. Large cohort and longitudinal cognitive studies reported in news coverage (NEJM/REACT summary). The Guardian+1
25. Additional empirical cohort and clinical practice publications captured by PubMed/PMC searches (see embedded PMC/MDPI/Lancet/Frontiers links above)