7. Voice and Its Disorders Flashcards
(72 cards)
1
Q
Larynx (and VFs): Basic Principles
A
*Valve located at top of trachea
*Helps close entry into trachea so food, liquids, and particles do not enter lungs
*Houses VFs (opening bet. VFs is “glottis”)
*VFs composed of layers: epithelium, the TA muscle, and lamina propria; Cover-body theory of phonation…
*Ventricular/false VFs lie above true VFs
*Aryepiglottic folds lie above ventricular folds; They separate the pharynx and laryngeal vestibule and help preserve airway
CN X: primary CN involved in laryngeal innervation (main branches: SLN and RLN)
2
Q
Superior Laryngeal Nerve (SLN) and Recurrent Laryngeal Nerve (RLN)
A
SLN: internal branch: provides all sensory info to larynx; external branch: provides motor innervation to the cricothyroid muscle
RLN: supplies all motor innervation to interarytenoid, posterior cricoarytenoid, thyroarytenoid, and lateral cricoarytenoid muscles; Supplies all sensory info below VFs; If lesion to RLN, pt may experience diff. adducting VFs
3
Q
Key Laryngeal Structures and Cartilages (9)
A
Hyoid bone Epiglottis Thyroid cartilage Cricoid cartilage Arytenoid cartilage Corniculate cartilages Cuneiform cartilages Intrinsic laryngeal muscles Extrinisic laryngeal muscles
4
Q
Hyoid Bone
A
- Larynx suspended from hyoid
* Many extrinisic laryngeal muscles are attached to hyoid
5
Q
Epiglottis
A
- Leaf-shaped cartilage
- Attached to hyoid
- Protects trachea by closing down inferiorly and posteriorly over laryngeal area, directing liquids and food into esophagus during swallowing
6
Q
Thyroid Cartilage (“Adam’s Apple”)
A
- Largest laryngeal cartilage
* Shields other laryngeal structures from damage
7
Q
Cricoid Cartilage
A
- Second largest laryngeal cartilage
- Completely surrounds trachea
- Linked with the paired arytenoid cartilages and the thyroid cartilage
8
Q
Arytenoid Cartilages
A
- Positioned on the cricoid cartilage on either side of the midline
- Shaped like pyramids
- Vocal processes are the most anterior angle of the base of the arytenoids; True VFs attach at the vocal processes
9
Q
Corniculate and Cuneiform Cartilages
A
Corniculate: Sit on apex of arytenoids; small, cone-shaped
Cuneiform: Tiny, cone-shaped cartilage pieces under mucous membrane that covers aryepiglottic folds
10
Q
Intrinsic Laryngeal Muscles
A
- These pairs of muscles have both attachments to structures within larynx
- Primarily responsible for controlling vocalization
- With one exception (PCAs), all are adductors
11
Q
Intrinsic Laryngeal Muscles (6)
A
Thyroarytenoids Cricothyroids Posterior cricoarytenoids (only abductors) Lateral cricoarytenoids Transverse arytenoids Oblique arytenoids
12
Q
Extrinsic Laryngeal Muscles
A
- One attachment to structure outside larynx and one within larynx
- All extrinisic laryngeal muscles attached to hyoid
- Elevate or lower position of larynx in neck; Give larynx fixed support
- Infrahyoids: “depressors”; depress laryx; impact pitch
- Suprahyoids: “elevators”; elevate larynx
13
Q
Extrinisic Laryngeal Muscles: Infrahyoids (4) and Suprahyoids (6)
A
Infrahyoids: Thyrohyoids, Omohyoids, Sternothyroids, Sternohyoids
Suprahyoids: Digastrics, Geniohyoids, Mylohyoids, Stylohyoids
14
Q
Age-Related Changes in the Larnx
A
- Hardening of laryngeal cartilages
- Degeneration and atrophy of intrinsic laryngeal muscles
- Degeneration of glands in laryngeal mucosa
- Degenerative changes in lamina propria
- Deterioation of cricoarytenoid joint
- Degenerative changes in conus elasticus
*These changes lead to “presbyphonia,” an age-related voice disorder characterized by perceptual changes in quality, range, volume/loudness, and pitch
15
Q
Pitch
A
- Perceptual correlate of frequency; Largely based on the frequency with which the VFs vibrate; This rate is often called the fundamental frequency(habitual pitch)
- Determined by mass, tension, and elasticity of VFs
- Higher pitch results when VFs are thinner, more tense, or both; Lower pitch results when the VFs are thicker, more relaxed, or both
16
Q
Pitch: Frequency Perturbation/Jitter
A
- Are variations in vocal frequency that are often heard in dysphonic patients
- Measured instrumentally as a pt sustains vowel; useful in early detection of vocal pathology
- Pts w/ voice probs (e.g., tremor, hoarseness) might show a large amount of jitter
- People with no laryngeal pathology can sustain a vowel with less than 1% jitter
17
Q
Volume
A
- Perceptual correlate of intensity; Determined by intensity of sound signal; Greater intensity means greater perceived loudness
- Sound is disturbance in air particles; it takes the form of waves that more forward and backward in mediums (e.g., air, water); “Amplitude” is extent of such movements; Greater the amplitude, the louder the voice
18
Q
Volume: Amplitude Perturbation/Shimmer
A
- Cycle-to-cycle variation of vocal intensity
- Measured instrumentally as pt sustains vowel; useful in early detection of vocal pathology
- Speaker w/ no laryngeal pathology has very small amount of variation in intensity w/ each vibratory cycle
- Pts who have difficulty with regularity of VF vibration (e.g., roughness) may show large amounts of shimmer
19
Q
Quality
A
Perceptual correlate of complexity; Refers to the physical complexity of the laryngeal tone, which is modified by resonating cavities; Determination of vocal quality is frequently subjective
20
Q
Quality Types: Hoarseness and Harshness
A
- Hoarseness: combo of breathiness and harshness, which results from irregualr/aperiodic VF vibrations, which also lead to variation in F0
- Harshness: rough and “gravelly;” associated with excessive muscular tension and effort; VFs adducted too tightly and air is released too abruptly
21
Q
Quality Types: Strain-Struggle and Breathiness
A
- Strain-struggle: phonation is effortful; sounds like “squeezing” voice at glottal level; initiating and sustaining phonation is difficult; talking fatigues; experience tension when speaking
- Breathiness: results from VFs being slightly open and air escapes through glottis and adds noise to the sound produced by VFs; Often feel like running out of air; Often soft, little variation in loudness, and restricted vocal range; May be due to organic (physical) or nonorganic (functional) causes
22
Q
Quality Types: Glottal/Vocal Fry
A
- When VFs vibrate very slowly
- Low-pitch, “crackly”
- Usu. at end of utterance when air flow rate and subglottal air pressure are low and lung volume is less
- For some pts, glottal fry may help modify vocal quality problems such as stridency
- Other patients work to eliminate vocal fry by slightly increasing subglottal aur pressure and slightly elevating their pitch level
23
Q
Quality Types: Diplophonia and Stridency
A
- Diplophonia: “Double voice;” Occurs when one can simultaneously perceive two distinct pitches during phonation; Usu. occurs when VFs vibrate at different frequencies due to different degrees of mass or tension; Ct with unilateral polyp, for example, may sound diplophonic
- Stridency: Shrill, somewhat high pitched, and “tinny;” Often caused by hypertonicity or tension of the pharyngeal constrictors and elevation of larynx; Tense pts may sound strident
24
Q
Case History: The Clinician Needs To…
*Remember: a multidisciplinary, team-oritented approach is critical through evaluation
A
- Obtain info re: onset, duration, causes, variability of probs (ask pt and significant others)
- Obtain info re: any associated symptoms/probs (e.g., slurred speech, diff. swallowing, excessive coughing)
- ID factors (e.g., health, environ, fam hx) that may contribute to problem
- Gather info re: prev. tx, med. intervention, or other attempts to deal with voice prob
- Obtain descriptions of daily vocal use and possible abuse or misuse patterns (ask pt and sig. others)
- *For culturally and linguisitically diverse cts: obtain specific perceptions of what constitutes “typical-sounding” voice in their culture
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Instrumental Evaluation (9)
* Indirect Laryngoscopy (Mirror Laryngoscopy)
* Direct Laryngoscopy
* Flexible Fiber-Optic Laryngoscopy
* Endoscopy
* Acoustic Analysis
* Videostroboscopy
* Electroglottography (EGG)
* Electromyography (EMG)
* Aerodynamic Measurements
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Indirect Laryngoscopy
Direct Laryngoscopy
Flexible Fiber-Optic Laryngoscopy
Indirect Laryngoscopy: Mirror (+light) to view laryngeal structures during phonation (usu. "eee") and during quiet respiration
Direct Laryngoscopy: Performed by surgeon when pt under anesthesia in outpatient surgery; Laryngoscope introduced through mouth and into pharyx and positioned above VFs; Pt cannot phonate so VF function cannot be determined by surgeon can obtain a direct microscopic view of larynx; Valuable when biopsy is required due to suspicion of laryngeal cancer
Flexible Fiber-Optic Laryngoscopy: Tube inserted through nasal passage, passes over velum, and into position above larynx; Fibers transmit laryngeal image to specialist's eyepiece; Pt able to speak and sing; Specialist can obtain an excellent prolonged view of vocal mechanism and photograph rapid VF movement
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Endoscopy
* Two types: flexible (inserted nasally) and rigid (inserted orally), using a 3.6mm tube
* (Fiber-optic) light at tip of scope and structures are illuminated by the light and viewed by specialist at other end of endoscope via window lens
* Endoscope can be attached to a video camera (videoendoscopy); A stroboscopic (flashing) light source can also be used
* W/ flexible endoscope, can view velopharyngeal (VP) mechanism, including VP valving; The endoscope (aka) nasopharyngoscope) can be lowered further to view laryngeal mechanism
* B/c pt can perform a variety of phonatory tasks, endoscopy may be used to study laryngeal anatomy and physiology in detail, incl. mucosal wave
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Acoustic Analysis
* Acoustic measurements can be used to evaluate effectiveness of voice therapy/vocal surgery
* "Sound Spectography:" graphic representation of a sound wave's intensity and frequency as a function of time; "Spectogram:" resulting picture that reflects resonant characteristics of vocal tract and harmonic nature of glottal sound source
29
Videostroboscopy
* Helpful in differentiating bet. functional and organic voice probs and detecting laryngeal neoplasms (tumors)
* Can use flexible fiber-optic laryngoscope, a rigid endoscope, or both
* Strobe light permits optical illusion of slow-motion viewing of VFs during a variety of tasks; Observer perceives rapidly presented images as a complete picture of cycle-to-cycle vibration
* Microphone on pts neck to record voice, then introduces scope, switches on stroboscopic light, and asks pt to phonate
* Stroboscopic image on monitor yields info re: periodicity/regularity of VF vibrations, VF amplitude, glottal closure, presence and adequacy of mucosal wave, and possible presence of lesions or neoplasms
30
Electroglottography (EGG)
* Noninvasive procedure yields indirect measure of VF closure patterns
* Surface electrodes placed on both sides of thyroid cartilage, and a high-frequency electrical current is passed bet. electrodes while pt phonates
* Glottal wave form results and specialist is able to view VF vibration
* EGG can also detect breathy and abrupt glottal onset of phonation
* Disagreeance re: efficacy of EGG as a diagnostic technique; Best for cross-reference tool
31
Electromyography (EMG)
* Invasive procedure directly measures laryngeal function to study pattern of electrical activity of VFs and to view muscle activity patterns
* Specialist inserts needle electrodes into pt's peripheral laryngeal muscles; The resulting electrical signals are judged as normal or indicative of pathology
* EMG is useful when attempting to determine VF pathology, esp. that caused by neurological and neuromuscular diseases; Also useful in verifying excessive muscle tension prior to the injection of BOTOX for pts w/ spasmodic dysphonia
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Aerodynamic Measurements
* Refers to airflows, air volumes, and average air pressure produced as part of the peripheral mechanics of the respiratory, laryngeal, and supralaryngeal airways
* Aerodynamic measurements to evaluate dysphonia, monitor voice changes and treatment progress, and fifferentiate between laryngeal and respiratory probs
* May want to assess pts' lung volume b/c breath support for optimal voicing may be lacking
* Specific measures can be made of the following parameters: "Tidal volume" (amnt of air inhaled and exhaled during normal breathing cycle), "Vital Capacity" (vol. of air pt can exhale after a max. inhalation), and "Total lung capacity" (total vol. of air in lungs)
* Common instruments: Wet spirometers, dry spirometers, manometric devices, and plethysmograhs
33
Resonance Assessment: Hyponasality vs Hypernasality
Hyponasality: when nasal resonance is absent on nasal sounds
Hypernasality: when too much nasal resonance is present on non-nasal sounds
**Important to take into account cultural/linguisitic backgrounds re: resonance (e.g., Chinese speakers may have more hypernasality than Americans perceive as normal)
34
Respiration Assessment: Breathing Types (3)
* Clavicular breathing: When pt inhales, shoulders elevate; Often there is strain and tension.
* Diaphragmatic-abdominal breathing: Utilizes abdominal region and lower thoracic cavity; Little to no chest or shoulder movement
* Thoracic breathing: Exhibits characteristics of both clavicular and diaphragmatic-abdominal breathing; No observable abdominal or upper thoracic expansion upon inspiration
35
Phonation Assessment: Simple Measures (2)
* Maximum phonation time (MPT): sustain "ah," 3 trials, compares MPT (in secs) w/ norms; Observe adequacy of respiration, glottal efficiency, and possible presence of vocal pathology (e.g., nodules)
* S/Z ratio: Divides longest /s/ by longest /z/. An s/z ratio of more than 1.4 is indicative of possible pathology
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Disorders of Resonance (4)
* Hypernasality
* Hyponasality
* Assimilative Resonance/Nasality
* Cul-de-Sac Resonance
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Hypernasality
* Most common resonance disorder
* When VP mechanism does not close opening to nasal passage during production of non-nasal sounds
* May be velopharyngeal inadequacy/insufficiency (VPI)
* Functional (e.g., deaf) or organic (e.g., cleft palate)
38
Hyponasality (aka Denasality)
* Pts often substitute oral sounds for nasals (bay vs may)
* Can be temporary (e.g., colds, allergies) due to obstructions of nasal cavity (e.g., nasal polyps or papilloma), enlarged ("hypertrophy of") adenoids/tonsils, or deviated septum
* May be mouth-breathers; sleep-apnea in severe cases
39
Assimilative Nasality
* Occurs when sound from a nasal consonant carries over to adjacent vowels (e.g., vowels in banana may sound hypernasal b/c next to /n/)
* Velar openings begin too soon and last too long
* Functionally or organically based
40
Cul-de-Sac Resonance
* Produced by backwards retraction of tongue; tongue is carried too far posteriorly in oral cavity
* Oral cavity is partially closed at back and open in front; Distored voice and resonance b/c tongue blocks some of the sound waves generated by larynx from reaching oral cavity; Person's voice can sound muffled or hollow
* Deaf people, those with neurological disorders, and kids with hypertrophied adenoids and tonsils may have cul-de-sac resonance
41
Treatment of Hypernasality
* Biofeedback
* Nasometer (and video/audio recordings)
* Tx techniques: Visual aids (e.g., mirror/tissue), Ear training, Increasing mouth opening, Increasing loudness, Improving articulation (e.g., exaggerated Cs). Changing rate, Decreasing pitch
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Treatment of Hyponasality
* Nasometer (and video/audio recordings)
* Techniques involve increasing awareness of nasal cavity as a resonator: Visual aids (eg., mirror/tissue), Focusing/directing tone into facial "mask," Nasal-glid stimulation
43
Carcinoma (Laryngeal Cancer) and Laryngectomy
* More common in men
* Contributing factors: *alcohol, *tobacco, exposure to environmental toxins, and GERD
* Early warning signs of laryngeal cancer: hoarseness, difficulty swallowing, persisting sore throat, ear pain, lump in neck or throat
* Tests for detection: physical examination, laryngoscopy, endoscopy, CT scan, MRI, and biopsy
* TNM design (medical chart): site of TUMOR, involvement of lymph NODES, and METASTASIS
* 3 types of medical treatment: surgery/laryngectomy, chemotherapy, and radiation
44
Ways Laryngectomees Produce Vocalizations (3)
External devices (e.g., artificial larynx or electrolarynx)
Esophageal speech: literally speak on burps; esophageal voice produced by a pharyngoesophageal segment (PES); 2 methods: injection and inhalation method
Surgical modifications or implanted devices in the laryngeal area (e.g., Blom-singer prosthetic device)
45
Physically-Based Disorders of Phonation:
| Granuloma
* A localized, inflammatory, vascular lesion, that's usually composed of granular tissue in a firm, rounded sac
* Frequently develop on the vocal processes of the arytenoid cartilages
* Can be unilateral or bilteral
* May be caused by vocal abuse, intubation during surgery, injury to larynx, and GERD
* Most often associated with contact ulcers
* Pts often sound breathy and hoarse; feel need to freq. clear throat
* Treated by surgery, voice therapy, or both
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Hemangioma
* Similar to granulomas, but are soft, pliable, and filled with blood
* Usually caused by intubation or hyperacidity to GERD; can also be congenital
* Usually surgically excised + follow-up voice therapy
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Leukoplakia
* Benign (but precancerious) growths of thick, whitish patches on surface membrane of mucosa; May extend into subepithelial space; May appear under ant 1/3 of VFs and under tongue
* Due to tissue irritation, esp. caused by smoking, alcohol, or vocal abuse
* Pts may sound hoarse, low-pitched, breathy, and soft in volume; Diplophonia may also be present
* Treatment usu. involves combo of surgery, voice therapy, and eliminating exposure to tissue irritants
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Hyperkeratosis
* Rough, pinkish lesion; often benign but may be precursors to malignancy
* Appears in oral cavity, larynx, or pharyx
* Hyperkeratotic growth occur due to tissue irritation and may be caused by smoking, GERD, and vocal abuse
* Voice symptoms: mild-severe hoarseness or harshness, reduced loudness, and low pitch
* Treatment involves eliminating tissue irritants, possible ablative surgery, and voice therapy
49
Laryngomalacia (aka Congenital Laryngeal Stridor)
*Soft, "floppy" laryngeal cartilages
*Epiglottis is particularly affected and is soft/pliable due to abnormal development
*When child breathes, epiglottis resists airstream, causing stridor, or rough, breathy noise upon inhalation
*Usually resolves spontaneously by age 2-3
(but in severe cases, child may have breathing probs and will require treatment)
50
Subglottal Stenosis
* Is the narrowing of the subglottic space
* Can be acquired or congenital
* Congenital: result of arrested development of the conus elasticus or interruption of the cricoid cartilage during embryological development; defined as a lumen 4.0 mm in diameter or less at level of cricoid
* Acquired: result of endotracheal intubation
* If stenosis is severe and there is no exchange of air, a tracheostomy may be needed; if moderately severe, kids often display exercise intolerance and stridor and may need surgical or endoscopic intervention followed by voice intervention
51
Papilloma
* Sometimes called "juvenile papillomas" b/c tend to occur primarily in children (but can occur in adults, too)
* When kids hit puberty, papillomas often cease
* Wart-like growths caused by human papilloma virus
* Pink, white, or both
* May be anywhere in airway (may/may not be larynx)
* Symptoms: Hoarseness, breathiness, low pitch
* Airway obstruction is a major concern
* Most pts treated through multiple surgeries
* Voice tx: May be helpful after surgical treatment; Tx can involve relaxation exercises, teaching pt to use amplification devices, and teaching to decrease supraglottic hyperfunction; Can't prevent recurrence
52
Laryngeal Trauma
* Refers to many kinds of injury to larynx
* More common in children vs adults
* Causes incl: burns, vehicle and sports-related accidents, attempted strangulations, gunshot wounds, etc
* Generally, surgery to reconstruct vocal mechanism
* Pts who smoke or have GERD must stop or have treatment for GERD before surgery
* Most pts get voice tx after surgery
53
Laryngeal Web
* Membrane that grows across ant. portion of the glottis
* 2 types: congenital and acquired (from trauma to inner edges of VFs); VFs may be traumatized by forceful/prolonged intubation, surgery, severe laryngeal infections, or accidental injury
* Treatment for infants(congenital): immediate surgery followed by tracheostomy
* Treatment for adults: surgery to remove web and after, surgeon places a "laryngeal keel" bet. VFs to prevent them from growing back together; Pt usu. undergoes 6-8 weeks of voice restn while keel is in place; After keel is removed, voice therapy may be needed
54
Paradoxical Vocal Fold Motion (PVFM)
| aka Laryngeal Dyskinesia
* Inappropriate closure/adduction of the VFs during inhalation, exhalation, or both
* Pts often appear asthmatic; Sometimes undergo tracheotomy; Patients display stridor (and some also display dysphonia
* Attributed to both psychological and physiological causes
* Treatment may incl. a combo of psychological, medical, and behavioral approaches
* Some pts do well w/ voice tx involving endoscopy and direct feedback in which they learn nature of disorder and how to relax entire vocal mechanism; Kids may respond well to visual biofeedback and relaxation exercises
55
Gastroesophageal Reflux Disease (GERD)
* When gastric contents spontaneously empty into esophagus when person has vomited or belched
* Symptoms: heartburn, acid indigestion, sore throat, and hoarseness
* Consequent pathological VF changes may occur, e.g., contact ulcers (bilateral ulcerations on medial surfaces of vocal processes of arytenoids)
* "Manometric evaluation" (form of aerodynamic eval)
* Treatment: antacids, propping up head at night, meds, not exercising directly after eating, dietary changes; Treatment plans incl. behavioral, medical, surgical, and voice tx
56
Paralysis
* Paralysis occurs when nerve supply is cut off from muscle (VFs are primarily muscle)
* Paralysis can result from: injury to RLN during surgery, neurological diseases, malignant diseases, intubation trauma, severe laryngeal trauma, stroke, CN X deficits
* Unilateral paralysis: Sometimes, nonparalyzed fold will be able to make contact (sounding normal) and sometimes other fold is too far from midline, which causes aphonia
* Bilateral: May lead to wide-open glottis, causing aphonia; When VFs paralyzed in abducted position, aspiration can occur; If paralyzed in adducted position, pt struggles for breath but voice is not significantly dysphonic
57
...and Ankylosis
* Ankylosis: stiffening of the joint(s)
* Movement of arytenoids is restricted b/c of a bone-joint disease (e.g., arthritis); Cancer can also cause ankylosis; VFs are attached to the arytenoids so when the arytenoids are stiff, VFs do not close fully
58
Treatment for VF Paralysis
* Unilateral paralysis treatment: doctors create a bulge (from teflon, collagen, Gelfoam, autologous fat) in paralyzed fold so easier for healthier fold to meet it
* Thyroplasty type 1: used to achieve VF medialization; surgeon creates small window in thyroid cartilage, medializes the VF, and places a small Silastic implant to keep the paralyzed fold medialized
* Nerve-muscle pedicle reinnervation: surgeon takes pedicle of neck strap muscle w/ innervation and sutures it either into adductors for medialization purposes or into posterior cricoarytenoids in order to promote adduction
* Depending on type of paralysis, these treatment techniques have been used to help w/ firmer VF closure: pitch elevation, increased loudness, increased breath support, pushing approach, hard glottal attacks, head turning/positioning
59
Spasmodic Dysphonia (SMD)
A laryngeal dystonia; Neurogenic causes w/ possible emotional side effects; Involves BS dysfunction
Abductor SD: created by intermittent, involuntary, fleeting VF abduction when pt tries to phonate; Loudness is reduced and pt is usually aphonic w/ breathy or whispered speech; Tx: BOTOX, speech tx involving relaxation techniques and continuous voicing, and pharmacological intervention
Adductor SD (most common): overpressure due to prolonged overadduction or tight closure of VFs; Voice may sound choked and strangled; Popular treatment techniques: CO2 laser surgery, RLN resection, *BOTOX injections, and voice therapy (can incl: inhalation phonation, increased pitch, relaxation, head turning, counseling, yawn-sigh approach, and soft, breathy phonation onset using /h/
60
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Neurologically-Based Disorders of Phonation:
Multiple Sclerosis (MS)
```
* Pt experiences progressive and diffuse demyelination of white matter, w/ corresponding preservation of axons at BS, cerebellum, and SC
* Pts may have impaired prosody, pitch, and loudness control, harshness, nreathiness, hypernasality, articulation breakdown, and nasal air escape
61
Myasthenia Gravis
* Neuromuscular autoimmune disease
* Produces fatigue and muscle weakness
* Decreased amount of acetylcholine at the myoneuronal junction
* Pts may sound hypernasal, breathy, hoarse, and soft in volume; May also have dysphagia and distorted artic
62
Amyotrophic Lateral Sclerosis (ALS)
| aka Lou Gehrig's Disease
* Progressive, fatal disease involving degeneration of upper and lower motor neuron systems
* Pts sound breathy, low-pitched, monotonous; Poor respiratory control
* Tx may focus on AAC that can be used even in later stages of the disease
63
Parkinson's Disease
* Caused by lack of dopamine (a neurotransmitter) in the substantia nigra of the BG
* Can be idiopathic (occuring in isolation) or secondary to other conditions such as dementia
* Pts often sound breathy, low-pitched, and monotonous
* Lee Silverman Voice Treatment emphasizes stimulating pts to increase respiratory and phonatory efforts and to sustain those efforts over time
64
Treatment Techniques for Patients with Neurological Diseases
Because pts w/ neurological diseases tend to manifest dysarthria, with some exceptions, treatment techniques often follow principles based on tx for dysarthria
Therapy strategies (to improve efficiency of overall system and increase intelligibility):
* Improve artic thru exaggerating Cs and slowing rate
* Improve resonance thru increasing mouth opening, decreasing tongue tension, and improving VP closure
* Improve prosody to decrease monopitch
* Improve respiration thru relaxation, increasing efficiency (and possibly frequency) of breathing
* Improve VF approximation (see "Treatment for VF Paralysis" flashcard)
65
Abuse-Based Disorders of Phonation:
| Vocal Nodules
* Pink/red, then white/gray as they become fibrous
* Usually bilateral
* Typically apear at the junction of the anterior and middle third portion of the VFs
* Develop over time due to prolonged vocal abuse
* Increase VF mass, causing slower vibration and lower pitch; Also make smooth VF approximation impossible, contributing to breathiness and hoarseness of voice
* Persisten nodules treated via voice tx or surgery
66
Polyps
* Softer than nodules and may be filled w/ fluid or ahve vascular tissue
* Tend to be unilateral (but can be bilateral)
* Sessile polyps: broad base on VF; Pedunculated polyps: attached to VFs by a stalk
* Traumatic use of VFs results in submucosal hemorrhage, leading to formation of tumorlike polyps
* Can grow over time or happen after one instance
* Usually sound breathy and hoarse; May have diplophonia
67
Contact Ulcers
* Sores or craterlike areas of ulcerated, granulated tissue that develop (usu. bilaterally) along poster third of glottal margin
* Causes: a) slamming together of arytenoids that occurs during low-pitched phonation accompanied by hard glottal attack and sometimes increased loudness, b) GERD, c) intubation after surgery
* Pts may complain of vocal fatigue and pain in laryngeal area; Freq. sound hoarse and often clear throats
* Voice tx is geared toward reducing phonation effort
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VF Thickening
* Prolonged use of vocally abusive behaviors can cause gradual VF thickening
* VFs usually thicken along anterior 2/3 of glottal margin
* Results in breathy voice w/ lowered pitch
* Often precursor to nodules or polyps
69
Traumatic Laryngitis
* Vocally abusive behaviors irritate VFs, which get swollen
* Consequently, the voice is hoarse and may be low-pitched with pitch breaks
* Voice tx usu. consists of vocal rest and strategies for changing the vocally abusive behaviors
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Phonotrauma: Specific Treatment Techniques
* Open-mouth approach: teach to speak w/ wider mouth opening; this helps to increase volume and improve oral-nasal resonance balance
* Chant-talk: words spoken in connected manner with soft glottal attack, even stress, prolongation of sounds, and absence of stress for individual words
* Digital manipulation of larynx: lowers pitch and decreases laryngeal tension
* Gentle voice onset: initiates phonation with /h/
* Yawn-sigh method: inhales on wide yawn followed by expiratory sigh and phonation
*Other techniques: teach to speak with appropriate pitch and volume, teach pt to reduce coughing and throat-clearing, teach pt to reduce tension, respiration training, encourage voice rest
71
Treatment for Disorders of Pitch
* In pts w/ a pitch that is too high, esp. young men with puberphonia (aka mutational falsetto), the larynx is often elevated w/ accompanying laryngeal tension
* B/c of this tension, relaxation, yawn-sigh, the open-mouth approach, and digital manipulation are often successful in lowering pitch; nonspeech vocalizations (e.g., glottal fry and coughing) may also be helpful
* Speech-range masking can help to lower vocal pitch (involves introducing masking noise during oral reading and pt usually spontaneosly increases volume)
* Visual and auditory feedback (e.g., Visi-Pitch)
* May also need psychological counseling; Cultural considerations re: ct's perceptions of normal pitch
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Psychogenic ("Functional") Voice Disorders
* Voice is abnormal in prescence of normal structures
* Mutational Falsetto is a psychogenic voice disorder
* Hysterical/Conversion aphonia: no evidence of physiological/neurological reason for voice loss (often after traumatic event)
* Tx: Counseling/psychotherapy or behavioral therapy
* Behavioral tx: masking, relaxation techniques, non-speech vocalizations, inhalation phonation, yawn-sigh, etc
