Ch. 7: Voice & Its Disorders Flashcards
(131 cards)
1
Q
Larynx
A
The biological valve located at the top of the trachea. It helps close the entry into the trachea so food, liquids, and other particles do not enter the lungs. Connects superiorly to the oral cavity and vocal tract and inferiorly to the lungs and trachea. Builds air pressure below it to assist in the performance of biological functions such as getting rid of bodily waste, coughing, heavy lifting, and child bearing. Houses the VF.
2
Q
Vocal Folds
A
Vibrate to produce voice. Adduct or abduct. Have a layered structure that is composed of the epithelium, the thyroarytenoid (TA) muscle, and the lamina propria.
3
Q
Glottis
A
Opening between the VF.
4
Q
Cover-Body Theory of Phonation
A
According to this theory, the epithelium, the superficial layer of the lamina propria, and much of the intermediate layer of the lamina propria vibrate as a “cover” on a relatively stationary “body.” The body is composed of the remained of the intermediate layer, the deep layer, and the TA muscle.
5
Q
Ventricular/False VF
A
Lie above the “true” VF. They do not usually vibrate during normal phonation and are only using during activities such as lifting and coughing.
6
Q
Aryepiglottic Folds
A
Lie above the ventricular folds. They separate the pharynx and laryngeal vestibule and help preserve the airway.
7
Q
Laryngeal Innervation
A
- CN VII (facial): Innervates the posterior belly of the digastric muscle of the VF.
- CN X (vagus: Primary CN involves in laryngeal innervation. Primary branches are SLN and RLN.
8
Q
Superior Laryngeal Nerve (SLN)
A
Has internal and external branches. The internal branch provides all sensory information to the larynx, and the external branch supplies motor innervation solely to the cricothyroid muscle.
9
Q
Recurrent Laryngeal Nerve (RLN)
A
Supplies all motor innervation to the interarytenoid, posterior cricoarytenoids, thyroarytenoid, and lateral cricoarytenoid muscles. It supplies all sensory information below the VF. If there is a lesion here, the patient may experience (among other problems) difficult adducting the VF.
10
Q
Hyoid Bone
A
Bone that the larynx is suspended from. Many extrinsic laryngeal muscles are attached to this bone.
11
Q
Epiglottis
A
A leaf-shaped cartilage that is attached to the hyoid bone. Protects the trachea by closing down inferiorly and posteriorly over the laryngeal area, directing liquids and food into the esophagus during swallow.
12
Q
Thyroid Cartilage
A
The largest of all the laryngeal cartilages. Sometimes called the Adam’s apple and is particularly prominent in men. Shields other laryngeal structures from damage. Composed of two lamina, or plates of cartilage, that are joined at midline and form an angle.
13
Q
Cricoid Cartilage
A
The second-largest laryngeal cartilage. Sometimes called the uppermost tracheal ring (however, it is quite different from the other tracheal rings). Completely surrounds the trachea. It is linked with the paired arytenoid cartilages and the thyroid cartilage.
14
Q
Arytenoid Cartilages
A
Cartilages positioned on the supraposterior surface of the cricoid cartilage on either side of the midline. Shaped like pyramids. The vocal processes are the most anterior angle of the base of the arytenoids. The true VF attach at the vocal processes.
15
Q
Corniculate Cartilages
A
Cartilages that sit on the apex of the arytenoids and are small and cone-shaped. They play a minor role in vocalization.
16
Q
Cuneiform Cartilages
A
Tiny, cone-shaped cartilage pieces under the mucous membrane that covers the aryepiglottic folds. They play a very minor role in the phonatory functions of the larynx.
17
Q
Intrinsic Laryngeal Muscles
A
These pairs of muscles have both of their attachments to structures within the larynx. With one exception, all are adductors. Primarily responsible for controlling vocalization. Include:
- Thyroarytenoids
- Cricothyroids
- Posterior cricoarytenoids (the only abductors)
- Lateral cricoarytenoids
- Transverse arytenoids
- Oblique arytenoids
18
Q
Extrinsic Laryngeal Muscles
A
These muscles have one attachment to a structure outside the larynx and one attachment to a structure within the larynx. All extrinsic laryngeal muscles are attached to the hyoid bone. These muscles elevate or lower the position of the larynx in the neck. They give the larynx fixed support. Includes the infrahyoid muscles: - Thyrohyoids - Omohyoids - Sternothyroids - Sternohyoids Includes the suprahyoid muscles: - Digastrics - Geniohyoids - Mylohyoids - Stylohyoids - Genioglossus - Hyoglossus
19
Q
Infrahyoid Muscles
A
Extrinsic laryngeal muscles that lie below the hyoid bone. Their primary function is to depress the larynx. They are sometimes called the depressors. They have a strong impact upon vocal pitch. Includes: (remember the acronym TOSS)
- Thyrohyoids
- Omohyoids
- Sternothyroids
- Sternohyoids
20
Q
Suprahyoid Laryngeal Muscles
A
Extrinsic laryngeal muscles that lie above the hyoid bone. Their primary function is to elevate the larynx. They are sometimes called elevators. Includes:
- Digastrics
- Geniohyoids
- Mylohyoids
- Stylohyoids
- Genioglossus
- Hyoglossus
21
Q
Mean Fundamental Frequency (MFF)
A
Mean fundamental frequency. Tends to decrease with age. MFF 19 y/o female → 217 Hz MFF 19 y/o male → 117 Hz MFF adult male → 100 – 150 Hz MFF adult female → 180 – 250 Hz MFF 70 – 94 y/o female → 201 Hz MFF 70 – 89 y/o male → 132 – 146 Hz
22
Q
Maximum Phonation Time (MPT)
A
Refers to a client’s ability to sustain “ah.” Usually, the client is asked to breathe deeply and “say ah for as long as you can.” MPT 3 – 4 y/o → 7.5 – 8.95 MPT 5 – 12 y/o → 14.97 – 17.74 MPT 18 – 39 y/o → 20.9 – 24.6 MPT 66 – 93 y/o → 14.2 – 18.1
23
Q
Vocal Changes Resulting from Puberty
A
Grils’ voices may lower by 3 – 4 semitones. Boys’ voices may lower as much as an octave. Boys may show pitch breaks, huskiness, and hoarseness as their pitch lowers due to laryngeal growth.
24
Q
Average Fundamental Frequency
A
Men → 125 Hz
Women → 225 Hz
25
Presbyphonia
Age-related voice disorder characterized by perceptual changes in quality, range, loudness, and pitch in older speakers’ voices.
26
Age-Related Vocal Changes
- Hardening of the laryngeal cartilages
- Degeneration and atrophy of the intrinsic laryngeal muscles
- Degeneration of glands in the laryngeal mucosa
- Degenerative changes in the lamina propria
- Deterioration of the cricoarytenoids joint
- Degenerative changes in the conus elasticus
27
Pitch
The perceptual correlate of frequency. Largely based on the frequency with which the VF vibrate. Determined by mass, tension, and elasticity of the VF. Higher pitch results when the VF are thinner, more tense, or both. Lower pitch results when the VF are thicker, more relaxed, or both.
28
Fundamental Frequency
Rate at which the VF vibrate. Generally considered a person’s pitch.
29
Jitter/Frequency Perturbation
Refers to variations in vocal frequency that are often heard in dysphonic patients. Can be measured instrumentally as a patient sustains a vowel. May occur in patients with voice problems such as tremor or hoarseness. People with no laryngeal pathology are able to sustain a vowel with less than 1% of this.
30
Volume
The perceptual correlate of intensity. Determined by the intensity of the sound signal. The more intense the sound signal, the greater its perceived loudness.
31
Amplitude
The extent of movement of air particles in response to a disturbance.
32
Shimmer/Amplitude Perturbation
Refers to the cycle-to-cyle variation of vocal intensity. It can be measured instrumentally as a patient sustains a vowel. A speaker with no laryngeal pathology should have a very small amount of variation of intensity with each vibratory cycle. Some experts believe that more than 1 dB of variation across cycles makes a patient sound dysphonic. Patients who have difficulties with regularity of VF vibration (e.g., roughness) might show large amounts of this.
33
Voice Quality
The perceptual correlate of complexity. Refers to the physical complexity of the laryngeal tone, which is modified by the resonating cavities. Frequently subjective.
34
Hoarseness
In this type of vocal quality, the voice shows a combination of breathiness and harshness, which results from irregular VF vibrations. In such cases, the fundamental frequency of the speaker varies randomly due to aperiodic vibration. Often sounds breathy, low-pitched, and husky. There may also be pitch breaks and excessive throat clearing.
35
Harshness
In this type of vocal quality, the voice is described as rough, unpleasant, and “gravelly” sounding. It is associated with excessive muscular tension and effort. The VF are adducted too tightly, and the air is then released too abruptly.
36
Strain-Strangle
In this type of vocal quality, the phonation is effortful, and the patient sounds as if she is “squeezing” the voice at the glottal level. Initiating and sustaining phonation are both difficult. Talking fatigues patients and they experience much tension when they speak.
37
Breathiness
In this type of vocal quality, the VF are slightly open (or not firmly approximated) during phonation. Air escapes through the glottis and adds noise to the sound produced by the VF. May be due to organic (physical) or nonorganic (nonphysical or functional) causes. Patients often complain that they feel like they are running out of air. This kind of voice is often soft, with little variation in loudness. Patients frequently show restricted vocal range.
38
Glottal Fry/Vocal Fry
Vocal quality that is heard when the VF vibrate very slowly. The resultant sound occurs in slow but discrete bursts and is of extremely low pitch. The voice sounds “crackly.” May be the vibratory cycle we use near the bottom of our normal pitch rate. Typically, it is produced near the end of a long phrase or sentence when air flow rate and subglottal air pressure are both low and lung volume is less.
39
Diplophonia
Means “double voice.” Occurs when one can simultaneously perceive two distinct pitches during phonation. Usually occurs when the VF vibrate at different frequencies due to differing degrees of mass or tension. E.g., might occur in a client with a unilateral polyp.
40
Stridency
This vocal quality sounds shrill, unpleasant, somewhat high pitched, and “tinny.” Often caused by hypertonicity or tension of the pharyngeal constrictors and elevation of the larynx.
41
Indirect Laryngoscopy (Mirror Laryngoscopy)
In this instrumental evaluation, the specialist uses a bright light source and a small, round, 21-25 mm mirror, angled on a long, slender handle, to lift the velum and press gently against the patient’s posterior pharyngeal wall area. The specialist maneuvers the mirror to view the laryngeal structures during phonation (usually the patient’s production of “eeeee”) and during quiet respiration.
42
Direct Laryngoscopy
This procedure is performed by a surgeon when a patient is under general anesthesia in outpatient surgery. The laryngoscope is introduced through the mouth into the pharynx and positioned above the VF. The patient cannot phonate, thus vocal function cannot be determined. However, the surgeon can obtain a direct microscopic view of the larynx. Valuable when a biopsy is required due to the suspicion of laryngeal cancer.
43
Flexible Fiber-Optic Laryngoscopy
This procedure utilizes a thin, flexible tube containing a lens and fiber-optic ight bundles. The specialist inserts the tube through the patient’s nasal passage, passes it over the velum, and maneuvers it into position above the larynx. The fibers transmit the laryngeal image to the specialist’s eyepiece. The patient is able to speak and sing. The specialist can obtain an excellent, prolonged view of the vocal mechanism and photograph rapid VF movement.
44
Endoscopy
Type of imaging study where a scope with a light at the tip is introduced orally or nasally. The light is fiber optic and comes from an external light source. The structures are illuminated by the light and viewed by the specialist at the other end of the endoscope through a window lens. Can be attached to a video camera. May be used to study laryngeal anatomy and physiology in detail, including the mucosal wave.
45
Sound Spectrography
The graphic representation of a sound wave’s intensity and frequency as a function of time. Very useful for quantitative analysis of speech.
46
Spectrogram
Picture resulting from sound spectrography. Reflects the resonant characteristics of the vocal tract and the harmonic nature of the glottal sound source.
47
Videostroboscopy
Imaging study that can be helpful in differentiating between functional and organic voice problems. It can also be used to detect laryngeal neoplasms (tumors). Uses a pulsing strobe light on an endoscope that permits the optical illusion of slow-motion viewing of the VF during a variety of tasks. The image yields information about the periodicity or regularity of VF vibrations, VF amplitude (horizontal excursion), glottal closure, presence and adequacy of the mucosal wave, and the possible presence of lesions or neoplasms.
48
Electroglottography (EGG)
Noninvasive procedure that yields an indirect measure of VF closure patterns. Surface electrodes are placed on both sides of the thyroid cartilage, and a high-frequency electric current is passed between the electrodes while the patient phonates. The laryngeal and neck tissue conducts the current. A glottal wave form results, and the specialist is able to observe VF vibration. Can also detect breathy and abrupt glottal onset of phonation. Cross-validate this tool with another measure. Researchers debate its efficacy as a diagnostic technique.
49
Elecromyography (EMG)
This invasive procedure directly measures laryngeal function to study the pattern of electrical activity of the VF and to view muscle activity patterns. The specialist inserts needle electrodes into the patient’s peripheral laryngeal muscles. The resulting electrical signals are judges as either normal or indicative of pathology. When the specialist interprets the electric signals she is looking for:
- Reduced or increased speech of muscle activation
- Extraneous bursts of muscle activity
- Onset or termination of muscle activity
Useful when attempting to determine VF pathology, especially that caused by neurological and neuromuscular diseases. Also useful in verifying excessive muscle activity prior to the injection of Botox for patients with spasmodic dysphonia.
50
Aerodynamic Measurements
```
Refer to the airflows, air volumes, and average air pressures produced as part of the peripheral mechanics of the respiratory, laryngeal, and supralaryngeal airways. Used to evaluate dysphonia, monitor voice changes and treatment progress, and differentiate between laryngeal and respiratory problems. Specific measures can be made of the following:
- Tidal volume
- Vital capacity
- Total lung capacity
Various instruments may be used to obtain these measures, such as:
- Wet spirometers
- Dry spirometers
- Manometric devices
- Plethysmographs
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Tidal Volume
Amount of air inhaled and exhaled during a normal breathing cycle.
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Vital Capacity
The volume of air that the patient can exhale after a maximal inhalation.
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Total Lung Capacity
Total volume of air in the lungs.
54
Visi-Pitch
Instrument used to measure pitch. The patient speaks into a microphone and the instrument displays his or her frequencies visually on a computer monitor. Measures dynamic range, intensity and frequency variability, pitch and loudness, and other parameters. It can also give a printout of these factors. Gives documented, quantitative measurements of a patient’s pitch characteristics.
55
Pitch Assessment
Assesses:
- The patient’s habitual pitch, or typical conversational pitch
- Whether the client is using optimal pitch
- Whether the pitch is appropriate to the client’s gender and age, rather than too high or too low
- Whether the patient is monopitched, with lack of appropriate inflections as judged by members or his or her culture
56
Loudness Assessment
Assesses:
- Parameters such as harshness, hoarseness, breathiness, and vocal tension
- Whether the client’s loudness is appropriate to daily situations
- Whether the client’s voice is too soft or too loud due to possible physical factors (e.g., asthma, hearing loss)
57
Resonance Assessment
Assesses the presence of:
- Hyponasality
- Hypernasality
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Respiration Assessment
In this type of assessment, the clinician looks for the following types of breathing:
- Clavicular breathing
- Diaphragmatic-abdominal breathing
- Thoracic breathing
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Clavicular Breathing
When the patient inhales, the shoulders elevate. Often there is strain and tension. Often inefficient.
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Diaphragmatic-
| Abdominal Breathing
This appropriate, efficient breathing utilizes the abdominal region and the lower thoracic cavity. There is little to no chest of shoulder movement. Ideal for professional voice users, including singers, teachers, and public speakers.
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Thoracic Breathing
The patient who uses this type of breathing exhibits characteristics of both clavicular and diaphragmatic-abdominal breathing. There is no observable abdominal or upper thoracic expansion upon inspiration.
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Phonation Assessment
Assesses:
- Maximum phonation time
- s/z ratio
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s/z ratio
This procedure is used to help determine whether there is laryngeal pathology present. The patient is asked to produce two long /s/ phonemes, then two long /z/ phonemes. The clinician divides the longest /s/ by the longest /z/. A ratio more than 1.4 is indicative of possible laryngeal pathology.
64
Hypernasality
The most common resonance disorder. Patient sounds like they are speaking through their nose. Results when the VP mechanism does not close the opening to the nasal passage during the production of non-nasal sounds. Their air and sound escape through the nose, adding unnecessary nasal resonance to non-nasal speech sounds. Can be caused by organic disorders, functional disorders, cleft palate, or VPI. Assessment can include subjective, perceptual judgments as well as use of instrumentation such as the Nasometer.
65
Velopharyngeal Inadequacy/
| Insufficiency (VPI)
Means that the velopharyngeal mechanism is inadequate to achieve closure. As a result, the nasal cavities are not sealed off appropriately from the oral cavity. The etiology is heterogeneous and may be neurological, structural, or learned. Major causes are:
- Decreased muscle mass of the velum
- Adenoidectomy or tonsillectomy
- Paresis or paralysis of the velum
66
Hyponasality/
| Denasality
A lack of appropriate nasal resonance on nasal sounds /m/, /n/, /ng. Patients often substitute oral sounds for nasal sounds (e.g., baby instead of maybe). Can be temporary (due to colds, allergies) or can occur due to obstructions (nasal polyps or papilloma), enlarged adenoids or tonsils, or deviated septum. May be mouth breathers. Assessment can include subjective, perceptual judgments as well as use of instrumentation such as the Nasometer.
67
Assimilative Nasality
Occurs when the sound from a nasal consonant carries over to adjacent vowels. The velar openings begin too soon and last too long, thus nasalizing vowels that occur next to nasal phonemes. Can be functionally or organically based. Assessment and treatment depend on etiology.
68
Cul-de-Sac Resonance
Produced by backward retraction of the tongue. The tongue is carried too far posteriorly in the oral cavity. The person’s voice can sound muffled or hollow. Common in people with deafness or neurological disorders.
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Focusing
Directing the tone into the facial “mask,” which is the area above the maxillary sinuses and around the nasal bridge. The clinician demonstrates and then has the patient say words with nasal sounds (e.g., moon, me) in an exaggerated way. This produces vibrations in the mask. The patient is asked to feel the vibrations, focusing his or her attention in the mask area. Appropriate resonance is then shaped from that point of reference.
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Nasal-Glide Stimulation
The clinician selects words with many glides and nasals (e.g., lawnmower, many, manners, lemon). The patient practices saying these words in various combinations. The combination of glides and nasals helps direct resonance more appropriately into the nasal cavity and gives the patient auditory and kinesthetic feedback about proper utilization of the nasal cavity.
71
Laryngeal Cancer
One of the most common forms of cancer. Occurs more frequently in men than women. A multifactorial disease. Can be caused by alcohol, tobacco, exposure to environmental toxins, gastroesphageal reflux, and a combination of these. People who are heavy smokers and drinkers are especially at risk. Early warning signs include hoarseness, difficulty swallowing, a sore throat that won’t go away, ear pain, and a lump in the neck or throat. Successful treatment is dependent upon early detection and intervention. Can be detected by physical examination, laryngoscopy, endoscopy, CT scan, MRI, and biopsy.
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T
Primary site of tumor.
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N
Involvement of the lymph nodes.
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M
Metastasis.
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Laryngectomy
Surgery to remove the larynx.
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Total Laryngectomy
Full larynx is surgically removed.
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Hemilaryngectomy
Only the diseased part of the larynx is surgically removed.
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Radical Neck Dissection
Lymphatic system in the neck is removed.
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Laryngectomee
Person who has had his or her larynx removed.
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Stoma
Opening in the lower part of the neck. Connected to the trachea. Patient breathes out of this opening.
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Electrolarynx/Artificial Larynx
An external handheld device that generates sound.
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Esophageal Speech
Patient essentially speaks through the esophagus using burps. Can use the injection method or inhalation method.
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Injection Method of Esophageal Speech
The patient impounds the air in the mouth as in saying /t/ or /p/. The impounded air is pushed back into the esophagus and then expelled, producing vibrations of the soft tissues in the esophagus—particularly the cricopharyngeus muscle. The patient shapes the resulting burp into speech.
84
Inhalation Method of Esophageal Speech
The patient is taught to inhale rapidly while keeping the esophagus open and relaxed. The inhaled air passes through the esophagus and sets its tissues into vibratory motion. The resulting sound is shaped into speech.
85
Blom-Singer Tracheoesophageal Puncture (TEPP
The tracheoesophageal wall, which separates the trachea and esophagus, is punctured. A shunt or tunnel is opened to connect the two structures. To keep the tunnel open, the device is inserted. Small 1.8 – 3.6 cm silicone or plastic tube. Designed to prevent the passage of fluid or food into the trachea.
86
Granuloma
A localized, inflammatory, vascular lesion, that is usually composed of granular tissue in a firm, rounded sac. Frequently develop on the vocal processes of the arytenoid cartilages in the posterior laryngeal area. They can be unilateral or bilateral. May be caused by vocal abuse, intubation during surgery, injury to the larynx, and gastroesophageal reflux. Most often associated with contact ulcers. Treated by surgery, voice treatment, or both.
87
Hemangioma
Similar to granulomas, but are soft, pliable, and filled with blood. Occur in the posterior glottal area. Usually caused by intubation or hyperacidity due to gastroesophageal reflux. Can also be congenital. Usually surgically excised. Follow-up voice therapy is needed to improve vocal quality.
88
Leukoplakia
Benign growths of thick, whitish patches on the surface membrane of the mucosa. May extend into the subepithelial space. Occur due to tissue irritation, especially that caused by smoking, alcohol, or vocal abuse. Benign but considered precancerous and must be monitored to ensure they do not develop into squamous cell carcinoma. Patients may sound hoarse, low-pitched, breathy, and soft in volume. Diplophonia may also be present. Treatment involves a combination of surgery, voice therapy, and elimination of exposure to tissue irritants.
89
Hyperkeratosis
Refers to a rough, pinkish lesion that can appear in the oral cavity, larynx, pharynx, or VF. Lesions are often benign but precancerous. Occur due to tissue irritation. Patients have mild to severe hoarseness or harshness, reduced loudness, and low pitch. Treatment involves eliminating tissue irritants, ablative surgery, and voice therapy.
90
Laryngomalacia
A congenital condition that involves soft, floppy laryngeal cartilages. The epiglottis is particularly affected. The epiglottis is very soft and pliable due to abnormal development. Stridor occurs in breathing. Occurs in young children.
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Subglottal Stenosis
The narrowing of the subglottic space. Can be acquired or congenital. Acquired can come from intubation. May develop stridor. May need surgery or voice intervention.
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Papilloma
Wart-like growths cause by the HPV virus. Occur mostly in children. Pink, white, or both and may be found anywhere in the airway. Symptoms are hoarseness, breathiness, and low pitch. Can cause airway obstruction. Typically requires surgery.
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Laryngeal Trauma
Refers to many kinds of injury to the larynx. Includes burns, MVAs, sports-related accidents, attempted strangulations, swallowing sharp objects, and gunshot wounds. Typical treatment is surgery and voice therapy.
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Laryngeal Web
A membrane that grows across the anterior portion of the glottis. Can be congenital or acquired. Laryngeal keel may be placed.
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Laryngeal Keel
A fingernail-sized, rudder-shape device surgically inserted between the VF after surgery to keep them from growing back together after webbing.
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Paradoxical VF Motion (PVFM) / Laryngeal Dyskinesia / Episodic Paroxysmal Laryngospasm (EPL)
There is an inappropriate closure or adduction of the true VF during inhalation, exhalation, or both. Patients appear asthmatic. Can be psychological or physiological.
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Gastroesophageal Reflux Disease (GERD)
Occurs when gastric contents spontaneously empty into the esophagus when the person has not vomited or belched. Patients may experience heartburn, acid indigestion, sore throat, and hoarseness. Contact ulcers may occur. Manometric evaluations are useful. Treatment includes antacids, positioning, prescription medications, and diet changes.
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Contact Ulcers
Bilateral ulcerations on the medial surfaces of the vocal processes of the arytenoid cartilages.
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VF Paralysis
Occurs when VF nerve supply is cut off. Can occur due to:
- Accidental injury of the RLN during certain surgical procedures (e.g., thyroidectomy)
- Progressive, debilitative neurological diseases (e.g., ALS)
- Malignant diseases, causing tumors outside the larynx to impact VF mobility
- Intubation trauma, causing compression of the RLN, dislocation of the arytenoids, and other difficulties
- Laryngeal trauma that is so severe its irreparable (e.g., gunshot wound)
- Stroke
- Vagus nerve deficits
Can be treated with injections of Teflon, collagen, Gelfoam, and autologous fat (patient’s own fat). Other treatments include thyroplasty type I and nerve-muscle pedicle reinnervation. Depending on the type of paralysis, the following treatment techniques have been used to help patients achieve firmer VF closure:
- Elevation in pitch
- Increased loudness
- Increased breath support, as well as breathing more often between phrases
- Push approach, in which the patient activates the glottal effort closure reflex by pushing against an object to increase VF medialization
- Hard glottal attacks
- Head turning or positioning, in which the patient changed head position to see which position creates the best voice
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Unilateral Paralysis
Only on VF is paralyzed and assumes a static position. In some cases, the normal fold may move toward the paralyzed fold to make contact. Causes aphonia.
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Bilateral Paralysis
Paralysis of both VF. May lead to a wide-open glottis, causing aphonia. Aspiration can occur if VF are abducted. If adducted, breathing will be hard but the voice is not significantly dysphonic.
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Ankylosis
Stiffening of the joints. The movement of the arytenoids is restricted because of a bone-join disease such as arthritis. Can also be caused by cancer. When the arytenoids are stuff, the VF do not close fully.
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Thyroplasty Type I
The surgeon creates a small window in the thyroid cartilage, medializes the VF, and places a small Silastic implant to keep the paralyzed fold medialized.
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Nerve-Muscle Pedicle Reinnervation
The surgeon takes a pedicle of a neck strap muscle with innervation and sutures it either into the adductors for medialization purposes or into the posterior cricoarytenoids in order to promote abduction.
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Spasmodic Dysphonia
A focal laryngeal dystonia. Can be psychological or neurogenic. Thought to involve brainstem dysfunction. Average onset is 38 y/o. Can be of the abductor or adductor.
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Abductor Spasmodic Dysponia
Created by intermittent, involuntary, fleeting VF abduction when the patient tires to phonate. Loudness is reduced, and the patient is occasionally aphonic, with breathy or whispered speech. Treatment includes Botox injections, speech therapy involving relaxation techniques and continuous voicing, and pharmacological interventions.
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Adductor Spasmodic Dysphonia
Dysphonia characterized by overpressure due to prolonged overadduction or tight closure of the VF. The voice may sound choked and strangled. Most common type of spasmodic dysphonia. Current treatments include CO2 laser surgery, RLN resection, Botox injections, and voice therapy.
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CO2 Laser Surgery
In this procedure, the paralyzed fold is thinned with a CO2 laser beam. This creates a 2-mm-wide groove, whose healing and scarring action pulls the VF away from the midline, widening the glottis. Repeated surgeries may be necessary.
109
Recurrent Laryngeal Nerve (RLN) Resection
In this surgery, the RLN is cut in order to paralyze the VF on that side. This reduces VF hyperadduction. Mixed success. Viable option for patients with severe SMD who do not wish to have repeated, frequent Botox injections.
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Botox Injections
Botox, a neurotoxin, is injected directly by needle into the VF, creating a flaccid paresis. Hyperadduction ceases. Usually repeated every 3 – 6 months. Current treatment of choice among many specialists.
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Multiple Sclerosis (MS)
Disease characterized by progressive and diffuse demyelination of white matter, with corresponding preservation of axons at the brainstem, cerebellum, and spinal cord. Patients may have impaired prosody, pitch, loudness control, harshness, breathiness, hypernasality, articulation breakdown, and nasal air escape. Treated with ACTH.
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Myasthenia Gravis
Neuromuscular autoimmune disease that produces fatigue and muscle weakness. There is a decreased amount of acetylcholine at the myoneuronal junction. Patients often sound hypernasal, breathy, hoarse, and soft in volume. Dysphagia and distorted articulation may also be present. Often treated with corticosteroids.
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Amyotrophic Lateral Sclerosis (ALS)
A progressive, fatal disease involving degeneration of the upper and lower motor neuron systems. Patients often sound breathy, low-pitched, and monotonous. There is poor respiratory control. Do not respond well to medications. Some patients respond to riluzole. Clinicians should focus on AAC use.
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Parkinson’s Disease
Disease caused by a lack of dopamine (a neurotransmitter) in the substantia nigra of the basal ganglia. It can be idiopathic (occurring in isolation or primary form) or secondary to other conditions such as dementia. Patients often sound breathy, low-pitched, and monotonous. Treatment includes L-dopa, voice treatment, and LSVT.
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Levodopa (L-Dopa)
Drug used to increase dopamine in the substantia nigra.
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Lee Silverman Voice Treatment (LSVT)
Program that emphasizes stimulating patients to increase respiratory and phonatory efforts and to sustain those efforts over time.
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Phonotrauma
Trauma or injury to the VF.
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Abusive Vocal Behaviors
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These behaviors are associated with excessive muscular effort, tension, and consequent irritation of the VF.
Includes:
- Excessive shouting
- Screaming
- Cheering
- Excessive talking
- Coughing
- Hard glottal attacks
- Throat clearing
- Strained and explosive vocalizations
- Excessive laughing and crying
- Speaking with inappropriate pitch, loudness, or both
- Speaking in noisy environments
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Vocal Nodules
Small nodes that develop on the VF and protrude from surrounding cells. In the beginning, they are reddish or pinkish. As they develop over time, they appear white or grayish because they become fibrous. Can be unilateral but are typically bilateral. Typically appear at the junction of the anterior and middle third portion of the VF. Usually the result of prolonged vocally abusive behaviors. Increase the mass of the VF. Frequently seen in children who scream and yell. Treatment involves voice therapy or surgery. Some doctors have been using laser therapy.
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Polyps
Masses that grow and bulge out from the surrounding tissue of the VF. Softer than nodules and may be filled with fluid or have vascular tissue. Tend to be unilateral as opposed to typically bilateral nodule. Can grow over time. Can be created by one extreme vocal abuse. More frequent in adults. Patients sound breathy and hoarse, may have diplophonia. May disappear with vocal rest and hygiene improvements.
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Sessile Polyps
Polyps that have a broad based on the VF.
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Pedunculated Polyps
Polyps that are attached to the VF by a stalk.
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Contact Ulcers
Sores or craterlike areas of ulcerated, granulated tissue that develop (usually bilaterally) along the posterior third of the glottal margin. Patients may complain of vocal fatigue and laryngeal pain. Sound hoarse and clear throats often. Can be caused by slamming together of arytenoid cartilages, GERD, or intubation. Treatment depends on etiology, never surgery, usually voice therapy.
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Vocal Fold Thickening
Prolonged use of vocally abusive behaviors such as throat clearing, screaming, and others can cause the VF to thicken slowly and gradually. Usually thicken along the anterior two thirds of the glottal margin. Results in a breathy voice with lowered pitch. Usually a precursor to nodes or polyps. Treatment is elimination of vocally abusive behaviors.
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Traumatic Laryngitis
Type of laryngitis that occurs when the patient engages in vocally abusive behaviors. VF get swollen, voice is hoarse and may be low-pitched with pitch breaks. Treatment includes vocal rest and therapy.
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Mutational Falsetto/
| Puberphonia
Occurs when a young man speaks with a high pitch although the larynx has grown normally and puberty is completed. Can occur due to psychosocial factors (e.g., embarrassment about the newly developed low voice), endocrine disorders, or neurologic diseases.
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Hormonal Voice Changes
Female voices can lower before menstruation due to lowered levels of estrogen and progesterone, caused by VF thickening. Drugs containing male hormones can thicken VF and decrease vocal pitch.
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Speech-Range Masking
An effective treatment technique for individuals wishing to lower their voice. The clinician asks the patient to begin oral reading and records the patient’s reading. Near the tenth word, masking is produced. Utilizing the Lombard effect, the voice usually spontaneously becomes louder and lower. The patient can then listen back to his lower voice and be encouraged that he is able to produce this type of voice.
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Lombard Effect
Effect when the patient’s voice becomes louder in the presence of background noise.
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Psychogenic/Functional Voice Disorders
Voice disorders that occur when the voice is abnormal in the presence of normal laryngeal structures. A laryngoscopic evaluation reveals essentially normal vocal structures. However, during attempted phonation, the VF may remain fully or partially abducted.
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Hysterical/Conversion Aphonia
Voice disorder where there is usually no evidence of a structural pathology. There is no known physiological or neurological basis for the patient’s voice loss. The loss can be sudden or gradual. Typically occurs after emotionally traumatic events. The voice loss may represent an unconscious attempt to avoid dealing with the traumatic event.
