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Hyperfunctional + Neurological Dysphonia Flashcards

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1
Q

Types of hyperfunctional dysphonias

A

-Muscle Tension Dysphonia
-Paradoxical VF Movement (or Vocal Cord Dysfunction)

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2
Q

Describe Muscle Tension Dysphonia

A

-Excessive, atypical, abnormal laryngeal movements
-Excessive tension during phonation
-May have Antero posterior and medial squeezing of supraglottic structures

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3
Q

Important to note when diagnosing muscle tension dysphonia

A

-Often mimics the perceptual attributes of spasmatic dysphonia (especially ADSD (adductor spasmatic dysphonia)

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4
Q

Two types of Muscle tension dysphonia?
Describe both

A
  1. Primary MTD: vocal dysfunction in the ABSENCE of structural or neurological alteration in the larynx
  2. Secondary MTD: vocal dysfunction in the PRESENCE of tissue reactions/lesions
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5
Q

Etiology of muscle tension dysphonia

A

May be a primary etiology of dysphonia OR could be compensatory for a vocal fold lesion of some other disease
or from an acute or resolved insult
-Adaptation after upper respiratory infection
-GERD
-High stress levels
-Personal/emotional factors + atypical voice usage

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6
Q

What is the functional etiology of MTD?

A

Functional imbalance with NO physical or organic cause

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7
Q

Anatomical structure of the VFs with muscle tension dysphonia?

A

Normal structure and capabilities

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8
Q

Development of muscle tension dysphonia

A

-ONSET: usually very sudden, but can be gradual dependent on cause being trauma or upper respiratory infection
-COURSE: intermittent/fluctuating- may return to normal for a period of time

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9
Q

What makes the voice better and worse with MTD

A

Patients usually cant pinpoint what makes the voice better or worse

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10
Q

Perceptual signs and symptoms associated with muscle tension dysphonia

A

-If VFs come together lax= breathy
-If VFs come together tight= Harsh voice
-Inappropriate pitch level, pitch breaks
-phonatory breaks, decreased pitch range
-Vocal fatigue & effortful voice
-Hard glottal attack
-Throat and neck pain/soreness
-Mouth opening, head/jaw position abnormalities
-Hoarse, raspy, strained voice

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11
Q

Physiological signs of MTD

A

-Supraglottic compression/ constriction (lateral and AP)
-VF length visibility
-False VF involvement
-Glottal closure patterns: incomplete, bowed, large anterior or posterior chink
-Reduced mucosal wave
-Reduced periodicity and symmetry

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12
Q

What is the patient complaint with muscle tension dysphonia

A

Variable

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13
Q

Who is MTD predominantly seen in?

A

-Male children
-Adult females

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14
Q

Voice stimulability testing with MTD

A

Will demonstrate ability for normal voicing in some situation

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15
Q

Sustained phonation versus connected speech with MTD

A

Same for both

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16
Q

Treatment for MTD

A

-Indirect treatment: vocal hygiene
-Direct treatment: behavioral therapy to restructure voice

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17
Q

What is the goal of treatment for MTD

A

-Primary MTD Goal: cure, usually improving within a few seconds
-Secondary MTD Goal: may never be corrected, goal is to maintain voice or find an easier way to produce better voice

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18
Q

Paradoxical vocal fold motion/Vocal cord dysfunction description

A

-Obstruction of airway with closure of VFs during inspiration due to laryngospasms
-Expiration WNL, Inspiration severely reduced

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19
Q

When diagnosing paradoxical vocal fold motion, what is important?

A

-Diverse causes and presentation pf PVFM make diagnosis difficult to catch at evaluation
-Rule out asthma, heart problems, pulomology problems, and allergies

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20
Q

Paradoxical vocal fold motion is often mistaken for what diagnosis?

A

Asthma

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21
Q

Etiology of Paradoxical Vocal fold motion

A

Potentially:
-Psychogenic
-Upper airway sensitivity (hyperactive airway)
-Neurological problem (CNS or PNS issue)

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22
Q

What are the triggers for developing paradoxical vocal fold motion

A

-Inhaled smoke, fumes, etc.,
-Temperatures
-Activity/exercise
-Intrinsic factors: shortness of breath or stress

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23
Q

Development of paradoxical vocal fold motion

A

-ONSET: sudden
-COURSE; variable, chronic history

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24
Q

Perceptual signs and symptoms associated with paradoxical vocal fold motion

A

-Primary characteristics is NOT voice change
-Primary characteristic: Mild to severe acute respiratory distress- obstruction of airway with VF closure through inspiration
-Hallmarks: inspiratory stridor, apparent inability to inhale/SOB, occasional momentary loss of consciousness, night tightness/pain

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25
Symptoms of paradoxical vocal fold motion may mirror what?
-Asthma attack -Laryngospasm: patient wakes from sleep with burning sensation in throat throught to be cause by reflux & subsides quickly
26
Why do individuals with paradoxical vocal fold motion often end up in the ER? How does this contribute to misdiagnosis?
Because symptoms mirror asthma attack or laryngospasm, often creating panic reaction Patients go to ER and treated symptomatically before diagnosis is made Patients dont respond to standard asthma therapy & end up testing negatively for asthma symptoms
27
Who is paradoxical vocal fold motion often seen in?
-Active teens/athletes -Females > Males; generally, under 40
28
Treatment for paradoxical vocal fold motion
-Voice therapy: rescue breathing, other breathing strategies to minimize symptoms, biofeedback -Anti-reflux medication -Intraveneous injection of diazepam (or placebo) -Verbal support -Hypnosis -Combination of medical, behavioral, and psychological approaches
29
Describe unilateral vocal fold paralysis
-Neurogenic paralysis of arytenoids towards midline, not being able to fully adduct
30
Which side is usually more affected with unilateral vocal fold paralysis and why?
The left side is more affected Extended course of the left RLN
31
Etiology of unilateral VF paralysis
1. surgical trauma (bruising during surgery) 2. Growth could be squishing the nerve -Idiopathic (unknown, viral infection, cold, etc.)
32
Development of Unilateral VF paralysis
-ONSET: Sudden (trauma/surgery) or Gradual (tumor growth) -COURSE: 8 to 12 months for nerve function to return; may worsen -DURATION: no treatment to bring nerve functioning back, but collagen injections could improve VF contact
33
Perceptual signs and symptoms of unilateral VF paralysis
-Breathy -Reduced loudness -Shorter phonation time -Chokes on thin liquids -Runs out of air
34
What makes the voice better and worse with unilateral VF paralysis
-Improved voice: holding on to one side, turning head to one side
35
Patient with unilateral VF paralysis is likely to come in with what complaint?
-Run out of air quickly
36
Voice stimulability testing for unilateral VF paralysis
-Turning head to paralyzed side and to other side to see if it makes a difference with their voice
37
Treatment for unilateral VF paralysis
-Collagen injections (helps temporarily) -Surgery- placing a shim in the middle to have the VFs permanently in the midline -Injection of material to paralyze problematic side -Behavioral voice therapy- best recovery when done within 6mo of onset For improvement therapy by 1 year post-onset
38
Physiological signs seen with unilateral VF paralysis
-Incomplete glottal closure -True VF asymmatry -Aperiodicity -Reduced mucosal wave -Supraglottic construction (false VFs) -Positioning of arytenoids over the paralyzed side -One true VF not fully adducted, while unaffected VF moves to midline during phonation
39
Sustained phonation vs connected speech with unilateral VF paralysis
Same- both poor
40
Difference between essential tremor and dystonic tremor
Essential tremor: tremor at the hands, legs, head, speech mechanism with no other neurological symptoms present Dystonic tremor- postural tremor observed in a body part affected by dystonia (neurological disorders)
41
Define dystonia
A movement disorder that causes muscles to contract and spasm involuntarily. -neurologic disorder
42
What is the etiology of tremors
CNS neurogenic -often essential tremors are associated with aging
43
Which population are tremors more commonly seen in?
Women > Men
44
Perceptual signs and symptoms of essential tremor
-May not be present at rest -Severity will determine the effect on speech intelligibility
45
Perceptual signs and symptoms of dystonic tremor
-Absent during quiet breathing -Increased effort may be reported -Tremor observed ONLY during purposeful activities (sustained speech or phonation)
46
Treatment for both types of tremors, essential tremor, and for dystonic tremor
-BOTH: Voice therapy: reduces syllable duration in a manner that reduces perceived tremor -ESSENTIAL: medication: Beta blockers may help with limp and head tremors -DYSTONIC: Botox injection
47
When treating dystonic tremor where are the botox injections injected
Into the interarytenoid and thyroarytenoid muscles
48
What neurologic disorder often co-occurs with spasmatic dysphonia
-Dystonic tremor
49
What makes the voice better and worse with tremors?
Nothing makes it better There are treatment techniques that may help: getting louder, enunciating, slowing down
50
When will tremor be present in voice more
-Wobbly voice more in low Hz when things are relaxed
51
Development of Tremor
-COURSE: stabilized quickly -DURATION: can be a really long time
52
Patient complaint with tremor
-Wobbly voice -Hoarse -Sounds scared, nervous, or anxious
53
Sustained phonation vs connected speech for tremors
SP: heard more clearly during sustained phonation CS: tremor may be mild, could be confused with spasmodic dysphonia
54
Voice stimulability testing for tremors
-More obvious during sustained phonation at normal pitch and loudness
55
describe spasmodic dysphonia
-Focal dystonic affecting laryngeal muscle control during speech -Task specific neurologic voice problem
56
Types of spasmodic dysphonia
1. Adductor SD: adduct too tightly together; irregular vocal arrests involving TA muscle 2. Abductor SD; open and closing sporadically 3. Mixed SD; intermittent tight adduction and sporadic abduction
57
Explain differential diagnosis for spasmodic dysphonia
-Differential diagnosis based on auditory-perceptial assessment (inherently problematic) AND trial of voice therapy (not effective)
58
What is spasmodic dysphonia often misclassified as?
MTD
59
Etiology of spasmodic dysphonia
-Idiopathic: CNS neurogenic
60
What predisposing factors are associated with the etiology of spasmodic dysphonia
Other focal dystonias: 1. Writer's cramp 2. Torticollis (neck) 3. Blepharospasm (eyelids)
61
Development of spasmodic dysphonia
-ONSET: gradual with mild symptoms -COURSE: progressively gets worse then eventually settles (starts as mild hoarseness> progresses into interrupted, strained phonation) -DURATION: may never return to normal, but may have slight improvements
62
What makes the voice better and worse with spasmodic dysphonia
Better: singing may be easier to produce (falsetto voice) Worse: stress, talking over the phone, talking in drive thru
63
Who is spasmodic dysphonia often seen in?
Predominantly adult females Between age 40-60 years
64
Voice in sustained phonation vs connected speech with spasmodic dysphonia
Sustained phonation is the best > Single words > Connected speech is the worst
65
Treatment of spasmodic dysphonia
-Botox injection, paralyzing the problematic (over-functioning) muscle -Voice therapy: educate patients about disorder, will NOT respond to therapy -Surgical technique: selective deinnervation-reinnervation
66
What is selective deinnervation-reinnervation?
Surgical technique used with SD Physically separates the VFs with a type 2 thyroplasty
67
What muscle is injected in ADSD & ABSD?
-ADSD: inject the muscle that adducts= LCA and TA -ABSD: inject the muscle that abducts= PCA
68
What is Meinge's Syndrome? What is another name for it?
-Aka: Orofacial dystonia -Dystonia of the head and neck (oral cavity, mastication/chewing muscles, eyelid muscles) involving involuntary movements -Symptoms present at rest and during specific tasks (speech, but not chewing) -Symptoms absent during sleep
69
Adductor SD will have more trouble with, while Abductor SD will have more trouble with?
1. ADSD: difficulties starting voicing, especially with vowels (whispering, crying, laughing =WNL) May only produce the first phoneme or have choppy/tremor voice Effortful and strained voice 2. ABSD: intermittent breathiness, with difficulty initiating vowels after a voiceless sound Non-effortful Voice disappears or is choppy with vowels after VL consonant not produced
70
If a SD patient responds to behavioral voice therapy, what is more than likely the voice disorder?
Muscle Tension Dysphonia Because SD doesnt respond to therapy generally. The treatment will be Botox/injections
71
Task during diagnosis to help with identifying Abductor SD & reasoning for task
-Task: Count from 60 to 70 Will prolong sounds: h, p, t, k, s, f -Task: Say, 'He is hiding behind the house' or 'Sally fell asleep in the soft chair' Will have drops in pitch and intermittent breathiness, Difficulty will present with initiating vowels following the voiceless consonant sounds
72
For tremors, diagnosis will be more evident during
Sustained phonation
73
Tasks during diagnosis to help with identifying Adductor SD and reasoning for task
-Count 80-90 -Task: say, 'Eddie is eighty and Eddie asked for an apple tree as a present.' or 'All of the otters ought to avoid aquariums' Will have intermittent spasms in TA and LCA during production of vowels, only producing the first phoneme or will have choppy voice Difficulty presents when initiating speech, especially with initiation of vowels
74
Historically, spasmodic dysphonia was labeled as being hysterical. Why?
Being more common in females
75
What are articulation problems seen with voice problems?
Reduced rate, reduced precision, reduced speech affecting intelligibility
76
Define tongue fasciculation
Indication of a motor neural problem Tongue ripples when at rest
77
Define myathenia gravis neurological condition
-Chronic autoimmune disorder -Weak voluntary muscles (fatigue function of head, neck, tongue, pharynx, and larynx)
78
Perceptual signs and symptoms seen with parkinsons disease
-Breathy voice -Monoloudness -Monopitch -Reduced syllable stress -Reduced articulatory contacts
79
What makes the voice better and worse with Parkinsons Disease
-Better: emphasis on 'intent' with slow, loud speech (better voice quality and articulation) -Worse: rapid movements of articulation (unintelligible)
80
Patient complaint with parkinsons disease
-Cant sustain good volume, think they are too loud
81
Treatment for parkinsons disease
-LSVT -Mixed results for deep brain stimulation
82
What is fixation of the cricoarytenoid joint?
Ankylosis of the cricoarytenoid joint
83
What are the causes of ankylosis of the cricoarytenoid joint?
-Asrthritis -Trauma -Joint disease
84
What can ankylosis of the cricoarytenoid joint be confused with? & what is the main difference?
Paralysis Pain is only present in ankylosis & presence of pyriform sinuses
85
Perceptual signs and symptoms of ankylosis of the cricoarytenoid joint
Unilateral: Hoarseness, breathiness Bilateral: stridor and dyspnea
86
Signs of unilateral ankylosis of the cricoarytenoid joint with a laryngeal
Lack of movement of the arytenoid Incomplete glottal closure
87
Signs of bilateral ankylosis of the cricoarytenoid joint with a stroboscope
Fixed/unmoving position of BOTH arytenoids Either lack of adduction or abduction of the VFs
88
4 types of vascular disorders
1. hemorrage 2. varix and ectasia 3. laryngeal web 4. blunt or penetrating trauma
89
Describe laryngeal webbing
Congenital disorder Result of incomplete maturation of developing larynx Sheet of tissues between the VFs Small webs at the anterior commissure may present problems
90
If laryngeal webs are extensive enough, what would be needed
Tracheostomy Surgery to split webs
91
Describe hemorrage vascular disorder
-Reddish color -Significant swelling -Usually unilateral -Can involve full or portion lengths of the VFs
92
Etiology of hemorrage vascular disorder
-Single episode of trauma voice use -Combination of heavy voice use + aspirin (or other anticoagulants and salicylates) -Extended use of steroids
93
Percceptual signs and symptoms of hemorrage vascular disorder
-Hoarse -Dryness -Vocal fatigue -Pain at time of precipitating event -Loss of upper range -Voice may be intermittently aphonia
94
Vascular hemorrage disorder is more frequently seen in?
Women
95
Explain blunt or penetrating trauma injuries
-Attempted strangulation -Penetrating neck wound -Blunt trauma resulting from a blow to the neck or from body being hurled with force -Necks sticking an object
96
In cases of severe blunt or penetrating trauma, what happens to the larynx?
-Laryngeal structures may be fractured or severely damaged -Composising airway -Voice difficulties
97
Surgical and therapeutic treatment of blunt or penetrating trauma
-Surgery: fix the airway and attempt to repair damaged structures -Therapy: understanding the constraints on the system and plan accordingly
98
What are chemical tracheobronchitis?
Inhalation injuries
99
The inhalation of gases, smoke, or steam can result in?
Longterm laryngeal and phonatory sequelae
100
Hot fumes cause what laryngeal reaction?
Reflex closure of the larynx to protect the trachea and lower tract
101
Symptoms of inhalation trauma
1. Swelling 2. Inflamation 3. Burns 4. Soot around the nose, mouth, and in oropharynx 5. Respiratory distress 6. Stridor 7. Wheezing 8. Hoarseness

Voice (5 decks)

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