Lecture 3 Org Flashcards
(100 cards)
1
Q
Causes for voice disorders
A
changes in [VF]:
1. mass
2. tension
3. control
2
Q
Etiologies
A
- Structural changes (nodules, lesions)
- Behavioural processes
- Psychological and psychiatric conditions
- Neurological disorders
- Degenerative processes
- Combinations of any of the above
3
Q
Historic incidences in adult voice disorder
A
- (1998): 3-10% in the general population
- (1979): overall prevalence 2.7%
- (1972): in 428 patients, 7.2% males and 5% females had a laryngeal pathology
4
Q
Incidence of voice disorders (1998 study)
A
1998:
* 1,262 ENT patients
* Most frequent voice disorders are benign lesions (nodules, polyps, edemas) and functional voice disorders
* More frequently in older populations (highest prevalence between 45-64 years)
- Gender differences:
– Males present more frequently with cancer, leukoplakias, hyperkeratoses
– Females present more frequently with nodules and psychogenic disorders
– Voice disorders more common in males
– females seek help more often than males
5
Q
Prevalences in young adults
A
22-44 years
Male: edema
Female: edema, polyps, nodules
6
Q
Prevalence in older adults
A
65+ years
male: vocal fold paralysis
female: vocal fold paralysis, cancer
7
Q
Prevalences in middle aged adults
A
45-64 years
Male: polyps, cancer
Female: edema, polyps, nodules, cancer
8
Q
Voice disorders in adults (2024 study)
A
(2024):
- Survey of 1,522 adults in the US
- Current voice disorder: 12.3%
- Lifetime voice disorder: 20.6%
- Recurrent problem: 9.5%
- Higher prevalences in teachers (42%), singers (31%) and professional singers (63%)
9
Q
The most frequent voice disorders in
children in the ENT clinic setting
A
- Subglottic stenosis (narrow airway)
- Vocal nodules (lesions)
- Laryngomalacia (larynx too flexible)
- Dysphonia without visible organic pathology
- Vocal fold paralysis (after injury, surgery)
10
Q
When does the larynx mature
A
Between 6 and 12 months
11
Q
Types of pediatric voice disorders
A
- laryngitis
- neurological problems
- allergies/airborne irritants
- laryngeal growths
- congenital malformations/birth defect
- prescription medications
- head/neck injury
- tissue damage in throat
- cancer in head/neck/throat
- gastroesophageal reflux
- other
12
Q
Vocal Nodules
A
- One of the most common benign lesions
- Inflammatory degeneration of the superficial layer associated edema and fibrosis
- Usually bilateral (‘clapping hands’)
- Sizes: pinhead-size to pea-size
13
Q
What is an edema?
A
a fluid-fulled pocket
14
Q
Where are vocal nodules located?
A
generally on the medial edge between the anterior 1/3 and the posterior 2/3s of the vocal fold
(point of greatest vibration amplitude)
15
Q
Types of vocal fold nodules
A
- acute vocal nodules
- chronic vocal nodules
16
Q
What is an acute vocal nodule?
A
– Usually gelatinous and floppy
– Overlying epithelium is unchanged
– From traumatic or hyperfunctional voice use
17
Q
What is a chronic vocal nodule?
A
– Harder, less flexible, increased fibrosis, thickened epithelium
– Increased stiffness of the vocal fold cover during vibration (transition and body often unchanged)
18
Q
What is the psychoanalytic characterization of affected individuals?
A
1990: talkative, socially aggressive, tense; may have acute or chronic interpersonal conflicts causing tension, anger…etc
- outdated
19
Q
Perceptual characteristics of vocal nodules
A
- Roughness
- Breathiness (caused by gaps)
- Increased laryngeal muscle tension
20
Q
Management of vocal nodules
A
- voice rest
- Phonosurgery for a compliant client who does not respond to treatment; should be followed by voice therapy
- Oral medications (steroids) for acute cases with vascular lesions (hemorrhage, varices, hematoma)
- surgical removal of the nodules without accompanying voice tx may result in recurrence
21
Q
Who gets vocal nodules?
A
2020: male and female children, adult females, untrained and uneconomical singers
22
Q
What are vocal fold polyps
A
- fluid-filled lesion in the superficial layer
- Sometimes related to a ruptured blood vessel from rapid onset and increase in size
- Believed to be caused by acute vocal trauma or misuse
23
Q
Where are vocal fold polyps located?
A
median 1/3 of the membranous vocal fold
24
Q
What are soprano pads?
A
small, protective bump in mid-part of VFs
non-pathological when they don’t cause voice issues
Mostly unilateral (but can be bilateral)
25
one difference between polyps and nodules?
polyps are generally larger
26
Types of vocal fold polyps
1. pedunculated polyp (attached to stalk)
2. sessile polyp (blister)
27
What are two other names for pedunculated polyps?
polypoid degeneration
Reinke's edema
28
What is Reinke's Edema?
* Reinke’s space fills with thick fluid
* Caused by longstanding trauma: e.g., vocal misuse combined with smoking
* Swelling affects the whole length of the vocal fold, glottal closure is usually complete
* Swelling bilaterally, sometimes unilaterally
29
Perceptual characteristics of Reinke's edema
- Increased mass and stiffness of the vocal fold but preserved closure
- Consistent changes: low pitch, hoarseness
- Sometimes called the ‘Johnny Walker’ voice (whiskey)
30
What population generally experiences Reinke's edema?
drinkers & smokers
31
Treatment of Reinke's edema
* Phonosurgery: Lateral VF incision and extraction of fluid (scars)
* Post-operative voice therapy for identification of detrimental behaviours, vocal hygiene, and improved voice production
* Voice therapy to facilitate the use of the new voice since the postoperative change can be quite drastic
32
What are the implications of a scar on the VFs?
the scar can contract and cause a groove (vocal sulcus)
33
What are cysts?
fluid-filled, whitish, and transparent sessile growths
34
Congenital and acquired cysts of the vocal folds
(1) Location?
(2) Cause?
(3) Uni-/bi-lateral?
* location: on the vocal folds, the ventricular folds or in the laryngeal ventricle
* Cause: blocked mucosal gland duct, or vocal misuse (i.e., develop from a polyp)
* Usually unilateral --> contralateral irritation of the mucosa may suggest a bilateral lesion such as vocal nodules!
35
Treatment of vocal fold cysts
* Cysts do not respond to behavioural
treatment.
* Phonosurgery
* Post-operative voice therapy (to avoid further irritation)
36
Papilloma
(1) What are they?
(2) Cause?
* Wartlike benign tumours that develop in the epithelium and can invade the lamina propria and the vocalis muscle.
* Probably caused by viral infection with Human Papilloma Virus (HPV).
37
Papilloma
(3) What strain is common in children?
(4) Incidence for both children and adults?
* Most common in children (Juvenile Onset Recurrent Respiratory Papilloma; JORRP),
* Incidence decreases with age for children and less common in adults but increasing incidence.
38
Papilloma
(5) What does it look like?
* Benign tumors do not metastasize and go into blood stream
* Fat dumb and happy (tumor can obstruct airway and motion of vocal folds)
39
Papilloma
(6) Removal (#of surgeries)
* This removal can entail numerous surgeries (around 40-50 surgeries for some kids)
* Laser surgery can still cause scarring (which leads to reoccurrence + lots of scar tissue in one place which leads to problems with voice quality)
40
The effects of papillomatosis on the vocal folds
* Severe dysphonia (affect on VF vibration)
* lesions affect the mass and stiffness (of the body & cover) of the VF in numerous locations
* Potential complications: Papillomas may spread throughout the airway and compromise breathing.
* Occasionally, the disease is fatal.
41
Treatment of vocal fold papilloma
* Aggressive treatment (due to rapid spreading)
* Interferon medication (suppresses replication of the virus)
* Laser surgery (repeated as necessary)
* Tracheotomy may be required if the airway
is severely compromised
42
What is the role of voice therapy in papillomatosis in the post-operative phase?
Rehabilitation of vocal function, especially in patients scarring from multiple operations
43
The role of voice therapy in papillomatosis during the Acute Phase
Some physicians argue that papilloma growth and severity can be reduced through relaxed voice use
*limited evidence*
44
Etiologic factors of granulomas
and contact ulcers
* gastroesophageal reflux (GERD)
* consequence of laryngeal intubation, especially if emergency or long-term
* persistent voice misuse: low-pitched pressed phonation (tight adduction of posterior arytenoids)
45
Treatment of granulomas and
contact ulcers
* Anti-reflux treatment if reflux is a factor.
* Phonosurgery: Risk of recurrence because of constant movement and mechanical pressure of the arytenoids.
* Voice therapy for reduction of the medial vocal fold compression and anti-reflux behaviours.
46
Vocal fold granulomas and
contact ulcers
(1) Location
(2) Type of lesion
(3) Cause
* Usually located on the vocal process of the arytenoid cartilage
* Often vascular lesions (can be filled with blood and interstitial fluid)
* Resulting from tissue irritation in the
posterior larynx
47
Characteristics of granulomas
and contact ulcers
* Only large lesions will affect the vibration of the vocal fold (phonation isn't always affected)
* Throat pain, vocal fatigue, restricted range
48
Perceptual characteristics of vocal fold polyps
* Mild to severe dysphonia depending on the location and nature of the polyp
* Larger polyps can cause inspiratory stridor
* Vocal fold stiffness depends on the etiology of the polyp: hemorrhagic polyps are stiffer than edematous polyps
* May persist longer than nodule
49
Treatment of vocal fold polyps
* Voice conservation
* If voice conservation brings no rapid improvement, phonosurgery is required, followed by voice therapy
50
Who gets vocal polyps?
people who yell/shout, or sing loudly
51
What is polypoid degeneration?
- most severe form of Reinke's edema
- entire vocal fold membrane is filled with viscous fluid
- vocal folds look swollen and enlarged
- may protrude more medially
52
Implications of congenital laryngeal webs on voice quality
* Depending on the extent of the web, laryngeal stridor and/ or respiratory distress may occur
* Depending on the size and thickness of the web, voice quality may be mildly to severely impaired (higher pitch)
53
Congenital laryngeal webs
(4) Implications on VF vibration
*Anterior part of VF will not vibrate, only the posterior part will vibrate
* Tiny VF -> higher pitch
* Will not be able to drop pitch, cough will also be high pitched (mechanical issue, unlike puberphonia)
54
Acquired laryngeal webs
(1) Cause
* A microweb (synechia) of the anterior
portion of the vocal fold can result from phonosurgery, laryngeal trauma or long-term intubation
55
Implications and treatment of Acquired laryngeal webs
Effect: Variable effect on voice quality
Treatment: phonosurgery
56
What is telangiectasias?
Visible dilated capillaries (little red spots)
*ENTs sometimes use telangiectasias and varix interchangeably
57
Treatment/therapy of congenital laryngeal webs
* Phonosurgical removal of the web (cutting near the anterior commissure)
* Insertion of a keel for several weeks
prevents reformation of a web (temporary tracheostoma necessary)
* Post-surgical voice rehabilitation
58
Four vascular lesions of the vocal folds
Hemorrhage, hematoma, telangiectasias, varix
59
What is a hemorrhage?
Blood flow from ruptured vessels in the vocal fold, often located in Reinke’s space (the superficial layer)
*ENTs sometimes use hematoma and hemorrhage interchangeably
60
What is a hematoma?
Accumulation of blood that has remained from a ruptured vessel
*ENTs sometimes use hematoma and hemorrhage interchangeably*
61
What are the effects of acquired laryngeal webs in male to female gender reassignment?
Webbing makes VF shorter, increasing pitch
Can be difficult to controlling webbing healing
62
What is a varix?
A clump of blood vessels that presents as an indurated, adynamic blood blister
*ENTs sometimes use telangiectasias and varix interchangeably*
63
True or false: vocal rest and steroids for hemorrhage
are helpful in removing the blood
true
64
Consequences of vascular lesions of the vocal folds
- Hemorrhage and hematoma can cause significant dysphonia through mucosal stiffness and/or scarring of the vocal fold cover (severe)
- Telangiectasias and varix may affect the amplitude, periodicity and symmetry of the mucosal wave. (often only noticed in singers)
65
Who suffers from vocal hemorrhage?
Can occur in anyone
(1991): Increased incidence among pre-menstrual women using aspirin products
66
Treatment of hemorrhage/hematoma
Usually good spontaneous resolution with voice conservation and rest
Alternatively: Rapid course of steroids
67
Treatment of telangiectasias and varix
Laser surgery if needed
68
Laryngeal trauma (2 types)
* Blunt or penetrating mechanical trauma (crushes laryngeal cartilages --> airway is compromised)
* Inhalation and thermal trauma (smoke/acid inhalation)
69
true or false: after the vascular lesion heals, voice therapy is not recommended
false, recommended to restore voice quality, as well as endurance and range.
70
Treatment for chronic laryngitis
* Identify and eliminate causative factors
* Voice therapy can have an important
supporting role in the modification of
misuse behaviours
71
What is acute laryngitis? cause?
Acute laryngitis: inflammation of the vocal fold mucosa
Exact etiology unknown; usually associated with viral infections of the upper respiratory tract and bacterial infections
72
True or false: acute laryngitis is not a possible symptom of COVID 19
false
73
Treatment for acute laryngitis
* External and internal hydration
* Rest
* If necessary, antibiotics and cough suppressants
74
What is Croup?
- Acute laryngitis in children
- Croup (laryngotracheobronchitis) is a more serious response to a laryngitis in children.
- Narrowing of the subglottic airway with hoarseness, a hacking cough, and stridor.
- Attacks can last between 30 and 60 minutes
75
What is chronic laryngitis?
* Long-standing mucosal inflammation, viscous mucus, epithelial thickening unassociated with a viral infection
* Mild to severe dysphonia, laryngeal fatigue and unproductive coughing and throat clearing
* Usually painless
* could be caused by smoking
76
Suicide attempts with bleach
Leaves severe burns in vocal tract (little rehabilitation that can be done for larynx in these cases)
77
Sulcus Vocalis
(1) Definition
(2) Layers of the VFs?
(3) Population affected?
* A ridge along the entire membranous portion of the vocal fold
* The sulcus involves the superficial layer and increases the stiffness of the vocal fold cover
* Found mostly in singers (bc they are more exposed to endoscopies/ENT visits)
78
Sulcus Vocalis
(3) Co-occurring conditions?
(4) Uni- or bi-lateral?
(5) Implications on voice quality
* Bowing: spindle-shaped gap between the vocal folds during phonation
(resulting in atrophy due to aging process, atrophy will result in consistent sulcus along length of VF)
* Usually bilateral
* Variable effect on voice quality, depends on the size of the glottal gap
79
Sulcus Vocalis
(6) Etiology
(7) Onset
(8) Detection/diagnosis
* Unclear; Disturbance in the embryologic maturation of the vocal foldcover?
* Acquired onset: Resulting from phonosurgery, aging or vocal fold paralysis.
* Difficult to detect and easily overlooked in videostroboscopy
80
Treatment/therapy of sulcus vocalis
* May not require treatment.
* Surgery is possible.
* Voice therapy may help to achieve optimum vocal efficiency with minimal strain
81
Presbylarynx
* Age-related changes in the laryngeal structure and function
* Decreased intrinsic muscle tone of the vocal fold --> VF might get thinner & lose mass [bowing closure]
* Decreased respiratory efficiency
* Decreased elasticity of the vocal fold
mucosa
82
Characteristics of presbylarynx
* Decreased pitch and loudness (instable)
* Decreased voice quality
* Usually from age 65+
* Vocal fold bowing (decreased muscle tone)
* Often falsetto compensation
83
Treatment of presbylarynx
* Voice therapy
* Endurance exercises, sustained vowel exercises, speaking louder
* Injection laryngoplasty will help the severe cases
84
Epithelial Hyperplasia: Leukoplakia and Hyperkeratosis
* Abnormal mucosal changes of the vocal folds
* Hyperplastic and irregular thickening of the epithelium
* Lesions may penetrate into the lamina propria
85
Epithelial Hyperplasia: Leukoplakia and Hyperkeratosis
(1) Precipitating factors
(2) Cancerous?
* Smoking, alcohol, chemical or toxic irritants
* Often pre-cancerous
86
Leukoplakia
* "White plaque”
* Thick white substance adheres to the vocal fold in diffuse patches
* Benign or malignant in nature
87
voice quality of leukoplakia
Rough, hoarse
88
Hyperkeratosis
* Layered build-up of keratinized cells on the
vocal folds
* Irregular margins caused by cell overgrowth
89
Treatment of epithelial hyperplasia
* Surgical removal because of the pre-
cancerous nature of these cells
* Biopsy and histological analysis of potential
malignancy
* Patient education to prevent recurrence (not always controlled by the patient; hope is that once the lesions are removed the cancer won't return)
* Post-operative voice therapy
90
What is keratin?
* Keratin: A fibrous scleroprotein that occurs
in the outer layer of the skin and in other
tissues such as hair, feathers, finger nails
and hooves
91
Effects of bronchodilators for allergies and asthma
influences airflow and air passage
92
effects of diuretics, corticosteroids and decongestants
influence the fluid level in tissues
93
effects of antihistamines, cough suppressants, and anti refluxiva
reduces secretions
94
effects of long hormonal therapies
change the vocal fold structure and permanently lower the pitch (especially testosterone)
95
Hormones and voice
1) Endocrine growth hormones change voice throughout the life-span.
2) Most marked changes in males during puberty.
3) In females, the onset of puberty, the menstrual cycle, pregnancies and menopause may alter voice quality.
males: drops an octave
females: drops a few semi tones
96
Rheumatoid arthritis (definition, symptoms, treatment)
A chronic immunologic and inflammatory disorder that affects synovial joints - including the cricothyroid and cricoarytenoid joints.
Symptoms: Pain during speech and swallowing, in severe cases mechanical fixation of the joints.
Treatment: Anti-inflammatories, corticosteroids.
97
Allergies
* Pharyngeal and nasal secretions may change resonance and affect the larynx.
* Anti-histamines can cause mucosal dryness.
* Prolonged intake of steroids can change the vocal folds.
98
Yeast infection: Candida albicans (and treatment)
* Fungus infections can lead to hoarseness, dryness and mild laryngitis
* Common in patients with compromised immune systems
* Treatment: Antifungal rinse
99
Gastroesophageal reflux disease
(GERD)
* Esophageal reflux can cause throat pain and dysphonia.
* Persistent GERD can lead to ulcerations or granuloma in the posterior larynx.
* Usually confined to the posterior larynx: Erythema, edema or hyperplasia of the interarytenoid rim (pachydermia laryngis).
* chest or throat pain
100
Ax and treatment of GERD
* Assessment: Transnasal PH-monitor for 24 hours.
* Treatment: Antacids, anti-reflux medication.
* Behavioural changes: Diet changes, weight changes, elimination of alcohol and caffeine (inhibit digestion), loose clothing, elevated headrest at night
