Lesions of the Vocal Cords--Lecture 2 Flashcards Preview

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Flashcards in Lesions of the Vocal Cords--Lecture 2 Deck (123):
1

Functional Voice Disorders Definition

The way the VFs move not due to a neuro problem or organic problem; psychological issues, paradoxical issues, etc.; how the VFs move; not impairment due to neurological issues or organic issues; neurological innervation is intact & no structural abnormality

2

Functional Voice Disorders Examples

Functional aphonia, paradoxical VF movement (PVFM), muscle tension dysphonia (MTD), ventricular phonation, traumatic laryngitis, puberphonia

3

Puberphonia

Child going thru puberty and still has high pitched voice (ENTs often say they are fine); nothing pathological or neurological but may still be hoarse (may be the way they are initiating movement of the VFs—best procedure in these cases is a videostroboscopy (can see how the cords move & any gaps, bowing, etc.)

4

Neurological Voice Disorders Definition

Neural innervation problem, anything involving neurology (BG, LMN, etc.; could be periph. Path of CN)

5

Neurological Voice Disorders Examples

VF paralysis, spasmodic dysphonia

6

Organic Voice Disorders Definition

There is a pathology that has created the voice problem

7

Organic Voice Disorders Examples

VF nodule, polyp, cyst, granuloma, contact ulcer, infectious laryngitis, reflux laryngitis, presbylarynx, sulcus vocalis, Reinke's edema/polypoid degeneration, leukoplakia/ erythroplakia, hyperkeratosis, papilloma, webbing, cancer

8

Secondary Conditions Causing Voice Disorders

PD, ALS, MS, Huntington's disease (chorea), MG, essential tremor, pseudobulbar palsy, bulbar palsy

9

Lesions of VFs Produce Pathological Changes Such As: (A lesion will produce a pathological change)

Increasing mass (can be unilateral or bilateral—will help us make diagnostic decisions—polyps are usually unilateral and nodules are usually bilateral)
Altering shape (gaps-breathy escape)
Restricting mobility
Increasing or decreasing tension

10

Mass Laryngeal Lesions in Childhood

Cri du Chat; bacterial, viral, fungal infections; hypertrophic laryngitis; papilloma; laryngomalacia; congenital laryngeal web; congenital subglottal stenosis; congenital cysts; hemangioma; polyps; laryngotracheal cleft; laryngocele
More than nodules cause voice d/o's

11

Clearance for voice tx from ____

ENT

12

Stridor

Some type of obstruction; could be midline VFs; have to inhale over obstruction; have to determine where it’s coming from (is it laryngeal or is it nasal cavity)

13

Cri du Chat

Genetic defect
Discovered in neonates & children
"cry of the cat"
Structural-based problem

14

Characteristics of Cri du Chat

Micrognathia, abnormal larynx (abnormally formed), beak-like profile, microcephaly, hypotonia, hypertelorism (wide-set eyes), MR, midline oral clefts
*Don't have to see all these things, but these are possibilities

15

Cri du Chat Vocal Characteristics

High-pitched, mewing cry
Painful cry
Flat or rising melody patterns
Strained quality (abnormal larynx)
Crying on inhalation w/ inhalatory stridor

16

Bacterial, Viral, & Fungal Infections:

Respiratory Distress
Airway Obstruction (Edema)

17

Croup

Viral--due to influenza virus
Affects children between 6 mos & 6 yrs of age
Inflammation & edema in the subglottal area

18

Fungal Infections Affecting Voice

Fungal Laryngitis, candidiasis, fungal infection secondary to chemotherapy

19

Candidasis

Thrush; yeast infection
Can usually be seen more in VF abduction; whitish spots on videos
Can develop in mouth or larynx

20

Fungal Infection Secondary to Chemo

When one's immune system is suppressed by something like chemotherapy, a fungal infection may be quite extensive

21

Coccidomycosis

Fungal infection from California's Central valley

22

Bacterial Infections Affecting Voice

Epiglottitis, bacterial laryngitis

23

Epiglottitis

A bacterial infection of the larynx is very serious as the swelling can nearly close off the airway in an adult and easily closes off the airway in a child; aka supraglottitis; The danger lies in the softness of the tissue which can easily expand, particularly the loose tissue of the arytenoids can be drawn in during inspiration

24

Bacterial Laryngitis

Video: VFs don’t have good flexibility; strained voice due to stiffness and a high pitch; lots of breathiness, decreased intensity
Decision about Pitch, Intensity, Quality, etc.

25

Anterior to mid cord gap & posterior to mid cord chink

pitch will be dropped inflammation; soft intensity due to gaps (leaks); breathy, strained, hoarse

26

Vocal qualities that often go together

Hoarse and breathy

27

Hoarseness

a friction set up at the level of the glottis
Is it mild, moderate, severe (affects treatment)

28

Viral Infections

May be the common winter cold: VFs are pink and swollen, the voice deep, the secretions thick.

29

Laryngitis Sicca

Laryngeal dryness
No cause or solution has been found
Some have speculated that it is autoimmune

30

Herpes Simplex Virus

Viral infection that may affect the larynx & needs medical attention
2 types: Type I and Type II

31

HSV Type I

Produces most cold sores
Watery blisters in the skin or mucous membrane

32

HSV Type II

Produces most genital herpes
Watery blisters in the skin or mucous membrane

33

Viral Croup

Most common form of airway obstruction in children 6 mos to 6 yrs
Respiratory tract infection

34

Viral Croup Causes:

Upper airway obstruction causing: barking cough, hoarse voice, inspiratory stridor, wheezing
Worried about swelling causing obstruction

35

Tx for Viral Croup

Epinephrine

36

Hoarse Vocal Quality

Includes breathiness (hoarse & breathiness)

37

Harsh Vocal Quality

No breathiness

38

Laryngeal Papilloma Location & Size

On & around the VFs (may be all over)
Wart-like

39

Laryngeal Papilloma Etiology

Uncertain but thought to be viral

40

Laryngeal Papilloma Vocal Sx's

Breathiness, low pitch, tension, aphonia (occasional), hoarseness (bad term)

41

Laryngeal Papilloma Management

Med-surg with associated voice therapy; keep recurring; have to be taken off with a laser

42

Congenital Laryngomalacia

Redundant (too much) arytenoid cartilage mucosa
Epiglottis omega shaped
Aryepiglottic folds sucked into glottis on inhalation/blown out on exhalation
Sx's resolve spontaneously w/in 6 to 18 mos

43

Other Associated Problems with Congenital Laryngomalacia

Gastroesophageal Reflux

44

Congenital Laryngomalacia Voice Characteristics

Congenital laryngeal stridor described as high pitched harsh & fluttering; becomes worse w/ crying & feeding
Swallow study needed to rule out aspiration pneumonia

45

Fluttering Sound in Congenital Laryngomalacia

From falling in/collapsing of epiglottis; structural issue

46

Congenital Laryngeal Web Location

Generally includes anterior commissure; can extend length of VFs; attachment can be infra & supra glottal as well as cordal

47

Congenital Laryngeal Web Etiology

Congenital: Didn't totally separate during development
Acquired: Anything that damages the larynx: chemicals, tubes, etc.

48

Vocal Sx's: Congenital Laryngeal Web

Elevated pitch, tension, diplophonia, hoarseness

49

Congenital Laryngeal Web Management

Combination of surgery & voice therapy

50

Congenital Subglottal Stenosis

Arrested embryonic development of conus elasticus
Maldevelopment of the cricoid cartilage
Obstructive narrowing of airway
Voice normal to impaired
Stridor present from birth
May require tracheostomy

51

Hyperfunctional Breathiness

Harshness, Straining (relaxation)

52

Hypofunctional Breathiness

Slow, weakness, not a strong voice (strengthening); can they cough; can they do /i/--/i/--/i/

53

Congenital Laryngotracheal Cleft

Embryonic failure of dorsal cricoid lamina fusion
Results in an interarytenoid cleft & open larynx posteriorly
Cry weak or aphonic due to cleft preventing apposition of the VFs
Aspiration pneumonia
Feeding problems-Affects feeding; may have to say feeding isn’t appropriate
Voice may not be impaired; may be normal

54

Congenital cysts are (location) vs. nodules & polyps

Unilateral in mid part of cord
Nodules & polyps are usually on the edges of the VF

55

Congenital cysts general appearance

Generally look to be embedded in the body of the cord; look like beebee that's encapsulated
Sometimes hard to find
Voice would be deep, breathy, hoarse

56

Nodules are bilateral or unilateral?

Bilateral

57

Pachydermia indicative of ____

Reflux in back of larynx
interarytenoid space

58

Congenital Laryngocele

Born with a weakness in the larynx
Congenitally large laryngeal ventricle
Enlarged by activities that increase intralaryngeal air pressure
Air filled or fluid filled
Herniation of laryngeal ventricle (space between false & true VFs)

59

Sx's/Factors of Congenital Laryngocele

Straining, coughing, vocal abuse, playing wind instruments, glassblowing, hoarseness, inspiratory stridor, dysphagia
Pt may be able to feel it and push it back (it will return)
Displaces membrane (shouldn’t come back after treatment)
“Lump in throat” often called globus sx—often considered something not actually there

60

Tx of Congenital Laryngocele

Medical-->Incision-->drainage

61

Voice/Dysphagia & Congenital Laryngocele

Sessile fluid filled cysts
Arise from laryngeal ventricle
Displace true & false VFs
Glottic & supraglottic obstruction
Swallowing problems
Voice impaired to aphonic
May obstruct airway-->stridor

62

Space between true & false VFs is in ____ cartilage

Thyroid

63

3 Types of Congenital Laryngocele

I. Internal Type
II External Type
III. Combination Type

64

Internal Type Congenital Laryngocele

Within the thyroid cartilage

65

External Type Congenital Laryngocele

Each protrudes above thyroid cartilage through thyrohyoid membrane
Either above cartilage or through membrane

66

Congenital Hemangioma

Birthmark/"raspberry"

67

Types of laryngeal injuries

Edema, hematoma, fractures of the larynx & tracheal stenosis, dislocation of arytenoids, inter-arytenoid fixation, lacerations, VF paralysis, laryngeal web, perforation of the pyriform sinus or esophagus, ulcer & granuloma of the vocal process, hemorrhage
See in hospital or OP setting
How long have they sounded like this? Vocal abuse/lots of screaming or yelling?

68

Hemorrhage

Voice may change due to swelling/differences in vibration (may slow down vibration of VFs)--functional category
Hemorrhagic laryngitis

69

2 types of reflux

GERD & LPR

70

GERD

Gastroesophageal reflux disease
Chronic digestive disease
Stomach acid backflows into esophagus

71

LPR

Laryngopharyngeal reflux disease
Extension of GERD
Stomach acid backflows into esophagus, larynx, & pharynx
Has to be this type of reflux to affect voice; white scalloping on posterior side (may have continuing hoarseness after tx)

72

Reflux Laryngitis

May see mucus banding (point of traumatic impact across larynx)
Mucus secretions: secretions fall over & cause scalloping
Elevating head of bed can help (using more pillows doesn't work)--wedges that you can sleep on, blocks; medications, etc.

73

Some Causes of Laryngeal Trauma

Automobile accidents, gunshot wounds, laryngeal intubation, nasogastric (NG) intubation

74

Focal Trauma

Laryngeal intubation & NG intubation
Ask about previous surgery (general anesthesia)—intubation—followup
Any correlations?

75

Laryngeal Intubation

Endotracheal tube is too large for Pt's airway
Mucosal ulceration leads to granuloma
Dislocation of arytenoid cartilage

76

Nasogastric Intubation

Damage to posterior cricoarytenoid
Mimic recurrent laryngeal nerve palsy
Cricoarytenoid is abduction of the VFs (damage would be that pt wouldn’t be able to open at least 1 VF); NG tubes are hard to place; if it’s bilateral damage—might have a hard breathing—may end up trached (due to muscle being traumatized, not damage to nerve)

77

Intubation Granuloma Location

Vocal process; bilateral or unilateral

78

Intubation Granuloma Etiology

Damage resulting from prolonged or faulty intubation to maintain airway (posterior--Something in the back is usually the only site that causes pain—have you had surgery?)

79

Function disorders are what will show up at our office when ____

the doctor says there's nothing wrong (structure looks good)

80

Vocal Abuse

Strenuous speaking, yelling/screaming, singing, coughing, throat clearing, velopharyngeal insufficiency
Coughing: "I've been coughing for 2 mos"--ask how it started, was there a lot of coughing, throat clearing, etc.

81

Vocal Misuse

Incorrect use of pitch or loudness
1. Elevated loudness levels, high background noise, heavy machinery, speaking over loud music, hearing loss
2. Elevated pitch levels, increased loudness leads to increased pitch, emotional stress, excessive muscular tension
Speaking or singing on the wrong pitch
Too loud: hearing loss, coaches, teaching, where they work
Straining with no lesion: elevated pitch
Straining with lesion: lowered pitch

82

Vocal Abuse in Children

Hyperadduction of VFs
Inflammation
Vocal nodules
Contact ulcers

83

Nodules in the _____; Contact ulcers in the ____

front; back

84

Posterior abnormal contact:

lowest pitch possible & glottal fry (produced back by arytenoids & causes them to slam together/rub)—pain also associated with anything posterior b/c of arytenoids

85

Sx's of Nodules

Client comments, vocal fatigue, vocal change, chronic throat clearing, intermittent loss of voice, poor pitch control, deterioration of voice during day, tender strap muscles

86

Exam for Nodules

Ask about voice in morning & how it changes throughout the day (gets worse through the day; voice is pretty good in the morning)
More hoarse as the day goes on
“does your neck feel sore?”
Watch for tension in neck

87

Location & Size of Nodules

Bilateral (unilateral rare); Juncture of anterior & middle 1/3 of VF
Pinpoint to in excess of 6 mm; can be very small

88

Description of Young Nodules

Soft; normal epithelium; pink
Easier to tx

89

Description of Mature Nodules

Firm; organized epithelium; whitish to yellow
(long presence—may not respond to voice therapy alone—may need medical management 1st then voice tx; voice may not return to normal right away after medical tx);
Often good to record voice before & after surgery

90

Vocal Rest after Surgery for Nodules

Counsel Pt about how to talk after surgery; quiet whisper is the best way to talk after surgery; have to teach this-no stress behind voice; MD will recommend how long; Writing is best, but most won’t do this; Stage whisper is just as abusive as talking--VFs still adducting

91

Full Abduction

Cords drawn wide apart in forceful inspiration

92

Quiet Whisper

Fold slightly separated along the anterior 2/3s & a triangular aperture remains posteriorly

93

Strong Whisper

Folds are adducted firmly along the anterior 2/3s & air is forced through the posterior triangle with considerable friction

94

Contact Ulcers

Ulceration of the folds in the arytenoid (posterior) region
Associated with trauma of hammer & anvil b/c arytenoids strike each other in a force type of phonation causing ulceration of the covering of arytenoid region

95

Visual Appearance of Contact Ulcer

A raised granuloma on 1 side & a crater on the other side
Pachydermia of the mucous membrane forms

96

Pachydermia

Abnormal thickening
Of the mucous membrane in contact ulcers

97

Contact ulcers develop in individuals having ____

Deep throaty voices (fry)
(In therapy, work on softer production)

98

Personality Characteristics & Contact Ulcers

Hyperactivity, emotional reactivity, family problems, aggressive/less mature, difficulty managing stressful situations

99

Characteristics of Contact Ulcers

Extreme tension of speech musculature coupled w/ generalized body tension
Forcing pitch below optimum
Glottal plosive attack

100

Speech Patterns and Contact Ulcers

Explosive Speech Patterns: predominate speech patterns; rigid melody or confined pitch; considerable breath pressure; hoarse quality

101

Contact Ulcers History

1961: Von Leden & Moore discovered cartilage performs rocking movement making a wide excursion in low frequencies & a prolonged approximation of surfaces in region of vocal processes which expose them to greater stress

102

Tx of Contact Ulcers

Altering fundamental frequency alters the length, thickness, & tilt of VFs so that on adduction shifting parts of stress occur & glottal impact doesn't always fall in the same region
What am I doing physiologically?—how is tx helping?

103

Polyps Location

Occurs in any vascular organs
Nasal or laryngeal mucosa
Unilateral or bilateral
Polyps are ANTERIOR
Majority are UNILATERAL
Nodules are bilateral; polyps are unilateral; but they occur at the same spot; they look different; their causes are very different

104

Polyps Size

Varies from small (6mm) to obstructive

105

Polyps Etiology

Airborne irritants (smoking, inhalation of toxic fumes, etc.), idiopathic

106

Polyps Description

Soft globular mass exhibiting mucoid degeneration
Pedunculated--with a pedicle or foot
Sessile--having no peduncle, but attached directly by a broad base
If the VFs have been damaged for many years, there will be lots of atrophy—be very clear about expectations—may be able to help some, but probably won’t make it 100% better
Polyps are transparent—can see thru them

107

Vocal Characteristics of Polyps

Typically have very deep, gravelly voice
Diplophonia, breathiness, low pitch, intermittent aphonia, hoarseness
VF tone & another tone from the polyp (gonna sound like harmony)
No breathiness-probably isn’t it (because nothing seems to be in the way)

108

Management of Polyps

Pretreatment recording & counseling; pretreatment photography
Surgical management
Post-op voice rest; post-op voice therapy
Polyps usually need surgery before therapy-Therapy about eliminating compensatory behaviors developed because of polyps

109

Polypoid Degeneration

Whole cords taken over by polyps (probably heavy smokers)

110

Physiologic Voice Disorders May Exhibit ____

Diplophonia

111

Diplophonia

2 distinct pitches during phonation

112

Etiologies of Diplophonia

Unilateral paralysis of true VF
Vibration of ventricular folds (false VFs)
Hyperfunctioning of the vocal mechanism
VFs vibrate at different frequencies
VF pathology
Edema in 1 cord, 1 functioning better than the other

113

Ventricular Phonation

Produced by vibration of the false vocal folds
May develop as purely functional or as a substitute voice for true vocal fold pathology
We use the false folds when we cough
May be psychological as well (afraid to damage true VFs)

114

Dysphonia Plicae Ventricularis

Ventricular phonation; musculoskeletal tension disorder
Low vs. high pitch
Hoarse
Diplophonia
Great amt of pressure behind using false folds in speech
Don’t use true folds, just false folds—only a little portion of it—smaller surface—high pitch
Low pitch is _____?
Want to eliminate using false folds and bring true folds together for speech

115

How many Forms of Ventricular Phonation?

6: Habitual origin, emotional, paralytic, cerebral type, cerebellar type, vicarious function
Some of these you may not want to change

116

Habitual Origin Ventricular Phonation

Most frequent & represents the extreme & end stage of hyperkinetic dysphonia due to constant vocal abuse

117

Emotional Ventricular Phonation

Occurs during times of stress or a crucial period of a psychoneurotic person; an emotional crisis may precipitate a psychogenic dysphonia by over adduction of the ventricular folds

118

Paralytic Ventricular Phonation

Due to paralysis of the true VFs, the ventricular folds take over the function of phonic glottal closure

119

Cerebral Type Ventricular Phonation

May be a sign of dysarthria resulting from brain disease; as a sign of spasticity the voice may change to choked, rough, low, & a squeezed sound

120

Cerebellar Type Ventricular Phonation

Lesions of the cerebellum may have ataxic, irregular, labored phonation with spasmodic over contraction of the ventricular folds

121

Vicarious Function Ventricular Phonation

Desirable compensatory adjustment when the ventricular folds are substituting for defective vocal folds

122

Presbylaryngis

A larynx that exhibits significant signs of aging such as: reduced control over phonation, changes in speaking & fundamental frequency, reduced pitch range & deterioration of vocal quality; loudness, resonance, & timing also affected
Have to make sure there is no neuro problem
“Presbylaryngis is a condition that is caused by thinning of the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and therefore do not meet in the midline. As a result, the patient has a hoarse, weak, or breathy voice. This condition can be corrected by injection of fat or other material into both vocal folds to achieve better closure.”

123

Presbyphonia

Acoustic properties associated with aging in the absence of other pathology: altered pitch, roughness, breathiness, weakness, hoarseness, tremulousness/instability