Miscellaneous Voice Pathology

Question 1

Name 3 inclusion criteria for irritable larynx syndrome

Answer 1

1. Symptoms of laryngeal tension (ie. dysphonia, laryngospasm with or without globus, chronic cough)
2. Visible and palpable evidence of tension on laryngoscopy and palpation
3. Presence of a sensory triggering stimulus such as an airborne substances, esophageal irritant, or odour
   - Need to rule out organic causes: Neurologic dx, psych, etc.

Question 2

Regarding Premenstrual Voice Syndrome, discuss:
1. What is the suspected pathophysiology?
2. What are the clinical features?
3. Treatment?

Answer 2

Pathophysiology:
- Thought to occur due to increased estrogen and progesterone just prior to menses, causing voice changes
- Usually noticed by professional voice users (ie. professional singers)

Clinical features: 2 of
1. Vocal fatigue
2. Decreased range
3. Loss of power

Treatment:
1. Modify work/practice/performance activities

Question 3

What are the typical voice changes seen in gender transitioning?

Answer 3

1. Female to Male experience hormonal effect of lowering voice
   - Hormone change sdo not increase the voice significantly for male –> female

Question 4

What are the treatment options to raise vocal pitch in Gender Reassignment?
What are the goals of surgery, and how can they be achieved?

Answer 4

1. SPEECH THERAPY (Primary Modality)
   - Changes in pitch, intonation, and articulation required
   - Need to increase pitch ~30Hz for females
   - Surgery is reserved for those who fail voice therapy

GOALS OF SURGERY:
1. Increased VF tension
2. Shorter VF
3. Decreased VF mass
4. Alter appearance

INCREASE VF TENSION:
1. Cricothyroid approximation or Type 4 thyroplasty
- CT approximation rotates forward
- ~1/3 fail (sutures break)
- Can be done awake

SHORTEN VF:
1. Wendler Glottoplasty (create an anterior glottic web)
- Anterior 1/3 denuded (stripped) then sutured, ± injection medialization or botox
- Can be done endoscopically
- Durable long-term results
- Decrease range and post-op hoarseness

2. Feminization Thyroplasty
   - Laryngofissure, remove 1cm thyroid cartilage
3. Anterior commissure advancement
   - Induced anterior scarring

DECREASE VF MASS:
1. CO2 laser
2. Intracordal steroids to produce atrophy
3. Remove TA muscle bulk, re-drape muscle flap ± suture

COSMETIC ALTERATIONS:
1. Thyroid prominence shaved (subperichondrial dissection)

Question 5

What are the different causes of velopharyngeal insufficiency?

Answer 5

1. History of cleft palate
2. Submucous cleft
3. Deep pharynx (Cranial base or cervical spine anomalies)
4. Irregular adenoids
5. Enlarged tonsils
6. Neurological injury
7. Syndromes: T22 (hypotonia), VCF
8. Complication of adenoidectomy, maxillary advancement or resection of nasopharyngeal tumors
   - Most post-op adenoidectomy VPI is transient and resolves in 6 weeks; if it doesn’t, surgical correction is indicated

Question 6

What are the symptoms of velopharyngeal insufficiency?

Answer 6

1. With exception of 3 nasal phonemes (m, n, ng), all phonemes in English language are produced with the palate closed
2. With VPI - all phones start to sound hypernasal (Especially vowels)
3. Nasal regurgitation of food

Question 7

What is the management of velopharyngeal insufficiency (VPI)?

Answer 7

NON-SURGICAL:
1. Speech therapy
2. Prosthetics (palatal lift or obturator)
3. Biofeedback with nasometry
4. CPAP (strengthens palate)

SURGICAL:
1. Pharyngoplasty
2. Pharyngeal flaps
3. Posterior pharyngeal wall augmentation