Neurogenic Voice Disorders

Question 1

CNS:

Answer 1

1. Motor cortex, primary motor strip, midbrain, brainstem
2. Broca’s area
3. Insula
4. Precentral gyrus
5. Basal ganglia/thalamus
6. Temporal lobes (Heschyl’s gyrus)

Question 2

Function of the Motor Cortex, Primary Motor Strip, Midbrain, and Brainstem (for voice, CNS):

Answer 2

motor control of larynx

Question 3

Function of Broca’s area (for voice, CNS):

Answer 3

voice response (preplanning)

Question 4

Function of the Insula (for voice, CNS):

Answer 4

motor planning for voice

Question 5

Function of the Precentral Gyrus (for voice, CNS):

Answer 5

voice production

Question 6

Function of the Basal ganglia/thalamus (for voice, CNS):

Answer 6

sensory info for vocalizing (motor)

Question 7

Function of the Temporal lobes (Heschyl’s gyrus) (for voice, CNS):

Answer 7

audition

Question 8

PNS (important for voice):

Answer 8

Cranial Nerves

Question 9

Which CN’s are important for phonation/voice? (4)

Answer 9

• Glossopharyngeal (IX)
• Vagus (X)
• Spinal Accessory (XI)
• Hypoglossal (XII)

Question 10

Glossopharyngeal (IX) and phonation/voice:

Answer 10

Motor to stylopharyngeus m. (elevates larynx)

Question 11

Vagus (X) and phonation/voice:

Answer 11

SLN, RLN: sensory & motor to larynx, motor to thorax

Question 12

Spinal Accessory (XI):

Answer 12

Neck accessory m.’s (SCM & trap), levator veli palatini & uvula

Question 13

Hypoglossal (XII):

Answer 13

Depression/elevation of larynx (via tongue m.’s), neck strap m.’s

Question 14

3 Branches of the Vagus:

Answer 14

Pharyngeal Branch
Superior Laryngeal Branch
Recurrent Laryngeal Branch

Question 15

Superior Laryngeal Branch of the Vagus:

Answer 15

Sensory: (internal branch) mucous membrane supraglottal larynx

Motor: (external branch) CT m.

Question 16

Recurrent Laryngeal Branch of the Vagus:

Answer 16

Right – loops behind R carotid & R subclavian

Left – loops around aortic arch

Motor: TA of vf, PCA (abductor), LCA (adductor), transverse arytenoids (adduction), oblique arytenoids (adduction) + all other laryngeal m.’s

*Very concerned with recurrent laryngeal nerve bc can cause vocal fold paralysis

Question 17

Neurogenic Etiologies (3):

Answer 17

• Congenital (Huntington’s)
• Lesion/tumor/disease (dysarthrias [can be caused by ALS or Parkinson’s], stroke, cancer)
• Trauma (TBI, n. trauma)

Question 18

Neurogenic Disorders can be:

Answer 18

• Lower motor neuron
• Upper motor neuron
• Mixed (upper + lower motor neuron type)
  ALS (most common), TBI, MS

Question 19

Lower motor neuron damage can cause (4):

Answer 19

• Vocal fold paralysis - part 2
• MG
• Guillaine-Barré
• Flaccid dysarthria

Question 20

Upper motor neuron damage can cause (4):

Answer 20

• Spastic dysarthria
• Hypokinetic dysarthria (PD)
• Hyperkinetic dysarthria (Spasmodic dysphonia - SD voice samples - NPRs Diane Rehm, essential tremor Huntington’s)
• Ataxic dysarthria

Question 21

Mixed (upper + lower motor neuron type) (3):

Answer 21

• ALS (most common)
• TBI
• MS

Question 22

Paramedial Position:

Answer 22

if a vocal fold is paralyzed in this position, the other vocal fold can compensate

Question 23

Spasmodic dysphonia can look a lot like muscle tension dysphonia. How do you tell the difference?

Answer 23

Muscle Tension Dysphonia isn’t neurological

Test the difference by looking at them while they laugh or yawn. MTD will back off when the patient is relaxed, SD will not bc it is neurological

Question 24

Types of Spasmodic Dysphonia (3):

Answer 24

Abductor Spasmodic dysphonia
Adductor Spasmodic dysphonia
OR Mixed Spasmodic dysphonia

• can also get laryngeal tremor with these
• not painful, but AD type can feel the strain
• usually do not get a functional disorder on top of this disorder
• proximal dyskinesia: movements not done on purpose also can coincide
• treat with Botox injected in the thyroarytenoid muscles
• Diane NPR has Adductor Spasmodic Dysphonia (hyperkinetic dysarthria)

Question 25

Abductor Spasmodic dysphonia:

Answer 25

vocal folds spasm open, breathy voice not common

Question 26

Adductor Spasmodic dysphonia:

Answer 26

vocal folds spasm closed (similar to how a spastic dysarthria patient sounds) most common

Question 27

OR Mixed Spasmodic dysphonia:

Answer 27

where they spasm open and they spasm closed

Question 28

Lower Motor Neuron Damage can cause (5):

Answer 28

- Flaccidity, weakness, reduced m. contraction, reduced ROM - Flaccid dysarthria - Vf paralysis or paresis (damage to recurrent laryngeal will result in paresis (sluggish or slow movement of the VF) OR paralysis) - MG - Guillaine-Barré *Generally unilateral and will be ipsilateral

Question 29

Why should you wait a year to do permanent surgery for vocal fold paralysis?

Answer 29

- A paralysis CAN turn into a paresis through regeneration (nerves CAN regenerate but it is VERY slow [up to a year]) - Wait a year to do permanent surgery for vocal fold paralysis: putting a silicone thingy in there to push the vocal fold

Question 30

UMN Damage can cause (4):

Answer 30

1. Spastic dysarthria 2. Hypokinetic dysarthria 3. Hyperkinetic dysarthria 4. Ataxic dysarthria

Question 31

Spastic dysarthria

Answer 31

- Spasticity/hypertonicity - Strain/strangle - Short phonation time - Monopitch

Question 32

Hypokinetic dysarthria

Answer 32

- Rigidity - Bradykinesia - Limited ROM - Resting tremor * Parkinson's * reduced loudness, short phonation time (effects both laryngeal and respiratory muscles), vocal fold muscles are not getting input for muscle tone—get boding of the muscles

Question 33

Hyperkinetic dysarthria

Answer 33

- Uncontrolled movements - Strain/strangle * Chorea * Huntington's

Question 34

Ataxic dysarthria

Answer 34

- Cerebellar lesion - Prosodic slowdown - Resonance changes - Inarticulation - “intoxicated” * cerebellum is affected (not precise movements), can affect gait (goes towards the affected side, stumbbling like drunk)

Question 35

What is bradykinesia?

Answer 35

slow movement

Question 36

Parkinson’s (hypokinetic dysarthria):

Answer 36

- hunched gait - bode appearance of the vocal folds. Basal ganglia is not making dopamine (Nuerotrasmitter), so tone is not there. - This causes resting tremor, some rigidity, muscle weakness, muscles have weakened and vocal folds will bode, and incomplete vocal fold closure bc of the lack of dopamine going to the muscles.

Question 37

Mixed Dysarthria (types):

Answer 37

Mix of dysarthria types (usually spastic & flaccid) 1. ALS – UMN & LMN 2. MS – myelin sheath degeneration 3. TBI - variable

Question 38

Why do we need myelin and what happens when it degenerates? (like in MS)

Answer 38

- Need myelin for protection of the axon AND rapid transmission (like needed for speech): - Muscles will start atrophying if the axon is getting damaged