Psychogenic Voice D/O's & Spasmodic Dysphonia Flashcards Preview

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Flashcards in Psychogenic Voice D/O's & Spasmodic Dysphonia Deck (50):
1

Functional/Psychogenic Voice Disorders

Refers to a group of voice disorders that exist in the absence of an organic laryngeal pathology

2

8 Interpretations of "Functional" d/o:

1. No apparent alteration of structure as detected by laryngoscopic exam
2. (-) laryngoscopic exam but (+) stroboscopic exam
3. Dysphonia disproportionately severe
4. D/o of nervous origin w/ variable sx's that are conducive to formation of organic lesions
5. D/o reversible as opposed to organic d/o's which possibly aren't
6. Function is altered
7. Incorrect motor utilization
8. Desire on the part of pt to mask the exact cause

3

2 Subdivisions of Functional Disorders

1. Disorders resulting from abuse or improper use of the vocal organ, &
2. Disorders that reflect psychotic or psychoneurotic mental states

4

Pts who demonstrate altered voices due to anxiety w/ absence of VF lesion or trauma exhibit these sx's

Weak intensity, hoarseness/breathiness, achy throat, lump in throat (sometimes referred to as globus sx)
Also check breathing pattern
When we hear these sx's, it doesn't automatically lead to this dx--it's a contributing factor to dx

5

What causes a hysterical reaction?

Pt may be under emotional strain & tighten down on larynx/exhibit laryngeal tension
Pt may have the breath taken away by shocking news which renders person speechless
Psychologist may be able to trace traumatic event that may have occurred earlier in life that's associated w/ present stress & is evoking hysterical reaction; may want to co-tx w/ a psychologist
What does losing your voice mean?—could mean being hoarse to the pt.
Pt’s often want to sit and talk about problems instead of getting tx

6

A Hysterical Voice Disorder is...

A psychogenic illness: physical or mental sx's of a disorder that aren't real; conversion sx's shown as a consequence of environmental stress or interpersonal conflict

7

Conversion Sx's

Motor paralysis; abnormal gait; ticks, tremor, rigidity; sensory d/o's such as a lack of sensation; excessive sensitiveness to pain; loss of sight, hearing, taste, & smell

8

Hysterical Aphonia

VFs appear to exhibit an adduction paralysis
Pt demonstrates normal abductions on deep inspiration & is able to obtain normal adduction on coughing & swallowing
Impairment is only on approximating VFs for voicing
Voice sounds strained aphonic whisper

9

How to differentiate b/t VF paralysis & hysterical aphonia

Have pt cough: Pt with paralysis will have aphonic & mushy cough (Mushy cough is not concluding that pt can adduct VFs and produce normal voice); Pt w/ hysterical aphonia will exhibit a strong normal cough

10

4 VF positions of the hysterical aphonic voice Pt

1. VFs are elliptical shaped: Pt unable to adduct & unphonated air escapes during voicing
2. Folds freely abducted & no attempt @ adduction
3. Both true & false folds tightly pressed together in spasm, w/ no vibration of true or false folds & no voice produced
4. VFs approximated tightly in anterior 2/3s, w/ a significant triangular aperture located in posterior 1/3

11

Broadnitz (grandfather of otolaryngology) & 1st therapy session with hysterical aphonia

Get voice back; since d/o has psychological component, you want to inspire confidence
Get pt's voice back by having pt try to hum, clear throat, or cough to get VFs to adduct
Once they get voice back, they could start with some other conversion reaction

12

Other techniques for getting voice in hysterical aphonia

Impede auditory feedback w/ earphones & ask pt to cough & speak to get normal voice
Provoke gag reflex
Obtain voicing by pulling on pt's tongue & asking him to say "ah"; once voicing is achieved have pt say words using "ah" vowels
Try to get pt to clear throat; once good throat clear is produced, get pt to continue the tone into vowel words; make sure the voice isn't stopped b/t throat clear & vowel; must be continuous to work

13

Mutational Falsetto

Failure to change from higher-pitched preadolescent male voice to lower pitched voice of adolescence & adulthood; does not occur due to physiological immaturity of the larynx or VFs

14

In mutational falsetto, VFs are ______

capable of producing a normal low pitched tone

15

Mutational Falsetto Predisposing Factors

Excessive muscular tension
Unusually early breaking of voice which renders boy self conscious
Desire to retain soprano voice for singing
Fear of assuming adult responsibility
Hero worship of boy/man w/ strong feminine tendencies
Delayed pubertal development
Severe deafness

16

Mutational Falsetto Anatomic Abnormalities

Small larynx & short VFs
Asymmetrical VFs
Paralysis of one VF

17

Characteristics of Mutational Falsetto (Puberphonia)

Larynx high in neck, VFs stretched thin anteriorly, eliptical shaped glottis (due to tension/tightness; strong, spastic, tense--want to relax it); shallow respiration; high or intermittently high in pitch; weak volume; monopitch; breathy or whispery voice; hoarse; immaturity, passiveness, effeminate characteristics; thin & strident tone

18

Laryngeal/Respiratory Postures/Movements for High-Pitched Mutational Falsetto Voice

Larynx is high in neck
Body of larynx is tilted downward, having effect of maintaining VFs in lax state
VFs are stretched thin anteriorly by contraction of cricothyroid muscles
Glottis is elliptical shaped
VFs offer little resistance to infraglottal air pressure
Respiration for speech is shallow

19

Rationale for tx in Puberphonia

Lower larynx to reduce stretching of VFs

20

Tx of Mutational Falsetto

Consists of lowering pitch to pt's optimum level
This is difficult task since social/psychological factors may interfere w/ rehab potential
Producing sharp glottal attack w/ therapist exerting downward pressure on larynx during phonation elicits low-pitched tone

21

Pitch

Tells about tension; point of contact changes with different pitches; you change how VFs come together (higher is more closure on the front)

22

Muscle Tension Dysphonia

Hyperfunctioning of muscles present secondary to psychogenic factors

23

Spasmodic Dysphonia--a psychogenic voice disorder or not?

No longer considered a psychogenic voice disorder; now a neurological disorder

24

Spasmodic Dysphonia Classifications

Classified as a d/o of the extrapyramidal system & is representative of a dystonia
A focal dystonia (of the VFs)
Also dystonic movement of the soft palate, tongue, & hypopharynx

25

Dystonia

A neurological movement disorder in which the sustained muscle contractions cause twisting & repetitive movements or abnormal postures

26

Causes of Spasmodic Dysphonia

No known cause
As many as 50% of pts report that their vocal sx's followed a severe upper respiratory infection; frequency of this experience has led some to postulate a viral injury to CNS as cause
Other MDs have speculated that head injury may cause it
Thought to be an extrapyramidal sign
May also be on psychogenic side of it (someone died in front of woman at church)

27

What is Spasmodic Dysphonia?

Permanent neurological condition that causes the voice to become difficult to use & understand b/c of uncontrollable spasms in the VFs
People typically experience "choking off" of voice as the VFs squeeze tightly together
In a small %age of pts, spasms pull VFs apart & voice "drops out from under" leading to a mixture of vocal sounds & whispers
Pts can have both adductor & abductor type
One is an adductor type and one is an abductor type (or mixed type)

28

Distinguish SD from ____

Pure vocal tremor; essential tremor (have them hold their hands out in front of them b/c you'll see tremor in hands)

29

How to test:

Always have them prolong /i/: choking off of voice, strained, strangled

30

Voice Characteristics of Adductor SD

Jerky, strained-strangled, harsh, low-pitch, irregular voice stoppage
Sensation of choking, feeling of tightness across neck & chest, straining, & wrenching movements
Most common type
True VFs (vocalis musculature) are spasmodically tightened (i.e. sudden, intermittent closures of the glottis) during phonation

31

3 Classifications of VF Movements of Adductor SD

1. Excessive sphincteric action of the intrinsic laryngeal muscles only
2. Intrinsic & extrinsic muscle movements are excessive & there is medial movement of the ventricular folds
3. Simultaneous contraction of all intrinsic & extrinsic muscles, closure of the ventricular folds & abnormal respiration movements (most severe)

32

Difficult Phrases for Adductor SD

Counting from 80-89 (the vowel)
"We mow our lawn all year."
"We eat eels every day."
"A dog dug a new bone."
"Where were you one year ago?"
"We rode along Rhode Island Avenue."
"Eeeee eee eee."
Determine SD on vowels--most problems on vowels

33

Difficult Phrases for Abductor SD

Counting from 60-69
"Peter will keep at the peak."
"The puppy bit the tape."
"When he comes home, we'll feed him."
"Tap the tip of the cap, please."
"Keep Tom at the party."
"See see see."

34

Abductor SD Characteristics

Less common form of SD resulting in spasmodic separation of VFs (sudden, intermittent glottal opening) during phonation
Sudden aphonic episodes in phonation disrupt connected speech by creating problems of voice volume, pitch maintenance, & syllable duration, as well as general speech fatigue due to substantial air wastage
Hear voice & then spastic separation of VFs

35

Tx Options for SD

Speech therapy (not for cure, but to learn to cope w/ problem)
Meds (none of which is routinely effective & some of which may have disagreeable side effects)
Surgery to paralyze 1 VF in order to weaken or abolish spasms
Botulinum toxin injection
*People don't seem to progress & get worse

36

Botulinum Toxin Injection

Meds produced by the same bacterium that causes the disease, botulism; bacterium itself is not injected; minuscule amount (1/800th) of the dangerous dose is used
Injections results last from 6 wks to 6 months depending on the pt

37

Essential Voice Tremor

Disease of involuntary movement
50% of cases inherited & worsen w/ age
Causes rhythmic changes in voice
Maybe only minor quavering of the voice or severe interruption in continuous voicing
It is rhythmical & presents across all voice tasks such as singing & whispering
May also have associated shaking of hands or head

38

Vocal Fold Dysfunction

AKA paradoxical VF movement disorder
Characterized by stridor due to VF adduction during inhalation obstructing airway
Normal VF movement during speech, however stridor b/t phrases
Obstruction is at VFs not lungs
Stridor on inhalation
Pts with asthma can get stridor
On inhalation, VFs should abduct, but w/ this, VFs slam shut (opposite of what should happen)
Going to feel smothered—can’t get air in—no problem with VFs themselves so voice should be normal unless they push voice out & strain a whole lot; Worry about pass out—emergency trach & don’t need it

39

VF Dysfunction Tx

Teach pt to do diaphragmatic breathing, know this is coming on, exhalation of voice, etc.—use own feedback to help them

40

Different Categories of Pts with VF Dysfunction

1. Idiopathic focal dystonia
2. Associated w/ or masquerading as asthma
3. Exercise induced stridor
4. Psychogenic
5. Associated w/ gastroesophageal reflux

41

Sx's of VF Dysfunction

Noisy obstructed breathing, choking episodes, chronic or intermittent hoarseness, difficulty swallowing, a sensation of lump in throat, chronic throat clearing & cough, excessive throat mucous

42

VF Dysfunction Attacks Occur:

After a meal
After the start of exercise
After bending over
Awakening the pt from sound sleep

43

Athlete Profile for El-VCD

Onset b/t 11-18; females have greater incidence (generally 3:1); high achieving
Type A personalities
High personal standards &/or social pressures
Intolerant to personal failure; competitive, self-demanding, perceives family pressure to achieve high level of success
"Choke" under pressure
May have recently graduated to higher level of competition w/in their sport

44

El-VCD vs. Asthma

Recalcitrant to asthma medications
Individuals w/ "asthma" after L-T steroid use might not truly have asthma, but VCD
Individuals w/ significant anxiety

45

EI-VCD

Exercise Induced VCD

46

Differential Diagnosis Evals of EI-VCD

Detailed case hx, pulmonary fx tests, lab tests, ENT/pulmonary/allergy evals, flexible laryngoscopy/ videostrob, SLP eval, supplemental PRN: psychological eval

47

D/D Must Rule Out in EI-VCD

Mass obstruction, bilateral VF paralysis, anaphylactic laryngeal edema, extrinsic airway compression, foreign body aspiration, infectious croup, laryngomalacia, exercise induced asthma/ asthma

48

Diagnosis of EI-VCD

Often mistaken for asthma
By exclusion=when pt fails to respond to asthma or allergy meds then VCD is finally considered

49

EI-VCD & Asthma

Can coexist independently
Can also coexist: Pt may experience LPR which causes asthma flare-up & then laryngospasm (VCD) from coughing; may experience chest (asthma) &/or laryngeal (VCD) tightness

50

Case Hx ?s for VCD:

Do you have more trouble breathing in than out?
Do you experience throat tightness?
Do you have a sensation of choking or suffocation? Do you have hoarseness?
Do you make a breathing-in noise (stridor) when you're having sx's? How soon after exercise starts do your sx's begin? How quickly do sx's subside?
Do sx's recur to same degree when you resume exercise?
Do inhaled bronchodilators prevent or abort attacks?
Do you experience numbness &/or tingling in your hands/feet or around your mouth w/ attacks?
Do sx's ever occur during sleep?
Do you routinely experience nasal sx's (postnasal drip, nasal congestion, runny nose, sneezing)?
Do you experience reflux sx's?