What are the components of voice production? (3)
Source (pulmonary/infraglottic -- diaphragm, intercostal musculature) Vibratory production (laryngeal -- extrinsic and intrinsic muscles) Resonance (supraglottic and oral phase)
True or False: Scoliosis and other msk issues can make a difference in voice production
What is special about the cricoid cartilage?
It's the only complete ring in your airway. Scar tissue or calcification developed at this level causes issues
Which muscle is the only muscle that opens your vocal folds?
Posterior cricoarytenoid muscle
What happens if you have one side of your vocal folds not moving? What about both sides?
One side not moving--you can still breathe but sound crappy. Both sides not moving--you can't breathe
True or False: Skull based lesions can cause difficulty swallowing
True. The innervation for vocal folds and swallowing is incredibly complicated and take a combination of signals from the cerebral cortex.
If a patient presents with a hoarse voice, what cancers should you be concerned about?
Thyroid and lung because of the pathways of the recurrent laryngeal nerves
What does the superior laryngeal nerve control?
Pitch changes in voice and sensation. So, for vital functions, the recurrent laryngeal nerve is more important (breathing and vocal production)
Descent of the ____ leads to lower vocal pitch
Larynx. In children, their larynx is higher up which causes a higher pitched voice. As the larynx descends with age, their voices get lower in pitch (due to laxity of musculature, etc).
What shapes the way that a voice sounds?
Supraglottic larynx, lips, teeth, tongue, palate, pharynx, nasal cavity, and sinuses
True or False: Vocal tract length effects frequency of voice
True. Shorter tract = higher fundamental frequencies. Adult males have lower pitch (longer tract) than children and females.
What is hoarseness?
Abnormal voice changes, breathy, raspy, strained, and weak
What is dysphonia?
General alteration of voice quality, usually a laryngeal source
What is dysarthria?
Defect in rhythm, enunciation, articulation of voice. This typically indicates a neurological or muscular problem
What is stridor?
Large airway noise from obstruction
What is stertor?
snoring sound from nose, nasopharynx, throat
What does inspiratory stridor indicate?
Supraglottic or extrathoracic problem
What does expiratory stridor indicate?
Tracheal or large bronchi intrathoracic problem
What does biphasic stridor indicate?
Laryngeal or immediate subglottis problem
Examples: Stenosis of the cricoid cartilage
Posterior glottic scar band
Cancer holding vocal cords in place
What are some causes of inspiratory stridor? (3)
1. In neonates, their epiglottis can be floppy and can fold over the airway during inspiration causing stridor. They will grow out of this. 2. Epiglottitis, from edema or infection 3. Epiglottic cancer
What is the thumb sign?
With epiglottitis, there is a thumb sign which shows the epiglottis pinching off the airway.
What is subglottic stenosis, what kind of physical exam finding will you get, and what kinds of things cause it?
Subglottic stenosis is stenosis of the cricoid cartilage. This can be caused by prolonged entubation and causes biphasic stridor. It can also be caused by autoimmune disorders or idiopathically.
This is a life-long problem. If you try to cut it, it just heals back. You can operate on patients every 6mo to a year.
What is a posterior glottic scar band?
This scar band can form intubation. The vocal cords are stuck together at the back.
What is croup?
Croup is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the wind pipe, which interferes with normal breathing and produces the classic symptoms of "barking" cough, stridor, and a hoarse voice. It causes subglottic inflammation and edema which leads to biphasic stridor.
This is more often seen in kids but can also be found in adults.
What is the most common cause of acute voice hoarseness? how about for chronic?
Viral laryngitis (acute)
Laryngeal reflux (chronic)
This is typically self-limiting and has other viral symptoms too
What can cause voice hoarseness?
- Viral laryngitis
- vocal abuse
- chronic cough
- neurological disorders
When should a patient with hoarseness see an otolaryngologist?
If the hoarseness lasts longer than 2-3 weeks.
If the hoarseness is associated with
- pain (ear pain radiation possible)
- coughing up blood
- difficulty swallowing
- a lump in the neck
- complete loss or severe change in voice lasting longer than a few days
What's going on here?
These are basically calluses that sit on the vocal folds. These are common and can happen with people who scream too often (think cheerleaders, loud families, etc). This are treated by changing the behavior that causes them. If you just take them off, they will be back with more of the same behavior.
*note, in the picture it's not the big pink things... it's the small pink things that are stuck right on the vocal folds.
What's going on here?
Vocal fold cysts.
You take it out and the patient needs to be quiet for a couple days for it to heal.
What can be used to partially paralyze muscles?
It can be injected through the neck into the vocal folds if the vocal folds bumping against each other are causing granulomas to form.
What is this?
This is caused by smoking.
These patients get have a proliferation of their lamina propria in their vocal cords. Treatment is to take out some of the fluid but not all of it as they need some to keep their vocal cords able to vibrate.
What can cause vocal fold hemorrhage? What is the problem with vocal fold hemorrhage?
Can becaused by cough or strain.
If healed incorrectly and develops fibrous tissue instead of lamina propria, the hoarse voice lasts forever.
What is presbyphonia and vocal fold bowing?
These are structural changes in the larynx and vocal cords that happen as you get older. Older people will develop weaker voices.
What is a vocal complication of post-radiation therapy?
Radiation kills cells that divide rapidly which includes your mucosa and salivary glands. This will cause patients to have thick mucus in their upper airway which can make it difficult for the vocal folds to vibrate.
What are the arytenoids? What can cause dislocation of an arytenoid?
The arytenoid cartilages are a pair of small three-sided pyramids which form part of the larynx, to which the vocal folds (vocal cords) are attached. These allow and aid in the vocal cords' movement.
Traumatic intubation (from placing the endotracheal tube) can dislocate an arytenoid. This is often not noticed until weeks later and doesn't move too well even if you pop it back in place.
What can be done to help a one-sided paralyzed vocal fold?
One-sided paralyzed vocal folds can be partially corrected by a procedure that pushes the paralyzed fold more towards the center.