Vocal Pathologies Flashcards by Alex Hill

Q

What are the 10 VF pathologies secondary to phonotrauma

A

Nodules
Polyps
Cysts
Contact Granuloma
Reinke’s Edema
Sulcus Vocalis
Recurrent Respiratory Papilloma
VF Scaring
9 & 10. Precancerous abnormal growths: Hyperkeratosis & Leukoplakia

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Q

Description of VF nodules

A

-Small benign growth on VFs mid-membranous portion
-On VF edge
-Bilateral masses

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Q

Types of nodules & describe each

A

Acute Nodules: soft, pliable, reddish appearance. Mostly vascular and edematous
Chronic Nodules: Hard, white, thick, and fibrosed. Hypertrophy/rough epithelium. Usually asymmetric in size

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Q

Etiology of Nodules

A

-Trauma related lesion of the lamina propria (damage to BMZ)
-Reaction of tissue to constant stress from frequent, hard oppositional movement of the VFs (Vocal Abuse)

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Q

Anatomical VF structure with Nodules

A

-Bilateral mass
-Located at MidMembranous portion (junction of the anterior third and posterior 2/3s of the VFs)

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Q

Development of Nodules

A

-ONSET: gradual reaction from constant stress on tissue
-COURSE: progressive without vocal rest> acute can improve with rest; fibrosed will not improve with rest
Voice continues to worsen with continued use (deteriorating across the day)
-DURATION: variable, can be 6mo or 5 years (acute heal quickly; fibrotic take longer to heal)

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Q

Perceptual signs and symptoms of Nodules

A

-Hoarseness & breathiness with degree relative to size and firmness
-Decreased projection/loudness
-Vocal fatigue
-Soreness/pain in neck lateral to larynx
-Sensation of something in throat

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Q

Acoustic signs associated with Nodules

A

-Increased jitter and shimmer
-Reduced phonational range (frequency range)
-Reduced dynamic range
-Evidence of noise on spectrum
-Increased s/z ratio (normal s, shortened z due to air leakage)
-Fundamental frequency WNL

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Q

Physiological signs seen during laryngoscope of Nodules

A

-Incomplete closure
-Increased vascularity
-Edema is not uncommon

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Q

Physiological stroboscope signs seen in Nodules

A

-Reduced amplitude at nodule site
-Reduced mucosal wave at nodule site
-Reduced glottal closure
-Symmetry and periodicity WNL

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Q

Structural changes seen with Nodules

A

-Increased mass of VF cover (BMZ thickening)
-Edema & disruption of BMZ
-Increased stiffness with chronic (fibrosed) nodules
-Decreased or unchanged stiffening with acute nodules
-Size of nodules affects the glottal closure

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Q

What makes voice better & worse with nodules?

A

Better voice: vocal rest
Worsening voice: continued use

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Q

Patient complaint for nodules?

A

-People think they are constantly yelling or angry
-Cant produce a soft, confidential voice or whisper
-Have to push harder to get voice out
-Reduced projection

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Q

What is the only vocal pathology from phonotrauma that is associated with a patient personality & what is it?

A

Nodules
Personality: outgoing, social people; talk too much too loud. Often have jobs requiring lots of vocal use

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Q

Why are nodules more common in women and young children?

A

Women due to having less HA in SLLP
Young children due to VF composition is not regular until they reach puberty

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Q

Voice stimulability (response to probes) in Nodules

A

Probes do not change voice quality because this is a structural change

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Q

In Nodules, how is the voice during connected speech vs sustained phonation

A

Same

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Q

Treatment of Nodules

A

-Behavior voice therapy to improve vocal environment
-Voice therapy would focus on voice behaviors reflective of personality & strategies to modify situational factors associated with vocal behaviors; vocal hygiene counseling; respiratory training; carry over strategies
-Patient education

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Q

Treatment goal for Nodules

A

Cure: improvement or resolution of pathology

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Q

What is the most common organic cause of dysphonia?

A

Nodules

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Q

Description of Polyps

A

-Unilateral Protruding mass in SLLP
-Varies in size, shape, and color
-Usually located at front region of VFs and are mid-membranous

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Q

4 Types of Polyps & describe each

A

Pedunculated: attached to VF by a slim stalk of tissue
Sessile: closely adhering to mucosa
Hemorrhagic: blood blisters, increased vascularity
Dissuse: covers half or 2/3 of the VF length

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Q

Etiology of polyps

A

Result from vocal abuse from single traumatic injury

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Q

Anatomical VF structure for Polyps

A

-Unilateral lesion (asymmetrical lesion)
-Mid-membranous portion of VFs

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Development of polyps

-ONSET: sudden (single traumatic vocal abuse event) -COURSE: persistent, progressively getting worse -DURATION: lifelong; voice will not return to normal

Perceptual signs and symptoms with Polyps

-Hoarseness -Breathiness -Sensation of something in throat -Short of breath

Acoustic signs of polyp

-Increased spectral noise -Increased jitter and shimmer

Physiological signs of Polyp seen with laryngoscope

-Large unilateral mass -Somewhat translucent appearance or blood filled

Physiological signs of Polyp seen with stroboscope

-Asymmetry of VF motion -Increased aperiodicity -Decreased vibratory amplitude -Glottal closure may be affected -Little to no mucosal way at lesion sight

Structural changes due to Polyp

-Increased mass of VF cover, changing epithelium and BMZ Increased vascularity

What makes the voice better and worse with Polyps?

Nothing really improves voice Worsens with vocal use

Patient complaint for Polyp patients

Cannot speak loudly Breathy voice

Voice stimulability (voice changes with probes) in Polyps

None Will not improve with probes

Voice during sustained phonation vs connected speech in Polyps

Same for both Intermittent breaks

Treatment for Polyps

-Behavioral therapy may be beneficial for small polyps -Surgical intervention (polyps are most responsive to surgery) & post-surgical behavioral therapy

Which vocal pathology is of greater severity between nodules and polyps

Polyps > Nodules

Describe cysts

Small spheres on the margins of the VFs

Types of Cysts

1. Retention Cysts (intracordal cysts)- Blockage of glandular duct with retention (buildup) of mucus due to inability to drain 2. Epidermoid Cysts- smaller than retention cysts, can empty intermittently, strong similarity to epidermal cysts on skin 3. Pseudocysts- appear in same area as polyps or nodules and have a translucent appearance

Etiology of Cysts

Unclear Thought to result from vocal trauma May be due to blocked glandular duct causing retention of mucus

Anatomical characteristics of VF Cysts

Smooth surface Generally whitish color and unilateral

Devenopment of Cysts

-ONSET: congenital or developmental (not as gradual as nodules) -COURSE: Long time, may grow larger -DURATION: Long time

Perceptual signs and symptoms associated w cysts

-Hoarseness -Lowered pitch -'Tired' voice -Reduced projection/loudness -Vocal fatigue

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Acoustic sign of Cysts

Significantly lowered phonational range

Physiological signs of Cyst seen with laryngoscope

Difficult to view Unilateral lesion

Physiological signs of Cyst seen with stroboscope

-COMPLETE ABSENCE of mucosal wave on or around cyst -Severely restrictred VF vibration -Round shape of the version is very visible -Greater aperiodicity -Fullness of VFs and dilated capiliary -Incomplete/reduced glottal closure -Decreased amplitude

Structural changes from Cysts

-As lesion grows, distance between cover and LP increases -Increased mass and stiffness of VF cover -Encapsulated subepithelial within SLLP or Vocal ligament

What makes voice better & worse for Cysts

Nothing improves Prolonged speaking makes it worse

Cyst Patient complaint

Vocal fatigue Intermittent hoarseness

Voice stimulability for cysts (voicing with probes)

Normal voice will not come back- this is a change in the structure

Voice during sustained phonation vs connected speech in Cyst patients

Equally poor Voice quality may not be as evident, depending on cyst location

Treatment for Cysts

-Behavioral voice therapy may minimize lesion, but presence will be constant -Surgical intervention- only way to rid cysts, but if cyst ruptures during surgery, it will return.

What is the main indicator a benign lesion is a cyst?

Complete absence of mucosal wave

Describe Reinke's Edema

Fluid buildup primarily in the superficial layer of VFs

Etiology of Reinke's Edema

Tissue reaction to trauma and misuse -Prolonged exposure to inflammatory stimuli + abnormal healing response -Can be a component of an allergic reaction

What is the most common form of misuse associated with Reinke's Edema

Smoking

Anatomical VF structure in Reinke's Edema

-Fluid collection in outermost layer of LP -Loose, pliable fibers -Bilateral lesion -Asymmetric in size

Development of Reinke's Edema

-ONSET: gradual -COURSE: gradual decline (consistently gets worse: gradual pitch decline> stiffness of amplitude further affects voice quality> possible breathing difficulties) -DURATION: gradual decline

Perceptual signs and symptoms with Reinke's Edema

-Hoarseness -Lowered pitch level -Short of breath (if partially blocking airway) -Slightly breathy phonation initially -Loss of pitch range -Increased vocal effort

Acoustic signs of Reinke's Edema

-Jitter and shimmer for /ah/ WNL -Jitter and shimmer for /oo/ signifiicantly greater

Physiological signs of Reinke's Edema seen with laryngoscope

-VFs enlarged -Fluid-filled, boggy structures -Not appearing firm or solid

Physiological signs of Reinke's Edema seen with stroboscope

-Vibration often symmetrical -Appearance may differ -Increased mucosal wave, with reduction as it thickens

Structural changes of Reinke's Edema

-Affects SLLP -Increased mass of VF cover -Increased stiffness -Collagen disrupted, thick fluid-like material develops

What makes voice better and worse in Reinke's Edema

-Nothing will improve voice because it is a structural change, but discontinuation of smoking will maintain voice quality -Continued smoking makes it worse

Patient complaints with Reinke's edema

-Low pitch -Hoarse -Shortness of breath if severe (due to partial airway obstruction)

Voice stimulability in Reinke's Edema

None

Voice quality during sustained phonation vs connected speech in Reinke's edema

No difference Both equally bad

Which vocal pathology is highly associated with heavy, long-term smokers & drinkers & those with lots of exposure to chemical irritants

Reinke's Edema

Is there a gender difference in Reinkes edema

Yes, more common in women

Treatment for Reinkes Edema

-Voice therapy will not eliminate the fluid, it will only eliminate the abusive patterns -Surgical intervention if there is an airway component + post-surgical voice therapy

Describe Sulcus Vocalis

-Long groove/depression lines in the upper medial edge of epithelium resulting in varying depth -Bowed lips parallel the free edge of the VFs going from SLLP to muscle -Bilateral

Etiology of Sulcus vocalis

Uncertain -Suspected cause: trauma (vocal abuse or emptied cyst), congenital defect, or developmental

Anatomical structure with Sulcus vocalis

Bilateral depression on upper medial edge of VFs

Development of Sulcus vocalis

-ONSET: Sudden event or congenital (always having a distinct voice) -COURSE: Consistent poor quality, will not return to normal -DURATION: Lifelong

What makes voice better and worse with Sulcus Vocalis

-Better: nothing because there is missing layer of VFs -Worse: Any vocal usage will worsen

Patient complain in Sulcus vocalis

Inability to project voice With continued use, complete loss

Voice quality during sustained phonation vs connected speech in Sulcus Vocalis

Equally poor

Perceptual signs and symptoms with sulcus vocalis

-Hoarse -Reduced loudness -Pitch disturbance -Breathy

Acoustic signs with sulcus vocalis

-MPT slightly shorter -Jitter and shimmer WNL -Reduced phonational range

Physiological signs of sulcus vocalis Seen in laryngoscope

-Sulcus viewed as depression along upper medial edge of VFs -Vary in length and depth

Physiological signs of sulcus vocalis seen in stroboscope

-Incomplete or spindle shaped glottal closure along full VF length -Eliminated or reduced mucosal wave -Decreased amplityude of vibration

Structural changes with Sulcus vocalis

Decreased mass VF cover May increase stiffness of VF cover around sulcus

Treatment for sulcus vocalis

None

Describe contact granulomas

Unilateral ulceration (lesion) on the medial surface of the vocal process of the arytenoid cartilages

Etiology of contact granuloma

-GERD -Intubation -Hard glottal attack (increased strain or tension with rapid and complete adduction of VFs prior to initiation of phonation)

Anatomical structure of Contact granuloma

-Cup and saucer appearance posterior part of VFs usually -Unilateral lesion, located on CARTILAGE -Can change in size quickly and jump sides

Development of contact granuloma

-ONSET: usually sudden, sometimes gradual -COURSE: can move/change locations. If etiology is intubation, will clear up quickly -DURATION: Dependent on etiology; reoccurring

Perceptual signs and symptoms of contact granuloma

-Hoarseness -Unilateral stabbing pain -Something in throat feeling -Excessive throat clearing -May not have voice quality problems, unless large enough to interfere with glottal closure

Acoustic signs of contact granuloma

Dependent on severity, but could be normal -Greater jitter and shimmer if hoarseness is present

Physiological signs of contact granuloma seen with laryngoscope

-Visible pinkish-white buildup on vocal process of arytenoids (usually on apex)

Physiological signs of contact granuloma seen with stroboscope

-Normal unless abnormal voice symtoms are pressent -Increased mass> increased stiffness -Size of granuloma interferes with glottal closure (could cause incomplete closure)

Structural changes with contact granuloma

-Membranous VF not involved (granulomas are on the cartilage) -Little change in mass or stiffness of cover, transition layers, or body

What makes voice better and worse with contact granuloma

Surgery makes it better and used to be done, but they always reoccur

Patient complaints with contact granuloma

Stabbing pain Often voice not affected, only when it gets bigger and affects VF vibration

Contact granuloma is more common in women, why?

Women have a smaller larynx & a thinner mucosal layer of vocal process

Treatment of contact granuloma

-Medication= GERD/Reflux treatment (suppression of acid production) -Voice therapy (alcohol/tobacco avoidance, eliminate vocal behaviors) -Surgery (used to be used a lot, but reoccurrance after surgery)

Describe recurrent respiratory papilloma

-Rare viral disease -Growth of exophytic, benign lesion (tumors or warts) from epithelial tissue in the upper respiratory tract within larynx, vocal cords, and trachea -Occurs in various parts of the larynx (starting in epithelium and tends to proliferate/multiply) -Can obstruct airway

Etiology of recurrent respiratory papilloma

Viral infection: Human papiloma virus (HPV) There is a vaccine for this

Anatomic characteristics of recurrent respiratory papiloma

Laryngeal mucosal membranes of the epiglottis, upper and lower margins of ventricles (false VFs), and true VFs Can grow anywhere from nasopharynx to the lungs (varying in size and grow very quickly)

Which of the benign lesions caused by Phonotrauma is rare? & why?

Recurrent Respiratory Papilloma Because there is a vaccine for it, but it used to not me used widespread

Perceptual signs and symptoms of recurrent respiratory papiloma

-Hoarsness is the primary symptom In children: weak cry, chronic cough, swallowing difficulty, stridor In adults: low pitch, breathiness, strained voice

Which of the benign lesions caused by phonotrauma presents differently in adults than children?

Recurrent REespiratory Papiloma

Physiological signs of Recurrent respiratory papiloma with Laryngoscope

-Whitish cluster of tisues -Raspbery-like texture

Physiological signs of recurrent respiratory papiloma with stroboscope

-Interferes with glottal closure: incomplete closure -Obstructed airway -Absent mucosal wave

Structural changes with recurrrent respiratory papiloma

-Increased VF mass and stiffness -Alters biomechanical characteristics of the mucosa

Treatment for recurrent respiratory papiloma

No long-term treatment that eradicates RRP -Surgical excisions can be done periodically to maintain airway and improve voice quality, but RRP reoccurs Overaggressive surgical removal can lead to VF scaring, granulation tissue, webbing, and stenosis -Highly resistant to voice therapy -Vaccine for prevention!

Explain history and administration of when HPV vaccine is given

Originally only promoted for girls So many boys did not receive the vaccine back in the day ALL should receive it though before being sexually active

What is recurrent respiratory papiloma sometimes misdiagnosed as?

Polyp

Another name for recurrent respiratory papiloma

Laryngeal Papilomatosis (LP)

Development of recurrent respiratory papiloma

-ONSET: children get it at birth from mother who has STD. Present in childhood or early adult -COURSE: Often misdiagnosed -DURATION: Life-long resurgence No typical profile, some individuals need surgery every few months, others every few years

What makes the voice better and worse with recurrent respiratory papiloma

Nothing Might worsen as lesion grows

Voice stimulability with recurrent respiratory papiloma

Will never be the same Nothing will make voice better

Sustained phonation vs connected speech voice quality with recurrent respiratory papiloma

Same- both equally bad

What is the vaccination to prevent recurrent respiratory papiloma

Gardisil Vaccination

How to mitigate VF scaring?

Engineering intervention: 1. Steroids 2. Platelet rich plasma 3. Implant HA (hyaluronic acid) 4. HA based hydrogels to scaffold tissue growth & fibroblast

There is little to no benefit for extended voice rest beyond how many days?

7 to 10+ days

Describe VF scaring

Incomplete, disorganized true VF tissue Tissue remodels during wound healing

Animal studies have found that the critical period is ___ post-injury?

Between 15 to 40 days post-injury

Describe the precancerous abnormal growth: hyperkeratosis

-Pinkish -Rough lesion -Commonly found on anterior commissure and arytenoid prominences (top of VF where it meets thyroid cartilage)

Etiology of the precancerous abnormal growth: hyperkeratosis

Chronic irritants: -Smoking -Env pollutants -GERD

What is the treatment for the precancerous abnormal growth: hyperkeratosis

Eliminate source of tissue irritation: quit smoking/lifestyle change

Description of the precancerous abnormal growth: Leukoplakia

-Whitish color patches on surface membrane of mucosal tissue -Extends into sub-epithelial space -Difficult to distinguish with cancer from imaging alone

Etiology of the precancerous abnormal growth: Leukoplakia

-Smoking -HPV -LPRD

Treatment of the precancerous abnormal growth: Leukoplakia

MUST quit smoking