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PRAXIS > 7. Voice and Its Disorders > Flashcards

7. Voice and Its Disorders Flashcards

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1
Q

Larynx (and VFs): Basic Principles

A

*Valve located at top of trachea
*Helps close entry into trachea so food, liquids, and particles do not enter lungs
*Houses VFs (opening bet. VFs is “glottis”)
*VFs composed of layers: epithelium, the TA muscle, and lamina propria; Cover-body theory of phonation…
*Ventricular/false VFs lie above true VFs
*Aryepiglottic folds lie above ventricular folds; They separate the pharynx and laryngeal vestibule and help preserve airway
CN X: primary CN involved in laryngeal innervation (main branches: SLN and RLN)

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2
Q

Superior Laryngeal Nerve (SLN) and Recurrent Laryngeal Nerve (RLN)

A

SLN: internal branch: provides all sensory info to larynx; external branch: provides motor innervation to the cricothyroid muscle

RLN: supplies all motor innervation to interarytenoid, posterior cricoarytenoid, thyroarytenoid, and lateral cricoarytenoid muscles; Supplies all sensory info below VFs; If lesion to RLN, pt may experience diff. adducting VFs

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3
Q

Key Laryngeal Structures and Cartilages (9)

A 
Hyoid bone
Epiglottis
Thyroid cartilage
Cricoid cartilage
Arytenoid cartilage
Corniculate cartilages
Cuneiform cartilages
Intrinsic laryngeal muscles
Extrinisic laryngeal muscles
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4
Q

Hyoid Bone

A
  • Larynx suspended from hyoid

* Many extrinisic laryngeal muscles are attached to hyoid

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5
Q

Epiglottis

A
  • Leaf-shaped cartilage
  • Attached to hyoid
  • Protects trachea by closing down inferiorly and posteriorly over laryngeal area, directing liquids and food into esophagus during swallowing
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6
Q

Thyroid Cartilage (“Adam’s Apple”)

A
  • Largest laryngeal cartilage

* Shields other laryngeal structures from damage

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7
Q

Cricoid Cartilage

A
  • Second largest laryngeal cartilage
  • Completely surrounds trachea
  • Linked with the paired arytenoid cartilages and the thyroid cartilage
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8
Q

Arytenoid Cartilages

A
  • Positioned on the cricoid cartilage on either side of the midline
  • Shaped like pyramids
  • Vocal processes are the most anterior angle of the base of the arytenoids; True VFs attach at the vocal processes
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9
Q

Corniculate and Cuneiform Cartilages

A

Corniculate: Sit on apex of arytenoids; small, cone-shaped

Cuneiform: Tiny, cone-shaped cartilage pieces under mucous membrane that covers aryepiglottic folds

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10
Q

Intrinsic Laryngeal Muscles

A
  • These pairs of muscles have both attachments to structures within larynx
  • Primarily responsible for controlling vocalization
  • With one exception (PCAs), all are adductors
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11
Q

Intrinsic Laryngeal Muscles (6)

A 
Thyroarytenoids
Cricothyroids
Posterior cricoarytenoids (only abductors)
Lateral cricoarytenoids
Transverse arytenoids
Oblique arytenoids
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12
Q

Extrinsic Laryngeal Muscles

A
  • One attachment to structure outside larynx and one within larynx
  • All extrinisic laryngeal muscles attached to hyoid
  • Elevate or lower position of larynx in neck; Give larynx fixed support
  • Infrahyoids: “depressors”; depress laryx; impact pitch
  • Suprahyoids: “elevators”; elevate larynx
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13
Q

Extrinisic Laryngeal Muscles: Infrahyoids (4) and Suprahyoids (6)

A

Infrahyoids: Thyrohyoids, Omohyoids, Sternothyroids, Sternohyoids

Suprahyoids: Digastrics, Geniohyoids, Mylohyoids, Stylohyoids

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14
Q

Age-Related Changes in the Larnx

A
  • Hardening of laryngeal cartilages
  • Degeneration and atrophy of intrinsic laryngeal muscles
  • Degeneration of glands in laryngeal mucosa
  • Degenerative changes in lamina propria
  • Deterioation of cricoarytenoid joint
  • Degenerative changes in conus elasticus

*These changes lead to “presbyphonia,” an age-related voice disorder characterized by perceptual changes in quality, range, volume/loudness, and pitch

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15
Q

Pitch

A
  • Perceptual correlate of frequency; Largely based on the frequency with which the VFs vibrate; This rate is often called the fundamental frequency(habitual pitch)
  • Determined by mass, tension, and elasticity of VFs
  • Higher pitch results when VFs are thinner, more tense, or both; Lower pitch results when the VFs are thicker, more relaxed, or both
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16
Q

Pitch: Frequency Perturbation/Jitter

A
  • Are variations in vocal frequency that are often heard in dysphonic patients
  • Measured instrumentally as a pt sustains vowel; useful in early detection of vocal pathology
  • Pts w/ voice probs (e.g., tremor, hoarseness) might show a large amount of jitter
  • People with no laryngeal pathology can sustain a vowel with less than 1% jitter
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17
Q

Volume

A
  • Perceptual correlate of intensity; Determined by intensity of sound signal; Greater intensity means greater perceived loudness
  • Sound is disturbance in air particles; it takes the form of waves that more forward and backward in mediums (e.g., air, water); “Amplitude” is extent of such movements; Greater the amplitude, the louder the voice
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18
Q

Volume: Amplitude Perturbation/Shimmer

A
  • Cycle-to-cycle variation of vocal intensity
  • Measured instrumentally as pt sustains vowel; useful in early detection of vocal pathology
  • Speaker w/ no laryngeal pathology has very small amount of variation in intensity w/ each vibratory cycle
  • Pts who have difficulty with regularity of VF vibration (e.g., roughness) may show large amounts of shimmer
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19
Q

Quality

A

Perceptual correlate of complexity; Refers to the physical complexity of the laryngeal tone, which is modified by resonating cavities; Determination of vocal quality is frequently subjective

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20
Q

Quality Types: Hoarseness and Harshness

A
  • Hoarseness: combo of breathiness and harshness, which results from irregualr/aperiodic VF vibrations, which also lead to variation in F0
  • Harshness: rough and “gravelly;” associated with excessive muscular tension and effort; VFs adducted too tightly and air is released too abruptly
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21
Q

Quality Types: Strain-Struggle and Breathiness

A
  • Strain-struggle: phonation is effortful; sounds like “squeezing” voice at glottal level; initiating and sustaining phonation is difficult; talking fatigues; experience tension when speaking
  • Breathiness: results from VFs being slightly open and air escapes through glottis and adds noise to the sound produced by VFs; Often feel like running out of air; Often soft, little variation in loudness, and restricted vocal range; May be due to organic (physical) or nonorganic (functional) causes
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22
Q

Quality Types: Glottal/Vocal Fry

A
  • When VFs vibrate very slowly
  • Low-pitch, “crackly”
  • Usu. at end of utterance when air flow rate and subglottal air pressure are low and lung volume is less
  • For some pts, glottal fry may help modify vocal quality problems such as stridency
  • Other patients work to eliminate vocal fry by slightly increasing subglottal aur pressure and slightly elevating their pitch level
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23
Q

Quality Types: Diplophonia and Stridency

A
  • Diplophonia: “Double voice;” Occurs when one can simultaneously perceive two distinct pitches during phonation; Usu. occurs when VFs vibrate at different frequencies due to different degrees of mass or tension; Ct with unilateral polyp, for example, may sound diplophonic
  • Stridency: Shrill, somewhat high pitched, and “tinny;” Often caused by hypertonicity or tension of the pharyngeal constrictors and elevation of larynx; Tense pts may sound strident
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24
Q

Case History: The Clinician Needs To…

*Remember: a multidisciplinary, team-oritented approach is critical through evaluation

A
  • Obtain info re: onset, duration, causes, variability of probs (ask pt and significant others)
  • Obtain info re: any associated symptoms/probs (e.g., slurred speech, diff. swallowing, excessive coughing)
  • ID factors (e.g., health, environ, fam hx) that may contribute to problem
  • Gather info re: prev. tx, med. intervention, or other attempts to deal with voice prob
  • Obtain descriptions of daily vocal use and possible abuse or misuse patterns (ask pt and sig. others)
  • *For culturally and linguisitically diverse cts: obtain specific perceptions of what constitutes “typical-sounding” voice in their culture
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25
Q

Instrumental Evaluation (9)

A
  • Indirect Laryngoscopy (Mirror Laryngoscopy)
  • Direct Laryngoscopy
  • Flexible Fiber-Optic Laryngoscopy
  • Endoscopy
  • Acoustic Analysis
  • Videostroboscopy
  • Electroglottography (EGG)
  • Electromyography (EMG)
  • Aerodynamic Measurements
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26
Q

Indirect Laryngoscopy
Direct Laryngoscopy
Flexible Fiber-Optic Laryngoscopy

A

Indirect Laryngoscopy: Mirror (+light) to view laryngeal structures during phonation (usu. “eee”) and during quiet respiration

Direct Laryngoscopy: Performed by surgeon when pt under anesthesia in outpatient surgery; Laryngoscope introduced through mouth and into pharyx and positioned above VFs; Pt cannot phonate so VF function cannot be determined by surgeon can obtain a direct microscopic view of larynx; Valuable when biopsy is required due to suspicion of laryngeal cancer

Flexible Fiber-Optic Laryngoscopy: Tube inserted through nasal passage, passes over velum, and into position above larynx; Fibers transmit laryngeal image to specialist’s eyepiece; Pt able to speak and sing; Specialist can obtain an excellent prolonged view of vocal mechanism and photograph rapid VF movement

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27
Q

Endoscopy

A
  • Two types: flexible (inserted nasally) and rigid (inserted orally), using a 3.6mm tube
  • (Fiber-optic) light at tip of scope and structures are illuminated by the light and viewed by specialist at other end of endoscope via window lens
  • Endoscope can be attached to a video camera (videoendoscopy); A stroboscopic (flashing) light source can also be used
  • W/ flexible endoscope, can view velopharyngeal (VP) mechanism, including VP valving; The endoscope (aka) nasopharyngoscope) can be lowered further to view laryngeal mechanism
  • B/c pt can perform a variety of phonatory tasks, endoscopy may be used to study laryngeal anatomy and physiology in detail, incl. mucosal wave
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28
Q

Acoustic Analysis

A
  • Acoustic measurements can be used to evaluate effectiveness of voice therapy/vocal surgery
  • “Sound Spectography:” graphic representation of a sound wave’s intensity and frequency as a function of time; “Spectogram:” resulting picture that reflects resonant characteristics of vocal tract and harmonic nature of glottal sound source
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29
Q

Videostroboscopy

A
  • Helpful in differentiating bet. functional and organic voice probs and detecting laryngeal neoplasms (tumors)
  • Can use flexible fiber-optic laryngoscope, a rigid endoscope, or both
  • Strobe light permits optical illusion of slow-motion viewing of VFs during a variety of tasks; Observer perceives rapidly presented images as a complete picture of cycle-to-cycle vibration
  • Microphone on pts neck to record voice, then introduces scope, switches on stroboscopic light, and asks pt to phonate
  • Stroboscopic image on monitor yields info re: periodicity/regularity of VF vibrations, VF amplitude, glottal closure, presence and adequacy of mucosal wave, and possible presence of lesions or neoplasms
30
Q

Electroglottography (EGG)

A
  • Noninvasive procedure yields indirect measure of VF closure patterns
  • Surface electrodes placed on both sides of thyroid cartilage, and a high-frequency electrical current is passed bet. electrodes while pt phonates
  • Glottal wave form results and specialist is able to view VF vibration
  • EGG can also detect breathy and abrupt glottal onset of phonation
  • Disagreeance re: efficacy of EGG as a diagnostic technique; Best for cross-reference tool
31
Q

Electromyography (EMG)

A
  • Invasive procedure directly measures laryngeal function to study pattern of electrical activity of VFs and to view muscle activity patterns
  • Specialist inserts needle electrodes into pt’s peripheral laryngeal muscles; The resulting electrical signals are judged as normal or indicative of pathology
  • EMG is useful when attempting to determine VF pathology, esp. that caused by neurological and neuromuscular diseases; Also useful in verifying excessive muscle tension prior to the injection of BOTOX for pts w/ spasmodic dysphonia
32
Q

Aerodynamic Measurements

A
  • Refers to airflows, air volumes, and average air pressure produced as part of the peripheral mechanics of the respiratory, laryngeal, and supralaryngeal airways
  • Aerodynamic measurements to evaluate dysphonia, monitor voice changes and treatment progress, and fifferentiate between laryngeal and respiratory probs
  • May want to assess pts’ lung volume b/c breath support for optimal voicing may be lacking
  • Specific measures can be made of the following parameters: “Tidal volume” (amnt of air inhaled and exhaled during normal breathing cycle), “Vital Capacity” (vol. of air pt can exhale after a max. inhalation), and “Total lung capacity” (total vol. of air in lungs)
  • Common instruments: Wet spirometers, dry spirometers, manometric devices, and plethysmograhs
33
Q

Resonance Assessment: Hyponasality vs Hypernasality

A

Hyponasality: when nasal resonance is absent on nasal sounds

Hypernasality: when too much nasal resonance is present on non-nasal sounds

**Important to take into account cultural/linguisitic backgrounds re: resonance (e.g., Chinese speakers may have more hypernasality than Americans perceive as normal)

34
Q

Respiration Assessment: Breathing Types (3)

A
  • Clavicular breathing: When pt inhales, shoulders elevate; Often there is strain and tension.
  • Diaphragmatic-abdominal breathing: Utilizes abdominal region and lower thoracic cavity; Little to no chest or shoulder movement
  • Thoracic breathing: Exhibits characteristics of both clavicular and diaphragmatic-abdominal breathing; No observable abdominal or upper thoracic expansion upon inspiration
35
Q

Phonation Assessment: Simple Measures (2)

A
  • Maximum phonation time (MPT): sustain “ah,” 3 trials, compares MPT (in secs) w/ norms; Observe adequacy of respiration, glottal efficiency, and possible presence of vocal pathology (e.g., nodules)
  • S/Z ratio: Divides longest /s/ by longest /z/. An s/z ratio of more than 1.4 is indicative of possible pathology
36
Q

Disorders of Resonance (4)

A
  • Hypernasality
  • Hyponasality
  • Assimilative Resonance/Nasality
  • Cul-de-Sac Resonance
37
Q

Hypernasality

A
  • Most common resonance disorder
  • When VP mechanism does not close opening to nasal passage during production of non-nasal sounds
  • May be velopharyngeal inadequacy/insufficiency (VPI)
  • Functional (e.g., deaf) or organic (e.g., cleft palate)
38
Q

Hyponasality (aka Denasality)

A
  • Pts often substitute oral sounds for nasals (bay vs may)
  • Can be temporary (e.g., colds, allergies) due to obstructions of nasal cavity (e.g., nasal polyps or papilloma), enlarged (“hypertrophy of”) adenoids/tonsils, or deviated septum
  • May be mouth-breathers; sleep-apnea in severe cases
39
Q

Assimilative Nasality

A
  • Occurs when sound from a nasal consonant carries over to adjacent vowels (e.g., vowels in banana may sound hypernasal b/c next to /n/)
  • Velar openings begin too soon and last too long
  • Functionally or organically based
40
Q

Cul-de-Sac Resonance

A
  • Produced by backwards retraction of tongue; tongue is carried too far posteriorly in oral cavity
  • Oral cavity is partially closed at back and open in front; Distored voice and resonance b/c tongue blocks some of the sound waves generated by larynx from reaching oral cavity; Person’s voice can sound muffled or hollow
  • Deaf people, those with neurological disorders, and kids with hypertrophied adenoids and tonsils may have cul-de-sac resonance
41
Q

Treatment of Hypernasality

A
  • Biofeedback
  • Nasometer (and video/audio recordings)
  • Tx techniques: Visual aids (e.g., mirror/tissue), Ear training, Increasing mouth opening, Increasing loudness, Improving articulation (e.g., exaggerated Cs). Changing rate, Decreasing pitch
42
Q

Treatment of Hyponasality

A
  • Nasometer (and video/audio recordings)
  • Techniques involve increasing awareness of nasal cavity as a resonator: Visual aids (eg., mirror/tissue), Focusing/directing tone into facial “mask,” Nasal-glid stimulation
43
Q

Carcinoma (Laryngeal Cancer) and Laryngectomy

A
  • More common in men
  • Contributing factors: *alcohol, *tobacco, exposure to environmental toxins, and GERD
  • Early warning signs of laryngeal cancer: hoarseness, difficulty swallowing, persisting sore throat, ear pain, lump in neck or throat
  • Tests for detection: physical examination, laryngoscopy, endoscopy, CT scan, MRI, and biopsy
  • TNM design (medical chart): site of TUMOR, involvement of lymph NODES, and METASTASIS
  • 3 types of medical treatment: surgery/laryngectomy, chemotherapy, and radiation
44
Q

Ways Laryngectomees Produce Vocalizations (3)

A

External devices (e.g., artificial larynx or electrolarynx)

Esophageal speech: literally speak on burps; esophageal voice produced by a pharyngoesophageal segment (PES); 2 methods: injection and inhalation method

Surgical modifications or implanted devices in the laryngeal area (e.g., Blom-singer prosthetic device)

45
Q

Physically-Based Disorders of Phonation:

Granuloma

A
  • A localized, inflammatory, vascular lesion, that’s usually composed of granular tissue in a firm, rounded sac
  • Frequently develop on the vocal processes of the arytenoid cartilages
  • Can be unilateral or bilteral
  • May be caused by vocal abuse, intubation during surgery, injury to larynx, and GERD
  • Most often associated with contact ulcers
  • Pts often sound breathy and hoarse; feel need to freq. clear throat
  • Treated by surgery, voice therapy, or both
46
Q

Hemangioma

A
  • Similar to granulomas, but are soft, pliable, and filled with blood
  • Usually caused by intubation or hyperacidity to GERD; can also be congenital
  • Usually surgically excised + follow-up voice therapy
47
Q

Leukoplakia

A
  • Benign (but precancerious) growths of thick, whitish patches on surface membrane of mucosa; May extend into subepithelial space; May appear under ant 1/3 of VFs and under tongue
  • Due to tissue irritation, esp. caused by smoking, alcohol, or vocal abuse
  • Pts may sound hoarse, low-pitched, breathy, and soft in volume; Diplophonia may also be present
  • Treatment usu. involves combo of surgery, voice therapy, and eliminating exposure to tissue irritants
48
Q

Hyperkeratosis

A
  • Rough, pinkish lesion; often benign but may be precursors to malignancy
  • Appears in oral cavity, larynx, or pharyx
  • Hyperkeratotic growth occur due to tissue irritation and may be caused by smoking, GERD, and vocal abuse
  • Voice symptoms: mild-severe hoarseness or harshness, reduced loudness, and low pitch
  • Treatment involves eliminating tissue irritants, possible ablative surgery, and voice therapy
49
Q

Laryngomalacia (aka Congenital Laryngeal Stridor)

A

*Soft, “floppy” laryngeal cartilages
*Epiglottis is particularly affected and is soft/pliable due to abnormal development
*When child breathes, epiglottis resists airstream, causing stridor, or rough, breathy noise upon inhalation
*Usually resolves spontaneously by age 2-3
(but in severe cases, child may have breathing probs and will require treatment)

50
Q

Subglottal Stenosis

A
  • Is the narrowing of the subglottic space
  • Can be acquired or congenital
  • Congenital: result of arrested development of the conus elasticus or interruption of the cricoid cartilage during embryological development; defined as a lumen 4.0 mm in diameter or less at level of cricoid
  • Acquired: result of endotracheal intubation
  • If stenosis is severe and there is no exchange of air, a tracheostomy may be needed; if moderately severe, kids often display exercise intolerance and stridor and may need surgical or endoscopic intervention followed by voice intervention
51
Q

Papilloma

A
  • Sometimes called “juvenile papillomas” b/c tend to occur primarily in children (but can occur in adults, too)
  • When kids hit puberty, papillomas often cease
  • Wart-like growths caused by human papilloma virus
  • Pink, white, or both
  • May be anywhere in airway (may/may not be larynx)
  • Symptoms: Hoarseness, breathiness, low pitch
  • Airway obstruction is a major concern
  • Most pts treated through multiple surgeries
  • Voice tx: May be helpful after surgical treatment; Tx can involve relaxation exercises, teaching pt to use amplification devices, and teaching to decrease supraglottic hyperfunction; Can’t prevent recurrence
52
Q

Laryngeal Trauma

A
  • Refers to many kinds of injury to larynx
  • More common in children vs adults
  • Causes incl: burns, vehicle and sports-related accidents, attempted strangulations, gunshot wounds, etc
  • Generally, surgery to reconstruct vocal mechanism
  • Pts who smoke or have GERD must stop or have treatment for GERD before surgery
  • Most pts get voice tx after surgery
53
Q

Laryngeal Web

A
  • Membrane that grows across ant. portion of the glottis
  • 2 types: congenital and acquired (from trauma to inner edges of VFs); VFs may be traumatized by forceful/prolonged intubation, surgery, severe laryngeal infections, or accidental injury
  • Treatment for infants(congenital): immediate surgery followed by tracheostomy
  • Treatment for adults: surgery to remove web and after, surgeon places a “laryngeal keel” bet. VFs to prevent them from growing back together; Pt usu. undergoes 6-8 weeks of voice restn while keel is in place; After keel is removed, voice therapy may be needed
54
Q

Paradoxical Vocal Fold Motion (PVFM)

aka Laryngeal Dyskinesia

A
  • Inappropriate closure/adduction of the VFs during inhalation, exhalation, or both
  • Pts often appear asthmatic; Sometimes undergo tracheotomy; Patients display stridor (and some also display dysphonia
  • Attributed to both psychological and physiological causes
  • Treatment may incl. a combo of psychological, medical, and behavioral approaches
  • Some pts do well w/ voice tx involving endoscopy and direct feedback in which they learn nature of disorder and how to relax entire vocal mechanism; Kids may respond well to visual biofeedback and relaxation exercises
55
Q

Gastroesophageal Reflux Disease (GERD)

A
  • When gastric contents spontaneously empty into esophagus when person has vomited or belched
  • Symptoms: heartburn, acid indigestion, sore throat, and hoarseness
  • Consequent pathological VF changes may occur, e.g., contact ulcers (bilateral ulcerations on medial surfaces of vocal processes of arytenoids)
  • “Manometric evaluation” (form of aerodynamic eval)
  • Treatment: antacids, propping up head at night, meds, not exercising directly after eating, dietary changes; Treatment plans incl. behavioral, medical, surgical, and voice tx
56
Q

Paralysis

A
  • Paralysis occurs when nerve supply is cut off from muscle (VFs are primarily muscle)
  • Paralysis can result from: injury to RLN during surgery, neurological diseases, malignant diseases, intubation trauma, severe laryngeal trauma, stroke, CN X deficits
  • Unilateral paralysis: Sometimes, nonparalyzed fold will be able to make contact (sounding normal) and sometimes other fold is too far from midline, which causes aphonia
  • Bilateral: May lead to wide-open glottis, causing aphonia; When VFs paralyzed in abducted position, aspiration can occur; If paralyzed in adducted position, pt struggles for breath but voice is not significantly dysphonic
57
Q

…and Ankylosis

A
  • Ankylosis: stiffening of the joint(s)
  • Movement of arytenoids is restricted b/c of a bone-joint disease (e.g., arthritis); Cancer can also cause ankylosis; VFs are attached to the arytenoids so when the arytenoids are stiff, VFs do not close fully
58
Q

Treatment for VF Paralysis

A
  • Unilateral paralysis treatment: doctors create a bulge (from teflon, collagen, Gelfoam, autologous fat) in paralyzed fold so easier for healthier fold to meet it
  • Thyroplasty type 1: used to achieve VF medialization; surgeon creates small window in thyroid cartilage, medializes the VF, and places a small Silastic implant to keep the paralyzed fold medialized
  • Nerve-muscle pedicle reinnervation: surgeon takes pedicle of neck strap muscle w/ innervation and sutures it either into adductors for medialization purposes or into posterior cricoarytenoids in order to promote adduction
  • Depending on type of paralysis, these treatment techniques have been used to help w/ firmer VF closure: pitch elevation, increased loudness, increased breath support, pushing approach, hard glottal attacks, head turning/positioning
59
Q

Spasmodic Dysphonia (SMD)

A

A laryngeal dystonia; Neurogenic causes w/ possible emotional side effects; Involves BS dysfunction

Abductor SD: created by intermittent, involuntary, fleeting VF abduction when pt tries to phonate; Loudness is reduced and pt is usually aphonic w/ breathy or whispered speech; Tx: BOTOX, speech tx involving relaxation techniques and continuous voicing, and pharmacological intervention

Adductor SD (most common): overpressure due to prolonged overadduction or tight closure of VFs; Voice may sound choked and strangled; Popular treatment techniques: CO2 laser surgery, RLN resection, *BOTOX injections, and voice therapy (can incl: inhalation phonation, increased pitch, relaxation, head turning, counseling, yawn-sigh approach, and soft, breathy phonation onset using /h/

60
Q 
Neurologically-Based Disorders of Phonation:
Multiple Sclerosis (MS)
A
  • Pt experiences progressive and diffuse demyelination of white matter, w/ corresponding preservation of axons at BS, cerebellum, and SC
  • Pts may have impaired prosody, pitch, and loudness control, harshness, nreathiness, hypernasality, articulation breakdown, and nasal air escape
61
Q

Myasthenia Gravis

A
  • Neuromuscular autoimmune disease
  • Produces fatigue and muscle weakness
  • Decreased amount of acetylcholine at the myoneuronal junction
  • Pts may sound hypernasal, breathy, hoarse, and soft in volume; May also have dysphagia and distorted artic
62
Q

Amyotrophic Lateral Sclerosis (ALS)

aka Lou Gehrig’s Disease

A
  • Progressive, fatal disease involving degeneration of upper and lower motor neuron systems
  • Pts sound breathy, low-pitched, monotonous; Poor respiratory control
  • Tx may focus on AAC that can be used even in later stages of the disease
63
Q

Parkinson’s Disease

A
  • Caused by lack of dopamine (a neurotransmitter) in the substantia nigra of the BG
  • Can be idiopathic (occuring in isolation) or secondary to other conditions such as dementia
  • Pts often sound breathy, low-pitched, and monotonous
  • Lee Silverman Voice Treatment emphasizes stimulating pts to increase respiratory and phonatory efforts and to sustain those efforts over time
64
Q

Treatment Techniques for Patients with Neurological Diseases

A

Because pts w/ neurological diseases tend to manifest dysarthria, with some exceptions, treatment techniques often follow principles based on tx for dysarthria

Therapy strategies (to improve efficiency of overall system and increase intelligibility):

  • Improve artic thru exaggerating Cs and slowing rate
  • Improve resonance thru increasing mouth opening, decreasing tongue tension, and improving VP closure
  • Improve prosody to decrease monopitch
  • Improve respiration thru relaxation, increasing efficiency (and possibly frequency) of breathing
  • Improve VF approximation (see “Treatment for VF Paralysis” flashcard)
65
Q

Abuse-Based Disorders of Phonation:

Vocal Nodules

A
  • Pink/red, then white/gray as they become fibrous
  • Usually bilateral
  • Typically apear at the junction of the anterior and middle third portion of the VFs
  • Develop over time due to prolonged vocal abuse
  • Increase VF mass, causing slower vibration and lower pitch; Also make smooth VF approximation impossible, contributing to breathiness and hoarseness of voice
  • Persisten nodules treated via voice tx or surgery
66
Q

Polyps

A
  • Softer than nodules and may be filled w/ fluid or ahve vascular tissue
  • Tend to be unilateral (but can be bilateral)
  • Sessile polyps: broad base on VF; Pedunculated polyps: attached to VFs by a stalk
  • Traumatic use of VFs results in submucosal hemorrhage, leading to formation of tumorlike polyps
  • Can grow over time or happen after one instance
  • Usually sound breathy and hoarse; May have diplophonia
67
Q

Contact Ulcers

A
  • Sores or craterlike areas of ulcerated, granulated tissue that develop (usu. bilaterally) along poster third of glottal margin
  • Causes: a) slamming together of arytenoids that occurs during low-pitched phonation accompanied by hard glottal attack and sometimes increased loudness, b) GERD, c) intubation after surgery
  • Pts may complain of vocal fatigue and pain in laryngeal area; Freq. sound hoarse and often clear throats
  • Voice tx is geared toward reducing phonation effort
68
Q

VF Thickening

A
  • Prolonged use of vocally abusive behaviors can cause gradual VF thickening
  • VFs usually thicken along anterior 2/3 of glottal margin
  • Results in breathy voice w/ lowered pitch
  • Often precursor to nodules or polyps
69
Q

Traumatic Laryngitis

A
  • Vocally abusive behaviors irritate VFs, which get swollen
  • Consequently, the voice is hoarse and may be low-pitched with pitch breaks
  • Voice tx usu. consists of vocal rest and strategies for changing the vocally abusive behaviors
70
Q

Phonotrauma: Specific Treatment Techniques

A
  • Open-mouth approach: teach to speak w/ wider mouth opening; this helps to increase volume and improve oral-nasal resonance balance
  • Chant-talk: words spoken in connected manner with soft glottal attack, even stress, prolongation of sounds, and absence of stress for individual words
  • Digital manipulation of larynx: lowers pitch and decreases laryngeal tension
  • Gentle voice onset: initiates phonation with /h/
  • Yawn-sigh method: inhales on wide yawn followed by expiratory sigh and phonation

*Other techniques: teach to speak with appropriate pitch and volume, teach pt to reduce coughing and throat-clearing, teach pt to reduce tension, respiration training, encourage voice rest

71
Q

Treatment for Disorders of Pitch

A
  • In pts w/ a pitch that is too high, esp. young men with puberphonia (aka mutational falsetto), the larynx is often elevated w/ accompanying laryngeal tension
  • B/c of this tension, relaxation, yawn-sigh, the open-mouth approach, and digital manipulation are often successful in lowering pitch; nonspeech vocalizations (e.g., glottal fry and coughing) may also be helpful
  • Speech-range masking can help to lower vocal pitch (involves introducing masking noise during oral reading and pt usually spontaneosly increases volume)
  • Visual and auditory feedback (e.g., Visi-Pitch)
  • May also need psychological counseling; Cultural considerations re: ct’s perceptions of normal pitch
72
Q

Psychogenic (“Functional”) Voice Disorders

A
  • Voice is abnormal in prescence of normal structures
  • Mutational Falsetto is a psychogenic voice disorder
  • Hysterical/Conversion aphonia: no evidence of physiological/neurological reason for voice loss (often after traumatic event)
  • Tx: Counseling/psychotherapy or behavioral therapy
  • Behavioral tx: masking, relaxation techniques, non-speech vocalizations, inhalation phonation, yawn-sigh, etc

PRAXIS (22 decks)

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