7. Voice and Its Disorders Flashcards
Larynx (and VFs): Basic Principles
*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)
Superior Laryngeal Nerve (SLN) and Recurrent Laryngeal Nerve (RLN)
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
Key Laryngeal Structures and Cartilages (9)
Hyoid bone Epiglottis Thyroid cartilage Cricoid cartilage Arytenoid cartilage Corniculate cartilages Cuneiform cartilages Intrinsic laryngeal muscles Extrinisic laryngeal muscles
Hyoid Bone
- Larynx suspended from hyoid
* Many extrinisic laryngeal muscles are attached to hyoid
Epiglottis
- 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
Thyroid Cartilage (“Adam’s Apple”)
- Largest laryngeal cartilage
* Shields other laryngeal structures from damage
Cricoid Cartilage
- Second largest laryngeal cartilage
- Completely surrounds trachea
- Linked with the paired arytenoid cartilages and the thyroid cartilage
Arytenoid Cartilages
- 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
Corniculate and Cuneiform Cartilages
Corniculate: Sit on apex of arytenoids; small, cone-shaped
Cuneiform: Tiny, cone-shaped cartilage pieces under mucous membrane that covers aryepiglottic folds
Intrinsic Laryngeal Muscles
- These pairs of muscles have both attachments to structures within larynx
- Primarily responsible for controlling vocalization
- With one exception (PCAs), all are adductors
Intrinsic Laryngeal Muscles (6)
Thyroarytenoids Cricothyroids Posterior cricoarytenoids (only abductors) Lateral cricoarytenoids Transverse arytenoids Oblique arytenoids
Extrinsic Laryngeal Muscles
- 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
Extrinisic Laryngeal Muscles: Infrahyoids (4) and Suprahyoids (6)
Infrahyoids: Thyrohyoids, Omohyoids, Sternothyroids, Sternohyoids
Suprahyoids: Digastrics, Geniohyoids, Mylohyoids, Stylohyoids
Age-Related Changes in the Larnx
- 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
Pitch
- 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
Pitch: Frequency Perturbation/Jitter
- 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
Volume
- 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
Volume: Amplitude Perturbation/Shimmer
- 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
Quality
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
Quality Types: Hoarseness and Harshness
- 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
Quality Types: Strain-Struggle and Breathiness
- 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
Quality Types: Glottal/Vocal Fry
- 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
Quality Types: Diplophonia and Stridency
- 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
Case History: The Clinician Needs To…
*Remember: a multidisciplinary, team-oritented approach is critical through evaluation
- 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
Instrumental Evaluation (9)
- Indirect Laryngoscopy (Mirror Laryngoscopy)
- Direct Laryngoscopy
- Flexible Fiber-Optic Laryngoscopy
- Endoscopy
- Acoustic Analysis
- Videostroboscopy
- Electroglottography (EGG)
- Electromyography (EMG)
- Aerodynamic Measurements
Indirect Laryngoscopy
Direct Laryngoscopy
Flexible Fiber-Optic Laryngoscopy
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
Endoscopy
- 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
Acoustic Analysis
- 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
Videostroboscopy
- 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
Electroglottography (EGG)
- 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
Electromyography (EMG)
- 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
Aerodynamic Measurements
- 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
Resonance Assessment: Hyponasality vs Hypernasality
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)
Respiration Assessment: Breathing Types (3)
- 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
Phonation Assessment: Simple Measures (2)
- 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
Disorders of Resonance (4)
- Hypernasality
- Hyponasality
- Assimilative Resonance/Nasality
- Cul-de-Sac Resonance
Hypernasality
- 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)
Hyponasality (aka Denasality)
- 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
Assimilative Nasality
- 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
Cul-de-Sac Resonance
- 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
Treatment of Hypernasality
- 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
Treatment of Hyponasality
- 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
Carcinoma (Laryngeal Cancer) and Laryngectomy
- 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
Ways Laryngectomees Produce Vocalizations (3)
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)
Physically-Based Disorders of Phonation:
Granuloma
- 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
Hemangioma
- 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
Leukoplakia
- 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
Hyperkeratosis
- 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
Laryngomalacia (aka Congenital Laryngeal Stridor)
*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)
Subglottal Stenosis
- 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
Papilloma
- 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
Laryngeal Trauma
- 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
Laryngeal Web
- 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
Paradoxical Vocal Fold Motion (PVFM)
aka Laryngeal Dyskinesia
- 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
Gastroesophageal Reflux Disease (GERD)
- 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
Paralysis
- 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
…and Ankylosis
- 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
Treatment for VF Paralysis
- 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
Spasmodic Dysphonia (SMD)
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/
Neurologically-Based Disorders of Phonation: Multiple Sclerosis (MS)
- 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
Myasthenia Gravis
- 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
Amyotrophic Lateral Sclerosis (ALS)
aka Lou Gehrig’s Disease
- 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
Parkinson’s Disease
- 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
Treatment Techniques for Patients with Neurological Diseases
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)
Abuse-Based Disorders of Phonation:
Vocal Nodules
- 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
Polyps
- 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
Contact Ulcers
- 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
VF Thickening
- 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
Traumatic Laryngitis
- 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
Phonotrauma: Specific Treatment Techniques
- 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
Treatment for Disorders of Pitch
- 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
Psychogenic (“Functional”) Voice Disorders
- 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
