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Voice and Resonance Disorders > Chapter 4: Pathologies of the Laryngeal Mechanism > Flashcards

Chapter 4: Pathologies of the Laryngeal Mechanism Flashcards

1
Q

What are the 4 categories of etiologies?

A

1) structural
2) medical
3) neurologic
4) psychological

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2
Q

What are 3 factors that influence the prevalence of voice disorders?

A

1) age
2) gender
3) occupation

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3
Q

How many adults report current voice disorder?

A

7%

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4
Q

How many adults report a voice disorder during sometime in their lives?

A

30%

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5
Q

Chronic voice disorders are more common among what 2 groups? and with history of what 4 things?

A

1) women
2) individuals 40-59 years old

History of:

1) heavy voice demands
2) reflux symptoms
3) chemical exposures
4) frequent upper respiratory infections

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6
Q

What are the 8 classifications of voice disorder pathologies?

A

1) structural pathologies
2) inflammatory conditions
3) trauma/injury
4) system conditions affecting voice
5) aerodigestive conditions affecting voice
6) psychiatric or psychological disorders affecting voice
7) neurological voice disorders
8) “other”

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7
Q

What is a structural pathology of the VFs?

A

any alteration to histological structure of the vocal fold

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8
Q

Changes in the layered structure of the VF (structural pathologies) can affect what 5 things that therefore affect what?

A

1) mass
2) size
3) stiffness
4) flexibility
5) tension

vocal quality, pitch, and loudness

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9
Q

Variations in vocal quality due to a structural pathology often reflects what 3 things?

A

1) lesion severity (size/site/depth)
2) habitual voice use patterns
3) presence/absence of compensatory adjustments

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10
Q

What are the 2 types of compensatory adjustments?

A

1) productive

2) maladaptive

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11
Q

What are 3 examples of productive compensatory adjustments?

A

1) improved breath support
2) enhanced vocal tract tuning
3) appropriate changes in pitch and loudness

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12
Q

What are 3 examples of maladaptive compensatory adjustments?

A

1) extreme muscle activation/effort
2) poor tone focus
3) inapropriate changes in pitch and loudness

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13
Q

What is a malignant lesion that will affect voice?

A

laryngeal carcinoma (typically squamous cell type originating from the epithelium)

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14
Q

How does a laryngeal carcinoma affect voice?

A

as it progresses, invades deeper layers of the VF including the vocalis, dysphonia varies based on location and depth of invasion

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15
Q

What are 4 carcinoma treatment options?

A

1) radiation therapy
2) chemotherapy
3) surgical excision
4) or combination

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16
Q

What are the 3 traditional and 3 “newer” benign epithelial and lamina propria abnormalities?

A 
Traditional:
1) polyps
2) nodules
3) cysts
"Newer":
1) pseudocyst(s)
2) fibrous mass(es)
3) reactive lesion(s)
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17
Q

What is the following called: bilateral, “relatively” symmetrical lesions on the medial edge between ant 1/3 and post 2/3 of VFs

A

vocal fold nodules

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18
Q

Where is the site of maximum collision and shearing forces on the VFs?

A

between anterior 1/3 and posterior 2/3

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19
Q

How do VF nodules occur?

A

inflammatory degeneration of SLLP with fibrosis and edema of VF cover
(transition and body typically not affected)

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20
Q

What are the 2 types of VF nodules and what are they like?

A

1) acute (immature, gelatinous and floppy)

2) chronic (mature, harder and more fixed to underlying mucosa)

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21
Q

For children, which gender is more likely to get vocal fold nodules?

A

boys

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22
Q

For adults, which gender are more likely to experience VF nodules?

A

women

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23
Q

What are 4 possibility personality factors for getting VF nodules?

A

1) extraverted (talkative)
2) socially dominant
3) stress reactive (tense), aggressive
4) impulsive

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24
Q

What are occupational factors that can cause VF nodules?

A

professions with extended/loud voice use (teachers, singers, etc.)

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25
Q

What kind of quality do VF nodules cause?

A

mild to moderate dysphonia

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26
Q

What is mild to moderated dysphonia due to VF nodules like?

A

roughness, breathiness related to gaps anterior and posterior to lesions, increased muscular tension

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27
Q

The severity of VF nodules depends on what 3 things?

A

1) extent/size of lesions
2) length of time since onset (chronic vs. acute)
3) degree of accompanying inflammation

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28
Q

What is treatment for VF nodules like?

A

first line = voice therapy

second line = surgical removal and post-surgical voice therapy

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29
Q

What is the following called: fluid-filled, exophytic lesion composed of gelatinous material in the SLLP with active blood supply, typically located on middle third of VF?

A

VF polyps

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30
Q

Vocal fold polyps are most often seen in __________, and they are often ____________, but can be ____________.

A

adults

unilateral, bilateral

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31
Q

What are the 2 types of polyps?

A

1) sessile (blister-like)

2) pedunculated (attached to a stalk)

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32
Q

What is the cause of vocal fold polyps?

A

acute vocal trauma (phonotrauma)

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33
Q

What are the voice effects of VF polyps?

A

mild to severe dysphonia

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34
Q

What is the severity of dysphonia in VF polyps dependent on? (3)

A

1) size, type, and location
2) degree of interference with glottic closure and VF vibration
3) presence of hemorrhagic blood vessel “feeding the lesion”

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35
Q

What are the treatments for VF polyps?

A

1) primary = voice conservation/rehabilitation

2) phonosurgery (and voice rehab)

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36
Q

What is the following called: Fluid-filled, typically unilateral, sessile lesions (sacs) on cephalic surface or medial edge of the vocal fold, embedded in the SLLP but extended into ILLP and DLLP?

A

VF cysts

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37
Q

What are the 2 types of VF cysts?

A

1) congenital

2) acquired

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38
Q

What can cysts be confused with and why?

A

nodules

cysts often associated with “reactive” thickening of contralateral VF suggesting bilateral lesions

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39
Q

How are cysts different than nodules?

A

create a stiff adynamic segment due to reduced vibratory freedom of the cover of the VF

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40
Q

What is the treatment for VF cysts?

A

surgical excision/dissection of the cyst off of the vocal ligament (from a superior and lateral approach to avoid scarring the VF)

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41
Q

What is the following called: SLLP becomes filled with viscous, gelatinous edema

A

Reinke’s Edema

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42
Q

What is polypoid degeneration?

A

severe form edema wherein the entire membranous VF is filled with fluid

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43
Q

What are the 2 etiologic factors of Reinke’s edema?

A

1) chronic phonotrauma

2) smoking

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44
Q

What are the 2 vibratory effects of Reinke’s Edema?

A

increased mass and stiffness

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45
Q

What are the voice effects of Reinke’s Edema?

A

signature low pitch and husky hoarseness described as a “whiskey” or “smoker’s” voice

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46
Q

What is the treatment for Reinke’s Edema?

A

surgery (accompanied/preceded by smoking cessation) and pre- and post-operative voice thearpy

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47
Q

What is vocal fold scarring?

A

permanent tissue changes in the structure of the lamina propria due to any number of etiologies

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48
Q

What are 3 potential etiologies of VF scarring?

A

1) lesion presence
2) chronic tissue irritation
3) latrogenic (postsurgical) changes

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49
Q

VF scarring can cause what? (3)

A

1) increased stiffness of VF (due to loss of layered structure)
2) reduces freedom of cover to oscillate (causing reduced mucosal wave during VF vibration)
3) reduces glottic closure in sever cases

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50
Q

Vocal fold scarring effects on voice depends on what 3 things?

A

1) severity
2) extent
3) location of scar

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51
Q

What is the treatment for vocal fold scarring?

A

no accepted/effective behavioral or surgical treatment

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52
Q

What is the following called: special form of scarring that forms a “ridge” or “furrow” along the SLLP that produces bowing or spindle-shaped gap, unilateral or bilateral

A

sulcus/sulcus vocalis

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53
Q

What are the two types of sulcus/sulcus vocalis?

A

1) small pit or divot (sulcus vocalis)

2) entire length of medial surface (sulcus vergeture)

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54
Q

What are potential etiologies of sulcus/sulcus vocalis?

A

1) congenital (abnormal embryological development of VF cover)
2) acquired following rupture of intracordal VF cyst
3) secondary to laser surgery
4) associated with age-related changes

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55
Q

What is the following called: unilateral or bilateral, vascular and inflammatory exophytic lesions related to tissue irritation in the posterior larynx typically on the medial surface of the arytenoid cartilages?

A

granulomas

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56
Q

What is the following called: ulcerated lesion on the same site often on opposite side of a granuloma?

A

contact ulcer

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57
Q

What are 4 symptoms of granuloma and contact ulcers?

A

1) pain
2) sore throat
3) with or without voice change
4) with or without affecting VF vibration

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58
Q

What are the two primary etiologies of VF vibration?

A

1) “mechanical” or “chemical” tissue irritants of posterior larynx
2) persistent voice misuse

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59
Q

What is a mechanical tissue irritant of the posterior larynx?

A

endotracheal intubation

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60
Q

What is a chemical tissue irritant of the posterior larynx?

A

laryngopharyngeal reflux

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61
Q

What type of persistent voice misuse that causes granuloma and contact ulcers like?

A

pressed, low-pitch voice with excess tension

62
Q

What are the 4 treatment types for granuloma or contact ulcers?

A

1) medical
2) surgical
3) behavioral
4) combination

63
Q

What are the 2 medical treatments for granuloma and contact ulcers?

A

1) antireflux regimen

2) unilateral (intracordal) Botox injection to reduce medial compression forces (to allow healing)

64
Q

What is the behavioral treatment for granuloma and contact ulcers?

A

reduce medial compression by reducing strain and pressed voice, pitch elevation, and reduction of “hard” glottal onsets

65
Q

What is the surgical treatment for granuloma and contact ulcers?

A

excision (if medical and/or behavioral treatments fail)

66
Q

Given the location and etiology of granuloma and contact ulcers, these lesions can be __________________ and ____________ can be common

A

recalcitrant

recurrence

67
Q

What are the three benign vocal fold pathologies that are often subsumed under “epithelial hyperplasia”?

A

1) leukoplakia
2) hyperkeratosis
3) erythroplaisa

68
Q

What is epithelial hyperplasia?

A

abnormal mucosal changes

69
Q

What two types of epithelial hyperplasia’s may be precancerous? And so what is recommended?

A

1) leukoplakia
2) hyperkeratosis
Direct microlaryngoscopy with biopsy is often recommended

70
Q

What is leukoplakia?

A

“white plaque”

71
Q

What is hyperkeratosis?

A

“excessive keratin”

72
Q

What is erythroplaisa?

A

“thickened and red”

73
Q

Which VF pathology results in a thick substance on superior surface of the VFs in diffuse white patches?

A

Leukoplakia

74
Q

Which VF pathology results in buildup of keratinized tissue, rough, irregular VF margins?

A

Hyperkeratosis

75
Q

Which VF pathology is due to a combination of hyperfunctional voice use and chemical irritation especially alcohol and tobacco use?

A

Erythroplasia

76
Q

What is RRP?

A

Recurrent respiratory papilloma

Papilloma = wart like growths that develop in the epithelium and invade deeper in the LP and vocal muscle

77
Q

Papilloma can grow ___________ and in large __________, and can ___________ and ___________ the airway

A

rapidly
clusters
proliferate and comprimise

78
Q

What is the etiology of RRP?

A

Human Papilloma Virus (HPV) infection

79
Q

What are the 2 types of HPV?

A

1) juvenile

2) adult

80
Q

What is juvenile HPV like?

A

1) onset at 2-4 yrs, same prevalence in boys and girls, can resolve spontaneously especially after puberty

81
Q

What are the effects HPV/RRP can have on voice?

A

1) can effect cover, transition, and body of VFs and produce significant stiffness, compromise vibratory function, and cause severe dysphonia
2) require multiple surgical treatments that lead to scarring and worsen dysphonia

82
Q

What are the treatment options for papilloma?

A

1) surgical

2) pharmacotherapy

83
Q

What is surgical papilloma treatment like?

A

laser or cold-steel excision,

recurrence is common requiring multiple de-bulking surgeries and increased likelihood of VF scarring

84
Q

What are the 3 options for pharmacotherapy treatment of papilloma?

A

1) interferon therapy (systemic)
2) intra-lesional Cidofovir VF injections (repeated)
3) sub-lesional Bevacizumab VF injections as an adjunct to surgical excision to limit disease recurrence

85
Q

What is Cidofovir?

A

antiviral medication designed to inhibit the HPV virus at injection site

86
Q

What is Bevacizumab (i.e., Avastin)?

A

angiogenesis inhibitor, designed to starve off papilloma

87
Q

What is the following called: fibrous tissue overgrowth that narrows the airway (typically subglottic just below the true VFs)

A

subglottic stenosis

88
Q

What is the following called: acquired scar across medial edges of the VFs beginning in the anterior commissure and extending posteriorly?

A

Glottic stenosis or anterior glottis web

89
Q

What are 3 possible etiologies of subglottic stenosis?

A

1) congenital
2) post-intubation scarring
3) laryngopharyngeal reflux

90
Q

What are 2 possible etiologies of glottic stenosis/web?

A

1) congenital (i.e., synechia)

2) acquired - secondary to surgery involving anterior membranous portion of the VFs

91
Q

What is the management option for subglottic stenosis/web?

A

surgery

92
Q

What are 4 types of vascular lesions?

A

1) VF hemorrhage
2) hematoma
3) varix
4) ectasia

93
Q

What are vascular lesions caused by and what do they cause?

A

traumatic injury to small blood vessels of the VF

focal or diffuse discoloration of VF

94
Q

What are vascular lesions often related to?

A

intense screaming, singing, coughing, or crying

95
Q

What population do vascular lesions occur in?

A

premenstrual women using blood thinners/anticoagulants (e.g., aspirin)

96
Q

What is the following called: small capillary on superior surface of VF ruptures abruptly and bleeds into the SLLP (Reinke’s space)?

A

hemorrhage

97
Q

What is the following called: accumulation of blood that has leaked from the ruptured vessel?

A

hematoma

98
Q

What is the following called: mass of blood capillaries that appears as small, longstanding blood blister that has hardened over time with an adynamic VF segment?

A

varix

99
Q

What is the following called: larger collection of varices?

A

ectasia

100
Q

Vascular injuries have the potential to increase __________ of the ________, with localized __________ in more severe cases.

A

stiffness
cover
scarring

101
Q

Vascular lesions can have what effect on voice?

A

vary from severe at time of bleed to mild later,

small varices or ectasias may have negligible effects on the voice

102
Q

What are 4 treatment options for vascular lesions?

A

1) aggressive voice conservation (complete voice rest)
2) medical (steroids)
3) laser cauterization (to stop bleed)
4) surgery (microexcision of persistent varix)

103
Q

What is another name for puberphonia?

A

mutational falsetto

104
Q

What is puberphonia?

A

post-pubescent males who speak in falsetto or near top of their modal frequency range

105
Q

What are effects on voice from puberphonia?

A

weak, breathy and raspy, unable to increase intensity or shout

106
Q

What are 4 proposed causes of puberphonia?

A

1) resistance to puberty
2) feminine self-identification
3) desire to maintain competent childhood soprano singing voice
4) embarrassment when voice lowers dramatically earlier than ones peers

107
Q

Puberphonia is associated with significant negative _________________ consquences including what?

A

socioemotional

rejection by peers in some cases

108
Q

What treatment type is typically effective for puberphonia?

A

behavioral voice therapy

109
Q

What is juvenile voice?

A

post-adolescent females with higher than normal pitch, breathy voice, child-like speech distortion and prosody, and high tongue carriage

110
Q

What are hypothesized etiologies of juvenile voice?

A

1) resisted transition into adulthood

2) habituated the altered laryngeal and vocal tract posture

111
Q

What is another name for presbyphonia?

A

presbylaryngeus

112
Q

What is presbyphonia?

A

voice disorder presumably related to processes of laryngeal aging

113
Q

What are voice effects of presbyphonia? 1/5

A

older sounding voice:

1) thin, muffled
2) decreased loudness
3) increased breathiness
4) pitch instability
5) lack of vocal endurance and flexibility

114
Q

What is the classical laryngeal appearance for presbyphonia?

A

slightly bowed glottic configuration (presumably related to “thinned/atrophic” VFs)

115
Q

What is an effective treatment for presbyphonia?

A

voice rehabilitative therapy, especially vocal function exercises (VFEs)

116
Q

What are 4 inflammatory conditions of the larynx?

A

1) rheumatoid arthritis
2) acute laryngitis
3) laryngopharyngeal reflux
4) chemical sensitivity/irritable larynx syndrome

117
Q

What are the 2 types of rheumatoid arthritis that are inflammatory conditions of the larynx?

A

1) cricoarytenoid arthritis

2) cricothyroid arthritis

118
Q

What are the 3 types of trauma to the larynx that can occur?

A

1) internal laryngeal trauma
2) external laryngeal trauma
3) arytenoid dislocation

119
Q

What are 3 types/causes of internal laryngeal trauma that can occur?

A

1) thermal
2) chemical
3) intubation/extubation

120
Q

What are 2 causes of external laryngeal trauma?

A

1) blunt force

2) penetrating wounds

121
Q

What are 2 potential causes of arytenoid dislocation?

A

1) external laryngeal trauma

2) intubation/extubation injury

122
Q

What are 3 systemic/whole body influences on the voice?

A

1) endocrine function
2) allergies
3) immunologic responses

123
Q

What are 4 groups of adverse effects that medications can have on the larynx?

A

1) drying/muscle atrophy/inflammatory events (bronchodilators/asthma meds)
2) drying effects vis reduced fluid levels (diuretics, corticosteroids, decongestants)
3) drying effects vis reduced upper airway secretions (antihistamines, antitussives)
4) altered vocal fold structure (via hormone therapies including estrogen and testosterone)

124
Q

What are nonlaryngeal aerodigestive disorders that affect the voice?

A

1) asthma
2) COPD
3) croup (acute laryngotracheobronchitis)
4) GERD
5) infectious diseases of the aerodigestive tract
6) mycotic (fungal) infections: candida

125
Q

What 3 nonlaryngeal aerodigestive disorders that are associated with acute or chronic symptoms of dyspnea?

A

1) asthma
2) COPD
3) croup (acute laryngotracheobronchitis)

126
Q

What are 4 psychological disorders affecting voice?

A

1) functional dysphonia
2) psychogenic voice disorder
3) factitious disorders or malingering
4) gender dysphoria

127
Q

What are the 3 criteria for a psychogenic voice disorder diagnosis?

A

1) symptom psychogenicity
2) symptom incongruity
3) symptom reversibility

128
Q

What are 3 peripheral nervous system pathologies that affect the voice?

A

1) superior laryngeal nerve paralysis (external branch): unilateral
2) recurrent laryngeal nerve paralysis (RLN): unilateral
3) recurrent laryngeal nerve paralysis (RLN): bilateral

129
Q

Unilateral external branch SLN paralysis causes what?

A

unilateral cricothyroid muscle dysfunction

130
Q

What are the laryngeal findings of external branch SLN paralysis unilaterally?

A

epiglottic petiole deviation to the side of weakness during high pitched voice as a possible diagnostic marker

131
Q

What are 4 phonatory effects of external branch SLN paralysis unilaterally?

A

1) mild dysphonia
2) loss of upper pitch range
3) voice characterized by weakness
4) increased physical effort expended to produce voice

132
Q

What are 2 laryngeal findings of RLN paralysis unilaterally?

A

1) inadequate VF closure

2) loss of VF muscle tone (flaccid, weak, bowed)

133
Q

What are phonatory effects of RLN paralysis, unilaterally? Severity? 4 phonatory effects?

A

can be mild to severe

1) breathiness
2) low intensity
3) low pitch
4) intermittent diplophonia

134
Q

What are 2 laryngeal effects of RLN paralysis, bilaterally?

A

1) abductor can’t abduct for respiration

2) adductor can’t adduct for airway protection

135
Q

What are phonatory effects of RLN paralysis, bilaterally?

A

1) permanently weakened
2) aphonic
3) 6-9 months post onset, VF contracture and fibrosis may occur, bringing them closer to midline allowing harsh, breathy phonation

136
Q

SLN or RLN paresis is the result of?

A

partial injury to one or both SLN or RLN branches

137
Q

RLN paresis effects?

A

observed reduced VF movement (speed and ROM) and tone

138
Q

SLN paresis effects?

A

hypomobility may also be observed

139
Q

What are the phonatory effects of SLN or RLN paresis? __________ characterized by (4)?

A

dysphonia:

1) breathiness
2) decreased pitch range
3) decreased loudness
4) decreased endurance

140
Q

What are 2 types of central neurologic disorders affecting voice?

A

1) movement disorders of the larynx

2) dysarthrias

141
Q

What are the 2 movement disorders of the larynx (CNS)?

A

1) spasmodic dysphonia (SD)

2) essential voice tremor

142
Q

What is spasmodic dysphonia?

A

focal, action-induced dystonia

143
Q

What are the 3 types of SD?

A

1) adductor spasmodic dysphonia (ADSD)
2) abductor spasmodic dysphonia (ABSD)
3) mixed SD

144
Q

What is ADSD voice like?

A

strained-strangled voice with voice stoppages/spasms

145
Q

What is ABSD voice like?

A

involuntary breathy bursts/spasms

146
Q

What is mixed SD voice like?

A

both strained voice stoppages and breathy bursts

147
Q

What are 6 voice, speech, and resonance disorder characteristics of dysarthrias?

A

1) flaccid (LMN)
2) spastic (UMN)
3) ataxic (Cerebellar Control Circuit)
4) hyperkinetic (BG control circuit)
5) hypokinetic (BG control circuit)
6) mixed dysarthrias

148
Q

Other disorders of voice use/laryngeal dysfunction include: (5)

A

1) phonotrauma
2) vocal fatigue
3) muscle tension dysphonia
4) ventricular phonation
5) paradoxical vocal fold motion

149
Q

What is phonotrauma?

A

voice abuse, misuse

150
Q

What is another name for vocal fatigue?

A

laryngeal myasthenia

151
Q

What are the two types of muscle tension dysphonia?

A

primary MTD

secondary MTD

Voice and Resonance Disorders (14 decks)

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