Chapter 4: Pathologies of the Laryngeal Mechanism Flashcards
What are the 4 categories of etiologies?
1) structural
2) medical
3) neurologic
4) psychological
What are 3 factors that influence the prevalence of voice disorders?
1) age
2) gender
3) occupation
How many adults report current voice disorder?
7%
How many adults report a voice disorder during sometime in their lives?
30%
Chronic voice disorders are more common among what 2 groups? and with history of what 4 things?
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
What are the 8 classifications of voice disorder pathologies?
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”
What is a structural pathology of the VFs?
any alteration to histological structure of the vocal fold
Changes in the layered structure of the VF (structural pathologies) can affect what 5 things that therefore affect what?
1) mass
2) size
3) stiffness
4) flexibility
5) tension
vocal quality, pitch, and loudness
Variations in vocal quality due to a structural pathology often reflects what 3 things?
1) lesion severity (size/site/depth)
2) habitual voice use patterns
3) presence/absence of compensatory adjustments
What are the 2 types of compensatory adjustments?
1) productive
2) maladaptive
What are 3 examples of productive compensatory adjustments?
1) improved breath support
2) enhanced vocal tract tuning
3) appropriate changes in pitch and loudness
What are 3 examples of maladaptive compensatory adjustments?
1) extreme muscle activation/effort
2) poor tone focus
3) inapropriate changes in pitch and loudness
What is a malignant lesion that will affect voice?
laryngeal carcinoma (typically squamous cell type originating from the epithelium)
How does a laryngeal carcinoma affect voice?
as it progresses, invades deeper layers of the VF including the vocalis, dysphonia varies based on location and depth of invasion
What are 4 carcinoma treatment options?
1) radiation therapy
2) chemotherapy
3) surgical excision
4) or combination
What are the 3 traditional and 3 “newer” benign epithelial and lamina propria abnormalities?
Traditional: 1) polyps 2) nodules 3) cysts "Newer": 1) pseudocyst(s) 2) fibrous mass(es) 3) reactive lesion(s)
What is the following called: bilateral, “relatively” symmetrical lesions on the medial edge between ant 1/3 and post 2/3 of VFs
vocal fold nodules
Where is the site of maximum collision and shearing forces on the VFs?
between anterior 1/3 and posterior 2/3
How do VF nodules occur?
inflammatory degeneration of SLLP with fibrosis and edema of VF cover
(transition and body typically not affected)
What are the 2 types of VF nodules and what are they like?
1) acute (immature, gelatinous and floppy)
2) chronic (mature, harder and more fixed to underlying mucosa)
For children, which gender is more likely to get vocal fold nodules?
boys
For adults, which gender are more likely to experience VF nodules?
women
What are 4 possibility personality factors for getting VF nodules?
1) extraverted (talkative)
2) socially dominant
3) stress reactive (tense), aggressive
4) impulsive
What are occupational factors that can cause VF nodules?
professions with extended/loud voice use (teachers, singers, etc.)
What kind of quality do VF nodules cause?
mild to moderate dysphonia
What is mild to moderated dysphonia due to VF nodules like?
roughness, breathiness related to gaps anterior and posterior to lesions, increased muscular tension
The severity of VF nodules depends on what 3 things?
1) extent/size of lesions
2) length of time since onset (chronic vs. acute)
3) degree of accompanying inflammation
What is treatment for VF nodules like?
first line = voice therapy
second line = surgical removal and post-surgical voice therapy
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?
VF polyps
Vocal fold polyps are most often seen in __________, and they are often ____________, but can be ____________.
adults
unilateral, bilateral
What are the 2 types of polyps?
1) sessile (blister-like)
2) pedunculated (attached to a stalk)
What is the cause of vocal fold polyps?
acute vocal trauma (phonotrauma)
What are the voice effects of VF polyps?
mild to severe dysphonia
What is the severity of dysphonia in VF polyps dependent on? (3)
1) size, type, and location
2) degree of interference with glottic closure and VF vibration
3) presence of hemorrhagic blood vessel “feeding the lesion”
What are the treatments for VF polyps?
1) primary = voice conservation/rehabilitation
2) phonosurgery (and voice rehab)
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?
VF cysts
What are the 2 types of VF cysts?
1) congenital
2) acquired
What can cysts be confused with and why?
nodules
cysts often associated with “reactive” thickening of contralateral VF suggesting bilateral lesions
How are cysts different than nodules?
create a stiff adynamic segment due to reduced vibratory freedom of the cover of the VF
What is the treatment for VF cysts?
surgical excision/dissection of the cyst off of the vocal ligament (from a superior and lateral approach to avoid scarring the VF)
What is the following called: SLLP becomes filled with viscous, gelatinous edema
Reinke’s Edema
What is polypoid degeneration?
severe form edema wherein the entire membranous VF is filled with fluid
What are the 2 etiologic factors of Reinke’s edema?
1) chronic phonotrauma
2) smoking
What are the 2 vibratory effects of Reinke’s Edema?
increased mass and stiffness
What are the voice effects of Reinke’s Edema?
signature low pitch and husky hoarseness described as a “whiskey” or “smoker’s” voice
What is the treatment for Reinke’s Edema?
surgery (accompanied/preceded by smoking cessation) and pre- and post-operative voice thearpy
What is vocal fold scarring?
permanent tissue changes in the structure of the lamina propria due to any number of etiologies
What are 3 potential etiologies of VF scarring?
1) lesion presence
2) chronic tissue irritation
3) latrogenic (postsurgical) changes
VF scarring can cause what? (3)
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
Vocal fold scarring effects on voice depends on what 3 things?
1) severity
2) extent
3) location of scar
What is the treatment for vocal fold scarring?
no accepted/effective behavioral or surgical treatment
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
sulcus/sulcus vocalis
What are the two types of sulcus/sulcus vocalis?
1) small pit or divot (sulcus vocalis)
2) entire length of medial surface (sulcus vergeture)
What are potential etiologies of sulcus/sulcus vocalis?
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
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?
granulomas
What is the following called: ulcerated lesion on the same site often on opposite side of a granuloma?
contact ulcer
What are 4 symptoms of granuloma and contact ulcers?
1) pain
2) sore throat
3) with or without voice change
4) with or without affecting VF vibration
What are the two primary etiologies of VF vibration?
1) “mechanical” or “chemical” tissue irritants of posterior larynx
2) persistent voice misuse
What is a mechanical tissue irritant of the posterior larynx?
endotracheal intubation
What is a chemical tissue irritant of the posterior larynx?
laryngopharyngeal reflux
What type of persistent voice misuse that causes granuloma and contact ulcers like?
pressed, low-pitch voice with excess tension
What are the 4 treatment types for granuloma or contact ulcers?
1) medical
2) surgical
3) behavioral
4) combination
What are the 2 medical treatments for granuloma and contact ulcers?
1) antireflux regimen
2) unilateral (intracordal) Botox injection to reduce medial compression forces (to allow healing)
What is the behavioral treatment for granuloma and contact ulcers?
reduce medial compression by reducing strain and pressed voice, pitch elevation, and reduction of “hard” glottal onsets
What is the surgical treatment for granuloma and contact ulcers?
excision (if medical and/or behavioral treatments fail)
Given the location and etiology of granuloma and contact ulcers, these lesions can be __________________ and ____________ can be common
recalcitrant
recurrence
What are the three benign vocal fold pathologies that are often subsumed under “epithelial hyperplasia”?
1) leukoplakia
2) hyperkeratosis
3) erythroplaisa
What is epithelial hyperplasia?
abnormal mucosal changes
What two types of epithelial hyperplasia’s may be precancerous? And so what is recommended?
1) leukoplakia
2) hyperkeratosis
Direct microlaryngoscopy with biopsy is often recommended
What is leukoplakia?
“white plaque”
What is hyperkeratosis?
“excessive keratin”
What is erythroplaisa?
“thickened and red”
Which VF pathology results in a thick substance on superior surface of the VFs in diffuse white patches?
Leukoplakia
Which VF pathology results in buildup of keratinized tissue, rough, irregular VF margins?
Hyperkeratosis
Which VF pathology is due to a combination of hyperfunctional voice use and chemical irritation especially alcohol and tobacco use?
Erythroplasia
What is RRP?
Recurrent respiratory papilloma
Papilloma = wart like growths that develop in the epithelium and invade deeper in the LP and vocal muscle
Papilloma can grow ___________ and in large __________, and can ___________ and ___________ the airway
rapidly
clusters
proliferate and comprimise
What is the etiology of RRP?
Human Papilloma Virus (HPV) infection
What are the 2 types of HPV?
1) juvenile
2) adult
What is juvenile HPV like?
1) onset at 2-4 yrs, same prevalence in boys and girls, can resolve spontaneously especially after puberty
What are the effects HPV/RRP can have on voice?
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
What are the treatment options for papilloma?
1) surgical
2) pharmacotherapy
What is surgical papilloma treatment like?
laser or cold-steel excision,
recurrence is common requiring multiple de-bulking surgeries and increased likelihood of VF scarring
What are the 3 options for pharmacotherapy treatment of papilloma?
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
What is Cidofovir?
antiviral medication designed to inhibit the HPV virus at injection site
What is Bevacizumab (i.e., Avastin)?
angiogenesis inhibitor, designed to starve off papilloma
What is the following called: fibrous tissue overgrowth that narrows the airway (typically subglottic just below the true VFs)
subglottic stenosis
What is the following called: acquired scar across medial edges of the VFs beginning in the anterior commissure and extending posteriorly?
Glottic stenosis or anterior glottis web
What are 3 possible etiologies of subglottic stenosis?
1) congenital
2) post-intubation scarring
3) laryngopharyngeal reflux
What are 2 possible etiologies of glottic stenosis/web?
1) congenital (i.e., synechia)
2) acquired - secondary to surgery involving anterior membranous portion of the VFs
What is the management option for subglottic stenosis/web?
surgery
What are 4 types of vascular lesions?
1) VF hemorrhage
2) hematoma
3) varix
4) ectasia
What are vascular lesions caused by and what do they cause?
traumatic injury to small blood vessels of the VF
focal or diffuse discoloration of VF
What are vascular lesions often related to?
intense screaming, singing, coughing, or crying
What population do vascular lesions occur in?
premenstrual women using blood thinners/anticoagulants (e.g., aspirin)
What is the following called: small capillary on superior surface of VF ruptures abruptly and bleeds into the SLLP (Reinke’s space)?
hemorrhage
What is the following called: accumulation of blood that has leaked from the ruptured vessel?
hematoma
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?
varix
What is the following called: larger collection of varices?
ectasia
Vascular injuries have the potential to increase __________ of the ________, with localized __________ in more severe cases.
stiffness
cover
scarring
Vascular lesions can have what effect on voice?
vary from severe at time of bleed to mild later,
small varices or ectasias may have negligible effects on the voice
What are 4 treatment options for vascular lesions?
1) aggressive voice conservation (complete voice rest)
2) medical (steroids)
3) laser cauterization (to stop bleed)
4) surgery (microexcision of persistent varix)
What is another name for puberphonia?
mutational falsetto
What is puberphonia?
post-pubescent males who speak in falsetto or near top of their modal frequency range
What are effects on voice from puberphonia?
weak, breathy and raspy, unable to increase intensity or shout
What are 4 proposed causes of puberphonia?
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
Puberphonia is associated with significant negative _________________ consquences including what?
socioemotional
rejection by peers in some cases
What treatment type is typically effective for puberphonia?
behavioral voice therapy
What is juvenile voice?
post-adolescent females with higher than normal pitch, breathy voice, child-like speech distortion and prosody, and high tongue carriage
What are hypothesized etiologies of juvenile voice?
1) resisted transition into adulthood
2) habituated the altered laryngeal and vocal tract posture
What is another name for presbyphonia?
presbylaryngeus
What is presbyphonia?
voice disorder presumably related to processes of laryngeal aging
What are voice effects of presbyphonia? 1/5
older sounding voice:
1) thin, muffled
2) decreased loudness
3) increased breathiness
4) pitch instability
5) lack of vocal endurance and flexibility
What is the classical laryngeal appearance for presbyphonia?
slightly bowed glottic configuration (presumably related to “thinned/atrophic” VFs)
What is an effective treatment for presbyphonia?
voice rehabilitative therapy, especially vocal function exercises (VFEs)
What are 4 inflammatory conditions of the larynx?
1) rheumatoid arthritis
2) acute laryngitis
3) laryngopharyngeal reflux
4) chemical sensitivity/irritable larynx syndrome
What are the 2 types of rheumatoid arthritis that are inflammatory conditions of the larynx?
1) cricoarytenoid arthritis
2) cricothyroid arthritis
What are the 3 types of trauma to the larynx that can occur?
1) internal laryngeal trauma
2) external laryngeal trauma
3) arytenoid dislocation
What are 3 types/causes of internal laryngeal trauma that can occur?
1) thermal
2) chemical
3) intubation/extubation
What are 2 causes of external laryngeal trauma?
1) blunt force
2) penetrating wounds
What are 2 potential causes of arytenoid dislocation?
1) external laryngeal trauma
2) intubation/extubation injury
What are 3 systemic/whole body influences on the voice?
1) endocrine function
2) allergies
3) immunologic responses
What are 4 groups of adverse effects that medications can have on the larynx?
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)
What are nonlaryngeal aerodigestive disorders that affect the voice?
1) asthma
2) COPD
3) croup (acute laryngotracheobronchitis)
4) GERD
5) infectious diseases of the aerodigestive tract
6) mycotic (fungal) infections: candida
What 3 nonlaryngeal aerodigestive disorders that are associated with acute or chronic symptoms of dyspnea?
1) asthma
2) COPD
3) croup (acute laryngotracheobronchitis)
What are 4 psychological disorders affecting voice?
1) functional dysphonia
2) psychogenic voice disorder
3) factitious disorders or malingering
4) gender dysphoria
What are the 3 criteria for a psychogenic voice disorder diagnosis?
1) symptom psychogenicity
2) symptom incongruity
3) symptom reversibility
What are 3 peripheral nervous system pathologies that affect the voice?
1) superior laryngeal nerve paralysis (external branch): unilateral
2) recurrent laryngeal nerve paralysis (RLN): unilateral
3) recurrent laryngeal nerve paralysis (RLN): bilateral
Unilateral external branch SLN paralysis causes what?
unilateral cricothyroid muscle dysfunction
What are the laryngeal findings of external branch SLN paralysis unilaterally?
epiglottic petiole deviation to the side of weakness during high pitched voice as a possible diagnostic marker
What are 4 phonatory effects of external branch SLN paralysis unilaterally?
1) mild dysphonia
2) loss of upper pitch range
3) voice characterized by weakness
4) increased physical effort expended to produce voice
What are 2 laryngeal findings of RLN paralysis unilaterally?
1) inadequate VF closure
2) loss of VF muscle tone (flaccid, weak, bowed)
What are phonatory effects of RLN paralysis, unilaterally? Severity? 4 phonatory effects?
can be mild to severe
1) breathiness
2) low intensity
3) low pitch
4) intermittent diplophonia
What are 2 laryngeal effects of RLN paralysis, bilaterally?
1) abductor can’t abduct for respiration
2) adductor can’t adduct for airway protection
What are phonatory effects of RLN paralysis, bilaterally?
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
SLN or RLN paresis is the result of?
partial injury to one or both SLN or RLN branches
RLN paresis effects?
observed reduced VF movement (speed and ROM) and tone
SLN paresis effects?
hypomobility may also be observed
What are the phonatory effects of SLN or RLN paresis? __________ characterized by (4)?
dysphonia:
1) breathiness
2) decreased pitch range
3) decreased loudness
4) decreased endurance
What are 2 types of central neurologic disorders affecting voice?
1) movement disorders of the larynx
2) dysarthrias
What are the 2 movement disorders of the larynx (CNS)?
1) spasmodic dysphonia (SD)
2) essential voice tremor
What is spasmodic dysphonia?
focal, action-induced dystonia
What are the 3 types of SD?
1) adductor spasmodic dysphonia (ADSD)
2) abductor spasmodic dysphonia (ABSD)
3) mixed SD
What is ADSD voice like?
strained-strangled voice with voice stoppages/spasms
What is ABSD voice like?
involuntary breathy bursts/spasms
What is mixed SD voice like?
both strained voice stoppages and breathy bursts
What are 6 voice, speech, and resonance disorder characteristics of dysarthrias?
1) flaccid (LMN)
2) spastic (UMN)
3) ataxic (Cerebellar Control Circuit)
4) hyperkinetic (BG control circuit)
5) hypokinetic (BG control circuit)
6) mixed dysarthrias
Other disorders of voice use/laryngeal dysfunction include: (5)
1) phonotrauma
2) vocal fatigue
3) muscle tension dysphonia
4) ventricular phonation
5) paradoxical vocal fold motion
What is phonotrauma?
voice abuse, misuse
What is another name for vocal fatigue?
laryngeal myasthenia
What are the two types of muscle tension dysphonia?
primary MTD
secondary MTD
