Disorders of Phonation and Their Treatment Flashcards
Location of Tumors in the Larynx
supraglottic, glottic, or subglottic.
Early warning signs of laryngeal cancer (5)
- hoarseness
- dysphagia
- persistent sore throat
- ear pain
- lump in neck or throat
Metastisis
spreading of cancer cells to other structures (can include node involvement).
Classification of Cancer
T - primary site of the tumor
N - involvement of the lymph nodes
M - metastasis
This is a TMN design
Treatment of Cancer
- surgery - e.g., laryngectomy (can be total or hemi). radial neck dissection occurs when their are lymphatic nodes that have to be removed.
- chemotherapy - can cause side effects like nausea, weight loss, and weakness
- radiation - side effects include skin burns, risk of cavities, edema, swallowing problems, diminished taste, sore throat, and xerostomia.
Issues of Rehabilitation of the Laryngectomee
Team approach is critical. They need pre and post operative counseling. Support groups are beneficial for rehabilitation (counseling between laryngectomees). Support the families as well as the patients.
Types of Alaryngeal Speech
- external devices - electrolarynx/artificial larynx
- esophageal speech - Voice is produced by pharyngoesophageal segment by either injection or inhalation (injection - swallows air for vibratory source, inhalation - patient speaks while inhaling)
- Surgery/implantations- TEP puncture (blomsinger tracheoesohpageal sphincter
Granuloma
localized, inflamatory, vascular lesion. Usually composed of granular tissue (Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) in a firm, rounded sac. Frequently develop in the vocal processes of arytenoid cartilages from contact ulcers. Patients sound breathy, hoarse, and feel like they need to clear their throat. They are treated by surgery and/or voice therapy.
Hemangioma
Similar to granuloma, except that they are soft and filled with blood. Often form in posterior glottis. Often caused by intubation or other types of laryngeal trauma. Treat with surgery first, then voice therapy to improve vocal quality.
Leukoplakia
benign growths of thick, white patches on the surface membrane of mucosa. May extend below epethilial layer. Caused by irritation (smoking, vocal abuse, etc.). Considered to be precancerous squamous cell carcinoma. Usually occurs on the anterior 1/3 of vocal fold and under the tongue. Patents sound hoarse, low-pitched, breathy, low volume, with possible diplophonia. Treatment with surgery, voice therapy, and reduction of irritants.
Hyperkeratosis
Hyperkeratosis is a layered buildup of keratinized cell tissue and is distinctive for its leaf-like appearance and consists of a horny overgrowth of irregular margins on the vocal folds. Causes and treatments are similar to patients with leukoplakia. A patient with hyperkeratosis may have more severe hoarseness or harshness.
laryngomalacia
also called congenital laryngeal stridor. Involves soft, floppy laryngeal cartilages, particularly the epiglottis. The epiglottis obstructs the airstream, causing stridor. Usually resolves by age 2-3. If the child has severe breathing trouble, then treatment will usually be initiated.
subglottal stenosis
narrowing of the subglottic space. Can be congenital or acquired. Congenital - arrested development of the conus elasticus or cricoid cartilage. Defined as a lumen 4.0mm in diameter or smaller at the level of the cricoid. Aquired - caused by endotracheal intubation or other trauma to subglottis.
In general, children with this condition will have intolerance for exercise and stridor. Surgical, endoscopic, and theraputic options are often used to treat this.
Papilloma
Tend to occur primarily in children. Wart-like growths caused by human papilloma virus. May be found anywhere in the airway. Hoarseness, breathiness, and low pitch can be observed, but airway preservation is of main concern. Voice therapy is usually used to help patients with the effects of surgical/medical intervention rather than prevention of papillomas.
Laryngeal Trauma
Injury to larynx. Can be thermal/chemical burns, motor vehicle or other accidents, attempted strangulation, gunshot wounds, or swallowing sharp objects. Surgery is used to repair the injured structures. Patients who smoke or have GERD need to resolve these issues first, or else the healing after the surgery will be impaired or ineffective. Effectiveness of voice therapy depends on the integrity and function of remaining repaired structures.
Laryngeal web
Membrane growing across anterior portion of the glottis. Can be congenital or acquired. Congenital- surgery plus tracheostomy for healing period. Acquired - surgery plus laryngeal keel (something to place on the vocal folds so they don’t heal connected). Voice therapy may be needed to return to normal phonation.
Paradoxical Vocal Fold Movement
PFVM - called laryngeal dyskinesia, inappropriate adduction of vocal folds during inhalation, exhalation, or both. Patients often appear asthmatic, may display stridor or dysphonia. Some get trached. It is considered to be a conversion disorder by some, neurological/pharmicological/environmental (irritants) by others. Treatment may be behavioral, surgical, of psychological.
Gastroesophageal Reflux Disease
GERD - patient may experience heartburn, acid indigestion, sore throat and hoarseness. Contact ulcers may form. Manometric evaluation in the esophagus to measure pressure is often used. Treatment involves medications, behavioral changes, surgery, in addition to possible voice therapy.
paralysis
Can be caused by:
- injury to recurrent laryngeal nerve (surgery for thyroidectomy)
- progressive disease (ALS)
- malignant disease (tumor)
- intubation trauma
- laryngeal trauma
- stroke
- vagus nerve deficits
Patients may sound somewhat normal, but will have trouble coughing/swallowing because of decreased pressure. Pitch and volume may be affected, accompanied by breathiness. Can be bilateral or unilateral.
ankylosis
Stiffness of joints, in this case the arytenoids. Can be caused by arthritis or cancer. Causes vocal folds to not close fully.
Spasmodic dysphonia
a type of dystonia (cramping “attacks” of muscle groups, aka involuntary muscle contractions). Can be described as focal laryngeal dystonia. Thought to be caused by brainstem dysfunction.Two types - Abductor and Adductor. With abductor - reduced loudness, aphonia, breathy speech. Treated with medicine, botox, relaxation and continuous phonation. Adduction - strangled/choked. Over-closed vocal folds. May be treated with a CO2 laser, Recurrent Laryngeal Nerve resection, botox, and voice therapy. Botox is currently the treatment of choice.
Multiple Sclerosis
MS - progressive and diffuse demylination of white matter in the CNS. Patients may have impaired prosody, loudness/pitch control, harshness, breathiness, hypernasality, articulatory difficulties, and nasal air emission.
Myasthenia Gravis
neuromuscular autoimmune disease that causes fatigue and muscle weakness. Patients may sound hypernasal, breathy, hoarse, and soft in volume. Gets worse as use continues with recovery after a period of rest.
amyotrophic lateral sclerosis
ALS - progressive and fatal. Destroys upper and lower motor neurons (not just myelin). Patients sound breathy, low-pitched, and monotonous. AAC is a compensatory approach. Cognition stays relatively unimpaired compared to MS.
