Disorders of Phonation and Their Treatment

Question 0

Location of Tumors in the Larynx

Answer 0

supraglottic, glottic, or subglottic.

Question 1

Early warning signs of laryngeal cancer (5)

Answer 1

1. hoarseness
2. dysphagia
3. persistent sore throat
4. ear pain
5. lump in neck or throat

Question 2

Metastisis

Answer 2

spreading of cancer cells to other structures (can include node involvement).

Question 3

Classification of Cancer

Answer 3

T - primary site of the tumor
N - involvement of the lymph nodes
M - metastasis
This is a TMN design

Question 4

Treatment of Cancer

Answer 4

1. surgery - e.g., laryngectomy (can be total or hemi). radial neck dissection occurs when their are lymphatic nodes that have to be removed.
2. chemotherapy - can cause side effects like nausea, weight loss, and weakness
3. radiation - side effects include skin burns, risk of cavities, edema, swallowing problems, diminished taste, sore throat, and xerostomia.

Question 5

Issues of Rehabilitation of the Laryngectomee

Answer 5

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.

Question 6

Types of Alaryngeal Speech

Answer 6

1. external devices - electrolarynx/artificial larynx
2. esophageal speech - Voice is produced by pharyngoesophageal segment by either injection or inhalation (injection - swallows air for vibratory source, inhalation - patient speaks while inhaling)
3. Surgery/implantations- TEP puncture (blomsinger tracheoesohpageal sphincter

Question 7

Granuloma

Answer 7

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.

Question 8

Hemangioma

Answer 8

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.

Question 9

Leukoplakia

Answer 9

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.

Question 10

Hyperkeratosis

Answer 10

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.

Question 11

laryngomalacia

Answer 11

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.

Question 12

subglottal stenosis

Answer 12

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.

Question 13

Papilloma

Answer 13

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.

Question 14

Laryngeal Trauma

Answer 14

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.

Question 15

Laryngeal web

Answer 15

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.

Question 16

Paradoxical Vocal Fold Movement

Answer 16

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.

Question 17

Gastroesophageal Reflux Disease

Answer 17

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.

Question 18

paralysis

Answer 18

Can be caused by:

1. injury to recurrent laryngeal nerve (surgery for thyroidectomy)
2. progressive disease (ALS)
3. malignant disease (tumor)
4. intubation trauma
5. laryngeal trauma
6. stroke
7. 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.

Question 19

ankylosis

Answer 19

Stiffness of joints, in this case the arytenoids. Can be caused by arthritis or cancer. Causes vocal folds to not close fully.

Question 20

Spasmodic dysphonia

Answer 20

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.

Question 21

Multiple Sclerosis

Answer 21

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.

Question 22

Myasthenia Gravis

Answer 22

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.

Question 23

amyotrophic lateral sclerosis

Answer 23

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.

Question 24

Parkinson’s Disease

Answer 24

a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people. It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine. Can be idiopathic (cause unknown) or occur with other problems (vascular parkinson’s or parkinsonism secondary to dementia with lewy bodies). Patients sound breathy, low-pitched, and monotonous. Treatment can include levodopa and LSVT-Loud.

Question 25

General Treatment Strategies for those with Neurological Disease

Answer 25

1) exaggerate speech/articulation
2) increase mouth opening to improve resonance
3) improve prosody
4) improve respiration with efficient breathing strategies
5) improve vocal fold approximation (e.g., glottal attack)

Question 26

Vocal Abuse

Answer 26

Phonotrauma, excessive or damaging vocal use. Teachers/professional voice users are most prone to this. Majority of abusive behaviors include increased muscle tension and increased effort, thus damaging vocal tissues. Therapy, medication, and surgery are used.

Question 27

Vocal Nodules

Answer 27

Develop over time, starting out as pink, and can turn white and fibrous (thus harder to treat). Can be unilateral or bilateral. Tend to become diffuse and less defined as the tissue becomes more irritated and damaged. Increases mass, which lowers pitch. Also causes breathiness and hoarsensess. Vocal rest is important.

Question 28

Polyp

Answer 28

Similar to nodules, except they are softer and filled with fluid or vascular tissue. Tend to be unilateral. Believed to be caused by submucosal hemorrhage. More often in adults. May sound breathy, hoarse, or diplophonic.