Dysphonia Flashcards
Dysphonia
disorder characterized by altered vocal quality, pitch, loudness or vocal effort that impairs communciation or reduces vocal related quality of life.
Supraglottic
Glottic
Subglottic
Many pathologies are possible: the hallmark sign is inspiratory stridor
the ____ cartilages are responsible for vocal cord motion (abduction/adduction)
he arytenoid cartilages are responsible for vocal cord motion (abduction/adduction)
POSTERIOR Cricoarytenoid Muscle
The arytenoid cartilage slides and rotates to open and close the glottis
Intrinsic muscles of the larynx (posterior cricoarytenoid muscle) insert into the arytenoid cartilages to produce vocal cord movement.
CNX (vagus)
Comes out of the skull base and send __ __ nerve branch behind the carotid to go through ___ muscle, tensing the vocal cord. Also supplies sensation for half of larynx above vocal cord
CNX also sends the ___ laryngeal nerve which goes underneath the subclavian to the larynx, supplying the ___ muscles of the larynx.
Comes out of the skull base and send SUPERIOR LARYNGEAL nerve branch behind the carotid to go through CAROTID muscle, tensing the vocal cord. Also supplies sensation for half of larynx above vocal cord
CNX also sends the recurrent laryngeal nerve which goes underneath the subclavian to the larynx, supplying the intrinsic muscles of the larynx (Intrinsic muscles of the larynx insert into the arytenoid cartilages to produce vocal cord movement)
Sensation above the cords is SLN, below the cords is RLN.
broad differential diagnosis in patients with dysphonia
Functional voice disorders
Tumors
Chronic non-infective laryngitis
Infection
Benign Mucosal abnormalities
Laryngeal trauma
Neurogenic Voice DIsorders
Note: if the voice widely fluctuates from normal to abnormal in relatively short periods of time, the cords are likely normal. If the voice sounds persistently abnormal and is never normal, there is likely an anatomic or neurologic abnormality in the larynx.
Definition, Etiology, Mechanism, Symptoms and management of Functional Dysphonia (most common)
Def: anatomically + physiologically intact larynx but voice is abnormal
Etiology: : poor vocal technique, psychologic factors
Mechanism: : excessive laryngeal muscle tension resulting in a restricted voice. Most likely due to poor vocal technique and psychological factors.
Symptoms: Can vary from aphonia to mild dysphonia to the sound of a restricted voice
Treatment: voice therapy
Most common cause of a mass-related dysphonia
Laryngeal papilloma (benign)
due to HPV types 6 and 11.
Treatment: removal to maintain airway and voice
complications: high recurrence rrate
Most common malignant mass of the larynx. Risk factor?
Squamous cell carcinoma almost exclusively used.
Presentation: gradual onset of a rough voice in a long term smoker. T1-T4.
Treatment: surgery or radiation therapy depending on T stage.
3 “main types” of Glottic infections
- Viral: most common. Treat with voice rest, resolves spontaneously
- bacterial: chronic infection, usually following viral upper resp infection or TB
- FungaL: monilia secondary to steroid inhalers. Manage with fluconazole.
Symptoms: very sore throat, can’t swallow saliva,fever, leukocytosis, stridor WHEN LAYING DOWN with no focal neck swelling/tenderness
What is this condition? Main bug? management?
Adult Epiglottitis!
Etiology: H. influenza in children, strep, staph, bacterial infection.
Investigations: flex scope in ER → normal oropharynz + swollen, red, angry epiglottis
Management; efer to ENT for admission +/- ICU +/- intubation. IV Abx and steroids will be sufficient for most.
Mechanism and causes of chronic laryngitis
Mechanism: changes in vocal cord structure because of chronic inflammation causes changes in the voice. Results in stiff, poorly vibrating vocal cord.
Causes: GERD, smoking, allergies, vocal abuse, occupational.
*carcinoma and other significant disease must be ruled out.
Often are due to vocal trauma from overuse, other forms of trauma may play a role: intubation, and smoking/reflux may contriubte to this abnoramlitiy
benign mucosal abnormalities. includes nodules, granulomas, polyps, cysts and sulcus.
Vocal nodules are a benign mucosal abnormality that often is a result of vocal abuse (singing, acting, yelling). Maximum trauma occurs at the junction of the ______ of the larynx.
Treatment?
Vocal Nodules (BMA)
Occurs as a result of vocal abuse (yelling, singing, acting)
Maximum trauma occurs at junction of the anterior one third and posterior two thirds
Treatment is usually initially voice therapy. Surgery is a last resort.
VOCAL GRANULOMAS aka INTUBATION GRANULOMAS
Vocal Process Granulomas
Mechanism: Secondary to trauma to the posterior glottic mucosa (vocal processes)
Area will ulcerate and then granulate.
Causes; intubation, vocal abuse, coughing, reflux or iatrogenic manipulation.
Treat: prevent trauma.usually will resolve spontaneously.
Definition: sudden onset hoarseness during vigorous vocal use Etiology: upper resp infection + vocal trauma–>bruise Management: vocal rest
vocal hemorrhage
treatment; vocal rest
differences in cause of unilateral vs bilateral polyps
unilateral polyps: upper resp infection + vocal trauma –> vocal hemorrhage –> formation of polyp during healing.
bilateral vocal polyps: usually seen in females. smoking+vocal abuse –> progressive lowering of vocal pitch.
Fairly sudden onset of a persistently dysphonic voice. what is this condition?
vocal cord cyst: essentially an obstructed mucus gland within the vocal fold
most common cause of laryngeal trauma (internal)
Internal Trauma
Epi: most common Etiology: ICU stays, vocal cord surgery, crash intubation
management of external laryngeal trauma: stable vs unstable airway
etiology of external lar. trauma: blunt force or penetrating trauma
stable airway: assess voice, ensure airway is normal –>. laryngoscopy +/- CT for fracture
unstable airway: create airway asap with TRACH or intubation
most common cause neurogenic voice loss
vocal fold paralysis
etiology: trauma, tumour, idiopathic or disease anywhere along the nerves;
SLN paralysis: minor vocal changes
RLN paralysis: causes more significant voice changes
Unilateral paralysis: voice is the issue
- Typically presents with “breathy voice,” weak cough
- Initially the patient may aspirate on liquids
- History will often reveal the cause, MRI or CT might be needed
Treatment: medialization of vocal fold if the voice is inadequate.
Bilateral paralysis: airway is the issue
Typically presents with upper airway obstruction symptoms
- If cords are abducted: poor voice and aspiration
- If cords are adducted: good voice and stridor
outline how unilateral vs bilateral paralysis of the vocal folds differ in symptoms
Unilateral paralysis: voice is the issue
- Typically presents with “breathy voice,” weak cough
- Initially the patient may aspirate on liquids
- History will often reveal the cause, MRI or CT might be needed
- Treatment: medialization of vocal fold if the voice is inadequate.
Bilateral paralysis: airway is the issue
Typically presents with upper airway obstruction symptoms
- If cords are abducted: poor voice and aspiration
- If cords are adducted: good voice and stridor
Spasmodic Dysphonia is a neurogenic voice disorder that results in focal dystonia. outline the difference in symptoms of the vocal adductors vs abductors are affectd by spasmodic dysphonia
Type of focal dystonia.
ADductor (95%): tight strangled breaking speech
Abductor: breathy spasmodic breaks in voice.
Exact etiology is unknown
Best treatment is currently botox.
Progressive tremor of voice in a more elderly patient. Often familial. Associated with hand and head tremors
Aka benign essential voice tremor
Neurogenic vocal tremor
Progressive tremor of voice in a more elderly patient. Often familial. Associated with hand and head tremors
Aka benign essential voice tremor
Moderate to severe cases may be Rx with botox.
Reasonably common. Biphasic stridor inspiratory more prominent
Most commonly idiopathic
Occasionally trauma
Typically: adult female with remote, routine intubation in the past.
Treatment: laser/cautery and dilation initially.
Subglottic Stenosis
Often feels like an obstruction at the laryngeal level. May present acutely, but more commonly presents with intermittent inspiratory stridor which resolves spontaneously.
Often occurs when anxious or upset, sometimes precipitated by severe cough
F>M!!!!
What condition is this? How do you confirm findings?
Paradoxical Vocal Fold Motion (PVFM)
Diagnosed by clinical suspicion. Confirmed by endoscopy. In mild intermittent cases, often only reassurance is needed.
In persistent cases, behavioural therapy by a voice therapist gives relief.
