Exam 1 Flashcards
Etiologies
Phonotraumatic behaviors, inappropriate vocal components, medically-related, personality-related
inappropaite vocal components that may impact voice
type of breathing (clavicular, shallow) Phonatory habits (glottal fry, monotone) Resonance (back or front focused) Pitch Loudness rate (doesn't stop for breath)
Medically related etiologies
surgical trauma (direct vs indirect) chronic illness/diorders (allergies, sinuses, smoking, arthritis, GI) Primary disorders (cleft palate, velopharyngeal insufficiency, deafness, cerebral palsy, neuro disorder)
Pathologies of voice disorders
structural, medical, neurologic, psychological
What are the three Ps of voice disorders
Predisposing
precipitating
perpetuating
Definition of a voice disorder
Quality pitch and loudness differs from vocal characteristics typical of speakers of similar age, gender, cultural background, and geographic location
What factors influence the prevalence of voice disorders
Age (40-59)
Gender (women)
occupation (vocally demanding)
Malignant lesions
laryngeal carcinoma- starts at epithelium and gets deeper eventually invades the vocalis muscle
nodules
aka fibrous masses inflammatory degeneration of SLLP bilateral acute to chronic risk factors- more common in young boys and older women. Extreverted, impulsive, tense, singers, teachers dysphonia (rough, breathy) Treatment- voice therapy, surgery
Cysts
aka psuedocyst fluid filled unilateral sensile lesion (sacs) on medial edge really hard nonmoving segment of VF diploponia can be confused with nodules no clear etiology treatment- surgical removal
Polyps
Aka reactive lesion fluid filled lesions gelatinous sessile (blister like) pedunculated ( attached to stalk) dysphonia treatment- voice conservation/rehab. phonosurgery
Reinke’s Edema
SLLP becomes filled with viscous gelatinous fluid
increase in mass and stiffness leads to a lower pitch (husky smokers voice)
causes- chronic phonotrauma, smoking
treatment- surgery with smoking cessation program
Polypod degeneration
severe form of edema wherein the entire membranous VF is filled with fluid
VF scarring
Scar is general term given to permanent tissue changes in the structure of LP due to any number of etiologies
increase stiffness
reduces freedom of cover to oscillate=reduced mucosal wave
effects depend on severity, extent and location of scar
no accepted surgical or behavioral treatment. use compensatory strategies
sulcus vocalis
special form of scarring that makes a ridge along the SLLP
forms spindle shaped gap
unknown etiology but maybe congenital, cyst ruptures, long term reflux
VF granuloma
unilateral or bilateral
vascular and inflammatory
sticks out from the surface
related to tissue irritation in posterior larynx, medial surface of the arytenoid cartilages
cup and saucer relationship with contact ulcer
treatment- medical (antireflux, botox injections). surgical, behavioral (voice therapy. reduced medical compression and strain. pitch elevation, reduce hard onset)
recurrence is common
contact ulcer
lesion on the same site, often opposite side of granuloma
Keratosis, Leukoplakia, and erthroplasia
all fall under “epithelial hyperplasia” =abnormal mucosal changes
may be precancerous so removal is recommended
Leukoplakia
white plaque
thick substance on surface of VFs in white patches
Hyperkeratosis
excessive keratin
build up of keratinized tissue
rough, irregular VF margin
Erthroplasia
thickened and red
due to hyperfunctional voice use and chemical irritation (alcohol, tobacco, etc)
Papilloma (RRP)
Recurrent respiratory papilloma
wart like growth on epithelium –> LP/Vocalis
eitiology- HPV
causes stiffness, severe dysphonia
treatment- surgery, pharmacotherapy, sub-lesional injections
subglottic stenosis
fibrous tissue overgrowth that narrows the airway typically subglottic below the true VFs
eitiology- congenital. post-intubation, laryngopharyngeal reflux
treatment- surgery
Glottic Stenosis and anterior glottic web
congenital or acquired
acquired web secondary to surgery involving anterior membranous position of the VFs
treatment- surgery
vascular lesions
caused by traumatic injury to small blood vessels of VF
discoloration of VF (either focal or diffuse)
caused by screaming, singing, coughing, crying
more common in premenstrual women on blood thinners
cause stiffness, scaring in severe cases
treatment- voice conservation, steroids, laser cauterization
surgery- get rid of varix
hemorrhage
type of vascular lesion
small capillary on surface ruptures
bleeds into SLLP
Hematoma
type of vascular lesion
accumulation of blood that had leaked from the ruptured vessel
varix
type of vascular lesion
mass of capillaries that appears as small longstanding blood blister hardened over time
casuses lack of movement in VF segment
typically don’t affect voice
Ectasia
type of vascular lesion
larger collection of varices
small ones don’t typically affect voice
maturational changes affecting voice
puberphonia
juvenile voice
presbyphonia
puberphonia
Voice is weak, breathy or raspy, cannot yell or shout
Proposed causes: resistance to puberty, feminine identity, desire to keep childhood singing voice, embarassment of lower voice than peers
Related to significant negative socioemotional consequences including rejection from peers
Treatment: behavioral voice therapy
Juvenile voice
Post adolescent females
Higher than normal pitch, breathy, child-like speech distortions and prosody, high tongue carriage
Etiology- unknown
Presbyphonia
Older sounding voice- thin muffled voice quality, decreased loudness, increased breathiness, pitch instability, lack of vocal endurance and flexibility.
Appearance is slightly bowed glottic configuration related to thinned or atrophic VFs
Treatment- vocal function exercises
Inflammatory conditions of the larynx
Rheumatoid arthritis
Acute laryngitis
Reflux
Chemical sensitivity/ILS
injury/trauma to larynx
Internal trauma → thermal, chemical, intubation/extubation
External → blunt force, penetrating wounds
Arytenoid dislocation
systemic conditions affecting voice
Whole body influences- Endocrine function
Allergies
Immune responses
Adverse medication effects-
Drying/muscle atrophy/inflammatory effects
Altered vocal structure (hormone therapies)
Nonlaryngeal Aerodigestive disorders
Asthma COPD Croup (acute laryngotracheobronchitis) GERD Infectious disease of the aerodigestive tract Mycotic (fungal) infections: candida
Psychological disorders
Functional dysphonia → manifestation of what is actually happening
Psychogenic voice disorder
Factitious disorders/malingering
Gender dysphoria
3 criteria for psychogenic voice disorder
Symptom pathogenicity (there is some link to something psychological) Symptom incongruity (everything looks intact and healthy but doesn’t line up with not having a voice/how they are presenting) Symptom reversibility
neurologic disorders- peripheral nervous system pathology
recurrent laryngeal nerve paralysis paralysis (unilateral or bilateral)
Recurrent Laryngeal Nerve Paralysis: Unilateral
Inadequate VF closure
Loss of VF muscle tone (Flaccidity, weakness, bowing)
Phonatory effects: mild-severe, perceptual symptoms: breathiness, low intensity, low pitch, intermittent diplophonia
Recurrent Laryngeal Nerve Paralysis: Bilateral
Abductor- VFs cannot abduct for respiration
Adductor- VFs cannot adduct for airway protection
Phonatory effects: Permanently weakened and aphonic in either case. 6-9 mo post onset VF contracture and fibrosis may occur bringing it closer to midline allowing harsh and breathy phonation.
Neurologic disorders affecting voice- central neurologic disorders
spasmodic dysphonia (adductor, abductor, or mixed) can include essential voice tremor
spasmodic dysphonia
action induced dystonia
Adductor spasmodic dysphonia- strained-strangled voice with voice stoppages with spasms. Voiced sounds.
Abductor Spasmodic Dysphonia- involuntary breathy bursts/spasms. Voiceless sounds
Mixed
Treatment- botox
“other” disorders
Phonotrauma (voice abuse/misuse)
Vocal fatigue (laryngeal myasthenia)
Muscle tension dysphonia (primary or secondary)
Ventricular phonation
Paradoxical vocal fold motion (PVFM) → emotional response, VF snap shut
What is the primary objective of a voice evaluation?
To identify causes
Describe vocal components
Develop management plan
What are secondary objectives of a voice evaluation
Patient education
Patient motivation
Establish credibility of voice pathologist
possible referral sources
Otolaryngologists and other medical specialists SLPs Vocal coaches/singing teachers Former patients Friends and family
Methods of examination
Indirect laryngoscopy
Fiberoptic laryngoscopy
Direct laryngoscopy
Laryngeal videostroboscoby
voice pathology evaluation
Patient interview
Perceptual voice assessment
Instrumental assessment of vocal function
Laryngeal videostroboscopy
voice evaluation should include…
history, oral peripheral exam, perceptual eval, patient self assessment
Gathering patient history
Of the problem
Chronology of the problem, etiologic factors associated with history, patient motivation
Medical
Medically related etiologic factors, awareness of patient personality
Social
work, home, recreational environments
Discover emotional, social, family, occupational activities, challenges, difficulties
More etiologic factors
Oral peripheral exam
Physical condition of oral mechanism
Whole body tension/laryngeal area tension
Swallowing difficulties
Laryngeal sensations
Perceptual eval
General quality- describe voice quality using descriptive terms (e.g. CAPE-V)
Respiration- breathing pattern, s/z ratio, max phonation time
Phonation- hard glottal attacks, glottal fry, breathiness, diplophonia
Resonance- hypernasal, hyponasal, assimilative nasality, cul de sac nasality, inappropriate tone focus
Pitch-pitch range, conversational inflection, subjective judgment of appropriateness
Loudness- appropriateness of volume, ability to shout/talk softly
Rhythm and rate- too fast/slow, interrupted (spasm or tremor)
Non-speech phonotrauma- throat clearing, coughing, unusual laugh
Patient Self- Assessment
Incorporates patient perspective
Physical, functional, and emotional implications
Tools: Voice handicap index (VHI), VHI-10, Voice-Related Quality of Life, Voice Activity and Participation Profile, Voice Symptom Scale, Aging Voice Index
Purpose of instrumental assessment
detection/screening- Identify existence of voice problem
Diagnosis- identify the differential source of the problem
Treatment- primary treatment tool, for behavioral modification, biofeedback, or patient education
Assess severity or stage of progression of problem and show treatment outcomes
Treatment outcomes should be objective, valid, automated, and sensitive to different voice qualities and severities- which instrumentation provides
Instrumental measures
Acoustic recording and analysis
Aerodynamic measurement
Laryngeal imaging
Electroglottography (EGG)- measure of VF contact area
Laryngeal Electromyography (LEMG)- Direct measure of muscle activity
Basics of technical Instruments
signal detection, signal manipulation, signal reconversion
Signal detection
microphone, camera, electrode, flow/pressure transducers
Signal manipulation or conditioning
filtering, amplification, digitization
Signal Reconversion
numerical form, visual display, speaker
acoustic measures
Analysis of vocal function
Clinical utility of acoustic measures depends on whether the measures
-Can discriminate between normal and disordered voices
-correlate with auditory-perceptual judgements of voice quality and severity
-Sufficiently stable to assess real change in performance across time
What are the 5 common measures
Fundamental frequency intensity perturbation measures ratio of signal (or harmonics) energy to noise spectral or cepstral
Fundamental frequency
rate of vibration of the vocal folds in Hz or cycles per second (cps)
Pitch
Mean Fo, Fo range
Intensity
Loudness
Referenced to sound pressure level (SPL) and measured on a logarithmic decibel (dB) scale
Habitual intensity and intensity range
Number of instruments used- sound level meters, acoustic analysis programs, and aerodynamic measurement devices
Perturbation measures
Cycle to cycle variability
Jitter- variability in frequency
Shimmer- variability in amplitude
Requires a quasi-periodic signal for reliable/valid perturbation analysis- doesn’t work for severely dysphonic voices
Ratio of signal (or harmonics) energy to noise
Normal voices= mostly periodic and high signal or harmonic energy, thus “high” SNR or HNR
Dysphonic voices- increased aperiodic or noisy components, thus “low” SNR or HNR
Sometimes given as NHR
Spectral or cepstral features
Ability to characterize the voice signal by extracting characteristics such as the fundamental frequency and the relative amplitude of harmonics vs noise without needing to identify cycle boundaries
Analyzes frames rather than cycles
Spectral analysis assess the interaction between glottal sound source and supraglottic influences
Types- spectogram: plots Fo and Io in the time domain. Line spectrum (plots all harmonic energies at a single point on the horizontal axis, with amplitude on the vertical axis
Employs fast Fourier Transform (FFT) analysis techniques to divide complex speech waveforms into individual harmonics
Frequency-intensity Profiling
Voice range profile
Phonetogram
Physiologic frequency range of phonation
Show physiologic limits
Useful for monitoring vocal range in professional voice users
2 major types of acoustic analysis of voice
- Time based measures- perturbation measures like jitter and shimmer
Limitations: depend on clear cycles. Based on the assumption of relatively steady pitch and loudness- sustained vowels - Frequency based measures- spectral and cepstral
Aerodynamic Measures
Indirectly assess laryngeal valve mechanism and vocal function Sublottic pressure Transglottal flow (glottal power) (laryngeal resistance) (vocal efficiency)
Phonation Threshold Pressure
The minimum subglottal pressure needed to initiate VF vibration
sometimes used to indirectly estimate pphonatory/vocal effort
aerodynamic equipment must be regularly _____
calibrated
What are the three components aerodynamic instruments measure the relationship between?
Pressure, flow, resistance
Pneumatochaograph
uses differential pressure across a known resistance to estimate flow rate
Has airflow mouthpiece or face mask
Common airflow measures
Mean flow rate (flow/time) Phonatory volume (total flow during a given speech task)
subglottal pressure measurement
Ps = subglottal pressure Measured indirectly by intraoral pressure during repeated productions of unvoiced /p/ + vowel syllable (pi pi pi pi) Oral tube between lips healthy VFs have lower PTP look for peak values
Resistance measurement
LR = laryngeal resistance
Quotient of peak intraoral pressure divided by the peak flow rate
Measured with same pi pi pi pi task
Reflects overall resistance of glottis
Estimates laryngeal valving function
Hyperfunction (valve too tight) = LR too high
Hypofunction (valve too loose) = LR too low
Normal
Laryngeal imaging
Provides more info about severity and etiology of a voice disorder than other instrumental measures
Shows laryngeal structure, movement, function
Use flexible or rigid endoscopes
90 vs. 70 degree rigid scopes
3 kinds of imaging techniques
stroboscopy
kymography
high speed
stroboscopy
Stroboscopic light flashes at specific moments to form a composite vibratory cycle
Flashes at a phase point in VF vibration that’s slightly faster than Fo
Produces an apparent slow mo effect (not really though)
A stable Fo can not be found if there’s significant aperiodicity in a voice
Kymography
Real-time imaging using a camera to scan a horizontal line of VF vibration
Limited to spatial/temporal changes of a single line of bilateral VF movement
Shows: Cycle-to-cycle variability, left or right sided asymmetry, Mucosal wave/amplitudeOpen or closed phrase timing, Phonatory onset/offset, Upper and lower vocal fold margin changes
Never allows for a complete view of VFs at once because the image is recorded from the scanline
high speed digital imaging
Direct recording of true VF vibration
Bright light, rigid endoscope, samples VF vibration
Fast enough for real-time recording of “actual” VF oscillation including: Phonatory onset/offset, Sustained voice, Changes in pitch and loudness
Unlike stroboscopy, HSDI does not rely on Fo to create the image so any patient’s voice regardless of severity can be recorded accurately
Visual perceptual judgments of stroboscopy/imaging
Gross observations -Glottic closure (static) -Supraglottic hyperfunction -Mucus -Genetic appearance and movement Vibratory features -Glottic closure (vibratory) -Phase closure -Symmetry -Mucosal wave -Stiffness / non vibrating portion / adynamic segment -Periodicity
electroglottography
Non-invasive tool that uses electric current passing through neck to measure VF contraction over time
Plots variable resistance across time and is a real-time display of VF vibratory pattern
Laryngeal electromyography
Direct measure of laryngeal muscle activity and function
Invasive (needle electrodes)
Laryngologist or neurologist may order
Used forL
-diagnosis/prognosis of suspected VF movement disorders (paralysis, paresis, dystonia, neuromuscular disorders)
-Distinguish VF paralysis from fixation of cricoarytenoid joint
-Guide botox injection for treatment of spasmodic dysphonia
CPT codes
Current procedural terminology
Set of codes used to describe medical, diagnostic, and surgical procedures and services
Important for billing
