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Voice Disorders > Exam #1 > Flashcards

Exam #1 Flashcards

1
Q

What are the 6 intrinsic laryngeal muscles involved in phonation?

A
  1. Transverse Interarytenoid
  2. Oblique interarytenoid
  3. Lateral cricoarytenoid
  4. Posterior Cricoarytenoid (PCA)
  5. Cricothyroid
  6. Thyroarytenoid
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2
Q

What is the action and innervation of transverse interarytenoid?

A

Inn: Vagus (CN X)
Act: medial approximation of arytenoids; closes the glottis (adduction)

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3
Q

What is the action and innervation of the oblique interarytenoid?

A

Inn: RLN of Vagus (CNX)
Act: Adduction. Medial approximation of the arytenoids; approximates the arytenoids and epiglottis

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4
Q

What is the action and innervation of lateral cricoarytenoid?

A

Inn: RLN of Vagus (CNX)
Act: adducts vocal folds by rotating the vocal processes of the arytenoids medially

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5
Q

What is the action and innervation of the posterior cricoarytenoid (PCA)?

A

Inn: RLN of X
Act: abducts the vocal folds and opens the glottis by rotating the arytenoids laterally
a. involved in changing pitch

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6
Q

What is the action and innervation of the cricothyroid?

A

Inn: (external branch of the superior laryngeal nerve (eSLN of X)
Act: decreases the distance between thyroid and cricoid; pulls thyroid anteriorly, lengthening and thinning the vocal folds, increasing longitudinal tension and pitch

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7
Q

What is the action and innervation of the thyroarytenoid (2 parts)?

A

a. Thyrovocalis- RLN of X, controls tension of VFs with the cricothyroid muscle
b. Thyromuscularis- RLN of X, lateral fibers participate in adduction (rotate); medial fibers shorten/relax VFS
c. involved in changing pitch

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8
Q

Intrinsic membranes of the larynx?

A

Elastic Membrane (2 parts):
1. Conus Elasticus
2. Quadrangular Membrane

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9
Q

What are the 4 cavities of the larynx?

A
  1. Vestibule
  2. Ventricle
  3. Rima Vestibuli
  4. Rima Glottidis (glottis)
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10
Q

Name the 5 layers of the vocal folds, including the three layers that comprise the lamina propria and the layers included in the body and cover.

A
  1. Squamous epithelium (superficial)
  2. Lamina propria (3 layers)
    a. Elastin fibres, random orientation; stretchy, almost gelatinous (superficial)
    b. Elastin fibres, anterior-posterior orientation; stretchy (intermediate)
    c. Collagen fibres, anterior-posterior orientation; not elastic, prohibits extension (deep)
  3. Thyroartenoid muscle
    Biomechanical description:
    o Cover = epithelium and 1st layer of lamina propria
    o Transition = 2nd and 3rd layers of lamina propria
    o Body = thyroarytenoid muscle
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11
Q

Explain how the larynx functions differently for various activities.

A
  1. To provide an open passageway for respiration
    * 1. Airway must be open at all three ‘valves’
    * 2. Supraglottic cavity
    * 3. False vocal folds
    * 4. True vocal folds
    * 5. intermediate/paramedial position (quiet respiration) – VFs are abducted approx. 8 mm
  2. To protect the airway by preventing entry of foreign materials into the respiratory tract
  3. Swallowing
    * 1. Protective function- failure to protect lungs during swallowing is life-threatening
    * 2. Larynx must prevent entrance of any substance into the airway that would be harmful to the lungs
  4. To serve as a valve during thoracic fixation (Valsalva maneuver)
    * 1. For pressure activities (sneezing, coughing, lifting, defecating, childbirth) require build-up of alveolar pressure
    * 2. Sufficient pressure is generated by compression of the thorax AND airway resistance at level of larynx (laryngeal closure) = VALSALVA maneuver
    * 3. Increased intrathoracic pressure
  5. To act as a sound source for the human voice
    * 1. Vocal folds are able to adduct to varying degrees
    * 2. not as tightly closed as is necessary for valving for life
    * 3. adducted just enough to be set into vibration
    * 4. this vibration produces a variable disturbance of the pressure between air molecules which transfers energy  acoustic energy!
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12
Q
  • Describe the process of phonation; the Myoelastic-Aerodynamic theory.
A
  • describes voice production as a combination of muscle forces (myo), tissue elasticity (elastic), and air pressures and flows (aerodynamic)
    1. To initiate phonation: medial compression (muscle force initiates medial compression)
    2. Subglottal pressure/tracheal pressure begins to build up quickly
    3. Once subglottal pressure becomes high enough (3-5 cmH20) the vocal folds are forced apart
    4. Rapid flow of air through the glottis.
    5. The rapid flow produces a negative air pressure between the vocal folds and they are pulled back together (Bernoulli effect)
    6. The vocal folds are also pulled back together by: elastic recoil and continuous muscle contraction
    7. Once the vocal folds are back together, the cycle (1-6) repeats itself again and again
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13
Q

Bernoulli effect?

A
  • Reduced velocity = increased pressure
  • Increased velocity = reduced pressure
  • abrupt increase in velocity results in a drop in pressure within the gas relative to the walls of the constriction through which it passes
  • this creates negative pressure between the VFs resulting in a vacuum between the walls of the constriction
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14
Q

Identify the first step in identifying a vocal pathology.

A

STEP 1: visit an ENT to rule out an organic disorder that might require medical treatment

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15
Q

Describe the contributing factors of muscle tension dysphonia.

A
  • Deviant body posture and misuse of neck and shoulder muscles- may be because of the tension
  • High stress levels- emotionality and voice
  • Excessive voice use- kids
  • Persistently loud voice use- certain family dynamics
  • Coughing/throat clearing- causes irritation and dryness in the laryngeal system
  • Laryngopharyngeal reflux disease- GERD
    *development of poor vocal hygiene habits as compensation (increased effort/poor vocal economy)
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16
Q

Visual characteristics of MTD?

A

o Visually:
o licking of lips
o swallowing
o throat clearing (complaint of lump in throat)
o stretching of neck, face, shoulder muscles- signs of pain/discomfort
o sipping water
o unplanned breathtaking

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17
Q

What are these perceptual characteristics of?

o Strained voice quality
o Phonation breaks
o Abnormal habitual pitch
o Breathiness
o Reduced loudness, specifically on extremes of pitch range

A

Muscle Tension Dysphonia (MTD)

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18
Q

Name pathologies associated with excessive muscle tension dysphonia.

A
  1. VF nodules
  2. VF polyps
  3. Reinke’s edema
  4. Laryngitis
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19
Q

These are perceptual characteristics of?

  • Breathiness and air wastage
  • Decreased habitual pitch and pitch range
  • Decreased habitual loudness and dynamic range
  • Hoarse voice quality- compensatory effect
  • Vocal fatigue
  • Tired/effortful speech
  • Medial compression is needed for vocal loudness
A

VF Nodules

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20
Q

Perceptual characteristics of??

  • Breathiness and air wastage
  • Decreased habitual pitch and pitch range
  • Decreased habitual loudness and dynamic range
  • Hoarse voice quality
  • Vocal fatigue
A

VF Polyps

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21
Q

Decreased pitch; increased hoarseness

Perceptual characteristics of?

A

Reinke’s Edema

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22
Q

Perceptual characteristics of…
* Hoarse
* Breathy
* Harsh
* Strained
* Low-pitched

A

Laryngitis

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23
Q

What are the psychogenic voice disorders?

A
  1. Puberphonia
  2. Psychogenic Aphonia
  3. Somatization Dysphonia
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24
Q

Which psychogenic voice disorder is this?

  • Failure of the voice to reflect the development of secondary sex characteristics in puberty
  • Can test cough pitch versus speaking
A

Puberphonia

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25
Q

Which psychogenic voice disorder is this?

  • Vocal symptoms (voicing only) are often the result of long-term or recent psychologically-damaging circumstances
A

Psychogenic Aphonia

26
Q

Which psychogenic voice disorder is this?

  • Symptoms may include laryngeal pain, neck and shoulder pain with stiffness, shortness of breath, depression, extreme vocal fatigue
  • Conversion disorder- occurs when a person has a neurological symptom (paralysis, seizures, deafness, blindness) but without a cause
  • Must have no physical evidence to support the cause of dysphonia/other related symptoms
A

Somatization Dysphonia

27
Q

Main features of the motor pathway?

A
  • Upper motor neuron
  • Lower motor neuron
28
Q

Main features of the sensory pathway?

A

o Primary neuron- dendrites innervate end receptor cells (e.g. skin, tongue); axon extends to the level of the brainstem – specific region of the brainstem where sensory nucleus is located
o Secondary neuron- Has cell body in the brainstem nucleus associated with the nerve; Axon extends to the thalamus (sensory “relay station”)
o Tertiary neuron- Has cell body in the thalamus; Axon extends to the primary sensory cortex

29
Q

Name the cranial nerves innervating voice and resonance?

A
  1. IX- glossopharyngeal
  2. X- Vagus
  3. XI- Accessory
  4. XII- Hypoglossal
30
Q

Describe glossopharyngeal (IX)

A
  1. Special sensory- Taste from posterior ⅓ of tongue
  2. General sensory- Pain, touch, proprioception from posterior ⅓ of tongue; General sensation from hard and soft palate, faucial pillars, upper pharynx, and tonsils
31
Q

Describe Vagus (X)?

A
  1. General sensory- Pain, temperature, and touch from the skin of the back of the ear and external auditory meatus, parts of the external surface of the tympanic membrane, and from the larynx and pharynx
  2. Motor: To the cricothyroid muscle via the external branch of the Superior Laryngeal Nerve (S L N); To all other intrinsic laryngeal muscles (P C A, L C A, I A) and the inferior pharyngeal constrictor via the Recurrent Laryngeal Nerve (R L N); Superior and middle pharyngeal constrictors, uvula, and all muscles of the velar sling (except the tensor veli palitini)
32
Q

Describe Accessory (XI)?

A
  1. Motor to trapezius and sternocleidomastoid muscles
  2. Tighter/more stressed if you have a functional voice disorder
  3. May be sore/fatigued; Potential impact on respiration
33
Q

Describe Hypoglossal (CN XII)

A
  1. Motor to all intrinsic tongue muscles, and most extrinsic tongue muscles
34
Q

Name the common neurological conditions that could impact voice?

A
  1. Vocal fold paralysis (unilateral and bilateral)
  2. Laryngeal dystonia (e.g. SD)
  3. Essential tremor (E T)
  4. Parkinson’s disease (P D)
  5. Acquired Brain Injury (e.g. Stroke/C V A; TBI)
35
Q

Identify the primary health care team members involved in the treatment of neurogenic voice disorders

A

Neurologist, surgeon, ENT, SLP

36
Q

Describe possible etiology with UVFP.

A
  1. Neoplastic – abnormal growth/proliferation of cells that results in compression on the nerve
  2. Traumatic (surgical and nonsurgical)- nerve is compressed or cut
  3. Medical disease- viral infection that causes inflammation
  4. Idiopathic
37
Q
  • Name the two main surgical options for unilateral vocal fold paralysis.
A
  1. Vocal fold medialization
    a. Injection laryngoplasty- external injection
    b. Thyroplasty- surgical implant (can have atrophy)
  2. Vocal fold re-innervation
    a. Leads to functioning vocal fold/CN
38
Q
  • Describe possible etiology associated with bilateral vocal fold paralysis.
A
  1. lesions high in the path of the Vagus nerve
  2. medullary nuclei
  3. base of skull tumour
  4. carcinoma
  5. trauma
39
Q

Name the main medical treatment options for bilateral vocal fold paralysis.

A
  1. Surgical
  2. Re-innevation
  3. Botulin Toxin A injections- stops muscles from continuing to fire; lasts 3-6 months
40
Q

Something to consider when working with young children with BVFP:

A

o how to manage tracheostomy
o use of tracheal valves
o minimize negative effects on expressive S-L development

41
Q

Describe adductor SD (symptoms, prevalence, when noticed the most, primary and secondary symptoms)

A

a. Noticed more in voicing
b. Most common form of S D (70% of cases)
c. Primary voice symptom is strain/strangle, and intermittent voice stoppages
d. Secondary voice symptoms are hoarseness/harshness, and tremor

41
Q

What are the 3 types of spasmodic dysphonia?

A
  1. Adductor SD
  2. Abductor SD
  3. Mixed SD
42
Q

Describe abductor SD

A

a. Less common form of S D (25% of cases)
b. Primary voice symptom is breathy dysphonia
c. Perceptually it sounds like a phonation break
d. Secondary voice symptom is delay of voice onset following voiceless consonants

43
Q

Describe mixed SD

A

a. Least common form of S D (<5% of cases)
b. Features of both subtypes are present, and either may be predominant

44
Q

Name the main medical treatment options for SD

A
  • (Voice therapy)
  • Surgical sectioning of the RLN
  • Injection of botulinum toxin type A (B T X-A)
  • Surgical modification of the vocal folds
45
Q

Describe the primary and secondary voice characteristics of essential voice tremor

A
  • Primary voice symptom is regular modulation of frequency or intensity, most notable during vowel prolongation
    o 5-6 Hertz frequency modulation
    o 5 deciBel intensity modulation
    **Secondary voice symptoms are strain/struggle as well as harshness
46
Q
  • Describe the characteristics of Parkinson’s disease-related hypokinetic dysarthria.
A

o Reduced loudness
o Breathy voice
o Monotone
o Intermittent and rapid rushes of speech

47
Q

Contrast spastic versus flaccid voice characteristics associated with cerebrovascular accident

A

Spastic
o UMN
o slowed articulation
o strained voice quality
o hypernasality
OR
Flaccid
o LMN
o breathy voice quality
o reduced loudness
air wastage

48
Q

Compare and contrast organic and inorganic/functional vocal pathologies.

A

Inorganic:
* Fatigue of laryngeal and respiratory muscles
* Straining non-muscular support and connecting tissue
* Poor vocal economy (large effort, little output)
* 2 broad categories:
o Muscle Tension Dysphonia (MTD)
o Psychogenic Dysphonia

Organic:
Disease, malformationENT should scope the client Damage to the nerves= neurogenic
Damage to the VFs= trauma
Polyps, trauma, congenital
Examples: Laryngeal webbing, cyst, leukoplakia, endocrine changes, etc…

49
Q

Describe the Conus Elasticus membrane.

A

Connects cricoid, thyroid, and arytenoid cartilages
a. extends from superior border of cricoid arch and lamina to upper limits of true vocal folds
b. consists of cricothyroid ligament and cricothyroid membrane
c. Medial and Lateral cricothyroid ligaments
d. Moving inferiorly

50
Q

Describe the Quadrangular Membrane.

A

Connects lateral margins of epiglottis to apex and medial surface of arytenoids
a. free inferior edges of these sheet-like membranes form the ventricular/vestibular ligaments (part of the false VFs)
b. superior edges of the quadrangular membrane form the aryepiglottic folds
c. Ventricular ligaments and aryepiglottic folds
d. Moving superiorly

51
Q

Which cavity of the larynx is the space between the entryway (aditus larynges) and the ventricular/vestibular folds?

A

Vestibule

52
Q

Which cavity of the larynx is the vertical space between the true VFs and the false VFs?

A

Ventricle

53
Q

Which cavity of the larynx is the horizontal space between the ventricular folds (False VFs?)?

A

Rima Vestibuli

54
Q

Which cavity of the larynx is the variable opening between true VFs (horizontal plane)?

A

Rima Glottidis (glottis)

a. Length from anterior commissure (at thyroid angle) to posterior commissure (between arytenoids) is approx. 20 mm in adults
b. Intramembranous portion – approx 3/5 of the length of the total glottis; between the folds themselves
c. Intracartilaginous portion – approx 2/5 of the length of the glottis; between the arytenoid cartilages

55
Q

Describe the Upper Motor Neuron

A

o Has cell body in the motor cortex (primary motor cortex)
o Axon extends to the motor nucleus of the brainstem
* For nerves that provide unilateral innervation of end muscles, all fibres cross over at the level of the brainstem…contralateral innervation
* For nerves that provide bilateral innervation of end muscles, some fibres cross over, some do not….they remain ipsilateral

56
Q

Describe the Lower Motor Neuron

A

o Cell body in brainstem nucleus** associated with the nerve**
o Axon extends to, and innervates, muscle fibres

57
Q

Describe the primary neuron of the sensory pathway

A

dendrites innervate end receptor cells (e.g. skin, tongue); axon extends to the specific region of the brainstem where sensory nucleus is located

58
Q

Describe the secondary neuron of the sensory pathway

A

Has cell body in the brainstem nucleus associated with the nerve; Axon extends to the thalamus (sensory “relay station”)

59
Q

Describe the tertiary neuron of the sensory pathway

A

Cell body in the thalamus; Axon extends to the primary sensory cortex

Voice Disorders (2 decks)

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