Former Quiz Questions

Question 1

In order from superior to inferior, your vertebrae are labeled as:

Answer 1

Cervical, Thoracic, Lumbar, Sacral, Coccygeal

Question 2

Your pectoral girdle is made up of what two bones?

Answer 2

Scapula and Clavicle

Question 3

The trachea first bifurcates into two ___________ bronchi.

Answer 3

Stem/Main Stem

Question 4

The primary muscle of inspiration is the ___________.

Answer 4

Diaphragm

Question 5

All of the following are points of attachment for the Diaphragm except ____________.

Answer 5

Illium

Question 6

The trachea is posterior to the esophagus and articulates with the superior aspect of the cricoid cartilage

Answer 6

False - Anterior/Inferior

Question 7

Contraction of the abdominal muscles will increase size of thoracic cavity.

Answer 7

False - Decrease

Question 8

Your esophagus passes through the diaphragm

Answer 8

True

Question 9

The terms “pleural cavity” and “intrapleural space” are synonymous.

Answer 9

True

Question 10

The right main stem bronchi drops at a less abrupt (wider) angle relative to the trachea compared to the left main stem bronchi. What is the clinical significance of this?

Answer 10

The clinical significance of this is that the aspiration of liquid and the aspiration of food is more likely to occur with the right bronchus.

Question 11

What is “pleural linkage” and why is it crucial to respiration?

Answer 11

Pleural Linkage is a mechanism where the lungs are “linked” (not attached) to the thoracic wall through negative pressure. It is crucial to respiration because it allows movements of the rib cage to be transmitted to the lungs.

Question 12

Which is not a passive force related to expiration?

Answer 12

Tension

Question 13

___________ are directly measured, whereas ___________ are inferred.

Answer 13

Volumes/Capacities

Question 14

___________ is the most common pulmonary function test, and specifically measures the volume and/or flow of air that can be inhaled or exhaled.

Answer 14

Spirometry

Question 15

Which statement about speech breathing is incorrect?

Answer 15

You breathe 12+ times per minute

Question 16

At Resting Expiratory Level (REL), ________ = Atmospheric pressure (Patm)

Answer 16

Alveolar pressure (Palv)

Question 17

Which capacity represents the lung capacity available for speech?

Answer 17

Vital Capacity

Question 18

Which equation corresponds with vital capacity?

Answer 18

IRV + TV + ERV

Question 19

Air flows from a region of low pressure to high pressure.

Answer 19

False - High to Low

Question 20

Any movement away from REL (Resting Expiratory Level) requires some sort of muscular effort.

Answer 20

True

Question 21

You are physically able to force out all of the air in your body, including Residual Volume and Dead Air.

Answer 21

False

Question 22

During speech breathing, our inspiration is more abrupt and frequency of breathing decreases.

Answer 22

True

Question 23

During speech breathing, expiration takes up 10% of the respiratory cycle.

Answer 23

False

Question 24

You have an adult client who asks you to clarify the difference between speech breathing and normal respiration. Please provide 3 examples regarding their respective differences, including a rationale for each (i.e. why is this important)

Answer 24

There are three examples that highlight the difference between speech breathing and normal respiration:

Example 1: During the normal respiratory cycle, humans breathe 12+ times per minute, and expirations are slightly greater than inspirations. During speech breathing, you breathe less than 12 times per minute, the frequency of your breathing decreases, inspiration is much more abrupt, and your expirations are notably lengthened. The important differences are that during speech breathing, because you are talking way more, your body has a much higher lung volume than during normal respiration; this affects how you breathe.

Example 2: In the normal respiratory cycle, inspiration takes 40-50% of the cycle and expiration takes up 50-60% of the cycle. During the respiratory cycle in speech inspiration takes up 10% of the cycle, and expiration takes up 90% of the cycle. The important difference here is with speech breathing, expiration takes up WAY more space in the respiratory cycle. Your cannot physically talk during inspiration, as it is impossible for our body to handle that function, so expiration needs to take the majority of space because you can only talk on the decline, in order to help us properly communicate.

Example 3: In speech breathing, there are rapid inspirations followed by prolonged expirations, and inspiration is much faster than during resting breathing.
This is important because during normal breathing, at REL lung pressure and atmospheric pressure are equalized. Whereas in speech breathing, speech usually is produced way above REL, which allows our body to use more passive recoil forces, and not as much expiratory muscle effort is required, as volume displacement is greater than rest breathing, where VC varies from 40% to 60%! And with speech breathing, our abdomen needs to stay active during both inspiration and expiration in order to prolong our speech.

Question 25

How and why might normal aging specifically impact speech breathing?

Answer 25

Normal aging can impact speech breathing in multiple ways:

Usually around seventy years of age, we can begin to notice a decline in both lung elasticity, and diaphragm elasticity, which will have an impact on the amount of air our body can take in, and how often our diaphragm moves per minute.
Also, our respiratory structures that are involved in speech breathing start to stiffen up, and are not quite as versatile than they were once before, meaning it may be harder to produce large quantities of air in order to speak a longer sentence.
Finally, by that age, we also start to experience change in laryngeal resistance, which can affect how much air passes through the larynx to produce vocal sounds.

Question 26

The ______ suspends the larynx and serves as attachment for extrinsic laryngeal muscles.

Answer 26

Hyoid Bone

Question 27

All the following laryngeal cartilages are unpaired except for the _______.

Answer 27

Arytenoid

Question 28

The primary muscle responsible for lengthening the vocal folds is the _________, and is innervated by the _________ .

Answer 28

Cricothyroid/Superior Laryngeal Nerve

Question 29

The arytenoids are specifically located on the _____________ .

Answer 29

Superior surface of the posterior quadrate lamina

Question 30

What structure forms the lower border of the laryngeal framework?

Answer 30

Cricoid

Question 31

Someone who was assigned female at birth would most likely have a shaper angle of fusion of the thyroid laminae compared to someone who was assigned male at birth.

Answer 31

False

Question 32

The hyoid bone is suspended in place via the stylothyroid ligaments.

Answer 32

False - Stylohyoid

Question 33

The epiglottis contributes to phonation.

Answer 33

False

Question 34

List the two laryngeal joints, what specific structures form them, and describe their significance to vocal fold movement.

Answer 34

Cricoarytenoid Joint:
This joint is also known as a diarthroidial joint! Meaning it is a flexible joint.
Location: The arytenoids sit on the superior aspect of the posterior quadrant lamina of the cricoid.
Meaning it allows the cricoarytenoid to rock, and it partially allows it to glide as well.
This joint allows rocking movements of the arytenoids, which helps move the vocal process either up and out, or it could move the vocal process down and inward.

Cricothyroid Joint:
Like the cricoarytenoid joint, this joint is known as a diarthroidial joint, meaning it is flexible!
Located on the inferior cornu of the thyroid cartilage that articulates with the lateral aspect of the cricoid.
However, unlike the cricoarytenoid joint, the cricothyroid joint allows the thyroid to move (rock) downwards.
This is important for vocal fold movement; it is important for change in the pitch of a person’s voice.

Question 35

The ______, located between the epithelium and SLLP, is the primary damage site for nodules.

Answer 35

Basement Membrane Zone

Question 36

According to the Bernoulli Effect, air flowing through a system creates a suction force ________ to the movement of air.

Answer 36

Perpendicular

Question 37

What type of pressure needs to build in order to blow apart the vocal folds during vibration?

Answer 37

Subglottic Pressure

Question 38

Which is not a factor that contributes to changing fundamental frequency (F0)?

Answer 38

Torque

Question 39

Stretching/elongating the vocal fold will _____ cross-sectional mass and _________ longitudinal tension.

Answer 39

Decrease/Increase

Question 40

All of the following statements about the termination of phonation are true except:

Answer 40

Results from contraction of the LCA

Question 41

All of the following are examples of phonation except _______.

Answer 41

Whispering

Question 42

A _________ vocal onset refers to adduction of the arytenoids (and subsequently the vocal folds) prior to the start of exhalation.

Answer 42

Glottal

Question 43

_______ is the psychological correlate of fundamental frequency (F0), whereas _______ is the psychological correlate of intensity.

Answer 43

Pitch/Loudness

Question 44

Sustained phonation depends on all of the following except ____________.

Answer 44

Asymmetric vocal fold mass

Question 45

The Superficial Layer of the Lamina Propria is also referred to as “Reinke’s Space”.

Answer 45

True

Question 46

The vocal folds must be abducted within 3mm to initiate vibration.

Answer 46

False

Question 47

Person “A” has greater static length and larger static mass of their vocal folds compared to Person “B”. Therefore, Person “A” will have a lower fundamental frequency.

Answer 47

True

Question 48

The Deep Layer of the Lamina Propria is the last layer of the true vocal folds.

Answer 48

False - Vocalis

Question 49

The vocal folds must be completely closed and touching to initiate vibration.

Answer 49

False - Within 3mm

Question 50

Explain one cycle of vocal fold vibration.

Answer 50

Vocal Fold Vibration:

First off, the true vocal folds are in an adducted position, meaning the arytenoids are contracted close together.
As the true vocal folds are adducted, subglottal pressure (also known as air pressure) begins to build up underneath.
This causes the true vocal folds to initiate separation inferiorly.
Once that subglottic pressure overcomes PTP, phonation threshold pressure (also known as medial compression), the true vocal folds get blown open by a puff of air.
While airflow in-between the true vocal folds continues to increase, that subglottal pressure begins to decrease.
That decreased pressure, and the elasticity, initiate the true vocal folds to move towards their midline.
First the inferior margin closes, followed by the superior margin; the true vocal folds move inferiorly to superiorly, similar to a zipper effect!
That whole process completes one cycle of vocal fold vibration.

Question 51

Which test is currently the most commonly used assessment for self-perceived impact of one’s voice, and is available in both a 30-question and 10-question format?

Answer 51

VHI

Question 52

The CAPE-V consists of all the following tasks except:

Answer 52

Pitch Glides

Question 53

Ratings for the CAPE-V are performed using what type of scale?

Answer 53

Visual Analog Scale

Question 54

Perturbation measures and cepstral measures are two assessments that fall under what category of measurement?

Answer 54

Acoustic

Question 55

The primary instrument used to complete aerodynamic measurements is a __________.

Answer 55

Pneumotachograph

Question 56

All sentences in the CAPE-V are loaded to reflect a specific set of phonemes.

Answer 56

True

Question 57

The CAPE-V can only be completed if the patient has a severely dysphonic voice.

Answer 57

False

Question 58

S/Z ratio provides an informal estimate of laryngeal efficiency.

Answer 58

True

Question 59

Throat clearing may be considered a negative vocal behavior.

Answer 59

True

Question 60

As a clinician, you would fill out the VHI based on listening to the patient.

Answer 60

False

Question 61

What are 3 important pieces of information you should gather when reading a patient’s medical history? For each example, include a brief rationale for why this would be important to know as a clinician.

Answer 61

Three Important Pieces of a Patient’s Medical History:

1.) Do they have a history of a previous voice disorder and/or have they received treatment for said disorder?
This allows us as the clinician to gather background information on the client, as we are able to analyze the previous treatment was used, and see what worked and what does not work, to help us create a new and improved plan for the patient.

2.) Does the patient have any known diseases? Such as GERD? Do their parents have a family history of voice disorders?
Here, the clinician is able to see if there is a history on either side of the patient’s family, and whether or not this disorder was genetically passed down, or if the disorder has never impacted the family. Allows the clinicians to get a better understanding of where the disorder could have came from.

3.) Is this patient a professional voice user? Does their career center around using their voice? How often do they use their voice on a day to day basis?

Knowing what a patient’s profession is helps the clinician see if this person uses their voice frequently, which could have caused the disorder. It allows us to analyze a person’s vocal quality more in-depth based on what the person does for a living. For example, if they are a singer, how often do they experience vocal distress?

Question 62

List 3 types of behaviors you may want to monitor during a voice evaluation and why.

Answer 62

1.) Look for any tension in the person’s neck. Is the patient clenching all their laryngeal muscles when they speak? Do they talk as if they are forcing speech out of their body? This is important to look for because we can see, as the clinician, we can use this information to determine if the patient has a voice issue. It helps us identify if something is there, yet they could be possibly ashamed to say it.

2.) Do they project their voice? Does the patient over-project their voice to compensate for their speech? This could be a sign that a patient is experiencing a voice issue, because they are trying to cover up the fact that there could be something underlying with their voice/vocal quality.

3.) Does the patient’s respiratory behavior during speech sound normal? Are they taking inappropriate breaths during speech? Do they sound out of breath when they talk? This could be a sign of a voice disorder, because if the patient demonstrates that they are unable to, lets say, talk only during exhalation, then it could be a sign that they are experiencing a voice disorder that affects respiration and the use of the diaphragm.

Question 63

Briefly describe how you would obtain data from/complete the following:

a) s/z ratio
b) Maximum Phonation Time

Answer 63

S/Z Ratio -
This task helps estimate the functionality of the patient’s larynx.
Here, you time the patient by having them hold out a prolonged /s/ and /z/ for as long as they can.
By doing so, you can see if the patient is able to hold out these sounds in their vocal folds, and you can analyze and collect data about the patient’s larynx, and whether or not it is functioning normally while producing these sounds, or are their audible signs of a disorder.
Meaning, you can see if there is an underlying issue with the patient’s larynx, and whether or not these issues, such as a lesion, is causing their voice disorder. For s/z, you ultimately are taking a ratio of “s” over “z”. Be careful of your wording, because it’s not giving us information about the “larynx” as a whole but an estimate of laryngeal efficiency.

Maximum Phonation Time (MPT) -
This test analyzes the patient’s laryngeal and respiratory functions. It obtains a patient’s respiratory levels by analyzing their breath replenishment patterns.
It studies how often the patient takes a breath, how long is the breath, do they release it or hold the breath in, how deep is their breath, and do they breath from their diaphragm or do they exhibit clavicular breathing? These characteristics, when analyzed, help us obtain the data needed. We are able to compare the patient’s MPT to the standardized norm, which can also help us identify any potential issues that could arise in the patient’s respiratory and laryngeal systems. Essentially, have the patient hold out a sustained vowel for as long as they can.

Question 64

_____ becomes ______ when a pulsed light is added.

Answer 64

Endoscopy/Stroboscopy

Question 65

Which type of endoscope is placed in the mouth and typically provides a clearer image of the vocal folds?

Answer 65

Rigid Endoscope

Question 66

Which is not a physiological parameter of the vocal folds assessed during stroboscopy?

Answer 66

Medial Compression

Question 67

Which measure would be obtained during EGG?

Answer 67

Contact Quotient

Question 68

The image shown is an output example taken from what type of instrument?

Answer 68

Videokymography

Question 69

Intramuscular electromyography (iEMG) is a useful instrument to record muscle activity for what types of voice disorders?

Answer 69

Vocal-fold Paralysis/Spasmodic Dysphonia

Question 70

Electroglottography allows for direct visualization of vocal fold vibration.

Answer 70

False - Indirect

Question 71

High-Speed Laryngeal Imaging does not require a strobe light to see a complete cycle of vocal fold vibration.

Answer 71

True

Question 72

Flexible strobscopy allows for a wider range of tasks to be performed, such as continuous speech.

Answer 72

True

Question 73

You are able to assess the activity of the Vocalis through surface EMG.

Answer 73

False

Question 74

Based on the image attached:
11.a) What instrument is this output from?

11.b) Briefly explain how this instrument works.

Answer 74

a.) This is an EGG Waveform graph! An indirect physiological measurement!
b.) EGG is a useful measurement tool that provides a waveform graph in correspondence to the amount of contact the vocal folds exhibit during the vibratory cycle!
During EGG, the patient will have small electrodes placed over their thyroid lamina, which will allow an electrical current to pass between them!
The key to analyzing the graph is looking at the peaks and troughs!
A peak represents the vocal folds in closed phase, and because there is good conduction, it increases the signal; hence the peaks!
When you see a trough, that represents the vocal folds in open phase! In open phase, there is poorer conduction, causing the signal to decrease; hence the troughs!
How is this measured?
Contact Quotient (CQ)!
This is where a ratio is taken of the period of time when the vocal folds were in contact to the entirety of the vibratory cycle!

Question 75

List one pro and one con to using High Speed Video compared to traditional stroboscopy.

Answer 75

High Speed Video vs. Stroboscopy:

Pro(s): It is a fantastic direct physiological measurement to use when studying the field of biomechanics, AND it can capture 2,000 to 8,000 image frames per second WITHOUT the requirement of a strobe light!

Con(s): It is incredibly fancy as it is not practical for every day use, and it is quite expensive, as it requires loads of data storage, plus the sharpness quality is not very high, making the images difficult to study!

Question 76

Please explain how stroboscopy works.

Answer 76

For starters, endoscopy turns into stroboscopy once you add in a pulse light!
Stroboscopy is an incredibly useful direct physiological measurement, as it is said to be the most used method in a clinical setting to study vocal fold vibration.
With stroboscopy, the vibration of the vocal folds is interpreted from sample images of the VF’s in real time.
What happens is flashes of light are set off by fundamental frequency (F0) with the use of a microphone.
You can use two types of endoscopes for stroboscopy:
A rigid endoscope, which is brighter and gives a better image of the VF’s when placed inside the mouth.
Or a flexible endoscope, which can go through the nasal cavity and allows the patient to perform a wider arrangement of tasks, such as continuous speech!
While conducting stroboscopy, there are seven parameters you MUST follow when studying the patient’s vocal folds!
1. Edge - here we look for how smooth each VF is.
2. Vibratory Amplitude - this assesses the lateral distance each VF moves from the midline; note, they are each rated individually!
3. Vibratory Behavior - Here we see if there is a presence or an absence of vibration in part or the entirety of each VF.
4. Mucosal Wave Excursion - Is there an extent of the propagation of the wave across the superior surface of each VF.
5. Phase Symmetry - This helps us determine if each VF is opening and closing together at the same time, like a mirror image!
6. Phase Closure - Here we see if the closed phase of VF vibration is predominate, or if open phase is predominate.
7. Periodicity - This assesses the regularity of successful VF vibrations!
For example, microphone picks up F0 which tells the computer how quickly to flash the strobe light, takes parts from multiple vibratory cycles and pieces them together to create the illusion of slow motion.

Question 77

____ are the most common benign vocal fold lesion in adults and children.

Answer 77

Nodules

Question 78

What type of vocal fold polyp is the most common, closely adheres to the mucosa, and is broad-based?

Answer 78

Sessile

Question 79

All of the following statements regarding polyps are true except __________ .

Answer 79

Can be treated solely with voice therapy

Question 80

_______________ is typically seen in smokers, occurs within the SLLP, and used to be referred to as “chronic polypoid degeneration”.

Answer 80

Reinke’s Edema

Question 81

In a diagnosis of vocal fold hemorrhage, the hemorrhagic area may appear reddish in color. This is referred to as ________________.

Answer 81

Erythema

Question 82

A diagnosis of ________ MTD occurs in the absence of pathology, whereas a diagnosis of _________ MTD occurs in conjunction with a previously diagnosed pathology.

Answer 82

Primary/Secondary

Question 83

Individuals diagnosed with puberphonia often exhibit a normal vocal quality and loudness level.

Answer 83

True

Question 84

Development of a functional voice disorder is primarily related to the way the voice is used.

Answer 84

True

Question 85

Early stage nodules are more amenable to treatment compared to later stages.

Answer 85

True

Question 86

Chronic traumatic laryngitis may result in vocal fold thickening.

Answer 86

True

Question 87

Based on the image shown:
11.a) What voice disorder is pictured?
11.b) List 2 observable characteristics of the vocal folds in the image (which is a screen shot) that lead to your diagnoses.

Answer 87

a.) The voice disorder that is pictured is Nodules.

b.) Some observable characteristics, that have led me to this diagnosis, include:

There are two white dumps on the free margins of both vocal folds. They also look similar to callouses you could get on your hands, say from weight lifting, which indicates these are nodules.
Another determining factor is that they are occurring bilaterally among the vocal folds, which is another characteristic of nodules. There is also one that appears to be slightly larger on one vocal fold than the other, and this is a common occurrence when observing nodules.

Question 88

Based on the image and your answer for #11, list 1 stroboscopic observation and 1 auditory-perceptual observation you would expect to note.

Answer 88

A stroboscopic observation that I should expect to see with someone that had nodules, is there is incomplete glottal closure when the person is trying to phonate. The vocal folds, if there are nodules present, should not be able to fully come together, which as a result should create a gap among the vocal folds, and as a result of the nodules being different sizes, it causes aperiodic vibration.
An auditory-perceptual observation I would expect to hear is a hoarse/breathy vocal quality. Because of the incomplete glottal closure, which you would have already observed, this increases the amount of air that is escaping during phonation. Which increases signal noice, causing the auditory perception of the patient’s voice to sound breathy, strained or pressed even.

Question 89

List the two primary patterns of hyperfunction seen in Muscle Tension Dysphonia, and briefly describe what they would look like during a stroboscopic evaluation.

Answer 89

The 2 Primary Patterns of Hyperfunction seen in MTD are:

Medial or Lateral Compression (Most Common):
During a stroboscopic evaluation, if the patient is exhibiting a hyperfunction pattern of medial/lateral compression, you should expect to see the vocal folds being hyper-adducted in a side-to-side manner. You should also expect to see medial compression occurring at BOTH the false vocal folds AND the true vocal folds.
Anterior - Posterior Compression:
During a stroboscopic evaluation, if the patient is exhibiting a hyperfunction pattern of anterior - posterior compression, you should expect to find a supraglottic larynx. Meaning, there should be a reduction in the space between the epiglottis and the arytenoid prominences, causing the pattern of hyperfunction to come from the top and bottom, or anteriorly and posteriorly.

Question 90

What is the primary clinical presentation of an individual with puberphonia?

Answer 90

The primary clinical presentation of an individual with puberphonia is the patient’s pitch is excessively high, often falsetto even. It is presenting as how an AMAB’s voice should sound prior to pubertal changes completing; as it puberphonia is more common in adolescent AMAB individuals than adolescent AFAB individuals. Something else that is presented clinically with puberphonia is a patient’s level of loudness, and their vocal quality, sound completely normal.

Question 91

Your patient has been on Advair for the past 3 months and has neglected to follow the appropriate swish-and-spit instructions. Which organic voice disorder may they be at risk of acquiring?

Answer 91

Infectious Laryngitis (fungal)

Question 92

During videostroboscopic evaluation of the patients voice (from question #1), the ENT notes that the vocal folds appear “reddened in response to irritation”. What is another term for this observation?

Answer 92

Erythema

Question 93

What type of voice disorder can occur after the initial formation of a contact ulcer?

Answer 93

Granuloma

Question 94

Which statement about Sulcus Vocalis is not true.

Answer 94

VF’s have an hourglass closure

Question 95

All of the following statements regarding intracordal cysts are true except ____.

Answer 95

Primarily occur on vocalis muscle

Question 96

In a total laryngectomy, the trachea is redirected to form a permanent external stoma

Answer 96

True

Question 97

Patients who opt for a TEP post-laryngectomy are able to utilize their own lung air supply versus esophageal air supply.

Answer 97

True

Question 98

A laryngeal web typically forms at the anterior commissure of the VF’s.

Answer 98

True

Question 99

Organic voice disorders are directly related to how the voice is used.

Answer 99

False - Indirectly

Question 100

Laryngeal webs may be congenital or acquired.

Answer 100

True

Question 101

A 36 year old patient was seen by an ENT after complaining of changes in his voice. The still image was taken from his stroboscopic examination and you notice a proliferation of wart-like vocal fold lesions.

Based on the image:

11a) What diagnosis do you suspect this patient to have?

11b) How can this be confirmed?

11c) What treatment may be recommended for this patient? Would traditional voice therapy be appropriate? Please give a brief explanation of your answers.

Answer 101

a.) Based on the image provided, I suspect this patient has papillomas!

b.) This can be confirmed from several indicators. For starters, if you take a look at the vocal folds, you can see that there are multiple growths occurring; they look wart-like, which is a key perceptual feature of papilloma. Another confirming feature is these wart-like growths appear to be at the glottal level, as they are sitting right on top of the vocal folds. However, the diagnosis can be officially made with a biopsy of the papilloma to ensure what we are seeing perceptually is correct.

c.) We typically would recommend surgery for a patient with papillomas, although general surgery brings a higher rate of recurrence. Most clinicians recommend CO2 laser surgery, as it has a lower rate of recurrence with papillomas; meaning there is a less likelihood of the papillomas returning. With surgery, however, antiviral agents are often used during the procedure, which can have effects on the voice. So, voice therapy can be appropriate here. In this patient’s case, it can reduce any compensatory or hyperfunctional behaviors of their vocal folds post surgery.

Question 102

A 36 year old patient was seen by an ENT after complaining of changes in his voice. The still image was taken from his stroboscopic examination and you notice a proliferation of wart-like vocal fold lesions.

Based on the image:

11a) What diagnosis do you suspect this patient to have?

11b) How can this be confirmed?

11c) What treatment may be recommended for this patient? Would traditional voice therapy be appropriate? Please give a brief explanation of your answers.

Answer 102

a.) Based on the image provided, I suspect this patient has papillomas!

b.) This can be confirmed from several indicators. For starters, if you take a look at the vocal folds, you can see that there are multiple growths occurring; they look wart-like, which is a key perceptual feature of papilloma. Another confirming feature is these wart-like growths appear to be at the glottal level, as they are sitting right on top of the vocal folds. However, the diagnosis can be officially made with a biopsy of the papilloma to ensure what we are seeing perceptually is correct.

c.) We typically would recommend surgery for a patient with papillomas, although general surgery brings a higher rate of recurrence. Most clinicians recommend CO2 laser surgery, as it has a lower rate of recurrence with papillomas; meaning there is a less likelihood of the papillomas returning. With surgery, however, antiviral agents are often used during the procedure, which can have effects on the voice. So, voice therapy can be appropriate here. In this patient’s case, it can reduce any compensatory or hyperfunctional behaviors of their vocal folds post surgery.

Question 103

Your patient, a 20 year old female, has been diagnosed with a contact ulcer. She presents with a breathy vocal quality, intermittent dysphonia, and mild laryngeal pain. In addition, she refuses to take any medication and frequently eats very acidic or spicy food

12a) During a stroboscopic examination, in what location would you expect to see her contact ulcer form?

12b) What other co-morbid diagnosis might you expect her to have, based on her case history?

Answer 103

a.) During a stroboscopic examination, I would expect this patient’s contact ulcer to form on the posterior third of her glottal margin, which is the cartilaginous portion of her vocal folds.

b.) Base on her case history, I would suspect that in addition to having a contact ulcer, that this patient may have laryngopharyngeal reflux. It is very common for this to occur in voice disorders, and half of patients do not experience symptoms. But, since the patient frequently eats acidic and spicy food, this could have caused their stomach acid to become higher than normal, and irritate the area around their arytenoids, which could contribute to misuse of the vocal folds. Causing the contact ulcer to form.

Question 104

Regarding a patient who has recently undergone a total laryngectomy….

Briefly describe the difference between using an electrolarynx and a TEP (tracheoesophageal puncture).

Answer 104

An electrolarynx is a device that is hand held, and you hold it up to your external stoma to produce speech. It is quite easy to learn, and you can demo it before surgery so the patient can learn how to use it. However, it can sound artificial and there is limited control of fundamental frequency and loudness.

A TEP is a small device that connects the trachea to the esophagus. It allows the patient to use their own lung air volume manually. They inhale air via their stoma, exhale air through the TEP to the esophagus via a one way direction, and then that air is released into the esophagus and passes the PE segment to initiate vibration. Patients tend to opt for this more often, as you can speak on a natural lung air supply, and it helps aid voice restoration more efficiently, keeping it as natural as possible.

Question 105

Which statement is true regarding lesions to the Superior Laryngeal Nerve (SLN) only:

Answer 105

Adduction and Abduction will not be impacted.

Question 106

Intermittent voice stoppages associated with voiced sounds is a perceptual characteristic of ________________ .

Answer 106

Adductory Spasmodic Dysphonia

Question 107

What is the primary treatment of choice for Spasmodic Dysphonia?

Answer 107

Botox injection

Question 108

You have a patient who demonstrates a rhythmic modulation in their voice during all phonatory tasks. What is the most likely diagnosis?

Answer 108

Essential Vocal Tremor

Question 109

All of the following statements about PVFMD are true except:

Answer 109

Requires surgical intervention

Question 110

Lesions resulting in vocal fold paralysis can occur at any point along the Vagus nerve (i.e. from the RLN branch and above).

Answer 110

True

Question 111

The primary treatment protocol for voice issues related to Parkinson’s Disease is Resonant Voice Therapy.

Answer 111

False - LSVT

Question 112

Individuals diagnosed with Paradoxical Vocal Fold Motion Disorder (PVFMD) typically present with normal spirometry measures.

Answer 112

True

Question 113

Heightened fight or flight responses may be observed in individuals diagnosed with a voice disorder of psychological origin.

Answer 113

True

Question 114

In Spasmodic Dysphonia, lesions of the larynx are typically seen during a stroboscopic exam.

Answer 114

False

Question 115

How would you differentially diagnose ADSD vs ABSD?
Please list 2 specific tasks you would utilize during an evaluation and how performance would differ between ADSD and ABSD.

Answer 115

When it comes towards differentially diagnosing ADSD vs ABSD, I would make my diagnosis based on perceptual characteristics:

Adductor Spasmodic Dysphonia (ADSD) is commonly characterized by an effortful vocal production, meaning the client’s voice sounds very strained in terms of its quality. With ADSD, the thyroarytenoid (TA) is very much involved, as it is so perceptually you’ll hear voice stoppages during the production of voiced sounds, and these stoppages occur because the VF’s are experiencing over-closure.

Abductor Spasmodic Dysphonia (ABSD) is way less common compared to ADSD. Perceptually, a person with ABSD has intermittent “breathy breaks” while producing any voiceless consonant; those breaks occur due to over-abduction of the VF’s. Those are two key differences between the two subtypes, as ADSD deals with voiced sounds and deals with over-closure or over-adduction, not over-abduction. With ABSD, pitch breaks are common to hear as well.

For both, you could do a prolonged speech task to determine what subtype this patient may have. With ADSD, you could differentiate it based on if the person sounds strained, and if the patient has ABSD, they may sound breathy. Another task you could do is having them do some CAPE-V sentences. This will help distinguish the two because with ADSD, the patient may have some stoppages during the sentences that contain loads of voiced sounds, and they do not show issues with voiceless sounds. Whereas with ABSD, it would be the other way around and you would hear those stoppages during the sentences that are heavy with voiceless sounds. You needed to include specific tasks ( e.g. “si-si-si” or “my mama makes lemon muffins”).

Question 116

Your patient is diagnosed with a left UVFP in the lateral position. Ultimately, you decide that surgical intervention is warranted. Please list and describe one medical management approach the ENT could perform. Include information on the basic procedures of this approach and how it would impact voice physiology.

Answer 116

One medical management approach the ENT could perform on a patient with a left UVFP in the lateral position is the medialization by injection, or the injection laryngoplasty approach. With this approach, the ENT could inject a couple of different bulking agents into the patient’s vocal folds. They could inject “autologous fat” into the one of the vocal folds; this helps plump up the vocal folds and brings them closer together. The ENT could also inject collagen as a bulking agent, or a hydroxyapatite, such as radiesse. All of these injectables share a similar task; they all are designed to bulk up the vocal folds. They get injected into one of the vocal folds to add more material to it, and then the thickening of the vocal fold brings it closer to the other vocal fold. This will impact the voice physiologically, because whereas before the client was experiencing difficulties bringing the vocal folds together to phonate, now they may have an easier time being able to phonate the vocal folds, which can produce good quality speech and improve the patients vocal qualities as well. This specifically impacts voice physiology because now sub glottal pressure can build to initiate phonation.