Functional disorders and disorders of neurological origin Flashcards
What is a neurological voice disorder?
Caused by interruption of nervous innervation supplied to the larynx, leading to abnormal control, coordination, or strength of laryngeal muscles
What is a functional voice disorder?
Arising from non-organic and non-neurologic causes
3 categories of phonatory dysfunction affected by neurological disorders
- Adduction/abduction
- Stability
- Coordination
Parkinson’s disease: hypo-adduction - perceptual, visual, management
Perceptual
- Monopitch, breathy, rough, reduced loudness, shorter bursts due to respiration affected, difficulty initiating phonation
Visual
- VF may appear normal or bowed (-> breathiness)
- Laryngeal tremor
- Abnormal phase closure and symmetry
Management
- LSVT LOUD: phonation and loudness
Myashthenia gravis: hypo-adduction - perceptual, visual, management
- Autoimmune neuromuscular disease
- 2x more women than men
- Fatigability, fluctuation of function
Perceptual: - Breathy, weak
- Muscle weakness on prolonged sounds
- Other: Stridor, reduced loudness, monotone, hypernasality, tremor
Visual - Fluctuating impairment of VF mobility: reduced phase closure and vibratory amplitude
Management - Pharmacological treatments to improve muscle contraction
- Surgery, removal of thymus gland
Unilateral vocal fold paralysis: hypo-adduction
- Complete immobility of one VF, can’t move toward midline
Perceptual - Aphonia through to normal voicing
- Breathy, rough, strained (trying to compensate)
Visual - Affected VF weak or bowed
- Passive vibration due to flow of exhaled air
Management - Wait and see 6-9 months
- Behavioural voice therapy
- Surgery, medialisation of VF + reinnervation to RLN)
Bilateral vocal fold paralysis
- Phonation may be preserved by airway obstruction an issue
- Often caused by surgical trauma, malignancies, intubation
Perceptual - Normal voicing through to severe breathiness/aphonia
- Inspiratory stridor if in adducted position
Visual - VF floppy/bowed
- Artytenoid cartilage on both sides does not abduct/adduct
Management - Wait and see 6-9 months if no airways obstruction
- Tracheotomy if airway obstructed
- Surgery, lateralisation of VF to widen glottis
Supranuclear palsy: hypo-adduction
- Rare prog neuro
- Damage to brain cells that control body movement/coordination
- Perceptual: strain, reduced loudness, breathy
Shy-Drager/Multiple Systems Atrophy: hypo-adduction
- Rare degenerative neuromuscular disorder
- Affects body’s involuntary functions, including motor control
- Can have VF paresis
- Perceptual: weak, reduced loudness, stridor
Laryngeal dystonia/spasmodic dystonia (phonatory instability): hyper-adduction
- Neuro disorder affecting intrinsic laryngeal muscle control
- Affects laryngeal adductory and abductory muscles during voice
- More women than men 3:2
Two varieties
1. Abductor laryngeal dystonia 15% - Uncontrolled opening of VFs
- Breathy, weakness
2. Adductor laryngeal dystonia 85% - Irregular closing of VFs
- Strain
Abductor laryngeal dystonia
Uncontrolled opening of VFs
Perceptual
- Weak and breathy
- Voice stoppages
- Delayed onset of voicing
Visual
- VF in open position when should be closed
Management
- Botox injection into laryngeal muscles
Adductor laryngeal dystonia
Irregular closing of VFs
Perceptual
- Strain
- Voice stoppages
- Delayed onset of voicing
Visual
- VF in closed position when should be open
Management
- Botox injection into laryngeal muscles
Huntington’s disease: hyper-adduction
- Chorea
- Perceptual: involuntary noises, monopitch, strain
Pseudobulbar palsy: hyper-adduction
- Progressive lesions that occur bilaterally in corticobulbar tract, usually from stroke
- Perceptual: hoarse
Amyotropic lateral sclerosis: phonatory stability
- Attacks neurons for controlling voluntary muscle contraction
- Spasticity and weakness
Perceptual - Weak, rough, strained, some hypernasaltiy
Visual - Incomplete VF closure
Management - No effective treatment
- AAC
Essential tremor: phonatory stability
- Rhythmic tremors that can involve larynx (+ head, arms, neck, tongue, palate, face)
- Laryngeal tremor most noticeable during vowel prolongation
- Can also affect connected speech: voice breaks, complete voice stoppage
Cerebellar ataxia: mixed disorder
- Disorder of cerebellum
- Muscle coordination and movement impacted
- Perceptual: hoarse
Multiple sclerosis: mixed disorder
- White and grey matter of CNS affected
- Perceptual: weakness, difficulty increasing loudness
Examples of functional voice disorders (5)
- Puberphonia
- Ventricular phonation
- Muscle tension dysphonia
- Conversion aphonia
- Paradoxical vocal fold dysfunction
Puberphonia: functional disorder
- Pitch hasn’t lowered in puberty
- Proposed to have either a psychological or physical basis
Perceptual - Pitch higher than typical
- Breathy
- Reduced loudness
Visual - Commonly normal adult male larynx
- Incomplete glottal closure
- Increased VF stiffness
- Laryngeal hyperfunction, maintaining high pitch
Management - In absence of physiological cause, management is behavioural, eg. voice therapy to reduce pitch
Ventricular phonation: functional disorder
- Use of false/ventricular VFs instead of/with true VFs
- Often associated with severe muscle tension or VF dysfunction as compensation
Perceptual - Voice sounds low pitch with reduced range
- Rough
- Strain
Visual - Atypicall adduction and vibration of VFs
Management - Need to demonstrate efficacy of phonation with true VFs, if so then voice therapy appropriate, needs to relax ventricular folds and allow true VF to vibrate
- Surgery
Muscle tension dysphonia
- Excessive tension of laryngeal muscles
- 3 subgroups of aetiologies: psychological, vocal misuse, compensation for underlying disease
Perceptual - Strain, high pitch, breathy, weak
Visual - Excessive contraction of laryngeal muscles
- Possible incomplete closure
Management - Focus on normal muscle use
- Indirect therapy: vocal hygiene, education
- Direct therapy: voice therapy
- Medical treatment for contributing factors, eg. reflux
- Surgery for secondary organic lesions
Conversion aphonia
- Manifestation of stress/depression/anxiety
- Psychogenic, unconscious stimulation of illness
- Emerges very quickly, can be associated with trauma or severe stress
- No evidence of cause or of patients faking it
Perceptual - Aphonia
- High pitch and very strained
- Neck pain, laryngeal muscle tightness
Visual - Normal non-phonatory movements
- VF movement irregular and insufficient vibratory cycle
Management - Complete physical examination
- Psychiatric treatment may be necessary (+ voice therapy?)
- CBT, hypnosis, antidepressants
PVFM
- Episodic/involuntary adduction of VFs, can occur on expiration
- Multifactorial causes
- Difficulty breathing/dyspnea, cough, stridor, tightness
- Rapid onset, resolution
Perceptual - Stridor, audible airway obstruction
- Strain, muscle tightness
- Chronic cough
- Roughness, strain, breathy, weak, diplophonia
Visual - Intermittent nature so won’t always show, ideally need to see it mid-flare up
Management 3 phases
1. Differential diagnosis of cause
2. Psychoeducation
3. Maintenance
Transgender voice
- Change voice pitch
- Perceptual: voice too high/too low, resonance, intonation, rate, loudness
- Visual: WNL for gender assigned at birth
- Management: Behavioural, surgical, HRT
