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MBBS IV - Junior Clerkship WCS > JC98 (ENT) - Dysphonia and Aphonia > Flashcards

JC98 (ENT) - Dysphonia and Aphonia Flashcards

1
Q

Anatomical structures that are affected in dysphonia and dysarthria

A

Dysphonia:
- True vocal cords

Dysarthria:
Structures for resonance: Nasal cavities, sinuses, pharynx, oral cavity
Structures for articulation: Tongue and teeth, Jaw movement

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2
Q

Mechanical function of true vocal cords

A

True vocal cords transform kinetic energy of airflow into sound energy

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3
Q

Anatomical layers of vocal cord

Which layer is responsible for voice production

A
  1. Epithelium (where sound wave is generated)
  2. Superficial lamina propria (gel-like, pliability of vocal fold)
  3. Intermediate lamina propria (like elastic rubber band)
  4. Deep lamina propria (like fascia)
  5. Vocalis muscle

Superficial lamina propria (gel-like, pliability of vocal fold)

  • transparent, soft layer to support epithelium so that sound wave can be generated on epithelium
  • Attachment to deeper layers prevents it from being blown away by airflow
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4
Q

Physiology of the glottic cycle for voice production

A
  1. Buildup of supporting air pressure splits the vocal cords apart&raquo_space;> gust of air through vocal cords
  2. Bernoulli’s Effect of exhaled airstream:
    - Narrow gap between cords increase air velocity
    - Higher air velocity equals lower air pressure
    - Vocal cords are sucked together and close
    - Air pressure builds and force open vocal cords again
  3. Continuous exhalation&raquo_space;> cyclical closure of vocal folds
  4. Airflow is chopped off into cyclical puffs of air, forming sound waves
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5
Q

Define causes of hyper/hyponaslity and ‘hot potato voice’

A

Hot potato voice - tonsillar hypertrophy, peritonsillar abscess, acute epiglottitis, oropharyngeal obstruction

Hyponasality: inadequate airflow through nose during speech (nose completely blocked)

Hypernasality: excessive airflow through nose during speech (e.g. cleft palate)

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6
Q

Ddx Voice disorders into 3 main categories

A
  1. Organic:
    - Lung, neurological, and vocal cord lesions
  2. Functional - e.g. muscle tension dysphonia
  3. Psychogenic - e.g. conversion disorder
    (know how to control vocal cord but subconscious problem prevents them from functioning)
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7
Q

Ddx organic causes of voice disorders

A

Lungs: Poor breathing support

  • Poor respiratory condition (e.g. asthma, COPD)
  • Poor coordination (normal lungs)

Neurological control:

  • Central: poor coordination between lungs and vocal cords (e.g. Parkinsonism)
  • Peripheral: RLN palsy, SLN palsy

Local vocal cord lesions:

  • Acute laryngitis
  • Vocal cord nodules
  • Vocal cord polyp
  • Reinke’s edema
  • Recurrent Respiratory Papillomatosis
  • Laryngeal cancer (SCC)
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8
Q

Nerve supple of vocal cord muscles

A

 Recurrent laryngeal nerve palsy (supplies supraglottis, all intrinsic muscles of larynx) – vocal cord palsy

 Superior laryngeal nerve palsy (supplies infraglottis, cricothyroid) - can’t sing high pitch

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9
Q

Patient with voice disorder presents with BREATHY VOICE

Ddx

A

Unilateral vocal cord palsy

Vocal cord nodule

Vocal cord polyp

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10
Q

Patient with voice disorder presents with low pitch, rough voice with exertion on speech

Ddx

A

Reinke’s edema

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11
Q

Patient with voice disorder presents with rapidly progressive hoarseness and stridor

Ddx

A

Recurrent Respiratory Papillomatosis

Laryngeal cancer

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12
Q

Vocal cord palsy

  • Presentation in unilateral vs bilateral palsy
  • Causes
A

Unilateral: Breathy voice (vocal cords cannot close properly), choking
Bilateral: breathing difficulty, suffocation

Causes:

1) Iatrogenic most common
- HN surgery (along course of RLN)
- Thyroid/ esophagus/ cardiac/ thoracic surgery

2) Recurrent laryngeal nerve lesion
- CA thyroid, esophagus, lung
- Ortner’s syndrome: big left atrium compressing on RLN

3) Brainstem lesion (RLN = branch of vagus)
4) Idiopathic (usually viral infection of external laryngeal nerve = branch of SLN)

5) Arytenocricoid joint lesion (vocal cord cannot move)
- Dislocation after intubation
- Rheumatoid arthritis
- Cancer infiltration from larynx/ hypopharynx

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13
Q

Vocal cord palsy treatment

A

Unilateral:

  • Voice therapy
  • Injection laryngoplasty: expand vocal cord, temporary
  • Medialization thyroplasty: Place Gore-tex to push paralyzed vocal cord to midline

Bilateral:

  • Tracheostomy to protect airway
  • Lateralization/ arytenoidectomy
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14
Q

Vocal cord nodules

  • Laterality?
  • Anatomical location
  • S/S
  • Cause
  • Tx
A

Anatomy:

  • Always bilateral and symmetrical
  • At membranous junction of anterior and middle 1/3 of vocal folds
S/S: 
Breathy voice (nodules block vocal cord closure)

Cause:
Chronic** vocal trauma&raquo_space; localized edema&raquo_space; fibrosis&raquo_space; nodules

Treatment:

  • Speech therapy (improve voice technique to reduce recurrence)
  • Excision
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15
Q

Vocal polyp

  • Laterality
  • S/S
  • Cause
  • Treatment
A

Anatomy:
- Unilateral

S/S: Breathy voice

Cause:

  • Acute vocal trauma (e.g. yelling)
  • Causes capillaries to burst, form hemorrhagic cyst
  • Hemoglobin is absorbed, fibrotic polyp remains

Treatment:
- Excision

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16
Q

Reinke’s edema

  • Anatomical location
  • S/S
  • Causes
  • Tx
A

Anatomy:
Fluid collection in Reinke’s space (i.e. superficial lamina propria = 2nd layer, gel-/ jelly- like)

S/S:
Effortful, low pitch, rough voice
(Need strong exhalation effort to build up subglottic air pressure to push heavy VC to move)

Causes:

  • Smoking
  • Laryngeal reflux (GERD)
  • Hypothyroidism

Tx:
 Correct underlying causes (stop smoking; PPI for GERD)
 Excision (remove jelly from vocal cord)

17
Q

Recurrent respiratory papillomatosis

  • Laterality? Morphology
  • S/S
  • Cause
  • Treatment
A

Bulky, irregular vocal cord

S/S:

  • Rapidly progressive hoarseness, airway obstruction (stridor)
  • Malignant transformation and tracheobronchial spread

Cause: HPV subtype 6,11

  • Children: In-utero transfer, birth tract contact
  • Adult: oral sex

Tx:
- Watchful waiting for spontaneous regression in puberty
- Surgical debulking: Laryngeal debrider or CO2 laser
+/- adjuvant medical therapy (IFN, chemotherapy)

18
Q

List 3 pre-malignant lesions of the vocal cord

A

Leukoplakia
Erythroplakia
Recurrent respiratory papillomatosis

Always biopsy to confirm benign or malignant

19
Q

Laryngeal cancer

  • Main histological type
  • S/S
  • Risk factor
  • Treatment
A
  • Main histological type: squamous cell carcinoma
  • S/S: Hoarseness, Stridor, Cervical lymphadenopathy
  • Risk factor: Smoking
  • Treatment
    Early: Radiotherapy, Laser excision, Partial laryngectomy
    Late: Total laryngectomy, Adjuvant chemo and radiotherapy
20
Q

Outline history taking questions for voice dysfunction

A

Onset/ pattern of hoarseness:
 Acute vs. chronic
 Episodic vs. progressive (CA larynx)

Associated “red flag” symptoms for CA larynx:
 Bleeding (in saliva, sputum)
 Shortness of breath
 Dysphagia

Ddx:

  • Known HPV infection
  • Recent overuse of voice ]

Social:
Smoking**
Occupation/ vocal demand (recreational singing: church, choir)

21
Q

Outline P/E and first-line screening for voice dysfunction

A

PE:
General: any respiratory distress (e.g. bilateral VC palsy) and need for intubation, constitutional S/S for malignancy
Pulmonary exam in full
Head and neck neurological exam for facial movement, tongue movement, jaw movement

Lung function test, imaging for lung diseases
Inspect larynx:

  • Indirect laryngoscopy
  • Flexible laryngoscopy
  • Rigid laryngoscopy
22
Q

Compare the modalities of laryngoscopy

  • approach
  • tests performed
  • gag reflex
  • Pros and Cons
A

Indirect laryngoscopy

  • Press down tongue, see larynx with dental mirror
  • Con: elicits gag reflex

Flexible laryngoscopy:

  • Trans-nasal
  • Pro: Less gag reflex
  • Con: Inferior quality of vision (low light)

Rigid laryngoscopy

  • Trans-oral
  • Stroboscopy test: intermittent light pulsates at fundamental frequency of voice cord vibration, see slow-motion cord movement
  • Pro: See subtle vocal cord lesions, best image quality
  • Cons: Worst gag reflex

Direct laryngoscopy: Not for clinical use, used for intubation or foreign body removal

23
Q

Investigations for TNM staging of laryngeal cancer

A

T - local tumor stage

  1. Flexible endoscopy (nodule/ polyp/ mass lesion) + biopsy for extent and histological Dx
  2. Upper panendoscopy (bronchoscopy + esophagoscopy) for Synchronous lesion in upper aerodigestive tract
  3. CT/MRI neck with contrast for extent and infiltration

N - Regional LN
- USG neck +/- fine needle aspiration cytology

M - distant metastasis
 CXR
 Blood test
 PET (expensive)

24
Q

Describe reconstruction after total laryngectomy

A

Remove the whole voice box (cricoid, thyroid cartilage, epiglottis) + neck dissection (cervical lymph node)

Trachea is brought to the skin by permanent tracheostomy (pump air into trachea directly)

After the defect is closed:
 Esophagus is connected to the mouth of patient
 Air flows out of the neck without going through mouth and nose – no vibrator to convert airflow into sound energy

25
Q

4 voice rehabilitation methods after total laryngectomy

A

Electrolarynx

Pneumatic device

Tracheoesophageal speech

Esophageal speech

26
Q

Electrolarynx

Mechanism

Pros and Cons

A

Mechanism:

1) Put the vibrator at neck
2) Vibrator generates vibration transmitted through soft tissue of neck into pharynx and oral cavity
3) air inside vibrates and makes sound

Pro: Easy to use
Con: Unnatural robotic voice, inconvenient device, need one hand

27
Q

Pneumatic device for voice rehabilitation

Mechanism

Pros and Cons

A

Mechanism:

  • Pneumatic device with internal rubber band at tracheostomy
  • Air goes through body of pneumatic device&raquo_space; rubber band vibrates&raquo_space; sound energy goes through straw

Pro: Better control of force and speed of breath

Con: Requires greater manual dexterity and coordination, Sputum may be trapped in the device

28
Q

Tracheoesophageal speech

  • Mechanism
  • Pros and cons
A

Mechanism:
Connection between trachea and esophagus (artificial fistula):
- When patient occludes tracheostome, exhaled airflow cannot go out through neck but through fistula into esophagus
- Air going through esophagus vibrates soft tissue wall of esophagus, create sound energy &raquo_space; then articulate through mouth
- a tracheoesophageal valve allows one-way flow

Pro: Good intelligibility, indwelling device is convenient

Cons: Requires greatest manual dexterity and coordination; Saliva, sputum at
posterior aspect require daily cleaning

29
Q

Esophageal speech

Mechanism
Pros and cons

A

Mechanism:
Swallow air into esophagus, then release air back (like burps) in a controlled fashion

Cons: Very difficult to learn

MBBS IV - Junior Clerkship WCS (131 decks)

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