LECTURE #14 - voice disorder Flashcards
where are the key structures for producing voice found ?
in the larynx
which muscles are the primary muscle involved in
generating voice ?
Thyroarytenoid muscle
when producing a voice, what are vocal cords doing ?
Adducted (closes together)
when vocal cords are abducted what does this mean ?
open, we are breathing
when vocal cords are adducted what does this mean ?
closed, speech
the process of producing voice involves the coordination of what 3 sub-systems ?
- Respiration
- Phonation
- Resonance
the following actions are in what phase of respiration ?
- chest expands
- ribs
- diaphragm contracts
breathing in
the following actions are in what phase of respiration ?
- chest contracts
- lungs
- diaphragm relaxes
breathing out
when phonating, what happens anatomically?
i. Arytenoids rotate to midline
* Laryngeal adductor muscles
ii. Vocal folds adduct
* Closes glottal opening
* “Phonating position”
iii. Subglottal air pressure builds
iv. Vocal folds blown apart
v. Vocal fold tissue recoils
when resonating, what happens anatomically ?
- The oral and nasal cavities ‘resonate’ sound as it leaves the mouth
- Sound produced by larynx is modified by the vocal tract
– e.g., lips, mandible, velum, palate shape airflow and
influence resonance and voice characteristics/quality
what is “voicing” ?
One cycle of phonation
* Vocal folds open and close
what do repeated cycles of phonation produce ?
sound
what parts of the body help shape airflow and influence resonance and voice characteristics/quality of resonance ?
lips, mandible, velum, palate
in voicing, what is pitch determined by ?
1) rate (frequency) of vocal fold opening/closing
2) size and mass of vocal folds
how do we measure voicing rate ?
In Hertz, vibrations/second, or cycles/second
what creates voice pitch ?
vibration of vocal folds
what is voice pitch responsible for ?
perceived pitch of speaker’s voice, even though other frequencies are present
F0 or pitch means …
Fundamental frequency
what is the typical voice for adult male ?
85-155 Hz
what is the typical voice for adult female ?
165-255 Hz
what is the typical voice for Child (age 10) ?
208-259 Hz
what is the typical voice for infant (12 months) ?
247-410 Hz
which age catergory has the highest frequency ?
Infant (12 months) 247-410 Hz
what is voice quality determined by ?
subjective judgements, size/shape of vocal folds
and oral/nasal cavities
what are example descriptions of voice quality ?
breathy, hoarse, hyper/
hyponasal
what are voice registers ?
Voice registers are different ranges of pitch that a person’s voice can produce
what are the 3 voice registers ?
Pulse, modal, falsetto
describe “pulse” :
- This is a very low, breathy sound, almost like a gentle vibrating hum or a subtle growl.
- It’s used for low, resonant sounds and is often felt more than heard.
describe “modal” :
- This is the “normal” speaking or singing voice.
- It’s the most commonly used register, producing a full, clear sound across a wide range of pitches.
- Most of our regular speech and singing occurs in modal voice.
describe “falsetto” :
- This is a higher, lighter, and breathier voice register.
- It’s used for high notes above the modal range, with less resonance and more airiness.
- Often used by men to reach notes in higher ranges, beyond their natural vocal register.
what is a voice disorder?
is any condition that affects the normal production of sound and speech. It involves changes in the pitch, volume, quality, or flexibility of the voice, making it difficult to speak or sing clearly.
which voice register is the lowest ?
pulse
which voice register is the highest pitch ?
falsetto
which voice is vocal fry ?
pulse
which voice register is typical voice/normal speech ?
modal
when voice is perceived by others as unusual and
draws attention to the person who is speaking, what is this reffered as ?
voice disorder
what is dysphonia/phonatory disorder ?
re essentially the same thing. Both terms refer to problems with the voice, making it sound hoarse, breathy, strained, or hard to understand.
in children what are voice disorders usually related to ?
related to vocal abuse/misuse and temporary
in adults what are voice disorders usually related to ?
More variable etiology and duration
what are some high-risk occupations of voice disorders ?
− Teachers
− Singers
− Salespeople
− Clerks
− Administrators and managers
− Factory workers
FILL IN THE BLANK
~__% of population at a given time
6%
FILL IN THE BLANK
~__% lifetime
3-&
what gender are voice disordes more common within ?
mostly female
what age group are voice disordes most common within ?
typically age 40-60
what are some pitch features of voice disorders ?
– Monopitch
– Pitch breaks
– Too low
– Too high
– Diplophonia
what are some quality features of voice disorders ?
– Hoarse/ rough
– Breathy
– Harsh
– Nasal
– Vocal tremor
– Strain/struggle
what are some loudness features of voice disorders ?
– Monoloudness
– Too loud
– Too weak
– Aphonia
– Spasmodic dysphonia
TRUE OR FALSE
voice quality disorders can affect in any combination or in isolation ?
TRUE
what is another name for voice disorders ?
dysphonia
what are 3 kinds of dysphonia ?
- Dysphonias related to irregular opening and closing of vocal folds
- Dysphonias related to incomplete glottal closure
- Resonance problems related to irregularities in nasal, oral, or pharyngeal cavities
what does dysphonias related to irregular opening and closing
of vocal folds lead to ?
– Hoarseness and/or harshness
– Acoustically and perceptually deviant
what does dysphonias related to incomplete glottal closure lead to ?
Breathiness
what does resonance problems related to irregularities in nasal, oral, or pharyngeal cavitieslead to ?
Nasal or vocal resonance problems
what are the three classification of voice disorders ?
- Vocal misuse
- Nervous system involvement
- Organic disease and trauma
what does vocal misuse / phonotrauma mean ?
normal anatomy but way they’ve been using their larynx has damaged their vocal folds
what are some types of vocal misuse/phonotrauma ?
- nodules
- polyps
- edema
- laryngitis
- aphonia
- puberphonia
what is “nodules” ?
breathiness and lowered pitch
what is “polyps” ?
breathiness and lowered pitch
what is “edema” ?
lowered pitch
what is “laryngitis” ?
breathiness and lowered pitch
what is “aphonia” ?
total loss of voice in spite of apparent normal vocal anatomy
what is “puberphonia” ?
unusually high pitch in spite of normal vocal anatomy
describe “Traumatic laryngitis” ?
– Swollen, irritated vocal folds
* Disrupts normal vocal fold vibration
– Leads to changes in voice quality or aphonia
– Due to abuse and misuse of voice, infections, irritants, acid reflux
what is the time frame of Traumatic laryngitis ?
Can be acute (~2-5 days) or chronic
describe “Vocal nodules” ?
– Small fibrous tissue along anterior, medial surface of vocal folds
– Usually bilateral
– Due to persistent vocal misuse, irritation
– Lead to breathiness, hoarseness, low volume, low pitch
in what type of vocal misuse/phonotrauma can vocal folds not fully come together ?
vocal nodules
describe “Vocal polyps” ?
– Small, soft, fluid-filled sacs on vocal folds or elsewhere along larynx
– Usually unilateral
– Due to single event of vocal misuse/trauma or smoking
– Leads to breathiness, hoarseness, diplophonia, and/or low pitch
what are some types of voice disorders with nervous system involvement ?
- parkinson disease
- myasthenia gravis
- spasmodic dysphonia
- lesions of peripheral nerves
- huntington’s chorea
- motor neuron disease
- multiple sclerosis
what is the type and vocal quality of Parkinson’s ?
monopitch and reduced loudness
what is the type and vocal quality of multiple sclerosis ?
impaired loudness control and hoarseness
what is the type and vocal quality of myasthenia gravis ?
breathiness
what is the type and vocal quality of spasmodic dysphonia ?
vocal strain/struggle
what is the type and vocal quality of lesions of peripheral nerves?
breathihess
what is the type and vocal quality of huntington’s chorea ?
hoarseness
describe the Nervous System Involvement in voice disorder (parkinson’s disease) ?
– 3 main motor symptoms: tremor, stiffness, slowness of movement
– 50-80% have an associated voice disorder
– Monotonic, low pitch, varied loudness
what is the type and vocal quality of motor neuron disease ?
hoarseness or strain/struggle
describe the Nervous System Involvement in voice disorder (Amyotrophic Lateral Sclerosis) ?
– Progressive diseases of nerves that stimulate muscles (also affects muscles required for speech)
– Initially: hoarse voice and vocal spasm
– Later: weak voice, hypernasality, no voice
– All will have a voice disorder
describe the Nervous System Involvement in voice disorder (Spasmodic Dysphonia) ?
- Adductor
i. Vocal folds spasm together during voiced sounds
ii. Leads to bursts of strained, strangled voice - Abductor
- Vocal folds spasm apart during voiced sounds
- Leads to bursts of excessive breathiness
- More rare
describe the Nervous System Involvement in voice disorder (Vocal fold paralysis) ?
– Due to damage to recurrent laryngeal nerve
* Caused by surgery, infection, tumour
– Typically unilateral
– Leads to breathy voice
– If bilateral, can lead to choking on liquids, breathing problems
what are some organic disease and trauma classified types of voice disorders ?
- laryngeal granuloma
- contact ulcer
- papilloma
- vocal fold hemorrhage
- laryngeal web
- inhalation trauma
- carcinoma
all the following organic disease and trauma classified voice disorders :
- laryngeal granuloma
- contact ulcer
- papilloma
- vocal fold hemorrhage
- laryngeal web
- inhalation trauma
- carcinoma
lead to what kind of voice quality ?
hoarseness
describe the organic disease & trauma classified voice disorder (laryngeal carcinoma) ?
– Approximately 5% of all forms of cancer
– Can cause persistent hoarseness, vocal fatigue, dysphagia, throat swelling, pain
– Risk factors
* Tobacco +/- moderate heavy alcohol use
* HPV
describe the organic disease & trauma classified voice disorder (laryngeal papilloma) ?
– Wartlike growths along vocal tract and respiratory system
* Due to HPV
– 60-80% cases in young children
– Leads to hoarseness and/or breathiness
– Can compromise airway
majority of voice disorders are pathophysiologic, what are the two aetiology of the voice disorder ?
- Organic causes
- Non-Organic/Functional
what are some organic causes examples of voice disorders ?
- Carcinoma, tumors, polyps, cysts
- Contact ulcers, nodules
- Trauma
what are some non-organic causes examples of voice disorders ?
- Stress and anxiety
- Conversion disorder, psychogenic
what is “coversion disorder” ?
cases where people have extremely high situations of psychological issues
what are 3 voice disorder impacts ?
- Can be signal of serious underlying disease conditions
- Can indicate individual needs help communicating
- Can contribute to communication breakdown and threaten functional independence
what can be described as “functional independence” ?
Negative impact on career, social interactions, and other activities of daily living
what are some primary assessment questions that SLP’s may ask?
- What are probable causes of the problem?
- What are physical symptoms of the problem?
- What is impact of the problem on the person?
- What options are available to treat the problem?
when assessing a voice disorder, who must we always get a referral ?
otolaryngology
what does “What are probable causes of the problem?” mean ?
abuse and misuse
what does “What are physical symptoms of the problem?” mean ?
mild? severe?
what does “What is impact of the problem on the person?” mean ?
intervention and treatment options to find the best track to take
what are the two kinsd if assessments of voice disorders ?
subjective & objective assessment
what do we do in a subjective assessment ?
- Case history
- perceptual evaluation
- observing body, movements
what do we do in a objective assessment ?
- Use of instruments to examine dynamic process of voice production
- Conducted in partnership with ENT
- Includes videoendoscopy (e.g., Fiberoptic nasoendoscope)
what does “case history” mean ?
Nature of disorder, how it affects individual (impact), history and duration, social/vocational use of voice, overall physical and psychological condition
what does “perceptual evaluation” mean ?
Rating pitch, loudness, quality, etc.
what are some examples of “observing body movements” ?
looking at things that may be impacting voice (neck tension, irregular breathing, etc.)
what are the 4 approaches to treating/managing voice
disorders ?
- Indirect therapy
- Direct therapy
- Surgery
- Prevention
what are forms of indirect voice therapy ?
- voice rest
- environmental adjustments
- patient education
- counselling
explain “voice rest” :
– No speaking, singing, whispering
– Shorten recovery time
explain “Environmental adjustment” :
– Microphones/amplifiers
explain “Patient education” :
- How voice is produced
- Negative consequences on vocal abuse/misuse
- counselling
explain “Counseling” :
- Stress management, psychosocial factors
- within our scope of practice to try and reduce stress
what are some things we can do to improve vocal hygiene ?
- avoid screaming
- avoid cold drinks
- drink warm water
- pause long conversations
- void prolonged gargling
- avoid whispering
what are forms of direct voice therapy ?
i. Vocal function exercises
ii. Respiratory training
iii. Confidential voice
iv. Lee Silverman Voice Treatment (LSVT)
descirbe “Vocal function exercises” :
– Exercises to strengthen & improve coordination
– Vowel prolongation
– Smooth ascending/descending pitch to stregthen pitch range (help glide)
descirbe “Respiratory training” :
- Teaches patient to coordinate muscles for breath and vocalization
- Focus on improving efficiency between airflow, vocal fold vibration, and phonation
- Patient completes daily exercises
- need good breathe, without good breathe we’ll have tension
descirbe “Confidential voice” :
- Relaxed, easy voice
- Reduces laryngeal tension and increases airflow
- will reduce friction in larynx and eventually building eventually building it back up
descirbe “LSVT” :
- Maximizes phonatory and respiratory function
- Teaches patients to produce a loud voice with maximum effort and to monitor voice
- Improves respiratory support, laryngeal muscle function, articulation, and animation
- Incorporates biofeedback (sound level meter)
- maximizes breath support and loudness
- intervention choice dpends on their disorder/cause of disorder
explain the “surgery” portion of a direct treatment ?
- Phonosurgery for nodules or polyps
- Injection laryngoplasty for vocal fold paralysis
- Botox for spasmodic dysphonia
- Laryngectomy
- Removal of entire larynx to prevent spread of cancer
- Trachea repositioned to form stoma for breathing
- Voice/speech therapy for alaryngeal speech follow surgery
what is Alaryngeal speech ?
refers to speech produced by individuals who do not have a functioning larynx (voice box)
what are the 3 kinds of alaryngeal speech we discuss in class ?
- Electrolarynx
- Esophageal speech
- Tracheo-esophageal (TE) speech
discuss “Electrolarynx” :
- Transoral or intraoral devices
- Vibration shaped by articulators
- creates electrical voice by vibrating
discuss “Esophageal speech” :
- Uses esophagus as a vibratory source
- Vibrating air shaped by articulators
discuss “Tracheo-esophageal (TE) speech” :
- Tracheoesophageal puncture (TEP) created surgically (Opening between trachea and esophagus)
- One-way valve placed in TEP
- Block stoma to redirect air through TE valve into esophagus
- Vibrating air shaped by articulators
for prevention factor of treatment of voice disorders, what is the acronym we look at ?
V
O
I
C
E
D
what does “V.O.I.C.E” stand for ?
V = value
O = optimize
I = invest
C = cherish
E = exercise
what are Cultural Considerations & Voice Disorders ?
- Social and cultural factors may influence
voices
– e.g., Habitual pitch of males and females, expectations for loudness
– May impact subsequent development of voice disorder - Transgender and transsexual voice training
– Using feminized or masculinized voice in safe way
