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Voice > Lesions of the Vocal Cords--Lecture 2 > Flashcards

Lesions of the Vocal Cords--Lecture 2 Flashcards

1
Q

Functional Voice Disorders Definition

A

The way the VFs move not due to a neuro problem or organic problem; psychological issues, paradoxical issues, etc.; how the VFs move; not impairment due to neurological issues or organic issues; neurological innervation is intact & no structural abnormality

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2
Q

Functional Voice Disorders Examples

A

Functional aphonia, paradoxical VF movement (PVFM), muscle tension dysphonia (MTD), ventricular phonation, traumatic laryngitis, puberphonia

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3
Q

Puberphonia

A

Child going thru puberty and still has high pitched voice (ENTs often say they are fine); nothing pathological or neurological but may still be hoarse (may be the way they are initiating movement of the VFs—best procedure in these cases is a videostroboscopy (can see how the cords move & any gaps, bowing, etc.)

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4
Q

Neurological Voice Disorders Definition

A

Neural innervation problem, anything involving neurology (BG, LMN, etc.; could be periph. Path of CN)

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5
Q

Neurological Voice Disorders Examples

A

VF paralysis, spasmodic dysphonia

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6
Q

Organic Voice Disorders Definition

A

There is a pathology that has created the voice problem

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7
Q

Organic Voice Disorders Examples

A

VF nodule, polyp, cyst, granuloma, contact ulcer, infectious laryngitis, reflux laryngitis, presbylarynx, sulcus vocalis, Reinke’s edema/polypoid degeneration, leukoplakia/ erythroplakia, hyperkeratosis, papilloma, webbing, cancer

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8
Q

Secondary Conditions Causing Voice Disorders

A

PD, ALS, MS, Huntington’s disease (chorea), MG, essential tremor, pseudobulbar palsy, bulbar palsy

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9
Q

Lesions of VFs Produce Pathological Changes Such As: (A lesion will produce a pathological change)

A

Increasing mass (can be unilateral or bilateral—will help us make diagnostic decisions—polyps are usually unilateral and nodules are usually bilateral)
Altering shape (gaps-breathy escape)
Restricting mobility
Increasing or decreasing tension

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10
Q

Mass Laryngeal Lesions in Childhood

A

Cri du Chat; bacterial, viral, fungal infections; hypertrophic laryngitis; papilloma; laryngomalacia; congenital laryngeal web; congenital subglottal stenosis; congenital cysts; hemangioma; polyps; laryngotracheal cleft; laryngocele
More than nodules cause voice d/o’s

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11
Q

Clearance for voice tx from ____

A

ENT

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12
Q

Stridor

A

Some type of obstruction; could be midline VFs; have to inhale over obstruction; have to determine where it’s coming from (is it laryngeal or is it nasal cavity)

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13
Q

Cri du Chat

A

Genetic defect
Discovered in neonates & children
“cry of the cat”
Structural-based problem

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14
Q

Characteristics of Cri du Chat

A

Micrognathia, abnormal larynx (abnormally formed), beak-like profile, microcephaly, hypotonia, hypertelorism (wide-set eyes), MR, midline oral clefts
*Don’t have to see all these things, but these are possibilities

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15
Q

Cri du Chat Vocal Characteristics

A 
High-pitched, mewing cry
Painful cry
Flat or rising melody patterns
Strained quality (abnormal larynx)
Crying on inhalation w/ inhalatory stridor
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16
Q

Bacterial, Viral, & Fungal Infections:

A 
Respiratory Distress
Airway Obstruction (Edema)
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17
Q

Croup

A

Viral–due to influenza virus
Affects children between 6 mos & 6 yrs of age
Inflammation & edema in the subglottal area

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18
Q

Fungal Infections Affecting Voice

A

Fungal Laryngitis, candidiasis, fungal infection secondary to chemotherapy

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19
Q

Candidasis

A

Thrush; yeast infection
Can usually be seen more in VF abduction; whitish spots on videos
Can develop in mouth or larynx

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20
Q

Fungal Infection Secondary to Chemo

A

When one’s immune system is suppressed by something like chemotherapy, a fungal infection may be quite extensive

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21
Q

Coccidomycosis

A

Fungal infection from California’s Central valley

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22
Q

Bacterial Infections Affecting Voice

A

Epiglottitis, bacterial laryngitis

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23
Q

Epiglottitis

A

A bacterial infection of the larynx is very serious as the swelling can nearly close off the airway in an adult and easily closes off the airway in a child; aka supraglottitis; The danger lies in the softness of the tissue which can easily expand, particularly the loose tissue of the arytenoids can be drawn in during inspiration

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24
Q

Bacterial Laryngitis

A

Video: VFs don’t have good flexibility; strained voice due to stiffness and a high pitch; lots of breathiness, decreased intensity
Decision about Pitch, Intensity, Quality, etc.

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25
Q

Anterior to mid cord gap & posterior to mid cord chink

A

pitch will be dropped inflammation; soft intensity due to gaps (leaks); breathy, strained, hoarse

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26
Q

Vocal qualities that often go together

A

Hoarse and breathy

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27
Q

Hoarseness

A

a friction set up at the level of the glottis

Is it mild, moderate, severe (affects treatment)

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28
Q

Viral Infections

A

May be the common winter cold: VFs are pink and swollen, the voice deep, the secretions thick.

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29
Q

Laryngitis Sicca

A

Laryngeal dryness
No cause or solution has been found
Some have speculated that it is autoimmune

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30
Q

Herpes Simplex Virus

A

Viral infection that may affect the larynx & needs medical attention
2 types: Type I and Type II

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31
Q

HSV Type I

A

Produces most cold sores

Watery blisters in the skin or mucous membrane

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32
Q

HSV Type II

A

Produces most genital herpes

Watery blisters in the skin or mucous membrane

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33
Q

Viral Croup

A

Most common form of airway obstruction in children 6 mos to 6 yrs
Respiratory tract infection

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34
Q

Viral Croup Causes:

A

Upper airway obstruction causing: barking cough, hoarse voice, inspiratory stridor, wheezing
Worried about swelling causing obstruction

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35
Q

Tx for Viral Croup

A

Epinephrine

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36
Q

Hoarse Vocal Quality

A

Includes breathiness (hoarse & breathiness)

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37
Q

Harsh Vocal Quality

A

No breathiness

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38
Q

Laryngeal Papilloma Location & Size

A

On & around the VFs (may be all over)

Wart-like

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39
Q

Laryngeal Papilloma Etiology

A

Uncertain but thought to be viral

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40
Q

Laryngeal Papilloma Vocal Sx’s

A

Breathiness, low pitch, tension, aphonia (occasional), hoarseness (bad term)

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41
Q

Laryngeal Papilloma Management

A

Med-surg with associated voice therapy; keep recurring; have to be taken off with a laser

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42
Q

Congenital Laryngomalacia

A

Redundant (too much) arytenoid cartilage mucosa
Epiglottis omega shaped
Aryepiglottic folds sucked into glottis on inhalation/blown out on exhalation
Sx’s resolve spontaneously w/in 6 to 18 mos

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43
Q

Other Associated Problems with Congenital Laryngomalacia

A

Gastroesophageal Reflux

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44
Q

Congenital Laryngomalacia Voice Characteristics

A

Congenital laryngeal stridor described as high pitched harsh & fluttering; becomes worse w/ crying & feeding
Swallow study needed to rule out aspiration pneumonia

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45
Q

Fluttering Sound in Congenital Laryngomalacia

A

From falling in/collapsing of epiglottis; structural issue

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46
Q

Congenital Laryngeal Web Location

A

Generally includes anterior commissure; can extend length of VFs; attachment can be infra & supra glottal as well as cordal

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47
Q

Congenital Laryngeal Web Etiology

A

Congenital: Didn’t totally separate during development
Acquired: Anything that damages the larynx: chemicals, tubes, etc.

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48
Q

Vocal Sx’s: Congenital Laryngeal Web

A

Elevated pitch, tension, diplophonia, hoarseness

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49
Q

Congenital Laryngeal Web Management

A

Combination of surgery & voice therapy

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50
Q

Congenital Subglottal Stenosis

A 
Arrested embryonic development of conus elasticus
Maldevelopment of the cricoid cartilage
Obstructive narrowing of airway
Voice normal to impaired
Stridor present from birth
May require tracheostomy
51
Q

Hyperfunctional Breathiness

A

Harshness, Straining (relaxation)

52
Q

Hypofunctional Breathiness

A

Slow, weakness, not a strong voice (strengthening); can they cough; can they do /i/–/i/–/i/

53
Q

Congenital Laryngotracheal Cleft

A

Embryonic failure of dorsal cricoid lamina fusion
Results in an interarytenoid cleft & open larynx posteriorly
Cry weak or aphonic due to cleft preventing apposition of the VFs
Aspiration pneumonia
Feeding problems-Affects feeding; may have to say feeding isn’t appropriate
Voice may not be impaired; may be normal

54
Q

Congenital cysts are (location) vs. nodules & polyps

A

Unilateral in mid part of cord

Nodules & polyps are usually on the edges of the VF

55
Q

Congenital cysts general appearance

A

Generally look to be embedded in the body of the cord; look like beebee that’s encapsulated
Sometimes hard to find
Voice would be deep, breathy, hoarse

56
Q

Nodules are bilateral or unilateral?

A

Bilateral

57
Q

Pachydermia indicative of ____

A

Reflux in back of larynx

interarytenoid space

58
Q

Congenital Laryngocele

A

Born with a weakness in the larynx
Congenitally large laryngeal ventricle
Enlarged by activities that increase intralaryngeal air pressure
Air filled or fluid filled
Herniation of laryngeal ventricle (space between false & true VFs)

59
Q

Sx’s/Factors of Congenital Laryngocele

A 
Straining, coughing, vocal abuse, playing wind instruments, glassblowing, hoarseness, inspiratory stridor, dysphagia
Pt may be able to feel it and push it back (it will return)
Displaces membrane (shouldn’t come back after treatment)
“Lump in throat” often called globus sx—often considered something not actually there
60
Q

Tx of Congenital Laryngocele

A

Medical–>Incision–>drainage

61
Q

Voice/Dysphagia & Congenital Laryngocele

A 
Sessile fluid filled cysts
Arise from laryngeal ventricle
Displace true & false VFs
Glottic & supraglottic obstruction
Swallowing problems
Voice impaired to aphonic
May obstruct airway-->stridor
62
Q

Space between true & false VFs is in ____ cartilage

A

Thyroid

63
Q

3 Types of Congenital Laryngocele

A

I. Internal Type
II External Type
III. Combination Type

64
Q

Internal Type Congenital Laryngocele

A

Within the thyroid cartilage

65
Q

External Type Congenital Laryngocele

A

Each protrudes above thyroid cartilage through thyrohyoid membrane
Either above cartilage or through membrane

66
Q

Congenital Hemangioma

A

Birthmark/”raspberry”

67
Q

Types of laryngeal injuries

A

Edema, hematoma, fractures of the larynx & tracheal stenosis, dislocation of arytenoids, inter-arytenoid fixation, lacerations, VF paralysis, laryngeal web, perforation of the pyriform sinus or esophagus, ulcer & granuloma of the vocal process, hemorrhage
See in hospital or OP setting
How long have they sounded like this? Vocal abuse/lots of screaming or yelling?

68
Q

Hemorrhage

A

Voice may change due to swelling/differences in vibration (may slow down vibration of VFs)–functional category
Hemorrhagic laryngitis

69
Q

2 types of reflux

A

GERD & LPR

70
Q

GERD

A

Gastroesophageal reflux disease
Chronic digestive disease
Stomach acid backflows into esophagus

71
Q

LPR

A

Laryngopharyngeal reflux disease
Extension of GERD
Stomach acid backflows into esophagus, larynx, & pharynx
Has to be this type of reflux to affect voice; white scalloping on posterior side (may have continuing hoarseness after tx)

72
Q

Reflux Laryngitis

A

May see mucus banding (point of traumatic impact across larynx)
Mucus secretions: secretions fall over & cause scalloping
Elevating head of bed can help (using more pillows doesn’t work)–wedges that you can sleep on, blocks; medications, etc.

73
Q

Some Causes of Laryngeal Trauma

A

Automobile accidents, gunshot wounds, laryngeal intubation, nasogastric (NG) intubation

74
Q

Focal Trauma

A

Laryngeal intubation & NG intubation
Ask about previous surgery (general anesthesia)—intubation—followup
Any correlations?

75
Q

Laryngeal Intubation

A

Endotracheal tube is too large for Pt’s airway
Mucosal ulceration leads to granuloma
Dislocation of arytenoid cartilage

76
Q

Nasogastric Intubation

A

Damage to posterior cricoarytenoid
Mimic recurrent laryngeal nerve palsy
Cricoarytenoid is abduction of the VFs (damage would be that pt wouldn’t be able to open at least 1 VF); NG tubes are hard to place; if it’s bilateral damage—might have a hard breathing—may end up trached (due to muscle being traumatized, not damage to nerve)

77
Q

Intubation Granuloma Location

A

Vocal process; bilateral or unilateral

78
Q

Intubation Granuloma Etiology

A

Damage resulting from prolonged or faulty intubation to maintain airway (posterior–Something in the back is usually the only site that causes pain—have you had surgery?)

79
Q

Function disorders are what will show up at our office when ____

A

the doctor says there’s nothing wrong (structure looks good)

80
Q

Vocal Abuse

A

Strenuous speaking, yelling/screaming, singing, coughing, throat clearing, velopharyngeal insufficiency
Coughing: “I’ve been coughing for 2 mos”–ask how it started, was there a lot of coughing, throat clearing, etc.

81
Q

Vocal Misuse

A

Incorrect use of pitch or loudness
1. Elevated loudness levels, high background noise, heavy machinery, speaking over loud music, hearing loss
2. Elevated pitch levels, increased loudness leads to increased pitch, emotional stress, excessive muscular tension
Speaking or singing on the wrong pitch
Too loud: hearing loss, coaches, teaching, where they work
Straining with no lesion: elevated pitch
Straining with lesion: lowered pitch

82
Q

Vocal Abuse in Children

A

Hyperadduction of VFs
Inflammation
Vocal nodules
Contact ulcers

83
Q

Nodules in the _____; Contact ulcers in the ____

A

front; back

84
Q

Posterior abnormal contact:

A

lowest pitch possible & glottal fry (produced back by arytenoids & causes them to slam together/rub)—pain also associated with anything posterior b/c of arytenoids

85
Q

Sx’s of Nodules

A

Client comments, vocal fatigue, vocal change, chronic throat clearing, intermittent loss of voice, poor pitch control, deterioration of voice during day, tender strap muscles

86
Q

Exam for Nodules

A

Ask about voice in morning & how it changes throughout the day (gets worse through the day; voice is pretty good in the morning)
More hoarse as the day goes on
“does your neck feel sore?”
Watch for tension in neck

87
Q

Location & Size of Nodules

A

Bilateral (unilateral rare); Juncture of anterior & middle 1/3 of VF
Pinpoint to in excess of 6 mm; can be very small

88
Q

Description of Young Nodules

A

Soft; normal epithelium; pink

Easier to tx

89
Q

Description of Mature Nodules

A

Firm; organized epithelium; whitish to yellow
(long presence—may not respond to voice therapy alone—may need medical management 1st then voice tx; voice may not return to normal right away after medical tx);
Often good to record voice before & after surgery

90
Q

Vocal Rest after Surgery for Nodules

A

Counsel Pt about how to talk after surgery; quiet whisper is the best way to talk after surgery; have to teach this-no stress behind voice; MD will recommend how long; Writing is best, but most won’t do this; Stage whisper is just as abusive as talking–VFs still adducting

91
Q

Full Abduction

A

Cords drawn wide apart in forceful inspiration

92
Q

Quiet Whisper

A

Fold slightly separated along the anterior 2/3s & a triangular aperture remains posteriorly

93
Q

Strong Whisper

A

Folds are adducted firmly along the anterior 2/3s & air is forced through the posterior triangle with considerable friction

94
Q

Contact Ulcers

A

Ulceration of the folds in the arytenoid (posterior) region
Associated with trauma of hammer & anvil b/c arytenoids strike each other in a force type of phonation causing ulceration of the covering of arytenoid region

95
Q

Visual Appearance of Contact Ulcer

A

A raised granuloma on 1 side & a crater on the other side

Pachydermia of the mucous membrane forms

96
Q

Pachydermia

A

Abnormal thickening

Of the mucous membrane in contact ulcers

97
Q

Contact ulcers develop in individuals having ____

A

Deep throaty voices (fry)

In therapy, work on softer production

98
Q

Personality Characteristics & Contact Ulcers

A

Hyperactivity, emotional reactivity, family problems, aggressive/less mature, difficulty managing stressful situations

99
Q

Characteristics of Contact Ulcers

A

Extreme tension of speech musculature coupled w/ generalized body tension
Forcing pitch below optimum
Glottal plosive attack

100
Q

Speech Patterns and Contact Ulcers

A

Explosive Speech Patterns: predominate speech patterns; rigid melody or confined pitch; considerable breath pressure; hoarse quality

101
Q

Contact Ulcers History

A

1961: Von Leden & Moore discovered cartilage performs rocking movement making a wide excursion in low frequencies & a prolonged approximation of surfaces in region of vocal processes which expose them to greater stress

102
Q

Tx of Contact Ulcers

A

Altering fundamental frequency alters the length, thickness, & tilt of VFs so that on adduction shifting parts of stress occur & glottal impact doesn’t always fall in the same region
What am I doing physiologically?—how is tx helping?

103
Q

Polyps Location

A 
Occurs in any vascular organs
Nasal or laryngeal mucosa
Unilateral or bilateral
Polyps are ANTERIOR
Majority are UNILATERAL
Nodules are bilateral; polyps are unilateral; but they occur at the same spot; they look different; their causes are very different
104
Q

Polyps Size

A

Varies from small (6mm) to obstructive

105
Q

Polyps Etiology

A

Airborne irritants (smoking, inhalation of toxic fumes, etc.), idiopathic

106
Q

Polyps Description

A

Soft globular mass exhibiting mucoid degeneration
Pedunculated–with a pedicle or foot
Sessile–having no peduncle, but attached directly by a broad base
If the VFs have been damaged for many years, there will be lots of atrophy—be very clear about expectations—may be able to help some, but probably won’t make it 100% better
Polyps are transparent—can see thru them

107
Q

Vocal Characteristics of Polyps

A

Typically have very deep, gravelly voice
Diplophonia, breathiness, low pitch, intermittent aphonia, hoarseness
VF tone & another tone from the polyp (gonna sound like harmony)
No breathiness-probably isn’t it (because nothing seems to be in the way)

108
Q

Management of Polyps

A

Pretreatment recording & counseling; pretreatment photography
Surgical management
Post-op voice rest; post-op voice therapy
Polyps usually need surgery before therapy-Therapy about eliminating compensatory behaviors developed because of polyps

109
Q

Polypoid Degeneration

A

Whole cords taken over by polyps (probably heavy smokers)

110
Q

Physiologic Voice Disorders May Exhibit ____

A

Diplophonia

111
Q

Diplophonia

A

2 distinct pitches during phonation

112
Q

Etiologies of Diplophonia

A

Unilateral paralysis of true VF
Vibration of ventricular folds (false VFs)
Hyperfunctioning of the vocal mechanism
VFs vibrate at different frequencies
VF pathology
Edema in 1 cord, 1 functioning better than the other

113
Q

Ventricular Phonation

A

Produced by vibration of the false vocal folds
May develop as purely functional or as a substitute voice for true vocal fold pathology
We use the false folds when we cough
May be psychological as well (afraid to damage true VFs)

114
Q

Dysphonia Plicae Ventricularis

A

Ventricular phonation; musculoskeletal tension disorder
Low vs. high pitch
Hoarse
Diplophonia
Great amt of pressure behind using false folds in speech
Don’t use true folds, just false folds—only a little portion of it—smaller surface—high pitch
Low pitch is _____?
Want to eliminate using false folds and bring true folds together for speech

115
Q

How many Forms of Ventricular Phonation?

A

6: Habitual origin, emotional, paralytic, cerebral type, cerebellar type, vicarious function
Some of these you may not want to change

116
Q

Habitual Origin Ventricular Phonation

A

Most frequent & represents the extreme & end stage of hyperkinetic dysphonia due to constant vocal abuse

117
Q

Emotional Ventricular Phonation

A

Occurs during times of stress or a crucial period of a psychoneurotic person; an emotional crisis may precipitate a psychogenic dysphonia by over adduction of the ventricular folds

118
Q

Paralytic Ventricular Phonation

A

Due to paralysis of the true VFs, the ventricular folds take over the function of phonic glottal closure

119
Q

Cerebral Type Ventricular Phonation

A

May be a sign of dysarthria resulting from brain disease; as a sign of spasticity the voice may change to choked, rough, low, & a squeezed sound

120
Q

Cerebellar Type Ventricular Phonation

A

Lesions of the cerebellum may have ataxic, irregular, labored phonation with spasmodic over contraction of the ventricular folds

121
Q

Vicarious Function Ventricular Phonation

A

Desirable compensatory adjustment when the ventricular folds are substituting for defective vocal folds

122
Q

Presbylaryngis

A

A larynx that exhibits significant signs of aging such as: reduced control over phonation, changes in speaking & fundamental frequency, reduced pitch range & deterioration of vocal quality; loudness, resonance, & timing also affected
Have to make sure there is no neuro problem
“Presbylaryngis is a condition that is caused by thinning of the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and therefore do not meet in the midline. As a result, the patient has a hoarse, weak, or breathy voice. This condition can be corrected by injection of fat or other material into both vocal folds to achieve better closure.”

123
Q

Presbyphonia

A

Acoustic properties associated with aging in the absence of other pathology: altered pitch, roughness, breathiness, weakness, hoarseness, tremulousness/instability

Voice (12 decks)

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