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
2
Q
Functional Voice Disorders Examples
A
Functional aphonia, paradoxical VF movement (PVFM), muscle tension dysphonia (MTD), ventricular phonation, traumatic laryngitis, puberphonia
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.)
4
Q
Neurological Voice Disorders Definition
A
Neural innervation problem, anything involving neurology (BG, LMN, etc.; could be periph. Path of CN)
5
Q
Neurological Voice Disorders Examples
A
VF paralysis, spasmodic dysphonia
6
Q
Organic Voice Disorders Definition
A
There is a pathology that has created the voice problem
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
8
Q
Secondary Conditions Causing Voice Disorders
A
PD, ALS, MS, Huntington’s disease (chorea), MG, essential tremor, pseudobulbar palsy, bulbar palsy
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
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
11
Q
Clearance for voice tx from ____
A
ENT
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)
13
Q
Cri du Chat
A
Genetic defect
Discovered in neonates & children
“cry of the cat”
Structural-based problem
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
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
16
Q
Bacterial, Viral, & Fungal Infections:
A
Respiratory Distress Airway Obstruction (Edema)
17
Q
Croup
A
Viral–due to influenza virus
Affects children between 6 mos & 6 yrs of age
Inflammation & edema in the subglottal area
18
Q
Fungal Infections Affecting Voice
A
Fungal Laryngitis, candidiasis, fungal infection secondary to chemotherapy
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
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
21
Q
Coccidomycosis
A
Fungal infection from California’s Central valley
22
Q
Bacterial Infections Affecting Voice
A
Epiglottitis, bacterial laryngitis
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
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.
25
Anterior to mid cord gap & posterior to mid cord chink
pitch will be dropped inflammation; soft intensity due to gaps (leaks); breathy, strained, hoarse
26
Vocal qualities that often go together
Hoarse and breathy
27
Hoarseness
a friction set up at the level of the glottis
| Is it mild, moderate, severe (affects treatment)
28
Viral Infections
May be the common winter cold: VFs are pink and swollen, the voice deep, the secretions thick.
29
Laryngitis Sicca
Laryngeal dryness
No cause or solution has been found
Some have speculated that it is autoimmune
30
Herpes Simplex Virus
Viral infection that may affect the larynx & needs medical attention
2 types: Type I and Type II
31
HSV Type I
Produces most cold sores
| Watery blisters in the skin or mucous membrane
32
HSV Type II
Produces most genital herpes
| Watery blisters in the skin or mucous membrane
33
Viral Croup
Most common form of airway obstruction in children 6 mos to 6 yrs
Respiratory tract infection
34
Viral Croup Causes:
Upper airway obstruction causing: barking cough, hoarse voice, inspiratory stridor, wheezing
Worried about swelling causing obstruction
35
Tx for Viral Croup
Epinephrine
36
Hoarse Vocal Quality
Includes breathiness (hoarse & breathiness)
37
Harsh Vocal Quality
No breathiness
38
Laryngeal Papilloma Location & Size
On & around the VFs (may be all over)
| Wart-like
39
Laryngeal Papilloma Etiology
Uncertain but thought to be viral
40
Laryngeal Papilloma Vocal Sx's
Breathiness, low pitch, tension, aphonia (occasional), hoarseness (bad term)
41
Laryngeal Papilloma Management
Med-surg with associated voice therapy; keep recurring; have to be taken off with a laser
42
Congenital Laryngomalacia
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
43
Other Associated Problems with Congenital Laryngomalacia
Gastroesophageal Reflux
44
Congenital Laryngomalacia Voice Characteristics
Congenital laryngeal stridor described as high pitched harsh & fluttering; becomes worse w/ crying & feeding
Swallow study needed to rule out aspiration pneumonia
45
Fluttering Sound in Congenital Laryngomalacia
From falling in/collapsing of epiglottis; structural issue
46
Congenital Laryngeal Web Location
Generally includes anterior commissure; can extend length of VFs; attachment can be infra & supra glottal as well as cordal
47
Congenital Laryngeal Web Etiology
Congenital: Didn't totally separate during development
Acquired: Anything that damages the larynx: chemicals, tubes, etc.
48
Vocal Sx's: Congenital Laryngeal Web
Elevated pitch, tension, diplophonia, hoarseness
49
Congenital Laryngeal Web Management
Combination of surgery & voice therapy
50
Congenital Subglottal Stenosis
```
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
Hyperfunctional Breathiness
Harshness, Straining (relaxation)
52
Hypofunctional Breathiness
Slow, weakness, not a strong voice (strengthening); can they cough; can they do /i/--/i/--/i/
53
Congenital Laryngotracheal Cleft
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
Congenital cysts are (location) vs. nodules & polyps
Unilateral in mid part of cord
| Nodules & polyps are usually on the edges of the VF
55
Congenital cysts general appearance
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
Nodules are bilateral or unilateral?
Bilateral
57
Pachydermia indicative of ____
Reflux in back of larynx
| interarytenoid space
58
Congenital Laryngocele
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
Sx's/Factors of Congenital Laryngocele
```
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
Tx of Congenital Laryngocele
Medical-->Incision-->drainage
61
Voice/Dysphagia & Congenital Laryngocele
```
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
Space between true & false VFs is in ____ cartilage
Thyroid
63
3 Types of Congenital Laryngocele
I. Internal Type
II External Type
III. Combination Type
64
Internal Type Congenital Laryngocele
Within the thyroid cartilage
65
External Type Congenital Laryngocele
Each protrudes above thyroid cartilage through thyrohyoid membrane
Either above cartilage or through membrane
66
Congenital Hemangioma
Birthmark/"raspberry"
67
Types of laryngeal injuries
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
Hemorrhage
Voice may change due to swelling/differences in vibration (may slow down vibration of VFs)--functional category
Hemorrhagic laryngitis
69
2 types of reflux
GERD & LPR
70
GERD
Gastroesophageal reflux disease
Chronic digestive disease
Stomach acid backflows into esophagus
71
LPR
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
Reflux Laryngitis
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
Some Causes of Laryngeal Trauma
Automobile accidents, gunshot wounds, laryngeal intubation, nasogastric (NG) intubation
74
Focal Trauma
Laryngeal intubation & NG intubation
Ask about previous surgery (general anesthesia)—intubation—followup
Any correlations?
75
Laryngeal Intubation
Endotracheal tube is too large for Pt's airway
Mucosal ulceration leads to granuloma
Dislocation of arytenoid cartilage
76
Nasogastric Intubation
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
Intubation Granuloma Location
Vocal process; bilateral or unilateral
78
Intubation Granuloma Etiology
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
Function disorders are what will show up at our office when ____
the doctor says there's nothing wrong (structure looks good)
80
Vocal Abuse
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
Vocal Misuse
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
Vocal Abuse in Children
Hyperadduction of VFs
Inflammation
Vocal nodules
Contact ulcers
83
Nodules in the _____; Contact ulcers in the ____
front; back
84
Posterior abnormal contact:
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
Sx's of Nodules
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
Exam for Nodules
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
Location & Size of Nodules
Bilateral (unilateral rare); Juncture of anterior & middle 1/3 of VF
Pinpoint to in excess of 6 mm; can be very small
88
Description of Young Nodules
Soft; normal epithelium; pink
| Easier to tx
89
Description of Mature Nodules
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
Vocal Rest after Surgery for Nodules
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
Full Abduction
Cords drawn wide apart in forceful inspiration
92
Quiet Whisper
Fold slightly separated along the anterior 2/3s & a triangular aperture remains posteriorly
93
Strong Whisper
Folds are adducted firmly along the anterior 2/3s & air is forced through the posterior triangle with considerable friction
94
Contact Ulcers
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
Visual Appearance of Contact Ulcer
A raised granuloma on 1 side & a crater on the other side
| Pachydermia of the mucous membrane forms
96
Pachydermia
Abnormal thickening
| Of the mucous membrane in contact ulcers
97
Contact ulcers develop in individuals having ____
Deep throaty voices (fry)
| In therapy, work on softer production
98
Personality Characteristics & Contact Ulcers
Hyperactivity, emotional reactivity, family problems, aggressive/less mature, difficulty managing stressful situations
99
Characteristics of Contact Ulcers
Extreme tension of speech musculature coupled w/ generalized body tension
Forcing pitch below optimum
Glottal plosive attack
100
Speech Patterns and Contact Ulcers
Explosive Speech Patterns: predominate speech patterns; rigid melody or confined pitch; considerable breath pressure; hoarse quality
101
Contact Ulcers History
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
Tx of Contact Ulcers
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
Polyps Location
```
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
Polyps Size
Varies from small (6mm) to obstructive
105
Polyps Etiology
Airborne irritants (smoking, inhalation of toxic fumes, etc.), idiopathic
106
Polyps Description
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
Vocal Characteristics of Polyps
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
Management of Polyps
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
Polypoid Degeneration
Whole cords taken over by polyps (probably heavy smokers)
110
Physiologic Voice Disorders May Exhibit ____
Diplophonia
111
Diplophonia
2 distinct pitches during phonation
112
Etiologies of Diplophonia
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
Ventricular Phonation
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
Dysphonia Plicae Ventricularis
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
How many Forms of Ventricular Phonation?
6: Habitual origin, emotional, paralytic, cerebral type, cerebellar type, vicarious function
Some of these you may not want to change
116
Habitual Origin Ventricular Phonation
Most frequent & represents the extreme & end stage of hyperkinetic dysphonia due to constant vocal abuse
117
Emotional Ventricular Phonation
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
Paralytic Ventricular Phonation
Due to paralysis of the true VFs, the ventricular folds take over the function of phonic glottal closure
119
Cerebral Type Ventricular Phonation
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
Cerebellar Type Ventricular Phonation
Lesions of the cerebellum may have ataxic, irregular, labored phonation with spasmodic over contraction of the ventricular folds
121
Vicarious Function Ventricular Phonation
Desirable compensatory adjustment when the ventricular folds are substituting for defective vocal folds
122
Presbylaryngis
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
Presbyphonia
Acoustic properties associated with aging in the absence of other pathology: altered pitch, roughness, breathiness, weakness, hoarseness, tremulousness/instability
