Neurogenic voice disorders Flashcards
What structures of the central nervous system control the larynx?
- motor cortex
- primary motor strip
- mid-brain
- brain stem
What is the function of Broca’s area?
Voice response (pre-planning)
What is the function of the insula?
Motor planning for voice
What is the function of the precentral gyrus?
voice production
What is the function of the basal ganglia/thalamus?
sensory info for vocalizing (motor)
What is the function of the temporal lobes (Heschyl’s gyrus)?
audition
Name the different structures important for speech/language and their function
- Broca’s area - voice response (pre-planning)
- Insula - Motor planning for voice
- precentral gyrus - voice production
- basal ganglia/thalamus - sensory info for vocalizing (motor)
- Temporal lobes (Heschyl’s gyrus) - audition
Peripheral nervous system includes what nerves?
cranial nerves
What are the cranial nerves important for phonation/voice?
- glossopharyngeal (CN IX)
- -Vagus (X)
- Spinal accessory (XI)
- Hypoglossal (XII)
what is the function of the glossopharyngeal nerve?
innervates stylopharyngeus muscle for motor movement. (elevates larynx)
What is the function of the vagus nerve?
- superior laryngeal nerve (above vocal folds)
- recurrent laryngeal nerve: sensory and motor to larynx, motor to thorax
What is the function of the spinal accessory nerve (XI)?
innervates
neck accessory muscles
levator veli palatini
uvula
What is the function of the hypoglossal (XII) nerve?
innervates tongue muscles to help depress/elevate larynx
innervates neck strap muscles
What are the branches of the vagus nerve?
superior laryngeal nerve
recurrent laryngeal nerve
What does the superior laryngeal nerve innervate?
sensory: (internal branch) mucous membrane supraglottal larynx
Motor: (external branch) innervates cricothyroid muscle
What muscles does the recurrent laryngeall nerve innervate?
Motor:
- thyroarytenoid muscle of vocal folds
- posterior cricoarytenoid muscle (abductor)
- lateral cricoarytenoid muscle (adductor)
- transverse arytenoids (adduction)
- oblique arytenoids (adductors)
- all other laryngeal muscles
The recurrent laryngeal nerve innervates _____ side.
same
Right recurrent laryngeal nerve innervates which vocal fold?
right vocal fold
Left recurrent laryngeal nerve innervates which vocal fold?
left vocal fold
What causes vocal fold paralysis?
damage to the recurrent laryngeal nerve
What is the pathway of the right recurrent laryngeal nerve?
Right recurrent laryngeal nerve loops behind right carotid and right subclavian arteries
What is the pathway of the left recurrent laryngeal nerve?
The left recurrent laryngeal nerve loops around aortic arch
Look at vagus nerve pathway and describe the pathway of the left and right recurrent laryngeal branches
right recurrent laryngeal nerve: female: loops behind the subclavian and common carotid arteries
left recurrent laryngeal nerve: male loops around aortic arch
What are the neurogenic etiologies?
- congenital
- lesions/tumor/disease
- trauma
What is a neurogenic congenital disorder?
Hungtington’s (genetic disposition)
A neurogenic lesion/tumor/disease can cause what?
dysarthria
stroke
cancer
What would be neurogenic trauma?
TBI
Name disorders caused by lesions in lower motor neuron ?
- Vocal fold paralysis
- Myasthenia gravis
- Guillaine-Barre
- Flaccid dysarthria
Flaccidity means:
weakness
reduced muscle contraction
reduced range of motion
Describe laryngeal function of flaccid dysarthria?
- weak vocal folds
- fibrillations
- atrophy
- fasciculations
- low tone (hypotonic)
What is the number one sign of flaccid dysarthria?
hypernasality
What are the voice qualities of flaccid dysarthria?
- Phonatory incompetence: breathy voice, audible inspiration and short phrases
- Resonatory incompetence: hypernasality, nasal emission, imprecise consonants, short phrases
- Phonatory - Prosodic insufficiency: harsh voice, monpitch, monoloudness
Vocal fold paralysis is due to what?
Unilateral lesion to the recurrent laryngeal nerve
The majority cases resulting in unilateral vocal fold paralysis are of what type?
Adductor type: paralyzed vocal fold cannot adduct or help with closing the glottal space.
Speech pathologist often see what kind of lower motor neuron disorder?
Vocal fold paralysis
What do you need to check for with a patient who has vocal fold paralysis?
Make sure they don’t have swallowing problems since vocal fold can’t come mid-line to help close glottis.
What factors into the highly variable presentation of unilateral vocal fold paralysis?
- location of paralyzed fold relative to the non-paralyzed fold.
- compensatory strategies to help close off the glottal space
What is the voice quality of vocal fold paralysis?-
breathiness
hoarseness
Surgery-knit scratched can damage what?
recurrent laryngeal nerve
What causes myasthenia gravis?
Reductions in the peripheral nervous system neurotransmitter, acetylcholine, via an autoimmune mechanism, resulting in severe decline in a muscle’s ability to contract.
What are the symptoms of myasthenia gravis?
- sound prolongations means muscle weakness increases
- dysphonia, weak and breathy
- inspiratory stridor
- reduced vocal loudness
- monotone voice
- hypernasality
- hoarseness
- tremor
What happens in Guillian Barre?
Voice problems result in speech issues.
Body attacks itself: nerve to muscle transmission is not happening
-Cerebral spinal fluid diagnosis
-slurring words (Bell’s palsy)
What causes spastic dysarthria?
Bilateral damge to the upper motor neuron system
What are the voice qualities of a patient with spastic dysarthria?
- spasticity
- hypernasality
- straing/strangle
- short phonation time
- monopitch/monoloudness
- harshness
Never sit ______ a patient with spastic dysarthria.
across
What is the laryngeal function of patients with spastic dysarthria?
- hypertonicity: excessive muscle tone
- reduced range of motion
- hyperactive reflexes
- vocal fold spasms
Name neurogenic disorders with upper motor neuron involvement.
- spastic dysarthria
- hypokinetic/hyperkinetic dysarthira
- mixed dysarthria
- ataxic dysarthria
What causes hypokinetic dysarthria?
Damage to the basal ganglia control circuit (UMN involvement)
- There is a loss of dopamine which is produced in basal ganglia
- muscle starts to lose nerve muscle transmission
What are the voice qualities of patients with hypokinetic dysarthria?
- reduced vocal intensity
- breathy voice quality
- inability to vary vocal pitch
- reduced phonation duration
- reduced intelligibility
- tremor in the voice
What is the laryngeal function of a patient with hypokinetic dysarthria?
- rigidity
- bradykenisia
- limited ROM
- resting tremor
The muscles in ______ disease can be trained as opposed to the muscles with an _____ disorder.
Parkinson’s
ALS
What disease is associated with hypokinetic dysarthria?
Parkinson’s disease
______ of vocal folds happens in Parkinson’s disorder because muscle atrophies, can’t keep tone
bowing
Why does bowing of vocal folds occur in Parkinson’s disease?
Because muscle atrophies, can’t keep tone
What happens with bowing of the vocal folds in parkinson’s disorder?
- There is a gap between vocal folds
- Prevents vocal folds from closing completely and from vibrating normally.
Parkinson’s disease affects what systems?
Phonatory and respiratory
What are the symptoms of Parkinson’s disease?
- affects posture
- reduced loudness/reduced intensity
- short phonation time
- laryngeal tremor
- breathy
What causes hyperkinetic dysarthria?
Any damage to the basal ganglia control circuit or portions of the cerebellar control circuit
What are other disorders associated with hyperkinetic dysarthria?
- neurogenic: spasmodic dysphonia
- essential tremor
- (Chorea) Huntington’s disease
What is spasmodic dysphonia?
Neurogenic voice disorder caused by irregular and uncontrollable spasms within muscles controlling the opening and closing the vocal folds.
What are the symptoms of hyperkinetic dysarthria
- uncontrolled movements
- strain/strangle
- excess loudness
- pitch control
What causes ataxic dysarthria?
Damage to the cerebellum or cerebellar control circuit (UMN involvement)
A person with ataxic dysarthria has ____ speech hence sounds
______.
slurred
drunk
What are the symptoms of ataxic dysarthria?
- prosodic slowdown
- resonance changes
- inarticulation “intoxicated”
What happens to the vocal folds in ataxic dysarthria?
There is in-coordination of vocal folds, not moving symmetrically.
What is usually the cause of death for patients with Parkinson’s Disease?
Aspiration/pneumonia because vocal folds stop coming together when they swallow. Liquids water get into lungs causing bacteria to grow.
Parkinson’s is a _____ _____ disease.
progressive degenerative
_______ disease can recover.
Parkinson’s
_____ doesn’t recover.
ALS
Why does a patient with ALS does not recover?
Weakness of respiratory muscles, failure to breathe
Akinesias are present in what type of dysarthria?
Hypokinetic dysarthria
What is the origin of spasmodic dysphonia?
-UMN neurogenic
What is the origin of muscle tension dysphonia/functional dysphonia?
Functional
If you can laugh or yawn there is no muscle tension which means ______ ________.
normal voicing
What is the most common mixed dysarthria?
Spastic-flaccid
What causes multiple sclerosis?
Myelin sheath degeneration
What diseases can have mixed dysarthria?
ALS
Multiple sclerosis
TBI
What causes ALS?
Damage to the UMN and LMN: it attacks the neurons responsible for voluntary muscle contraction.
What are the voice characteristics for a patient with ALS?-
- weak voice
- hoarseness
- roughness
- strained voice
- hypernasality
- decreased speech intelligibility
- slow rate of speech
What happens to the vocal folds in ALS?
Incomplete vocal fold closure
What kind of dysarthria results of ALS?
Mixed dysarthria
flaccid-spastic
-spastic-flaccid
What are the voice qualities of MS?
- abnormally long pauses between words or individual syllables of words
- hypernasal
- difficulty raising the vocal loudness due to the inability to generate sufficient expiratory muscle force
- weak phonation, harshness
- disturbances of respiratory cycle
What are the visual features of multiple sclerosis?
- reduced vocal fold closure
- weakened laryngeal muscles
What voice qualities result from a TBI?
hoarseness
inspiratory and expiratory stridor
What type of dysarthrias are associated with MS?
Ataxic
Mixed
