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CETP > Section 7 > Flashcards

Section 7 Flashcards

1
Q

Name the internal muscles of the larynx and their function.

A

Cricothyroid: increases vocal pitch as a results of tightened vocal fold
Posterior cricoarytenoid: moves VF out of the airway, stopping sounds
Lateral cricoarytenoid: moves VF into the airway, voicing posture
Transverse arytenoid: adducts VF
Oblique arytenoid: adducts VF
Thyroarytenoid: makes up VF, can change in shape and length

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2
Q

What are transient utterances?

A

Produced at level of larynx in the form of a sudden explosive burst
Produces glottal stop-plosive similar to the downstream production of
the voiceless stop-plosive consonants
Involves initial blockage of laryngeal airstream by full adduction of vocal folds. Air pressure builds up within tracheal space before being
released.
Example would be “uh-oh”

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3
Q

What are sustained utterances?

A

Two types: turbulent noise production and voice production
Turbulent noise production: air flowing from breathing apparatus encountering constrictions within laryngeal airway. Constrictions cause
air to flow turbulently and produce a broad range of frequencies. /h/ is one example, as is whispering
Voice production: results from vibration of vocal folds. Vibration modulates the airstream into air “puffs”, resulting from closing and
opening of the laryngeal airway. Repeated, sudden decreases in airflow are what acoustically excite the upper airway during voice
production

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4
Q

Describe the movements of vocal folds

A

Close from bottom to top and front to back simultaneously
Vocal folds move towards the midline
Subglottal air pressure builds and blows VF apart
Muscle recoil (elasticity) and Bernoulli Effect (increase in velocity decreases pressure between the VF and sucks them back together again) creates vibration

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5
Q

What are the pitch ranges for men and women?

A

Female Average: 137-832 Hz (695 Hz)

Male Average: 82-507 Hz (425 Hz)

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6
Q

What are the fundamental frequencies for men and women?

A

Adult Males: 125 Hz
Adult Females: 225 Hz
Children vary, 250-300 Hz, decreasing with age

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7
Q

What is the normal levels of jitter and shimmer in voice?

A

Jitter (variability of FF):
Males - Younger: 30.8, Older: 39.8
Females - Younger: 15.1, Older: 23.8
Shimmer (variability of intensity of vocal emission):
Males - Younger: 0.24 dB, Older: 0.37 dB
Females - Younger: 0.21 dB, Older: 0.25 dB

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8
Q

What is a voice disorder?

A

Cccurs when voice quality, pitch, and loudness differ or are inappropriate for an
individual’s age, gender, cultural background, or geographic location. Present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not
perceive it as different or deviant.

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9
Q

What are the three causes of voice disorders?

A

Organic: dysphonia caused by underlying structural or neurogenic disease/disorder/ impairment
- structural: result from physical changes in the voice mechanism
- Neurogenic: problems in the CNS or PNS innervation that affects vocal folds
Functional: result from improper or inefficient use of the voice mechanism when the structure is normal
Psychogenic: psychological stressors lead to habitual, maladaptive aphonia, or dysphonia

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10
Q

Name some structural voice disorders.

A

Vocal fold abnormalities: nodules, edema, stenosis, sarcopenia
Laryngeal inflammation
Trauma to the larynx
Hearing loss: can develop a flat tone or lack inflection
Removal of larynx

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11
Q

Name some neurologic-based voice disorders.

A

Recurrent laryngeal nerve paralysis
Adductors/abductor/mixed spasmodic dysphonia
Parkinson’s disease: damage tot eh substantia nigra causes motor difficulties
Multiple sclerosis: episodes of dysfunction in the nervous system result in hoarseness and poor control of volume/pitch

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12
Q

What are some functional causes of voice disorders?

A

Phonotrauma: yelling, screaming, throat-clearing
Muscle tension dysphonia
Ventricular phonation: ventricular folds compress and squeeze over the true vocal folds
Vocal fatigue

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13
Q

Name some psychogenic causes of voice disorders.

A

Chronic stress disorders: could lead to muscle tension dysphonia
Anxiety
Depression
Conversion reaction

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14
Q

Name the different means fo alaryngeal speech.

A

Electroarynx
Esophageal speech
TEP

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15
Q

Describe the electrolarynx

A

Requires use of hands
Is placed under neck, and button is pushed to produce
vibration that is transferred through the skin to the throat
Can be used immediately after surgery with an oral
adapter (if the neck is too tender after surgery)
Characteristics: voice sounds robotic/mechanical

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16
Q

Describe esophageal speech.

A

Difficult to learn (requires practice)
Involves inhaling air into the upper esophagus and using
air pressure in the esophagus to produce vibrations for
speech.
Air is taken in through the mouth, down to the esophagus. The tongue is placed against the roof of the mouth to hold the air down.
Can’t be initiated until pt is on regular diet
Contraindications: dysarthria, surgery involving reconstruction of pharynx/ esophagus, lack of availability of esophageal speech training
Characteristics: Quieter and more strained than laryngeal
speech, Fewer words can be
produced in one breath, Low pitch (between
50-100 Hz)

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17
Q

Describe TEP

A

Requires pt to occlude an opening that is surgically made between the trachea and esophagus. A small valve fits into the opening.
Pt’s cover their stoma with a finger, forcing air through the valve, prodigy sound by making the walls of the throat vibrate
Contraindications: esophagectomy or extensive tracheal resection, severe esophageal dysmotility, poor cognition, decreased motor or visual ability making function/cleaning difficult

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18
Q

Name some psychosocial and educational/vocational impacts of voice disorders.

A

Psychosocial: Increased risk of depression, anxiety, and/or somatic concerns
Perceived stress may be elevated in female pt’s
Pt’s may be self-conscious and/or embarrassed about voice
Pt’s may feel unclear about their prognosis, and the unpredictability of their voice/future

Educational/vocational:
May require pt to take time off work/school
Depending on vocation/ lifestyle, work/education may be contributing to
voice disorder (e.g. environment, demands on voice etc)
May impact singing, ability of people to understanding pt, threat to occupation (e.g. singers, call centre, teachers etc.), increased fatigue/effort

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19
Q

What may be included in a screening for a voice disorder?

A

Evaluation of voice characteristics related to respiration, phonation, and resonance as well as vocal range and flexibility (eg. pitch, loudness, range, and endurance)

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20
Q

What might be important in a case history for a voice disorder?

A

History and description of symptoms (e.g. onset and variability)
Relevant background information (work, education, demands on voice in daily life etc)
Relevant medical diagnoses/ history
Previous voice treatment, including strategies used and/or professionals
seen
Daily habits related to vocal hygiene
Goals for speech therapy

21
Q

What might be looked at in a auditory perceptual assessment?

A 
Subjective Assessment based on clinical impressions of SLP
Voice Quality
Resonance
Phonation
Rate
22
Q

What might be assessed regarding voice quality?

A

Consensus features assessed during production of sustained vowels, sentences, and running speech
Roughness—perceived irregularity in voicing source
Breathiness—audible air escape in voice
Strain—perception of excessive vocal effort
Pitch (perceptual correlate of fundamental frequency)—deviations from
normal relative to age, gender, and referent culture
Loudness (perceptual correlate of sound intensity)—deviations from normal
relative to age, gender, and referent culture
Overall severity—global, integrated impression of voice deviance
Additional perceptual features
Diplophonia, aphonia, pitch instability, tremor, vocal fry, falsetto, wet/gurgly

23
Q

What might be assessed regarding resonance?

A

Assess resonance quality (normal, hyponasal, hypernasal, cul-de-sac).
If abnormal, assess stimulability for normal resonance.
If normal, evaluate the focus of resonance (oral, pharyngeal/ laryngeal, nasal).

24
Q

What might be assessed regarding phonation?

A

Voice onset/offset (e.g., delayed voice onset; quality of voice at onset)
Ability to sustain the voice to achieve appropriate phrasing during speaking
Ability to demonstrate strong and consistent rate of vocal fold valving during
diadochokinesis

25
Q

What might be assessed in regards to rate?

A

Deviations from normal relative to age, gender, and referent culture

26
Q

Name some instrumental voice assessments.

A

Laryngeal imaging
Acoustic assessments
Aerodynamic assessments

27
Q

Name some laryngeal imaging techniques.

A

Videolaryngoendoscopy: Visualizes vocal fold edges, focal fold mobility, and supraglottic activity
Videolaryngostroboscopy: Visualizes regularity, amplitude, mucosal wave, left/right phase
symmetry, vertical level (level difference in vertical plane between vocal folds during maximum closed phase of glottic cycle), glottal closure pattern, and glottal closure duration

28
Q

Name some acoustic voice assessments.

A

Vocal amplitude:

  • Sound pressure level (SPL) in decibels (dB)- e.g. typical sound level of voice in connected speech
  • Minimum and maximum vocal SPL- softest/loudest phonation

Vocal frequency:

  • Mean f0 (Hz)
  • Vocal f0 standard deviation
  • Minimum and maximum f0

Vocal signal quality:
- Relative amplitude (vocal cepstral peak prominence)- measured during sustained vowels and connected speech samples

29
Q

What are some aerodynamic assessments?

A

Glottal airflow: average estimated from oral airflow rate during vowel production
Subglottal air pressure: Average estimated for intraoral air pressure produced during repetition of stops
Mean vocal SPL and f0

30
Q

What are some possible competents of a voice assessment?

A 
Screening
Case history
Oral Mech
Self-assessment
Assessment of respiration
Auditory-perceptual assessment
Instrumental assessment
31
Q

What might be looked at in a respiration assessment?

A

Respiratory pattern (abdominal, thoracic, clavicular)
Coordination of respiration with phonation (breath-holding patterns, habitual
use of residual air, length of breath groups)
Maximum phonation time
s/z ratio to assess for glottal insufficiency, which may be indicative of laryngeal pathology

32
Q

What are some advantages and disadvantages of an electrolarynx?

A

Advantages: use immediately post surgery, easy to learn
Disadvantages: mechanical sound, expensive

33
Q

What are some advantages and disadvantages of an esophageal speech?

A

Pro: no cost, more natural sounding
Con: hard to learn, tension and stress can impede speech

34
Q

What are some advantages and disadvantages of TEP?

A

Pro: quick and easy to learn, more natural sounding
Con: not everyone will be a candidate, needs to be cleaned and cared for daily

35
Q

What are some indirect voice intervention strategies?

A

Vocal Hygiene/Patient Education/Behavioural Modifications:
- Importance of hydration, addressing patient’s hydration (how much H2O in a day, caffeine, alcohol)
- Effect of irritants on the voice mechanism (reflux, smoke, environmental, etc)
- Educate patient on how the voice works → discuss helpful vs harmful voice use
- Identifying vocal misuses and discuss remediations, eg., habitual throat clearing, frequent yelling (Peds: vocal abuse - loud phonation, imitation of animals and machine noises, hard glottal
stops, coughing, yelling across a distance, etc, If patient is a singer, observe and assess both speaking and singing technique)
- Address any underlying/ related health conditions that might be affecting voice
- Discuss opportunities for voice rest/conservation
- Voice rest = complete silence (Not needed for nodules, polyps, fatigue, No throat clearing, coughing, whispering)
- Voice conservation = thoughtful voice use
- Compensatory strategies = voice amplification

36
Q

What are some direct voice therapies?

A 
Respiratory training/ abdonminal breathing
Resonant voice therapy
Semi-occluded vocal tract
Vocal function exercises
Manual therapy/massage
Stretch and flow
Lee silverman voice treatment
37
Q

Describe respiratory training/abdonaminal breathing.

A

For hyper- and hypo- functional voice disorders
3 part vocal system = respiratory-phonatory-resonating
Respiration = power source
Changing the way they breathe
Promote diaphragmatic breathing

38
Q

Describe resonant voice therapy.

A

Description: voice has forward focus → voice should feel easy and should feel vibration in face
- Important to increasing glottic closure, decrease nodules, project voice, decrease hoarseness in voice
Theory: vocal tract postures achieved with /m/ and other “resonant” or “forward focused” sounds tend to produce light VF contact (therefore limiting contact stress), and requires least amount of lung pressures to vibrate VFs
Pros: Resonant voice is relatively strong, clear voice which appears to provide some protection from injury and is easy to produce
Cons:
- Can be difficult for some clients to grasp
- Some clients will physically “push” to achieve forward focus, which may worsen tension/voice quality

39
Q

Describe SOVT.

A

Description: narrowing or partial occlusion at the mouth (“oo”, straw phonation, lip trills, fist at
mouth, cup with water)
Theory: stretches and spreads VFs, therefore results in less stress and impact on VFs
- When narrowing the end of the vocal tract, create back pressure so air pressure and acoustic pressure is coming forward and bounces off partially closed vocal tract. Back pressure helps with vibration, requiring less physical effort from larynx
Pros: Easy, portable, very effective as a warm up and cool down or for vocal breaks during the day
Cons: straw is very useful but cannot be connected to speech → one workaround is to speak/sing into a cup with a hole in the bottom, a closed fist, or a mask with a hole in it

40
Q

Describe vocal function exercises.

A

Use: vocal fold paralysis + paresis; normal voice (preventative and habilitative)
Description: Series of systematic vocal manipulations designed to strengthen and balance the laryngeal musculature
Theory: Practice on maximal prolongations should improve strength and endurance of VF muscles and the coordination of respiration and phonation. By performing pitch glides to high and low pitches, the cricothyroid and VF muscles should be lengthened and shortened, inducing flexibility and strength
Pros: for hypofunctional voice
Cons: requires (consistent) practice, by-in, patients not understanding benefits

41
Q

What are some exercises used in vocal function exercises?

A
  1. Warm up → sustained “eee”
  2. Stretching exercise → glide from lowest note to highest note on the word “knoll”
    - Goal: no voice breaks
  3. Contracting exercise → glide from highest note to lowest note on the word “knoll”
    - Goal: no voice breaks
  4. Power exercise → sustain the musical notes (C-D-E-F-G) for as long as possible on the word “old” without the /d/
42
Q

Describe manual therapy/massage.

A

Any type of physical manipulation or touch to neck/laryngeal area
Use: for patients 1º or 2º MTD
Theory: draws attention to excess tension, reduced tension, rebalances (para)laryngeal muscles
Pros: passive for the patients, many patients enjoy it
Cons: requires specific training, some patients may not like having their neck touched
Types:
1. Digital laryngeal manipulation
2. Circumlaryngeal Massage
3. Manual Therapy

43
Q

Describe digital laryngeal manipulation.

A

Interferes with habituated patterns of muscle imbalance
Observe effects on voice with each manoeuvre → shape moments of improved voice with digital/ tactile cueing, and slowly fade tactile cues
a) Push back manoeuvre → should hear pitch change
b) Pull down manoeuvre → prevents laryngeal elevation
c) Medial compression and downward traction

44
Q

Describe circumlaryngeal massage.

A

Pressure applied in a circular fashion over tips of hyoid bone and within thyrohyoid space. As
patient vocalizes, the procedure is repeated over posterior borders of thyroid cartilage and larynx
pulled downward

45
Q

Describe manual therapy.

A

Applying gentle + sustained pressure into the connective tissue to eliminate pain + improve ROM
Engage patient in dialogue to get constant feedback
Requires specific training

46
Q

Describe stretch and flow.

A

Description: “a structured physiological voice intervention characterized by a hierarchy of progressively challenging vocal tasks designed to rebalance the respiratory, phonatory, and
resonatory subsystems of voice prod’n”
- Trains patients not to hold breath as they talk
Theory: “initiate volitional control over vocal subsystems, using voiced + unvoiced airflow stimuli, while maintaining a perception of minimal muscular effort during phonation”
Pros: easy to complete
Cons: have to follow the hierarchical, requires consistent practice

47
Q

Describe LVST.

A

Description: Intensive, repeated practice speaking louder with feedback (visual feedback from sound-level meter)
Theory: loud voice generates improved respiratory support, articulation, and even facial expression + animation
Pros: very effective, highly studied
Cons: heavy work load for patients; unrealistic for someone, SLP needs to be certified, structured process

48
Q

What are the 5 components of LSVT?

A

Think loud, think shout
Speech effort must be high
Tx must be intensive (4 days/wk + daily at-home practice for 4 weeks)
Pts must recalibrate their loudness level
Improvements quantified over time

49
Q

What are interventions for neurological voice disorders?

A

Often compensatory in nature, use of AAC (early in progressive diseases)
Tx will often focus on compensatory strategies to improve intelligibility (same approach as motor speech)
Slow speech rate, shorten breath groups if resp support is compromised, exaggerated arctic, repetition, awareness of message breakdown
Spasmodic dysphonia → botox, some voice tx may help (easy/soft onset for ADSD), address excess tension if present; breath support for voicing)
ALS → voice banking early
- Some research indicates benefit from EMST in PD + ALS

CETP (12 decks)

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