VOICE Flashcards
voice
sound produced by the larynx & modified by the vocal tract
phonation
expiration of air through vibrating vocal folds
what is a voice disorder
abnormal voice quality resulting from anatomic, physiologic, or psychogenic causes
voice that draws attention to itself/doesn’t align w/ one’s gender identity/age
dysphonia
abnormal voice or voice problem
sometimes colloquially described as hoarseness
aphonia
no voice
voice disorders incidence
~30% of people will experience at some point in their lives
voice disorders prevalence
8% of adults currently report voice difficulties
only about 10% of them will seek treatment
voice disorders prevalence in children
1.4-6%
risk factors for voice disorders
longer NICU stays
females (adults)
males (kids)
aging
alc & smoking
reflux
dehydration
phonotrauma
prolonged intubation
high vocal demands
illness (upper respiratory infection)
surgery (to head or neck)
trauma to head or neck
neurological conditions
populations at risk
teachers
singers
atorneys
telemarketers
service & industry workers
manufacturing workers
voice disorders consequences
missed days at work / school
lower productivity at work / participation in school
anxiety & depression
functions of the larynx
airway protection
allows us to breathe
swallowing assistance
phonation
thoracic function
swallowing assistance
laryngeal movement upward & forward propels food back into esophagus
pulls upper esophagus open
respiratory valve
oxygen in, carbon dioxide out
airway protection
adduction of vocal folds & ventricular folds
& closure of epiglottis against arytenoids & aryepiglottic folds
during swallong
coughing, throat clearing
abdominal (thoracic) fixation
adduction of vocal folds effectively fixes air in abdomen
gives firm foundation to push/pull
communicative functions of the larynx
carry linguistic info & affective info about the speaker
suprasegmental phonation
prosody:
stress, intonation, rhythm
Is the hyoid bone part of the larynx
considered part of laryngeal framework but not technically part of larynx
what is the hyoid bone important for
suspension point for larynx
important site for the muscular attachments of the larynx via the suprahyoid & infrahyoid muscles
cricothyroid joints
will stretch or relax the vocal folds when acted upon by intrinsic laryngeal muscles
cricoarytenoid joints
rock of arytenoids (vocal processes move down & inward or up & outward)
sliding of arytenoids (anterio-posterior movement)
thyroid connection points
cricoid
vocal folds
thyroid relationship to vocal folds
attaches to front of vocal folds
thyroid landmarks
laryngeal prominence
superior & inferior cornu
lamina
angle
cricoid connection points
thyroid
1st tracheal ring
arytenoids
cricoid relationship to vocal folds
below
cricoid landmarks
facets
arch
lamina
epiglottis connection points
thyroid
base of tongue
epiglottis relationship to vocal folds
above
epiglottis landmarks
body
lingual surface
petiolus
arytenoids connections points
cricoid
arytenoids relationship to vocal folds
vocal process attaches to vocal folds & opens/closes them
arytenoids lanmarks
vocal process
muscular process
apex
corniculate / cuneiform connection points
arytenoid
corniculate / cuneiform relationship to vocal folds
above
corniculate / cuneiform landmarks
on top of arytenoids
laryngomalacia
cartilages too soft
flapping into airway
glottis
space between vocal folds
cricothyroid joints
stretch & relax vocal folds
cricoarytenoid joints
rocking & sliding of arytenoids
rocking of arytenoids
vocal processes rotate medially & laterally
sliding of arytenoids
anterior-posterior movement of carilage
ventricular folds
false vocal folds
extend from laryngeal cavity’s side walls into airway
ventricular folds attachments
thyroid anteriorly
arytenoids posteriorly
ventricular folds in relation to vocal folds
superior (?)
thyroarytenoid function
shortens, thickens, adducts (CLOSES), & tenses vocal fold body
relaxes vocal fold cover
thyroarytenoid location
inside vocal fold
main mass of vocal folds
aka vocal fold body
posterior cricoarytenoid location
back of cricoid to muscular process of arytenoid
PCA function
abducts (OPENS) vocal folds
lateral cricocarytenoid location
cricoid upper rim to muscular process of arytenoid
LCA function
rocks arytenoids forward & medially to adduct (CLOSE) membranous vocal folds
cricothyroid function
tenses, thins, & lengthens vocal folds by rotation or sliding
transverse interarytnoids location
back surface of 1 arytenoid to back of another
transverse interarytenoids function
pulls arytenoids towards one another
adducts cartilaginous vocal folds (back portion)
oblique interarytenoids location
above transverse interaytenoid
arytenoids muscular process –> apex of another
some muscle fibers extend around side of epiglottis to form aryepiglottic muscle
oblique IA function
tips arytenoids toward each other to adduct (CLOSE) cartilaginous vocal folds
oblique IA / aryepiglottic muscle function
pulls epiglottis back & down to cover laryngeal opening
recurrent laryngeal nerve
motor to all intrinsic muscles except to CT
sensory to subglottic region
superior laryngeal nerve external branch
motor to CT
superior laryngeal nerve internal branch
sensory to supraglottic region
upward movement of larynx
epiglottic inversion & propels food to esophagus vs trachea
higher vocal pitch (tense vf & make them thinner)
downward movement of larynx
lower vocal pitch (relax vf & make them thicker)
forward movement of larynx
opens esophagus for food to enter
supra hyoid muscles function
elevate larynx
infrahyoid muscles function
depress larynx
phonation
vocal fold vibration
what muscles are NOT involved in phonation
aBductory (OPEN) muscles
myoelastic aerodynamic theory - myo
muscles adduct vfs
establish levels of tension & elasticity
myoelastic aerodynamic theory - elasticity
allows vfs to come apart & return in each cycle
myoelastic aerodynamic theory - aeirdynamic
subglottic pressure form the lungs drives vibration
myoelastic aerodynamic theory - physical
forces set the vocal folds into motion in each cycle
vibratory cycle
vfs adduct via adductory muscles
subglottic pressure builds & pushes vfs apart, bottom up
elasticity of vfs & Bernoulli effect brings vfs back together
Bernoulli effect
air flow through small passage, increases velocity
increased velocity = decreased pressure
pressure drop sucks vfs back together
vf layers
epithelium
lamina propria - superficial, intermediate, deep
muscle - thyroarytenoid
what happens as you move deeper through the tissues
they become stiffer / less elastic
which layers are most important for vf vibration
top 2
epithelium & superficial lamina propria
aka cover
do the body & cover of the vf vibrate the same
no
vocal ligament
intermediate & deep lamina propria
needs to be able to stretch w/out breaking
restricts separation of arytenoids & thyroid
fundamental frequency
rate at which vfs vibrate
measured in cycles / second
Hz
male vf
125 Hz fund freq
longer & thicker
more mass –> less vf vibration / sec
female vf
250 Hz fund freq
shorter & thinner
less mass –> more vf vibration / sec
how do we change fund freq (pitch)
the greater the stiffness of vfs –> the faster they vibrate –> the higher the fund freq of the voice
what muscle facilitates higher pitch
cricothyroid
increases vf length & stiffness of body & cover
decreases thickness
what muscle facilitates lower pitch
thyroarytenoid
increases stiffness of muscular portion of vf
while slackening non-muscular vf cover
increases thickness
secondary way to increase fund freq
elevation of larynx
using suprahyoid muscles
increases vf stiffness by pulling downward on vfs
or:
increase subglottic pressure
how to decrease fund freq
decrease vf stiffness
- contract TA
- relax CT
- lower larynx (infrahyoid muscles)
decrease subglottic pressure
intensity
measure of sound’s physical magnitude
dB
loudness
how do we increase intensity
tight vf closure –> builds subglottic pressure
big breath
create space in mouth –> allow sound to travel into space
amplitude
distance vfs separate during phonation
what does it mean when vfs separate very far
more abrupt vf movement to midline
faster airflow decline`
what does higher intensity look like on a glottogram
higher peak = vfs came apart further –> come back together harder
longer closed phase –> to build subglottic pressure
monoloudness
lack of normal variation in intensity
loudness variations
extreme variations in intensity
vocal quality
sound of the voice beyond pitch & loudness
influenced by source & filter
vocal folds
breathy, strain, rougness
resonance
happens above the vocal folds
pharynx, oral, & nasal cavity
huge aspect of quality
voice registers
similar voice quality produced across range of pitches via specific pattern of vf vibration
pulse = low pitch
modal = medium, conversational register
loft/falsetto = high pitch
T/F - the larynx sits lower in the neck in adults than children
true
T/F - the layer structure of the vfs is fully formed at birth
false
where is the cricoid in infant larynx
C3-C4
where are adults cricoid
C7
thyroid & hyoid placement at birth
on top of each other w/ little space between them
gradual separation
implications of softer laryngeal cartilage in infants
less susceptible to blunt force trauma
more susceptible to airway invasion
harden w/ age
when do babies develop layered structure of vfs
4 years
affects what they can do w/ their voices –> ex: tone stability
how do the laryngeal cartilages age
cartilages become stiff & turn to bone
epiglottis & arytenoids become hard
joints become eroded & sometimes deformed – can affect movement
how do vfs age
changes in layer structure
muscle atrophy
decreased elasticity
does laryngeal aging happen earlier in males or females
males by about a decade
older men have higher or lower fund freq than younger men
higher
muscle atrophy, LP thinning, loss of mass ==> faster vf vibration
older women have higher or lower fund freq than younger women
lower
edema ==> slower vf vibration
signs
observable &/or measurable features of voice problem
symptoms
patient experience of voice problem
types of voice disorders
(organic)
structural
neuro-motor / neurological
functional
types of treatment for voice disorders
indirect voice therapy / vocal hygiene (habit / lifestyle changes)
direct voice therapy
phonosurgery
hearing testing / intervention
medications
counseling
etiological factors
phonotrauma
poor vocal hygiene
nerve famage
age related
neurological disease
muscular imbalances
hypofunction
too loose
vocal fold muscles don’t close vfs enough during voicing
breathiness, hoarseness, aphonia
hyperfunction
too tight
vfs &/or ventricular fold muscles are overly tense
compress or stretch vfs too tightly during voicing
too loud, too high, too strained
presbyphonia
normal voice changes related to aging (65+)
reduced respiratory efficiency
loss of elasticity in cover
less muscle in TA
ossification of cartilage
presbyphonia auditory perception
thin & muffled
decreased loudness
breathy
instable pitch
lack of vocal endurance
presbyphonia treatment
voice therapy
phonosurgery
what is the most at risk pop for nodes
pre pubescent children & adult women
higher voice = higher fund freq = vfs hitting each other more often
can nodes be unilateral
no
always bilateral
nodes signs / symptoms
frequent voice loss
vocal fatigue
voice changes w/ use
vocal effort
rough, hoarse
breathy
strain
nodes managment / treatment
behavioral voice therapy + vocal hygiene
phonosurgery not necessary & has risks
vf scar
permanent tissue changes in cellular structure of the lamina propria
prevents regular wave like motion of cover
vf scar cause
intubation
surgery
trauma
voice use
radiation therapy
vf scar signs / symptoms
mild to severe reductions in vocal quality
increased vocal fatigue & effort
voice breaks
vf scar management / treatment
phonosurgery & voice therapy can help but won’t fix
reinke’s edema / polypoid degeneration
buildup of fluid in the superficial layer
reinke’s edema cause
cig smoke
sometimes hormonal –> post menopausal
reinke’s edema signs / symptoms
low pitch & roughness
misgendered on phone
vocal fatigue w/ use
swelling
reinke’s edema treatment
quit smoking
vocal hygiene
phonosurgery / voice therapy
laryngitis
inflammatory condition of vf cover
laryngitis cause
reaction to a viral &/or bacterial infection
voice overuse
laryngitis signs / symptoms
aphonia
rough, breathy
laryngitis treatment
rest
hydration
antibiotics
laryngeal papillomatosis
caused by exposure to HPV
wart growths on vfs
laryngeal papillomatosis signs / symptoms
reduced vocal quality
vocal effort
vocal fatigue
breathing difficulties
laryngeal papillomatosis managment
requires multiple, frequent surgeries –> can lead to vf scar
voice therapy
laryngeal cancer
normal tissues divides & grows uncontrollably
may spread to adjacent structures
laryngeal cancer cause
smoking & heavy drinking
HPV
laryngeal cancer signs / symptoms
hoarseness
change in pitch –> typically lower
vocal strain
sore throat
persistent cough
noisy breathing
swallowing problems
laryngeal cancer management
combined modality (surgery, radiation, chemo)
continued surveillance
SLP
muscle tension dysphonia
increased muscle activity in head & neck
can be secondary to other voice disorders or neck/shoulder pain
common in adult women
MTD symptoms
high vocal demand
increased vocal effort / strain
voice quality changes
stress
throat pain
MTD causes
compensation for pathology
stress
visual features of MTD
hyper or hypofunction –> prevents normal vibration or any vibration
ventricular compression or phonation
MTD management
voice therapy
counseling / psychotherapy
puberphonia / mutational falsetto
when male voice does not lower at puberty despite otherwise normal maturation
puberphonia signs & symptoms
high pitch
weak
breathy
vfs remain stretched
puberphonia managment
voice therapy
unilateral true vf paralysis
complete immobility of 1 vf due to nerve damage or joint fixation
contralateral (opposite) damage
vf paralysis cause
surgical trauma
idiopathic –> viral infection
neurologic disease
cancer
accidental trauma
vf paralysis signs / symptoms
diplophonia –> 2 pitches at one time
highly adducted position –> normal voice or dysapnea
highly abducted –> breathy, weak, dysphagia (swallowing issues)
vf paralysis management
sometimes “wait & see”
voice therapy
surgery
what do gender affirming communication services address
resonance
intonation
rate
nonverbals
vocal intensity
pediatric voice disorders
nodes very common
inducible laryngeal obstruction
vf adduction occurs on inspiration
ILO signs & symptoms
noisy inhalation
feel obstruction in throat during inhalation
ILO treatment
respiratory retraining w/ SLP
what can ILO masquerade as
asthma
what is the gold standard of care in the voice clinic
multidisciplinary approach
SLP, ENT, nurse, medical assistant, other specialists
SLPs do
asses vocal function
diagnose functional voice disorders
provide behavioral treatment
SLPs do NOT
make medical diagnoses
provide medical treatment / management (ENT)
eval componenets
history
auditory eval
laryngeal imaging
acoustics
aerodynamics – subglottic pressure, airflow
stimulability
case history goals
determine
- chronological history of problem
- etiological factors
- patient motivation
discuss
- medical & social hisotry
laryngopharyngeal reflux
acidic & nonacidic contents backflow into pharynx & larynx
laryngopharyngeal reflux symptoms
coughing
voice changes
sore throat
excessive phlegm
dysphonia
what is it important to LOOK for when working w a patient
breathing patterns
bodily tension
posture
formally - laryngeal imagine
what is it important to LISTEN for when working w a patient
pitch
loudness
quality –> consistent or inconsistent
formally - auditory perceptual eval
auditory perceptual assessment goals
describe the degree of deviation in voice quality/tone focus, pitch, & loudness
severity ratings
normal
mild
moderate
severe
auditory perceptual measures of voice quality
formalized eval tools to increase reliability
CAPE-V & GRBAS
laryngeal imaging goals
describe apparent structure & function of vfs
can vf movement be assessed w/ a mirror exam? why or why not?
no
the vfs move faster than the human eye can see
endoscope
used in oral rigid laryngoscopy
an instrument that is passed into the body
oral rigid endoscopy advantage
offers stable, high res view of larynx & vfs that is minimally invasive
oral rigid endoscopy disadvantages
patient may not tolerate
sample limited to /i/
transnasal flexible laryngoscopy
a flexible endoscope is passed through the nasal cavity
transnasal flexible laryngoscopy advatages
allows for assessment of vf function during connected speech & song production
provides broader view of vocal tract & supraglottic region
can be used for biofeedback
transnasal flexible laryngoscopy disadvantage
sometimes possible darker image w/ older tech
more invasive than rigid
less stable image interrupted by laryngeal movements like swallowing
visual exam
both of the oral & flexible laryngoscopic techniques can be coupled w/ videostroboscopic equipment
digital laryngostroboscopy
imaging the larynx using a strobe light
allows us to visualize vf vibratioin by detecting fund freq
flashing light at points across vibe cycle by timing lights to fund freq providing the illusion of apparent motion
mucosal wave
wave length motion of the vfs while they vibrate
amplitude
how far open the vfs go
supraglottic activity
constriction of supraglottic structures
glottic closure
how well the glottis closes
complete
anterior gap
posterior gap
hourglass
spindle
irregular
incomplete
free edge contour
smoothness of the edge of the vocal fold
normal
concave
convex
irregular
rough
acoustic measurement goals
provide info about physical sound properties of voice
intensity, fund freq, dynamic range, quality
acoustic measures
recorded voice via mic hooked up to computer w/ measurement software
norm values by age & sex
considered objective but only as good as the clinician
aerodynamic measurement goals
describe laryngeal airway
hope open or closed airway is during phonation
considered objective
measured w/ a mask
types of aerodynamic measures
subglottic pressure
translaryngeal airflow (airflow through vfs)
phonation thresholf pressure (min amount (quietest voice) of subglottic pressure required for vf vibration)
what is the first line treatment before more invasive approaches
voice therapy
goals of voice therapy
restore the best possible voice
reeducate patient on how to effectively use voice
voice therapy research
superior
but hard to study
what does successful treatment of voice disorders depend on
correct diagnosis
proper functional assessment
SLP knowledge & skill
patient investment
vocal hygiene
water intake
caffeine intake
smoking/alc
chronic throat clearing, coughing, grunting, screaming
allergies
abdominable breathing goal
promote relaxed expansion of ribs & abs
efficient inhalation
greater airflow into lungs & less tension
semi-occluded vocal tract exercises (SOVTs) goal
less impact & stress on vfs
back pressure in vocal tract from partial closure of mouth
max vocal efficiency w/ minimal vocal effort
