Voice Conditions Flashcards
What are the three abnormal voice qualities?
Breathy, rough, strained
Breathy - incomplete glottal closure → turbulent airflow
Rough - aperiodic vocal fold vibration → irregular mucosal wave
Strained - considerable medical compression of true vocal folds
What does breathy vocal quality imply?
Incomplete glottal closure → turbulent airflow
What does rough vocal quality imply?
Aperiodic vocal folds vibration (hindi sabay vibration ng vocal folds)→ irregular mucosal wave (garalgal)
What does strained vocal quality mean?
Considerable medial compression of true vocal folds (ipit)
What does harsh vocal quality mean?
Strained + rough
What does hoarse vocal quality mean?
Strained + rough + breathy
What are organic voice disorders?
Organic voice disorders are related to structural deviations of the vocal tracts (lungs, muscles of respiration, larynx, pharynx, and oral cavity) or to diseases of specific structures of the vocal tract.
- Structural deviations
- Additive growth
- Loss of structure
What are the congenital organic voice disorders?
Laryngomalacia
Subglottic stenosis
Esophageal atresia and tracheoesophageal fistula
This is the inward collapse of the supraglottic structures of the larynx during inspiration” (Holinger, 1997). This accounts for 75% of all congenital anomalies of the larynx and is the most prevalent cause of stridor in the neonate (Elluru, 2006). In most children with the condition, symptoms are evident at birth or within the first few hours or days of life (Andrews and Summers, 2002). Severe ______________ is associated with the primary symptoms of inspiratory stridor, suprasternal retraction, substernal retraction, feeding difficulty, choking, post feeding vomit, failure to thrive, and cyanosis (Lee and colleagues, 2007) → shorter utterances.
Laryngomalacia
This is the narrowing of the space below the glottis and above the first tracheal ring. Although rare, it is one of the most common causes of chronic upper airway obstruction in infants and children. It can be congenital or acquired. The congenital __________ is the second most common cause of stridor in neonates, infants, and children. Acquired ___________ is the most common acquired anomaly of the larynx in the pediatric age group, and is the most common abnormality necessitating tracheotomy in children below one year of age
Subglottic stenosis
This represents a failure of the esophagus to develop as a continuous passage. Instead, it ends as a blind pouch.
Congenital esophageal atresia
This represents an abnormal opening between the trachea and esophagus.
Tracheoesophageal fistula
The standard intervention is surgery. However, surgery is not without risks, such as severe respiratory distress, recurrent aspiration pneumonia, failure to thrive, and dysphagia. Any attempt at feeding could cause aspiration pneumonia because the milk or other liquid collects in the blind pouch and overflows into the trachea and lungs. While a fistula between the lower esophagus and trachea may allow stomach acid to flow into the lungs and cause damage. Because of these dangers, patients should be treated as soon as possible after birth.
Esophageal atresia and tracheoesophageal fistula
Treatment by the SLP focuses primarily on feeding (Khan and colleagues, 2009), and secondarily on voice (Oestreicher‐Kedem and colleagues, 2008). The clinician may suspect dysphagia and dysphonia because unilateral vocal fold paralysis has been associated in a small percentage of patients treated surgically for these conditions. Decrease of loudness and shorter utterances due to lack of air support.
Esophageal atresia and tracheoesophageal fistula
These are small ulcerations that develop on the medial aspect of the vocal processes of the arytenoid cartilages due to irritation. The typical symptoms are deterioration of voice after prolonged vocalization (vocal fatigue), accompanied by pain in the laryngeal area or sometimes pain that lateralizes out to one ear. Watterson and colleagues (1990) also found hoarseness or roughness reported 75% of the time and throat clearing in 65% of the 57 cases of these conditions. This is the result from one of three causes or a combination of these:
- hard glottal attack along with throat clearing and coughing,
- LPR, and
- endotracheal intubation → roughness and breathiness
Granulomas (contact ulcers)
These are usually unilateral, occurring on the vocal folds (inner margin, superior or inferior surface) or anywhere on the ventricular folds. They are often caused by an abnormal blockage of the ductal system of laryngeal mucous glands (Case, 2002), but there are other causes. This may also be congenital or acquired. This often appears soft and pliable and fluid filled, in contrast to the hard, fibrotic structure of a vocal nodule. Voice therapy postsurgically is usually confined to helping the patient eliminate any voice compensations (such as increased glottal attack) that may have been used to minimize the negative voice consequences of the cyst
–symptoms would be roughness and breathiness. + Increased glottal attack
Vocal cysts
Inflammation of the larynx. Often develops in a patient who has had a fever, headache, runny nose (rhinorrhea), sore throat, and coughing. This can also include complaints of odynophagia (sore swallowing), hyperemia (increased blood flow to area), and dysphonia (Dworkin, 2008). Although most problems are viral in origin, the more severe problems (often accompanied by high fever and a very sore throat) may be caused by bacterial infections → strain, roughness. Strome (1982) recommends voice rest, humidification, increased fluid intake (hydration), reduced physical activity, and analgesics. From a voice conservation point of view, absolute voice rest—no attempts at spoken communication, including voice or whisper—should be initiated by the patient with such a laryngeal infection.
Infectious laryngitis
Why is whispering discouraged in cases of infectious laryngitis and other organic changes to the larynx?
Whispering should be discouraged because most people produce a glottal whisper by placing the vocal folds in close approximation to one another, which in effect produces a light voice. The irritated, swollen tissues continue to touch and to vibrate. What infectious laryngitis patients need is total voice rest for a period of two or three days, with the vocal folds in the open, inverted‐V position, and increased fluids (hydration).
These are wart-like growths that are viral in origin, that occur in the ark, moist caverns of the airway, frequently in the larynges of young children. Most common causes of pediatric hoarseness, posts a threat to the airway.
Red flags: shortness of breath and hoarseness. When RRP occurs in the larynx, the additive mass often contributes to dysphonia.
Papilloma
Hindi siya sa middle ng vf nagaappear, mostly sa bandang dulo yung “u” part
A child presents continued hoarseness for more than 10 days, independent of cold or allergy. What should an SLP do?
For this reason, the voice clinician should be particularly alert to any child who demonstrates dysphonia. Any child with continued hoarseness for more than 10 days, independent of a cold or allergy, should have the benefit of a laryngeal examination to identify the cause of the hoarseness.
Passage of gastric juice to the esophagus. It can lead to esophagitis; ulceration; dysphagia; and Barrett’s metaplasia, which is a precancerous condition.
Gastroesophageal reflux (GERD)
Gastric juices move superiorly and through the upper esophageal sphincter, the disorder is identified as _________________, as the contents spill into the pharynx → roughness and breathiness. Other symptoms: morning hoarseness, heartburn, sleeping troubles, sour mouth taste, glottal redness, contact irritation
Laryngopharyngeal reflux (reflux laryngitis)
This may be either congenital or acquired and is of unknown etiology, although vocal abuse and laryngopharyngeal reflux may play a role in the acquired form (Belafsky and colleagues, 2002). In _________, on endoscopy or stroboscopy, we see a furrowed or indentation medial edge of the vocal fold, usually bilaterally symmetrical. The spindle configuration may involve all or any segment of the edge of the fold. The furrow may be confined to the superficial layer of the mucosa or penetrate into the vocal ligament and muscle (Giovanni and colleagues, 2007). The patient presents clinically with some degree of dysphonia, often referred with a confusing array of previous diagnoses such as bowing, presbylaryngis, paralysis, or thyroarytenoid atrophy (Hirano and colleagues, 1990).
What are its symptoms?
Sulcus vocalis
Symptoms: strained, little pitch change, low intensity
This is the age-related atrophy of the vocal folds.
What are its symptoms?
Presbylarynx
Symptoms: weak voice, restricted pitch range, decreased stamina → shorter utterance length
Web growing across the glottis between the two vocal folds inhibits normal fold vibration, often producing a high‐pitched, rough sound during vibration and seriously compromising the open glottis. Webs may be congenital or acquired. Acquired webs result from some kind of bilateral trauma of the medial edges of the vocal folds. Anything that might serve as an irritant to the mucosal surface of the folds may be the initial cause of the webbing. Because the two vocal folds are so close together at the anterior commissure, any surface irritation due to prolonged infection or trauma may cause the inner margins of the two fold surfaces to grow together. Depending on the size of the web, the baby will produce stridor (inhalation noises), shortness of breath, and often a different high‐pitched (squeal) cry. Approximately three‐fourths of all laryngeal webs cross the glottis (Strome, 1982). This also may cause severe dysphonia as well as shortness of breath depending on how extensively the webbing crosses the glottis.
Laryngeal webbing
Since pinapaliit yung butas ng VF, nagpproduce ng sipol (stridor)
Cancer or carcinoma in the vocal tract is a life‐threatening disease that requires comprehensive medical–surgical management.
Laryngeal cancer
True or False. Lip and intraoral cancers rarely contribute to changes in voice, but they may have obvious negative effects on articulation.
t
True or False. Extensive oral lesions involving the tongue, perhaps even requiring partial or total surgical removal of the tongue (glossectomy), or palatal and velar cancer can seriously affect articulation, vocal resonance, and, of course, swallowing.
t
Laryngeal cancers can be classified into three groups, depending on the site of the lesion:
(1) supraglottal, involving structures such as the ventricular and aryepiglottic folds, the epiglottis, the arytenoid cartilages, and the walls of the hypopharynx; (2) glottal, from the anterior commissure to the vocal process ends of the arytenoids; and (3) subglottal, involving the cricoid cartilage and trachea.
Contact granulomas (ulcers) are multifactorial in nature and are considered a chronic inflammatory disease of the larynx. They seem to result from one of three causes or a combination of these:
Hard glottal attack along with throat clearing and coughing, laryngopharyngeal reflux, and endotracheal intubation.
Behavioral voice therapy in combination with medical intervention is a powerful approach
CASE4: A 38‐year‐old music salesman presented to the clinic with pain in the laryngeal area following a bout of bronchitis and extensive coughing and throat clearing. He reported occasionally coughing up small amounts of blood. He said he lifts weights but reported the healthy strategy of exhaling while flexing. He does not smoke and he reports minimal water intake. Vocal quality was normal in pitch and quality. He coughed and throat‐cleared throughout the assessment. The salesman was overheard chastising an employee on his cell phone using a hard glottal attack. He said he was recently prescribed anti‐reflux medication by his physician. The patient’s F0 for a sustained /a/ revealed 161Hz with a RAP of .236% and shimmer of 1.56%. Transglottal airflow was 138 ml/s. This client most likely presents with:
A. Adult-onset papilloma
B. Contact granuloma
C. Laryngomalacia
D. A laryngeal cyst
Answer: B. Contact granuloma
A 38‐year‐old music salesman presented to the clinic with pain in the laryngeal area following a bout of bronchitis and extensive coughing and throat clearing. He reported occasionally coughing up small amounts of blood. He said he lifts weights but reported the healthy strategy of exhaling while flexing. He does not smoke and he reports minimal water intake. Vocal quality was normal in pitch and quality. He coughed and throat‐cleared throughout the assessment. The salesman was overheard chastising an employee on his cell phone using a hard glottal attack. He said he was recently prescribed anti‐reflux medication by his physician. The patient’s F0 for a sustained /a/ revealed 161Hz with a RAP of .236% and shimmer of 1.56%. Transglottal airflow was 138 ml/s. The near normal acoustic measures are likely due to the fact that the lesions are:
A. Located on the nonvibrational portion of the glottis
B. Soft and pliable
C. Located lateral to the glottal margin
D. Pedunculated
Answer: A. Located on the nonvibrational portion of the glottis
A 38‐year‐old music salesman presented to the clinic with pain in the laryngeal area following a bout of bronchitis and extensive coughing and throat clearing. He reported occasionally coughing up small amounts of blood. He said he lifts weights but reported the healthy strategy of exhaling while flexing. He does not smoke and he reports minimal water intake. Vocal quality was normal in pitch and quality. He coughed and throat‐cleared throughout the assessment. The salesman was overheard chastising an employee on his cell phone using a hard glottal attack. He said he was recently prescribed anti‐reflux medication by his physician. The patient’s F0 for a sustained /a/ revealed 161Hz with a RAP of .236% and shimmer of 1.56%. Transglottal airflow was 138 ml/s. Laryngostroboscopic examination will most likely reveal:
A. An anterior web
B. Vocal nodules
C. Granulated tissue at the posterior aspect of the glottis
D. Bowed vocal folds
Answer: C. Granulated tissue at the posterior aspect of the glottis.
A 38‐year‐old music salesman presented to the clinic with pain in the laryngeal area following a bout of bronchitis and extensive coughing and throat clearing. He reported occasionally coughing up small amounts of blood. He said he lifts weights but reported the healthy strategy of exhaling while flexing. He does not smoke and he reports minimal water intake. Vocal quality was normal in pitch and quality. He coughed and throat‐cleared throughout the assessment. The salesman was overheard chastising an employee on his cell phone using a hard glottal attack. He said he was recently prescribed anti‐reflux medication by his physician. The patient’s F0 for a sustained /a/ revealed 161Hz with a RAP of .236% and shimmer of 1.56%. Transglottal airflow was 138 ml/s. This hyperplastic laryngeal abnormality is most likely secondary to:
A. Laryngopharyngeal reflux
B. Chronic laryngeal collisional forces of coughing and throat clearing
C. Hard glottal attack
D. All of these
Answer: D. All of these
A 38‐year‐old music salesman presented to the clinic with pain in the laryngeal area following a bout of bronchitis and extensive coughing and throat clearing. He reported occasionally coughing up small amounts of blood. He said he lifts weights but reported the healthy strategy of exhaling while flexing. He does not smoke and he reports minimal water intake. Vocal quality was normal in pitch and quality. He coughed and throat‐cleared throughout the assessment. The salesman was overheard chastising an employee on his cell phone using a hard glottal attack. He said he was recently prescribed anti‐reflux medication by his physician. The patient’s F0 for a sustained /a/ revealed 161Hz with a RAP of .236% and shimmer of 1.56%. Transglottal airflow was 138 ml/s. The most comprehensive approach to this vocal fold pathology is:
A. Surgical removal of the abnormality
B. Continued anti‐reflux regimen and intervention for reduced hard glottal attack
C. Vocal hygiene only
D. Voice rest
Answer: B. Continued anti‐reflux regimen and intervention for reduced hard glottal attack
Which of the following is NOT an abnormal voice quality?
A. Breathy
B. Rough
C. Clear
D. Strained
Answer: C. Clear
A breathy vocal quality typically results from:
A. Irregular mucosal wave
B. Incomplete glottal closure
C. Medial compression of the vocal folds
D. Excessive airflow
Answer: B. Incomplete glottal closure. Breathy vocal quality results from incomplete glottal closure, leading to turbulent airflow.
What combination of qualities characterizes a hoarse vocal quality? What combination of qualities characterizes a hoarse vocal quality?
A. Strained + rough + breathy
B. Strained + rough
C. Breathy + rough
D. Breathy + strained
Answer: A. Strained + rough + breathy
Select all that apply: Which of the following are congenital organic voice disorders?
A. Laryngomalacia
B. Subglottic stenosis
C. Esophageal atresia
D. Granulomas
Answer: A, B, C
Which of the following disorders is described by the inward collapse of the supraglottic structures during inspiration and is the most common cause of stridor in neonates?Which of the following disorders is described by the inward collapse of the supraglottic structures during inspiration and is the most common cause of stridor in neonates?
A. Subglottic stenosis
B. Esophageal atresia
C. Laryngomalacia
D. Tracheoesophageal fistula
Answer: C. Laryngomalacia
A patient with subglottic stenosis is likely to present with:
A. Inspiratory stridor
B. Vocal nodules
C. Coughing and throat clearing
D. Unilateral vocal fold paralysis
Answer: A. Inspiratory stridor. Subglottic stenosis typically presents with inspiratory stridor due to the narrowed airway.
A small ulceration on the medial aspect of the arytenoid cartilages is most likely to be:
A. Papilloma
B. Cyst
C. Granuloma (Contact Ulcer)
D. Laryngomalacia
Answer: C. Granuloma
What is the typical cause of infectious laryngitis?
A. Viral infection
B. Gastroesophageal reflux disease (GERD)
C. Smoking
D. Overuse of vocal folds
Answer: Viral infection
Why is whispering discouraged for patients with infectious laryngitis?
A. It causes complete vocal fold closure
B. It creates excessive medial compression
C. It can lead to further irritation and swelling of the vocal folds
D. It promotes dehydration of the vocal tract
Answer: C. It can lead to further irritation and swelling of vocal folds
Case: A 5-year-old child presents with continued hoarseness for more than 10 days without a cold or allergy. What is the most appropriate next step for the SLP?
A. Recommend voice rest and follow-up in one week
B. Suggest speech therapy exercises
C. Refer the child for a laryngeal examination
D. Advise increased hydration and vocal rest
Answer: C. Refer the child for a laryngeal examination
Which condition is characterized by wart-like growths that are viral in origin, commonly causing pediatric hoarseness?
A. Laryngomalacia
B. Papilloma
C. Granuloma
D. Sulcus vocalis
Answer: B. Papilloma
Which of the following describes gastroesophageal reflux disease (GERD)?
A. Passage of gastric juice into the lungs
B. Passage of gastric juice to the esophagus
C. Viral infection in the vocal folds
D. Failure of esophageal development
Answer: B. Passage of gastric juice to the esophagus.
Which condition is characterized by a furrowed or indentation along the medial edge of the vocal fold?
A. Granuloma
B. Papilloma
C. Sulcus vocalis
D. Subglottic stenosis
Answer: C. Sulcus Vocalis
Presbylarynx typically presents with:
A. Weak voice and restricted pitch range
B. Shortness of breath and stridor
C. Increased glottal attack
D. High-pitched, rough sound
Answer: A. Weak voice and restricted pitch range
Select all that apply: Which of the following are possible causes of contact granulomas?
A. Hard glottal attack
B. Laryngopharyngeal reflux (LPR)
C. Endotracheal intubation
D. Congenital subglottic stenosis
Answer: A, B, C
What is the main goal of treatment for esophageal atresia and tracheoesophageal fistula?
A. Vocal hygiene
B. Voice therapy
C. Feeding management
D. Surgical correction
Answer: C. Feeding management is the primary goal for esophageal atresia and tracheoesophageal fistula.
A patient with suspected laryngeal webbing may present with:
A. Hoarse voice and high-pitched cry
B. Shortness of breath and stridor
C. Dysphagia and coughing
D. Hypernasality
Answer: B. Laryngeal webbing often causes stridor and difficulty breathing.
A patient has been diagnosed with laryngopharyngeal reflux. Which of the following symptoms would you expect to see?
A. Stridor, coughing, and failure to thrive
B. Morning hoarseness, heartburn, and rough voice
C. Nasal congestion, shortness of breath, and headache
D. Pain during swallowing and excessive throat clearing
Answer: B. Laryngopharyngeal reflux presents with morning hoarseness, heartburn, and a rough voice.
Which of the following interventions is discouraged for a patient diagnosed with presbylarynx?
A. Surgical correction
B. Vocal exercises to increase stamina
C. Increased hydration
D. Voice therapy to improve pitch range
Answer: A. Surgical correction is typically avoided in presbylarynx unless necessary.
Case: A 38-year-old music salesman with pain in the laryngeal area after bronchitis reports throat clearing, coughing, and occasional blood in his cough. He has been prescribed anti-reflux medication and exhibits a normal pitch with increased roughness. Which condition is most likely?
A. Papilloma
B. Cyst
C. Contact granuloma
D. Laryngomalacia
Answer: C. Contact granuloma is most likely due to the combination of reflux, throat clearing, and coughing.
The muscle control and innervation of the muscles of respiration, phonation, resonance, and articulation may be impaired from birth or from injury or disease of the peripheral or central nervous system occurring at any age
Neurogenic voice disorders
What cranial nerve is this? Its primary motor innervation is to the superior pharyngeal constrictor in the pharynx and to the stylopharyngeus muscle.
Cranial Nerve IX, Glossopharyngeal Nerve
Includes two major categories: neurogenic paralysis and mechanical fixation (Woodson, 2011).. Voice per se is of secondary concern to respiratory survival and feeding.
Where is the lesion?
Bilateral vocal fold paralysis
It is usually the result of lesions high in the trunk of the Vagus nerve or at the nuclei of origin in the medulla
The vocal folds remain at the midline, causing serious respiratory problems for which most patients will need a tracheostomy.
Bilateral abductor paralysis/paresis → strained voice (main concern is breathing)
Paresis - partial loss of movement due to a neurological infarct
The vocal folds neither fold. It is capable of moving to the midline. It is stuck in an open position. Neither vocal fold is capable of moving to the midline, thus making phonation impossible and placing the individual at risk for aspiration.
Bilateral adductor paralysis → breathy vocal quality. So the main concern here is feeding and aspiration.
What is the treatment for bilateral vocal fold paralysis?
Surgical reinnervation
The patient may have difficulty breathing. His vocal quality was observed to be strained. Thus, the patient needed tracheostomy.What neurogenic voice disorder does the patient have?
Bilateral abductor paralysis
There is glottic incompetence due to the inability of the affected true vocal fold to adduct completely and meet the normally mobile opposing true vocal fold. The paralyzed vocal fold is fixed in the paramedian position, that is, neither fully abducted nor adducted. The vocal fold remains at the paramedian position for both inspiration and expiration (including attempts at phonation). The etiology can be broadly divided into four categories: neoplastic, traumatic, secondary to medical disease, and idiopathic.
Unilateral vocal fold paralysis
What are the vocal characteristics of a person with UVFP?
The voice in UVFP is markedly dysphonic or aphonic. Perceptual characteristics include breathy, hoarse vocal quality; reduced phonation time; decreased loudness and monoloudness; diplophonia; and pitch breaks.
The breathy vocal quality, reduced loudness, and short phonation times result from air escape through an open glottis during phonation.
Hoarseness, pitch breaks, and diplophonia result from the reduced ability to adjust the internal tension of the paralyzed vocal fold. Secondary muscle tension may contribute to the perception of hoarseness.
True or false. Disease or trauma to the recurrent laryngeal nerve on one side is the most common form of vocal fold paralysis.
What are the four etiological categories of UVFP?
- neoplastic (compression or infiltration of the Vagus or RLN)
- traumatic (surgical and nonsurgical),
- secondary to medical disease, and
- idiopathic (Tucker, 1980).
This is a relatively rare voice disorder that results from laryngeal dystonia. Dystonia is a neurological dysfunction of motor movements, either more generalized to major body movements or seen in focal disorders, such as in the eyelids (blepharospasm), in the neck (spasmodic torticollis), or in the larynx (SD). As such, it is a hyperkinetic movement disorder.
Spasmodic dysphonia
A patient with SD will exhibit what quality of voice?
Exhibits a strain-strangled and harsh voice with able effort in pushing the air out during most voicing attempts. Endoscopic examination shows that this voice results from hyperadduction of the true vocal folds, often accompanied by tight closure of the false vocal folds with supraglottal constriction of the aryepiglottic vocal folds and contraction of the lower pharyngeal constrictors.
True or False. Spasmodic dysphonia can also be a psychogenic condition and be heterogeneous, wherein occurrence of voice problem only occurs during communicative purposes.
True
This is a type of spasmodic dysphonia wherein there is tight laryngeal adduction (most common).
Adductor spasmodic dysphonia
This type of spasmodic dysphonia wherein normal voicing is interrupted by sudden abduction, resulting in fleeting aphonia.
Abductor spasmodic dysphonia
What is the most common type of dysphonia?
Adductor spasmodic dysphonia
This is the most common voice disorder seen in both children and adults. It is the most common manifestation of vocal hypertension–using too much muscular effort to phonate.
Muscle tension dysphonia
Two broad causes of functional voice disorder
Excessive muscle tension
Psychogenic
This is a persistent dysphonia that results from excessive laryngeal and related musculoskeletal tension and associated hyperfunctional true and/or false vocal fold vibratory patterns. There are no laryngeal structural abnormalities.
Muscle tension dysphonia
What are the causes of muscle tension dysphonia?
Deviant posture
Misuse of shoulder and neck muscles
Vocal abuse
Vocal misuse
What is vocal misuse?
Improper use of voice–it could have been used properly, but wasn’t.
Example: speaking with a hard glottal attack, singing/speaking outside one’s pitch range, speaking with an excessive intensity level
What is vocal abuse?
Deleterious behaviors and events
Example: yelling, excessive talking/singing, excessive coughing/throat clear, smoking, grunting, excessive crying/laughing
Sometimes known as dysphonia plicae ventricularis, refers to the pathological interference of the false vocal folds during phonation.
Ventricular dysphonia
“… Phonation using false vocal fold vibration rather than true vocal fold vibration, most commonly associated with severe muscular tension and occasionally may be an appropriate compensation for profound true vocal fold dysfunction.” Sometimes this becomes the substitute voice of patients who have had resection due to severe disease of the true folds (such as cancer, severe recurrent respiratory papilloma, or large polyps). This is usually low-pitched because of the large mass of vibrating tissue of the ventricular bands (as compared to the smaller mass of vibrating tissue of the true folds) or from the combined mass of the true and false vocal folds.
Ventricular dysphonia
Ventricular dysphonia has two broad headings. What are they?
- Compensatory - reaction to true vocal folds disease (paralysis, true vocal cord surgery etc.,) incapable of normal vibration.
- Noncompensatory (capable of normal vibration):
(1) habitual - caused by excessive vocal use,
(2) psycho-emotional - is provoked by physical and psychogenic tension and distress,
(3) has no known origin and is classified as idiopathic
These are the most common benign lesions of the vocal folds in both children and adults. They are caused by continuous abuse of the larynx and misuse of the voice. These are generally bilateral, whitish protuberances on the glottal margin of each vocal fold. With continuous phonotrauma, this becomes more fibrotic and may be slightly larger, or it may become more focused, smaller, and harder. What is this?
Where are they usually located?
Vocal fold nodules
located at the anterior-middle third junction
What therapy is effective in reducing or eliminating vocal nodules?
Symptomatic voice therapy
True or False. As the bilateral nodules approximate one another on phonation, there is usually an open glottal chink anterior and posterior to the nodule contact point, which results in a glottal hourglass figure. This open glottal chink (produced by the nodules coming together in exact opposition to one another) results in a lack of complete vocal fold adduction. This faulty approximation leads to breathiness in the voice and air wastage, the perception of which increases as nodule size increases(Shah and colleagues, 2005, p. 93).
True
This is a focal abnormality of the superficial lamina propria, usually at the same site where vocal fold nodules occur. “Gelatinous in nature”. These are usually unilateral. Unlike vocal nodules, which result from continuous or chronic vocal fold irritation, ______ are often precipitated by a single vocal event. For example, a patient may have indulged in excessive vocalization, such as screaming for much of an evening, which produced some hemorrhaging on the membrane at the point of maximum glottal contact. Such hemorrhagic irritation eventually results in formation of either a translucent, fibrotic, hyaline, hemorrhagic, or mixed ______ that adds mass to the vocal fold. Once a small _______ begins, any continued phonotrauma will irritate the area, contributing to its continued growth (Petrovic and colleagues, 2009; Nakagawa and colleagues, 2012).
Which layer of the vocal fold?
Vocal fold polyps
Layer: slightly deeper within the superficial lamina propria
Chronic diffuse swelling of the vocal fold. This is also referred to as polypoid degeneration of the vocal fold. It is usually bilateral but can be more pronounced on one side. Within the lamina propria, the collagen architecture is disrupted, and a thick, gelatinous, fluid-like material develops in Reinke’s space. It is associated strongly with smoking, frequently with chronic vocal hyperfunction, and occasionally with laryngopharyngeal reflux
What layer of the vocal folds?
Reinke’s edema
Layer: superficial lamina propria of the VF
Patients experience swelling of the vocal folds as a result of excessive and strained vocalization. Phonotrauma, such as yelling, screaming, abrupt and strained voice usage, chronic coughing, habitual throat clearing, and forceful singing are common causes
Traumatic laryngitis
There are two types of traumatic laryngitis. What are they? Differentiate the two.
Acute laryngitis - VF increases in mass and size due to actual trauma
Chronic laryngitis - due to “speak above” the acute laryngitis → compounding problem
What are the voice characteristics with excessive muscle tension disorders?
Diplophonia
Phonation breaks
Pitch breaks
What is diplophonia?
- Double voice
A diplophonic voice is produced with two distinct frequencies occurring simultaneously. Diplophonia is the consequence of irregular vocal fold vibration.
Is more likely to be heard in patients with mass lesions, vocal fold paralysis, vocal fold scarring, laryngitis and other inflammatory conditions, muscle tension dysphonia, puberphonia, or paradoxical vocal fold movement
What are phonation breaks?
A phonation break is a temporary loss of voice that may occur for only part of a word, a whole word, a phrase, or a sentence.
The individual is phonating with no apparent difficulty when suddenly a complete cessation of voice occurs. Such a fleeting voice loss is usually situational, and it usually happens after prolonged hyperfunction.
What are pitch breaks? What are its 2 types
Sudden interruption in pitch in an otherwise normal laryngeal structure.
There are two types of pitch breaks:
(1) normal pitch breaks occurring in boys experiencing puberty
(2) prolonged hyperfunction speaking in an inappropriately low pitch
What is puberphonia?
It is an inappropriate and unintentional use of high-pitched voice beyond pubertal age in males. It is usually seen in the immediate post pubescent period when the male laryngeal mechanism has undergone significant changes in size and function caused by hormonal changes.
Other names for puberphonia are falsetto, mutational falsetto, juvenile voice, and incomplete voice mutation.
What is functional aphonia? It is closely tied to?
- Speaking in a whisper (aphonic voice) but using same rhythm and prosody as normal speech
- Closely tied to psychological experiences
- Onset can widely vary, depending on the reason (contextual factors)
- Differential diagnosis from organic causes must be done
Which cranial nerve provides motor innervation to the superior pharyngeal constrictor and stylopharyngeus muscle?
a) Cranial Nerve X
b) Cranial Nerve VII
c) Cranial Nerve IX
d) Cranial Nerve XII
Answer: C. Cranial Nerve IX
In bilateral vocal fold paralysis with adductor paralysis, what is the primary concern?
a) Breathing difficulties
b) Strained voice
c) Aspiration and feeding problems
d) Excessive loudness
Answer: C. Aspiration and feeding problems
What is the most appropriate treatment for bilateral vocal fold paralysis?
a) Voice therapy
b) Vocal rest
c) Surgical reinnervation
d) Botox injection
Answer: C. Surgical reinnervation
A patient with unilateral vocal fold paralysis (UVFP) is likely to present with which of the following vocal characteristics?
a) Strain-strangled voice
b) Breathy voice
c) Diplophonia
d) Pitch breaks
(Select all that apply)
Answer: B, C, D → UVFP presents with breathy voice, diplophonia, and pitch breaks due to incomplete glottal closure.
Which of the following is true regarding unilateral vocal fold paralysis?
a) The paralyzed fold is fully adducted during phonation.
b) The voice quality is often breathy and hoarse.
c) Vocal fold paralysis always results from trauma.
d) The paralyzed fold is fixed in the paramedian position.
Answer: B, D → UVFP causes breathy, hoarse voice with the paralyzed fold fixed in a paramedian position.
What are the four major etiological categories of unilateral vocal fold paralysis?
a) Neoplastic, traumatic, psychogenic, idiopathic
b) Neoplastic, traumatic, secondary to medical disease, idiopathic
c) Traumatic, congenital, secondary to surgery, idiopathic
d) Genetic, environmental, traumatic, neoplastic
Answer: B. Neoplastic, traumatic, secondary to medical disease, idiopathic
Spasmodic dysphonia is classified as a:
a) Hypokinetic movement disorder
b) Hyperkinetic movement disorder
c) Mixed movement disorder
d) Idiopathic disorder
Answer: B. Spasmodic dysphonia involves hyperkinetic movement, leading to voice issues.
A patient presents with a voice characterized by abrupt breathy breaks and intermittent aphonia. What type of spasmodic dysphonia do they likely have?
a) Adductor spasmodic dysphonia
b) Abductor spasmodic dysphonia
c) Mixed spasmodic dysphonia
d) Psychogenic dysphonia
Answer: B. Abductor spasmodic dysphonia; Abrupt breathy breaks and aphonia are signs of abductor spasmodic dysphonia.
Which of the following is the most common type of spasmodic dysphonia?
a) Adductor spasmodic dysphonia
b) Abductor spasmodic dysphonia
c) Psychogenic dysphonia
d) Vocal fold paresis
Answer: A. Adductory Spasmodic Dysphonia
Muscle tension dysphonia is caused by which of the following?
a) Psychogenic trauma
b) Excessive muscular tension
c) Vocal fold lesions
d) Weak respiratory support
Answer: B. Excessive muscular tension
Which of the following best describes muscle tension dysphonia?
a) Dysphonia caused by a neurological disorder
b) Dysphonia caused by excessive laryngeal and musculoskeletal tension
c) Dysphonia resulting from vocal fold lesions
d) Dysphonia caused by vocal fold paralysis
Answer: B. Dysphonia caused by excessive laryngeal and musculoskeletal tension
A patient is diagnosed with ventricular dysphonia. This condition occurs when:
a) The vocal folds are paralyzed
b) The false vocal folds vibrate during phonation
c) There is a mass on the vocal folds
d) The patient overuses their voice
Answer: B. The false vocal folds vibrate during phonation
Which of the following are causes of vocal misuse?
a) Speaking with a hard glottal attack
b) Singing outside one’s pitch range
c) Smoking
d) Screaming excessively
(Select all that apply)
Answer: A, B
A. Speaking with a hard glottal attack
B. Singing outside one’s pitch range
Which of the following voice characteristics are typical of excessive muscle tension disorders?
a) Diplophonia
b) Strain-strangled voice
c) Pitch breaks
d) Phonation breaks
(Select all that apply)
Answer: A, C, D Diplophonia, Pitch breaks, Phonation breaks
True or False: Diplophonia is the simultaneous production of two distinct pitches due to irregular vocal fold vibration.
Answer: True
Which of the following vocal pathologies is most likely caused by a single traumatic vocal event?
a) Vocal fold nodules
b) Vocal fold polyps
c) Reinke’s edema
d) Muscle tension dysphonia
Answer: B. Vocal fold polyps
True or False: Vocal fold nodules are typically unilateral.
False. Vocal nodules are typically bilateral.
What is the most effective treatment for vocal fold nodules?
a) Surgical removal
b) Vocal hygiene education
c) Symptomatic voice therapy
d) Botox injections
Answer: C. Symptomatic voice therapy
Which of the following voice characteristics are likely to be present in a patient with Reinke’s edema?
a) Low-pitched voice
b) Strain-strangled voice
c) Increased loudness
d) Hoarseness
Answer: A, D → Reinke’s edema causes a low-pitched, hoarse voice due to increased vocal fold mass.
Which of the following is a characteristic of traumatic laryngitis?
a) Unilateral vocal fold paralysis
b) Swelling of the vocal folds due to phonotrauma
c) Adductor spasmodic dysphonia
d) Chronic respiratory infections
Answer: B. Swelling of the vocal folds due to phonotrauma
Phonation breaks, sudden voice interruptions during speech, are most commonly caused by:
a) Structural abnormalities of the vocal folds
b) Prolonged vocal hyperfunction
c) Neurological impairment
d) Lack of respiratory control
Answer: B. Prolonged vocal hyperfunction
True or False: Pitch breaks are commonly observed in adolescent boys during puberty.
Answer: True
