Voice Disorders

Question 1

mucosal wave action

Answer 1

during phonation. movement of the mucous membrain of the vocal folds

Question 2

ventricular/false vocal folds

Answer 2

used during lifting and coughing. protect the vocal folds and protect the airway during swallowing.

Question 3

aryepiglottic folds

Answer 3

course from arytenoid cartilage and lateral portion of the epiglottis on each side and form the lateral borders of the laryngeal inlet.

Question 4

primary cranial nerve involved in laryngeal innervation

Answer 4

X Vagus Nerve

Question 5

Arytenoid cartilages

Answer 5

when they move medially and rock at the crocoarytenoid joint, the vocal folds adduct. lateral movement causes abduction.

Question 6

Voice changes throughout the lifespan

Answer 6

-as people become older, their voices become lower in pitch (until men in their 60s)
-in adulthood, men have MFF of 100-150 hz (125 avg) while women have 180-225 (225 avg)
-as we age, laryngeal cartilages harden, atrophy of the intrinsic laryngeal muscles, degenerative changes in lamina propria, deterioration and decreased flexibility of the cricoarytenoid joint, and degenerative changes in the conus elastic may cuase presbyphonia which causes perceptual changes in quality, range, loudness, and pitch as we age.
-A females voice lowers in frequency as long as she lives while mens frequency gets higher in his 60s and every decade after that.

Question 7

pitch

Answer 7

VFs vibrate to make sound for voice. Frequency is the number of cycles per second (rate the VFS are vibrating). Higher frequencies have more cycles per second than lower. pitch is the perceptual correlate of frequency.

Pitch is determined by mass, tension, and elasticity of the vocal cords. Higher pitch results when the vocal cords are thinner, more tense, or both. Lower pitch is with thicker, more relaxed or both VFs.

Question 8

fundamental frequency

Answer 8

considered an individuals habitual or typical speaking pitch

Question 9

Frequency perturbation/jitter

Answer 9

irregularities in vocal fold vibration that are often heard in dysphonic patients.

Question 10

Loudness

Answer 10

perceptual rating of intensity. determined by the amplitude of the sound signal. The larger the amplitude of vibration, the more intense the sound.

Question 11

Quality

Answer 11

The perception of the sound of an individuals voice. It is subjective.

Question 12

Types of vocal quality

Answer 12

hoarseness: breathiness and harshness
harshness: rough, unpleasant, gravelly
strain/strangle: phonation is efforful and sounds like voice is squeezed out
breathiness: vocal cords being open with air escape.
glottal fry: crackly, low pitch. typically produced at the end of a long phrase.
diplophonia: double voice. Vfs vibrate at different frequencies due to differing degrees of mass or tension (e.g., polyp)
stridency: unpleasant, high pitched and tinny sound. often due to tension.

Question 13

Evaluation of voice D/O

Answer 13

case hx
Team oriented approach (ent evaluation)
-indirect laryngoscopy: mirror
-direct: general anesthesia
-flexible: can be strobe of not. ENT uses this to evaluate pt.
Acoustic analysis
aerodynamic measures
perceptual evaluation
quality of life evaluation

Question 14

spectrogram

Answer 14

resulting picture reflects the resonant characteristics of the vocal tract and harmonic nature of the glottal sound source.

Question 15

aerodynamic measurement

Answer 15

tidal volume: amount of air inhaled or exhaled during normal breathing cycle
vital capacity: volume of air a patient can exhale after max inhalation
total lung capacity: total volume of air in the lungs

measured with spirometers, manometric devices, and plthysmographs.

Question 16

acoustic measurements

Answer 16

visi pitch, CSL. measures dynamic range, intensity, frequency, pitch, loudness, etc

Question 17

perceptual evaluation

Answer 17

pitch, loudness, resonance respiration, phonation,

Question 18

phonation assessment

Answer 18

max phonation time
s/z ration: indicates the efficacy of glottal closure. divides the longest s by the longest z. an s/z ration of more than 1.4 is indicative of possible pathology. Because z is a voiced sound, pathology could interfere with glottic closure and reduce length of time.

Question 19

Hypernasality

Answer 19

when the VP mechanism does not close the opening to the nasal passage during production of non nasal sounds. Air and sound escape through the nose adding unnessary nasal resonance. Can occur due to funcional or organic factors. Cleft palate is a major cause. VPI also causes

Question 20

Hyponasality

Answer 20

lack of appropriate nasal resonance on nasal sounds. Can be temporary (colds). Can also occur due to obstructions in the nasal cavity (polyps).

Question 21

cul-de-sac resonance

Answer 21

speech that sounds muffled or hollow. 3 types:
oral: sound partially blocked from exiting the oral cavity. Backward retraction of the tongue.
nasal: sound partially obstructed from exiting nasal cavity. mostly occurs with VPI combined with blockage in the nasal cavity
pharyngeal: sound blocked from exiting oropharynx. tonsils, adenoise, structural abnormalities

**Regardless of where, it is always caused by structural abnormality

Question 22

Treatment of nasality issues

Answer 22

-medical intervention if needed
-hypernasality: nasometer gives visual feedback, increasing mouth opening for oral resonance, increaseing pt’s loudness, improving articulation, changing speaking rate, decreasing pitch which can contribute to greater oral resonance
-hyponasality: feedback. Directing voice into mask of the face (RV), nasal glide stimulation

Question 23

hypofunctional voice disorder

Answer 23

caused by inefficient muscle action of the vocal mechanism. Vocal cords do not come together fully. vocal quality is breathy, hoarse, decreased loudness, and possible aphonia.

Question 24

hyperfunctional voice disorders

Answer 24

excessive muscle action of the vocal mechanism. not enough airflow. voice is tense, strained, rough, and hoarse.

Question 25

vocal nodules

Answer 25

develop on the superficial layer of the lamina propria of the vocal folds. callous like. can be unilateral but are typically bilateral. due to prolonged vocal abuse. most frequently seen in children who scream/yell. voice therapy should be initial form of treatment.

Question 26

vocal polyps

Answer 26

softer than nodules and may be filled with fluid or have vascular tissue. Tend to be unilateral.

Sessile polyps: broad base and blister like
pedunculated: attached to the vf by a stalk

**believed that trauma results in hemorrhage which leads to polyp. Can happen over time or from one traumatic event.

Question 27

vocal fold cysts

Answer 27

unilateral and filled with mucus like fluid. Result of vocal abuse. surgical removal of the cyst is recommended. However, after surgery vocal therapy is recommended for hygeine.

Question 28

granuloma

Answer 28

localized inflammatory vascular lesion usually composed of granular tissue in a firm, rounded sac. develop on the vocal processes of the arytenoid cartilages in the posterior laryngeal area. Can be unilateral or bilateral. can be caused by vocal strain, intubation, injury and LPR.

treated by surgery, voice therapy, or both. However, recurrence with surgery is high. Therefore, non-surgical treatments first is recommended.

Question 29

contact ulcer of the vocal cords

Answer 29

sores or crater like areas of ulcerated, granulated tissue that develop (usually bilaterally along the posterior third of the glottic margin). Caused by gerd, intubation, or patients who speak forcefully and talk excessively. no surgery. Voice therapy or GERD tx.

Question 30

hemangioma

Answer 30

similar to granulomas but are soft, pliable, and filled with blood. usually caused by intubation or GERD. can also be congenital. usually surgically removed with speech therapy after surgery.

Question 31

hyperkeratosis

Answer 31

rough, pinkish lesion that can appear in the oral cavity, larynx, or pharynx. Often benign but precursors to malignancy. Treatment involves eliminating tissue irritants, maybe ablation surgery, and voice therapy.

Question 32

Leukoplakia

Answer 32

benign growths of thick, whitish patches on the surface of the vocal cords. Occur due to tissue irritation, especially smoking, alcohol, or vocal abuse. Considered precancerous and must be monitored. Tx involves combo of surgery, voice tx, and eliminating exposure to tissue irritants.

Question 33

Laryngomalacia

Answer 33

congenital condition involves soft, floppy laryngeal cartilages. Epiglottis if particularly affected. Most common cause of stridor in infants. When the child breathes, the epiglottis resists the airstream, causing stridor or rough breathy noise on inhalation. Condition usually resolves spontaneously by the age of 2-3, no treatment usually needed. However, may require assistance with breathing if severe.

Question 34

subglottal stenosis

Answer 34

narrowing of the subglottal space. Can occur due to intubation or can be congenital. Patients may need surgery followed by voice therapy.

Question 35

papilloma

Answer 35

caused by HPV. Can happen due to perinatal infection or as an adult. wart like growths. Repeated surgeries often needed. Therapy does not help with recurrence but can help with improvement of voicing.

Question 36

laryngeal web

Answer 36

membrane that grows across the anterior portion of the glottis. can be congenital or acquired (due to trauma to the inner edges of the vocal cords). Will most likely cause difficulty breathing/stridor. requires surgery to remove the web. After surgery, a laryngeal keel (fingernail sized, rudder shaped stent device) to keep the web from growing back and is removed after a few weeks. After removal, speech therapy is required.

Question 37

sulcus vocalis

Answer 37

thinning and bowing of the superficial lamina propria of the vocal folds. Can be unilateral or bilateral. Cause unknown but believed to be related to a smoking hx, congenital, or result of trauma or infection. Sulci are classified by how deep the depression extends. May sound hoarse and use increased vocal effort.

Question 38

ankylosis

Answer 38

stiffening of the joints. movement of the arytenoids are restricted. Cancer can also cause this. When this happens, the vocal folds do not fully close.

Question 39

PVFM

Answer 39

VCD. attributed to both psychological physiological causes.

Question 40

paralysis of the vocal cords

Answer 40

due to accidental injury of the RLN during surgery (thyroid, cardiac), progressive neuro diseases. malignant diseases, intubation trauma, laryngeal trauma, stroke, vagus nerve deficits.
-unilateral: depending on location of paralysis depends on voicing and management
-bilateral: may lead to wide open glottis with aphonia, aspiration. When paramedian, can be life threatening due to obstruction of the airway.

Question 41

spasmodic dysphonia (definition and types)

Answer 41

focal laryngeal dystonia. has neurogenic causes with emotional side effects. currently thought to be due to abnormal function of basal ganglia.
-abductor: intermittent, involuntary abduction of vocal cords causing breathing and aphonic moments. Tx includes botox and speech tx to relax techniques and continuous voicing, pharma intervention.
-Adductor: most common. overpressure due to prolonged over adduction of the vocal cods or tight closure of the vocal folds. Voice sounds strained/strangled. Treatment options include:
CO2 laser-creates groove and healing and scarring pulls VF away from midline widening the glottis.
RLN resection: RLN is cut to paralyze vocal fold on that side. Used with severe SMD who do not want botox
botox injections: neurotoxin injected directly into the VFs and creates a flaccid paralysis and hyperadduction ceases. Need to repeat every 3-6 months.
-voice therapy can include inhalation phonation, increased pitch, relaxation, head turning, counseling, yawn-sigh, flow phonation. No pushing techniques

Question 42

multiple sclerosis

Answer 42

progressive and diffuse demyelination of white matter. Impaired prosody, pitch, loudness control, harshness, breathiness, hypernasality, artic breakdowns.

Question 43

MG

Answer 43

neuromuscular autoimmune disease produces fatigue and muscle weakness. Decreased amount of acetylocholine at the myneuronal junction so mucles as difficulty contracting. Tx with corticosteroids.

Question 44

Parkinsons voice

Answer 44

lack of dopamine in the substantia nigra of the basal ganglia. breathy, lower vocal intensity, monotonous. Tx includes LSVT Loud.