Made up of different layers Outer layer = epithelium Below the epithelium = lamina propria - Superficial layer = Reinke’s space - Intermediate layer – less flexible than Reinke’s space - Deep layer – less flexible than the first two layers Below the lamina propria = thyroarytenoid muscle

Cricoarytenoid joints - Adduction - Abduction Cricothyroid joints - Downward tilt of the thyroid cartilage - Upwards tilt cricoid cartilage

Voice Disorders Flashcards by Kasey Woods

Laryngeal skeleton:

1 Bone – hyoid bone
Hyoid membrane

6 Cartilages:
Thyroid
   -Thyroid notch
Cricoid
Epiglottis - unpaired
Arytenoid (2)
  -Vocal process and muscular process
Corniculate (2)
Cuneform (2)

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Laryngeal Cavities:

Vestibule
Laryngeal ventricle
Glottis

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Vocal Folds

Made up of different layers

Outer layer = epithelium

Below the epithelium = lamina propria

Superficial layer = Reinke’s space
Intermediate layer – less flexible than Reinke’s space
Deep layer – less flexible than the first two layers

Below the lamina propria = thyroarytenoid muscle

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Cover-Body Model

Cover = epithelium and superior layer of the lamina propria
Loose and pliable; vibrates the most

Vocal ligament = intermediate and deep lamina propria layers
Stiffer

Body = thyroarytenoid muscle
Stiffest

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Extrinsic Muscles of the Larynx

Extrinsic – connect to the hyoid bone and a structure outside of the larynx

Divided into suprahyoids and infrahyoids

Suprahyoids- attach above the hyoid bone; contraction elevates the larynx

Infrahyoids- attach below the hyoid bone; contractions depresses the larynx

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Intrinsic Muscles of the Larynx

Intrinsic – either abduct or adduct the vocal folds
Abduct – contraction opens the vocal folds
Adduct – contraction closes the vocal folds

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Intrinsic Muscles of the Larynx

Intrinsic – either abduct or adduct the vocal folds

Intrinsic muscles – adduction

Lateral cricoarytenoids (insert into the muscular process)
Interarytenoid – transverse and oblique

Intrinsic muscles – abduction
-Posterior cricoarytenoid

Tensors – control vocal pitch
-Cricothyroid – pars rectus and pars oblique

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Ligaments of the Larynx

Thyroepiglottic ligament

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Joints of the Larynx

Cricoarytenoid joints

Adduction
Abduction

Cricothyroid joints

Downward tilt of the thyroid cartilage
Upwards tilt cricoid cartilage

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Laryngeal Innervation

Vagus (not Vegas) X

Divided into three main branches:

Pharyngeal nerve – motor information to some soft palate muscles

Superior laryngeal nerve
Internal – sensory information to larynx
External – motor information to the cricothyroid muscle

Recurrent laryngeal – motor information to all intrinsic muscles of the larynx except cricothyroid

Right recurrent loops around subclavian artery
Left recurrent loops around the arch of the aorta (heart) – cardiac problems could cause vocal fold paralysis

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Myoelastic-Aerodynamic Theory:

Muscle force - Lateral cricoarytenoid and interarytenoid muscles contract

Tissue elasticity – vocal folds

Air pressures – subglottal pressures

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Bernoulli Principle:

Air increases velocity (speed) and decreases in pressure when passing through a narrow channel

This draws the vocal folds medially

Positive air pressure opens the vocal folds and negative air pressure closes the vocal folds

One cycle of vocal fold vibration

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Voice Production

Mucosal wave created from vocal fold movement

Open from bottom to top
Close from top to bottom

Voiced speech sounds – vocal folds come together and vibrate
Voiceless speech sounds and inhale – vocal folds are apart

Fundamental frequency – rate of vocal fold vibration
  -Measured in cycles per second/Hertz
     Children 250-300 Hz
     Adult females 190-250 Hz
     Adult males 180-250 Hz

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Pitch & Loudness

Raise pitch:
Vocal folds lengthen, tighten, and increase tension

Lower pitch:
Vocal folds relax, increase mass, and decrease vibration

Increase loudness:
Vocal folds are held together tightly
Subglottal pressure builds, then forcefully blows apart vocal folds
Vocal folds close more forcefully

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Infant Larynx

Positioned high in the neck
-Gradually lowers until ~ age 15-20

Smaller

Vocal folds are short

Complex vocal ligament layers emerge around age 3 years

Neurologically immature (coordination improves w/ maturation)

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Puberty & Laryngeal Development

Cartilages enlarge

Epiglottis flattens and becomes less bulky

Males- angle of thyroid cartilages decreases (Adam’s apple - thyroid notch becomes more visible)

Males – laryngeal mucosa become stronger and thicker

Vocal folds grow

Pitch lowers

Mature voice ~18 years

Aging & Laryngeal Development

Cartilages ossify – stiffen

Thinning and atrophy of vocal fold muscles

Bowing vocal folds

Reduced lubrication

“Senescent voice”
Tremulous, weak, hoarse, or breathy
Good physical health – good vocal quality

Voice Disorders

Structural disorders – physical changes in the vocal mechanism
E.g., changes in vocal fold tissue and the aging larynx

Neurogenic disorders – problems with CNS or PNS innervation of the larynx – affects vocal functioning
E.g., vocal tremor, spasmodic dysphonia, or vocal fold paralysis

Functional disorders- improper or inefficient use of the vocal mechanism
E.g., vocal fatigue, muscle tension aphonia, ventricular phonation

Overlap is common

Signs & Symptoms of Voice Disorders

Dysphonia – altered pitch, loudness or vocal effort

Breathiness (puffs of air escape the VF)
Hoarseness (irregularity in quality)
Harshness (strained/strangled voice quality; increased tension)
Tremor (quivering sound)
Phonation breaks (VF not closing)

Other signs and symptoms:

Increased vocal effort
Fatigue
Excessive cough and/or throat clearing
Short of breath

Laryngomalacia (luh ring oh muh lay she uh)

Structural VD

Congenital:

Lack of calcium results in weak cartilage above the glottis; the cartilages may collapse under force of respiration
Tracheomalacia may also be present (weakness in the carts of the trachea; can also collapse)
Stridor - noisy breathing (due to floppiness of carts falling into airstream)
Gastroesophageal reflux
Surgical intervention may be needed to correct airway obstruction

Laryngeal Web

Structural VD:
Webbing of the glottis
- a thin sheet of connective tissue btwn the VF; can be complete or partial
- VF are unable to seperate

Congenital laryngeal atresia – complete web (more severe)

Surgical intervention
Can have mild to severe effect on voice

Papilloma

Structural VD:
Benign, wart-like growths on the epithelium of the vocal folds
-Spread from vocal folds up; subglottic (into the trachea) considered aggressive

Cause:
Human papilloma virus

Symptoms:
Hoarseness, stridor, aphonia, and respiratory distress

Treatment:
Laser removal and therapy

Can occur in both children and adults; more severe in children bc the larynx smaller

Subglottic Stenosis

Structural VD:
Can be congenital or acquired
  -Accident or surgical trauma
  -GERD
  -Radiation therapy

Narrowing of the larynx below the vocal folds:

Thickened cartilage and/or tissue
Varying degrees

Treatment:
Laser therapy to remove excess tissue or cartilage or reconstruction

Rheumatoid Arthritis (RA)

Structural VD:

Inflammation in multiple joints
Etiology unknown – commonly seen in thirties and forties
Cricoarytenoid joint can develop RA

Symptoms:
Hoarseness, pain in the ear when swallowing (due to nerve innervation), labored breathing, stridor, globus sensation in throat

Joints may become fixed or immobile – airway compromise

Treatment – cool humidification, anti-inflammatories, steroids

Laryngeal Trauma

Structural VD: Blunt injury to the neck or injury to the larynx -Damage to cricoarytenoid joint and/or arytenoid cartilages -Can result in fibrosis (scarring) Symptoms: hoarseness, dyspnea, and dysphagia Without fibrosis, can exhibit full recovery

Sulcus Vocalis

Structural VD Bowing of the vocal folds (spindle shaped gap) caused by the development of a groove -Usually bilateral -Cause – unknown Symptoms: dysphonic

Vocal Fold Paralysis

Neurogenic VD: Unilateral or bilateral; abduction or adduction -Pharyngeal nerve damage = hypernasality -Recurrent laryngeal nerve damage = abduction and adduction affected -Superior laryngeal nerve damage = problems with pitch ``` Potential causes: Trauma Progressive diseases Viral infection Heart problems* (may be unknown to client) Idiopathic ```

Spasmodic Dysphonia

Abnormal involuntary movements of one or muscles of the larynx Action induced and task specific Vocal fold movement is strained Voice is strained, jerky, tight, or hoarse May have periods of aphonia or spasms Causes: Historically thought to be psychogenic Neurogenic – focal dystonia of the larynx

Adductor SD

Most common; intermittent, tight adduction of the vocal folds Symptoms: - Strained, forced voicing - Intermittent aphonia or voice breaks - Stutter-like phonatory blocks and delayed onset of phonation - Vocal tremor - Monoloudness and/or intermittent bursts of loudness - Monopitch

Mixed SD

Because it’s never simple! Combination of adductor and abductor Strained vocal quality with breathy breaks Primarily adductor or abductor

Abductor SD

Normal or breathy voice quality with involuntary period of aphonia Vocal fold spasms in the abducted position Aphonia triggered by voiceless consonants ``` Symptoms: Vocal tremor Reduced speech intelligibility Monoloudness Hyperventilation ```

Nodules

Benign growths on the epithelium Usually bilateral Occur where vibration is most vigorous Vascular and pliable and then hard and fibrous Symptoms: low pitch, hoarseness, and breathiness

Polyp

Benign tumors of the mucosa Unilateral, soft and pliable Caused by abuse and other issues like allergies Symptoms: low pitch, hoarseness, and breathiness

Contact Ulcer

Mucosal covering of the tip of the vocal process erodes Granulation tissue can develop around the ulcer Causes: misuse of voice – loud at low pitch or GERD or intubation trauma Symptoms: Pain which can radiate to ear Breathy and hoarse

Assessment of Voice Disorders

Team approach Members: Otolaryngologist, SLP, singing teacher, neurology, and others ``` SLP’s role: Evaluate vocal symptoms, determine severity, diagnose, and improve vocal function Know when to refer and who to refer to Counseling Advocate ``` Screening: - Evaluate respiration, phonation, and resonance - Formal or informal screening tasks or questionnaires Comprehensive Assessment: - Case history - Oral mechanism exam - Auditory-Perceptual assessment - Acoustic assessment - Aerodynamic assessment - Imaging