Voice Disorders

Question 1

Frequency

Answer 1

• An acoustic phenomena
• The vibration of the folds is directly related to the frequency and quality of the sound of the person’s voice
• The number of times per second that the vocal folds vibrate a cycle is the frequency of vibration (not completely consistent) (mucosal wave)
• The average frequency on which a person speaks is the *fundamental frequency *

Question 2

Pitch

Answer 2

• Perceptual phenomena (cannot be measured physically)
• The avg. adult male’s fundamental frequency is ~130 HZ, the avg. adult female’s fundamental is ~230 Hz
  
  • in geriatric populations, male’s tend to rise slightly and female’s drop slightly
• Theoretically, the vocal folds should vibrate relatively the same from period to period; but, their periodicity (cycle to cycle) is not perfect
• These periodic changes in vocal fold vibrations are called frequency perturbation or jitter (never 0)

Question 3

Amplitude

Answer 3

• Intensity is an acoustic phenomena,
• Loudness is a perceptual phenomena
• Amplitude (amount of displacement is the vocal folds when they vibrate)
• There are small amplitude changes (frequency pertubation and amplitude perturbation) from cycle to cycle; periodicity is not perfect
  
  • Higher perturbation would correlate to poorer quality;
  • Lower perturbation should correlate to better quality
• Cycle to cycle changes will result in increased perturbation scores and changes in quality
• Changed pitch related to a more consistent change in the vocal folds
• The avg. person is able to vary his/her pitch by about two octaves (16 whole notes)

Question 4

How are voice disorders classified?

Answer 4

1. Etiologic
2. Kinesiologic
3. Perceptual

Question 5

Etiologic Voice Disorders

Answer 5

• Medical model
• Deals w/ the causes of the disorder, typically discussed relative to organic or nonorganic
• Structural issue = organic problem
• Functional = nonorganic

Question 6

Kinesiologic

Answer 6

• Has to do with movement of the vocal folds; how they vibrate
• Usually described as either hypofunctional or hyperfunctional
  
  • Medially compression (not enough – breathy; too much – harsh)

Question 7

Perceptual

Answer 7

• Based on what you hear:
  
  • Quality
  • Resonance
  • Loudness
  • Pitch

Question 8

Perceptual Qualities of Pitch in Voice Disorders

Answer 8

1. Monopitch
2. Inappropriate pitch
3. Pitch breaks
4. Reduced pitch range

Question 9

Monopitch

Answer 9

Lacks variation during speech or other vocal activities; may relate to an organic/nonorganic problem

Question 10

Inappropriate Pitch

Answer 10

Relative to age and gender, exceeding the range considered appropriate – either too high or too low

Question 11

Pitch Breaks

Answer 11

Unexpected and sudden shifts in pitch, upward/downward; common in puberty but can also be observed with organic/neurological etiologies

Question 12

Reduced Pitch Range

Answer 12

We tend to be able to vocalize about 2 octaves; usually it’s the upper range that is reduced

Question 13

Perceptual Qualities of Loudness in Voice Disorders

Answer 13

1. Monoloudness
2. Loudness variation
3. Reduced loudness range

Question 14

Monoloudness

Answer 14

A reduction in the ability to vary the vocal loudness; unrelated to how loudness level of the voice

Question 15

Loudness Variation

Answer 15

Opposite of monoloudness; either too loud or too soft, it be related to hearing impairment, personality/habit, neurologic, or respiratory problems

Question 16

Reduced Loudness Range

Answer 16

In a single patient, this is often observed along with reduced pitch range

Question 17

Perceptual Qualities of Quality in Voice Disorders

Answer 17

1. Breathy
2. Rough
3. Hoarse
4. Harsh
5. Tremor
6. Strain/struggle
7. Diplophonia
8. Glottal fry
9. Wet
10. Stidor
11. Throat clearing
12. Cough

Question 18

Breathy

Answer 18

Air escaping through the glottis during phonation because of inadequate glottal closure; because of this the voice is often somewhat weak; a severe form of breathiness is called aphonia (no voicing)

• Consistent (aphonia)
• Episodic (aphonia)

Question 19

Rough

Answer 19

A lack of periodicity in the voice (without accompanying breathiness); there is a perceived irregularity in the voice

Question 20

Hoarse

Answer 20

• Most common characteristic of voice problems.
• There is aperiodic vibration of the folds along with leakage of the air through the glottis.
• Some would characterize it as a cross between breathiness and roughness.
• Related to perturbation with considerable noise in the spectrum

Question 21

Harsh

Answer 21

• The opposite of breathy
• Related to “roughness” with aperiodicity in the voice.
• The folds are too tightly adducted, often described as tense.
• Could see hard glottal attacks and tension in the head and neck.

Question 22

Tremor

Answer 22

• A regular, rhythmic variation and pitch and loudness that are not under voluntary control
• Perceived as unsteady or quivering. Usually relates to CNS damage

Question 23

Stain/Struggle

Answer 23

Usually seen as difficulty in initiating or maintaining phonation; minimal periods of aphonia or voice stoppages may be observed

Question 24

Diplophonia

Answer 24

• Means “double voice.”
• There are two distinct fundamental frequencies heard at the same time; this may be observed in either the true or false vocal folds (or both)

Question 25

Glottal Fry

Answer 25

• Extremely low pitched phonation, has a rough vocal quality, except this is periodic.
• May be observed normally when a person dips into the pulse register usually at the end of an utterance and often when the person is speaking near the bottom of their pitch range.
• Not considered abnormal, unless the person typically speaks within the pulse register
• People who consistently utilize it may also increase glottal tension to accomplish communicative needs.

Question 26

Wet

Answer 26

A liquid sounding voice quality, often accompanied with a hoarse quality; certainly may be observed in a patient who is silently aspirating or has drainage issues

Question 27

Stridor

Answer 27

A term that refers to noisy breathing that can accompany inspiration, expiration, or both; it is indicative of a narrowing of the airway; may be structural, neurologic, or psychologic in etiology

Question 28

Throat Clearing

Answer 28

May relate to clearing mucous from the folds or a feeling of “something in the throat” (globus sensation); it is less damaging to the folds than coughing but with similar physiology

Question 29

Cough

Answer 29

Triggered by reflexes below the level of the folds; concern would relate to the etiology and frequency of the cough; can be damaging

Question 30

Causes of Organic Voice Disorders

Answer 30

1. Changes in the mass/tension of the vocal folds due to physical changes in the folds, and
2. Changes in the neurologic innervation to the vocal folds.
3. Some structural changes to the folds are such because of vocal abuse or misuse issues; in this sense, the etiology is clearly behavioral but has created a structural or organic disorder

Question 31

Changes in Mass/Tension

Answer 31

1. Laryngeal Web
2. Palpilloma
3. Keratosis/Leukoplakia
4. Cysts
5. Nodules
6. Polyps

Question 32

Laryngeal Web

Answer 32

• Congenital, a web of tissue covers part or all of the glottis (or at some other location within the larynx)
• Congenital webbing is caused by failure of the glottis to separate in the embryo
• Acquired webs can occur due to trauma. Inhalatory stridor is likely

Question 33

Papilloma

Answer 33

• The most common laryngeal tumor in childhood, may also be seen in adults.
• Lesions are benign and effect the epithelium,thought to be caused by a virus.
• Due to proliferation, surgical excision is typical, however, they can reoccur
• You would likely observe aperiodic vf vibration and accompanying perceptual problems related, observe stridor, if the lesions are large enough

Question 34

Keratosis/Leukoplakia

Answer 34

• A thickening of the epithelial lining (can be seen wherever there is epithelium).
• Benign but can be pre-cancerous.
• Smoking, pollutants, and other factors are often thought to be causes, getting rid of the irritant is the best treatment.

Question 35

Cysts

Answer 35

• A sac of tissue containing a liquid or semi-solid substance on the superficial layer of the Lamina Propria, etiology is unknown.
• Cysts tend to produce a stiffer and more asymmetrical vibratory pattern compared to nodules and polyps.
• Vocally, the patient will present with hoarseness

Question 36

Nodules

Answer 36

• Most common vocal fold lesion in adults and children.
• Small, densely packed collection of cells, often bilateral, commonly found along the free margin of the fold at the midpoint of the foldthey are caused by vocal abuse/misuse
• Begin as edema, becoming fibrous: the submucosal edema loosens the mucosa from the vocal ligament, and the nodule appears within the superficial layer of the LP.
• Become more fibrous and firm, compared to polyps, if the edema doesn’t become fibrous, it may degenerate into a polyp
• Voice will be likely hoarse and breathy. A reduced pitch range is seen with many speakers/singers