Voice Disorders Midterm Flashcards
Modified Jaw Release Exercise
Purpose: To release the jaw to the neutral, rest position.
- Sit comfortably with your feet flat on floor. Rub your hands together rapidly to warm them.
- Close your eyes & gently cup your jaw so that it rests in the warm palms of your hands.
- Ask your jaw to release & allow the teeth to part slightly. You can now feel the freeway space of ~2-4 mm between the teeth.
- Gently remove your hands without adjusting your jaw & note what you feel in your jaw.
Can be used in a session to set up the larynx for easy phonation. Hourly practice during the day reinforces a more released posture.
8 Mantras for a New Clinician
- It is impossible to remember and implement everything you have learned in your coursework.
- Your skills will improve as you gain more experience.
- Listen to the patient’s account of his voice problem. Be in the present, explore, and ask for more information regarding his perspective.
- Every patient is unique.
- Remember that you do not empathize with the patient in the way you do with family and friends in your personal life.
- You cannot persuade or convince anyone of anything.
- No technique or model works for every patient.
- It is okay to say, “I don’t know”
Hypothesis
- Simple declarative statement that incoporates cause & effect, and can be tested.
- Based on behavior, not judgement or assumption.
- Critical reasoning: Observe behavior, listen to the voice, take history, incorporate patient’s perspective.
Goal of All Rehabilitiation
To facilitate change.
Plan
Individualized management strategy for this specific patient and his particular symptoms.
Develop hypotheses based on knowledge of…
- Normal anatomy & physiology
- Anatomical changes
- Manner of phonation
- Symptoms
Test Hypotheses
- Engage in therapeutic behaviors
- Observe the results
- Ask about sensations in head, neck, and thorax
- If the results support hypothesis - accept it.
- If the results do not support hypothesis - modify or reject it.
Perpetual Characteristics of Voice Problems
- Pitch
- Loudness
- Quality
Classification of Probable Underlying Physiological Breakdown
- Aperiodicity in vibration
- Adduction & Stiffness of vocal folds
- Changes in resonance
- Breath Control
Aperiodicity of Vibration
- Roughness
- Vocal Fry
- Creaky Voice
- Pitch Breaks
- Voice Breaks
- Aphonia
- Tremor
- Diplophonia
Rough Voice
- VF aperiodicity
- Difference in weight between VFs
- Change in stiffness between VFs
Vocal Fry
- Arytenoid cartilages are tightly adducted & VFs are relatively slack & compact
- Loose glottal closure
- Low airflow rate
- Low subglottal air pressure
Creaky Voice
- Foreceful adduction of arytenoid cartilages & medial compression of VFs
- Stiffened & lengthened VFs
- Stiff vocal tract
Pitch Breaks
- Instantaneous, involuntary change in speed of vibration of VFs
- Abrupt change in length & stiffness of VFs
- Differential weighting of VFs
Phonation Breaks
- Instantaneous, involuntary stoppage of vibration of VFs
- Abrupt change in length and stiffness of VFs
- Differential weighting of VFs
- Abrupt abduction of VFs
Aphonia
• VFs do not vibrate
- Adducted out of breath stream
- Stiffened to stop vibration
- Voiceless consonanty (aphonic) - /f, h, k, p, s, t/
- Whisper - an aphonic production
- Loud whisper - 20 dB quieter than conversational speech
Aphonia (hypotheses of probably underlying physiology)
- Absence of vibration of VFs
- Passive stiffening of VFs - Swelling or other increase in mass of VFs
- Passive decrease in tone of VFs - Paralysis or other neurological disorder
- Mismatch between strenth of expiratory drive & stiffness of VFs
Tremor
- Involuntary, rhythmic, oscillating movement of VFs, intrinsic laryngeal muscles, or extrinsic laryngeal muscles - Neurological or phsyiological
- Involuntary, rhythmic, oscillating movements in the diaphragm produce inconsistent subglottal air pressure - Neurological or physiological
- Referred tremor from involuntary tremor in the head, hand, etc. to the larynx - Neurological or physiological
Diplophonia
- Asychronous vibration of VFs
- Different weighting of VFs
- Different length and stiffness of VFs
Adduction and Stiffness of Vocal Folds and Vocal Tract
- Breathy
- Abrupt initiation
- Pressed phonation
- Strident
- Strained - strangled
- Presistent falsetto
- Virilzation
- Inappropriate pitch variability
- Limited pitch range
Breathy
- Inadequate adduction of VFs - Paralysis
- Gab anterior and posterior to vocal fold lesion allows air to leak
- Lack of adduction of VF - neurological problem, alkalosis
- Bowing of VFs - neurological, aging, surgical damage
Abrupt Initiation of Phonation
- Hyperadduction & stiffening of VFs prior to onset of phonation
- Build up of subglottal air before initiation of phonation
Pressed Phonation
- Hyperadduction & excessive stiffness of VFs
- Excessive subglottal pressure
- Stiffness above & below glottis
- Abrupt initiation of voice
- Long closed phase of vibration
Strident
- Hyperadduction & ecessive stiffness of VFs
- Excessive subglottal pressure
- Increased stiffness of vocal tract
- Abrupt initiation of voice
Strained - Strangled
- Hyperadduction of arytenoid cartilages & vocalis muscle - learned behavior or neurologically based
- High subglottal air pressure
- Small range of excursion of VFs due to high muscle tone
Persistent Falsetto
- Excessive length & stiffness of VFs
- Excessive elevation of larynx (extrinsic laryngeal muscles)
- Decreased space between hyoid bone & thyroid cartilage
- Tighness in jaw and tongue
Virilized Voice
- VFs shortened and stiffened
- Larynx lowered in throat (extrinsic laryngeal muscles)
- Reduced air flow between VFs
Inappropriate pitch variability
- Excessive changess in length of VFs
- Monopitch: VFs excessively stiffened
- Excessive pitch changes: VF stiffness varies excessively
Limited pitch range - Loss of high & low notes
• Excessive, passive stiffness of VFs
Changes in Resonance
- Hypernasality
- Hyponasality
- Back quality
Hypernasality
- Changes in resonance
- Ineffective closeure of velopharyngeal port
- Nasal emissions
Hyponasality
- Changes in resonance
- Excessive closure of velopharyngeal port (swollen adenoids)
- Nasal congestion
Back quality
- Changes in resonance
- Excessive dilation of the pharyngeal musculature
Breath Control
- Fading at end of breath groups
- Inappropriate loudness
- Inappropriate loudness variability
- Limited loudness range
Fading at end of breath groups
- Decreased abdominal support
- Inadequate inhalation to support length and duration of connected speech and singing
- Inefficient chencking action
- Air leak at level of glottis
Inappropriate loudness (Quiet)
- Inadequate inhalation
- Inadequate medial compression of vocal folds
- Vocal fold paresis or paralysis
- Gaps anterior and posterior to a lesion
Inappropriate Loudness (Loud)
- Inadequate checking action
- Excessive medial compression of vocal folds
Inappropriate Loudness Variability
- Inadequate inhalation
- Inefficient breath control - checking action
Limited Loudness Range
- Insufficient expiratory drive
- Inefficient breath control - checking action
- Air leak at level of glottis
- Excessive medial compression of VFs
Context from witch you and your patient will develop the rehabilitation goals
- Anatomic
- Growth and development
- Vocal physiology
- Motor learning theory
- Cognition
- Self-regulation
Physiology of Normal Voice Production
- Respiration
- Phonation
- Resonation/Articulation
Freedom to Act - Energetic Rest
- Closely related to effective voice production
- Spectrum of movement ranges from the body’s most lax position to its stiffest - Freedom to act resides BETWEEN these extremes
- “Energetic Rest” or “State of Release” - Body is ready to spring alertly into action without strain or stiffness
As a clinician you need to have a physiological rational for exercise:
- Contributes to the partnership you hope to build during this process
- Clarifies the purpose of procedures
- Facilitates adherence to practice and other recommendations
Innervation for Inhalation
- T1-T12 - Spinal intercostal muscles
- C2-3, C5-8, CN XI - Posterior neck muscles
- C3-5 Phrenic nerve - Diaphragm
Innervation for Exhalation
T1-T12 - Spinal intercostal muscles
Establishment of Respiration Cycles
- Newborn Stage 1 - lasts a few minutes following birth, establishment of postnatal respiration
- Newborn Stage 2 - Lasts sevveral hours to a day or more, all parts of chest & abdomen expand and contract together
- Newborn Stage 3 - Lasts several days or weeks, rapidly fluctuating rates, variable rhythms, and a wide variety of respiratory patterns
- Newborn Stage 4 - Begins several weeks after birth, stable rhythms & respiratory patterns as chest & abdomen expand and contract
- Around 8 Months - rhythmic diaphragmatic & thoracic movements are established
Child Respiration
By age 7 thoracic breathing predominates
Adult Respiration
20-21 Years of age adult vital capacity has developed
Aging of the lungs
80+ : May have increased compliance in lungs & increased stiffness of chest wall
- Decreased vital capactiy
- Reduced Voice Loudness
- Limited Pitch Range
Active (muscular forces) during respiration
- Inhalatory to expand and elevate the chest wall
• Diaphragm & external intercostal muscles - Exhalatory to collapse the chest wall during forced exhalation
• Abdominal musculature, transversus abdominis, external & internal obliques & rectus abdominis - Checking action to control speed of exhalation
• External intercostal muscles
Passive (non-muscular forces) during respiration
- Elasticity
- Gravity
- Pleural linkage
• Oppositional relationship between lungs (to shrink and collapse) & chest wall (to expand)
Pleural Linkage
- Thin, airtight membrane (visceral pleura) envelops lungs and a similar membrane (parietal pleura) lines inside of chest
- Intrapleural fluid binds chest wall to lungs via negative pressure
- Midrange of vital capacity where freedom to act is greatest
- The pull from elastic recoil of pulmonary chestwall unit reduces need for muscular activity during quiet breathing
Total Lung Volume
All air in lungs : ~ 6,000 mL
Vital Capcity
Total amount of air that can be expired ~4,000 mL
Tidal Volume
Midrange of vital capacity (35-60% VC) ~500 mL
Inspiratory Reserve
Air forcibly inhaled after quiet inspiration (60-100% VC) 2500+ mL
Expiratory Reserve
Air forcibly exhaled after quiet exhilation (0-34% VC) 900+ mL
Residual Volume
Air that keeps lungs inflated ~1200mL
Pulmonary Function Testing
- Manometer
- Catheter in mouth and nose
- Whole body plethysmograph
- Pneumotachometer
- Rothenberg mask with air chamber
- Spirometer (SpiroPet)
- Stopwatch (maximum phonation time)
Maximum Phonation Time
Norms:
• Children ~ 10 sec.
• Adults ~ 20 sec.
• Females ~25.7 sec
• Males ~34.6 sec.
Duration Too Short:
• Respiratory problem
• Lack of checking action
• Glottal insuffienciency
• Velopharyngeal insufficiency
• Errors in data collection
Duration excessively long suggests:
• Singer
• Pressed phonation
• Hyperadduction of VFs
• Errors in data collection
Calculate Phonation Quotient
Phantion Quotient = Vital Capactiy divided by maxium phonation time
Phonation Quotient Norms
• Range 100-200 cc/sec
Phonation quotient too low:
• Lack of checking action
• Glottal insufficiency
• Velopharyngeal insufficiency
• Errors in data collection
Phonation quotient excessively high:
• Singer
• Pressed phonation
• Hyperadduction of VFs
• Errors in data collection
Objective Measurement of Sustained /s/ & /z/
Norms for sustained /s/ and /z/:
• Normal /s/ for child is 9 sec
• Normal /z/ for child is 11 sec
• Normal /s/ for adult is 16 sec
• Normal /z/ for adult is 19 sec
Short duration for both suggests:
• Respiratory Problems
• Lack of checking action
• Errors in data collection
Excessively long duration for both suggests
• Singer
• Errors in data collection
Objective Measurement of s/z ratio
Norms for s/z ratio
• Normal range is slightly less than 1 (between .7 & .99)
Less than .7 suggests:
• Increased medial compression
• Excessive stiffness of VFs
• Constriction in Vocal Tract
• Inappropriately loud voice
• Pressed phonation
• Errors in data collection
Greater than 1 suggests:
• VF involvement
• Glottal insufficiency
• Velopharyngeal insufficiency
• Errors in data collection
Newborn Vocal Tract
- Vocal Tract is Short
- Tongue almost fills oral cavity
Young Child’s Vocal Tract
Age 4:
- Vocal Tract lengthens as the larynx descends
- Posterior 1/3 of tongue descends into pharynx
Child’s Vocal Tract
By Age 5:
• Pharynx has adult configuration
Independent Linear Source Filter Theory
- Gunnar Fant & Ken Stevens
- Sound is generated by an independent source (eg. VFs/Vocal Tract) & modified into speech by radiation characteristics of a linear acoustic fiter (vocal tract)
- Sensations of resonance are sympathetic vibration of air in vocal tract
Indpendent Linear Source Filter Theory Sounds
Voiced Sounds (vowls, nasals) • Source = periodoic glottal source • Filter = pharynx, jaw, soft palate, tongue, lips
Voiceless Fricatives (f,s) • Source = Turbulent noise from constriction in vocal tract • Filter = pharynx, jaw, soft palate, tongue, lips
Voice Fricatives (v,z) • Source = periodic glottal sournce • Source = turbulent noise from constriction in vocal tract • Filter = pharynx, jaw, soft palate, tongue, lips
Non-linear Interactive Source - Filter Theory
- Ingo Titze (1994)
- Filter + Inertive Reactance
Acoustic Response - Inertance
- Inertive ractance (sluggish response) of air column facilitates self sustained vibration
- Inertance: Lowers phonation threshold pressure, assists VFs in self-sustained vibration
Inertance
- When VFs vibrate, glottis opens and closes
- During opening, open, and closing phases, air flows through glottis
- Transglottal airflow bumps into a plug of air above VFs. Due to inertia, plug is sluggish
- Air flows through glottis and pushes against stationary air plug
- Eventually, glottal air flow overcomes inertia & pushes air plug toward mouth
- During closed phase of vibration, air does not move through glottis
- Due to inertia, air plug in vocal tract continues to move after glottis closes
- Continued movement of air plug in vocal tract creates a vacuum above VFs and facilitates closure of glottis
- Eventually, plug of air stops moving
Back Pressure
Semi- occlusion that opposes desired air flow; creates resistance
Higher supraglottal pressure diminshes airflow across glottis by creating an opposing force throughout vocal tract (Pascal’s Law)
Effects of Back Pressure - Semi Occluded Vocal Tract
- Spreads VFs apart to avoid excessive collision forces
- Keeps amplitude of vibration small
• Decreases transglottal pressure
- Transglottal pressure drop (differential) = pressure difference between supraglottal & subglottal pressures
Semi-occluded Vocal Tract Procedures
- Phonation through Straw
- Wave in a cave
- Homemade manometer
- Inverted megaphone
- Card kazoo
- Airway reflex maneuver
- Puffy cheeks exercise
- Voiced consonants
Semi-Occluded Vocal Tract Sounds
Higher to lower back pressure
- Stops
- Affricatives
- Fricatives
- Nasals
- Glides
- Closed Vowels
- Vowels
Resonance
- Conscious attention to sensations - enhances self-oscillation of the VFs & back pressure
- Release of extraneous muscle activity in head & neck enhances strenth of these vibrations
- Most apparent on nasal sounds (m,n,…)
- Less noticeable on vowels & some continuant phonemes (r, v, z, j, etc)
Supraglottal Pressure
Supraglottal pressure (back pressure) reduces the transglottal pressure drop (ie decreases effort require to vibrate the VFs)
Subglottal Pressure - Supraglottal Pressure = Transglottal Pressure
Psub - Psupra = TGP
