comd 472 PPT 3 Etiologies and Pathologies of Voice Disorders

Etiologies

Causes

Pathologies

Physical manifestations of disease

Common Etiologies

Vocal misuse

Medically related

Primary disorders

Personality related disorders

Vocal Misuse

Involves traumatic behaviors and inappropriate vocal components

Traumatic Behaviors

Forceful behaviors such as screaming, yelling, excessive coughing, making weird voices

Inappropriate Vocal Components

Can happen at any of these levels

Respiration - are they getting enough air? Deep v shallow breathing

Phonation - anything at the larynx level

Resonance - voice is in the wrong spot, think hyper/hyponasality

Pitch - too high/low for the person

Loudness - are they talking at the correct loudness for the environment

Rate - is their pace too fast or too slow

Medically Related

Trauma - hard contact sport, an accident

Direct surgery

Indirect surgery

Chronic illness

Traumatic Laryngitis

Resolves within a few days to 2 weeks

Traumatic Laryngitis Cause

Trauma to the vocal fold tissue

Traumatic Laryngitis Physical Characteristics

Vocal folds are erythematous (red) and swollen

May be accompanied by vocal fold hemorrhaging (bruising)

Traumatic Laryngitis Perceptual Characteristics

Hoarse

Low pitched

Breathy

Chronic Laryngitis Cause

Results if vocal abuse continues, particularly if the patient with laryngitis is using effort or straining to speak

Vocal Fold Cysts Causes

May be due to blockage of mucosal glandular duck with subsequent retention of mucus

It may occur after vocal abuse but could also be congenital

Vocal Fold Cysts Physical Characteristics

Cysts

Usually unilateral

Absent mucosal wave

Increases the VF mass/stiffness of VF cover

Irregular glottal closure

Occurs more often in woman

Cysts

Sacs of tissue that contain either liquid (mucous) or a semisolid substance (epithelial cells)

Vocal Fold Cysts - Perceptual

Hoarse

Breathy

Might be low pitch

Decreased loudness

Vocal Fold Cysts - Acoustic

Decreased pitch range

Aperiodicity

Increased noise levels

Vocal Fold Cysts - Aerodynamic

Increased airflow (little data)

Vocal Fold Cysts - Patient Complaints

Hoarseness

Vocal effort/strain

Vocal fatigue

Contact Ulcers/Grandulomas - Causes

GERD or LPR Vocal misuse

Misuse/abuse

Intubation trauma

Contact Ulcers - Causes - GERD OR LPR

Effects of stomach acid and enzymes on VF

GERD

Gastro Esophageal Reflux Disease

LPR

Laryngeal Pharyngeal Reflux

Contact Ulcers/Grandulomas - Physical Characteristics

Inflammatory necrotic lesions

Comprised of lymphocytes and fibrotic connective tissue

Usually unilateral

Variable closure - complete to incomplete

Mucosal wave possibility decreased

Lymphocytes

A type of white blood cell that forms a vital part of your immune system by helping your body fight infections and diseases

Contact Ulcers/Grandulomas - Perceptual

May or may not be low pitched , hoarse, beathy

Contact Ulcers/Grandulomas - Acoustic

Depends on severity

Possible decreased fundamental frequency

Contact Ulcers/Grandulomas - Aerodynamics

Normal or increased airflow

Normal Ps (little data)

Contact Ulcers/Grandulomas - Patient Complaints

Vocal fatigue

Sensation of something in the throat

Pain on phonation

Voice worsens with prolonged use

Reflux Laryngitis - Causes

GERD

LPR

Reflux Laryngitis - Physical Characteristics

Both may cause voice problems

Regurgitation of acid and stomach enzymes are irritants to the VFs which can cause VF edema, erythema, arytenoid and posterior commissure hypertrophy, pachydermia ( thickening of tissue between the arytenoids

Reflux Laryngitis - Perceptual

Hoarseness

Breathing’s

Maybe decreased fundamental frequency

Vocal fatigue

Reflux Laryngitis - Acoustic

Increased noise

Infectious Laryngitis - Cause

Inflammatory response of the larynx due to a viral infection (severe head or chest cold)

Infectious Laryngitis - Physical Characteristics

Vocal folds and laryngeal inlet appear red and swollen

Symptoms- total voice loss, hoarseness, breathiness, low pitch

Infectious Laryngitis - Viral Treatment

Voice rest, water, anti-inflammatory medications, non-mentholated lozenges

Infectious Laryngitis - Bacteria Treatment

vocal rest, water, anti-inflammatory medications, non-mentholated lozenges

*A physician may prescribe antibiotics

Laryngeal Papilloma - Causes

HPV - human papilloma virus

Laryngeal Papilloma - Physical Characteristics

Two types: Early childhood onset and Adult onset

Wart-like growth

Can also be found ion the trachea and oropharynx

Incomplete glottis closure

Absent mucosal wave

Increase mucosal wave

Increases VF mass and stiffness

Laryngeal Papilloma - Treatment - Before Puberty

VPF surgically removed

Tend to re-occur until puberty, resulting in multiple surgeries

Laryngeal Papilloma - Treatment - After Puberty

Most cases (80%) spontaneously resolve after puberty

Adults - surgery

Laryngeal Papilloma - Perceptual

Hoarseness

Breathiness

Strained

Laryngeal Papilloma - Acoustic

No Data

Laryngeal Papilloma - Aerodynamic

No data available BUT due to increased stiffness of VF, subglottal pressure is likely increased

Scarring due to repeated surgeries will further increase stiffness and decrease mucosal wave

Laryngeal Papilloma - Patient Complaints

Trouble breathing

Decreased pitch and loudness range

Vocal effort/strain

Laryngeal Web - Causes

Congenital

Acquired post-surgically

After laryngeal trauma

Laryngeal Web - Physical Characteristics

Band of tissue that forms in the anterior 1/3 of glottis

Laryngeal Web - Physical Characteristics - Infants

Inhalators stridor may be present

Shortness of breath

Hugh pitched crying

Laryngeal Web - Perceptual

Voice is hoarse

High pitched

Leukoplakia & Hyperkeratosis - Description

Pre-cancerous lesion

Range from flat plaque-like whitish patches (leukoplakia) to warty lesions (keratosis)

Arise from epithelium

Leukoplakia & Hyperkeratosis - Cause

Constant irritation to VF

Leukoplakia & Hyperkeratosis - Physical Characteristics

Can be unilateral or bilateral

VF edges may be rough

Increased VF mass and swiftness Decreases mucosal wave

Irregular glottis closure

Aperiodicity

VF are asymmetric

Leukoplakia & Hyperkeratosis - Perceptual

Hoarse

Rough

Sulcus Vocalis - Description

A longitudinal groove or indentation in upper edge of the VFs that parallels the free margins

In SLP layer

Sulcus Vocalis - Cause

Congenital or traumatic (abuse/misuse)

May also be due to a rupture VF cyst

Sulcus Vocalis - Physical Characteristics

Unilateral or bilateral

Incomplete glottic closure

Decreased mucosal wave and amplitude of vibration

Increased VF cover stiffness but decreaseS mass of cover

Sulcus Vocalis - Perceptual

Hoarse

Breathy

Laryngeal Cancer - Description

90% are malignant squamous cell carcinomas

Can be supraglottic, glottic and/or subglottic

Laryngeal Cancer - Symptoms

Hoarse, dry, rough, low pitched, breathy

Globes sensation

Inhalators stridor

Throat pain

Painful/problems swallowing

Shortness of breath

Laryngeal Cancer - Risk Factors

Smoking

Alcohol

Smoking & Alcohol

Environmental irritants

Chemicals

Asbestos

Laryngeal Cancer - Perceptual

Chronic hoarseness

Lump in neck

Swallowing problems

Neck tenderness

Pain during swallowing

Laryngeal Cancer - Acoustic

Depends on extent/severity

Increased frequency/intensity disturbances

Decreased pitch range

Increases fundamental frequency

Increased noise levels

Laryngeal Cancer - Aerodynamic

Increased airflow rates (little data)

Ventricular Phonation - Description

Adduction and use of the false or ventricular vocal folds for phonation

Often seen in patients with a primary underlining, vocal pathology nodules which results in severely decreased glottic closure and increased airflow

Ventricular Phonation - Diseases include

Vocal fold papillomas

Vocal fold paralysis

Large vocal fold nodules

Ventricular Phonation - Physical Characteristics

Increase laryngeal muscle tension to compensate for air wastage

Inability to build, sufficient subglottic pressure

decreased loudness

Pt. ‘recruits’ the false vocal folds to compensate

Adducted, FVF, overlap with true VFs and ‘loads’ them causing abnormal vibrations

FVFs may also vibrate, causing ‘diplophonia’

Ventricular Phonation - Perceptual

Hoarse

Low pitched

• combined mass of the true and false folds

Breathy

Monotone

Diplophonia

A voice condition, where a person produces two different pitches or tones at the same time

Ventricular Phonation - Acoustic

Decrease in pitch range

Ventricular Phonation - Patient Complaints

Vocal effort/strain

Possibly pain/discomfort

Muscle Tension Dysphonia - Causes

Excessive extrinsic laryngeal muscle tension, including tension in supra- and infrahyoid, muscles, and neck muscles

Excessive internal/supraglottic laryngeal muscle tension

Can occur by itself, or secondary to a primary vocal pathology as a negative compensatory strategy

Muscle Tension Dysphonia - Clinical Signs

Elevated laryngeal height

Narrow, tense thyrohyoid space

Tension in suprahyoid muscles

Tense, tight thyrohyoid muscles

Inability to lateralize the larynx (rock left to right)

Muscle Tension Dysphonia - Videoendoscopic Signs

Laryngeal anterior – posterior compression

Laryngeal, medial lateral compression, (may involve FVFs)

VF hyperadduction and foreshortening

Supraglottic squeezing (sphincter-like closure)

Muscle Tension Dysphonia - Perceptual Characteristics

Harsh

Hoarse or breathy

Tense/tight

Effortful

Pitch and/or phonation breaks

Normal pitch or elevated pitch

Muscle Tension Dysphonia - Patient Complaints

Vocal fatigue

Tight, tense throat

Laryngeal pain/discomfort

Psychogenic Voice Disorder - Puberphonia

Persistence of a child-like voice quality after puberty

Learned or psychogenic in nature

Voice is high pitched

Possibly hoarse and breathy

Vocal pitch often lowers when shouting or heavy lifting

Psychogenic Aphonia or Dysphonia

The complete loss of voice or a disordered voice with no underlying physical causes

Sudden onset or preceded by periods of voice loss or dysphonia

Often associated with some type of fear, stress, or traumatic event

VFs appear healthy while non-speech/vegetative functions such as throat clearing, coughing, laughing etc show normal phonation

Paradoxical Vocal Cord Movement (PVCM)

Adduction of VFs during quiet breathing

• stridor (high pitched, wheezing sound)

• Shortness of breath

• Voice maybe hoarse, weak, breathy

No known cause

Primary concern is ability to breathe

Patients complain of throat tightness, wheezing, shortness of breath, chest/lung tightness, irregular breathing patterns, and cough

Unilateral VF Paralysis/Paresis - Causes

Unilateral Vegas Nerve (CN X) lesion

RLN disease or trauma

• Injury to the left vs right side

90% of unilateral VFP

Results in flaccidity and decreased tone and dysphasia

Unilateral brainstem strokes

Unilateral injury to the RLN (branch of CN X) during thoracic or neck surgery

Neck/laryngeal trauma

Viral infection

Unilateral VF Paralysis/Paresis - Physical Characteristics

Affected VF is usually in paramedian position

Regarding vibrations

• VF have some anterior approximation

• Healthy VF sometimes crosses the midline to aid adduction

• Airflow sets affected fold into vibration

• Bernoulli effect may aid in VF closure

Unilateral VF Paralysis/Paresis - Perceptual

Breathy

Decreased loudness and loudness range

Hoarse

Decreased pitch range

Bilateral Vocal Fold Paralysis - Causes

50% of cases - bilateral damage to RLN during thyroid surgery

Trauma

Neurological disease/injury

Bilateral cerebral damage

Bilateral damage to the brainstem in the region of CN X

Incubation injury

Viral infection

Malignancy

CVAs may cause voice problems if they are lower bilateral lesions specifically in the brainstem

Malignancy

The presence of abnormal cells that grow in an uncontrolled way, invade nearby tissue, and can spread to other parts of the body

Bilateral Vocal Fold Paralysis - Characteristics - Abductor Paralysis

Affects the cricoarytenoid muscle in the larynx

Voice may be strained, strangled, monotone, low pitched, low volume, hypernasal

Voice is secondary concern to respiratory safety

Bilateral Vocal Fold Paralysis - Characteristics - Adductor Paralysis

Can affect any of the following muscles:

Lateral cricoarytenoid

Oblique arytenoid

Ttransverse arytenoid

Characterized by:

Aphonia and severe dysphasia

Feeding safety is primary concern

Bilateral Vocal Fold Paralysis - Additional Characteristics

May see tongue, velum, and pharyngeal muscle weakness or paralysis

Tracheotomy is usually required

Bilateral Vocal Fold Paralysis - Damage to SLN

Most common cause -

• Thyroid surgery, can be unilateral or bilateral

• May also be due to a virus

Results in paralysis or paresis of CT muscle

Bilateral Vocal Fold Paralysis - Damage to SLN - Symptoms

Bowing and rotation of VF on affected side

Decreased pitch range

Decreased speaking pitch

Breathiness due to bowing

May recover spontaneously

Can be extreme tense or unable to tense muscles

Vocal Fold Bowing - Cause

Associated with presbylaryngis or presbyphonia or ‘aging voice’

Atrophy of muscle due to subtle decrease in nerve input resulting in ‘hypotonicity’

Can also be observed in younger pts due to an increase in laryngeal muscle tension

Presbylaryngitis

Age related structural changes in the voice box

Vocal Fold Bowing - Characteristics

Vocal folds take on a ‘bowed shape’

Only the posterior and anterior aspects of the VF adduct

Usually bilateral

Must rule out all other possible underlying disease factors such as Parkinson’s, other neurological diseases, etc

Vocal Fold Bowing - Perceptual

Higher pitch

Hoarse

Breathy

Strained/effortful due to compensating with increased muscle tension

Vocal Fold Bowing - Acoustic and Aerodynamic

Decreased pitch and loudness ranges

Increased noise in voice

Possible vocal tremor

Increased airflow

Vocal Fold Bowing - Patient Complaints

Vocal fatigue

Trouble being heard/projecting the voice

Dislikes the sound of voice

Strained/effort

Spasmodic Dysphonia - Description - Focal Dystonia

Involuntary muscle contractions in an isolated body part

• In this case either the VF abductors, the adductors, or both

Laryngeal muscles contract spontaneously, irregularly, and uncontrollably

• Psychogenic component

Due to effect disorder has on patient’s communication, and thus, work, social, and family life

More common in women (60-85%)

Onset - middle age

Spasmodic Dysphonia - Adductor

Most common

VF muscles LCA, IA, TA spasm periodically causing undesired hyper function of the muscles resulting in a harsh, strained, strangled sound with obvious effort

Spasmodic Dysphonia - Abductor

VF muscle PCA spasms periodically causing undesired hyper function of the muscle resulting in a breathy, hoarse, weak voice, and decreased loudness is a problem

Spasmodic Dysphonia - Mixed

A combination of LCA, IA, TA, and PCA muscles that spasm periodically

Essential Tremor of the Larynx

Can be isolated to the voice, but may be associated with tremors in the head, hands, tongue, etc.

Has a frequency of 4-7 Hz

Characterized by regular or steady fluctuations in loudness and pitch

Always present in strained phonation but can be present in speech

Is quiet at rest but present during volitional moment

Onset is middle to late middle age.

Amyotrophic Lateral Sclerosis

Progressive disease of unknown cause

Affects upper and lower motor neurons (cortex, brainstem, and spinal cord)

Lack of Innervation to muscles causes muscles waiting, twitches, weakness, and spasticity

Articulation problems, dysphasia

Voice has hoarseness, harshness, strain and struggle, hyper-nasality*, and is breathy