Human Communication Disorders Exam 5

voice

_ is our primary means of emotional and linguistic expression and an essential feature of speech

• _ reflects gender, personality, personal habits, age, and one’s general health

• _ characteristics help listeners infer traits such as friendliness and trustworthiness

• The _ mirrors mood, attitudes, and feelings

resonance

The quality of the voice that is produced from sound vibrations in the pharyngeal, oral, and nasal cavities

velopharyngeal dysfunction (VPD)

Failure of the velopharyngeal mechanism to separate the oral and nasal cavities during speech production and swallowing

voice pitch

Perceptual correlate of F0 associated with rate of vocal fold vibration

– Measured in Hertz (Hz), the number of complete vibrations/sec

– F0 is around 125 Hz for men, 250 Hz for women, and 500 Hz for children

– Frequency of the voice constantly varies during speech

Varying pitch has linguistic significance

– Modifications in length and tension of the vocal folds are necessary to produce pitch change

monopitch voice

Result of not varying habitual speaking frequency

vocal loudness

Perceptual correlate of intensity

– Measured in decibels (dB)

– Monoloudness: A voice that lacks normal variations of loudness during speech

– Conversational speech averages around 60 dB

– Alveolar pressure is the major determinant of vocal intensity

monoloudness

A voice that lacks normal variations of loudness during speech

voice quality

Unique traits of an individual’s voice quality are derived from the anatomy of the larynx, shape of the vocal tract and its resonant characteristics, and suprasegmental aspects of speech

– Voice quality is based on genetics and learned behaviors

lifespan issues

Laryngeal cartilages and joints begin to ossify or calcify around the third (men) and fourth (women) decades

– Changes in pulmonary function, neuromuscular properties of the intrinsic muscles, and vocal fold tissue occur with advancing age

– Presbyphonia: Voice disorder characterized by perceptual changes in pitch, pitch range, loudness, and voice quality in older individuals

– Menopause and hormone-related factors causing edema may be responsible for the change in women (lowered F0)

– For men, age-related changes to laryngeal muscle due to atrophy may be responsible for increased F0 in older me

presbyphonia

Voice disorder characterized by perceptual changes in pitch, pitch range, loudness, and voice quality in older individuals

resonance and anatomical structures

Largely determined by velopharyngeal structure and function

– Structures include

▪ Velum

▪ Lateral pharyngeal walls

▪ Posterior pharyngeal wall

– Velopharyngeal port remains open most of the time to allow nasal breathing and for nasal consonants

– Must close for production of oral speech sounds

lifespan issues with resonance

Closure patterns may vary among individuals and can change over time

– After adenoidectomy, young children may have to change their closure patterns

– Velopharyngeal function during speech production remains intact and unchanged from young adulthood through advanced age

disorders of voice and resonance

• Deviations may be in voice quality, pitch, and/or loudness • Approximately 1 in 13 adults in the United States experience a voice disorder each year

• Only 10% will see treatment

• In children 3–10 years old, the prevalence of voice disorders is about 6%, with boys affected more than girls

• Loud talking, coughing, or throat clearing may predispose some to voice disorders

• Certain occupational groups such as teachers and singers are more prone to voice disorders

• Pediatric and adult voice disorders can be associated with vocal misuse or abuse, neurological disorders, psychological conditions, or a combination

• Perceptual signs and case history are initial benchmarks in differential diagnosis

• When one or more perceptual aspects of voice are outside the normal range for an individual’s age, sex, cultural background, or geographic location, a voice disorder exists

• Those who access voice treatment for gender-affirming or transgender care have a voice difference rather than disorder

organic voice disorders

Have an underlying physical or neurological basis

Physical changes to the larynx can result from aging or structural abnormalities

• Neurological disorders interfere with normal vocal fold vibration as the result of damage to central or peripheral nervous system substrates

functional voice disorders

Manifest as the result of vocal misuse or abuse and/or psychological factors (e.g., stress) but do not result in changes in structure

vocal nodules

can lead to voice disorders or dysphonia

– Common vocal fold pathology secondary to vocal misuse or abuse

– Localized growths at the point of maximal contact during vocal fold vibration

– Generally bilateral and soft and pliable at first; can become hard and fibrous, interfering with vocal fold vibration

– Occur more frequently in adult women

– Primary perceptual symptoms are breathiness and hoarseness

vocal polyps

can lead to voice disorders or dysphonia

– Caused by trauma to the vocal folds associated with vocal misuse or abuse

– Fluid filled lesions that develop with blood vessels rupture and swell

– Tend to be unilateral, larger than nodules, vascular, and prone to hemorrhage

– Sessile polyps: closely adhere to vocal folds– Pedunculated polyps: Attached by a stalk

– Hoarseness, breathiness, sudden voice breaks, and diplophonia are the primary vocal symptoms

– Feeling of something in the throat; airway obstruction can occur

contact ulcers and granulomas

can lead to voice disorders and dysphonia

– Contact ulcers are small, reddened ulcerations on the posterior surface of the vocal folds in the region of the arytenoid cartilages

– Usually bilateral and painful

– As they heal, they can become a granuloma

– GERD is a significant contributing factor

– Can result as a result of trauma during intubation

– Primary voice symptoms are hoarseness and breathiness

– Throat clearing and vocal fatigue are present

laryngitis

can lead to voice disorders and dysphonia

– Inflammation of the vocal folds that can result from exposure to noxious agents, allergies, GERD, or vocal abuse

– Acute laryngitis: Temporary swelling that can result in hoarseness, lowered pitch, and intermittent voice breaks

– Chronic laryngitis: Result of vocal abuse during periods of acute laryngitis and can lead to deterioration of vocal fold tissue

– The vocal folds become dry and sticky, resulting in persistent cough and complaints of sore throat

– Voice symptoms range from hoarseness to near aphonia, lowered pitch, effortful speaking, and complaints of vocal fatiguea

acute laryngitis

Temporary swelling that can result in hoarseness, lowered pitch, and intermittent voice breaks

chronic laryngitis

Result of vocal abuse during periods of acute laryngitis and can lead to deterioration of vocal fold tissue

papillomas

can lead to voice disorders or dysphonia

– Caused by HPV and are the most common abnormal laryngeal pathology in children younger than 6 years

– Noncancerous, but can obstruct the airway

– Children exhibit inspiratory stridor

– Second most common benign laryngeal abnormality in children and the second most frequent cause of childhood hoarseness

laryngeal papillomas

small, wart-like growths on vocal folds and interior of larynx

webs

can lead to voice disorders or dysphonia

Can be congenital or acquired, or the result of trauma or prolonged infection

– Can interfere with breathing, causing stridor and shortness of breath

– Must be removed surgically

– Voice quality can range from normal to severely dysphonic

– May produce a high-pitched, hoarse quality, and/or aphonia

laryngeal webs

Result of connective tissue growing between the vocal folds

laryngeal cancer

can lead to voice disorders or dysphonia

– Laryngeal cancer has been linked to cigarette smoking and excessive use of alcohol, although there are additional risk factors

– Laryngeal cancer is the second most common head and neck cancer in the United States

– An early sign is persistent hoarseness in the absence of colds or allergies

– It is often necessary to remove the entire larynx to prevent the spread of the cancer to other parts of the body

– The trachea is repositioned to form a stoma on the anterior aspect of the throat for breathing

neurologic voice disorders

Disorders of the CNS or PNS can result in speech and voice disorders that are characterized by muscle weakness, paralysis, discoordination, or involuntary movements

– Generally called dysarthrias, and involve generalized neurological damage resulting in complex patterns of speech and voice symptoms

damage to CNX (vagus)

Unilateral and bilateral vocal fold paralysis

▪ The recurrent laryngeal nerve supplies most of the laryngeal muscles for phonation

▪ Voice symptoms include hoarseness and breathiness; the voice can be weak or totally absent

▪ Potentially life-threatening if fold are paralyzed in the adducted position

parkinson disease

can lead to voice disorders or dysphonia

Degenerative disease that results in depletion of dopamine, interfering with basal ganglia circuitry functioning

▪ Rigidity of intrinsic laryngeal muscles and vocal fold bowing are common

▪ Voice characteristics include reduced loudness, monopitch, monoloudness, hoarseness, harshness, breathiness, and voice tremor

amyotripic lateral sclerosis (ALS)

neurological voice disorder

Motor neuron disease characterized by degeneration of both the upper and lower motor neurons causing flaccid and spastic weakness and ultimately paralysis

▪ Voice symptoms include reduced loudness, monoloudness, inspiratory stridor, harshness, strain, strained/strangled, wet-gurgly

spasmodic dysphonia (SD)

▪ Neurological voice disorder reflecting damage to the basal ganglia and cerebellar control circuits

▪ Involves abnormal, involuntary movements of the larynx, with adductor-type SD occurring in most cases

▪ Average age of onset is 45–50 years of age, with women affected more than men

▪ Voice characteristics include strained, effortful, tight voice and intermittent voice stoppages

functional voice disorders

Can result from misuse, abuse, or overuse of the voice or psychological stress factors, without causing physical changes to the larynx

muscle tension dysphonia (MTD)

functional voice disorder

Generally associated with hyperfunction of laryngeal muscles in the absence of structural or neurological abnormalities

– Voice characteristics include hoarseness, strain, harshness, aphonia, intermittent pitch breaks, pain and discomfort when the laryngeal area is palpated

resonance disorders

Can accompany voice disorders or be caused by structural abnormalities such as clefts of the palate

Cleft: Abnormal opening in an anatomical structure caused by a failure of the structures to fuse or merge correctly early in embryonic development

• A resonance disorder may develop when there is a blockage in the nasopharynx that impedes sound from traveling through the nose for production of nasal sounds

• Hypernasality secondary to velopharyngeal dysfunction (VPD) occurs when the velopharyngeal mechanism fails to decouple the oral and nasal cavities

velopharyngeal dysfunction (VPD)

can result in audible nasal emission, which can result in a nasal rustle or nasal turbulence

• When there is an insufficient amount of nasal resonance for nasal sounds, speech may sound hyponasal

• Hyponasality occurs when there is a partial blockage somewhere in the nasopharynx or nasal cavity

• When there is a complete blockage, denasality occurs

functional mutism

functional voice disorder

May occur in schizophrenia, severe depression, or other psychiatric conditions

– May be a sign of conversion disorder

– Voice characteristics: May make no attempt to speak or may mouth words without voice or whispering

– Vocal fold adduction is normal based on ability to produce a normal cough

cleft

Abnormal opening in an anatomical structure caused by a failure of the structures to fuse or merge correctly early in embryonic development

evaluation of voice and resonance disorders

• At a minimum, a voice evaluation requires an otolaryngologist and an SLP

• For evaluation of resonance disorders, particularly of VPD secondary to cleft palate, a cleft palate or craniofacial team is necessary

voice evaluation

Primary objectives are to determine the presence or absence of a voice disorder, determine the nature of the voice disorder, and determine the severity of the voice disorder

• The individual must have an examination performed by an otolaryngologist

• Direct observation of the laryngeal structures can be achieved with an endoscope

• Rigid or flexible endoscopy can be used

• Imaging the rapid movements of the vocal folds during vibration requires the use of videostroboscopy

case history

voice evaluation

Description of the voice problem, when it started, the duration, what the client believes might be causing it, how it affects daily life activities, the person’s social and vocational use of the voice, and his or her overall physical and psychological condition

• For individuals seeking gender-affirming care, case history gathering will involve listening to what the client wants in terms of gender expressiona

auditory-perceptual evaluation

voice and resonance evaluation

describe pitch, loudness, and voice characteristics

CAPE-V

voice evaluation

a tool to help SLPs standardize the way in which these parameters of voice are evaluated and judged

• Speech tasks include sustained vowel prolongation of /a/ and /i/, sentence repetition, and elicitation of a 20-second spontaneous speech sample

• May also include detailed acoustic and physiological measurements of vocal function compared to normative data

• Quantitative acoustic measurements are made by using specially designed computer hardware and software or freeware

pneumotachometer

voice evaluation

measures airflow through the larynx and indicates the average openness of the larynx

Voice Handicap Index

can help determine the psychosocial handicapping effects of a voice disorder

perceptual judgements of resonance

must also be made because abnormalities of resonance can affect the perception of voice quality or can lead to hyperfunction of the voice as a compensatory response

resonance evaluation

• Case history is important

• Auditory-perceptual evaluation is the gold standard

• There are standardized rating scales

• Ask client to repeat sentences containing voiced, oral sounds with few high pressure consonants for assessment of hypernasality

• Ask client to repeat sentences that contain mostly nasal sounds for assessment of hyponasality

• Presence of audible nasal emission can be determined by having the client repeat sentences loaded with high-pressure consonants

nasometer

resonance evaluation

Measures simultaneously the relative amplitude of acoustic energy being emitted through the nose and mouth during phonation; a nasalance score is computed

videonasendoscopy/fiberoptic endoscopy

resonance evaluation

Insertion of a flexible endoscope through the nose providing an image of the nasopharynx and velopharyngeal function

multi-view videofluoroscopy

resonance evaluation

A motion picture X-ray of velopharyngeal function from three different perspectives

MRI

resonance evaluation

provides visualization of the velopharyngeal mechanism in real time during speech production

treatment of voice and resonance disorders

may involve behavioral, medical, surgical, and/or prosthetic interventions by a multidisciplinary team

• aims to restore or modify voice and resonance for purposes of effective communication and improved quality of life

behavioral treatment for structural abnormalities associated with voice and resonance

Identify behaviors that contributed to the laryngeal pathology

• Provide education about vocally abusive behaviors and how this can result in trauma and laryngeal pathology

• Educated about good vocal hygiene

• Clients may be taught to modify hyperfunctional behaviors more directly

• Direct treatment approaches are called physiologic therapy

intervention for structural abnormalities associated with voice and resonance

An alternative voice production method will be necessary for patients who require total removal of the larynx

• Some alaryngeal speakers learn to use esophageal speech

• Behavioral treatment to manage VPD after surgical repair of cleft palate is often necessary

• CPAP treatment is an 8-week muscle resistance home-training program designed to strengthen muscles of the soft palate

• Direct intervention for speech sound development should begin prior to the first palatal surgery

medical/surgical treatment for structural abnormalities associated with voice and resonance disorders

Small unilateral polyps require surgical removal

• Contact ulcers and granulomas tend to reappear after surgical removal, so managing GERD with medication in combination with behavioral treatments that address vocal hygiene prior to surgery is strongly recommended

• Early stage laryngeal cancers are frequently managed with radiation or transoral microsurgery

• Total laryngectomy is performed in more advanced cases of laryngeal cancer

• Children born with palatal clefts undergo surgical closure of the cleft, called a primary palatoplasty, around 12 months of age

• If a child also has a cleft lip, surgery to repair it frequently occurs before 3 months of age

• Superiorly based pharyngeal flap or sphincter pharyngoplasty are secondary surgeries effective for managing continued VPI after cleft palate repair

electrolarynx

prosthetic treatment for voice and resonance

A battery-powered device that has a vibrating diaphragm that is placed on the lateral aspects of the neck; the vibration excites the air in the vocal tract, serving as an alternate form of voicing

tracheoesophageal puncture (TEP)

prosthetic treatment for voice and resonance

A one-way prosthetic valve inserted through a surgical opening created between the trachea and esophagus; the speaker occludes the stoma and exhaled air is redirected to the esophagus, allowing the speaker to use respiratory air and the cricopharyngeous muscle for voice production

following surgical repair (prosthetic treatment)

Following surgical repair of a cleft palate, a fistula, or open hole between the nasal and oral cavities may spontaneously occur

• A palatal obturator can be used to cover the fistula

• For a velum that is too short, a speech bulb obturator may be used

behavioral treatment for neurological diseases associated with voice and resonance disorders

LSVT

LSVT is an evidence-based behavioral approach directly targeting respiratory and laryngeal systems

• LSVT is an intensive treatment program originally designed for those with Parkinson disease

• Its focus is systematic increase of phonatory effort using multiple repetitions

• LSVT is beneficial for improving voice function in patients with PD and other progressive and nonprogressive neurological diseases across the lifespan

medical/surgical management for neurological diseases associated with voice and resonance disorders

Indirect benefits to voice and resonance may be achieved with pharmacological management

• Examples include dopamine replacement agents and Mestinon (for MG)

• Botox injections into laryngeal muscles is the standard of care for SD and may be beneficial in voice tremor

• Medialization laryngoplasty/type I thyroplasty is a surgical procedure for unilateral vocal fold paresis or paralysis

• Injection pharyngoplasty: A gel can be injected in the posterior and lateral pharyngeal walls to improve resonance

medialization laryngoplasty/type I thryoplasty

neurological disease

a surgical procedure for unilateral vocal fold paresis or paralysis

injection pharyngoplasty

neurological diseases

A gel can be injected in the posterior and lateral pharyngeal walls to improve resonance

prosthetic management for voice and resonance with neurological disease

Portable voice amplifier

• Swimmer’s clip for hypernasality and nasal emission

• A palatal lift can be used to manage an immobile velum

intervention for functional voice disorders

Voice disorders associated with psychological or stress conditions have the potential for full recovery since structural or neurological abnormalities are not contributing

• These voice disorders can occur in the context of acute emotional distress or stress

• Some research suggests that depression, trauma, and adverse life events occur more frequently in these individuals, however

behavioral treatment for voice

When behavioral treatment is successful for functional voice disorders, referral to other providers for psychiatric or psychological treatment is often unnecessary

• Significant improvement or return to normal voice can be accomplished in just a few sessions

• MTD, conversion aphonia or dysphonia, and functional mutism respond positively to symptomatic treatment that addresses vocal hyperfunction and involved empathetic discussion about the possible link between psychological factors and physical voice symptoms

behavioral treatment for functional voice disorders

Discussion of the diagnosis that includes a rationale, explanation of potential success, and reassurance there are no organic barriers

• Identification of the behaviors that represent the disorder • Symptomatic treatment that reduces tension

• Light-touch laryngeal manipulation or massage

• Debrief sessions following successful symptomatic treatment

other healthcare providers for behavioral treatment for voice

• Some individuals have more complex, chronic mental health conditions or the situation causing stress or distress is still ongoing

• In such cases, referral to other healthcare providers is warranted

• For those unwilling to accept the diagnosis of “functional” and who continue to assert an organic basis, behavioral voice therapy alone is unlikely to yield positive outcomes

intervention for gender-affirming voice and communication patterns

Gender includes gender identity and the relationship with one’s body, appearance, gender roles, gender norms, and gender stereotypes

• Sex (male/female) refers to biological identity assigned at birth

• The SLP, as part of the multidisciplinary team, plays a critical role in providing voice, resonance, and communication therapy to individuals who wish to better reflect their authentic self

bejavioral treatment for gender-affirming voice and communicaiton patterns

• Focus on self-expression, self-esteem, feelings, and attitudes while emphasizing empathy and trust

• Therapy and homework may involve the individual reflecting and observing their own gender expressive strategies and those of others

• For some, altering speaking F0 can be achieved with behavioral voice therapy alone

• Education about vocal health and vocal hygiene is necessary when altering voice expression

Behavioral techniques to achieve a more feminine-sounding resonance include slight retraction of the lips to shorten the vocal tract

• Both F0 and formant frequencies need to be shifted to be perceived as the opposite gender

• May involve practicing stereotypically female or male language and nonverbal communication behaviors

• Person-centered counseling involves connecting with the client and guiding them to feel independent and self-confident as their voice and communication characteristics are modified

• Treatment focused on listening to male and female voices, vocal drill, and singing with progression to speech are successful

medical/surgical treatments intervention for gender-affirming voice and communication patterns

Hormone medications are common treatments for transgender males and females

• HRT for transgender females does not significantly alter pitch

• Surgical treatments to alter length and tension of the vocal folds to change vocal pitch range are available

• Culturally competent training and education for SLPs to adequately serve this population must be expanded

efficacy of voice and resonant treatment

Treatment has been shown to be reasonably effective

• Individuals born with cleft palate who receive medical and behavioral intervention earlier in their life generally speak normally by the time they are adolescents

• Voice and communication therapy as part of gender-affirming care is effective when provided by SLPs with technical expertise, experience working with voice clients, and a nurturing, caring clinical approach

• Changing habituated behaviors that contribute to vocal misuse or abuse is hard work and takes time