Week 4: Pathologies of the Laryngeal Mechanism

What are risk factors of voice dx?

• age: older adults

• gender: women

• occupation: jobs that require heavy vocal demands (teachers, vocal performers)

• history: reflux symptoms, chemical exposures, URI

T or F: SLPs and physicians can diagnose laryngeal pathology

False!

• Only physicians can diagnose; treatment by SLPs require evaluation by physician to rule out laryngeal pathology

What are the 3 classification systems of voice dx?

• physiologic/structural base

• neurologic base

• psychogenic and functional base

Benign lesions in the VFs _____________ and _____________________ are most prevalent pathology group

epithelium; superficial layer of lamina propria (SLLP)

What are 3 examples of benign lesions in the VFs?

• vocal fold nodules

• vocal fold polyps

• vocal fold cysts

What are characteristics of vocal fold nodules?

firm, callus-like tissue growth

Where do vocal fold nodules typically appear?

spot where vocal folds slam together during closure/adduction

What is the etiology of vocal fold nodules?

vocal misuse (phonotrauma)

What are voice symptoms of vocal fold nodules?

mild to moderate dysphonia, roughness and breathiness, increased muscular tension

How do you manage vocal fold nodules?

• voice therapy (first line)

• surgical removal (secondary option)

What are characteristics of vocal fold polyps?

fluid-filled growth in SLLP

What is the etiology of vocal fold polyps?

vocal misuse (phonotrauma)

What are 2 types of vocal fold polyps?

• sessile (blister-like)

• pedunculated (attached to a stalk)

What are voice symptoms of vocal fold polyps?

• mild to severe dysphonia depending upon size, type, and location

• persistant hoarseness, roughness, and breathiness

How do you manage vocal fold polyps?

combination of surgery and voice tx is optimal

What are characteristics of vocal fold cysts?

fluid-filled sacs

What is the etiology of vocal fold cysts?

no clear etiology

• mucous gland blockage?

• phonotrauma?

How do you manage vocal fold cysts?

• surgical excision

• typically do not respond to behavior voice tx

Identify VF polyps, nodules, and cysts

• A = nodules

• B = polyps

• C = cysts

What is an example of malignant lesions?

laryngeal cancer/laryngeal carcinoma

What are characteristics of laryngeal cancer/carcinoma?

abnormal/cancerous growth of cells in surface tissue of larynx

• dysphonia severity varies according to location and extent of tumor invasion

Where is laryngeal cancer/carcinomas typcially located?

originates from epithelium and invades deeper layers of VF including vocalis muscle as tumor progresses

What is the etiology/risk factor of laryngeal cancer/carcinomas?

• smoking

• alcohol use

What are voice symptoms of laryngeal cancer/carcinomas?

• persistent hoarseness, difficulty breathing

• advanced stages: pain, airway compromise, dysphagia

How do we manage laryngeal cancer/carcinomas?

• radiation therapy

• surgical excision

• chemotherapy

• combination approach

What are characteristics of Reinke’s edema?

thick, sticky fluid-filled growth in the SLLP/Reinke’s space

What is the etiology of Reinke’s edema?

• chronic phonotrauma

• smoking

What are voice symptoms of Reinke’s edema?

• signature low pitch and husky hoarseness

• “whiskey” or “smoker’s” voice

How do we manage Reinke’s edema?

• phonosurgery

• pre- and post-surgery voice tx

What are characteristics of vocal fold scarring?

permanent tissue changes in structure of lamina propria due to any number of etiologies (phonotrauma, surgery)

What are voice symptoms of vocal fold scarring?

vary depending on severity, extent, and location

• roughness, strain; loss of flexibility in pitch, loudness, endurance

How do we manage vocal fold scarring?

behavioral voice tx; however, dysphonia is usually persistent

What are characteristics of sulcus or sulcus vocalis?

special form of scarring that forms “ridge” along SLLP that produces bowing or spindle-shaped gap

What is the etiology of sulcus or sulcus vocalis?

etiology unknown, but possibly:

• congenital?

• VF cyst rupture?

• laser surgery?

• age?

What are voice symptoms of sulcus or sulcus vocalis?

hoarse, rough, breathy voice

How do we manage sulcus or sulcus vocalis?

behavioral tx and phonosurgery have mixed success

What are characteristics of a contact ulcer and granuloma?

• ulcer = initial open sore in the posterior larynx

• granuloma = develops as body tries to heal ulcer; body overproduces healing tissue creating a small benign lump or mass over ulcer

What are voice symptoms of contact ulcer and granuloma?

pain, sore throat, voice change if VF vibration impacted

What is the etiology of a contact ulcer and granuloma?

mechanical or chemical trauma, persistent voice misuse

How do we manage contact ulcer and granuloma?

medical (meds, botox), surgical excision, behavioral voice tx, or a combination

What are 3 examples of benign pathologies showing abnormal mucosal changes?

• hyperkeratosis

• leukoplakia

• erythroplasia

What is hyperkeratosis?

• excessive keratin, buildup of keratin tissue

• rough, irregular VF margins

What is leukoplakia?

thick white patch or plaque on superior surface of VFs

What is erythroplasia?

thick red lesion, due to combination of hyperfunctional voice use and chemical irritation

What are characteristics of papillomas?

wart-like growth

• develops in epithelim

• can invade lamina propria and vocalis

• can grow rapidly in large clusters and compromise airway

What is the etiology of papillomas?

HPV

What are voice symptoms of papillomas?

mild dysphonia to complete aphonia depending on extent of disease and aggressiveness of treatment

Papilloma management is aggressive due to _______________ and ________________

diffuse locations; rapid spread

How do we manage papillomas?

pharmacotherapy

What are prominent concerns with papillomas?

can spread within upper airway and compromise respiration, requiring tracheostomy

what is stenosis

fibrous tissue overgrowth, narrows airway

what is anterior glottic web

acquired scar across medial edges of VFs beginning in anterior and extending posteriorly

what is the etiology of subglottic stenosis

congenital; post-intubation scarring; LPR

what is the etiology of glottic web

congenital; acquired after phonosurgery involving anterior VFs

how do you manage stenosis and glottic web

surgery

what are vascular lesions

traumatic injury to small blood vessels in the VFs; focal or diffuse discoloration of VFs

etiology of vascular lesions

phonotrauma

what are voice symptoms of vascular lesions

• varies from severe (time of bleed) to mild (later)

• small varices may have minimal effects on voice

treatment of vascular lesions

• complete/total voice rest

• medical: steroids

• laser treatment to stop bleed

• surgery: microexcision of persistent varix

2 examples of vascular lesions

• varix and ectasia

• hemorrhage

what is varix and ectasia

• varix/varices = enlarged, swollen veins

• ectasia = dilation/enlargement of a vessel

voice symptoms of varix and ectasia

may lose vocal range in higher frequencies; hoarseness

management of varix and ectasia

• voice rest until any blood is reabsorbed

• vocal hygiene

• phonosurgery if needed

what is a hemorrhage

a tiny blood vessel on VF breaks and bleeds into the SLLP

voice symptoms of hemorrhage

when SLLP is affected, effects can be devastating and range from dysphonia to complete aphonia

management of hemorrhage

• phonosurgical excision of microvascular lesions may prevent a VF hemorrhage

• in acute phase: complete voice rest to heal tissue

what is presbyphonia/presbylaryngis

processes of laryngeal aging with “older” sounding voice

voice symptoms of presbyphonia/presbylaryngis

• thin, muffled voice quality

• decreased loudness

• increased breathiness

• pitch instability

• lack of vocal enduracne and flexibility

treatment of presbyphonia/presbylaryngis

voice therapy to improve glottal closure, especially vocal function exercises (VFEs) can be effective

what is laryngitis

swelling and inflammation of the larynx and vocal cords, which causes a hoarse voice or temporary voice loss

etiology of laryngitis

URIs, viral/bacterial infection

laryngitis management

• often resolves w/ rest and hydration

• antibiotics

• vocal hygiene

what is candida

yeast/fungal infection that occurs due to weakness within the immune system

voice symptoms of candida

moderately hoarse, breathy, pain may be present

management of candida

medication, good vocal hygiene

what is puberphonia (aka mutational falsetto)

• post-teen males continue to speak in a high pitched voice

• associated w/ negative socioemotional consequences

symptoms of puberphonia

weak voice, breathy or raspy, unable to increase intensity or shout

etiology of puberphonia

poorly understood

treatment of puberphonia

behavioral voice tx

what is ventricular phonation

use of ventricular folds during voicing instead of true VFs; can be compensatory or functional

voice symptoms of ventricular phonation

• reduction in vocal range and loudness

• roughness and hoarseness

• vocal fatigue

• pain in ears

management of ventricular phonation

if true VFs are unable to produce voice, voice tx or phonosurgery

what is muscle tension dysphonia

functional voice dx w/ intact VF structure

etiology of muscle tension dysphonia

• increased muscle activity in the head and neck

• environmental, physical, and emotional life stressors

• LPR

voice symptoms of muscle tension dysphonia

• strained, hoarse, high pitch

• when VF tension appears high, folds may never adduct leading to breathiness

management of muscle tension dysphonia

voice tx

what is SLN paralysis

unilateral cricothyroid dysfunction

possible diagnostic marker of SLN paralysis

epiglottis deviation to the side of weakness during high pitched voice

phonatory effects of SLN paralysis

mild dysphonia, loss of upper pitch range, weakness, increased physical effort to produce voice

management of SLN paralysis

• monitor and treat cause

• voice tx to reduce compensatory hyperfunction

• surgery for persistent cases

what is RLN paralysis

unilateral or bilateral dysfunction of intrinsic laryngeal muscles (except cricothyroid) affecting VF adduction and abduction

etiology of RLN paralysis

surgery, viral infection, trauma

symptoms of RLN paralysis

• unilateral: breathy/weak dysphonia, vocal fatigue, weak cough, aspiration due to incomplete glottal closure

• bilateral: near-normal voice but with stridor and airway compromise

management of RLN paralysis

• voice tx

• temporary medialization

• permanent medialization

• airway management

spasmodic dysphonia

rare, chronic disorder in which the muscles of VFs spasm

types of spasmodic dysphonia

• adductor: spasms make folds slam together and stiffen

• abductor: spasms hold folds open, letting air escape

• mixed

etiology of spasmodic dysphonia

• abnormal functioning of the basal ganglia and cerebral cortex

• genetic component

• stress

voice symptoms of spasmodic dysphonia

• voice breaks, vocal tremor, absent while laughing, crying, or whispering

• adductor: strained, strangled, choppy speech w/ words cut off

• abductor: weak and breathy voice

management of spasmodic dysphonia

• no cure exists

• botox injections into affected laryngeal muscles = most common treatment