Week 3: Etiologies of Voice Dx

What are the 4 major categories of voice dx etiologies?

• etiologies of vocal misuse

• medically related etiologies

• primary disorder etiologies

• personality related etiologies

Describe etiologies of vocal misuse

functional voicing behaviors that contribute to developmental and maintenance of laryngeal pathologies

What are 2 types of vocal misuse?

• phonotraumatic behaviors

• inappropriate vocal components

What are phonotraumatic behaviors?

trauma to vocal folds

• vocal folds adduct too vigorously causing hyperfunction of laryngeal mechanims

• can cause maladaptive laryngeal mechanism changes if habituated

Examples of phonotraumatic behaviors

• shouting

• loud talking

• screaming

• vocal noises

• chronic coughing

• throat clearing

What is the most prevalent form of phonotraumatic behaviors?

chronic throat clearing

• primary symptoms of common cold or URI

• secondary response to perceived laryngeal sensations

List 5 inappropriate vocal components

• breathing

• phonatory habits

• pitch

• loudness

• rate

Inappropriate Vocal Components: shallow breathing

does not support phonation; may result in low intensity and breathiness

Inappropriate Vocal Components: depleted normal tidal expiration

increases laryngeal muscle tension and contributes to vocal hyperfunction

Inappropriate Vocal Components: frequent hard glottal attack

complete, rapid adduction of vocal folds, buildup of subglottic pressure, explosion of folds when initiating phonation

Inappropriate Vocal Components: frequent glottal fry phonation

• not an established cause of vocal fold damage; more often symptom of underlying disorder than cause

• habitual, effortful fry may add to laryngeal tension/fatigue in some people (limited evidence)

Inappropriate Vocal Components: monopitch

• too high; too low; lacking in variability

• habitual use of inappropriate pitch may create laryngeal tension and strain

  • ex. deliberately talking lower to sound more authoritative

Inappropriate Vocal Components: change in pitch

• common symptom of voice dx

• "my voice is higher than it used to be” or “my voice dropped”

T/F: Abnormal pitch is a symptom, not the cause, so we don’t target it directly. We work on pitch directly only when it’s been isolated as the primary cause.

true

Inappropriate Vocal Components: monoloudness

• too loud; too soft; lacking in variability

• speaking very loudly = phonotrauma

• speaking very softly = disrupts balance between airflow and muscular activity; increases demand on intrinsic laryngeal muscles

  • may result in vocal strain and fatigue

Vocal loundness depends on how far the vocal folds swing open and how fast they snap back to midline, both driven by_________ ____ _________ and ________.

subglottic air pressure; airflow

Inappropriate Vocal Components: rapid speech rate

without refilling enough air, the rapid speech rate may result in insufficient breath support and overcompensation of laryngeal muscles

What are 2 types of medically-related etiologies?

• surgical interventions (direct or indirect)

• chronic illnesses or health conditions (direct or indirect)

________ surgical traumas are surgeries that ______ ___ ______ the actual anatomy of phonation, resonance, or articulation.

direct; remove or change

What are examples of DIRECT surgical trauma?

• laryngectomy (removal of part or all of larynx)

• glossectomy (removal of part or all of tongue)

• mandibulectomy (removal or part or all of mandible)

• palatal surgery

• other head and neck surgery

T/F: DIRECT surgical traumas are surgeries that need endotracheal intubation

False! its indirect

T/F: INDIRECT surgical traumas are surgeries to the thyroid gland, heart, lungs, cervical spine, or arteries that accidentally injure the recurrent and/or superior laryngeal nerves

True! it causes trauma to the nerve supply of the larynx

Examples of INDIRECT surgical traumas

• thyroidectomy

• intubation

Describe a thyroidectomy and its potential impacts to the voice

• removal of the thyroid gland

• potential damage to RLN = unilateral vocal fold paralysis

• potential damge to external branch of SLN = losing pitch range in high notes even w/o a full paralysis

What is the function of the RLN?

motor innervation to all instrinsic laryngeal muscles except the cricothyroid muscle

What is the function of the SLN?

motor innervation of the cricothyroid muscle

Describe intubation and its potential impacts to the voice

• passing a breathing tube between vocal folds for airway management and anesthesia

• prolonged intubation = damage to folds and arytenoid cartilages

What are 3 types of chronic illnesses that may damage the voice?

• upper airway conditions

• lower airway conditions

• reflux conditions

What are upper airway conditions? Possible consequences?

• conditions that produce post-nasal drip or cause a sore throat

  • ex. allergies, chronic sinusitis, URI

• possible consequences = coughing, throat clearing

What are lower airway conditions? Possible consequences?

• conditions that compromise the respiratory system

  • ex. asthma, chronic obstructive pulmonary disease (COPD)

• possible consequences

  • increased responsiveness and hyperactivty of the trachea and bronchi

  • reduced respiratory support

  • vocal fold tissue irritation

What are reflux conditions? Possible consequences?

• conditions that affect the larynx or pharynx

  • ex. GERD, LPR

• possible consequences = tissue and vocal function changes, throat clearing

What is GERD?

gastroesophageal reflux disease

• reflux into the esophagus

• hallmark symptom = heartburn

What is LPR?

laryngopharyngeal reflux

• when the refluxate reaches the larynx and pharynx

• AKA silent reflux

Describe primary disorder etiologies

voice problem is secondary condition of larger, primary health condition

• primary conditions: require appropriate medical, surgical, educational, and rehabilitative interventions

• secondary: vocal symptoms

Examples of primary disorder etiologies

• cleft palate → velopharyngeal insufficiency, hypernasality

• deafness

• cerebral palsy → motor disorder

Describe personality-related etiologies

tensions and stresses of daily life may contribte directly to abnormal functioning of sensitive vocal mechanism

• ex. environmental/life stress, identity conflict

Voice is a sensitive indicator of _________, ________, and _____ ___________

emotions; attitudes; role assumptions

Vocal symptoms in personality-related etiologies may…

• reflect bodily tension in the intrinsic and extrinsic larygneal muscles (muscle tension dysphonia)

• signal a much more serious psychological disorientation

What is an SLPs role in treating personality-related voice dx?

• realize limitations

• refer to mental health professionals as appropriate; treating “whole person”

A clinician evaluates a client whose vocal folds adduct too vigorously during speech, producing hyperfunction that, over time, has led to mucosal tissue change. This pattern is best classified as:

A. A primary disorder etiology
B. A phonotraumatic behavior

C. An indirect surgical trauma

D. A personality-related etiology

B. A phonotraumatic behavior

Which statement about habitual glottal fry (vocal fry) is most accurate?

A. It is a well-established primary cause of vocal fold lesions

B. It is more often an inappropriate vocal component, sometimes may indicate an underlying disorder

C. It reliably produces bilateral vocal fold paralysis

B. It is more often an inappropriate vocal component, sometimes may indicate an underlying disorder

A patient experiences reduced high-pitch range following a thyroidectomy. Injury to which nerve(s) best explains this presentation?

SLN because it innervates cricoidthyroid muslce

A patient reports frequent throat clearing and a sesnation of a “lump” in the throat but denies heartburn. Laryngoscopy shows posterior laryngeal irritation. This presentation is most consistent with:

A. GERD
B. Laryngopharyngeal reflux (LPR)
C. Velopharyngeal insuffiency
D. Hard glottal attack

B. Laryngopharyngeal reflux (LPR)