Voice Disorders Final Prep

What two systems and their parts make of the Nervous System?

CNS

• cerebral cortex

• cerebellum

• brainstem

• spinal cord

PNS

• cranial nerves

• spinal nerves

What nerve pathways are in the PNS?

sensory and motor (afferent and efferent)

What areas in the sensory and motor areas contribute to production of voice?

• cerebral cortex

• cerebellum

• basal ganglia

The ___ and left ____ lobes are primarily involved with motor aspects of voice production.

frontal and left temporal

What is normal voice based on?

Ability to hear and process ongoing voice production

What sensory function does CN IX (glossopharyngeal) have?

• taste and general sensation back 1/3 tongue

• pharynx

• larynx

• viscera

What sensory function does CN X (vagus) have?

• pharynx

• larynx

• viscera

What motor function does CN IX (glossopharyngeal) have?

• constrictors

• stylopharyngus

• visceral motor (parotid glands)

What motor function does CN X (vagus) have?

• palate

• pharynx

• larynx

• esophagus

What motor function does CN XI (spinal accessory) have?

• trapezius

• sternocleidomastoid

What motor function does CN XII (hypoglossal) have?

tongue (intrinsic+extrinsic)

What are the neurogenic voice conditions?

• vocal fold paralysis

• spasmodic dysphonia (SD)

• essential voice tremor

• parkinson disease (PD)

• cerebrovascular accident (CVA)

• TBI

What is vocal fold paralysis?

damage to Vagus nerve anywhere

What is the SLPs role in vocal fold paralysis?

Collaborate with ENT to confirm diagnosis and rule out mechanical causes

What does the type and extent of dysphonia depend on with vocal fold paralysis?

• lesion site

• damage is unilateral or bilateral and partial or complete

What are the characteristics of unilateral vocal fold paralysis?

Visual

• paralyzed VF is fixed, not fully adducted/abducted

Perceptual

• dysphonia, breathy, hoarse vocal quality, reduced phonation time, decreased loudness and monoloudness (diplophonia+pitch breaks)

Why do SLPs wait to treat unilateral vocal fold paralysis? What does therapy look like?

Usually spontaneously recovers within first 9 to 12 months; behavior therapy+voice facilitating approaches

What neurogenic voice disorder is this?

unilateral vocal fold paralysis (UVFP)

If UVFP isn’t resolved within the first 9-12 months, what medical management options are there?

VF medialization

• injection laryngoplasty

• thyroplasty

VF re-innervation

What is injection laryngoplasty? And what disorder does it help?

• provides support to a vocal fold that lacks either the bulk or mobility it had

• injects chemicals to increase vocal quality

• helps VF paralysis

What is thryoplasty? And what disorder does it help?

• free-moving wedge is used to move the VF to midline, rectangular window is cut from thyroid cartilage on paralyzed side

• patient is conscious to produce voice to understand where wedge helps best

• helps VF paralysis

What is bilateral vocal fold paralysis?

• result of lesions high in vagus nerve

• can be adductory or abductory

What neurogenic voice disorder is this?

bilateral VF paralysis

What is the gold standard treatment for BVFP?

surgical procedures to open the posterior glottis airway

What is spasmodic dysphonia (SD)?

from laryngeal dystonia (hyperkinetic movement disorder) aka involuntary repetitive movements

What are the types of spasmodic dysphonia and their differences?

Adductor SD

• most common

• symptoms: strain & intermittent voice stoppages; hoarseness & tremor

• hyperadduction VF, tight closure of false VF

Abductor SD

• less common

• symptoms: fleeting aphonia, VFs abduct suddenly

Mixed SD

• least common

• features of abductor and adductor

What are the management options for spasmodic dysphonia?

• voice therapy

  • few positive outcomes

  • best with combo of behavioral and medical

• surgical resection of the RLN

• injection of BTX-A

• surgical modification of VF

What is RLN? What disorder does it treat?

• first surgical procedure for SD

• injection of lidocaine into RLN to produce temporary unilateral adductor paralysis

• if there is improvement in airflow, then RLN may be cut permanently

• long-term results = mixed

• long-term results of paralyzing thryoarytenoid bilaterally = more promising

What is BTX-A injections? What disorder does it treat?

• gold standard for treating SD!!!!

• mild symptoms occur up to 2 weeks after

• **combined with voice therapy is best

• treats SD & essential voice tremor

What is essential voice tremor?

• presents in tongue, velar, pharyngeal, laryngeal structure producing tremor in 4-7 second ranges

• like a hyperkinetic dysarthria

How is diagnosis of essential voice tremor differentiated?

• eliminating contextual speech, asking patient to sustain production of vowels in isolation

• normal larynx, alternate tension changes

What is deep brain stimulation? What disorder does it treat?

• reduces periodic modulations in fundamental frequency and intensity

• helps essential voice tremor

What treatments are used for essential voice tremor?

• BTX-injections

• deep brain stimulation

• pharmacotherapy

• voice therapy

  • reduce voice intensity

  • elevate voice pitch a half note

  • attempting to shorten vowel duration

What is Parkinson’s Disease and the symptoms?

• hypokinetic dysarthria

• symptoms

  • reduced loudness, breathy voice, monotony of pitch, intermittent and rapid rushes of speech, reduced articulatory contacts

What are the treatment options for Parkinson’s disease?

• automatic speech → intentional speech to improve loudness, voice quality, appropriate pitch, rate

• LSVT and SPEAKOUT

How is the voice affected by a stroke?

• voice and connected speech changes depend on lesion

• paralysis is rare as a result of stroke

• vocal quality is spastic or flaccid

What is the difference between spastic and flaccid voice quality?

Spastic

• slowed artic, strained voice, hypernasality

Flaccid

• breathy voice with diminished loudness and air wastage

How do you diagnose voice issues from a stroke?

• laryngeal stroboscopy shows laryngeal dysfunction + assess mucosal wave

• touching endoscope tip to arytenoids bilaterally to see sensation

• pooling of secretions in the hypopharynx

What are the treatment options for vocal issues from stroke?

• tracheotomy/airway management

• dysphagia/aspiration

• secretion management

• dysphonia

What vocal issue stems from TBI?

Dysarthria

• can be: temporary/chronic, mild/severe, accompanied or not by other language and cognitive disorders

What treatments are effective for TBI? What should intervention focus on?

• auditory feedback, counseling, respiratory training

• alter pitch upward, reduce vowel duration within words, increasing naturalness of convo

What variables determine a patient’s compliance?

• clinician-related barriers; ex. lack of empathy, lack of support

• clinic-related factors; ex. commutes, scheduling

How do you increase client compliance?

• apply voice facilitating approaches ASAP

• capitalize success by making sure client leaves with homework that has audio from session

• virtual reality

What is the difference between symptomatic voice therapy and voice facilitating approaches?

Symptomatic

• modifies deviant vocal symptoms like breathiness, inappropriate pitch, loudness, hard glottal attack

Voice Facillitating

• targets a more optimal vocal response

• once elicited → behavior is shaped, stabilized, and habituated using pattern increasing in difficulty

What are the 2 steps to voice facilitating approaches?

1) identify behaviors which need to be eliminated

2) stimulate desired target behavior by using an approach

**stabalize → generalize

How do you determine what voice facilitating approaches to use?

• underlying etiology/diagnosis

• response to therapeutic probes administered during the diagnostic eval

• your comfort teaching a particular approach

• patient’s acceptance of using the approach

What screenings are used for voice and what are their aspects?

Quick Screen for Voice

• 1o min

• students in pre-school to high school

• responds to checklist of observations during tasks

• fails: if 1+ disorders in production in any section

Voice Screening from in the Boone Voice Program for Children

• quick+easy

• students on all grades

• listen to natural sample of voice and speech and rate each scale

• fails: if child fails any of the 5 clinical parameters

What do all screening protocols address?

Respiration, phonation, resonance

What is strongly suggested for a voice evaluation?

Case history questionnaire completed in advance

What is included in the physical voice exam?

• assessment of general physical condition

• ear, nose, throat eval

• additional areas depending on age and observed signs

• if needed, consult other specialists

What does ASHA define as the SLP and Physician roles in medical evaluation?

A physician who has a discipline in the complaint has to examine all patients in addition to the SLP. It can be before or after the SLPs eval

What is the purpose of voice assessment?

• know strengths and deficits

• effect of the disorder on individual’s activities and participation

• contextual factors that serve as barriers/facilitators of communication

What are the components of the voice evaluation and their order?

• case history

• patient interview

• non-instrumental assessment

• instrumental assessment

TF: All components of the voice evaluation are done each time.

False

What is included in the case history?

• reason for referral

• prelim info that can help hypothesis

• medical status, education, occupation/vocations, cultural/linguistic background, auditory/visual status

TF: Older adults with hearing loss are more likely to have dysphonia.

True

What is involved in the patient interview?

• Description of the problem/cause

• Onset/duration of problem

• Variability of problem

• Description of voice usage

• Psychological screening (stress/anxiety)

• Additional info

  • previous voice therapy/approaches, similar voice problems in family, social history

What are voice disorders commonly confused with?

Common colds

What disorder is associated with lower voice quality in the morning and improved voice quality at night?

LPRD

What disorder is associated with better voice quality in the morning and worse voice quality at night?

Hyperfunction

What is included in the non-instrumental assessment?

• behavioral observation

• oral mech exam

• auditory-perceptual rating

• voice-related QOL

What specifically is examined during an oral mech exam?

• look for neurologic signs

• observe breathing patterns

• examine for neck tension (move larynx side to side)

• examine oral cavity

• listen for oral/nasal resonance balance

What are the auditory-perceptual ratings used?

GRBAS scale

• grade, roughness, breathiness, aesthenic, strain

• 4-point rating scale 0-3 for each parameter

CAPE-V

• severity, roughness, breathiness, strain, pitch, loudness

• rate 6 aspects by placing a mark on a line

What scale is used to measure voice-related QOL?

Voice Handicap Index (VHI)

• tests 3 subscales - functional, physical, emotional

• rated 0-4

What is included in the instrumental assessment?

• laryngoscopy/phonoscopy

• acoustic analysis

• aerodynamic analysis

Who can perform a laryngoscopy?

Clinicians with expertise and training in laryngoscopy’s

What are the elements of a phonoscopic exam?

respiratory behavior, vegetative voicing, fundamental frequency range, intensity range at different frequencies, different modal registers, different phonetic contexts, voicing of variable duration

What are the different visual examinations of the larynx?

• Indirect laryngoscopy

• Direct laryngoscopy

• Fiberoptic laryngoscopy

  • Flexible

  • Rigid

• Stroboscopy

• High-speed digital imaging

What can indirect and direct laryngoscopy’s not do?

Cannot see vibrations

What is the difference between flexible fiberoptic laryngoscopy and rigid fiberoptic laryngoscopy?

Flexible = scope is flexible

Rigid = can’t see repetition

What is a laryngostroboscopy? What are it’s limitations?

Synchronizing the flash of stroboscopic light with the F0 of the VF vibration reveals an average pattern of vibration across multiple cycles

Limitations: severely dysphonic patients

What is high-speed digital imaging? What are it’s advantages & limitations?

Captures high quality images of the larynx structures

Advantages

• doesn’t need periodic phonation

• provides additional info on VF movement including observation of phonatory onset

Limitations

• no audio

• can’t use flexible endoscopy with it

• limited sample of phonation

What can be observed in a laryngoscopic observation?

• VF edges

  • medial edge for smoothness, straightness, presence of mass

• Glottic closure

  • complete, hour-glass, spindle-shaped, incomplete, irregular

• Amplitude of vibration

  • how far VFs move laterally during phonation (one half visible width)

  • can be affected by F0 and intensity

• Mucosal wave

  • “ripple like motion”

  • should travel ½ width of VF

• Vertical level approximation

  • VFS must meet on same vertical plane

  • VF overlap = not on same plane

  • needs light

• Supraglottic activity

  • look for medio-lateral/antero-posterior involvement

  • rated during normal pitch & loudness

  • doesn’t need light

• VF mobility

  • evidence of paralysis of one or both VF

  • can be normal, limited adduction, limited adduction, fixed (needs position)

• Phase closure

  • observe how long it takes for VF to begin to part from midline until lower lips approximate

• Phase symmetry

  • degree VFs appear to be mirror images of each other in motion

  • out of phase seen during onset and it moves in the same direction

• Non-vibrating portion

  • immobility of any part of the membranous VF (body or mucosal)

  • percent of VF non-vibrating

• Regularity

  • consistency of duration of successive cycles of VF vibration

• Overall laryngeal function

  • normal, hypofunctional, hyperfunctional, tremulous, spasmodic

What are the types of glottic closure?

Complete

• glottis without evidence of any gapping during max VF adduction

Hour-glass

• presence of anterior/posterior gap with mid-membranous VF closure

Spindle-shaped

• glottal appearance where both anterior/posterior portions of the VF fold are closed, but a large gap remains in the middle

Incomplete

• when the VF fails to touch

Irregular

• 1 or both VFs approximate in an irregular fashion

How does fundamental frequency and intensity affect amplitude of vibration?

Higher F0 = lower excursion

Greater intensity = increased excursion

How does fundamental frequency and intensity affect the mucosal wave?

Higher F0 = decreased wave

Higher intensity = increased wave

How do you determine vocal hypofunction and hyperfunction based on phase closure?

Hypofunction = open phase predominates

Hyperfunction = closed phase predominates

How do you make acoustic measurements valid?

• discriminate normal from dysphonic voice

• correlate positively with clinician’s auditory-perceptual judgements

• be sufficiently stable to assess change across time

What acoustic analyses can be measured during evaluation and what do they analayze?

• sound spectrography

  • time for loudness and frequency

• frequency-related parameters

  • frequency variability

  • MPFR

• intensity-related parameters

  • avg intensity (loudness), 65-80dB

  • intensity variability (range of intensities in connected speech)

  • dynamic range (softest nonwhisper to loudest shout)

  • voice range profile (VRP), see patient’s min/max intensity lvls

• vocal perturbation-related parameters

  • short-term cycle to cycle variability in the vocal signal

  • small amount is normal

  • jitter + shimmer

• vocal noise-related parameter

  • harmonic + inharmonic

  • ratios: harmonics → noise (HNR), noise → harmonics (NHR), signal → noise (SNR)

What is fundamental frequency (F0)?

rate of vibration of the VF

What is frequency variability in dysphonic patients?

Frequency can be either more or less variable than expected

What is maximum phonational frequency range? What is a healthy one?

Range of vocal frequencies encompassing lowest register to falsetto register

Healthy = 2.5-3 octaves, smaller in older adults

What does a compressed VRP indicate?

Spastic dysarthria (abnorm freq and intensity range)

What is the difference between sparkle and jitter?

Sparkle = short-term variability in amplitude

Jitter = short-term variability in fundamental freq

What is an important disclaimer with vocal perturbation measures?

Should be interpreted in combo with other instrumental data, auditory-perceptual, observations

What voice noise measures are identified in dysphonic patients?

Low HNR or SNR + high NHR

What is an electroglottographic analysis and how does it determine voice quality?

non-invasive procedure for obtaining an estimate of VF contact patterns during phonation

• electrodes are placed on each side of thyroid cartilage

• normal = high consistent peaks

• breathy = consistent lower peaks

• hoarse = inconsistent peaks

What is an aerodynamic analysis measure and what can be done in the clinic?

Patient’s ability to use the larynx to regulate the flow of air for phonation

• breathing patterns

  • clavicular (abnorm)

  • thoracic (norm)

  • diaphragmatic-ab (norm)

• measures in clinic

  • lung volumes/capacities

  • air pressure

  • airflow

  • laryngeal resistance

How do you measure phonatory-respiratory efficiency? Describe those methods.

Maximum phonation time (MPT)

• longest period during which a patient can sustain phonation of a vowel sound (/a/)

  • shorter if laryngeal flow is high

  • longer if laryngeal flow is low

• cannot distinguish deficit in breath support

S/Z ratio

• indirect index of laryngeal airflow

• sustain /s/ and /z/

  • normal = 1

  • mass lesions= >1.40

What is an ambulatory phonation monitor used for?

APM is worn to capture voice parameters of an entire day

What are the special populations that we provide voice therapy to?

• aging voice

• pediatric voice

• professional voice

• deaf/hard of hearing

• transgender patients

What percent of the caseloads for SLPs are elderly clients with communication impairments?

19%

What is presbyphonia?

Age-related weakness of voice in elderly

What is the most common cause of dysphonia in the elderly?

VF atrophy

What are the auditory-perceptual features of the elderly voice?

• tremor

• hoarseness

• breathiness

• voice breaks

• decreased loudness

• slower speaking rate

• change in habitual pitch

What are the laryngeal signs of the elderly voice?

• mild bowing of the VF margins

• spindle-shaped glottis

• more anteriorly placed glottal gaps

• prominent arytenoid cartilage vocal processes

• VF edema

• Asymmetry of VF vibration

• Predominant open phase

What are the voice-related physiological changes of the elderly voice?

• lengthening of vocal tract/oral cavity

• reduction in pulmonary function

• laryngeal cartilage ossification

• increased stiffening of the VF

• reduction in VF closure

What are the acoustic features of the elderly voice?

• increased F0 in males

• decreased F0 in females

• decreased SPL

• increased noise to harmonics ratio

• inconclusive findings on changes in jitter/shimmer

What does increased SPL mean for intensity?

Greater intensity

How do you treat presbyphonia?

Voice therapy

• strengthening exercises for respiratory/phonatory control

• vocal hygiene

• improve respiratory efficiency

• increase speech rate

Surgery

• laryngoplasty

• thyroplasty