Voice Science Exam 2 Review

aerodynamics

generation of air pressures and airflows

kinematics

the motion of structures

acoustics

the resulting sound; vowels, consonants, voice quality, loudness, and pitch

sound output quality

When combining the laryngeal source sound and vocal tract filtering, what term should be used?

voice quality

What term should we use when we refer to the sound from the larynx?

organic disorders

innervation; structural; when tissue problems are the primary and initial issues to resolve

organic disorders

Examples of this kind of disorder are paralysis, granulomas, nodules, polyps

functional disorders

behavioral, psychological; when behavioral, vocal use, habit, learned, maladaptive, “vocal technique” problems are the primary and initial issues to resolve

Examples of this kind of disorder are tension disorders, muscle fatigue from use of pitch that is too low, and hoarseness due to poor technique, rather than the presence of a lesion

shouting (functional) can lead to swellings (organic)

Example of a functional problem leading to an organic problem?

laryngitis (organic) can lead to too much muscle tension and poor coordination of laryngeal structures (functional)

Example of an organic problem leading to a functional problem?

congenital

neurological or neuromotor problem from birth

biochemical

chemical imbalances of the nervous system, especially at neural junctions

accidental

nerve crush, laceration; thyroid gland surgery (cuts the recurrent laryngeal nerve)

congenital, biochemical, accidental

Organic problems can be classified as?

results of innervation problems

• Dyscoordination of respiratory, laryngeal, vocal tract/articulatory systems, separately to pervasively

  • Poor timing of muscle contractions and structural movements

  • Inappropriate level of muscle contractions is deviant enough to produce significant communication difficulties

• Limitations in operational potentials

  • Displacement, speed, range, reaching targets, and weakness

    • Arytenoid cartilages will not move correctly or at all'

    • VF muscles will not contract correctly

    • Full paralysis suggests they will not contract at all

    • Abnormal adduction probable

    • Asymmetry of the muscle contraction

anterior glottal webs, tracheal stenosis

Example of a congenital structural, morphological abnormality?

hormonal, allergies, pollutants, air particles, infection, disease

Example of a biochemical structural, morphological abnormality?

fracture, laceration, dislocation, swelling

Example of an accidental structural, morphological abnormality?

inefficiencies/overuse, psychological, coughing/throat clearing

Examples of functional vocal problems?

results of functional problems

• inefficient coordination of muscles

• poor coordination of antagonistic muscle groups

• vocal fold tissue changes

overuse

repeated use of the larynx to phonate

large tissue forces

high tissue stresses, such as high impact, compression, and whipping forces

loud voicing, shouting, coughing/throat clearing

Examples of large tissue forces?

misuse

inefficient use of the larynx and body to produce phonation; “inefficient vocal technique” or “poor vocal technique

0.05-0.10 mm

epithelium length?

stratified squamous

what kind of epithelium?

epithelium functions

maintains the shape of the VF and protects tissue lateral to epithelium; microvilli on the cells extending into the airway that hold mucus on the surface

superficial, intermediate, deep

lamina propria is made up of?

0.5 mm

superficial layer length?

superficial layer

• Loosely organized elastin fibers surrounded by interstitial fluid (proteins)

• Has the lowest concentration of elastic and collagen fibers of the three layers of the LP

• Easily elongated

• Like a mass of “soft gelatin”; moves quite easily

• 0.5 mm in the middle of the VF

• Known as Reinke’s space

intermediate layer

• Primarily elastin fibers oriented in the A-P (anterior-posterior) direction

• Some collagen fibers also; elastin and collagen fibers more densely packed than in the superficial layer, and less interstitial fluid than in the superficial layer

• Like “soft rubber bands”

deep layer

• Primarily collagen fibers oriented in the A-P direction, dense tissue

• Like “cotton thread”, which limits elongation

• Intermediate plus deep are 1-2 mm in lateral thickness (together)

1-2 mm

length of the intermediate + deep layers?

thyroarytenoid muscle

o   Major portion of the VF

o   7-8 mm thick – lateral depth

o   Like “stiff rubber bands” (depending on contraction level – stiffer with greater contraction)

o   Note that the TA is the vocalis (medially) and muscularis or lateral TA (laterally)

7-8 mm

thyroarytenoid muscle length?

mucosa

epithelium + lamina propria = ???

salivary glands

secrete mucus to help lubricate the VFs; superior, lateral, and inferior to the vibrating edge of the VFs

conus elasticus

continuation of the vocal ligament inferiorly; stiffer inferiorly, giving structure to the inferior VF surface

vertically

Lateral thyroarytenoid muscle has extension in which direction?

vocal fold vibration, surgical intervention

why are the layers of the vocal folds important?

epithelium, superficial, intermediate, deep, muscle

what are the five real layers of the vocal folds?

nodules and polyps

benign focal (small region) lesions of the vocal folds

vocal fold tissue trauma

what is the primary cause for both nodules and polyps?

vocal fold tissue trauma examples

-              From mechanical trauma, micro-trauma, and altered vascular permeability (rupture)

-              Too much force externally and/or internally relative to VF tissue:

o   Rubbing of the vocal folds together (friction; external)

o   Impact (compression; coming together with large force; external)

o   Overstretching of the mucosa (dynamic over-strain; amplitude of motion too great; internal)

o   Whip-like motions of tissue during vibration when not touching (high acceleration of mucosa; internal)

-              High impact pressures; phonating too loudly

o   Higher subglottal pressure  louder voicing (glottal flow)

o   Higher subglottal pressure  increases the lateral excursion of the VFs 

-              Overuse

o   Phonating longer than the VFs can endure

o   Repetitive injury

o   Cumulative damage: there is a limit to tissue endurance before the tissue changes a great deal

o   Recover will be longer when there is more damage to the tissue

anterior to posterior mid-membranous

where do nodules and polyps occur most often?

superficial

nodules and polyps are both related to damage within the ________ layer

nodule damage locations

• Much more epithelium-related than polyps

• Protein deposition in the most superficial portion of the LP

• Have excess fibrous tissue

• Basement membrane thickened

polyp damage locations

• Damage more so in superficial layer rather than epithelium

  • Perhaps NO damage to epithelium

• Usually unilateral due to

  • Asymmetric vessel arrangement (right VF vs left VF)

  • A vulnerable (fragile) vessel in the medial superficial layer (where impact forces are large)

• Sessile, pedunculated, edematous, or hemorrhagic

wound repair, tissue regeneration

Tissue disruption leads to??

hyperplasia

creation of extra cells

F0 and Ps used in speaking

1.        There is more mass weight to the VF and thus F0 may be lower

2.        The greater the glottal obstruction, and thus the greater the breathiness (unmodulated airflow when the glottis doesn’t close all the way)

3.        The greater the VF motion instability

4.        The greater the acoustic perturbation (leading to rough voice quality)

5.        The less motion of the VF at that lesion location

6.        Note: the size of the lesion has nothing to do the degree of hoarseness produced and heard

using greater glottal adduction or subglotall pressure

how might a client compensate for a glottal obstruction to improve closure?

reduce amount and loudness of talking and voice use, reduce adduction, adopt an appropriate pitch, improve vocal technique

How would an SLP treat a client with voice therapy?

treatment for large, pedunculated polyps

surgery may be the first and best choice because the condition has a poor chance of being reduced in size by rest and therapy

treatment for small polyps

should absorb with healthy tissue as a result if the person reduces maladaptive phonation behaviors

treatment for nodules

if these do not respond well to therapy after 6-12 months, surgery should be considered; may not go away, but clinically we want them to become smaller and softer so they don’t disrupt phonation as much

women, men

Nodules are more common in adult _______ than adult _______ .

why are nodules more common in adult women than adult men?

1.        More collisions per second – because F0 is higher in women

2.        VFs move faster – the higher pitches create higher velocities and accelerations of the tissues, creating more “whip” motion and higher internal strain

3.        Periodic change in edema – due to hormone cycles; makes the VFs more susceptible to change (easier to experience phonotrauma when the VFs are swollen)

4.        Are the hyaluronic acid differences important here?

boys, girls

Nodules are more common in young _______ than young _______ .

louder vocal behaviors by boys

why are nodules more common in young boys than young girls?

infections, dehydration, endocrine imbalance, smoking, alcohol consumption, exposure to irritants, allergy reactions

predisposing factors

6.6%

what percentage of U.S. adults have a voice problem?

nodules, edema, polyps, cancer, paralysis

What are the 5 most common laryngeal pathologies?

no

Can we diagnose vocal lesions/disorders by just the sound of the voice?

describe tissues, structural movement of arytenoids/vocal folds

What is the role of the SLP in diagnosing vocal lesions?

What should SLPs know to choose the best therapy approach?

o   Appearance: what the larynx and VFs look like (lesions, symmetry of anatomy, texture, color)

o   Function: how the VFs are functioning (symmetry of motion, mucosal wave, amplitudes, length change, etc.)

o   Medical diagnosis: what the diagnosis is (from the MD and other health professionals)

o   Medical/surgical management: what the medical/surgical management is or will be (type, amount, goals)

compensation

what the client is doing behaviorally to make up for the structural abnormalities that affect glottal configuration, subglottal pressure, and vocal fold vibration

compensation examples

• increasing/decreasing adduction

• using more/less lung pressure

• raising/lowering the speaking pitch

• raising/lowering thte larynx

noun

mucus is the _____ .

adjective

mucous is the _______ .

mucous membrane

mucosa refers to the ________ .

posterior glottis contact ulcers

‘trauma’ causing ulcers and granulomas

ulcers

raw sores, pale or red in color of the mucous membrane covering the vocal aprocesses

symptoms of ulcers

o   Localized throat pain

o   Ear pain

o   Throat tickle

o   Sensation of dryness

o   Lump in throat, globus

o   Need to clear throat

o   Non-productive cough

signs of ulcers

o   Often edema and redness in region

o   Possible concave area on opposing side

soon after or a few weeks to a few months after intubation

when do symptoms first appear for ulcers?

no

are symptoms related to age?

ulcer signs of vocal impairment

• Swelling of mucosal tissue, ulceration, and granuloma lead to

  • Hoarseness, roughness, breathiness

  • Aphonic breaks

  • Compensation can cause muscle tension dysphonia

ulcer recovery

o   Since this is NOT due to vocal misuse,

§  Spontaneous recovery should occur  normal voice in a few days

§  If no spontaneous recovery, suspect

·      Significant damage due to LONG duration of tube in glottis

·      Reflux (that keeps the tissue irritated)

o   if voice problems lasts for more than a few days,

must see a laryngologist and SLP for laryngeal assessment

GERD, LPR

What 2 reflux disorders can cause ulcers and granulomas?

GERD

what is the primary cause of ulcers and granulomas?

gastroesophageal reflux disease

what does GERD stand for?

laryngopharyngeal reflux

what does LPR stand for?

GERD

o   Acid and pepsin from the stomach flow up into the esophagus

o   Lower esophageal sphincter doesn’t keep fluids in the stomach

o   LES has smooth muscle that relaxes

o   Diaphragmatic sphincter just above the LES also might relax (this sphincter has striated muscle)

typical causes of GERD

o   Weak LES

o   Ingestion of certain foods (fatty foods, chocolate, caffeine, alcohol, acidic foods)

o   Pressure on stomach (obesity, pregnancy, physical activity)

o   Retention of contents within stomach (delayed stomach emptying) = gastroparesis

LPR

occurs when acid and pepsin spill out of the esophagus onto the larynx and pharynx

for both GERD and LPR

o   Often occur at night when sleeping when the posture is horizontal and gravity is not as influential to keep contents down in the stomach

o   Occur during the day (upright posture) probably due to physical activity, pressure on the LES, and apparently to anxiety

o   Similar ulceration as with rubbing intubation lesion

§  Usually on vocal process, unilateral, with granuloma mass formation

symptoms of GERD and LPR

§  Localized throat pain

§  Ear pain

§  Throat tickle

§  Dryness

§  Lump

§  Need to clear

§  Non-productive cough

§  Mild to moderate hoarsenss

§  Aphonic breaks

§  Possible muscle tension dysphonia and fatigue

§  Bitter taste in mouth

§  “bad” breath (halitosis)

§  Pitch range reduction

§  Inconsistent voicing from day to day

·      Probably as a result of tissue change being different from day to day

signs of GERD and LPR

edema and redness, indentation

20-40 years old

what is the typical age of onset for GERD or LPR?

yes

can GERD exist at any age?

GERD, LPR appearance

§  Starts as small, pale, concave lesions with cartilage exposed

§  Then becomes covered with necrotic tissue,

·      Followed by hyperemic margins,

·      Followed by raised, sessile, pale-appearing granuloma

§  Extreme case – granuloma obstructs the airway

reflux medications, temporary paresis, botox

what can we use for treatment of GERD and LPR?

phonatory mechanical trauma to the vocal folds

§  Persistent low pitch in speech or singing AND

§  Hard glottal attacks AND

§  Hyperadduction of vocal processes

Chronic cough, throat clear

non-phonatory mechanical trauma to the vocal folds

LPR

what should we always suspect/rule out with any voice client?

antacids, H2-blockers, proton-pump inhibitors, prokinetics

medication treatment for GERD and LPR

LINX

small flexible band of interlinked titanium beads with magnetic cores; magnetic attraction between the beads is intended to help the LES resist opening

reduce high impact forces/tissue irritation, advise lifestyle changes (diet), support understanding of physiology

What does voice therapy for GERD and LPR look like?