Voice and Resonance Etiologies

Reinke’s Edema Patient complaints

• vocal fatigue

• hoarseness

• gravelly voice

• difficulty breathing

• lower voice (masculinized)

Reinke’s Edema Perceptual symptoms

• Severe/persistent deteriorating changes in vocal quality

• Pitch lowers

• alternates back and forth Dysphonia = hoarse Aphonia = must whisper

Dysphonia

hoarse

Aphonia

must whisper

Reinke’s Edema Etiology Behavioral

• smoking

• alcohol use

• phonotrauma

  • yelling

  • excessive talking

  • coughing

  • throat clearing

Reinke’s Edema Etiology Medical

• Hypothyroidism

• Laryngopharyngeal Reflux LPR

Phonotrauma

• yelling

• excessive talking

• coughing

• throat clearing

Voice Therapy (behavioral) for medical conditions

Identify, modify, remove sources of vocal abuse/misuse and phonotrauma

Vocal Polyp - Voice Therapy

• Identify, Modify, eliminate phonotruama

• vocal rest

  • relative

  • none whatsoever

• Vocal hygiene

Polyp treatment

May disappear on it’s own

Voice Therapy

Medicine: Low does Oral steroids

Surgical removal if: lesion is very big, lesion has not responded to voice therapy treatment.(Microlaryngoscopy w/surgical excision)

Reinke’s treatment

Voice therapy: identify/modify/remove sources of vocal abuse

Medication: anti reflux

Surgery: Often Unilateral, and vocal folds adjust/balance out

Vocal Polyp -patient reported symptoms

pain when shouting

neck pain

lump in throat (globus)

vocal fatigue

Vocal Polyp - perceptual symptoms

Diplophonia = 2 distinct frequencies

Sudden phonation breaks

Hoarse

Breathy

Diplophonia

voice produces two distinct pitches/frequencies

Why do phonation breaks happen with pedunculates?

it flops in and out of trachea and vocal folds while person is phonating

vocal polyp - Laryngoscopic findings

typically unilateral

fluid/blood filled

found at junction of anterior middle 1/3 of vocal fold margin

What is a vocal polyp?

benign extension of the epithelium on the free margin of the vocal fold; typically unilateral

Nodules - Voice therapy

Program of good vocal hygiene

Behavioral: Identify, modify, eliminate vocal abuse/misuse

What is Reinke’s Edema?

Laryngeal condition caused by vocal fold edema in Reinke’s space (2nd layer under epithelium)

elephant ear configuration

LPR -Medication Management

Medication:

• Antacids (tums)

• H2 Blockers (zantac)

• Protein pump inhibitor (Prilosec)

LPR Mediosurgical Management

Testing: 24 hour Ph monitor

Surgery: fundoplication - tightens LES

Vocal NoduleS-Laryngoscopic Findings

ALWAYS bilateral

Location: juncture of anterior 1/3, posterior 2/3 margins of vocal folds

Acute Stage: soft. reddish vascular

Chronic Stage: hard, white, thickened fibrotic (little edema surrounding nodules)

Vocal Nodules -Treatment

Voice Therapy only: behavioral changes needed

• identify, modify, remove voice abuse/misuse

Mediosurgical management is contraindicated

Vocal Nodules-Mediosurgical treamtent

Contraindicated for Vocal Nodules, behavioral only

Etiology DRIVES

Treatment

Whatever caused it will suggest how to treat

Vocal Nodules - Perceptual symptoms

Relatively low pitch

Hoarseness (breathiness, harshness)

Scratchy voice

Tightness in Voice

Vocal Nodules - patient reported symptoms

Vocal fatigue

takes effort to speak

tension in throat

Vocal Nodules - etiology

1. phonotrauma (vocal abuse - excess pitch, singing/speaking, throat clearing, coughing)

2. Smoking, speaking in smokey environment

3. alcohol abuse

4. hard glottal attacks

5. phonation against resistance (exercise grunt)

Vocal Nodules - 4 facts

1. One of the most common voice disorders

2. Public sees “calluses”

3. Location helps diagnosis

4. results from vocal abuse/misuse

Vocal Nodules - why is pitch lower

vocal folds are heavier, have more mass, therefore vibrate slower

LPR - Laryngoscopic findings

1. Ulcers

2. Erythema (reddening) of the aretnoids

3. thick, excessive mucus

4. Edema

LPR - voice therapy behavioral management

1. identify/modify/eliminate GERD contributors

2. Avoid foods that relax LES (caffeine, sugar)

3. lose weight

4. wear loose fitting clothing

5. elevate head during sleep

6. eat 3-4 hours BEFORE lying down

7. stay hydrated

8. use air humidifer

Vocal Hygiene

stay hydrated

Use air humidifier

GERD & LPR share these symtpoms

Dysphagia - trouble swallowing

Odynophagia - pain when swallowing

LPR - symptoms

1. Dysphonia (hoarse)

2. Excessive mucus

3. chronic coughing/throat clearing

4. globus (lump in throat feeling)

5. breathing difficulties

6. vocal fatigue

7. ulcers

Not directly associated with heartburn

LPR/GERD causes

1. Hiatal Hernia

2. Obesity/pregnancy

3. smoking/alcohol (LES relaxes)

4. Diet high in: caffeine, chocolate, alcohol, citrus fruits (relaxes sphincters)

LPR - etiology

LES relaxes

stomach acid, bile, pepsin escapes

LPR - what is it?

Backflow of gastric fluid through the esophagus into larynx or pharynx (throat)

“Silent reflux” - UES is dysfunctional

GERD - what is it?

Gastroesophogeal Reflux disease - backflow of GASTRIC fluid from stomach into the esophagus (through LES)

Reinke’s - Laryngoscopic findings of vocal folds

1. floppy

2. grayish pink or red

3. fluid filled

4. enlarged/swollen

5. elephant ear

Reinke’s - why trouble breathing?

obstruction of airway

Vocal Polyp - etiology

Phonotrauma: shouting, loud talking, throat clearing

Secondary reactions: allergies, thyroid imbalance, upper resp infection, excessive alcohol use, excessive cigarette smoking

Vocal Polyp - types & description

Sessil - broad base attachment of fluid filled pocket

Pedunculated - blood filled, looks like a stalk of broccoli

During these timeframes one should not speak in abusive manners

Allergy episode

URI - Upper respiratory infection

Menstrual cycle (vocal folds bloated)

Medicine risk factors

aspirin - can cause vocal fold hemorrhage