Chapter 1-3

The basics

Which of the following serves as the anterior attachment for the vocal folds?

a. Cricoid cartilage.

b. Anterior commissure.

c. Thyroid notch.

d. Corniculate cartilage.

e. all of the above

b. Anterior commissure.

The vocal folds attach anteriorly to the anterior commissure of the thyroid cartilage. The two vocal folds merge as they course toward this point

Which of the following serves as the posterior attachment for the vocal folds?

a. vocal process

b. cricoid cartilage

c. anterior commissure

d. epiglottis

e. none of the above

a. vocal process

The arytenoid cartilage consists of two projections at its base: the muscular process and the vocal process. The vocal process projects toward the front and serves as the posterior attachment of the vocal folds. At rest, the two vocal processes are separated allowing for an abducted glottal configuration and allowing air to flow through the glottis for respiration.

Which of the following influences laryngeal movement in the vertical plane (up and down)?

a. activity of the intrinsic laryngeal muscles

b. activity of the lateral cricoarytenoid

c. movement of the hyoid bone

d. movement of the arytenoid cartilages

e. both a and b

c. movement of the hyoid bone

The larynx is suspended, or hangs, from the hyoid bone via membranes and ligaments. As the hyoid bone moves, so moves the larynx. Hyoid movement can cause the larynx to move in a superior and anterior direction, or an inferior direction.

What allows the arytenoid cartilages to swivel so that the vocal folds can adduct/abduct

a. cricothyroid muscle

b. laryngeal elevators

c. cricothyroid joint

d. cricoarytenoid joint

e. none of the above

d. cricoarytenoid joint

The cricoarytenoid joint allows the arytenoid cartilages to swivel and slide along the surface of the cricoid. These movements allow the vocal processes to approximate for glottal adduction, or separate for glottal abduction.

Which of the follow form the vocal fold cover?

a. Intermediate and deep lamina propria

b. vocalis and superficial lamina propria

c. epithelium and superficial lamina proproia

d. true and false vocal folds

e. both a and d

c. epithelium and superficial lamina proproia

The vocal fold cover consists of the epithelium and superficial layer of the lamina propria. Together these layers are highly mobile and will oscillate quite easily during phonation when the tissue is healthy.

Which of the following are forces that facilitate vocal fold oscillation during phonation?

a. transglottal pressure gradients and flow vortices

b. medial compression and tongue pressure

c. lung contraction and velar constriction

d. bernoulli’s effect and tracheal decoupling

e. all of the above

a. transglottal pressure gradients and flow vortices

Transglottal pressure gradients and flow vortices create regions of negative pressure which influence the edges of the vocal folds to approximate each other. Along with subglottal pressure, these help sustain vocal fold oscillation.

How might the presence of a glottal gap influence the resulting acoustic sound spectrum?

a. it would decrease fundamental frequency

b. it would elevate fundamental frequency

c. it would increase the amount of noise.

d. it would decrease the amount of noise

e. all of the above

c. it would increase the amount of noise.

A glottal gap refers to an opening in the vocal folds during phonation. This results in excess air escaping through the glottis. The acoustic characteristic of this air is nonharmonic energy, also referred to as spectral noise.

Which of the following influences fundamental frequency phonation?

a. position of the velum

b. interplay between cricothyroid and thyroarytenoid

c. position of cricoarytenoid joint and corniculate cartilages

d. dynamic movement of the hyoid bone

e. both a and b

b. interplay between cricothyroid and thyroarytenoid

The cricothyroid muscle and thyroarytenoid muscle are antagonistic to each other. Their interplay determines the longitudinal tension of the vocal folds, which influences fundamental frequency.

Which of the following plays the least important role during phonation?

a. thyroid cartilage

b. arytenoid cartilage

c. cricoid cartilage

d. epiglottis

e. none of the above

d. epiglottis

The epiglottis can influence the resonance properties of the vocal tract, but has minimal influence on vocal fold oscillatio

Which of the following terms represents a deviation in voice quality?

a. loudness

b. dysphagia

c. dysphonia

d. inertive reactance

e. none of the above

c. dysphonia

Negative impacts on phonation and voice quality are perceptually labeled as dysphonia.

Which of the following is the primary sensory nerve for the larynx?

a. the pharyngeal branch of the vagus nerve

b. the recurrent laryngeal branch of the vagus nerve

c. the internal branch of the SLN

d. the external branch of the SLN

e. the glossopharyngeal nerve

c. the internal branch of the SLN

The vagus nerve has numerous branches among which include the pharyngeal branch, recurrent laryngeal nerve, and superior laryngeal nerve. The superior laryngeal nerve itself branches into the external division and internal division. The internal branch of the superior laryngeal nerve provides the sensory receptors to the mucosa throughout the laryngeal region.

Which of the following are suprahyoid muscles that elevate the larynx?

a. omohyoid and thyrohoid

b. thyrohyoid and sternothyroid

c. geniohyoind and mylohyoid

d. digastric and sternothyroid

e. diaphragm and external intercostals

c. geniohyoind and mylohyoid

The geniohyoid and mylohyoid originate at the inner surface of the mandible, attaching the hyoid bone inferiorly. When they contract, their muscle fibers shorten, raising the hyoid bone. As the hyoid bone elevates, it also raises the larynx, which is suspended from the hyoid bone by membranes and ligaments.

The opening into the larynx, which is the space encircled by the aryepiglottic folds, is known as the

a. laryngeal valve

b. laryngeal vestibule

c. laryngeal hole

d. trachea

e. diaphragm

b. laryngeal vestibule

A vestibule is an opening to a space. The most superior region of the larynx is surrounded by the epiglottis and aryepiglottic folds. These encircle an open space, called the laryngeal vestibule, which effectively serves as the top opening to the larynx

The space in-between the left and right true vocal folds is known as the

a. glottis

b. trachea

c. larynx

d. vestibule

e. ventricle

a. glottis

The term “glottis” refers to the space between the vocal folds. Muscular action can serve to open the glottis or close the glottis. A patient with vocal fold paralysis that impairs his or her ability to close the vocal folds is said to have “glottal incompetency.”

Supraglottic pressures generated by the manipulations in the vocal tract act as a force on the vocal which influences vibration. This force is called

a. resonance

b. frequency

c. pitch

d. inertive reactance

e. none of the above

d. inertive reactance

When the anterior vocal tract is narrowed and the regions above the vocal folds are widened, it creates a backward-directed pressure and impedance matching of intraglottal and supraglottal resistance, via a physical phenomenon known as inertive reactance. Inertive reactance serves to help separate the vocal folds during vibration and also amplify the resulting acoustic energy.

Which of the following is a nonbiological role of the larynx

a. impounding air to fixate the thorax

b. acting as a valve for respiration

c. serving as a vibratory source for voice production

d. creating subglottal pressure to generate a cough

e. all of the above

c. serving as a vibratory source for voice production

The nonbiological role of the larynx relates to voice production for communication purposes. It is considered an “overlaid” or secondary function of the larynx is not needed for survival. Although without a voice communication can be difficult, many other means of communication exists and are used on a daily basis.

The vocal folds consist of a layered structure, functionally divided into the cover, vocal ligament, and body. Which layers make up the vocal ligament?

a. Epithelium and superficial lamina propria

b. intermediate and deep lamina propria

c. deep lamina propria and vocalis muscle

d. vocalis muscle and epithelium

e. none of the above

b. intermediate and deep lamina propria

The intermediate and deep layers of the lamina propria collectively form the vocal ligament. The vocal ligament serves to connect the vocal fold cover to the body, in addition to absorbing physical stress caused by manipulations to vocal fold length and tension.

Which of the following muscles adduct (close) the vocal folds?

a. posterior cricoarytenoid and interarytenoid

b. lateral cricoarytenoid, interarytenoid, and thyrohyoid.

c. lateral cricoarytenoid, interarytenoid, and thyroarytenoid

d. posterior cricoarytenoid, lateral cricoarytenoid, and interarytenoid.

e. interarytenoid and thyrohyoid

c. lateral cricoarytenoid, interarytenoid, and thyroarytenoid

Contraction of the lateral cricoarytenoid, interarytenoid, and thyroarytenoid (muscularis) will move the vocal process medially, causing the vocal folds to adduct. The number of motor units recruited in each muscle during contraction will determine the degree of medial compression in vocal fold closure. Medial compression is one factor that can influence subglottal pressure during phonation.

Which of the following muscles is a tensor of the vocal folds?

a. cricothyroid

b. posterior cricoarytenoid

c. lateral cricoarytenoid

d. interarytenoid

e. none of the above

a. cricothyroid

The cricothyroid and thyroarytenoid (vocalis) serve as vocal fold tensors. A dynamic interplay between these muscles allows a speaker or singer to adjust fundamental frequency to produce speech prosody and the various transitions between musical notes.

The most extreme form of the laryngeal adductor reflex results in prolonged tonic contraction of the laryngeal adductor muscles, including those that adduct the ventricular folds and laryngeal vestibule. This is also known as

a. laryngospasm

b. cough

c. throat clear

d. dysphonia

e. all of the above

d. dysphonia

Dysphonia is a term that represents a perceptual change in voice quality or function

Which of the following is a characteristic that differentiates functional from organic voice disorders?

a. organic vd can cause exophytic lesions to develop on the vf

b. functional vd include a behavioral hyperfunction

c. functional vd have no known primary etiology that is neurological, structural, or systemic

d. organic vd occur without behavoiral hyperfunction

e. all of the above

functional vd have no known primary etiology that is neurological, structural, or systemic



A primary difference between functional and organic voice disorders is that functional disorders are caused by behaviors, while organic disorders are not. Organic disorders are caused by neurological, structural, or systemic conditions.

Which of the following is *not* an impaired characteristic of a voice disorder?

a. quality

b. dialect

c. loudness

d. flexibility

e. none of the above

dialect

Dialect is a linguistic or articulatory attribute, not a vocal attribute.

Which of the following correctly describes a vocal handicap?

a. the individual cannot adduct one vf completely

b. the individual is unable to generate the same amount of loudness

c. the individual exhibits a vocal tremor when speaking

d. the individual must take time off from work because of voice problems

e. both a and d

the individual must take time off from work because of voice problems



A handicap is a restriction in life activities—an individual who has to take time off work due to a voice problem would meet this definition.

Which of the following are etiologies of vocal process granulomas?

a. Vocal behaviors and laryngopharyngeal reflux.

b. Intubation and medication.

c. Medication and vocal behaviors. \n d. Laryngopharyngeal reflux and viral infections.

e. Both c and d.

Vocal behaviors and laryngopharyngeal reflux.



Vocal process granulomas can be caused by multiple factors, including vocal behaviors, reflux, and intubation trauma.

Why do benign mid-membranous lesions tend to occur and where?

a. The length of the vocal folds causes the middle to swell first.

b. That region of the vocal folds experiences the greatest impact stress.

c. The frequency of vibration is greatest in that region.

d. It is by random chance.

e. None of the above.

That region of the vocal folds experiences the greatest impact stress.



During oscillation, the mid-membranous region of the vocal folds experience the greatest amount of impact stress due to the physical properties of the vocal fold tissue and physical forces influencing their oscillation. Early swelling after heavy vocal use tends to occur in this region, as do *benign lesions such as nodules, polyps, and cysts.*

What is the key difference between primary MTD and secondary MTD?


1. Secondary MTD can result in breathiness and roughness.
2. Primary MTD is present without structural, neurological, or systemic causes.
3. Primary MTD is caused by functional hypercontraction of laryngeal muscles.
4. Secondary MTD can lead to changes in the vocal fold tissue.
5. All of the above.

Primary MTD is present without structural, neurological, or systemic causes.



Primary MTD is the presence of dysphonia without an accompanying organic condition. It is due to functional behaviors that persist over time, and does not develop secondary to some other condition.

Why would vocal process granulomas cause pain but not vocal fold nodules?


1. Impact stress is greater in the posterior region of the vocal folds.
2. Granulomas can be larger than nodules.
3. There are pain receptors in the posterior region of the glottis.
4. Granulomas require surgery, which will result in painful swelling.
5. All of the above.

There are pain receptors in the posterior region of the glottis.



Pain receptors within the larynx at the level of the vocal folds are located primarily in the posterior glottal region, at the region of the vocal processes and interarytenoid space. The lack of pain receptors on the vocal fold tissue explains why we do not feel pain when they collide during phonation.

Endoscopic signs of MTD might include

a. Supraglottal constriction of the larynx.

b. Anterior laryngeal webbing.

c. Loud voice with low pitch.

d. Glottal insufficiency with one vocal fold failing to adduct.

e. None of the above.

Supraglottal constriction of the larynx.



MTD is characterized by hypercontraction of laryngeal muscles. This can include the ventricular muscles, which are extensions of the thyroarytenoid. This will cause the false vocal folds (the ventricular folds) to move medially and constrict or narrow the larynx.

Nodules and polyps are thought to develop from phonotrauma that damages what vocal fold layer?

a. Intermediate lamina propria.

b. Deep lamina propria.

c. Vocalis muscle. \n d. Basement membrane zone.

e. All of the above.

Basement membrane zone.



The basement membrane zone lies immediately beneath the vocal fold epithelium, and contains fibers that connect the epithelium to the superficial layer of the lamina propria. Damage to these connections, and the repair process that follows, is thought to lead to the development of vocal nodules secondary to chronic phonotrauma.

Which organic voice disorder is characterized by a tissue bridge at the anterior region of the glottis?

a. Papilloma. \n b. Unilateral vocal fold paralysis.

c. Laryngeal web. \n d. Laryngopharyngeal reflux.

e. None of the above.

Laryngeal web.



Laryngeal webs are characterized by tissue of the left and right vocal folds attached, or bridged, together. Most often this occurs at the anterior commissure and anterior regions of the vocal fold tissue.

What theory explains the underlying etiology leading to the development of pseudocysts?


1. There is a viral infection isolated to the larynx.
2. There is an underlying vocal fold paresis.
3. There is a bacterial infection throughout the body.
4. There is an endocrine disorder causing a hormonal imbalance.
5. Both a and c.

There is an underlying vocal fold paresis.



Pseudocysts appear as blister-like exophytic lesions at the mid-membranous region of the vocal folds. Contemporary theory links their formation to an underlying paresis, which results in compensatory phonotrauma leading to the appearance of an edematous cyst-like lesion.

What theory explains the development of a vocal fold epidermoid cyst?




1. There is blockage of a mucous gland duct.
2. There is viral infection isolated to the vocal fold lamina propria.
3. There is a trapped epithelial cell in the vocal fold lamina propria.
4. There is arthritis in the cricoarytenoid joint.
5. All of the above.

There is a trapped epithelial cell in the vocal fold lamina propria.



Throughout the day, the vocal fold epithelium continually replaces cells. Old cells are typically shed off and swallowed or cleared via secretions and saliva. If a cell becomes trapped within the epithelium, it is thought the cellular response can lead to formation of a cyst, entrapping the old epithelial cell.

What is believed to be the cause of laryngeal papillomatosis?

a. Human papilloma virus. \n b. Bacterial infection leading to tissue change.

c. Vocal fold paralysis.

d. Phonotrauma. \n e. None of the above.

Human papilloma virus.



Laryngeal papillomatosis is associated with a number of different human papilloma virus (HPV) subtypes but most frequently HPV 6 and HPV 11, which are believed to be passed to a child from the mother at birth or at any other time by human-to-human contact.

A difference between vocal fold nodules and polyps is________.

a. Polyps occur at the mid-membranous region.

b. Nodules are due to phonotrauma.

c. Polyps occur in males and females.

d. Nodules are typically bilateral. \n e. All of the above.

Nodules are typically bilateral.



Vocal fold nodules are symmetrical or quasi- symmetrical bilateral lesions which can vary in size and shape depending on their stage of development and the patient’s voice use patterns.

Symptoms of adductor spasmodic dysphonia become more severe on what type of stimuli?

a. Unvoiced sounds.

b. Voiced sounds.

c. Phrases. \n d. Sentences.

e. none of the above

Voiced sounds.



The process of differential diagnosis for SD can be informed by evidence from task-specific vocalizations. Speakers with ADSD also tend to be more dysphonic on stimuli loaded with voiced sounds compared to stimuli loaded with unvoiced sounds.

Which of the following correctly describes the impairment of paradoxical vocal fold motion?


1. Involuntary vocal fold abduction during exhalation.
2. Increased muscle tone causing rigidity at rest and during phonation.
3. Involuntary vocal fold adduction during inspiration.
4. Adduction occurs at the onset of phonation.

Involuntary vocal fold adduction during inspiration.



Paradoxical vocal fold movement (PVFM) is characterized by transient but repetitive episodes of inappropriate and involuntary adduction of the vocal folds during inspiration. This has the effect of narrowing the airway and causing dyspnea, and can result in compensatory hyperfunction in the laryngeal and respiratory muscles that cause expiration to be labored and rushed with a negative impact on phonation.

Which of the following vocal tasks often perceptually reveals a vocal tremor best?

a. Sustained vowel. \n b. Rapid breathing cycles.

c. Reading the rainbow passage.

d. Reading CAPE-V sentences. \n e. All of the above.

Sustained vowel.



Vocal tremor, especially when mild, is best perceived when a patient produces a sustained vowel. Because healthy phonation is typically stable during sustaining vowels, the rhythmic nature of the tremor will stand out during these productions

Perceptual characteristics of presbylaryngis include

a. Excessive loudness and low pitch. \n b. Rough voice quality with tremor. \n c. Voice breaks with hoarse voice.

d. Reduced loudness and breathy voice.

e. None of the above.

Reduced loudness and breathy voice.



Breathiness and reduced loudness are the most salient perceptual characteristics of presbylaryngis and are the basis for describing this condition by its other name, presbyphonia.

Incomplete maturation of the laryngeal cartilages at birth can cause a condition known as

a. Laryngocele. \n b. Laryngomalacia.

c. Osteoarthritis.

d. Papillomatosis.

e. All of the above.

Laryngomalacia.



Laryngomalacia is a congenital condition caused by incomplete maturation of the cartilaginous framework of the larynx. It is one of the most common causes of inhalatory stridor in infants. The condition affects the rigidity of the laryngeal cartilages, resulting in abnormal pliability and positioning of cartilages that can obstruct the airway.

Why is laryngopharyngeal reflux most likely to irritate the posterior larynx than the anterior larynx?


1. The upper esophageal sphincter is located behind the posterior larynx.
2. Reflux migrates from the anterior larynx to the posterior larynx.
3. Tissue in the posterior larynx is different from that of the anterior larynx.
4. There are more sensory receptors in the posterior larynx.
5. Both b and c.

The upper esophageal sphincter is located behind the posterior larynx.



Reflux consists of stomach contents which migrate upward through the esophagus. The superior opening of the esophagus is the upper esophageal sphincter, which sits immediately behind the posterior region of the larynx.

Which of the following voice evaluation procedures is a direct form of evaluation?

a. Voice Handicap Index.

b. CAPE-V ratings of roughness, breathiness, and strain.

c. Case history examination.

d. Laryngeal stroboscopic examination.

e. None of the above.

d. Laryngeal stroboscopic examination.

A voice is normal/typical if it does not deviate substantially from our internal gauge of parameters such as ___________________.

a. Loudness. 

b. Quality.

c. Pitch.

d. Articulation. 

e. a, b, and c.

e. a, b, and c.

The voice clinician decides to go ahead with a treatment plan for vocal nodules even though, following further voice evaluation, the patient has no signs or symptoms obtained via case history and perceptual evaluation consistent with the diagnosis. This may be an example of ______________. a. Diagnosis momentum. 

b. Anchoring bias.

c. Confirmation bias. 

d. Premature closure. 

e. Availability bias.

a. Diagnosis momentum. 

Which of the following is associated with poor voice quality and excessive throat clearing first thing in the morning?

a. Postnasal drip.

b. Laryngopharyngeal reflux.

c. Hyperfunctional voice use. 

d. Psychosomatic conditions. 

e. a and b.

e. a and b.

Why is auditory-perceptual evaluation of voice a necessary and valuable component of the voice diagnostic?

a. Perceptual evaluation methods are available to all clinicians.

b. The perceived characteristics of the voice are often the reason that a patient has presented themselves or has been referred for in the first place.

c. The perceived characteristics of the voice present a gauge by which the success of therapy will be evaluated.

d. Perceptual evaluation provides a direct method of laryngeal evaluation.

e. a, b, and c.

e. a, b, and c.

The term used to describe the pitch level around which normal pitch inflections/variations occur and is used most often in everyday speech is _____________________.

a. Habitual pitch. 

b. Monopitch.

c. Intonation. 

d. Tremor. 

e. All of the above.

a. Habitual pitch.

The perceptual attribute that corresponds to the magnitude of sound pressure disturbances is _________________________.

a. Quality. 

b. Pitch.

c. Loudness.

d. Duration.

e. All of the above.

c. Loudness.

A respiratory pattern that results in a weak, shallow inspiration and mainly uses the secondary/accessory muscles of respiration is ____________.

a. Thoracic breathing. 

b. Clavicular breathing.

c. Diaphragmatic-abdominal breathing. 

d. Inhalatory stridor.

e. a or b.

b. Clavicular breathing.

A disordered voice quality that is often described as “gravelly” and is associated with irregularity of vocal fold vibration is ______________________. 

a. Strain.

b. Breathiness.

c. Monopitch.

d. Roughness.

e. None of the above.

d. Roughness.

Which of the following evaluation procedures is not an impairment-level measure?

a. Auditory-perceptual evaluation of voice.

b. Acoustic analysis methods.

c. The Voice Handicap Index. 

d. Aerodynamic measurement. 

e. Laryngeal stroboscopy.

c. The Voice Handicap Index.