Voice 2a) - Etiologies

general description of VF nodules

bilateral bumps at the juncture of the anterior and middle 2/3 of the VFs

true or false: there is considerable variation in VF nodules

true

prevalence of VF nodules in school age (Killic)

30%

VF nodules involves inflammatory mid-membranous generation of what?

the basement membrane zone and superficial layer of lamina propria

Etiology VF nodules

phonotrauma and hyper function from:

• talking/shouting

• throat clearing

• sound effects

• singing

VF perceptual ax

• breathy

• decreased pitch

• flat

• deteriorates throughout the day

VF visual ax

• hourglass closure/open glottal chink (ant/post)

• increased mass of TVFs

• decreased amplitude and mucosal wave

• edema/erythema

true or false: VF nodules only affect closure and pliability

false: they can affect closure, pliability, and symmetry

VF nodule initial management

behavioural voice tx

young clients may need psych support

VF nodule treatment (+vascular lesions)

oral steroids may help

surgery for VF nodules?

if removed surgically w/o any voice treatment, nodules likely to return

Reinke’s edema

chronic diffuse swelling of the superficial lamina propria of the VF

what happens to the lamina propria in RE?

the collagen architecture is disrupted and a thick, gelatinous fluid like material develops in Reinke’s space

true or false: RE is usually unilateral

false: usually bilateral

what does RE often affect?

the anterior 2/3s of glottal margin (vibrating portion) or membrane covering the muscular portion of the folds

true or false: RE is non-cancerous

true

common causes of RE

• smoking

• chronic vocal hyperfunction

• laryngopharyngeal reflux

• prolonged exposure to inflammatory stimuli accompanied by abnormal healing

RE effect on closure

VFs may not fully close → breathy or hoarse voice

reduced closure due to large swollen tissue → also lower pitch from mass

RE effect on symmetry

often bilateral, but sometimes more pronounced on one side so vibrations may not be symmetrical

RE effect on pliability

less pliable because of the mass, but variable (some may be more pliable)

Ax for RE

• laryngeal exam high priority

• 4 kinds: edema of one fold, edema of both, edema of one with a lesion on either, edema of both with a lesion on one or both

• CAPE-V

• Self perception of QoL

voice tx for RE

• eliminate cause of problem

• promote proper use of voice

is surgery recommended for RE?

often no, not a permanent solution but if behavioural tx not successful surgery may be indicated

what are VF polyps

focal abnormalities within the superficial lamina propria that are slightly deeper than nodules

true or false: VF polyps are often unilateral

true, with a reactive lesion found immediately across from the polyp

what do VF polyps result from?

a single vocal event (like yelling at a concert)

what kinds of polyps are there?

translucent, fibrotic, hyaline, hemorrhagic, or mixed

what increases likelihood of polyps?

smoking

true or false: VF polyps can potentially result from long term vocal abuse/irritation

true

once a small polyp begins….

any continued phonotrauma will irritate it, adding to its growth

VF polyp perceptual findings

• hoarseness and breathiness

• moderate dysphonia

sessile

a polyp attached to the VF

pedule

a polyp that has a stalk like growth

VF polyp effect on closure

worse glottal closure (incomplete depending on size and location)

VF polyp effect on symmetry

• usually unilateral (physical asymmetry and asymmetric closure)

• vibration asymmetry

• phase delay due to mass

VF polyp effect on pliability

smaller mucosal wave amplitude, magnitude, and persistence

surgical interventions for VF polyps

• microflap: lifting flap, removal, flap placed back

• epitelial cordotomy: microdissection

• most effective followed by vocal rest

improvement for VF polyps

• type of polyp associated with improvement (translucent more likely)

• smaller more likely to improve

• voice tx often provided in combo with surgery

true or false: voice therapy only is not a warranted first course of treatment before surgery for VF polyps

fasle

voice tx for VF polyps

• coaching for avoiding vocal abuse

• altering pitch and volume

• how to breathe to best support speech

• how to reduce pressure on the VFs

VF cyst description

• benign

• usually unilateral

• occur on VFs or anywhere on ventricular folds

how do cysts often appear compared to VF nodules?

soft and pliable vs hard and fibrotic

true or false: clients with VF polyps always experience dysphonia

false: it depends on the site of lesion

what cyst location is more prone to dysphonia?

saccular cysts between the false VFs and thyroid cartilage

common causes of cysts

• can develop in utero

• repetitive phonotruama

• glands becoming clogged and mucous becomes trapped

what are the two kinds of cysts?

1. mucous glands in vocal folds become plugged in the middle portion of the upper lamina propria

2. cyst fills with keratin in the deep layers of the lamina propria

perceptual ax cysts

• pitch instability

• breathiness

• hoarseness

• roughness

• airway obstruction

cyst effect on closure

• unilateral → one VF is closing completely while one is not

• bilateral → hourglass closure or chink

• more flexible than nodules → may assist with more closure

cyst effect on symmetry

• unilateral → each VF is moving differently which affects amplitude and mucosal wave

• typically not symmetrical when they are bilateral

tx for cysts

• voice therapy and transoral microlaryngeal surgery

true or false: it is rare for a VF cyst to resolve without surgery

true

voice therapy management for cysts

education on vocal hygiene and reducing vocal abuse

strategies to reduce hyperkinetic behaviours to obtain best vocal fold vibration

laryngeal papilloma is aka

recurrent respiratory papillomatosis (RRP)

laryngeal papilloma description

wart like tumours that grow in the larynx on or around the vocal folds due to a viral infection of epithelial cells

the majority of cases of laryngeal papilloma are caused by what?

HPV types 6 and 11

LP effect on closure

improper closure due to increased mass

LP effect on symmetry

can be unilateral or bilateral → asymmetric closure and vibration

LP effect on pliability

more/less pliable depending on the density and placement

LP perceptual ax

• breathy vocal quality

• hoarseness (main symptom)

• chronic coughing

LP visual ax

• tumor (masses)

• edema

true or false: LP treatment is curative

false: considered palliative

true or false: LP Treatment is often surgical

true, due to the resilience of HPV

other tx for LP

• laser therapy (no general anesthesia)

• antiviral meds

• HPV and mumps vax

• voice therapy to avoice excessive strain

true or false: you are not able to restore full function with only behavioural management in LP

true

laryngeal web description

congenital or acquired condition characterized by a layer of tissue connecting the VFs

a laryngeal web grows across the ___ in the anterior to posterior direction

glottis

laryngeal web sometimes called a

synechia

what kind of sound does a LW often cause?

high pitched and rough

LW congenital causes

glottal membrane failing to separate in embryonic development

• may be associated with velocardiofacial syndrome

LW acquired causes

• often results from long term intubation or post VF surgery

• can be seen after laryngeal infection of external trauma to the VFs

• can occur due to the proximity of the VFs

LW effect on closure

inhibits normal VF vibration, limits VF opening

LW effect on symmetry

web grows symetrically and is surgically removed, maintaining symmetry

LW effect on pliability

webbing limits VFs’ ability to vibrate freely

intensity of the webbing determines how pliable VFs are

LW vocal quality

• weak

• high pitched, rough sound

• inhalatory stridor (congential)

• SOB

• high pitched/abnormal cry in babies

• hoarse

• wheezing

LW congenital ax

genetic testing for chromosome 22q deletion

weak cry and aphonia since birth

true or false: if LW is congential it requires surgery immediately

true

LW management

dilation: small balloon in airway to widen or break web

surgery: opening into larynx to cut through the web → cover the VFs to make sure the web does not grow back then coverings removed after 6-8weeks

• vocal rest needed as long as covering is in place

may require temporary trach

variable recovery time

MTD description

a spectrum of disturbed VF behaviour caused by increased tension of the (para)laryngeal musculature

MTD etiologies

• vocal misuse/overuse

• psychological/personality disorders

• compensatory vocal habits due to LPR, URI, and/or underlying pathology

• maybe neurologic (motor control disorder → improperly process what they hear)

MTD perceptual ax

• effortful voicing

• vocal fatigue

• odynophonia

MTD visual

• excessive glottic and supraglottic medial contraction

• A-P contraction of supraglottal muscles

• decreased vibratory amplitude

• psychogenic VF bowing

• variety of glottic gaps

behavioural tx for MTD

• biofeedback

• relaxation

• resonant voice tx

• circumlaryngeal massage

• manual therapy techniques

• accent method

• semi occluded vocal tract exercises

MTD respiratory patterns

• shallow clavicular and accessory muscle breathing

• limited abdominal excursion at rest and during vocalization tasks

• increased breath-holding patterns

Ventricular phonation description

use of the FVFs during phonation either instead of or along with the TVFs

two causative conditions for ventricular phonation

1. non-compensatory: habitual, psycho-emotional, ideopathic

2. compensatory: appropriate compensation for profound true VF dysfunction

ventricular phonation perceptual ax

• low pitch

• reduced pitch variability

• diplophonia

• hoarse and breathy quality

ventricular phonation visual ax

• looks normal with abduction

• ventricular movement/compression during adductory tasks

• hypertrophy of ventricular folds

what do you do first in ventricular phonation management?

assess the function and capability of the TVFs

ventricular phonation tx

- if TVFs are capable:

• behavioural voice tx

• biofeedback

• relaxation

• inspiratory phonation

• labial constriction

- psychotherapy

- pharmacological (botox)

- surgical (excision or laser surgery)

puberphonia description

voice doesn’t drop in adolescent males during/after puberty despite anatomical changes

Puberphonia psychological cause?

maybe difficulty transitioning into adulthood

puberphonia physical cause?

• hearing impairment

• immature laryngeal maturation

• poor neuromuscular coordination

• endocrine disorder

• neurological condition

puberphonia perceptual Ax

high pitch

breathy

puberphonia visual ax

• incomplete glottal closure

• increased pitch/length of folds

• decreased amplitude and mucosal wave

• in some cases hyperfunction (not all!!)

management for puberphonia

if no identifiable physical/organic cause, behavioural tx

techniques for puberphonia

cough → hum, all voiced word (record for feedback)

light pressure on thyroid cartilage

transitioning reflexive pitch to volitional pitch (principles of motor learning)