SLP 563 - Quiz 2

structural pathologies of the VF

any alteration in the histological structure of the VF

changes in the layered structure of the VF may affect the...

- mass

- size

- stiffness

- flexibility

- tension of vibrating mechanism

- alter vocal quality, pitch, loudness

malignant VF lesion

laryngeal carcinoma

laryngeal carcinoma

- typically squamous cell type originating from epithelium

- invades deeper as tumor progresses

- dysphonia severity varies

risk factors for laryngeal carcinoma

- smoking

- alcohol use

- maybe laryngopharyngeal reflux

treating laryngeal carcinoma

- radiation therapy

- chemotherapy

- surgical excision

traditional labels for benign VF abnormalities

- polyps

- nodules

- cysts

VF nodules

- bilateral, relatively symmetrical lesions

- medial edge of VF between ant. 1/3 and post. 2/3

- inflammatory degeneration of SLLP with fibrosis and edema of VF cover

acute VF nodules

- immature

- gelatinous, floppy

chronic VF nodules

- mature

- harder, more fixed to underlying mucosa

age and gender trends of VF nodules

- boys > girls

- women > men

personality/occupation factors of VF nodules

- talkative, socially dominant, stressed/tense

- singers, teachers, extended loud voice use

VF nodules: dysphonia

- mild to moderate

- roughness, breathiness

- gaps ant/post to lesions

- increased muscular tension

severity of dysphonia for VF nodules varies depending on...

- extent/size of lesions

- length of time since onset

- type of nodules

- degree of inflammation

VF nodules treatment

- first line is voice therapy

- surgical removal is needed by a skilled laryngologist (only after attempted therapy)

VF polyps

- fluid-filled, exophytic lesion composed of gelatinous material in SLLP with active blood supply

- typically located on middle third of the VF

- often unilateral

types of VF polyp

- sessile (blister like)

- pedunculated (attached to stalk)

causes of VF polyps

acute vocal trauma (i.e. yelling)

voice effects from VF polyps

- mild to severe dysphonia

- depending on size, type, location, degree of interference

treating VF polyps

- voice conservation/rehabilitation

- phonosurgery

VF cysts

- fluid-filled, typically unilateral, sessile lesions (sacs) on cephalic surface or medial edge of the VF

- can be congenital or acquired

- embedded in SLLP, but often extend into ILLP and DLLP

etiology of VF cysts

- not clear

- mucous gland blockage?

- phonotrauma?

a cyst can often be associated with...

"reactive" thickening of the contralateral VF (i.e., opposite to the cyst) suggesting bilateral lesions,

unlike nodules, cysts create a...

stiff adynamic segment due to reduced vibratory freedom of the cover of the VF

treating VF cysts

surgical excision/dissection of the cyst off of the vocal ligament (from a superior and lateral approach to avoid scarring of the vocal fold)

Reinke's edema

- SLLP becomes filled with viscous, gelatinous fluid

- "polypoid degeneration" is a severe form of edema wherein the

entire membranous VF is filled with fluid

causes of Reinke's edema

- chronic phonotrauma

- smoking

vibratory effects of Reinke's edema

- increased mass and stiffness (requiring more subglottic pressure)

voice effects of Reinke's edema

- signature low pitch and husky hoarseness

- smoker's voice

treatment of Reinke's edemea

- surgery

- smoking cessation program

- pre and post op voice therapy

VF scarring

"permanent" tissue changes in the structure of lamina propria (LP)

etiologies of VF scarring

- lesion presence (cyst, cyst burst)

- chronic tissue irritation (related to phonotrauma or other causes)

- iatrogenic changes

VF scarring increases...

stiffness of VFs

VF scarring reduces freedom of cover to...

oscillate = reduced mucosal wave during VF vibration

VF scarring reduces...

glottal closure in severe cases (non-vibrating scar, adynamic VF)

effects on voice from VF scarring

- vary depending upon severity, extent, and location of scar

- may compensate adynamic VF with supraglottic closure

treatment of VF scarring

no accepted/effective behavioral or phonosurgical treatment

sulcus vocalis

- special form of scarring that forms a "ridge" or "furrow" along the SLLP that produces bowing or spindle-shaped gap

- unilateral or bilateral

causes of sulcus vocalis

- unknown

- congenital

- acquired following cyst rupture

- s/s laser surgery?

- age-related?

VF granuloma

unilateral or bilateral, vascular and inflammatory exophytic lesions related to tissue irritation in the posterior larynx typically on medial surface of arytenoid cartilage(s)

VF contact ulcer

ulcerated lesion on the same site often on opposite side of granuloma (cup/saucer relationship)

s/s of granuloma and contact ulcers

- pain, sore throat

- with or without voice change

- doesn't really affect VF vibration

causes of granuloma and contact ulcers

- mechanical irritants (ET tube)

- chemical irritants (laryngopharyngeal reflux)

- persistent voice misuse

medical treatment of granuloma and contact ulcers

- antireflux regimen

- botox injections

behavior treatment of granuloma and contact ulcers

- voice therapy

- reduce medial compression by reducing strain & pressured voice

- reduce hard glottal onsets

surgical treatment of granuloma and contact ulcers

excision (only if fail medical/behavioral)

given location and etiology, granuloma and contact ulcers can be...

recurrent, recalcitrant

keratosis, leukoplakia, erythroplasia

3 benign VF pathologies under "epithelial hyperplasia" = abnormal musocal changes

leukoplakia

- white, thick plaque on superior surface of VFs in diffuse patches

- may be precancerous

hyperkeratosis

- excessive keratin

- rough, irregular VF margins

- may be precancerous

erythroplasia

- thickened and red

- due to combination of hyperfunctional voice use and chemical irritation (alcohol, tobacco)

recurrent respiratory papilloma (RRP)

- wart-like growths that develop in the epithelium and invade deeper in the LP and vocalis muscle

- can grow rapidly and in large clusters

- can proliferate and compromise the airway

causes of RRP

- Human Papilloma Virus (HPV) infection

types of RRP

- juvenile: onset 204 years old, can resolve spontaneously (after puberty)

- adult: persistent and progressive

effects on voice from RRP

- lesions can affect the cover, transition, and body of the VFs

- significant stiffness, compromised vibratory function, severe dysphonia

- multiple surgical treatments lead to scarring with worsening dysphonia

treating RRP

- multiple de-bulking surgeries

- pharmacotherapy (interferon, injections)

subglottic stenosis

fibrous tissue overgrowth that narrows the airway (typically subglottic just below the true VFs)

glottic stenosis or anterior glottic web

acquired scar across medial edges of the VFs beginning in the anterior commissure and extending posteriorly

causes of subglottic stenosis

- congenital

- post-intubation scarring

- laryngopharyngeal reflux

causes of glottic stenosis/web

- congenital or acquired

- acquired web 2/2 surgery involving anterior membranous portion of the VF

treatment of subglottic stenosis and web

surgery

vascular lesions

- caused by traumatic injury to small blood vessels of the VF

- focal or diffuse discoloration of VF

causes of vascular lesions

- intense screaming, singing, coughing, crying

- premenstrual women using blood thinners

vascular lesions: hemorrhage

small capillary on superior surface of VF ruptures abruptly and bleeds into SLLP

vascular lesions: hematoma

accumulation of blood that has leaked from the ruptured vessel

vascular lesions: varix

mass of blood capillaries that appears as small, long standing blood blister that has hardened over time with an adynamic VF segment

vascular lesions: ectasia

larger collection of varices

symptoms of vascular lesions

- increased stiffness of VF cover, localized scarring

- severe voice quality at time to bleed, can vary to mild later

treating vascular lesions

- aggressive voice conservation

- medical (steroids)

- laser cauterization

- surgery if persistent varix

puberphonia

- post-pubescent males who speak in falsetto or near top of their modal frequency range

- weak, breathy, raspy voice

- unable to increase intensity or shout

- associated with significant negative socioemotional consequences

causes of puberphonia

- resistance to puberty

- feminine self-identification

- desire to maintain a competent childhood soprano singing voice

- embarrassment when voice lowers dramatically earlier than one's

peers

treating puberphonia

behavioral voice therapy

juvenile voice

- post-adolescent females with higher than normal pitch

- breathy voice

- "child-like" speech distortions and prosody

- high tongue carriage

causes of juvenile voice

- women who resisted transition into adulthood

- habituated altered laryngeal and vocal tract posture

- trauma

presbyphonia

- voice disorder related to processes of laryngeal aging

- slightly bowed glottic configuration, presumable related to thinning VF

symptoms of presbyphonia

- thin, muffled voice quality

- decreased loudness

- increased breathiness

- pitch instability

- lack of vocal endurance and flexibility

treating presbyphonia

vocal function exercises (VFEs)

a change in larynx is _____ aging; a change in voice is _____

normal; presbyphonia

inflammatory conditions of larynx

- rheumatoid arthritis

- acute laryngitis

- laryngopharyngeal reflux

- chemical sensitivity/irritable larynx syndrome

trauma/injury to larynx

- internal: thermal, chemical, intubation

- external: blunt force, penetrating wounds

- arytenoid dislocation

systemic conditions affecting the voice

- endocrine function

- allergies

- immunologic responses

adverse effects of medications on the larynx

- drying effects (reduced fluids/secretions)

- muscle atrophy

- inflammatory effects

- altered VF structure

nonlaryngeal aerodigestive disorders affecting voice

- asthma

- COPD

- croup

- GERD

- infectious diseases

- fungal infections

neurologic disorders affecting voice

- peripheral nervous system pathology

- movement disorders

- central neurologic disorders

peripheral nervous system pathology

paresis or paralysis of superior or recurrent laryngeal nerve (or both)

causes of peripheral nervous system pathology

surgical trauma, cardiovascular/neurologic diseases, accidental trauma

RLN paralysis: unilateral

- breathy, hoarse, weak voice

- mild to severe dysphonia

treating unilateral VF paralysis

- voice therapy

- phonosurgical management

- medialization thyroplasty

- laryngeal reinnervation

laryngeal medialization laryngoplasty

- injection of resorbable material

- bioimplants

RLN paralysis: bilateral

more rare

SLN paralysis: unilateral

- very rare

- mild dysphonia

- loss of upper range

- weak voice

movement disorders of the larynx

- spasmodic dysphonia (ADSD, ABSD, mixed)

- +/- essential voice tremor

essential voice tremor

- not a type of SD but can co-occur

- consistent quiver or shakiness throughout all sounds

- often a hand tremor too

spasmodic dysphonia (aka laryngeal dystonia)

- worse symptoms initially, then plateau over 1-2 years

- unknown cause

- laryngoscopy looks "normal"

listening for SD

- sound-specific voice breaks or spasms affecting voice quality

- halted, strained, strangled, breathy, jerky, squeezed, hoarse

in SD, when does the voice sound normal?

- laugh, sing, scream, yawn, whisper

- falsetto, emotional speech

in muscle tension dysphonia, the voice does not...

ever sound normal (even in laughing, singing, etc.)

adductor spasmodic dysphonia (ADSD)

- strained-strangled voice with voice stoppages/spasms

- heavy on voiced sounds and all vowels

- most common

how ADSD occurs

VF close for prolonged periods of time during voiced sounds

primary muscle affected in ADSD

thyroarytenoid (sometimes LCA)