Etiology of Voice Disorders

Etiologies of Voice Disorders:

• voice disorders may arise from a wide array of possible etiologies

• the more aware the voice pathologist is of these possible causes, the more likely that efficient diagnoses & management plans may be established

What are the two ways voice disorders can be classified?

• organic/structural

• functional/psychogenic

(Classification System) By structural/histopathological characteristics:

• location & impact of lesion

  • e.g., carcinoma

(Classification System) By neuropathological characteristics:

• motor speech disorder classification

  • e.g., spastic dysarthria (UMN)

(Classification System) By psychopathological/personality profile:

• Based on DSM-IV of Mental Disorders

  • e.g., Generalized Anxiety

(Classification System) By behavioral etiology of signs/symptoms:

• Phonotrauma

  • e.g., vocal fold polyp

What are the major categories for etiology of voice disorders?

• Phonotrauma

• Medically-related etiologies

• Primary disorder

• Personality-related

Phonotrauma:

• functional voicing behaviors that contribute to the development of voice disorders

• Voice behaviors that cause trauma to the VFs by adducting too vigorously

Etiologies of Vocal Misuse:

• Functional voicing behaviors that contribute to the development and maintenance of laryngeal pathologies

• Phonotrauma

How can phonotrauma impact voice?

• Benign mucosal pathology

• Inappropriate vocal components

  • Pitch

  • Loudness

  • Breathing strategies

  • Phonation habits

  • Speech rate

What are examples of phonotraumatic behaviors?

• Shouting

• Loud talking

• Screaming

• Vocal noises

• Coughing

• Throat clearing

What can inappropriate vocal components negatively affect?

• Respiration

• Phonation

• Resonance

• Pitch

• Loudness

• Rate

(Respiration) What is the typical subglottic air pressure necessary to initiate phonation?

• Between 3 - 7 cm/H20

(Respiration) What is the typical airflow for speech production?

• Ranges from 50 – 200 mL H20/sec

(Respiration) What influences the mucosal covering and muscles of the vocal folds?

• Mass lesion, poor muscular control or incoordination, neural problems, or normal aging

  • Example: vocal fold cyst versus vocal fold paralysis

(Phonation) How can phonation be initiated?

• Harsh or hard glottal attack

• Aspirate attack

• Static attack

(Phonation) What are the registers?

• Glottal fry (pulse)

• Modal (chest)

• Loft register (falsetto)

Resonance:

• Wide range of acceptable resonance patterns

  • Organic basis from VPD

  • Functional resonance disturbances

    • Raised larynx results in shortened vocal tract = raising all formant frequencies

What is pitch?

• Perceptual correlate of F0

• Misuse can refer to pitch levels that are either too high, too low, or those lacking in variability

• Habitual use of “inappropriate” pitch may create laryngeal tension & strain

What is a common symptom associated with mass lesion or other changes to the vocal fold cover?

• Change in pitch!

What is loudness?

• Perceptual correlate to vocal intensity

• Determined by lateral excursion of the vocal folds & speed by which they return midline

• Dictated by subglottic air pressure and airflow

(Loudness) What can speaking softly (whispering) result in?

1. A disturbance between balance of airflow & muscular activity

2. Decreased airflow may cause more demands on the

   intrinsic muscle system

3. May result in vocal muscle strain and fatigue

4. DO NOT WHISPER!

Rate:

• May contribute to problems in voice production and perception when speech is produced too rapidly

(Rate) What is very rapid speech related to?

• Vocal hyperfunction!

  • Not using proper breath support

  • Increased laryngeal muscle tension

What are medically-related etiologies?

• Medical/surgical interventions which directly cause a voice disorder

• Medical/health conditions which may directly or indirectly contribute to the development of a voice disorder

Surgical Trauma (Direct):

• Laryngectomy of any kind

• Glossectomy

• Mandibulectomy

• Palatal surgery

• Other H/N combos

Surgical Trauma (Indirect):

• Thyroidectomy

• Cardiac

• Carotid

• Laminectomy

• Lung

• Hysterectomy

• Any intubation

Chronic Illnesses/Disorders:

• “sinus”

• allergies

• respiratory illnesses

• frequent URI

• gastrointestinal disorders

• emotional disorders

• hormonal imbalance

• arthritis

• smoking

• alcohol/drug use

What are primary disorder etiologies?

• Major disorders w/ secondary vocal symptoms

  • cleft palate

  • velopharyngeal dysfunction

  • deafness/HOH

  • cerebral palsy

  • neurologic disorders

  • accidental/trauma

What are personality-related etiologies?

•  Tensions and stresses of daily life may contribute

  directly to the abnormal functioning of the sensitive

  vocal mechanism

  • Environmental/life stress

  • Identity conflict

What is the voice pathologist role in determining the cause of a voice disorder?

• Listening

• Observing

• Examining

• Describing

Voice Pathology Evaluation:

• Identify the causes of the disorder

• Describe the present vocal components

• Develop an individualized management plan

Reason for the Referral:

• Establish the exact reasons for patient referral

• Establish patient understanding of the referral

• Develop the patient’s knowledge of his or her

  voice disorder

• Establish the credibility of examiner

Case History:

• History of the Problem

• Medical History

• Social History

What are the goals when obtaining the history of the problem?

• Establish the chronological history of the problem

• Seek etiologic factors associated with the history

• Determine patient motivation

What are questions designed to yield a chronological history of the voice disorder?

• When did you first notice your difficulties with voice

• Was this the first time you ever experienced vocal difficulties?

• How did the problem progress from there?

• What finally made you decide to see your doctor

• How much does this problem actually bother you

• Have you ever lost your voice completely?

• Do you have a pet?

• Are you interested in doing something about it?

What are the goals when obtaining medical history?

• Seek medically related etiologic factors

• Help establish awareness of the patient’s basic

  personality

What information should you obtain for medical history?

• Questions about past surgeries and

  hospitalizations

• Smoking history

• Alcohol/drug use

• Hydration

• How they “feel” about their physical and

  emotional well-being

What are the goals when obtaining social history?

•  Know the patient’s work, home, recreation

• Discover emotional, social, and family factors

• Seek more etiologic factors for the disorder

What are questions that yield information about work, home, recreational, & social lifestyles?

• Helpful to explain to patients that you need to get

  to know who they are…

  – Are you married, single, or divorced?

  – Do you have children?

  – Does anyone else live in your home?

  – Specifically, what do you do in your work?

  – What is the work environment?

  – How much talking is required?