Speech Disorders Exam 3 - Voice Disorders

What is the prevalence of voice disorders for children? What about adults?

Children: 3-6% (depend on source + definition; can be as high as 23%)

Adults: 3-9%

true or false: voice disorders can affect anyone at any age

True

Does voice disorders more commonly affect women or men?

Men (true for all speech language disorders)

How does the location of the larynx change as we age?

The location of the larynx lowers as we age.

-> C3 at birth, C6 at 5 years, C7 at 15-20 years

How do the vocal folds change with age? What is the difference between men and women?

The vocal folds are about 3 mm at birth. By puberty VF of boys grow to 10 mm and thicken, for girls, less change and no thickening. By adulthood, men VF are 17-20 mm and women are 12.5-17 mm (18-20 years)

Why do men have a lower pitch

their VF are longer with more mass

List the six cartilages. State if they're paired or unpaired and location.

- cricoid: unpaired; located lower anterior for VF attachment

- thyroid: unpaired; vocal fold attachment right below prominence on anterior & inferior (VF origin)

- arytenoid (including muscular and vocal processes): paired; located on top of posterior superior of cricoid

-> vocal process: posterior attachment of VF (VF insertion)

-> muscular process: abductor/adductor attachments

- corniculates: paired; located on top of arytenoids

- cuneiforms: paired

- epiglottis: unpaired

What are the intrinsic laryngeal muscles?

- Lateral cricoarytenoids (paired)

- Posterior cricoarytenoids (paired)

- cricothyroid (glottal tensor)

- thyrovocalis (glottal tensor)

- thyromuscularis (glottal relaxor)

What are the lateral cricoarytenoids? What do they do and what is their origin and insertion?

Lateral cricoarytenoids (paired): adductor

-> origin: lateral cricoid; Insertion: muscular process

*used for swallowing not phonation

What are the posterior cricoarytenoids? What do they do and what is their origin and insertion?

Posterior cricoarytenoids (paired): abductor

-> origin: posterior cricoid; insertion: muscular process

*used for swallowing not phonation

What intrinsic muscles are glottal tensors?

- cricothyroid: helps tilt cartilage down and is used to stretch the vocal folds to make pitch go up

- thyrovocalis: the deepest of the five VF layers; attached just below the prominence (anterior) and vocal process (posterior)

What intrinsic muscle is a glottal relaxer?

thyromuscularis: exterior muscle of the vocal folds; when they contract the thyrovocalis relaxed and pitch goes down.

What are the two extrinsic muscles?

digastric muscle and the omohyoid muscle

* for swallowing

What is the digastric muscle? What does it do and what is it's origin and insertion?

laryngeal elevator- raises larynx

- origin: mandible and mastoid process - they join up together and insert into the hyoid bone, so when the muscle contracts it raises the hyoid bone, in turn elevating the larynx

What is the omohyoid muscle? What does it do and what is it's origin and insertion?

laryngeal depressor- lowers larynx

- origin for inferior is scapula and eventually the superior part is going to insert into the hyoid bone, pulling the hyoid bone down, in turn pulling the larynx down

What is the difference between intrinsic and extrinsic muscles?

Extrinsic muscles are outside of the larynx, intrinsic muscles are inside the larynx and they make fine adjustments

What is the primary function of the larynx?

swallowing and protection of the airway, not phonation

-> epiglottis folds down and VF adduct to protect airway when swallowing

Describe the speech function of the vocal folds (overlaid function) - hint: describe bernoulli effect

Bernoulli effect: aerodynamic principle where air starts to build subglottaly, pushing the VF apart, the air bursts through causing the subglottal pressure to drop causing the VF to slam shut.

What are the three ways the vocal folds can come together for phonation (vocal attack)?

- simultaneous: VF come together just at the time you want to phonate (most efficient)

- breathy: VF are too far apart to vibrate efficiently so you have to force more air through

- hard: vocal folds are closed prior to phonation so the subglottal pressure has to build enough to blast them apart to phonate again

How does someone change the pitch and intensity of their voice?

- glottal tensors (pitch)

- force more air through glottis (increase intensity)

-> the more intense, the more subglottal pressure

True or false: phonation only involves the CNS

False: phonation involves the CNS and PNS

The motor system for phonation includes....

primary motor strip and brocas area

The sensory system for phonation includes...

primary sensory strip

-> audition too (auditory cortex and wernicke's area)

Other CNS systems (excluding motor and sensory systems) include...

Basal ganglia and cerebellum

What neural pathways are included in phonation?

- pyramidal system, including corticobulbar tract

- CN X Vagus

Why is CN X involved in phonation? What are the two branches of CNX and what muscles do they innervate?

parts to CN X innervate with intrinsic laryngeal muscles

-> superior laryngeal nerve (innervates cricothyroid m. only)

-> recurrent laryngeal nerve (innervates with other 4 intrinsic muscles, including thyrovocalis; aka true VF)

Describe how unilateral and bilateral damage to CN X from incubation can affect the voice

- unilateral: flaccid/weak VF accompanied by hoarse and breathy voice

- bilateral: paralyzed VF in the paramedian position (partly abducted so person can breathe)

Exam of laryngeal structures: indirect laryngoscopy

- dental mirror: difficult to get full image

- fiber-optic endoscopy: thread small, thin scope up a persons nostril and down their pharynx; a camera with a light hovers just above VF (clear view)

- rigid stroboscope: metal scope gets inserted into mouth; light and camera

Exam of laryngeal structures: direct laryngoscopy

has to be done by physician

- comes in direct contact with vocal folds and take a sample

- used for thing such as biopsy to diagnose cancer

What is a stroboscopy?

light shines down as a strobe to make movement seem as though it's in slow motion

- you can see contact area better with strobe

- used with rigid stroboscope, fiber optic endoscopy (can use regular or strobe light)

What are alternative methods to evaluate vocal folds?

CT scan, MRI, or ultrasound

What is the medical personnel (team) for voice disorders?

- otorhinolaryngologist (ENT)- referrals for diagnosis

- neurologist- nerve specialist (vagus)

- psychiatrist & psychologist- psychogenic voice disorders

- radiologist- diagnostic test (imaging) and treatment (radiology)

- plastic surgeon- reconstruction to speech mechanisms

- medical pathologist- stages and grades biopsy to send to ENT

How is drug treatment important when evaluating voice disorders?

- as an SLP being familiar with drugs that affect the voice

- ask on case history what drugs they take (pharmacological and non-pharmacological)

-> ex: anti-histamines, anti-depressants, anti-hypertensive, anti-psychotics (caffeine can also have a drying effect on VF)

What is phonosurgery and how is it performed for a vocal pathology?

- phonosurgery is a generic term for procedures aimed at improving the voice (ex: reconstruction, removal of pathology, surgery to restore function)

- surgery on vocal pathology (ex: nodules): outer layers are picked up and vocal nodules are plucked off and exterior layers are put back on (prevent affecting thyrovocalis m. which can fundamentally alter the parameters of someones voice).

What are the five parameters of the voice?

1. pitch

2. loudness

3. quality (hoarseness & roughness)

4. non-phonatory behaviors

5. aphonia

Describe pitch (normal)

- pitch is perceived

- it is the psychological correlate of frequency (Hz)

Pitch: fundamental frequency

- most common pitch you hear

- male = 125-130 Hz

- female = 230 Hz

-> about an octave difference between women and men

Pitch: developmental effects

as people reach 60 years men's voices get higher and womens voices get lower due to hormonal and physical changes

Optimal vs. habitual pitch

- optimal: most suitable for somebody to talk at

- habitual: what is most commonly spoken at

*optimal and habitual are ideally the same, but sometimes it is not

How do you measure optimal pitch?

- have person do yawn-sigh technique (have them yawn then sigh until they reach the most optimal level)

- have them glide down to the most comfortable note then have them go up about two notes

Describe pitch range and how it is measured

- non-singers have about a two octave pitch range (going from lowest to highest without strain)

- measure using visi-pitch (device): can visualize frequencies

- singers have an extended pitch range

Pitch (disordered): mono-pitch

lacking in inflectional variation, possible causes: neurological damage or personal preference

Pitch (disordered): inappropriate pitch

outside normal range for age/gender

- too high: underdeveloped larynx

- too low: endocrine problem/hypothyroidism

- pitch breaks: common during puberty, sign of pathology/neurological damage

Loudness (normal): what is it

- physical measurement in dB

- psychological correlate of amplitude

- varies with degree of subglottic pressure (more = louder)

- durational changes of VF adduction

How loud is conversational speech and what does durational changes of VF adduction mean?

- about 60 dB at conversational level

- about 50% of the time the VF are in the open position, about 37% of the time they are in the closing position, and about 13% of the time they are in the closed - this changes as you get louder than conversational speech

What does it mean to use higher intensities?

more air coming through glottis, more subglottal pressure, so VF have to squeeze together more during high intensities (more harsh on VF)

How do you measure loudness?

sound level meter: a box with a microphone at the end; stand a certain distance from the person and measure loudness

What kind of scale is used for dB?

logarithmic scale, so any increase makes a large difference

What is the dB for softer speech and louder speech?

normal = 60 dB; softer = 50-55 dB; louder = 70 dB

Loudness (disordered): monoloudness

lacking in normal variation in loudness, possible cause: neurological damage, psychiatric problem, or habit

Vocal quality: measurement

- not an objective measure

- easier to determine with experience

Voice quality: hoarseness

various etiologies that result in edema (swell with fluid), result from various pathologies (ex: nodules)

-> not vibrating at exactly the same rate

Voice quality: breathiness

too much air through glottis, possible cause: lesion on VF or neurological damage

Voice quality: tremor

variations in pitch and loudness, possible causes: neurological damage of CNS

Voice quality: strained & strangled

difficulty initiating /maintaining voice, possible cause: neurological damage or psychological problems

-> voice fades in and out

Non-phonatory behaviors

Stridor: noisy breathing caused by blockage in the respiratory system

(consistent) aphonia

- aphonia: without voice

- transient aphonia: temporary (ex: laryngitis)

- consistent aphonia could be due to vocal fold paralysis, neurological damage (cns or pns), or psychogenic voice problems

- episodic aphonia: comes and goes from sporadic losses due to cns/psychological problems

Why is it difficult to decide who needs voice therapy?

voice disorders can be subtle or hard to detect

How do you measure voice disorders? What is the challenge with measuring?

- Some are objective (pitch) and others are subjective (quality)

- The challenge is combining scientific and perceptual judgement

Who makes referrals for voice disorders?

Most referrals come from physicians, SLP is the next person to go to for therapy

-> however, SLP are sometimes the first to see someone (ex: children in school)

When do you refer to physician?

- If difference in quality is noticed (persistent hoarseness, breathiness, etc.)

- breathing difficulty

-> ask how long they've had it for and if they were sick recently

When don't you refer to a physician?

- high pitched, slight nasal, soft or loud (but if persistent, refer)

- experience vs. non-experienced SLP

- But... when in doubt refer

Describe the referral process for SLP's in schools

- teachers are often the first to notice a problem, SLP's should work with them closely

- If SLP noticed, inform nurse/medical personnel

- nurse talks to parent

- parent calls physician who refers to nurse then SLP

How do you screen for voice disorders?

- multiple screenings may be needed to determine persistence

- counting from 1-20 is all you need

What data should you obtain for a detained case history and full eval

- depends on the disorder (ex: laryngectomy patient vs. knowing nothing before hand)

- background of disorder (onset, treatment history, related illness, etc) - if stress is a factor referral may be needed

- careful medical review, including drugs

- possible exacerbating influences (caffeine, smoking, drinking - all drying)

- duration of disorder (if more than a couple weeks, consult with physician)

- Social (activities they do, e.g., sports) and vocational (inhale toxic air/misuse voice, e.g., construction) use of voice

- objective and subjective measurements (jitter, shimmer, fundamental frequency, pitch range)

-> Jitter: cycle variations of frequency (miliseconds)

-> shimmer: cycle variations of amplitude (milivolts)

-> Jitter and shimmer can be measured through visi-pitch/computerized speech lab and there should be no more variation than 1.0 for jitter and shimmer

What type of instrumentation is used in a full eval and what does it do?

- instrumentation is used to provide objectivity

- visi-pitch or computerized speech lab

- electroglottograph: charts movement and contact of VF movement by placing sensors on throat next to where the VF are (laryngeal prominence)

- audio recorder: can be helpful for client in therapy; clinician can see where they started and how they've improved

- sound level meter: can help teach conversational level (maximum vocals are between 100-110 dB - vocal abuse level - minimum vocals are 40 dB

Who makes a final diagnosis for voice disorders?

because SLP's aren't physicians, we can only review findings and report them. Final diagnosis must be made by MD

How do you evaluate resonance?

- VP port problems can result in hyper (common w/ cleft palate)/hyponasality (congestion/deviated septum)

- nasometer is the most common instrument to assist - metal piece sits between nose and mouth with microphone and the SLP reads predetermined passage and knows exactly how much nasal there should be

How do you evaluate respiration?

- most patients with voice disorders have sufficient respiratory support. However, some may not (ex: Parkinson's)

- spirometers measure vital capacity (25-40% of VC is used for speech)

What is maximum phonation duration?

- typically part of a voice evaluation

- measures how long one can sustain phonation (decreases with age)

- young healthy men: 20 sec; young healthy women: under 20 sec

- s/z ratio: should be 1.0 (this can vary, over 1.4 is bad) - duration of s and z; very little air should be leaving the glottis when producing z

Describe ceiling pitch versus basal pitch

- basal pitch: lowest comfortable pitch

- ceiling pitch: highest comfortable pitch without strain

- pitch range is between BP and CP

Quality: describe hypofunctional

Too little pressure; VF don't come together well

-> breathiness

-> whisper (vf just abducted enough)

-> aphonia

Quality: describe hyperfunctional

VF are pressed too hard together

-> pressed - harsh phonation

-> spastic

-> (hard) glottal attack - VF are adducted prior to phonation and if they pronate it takes a lot of pressure to push them open

What are the five types of voice disorders?

Dysphonia: refers to voice disorder

- Functional (misuse/abuse)

- Neurogenic (damage to cns/pns)

- Organic (medical disorders, ex: cancer)

- Psychogenic (psychological)

What are functional voice disorders?

- abusive (screaming, excessive cough) and misuse (talk excessively) behaviors

- related to structural damage, affecting vibration

- types of lesions/disorders (vocal nodules)

What are vocal nodules?

- anterior 2/3 of VF, bilateral, located within the superficial layer of the lamina propia- a bit deeper than squalus epithelium (outer layer)

- soft and pliable (red) at first but can become white, hard, and fibrous

are vocal nodules more common in women or men

Women, especially between 20 and 50 yrs

What are the voice characteristics for vocal nodules?

- don't hurt

- raspy, hoarse voice (abnormal s/z ratio)

- breathy, increased respiration, less durable

- has to add pressure to talk (physically tiring)

- pitch usually too low because VN are adding mass VF

What are the two goals for therapy when reducing abuse behaviors (functional voice disorders)?

1. Identify and reduce all forms of abuse

2. Instruct the client about and help them maintain good behaviors

What are ways to motivate reducing/eliminating abusive behaviors (FVD) in and out of therapy?

- creating checklist

- reinforce (either externally or internally driven; reward system)

- in the first sessions talk about vocal rest

- use voice recorder in the first session and replay back in later sessions (motivate how the voice is changing overtime)

- encouraging clients to maintain good behaviors

What is vocal hygiene?

Hygiene is fostering a general understanding of the voice, voice therapy, and how to prevent re-occurrence

How do you teach good hygiene?

- begin with a review of anatomy

- review proper breathing

- tell client to hum - idea is to feel lips tingle as well as your nose and eyes vibrating (help teach to project voice forwards)

- start with nasal sounds in syllables, then gradually increase length and complexity

What is the goal for teaching vocal hygiene?

Learn how to project your voice/facilitate efficient phonation

What is the dismissal criterial for vocal hygiene therapy?

Physician deems the client as okay, client feels enough change has occurred, voice parameters within normal limits

Functional voice disorders: what are contact ulcers?

Ulcerations at the posterior end of the VF near the arytenoids

- usually bilateral

- etiology: usually occur due to gastric reflux (gastric fluids spill over to VF; its persistent)

What is the intervention for contact ulcers?

Some suggest vocal therapy/vocal rest (but not all), surgery is often recommended, sometimes medications

How are contact ulcers different from vocal nodules

Contact ulcers are painful, vocal nodules are not

Functional voice disorders: what are polyps?

Usually unilateral, can happen after a single occurrence, not always painful

- etiology: cause by trauma to VF formed by broken blood vessels that swell and fill with fluid (edema)

What are the two kinds of polyps?

-sessile: slight bump, less protruding than pedunculated

- pedunculated: protruding bump on VF. Sticks out

What are the voice characteristics of polyps?

Hoarseness, breathiness, deeper voice (more mass)

What is the intervention for polyps?

Combination of surgery and therapy (to reduce behaviors) for hygiene

How are polyps different from vocal nodules?

- polyps are usually unilateral

- polyps can happen after a single occurrence

Functional voice disorders: actute (and chronic) laryngitis - etiology for transient and chronic

- Transient: Inflammation of vocal folds can be due to a cold, causing the VF to swell (edema) making VF more massive

- Chronic: can be due to inflammation from toxic agents such as tobacco smoke; can lead to dehydration, thickened and swollen VF, and can lead to atrophy

What are the vocal characteristics of both transient and chronic voice characteristics?

Transient: rough phonation, raspy/lower pitch voice

Chronic: persistent cough, throat aches, aphonia

What are the voice characteristics for contact ulcers?

Hoarseness, breathiness, excessive throat clearing, vocal fatigue

What are neurogenic voice disorders?

- result from motor and/or sensory deficits

- some are from damage to the CNS, many are from damage to the PNS

- symptoms follow site of lesion

-> ex: unilateral damage -> single vocal fold -> flaccid dysarthria

- problems occurs with speech as well as the biological function

What are the three systems/sets of tracts that facilitate motor control for speech

- pyramidal system: voluntary; initiate movement (3 tracts)

- extrapyramidal system: control of movement

- cerebellar system: coordination

Pyramidal system: corticobulbar tract (function and pathway)

- Function: initiate movement; connect with motor components of cranial nerves (especially CN X vagus)

- pathway: motor strip -> corona radiata -> internal capsule -> cerebral peduncle -> brainstem (CN nuclei) -> medulla for CN X vagus

What are upper motor neurons? What vocal characteristics does UMN damage cause?

- located entirely in CNS

- effect of UMN lesion (ex: spastic dysarthria)

- vocal characteristics: harsh strain & strangled phonation, monoloudness, excess unequal stress of syllables, hypernasality

What are lower motor neurons? What vocal characteristics does LMN damage cause?

- location: begin at spinal cord and go out to muscle

- effect of LMN lesions: flaccid/weakness (ex: muscular dystrophy, myasthenia gravis)

- vocal characteristics: harsh voice, reduced loudness, breathy