Voice Disorders Exam 2

what is etiology?

• the study of the cause or origin of disease

• what caused or contributed to the voice problem

what is pathophysiology?

• the study of the biological process associated with disease

• includes the study of recovery mechanisms

what is phonotrauma?

• refers to abnormal voicing behaviors that contribute to the development of voice disorders such as vocal fold injury due to misuse and overuse of voice

• mechanical injury to the vocal fold mucosa from excessive and repetitive collision and shear forces during forceful voice use or other laryngeal behaviors

Examples of things that cause phonotrauma?

• shouting

• loud talking

• screaming

• vocal noises

• coughing

• throat clearing

what are vocal registers?

• perceptually distinct regions of vocal quality as pitch/loudness is changed

examples of vocal registers

• glottal fry/pulse - lowest range

• modal - normal range

• Loft/falsetto/head - higher pitch/range

• chest - lower pitch

vocal fold nodules description:

• usually bilateral (paired bumps)

• often symmetric

• medial edge at junction of anterior 1/3 and posterior 2/3 point of greater vibration

• caused by phonotrauma

• often causing hourglass closure

vocal fold nodules picture:

vocal fold polyp description:

• usually unilateral

• mid-membranous fold

• sessile (broad/blister-like) or pedunculated (stalk)

• often vascular/fluid-filled w/ potential reactive lesion appearing on the opposite fold

• may follow a single intense phonotraumatic event

vocal polyp picture:

vocal fold cyst description:

• usually unilateral

• encapsulated, opaque, round mass

• often medial edge/mid-membranous fold

• superficial or deeper in LP

• associated with granular blockage and/or mucous collection after an injury

• often stiffens/limits mucosal wave locally

vocal fold cyst picture:

Reinke’s edema description:

• usually bilateral

• diffuse “baggy” swelling of superficial LP

• gelatinous fluid

• can be caused by smoking/LPR/irritants/phonotrauma

• can cause low-pitched rough voice

• increased mass of VF

Reinke’s edema picture:

vocal fold hemorrhage description:

• blood visible through the epithelium

• color can change from bright red to yellow/brown as it resolves

• causes sudden voice change/loss after voice use

• blood leaked into LP

• caused by anticoagulants/bleeding risk/phonotrauma

vocal fold hemorrhage picture:

varix/ectasia description:

• prominent/enlarged or dilated blood vessel

• may have normal voice or fatigue

• risk for hemorrhage depending on location

varix/ectasia picture:

sulcus vocalis description:

• longitudinal furrow/groove along the medial membranous edge

• loss of viscoelasticity

• can be congenital or related to a ruptured cyst

• deeper types = more dysphonia

sulcus vocalis picture:

vocal fold scar description:

• may not be a “mass”

• tissue looks/behaves stiff

• reduced/absent mucosal wave

• permanent microarchitectural change in LP

• history of phonotrauma, surgery, radiation, trauma, hemorrage, acid exposure

vocal fold scar picture:

laryngeal cancer/malignant lesion description:

• irregular growth

• may be opaque/white, with irregular margins, abnormal color, mass, and stiffness

• unilateral or bilateral

• think irregular invasive-looking lesion rather than smooth benign mass

• hoarseness/sore throat

• smoking and alcohol are major risks

laryngeal cancer/malignant lesion picture:

granuloma/contact ulcer description:

• posterior glottis at vocal process of arytenoid

• granuloma = exophytic mass

• contact ulcer = superficial ulcer

• “cup and saucer” may occur

• caused by LPR, intubation, cough/throat clearing, pressed low-pitched voice

granuloma/contact ulcer picture:

recurrent respiratory papillomatosis description:

• irregular “grape-like” clusters with punctate/vascular appearance

• HPV associated

• may recur and require repeated surgery

recurrent respiratory papillomatosis picture:

glottic web description:

• tissue bridge most often at the anterior commissure

• congenital or acquired after surgery/trauma

• reduced vibrating length can produce an abnormally high F0

glottic web picture:

presbylaryngis/presbyphonia description:

• bowing/atrophy of the vocal folds with age

• a spindle-shaped gap may be seen

• loss of tissue bulk

• breathy/thin/weak voice, reduced volume, instability

presbylaryngis/presbyphonia picture:

what changes in the phonatory system are brought by aging between infancy and childhood?

• larynx descends in the neck

• hyoid and thyroid overlap in newborns and separate with descent

• the epiglottis becomes less curved/flattens with development

when are changes in the phonatory system brought by aging the most rapid?

• the first 3 years, then slows until puberty

describe vocal fold proportion change brought by aging:

• at birth: a large portion of the VF length is the arytenoid/vocal process

• by 3: the membranous portion becomes dominant

• in adults: the membranous portion is about 2/3 in total length

describe the change of the lamina propria brought by aging:

• 2-layer structure is established by age 5

• 3-layer fiber composition is established around age 13

prepubertal children common show a _____ _____ ___.

• posterior glottal gap

  • 85% of girls, 68% of boys ages 5-11

  • also common in young adult females

describe changes in the phonatory system brought by puberty:

• sexual dimorphism becomes more apparent (roughly 11-16)

• male laryngeal/vocal fold growth is greater

• boys’ VF grow faster, and F0 drops more dramatically

• girls have a smaller degree of voice change

what phonatory system changes are brought by adulthood/older age?

• cartilage ossification begins by the end of the second decade and continues with age

• aging may involve loss of VF tissue bulk/atrophy, bowing, reduced respiratory muscle strength, and altered neuromuscular control

what is presbyphonia?

• voice changes associated with advanced age; may present with vocal fold bowing, breathy/thin or “muffled” voice, inadequate volume, and unstable quality.

what is the clinical relevance of changes in the phonatory system brought by aging?

• age changes what is “normal”

• pediatric airway size makes even small structural changes clinically important

• do not pathologize a normal posterior gap in a child/young woman or normal developmental F0 differences

• in older adults, distinguish expected aging from treatable pathology and assess functional impact rather than age alone

what is inflammation?

• the immune system’s response to an irritant

what are possible triggers/causes of inflammation in the larynx?

• pathogens (bacteria, viruses, fungi)

• external injury/phonotrauma

• chemical or radiation effects

• refluxed gastric contents

• allergens/immune reactions

• autoimmune disease

• other medical conditions

signs of inflammation in the larynx:

• redness

• heat

• swelling

• pain

• loss of function

what do inflammatory mediators such as histamine and bradykinin do?

• dilate/widen small blood vessels

• allow immune cells/fluid into tissue

• produce swelling

• irritate nerves

• can increase mucus production

label the 3 stages of wound healing?

1. inflammation

2. proliferation

3. remodeling

when does the inflammation/haemostasis stage take place?

• 0-2 days

when does the proliferation stage take place?

• 2-9 days

when does the remodeling stage take place?

• ~9-14 days onward; may continue up to ~2 years

describe the inflammation stage of wound healing

• haemostasis: tissue stops the bleeding

• inflammation happens

• immune cells start to migrate to the site that needs fixing

describe the proliferation stage of wound healing

• number of cells increases and the cells synthesizing proteins needed for extracellular matrix (ECM) reconstruction

• granulation tissue starts to form, and it serves as a substitute for the lost tissue

• broken blood vessels are repaired by the regeneration of new blood vessels (angiogenesis)

• an epithelium that was broken becomes re-epithelialized, meaning a new epithelial layer will start to emerge to cover the wound

describe the remodeling stage of wound healing

• the granulation tissue will become remodeled more like the original architecture of the lost tissue

• the wound is now closed by the contraction of the epithelium

clinical relevance of the stages of wound healing:

• tissue changes over time

• vocal loading and treatment decisions should respect the healing phase

• repeated trauma can disrupt normal healing and contribute to disorganized/thickened tissue, fibrosis, scar, or recurrent lesions

if tissue is still in a proliferative/healing process and the mass is simply removed without addressing the cause (such as in granuloma/contact ulcer), what happens?

• the tissue may re-enter the wound-healing cycle and the lesion can recur

List the systemic conditions that can contribute to voice disorders

• endocrine disorders:

  • hypothyroidism

  • hyperthyroidism

  • sexual hormone imbalance

• autoimmune disorders:

  • allergy

  • HIV and AIDS

  • Sjogren’s syndrome

  • Wegener’s disease (GPA)

Describe how the systemic endocrine disorder of hypothyroidism contributes to voice disorders:

• prolonged low thyroid hormone may produce vocal fold edema

• mild-moderate dysphonia

• vocal fatigue

• reduced frequency/intensity ranges

Describe how the systemic endocrine disorder of hyperthyroidism contributes to voice disorders:

• elevated thyroid hormone

• breathy or tremulous quality

• reduced loudness

Describe how the systemic endocrine disorder of sex-hormone imbalance contributes to voice disorders:

• menstruation, pregnancy, menopause, and exogenous hormones/androgens can alter voice

• androgenic effects may lower/masculinize the voice

Describe how the systemic autoimmune disorder of allergies contributes to voice disorders:

• histamine-related mucosal edema/inflammation and increased secretions

• may cause dysphonia and hyponasality

Describe how the systemic autoimmune disorder of HIV/AIDS contributes to voice disorders:

• dysphonia may result secondarily from recurrent upper respiratory infection (URI) or laryngeal candidiasis

Describe how the systemic autoimmune disorder of Sjogren’s syndrome contributes to voice disorders:

• dry mucosa/thick mucus

• dysphonia, fatigue, compensatory muscle tension dysphonia (MTD), and potentially increased phonotrauma

Describe how the systemic autoimmune disorder of Wegners’s syndrome (granulomatosis with polyangiitis) contributes to voice disorders:

• vasculitis may cause subglottic stenosis, nasal obstruction, or neurologic impairment/VF paralysis

• voice changes are secondary to structural/neural disease

List the neurogenic conditions that can contribute to voice disorders

• peripheral disorders

  • vocal fold paralysis

    • unilateral RLN paralysis

    • bilateral RLN paralysis

• central disorders

  • spasmodic dysphonia/laryngeal dystonia

  • vocal tremor

  • Parkinson’s disease

  • myasthenia gravis

Describe how the neurological peripheral disorder of unilateral RLN paralysis contributes to voice disorders:

• one immobile fold

• breathy/weak voice if closure is poor

• severity depends strongly on resting position and compensation

Describe how the neurological peripheral disorder of bilateral RLN paralysis contributes to voice disorders:

• if folds are near the midline, voice may be relatively good but airway can be dangerously restricted with inspiratory stridor

• if lateral, airway is better but voice is breathier/rougher

Describe how the neurological central disorder of spasmodic dysphonia/laryngeal dystonia contributes to voice disorders:

• task-specific CNS disorder causing involuntary laryngeal spasms during speech

Describe how the neurological central disorder of Parkinson’s disease contributes to voice disorders:

• reduced dopamine; basal ganglia dysfunction

• weak voice, monoloudness, monopitch, rapid rate, reduced articulatory range

• voice can often improve with cueing (“think loud”)