voice & resonance disorder

Vocal pitch

• Fundamental frequency 

• Hz

• For men: 80-155 Hz

• For women: 165-255 Hz 

• But as we age it changes 

  • For women it changes lower 

  • For men it changes higher 

Vocal loudness

• Pressure that is exerted onto the vocal folds from the lungs 

• dB

Voice quality 

• Unique characteristics of an individual’s voice related to laryngeal anatomy and learned behaviors 

• age/hormone related changes to the performance of vocal folds

Resonance

• velopharyngeal structures and closure shape the sound coming out

Organic disorders

Underlying physical or neurological basis

• vocal nodules

• vocal polyps

• contact ulcers and granulomas

• laryngitis

• papillomas

• webs

• cancer

vocal nodules

• Growth on one or both sides of the vocal folds and hardens over time 

• voice: hoarse and breathy

Vocal polyps

• Fluid filled lesions on one side of the vocal fold resulting from ruptured or swelling blood vessels 

• Caused by singular events 

• Voice: hoarse/breathy/sudden voice breaks/ diplophonia

Diplophonia

• is perception of two different pitches during phonation

Functional Voice disorders

improper use or coordination of the vocal mechanism

Muscle tension dysphonia

• activity

• voice: hoarseness

tight throat muscles strain the voice box (larynx) during speaking

Conversion dysphonia

• involuntary whispering, loss of voice

• psychogenic voice disorder believed to be a result of converting stress, anxiety and depression int physical symptoms

Functional mutism

• mouthing words without voice or nonspeaking

• may occur in schizophrenia and other psychiatric conditions

• vocal fold adduction still working because they can still cough

resonance disorder

• disruption of normal balance of oral and nasal resonance due to structural abnormalities or blockage in nasopharynx

• ex: Velopharyngeal dysfunction, cleft palate

Velopharyngeal Dysfunction (VPD)

limitations in partitioning between oral.nasal cavity resulting in too much air escaping through nasal cavity or insufficient air

hypernasality

too mush air escaping through the nasal cavity

hyponasality

insufficient air, sounds like a bad cold

Cleft palate

is caused by a failure of structures to fuse or merge correctly during embryonic development (4th -7th) week pregnancy

• the opening can cause feeding problems

• surgery for cleft palate/lip recommended before the age of 1

Speech pattern for cleft palate

• atypical consonant production

• atypical nasal resonance and nasal airflow

• VPD

• dysponia

voice and resonance evaluations

• Otolaryngologist (ENT)

• endoscope

• nasoendoscope

• case history

• Pneumotachometer

• Nasometer

• electropalotography

• X-Ray/MRI

Pneumotachometer

can measure air flow and air pressure around vocal folds

Nasometer

can measure acoustic energy flowing through nose and mouth

Electropalatography

visualizes tongue-palate interactions

Management of voice/resonance disorders

• vocal function exercises

• resonant voice therapy

• LSVT (Lee silverman voice treatment)

• yawn-sigh technique

• surgical intervention

LSVT

Lee Silverman voice treatment

• works to increase vocal loudness

Yawn-sigh technique

phonation through a straw to increase air pressure through vocal folds

Motor speech disorder with neurological basis

• affects planning, coordination, timing and execution of movement patterns used for speech production

dysarthria

disturbance of mechanisms that control speech musculature

• they still can understand the language

• there is consistency in the pattern of speech errors

• flaccid dysarthria

• Spastic dysarthria

• ataxic dysarthria

• hypokinetic dysarthria

• hyperkinetic dysarthria

• mixed dysarthrias

apraxia

can still talk but they cannot plan their speech

• they struggle to comprehend

• there is inconsistency

• damage to LH, motor and pre-motor areas of frontal left lobe

• island fluency

cerebellum

little brain

• helps coordinate all input received from the brain and spinal cord

• control circuits coordinate fine, complex motor activities like speech production

• damage here can result in discoordination of voluntary movement

Cranial & Spinal Nerves

• Peripheral Nervous System (PNS) : 12 pairs of cranial nerves and 31 pairs of spinal nerves

Cranial nerves

• important for speech production

basal ganglia

subcortical nuclei in the brain

• regulates motor planning

• automaticity of learned movement sequences

• helps initiate desired movements while suppressing unwanted ones

• damage here can result in reduced or slowed movement or obnormal movements

Upper Motor Neuron system (UMN)

located in the cerebral cortex, part of the central nervous system

contralateral: affects body structure on the opposite side of the body

bilaterally: both side UMN innervates the speech mechanism

Lower Motor Neuron (LMN)

located in the brainstem, cranial nerves, spinal cord

• part of the peripheral nervous system that connects the central nervous system

• ipsilateral: same side of the body

Flaccid Dysarthria

muscle are weak and reduced tone, eventually there is a atrophy of muscles

• damage to lower motor neurons or to the muscle itself

• breathiness, monopitched, hypernasal, short phrases, imprecise articulation

Spastic Dysarthria

weak, spastic muscles, hyperactive reflexes, increased muscle tone

• bilateral damage to upper motor neurons

• slow speech

• strain/strangled voice quality

• excess stress

Ataxic dysarthria

incoordination; reduced muscle tone; poor accuracy and timing of movement

• damage to the cerebellum

• irregular breakdowns in articulation

Hypokinetic dysarthria

reduced movement; muscle rigidity and stiffness; difficulties starting and stopping movements

Hyperkinetic dysarthria

involuntary movements; tics

• damage to basal ganglia

• irregular breakdowns in articulation; prosodic abnormalities

mixed dysarthria

combination of two or more dysarthria

• damage to multiple brain structures

• imprecise articulation; slow rate, harsh voice; monopitch; monoloudness; hypernasality; excess and equal stress

flaccid

bells palsy

Spastic

cerebral palsy

ataxic

multiple sclerosis

hypokinetic

Parkinson’s

hyperkinetic

huntington’s disease, Tourette syndrome

• genetics: odds ratio higher for first degree relatives

• toxic prenatal exposure: 35% risk increase of tic disorder in offspring of maternal smoking during pregnancy

Chorea

is not dysarthria

• it is commonly seen in Huntington’s disease

• rapid and unpredictable movements

• prosodic abnormalities

Hyperkinetic treatments

interventions to reduce tics

• behavioral

• dopamine blocking medications

• TMS (Transcranial magnetic stimulation)

apraxia

is a motor speech disorder

• individual may be able to write and type words but they cannot produce it correctly

Aphasia and apraxia often co-occur

motor speech disorder: observational evaluation

• examine the oral physical and mechanical properties

• symmetry, configuration, color, general appearance of jaw, kips, tongue, teeth, and hard and soft palate

• range of motion, force, speed and direction of the jaw, lip, and tongue during movement

motor speech disorder: instrumental methods of evaluation

• respiratory function during speech production

• phonatory initiation, maintenance, cessation,

• pitch and pitch variability

• loudness and loudness variability

• volitional pitch-loudness variations

• velopharyngeal function

motor speech disorder: Speech production tasks evaluation

• imitation of single words of varying lenths

• sentence imitation

• reading aloud

• spontaneous speech

• rapid repetition

• engaging repetitive tasks to see consistency of performance

treatment of dysarthria

evidence is weak supporting non-speech oral motor treatments

• read aloud with pause training to take a breath can improve respiratory coordination

• voice amplifier

• Lee Silverman voice treatment (LSVT)

• Alphabet boards

• AAC technologies

• Electropalotography