SHS 719 Exam 2: Pediatric Voice Disorders

What is a Voice disorder?

can include a variety of issues related to voice. Usually classified into two major areas: Aphonia and Dysphonia

What is Aphonia?

absence of phonation - no audible voice

What is Dysphonia?

phonation characterized by abnormal voice quality, pitch, loudness, resonance, or duration relative to a person's age, gender, gender identity, cultural background, or geographic location

What are Functional Voice Disorders?

Voice disorders where the vocal mechanism is normal and the cases are behavioral (e.g. vocal abuse)

What are Organic Voice Disorders?

Voice Disorders where the laryngeal structural changes or neurological problems may impair voice production

T/F: Determining the difference between an Organic or Functional Voice Disorder can be difficult depending on the case.

True

An example of how determining the difference between the 2 types of Voice Disorders can be difficult:

Hoarseness may originally be thought to be a functional voice disorder due to vocal abuse, overuse, etc. However, if further investigation is done and there are nodules on the vocal folds, then we might now be treating an organic voice disorder rather than functional.

What are the different types of disorders when it comes to Dysphonia?

1. Disorders of Pitch (Frequency)

2. Disorders of Loudness (Intensity)

3. Disorders of Quality

4. Disorders of Resonance

T/F: While aphonia is the absence of voice, a total and constant absence of voice is rare in children.

True

What are the 4 kinds of Disorders of Pitch?

1. Inappropriate Pitch

2. Pitch Breaks

3. Monopitch

4. Diplophonia

What is frequency?

measure of the physical property of sound that is measured in terms of Hertz

What is fundamental frequency?

the average frequency of vocal fold vibrations in an individual

T/F: Pitch patterns vary from speaker to speaker

True

T/F: Pitch patterns that significantly deviate from those of peers within a verbal community may be a disorder of pitch.

True

How is pitch judged?

by a speaker's age, size, gender, gender identification, and cultural background

Vocal pitch is generally assessed in terms of what?

Habitual Pitch and Pitch Range

What is Habitual Pitch?

The average pitch heard in a continuous sample of speech

What is Pitch Range?

the lowest possible pitch (basal) and highest possible pitch (ceiling) and the variations in between

T/F: Disorders of Pitch arise due to the inappropriate frequency with which the vocal folds vibrate, breaks in the cycles of vocal fold vibrations, lack of normal variations in the frequency of vibrations and asynchronous vibrations of the two folds.

True

T/F: Pitch disorders can have both functional and organic causes.

True

Inappropriate Pitch notes that the vocal pitch is inconsistent with the child's what?

age, size, and gender

The fundamental frequencies of boys and girls voices begin to differ when?

Between the ages of 7-12

At age 7, boys and girls have roughly the same pitch range of what?

And an average habitual pitch of what?

220-310 Hz Pitch Range

260 Hz Habitual Pitch

T/F: By the age of 18, male voices average 125 Hz, and female voices average 205 Hz.

True

What is mutational falsetto or Puberphonia?

a very high pitch in post pubescent males and a high pitch with immature resonance patterns in females

T/F: Excessively low pitch in children is unusual, but could occur as a result of sever reflux, significant vocal fold edema, or faulty learning.

True

What are pitch breaks?

when the vocal pitch breaks unexpectedly and are a deviation in the smooth rates which with the vocal folds normally vibrate

T/F: Pitch Breaks occur as a normal part of maturational voice changes in boys and are not a clinical problem.

True

T/F: Pitch Breaks also could occur due to habitually produced inappropriate pitch, as well as due to vocal fatigue due to hyper function and speaking with excessive muscular function.

True

What is Monopitch?

absence of normal pitch variations which maybe due to a neurological disorder

T/F: In children, Monopitch maybe a feature of dysarthria associated with cerebral palsy.

True

What is Diplophonia?

simultaneous production of two distinct frequencies which occurs when two vocal folds vibrate at different rates because of a lesion, swelling, scarring, or vocal fold paralysis, or when another vibrating source is present in addition to the vocal folds

What are the 2 Disorders of Loudness?

1. Excessively Loud Voice

2. Excessively Soft Voice

What is intensity?

measure of the physical properties of a sound stimulus

What is loudness?

a judgement that listeners make based on their auditory sensation

T/F: Vocal loudness is determined by amplitude of vibrations.

True

What is excessively loud voice?

Voice that is too loud in most every day speaking situations, is socially inappropriate, and calls attention to itself.

T/F: Excessive loudness can lead to more serious problems, including the development of nodules, polyps, or laryngeal hyper function.

True

What is excessively soft voice?

Voice that is too soft, interferes with communication and fails to meet the demands of social interaction

What are the 4 types of Disorders of Quality?

1. Breathiness

2. Harshness

3. Hoarseness

4. Tense Voice

What is Breathiness?

Phonation with excessive and audible air leakage

T/F: In children, breathiness is usually the result of vocal fold edema, nodules, or polyps.

True

What is Harshness?

Aperiodicity of vocal fold vibrations that results in an unpleasant, strident, or rough voice

What is Hoarseness?

a combination of harshness and breathiness - a grating or husky voice that includes phonation breaks, diplophonia, and low pitch also characterize it. A hoarse voice may sound dry or wet.

What is Tense Voice?

Phonation produced with excessive adduction and medial compression of the folds. Voice sounds tight, strained & effortful. Can contribute to laryngeal hyperfunction as well.

What are the 4 types of Disorders of Resonance?

1. Hyponasality

2 Hypernasality

3. Cul-de-sac Resonance

4. Assimilation Nasality

What is resonance?

modification of the laryngeal tone by the cavities of the throat, mouth, and nose that lie above the vocal folds as well as changes vocal tone

What is Hyponasality?

Inadequate nasal resonance- because of too little nasal resonance, a child can sound "Stuffed up"

What is Hypernasality?

excessive nasal resonance on nonnasal speech sounds

What is Cul-De-Sac Resonance?

A tongue posteriorly retracted deep into the oral cavity and hypo pharynx results in muffled bottom of the sac resonance

T/F: Cul-De-Sac Resonance is generally associated with oral apraxia, cerebral palsy, deafness, or faulty learning.

True

What is Assimilation Nasality?

This is when oral sounds that surround nasal sounds become nasalized. Disorder of accurate opening and closing of the velopharyngeal port needed to discriminate oral and nasal sounds.

What is Nasal Emission?

- The audible escape of unvoiced air through the nares during the production of speech.

- It is not technically a resonance disorder.

- affects the production of such pressure consonants as stops, fricatives, and affricates, suggesting VPI.

T/F: Nasal Emissions may co-occur with other resonance disorders.

True

What is Functional Aphonia?

-A loss of voice or inability to produce phonation of speech in the absence of organic pathology.

- can be constant or intermittent

- may develop secondary to a physical condition such as flu or laryngeal surgery

- may have sudden onset

What is Laryngeal Imaging?

Laryngoscopy is the viewing of the larynx and surrounding structures by using a laryngeal mirror or a rigid or flexible fiberoptic endoscope.

What is a Laryngeal Mirror?

a small round mirror mounted at an angle on a long thin handle

What is a Rigid Endoscope?

a firm tube that is inserted into the oral cavity and oropharynx

What is a Flexible Endoscope?

a bendable tube that is inserted into the nasal passage and can be placed above the velum in the nasopharynx to assess VP structure and function

What is a Stroboscope?

refers to the use of a strobe light in conjunction with a flexible or rigid scope

T/F: It is in the official position of ASHA that endoscopy is an imaging procedure that IS INCLUDED in the scope of practice for SLPS.

True

What is Vocal Misuse?

- inappropriate pitch

- inappropriate loudness

- poor respiratory patterns

- hyperfunctional phonation patterns

- inappropriate rate of speech

What is Phonotrauma or Vocal Abuse?

- shouting, yelling, screaming

- loud or incessant talking

- vocal noises during play

- frequent or chronic coughing or throat clearing

- faulty respiratory habits

-hard glottal attacks

- participation in vocally strenuous activities

T/F: There is a vocal abuse/misuse inventory available to assess these behaviors.

True

Clinical Assessment of Pitch

1. measure habitual pitch

- sample the child's pitch at several points during one or more of the following tasks: counting 1-10, sustain /a/, spontaneous speech sample

2. measure pitch range

- measure the highest, lowest, and overall pitch ranges of the child's voice during tasks and listen for any changes in voice quality that occur when pitch changes

Clinical Assessment of Loudness

1. Measure loudness range

- have the child count starting at a whisper for the first number and gradually get louder with each number until they get to their loudest.

2. Measure average loudness.

- use an instrument and measure the child's vocal intensity at several points in a speech sample to calculate the average decibel level.

Clinical Assessment of Vocal Quality

- administer the CAPE-V: Consensus Auditory-Perceptual Evaluation of Voice

Which Measures:

overall severity, roughness, breathiness, strain, pitch, loudness

- assess conversational speech

- Measure the s/z ratio

- assess vocal endurance

- assess coughing and throat clearing

- identify hard glottal attacks

Clinical Assessment of Resonance

- May only need to address this as part of the orofacial examination as resonance does not always accompany other voice disorders

- Use the Resonance and Velopharyngeal Function Protocol to clinically asses without instrumentation.

Diagnose Dysphonia if:

- The assessment documents a voice disorder of pitch, loudness, quality or resonance.

- There is evidence of vocal misuse or phono traumatic behaviors that are related to the diagnosed voice problem.

- There is a physician's diagnosis of laryngeal pathology associated with vocal misuse or phono traumatic behaviors

Diagnose Functional Aphonia if:

- the child demonstrates a complete loss of voice or the inability to produce phonation for speech and a laryngologist has ruled out organic pathology or etiology.

- there is case history evidence of some gain from the problem - alternatively, there is evidence of a URI or illness requiring complete vocal rest that proceeded aphonia.

- The child produces phonation on such non speech acts as coughing, throat clearing, or laughing

Diagnose Organic or Neurological Voice Disorder if:

- The assessment supports a voice disorder of pitch, loudness, quality or resonance

- the voice disorder is associated with a medically diagnosed organic or neurological condition

Diagnose a Hyperfunctional Voice Disorder if:

- the child demonstrates a voice disorder of pitch, loudness, quality or resonance that is associated with a pervasive pattern of excessive effort and tension that affects the muscles and structures of the larynx.

- An ENTs examination has confirmed the presence of laryngeal hyper function

- laryngeal hyperfunction is associated with vocal abuse or misuse.

- laryngeal hyperfunction is associated with an effort to compensate for such structural deviations as congenital malformations, webs, papillomas, paralysis,nodules, polyps, etc.

Diagnose velopharyngeal incompetence (VPI) if:

- The assessment documents hypernasality or assimilation nasality in the absence of any unrepaired palatal cleft

- A medical examination confirms VPI.

Post Assessment Counseling

- Make a tentative diagnosis

- Make Recommendations

- Suggest Prognosis

- Answer FAQs

Recommendation Possibilites

1. The child's voice appears to be within normal limits and therefore therapy is not recommended at this time

2. The child has a voice disorder, but needs to be referred to an otorhinolaryngologist before initiating voice therapy.

3. Child needs to be referred to other professionals.

4. Voice therapy is recommended and will include direct therapy and behavior modification

5. Voice therapy is not recommended because the child has VPI and the necessary medical intervention has not been completed. Child can be re-evlauated after.