Voice Post-Midterm Content (omitting Estill)

What are the three categories of voice disorders?

Uncoordinated/abnormal vocal fold movement
Impaired vocal fold closure
Impaired vocal fold vibration

When looking for uncoordinated/abnormal VF movement, what should you assess? (List 6)

1. Starts with assessment of arytenoid motion
2. Weak and/or asymmetrical abduction or adduction of the vocal folds (paresis, synkinesis)
3. Immobility of vocal fold/s (paralysis)
4. Spasms during adduction, abduction, or both
5. Abnormal, involuntary movement of vocal folds or move
6. Vocal fold immobility/paralysisment of the larynx

What does a laryngeal dystonia sound like?

creek, person talks in constricted slack

What causes VF paralysis? RLN
Which side is injury more common?

Arytenoids will not close (or open), get a glottal gap
If paralysis is in an adducted position, vibration may not be impacted (unilateral)

What causes VF paralysis? ESLN

May see inability to change frequency or tension in the vocal folds

At what point is a VF consisted paralyzed? What should it be referred to prior to this point?

Vocal fold considered immobile unless severing of nerve is known or after 6 months post injury without return of vocal fold movement

What are 4 etiologies that can cause damage to the RLN?

Damage to RLN commonly caused by tumor,cancer, trauma, surgery, or upper respiratory infection (a lot is caused by a virus: post viral vagal neuropathy)

When is the possibility of RLN damage increased?

increased especially inheart, neck, thyroid, and other chest or neck surgeries (carotid endarterectomy)

Explain how the intubation cuff may cause paresis or paralysis

If the cuff for intubation was too large or they were under for a long time, the nerve maybe damages

What does a client with paralysis’s overall impact of voice production depend on?

The effect on voice production depends on which nerve is damaged and how far from midline vocal fold is fixed.

What may be observed if a client has SLN paralysis?

SLN paralysis may cause little to no ability to change frequency, will note lax or sagging vocal fold on laryngeal exam

What may a clinician be able to hear in the vocal quality of an individual with RLN paralysis?

RLN paralysis may cause too much air escaping,breathy voice quality, dynamic laryngeal pathology

What is a deviated pedial indicative of?

VF is saging & leans to impacted side

What do paralysis symptoms depend upon?

Dependent upon position of paralysis

What is vocal fold paresis?

Different from VF paralysis
A weakness is present in the muscle

What can a clinician see that indicates paresis?

Often seen by a chasing mucosal wave (a wave on one of the vocal fold looks like it is chasing the other wave; not a symmetrical wave)

What is etiology for paresis?

What is a common cause of paresis?

Etiology is uncertain; could be caused by an upper respiratory infection or damage (e.g., stretching) to a nerve during surgery

Commonly due to upper respiratory infection (think a cold or virus)

Do antibiotics treat a virus?

Antibiotics do not treat a virus, must wait until it is bacterial

What may be observed on a strobe if an individual has VF paresis?

Stasis of mucous & AP squeeze may be seen

List the 2 types of laryngeal dystonia and what happens in both?

Laryngeal Dystonia of the adductor type & Laryngeal Dystonia of the abductor type

What is Laryngeal Dystonia of the adductor type (ADSD)?

the vocal folds spasm shut during phonation

What is Laryngeal Dystonia of the abductor type (ABSD)?

the vocal folds spasm open

Is the origin of laryngeal dystonias psychogenic or organic or both?

Debate about whether origin is psychogenic or organic or both

may appear & don't know why

What is believed to cause laryngeal dystonias?

Believed to be neurological with implications to Basal Ganglia

How can an SLP differentiate between ADSD, ABSD, and an essential tremor?

Adductor spasmodic dysphonia: way mow our lawn all year (tight)

Abductor: will hear the opening

Dystonias respond similarly to different contexts like stuttering

Dystonia→ sustain phonation
Tremor will waver, but dystonia can sustain

Explain what a person will sound like in connected speech with ADSD

Patients with ADSD will have voice breaks and strain with connected speech

Use all voiced samples to test (“We mow our lawn all year.”)

Can sing relatively, sustain vowels, and whistle relatively smoothly

Is voice therapy effective for SD-only? If not, what is another treatment option?

No; botox

What does the placement of the botox for SD depend on?

The type of spasmatic dysphonia (can be done in office)

What does botox do?

Botox weaken/paralyzes th muscle.
Botox is NOT used to augment

Where is botox placed in ADSD?

botox into the LCA & TA

Where is botox placed in ABSD?

PCA is where the botox will go

After botox, what should clients be careful of?

Very careful with swallowing

What happens if the client's spasm come back after botox for spasmodic dysphonia/laryngeal dystonia?

Do not do therapy after therapy, when the spasms comeback, refer back to the laryngologist…never send a client to a local ENT for botox. It should be done by someone who knows what they are doing

What type of surgery have been effective for patients with spasmodic dysphonia?

RLN denervation-reinnervation surgery

What is creak?

talks with a slack sound & cannot get out of it; some all calling it a dystonia

Expand PVFMD

Paradoxical Vocal Fold Motion Disorder

What is PVFMD?

Abnormal VF movement even during breathing

Explain the historical thoughts behind vocal cord hysteria?

historically was categorized into a psychological disorder

Is PVFMD mre common in males or females?

females

What may exaggerate PVFMD?

Often exacerbated by laryngo-pharyngeal reflux (LPR) and allergies, and may be present after an upper respiratory infection (URI)

Who may PVFMD be seen in?

Seen in a wide spectrum of people: high performing athletes and scholars, traumatized or anxious people, people with difficult to control asthma, and individuals with a chronic cough

What are 6 common complaints in clients with PVFMD?

Common complaints: shortness of breath, stridor, coughing, wheezing, throat tightness, chest tightness, sighing, dysphonia/aphonia, dizziness, finger, toes or perioral tingling, choking, globus sensation, feeling like they “can’t get enough air in”

Explain the VFs in PVFMD

Vocal folds behave in a paradoxical manner; they adduct (close) instead of abduct (open), mostly during breathing

What may be seen on the scope for individuals with PVFMD? (List 5)

FVF constriction
Chaing wave when voicing started
Poor anterior closure
AP squeeze
Atrophy on right
Right paresis that causes issues with breathing & coughing

What is an essential tremor?

Involuntary tremor

What is adisorders that may co-occur with essential tremor? What is it often confused as?

With concomitant MTD, often confused with ADSD

How may a client sound with an essential tremor?

sound jumpy

what is Synkinesis

movement of one muscle causes movement in another

explain Synkinesis with VFs

Appears as if one vocal fold adducts and then other adducts, the same for abduction

What is arytenoid dislocation caused by?

caused by trauma

What is laryngomalacia?

Soft and floppy larynx
Usually improves as infant develops
Cartilage and muscles are not as developed in comparison to an infant with more typically development.

What is the most common cause of noisy breathing in infants?

Laryngomalacia

Who is laryngomalacia most commonly seen in?

infants

Explain impaired vocal fold closure

Impaired and abnormal glottal closure during the closed phase of vibration

Do individuals with impaired vocal fold closure have normal arytenoid movement?

May or may not have normal arytenoid movement

What may cause impaired VF closure? List 4

lesion, scar, sulcus, edema and others, as well as impaired adduction

What type of VF closure is this?

complete

What type of VF closure is this?

anterior gap

What type of VF closure is this?

irregular

What type of VF closure is this?

spindle

What type of VF closure is this?

posterior gap

What type of VF closure is this?

hourglass

What type of VF closure is this?

incomplete

What factors/pathology may present with complete VF closure?

typical edema, muscle tension

What factors/pathology may present with an anterior gap during VF closure?

scar lesion

What factors/pathology may present with irregular VF closure?

scar, lesion, sulcus

What factors/pathology may present with spindle VF closure?

paresis, paralysis, atrophy, UL lesion

What factors/pathology may present with a posterior gap during VF closure?

scar, attractor state (if they talk in a breathy voice, lesion, granuloma

What factors/pathology may present with hourglass VF closure?

nodules, bilateral lesions

What factors/pathology may present with incomplete VF closure?

paralysis, lesion, scar

What factors/pathology may present with VF closure is the client endured traumatic intubation?

anything that can leave a scar

What factors/pathology may present with VF closure is the client endured typical intubation?

usually any weakness

What are three examples of lesions of the epithelium?

keratosis, papilloma, cancer

What type of lesion to the superficial lamina propria results in diffuse damage

reinke's edema

What are 4 types of lesions to the superficial lamina propria results in focal damage

Nodules, polyp, cyst, reactive lesion
Scar

What are 2 types of lesions to the superficial lamina propria that results in vascular damage?

Varices & Ectasias (spider-like)

What lesion causes damage to all layers of the VFs

Carcinoma

What is this?

Keratosis or Leukoplakia

What is Keratosis or Leukoplakia?

Plaque-like growths or thickening skin-like mucosa that form on vocal folds

What causes Keratosis or Leukoplakia?

Linked to cigarette smoke or environmental pollutants

What is the treatment for Keratosis or Leukoplakia?

Treatment includes surgery or drug therapy

What causes Recurrent Respiratory Papillomatosis or Laryngeal Papillomatosis?

Exposure to human papilloma virus – HPV 6 and 11

What can prevent HPV?

Gardasil vaccine can prevent HPV

Explain Respiratory Papillomatosis or Laryngeal Papillomatosis & respiration

Depending on extent of disease, airway can become comprised and respiration impaired

Treatment for Laryngeal Papillomatosis

Surgery used to remove (disease can grow back) and drug therapy (new types of injections have been used to decrease or reduce extent of disease)
Voice therapy is also indicated

What is Laryngeal Papillomatosis?

Wart-like, benign (noncancerous tumors develop on the larynx (or other respiratory structures

What is this?

Recurrent Respiratory Papillomatosis or Laryngeal Papillomatosis

What is this?

Vocal Fold Carcinoma

What is the origin for VF carcinoma?

Usually starts in epithelium, but can spread to transition and body

What is Vocal Fold Carcinoma?

Abnormal cell growth – 90% is squamous cell carcinoma

What can cause Vocal Fold Carcinoma?

Caused by exposure to cigarette smoke, alcohol, and acid reflux, but can get it without exposure to smoking

What is this?

Reinke's edema

What is reinke's edema?

Fluid filled swelling in SLP
Vocal folds looks like elephant ears

What causes Reinke's edema?

Usually caused by exposure to cigarette smoke though alcohol and acid reflux can cause or increase severity

explain the vocal quality of people with reinke's edema

lowered pitch caused by increased mass of vocal folds (big, bulky, floppy folds), stiffness caused by fluid, characteristic “smoker’s voice”

What is the treatment for reinke's edema?

Surgery more effective because of the diffuse nature of the fluid, concern for breathing

Fluid is aspirated from vocal folds during surgery.

BIG CAUTION: fluid will return if person does not stop smoking….in these cases voice therapy is usually the better choice

What are vocal fold nodules?

Bilateral White fibrous lesions
Symmetrical pairs (one on each vocal fold)

Where are VF nodules usually seen?

usually seen on the anterior ⅔ of the vocal folds

What causes VF nodules?

Caused by long standing chronic, focal impact stress (e.g., cheerleaders, teachers)

What are vocal fold polyps?

unilateral fluid-filled sac