Voice

corniculate cartilages

small cartilages on top of arytenoids

cuneiform cartilages

located within the aryepiglottic folds 

healthy vocal folds are...

• straight 

• pearly white 

• move symmetrically 

• obtain complete closure during phonation 

• intact mucosal wave during phonation 

voice disorder

a voice disorder is characterized by the abnormal production and/or absence of vocal quality, pitch, loudness, resonance, and/or duration, which is appropriate for an individual’s age and/or sex (ASHA definition) 

true vocal folds

vibrate and are straight, pearly white, moist (A, B)

false vocal folds

don’t vibrate and are not white, help support phonation (C, D)

mucosal wave

pattern that cover of vocal folds goes through

Body-Cover Model (Hirano, 1974)

cover = portion of vocal folds that vibrate, outermost layers of vocal folds 

body = muscular portion of vocal folds, deeper layers of vocal folds, bulk of vocal folds 

functional voice disorder

inefficient use of an intact vocal mechanism, can cause an organic voice disorder

organic voice disorder

anatomic/physiologic basis

muscle tension dysphonia (MTD)

• functional voice disorder

• excessive muscle tension

mutational falsetto (puberphonia)

• functional voice disorder

• high-pitched voice in males after puberty

vocal fold nodules

• organic, structural

• bilateral callous-like bumps

• form over time

vocal fold polyp

• organic, structural

• unilateral fluid-filled bump, like a blister

• can form in one moment of voice use

• voice isn’t clear, it’s breathy and there’s too much airflow

• higher pitches are more difficult to produce

vocal fold hemorrhage

• organic, structural

• bruise, broken blood vessels

• can form in one moment of voice use

vocal fold cyst

• organic, structural

• fluid-filled sac within the vocal folds

• could be congenital or develop over time

structural voice disorder

physical changes in the vocal mechanism, organic

granuloma

• organic, structural

• inflammatory mass that forms following irritation or trauma

  • intubation, laryngopharyngeal reflux (LPR)

• form on posterior third of the vocal folds (near arytenoid cartilages)

• causes person to not be able to build up the needed subglottal air pressure

• difficulty with swallowing and aspiration

vocal fold atrophy

• organic, structural

• thinning and bowing of the vocal folds

• often age-related

• posterior gap causes a spindle vibrating pattern

Reinke’s edema

• swelling of the vocal folds

• “Smoker’s voice”

  • related to smoking

• requires surgical intervention (drain the fluid)

laryngeal cancer

• organic, structural

• cancerous tissue that develops in the larynx 

• often requires both radiation and surgical intervention 

• not diagnosed by SLP’s, if you see something off you need to let them know that they need to get evaluated 

• a lot of time people with laryngeal cancer will end up with an electro larynx

neurological voice disorder

change in CNS or PNS that affect innervation of vocal mechanism, organic

essential tremor

• involuntary movement of the larynx during all phonation 

• usually part of a disease process 

  • ex. Parkinson’s, Huntington’s 

vocal fold paralysis

• no movement 

• often results after surgery or stroke 

• unilateral paralysis is more of a concern for voice 

• bilateral paralysis is more of a concern for breathing 

• from nerve damage, usually cranial nerves 

• sometimes comes back, sometimes doesn’t 

vocal fold paresis

• organic, neurological

• weakness, sluggish moving vocal folds 

• can occur after a viral infection (post-viral vagal neuropathy) 

  • vagal nerve damage after virus  

  • vagal innervates pharynx, vocal folds, larynx 

adductor spasmodic dysphonia

• vocal folds spasm closed during phonation 

• can sustain a vowel and sing 

• main treatment is Botox injections to weaken the muscles in spasm 

• can’t breathe for a moment, can’t talk 

• can be due to exercise intolerance 

abductor spasmodic dysphonia

• vocal folds spasm open during phonation 

• can sustain a vowel and sing 

• main treatment is Botox injections to weaken the muscles in spasm 

• aphonic, but can breathe 

• can be due to exercise intolerance 

psychogenic voice disorders

• rare, result of psychological stress

• no structural or neurological pathology

• loss of volitional control of phonation as a psychological basis (anxiety, depression, conversion disorder, personality disorder)

• shoulders are held up too high because of anxiety (etc.), muscles around larynx tighten and larynx is raised up too high 

conversion disorder

• loss of one or more bodily functions after stressful/traumatic event (blindness, inability to speak, numbness, paralysis) 

• person thinks they have something wrong with them, nothing points to why, it’s because of a traumatic/psychological event 

dysphonia

• dys = bad, difficult 

• phonia = sound 

hyperfunction

• strain

• too much muscle (pressure), not enough airflow

• ex. muscle tension dysphonia

hypofunction

• breathy

• not enough muscle (pressure), too much airflow

• ex. vocal fold lesion, paralysis, paresis, etc.

vocal quality

how the voice sounds, often discussed using perceptual terms

breathy

vocal folds do not close completely during phonation, glottal insufficiency

harsh or rough

irregular or inconsistent vibration of vocal folds

hoarse

combination of breathy and harsh, commonly used umbrella term to qualify a disordered, dysphonic voice

videostroboscopy

• uses a light attached to an endoscopic camera that allows you to visualize the vocal folds during phonation 

• rigid videostroboscopy goes through mouth 

• flexible videostroboscopy goes through nose 

stimulability

someone’s ability to respond to cues you give them

integrated implicit-explicit approach to voice therapy 

• implicit = auditory component; use of facilitators 

  • facilitator example would be having client say “uh-oh” to get the closure they need, then follow up with a word, ex. “uh-oh dog,” slowly work up to conversation 

• explicit = instruction in the anatomy and physiology of vocal mechanisms; teach them how things work 

• integration = use both together to best facilitate learning 

hierarchy (for voice therapy)

1. facilitator

2. words

3. phrases

4. sentences

5. reading

6. spontaneous conversation