CSD 538 FINAL REVIEW

Things to know:

Newborn VF length= 2.5 - 3.0 mm

Application Question: Opera singer who is on tour and has VF hemorrhage. Which would be the best treatment option for this patient?

  • Vocal rest and healthy vocal habits (drink more water, avoid caffeine/alcohol/tobacco)

Review the following:

Impact of cleft palate on speech, resonance, and feeding

  • Articulation errors due to cleft:

    • nasal emissions with consonants-plosives, fricatives, affricates

    • Turbulent nasal air emission

    • Compensatory articulation-glottal stops, weak omitted sounds

    • Nasal grimace

    • Articulators are unable to meet in the right positions due to restrictions from the cleft

  • Voice Disturbance:

    • Dysphonia- breathiness, hoarseness, glottal fry can mask hypernasality and nasal emissions

    • Short utterances due to wasted air from poor velopharyngeal closure

    • Vocal cord nodules- glottal stops=strain on larynx

  • Feeding:

    • babies are unable to suck on nipple during feeding and cleft can cause nasal regurgitation (food coming up through the nose)

  • Resonance:

    • Resonators are also unable to create proper airflow which can cause limited or excessive nasality. Feeding is difficult for babies with cleft lip/palate because they are unable to latch and suck.

What is the difference between hypernasality and hyponasality?

  • Hypernasality:

    • An excessive quantity of nasal resonance during speech is referred to as hypernasality. It happens when airflow via the nose is improperly produced during speaking sounds, giving the voice an excessively nasal tone.

  • Hyponasality:

    • is defined by a loss of typical nasal resonance during speech. It happens when sounds that normally require nasal resonance are produced with inadequate airflow through the nose.

What is Velopharyngeal insufficiency (VPI)?

  • The insufficient closure of the velopharyngeal port during speaking is a defining feature of velopharyngeal insufficiency (VPI). The velopharyngeal port is the orofacial-nasal opening, and normal speech resonance depends on its proper closure.

How does unilateral vocal fold paralysis occur?

  • When one of the larynx's vocal folds is paralyzed, it is known as unilateral vocal fold paralysis. Damage or malfunction of the nerves that regulate the movement of the vocal folds is usually the cause of UVFP.

  • Can occur during: surgery (thyroid/cardiac), neurological conditions (stroke,tumor), viral infections, neck trauma, can also be idiopathic.

  • Damage to Recurrent Laryngeal Nerve (RLN), either from viral onset, idiopathic, tumor compressing a nerve, or nerve injury.

In bilateral vocal fold paralysis, what will the patient struggle with if folds are paralyzed in an abducted position? What changes if the folds are paralyzed in a closed position?

  • A patient with bilateral VF paralysis in abduction would struggle to create voiced sounds and increase their volume. They would have a breathy and weak vocal quality because their VFs are open and would have swallow issues because the glottis is open.

  • Alternatively, bilateral VF paralysis in the adducted position would create difficulty breathing since their VFs are closed. They would have a strained, rough, vocal quality since air is not coming through the VFs.

What is the most common type of Spasmodic Dysphonia? What muscles are injected with Botox for Adductor SD? What muscles for Abductor SD?

  • Adductor Spasmodic Dysphonia (ADSD) is the most common form of SD. Botox is injected either unilaterally or bilaterally and innervates the muscle to temporarily block the release of acetylcholine at neuromuscular junction. This induces parisis to allow VFs to open more.

    • The most prevalent kind of spasmodic dysphonia is adductor SD. The involuntary contractions or spasms of the muscles that bring the vocal folds together during speech are its defining feature.

    • Injections of Botox are frequently administered to the thyroarytenoid (TA) muscle.

    • Less often than adductor SD, abductor SD occurs. When speaking, they spread the vocal folds apart. Speech becomes strained and often breathy as a result.

    • It is common practice to inject Botox into the posterior cricoarytenoid (PCA) muscle.

What are the speech/voice characteristics of the different types of SD?

  • Abductor SD (ABSD)

    • Characteristics: weak and breathy. VFs opened when it should be closed.

  • Adductor SD (ADSD)

    • Characteristics: strained. VFs are closed when they should be opened.

What does Botox do to nerve transmission?

  • Botox gives the ability to temporarily interrupt nerve-muscle communication.

  • By inhibiting acetylcholine release, Botox induces temporary muscle paralysis.

  • (Acetylcholine is responsible for transmitting signals from nerve cells to muscles, leading to muscle contraction.)

What is laryngomalacia? What are signs/symptoms?

  • A frequent congenital condition affecting the larynx

    • The soft tissues of the larynx are more floppy than typical in laryngomalacia, which causes the airway to partially collapse when breathing.

  • Signs and symptoms:

    • Noisy Breathing (Stridor), Worsening with Feeding, Retractions, Feeding Difficulties, Gastroesophageal Reflux, Cyanosis (bluish discoloration of the skin)

What may contribute to polypoid degeneration of the vocal folds?

  • Polypoid degeneration- Severe form, membranous portion becomes permeated with the fluid

  • Long-standing trauma or chronic exposure to irritants can contribute to polypoid degeneration

    • Cigarette smoke

    • Laryngopharyngeal reflux

What are vocal nodules and how do they form? What about vocal fold polyps?

  • Vocal nodules are:

    • The most common benign pathology

    • Inflammatory degeneration of the superficial layer of the lamina propria

    • Typically form bilaterally

    • May be acute or chronic

    • Caused by high impact stress during phonation or phonotraumatic behaviors

    • Typically are firm and callous-like

  • Vocal fold polyps

    • Fluid-filled lesion

    • Develops in the superficial layer of the lamina propria

    • Has its own blood supply

    • Typically forms unilaterally

    • Sessile pedunculated in appearance

    • Cause thought to be from acute vocal trauma or from phonotraumatic behaviors

    • Can occur as the result of a single traumatic incident

What are the options for speech post-laryngectomy? Which option sounds the most natural?

  • Esophageal speech (burp speech)

  • Tracheoesophageal prosthesis

  • Electrolarynx

  • Most natural= Tracheoesophageal prosthesis

What is leukoplakia? What risk is associated with this diagnosis?

  • White plaque like formation occurring on the vocal fold surface

    • Usually found at the anterior portion of the vocal fold but may extend into the interarytenoid area

    • Considered a precancerous state and should be biopsied

  • Primary cause is chronic irritation

    • Primary irritation is cigarette smoking

    • Environmental exposure to irritants

    • Alcohol use

    • Other inhaled drugs

  • Risk associated:

    • could be cancer

What are the symptoms of laryngeal cancer? What are the primary contributing factors?

  • Symptoms:

    • Hoarseness

    • Change in pitch (typically lower due to mass effect)

    • Vocal strain

    • Sore throat or globus sensation

    • Persistent cough

    • Stridor

  • Primary contributing factors:

    • Smoking

    • Alcohol use

    • Reflux

    • HPV

What is the difference between a laryngectomy stoma and a trach tube? Why is this important?

  • A tracheostomy:

    • is a surgical procedure that creates an opening through the neck into the trachea. There is still a connection from the nose or mouth to the lungs, so traditional airway manipulation will work. The tracheostomy can be short-term or permanent.

  • A laryngectomy:

    • is the surgical removal of the larynx, completely and permanently. The remaining trachea is sutured to the anterior neck. There is NO CONNECTION from the nose or mouth to the lungs, so traditional airway manipulation will not work. Laryngectomy patients are known as Neck Breathers - individuals who breathe through a neck stoma.

  • It is important because the appearance of the stoma can be confused for either one.

    • For a laryngectomy, it is impossible to deliver oxygen to the lungs with nasal cannula, face mask, or bag-mask ventilation. Attempts to intubate the trachea from above the stoma via the oral or nasal route will be unsuccessful.

What is medialization thyroplasty commonly used to treat?

  • Thyroplasty is typically used to treat unilateral vocal fold paralysis. A mesh device is placed into the paralyzed VF to bring it closer to the working VF. They can also be used to treat spasmodic dysphonia and help transgender patients achieve the pitch they are wanting.

What are the goals of voice therapy? What is the patient’s role in therapy?

  • Goals:

    • Aronson, 1985 – the objective is “the best possible voice within a patient’s anatomic and physiologic capabilities”

    • Colton and Casper, 1990 – “To restore the best voice possible, a voice that will be functional for purposes of employment and general communication”

    • Enhance voice quality by optimizing conditions under voice production

  • Patient’s Responsibility:

    • Completing their home exercise program outside of therapy sessions and maintaining vocal hygiene. The patient is also the one determining what they are looking to get out of therapy regarding their voice.

Review the treatment approaches and what they are commonly used for.

  • Hygienic Voice Therapy

    • Focus on behavioral causes of voice disorder and modifying/eliminating those factors to improve vocal quality.

  • Symptomatic Voice Therapy

    • Modification of deviant vocal symptoms such as breathiness, inappropriate pitch, loudness, hard glottal attacks, etc.

    • Focuses on modifying aberrant vocal symptoms observed by the patient or SLP, such as: high pitch, breathy voice, or hard glottal attack

    • There is a hierarchical pattern:

      • Patient identifies the behavior that needs to be eliminated or modified

      • Stimulate the desired target behavior by using facilitating techniques

        • Chant talk

        • Chewing/yawn-sigh

        • Confidential voice

        • Counseling

        • Head position

        • Laryngeal massage

        • Open mouth approach

        • Pitch Inflection

  • Psychogenic Voice Therapy

    • Focus on psychosocial and emotional factors that caused voice disorder. Once that is treated, then the voice will improve.

  • Physiological Voice Therapy

    • Vocal function based on objective voice assessment (laryngeal function study)

    • Strives to improve the balance among voice respiratory support, laryngeal muscle strength, control and stamina, and supraglottic modification of the laryngeal tone

    • Promotes a healthy vocal fold cover

    • concentrates on the modification of the underlying physiology of the voice producing mechanisms: respiration, phonation, resonance

    • Direct exercises are used to activate the laryngeal muscle and work other subsystems, such as respiratory and supraglottal systems

    • Examples:

      • Vocal Function Exercises-helps with hypo-hyperfunction voice disorders.

        • Vocal warm up, pitch glides, prolonged vowel /o/ at selected pitch

      • Lessac-Madsen Resonant Voice Therapy-helps w/ hypo-hyperfunctional voice disorders

        • Goal is for patient to use least amount of respiratory effort and stress on vocal folds

        • 45 min sessions, 1-2 per week, for 6-8 weeks

        • Sounds→words→phrase→chant→conversation

        • ***patient must be able to feel the vibrations in the first session, otherwise choose different tx method

      • Lee Silverman Voice Treatment-Increase loudness by increasing effort and coordination during speech production

        • 4x/week, 4 weeks, 1 hr per session

        • Used with Parkinson’s Disease

      • Inspiratory and expiratory muscle strength training

      • Semi Occluded Vocal Tract Exercises- Some backflow of air which may help entrain better vibration of vocal folds

        • Can be used with lip/tongue trills, blowing bubbles with a straw, or bilabial fricatives

      • Call Technique- open throat and mouth like a megaphone and shout functional phrases. Emphasize the consonant and stretch the vowels.

  • Eclectic Voice Therapy

    • Uses a combination of other approaches to provide the most effective therapy.

What happens to the larynx if infected with human papilloma virus? What are the treatments?

  • Associated with an increase in cancers located in tonsils and base of tongue

    • First reported in 1983

  • Treatments associated:

    • Surgery alone

    • Transoral robotic surgery (TORS)

    • Full course radiation therapy (XRT)

    • Combination radiation and surgery

    • Chemotherapy before or during radiation

What are psychogenic disorders? Who are appropriate referrals for these patients?

  • Unexplained physical symptoms without relevant organic pathology

    • Accounts for about 45% of visits to clinics

    • Psychogenic and neurogenic symptoms can co-occur

    • May manifest as a speech/voice disorder

    • Voice is most common type

    • Speech: fluency, pseudo foreign dialect, infantile speech, prosodic

    • Differential diagnosis: the symptoms must fit the”rules” of a motor speech or voice disorder

  • Many psychogenic disorders can be treated by SLP’s

    • Prognosis is good

    • Patient’s belief that problem is organic must be addressed

  • Appropriate referrals

    • Behavioral therapy

    • Respiratory therapy

What are typical problems of singers? How are their complaints different?

  • Common complaints of singers include:

    • Loss of upper notes

    • Loss of flexibility

    • Prolonged warm-up

    • Difficulty singing loudly or softly

    • Difficulty with register changes (passagio)

  • Considerations for working with singers:

    • Singers may be prone to reflux

    • Problem may be in the speaking voice

    • Voice issues may be subtle, not readily visible on strobe exam

    • While under a scope, have them sing for you and see what you notice

What is irritable larynx syndrome?

  • 1st described in 1999

  • Hypothesis is: ILS develops as a reaction to changes in the central nervous system, leaving sensorimotor pathways in hyper-excitable state. Adaptation to chronic noxious stimuli results in an altered response

Review the function of the intrinsic laryngeal muscles.

  • Responsible for the movements of the laryngeal cartilages and finer control of the laryngeal structures

  • Total of 5- all of which are paired

  • These muscles work together to regulate the tension in the vocal ligament and the size and shape of the glottal space

Define vocal fold mobility.

  • The degree of vocal fold movement during phonation

Define stroboscopy. How is it different from true slow motion?

  • Digital Laryngostroboscopy:

    • Imaging the larynx using a strobe light

    • Provide great image quality:

      • Allow retrieval of the images for later examination

      • Allow pre to post comparison of the laryngeal image

  • Videostroboscopy:

  • Most commonly used visual imaging for voice disorders

  • Parameters that are rated:

    • Glottal closure

    • Supraglottic activity

    • Vertical level of approximation

    • Vocal fold edge

    • Vocal fold mobility

    • Amplitude of vibration

    • Mucosal wave

    • Non-vibration portion

    • Phase closure

    • Periodicity

    • Overall laryngeal function

  • Laryngostroboscopy and videostroboscopy is different from true slow motion because true slow motion allows us to view the vocal fold movement in slow motion and stroboscopy does not allow us to see this or only allows us to review it frame by frame