Voice Disorders - SLH 371 Spring 2021

Introduction to Voice Disorders

Learning Objectives

• Define dysphonia and describe its signs/symptoms.
• Define and describe:
  • Neurologic voice disorders
  • Structural voice disorders
  • Functional voice disorders

Notice

• Some images and videos may be graphic; viewer discretion is advised.

Voice Disorders

• A voice disorder (dysphonia) occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location AND when an individual expresses concern about having an abnormal voice that does not meet daily needs (even if others do not perceive it as different).

Symptoms of Voice Disorders

• Increased effort when speaking.
• Decreased vocal endurance (fatigue).
• Variable vocal quality throughout the day.
• Running out of breath quickly.
• Frequent coughing/throat clearing.
• Excessive throat tension/pain/tenderness.

Signs & Symptoms

• Roughness: aberrant VF vibration
• Breathiness: audible air escape
• Strained quality: increased effort, tense or harsh sound
• Strangled quality: as if talking with the breath held
• Abnormal pitch: too high, too low, pitch breaks, decreased range
• Abnormal loudness: too high, too low, unsteady, decreased range
• Aphonia: loss of voice
• Asthenia: weak voice
• Gurgly/wet sounding voice
• Hoarse voice: raspy, audible aperiodicity
• Pulsed voice: fry register, audible creaks in sound
• Shrill voice: high, piercing sound
• Tremulous voice: shaky voice, rhythmic pitch and loudness undulations

Types of Voice Disorders

• ORGANIC: Physiologic in nature
  • Structural: physical changes in the voice mechanism
  • Neurogenic: due to problems with the nervous system
• FUNCTIONAL: Result from improper or inefficient use of the vocal mechanism
• PSYCHOGENIC: Psychological stresses lead to habitual dysphonia/aphonia

Neurogenic Voice Disorders

Dysarthrias: Motor Speech Disorders

• Flaccid Dysarthria (LMN)
  • Breathiness
  • Diplophonia
  • Pitch breaks
  • Reduced loudness
• Spastic Dysarthria (Bilateral UMN)
  • Harshness
  • Low pitch
  • Strained-strangled quality
  • Pitch breaks
• Unilateral UMN Dysarthria (Unilateral UMN)
  • Reduced loudness
• Ataxic Dysarthria (Cerebellum)
  • Excess loudness variations
  • Vocal tremor
• Hypokinetic Dysarthria (Basal Ganglia)
  • Breathiness
  • Reduced loudness
• Hyperkinetic Dysarthria (Basal Ganglia)
  • Harshness
  • Low pitch
  • Strained-strangled quality
  • Pitch breaks
  • Excess loudness variations
  • Voice stoppages
  • Vocal tremor

Spasmodic Dysphonia

• Phonatory spasms without evidence of any other motor speech disorder or laryngeal pathology
• Occurs only during phonation
• 3 types:
  • Adductor-type: strained-strangled voice stoppages
  • Abductor-type: involuntary breathy bursts
  • Mixed

VF Paralysis

• Peripheral involvement of the superior or recurrent laryngeal nerve
• Unilateral or bilateral
• Many etiologies:
  • Surgical trauma
  • Cardiovascular disease
  • Neurological diseases
  • Accidental trauma
  • Tumor pressing on nerve
  • Viral infection
  • Idiopathic
  • etc.

Structural Voice Disorders

• Only physicians can make medical diagnoses of laryngeal pathology

Structural Voice Disorders

• Changes in the mucosal layers or vocal fold body will impact VF:
  • Mass
  • Size
  • Stiffness
  • Flexibility
  • Tension
• …which can impact glottal closure and alter vocal quality, frequency, and intensity

Nodules

• Inflammatory degeneration of the superficial layer of the lamina propria with associated fibrosis and edema
• Common, benign vocal fold lesion
• Usually bilateral and symmetric
• On medial edge of VF
• Typically in middle ⅓ of VF at greatest point of VF vibration
• Caused by traumatic or hyperfunctional voice use
• Roughness
• Breathiness
• Increased muscle tension

Polyps

• Fluid-filled lesion composed of gelatinous material that develops in the superficial layer of the lamina propria
• Sudden onset and rapid increase in size
• Usually unilateral
• Typically in middle ⅓ of VF at greatest point of VF vibration
• Caused by traumatic or hyperfunctional voice use
• Voice effects depend on polyp size
• May cause audible inspiration
• May not impact phonation, depending on polyp location

Reinke’s Edema

• Superficial layer of the lamina propria becomes filled with viscous fluid
• Excessive swelling along the entire VF length
• Usually complete glottic closure
• Increased VF mass & stiffness
• Caused by chronic vocal abuse and smoking
• Dramatically lower pitch
• Husky hoarseness
• “Smoker’s voice”

Acute Laryngitis

• Inflammation of the vocal fold mucosa due to infection
• Mild to severe dysphonia with lowered pitch and intermittent pitch breaks
• Edema (swelling)
• Erythema (redness)
• Associated with upper respiratory inflammation due to bacterial, viral or fungal infections or vocal abuse

Laryngeal cancer

• Mostly squamous cell type, originating from epithelium
• Symptoms:
  • Persistent hoarseness
  • Difficulty breathing
  • Pain with or without vocalizing
• Caused by chronic irritation of the laryngeal epithelium and mucosa by carcinogenic agents, such as alcohol and tobacco
• HPV is an increasing cause of head & neck cancer

Functional Voice Disorders

Phono-trauma

• Functional voicing behaviors that contribute to development of voice disorders
  • Shouting
  • Loud talking
  • Screaming
  • Vocal noises
  • Coughing
  • Throat clearing
• Can lead to structural voice disorders

Muscle tension dysphonia

• Excessive tension of the (para)laryngeal musculature which leads to dysphonia
  • Primary: In the absence of organic voice disorders
  • Secondary: In the presence of organic voice disorders
• Can be due to personal factors, compensation for underlying organic pathology, and/or vocal abuse

Summary

• Voice disorders (dysphonia) occur when voice changes interfere with an individual’s daily life
• Dysphonia can be caused by neurologic, structural, functional, and/or psychogenic causes