11 Voice Disorders
Focus Questions
What is a voice disorder?
How are voice disorders classified?
What are the defining characteristics of voice disorders?
How are voice disorders identified?
How are voice disorders treated in evidence-based practice?
Introduction
Tools and Techniques for Examination:
Glottiscope
Laryngoscope
Laryngeal Mirror
Endoscopy
Videostroboscopy
What Is a Voice Disorder?
Definition: A complex, dynamic product of vocal fold vibration that allows vocalization.
States of Vocal Folds:
Adduction (Active): Vocal folds are closed.
Abduction (Rest): Vocal folds are open.
Pharyngeal Resonance: Actual vibration of air affects voice quality.
Definitions
Frequency: Rate of vocal fold vibration;
Expressed in cycles per second, or hertz (Hz).
Pitch: Psychological or perceptual equivalent of frequency.
Intensity: Physical measure of sound pressure;
Reported in decibels (dB).
Loudness: Perceptual correlate of intensity.
Phonatory Quality: Evaluation of how well vocal folds function during the vibratory cycle.
A Voice Disorder
Definition: Individual's pitch, loudness, or phonatory quality differs significantly from peers of similar age, gender, cultural background, and ethnicity.
Terminology
Voice Quality (Table 11.1):
Dysphonia: Umbrella term for disordered voice.
Aphonia: Total loss or lack of voice.
Additional Terms: Breathy, hoarse, rough, jitter, diplophonic, pressed, ringing, flutter, creak.
Vocal Fold Functioning
Hypofunction: Vocal folds underfunctioning with inadequate tension.
Hyperfunction: Vocal folds overly tense and compress too tightly.
Diplophonia: “Double pitch,” where vocal folds produce two different pitches simultaneously.
Voice Without a Larynx
Laryngectomy: Surgical removal of the larynx.
Alaryngeal Communication: Communication method for those without a larynx.
Prevalence and Incidence of Voice Disorders
In Adults:
Prevalence Rate: Approximately 25-30%.
Incidence: Higher in women than men.
Common Causes:
Vocal nodules
Edema/swelling
Laryngitis
Polyps
Carcinoma
Vocal Fold Paralysis
In Children:
Prevalence Rate: 4-6% with significant voice problems.
Age-Specific Data:
4% of 2-6 year-olds show hoarseness.
6% dysphonia occurrence in 8-year-olds (7.4% boys, 4.6% girls).
Most Common Cause: Vocal nodules.
Barriers to Treatment
Reasons for Lack of Treatment:
Access to treatment
Lack of knowledge
Social perceptions regarding vocal quality.
How Are Voice Disorders Classified?
Vocal Abuse
Definition: Chronic or intermittent overuse/misuse of the vocal apparatus.
Abusive Behaviors Include:
Talking in noisy environments.
Frequent throat clearing or coughing.
Consumption of caffeine products.
Yelling, screaming, and cheering.
Giving speeches or lectures.
Exposure to smoky environments.
Vocal Nodules
Nickname: Teacher’s nodules or singer’s nodules due to higher prevalence in these professions.
Varieties:
Acute: Bruises on vocal folds.
Chronic: Thicker and hardened nodules over time.
Contact Ulcers and Granuloma
Contact Ulcers: Inflamed lesions on arytenoid cartilages in posterior larynx.
Granuloma: Mass of tissue formed as a healing response to ulcers.
Causes:
Repeated forceful contact.
GERD (gastroesophageal reflux disease).
Neurogenic Disorders
Definition: Result from damage or disease to the neurological systems involved in vocal production.
Systems Involved: CNS and PNS, particularly the vagus nerve.
Types of Neurogenic Disorders
Examples Include:
Vagus Nerve Lesions: Lesions affecting the vagus nerve can lead to dysphagia, hoarseness, and cardiovascular dysregulation, illustrating its crucial role in autonomic functions.
Spasmodic Dysphonia: A voice disorder caused by involuntary movements of the laryngeal muscles, leading to breathy or interrupted speech.
ALS (Amyotrophic Lateral Sclerosis): A progressive neurodegenerative disease that affects motor neurons in the brain and spinal cord, leading to muscle weakness, atrophy, and eventual loss of voluntary control.
Parkinson’s Disease: A progressive neurological disorder characterized by motor symptoms such as tremors, rigidity, and bradykinesia, as well as non-motor symptoms including cognitive impairment and mood disorders.
Iatrogenic Etiology: The onset of a condition caused by medical treatment or examination, which can lead to unintended complications such as voice changes or neurological issues.
Vocal Tics and Tourette Syndrome: A neurodevelopmental disorder characterized by repetitive, involuntary movements and vocalizations, often associated with comorbidities such as ADHD and OCD.
Paradoxical Vocal Fold Movement: A condition where the vocal cords involuntarily close during inhalation or exhalation, leading to difficulty breathing, which can be exacerbated by stress or anxiety.
Psychogenic Disorders
Definition: Nonorganic disorders linked to emotional and psychological factors.
Triggers: Psychological or emotional stressors.
Impact: Anxiety due to fear of reinjury.
Psychopathology Sub-Categories
Conditions Include:
Stress
Anxiety
Depression
Acute Stress Disorder
Generalized Anxiety Disorder
Performance Anxiety (stage fright)
Conversion Disorder
Mutational Falsetto and Juvenile Voice Disorder
Mutational Falsetto: Male child/adolescent exhibiting inappropriately high voice.
Juvenile Voice Disorder: Women maintaining a juvenile voice into adulthood.
Alaryngeal Communication
Definition: Voice production methods for those without a larynx.
Techniques Include:
Tracheostomy:
Laryngectomy (laryngectomee).
Defining Characteristics of Voice Disorders
Impact on Voice Characteristics:
Resonance: the port closes imperfectly because of structural or muscular problems
Common causes
Anatomical problems
Neurophysiological disorders
Allergies
Hyper- and hyponasality
Acute rhinitis
Allergic rhinitis
Papilloma
tonsillitis
Pitch and Loudness: Affected by various factors including habitual and optimal pitch, basal and ceiling pitch, vocal range, monotonicity, under- and over-loudness.
Phonatory Quality: Phonation is the production of voice via the vocal folds, includes various disturbances such as hard glottal attack, glottal fry, breathy phonation, and spasticity.
How Are Voice Disorders Identified?
Voice Team Involves:
Primary Care Physician
Otolaryngologist
Speech-Language Pathologist (SLP)
Psychologist or Psychiatrist
Educators (general and special)
Voice Teacher
Voice Coach
Warning Signs of Voice Disorders
In Children:
Frequent yelling, screaming, or crying.
Losing voice consistently when sick.
High effort required to talk.
In Adolescents and Adults:
Changes in resonance, pitch, loudness, or phonatory quality lasting over 2 weeks.
The Assessment Protocol
Assessment Steps:
Case History and Interview
Oral-Motor Examination
Clinical Observation
Instrumental Observation Techniques:
Acoustic Analysis
Aerodynamic Studies
Electroglottography
Videostroboscopy
Treatment in Evidence-Based Practice
Purpose of Voice Assessment: To gather relevant information about etiology and perceptual features of an individual's voice disorder.
Goals:
To teach absent vocal behavior.
To substitute inappropriate vocal behavior with appropriate one.
To strengthen weak or inconsistent vocal behaviors.
Treatment for Vocal Abuse
Conditions: Vocal abuse leading to nodules and ulcers.
Treatment Methods:
Surgery: On the vocal folds.
Voice Treatment Components (Holmberg et al., 2001):
Vocal hygiene
Respiratory exercises
Loudness reduction
Relaxation training
Carryover activities
Treatment for Neurogenic Disorders
Characteristics: Result from physiological causes affecting voice production.
Treatment Options Include:
Phonosurgery
Thyroplasty
Botox Injections
Voice Therapy
Treatment for Psychogenic Disorders
Approach: Multidisciplinary treatment program focusing on emotional and psychosocial factors.
Focus Areas: Counseling, tension reduction, and eliminating voice misuse.
Treatment for Alaryngeal Communication
Need: Individuals without a larynx must learn alternative voice production methods.
Terminology:
Stoma
Esophageal Speech
Tracheoesophageal Puncture
Tracheoesophageal Speech