Chapter 6: Voice Disorders

 

Basic Vocabulary

Words
  • Edema - Swelling
  • Velum - Soft Pallet
  • Aphonia - Loss of Voice
  • Atrophy - Reduction in Tissue
  • Hyperfunction - Increased Muscle Activity
  • Hypofunction - Reduced Muscle Activity
Prefixes
  • A - total loss
  • Dys - abnormal
  • Hyper - over/excessive
  • Hypo - under/inadequate
  • Ad - to/toward
  • Ab - away from
Voice quality can be described:

  • Harsh - excessive muscle tension

  • Breathy - partial whisper

  • Hoarse - voice that is both harsh and breathy, irregular vocal fold vibrations

  • Speech Language Pathology - vocal folds in action

Vocal Fold Abnormalities that Affect Voice

  • a variety of structural changes in the vocal folds can affect the voice
  • Nodules - calluses that develop on the vocal folds
    • Most common form of vocal fold abnormality
    • Male children 5-10 years old and adult females
    • Extroverted, “talkers”
    • Hoarse voice quality
    • Nodules form in pairs at the point of maximum contact along the length of the vocal fold where the amplitude of vibration is greatest
    • Patient alters phonatory behavior to eliminate vocal abuse, the nodules will almost always be eliminated

 

Vocal Misuses and Abuses of the Larynx

  • Talking in a noisy environment
  • Yelling, screaming, or cheering
  • Frequent coughing or clearing of the throat
  • Giving speeches or lectures
  • Using caffeine products
  • Spending time in smoky environments

Treatment Techniques

  • Yawn-Sigh
    • Vocal folds are abducted during a yawn and they are not fully adducted during a sigh
    • Helps patient feel/hear/produce a less tense sounds
    • Extend breathy phonation into vowels, open syllables, words, phrases, and sentences

Polyps

  • Polyps - Blisters
  • Polyps are relatively common
  • Shapes:
    • Pedunculated - small balloons connected to the vocal fold by a narrow foot
    • Sessile [ˈseˌsīl]  - spread over a relatively large area of the vocal fold
  • Abuse (one time), unilateral, breathy/hoarse
  • Voice therapy to reduce vocal misuse/abuse, surgery

 

Contact Ulcers

  • Contact ulcers and the granulomas that develop at sites of ulceration arise at the vocal processes (on the vocal folds between the arytenoids cartilages)
  • Site is further back than the midpoint where nodules and polyps typically form

 

  • Causes:
    • Excessive slamming together of the arytenoid cartilages during the production of low pitches
    • Frequent nonproductive coughing and throat clearing
    • Gastric reflux
    • Intubation trauma

Papilloma

  • The human papillomavirus can cause warts on the vocal folds
  • Grow large
  • Not common
  • Hoarse voice quality
  • Surgery, developing good vocal hygiene

 Bilateral papillomas on the vocal cords

Carcinoma

  • Carcinoma - Cancer of the larynx
  • Frequently arises from exposure to inhaled smoke
  • Preoperative and postoperative care is laryngectomy is needed

 Squamous cell carcinoma of the larynx

Voice Disorders Resulting from Neurological Impairment

  • Paresis - partial loss of the capacity to carry out a voluntary movement
  • Paralysis - total loss of the capacity to carry out a voluntary movement

Paralysis

  • Paralysis Causes - Cranial nerve cut in surgery (usually vegas), Stroke
Treatment for Unilateral Vocal Fold Paralysis
  • Unaffected side “overadducts” to approximate the paralyzed fold
  • Surgery involves physically moving the affected vocal fold closer to midline so that the unaffected fold can contact it during phonation
Bilateral Paralysis
  • Bilateral paralysis is less frequent
    • Results from CNS damage
    • If neural input to both recurrent laryngeal nerves is eliminated both fold assume a static position, glottis is compromised resulting in difficulty breathing (dyspnea)
    • Surgery
    • Voice typically remains functional

Spasmodic Dysphonia

  • Rare disorder
  • Accepted as a neurological problem involving a disturbance in the basal ganglia that causes disordered muscle tonicity

 

  • Types:
    • Adductor spasmodic dysphonia - strain-strangled voice quality, uncontrolled contractions of the adductor muscles
    • Abductor spasmodic dysphonia - causes inappropriate contraction of the laryngeal abduction muscles, periods of aphonia
    • Mixed spasmodic dysphonia - sudden abductions as well as sudden adductions
    • Dysphonia Treatment - Botox into the vocal folds

Vocal Abnormalities Unrelated to Structural Change

  • Conversion Aphonia/Dysphonia - patient reports change/loss of voice but medical examination fails to uncover an organic cause for the problem
    • Psychogenic cause of the voice disorder may be suspected
    • Sudden onset
    • Careful interview
    • Restored within an hour
    • Referral to a mental clinician

Voice Disorders

  • Puberphonia - mutational falsetto involves the continued use of a high-pitched voice by a post pubertal male
    • Functional disorder
    • Easy correction
  • Muscle Tension Dysphonia - caused by inordinate tension in the laryngeal muscles
    • Result from the simultaneous contraction of the muscles that close and open the vocal folds
    • Hypertensive, “knots”
    • Benefits from laryngeal massage
    • Hoarse
    • Report fatigue and laryngeal discomfort
    • Hard driven, upwardly mobile, Type A personalities

Voice Evaluation

  • Voice Evaluation Team - otolaryngologist, speech therapist
  • Voice Evaluation Interview - History (how voice disorder started, etc.)
  • Perceptual Assessment - clinician makes judgements regarding the pitch, volume, and quality of voice during a variety of tasks (sometimes recorded)

 

  • Clinicians use scales for grading vocal parameters
  • Assessments
    • The Consensus Auditory Evaluation of Voice (CAPE-V)
    • The Voice Handicap Index (VHI)
  • Instrumental Evaluation
    • Flexible videoendoscopy
    • Stroboscopy - slow motion technique that allows the clinician to examine closely the movement characteristics of the vocal folds
    • Visi-Pitch - provides objective data on a number of acoustic parameters

Laryngectomy

  • Laryngectomy - removal of the larynx (cancer)
  • Surgical removal of the larynx requires that the trachea be redirected to an opening on the front of the neck known as the tracheal stoma
  • Artificial larynx
  • Electrolarynx

Esophageal Speech

  • Esophageal Speech - air is actively injected down the esophagus past an area known as the pharyngeal-esophageal (PE) segment
  • Air is released and passes by the PE segment and draws the walls of the esophagus into vibration, much like air passing through the true vocal cords
  • Esophageal walls are much larger in mass - esophageal speech is much lower in pitch

Tracheoesophageal Speech

  • Tracheoesophageal Speech - air is routed from the lungs into the esophagus via a tracheoesophageal speech prosthesis
  • Additional surgery to create a small opening between the trachea and esophagus in which the prosthesis is inserted
  • Cover the stoma or be fitted with a valve
  • Most natural speech with the least therapy

Prevention of Voice Disorders

  • Vocal Hygiene is daily regimen of good habits to maintain the health of your vocal folds
  • These include eliminating inappropriate vocal habits and situations that place unnecessary wear and tear on the voice and common-sense behaviors which contribute to efficient voice production and overall voice health
  • The following is a list of some tips for keeping your voice healthy:
    • Avoid irritants:
    • cigarettes and secondhand smoke
    • manage reflux with over the counter (OTC) medication/see an ENT who specializes in voice disorders for prescription medications which may be less drying
    • Take care of your body:
    • Maintain good hydration: Drink 6-8 ounce glasses of water/day
    • Rest
    • Exercise
    • Good Nutrition
    • Maintain good vocal habits:
    • Avoid throat clearing and coughing
    • Avoid whispering
    • Warm up your voice before making big demands on it
    • Avoid repeated stress on the voice
    • Use good posture
    • Control environmental factors that may negatively impact your voice