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

  

Carcinoma

• Carcinoma - Cancer of the larynx

• Frequently arises from exposure to inhaled smoke

• Preoperative and postoperative care is laryngectomy is needed

  

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