Intrinsic laryngeal muscles.
3. Lateral Cricoarytenoid
5. Posterior Cricoarytenoid
Function of Cricothyroid
Depresses thyroid relative to crichoid, tensing vocal folds.
Function of thyroarytenoid
Body of vocal folds
Pulls arytenoid side of VF toward the thryroid side of VF, thus shortening them
Function of thyroarytenoid
Strengthen glottic closure. Keep VF together to resist the airstream from the lungs.
Function of thyroarytenoid
Function of Lateral Crichoid Arytenoid
They rotate the arytenoid cartilages medially, causing the vocal folds to adduct. They are the main vocal fold ADDuctor.
Function of Interarytenoids
Pull arytenoids toward each other, increasing medial compression of VF.
Function of Posterior Cricoarytenoids
Primary ABductor of VF; Open the glottis by pulling the back ends of the arytenoid cartilages together. This pulls the front ends (where the vocal folds attach) apart, therefore pulling the vocal folds apart.
Superior external laryngeal muscles
Mylohyoid, Stylohyoid, Digastric, Geniohyoid
Inferior external laryngeal muscles
Thryohyoid, Sternohyoid, Sternothyroid, Omohyoid
Collective function of external laryngeal muscles
Position larynx in neck
3 Layers of Vocal Folds
Epithelium, Lamina Propria, Body (Vocalis)
3 Layers of Lamina Propria
Superficial, Intermediate, Deep
Underlying Theory of Myoelastic-Aerodynamic Theory
Bernoulli Effect, Myoelastic properties of VF
As speed increases, pressure decreases. Negative pressure sucks two VFs together.
Myoelastic properties of VF
The most superficial layers of the vocal fold structure are moveable and elastic.
5 Steps of Passive Vibration
Subglottal pressure increases under ADDuction; Sublottal pressure overcomes the VF;
VF blow apart causing drop in pressure;
Negative pressure sucks VF back together;
Elastic properties of VF cause them to bounce back together;
Body of VF according to Hirano
Body is intermediate and deep layers of Lamina Propria (aka transition) and Vocalis Muscle;
Cover of VF according to HIrano
Cover is epithelium and superficial layer of Lamina Propria (aka Reinke's space);
Hirano's Body-Cover Theory
Body is stiff and contractile which provides stability, while cover is pliable, elastic, and non-muscular which allows for vibration.
Length, Tension, Density, Airflow
Factors affecting pitch
Relationship of VF length and pitch
Relationship between rate of airflow and pitch
Perceptual Correlate of Pitch
Fundamental Frequency (rate of vf vibration measured in Herz)
3 Vocal Registers
Normal, Falsetto, Vocal Fry
Perceptual Correlate of Loudness
Sublottal pressure and Vibratory Pattern
Factors affecting loudness
Relationship between subglottal pressure and intensity
Relationship between vibratory pattern and intensity
Relationship between density and pitch
Relationship between VF tension and pitch
Impacts Quality of voice
Integrity of VF Vibration
Two types of vocal fold thickening
Swelling and Edema
Causes of VF thickening
URI, Pscyhological issues, environment/toxins, personality, endocrine imbalance, vocal abuse/misuse, post-surgical irritation
Treatment of VF thickening
Tissue reaction to frictional trauma between VF between the anterior 1/3 and posterior 2/3 of VF
1st stage of vocal nodule development
Localized, slight reddening on free margin of VF. Nodules appear gelatinous and floppy.
2nd stage of vocal nodule development
Localized swelling or thickening on edge of VF. Nodules appear to be grayish, translucent thickenings.
3rd stage of vocal nodule development
Definite nodule forms with fibrotic tissue replacing the thickening. Nodules are hard, white or gray.
Vocal Characteristics of Nodules
Hoarse, Breathy, Limited Pitch Range, Lowered Pitch, Frequent Throat Clearing
Causes of Polyps
URI, Contaminants in the air, Continued vocal abuse, Single Traumatic Vocal Event
Location of Polyps due to vocal abuse
Junction of anterior 1/3 and posterior 2/3 of vocal folds
2 types of polyps
Pendunculated and Sessile.
Location of Polyps not due to vocal abuse
Supra and subglottic regions of larynx
Rarely seen in children
Seen in adults and children
Vocal Characteristics of Polyps
Hoarse, Harsh, Frequent Throat Clearing, Vocal Fatigue due to increased effort to phonate. Can cause sudden voice breaks or vocal shut offs.
Treatment of Polyps
Usually surgery and patient education. If caused by abuse, delay surgery and begin voice therapy. Perform surgery after swelling goes down a little.
Treatment of Nodules
Cause of nodules
Repeated vocal abuse
Treatment of nodules
Sometimes surgery; other times vocal therapy to reduce the size and educate the patient.
Generally seen in men. Voice appears to not lowered during puberty.
Causes of mutational falsetto
Not enough endocrine to change voice. Possibly a conversion disorder.
Treatment for Mutational falsetto
Vocal therapy to help find their modal pitch. Model lower pitch and have them match it. Might use cough-hum or visipitch.
Patient produces an involuntary whisper. They have no voice, but their larynx is normal.
Causes of functional aphonia
Conversion disorder or failure to put VFs in preparatory position for phonation. May occur after severe laryngitis or URI or surgery or traumatic event
Treatment for functional aphonia
Help them find their voice. Counsel to find out what they are avoiding. Do something non-speech to get speech out like cough-hum, tickle, etc
Symptoms of functional aphonia
Communicate well by gesture, whispering, and animated facial expressions.
Aging voice due to decreased respiratory efficiency, loss of elasticity of VF. Slight bowing of VF. Begins after age 5.
Hoarseness and throat paint with through clearing. Hyperplasia or swelling of posterior/interarytenoid rim.
Treatment of GERD-related voice problems
Medication, diet, repositioning.
Treatment of functional voice disorders
Muscle Tension Dysphonia
Excessive Muscle Tension
Symptoms of Muscle Tension Dysphonia
Strained, strangle, tense, harsh, diplophonia
Causes of MTD
Tension in strap muscles. Begins with extrinsic muscles but moves to intrinsic muscles.
Treatment of MTD
Reduce tension; Relaxation exercises?
Loss of voice. Can be functional or infections.
Symptoms of laryngitis
Loss of voice, harsh, breathy.
Causes of Laryngitis
Swelling of VF after excessive/strained vocalization.
Treatment for functional laryngitis
Therapy, Modified vocal rest, vocal hygiene, education
Treatment for infectious laryngitis
Anti-viral medicine, modified vocal rest, etc
When false vocal fold's vibrate. It is seen in patients with a severe vocal fold pathology. May hear diplophonia.
Paradoxical VF movement
Often mistaken for asthma
Adduction during inspiration and/or exhalation.
Paradoxical VF movement
Symptoms of Paradoxical VF movement
Wheezing, dyspnea, cough, stridor
Pain during phonation
Causes of Paradoxical VF movement
UMN or LMN; Brainstem compression; Conversion disorder.
Diseases causing paradoxical VF movement
Encephalopathy, Arnold-Chiari malformation; Irritant exposure, CVA, MG, ALS, stress
Treatment of SEVERE paradoxical VF movement
Intubation so that the patient can breathe
Treatment of paradoxical VF movement with organic causes
Eliminate organic cause through Helliox therapy or botox.
Treatment of paradoxical VF movement
patient education, terminate unnecessary medications, psychotherapy, teach tension identification and control, teach them to let go of tension
Essential Vocal Tremor
Rhythmic tremors. Affect other parts of body than larynx. Most noticeable on prolonged vowels.
Treatment of Essential Tremor
Medication and injections of botox. Voice therapy not usually successful due to neurogenic basis.
Symptoms of adductor spasmodic dysphonia
Strained/Strangled vocal quality. intermittent, tight adduction. VC appear normal. Not able to shout
Symptoms of abductor SD
normal or minimally dysphonic or breathy; voicing suddenly interrupted by temporary abduction of VF; glottal chink is observable at moment of aphonia
Causes of SD
may be psychological OR organic/neurologic
Surgical treatment of SD
RLN section to paralyze VF
Medical treatment of SD
Symptoms of Contact Ulcer/Granuloma
Pain in pharyngeal area radiating toward neck or ear; throat ticklet; need to clear through; aching or dryness of throat
Vocal characteristics of contact ulcer/granuloma
Low pitch, hoarse, persistent glottal attacks, loud voice
Causes of contact ulcers
person who uses voice intensively in ever day life, hard driven, tense personality, irritants
a band of tissue varying in size that extends across the glottis between the two vocal folds.
Causes of Laryngeal Web
prolonged infection or trauma OR
failure of glottal membrane to separate during embryonic development
Symptoms of Laryngeal Web
1. Various degrees of breathing problems
2. higher than normal pitch due to shortened and restricted vibratory pattern.
3. harsh quality
4. shortness of breath
Congenital anomaly of the larynx
Symptoms of Laryngomalacia
Noisy respiration an dinspiratory stridor
Larynx is underdeveloped.
Wart-like growth in larynx that appears gray-pink, with berry shaped projections arising from anterior laryngeal area, spreading to supra and subglottal regions.
Caused by a virus
Cause of Papilloma
Vocal characteristics of papilloma
Hoarseness, aphonia, stridor, shortness of breath, croupy like cough.
Superficial layer of lamina propria becomes filled with fluid because of long standing trauma. VF look like long fluid filled bags or balloons
Extreme Reinke's Edema
Cause of REinke's Edema
Extreme vocal abuse
Treatment of Reinke's Edema
Vocal characteristics of REinke's Edema
Whisky/Smoker's voice; low and husky hoarseness;
Inability of one or both folds to move due to a lack of innervation of intrinsic muscles of the larynx
10% CNS, 90% vagus nerve damage