Voice Disorders

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Intrinsic laryngeal muscles.

1. Cricothyroid
2. Thyroarytenoid
3. Lateral Cricoarytenoid
4. Interarytenoids
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

Bernoulli Effect

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

Inverse

Relationship between rate of airflow and pitch

Proportionate

Perceptual Correlate of Pitch

Fundamental Frequency (rate of vf vibration measured in Herz)

3 Vocal Registers

Normal, Falsetto, Vocal Fry

Perceptual Correlate of Loudness

Intensity (decibels)

Sublottal pressure and Vibratory Pattern

Factors affecting loudness

Relationship between subglottal pressure and intensity

Proportionate

Relationship between vibratory pattern and intensity

Proportionate

Relationship between density and pitch

Inverse

Proportionate

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

Draining fluid

Tissue reaction to frictional trauma between VF between the anterior 1/3 and posterior 2/3 of VF

Vocal Nodules

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

Polyps

Rarely seen in children

Nodules

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

?????

Usually unilateral

Polyps

Usually bilateral

Nodules

Cause of nodules

Repeated vocal abuse

Treatment of nodules

Sometimes surgery; other times vocal therapy to reduce the size and educate the patient.

Mutational falsetto

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.

Functional aphonia

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.

Presbylaryngeus

Aging voice due to decreased respiratory efficiency, loss of elasticity of VF. Slight bowing of VF. Begins after age 5.

GERD symptoms

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

Identify abuse
Eliminate it
Patient education
Vocal hygiene
Facilitating Techniques

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?

Laryngitis

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

Ventricular Dysphonia

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

Dyspnea

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.

Spasmodic Dysphonia

Vocal stuttering.

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

BOTOX

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

Laryngeal Web

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
5. STRIDOR

Laryngomalacia

Congenital anomaly of the larynx

Symptoms of Laryngomalacia

Noisy respiration an dinspiratory stridor

Larynx is underdeveloped.

Laryngomalacia

Papilloma

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.

Reinke's Edema

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

Polypoid degeneration

Cause of REinke's Edema

Extreme vocal abuse

Treatment of Reinke's Edema

Surgery

Vocal characteristics of REinke's Edema

Whisky/Smoker's voice; low and husky hoarseness;

VF Paralysis

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

VF Paralysis

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