Voice Disorders Outline - COMD 4365 - 11/19/2024 PDF

# VOICE DISORDERS ## Chapter 11 ## WHAT IS A VOICE DISORDER? (page 355) ### Definitions | Term | Definition | |--------------|----------------------| | Voice | | | Phonation | | | Resonance | | | Articula...

# VOICE DISORDERS ## Chapter 11 ## WHAT IS A VOICE DISORDER? (page 355) ### Definitions | Term | Definition | |--------------|----------------------| | Voice | | | Phonation | | | Resonance | | | Articulation | | | Frequency | | | Adduction | | | Abduction | | | Pitch | | | Phonatory Quality | | ## 3 VF CHARACTERISTICS RELATING TO FUNDAMENTAL FREQUENCY (F0) (PAGE 357) **Frequency = Pitch** **Intensity=Loudness** (page 313) | VF Characteristic | Impact on F0 | |-------------------|---------------------------------------------------------------------------| | Length | Longer VF contribute to a lower F0 | | Mass | Thicker VF contributes to a lower F0 | | Tension | Greater tension contributes to a higher F0 | **Fundamental Frequency = F0; mean/average of rates of vibration for the vfs** **Lengthened vf=increased speed of vibration=increased fundamental frequency** **What happens to FO when we get older? When do we go through the biggest increase in FO? When does F0 begin to decrease, especially in women?** ## FUNDAMENTAL FREQUENCY (FO) AVERAGES (page 357) - 250 Hz - 180-220 Hz - 120-140 Hz ## Intensity (page 357) - Physical measure of sound pressure, reported in dBs; aka loudness ## 2 FEATURES OF VF PRODUCTION RELATING TO INTENSITY (page 357) 1. Amount of airflow from the lungs 2. Amount of resistance to the airflow offered by the vocal folds ## Voice Disorder - When an individual's pitch, loudness or phonatory quality differs from that of a person of a similar gender, age, cultural background, and racial or ethnic group and is serious enough to draw attention and to detract in some way from performance in everyday contexts, like school, work, home, community ## Terminology: dysphonia vs. aphonia; See Table 11.1 ## VF FUNCTIONING - hypofunction vs. hyperfunction - spasticity (voice starts/stops intermittently) ## DIPLOPHONIA: "double pitch" - Occurs when VF produce 2 different pitches/rates simultaneously, usually because they are of different mass - Can occur if one vf is paralyzed or hypofunctioning ## VOICE WITHOUT A LARYNX (PAGE 361) ### LARYNGECTOMY: REMOVAL OF LARYNX - Usually done to remove cancer - Surgery and radiation therapy are combined for treatment - Can occur due to trauma or when larynx is too damaged to protect the respiratory system - Speech is conducted through alaryngeal communication ## VOICE DISORDERS IN ADULTS (PAGE 361) - Voice disorders are relatively high compared to other disorders of communication - Most common cause for adults include nodules, edema (swelling; laryngitis; polyps; carcinoma; and vf paralysis) - ENTs able to visualize and can make more precise diagnosis - 1/3rd are short-term problems that appear on several occasions (colds, respiratory infections) - General population = 25-30% - Teachers 58-60% - Greatest risks include use/overuse and noisy environments - (page 3361) ## VOICE DISORDERS IN CHILDREN (page 362) - 4-6% overall in children - Most common cause is vocal nodules - Results in breathy or hoarse vocal quality bilateral - Can result from physiological factors (gastroesophageal reflux, low blood circulation, dehydration and laryngeal tension - Most often associated with psychological and social factors (anger, anxiety, distractibility, frustration, interpersonal problems, hyperactivity, and loud talking) - More likely in males ## REASONS WHY VOICE DISORDERS MAY NOT BE TREATED (PAGE 363) - Access to treatment - Knowledge of treatment related to voice disorders - Social perceptions ## HOW ARE VOICE DISORDERS CLASSIFIED (page 364) - See Table 11.2 ## VOCAL ABUSE - Neurogenic Disorders - Psychogenic Disorders ## VOCAL NODULES + CONTACT ULCERS, GRANULOMA = VOCAL ABUSE ## Most common cause of voice disorders in children and adults - Related to chronic or intermittent overuse or misuse ## Vocally abusive behaviors include: - Talking in noisy environments - Using caffeine products - Coughing or clearing of throat frequently - Drinking alcoholic beverages - Yelling, screaming, and cheering - Giving speeches or lectures without a microphone - Spending time in smoky environments - Speaking loudly for a long period without proper breath support ## VOCAL ABUSE (Page 364) - 1m of speaking = 9k/cycles - (page 314) ## VOCAL NODULES (page 365) - AKA teacher's nodules and singer's nodules - Small, bilateral protuberances or calloused growths on the inner edges of VF - Most frequent causes of hoarseness in adults and children; Most prevalent in young children and adults who overuse or misuse the voice - Acute and chronic types - Acute=bruises on vf that over time will thicken and harden into fibrous protuberances that become chronic nodules - Body's response to an irritant or vf repeated hard contact at midline - Impede seamless contact and allow air to escape during phonation, resulting in a breathy or hoarse vocal quality - Temperament and general health may be a factor in increasing risk - Adults with nodules have greater anxiety and GERD ## CONTACT ULCERS, GRANULOMA (Page 366) - Inflamed lesions, or ulcers, that develop on the arytenoid cartilages in the posterior region of the larynx - Result from repeated forceful contact with the VF and progress from tissue irritation to necrosis, or death of the tissue resulting in a mass of tissue, or granuloma, at the site of the ulcer - Typically results in breathy, low voice quality - Affect men more than women (4:1) - Can also result from acidic irritation to the laryngeal areas due to chronic reflux (GERD; Gastroesophageal Reflux Disease) or heartburn, indigestion, or acid reflux disease where acid from the stomach backs up into the esophagus - Effects larynx's functions and structure, including laryngeal irritation, vocal nodules, contact ulcers, and granuloma - Nonmalignant but can contribute to a variety of voice quality (hoarseness, voice breaks), as well as chronic irritation of laryngeal area - Constant throat clearing associated with GERD is likely the cause of ulcers and granulomas that appear on arytenoid cartilages ## NEUROGENIC VOICE DISORDERS (Page 367) - Spasmodic Dysphonia - ALS - Parkinson's disease - Iatrogenic - Vocal Tics - Vagus Nerve Lesion - Paradoxical Vocal Fold Movement ## VAGUS NERVE LESION (Page 368) - Lesions can result due to surgical damage (thyroid surgery), trauma, and viral infections - Vocal fold paralysis (usually unilateral) results from vagus nerve damage - Abduction paralysis=VF adducted position=voice usually not affected; breathing is - Adduction paralysis=VF abducted position=voice is affected - Complete paralysis-completely open/closed; closed blocks airway and tracheostomy (artificial airway placed below the larynx so individual can breathe) is performed - What cranial nerve is the Vagus Nerve? ## SPASMODIC DYSPHONIA (page 369) - A disorder affecting motor control of the larynx - Hallmark: Spasms that result in intermittent voice stoppages - Now considered laryngeal dystonia (laryngeal=in larynx; dystonia=abnormal movements) - Severity ranges from mild to severe ## SPASMODIC DYSPHONIA (page 369) ### DIAGNOSIS IS BASED ON: - An occasionally normal voice - Intermittent breaks in voicing - Normal sounding whisper - Different Improved voice at high pitches - Worsening voice with stress - Periods of significant dysphonia - Voice descriptions: jerky, grunting, squeezed, groaning, and stuttering-like - Vocal tremors common ### TYPES: - Adductor type=most common (50% of cases)=hyperfunctioning voice (strangled, strained, and squeezed) - Abductor type less common; hypofunctioning (breathy and open); - Mixed SD=intermittent experience of both adductor and abductor characteristics. ## ALS (Amyotrophic Lateral Sclerosis; Lou Gehrig's disease) (page 369) - Progressive degenerative neuromuscular disease resulting in muscular weakness, fatigue, and atrophy as well as muscular spasms, tremors, and cramping - Cause unknown; life expectancy < 10 years - Cognition remains intact; muscular processes rapidly deteriorate - Later stages the individual cannot produce voice or speech and is aware of loss of function - AAC an option for alternative way to communicate - Voice disorders common; voice function deteriorates over time - Soft, breathy, low in pitch and loudness with limited variability and hyperarticulating speech sounds due to reduced precision and decreased coordination of motor processes needed to articulate ## PARKINSON'S DISEASE (page 370) - Progressive degenerative neurological disease caused by depletion of dopamine - Affects communication abilities and voice - Individuals exhibit impaired respiratory and laryngeal systems, resulting in: - Weakened respiratory system ( reduced loudness; breathy, weak voice) - Rigid muscular tone (+ laryngeal muscles; VF cannot forcefully adduct, resulting in hoarseness and monotonic pitch) - Lee Silverman Voice Treatment (LSVT) program is effective in improving respiratory strength and VF adduction ## IATROGENIC ETIOLOGY (page 370) - Symptom or disorder resulting from medical or clinical treatment - Vocal fold movement impairment (VPMI): a disorder of laryngeal functioning, - Nearly 50% of cases attributable to iatrogenic causes present when one or both of the VFs function poorly (e.g. incomplete closure at midline) - Can result from surgery to the spine, chest, or thyroid, as well as from intubation procedures used during surgery ## VOCAL TICS AND TOURETTE SYNDROME (page 370) ### VOCAL TIC DISORDER - Individual produces sudden, rapid, recurrent vocalizations, including clicks, yelps, snorts, and coughs many times per day for 1 year causing significant stress and impairment in key areas of functioning including interpersonal relationships and occupational or academic performance ### TOURETTE SYNDROME - Vocal tics occur simultaneously with other motor tics affecting the head, torso, and extremities, including eye blinking, twirling, or deep knee bends - Note: - Vocal tics in either above are not due to known physical cause - Research indicates it is related to CNS dysfunction - Almost 1% of population are affected ## PARADOXICAL VOCAL FOLD MOVEMENT (PVFM) (page 371) - A voice disorder in which VFs without paralysis or paresis close during periods in which they should be open, like when breathing. - Occurs in both children and adults - Most common in females and people from 10-40 years of age - Often seen in high-achieving individuals and competitive athletes - Individuals report feeling as if they are choking or have a tightness in throat, difficulty breathing, coughing, wheezing, and stridor - Once attributed purely to anxiety or stress, recent research also shows contributing physical etiologies, like GERD, asthma, brainstem abnormalities, hyperimmune disorders or dystonia - Pure psychogenic PVFM is rare - Contributing or co-occurring condition determines course of treatment, which may involve intercollaboration with a medical team ## PSYCHOGENIC VOICE DISORDERS (page 371) - AKA nonorganic disorders; connected to emotional and psychological characteristics. - Psychogenic dysphonia: used to describe disordered voice quality that results from an emotional or psychological event. - Voice conveys emotional and psychological states, like fear, excitement, anxiety, or shock. - Voice conveys our personality. - What is an organic vs. non-organic or functional disease? ## Psychogenic Voice Disorders - Psychological or emotional experience - Psychopathology - Mutational falsetto and Juvenile voice ## PSYCHOLOGICAL OR EMOTIONAL EXPERIENCE (Page 371) - Voice is affected post injury or traumatic experiences - Vulnerability and anxiety about voice can extend to hypochondria or result in chronic worry of a lapse - Anxiety can cause changes in memory, concentration and emotional well-being which can worsen vocal problem ## PSYCHOPATHOLOGY (Page 372) - Psychopathological conditions can affect quality of voice, like - Stress - Anxiety - Depression - Other psychopathological conditions that may affect voice: - Acute Stress Disorder - Generalized Anxiety Disorder - Performance Anxiety or Stage Fright - Conversion Disorder - "la belle indifference" - Treatment of primary diagnosis can alleviate voice-related symptoms. Others may benefit from voice treatment. ## MUTATIONAL FALSETTO AND JUVENILE VOICE DISORDERS (page 372) - Voice characteristics inconsistent with individual's age and gender. ### MUTATIONAL FALSETTO - AKA puberphonia: inappropriately high voice in a male child or adolescent - Puberty voice shifts that may be due to undergrowth of larynx or endocrine imbalance; considered organic mutational falsetto - Medical treatment may be needed ### JUVENILE VOICE DISORDER - Woman who maintains juvenile voice into adulthood - Pitch does not drop after puberty and often accompanied by low intensity, nasality and breathiness. ## ALARYNGEAL COMMUNICATION (page 373) - Communication without a larynx often due to tracheostomy or laryngectomy ## TRACHEOSTOMY (page 373) - Surgical procedure that inserts a tracheostomy tube (trach) through neck and below vocal folds to direct air into the lungs - Causes include progressive neuromuscular conditions (e.g., muscular dystrophy), spinal cord injury, genetic syndromes, premature birth, or vocal folds are not working properly (laryngeal cancer; bilateral vocal fold paralysis) - Individual unable to communicate - Adults: Can use voice-output devices - Children: Depending age of insertion, can speech, language and communication can be compromised. - Passy-Muir Valve: Allows speech / communication through vale system that sends air downward into the lungs during inhalation and directs exhales air over VF to produce speech while ventilated. ## LARYNGECTOMY (page 374) - Removal of the larynx due to trauma, (e.g., car accident), to prevent the spread of cancer, or to treat an advanced cancer - Laryngectomee: person whose larynx has been removed ### LARYNGEAL CANCER - High mortality rate, African American males have highest rates - Linked to tobacco use; alcohol elevates risks, especially when combined - Other risks: nutritional inadequacies, occupational exposures, and studies show causal relationship with GERD - Early identification important - Symptoms: hoarseness, stridor, laryngeal pain, discharge, and swelling of the neck #### GOALS - Goal #1: remove malignancy - Goal #2: maintain the body's functions and structures - Conservation approach: cordectomy, hemilaryngectomy - Near-Total or Total Laryngectomy: When larynx cannot be conserved - Requires alternative ways to communicate ## WHAT ARE DEFINING CHARACTERISTICS OF VOICE DISORDERS? (page 376) - Resonance - Pitch - Loudness - Phonatory Quality ## RESONANCE (page 376) - Velopharyngeal port: back of the oral cavity where the oral and nasal cavities meet - Open at rest & when producing nasal consonants - Raises when no airflow is released into the nasal cavity - VELOPHARYNGEAL DYSFUNCTION - Causes include: - ANATOMICA PROBLEMS (e.g., cleft palate) - NEUROPHYSIOLOGICAL DISORDERS (e.g., CP, MD, head injuries, meningitis, apraxia, etc.) - ALLERGIES ### HYPERNASALITY - Velopharyngeal port remains open - Too much resonance in nasal cavity - Can affect pressure consonants (e.g., /b/, /p/and/t/ ### HYPONASALITY - Nasal cavity is blocked; Too little nasal resonance - Voice sounds stuffy and congested - Pitch and loudness can be affected - Makes breathing difficult - Some conditions that cause hyponasality: - Acute rhinitis - Allergic rhinitis - Papiloma - Tonsillitis ## PITCH (page 378) - Glottal Fry: pitch is unusually and chronically low, produced on tightly approximated vocal folds and sounding like a "poorly tuned motorboat engine" - Habitual Pitch - Optimal Pitch - Basal Pitch - Ceiling Pitch - Vocal Range ## LOUDNESS (page 378) ### Monotonic - Overly soft or overly loud vocal quality - Both are forms of vocal abuse ### Overloudness - Air pressure under the vocal folds builds up - A characteristic of deaf or HOH ### Underloudness - Can result from lack of respiratory force due to neurological injury or disease (e.g., TBI), Parkinson's disease, MS - Can occur due to social or psychological reasons (e.g., being robbed, etc. - Can cause vocal strain and fatigues due to muscles working harder due to inadequate for of the airstream ## PHONATORY QUALITY (page 379) - Hard Glottal Attack - Glottal Fry - Breathy Phonation - Spasticity - Hoarseness ## HOW ARE VOICE DISORDERS IDENTIFIED? (page 379) - Collaboration with a voice care team to: - Come to a more accurate and thorough dx - A more comprehensive description of how the voice disorder affects the individual both physiologically and psychologically - Enhances design of comprehensive and coordinated tx approaches - Holistic process can include: PCP, otolaryngologist, SLPs, psychologist or psychiatrist, teachers, voice teacher or voice coach, etc.) ## WARNING SIGNS OF VOICE DISORDERS (page 379) - Identify warning signs of possible resonance, pitch, loudness, or phonatory quality disturbance. ### Children: - Yelling, screaming, crying frequently - Cold? Allergies? - Psychological well-being ### Adults: - Changes in resonance, pitch, loudness, or general phonatory quality that lasts longer than 2 weeks - 1st referral: otolaryngologist to check for structures of the laryngeal system and determine whether a potentially serious underlying medical condition exists - 2nd Referral: SLP who specializes in voice treatment ## ASSESSMENT PROTOCOL (page 380) - Case Hx and Interview - Oral-Motor Examination - Clinical Observation - Instrumentation Observation - Account for as much as 70% likelihood that a child develops stuttering ## HISTORY OF VOICE USE - Medical hx - Chronological hx of the problem - Symptoms and possible etiology of the problem - Use of voice in different environments (home, school, work, community) - Motivation for seeking help - How voice difficulties impact ADLs - For children, may need to obtain information from parent/caregiver. - For adults VHI (Voice Handicap Index) can be used to evaluate impace of a voice disorder. - VHI assesses functional, physical, and emotional domains. - A pediatric and adult version available. ## CASE HISTORY AND INTERVIEW (page 380) ## ORAL-MOTOR EXAMINATION (page 381) - Used to rule out structural and functional problems - Includes motion of all articulators and any sensations associated with movements (e.g., tickling, burning, or aching) - Velum very important - Symmetry - signs of atrophy - edema, or swelling - Velopharyngeal Insufficiency - Production of "ah" elevation can be used to check for deviation - Laryngeal mirror under nostrils to check for nasal emission during the production of non-nasal sounds ## CLINICAL OBSERVATION (PAGE 381) - Perceptual Observation - Highly subjective - Relies on clinician's listening ear - Knowledge and experience in working with voice increases validity ## INSTRUMENTAL OBSERVATION (page 382) ### Acoustic Assessment Evaluates frequency (pitch) and intensity (loudness) of voice, including maximal range and habitual levels of each - Documents jitter (perturbations or changes in frequency) and shimmer (perturbations or changes in intensity) in a phonatory cycle - Helps determine whether frequency, intensity, and resonance characteristics differ from normative references. ### Aerodynamic Assessment - Provides an objective measure of airflow, air pressure, and vocal fold resistance against airflow from the lungs (subglottal airflow)clients wear a facemask while their airflow is analyzed by computer - Results reflect the flow of air through the laryngeal mechanism and how well the vocal folds resist the airflow ### Electroglottography (EEG) - Allows an objective examination of VF contact during voicing - Uses electrodes on the surface of the neck to monitor voltage changes in VFs as they vibrate - Provides a graphic representation of VFs as they close/open to show whether contact is normal or the VFs are over- or underadducted ### Videostroboscopy - VF apparent movement is slowed down, and the vibratory cycle can be closely observed during sustained vibration - Used by both - SLPs--to see how the larynx functions and how that functioning might be improved throughout therapy - Otolaryngologists--to study structures of the larynx) - High-speed Videostroboscopy (HSV) can view VFs during conversational speech (vs. conventional stroboscopy at sustained speech) - Laryngoscopy examines VFs and laryngeal system using a flexible endoscope passed through the nasal cavity - Provides a close-up view of VFs, allows several people to study the larynx simultaneously and permits permanent video monitoring of change in the vocal mechanism over time - VFs can vibrate as fast as 1,000 cycles per second! ## INSTRUMENTAL OBSERVATION (page 384) ## HOW ARE VOICE DISORDERS TREATED IN EVIDENCE-BASED PRACTICE? (page 384) - General Voice treatment possible goals: - To teach a vocal behavior that is absent - To substitute an appropriate vocal behavior for an inappropriate one - To strengthen vocal behaviors that are weak or inconsistent ## Treatment (page 385) - Vocal Abuse - Neurogenic Disorders - Psychogenic Disorders - Alaryngeal Communication ## Treatment for Vocal Abuse (page 385) - Surgery, therapy, both ### Therapy - Vocal hygiene programs - Laryngeal massages - Biofeedback - Voice-production exercises - Counseling - Relaxation training - Respiration exercises - Carryover activities ## Treatment for Neurogenic Disorders (page 386) ### Medical Interventions and Therapy - Phonosurgery: Medical intervention focused on the improvement, alteration, or restoration of the voice - Thyroplasty: modification of the thyroid cartilage to adjust tension and position the VFs - used to treat breathy dysphonia from VF paralysis or other VR damage - Improves vocal intensity and frequency - Botox is used to treat spasmodic dysphonia; effects are temporary and re-injections are needed regularly - Lee Silverman Voice Treatment (LST) -an intensive 1-month program using repeated exercises designed to improve phonatory strength for those with Parkinson's disease and positive effects seen with other populations - Increases intensity and frequency of voice and the general rate and articulation of speech ## Treatment for Alaryngeal Communication (page 386) ### Counseling - To explore options for producing voice and help clients make the best choices for their needs and interests ### Artificial larynx - A vibrating power source placed against the neck or in the mouth that allows sound to be shaped through articulators - Mechanical sound and differentiating similar-sounding consonants may be a problem ### Esophageal speech Air trapped in the esophagus is used to produce voice; it can be very difficult for some. ### Tracheoesophageal speech - Puncture to create a channel between trachea and esophagus; stoma forces air into esophagus, providing air source for speaking; person can speak longer and more loudly than with esophageal speech ## CAPE-V (page 382) - Used to assess voice - Utilizes 3 activities: - Sustained production of the vowels /a/ and i/ three times each - Production of 67 sentences - Conversational speech in response to prompts - Clinician rates the overall severity of any perceived voice problems as well as 5 attributes of the individual's voice (e.g., roughness, breathiness, strain, pitch, and loudness) - Also, studies systems that support vocal production: - Coordination and adequacy of inhalation and exhalation of breath support when speaking