Voice Disorders - A Comprehensive Guide PDF

**Voice** **Voice?** It is our primary means of expression and an essential features of human attribute. - Frequency for men: 125 - Women: 250 - Children: 500 **What is voice disorders?** It is any deviation in voice quality, pitch and loudness - Pitch: frequency, the number of cycles...

**Voice** **Voice?** It is our primary means of expression and an essential features of human attribute. - Frequency for men: 125 - Women: 250 - Children: 500 **What is voice disorders?** It is any deviation in voice quality, pitch and loudness - Pitch: frequency, the number of cycles per sec is the rate at which the vocal folds vibrate. - Loudness: Amplitude of the sound signal, the larger the amplitude the more intense and so louder. **Causes?** (asha) **Disorders of vocal pitch** 1. **Monopitch voice**: lacks natural variations, A neurological problem, A psychiatric problem, and Reflects a person's personality. 2. **Inappropriate pitch:** A pitch that is outside the norms for age or sex, Inappropriate pitch may reflect habit or personal preference 3. **Pitch breaks:** Sudden uncontrolled upward or downward changes in pitch. Among men through puberty. They may show pitch breaks, huskiness, and hoarseness due to laryngeal growth. **Puberphonia or mutational falsetto:** it is functional; voice disorder that is characterized by the use of high pitched voice after puberty. **Treatment:** **Disorders of vocal loudness** 1. **Monoloudness:** voice lacks normal variation 2. **Loudness variations:** extreme variations in vocal intensity in which the voice is too soft or too loud. **Disorders of vocal quality** 1. **Hoarseness/roughness:** voice lacks clarity and the voice is noisy. combination of harsh and breathy voice which results from irregular VF vibrations. They often sound breath, low pitched, and husky. Accompanied with pitch break and excessive throat clearing. 2. **Breathiness:** it is the perception of audible air escaping through the glottis during phonation. It results from opening in VF or incomplete closure. 3. **Harshness:** rough and unpleasant sound. Associated with great muscular tension and effort. Too tight adduction and abrupt air release 4. **Vocal tremor:** هزه في الصوت lacks of CNS control on laryngeal mechanism. 5. **Strain/struggle and hoarseness similar**, difficulty initiating and maintaining voice, effortful phonation. 6. **Diplophonia:** double sound. Occurs when VF vibrate at different frequencies due to different degrees of mass or tension (unilateral polyp) **Nonphonatory vocal disorders:** 1. **Stridor:** noisy breathing, narrowing of airway. 2. **Aphonia:** Persistence absence of voice and Perceived as whispering. It is loss of voice. It caused by vocal fold paralysis. **Unilateral vocal fold paralysis** - When one vocal fold is paralyzed and is not too far from the norm, voice is possible. - Unilateral vocal fold paralysis is when only one fold will not move or move a little bit. - Hoarse and breathy voice quality. - In unilateral, vocal folds vibrate at different speeds and that causes diplophonia. **Treatment:** voice therapy, collagen or Teflon can be injected surgically into a paralyzed vocal fold to make it larger. This allows the other fold to move closer to it and may help your voice. **Bilateral vocal fold paralysis** - It means that both vocal folds will not move. They become stuck halfway between open and closed. - There will be a problem in breathing and swallowing, so people with this condition often need a tracheotomy, which is an opening made in the neck. You might have surgery to bring one or both vocal folds closer to the middle. They breathe through this opening, and it keeps food from going into their lungs when they eat. The voice is absent. **Vocal abuse and misuse** 1. **Abuse:** throat clearing excessive taking 2. **Misuse:** screaming or yelling ( wrong behavior). - **Vocal nodules:** Localized growths on the VFs , frequent, hard VF attacks (abnormal closure of vocal folds), usually bilateral and it appears on one. Nodules are soft early in their formation and become hard. Result in hoarse & breathy voice. Speech therapy: vocal hygiene. Surgical intervention: longstanding nodules. - **Vocal polyps:** Developed when vessels in the VFs rupture and swell, developing fluid-filled lesions. larger than nodules. Unilateral, Surgery & voice therapy. Breathiness. - **Contact ulcers:** related to gastric reflux, treatment medication then surgery. Hoarse and Breathy voice. Bilateral. - **Acute Laryngitis:** Inflammation of the vocal folds due to exposure to noxious agents. hoarseness. - **Chronic Laryngitis**: Results from vocal abuse during periods of acute laryngitis, VF appear swollen, thickened & reddened. Voice can range from mild hoarseness to aphonia. - **Laryngeal Papilloma** (various, children below 6,), growth on laryngeal structure in cluding vocal folds. Stridor, aphonia - **Congenital webbing** (tissue form at VF, horse) - **Parkinson diseases:** harshness and breathiness, monoloudness, and monopitch. **-How to assess voice?** 1. **Case history** - Patient complaint - Demographic information (married, education, - Health status & medical history - Vocal activities & personal habits - Vocal hygiene 2. **Physical Examination and Perceptual judgment** - Muscle tension( listen to the pt voice and then judge subjectively if it is breathy or harsh - Breath support ( shallow breath or diaphragmatic breathing), to support speech. - Postural alignment ( CP, spastic or flaccid or problem in vertebral column). To support breath system. 3. **Acoustic & aerodynamic measures ( جزء نحسبو بنفسنا وجزء بالاجهزة)** - Maximum phonation time: Prolong or sustain sound (a). Normal is 15 sec and more. Men 15-25, women: 25-35 - **Aerodynamic Measurements:** with Spirometer - Tidal volume: amount of air inhaled and exhaled during a normal breathing cycle. - Vital capacity: air volume that can be exhaled after a maximal inhalation - Total lung capacity: total volume of air in the lungs - s/z ratio: ( يمد صوت س وصوت ز وتقسميهم على بعض اذا كان اكثر من 1.4 معناته ) - Fundamental frequency: how many time the vocal folds adduct and abduct in second, number of cycle in sec. - Jitter : for frequency. cycle-to-cycle variation in frequency. Can be measured instrumentally on sustained vowel. **Those with voice problems show high jitter**. Calculate variation of frequency in cycle. If it is more than 1 it is disorder. - Shimmer: loudness. Variation in loudness if it is more than 3.8, it is disorder. cycle-to-cycle variation in amplitude, measured instrumentally on a sustained vowel. Those who have difficulty **with regularity of VF vibration might have high shimmer.** - **To measure shimmer and jitter use Time-Frequency Analysis Software (TF-32).** - **Use visipitch to measure jitter, shimmer ad maximum phonation time.** 4. **Laryngeal imaging** , use Videoendoscopy/ videostroboscopy - Videoendoscopy: continuous light, Flexible, through nose - Videostroboscopy: pulsing light, rigid and flexible, through mouth, several images. - **Endoscopy and Stroboscopy** allows Identification of organic lesions and listen to the patient's voice & observing the VF movement - **Stroboscopy** provides information on a number of anatomical & physiological variables including: - Mucosal wave: visualization & quantification of mucosal wave deformity - Glottal closure: describing shape of the glottis at closure - Vibratory behavior: Presence or absence of vibration in particular locations **Treatment:** - **Behavioral voice therapy** ( hygiene or voice therapy). - **Vocal Function Exercises:** a systematic protocol to increase the flexibility of the vocal folds through structured practice and can be used with hypo-hyperfunctional disorders. It is a physical therapy consists of 4 exercises that should be practiced twice daily two times in each and to be completed as soft as possible without tension.1.Diphragmatic breathing and sustaining of /mi/ phonation for a maximal phonation time then stretching and gliding then sustaining of 4 different levels. - **Counseling** ( help them to understand - **Surgical intervention** (ploys or... - **Medication** (gastric - **Hard glottal Attack:** using pushing or valsalva maneuvers to facilitate vocal fold closure in hypofunctional voice disorders. Coughing or throat clearing can also be used to achieve the same goal. - **Yawn-Sigh:** used for hyperfunctional voice disorders, because the goal is to increase airflow. Yawn then sigh with dropping the tongue (to drop the larynx and retract the vocal folds, reducing the tension). **What is resonance disorders?** It result when there is any disruption to the normal balance of oral and nasal cavity. **It caused by** structure abnormality: cleft palate, Or Blockage in nasopharynx **Velopharyngeal insufficiency:** the soft palate won't elevate enough to separate the oral cavity from nasal 1-**Hypernasality :** It affects all the sounds. The organism is not performing well. The velopharyngeal mechanism fails to separate the oral from nasal cavity. All the oral have nasal sound. - **Nasal emission**: all the sound that required build up air in oral cavity this air will escape to the nasal cavity because of VIP. It occurs when the induvial with VPI build up air pressure in oral cavity for production high pressure sounds, the air pressure escape through nasal cavity. (b,p, s, sh, j). it is not necessary come with hypernsality. 2-**Hyponasality:** there is partial blockage in nasal cavity or pathway for the nasal cavity, so the it affect nasal sound. 3-**Cul de sac:** it occurs when the sound resonates in the throat or nose, and is trapped in that area. The sound will be muffled. **-Assessment of hypernasality:** - Mirror testing: put the mirror under the nose and let the child say plosive sound or words like baba if the air on the mirror, this is hypernasality. - Pinch the nose and say baba then say baba without pinching, if there is differences, therefore, there is hypernasality. - Nasometer : calculate the hyper and hypo measure the air flow in both oral and nasal cavity. - Viedoflousrcopy: Give view velopharyngeal cavity. - For the hyponasality: ask the child to say (mama) if he substituted the m with the b or it was distorted, then it is hyponasaity. **Treatment of hyper and hypo** - **Cleft palate :** surgery which is palatal repair, then if there is opening, put prosthesis - **Behavioral management:** CPAP is 8 weak muscle resistance program designed to strength the muscle of the soft palate. It a device that is used for pt with sleep apnea. It generates continuous positive air pressure that is delivered through a nose mask. Treatment involves production of 50 words and 6 sentences while pressure is delivered through the nose. Strength the tissue of soft palate, and control air way and let it go from oral cavity. - During treatment: the velum work against the increase air pressure in the nasal cavity while producing syllables contain nasal, vowels and oral. The velum elevate on nonsasal and to be lowered on nasal. Nasal air pressure is increased during velar elevation. - **Articulation treatment:** Bottom up drill approach is good to work to discriminate between nasal and oral sound. If there is air go through nasal cavity, then use swimmers' nose clip to prevent nasal air escape. **Pt with hypernsality**, cleft palate and dysarthria. Glottal stop Or there is voice disorder with velophrahnral infuccinency, eliminate glottal attack. Cleft lip and palate **Cleft Lip:** Clefts to the lip alone are rare, usually associated with cleft palate. They are more often unilateral than bilateral and they occur more frequently on the Lt side than the Rt. Cleft lip alone rarely cause speech disorders. **Cleft Palate:** opening in the hard palate, soft palate, or both, due to disruption of the embryonic growth processes. Generally males have a higher frequency and tend to exhibit greater severity of cleft palate than females who tend to exhibit higher frequency of palatal cleft. **Etiology:** They are related to a variety of genetic, choromosomal, environmental, and mechanical factors. **Major types:** - Cleft lip (complete, incomplete, uni/bilateral) - Alveolar process cleft (uni/bilateral, median, or submucous) - Cleft of the pre-palate (combination of previous types with or without pre-palate protrusion or rotation) - Cleft of the palate ( of the soft, of the hard, or submucous) **Communication Disorders Associated with Clefts** 1. **Hearing Loss:** They are prone to middle ear infection and hearing loss. The most common cause of hearing loss in children with cleft is otitis media with effusion = CHL. It can persist after surgery. 2. **Speech Sound Disorders:** More significant if the repairing is not early or inadequate. - Obligatory errors exist due to structural abnormalities that result in velopharyngeal insufficiency and oral structural deviations (e.g., oronasal fistulas, dental deviations, or malocclusions). They are not likely to improve until the structural cause is addressed though physical management (e.g., surgery or prosthetic intervention). Obligatory errors include the following: - Hypernasality on vowels, liquids, and glides (in severe cases, voiced oral consonants may also be nasalized). - Articulation errors related to dental status or malocclusion (e.g., sibilant distortion with Class III dental malocclusion). - Obligatory nasal air emission due to VPD or fistula, that is consistent across the oral pressure consonants (stops, fricatives, and affricates). This pattern of airflow into the nasal cavity can persist postoperatively, despite adequate VP closure. 3. **Language Disorders:** Initially delayed language development with siginificant improvement when growing. Those with genetic disorder, hearing loss, and sensory problems. They usually present with normal receptive skills but delay in expressive. 4. Laryngeal and phonatory Disorders: Laryngeal hyperfunction from attempting to compensate for loss of pressure at the VP valve may result in muscle tension dysphonia with or without changes to the vocal folds (e.g., vocal nodules; inflammation and edema). Soft voice syndrome due to loss of pressure through the VP port or when the child reduces vocal intensity as a compensatory strategy to minimize or disguise hypernasality, nasal emission, or hoarseness 5. Feeding and Swallowing - Babies with cleft lip only typically have little feeding difficulty. Once the nipple is positioned in the baby\'s mouth, he or she can usually achieve sufficient compression of the nipple against the intact palate. - Babies with cleft palate---with or without cleft lip---may have more significant feeding difficulty. They are unable to separate the nasal cavity from the oral cavity and therefore cannot create the negative pressure necessary for sucking. In addition, they may have difficulty compressing the nipple to express milk because the palatal surface is not intact. Potential problems associated with feeding difficulties include fatigue due to excessive energy expended during feeding; poor weight gain due to inadequate nutritional intake; excessive air intake; and nasal regurgitation **How to assess cleft palate**: oral mech to see fistula (air go through) and submucosal cleft, and language, hearing, artic. **Fistula:** it is the breakdown of primary surgical repair.