PPT 4 - Pathologies PDF

EXAM Images on Exam will be obvious Paper Exam Remember to pay attention to underlying physical changes to remeber symtpoms The best way to study is to think about how...

EXAM Images on Exam will be obvious Paper Exam Remember to pay attention to underlying physical changes to remeber symtpoms The best way to study is to think about how Pathologies the disorder impacts the vocal fold system instead of memorizing every symptom. Find a way to group them to make it easier and notice how they differ Voice disorders from each other. There are several of them but we will cover the most common ones.  Pathologies Overlapping influence of multiple primary and secondary factors Sometimes conditions can overlap Treatment should focus on predisposing factors and current barriers Focus on the bigger things than the smaller ones as you go.  Incidence 3-10% in general population Includes short term and long range 30% report a lifetime prevalence in a study in Utah and Iowa ex. laryngitis, nodules, etc. They experienced a voice problem at least 1x School teachers have reported a high incidence amongst occupations Recommend headset microphones to prevent voice disorder  Incidence of Voice Disorders Varies demographically by : – Region Region: chemicals, pollutants, bad environments, etc. – Age voice nodules, older woman = neurological voice disorders, older population = diff. Age: some disorders are more likely to happen to certain ages. younger women = ones – Sex Sex: Adults = women have more VD (possibly due to A&P differences, higher pitch=more VF vibrations even though saying the same sound/word = vibratory – Race Children = boys have more VD dose is more increasing likelihood of disorder; + hormonal differences etc.);n – Occupation CDC: Race breakouts of voice Occupation: any extroverted talkative job. disorder cases. sales person, SLPS, teachers, coaches etc. Data may not be good depending on SEX: female might have small post. gap. Pos. gap region/circumstance is not normal for men and anterior is not normal of pooling. W: 84% for both genders. B: 11% A: 9% Voice Disorders, Second Edition (Sapienza & H: 9% Ruddy, 2012)  Common Professions to have Voice Disorders Occupations Teachers Air traffic controllers/pilots Don't talk as much but due to more stress b/c muscle tension Factory workers Lawyers if talking over noise/chemicals they're exposed to Preachers Military personnel Telemarketers TV and radio Ministers broadcasters Sales personnel Sports coaches yapping & yelling Stage performers Aerobic/fitness instructors Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Common definitions for voice quality Breathy: perceived as whispery/airy. Pathologies: Paralysis, Associated with hypoadduction. Growth blocking VF closure, etc. Air escaping through vocal folds/Poor vocal fold closure = Airy Voice. Harsh/Rough: described with terms like coarse, strident, raspy. Associated with hyperadduction, irregular vibration Closing but too tight or vibrating irregularly Hoarseness: combination of breathy and rough Pathologies: Smoking, Reki's, Muscle Tension, Large growth not allowing VF closure but growth Hoariness = Both Breathy and Harsh/Rough is heavy so it is causing irregular vibration Instability: varying quality over time Ex. morning/night, over the conversation, over a few days  Common definitions of voice quality Strain: impression of vocal effort Sounds like they're trying really hard. Diplophonia: irregularities in vocal fold vibration pattern. Perception of two pitches to the voice. Closest similarity: when mucus is on your throat and you feel the vibration from your voice & the mucous. Pathologies: Growth/lesion, Poor muscle strength  Pathology Classifications Structural pathology Biggest category. Growths, lesions, bumps, etc. Inflammatory Trauma/ Injury Systemic conditions Ex. autoimmune conditions Aerodigestive conditions Ex. GI issues (acid reflux?) Psychiatric/ psychological disorders Ex. Mental health issues Neurologic voice disorders Damage to PNS (VF paralysis) or damage to CNS (Parkinsons, ALS, etc.) Other disorders of voice Things that don't fit in the categories. What we learn is not comprehensive, we are covering what a general SLP should know, not a specializing one. Structural Pathologies of the Vocal Folds Any alteration in the histological structure of the vocal fold. – Changes in the layered structure of the vocal fold may affect the… Mass, Increase in mass, loss of muscle mass Size, Stiffness, Flexibility, and Tension of the vibrating mechanism. – These changes may alter vocal quality, pitch, and loudness.  Structural Malignant epithelial dysplasia Benign – Nodules – Polyps – Cysts – Reactive lesion Growth on side causes friction on the other side leading to a reactive lesion. – Reinke’s edema and polypoid degeneration – Vocal fold scarring – Granuloma and contact ulcer – Keratosis, leukoplakia – Recurrent respiratory papilloma – Subglottic and laryngeal/glottic stenosis, acquired anterior glottic web – Vascular lesions: Vocal fold hemorrhage, hematoma, varix and ectasia  Malignant vs. Benign Lesions Malignant – Laryngeal Carcinoma (typically squamous cell type originating from the epithelium). – As tumor progresses, it invades the deeper layers of the vocal fold including the vocalis muscle. – Dysphonia severity varies according to location and extent of tumor invasion. Risk Factors for Laryngeal Carcinoma… – Smoking If hoarseness doesn't improve in 3 week, go – Alcohol Use see a specialist (ideally ENT, at least PCP) – ? Laryngopharyngeal Reflux Usually severe reflux for a long time that has not been managed.  Benign Epithelial & Lamina Propria Abnormalities of the VF Some disagreement exists among clinicians regarding how to classify various lesions of the superficial layers of the vocal folds. “Traditional” labels include… – Polyps, – Nodules, – Cysts. Interchangeable terms. The newer names for these things are referring to “Newer” labels include… the same things the traditional names are referring to. – Pseudocyst(s), – Fibrous mass(es), – Reactive lesion(s).  Vocal Fold Nodules Common benign pathology Caused from phonotraumatic behaviors *Lecture showed Vocal Fold Nodules - loud voice use, a lot of voice use YouTube video* of - occupational voice users: coaches, NORMAL VF singers, teachers - going out to loud places: concerts, https://www.youtube.com sports games, etc. /watch?v=9Tlpkdq8a8c Need to Know: Location of nodules Are there any growths? are typically mid-membranous b/c How are the VF moving? during VF vibration that is the point of Color/texture changes? maximum impact leading to blister callous like structures. - This vid has slight opening at VF. In female Usually bilateral, sometimes a nodule VF there is a small gap in on one side and cyst on another side. posterior VF, but it should If it bilateral, more likely to be cyst, polyp, or you made a mistake goofy. not be large! Hers is normal. B/c of nodule, there is gap anterior - Higher pitch, harder to Voice Disorders, Second Edition (Sapienza & and superior leading to airy voice. close. Better closure, Ruddy, 2012)  Vocal Nodules Description and Etiology Inflammatory degeneration of the superficial layer of the lamina propria, fibrosis and edema swelling of the cover thickening cover = epithelium + superficial layer of LP Typically form bilaterally - nodules form in cover High impact stress during phonation Types – (1) Acute short event – (2) Chronic long term effect – (3) Reactive nodular change Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Nodules Description and Etiology Chronic – Visually appears Firm Callous-like Fixed to the underlying mass of the mucosa Chronic: pinpoint nodules (pointy nodules), blood vessels (worsen nodules), swelling Acute: tender swelling, softer, looks more pliable Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Nodules Description and Etiology Reactive Nodular Change An initial growth causing second growth due to constant touching. – Creates a contralateral reaction May do surgery first depending on client. But if cyst caused a nodule, when the cyst goes, the nodule should go away too. – Can develop into a larger and more discrete nodule Video Link: https://www.youtube.com/watch? ON EXAMS do not say v=jOQ0-XGUN5o there bumps on vocal folds: Notes on it: say lesions, mass, swelling. - VF are white but not inflamed - VF are thick and swollen - Nodule bumps in mid-membranous section - Only the midpart where nodules are touch aka Hourglass Closure. Top and bottom of VF do not touch. - Vibration is affect, VF are heavier & do not vibrate the same. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Nodules In Children, boys have greater chance of getting nodules. 3:1 ratio of boys to girls getting them. Mainly due to noises boys make when they play + some a&p differences. Age and Sex Trends: Inforadults, women have nodules a lot more than men. It's rare men to get nodules, they are more likely to get polyps. Possible Personality Factors (Women with Nodules): Stress-reactive People who are extroverted, outgoing, socially dominant, etc. people tend to response w/ vocal/verbal reactions (yelling) Aggressive, impulsive = more yelling Occupational Factors: Singers, preachers, teachers, SLPs, salespeople, cheerleaders, etc.  Vocal Nodules Perceptual Signs and Symptoms Voice quality varies from early to mature formation – Raspy In general, across – Hoarse all VF pathologies, one of the first complaints is loss of – Breathy VF range. – Easily fatigues due to losing air in the spaces (hourglass vf) air is escaping that should EXAM TIP: When asked to tell 2 features/perceptual Singers not have left. signs or symptoms a PT with nodules or Nodules with LPR cysts has, say – Loss of vocal range hoarse, roughness, More on vocal range: and breathiness. Say endurance: them separately, – Loss of vocal endurance go as high and low and loss of Singers w/ nodules will complain of don't assume loss of vocal range so they cannot Roughness implies hoarse and breathy. More on fatigue: endurance. Can't sing as long and Some people just Lesions in the center of nodules can prevent have breathy and no get tired -> leading back to easily hoarse, etc. Make good voice production and vf won't vibrate fatiguing enough unless they put them at a certain sure you understand the symptoms when position. Sometimes that is speaking at a Voice Disorders, Second Edition (Sapienza & you put them down. higher pitch sometimes that is holding them tight. This all adds to fatigue. Ruddy, 2012)  Vocal Nodules Perceptual Signs and Symptoms Physiologic factors: – Increased glottal airflow – Increased respiratory effort More air escaping at a faster rate b/w VF. VF sits on top of trachea & if there's a gap then air is escaping thru that gap. To makeup for air loss, you work harder to support your voice by taking deeper or quicker breaths – Overpressure of the vocal folds A person may have to hold VF in a certain position to get voice out. – Asymmetric vocal fold vibration Nodules can be asymmetrical even though they are bilateral so vibration can still be affected. Asymmetry can be b/c one nodule is bigger/smaller than the other/ This can create roughness or diplopodia. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Nodules Different Levels: Mild, Moderate, Severe Dysphonia/ - This depends on extent and size of lesion. - Length of time since onset. Chronic (more severe hoarseness) or Acute? Treatment: You need to make sure you change the way you use your – First line = voice therapy, voice, so you don't damage it again – Surgical Removal by “skilled” laryngologist and only… You need specialized laryngologist, not a general ENT b/c VF are sensitive and if the surgery creates a scar, we cannot fix it. If/when patient has been compliant with voice therapy, but did not respond completely/satisfactorily, Surgery to be followed by post-surgical voice therapy.  Finish in Vocal Fold Polyps in-person Description and Etiology class on Tues. 9/17 Fluid-filled lesion Develops in the superficial layer of the lamina propria Has its own blood supply You might see a blood supply going toward polyp Typically forms unilaterally Most often in adults More common in men Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Polyps Description and Etiology flat Sessile (blister-like) or pedunculated (attached comes out to a stalk) in appearance Cause thought to be from acute vocal trauma sporting event, concert, etc. or from phonotraumatic behaviors Can occur as the result of a single traumatic incident Nodules more common for long term damage. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Polyps Perceptual Signs and Symptoms Mild to severe dysphonia Typical voice symptoms – Hoarseness – Roughness – Breathiness – Globus sensation feeling of lump in throat – Effortful phonation – Loss of vocal endurance A pedunculated polyp that falls below the vocal fold edge may cause difficulty breathing Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Polyps Treatment: – Voice Conservation/Rehabilitation (primary) – Phonosurgery (and voice rehabilitation). B/c they are filled w/ fluid they can burst. Surgery + Voice therapy. Most of them time surgery first do they do not hemorrhage. If hemorrhage happens, PT may be asked not to speak until healing.  Think about where if the pathology Cysts located? How big is it? This will help determine the impact it has. Description and Etiology Benign mucus-filled lesion surrounded by a membrane Located near the vocal fold surface – Embedded in SLLP, but often extend into ILLP and DLLP (i.e., the vocal ligament). The causes include: – Phonotraumatic behaviors – Glandular blockage Appear at the mid-membranous portion Can present congenitally Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Cysts Perceptual Signs and Symptoms Can create adynamic layer, part of VF that wont move -> good way to differentiate from nodules. Generally result in mild to severe hoarseness Voice quality is a function of the size, shape and firmness Globus sensation may be present Throat clearing and cough Unlike nodules, cysts create a stiff adynamic segment due to reduced vibratory freedom of the cover of the VF. Treatment-Surgical excision w/ therapy Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Generalized Edema/Reinke’s Edema/Polypoid Degeneration/Diffuse Polyposis Description and Etiology Buildup of fluid in the superficial layer Polypoid degeneration- severe form, membranous portion becomes permeated with the fluid Long-standing trauma or chronic exposure to irritants – Cigarette smoke Polypoid – Laryngopharyngeal reflux (Worse version Based off picture from right of - Drop pitch Reinke's - Erratic vibration = roughness, Edema) diplopia, mild-mod-severe In hoarseness Superfici - Shortness of breath al layer - Usually due to smoking so of LP co-morbidities of COPD making shortness of breath worse Voice Disorders, Second Edition (Sapienza & - TX = Surgery, quite smoking Ruddy, 2012)  Generalized Edema/Reinke’s Edema/Polypoid Degeneration/Diffuse Polyposis Perceptual Signs and Symptoms Voice symptoms – Lowered pitch and varying degrees of hoarseness Increased vocal fold mass Swelling can become large enough to cause symptoms of dyspnea Sleep apnea can occur Surgery and smoking cessation Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Scarring Scar is general term given to “permanent” tissue changes in the structure of lamina propria (LP) due to any number of etiologies… Important to go to someone who is trained for surgery so they don't give you scar. – Lesion presence, 4-7 days silence for recovery, follow it so you don't get a scar! – Chronic tissue irritation (related to phonotrauma or other causes), – Iatrogenic (postsurgical) changes. Scar… – Increases stiffness of VFs (owing to loss of layered structure of VF), – Reduces freedom of cover to oscillate = reduced mucosal wave during VF vibration. – Reduces glottic closure in severe cases (because of non-vibrating scar and adynamic VF). Effects on voice vary depending upon severity, extent, and location of scar. No accepted/effective behavioral or phonosurgical treatment. Scar location determines effect on voice. Scar on middle VF can have impact but scar on edges may not.  Sulcus/Sulcus Vocalis Special form of scarring that forms a “ridge” or “furrow” along the SLLP that produces bowing or spindle-shaped gap. – Unilateral or Bilateral, – Small pit or divot (sulcus vocalis) vs. entire length of medial surface (sulcus vergeture). Etiology unknown, but possibly… – Congenital (abnormal embryological develop of VF cover)? – Acquired following rupture of intracordal VF cyst? – Secondary to laser surgery? – Associated with age-related changes?  Contact Ulcers/Granulomas Description and Etiology More common in men. Found along the vocal processes Contact ulcers- raw sores on the mucus membrane of the arytenoid processes Granulomas tend to grow over contact ulcers until cause of irritation is addressed or on the opposite side Unilaterally or Bilaterally Benign growths that can result from – Laryngopharyngeal reflux irritation – Intubation trauma – Phonotrauma Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Contact Ulcers/Granulomas Perceptual Signs and Symptoms Globus sensation Sharp pain in specific spot = Provoke chronic throat clearing ulcer granulomas/acid Coughing They tend to Bitter taste in the mouth sleep on the side the ulcer is on. Discomfort or pain Can prevent vocal fold closure Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Contact Ulcers/Granulomas Perceptual Signs and Symptoms Effects on the voice: Since the bumps are on the cartilaginous parts of VF, it's easier to assume it's an ulcer over nodule – Hoarseness Tissue in the back can be uneven due to reflux – Breathiness – Difficulty increasing vocal loudness – Reduced pitch range – If unilateral may have minimal to no change in voice quality Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Granuloma & Contact Ulcer Treatment: Medical, Surgical, Behavioral, or a Combination. – Medical: Pharmacologic Antireflux Regimen (including medications), Unilateral (intracordal) Botox injection to reduce medial compression forces (to allow healing). – Behavioral: Voice Therapy Reduce medial compression by reducing strain & pressed voice, pitch elevation, reduce “hard” glottal onsets. Let them know clearing throat won't help b/c nothing is "stuck" in your throat & it can make things worse – Surgical: Excision (if fail medical and/or behavioral management). – Given their location and etiology, these lesions can be recalcitrant and recurrence can be common.  Leukoplakia/Hyperkeratosis Description and Etiology *Leukoplakia = “white plaque”, – Thick substance on superior surface of VFs in diffuse white patches. *Hyperkeratosis = “excessive keratin”, – Buildup of keratinized tissue, rough, irregular VF margins. Usually found at the anterior portion of the vocal fold but may extend into the interarytenoid area Considered a precancerous state and should be biopsied Primary cause is chronic irritation – Primary irritation is cigarette smoking – Environmental exposure to irritants – Alcohol use – Other inhaled drugs Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Leukoplakia/Hyperkeratosis Perceptual Signs and Symptoms Voice quality – Rough – Hoarse Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Recurrent Respiratory Papilloma (RRP) If mom has it during pregnancy, it can get passed onto kid - Reoccuring - Everytime surgey is done, it affects the tissue & can cause hoarse voice Papilloma: – Wart-like growths that develop in the epithelium and invade deeper in the LP and vocalis muscle. – Can grow rapidly and in large clusters. – Can proliferate and compromise the airway. Etiology: Human Papilloma Virus (HPV) infection. – Types: Juvenile (in children, onset at age 2-4 yrs., boys = girls), can resolve spontaneously, especially after puberty. Adult (males > females), persistent and progressive. – Effects on Voice: Lesions can affect the cover, transition, and body of the VFs and produce significant stiffness, compromise vibratory fxn, and cause severe dysphonia. Multiple surgical treatments lead to scarring with worsening dysphonia.  RR Papilloma Treatment: – Surgical (laser or cold-steel excision), but recurrence is common requiring multiple de-bulking surgeries (and increased likelihood of VF scarring). – Pharmacotherapy (as a primary or secondary approach):  Subglottic Stenosis Description and Etiology Congenital or acquired Narrowing of the tissue below the level of the glottis Associated with a malformed cricoid cartilage occurring in utero Acquired subglottic stenosis – Caused by prolonged intubation – Can occur with other forms of mechanical trauma Adult Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Subglottic Stenosis Perceptual Signs and Symptoms Congenital subglottic stenosis – Inspiratory and expiratory stridor wheezing sound – Low pitch cough – Dyspnea shortness of breath – Significant chestwall movements Pediatric – Nasal flaring during breathing Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Subglottic Stenosis Perceptual Signs and Symptoms Acquired subglottic stenosis – Same symptoms can exist with the addition of Abnormal speaking voice –Hoarseness and/or breathiness An associated vocal fold paralysis may exist if mechanical (ex. intubation) trauma was the cause of the stenosis Management of Subglottic Stenosis and Web: Surgery Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vascular Lesions – Hemorrhage = small capillary on superior surface of VF ruptures abruptly and bleeds into SLLP (i.e., Reinke’s space). EXAM QUESTION!!! – Hematoma = accumulation of blood that has leaked from the ruptured vessel. – Varix = mass of blood capillaries that appears as small, longstanding blood blister that has hardened over time with an adynamic VF segment. – Ectasia = larger collection of varices.  Vocal Fold Hemorrhage Description and Etiology After surgery and after hemorrhage, complete voice rest is recommended. Damage to the tissues as a result of exposure to blood – Extremely small delicate blood vessels which traverse the various tissue layers When superficial layer of the lamina propria is affected the effects can be devastating – Dysphonia – Complete aphonia same – Absence of voice thing Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Hemorrhage Description and Etiology Causes: – Phonotrauma or traumatic injury Surgical or medical procedures Prolonged levels of high intensity voice Excessive crying (tension on VF) Use of anticoagulant may also increase the risk Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vocal Fold Hemorrhage Perceptual Signs and Symptoms Hoarseness – Ranging from minimal/mild to complete aphonia or loss of voice Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Vascular Lesions Vascular injuries can increase stiffness of the cover, with localized scarring in more severe cases. Voice quality can vary from severe at time of bleed (acutely) to mild later. Small varices or ectasias may have negligible effects on voice (except in singers and/or professional voice users where even small vascular lesions may have disastrous effects). Treatment: – Aggressive Voice Conservation (i.e., complete voice rest). – Medical (Steroids). – Laser Cauterization (to stop bleed). – Surgery: Microexcision of persistent varix.  Mass lesions or abnormalities of the vocal fold cover 1. 2. 3. 2. Nodules 3. Cyst 1. Polyp 4. Ulcer,Granduloma. 5. On exam you don't4.have to specific ulcer or grandulma. Just say both 5. Hyperkeratosis 6. 6. Cancer  Structural Congenital and maturational changes affecting voice – Congenital web – Laryngomalacia – Puberphonia: mutational falsetto and juvenile voice – Presbyphonia or presbylaryngeus  Floppy arytenoid Laryngomalacia process & epiglottis causes stridor in infants bc of their A&P Diagnosis and Etiology Sounds worse when they sleep which scares parents Most common cause of inspiratory stridor in infancy Majority of children Congenital condition of unknown etiology outgrow it! Airway obstruction as cartilages are susceptible to collapse during the inspiratory phase Kids who might be at Characterized by risk are pre-mes & kiddos with other – Floppy epiglottis health issues – Large aryepiglottic folds – Large arytenoids process If the cartilages are very soft the entire larynx may be seen to collapse during inspiration Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Laryngomalacia Perceptual Signs and Symptoms Intermittent inspiratory stridor – Starts just after a few days or weeks following birth – The degree of stridor increases as the depth and rate of breathing is increased Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Presbylaryngeus Description and Etiology Aging Voice Aging affects physiological functions and deteriorations occur in: – Circulation – Glandular Fx – Urinary tract – Digestive Fx – Respiratory Fx – Joint Fx Can affect voice – Muscle Fx Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Presbylaryngeus Description and Etiology, cont. This leads to weaker voice Sarcopenia – Wasting and thinning of muscle tissue Effects on the thyroarytenoid muscle – Becomes thinner – Less pliable – Collagen in the deeper portions becomes dense Bowing of edges of VF can cause VF to not close all the way -> TX: Voice rehab, specifically Vocal Function Exercises Breathiness Vibration affected = Hoarseness Voice Disorders, Second Edition (Sapienza &Tremors Ruddy, 2012)  Presbylaryngeus Perceptual Signs and Symptoms Softer, altered pitch with some accompanying roughness Tremor may be associated with aging Reduced vocal loudness Pitch differences are observed between the sexes – Male pitch tends to become higher with age – Female pitch tends to lower with age Hormonal Changes Impact this too Voice rehabilitative therapy, especially Vocal Function Exercises (VFEs) can be effective. Poor Voice + Hearing Loss = Hard to hear friends/Socialize = Depression & Isolation Don't Dismiss Patients! Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Puberphonia/Functional Falsetto Changes in puberty voice that are different than expected Description and Etiology Adolescent males who have seemingly maladjusted growth of the larynx Can be seen in females too but not as drastic – Maintenance of a high-pitched voice Psychosocial repercussions for the male who is not past puberty Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Puberphonia/Functional Falsetto Description and Etiology Several causes of puberphonia have been proposed – Psychological basis to the process – Acceptance of the new male voice – Social immaturity – Male identity problems Don't wanna let go of old voice Physical reasons – Presence of a hearing impairment No bio feedback – Immature laryngeal maturation – Poor neuromuscular coordination Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Puberphonia Perceptual Signs and Symptoms The pitch is higher than it should be Breathy aka Falsetto Voice Low vocal loudness Treatment: Behavioral therapy Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Juvenile Voice Post-adolescent females with higher than normal pitch, breathy voice, child-like speech distortions and prosody, and high tongue carriage. Etiology unknown, but hypothesized… – Women who resisted transition into adulthood or, Subconscious. Maybe due to trauma – Habituated the altered laryngeal and vocal tract posture.  Inflammatory Criciarytenoid and cricothyroid arthritis Acute laryngitis Laryngopharyngeal reflux Chemical sensitivity/ irritable larynx syndrome SENSITIVE AND REACTIVE LARYNX TO REFLUX, PERFUME, CHEMICALS IN AIR, ETC.  Dislocation of the Cricoarytenoid Joint Description and Etiology Resulting from injury after a traumatic dislocation – Potentially from intubation – Disease such as inflammation Fixation of joints, Looks like VF paralysis but you Rheumatoid arthritis need to check pt HX. It's not a nerve problem, it's a joint problem! Results in stiffness and/or fusion of the cricoarytenoid joint Cricoarytenoid joint sits above VF so if it doesn't move, it restrict VF Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Dislocation of the Cricoarytenoid Joint Perceptual Signs and Symptoms Breathy or rough voice quality Difficulty prolonging a sustained vowel Pain during swallowing Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Laryngitis Description and Etiology Inflammatory condition of the vocal fold mucosa Caused by: – Reaction to a viral and/or bacterial infection – Traumatic conditions Swelling, Edema, Inhaling chemicals etc. – Autoimmune diseases Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Laryngitis Perceptual Signs and Symptoms Generally produces hoarseness – Mild Sore throat, cough and a fever – Severe Caused by continued voice use during the bout of laryngitis 4-5 days normally, more than 2-3 weeks need to see doctor Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Trauma or injury Internal laryngeal trauma – Thermal and chemical exposure – Intubation/ extubation injury External trauma and arytenoid dislocation Either penetrating or blunt Examples: – Gunshot and knife wounds, dropping a heavy object on to the neck, fistfight, sports injury, attempted strangulation Displaced Structure  Laryngeal Trauma Perceptual Signs and Symptoms Hoarseness Inspiratory and expiratory stridor Pain at rest or doing voicing (odynophonia) Dyspnea Shortness of breath Dysphagia Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Systemic conditions If you see these things in HX and there are no other causes for voice problems, the medications for these conditions could cause voice problems. Endocrine disorders – Hypo/hyperthyroidism – Sexual hormonal imbalances – Growth hormone abnormalities (hyperpituitarism) Immunologic disorders – Allergies Allergy meds dry you out – Sjögren’s Condition that dries out all of your glands, causes fatigue – Systemic lupus erythramatoses Good & bad days, use compensation strategies. Adverse effects of medications on the larynx  Aerodigestive disorders Other problematic meds: Blood thinner (vocal fold hemmorage), Asthma med Respiratory diseases Advel? (extreme... i forgot what she said) – Asthma and chronic obstructive pulmonary disease Asthma - paradoxial vocal fold motion looks similar to asthma and/or can coexist with asthma Gastroesophageal reflux disease Reflex escaping UES and irritating larynx Infectious diseases of the aerodigestive tract – Laryngotracheobronchitis (croup) More common in children, typically viral. – Mycotic (fungal) infections: candida Candida in laryngeal spaces. Adevl (med) can cause candida.  Psychiatric and psychological disorders Psychogenic conversion aphonia and dysphonia Factitious disorders/ malingering GenderWilldysphoria or gender reassignment address when going over gender dysphoria TX. Factitious Disorders: Faking it. Example someone faking it for worker's compensation. Ex 2. Child trying to get parent attention so child puts on a fake voice. Could be subconscious. Make them feel relaxed & drop their guard, then assess for consistency in their voice. When they cough or laugh voice might be fine, but go back to being abnormal when they speak.  Conversion Aphonia Management Under Functional Dysphonia- no apart anatomical cause but a functional one. Things are not functioning how they should despite normal anatomy. If it is caused by a psychological cause then it is conversion aphonia. Psychiatric treatment Voice therapy Cognitive behavioral therapy Antidepressants Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  We will not go in depth on ones we Neurologic disorders covered in MSD. Cricothyroid - tensor & pitch changer. If there is a problem, the client will have problems with changing pitch, such as making PNS pathology Sensory component: dysphagia pitch go higher. – SLN paralysis: unilateral or bilateral – RLN paralysis: unilateral or bilateral All the motor functions for intrinsic muscles. – SLN and RLN paresis Paresis: weakness, Paralysis: complete damage to nerve. – Myasthenia Gravis You can do some therapy with them, not a lot b/c they tire LMN disorder. Weakness & fatigue will increase over time. Movement disorders out. – Spasmodic dysphonia Laryngeal dystonia Adductor SD (ADSD) Abductor SD (ABSD) Mixed – Essential Vocal Tremor  Unilateral True Vocal Fold Paralysis Description and Etiology Complete immobility in one vocal fold The Recurrent Laryngeal Nerve (RLN) – Primarily responsible for vocal fold abduction and adduction – Branch of cranial nerve X, the vagus nerve Vocal fold paralysis is typically considered a symptom of an underlying disease process PT overcompensates by Medial Paramedial - around medial. squeezing down on supraglottis A little bit of voice but w/ breathiness Abducted - a lot of breathiness Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Unilateral True Vocal Fold Paralysis Perceptual Signs and Symptoms Causes: May exhibit Left side of RLN are longer, making it more likely to get injured in surgery bc it innervates more things. – Aphonia – Completely normal voicing Viral infections are one of the major causes of VF paralysis. Highly variable Tumor pressing on nerve. Make sure they follow up w/ doctor. When paralyzed in a highly abducted position: – Breathy If the glottal gap is huge, voice therapy may not be as helpful so they will – Weak realistically need surgical intervention Dysphagia is common to see significant improvement. – Due to difficulty closing the glottis Paresis: arytenoid might still be moving. Paralysis: arytenoid may not move. Not a full proof way b/c sometimes arytenoid might look like it's moving when its not. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Bilateral True Vocal Fold Paralysis Description and Etiology Unilateral is easier to treat. Same causes: cancer, surgical trauma etc. Commonly results from BIG ISSUE: If both VF are paralyzed at midline, Pt cannot breath! Surgery asap!!! – Surgical trauma, malignancies, endotracheal intubation neurologic disease, or idiopathic causes Life threatening when the folds are fixed in the paramedian position Can sometimes be confused with bilateral arytenoid cartilage fixation Dr. J said something about VF scissoring? Paralyzed in abductor = really breathy voice. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Bilateral True Vocal Fold Paralysis Perceptual Signs and Symptoms Voice really depends on where paralysis is. Ideal position is Voice is highly variable: paramedial if you have to be paralyzed. There will be stridor but at least you can breathe and your – Completely normal phonation voice isn't entirely breathy. – Complete aphonia – Inspiratory stridor May signal airway obstruction Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Superior Laryngeal Nerve Paralysis Description and Etiology The superior laryngeal nerve (SLN) – Branch of the vagus nerve – Bilaterally innervates the cricothyroid Occurs through: – Trauma – Neoplastic – Infectious conditions with viral infections Damaged during surgery of the thyroid gland Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Superior Laryngeal Nerve Paralysis Perceptual Signs and Symptoms Extension of the disruption in the ability to: – Adduct – Elongate to increase pitch Cricothyroid affects pitch. Very important to singers! Characteristics of voices: – Weak, breathy voice, hoarse and disruption in vocal frequency ranges Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  FINISH NEXT CLASS. Spasmodic Dysphonia & DX PPT (5) Description and Etiology questions! Think of midterm Unknown origin although thought to be related to basal ganglia dysfunction Affects the laryngeal adductory and abductory muscles during phonation Two Types: – Adductor SD Roughness Irregular closure of the vocal folds – Abductor SD Breathiness – Mixed SD Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Spasmodic Dysphonia Description and Etiology Associated with: – Presence of writer’s cramp, essential tremor, remote diagnosis of mumps or measles or major life stress Previously considered a psychological disorder Predominately with onset typically occurring during the fourth decade of life – Primarily affecting anxious individuals, possibly brought about by the pressures and losses associated with middle age Most commonly starts in 40s, more common with high anxiety, or recent surgery Used to be believed as a psychological disorder, in relation to hysteria Found to be neurological, not psychological and no clear cause Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Spasmodic Dysphonia Perceptual Signs and Symptoms The voice quality: – Abductory MTD - all sounds hard ADSD - voiced sounds harder Weak and breathy AD - voiceless harder For SD: A lot of it is perceptual. Some neurological – Adductory testing can be done. Strained Abductory and adductory spasms – Perceived as stoppages in voice Sustained vowel production Delayed onset ADSD is often confused with muscle tension dysphonia (MTD) Treatment for the two is very different so correct diagnosis is important Trying to push through spasmodic dysphonia can lead to a MTD, which can make diagnosis tricky b/c of the co-morbidity. Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Essential Voice Tremor Description and Etiology Hyperkinetic movement disorder Most common movement disorder Affects the extremities – Hands and limbs More common in those of advancing age Essential tremor of the larynx is centrally driven Symptomatically tremor is worsened by – Anxiety, fatigue, and excitement Symptomatic relief with alcohol intake red flag Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Essential Voice Tremor Perceptual Signs and Symptoms Easy to identify perceptually during vowel prolongation Audible and rhythmic cycles of the tremor occurring every 4 to 6 Hz Also characterized by – Pitch and voice breaks Difficulty differentiating essential voice tremor from adductor spasmodic dysphonia – Laryngeal EMG can help differentiate between the two Surface: Circular things placed on neck, primary for extrinsic laryngeal muscles Needle: Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Neurologic disorders contd. CNS disorders – Amyotrophic Lateral Sclerosis Progresses fast, not a lot you can do besides voice banking & compensatory b/c it progress too quickly. – Parkinson’s diseaseHypokinetic Dysarthria, loss of range, pitch & loud. Breathiness, roughness. Biggest voice complaint is low voice. – Multiple sclerosis – Huntington’s chorea – Myasthenia gravis  Hypophonia Associated with Parkinson’s Disease Description and Etiology Neurodegenerative disease of the extrapyramidal system Unknown cause Genetic and environmental triggers Get misdiagnosed as presbilaryngus b/c of Note flat affect, hand writing, to know if it is Parkinson's Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Hypophonia Associated with Parkinson’s Disease: Perceptual Signs and Symptoms Hypokinetic dysarthria Voice quality: – Decreased vocal pitch and loudness range – Breathiness – Roughness – Hoarseness – Vocal tremor The speech is altered in its timing with slower than normal speech rate Can also result in an abnormally fast rate of speech Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Multiple Sclerosis Description and Etiology Autoimmune and inflammatory disease of neurogenic origin Demyelination and axonal damage – Progressive disability More females diagnosed Day to day, week to week, fluctuations on progress Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Multiple Sclerosis Perceptual Signs and Symptoms General Symptoms Fatigue, numbness, difficulty with walking, bowel and bladder dysfunction, vision problems, depression, Speech production impairments Spastic, ataxic, or mixed dysarthria Voice Symptoms: Abnormally long pauses between words or syllables Words are slurred Hypernasal sound quality Difficulty raising the vocal loudness Weak phonation Disturbances of the respiratory cycle Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Management of Voice in Cerebral Vascular Accident (CVA) Effectiveness of 4-weeks of LSVT was completed for the treatment of 10 individuals with dysarthria following CVA Perceptual and acoustic measures and everyday communication outcome measures were made – Before, immediately following, and 6 months post-treatment Patients demonstrated: – Increased vocal loudness in sustained phonation and connected speech – Increased vocal frequency range – Improved word and sentence intelligibility Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Other Vocal abuse, misuse, phonotrauma Vocal fatigue Muscle tension dysphonia (primary and secondary) Ventricular phonation (plica ventricularis) Paradoxical vocal fold motion (Vocal fold dysfunction) or episodic dyspnea  Ventricular Phonation Description and Etiology Use of the ventricular folds during voicing instead of, or along with, the true vocal folds Common conditions with ventricular phonation: – Accompanying severe muscle tension – Severe true vocal fold dysfunction Compensatory technique Some people compensate by pushing down hard - hyper function - fatigue, pain, loss of ability to control voice Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Ventricular Phonation Perceptual Signs and Symptoms Low pitched Reduction in vocal range Reduction in loudness Pitch variability Roughness Hoarseness Vocal fatigue Globus sensation Sometimes this is the best they can do Alterative can be to use a mic Pain in the ears Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Muscle Tension Dysphonia Description and Etiology Increased muscle activity in the head and neck Responses on case history often include: – Stress, anxiety, depression, high vocal demand, issues with time management, and general complaints of being overloaded both physically and emotionally Other conditions associated with MTD include: – Laryngopharyngeal reflux Primary: no muscle abnormality Secondary: caused by overcompensating (ex. SD) Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Muscle Tension Dysphonia Perceptual Signs and Symptoms Voice quality: – Strained For Severe: Botox can still help and then treatment can be done while muscles are relaxed to support treatment. – High pitch When vocal fold tension appears high – Folds may never adduct Breathiness weakness to the sound quality Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Paradoxic Vocal Fold Dysfunction Description and Etiology Old names: vocal cold dysfunction, paradoxical vocal fold dysfunction, New: Induced laryngeal dysfunction Complex disorder where vocal fold adduction occurs on inspiration Paradoxic vocal fold motion (PVFM) with dysphonia is episodic paroxysmal laryngospasm (EPL) Describes intrinsic laryngeal abnormal activity PVFM/EPL can masquerade as – Asthma patient complaints can be similar to what an asthma patient might complain about – Vocal fold paralysis – Laryngeal edema Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)  Paradoxic Vocal Fold Dysfunction Perceptual Signs and Symptoms More common with high school athletes due to pressure on them to preform - Track & Swimming (academic stress + athletic stress) Other causes: heartburn, chemical sensitivity, temperature/humidity changes, Inspiratory/expiratory stridor Dyspnea Muscle tightness Intermittent or chronic cough Aphonia Dysphonia Sometimes can co-occur with asthma but it does get hard to Breathy voice diagnosis and treat with co-morbidities Diplophonia Dysphagia Heartburn Posterior chink during abduction Globus sensation Voice Disorders, Second Edition (Sapienza & Ruddy, 2012)