Week2.2 Voice disorders-quaz.pdf

Definition of voice disorder Occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone et al., 2010; Lee et al., 2004) Incidence and prevalence: In Adults in USA, the incidence...

Definition of voice disorder Occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone et al., 2010; Lee et al., 2004) Incidence and prevalence: In Adults in USA, the incidence is 1 in 13 In pediatric, 41% to 73% identified with vocal nodules ( Martins et al., 2015) It occurs more in female than male Teachers are twice likely to have voice disorders compared to the general population Date Your Footer Here 1 Role of SLP in voice disorders - Prevention - Screening and assessment - Performing instrumental procedures to visualize vocal folds (using flexible and rigid laryngoscopes) and other instruments that measure the aerodynamic system - Treatment and management - Collaboration with other related medical professionals including: Date SLPs diagnose voice disorders but do not give medical diagnosis (e.g., laryngeal cancer )….SLPs should make referral to otolaryngologist otolaryngologists/laryngologists, pulmonologists, allergists, gastroenterologists, neurologists, endocrinologists, mental health professionals, and vocal coaches or voice teachers. Your Footer Here Types and causes of voice disorders Functional voice disorders Atypical /psychogenic voice disorders Neurogenic voice disorders Local irritation/ systemic effect Neoplastic (tumor either benign or malignant ) Date Your Footer Here 3 Functional voice disorders The voice disorders that occur due to misuse/abuse/overuse of voice ( e.g., teachers) leading to vocal fold damage Vocal cyst Vocal nodules Vocal fold signs: Vocal nodules Vocal polyps Vocal cyst Reinke’s edema Reinke’s edema Date Your Footer Here Vocal polyp 4 Atypical /psychogenic voice disorders Dysphonia due to psychiatric illness or non-specific cause Larynx structures appear normal Vocal fold signs: Normal structure Date Your Footer Here 5 Neurogenic voice disorders Dysphonia that occur due to neurological damage/disorders such as : Recurrent laryngeal nerve/superior laryngeal nerve Brain stem stroke Parkinson’s disease TBI Myasthenia gravis Date Vocal fold signs: Paresis Paralysis Tremor Spasmodic Your Footer Here 6 Voice disoders due to Local irritation/systemic effects Dysphonia that occurs due to: Gastroesophegeal reflux (GERD) Drugs (e.g., corticosteroids, antihistamines) Irritative inheld substance (cigarette, environmental) Intubation Vocal fold signs: Edema Reinke’s edema granuloma Date Your Footer Here 7 Voice disorders resulted from neoplastic diseases Dysphonia occurs due to growth of tumor (either benign/malignant) on larynx and vocal folds Vocal fold signs: Papilloma (benign) Amyloid ( malignant) Amyloid tumor Redrigous et al., 2010 Date Your Footer Here 8 Assessment of voice disorders Case history Auditory-perceptual evaluation Instrumental examination Date Your Footer Here 9 Assessment of voice disorders Case history Comprehensive case history is essential. Among the general history information, these elements are critical to voice assessment: - Reason for referral and medical history - Onset of the problem and duration of dysphonia - Occupation - Social and leisure activities - Eating and drinking habits and types (e.g., smoking, caffeine intake..etc) - Patient’s personality - psychological status - Self-rating of the dysphonia and its impact on the patient Date Your Footer Here 10 Assessment of voice disorders Auditory perceptual analysis Is also an essential component of the assessment and used to judge voice quality and see if there is any deviation from normal voice. - This skill is developed with time as the SLP listen to many voices. Also, inter-rater ad intra-rater could be used to ensure accuracy in judgment. Date Your Footer Here 11 Voice Quality Voice Quality: roughness—irregularity in voicing source breathiness—audible air escape in voice strain—perception of excessive vocal effort pitch—perceptual correlate of fundamental frequency Additional perceptual features diplophonia aphonia pitch instability tremor vocal fry falsetto wet/gurgly quality loudness—perceptual correlate of sound intensity overall severity—global, integrated impression of voice deviance ASHA Date Your Footer Here 12 INSTITUTE FOR VOICE ANALYSIS AND REHABILITATION (Evaluation Form) NAME: TYPE OF CASE: AGE: ADDRESS: DOB: TELEPHONE: DATE: EXAMINER: REFERRAL: 1. Establish referral source REASON FOR REFERRAL: 1. Establish exact reason for patient referral 2. Establish patient understanding for referral 3. Develop knowledge of the voice disorder 4. Establish credibility of examiner Joseph Stemple HISTORY OF THE PROBLEM: 1. Establish the chronology of the problem 2. Seek etiologic factors associated with the history 3. Determine patient motivation MEDICAL HISTORY:1. Seek medically-related etiologic factors 2. Establish awareness of patient’s personality Joseph Stemple SOCIAL HISTORY: 1. Identify work, home, recreational environments 2. Discover emotional, social, family difficulties 3. Seek more etiologic factors ORAL-PERIPHERAL EXAMINATION: 1. Determine physical condition of oral mechanism 2. Observe whole body tension 3. Observe laryngeal area tension 4. Check for swallowing difficulties 5. Check for laryngeal sensations Joseph Stemple PERCEPTUAL EVALUATION General Quality: 1. Describe voice quality using descriptive terms. May use scale system 2. Examine inappropriate use of voice components Respiration: 1. Describe type of breathing pattern (supportive/nonsupportive) 2. s/z ratio 3. Maximum phonation time Phonation: 1. Hard glottal attacks 2. Glottal fry 3. Breathiness 4. Diplophonia Joseph Stemple Perceptual Evaluation cont. Resonance: 1. Hypernasal 2. Hyponasal 3. Assimilative nasality 4. Cul de sac nasality 5. Inappropriate tone focus Pitch: 1. Test present pitch range 2. Describe conversational inflection 3. Make subjective judgment of appropriateness (optimum pitch?????????) Loudness: 1. Too loud, soft, appropriate 2. Check ability to shout/talk softly Perceptual evaluation cont. Rhythm and Rate: Non-Speech Abuses: 1. Too fast 2. Too slow 3. Interrupted 1. Throat clearing 2. Coughing 3. Unusual laugh CAPE-V IMPRESSIONS: Summarize the etiologic factors associated with the development and maintenance of the voice disorder PROGNOSIS: Analyze the probability of improvement through voice therapy RECOMMENDATIONS: Outline the management plan Assessment of voice disorders Auditory perceptual analysis Date Your Footer Here 19 Assessment of voice disorders Auditory perceptual analysis Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) form as an example Date Your Footer Here 20 Assessment of voice disorders Instrumental voice assessment Date Your Footer Here 21 Instrumental Measures in the Voice Laboratory  laryngeal videostroboscopy  high speed digital imaging (HSDI)  aerodynamic assessment  acoustic recording and analysis  electroglottography  electromyography By Dr.Vrushali Angadi, PhD, CCC-SLP Laryngeal videostroboscopy Endoscopes  Two different endoscopes used for laryngeal viewing: Rigid endoscope: 70 degree, oral placement Flexible endoscope: Nasal placement By Dr.Vrushali Angadi, PhD, CCC-SLP Rigid endoscopy  Advantages: Allows close view of the larynx Larger magnification Stable lens to object distance ▪ Disadvantages: Sample is limited to a sustained /i/ Difficulty recording with a hyperactive gag reflex. Sample is never fully representative of voicing during habitual speech By Dr.Vrushali Angadi, PhD, CCC-SLP Flexible endoscopy Advantages:  Helps view the larynx during connected speech tasks  Allows a broader view of the vocal tract and supraglottic region, tonsil and base of tongue region Disadvantages: ▪ Darker image ▪ Limited by disruptive movements of the velum or swallows. ▪ At times it is difficult to achieve a stable image. By Dr.Vrushali Angadi, PhD, CCC-SLP Laryngeal Videostroboscopy  demonstrates the gross movements of the laryngeal structures  provides immediate image of presence or absence of pathology and a permanent visual record  demonstrates the characteristics of vocal fold vibration and the integrity of the mucous membrane fold covering By Dr.Vrushali Angadi, PhD, CCC-SLP Instrumental Components of Stroboscopy  rigid or flexible endoscope  video camera  light source: halogen and     xenon (strobe light) digital recorder monitor printer computer interface By Dr.Vrushali Angadi, PhD, CCC-SLP Normal vocal folds: Structure Trachea Arytenoid Vocal process True vocal fold Epiglottis: Laryngeal surface False vocal fold Anterior commissure By Dr.Vrushali Angadi, PhD, CCC-SLP Assessment of voice disorders Normal vocal fold and voice during stroboscopy examination Date Your Footer Here 30 Under stroboscopic/xenon light: To assess vibratory features  Glottic closure  observed during vibration of the vocal folds  Amplitude of vibration  lateral excursion of the vocal folds.  Mucosal wave  may be affected by pathology, scarring, pitch, loudness, hyperfunction, hypofunction, anxiety, subglottic driving force  Non-vibrating portion  scarring or lesion By Dr.Vrushali Angadi, PhD, CCC-SLP Assessment of Stroboscopy Parameters cont.  Phase closure  closed and open phase timing should be equal  Phase symmetry  mirror image By Dr.Vrushali Angadi, PhD, CCC-SLP Example of Mass lesions or abnormalities of the vocal fold cover 1. 4. 2. 5. 3. 6. By Dr.Vrushali Angadi, PhD, CCC-SLP Vocal fold paralysis: Video Glottic closure examples 1.Larger than normal posterior gap 3. Spindle shaped 2.Hourglass closure 4. Irregular closure By Dr.Vrushali Angadi, PhD, CCC-SLP Glottic closure examples continued Incomplete closure Anterior gap By Dr.Vrushali Angadi, PhD, CCC-SLP Antero-posterior compression: hyperfunction By Dr.Vrushali Angadi, PhD, CCC-SLP Aerodynamic analysis Aerodynamic Analysis of Voice  Aerodynamic measurement of voice production concerns measurements of air pressures and air flows that are meaningful in clinical diagnosis and treatment. These measures may help interpret:  valving activity of the larynx  vocal fold structure  vocal fold configuration  vocal fold movement By Vrushali Angadi, PhD, SLP-CCC AERODYNAMICS (Baken & Orlikoff, 2000)  The vocal tract is an aerodynamic sound generator and resonator system.  Variations in the flow of air through it reflect changes in the “manner” of consonant & vowel articulations.  Evaluation of airflow can provide insight into speech or voice system dysfunction and efficiency. By Dr.Vrushali Angadi, PhD, CCC-SLP AERODYNAMICS  Consider  What could increased flow tell us about the closure of the vocal folds?  What could decreased flow tell us?  What could high subglottic pressures tell us about happenings at the level of the glottis?  What disorders could this be applied to? By Dr.Vrushali Angadi, PhD, CCC-SLP Aerodynamic Analysis of Voice cont.  Instruments for measuring pressure and flow:  U tube manometer  wet spirometer  hot wire anemometer  pnuemotachograph  magnetometers By Dr.Vrushali Angadi, PhD, CCC-SLP Aerodynamic Analysis of Voice cont.  Aerodynamic Recording Considerations  requires airtight seals around the lips or mask to face  as natural speech as possible must be encouraged in this foreign environment  multiple trials are necessary to ensure a stable baseline  instrument calibration is required prior to each examination session Aerodynamic Analysis of Voice cont.  Common aerodynamic measures:  airflow volume  volume of air in the lungs available to drive the vocal folds for voice production  measured in liters, will vary with age, sex, size, health  maximum phonation time (MPT)  maximum time that a vowel may be sustained while using maximum airflow volume  will vary with lung capacity, age, sex, size, health  for therapy purposes, MPT is calculated using vital capacity measure  airflow rate (determined from above measures)  rate at which air passes between the vocal folds during phonation  Volume divided by MPT (volume in liters /MPT in sec)  measured in liters/sec, with normal rate = 80-200 ml/sec Acoustic analysis Computerized Speech Lab (CSL) Fundamental frequency - Habitual pitch - Speaking pitch Intensity Spectrogram - Formant and vowel/consonant relationship Date Your Footer Here 45 Voice Therapy Date Your Footer Here 46 Voice Therapy Orientations hygienic voice therapy symptomatic voice therapy psychogenic voice therapy physiologic voice therapy eclectic voice therapy Date Your Footer Here By Dr.Joseph Stemple 47 Hygienic Voice Therapy Concentrates on discovering the behavioral causes of the voice disorder and modification/elimination of the causes to improve the vocal condition and the voice quality organized and promoted by every voice text there is always a cause for a voice disorder; discover, modify/eliminate and the voice improves weakness: the cause may no longer be the precipitating factor Date Your Footer Here By Dr.Joseph Stemple 48 Symptomatic Voice Therapy Modification of deviant vocal symptoms such as breathiness, inappropriate pitch, loudness, hard glottal attacks, and so on organized and promoted by Daniel Boone in his text The Voice and Voice Therapy (1971) if the voice component is inappropriate, modify that component weakness: what is symptom/cause? Date Your Footer Here By Dr.Joseph Stemple 49 Psychogenic Voice Therapy Focus is on emotional and psychosocial status of the patient that led to and maintained the voice disorder organized and promoted by Arnold Aronson in his text Clinical Voice Disorders: an interdisciplinary approach (1980) there is always a psychosocial reason for the behavior that led to the voice disorder; treat the psychosocial problem and the voice improves weakness: psychosocial contribution may be over-stated Date Your Footer Here By Dr.Joseph Stemple 50 Physiologic Voice Therapy Based on expanded knowledge of vocal function as evaluated through objective voice assessment Strives to improve the balance among voice respiratory support, laryngeal muscle strength, control and stamina, and and supraglottic modification of the laryngeal tone Promotes a healthy vocal fold cover Date Your Footer Here By Dr.Joseph Stemple 51 Continue…Physiologic Voice Therapy organized and promoted by Colton and Casper (1990) and Stemple, Glaze and Gerdeman (1993) concentrates on the modification of the underlying physiology of the voice producing mechanisms: respiration, phonation, resonance weakness: does not account for behavior Vocal Function Exercises (VFC) Date Your Footer Here By Dr.Joseph Stemple 52 Continue…Physiologic Voice Therapy Date Your Footer Here By Dr.Joseph Stemple 53 Eclectic Voice Therapy Combination of any and all of the previous orientations to affect positive vocal change As voice pathologists, we should be aware of all management approaches and use those which are most effective not only for the patient, but for the therapist as well Date Your Footer Here By Dr.Joseph Stemple 54