Chapter 6 Notes
Chapter 6 Notes 1230.0
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Date Created: 10/10/15
Chapter 6 Voice Disorders In this chapter we consider voice disorders that result from dysfunction at a strategic point in the speech production mechanism The vocal fold tissues become swollen edema which can result in complete loss of voice Typically speechlanguage pathologists use three descriptors Harsh Breathy Hoarse A harsh voice is asscotiated with excessive muscle tension The vocal folds are pressed together tightly with a quick release during each cycle of vibration A breathy voice is produced with a partial whisper The vocal folds are brought together so that they vibrate but a space between them remains The larger the space between the folds the greater the fricative noise and the breathier the phonation A voice that is both harsh and breathy is termed hoarse It results from irregular vocal fold vibrations typically from differences in the mass and shape of the two folds Some voice disorders results from tissue enlargement while others are the result of a reduction in tissue atrophy Some are caused by increased muscle activity hyperfunction Others are caused by reduced muscle activity hypofunction Increased or decreased muscle activity can result in tissue changes A variety of structural changes in the vocal folds can affect the voice The most common form of vocal fold abnormality seen by otolaryngologists Most often found in male children ages 5 to 10 and adult females They can develop in persons who do not scream but who abuse their vocal folds in other ways Nodules are similar to calluses that develop on the vocal folds in response to trauma They form in pairs at the point of maximum contact along the length of the vocal fold where the amplitude of vibration is greatest If the patient alters phonatory behavior to eliminate vocal abuse the nodules will almost always be eliminated Enlisting the patient as a partner in this process is empowering for the patient and can be an important part of the therapeutic process Also relatively common form of vocal abnormality Much like blisters that assume one of two basic shapes Some are like small balloons connected to the vocal fold by a narrow stalk or foot pedunculated Others are spread over a relatively large area of the vocal fold sessile Most clinicians believe that polyps develop from vocal fold abuse even one time abuse However a soft pliable mass on one vocal fold does not tend to irritate the other fold so polyps typically are unilateral With polyps the voice tends to be breathy or hoarse they can also cause double voice or diplophonia Polyps are most typically treated by speechlanguage pathologists Longstanding polyps that do not respond to voice therapy may be surgically removed Contact ulcers and the granulomas that develop at sites of ulceration arise at the vocal processes The develop from a number of disparate causes including Excessive slamming together of the arytenoid cartilages during the production of inappropriately low pitch Frequent nonproductive coughing and throat clearing Gastric re ux resulting in acidic irritation of the membrane covering the arytenoids cartilages Intubation trauma that can occur during surgery under anesthesia Speechlanguage pathologists work with patients who present the first two causes because they are habit patterns amendable with treatment The human papillomavirus causes warts that can occur on any skin or mucous membrane surface When they occur on the vocal folds they can grow so large that they compromise the airway which makes breathing difficult Laryngeal papillomas are not common and are continuing to decrease given the availability of immunizations to prevent development of the disease They usually go away without treatment however surgical removal is necessary in the case of papillomas that threaten the airway These growths tend to recur necessitating repeated surgical procedures Any form of aggregation to the papilloma that may arise from poor vocal hygiene or vocal abuse and misuse can cause the papilloma to grow more rapidly Children with papillomas may go undetected because some professionals assume incorrectly that the child s hoarseness is caused by vocal nodules This type of mistake demonstrates how the voice quality can sound the same for a variety of voice disorders Cancer of the larynx affects approximately 12500 new patients each year Laryngeal cancer frequently arises from exposure to inhaled smoke that may occur over years Coincident smoking and alcohol consumption dramatically increases the chance of developing laryngeal cancer Patients with extensive laryngeal carcinomas may be candidates for complete removal of the larynx because of the lifethreatening nature of cancer For those who must undergo this radical procedure the responsibility of the speechlanguage pathologist is to provide preoperative and postoperative counseling They also provide postoperative therapy intended to optimize the communication abilities of the patient SLPs teach patients about the variety of alaryngeal speech options that are available to them Damage to the nervous system can cause muscle weakness paresis or a total inability to contract one or more muscles of the larynx paralysis The RLN of the vagus or 10th cranial nerve innervates all the intrinsic laryngeal muscles except the cricothyroid The RLN because of its location is prone to damage during neck and chest surgery The number one cause of vocal fold paralysis is considered to be iatrogenic or at the hand of the surgeon Patients may be referred for surgical care Surgery in the case of unilateral vocal fold paralysis involves physically moving the affected vocal fold closer to midline so that the unaffected fold can contact it during phonation Unilateral vocal fold paralysis is fairly uncommon but bilateral paralysis is even less frequent Surgery may be necessary to create an open airway sufficient for breathing Which aspects of phonation are affected is dependent on which nerves are damaged Spasmodic Dysphonia SD is a rare disorder probably affecting no more that 12 people per 10000 in the US Patients with SD have less difficulty during singing and improvement when pitch is raised SD is accepted as a neurological problem involving a disturbance in the basal ganglia that causes disordered muscle tonicity dystonia There are three types of SD Adductor Spasmodic Dysphonia The most frequent SD Abrupt uncontrolled contractions of the adductor muscles Results in a strainstrangle voice quality Abductor Spasmodic Dysphonia Causes inappropriate contraction of the laryngeal abductor muscles Mixed Spasmodic Dysphonia The patient will present both sudden abductions and adductions The preferred manner of treatment for this is repeated injections of botulinum toxin BOTOX into the muscles of the larynx It reduces the contractions of the affected muscles but does nothing to address the underlying problem The entire cycle from injection to relapse usually occurs over a period of 3 to 6 months The SLP works with patients with SD prior to and following medical intervention They teach patients various techniques that may prolong the normal voice phase Most voice disorders are related to tissue changes in the larynx or abnormal changes in the nervous system However a number of disturbances can occur in the absence of underlying pathology A patient may report a total loss of voice aphonia or an extremely abnormal voice dysphonia and yet a thorough medical examination fails to uncover an organic cause for the problem Voice problems of this sort frequently have a sudden onset and a careful interview of the patient and family often reveals previous occurrences of the problem In many cases voice is restored within an hour or less Referral to a mental health clinician may be indicated in some but not necessarily all cases Puberphonia also known as mutational falsetto involves the continued use of a highpitched voice by a postpubertal male The condition may be the result of unresolved psychological issues or it may be a learned behavior This disorder is described as functional Individuals with muscle tension dysphonia MTD display disordered voices that are caused by inordinate tension in the laryngeal muscles It appears to be the result from the simultaneous contraction of the muscles that close adductor and open abductor the vocal folds The patient might develop knots that may benefit from laryngeal massages The voice of an individual with MTD is usually quite hoarse Whatever the cause of MTD voice therapy directed toward facilitating a reduction in muscle tension can have a dramatic effect on these individuals Voice disorders are best managed by the joint effort of a team The core elements of such a team are the otolaryngologist and SLP Remember that what you hear in terms of vocal quality may sound the same for different vocal pathologies The interview is intended to provide extensive information concerning the patient and the problem It is important to explore the patient s health history family situation dietary habits use of stimulants and the level of concern regarding the voice problem During the interview the patient may describe his voice problem using a number of terms The nine primary symptoms are Hoarseness Pitch breaks or inappropriately high pitch Fat1gue t 39 t l Breathiness S ramS mgg e T Reduced pitch range remor L 39 th thl t lb Lack of voice aphonia umpm 6 03 g 0 us Some symptoms such as something in my throat and fatigue are not known as signs The clinician makes judgements regarding the pitch loudness and quality of the voice during a variety of tasks A highquality recording of the patient is obtained in the interview Typically the recording includes the patient s name the recording date sustained vowel productions counting reading singing spontaneous conversation pitch and loudness glissandos Numerous terms are used to describe abnormalities of voice but we can describe voice quality disorders using three Breathy Harsh and Hoarse In judging the pitch loudness and quality of a patient s speech clinicians use scales for grading the parameters of interest A sixpoint scale regarding hoarseness might use the following assignments 1normal voice quality 4moderate hoarseness 2mild hoarseness 5moderate to severe hoarseness 3mild to moderate hoarseness 6severe hoarseness The Consensus Auditory Evaluation of Voice CAPEV was developed as a tool to describe auditory perceptual attributes of a voice problem that could be communicated among clinicians It includes perceptual ratings of overall voice severity roughness breathiness strain pitch and loudness Next to each scale are two letter C and I C indicates that the attribute was present throughout the task I indicates that the attribute was inconsistent within or between tasks The ratings are based on a series of brief tasks that are recorded including production of two sustained vowels reading of six sentences and responses to requests or sentences The CAPEV can be used to determine changes in voice as a function of treatment or the progression of some diseases However the CAPEV does not provide information on the psychosocial effects of the disorder The Voice Handicap Index VHI is a series of statements that are used to see how the person with a voice disorder feels that their daily life is effect by the disorder It includes 30 questions divided into emotional functional and physical subscales A pediatric version of the VHI has also been developed A voice evaluation that does not include instrumental assessment is considered a screening procedure A exible videoendoscopy enables the clinician to visualize the vocal folds and surrounding area using a camera and light source Once the voice evaluation is complete the task of the SLP is to make recommendations regarding referrals and the need for treatment The larynx sits at the top of the trachea or windpipe and serves as a protective valve as well as a sound generator Surgical removal of the larynx requires that the trachea be redirected to an opening on the front of the neck known as a tracheal stoma Larygectomees routinely wear some protective device over the stoma to ensure that foreign matter does not enter the lungs The loss of the ability to phonate can be devastating SLPs play an important role in counseling patients both before and after surgery They also help ensure that these individuals regain the ability to communicate verbally There are two types of artificial larynxes patients can choose to use after surgery One type involves a handheld battery activated diaphragm that creates a sound source that when held up in the air actually sounds very obnoxious When held against the neck however it produces a spectrum of tones that can be modulated by the articulators to produce intelligible speech The second type is similar to the first the major difference is that the device is presented directly to the mouth by means of a small tube Some patients are quite pleased with these artificial larynxes but others dislike them One option for speech production after laryngectomy is to force air down into the esophagus and then release the impounded air pressure in such a way as to cause the vibration in the wall of the esophagus Esophageal speech is quite low pitched and because there is little voluntary control of the muscles in this area pitch variability and utterance length and loudness is limited In trachoesophageal speech air is routed from the lungs into the esophagus via a trachoesophageal speech prosthesis Patients undergo additional surgery to create a small opening between the trachea and esophagus in which the prosthesis is inserted The laryngectomee must either cover the hole stoma on the front of the throat with a finger or be fitted with a tracheostomal valve The patient can produce longer phrases with greater pitch and loudness variability than esophageal speakers Not all laryngectomies are candidates for trachoesophageal speech Whichever method is adopted by the patient SLPs play a critical role in their rehabilitation