1
Q
What is the function of the epiglottis?
A
Protects the airway during swallowing.
2
Q
Name the extrinsic laryngeal muscles.
A
Suprahyoids: Digastric, Geniohyoid, Mylohyoid, Stylohyoid
Infrahyoid: Omohyoid, Sternohyoid, Thyrohyoid
3
Q
Name the muscle: Pulls hyoid anteriorly and superiorly or posteriorly and superiorly, thereby potentially elevating the larynx. It’s function is to elevate the larynx and depress jaw/mandible.
A
Digastric muscle
4
Q
What is the origin, insertion, and function of the digastric anterior belly muscle?
A
O: lower border of mandible near mandibular symphasis
I: Intermediate tendon
F: elevates larynx, depress jaw/mandible
5
Q
What is the origin, insertion, and function of the digastric posterior belly muscle?
A
O: Mastoid process
I: Intermediate tendon
F: elevates larynx and hyoid, depresses jaw/mandible
6
Q
The geniohyoid and myohyoid muscles are intrinsic or extrinsic laryngeal muscles?
What are their functions?
A
Extrinsic. Both pull the hyoid anteriorly and superiorly, potentially elevating the larynx.
7
Q
Is the stylohyoid an intrinsic or extrinsic laryngeal muscle?
What is it’s function?
A
Extrinsic. Elevates larynx
8
Q
What is the origin, insertion and function of the geniohyoid muscle?
A
O; mental spine mental symphasis of mandible.
I: hyoid body
F: elevate hyoid and larynx
9
Q
What is the origin, insertion and function of the mylohyoid muscle?
A
O: mylohyoid line on inner surface of mandible.
I: midline raphe
F: Elevate larynx
10
Q
What is the origin, insertion, and function of the stylohyoid muscle?
A
O: styloid process of temporal bone
I: body of hyoid
F: elevates larynx; draws hyoid superiorly and posteriorly
11
Q
Are infrahyoid intrinsic or extrinsic laryngeal muscles?
A
Extrinsic.
12
Q
Name the infrahyoid muscles.
A
Omohyoid, sternohyoid, and Thyrohyoid
13
Q
What is the O, I, and F of the Sternohyoid.
A
O: Manubrium of sternum and end of clavicle
I: Lower border body of hyoid
F: Pulls down on hyoid; lowers larynx
14
Q
What is the origin and function of the Sternothyroid?
A
O: Manubrium of sternum and first coastal cartilage and inserts on oblique line of thyroid.
F: Lowers larynx; pulls down on thyroid
15
Q
What is the origin, insertion, and function of the Thyrohyoid?
A
O: on oblique line of thyroid
I: on hyoid
F: elevates larynx or depresses hyoid
16
Q
Name the intrinsic laryngeal muscles.
A
Posterior cricoarytenoids, lateral cricoarytenoids, arytenoids (transverse and oblique), cricothyroids, and thyroarytenoids
17
Q
What is the O, I, and F of the posterior cricoarytenoids?
A
O: post. surface of cricoid cartilage
I: muscular process of the arytenoid cartilage
F: abducts the vocal folds (by rocking the AC back, thus rotating vocal processes away from the midline)
** are the only laryngeal abductors
18
Q
What is the O, I, and F of the lateral cricoarytenoids?
A
O: upper border & anterolateral arch of cricoid
I: Into muscular process of arytenoids
F: adducts vocal processes and adducts membraneous portion of vocal folds
19
Q
True or false? the RLN innervates Post. and lateral cricoarytenoid.
A
True. it innervates all intrinsic muscles except the cricothyroid.
20
Q
What is the O, I, and F of the Interarytenoid obliques fibers?
A
Origin: posterior part of
muscular process of AC
Inserts: Courses up & across to apex of opposite arytenoid.
Function: Adducts the arytenoid cartilages and thus cartilagineous glottis
21
Q
What is the O, I, and F of the Interarytenoid transverse fibers?
A
O: lateral-posterior aspect of AC
I: courses across to opposite AC
F: Adducts the arytenoid cartilages and thus cartilagineous glottis
22
Q
Name the cricothyroid muscles and are the intrinsic or extrinsic muscles?
A
pars oblique and pars recta; intrinsic
23
Q
What innervates the cricothyroid muscles?
A
SLN
24
Q
Cricothyroid muscles: What is the Pars oblique O, I, F ?
A
O: anterolateral arch of cricoid
I: inferior horn of thyroid
F: - Decreases distance between thyroid and cricoid cartilages
-increases distance between thyroid and arytenoid cartilages.
- lengthens VFs which increase longitudinal tension of folds and results in an increase in pitch
25
Cricothyroid muscles: What is the Pars recta location and function?
Location: courses vertically to lower margin of thyroid
F: - Decreases distance between thyroid and cricoid cartilages
-increases distance between thyroid and arytenoid cartilages.
- lengthens VFs which increase longitudinal tension of folds and results in an increase in pitch
26
What is the O, I, and F of the thyroarytenoid muscle?
```
O: deep surface of the thyroid angle
I: lateral/inferior aspect of vocal processes of arytenoids - some fibers attach to the muscular process
F: - can increase or decrease pitch
-Decreased distance between thyroid and arytenoid cartilages.
- Shortens vocal folds
- relaxes cover
- tenses body
- bulks vocal folds
- aids in adduction
```
27
Which cranial nerve innervates the larynx?
CN X
28
What is the function of CN X as it relates to the larynx?
1) provide sensory innervation
| 2) motor innervation to intrinsic laryngeal nerves
29
What two nerve branches of CN X serve the larynx?
1) Superior Laryngeal Nerve
| 2) Recurrent Laryngeal Nerve
30
To which muscles does the SLN provide motor innervation?
cricothyroid and inf. pharyngeal constrictor
31
What are the SLNs sensory functions?
1) sensory info from the superglottic area of the larynx
| 2) Sensory info from surface of inferior pharyngeal constrictor
32
To which muscles does the RLN provide motor innervation?
all intrinsic laryngeal muscles except the cricothyroid.
33
what is the sensory function of the RLN?
info from infraglottic larynx
34
What is the composition of the vocal fold 3 layer model?
1. Cover (lamina propria, superficial)
2. Transition (intermediate and deep)
3. Body (vocalis)
35
What is the composition of the vocal fold 5 layer model?
1. Epithelium (outer thin capsule)
2. Superficial layer lamina propria - reinke's space
3. Intermediate layer lamina propria
4. deep layer lamina propria
5. thyroarytenoid
36
What is the composition of the vocal fold cover?
- mucous membrane
- epithelium
- superficial lamina propria, mostly elastin fibers and some collagen. (e.g. like jello covered w/ plastic wrap...aka reinke's space)
37
What is the composition of the vocal fold transition layer?
- intermediate lamina propria, (more collagen and elastin, like a bundle of rubber bands)
- deep lamina propria (lots of collagen, like a bundle of cotton threads)
38
What is the composition of the vocal fold body layer?
thyroarytenoid muscle, vocalis, and muscularis
39
what is the basement membrane zone?
secures epithelium to superior lamina propria.
40
what is the basement membrane zone's relationship to VF nodules?
Fibronectin (scar formation) found in BMZ and also found in nodules NOT polyps
41
Cell bodies of CN X are in the ______ _______ in the medulla.
nucleus ambiguous
42
Explain myoelastic.
myoelastic refers to the laryngeal muscle activity that occurs during phonation and effects the laryngeal muscle activity on the elasticity of the vocal folds.
43
explain aerodynamic, and the 2 determinants of VF vibration.
refers to the aerodynamic determinants of the vibratory cycle, i.e., the opening and closing phases of vibration.
Determinants:
1. subglottal pressure (Ps)
2. negative pressure due to the Bernoulli effect
44
Describe Ps and phonation (myoelastic-aerodynamic theory of phonation)
- VFs adduct
- Ps builds below VFs - Ps is the opening force
- membraneous VFs open, a puff of air escapes and the glottis closes abruptly afterward.
- One puff follows another and audible air pressure wave is set up at glottis and in the VT
- for vibration to occur, pressure must be greater BELOW the VFs than above
45
Describe opening and closing phase of VF vibration.
- opening phase is due to build up of Ps
- closing phase is result of a) the elasticity and mass of the VFs which moves VFs back to midline position b) the Bernoulli Effect - negative pressure between the VFs
46
What is the Bernoulli Effect?
- when gas/liquid flows thru a constricted passage, the velocity increases while the outward pressure of the molecule of the gas decreases.
- the pressure drop is perpendicular to the direction of the flow
- if the walls are pliable, the decrease in the outward pressure of the flowing gas molecules moves the walls toward each other
47
What is the Bernoulli effect and the vocal folds?
- subglottal pressure forces VFs apart.
- the narrow space that created in the glottis causes velocity of the air molecules to increase as they pass through the glottis.
- the increase in air molecule velocity results in a decrease in pressure between VFs
- the decrease in pressure causes the walls of the glottis (VFs) to come together, along w/ the natural elastic recoil of the VFs - this closes the VFs.
48
What is the composition of the vocal fold transition layer?
intermediate and deep lamina propria. (intermediate is collagen and elastin, like a bundle of rubber bands. deep is lots of collagen like a bundle of cotton threads)
49
What is Phonation Threshold Pressure (PTP) and what affects PTP?
PTP is the minimum amount of subglottal pressure required to initiate VF vibration.
PTP is affected by:
1) VF tension - (PTP is higher for higher pitches)
2) VF Viscosity - greater viscosity =increased PTP
3) VF thickness - greater thickness = decreased phonation (VFs are less stiff)
50
What is the movement of VFs during vibration? (e.g. opens top to bottom, anterior to posterior)
Opens bottom to top, anterior to posterior.
51
Inertia: a property of matter by which it continues in its _______ state of ____ or uniform motion in a straight line, unless that state is _____ by an ______ force
existing; rest; change; external
52
True or false: VF vibration is assisted in both direction (opening and closing) by changes in supraglottal pressure.
true.
53
True or false The build up and release of supraglottic pressure is delayed in respect to opening and closing of VFs - this creates vocal tract inertance.
True
54
Nonlinear tissue movement: what are the characteristics of convergent glottis?
VFs are opening from bottom to top, transglottal pressure is positive, net tissue velocity is outward, and air molecules converge.
55
Nonlinear tissue movement: what are the characteristics of divergent glottis?
VFs are closing bottom to top, transglottal pressure is negative, net tissue velocity is inward, air molecules diverge
56
Explain the Cover Model.
- at low intensity (soft) speech or in falsetto singing, only the VF cover is in vibration.
- when CT contracts, the VFs lengthen, longitudinal tension in the VF cover increases and frequency increases.
- if TA contracts in this condition, pitch will lower because the VFs will shorten and the cover will become loose and lax due to the decrease in tension/stress.
57
Explain the Body-Cover Model.
- during normal to high intensity speech or singing in chest or head register, BOTH the VF body and cover are in vibration.
- high intensity (loud) phonation results in increased amplitude and depth of vibration and thus the TA muscle is likely involved in vibration.
- If the TA contracts in this condition, the overall stiffness/tension of VFs will increase and frequency will increase as long as CT muscle activity is not at its maximum.
- If CT activity is at maximum then the frequency will decrease because contraction of TA in this case will shorten the VFs and the resultant shortening will decrease the overall VF stiffness.
58
To increase intensity, one must increase ____, and often frequency will increase as well. WHY?? and what is it called?
- subglottal pressure Ps.
- Increased intensity = increased amplitude of vibration which causes VFs to lengthen thus increasing VF tension which increases frequency.
- This is called dynamic strain
59
What is vocal register?
a series of frequencies that are perceptually similar in quality and are produced in the same physiological manner.
60
What is register transitions?
a sudden change in vocal timbre or mode vibration. Can have their origin in either 1) a change in muscle activity that results in a change in mode of vocal fold vibration, OR, 2) possibly subglottic resonances interfering with VF vibration
61
Vocal registers: what are the characteristics of Modal/chest register?
- thicker VFs (rctng glottis)
- complete VF closure
- closed phase of vibration is equal in duration or longer than open phase.
- greater in mid and upper frequency harmonics
- greater amplitude of vibration and mucosal wave excursion
62
Falsetto is used to produce the highest pitches in one's frequency change. What are the characteristics?
- vocal folds appear elongated, thinner, and stiff
- Incomplete or bow shaped glottal closure
- open phase of vibration is longer than closed phase
- only anterior 2/3's of VFs vibrate
- decreased energy in the mid and upper harmonics
- decreased amplitude of vibration and lateral excursion of the mucosal wave
- greater air flow than chest
- sometimes a breathy quality
63
Glottal fry occurs at the low frequencies about 70-90 Hz. What are the characteristics of glottal fry?
- very long closed phase
- long closed phase
- double open phase
- tightly adducted but flaccid appearing VFs
- low air flow
64
What are the 3 ways to control intensity?
1) below the larynx (increases Ps)
2) at the larynx (increased VF adduction)
3) Above the larynx (VT adjustments)
65
Intensity control: Explain how it is controlled below the larynx.
respiratory drive must be adequate in order to produce normal to high intensity phonation. High intensity phonation require increased subglottal pressure. Increasing Ps requires greater volume of air and increased VF adduction
66
Intensity control: Explain how it is controlled at the larynx.
Increased VF adduction. Longer duration of the closed phase allows Ps to build and faster VF closure results in increased intensity. The faster the VFs close, the greater the transglottal pressure drop.
*The greater the transglottal pressure drop, the greater the intensity of the sound*
MFDR – Maximum Flow Declination Rate. This is how rapidly the air flow goes to ‘0’ at the moment of VF closure
67
Intensity control: Explain how it is controlled above the larynx.
The vocal tract acts a as resonator. Any harmonic in the vicinity of a VT formant gets a boost in amplitude (greater intensity)
68
what are the determinants of vocal quality?
it is determined by the periodicity of vocal fold vibration and degree of glottic closure.
69
Name the Five Parameters Used to Describe Voice Production
Quality: breathy, hoarse, raspy, gravelly, strangled, strained etc
Pitch – low, normal, high
Pitch is perceptual correlate to frequency
Loudness – soft, normal, loud
Loudness is perceptual correlate to intensity
Resonance – timber: dark, bright, throaty/back,
Nasal etc
Register – glottal fry, modal, falsetto
70
what are the types resonance?
timber: dark, bright, throaty/back,
| Nasal etc
71
Primary purposes of a videostroboscopy.
1) Identify physiologic correlates of perceived resonance and voice quality
2) document status of speech anatomy and physiology
3) assist educational and clinical discussion among clinicians, patients, and others
72
True or false?
| videostroboscopy provides qualitative and quantitative data on vocal function of the normal and disordered larynx.
True
73
True or false?
- Videostroboscopy provides info regarding the nature of VF vibration, and the presence of VF pathology and its effect on VF vibration
True
74
True or false?
| Videostroboscopy does not provide a permanent record for patient history
False - it is a permanent record
75
How does a videostroboscopy work in a normal phase?
Each flash of light illuminates a different part of each successive vibratory cycle. Software combines portions of each cycle into one picture. The patient’s fundamental frequency (Hz) is used to determine where in the cycle to flash light. (dependent on periodicity of glottal cycle)
76
How does a videostroboscopy work in a locked phase?
used to assess periodicity.
The light flashes and the camera takes a picture at the same point in every vibratory cycle.
If the vibration is periodic, the VFs will appear to stand still. If the vibration is not periodic, the VFs will move.
77
Describe an oral endoscopy?
Tasks:
1) Sustained /i/ at comfortable pitch & loudness – assess during both normal & locked modes.
2) Short repeated /i/ then sniff
3) Deep sniffs
4) Pitch glides up and down on /i/
5) High pitched phonation on /i/ loud & soft
6) Loud and soft /i/ at comfortable pitch
78
define periodicity
degree of regularity of VF vibration (use locked phase)
79
What is phase symmetry?
a measurement of the degree to which the VFs mirror each other’s movement during vibration.
(Do VFs come to midline (close) together and open together?)
80
What is phase closure?
Represents the durations of the open and closed phases during an observed vibratory cycle. Should be about 50/50 or 40/60
81
Under what phonatory conditions do we assess and rate the mucosal wave and amplitude of vibration?
This is always rated during phonation at comfortable pitch and loudness.
82
what are the benefits of a nasendoscopy?
- Patient can speak normally and sing
- Excellent view of supraglottic structures and velar function
- Less likely to elicit strong gag reflex
83
what are the drawbacks of a nasendoscopy?
- Image and color distortion, poor magnification
| - Light less bright
84
VF nodules
Causes: from chronic abuse
Salient features: Bilateral, occurs at juncture of anterior 1/3 and posterior 2/3's of VF, more common in adult women, but more common in male children.
85
Salient characteristics and cause of VF polyps
- usually unilateral, but can be bilateral
- can occur anywhere on the VF
- soft fluid filled outgrowth
- can be hemorrhagic or not
- diplophonia
- caused by sudden VF injury from an acute episode of vocal abuse
86
Reinke's Edema
cause is usually smoking, more common in women, low habitual pitch, increased mass, bilateral or unilateral
87
traumatic laryngitis
- usually caused by excessive yelling, screaming, or loud talking
- Vocal folds are erythematous (red) and swollen.
- Voice is low pitched, and breathy
- Resolves within a few days to 2 weeks
- May be accompanied by vocal fold hemorrhage
- Chronic Laryngitis – results if vocal abuse continues, particularly if patient w/ laryngitis is using more effort or straining to speak …what we call negative compensatory strategies
88
VF hemorrhage
Ruptured blood vessel in submucosal layer due to damage to the small, delicate blood vessels of the VF layers
VF tissues are damaged by the blood
Cause is usually phonotrauma or trauma to VFs during surgery or medical procedure
Use of anticoagulant medications such as aspirin, ibuprofen and Coumadin increases the risk
Increases VF stiffness and mass
89
VF cysts
- Rough, breathy, might be low pitched, decreased loudness
- increased noise levels
- effort/strain, vocal fatigue
90
what are the videostroboscopic characteristics of VF nodules?
- Hourglass closure
- bilateral lesions at juncture of anterior 1/3 and posterior 2/3 of membraneous VFs
- decreased or absent mucosal wave in region of the nodule
- decreased amplitude of vibration
91
what are the videostroboscopic characteristics of VF polyps?
- Hour glass or irregular closure
- Increased mass, unilateral
- Incomplete closure – depends on size and type
- Affected side vibrates at decreased frequency
- Pedunculated may not affect vibration
- Mucosal wave increased or decreased
- Amplitude of vibration as above
92
what are the videostroboscopic characteristics of Reinke's Edema?
Increased mass, unilateral
- Incomplete closure – depends on size and type
- Affected side vibrates at decreased frequency
- Pedunculated may not affect vibration
- Mucosal wave increased or decreased
- Amplitude of vibration as above
93
what are the videostroboscopic characteristics of VF Hemorrhage?
patchy red area on VF surface
decreased mucosal wave
decreased amplitude of vibration
non-vibratory portion at hemorrhage site
94
what are the videostroboscopic characteristics of VF
- Absent or decreased mucosal wave
- Decreased amplitude of vibration
- Increase VF mass/stiffness of VF cover
- Irregular or hourglass closure
95
Muscle tension dysphonia is caused by what type of tension?
- Excessive extrinsic laryngeal muscle tension, including tension in supra- and infrahyoid muscles and neck muscles
- Excessive internal/supraglottic laryngeal muscle tension
96
What type of videoendoscopic signs of supraglottic and intrinsic muscle tension do we see with dysphonia (e.g. anterior, posterior)
- Anterior –posterior compression
- Medial lateral compression
- VF hyperadduction and foreshortening
- Supraglottic squeezing
- Incomplete glottic closure, anterior gap or bowing
97
is muscle tension dysphonia (MTD) primary or secondary?
can be either
98
True or false? Muscle tension dysphonia may present with intrinsic or extrinsic muscle tension.
True
99
True or false? Muscle tension dysphonia may present with base of tongue (BOT) tension, but not floor of mouth (FOM) tension.
False - can present with either
100
What is ventricular phonation?
| Is it a primary or secondary disorder?
- Adduction and use of the false or ‘ventricular’ vocal folds for phonation.
- Pt. increases laryngeal muscle tension to compensate for air wastage, inability to build Ps, and decreased loudness.
-either primary or secondary
101
what is puberphonia?
- Persistence of a child-like voice quality after puberty
- Learned or psychogenic in nature
- Voice is high pitched, possibly hoarse and breathy, decr. loudness; pitch often lowers when they shout or do heavy lifting
- Incomplete glottic closure, stiff VFs, decreased amplitude
- Dx must rule out laryngeal structural defects, endocrine disorder & diseases that might affect the larynx
102
what is conversion aphonia?
- Complete loss of voice (aphonia) with no underlying physical cause
- Nonphonatory VF movements are normal. On phonation, VF movement is irregular & adduction inadequate to produce vibration
- Onset is sudden or preceded by periods of voice loss or dysphonia
- Onset of aphonia is associated with fear, stress, or traumatic event
- Non-speech / vegetative functions such as throat clearing, coughing, laughing etc show normal VF movement and vibration
103
what is paradoxical vocal cord movement (PVCM)?
Characterized by adduction of VFs during quiet breathing
| -Concerns are non-vocal. Primary concern is ability to breathe
104
what is the cause of paradoxical vocal cord movement (PVCM)?
No known cause– may be learned, maybe due to hyperactivity of the airway, a neurological problem, a psychological problem, or unspecified medical problem
105
what is paradoxical vocal cord movement (PVCM) characterized by?
stridor, shortness of breath
106
what is paradoxical vocal fold movement (PVFM)?
Vocal fold adduction occurs during inhalation
107
what is the cause of paradoxical vocal fold movement (PVFM)?
Unknown cause but may be related to stress, performance anxiety, reflux, allergies, brainstem or vagal disturbances, or have a psychological component.
108
paradoxical vocal fold movement (PVFM) is most common in what population(s)?
Often seen in athletes – most common in adolescent athletes and in women ages 20-40 y/o.
109
What is granuloma?
-Form on the medial aspect of the posterior third of the vocal folds (cartilaginous portion)
-Granulomas are comprised of lymphocytes and fibrotic connective tissue
Usually unilateral but can be bilateral
-Variable glottic closure – complete to incomplete
-Mucosal wave may be decreased
110
What are 3 causes of granulomas?
1. GERD or LPR
2. Phonotrauma
3. Intubation trauma
111
Are granulomas more common in men or women?
men
112
```
Heartburn
-Rapid vocal fatigue
-Sore, burny throat
-Globus sensation in the throat
-Excessive throat mucus
-Increased throat clearing
-Chronic ,dry cough or tickle
-Waking up choking or coughing
-Acid taste in the mouth,
-Regurgitation
These are all symptoms of what disorder(s)?
```
GERD and LPR
113
what is reflux laryngitis: GERD & LPR?
Regurgitation of acid and stomach enzymes are irritants to the VFs
114
what does reflux laryngitis: GERD & LPR cause?
VF edema, erythema, arytenoid and posterior commissure hypertrophy, pachydermia (thickening of tissue between the arytenoids)
115
what is infectious laryngitis?
Inflammatory response of the larynx due to a viral or bacterial infection
116
How do the VFs and laryngeal inlet appear with infectious laryngitis?
red and swollen
117
what are the symptoms of infectious laryngitis?
total or partial voice loss, breathiness, low pitch
118
What is laryngeal papilloma?
wart-like growths
119
What are the two types of laryngeal papilloma?
| What is the treatment?
- Adult and juvenile.
| - remove surgically, but some juvenile cases (20-40%) resolve on their own.
120
What is the cause of laryngeal papilloma?
Human papilloma virus (HPV)
121
What are the videostoboscopic characteristics of laryngeal papilloma?
Incomplete glottic closure, absent mucosal wave, increased VF mass and stiffness
122
what is laryngeal web?
presence of a laryngeal web
123
what is the cause of laryngeal web?
Congenital or acquired post-surgery or after laryngeal trauma
124
what is the characteristic of laryngeal web?
The web is a band of tissue that forms in the anterior 1/3 of glottis
125
what are the symptoms of laryngeal web?
Inhalatory stridor may be present, shortness of breath, and high pitched crying (infants). may be problems sustaining phonation
126
what is laryngomalacia?
Soft laryngeal cartilages . May collapse into airway on inhalation. Resolves with maturation.
127
what are the endoscopic signs of laryngomalacia?
collapse of laryngeal cartilages in inspiration
enlarged/floppy arytenoid cartilages
excessive AC mucosa
128
what is leukoplakia and hyperkeratosis?
range from flat plaque-like whitish patches (leukoplakia) to warty lesions (keratosis). Arise from epithelium.
129
what is the cause of leukoplakia and hyperkeratosis?
Constant irritation to VFs from Smoking, Alcohol ingestion, GERD or LPR, environmental pollutants, coughing/throat clearing
130
what is the characteristics of leukoplakia and hyperkeratosis?
Can be unilateral or bilateral and VF edges may be rough. Increases VF mass and stiffness, decreases mucosal wave and amplitude, irregular glottic closure, aperiodicity, VFs are asymmetric
131
what is sulcus vocalis?
A longitudinal groove or indentation in the upper edge of the VFs that parallels the free margins.
-In the SLP layer – causes a loss of VF tissue
132
what is the cause of sulcus vocalis?
1. Congenital
2. Related to phonotrauma
3. Related to smoking
4. Due to a ruptured VF cyst
133
what are the endoscopic features of sulcus vocalis?
- Incomplete glottic closure which is sometimes spindle shaped.
- Decreased mucosal wave & amplitude of vibration.
- Increased VF stiffness but decreased mass.
134
Ford Sulcus Classification (1996)
Type I – entire VF length into SLP only
Type 2a – entire VF length includes SLP up to the VL. Causes moderate dysphonia
Type 2b – entire SLP and VL and may involve TA muscle. Causes severe dysphonia.
135
what is laryngeal cancer?
90% are malignant squamous cell carcinomas & can be supraglottic, glottic and/or subglottic
136
laryngeal cancer symptoms?
Globus sensation – ‘full feeling’ in throat
May observe inhalatory stridor
Throat pain, painful swallowing, problems swallowing, shortness of breath, halitosis
137
Risk factors for laryngeal cancer?
Risk Factors – smoking, -alcohol, smoking & alcohol, environmental irritants, chemicals, smoking & asbestos
- Typical pt. – 60-65 y/o male -heavy smoker w/mod alcohol intake
- H & N cancers accounts for 2% - 5% of all cancers
- 1% of all cancer deaths are from laryngeal cancer
- 50% - 70% of all laryngeal cancer deaths are associated w/ smoking
- Alcohol & smoking increase risk up to 22x’s !!!!
- Male to female ratio 5 to 1 (1985) – but is increasing
138
Neurological Voice Disorders: what are the disorders related to adduction/abduction?
- VF paralysis
- VF paresis
- SLN paresis
- adductor spasmodic dysphonia
- Huntington's chorea
139
Neurological Voice Disorders: what are the disorders related to stability problems?
- Parkinson's, ALS
| - Essential tremor
140
Disorders: what are the disorders related to coordination problems?
abductor spasmodic dysphonia?
141
What are the causes of bilateral VF paralysis?
- Iatrogenic (surgical trauma) 44%
- Malignancies-17%
- Intubation -15%40
- Progressive neurological disorders – 12%
- cerebral damage
- damage to brainstem in area of CN X
142
Bilateral paralysis information
According to Aronson and Bless(2009), site of lesion determines whether the VFs are paralyzed in the abducted or adducted position. Bilateral lesions of the RLN will result in bilateral paralysis of the PCA muscle and the VFs will be in the adducted position, while bilateral lesions to CN X above the origin of the pharyngeal, SLN and RLN branches will result in bilateral VF paralysis of the TA, LCA and IA muscles and the VFs will be in the abducted position. Voice quality and presence of aphonia will depend on VF position. Hypernasality may be observed if site of lesion is above the pharyngeal branch of CN X.
When the site of lesion is above the branches of CN X and the VFs are paralyzed in the abducted position, airway protection is compromised and swallowing and respiratory safety are the primary concerns. When the lesion is below the branching in the RLN and the VFs are paralyzed in the adducted position, voice is functional but respiration is compromised.
143
Unilateral paralysis causes
- 50 % Iatrogenic (surgical injury)
- 36 % Idiopathic
- 24% Other : extralaryngeal tumor, intubation, viral
144
Unilateral VF paralysis information
complete immobility or paralysis of one VF. The most common cause is injury to the RLN from surgery. The RLN provides innervation to the TA, LCA, IA and PCA muscles. Diagnostics include videstroboscopy. Electromyography, a technique which measures muscle activity, may be performed to confirm the paralysis. If the etiology of the paralysis is unknown, then an MRI may be ordered to rule out the presence of tumors or other structural changes that may be impinging on the nerve. When a nerve is injured during surgery, there is a possibility that it may recover and regenerate. Recovery time is 8 – 12 months.
145
True or false?Unilateral Vagus Nerve (CN X) lesions account for 90% of unilateral VF paralysis and cause flaccidity, decreased tone, & dysphagia
true
146
True or false? Common cause of unilateral VF paralysis is disease or trauma to RLN, w/ injury to left RLN more common than to right
true
147
True or false? unilateral brainstem strokes, unilateral trauma to RLN, or viral infections are causes of unilateral VF paralysis
true
148
unilateral VF paralysis/paresis information
Affected VF is usually in paramedian position
Regarding vibration,
1) VFs may have some anterior approximation
2) Healthy VF sometimes crosses midline to aid adduction
3) Airflow sets affected fold into vibration
4) Bernoulli Effect aids in VF closure
Voice is hoarse, breathy, weak, sometimes strained
Spontaneous Recovery: In cases of trauma to RLN, time frame is 8-9 months or up to a year. Corrective surgery not considered til after this time
149
What are you looking for with unilateral paralysis?
Muscle tension – secondary to paralysis
Intrinsic - A-P or medial-lateral compression, supraglottic sphinctering
Extrinsic – elevated larynx, neck tension
150
SLN paralysis causes
Most common cause: thyroid surgery, can be unilateral or bilateral, BUT may also be due to virus. Results in paralysis of CT muscle
151
SLN paralysis videostroboscopy characteristics
- Ascending and descending pitch glides
- Look for rotation of posterior glottis to affected side
- Look for difference in vertical level of VFs
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SLN paralysis effect on phonation
inability to raise pitch
- decreased pitch range
- decreased VF closure
153
SLN paralysis effect on phonation
- inability to raise pitch
- decreased pitch range
- decreased VF closure
154
VF paresis is not usually underdiagnosed. True or false?
False. is often masked by laryngeal muscle tension
155
VF paresis causes.
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Neuropathy
Goiter / Thyroiditis
Idiopathic
Viral
Trauma
Lyme’s Disease
Stroke
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156
VF paresis videostroboscopy tasks?
- Rapid repeated ‘ee’
- Repeated ‘ee-hee-
- ‘pa, ta, ka’
- Whistling
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VF paresis videostroboscopy characteristics?
- nodules or cysts
| - inadequate or variable glottic closure
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Presbyphonia or Presbylaryngis means what?
aging voice
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Causes of Presbyphonia or Presbylaryngis?
- decreased innervation
- muscle atrophy=hypotonicity
- stiffer, thinner mucosa in males
- thicker, edematous mucosa in females
- ossification of cartilages
- loss of collagen & elastin fibers
- submucus glands atrophy
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Presbyphonia Videostroboscopic signs?
- Vocal processes prominence
- Atrophy and VF thinning
- VF bowing
- Glottic gap
- Decreased amplitude of vibration
- Edema
- Yellowish discoloration
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Presbyphonia perceptual characteristics?
- Breathy
- Low pitch
- Tremor
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what is Spasmodic Dysphonia – Focal Dystonia
abnormal movement with the VF adductor, abductor, mixed
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Spasmodic Dysphonia cause?
CNS lesion – possibly basal ganglia and supplementary motor areas
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Spasmodic Dysphonia effects on phonation?
Irregular, uncontrollable muscle movements disrupt VF vibration
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True or false? With spasmodic dysphonia you must differentially dx from vocal tremor and MTD
True
166
True or false? Spasmodic dysphonia affects men more, age of onset between 30-50 years, reported occurring after URI, laryngeal trauma, vocal or emotional stress
False - women
167
describe spasmodic dysphonia when it involved the adductors
VF adductors (LCA, IA, TA) spasm periodically causing undesired hyperadduction. Result is harsh, strained, strangled sound with obvious effort. Most common.
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describe spasmodic dysphonia when it involved the abductors
VF abductor (PCA) spasms and abduct VF causing a breathy, hoarse, weak voice, decreased loudness is a problem.
169
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Do these symptoms describe SD adductor or SD abductor?
-Breathiness
-Phonation breaks
-Difficulty transitioning from
voiceless stops to vowels
-Pitch breaks
-Prolonged vowels
```
abductor
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Do these symptoms describe SD adductor or SD abductor?
- Strain – struggle -Phonation breaks
- Pitch breaks
- Hoarseness & breathiness
- Harshness
- Vocal effort
adductor
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What is the cause of essential tremor?
CNS lesion, likely extrapyramidal system
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essential tremor is characterized by what?
-Tremor, frequency & intensity modulations
-Voice stoppages
-Strain – struggle
-Harshness
- monopitch
-steady fluctuations in loudness and pitch.
Tremor causes phonatory instability.
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SD or Vocal Tremor or Muscle Tension Dysphonia? How do you differentially diagnose?
Step one – Perform laryngeal palpation
Step two – Perform laryngeal massage and teach supraglottic relaxation exs.
-If dx is MTD, voice will improve significantly
-If dx is tremor, tension / strain-strangle quality will decrease and only tremor will be present
-If dx is SD, very little change will be observed. Also – MTD is consistent, SD is not
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what is Pseudobulbar Palsy?
results in a hyperkinetic spastic dysarthria where muscle weakness and spasticity co-exist. Thus, there is both hyperadduction and incomplete VF closure.
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what is Pseudobulbar Palsy effects on phonation?
Laryngeal muscle weakness and hyperactivity co-exist causing both hyperadduction and incomplete closure
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what is Pseudobulbar Palsy perceptually characterized by?
- Breathiness
- Strain / struggle
- Harshness
- Monopitch
- Monoloudness
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What are the 3 primary components to vocal hygiene?
1) Maintain the vitality of the vocal fold mucosa! Avoid trauma to the mucosa
2) Treat the muscles of the vocal mechanism like any athletic mechanism
3) Use the mechanism wisely
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Why is hydration important, and how can you increase hydration?
Hydration is the most important concept.
The mucosal covering of the vocal folds must be wet and slippery in order to vibrate optimally.
Drink 8-10 glasses per day
Water can be anything except caffeinated and alcoholic beverages, or dairy
Use a room humidifier, or a facial steamer
AVOID mentholated lozenges
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what are vocal hygiene risks?
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Voice Usage –
1) types of voice use
2) amount of voice use (vocal demands)
Caffeine and Alcohol use
Smoking
Hydration
Recreational drugs
Food intake
Types of exercise
Amount of sleep
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What are the reflux management components?
1) caffeine
2) alcohol
3) chocolate
4) onions and garlic
5) citrus and tomato
6) hot spicy foods and fatty, greasy foods
Eat 3-4 hours before bed – no less !!
Don't overeat
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what are the components of vocal history?
-Prior voice problems or voice therapy
-Prior vocal training for speech or singing
-Onset & duration of vocal problem – gradual or sudden?
-Current daily vocal demands
-Sensory symptoms and laryngeal or neck pain
Pain : Where, what type, when and how often and severity
-Changes in voice over the course of the day/week or during different types of usage or duration of usage.
-What are coping strategies?
-Vocal Hygiene
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How do we assess breathing?
1 ) Observe patient’s breathing pattern while engaged in spontaneous conversation during hx intake and during assessment tasks, also observe while they are sitting quietly.
2) Have patient stand and speak spontaneously, place one hand on abdominal wall and the other on the lower back., then place hands on lateral ribs.
3) Singers and other professional voice users: repeat #2 during singing, acting monologue, comic routine, broadcast text etc.
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what are the important medical history information for voice?
Prior surgeries
Current medical conditions or diseases
Physical disabilities – hearing, vision, sensory, postural (back, neck, shoulder problems)
Allergies
Current medications, supplements, herbs etc
IMPORTANT: Respiratory conditions,
cardiac conditions or surgery, hx of reflux and allergies, surgeries involving neck, thoracic cavity, oral cavity, pharynx, palate, nasal cavities, abdominal musculature, back or shoulders, lung lobectomies, neurological problems
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What are the goals of voice assessment?
Explain findings to pt. and compare with normal voice production
Obtain client’s perception of voice and their perceived handicap to establish realistic goals
Determine if pt is mentally and physically able to engage in tx process, i.e., physical stamina and motivation
Outline treatment plan, if appropriate (discuss rationale and timing)
Address client concerns/questions and develop good relationship w/ pt.
NOT to make medical diagnoses – the ENT makes the Medical dx
We may aid ENT in differential dx as well as identification of contributing and precipitating factors
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what do we assess when palpating for laryngeal muscle tension? AND are they speaking or singing for assessment?
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laryngeal height
2) Thyrohyoid space
3) Thyrohyoid muscles
4) Suprahyoid muscles – FOM muscles
5) Laryngopharyngeal constrictors
6) Base of tongue BOT)
Jaw tension – palpate masseter
Neck and shoulder tension – check ROM and palpate muscles
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-They are speaking and singing
CD 661 Voice Disorders
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