1
Q
Ventilation
A
process of moving air into and out of the airways and lungs in order to exchange oxygen and carbon dioxide
2
Q
Respiratory System Anatomy
A
- pulmonary apparatus
- chest wall
- muscles
3
Q
Pulmonary Apparatus
A
O2 inhaled into lungs and then carried to all cells in the body; CO2 is carried from body to lungs and exhaled
- consists of
- trachea*
- bronchi*
- bronchioles*
- alveoli
- lungs - bronchial tree
4
Q
Bronchial Tree: Trachea
A
- 10-16 cm long
- 2-2.5 cm diameter
- inside lined with cilia (filtering system to clean air entering lungs)
- splits into two branches, primary bronchi
5
Q
Bronchial Tree: Bronchi
A
- Primary bronchi (one in each lung)
- Secondary Bronchi
- Tertiary Bronchi
Keep subdividing until divide into bronchioles (no cartilage, just smooth muscle); branch into terminal bronchioles (respiratory bronchioles)
6
Q
Alveoli
A
- Respiratory bronchioles open into alveolar ducts
- each duct leads to an alveolus
- tiny air-filled sac- approx. 480 million in adult lung
- filled with surfactant
- exchange of O2 and CO2 takes place here
7
Q
Lungs
A
-porous and elastic (size and shape changes)
-asymmetrical, right lung larger than left
(R=three lobes, L=2 lobes)
-pink in infants
-gray-black color in adults
8
Q
Chest Wall
A
- Houses the pulmonary apparatus
- consists of
- rib cage*
- abdominal wall
- abdominal contents
- diaphragm* - thoracic cavity
9
Q
Rib Cage
A
- 12 ribs on either side
- attached to sternum, cartilage
10
Q
Abdominal Wall
A
Forms the boundaries of the abdominal cavity
11
Q
Abdominal Contents
A
includes all organs within the abdominal cavity
- stomach
- intestines
- lower esophagus
- colon
- appendix
- liver
- kidney
- pancreas
- spleen
12
Q
Diaphragm
A
- forms the roof of the abdominal cavity and the floor of the rib cage
- large dome-shaped muscle stretching from one side of the rib cage to the other
- shaped like a inverted-bowl when relaxed, flattens when contracted (lowers rib cage)
- important for breathing AND for speech
13
Q
Muscles of Respiration
A
- External intercostal muscles
- Internal intercostal muscles
14
Q
External Intercostals
A
11 muscle pairs that run between the ribs. fibers run downward and forward. functions to pull up and elevate rib cage
15
Q
Internal Intercostals
A
11 muscle pairs located underneath the external intercostals. fibers run downward and backwards (at a right angle to that of external ICs). function to pull down and lower rib cage
16
Q
Accessory Muscles of Respiration
A
extra muscles (neck, thorax and abdominal) that may be recruited during respiration
17
Q
Pleural Linkage
A
Pleural linkage is an external force needed for respiration
It is created by the linkage between the lungs and the thorax:
-each lung is covered by a membrane (visceral pleura)
-inner surface of thorax is lined with a membrane (parietal pleura)
-between the two membranes is a small space (pleural space)
-the difference between the pressure inside the lungs (alveolar pressure) and pressure in pleural space(intrapleural pressure) is called transpulmonary pressure
-intrapleural pressure is negative, transpulmonary pressure is positive, and alvolar pressure changes from slightly positive to slightly negative as a person breathes
18
Q
Moving Air Into and Out of the Lungs
A
- air moves in and out of the lungs by increasing and decreasing air pressure in the lungs
- known as inhalation (inspiration) and exhalation (expiration)
19
Q
Inhalation
A
when palV is negative, air is forced to enter lungs (moves from high to low pressure)
- to decrease Palv, volume of lungs and thoracic cavity must be englarged
- done by contracting diaphragm (increases vertical dimension of thorax) and external intercostal muscles (pull rib cage upwards)
- lunge expand–> Palv below Patmos–> air from atmosphere flows into respiratory system via mouth or nose
- done by contracting diaphragm (increases vertical dimension of thorax) and external intercostal muscles (pull rib cage upwards)
20
Q
Exhalation
A
When Palv is positive, air moves out of lungs.
To increase Palv, volume of lungs must decrease
-done by relaxing diaphragm (decreases vertical dimension of thorax) and internal intercostal (return rib cage to original position)
-Lungs decrease–> Palv rises above Patmos –> air (containing CO2) from body atmosphere flows out of the lungs and respiratory system via mouth or nose
21
Q
Rate of Breathing
A
- measured in breath per minute (BPM)
- Born with a very high rate of breathing 40-70 BPM
- decrease as a child matures into an adult: 12-18 BPM
- due to anatomical and physiological changes (increase in alveoli number and size)
- also due to maturation of the nervous system
22
Q
Lung Volumes and Capacity
A
- lung volume refers to the volume of air inside the pulmonary apparatus
- movements involved in respiration can cause a change in lung volume by moving air into or out of the pulmonary apparatus
- 4 lung volumes and 4 lung capacities
23
Q
Resting Expiratory Level (REL)
A
- state of equilibrium in the respiratory system–air does not go in or out
- occurs when palv=patmos
- occurs at the end of every breath in and every breath out (brief instant)
- lung volumes and capacities are measured in relation to REL, and expressed in liters or milliliters
24
Q
Lung Volumes
A
- Tidal Volume (TV)
- Inspiratory reserve volume (IRV)
- Expiratory Reserve volume (ERV)
- Residual volume
25
Tidal Volume (TV)
air volume inhaled and exhaled during a respiration cycle
26
Inspiratory Reserve volume (IRV)
amount of air that can be inhaled above TV
27
Expiratory reserve volume (ERV)
amount of air that can be exhaled below TV
28
Residual volume
air remaining in lungs after maximum exhalation
29
Lung Capacities
- vital capacity (VC)
- functional residual capacity (FRC)
- inspiratory capacity (IC)
- total lung capacity (TLC)
30
Vital Capacity
volume of air that can be exhaled after max. inhalation (IRV+TV+ERV)
31
Functional Residual Capacity (FRC)
volume of air remaining in lungs at the end expiratory level (ERV+RV)
32
Inspiratory capacity (IC)
max. volume of air that can be inspired from end expiratory level (TV+IRV)
33
Total lung capacity (TLC)
total amount of air lungs can hold (TV+IRV+ERV+RV)
34
LIfe Breathing
unconscious process determined by needs of body at particular time
Ex. take in greater amounts during vigorous exercise vs quite breathing
35
Speech Breathing
life breathing+ linguistic considerations
36
Linguistic Considerations
- continuous vs. intermittent
- scripted vs. unscripted
- quite vs. loud
- level of emotion, mood, excitement
both inspiration and expiration is influenced by linguistic factors
37
Inspirations
- timing of inspirations (most likely to occur at end of linguistic structural boundaries)
- inspirations are larger/deeper when followed by longer breath groups
38
Expiration
- expiration containing more speech units end with smaller lung volumes
- silent pauses when linguistic expectations are high
39
1. Location of air intake
| life breathing vs. speech breathing
- intake and exhale through nose for life breathing
- inhale and exhale through mouth for speech breathing
- speech breathing entails quicker inhalation
- speech breathing entails production of oral sounds on exhalations
40
2. Ratio of time for inhale vs. exhale (I/E Ratio)
| life breathing vs. speech breathing
-life breathing= 40%-60%
-speech breathing= 10%-90%
speech produced on expiration
-exhale during speech breathing up to 25 sec
-exhale during life breathing up to 2 sec
41
3. Volume of air
| life breathing vs. speech breathing
- life breathing tidal volume= 500ml, 10% of vital capacity
- speech breathing tidal volume is variable, depending on length and loudness of upcoming utterance, approx 20-25% of vital capacity
42
4. Muscle activity for exhalation
| life breathing vs. speech breathing
- for both life breathing and speech breathing inhalation is a possessive process
- for life breathing, exhalation is also possive
- for speech breathing, exhalation is active
43
5. Chest wall position
| life breathing vs. speech breathing
- relative to rib cage, abdomen displaced outward in life breathing
- relative to rib cage, abdomen displaced inward in speech breathing
44
Conversational Interchange and Speech Breathing
The behavior of one conversational partner influences the behavior of the other conversational partner
45
Long-Term Oscillations
Ventilation patterns of each conversational partner become more similar
46
Short-Term Oscillations
Breathing movements during listening align with speech breathing movements of conversational partner.
47
Age and Speech Breathing
- changes in structures and functions of breathing apparatus with age
- major changes in speech breathing occur in 7-8 decade of life
- speech breathing becomes less economical. Three major changes:
1. start from larger lung volumes
2. use more of the vital capacity
3. expend more air per syllable production
48
Spirometer
- tool for measuring the movement of air into and out of the lungs (ventilation)
- results displayed on a spriogram
- identifies abnormal ventilation patterns resulting from respiratory disorders
49
Classification of Respiratory Disorders
1. Obstructive
2. Restrictive
3. Central
50
Obstructive Respiratory Problems
- narrowing or blockage of airway due to foreign body, inflammation, or muscle spasms
- symptoms: coughing, shortness of breath, chest tightness
- examples: asthma, bronchitis, emphysema
51
Restrictive Respiratory Problems
- restrict lung expansions and are characterized by reduced lung volume
- symptoms: difficulty expanding lungs, reduced lung volume, chest pain, dry cough, wheezing, shortness of breath post-exercise
- example: pneumonia, neuromuscular diseases (parkinson's)
52
Central Respiratory Problems
- neurological dysfunction in the respiration brain centers in the brainstem
- symptoms: hypoventilation (inadequate ventilation)
- examples: drugs, stroke, brain tumor
53
Symptoms of Respiratory Disorders
1. Dyspnea
| 2. Stridor
54
Dyspnea
Perceived breathing discomfort in breathing that can vary from mild to extreme
- individual may perceive the sensation as SOB, the need to work harder, and/or chest tightness
- may occur during speech (speech-related dyspnea)
- sometimes occurs in healthy individuals during times of high stress or emotion
55
Stridor
- audible sound that occurs during inspiration and/or expiration
- results from turbulent air flow as it passes through a narrowed or obstructed segment in the airway
- the sound may be high or low pitched
- inspiratory stridor most common type
56
Speech Breathing Disorders
Potential professional involvement
- pulmonologist
- respiratory therapist
- neurologist
- physical therapist
- speech language pathologist
- psychologist
57
Principles of Clinical Management
| in Speech Breathing Disorders
1. Amount of air needed to produce speech is approximately 20% of vital capacity, but this air must be managed efficiently for speaking purposes.
2. Treatment MUST ALWAYS be tailored to the individual patient and their specific respiratory difficulty.Respiratory symptoms may arise from different origins.
3. Treatment sequence should always run from: pressure variables -> volume variables ->chest wall shape
4. Treatment exercises should be practice in speech contexts rather than nonspeech contexts.
58
Some Clinical Conditions that
| Affect Speech Breathing
* Neurological Disorders:
* Parkinson’s Disease
* Cerebellar Disease
* Cervical Spinal Cord Injury
* Cerebral Palsy
* Voice Disorders
* Asthma
* Paradoxical Vocal Fold Motion
59
Parkinson’s Disease (PD)
```
Progressive neurological disease characterized by muscle
rigidity (restricts ROM), resulting in speech that is
characterized by:
- Monopitch, lower than normal pitch
-Imprecise articulation
- Variable speech rate
- Breathy and weak voice quality
- Monoloudness, low vocal intensity
```
60
PD vs. Healthy Controls:
| Resting Tidal Breathing
• Faster breathing rate.
• Greater minute ventilation.
• Smaller relative contribution of the rib cage to lung
volume.
61
Three Functions of The Larynx
1. Breathing
2. Voicing/Phonation
3. Airway protection
62
Larynx includes:
```
1. Laryngeal skeleton
• 1 bone
• 3 unpaired cartilages
• 3 paired cartilages*
2. Laryngeal joints
3. 3 pairs of soft tissue folds
4. Extrinsic laryngeal muscles
5. Intrinsic laryngeal muscles
```
63
Laryngeal Skeleton: Hyoid bone
Small U-shaped bone that attaches to tongue, and to the larnyx via the hyothyroid membrane
• Body up front and major horns forming long sides of the U
• Each major horn has a small protrusion, the minor horn
64
Laryngeal Skeleton: Thyroid Cartilage
Largest cartilage of the larynx. Formed by two plates
fused in the middle (laryngeal prominence/Adam’s apple).
Superior and inferior horns. Vocal fold attached to inner
surface. Unpaired.
65
Laryngeal Skeleton: Cricoid cartilage
Cartilage ring. Narrow in front and larger at back. Located below thyroid. Unpaired.
66
Laryngeal Skeleton: Epiglottis
Elastic cartilage flap. Attached to inner surface of thyroid cartilage (thyroepiglottic ligament) and body of hyoid bone
(hyoepiglottic ligament). Important for swallowing—covers larynx to keep airway clear from food and liquid. Less
important for voice. Unpaired.
67
Laryngeal Skeleton: Arytenoid Cartilages
Pair of small pyramid-shape structures located on superior surface of cricoid. Attached to the vocal cords, which allow and aid in the vocal cords' movement.
Crucial role in voice production.
68
Laryngeal Skeleton: Corniculate Cartilages
Small, elastic pair of rods located at apex of arytenoids (not present in everyone). Not necessary for voice production.
69
Cuneiform Cartilages
Pair of small, club-shaped cartilages. Lie anterior to the corniculate cartilages. Form small, whitish elevations on the surface of the mucous membrane just anterior of the
arytenoid cartilages.
70
Laryngeal Joints: Cricoaryenoid joints
Attach to base of each arytenoid and to superior surface of cricoid. Joints are diarthrodial, enabling a wide range of
movement (side to side, back & fourth). Instrumental in vocal fold abduction and adduction.
71
Laryngeal Joints: Cricothyroid joints
Located between each inferior horn of the thyroid and the sides of the cricoid. Enables movement of either cricoid or thyroid cartilages. Distance between
arytenoids and front of thyroid increases, stretching VFs
Main agents of F0 regulation in speech
72
Soft Tissue Folds: Aryepiglottic folds
```
Most superior of the soft tissue folds
◦ Run from epiglottis to arytenoid apex
◦ Contract to pull epiglottis backward and close larynx
entrance
◦ Primary function: Airway protection
```
73
Soft Tissue Folds: Ventricular folds
Also known as false vocal folds
◦ Inferior to aryepiglottic folds, superior to true VF
◦ Close during swallow, open during phonation
◦ Primary function: Airway protection
◦ Minimal role in phonation
74
Soft Tissue Folds: True Vocal Folds
```
Also known as vocal cords
◦ Most complex of soft tissue folds
◦ Stretch horizontally across the larynx
◦ Vibrate, modulating air flow for speech
◦ Primary function: phonation
◦ Consist of five layers
```
75
True Vocal Fold Layers
1. Epithelium: Thin shell which maintains shape of the VFs
2. Superfical layer: (aka Reinke's space); fibrous
components provide strength and resilience so VFs may
vibrate freely but still retain their shape
3. Intermediate layer: elastic fibers provide support to
VFs
4. Deep layer: collagen fibers provide support to VFs
5. Vocalis muscle: (aka thyroarytenoid); main body of VF
76
Glottis
The space between the true VFs
• Shape varies, depending on VF positioning
• Figure 5.10, p. 160
77
Extrinsic Laryngeal Muscles
```
One point of attachment within larynx and one point outside larynx
• Strap muscles
• Anchor larynx within neck
• Consists of infrahyoid and
suprahypid muscles
```
78
ELM: Infrahyoid Muscles
```
Infrahyoids pull larynx downward (external attachment point
BELOW hyoid bone):
1. Sternohyoid
2. Sternothyroid
3. Omohyoid
4. Thyrohyoid
```
79
ELM: Suprahyoid Muscles
```
Suprahyoids pull larynx upward (external attachment point
ABOVE hyoid bone):
1. Digastric (A & P)
2. Stylohyoid
3. Mylohyoid
4. Geniohyoid
```
80
Intrinsic Laryngeal Muscles
1. Lateral cricoarytenoid (LCA): adductor
2. Interarytenoid (IA): adductor; unpaired muscle; two bundles of muscle (transverse and oblique portions)
3. Posterior cricoarytenoid (PCA): abductor
4. Cricothyroid (CT): elongates the vocal folds; increases tension and increases pitch
5. Thyroarytenoid (TA): body of vocal fold (5 layers); thyromuscularis (lateral fibres); thyrovocalis (medial fibres)
81
Myoelastic-Aerodynamic Theory of
| Phonation
Most widely accepted theory of phonation/voice production
- Describes phonation as an interaction of muscle force (myo), tissue elasticity (elastic), and air
pressures and flows (aerodynamic)
82
Bernoulli Effect
As the velocity of a gas increases its pressure decreases:
| Application to VF movement:
83
Additional Facts
• One opening/closing of the glottis constitutes one
cycle of VF vibration
• Cycle of vibration conceptualized in 4 stages of
movement: opening, open, closing, closed
• During speech, VF open/close hundreds of times per
second
84
Mucosal Wave
- VFs open from bottom to top
- VFs close from top to bottom
Vertical phase difference: timing lag between opening and closing of superior and inferior portions.
- VFs open from back to front
- VFs close from front to back
Longitudinal phase difference: timing lag between opening and closing of anterior and posterior portions.
Vo
85
Voice Quality
* Harmonics correspond to vocal quality
* Quality can distinguish speakers
* Dependent on three primary factors:
86
1. Vocal folds vibrate
| Voice Quality
◦ Hyperadducted: excessive medial compression
| ◦ Hypoadducted: insufficient medial compression
87
2. Velopharyngeal Valving
| Voice Quality
• Hypernasality: excessive nasal resonance from
inadequate VP closure during oral sounds
• Hyponasality: insufficient nasal resonance from
conditions that prevent airflow through nasal cavities
88
3. Vocal tract shape and configuration
| Voice Quality
Length of vocal tract
◦ Degree of arching of hard palate
◦ Size of oral cavity relative to pharyngeal cavity
89
Normal Voice
```
Depends on:
Sex
Gender
Age
Build
Culture
Region
Personality
Degree of voice use
Health of speaker
How voice is used
Normal V
```
90
Normal Voice Quality Parameters
- Maximum frequency range:
- Speaking F0
- Maximum phonation time*
- Minimum-maximum intensity at various F0 levels
- Periodicity of vibration
- Noise generated by turbulent airflow
91
Abnormal Voice Qualities
Aphonic
- Perception: no sound or whisper
- Physiologic Components: inability to set vocal
92
Acoustic Measurement of Phonation
1. Frequency measures
2. Intensity measures
3. Perturbation measures
93
Average Fundamental Frequency (F0)
```
• Rate of vocal fold vibration
• depends on length, tissue density & tension
• Corresponds to voice pitch
• Averages:
• Children = 250-300Hz
• Adult Females = 180-250Hz
• Adult Males = 80-150Hz
• Measured during sustaining vowel, reading aloud, or
conversational speech
```
94
Frequency Variability
* F0 constantly changing
* Emotions, mood, social context, grammatical functions, etc.
* Contributes to prosody (melody)
* F0 standard deviation (SD)
* Normal speech = 20-35Hz
* F0 range
* Children higher range than adults
* Females have higher range than males
* Monotone: Reduced ability to vary pitch
95
Average Amplitude Level
Overall level of amplitude
• Corresponds to voice loudness
• Levels depend on speaking situation
• Chatting in classroom vs. cheering at football game
• Normal conversation = 60-80 dB SPL
• Same for adults (males & females) and children
• Measured during sustaining vowel, reading aloud, or
conversational speech
96
Amplitude Variability
Changes depending on many factors
• Mood, message being conveyed, social context, etc.
• Conveys interest in voice
• Greater excitement/enthusiasm, greater variability
• Amplitude standard deviation (SD)
• Neutral, unemotional sentence = 10 dB SPL
• Monoloudness: Reduced ability to vary loudness
(sound flat)
97
Jitter & Shimmer
• Cycle-to-cycle differences in the frequency (jitter) and
amplitude (shimmer) of each cycle of VF vibration
• To little jitter & shimmer in the voice results in the
perception of unnaturalness
• Normal voice = approx. 1% jitter
• Noraml voice = approx. 0.5dB shimmer
• Calculated using software programs
• E.g., Praat, Kay Pentax
98
Electroglottography (EGG)
• Also called laryngography
• Non-invasive tool to evaluate VF function
• High-frequency current passed through two surface
electrodes placed on either side of thyroid cartilage
• Tissue conducts electricity well
• VF closed, resistance is low
• VF open, resistance is high
• Changing resistance as glottis opens/closes is displayed
on screen as waveform
99
Videostroboscopy
```
• A scope is inserted in pharynx to show details of
larynx structure and function
• Via mouth (rigid) or nose (flexible)
• Image projected to video monitor
• Patient is awake
• Patient produces /i/ vowel
```
100
Videostroboscopy
| Parameters
```
Vocal fold edge
• Glottic closure
• Extent of opening
• Phase closure
• Mucosal wave
• Amplitude of vibration
• Phase symmetry
• Periodicity/Regularity
• Nonvibrating portion of vocal fold
```
Vocal fold edge: smoothness/roughness of medial VF
margins
Glottic closure: degree and pattern of closing during
vibration cycle (complete/incomplete, posterior/anterior
gap)
Extent of opening: How open?
Phase closure: relative duration of open/closed
phrases of vibratory cycle
Mucosal wave: is this taking place correctly
Amplitude of vibration: extent of lateral excursion
of VF
Phase symmetry: degree to which VF mirror each
other during vibration (constant/intermittent)
Periodicity: degree of consistency from one vibratory
cycle to the next
Nonvibrating portion of vocal fold: any portions
that do not vibrate?
101
Acoustic & Visual Analysis
What is the best way to capture the many
characteristics of voice production?
• Is there just one measure that could do it all?
• What combination of measures provides the most
(essential) information for diagnosing and managing
voice disorders?
102
Gold-standard
-A combination of “seeing” and “hearing”
-A visual image and acoustic measures (F0, intensity,
perturbation measures) made from the voice sample.
103
Changing F0
* Newborn F0 = 400-600 Hz
* Pre-teen F0 = 230-250 Hz
* Puberty F0 = differential change in F0
* Males decrease more than females
* Adult F = 180-250 Hz
* Adult M = 80-150 Hz
* Aging F0 = differential change in F0
* Men increase in F0 due to a thinning of VFs
* Women decrease in F0 due to increased VF mass
104
Laryngeal Aging
Presbylaryngis: Aging of laryngeal mechanism
(natural degeneration).
• Presbyphonia: Vocal changes resulting from the aging
process.
105
Common Complaints about the
| Aging Voice
* Pitch changes
* Reduced volume
* Decreased ability to project voice (thin voice)
* Difficulty being heard in noisy situations
* Breathiness
* Reduced vocal endurance (vocal fatigue)
* Tremor or shakiness in voice
* Singing difficulties (decreased pitch range)
106
Three primary types
```
1. Organic
• Structural
• Neurogenic
2. Functional
3. Psychogenic
```
107
Organic Voice Disorders:
| Structural
* Caused by some lesion of the larynx
* Nodules
* Polyps
* Reinke’s Edema
* Papilloma
* Contact Ulcers
* Granuloma
* Cysts
108
Vocal Nodules
• Benign mass of tissue on vocal folds (small pink/gray
protrusion)
• Junction of anterior 1/3 and posterior 2/3 of VFs
• Bilateral
• Impair VF vibration (reduces or obstructs
the ability of the VF to create rapid changes in air
pressure)
109
Vocal Nodule: Cause
Excessive talking without resting voice
• Straining or unnatural use of the voice for long periods
• Screaming or yelling
• Loud talking in noisy environments
• Throat clearing or excessive coughing
• Abnormally low or high speaking pitch
• Poor breath support in speaking/singing
• Poor diet or health can be a contributing factor
110
Vocal Nodules: Symptoms
* Hoarseness
* Rough or scratchy voice
* Breathy voice
* Decreased loudness
* Increased vocal effort
* Painful speech production
* Frequent vocal breaks
* Reduced vocal range
111
Vocal Nodules: Treatment
• Voice therapy is often the first step in resolving
nodules
• Treatment usually 4-8 weeks
• Results may vary depending on how long the nodules
have been present and patient compliance with the
therapy program
• Surgical removal may be appropriate in some cases
112
Vocal Polyps
* Benign tumor on vocal folds
* Unilateral or bilateral
* Larger than nodules
* More pliable than nodules…like blisters
* Various forms:
* Stalk-like growth (pedunculated)
* Blister-based lesion (broad-based)
* Cause similar to nodules
* smokers polyps
* Symptoms same as vocal nodules
113
Treatment: Polyps
Does not usually respond to voice therapy (perhaps
short course to reduce swelling and irritation)
• Surgical removal in most cases
• Smoker's polyps are not likely to be removed unless the
individual stops smoking
• Voice therapy post-surgery to address underlying issue
114
Reinke’s Odema
```
• Swelling of the vocal folds
• Uneven, sac-like appearance
• Fluid collection (edema) in Reinke’s space (superficial
lamina propria).
• Caused by:
• Smoking
• Chronic vocal abuse and misuse
• Gastroesophageal reflux (GERD)
• Hormonal changes (e.g., pregnancy, thyroid disease).
```
115
Reinke’s Edema: Symptoms
Variable, depending on degree of swelling
• If minimal:
• slight decrease in pitch
• If moderate-severe:
• Significantly lowered pitch
• Vibration changes
• Severe hoarseness and roughness of voice
116
Reinke’s Edema: Treatment
* Surgical release and removal of fluid
| * Voice therapy post-surgery to address underlying issue
117
Papilloma
• Wart like lesions caused by virus
• Can occur anywhere throughout larynx and upper
airway
• Spread rapidly
• Tendency to reoccur
• Symptoms are severe hoarseness and breathiness
118
Papilloma: Treatment
• Surgical treatment is standard care.
• Goal to remove as much of the papillomatosis as possible
without scarring the vocal cords, which may result in
irreversible hoarseness.
• Voice therapy post surgery:
• Seven days complete vocal rest post-surgery.
• Then encourage optimal vocal quality
119
*Carcinoma (Laryngeal Cancer)
• Malignant tumor on vocal folds
• Unilateral or bilateral
• Most often the result of chronic irritation due to
cigarette smoke
• Often not detected until voice symptoms are present
• Symptoms similar to nodules
* ? Voice disorder
120
Carcinoma: Treatment
```
• Depends on the nature and severity of the cancer, but
treatment options include:
• Surgery
• Radiation
• Chemotherapy
• May require complete removal of larynx
(laryngectomy)
• SLP involvement in voice rehab post-surgery (voicing,
breathing, & swallowing)
```
121
Organic Voice Disorders:
| Neurogenic
```
• Caused by some problem in the nervous system as it
interacts with the larynx
• Paralysis/Paresis
• Spasmodic Dysphonia
• Voice problems caused by another
neurological disorder (e.g., PD, ALS)
• Tremor (Benign Essential Tremor)
```
122
Vocal Fold Paralysis/Paresis
* One of both VF do not move
* Bilateral VF paralysis: both VF in paramedian position
* Unilateral VF paralysis: one VF in paramedian position
* Results in gap between VF
* Disrupts vibration
* Allows air to leak through
* Paresis: some movement, but movement is reduced
123
Vocal Fold Paralysis: Causes
* Injury to VF during surgery
* e.g., damage to CN 10 (RLN)
* Neck or chest injury
* Stroke
* Tumors (brainstem, neck, chest, bronchi)
* Neurological conditions
* Neuritis
124
Vocal Fold Paralysis: Symptoms
```
Hoarseness
• Breathy voice
• Inability to speak loudly
• Limited pitch and loudness variations
• Voicing that lasts only for a very short time (1 sec)
• Choking or coughing while eating
• Possible pneumonia due to food and liquid being
aspirated into the lungs
```
125
Vocal Fold Paralysis: Treatment
Bilateral paralysis:
• Tracheotomy often required for airway protection (allowing
person to eat safely).
• Surgery to bring one or both vocal cords closer to midline.
• Unilateral paralysis:
• Medialization thyroplasty (move paralyzed VF toward midline),
or injection of a substance to increase size of paralyzed VF.
• Behavioral techniques with SLP (e.g., turning head to one
side).
126
Spasmodic Dysphonia
* Neurological movement disorder.
* Involuntary spasms of the vocal folds
* Laryngeal dystonia (focal)
* Three types:
* Adductor spasmodic dysphonia:
* Increased closing of the vocal folds.
* VF slam together and stiffen.
* Abductor spasmodic dysphonia:
* Increased opening of the vocal folds.
* Air escapes through VF.
* Mixed spasmodic dysphonia: very rare.
Gradual onset with no obvious explanation (no
structural abnormalities)
• No known etiology
• Spasms get worse when stressed
• Often mistaken for psychogenic voice disorder
• Rare disorder: 1-4/100,000 people
• Onset between 30-50 years of age
127
Spasmodic Dysphonia: Symptoms
• Adductor SD:
• Strained-strangled, tight voice
• Groaning and effortful speech
• Choppy speech (spasms interrupt speech)
• Abductor SD:
• Breathy, weak voice
• Pitch breaks
• Task-specific dysphonia: Spasms during attempts to
speak. Larynx functions normally during breathing and
swallowing
128
Spasmodic Dysphonia: Treatment
• No cure
• Botulinum toxin (Botox) injections into one or both
vocal cords (adductor)
• Blocks nerve impulse to the affected muscles à weakens
laryngeal muscles à smoother, less effortful voice
• SLP involvement following injections to optimize voice
production
• In serve cases, AAC devices may be used
129
Voice problems caused by another
| Neurological Disorder
Considered within the framework of motor speech
disorders:
• Classified according to site of damage/lesion.
• Neurological disorders associated with voice
disorders:
• Hypoadduction
• Parkinson’s disease
• Myasthenia gravis
• Hyperadduction
• Huntington’s disease
• Pseudobulbar palsy
130
Functional Voice Disorders:
• Caused by poor muscle functioning (nothing
structurally wrong with the voice i.e., no nodules,
polyps, paralysis, etc.). All functional disorders fall under
the category of muscle tension dysphonia.
• Muscle tension dysphonia (MTD)
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Muscle Tension Dysphonia (MTD)
```
• Laryngeal muscles not functioning properly despite
normal anatomy.
• Different patterns of muscle tension:
• Pharyngeal constriction
• Ventricular phonation
• Vocal fold bowing
• Hyperadducation*
• Hypoadduction*
```
132
MTD: Causes
• Prolonged illness.
• Continued voice use during laryngitis due to illness.
• Prolonged overuse
• Prolonged underuse (such as after a surgery)
• Trauma, such as an injury, chemical exposure, or
emotionally traumatic event
133
MTD: Voice Characteristics
• Rough, hoarse, raspy, coarse
• Weak and breathy
• Strained, pressed, squeezed, tight, tense
• Jerky and shaky
• Giving out gradually, or becoming weaker or more
tense as voice use continues
• Excessively high or low pitch
• Inability to produce a loud or clear voice
134
MTD: Treatment
• Voice therapy
• Very (very) occasional, medical or surgical treatments
may be used
135
Psychogenic Voice Disorders
Disordered voice in the absence of structural or
neurological pathology to account for the dysphonia
• Conversion dysphonia or Aphonia
• Puberphonia (mutational falsetto)
136
Conversion Dysphonia/Aphonia
• Involuntary whispering (normal larynx)
• Results of psychological trauma/conflict
• Single traumatic event (e.g., accident, death) and voice
change within a short time
• Long term psychologically damaging circumstance
• Approx. 80% of patients with conversion dysphonia are
female (Aronson, p. 144)
• Voice therapy AND psychotherapy to address
underlying problem
137
Puberphonia/Mutational Falsetto
The persistence of adolescent voice even after puberty
• Resists the maturing and lowering pitch of the adult voice
(maintains higher pitch)
• Laryngeal capability of producing normal low-pitched
voice is present
• Vocal exercises with SLP to elicit a normally lowpitched
voice, but psychotherapy may be necessary to
maintain the more adult voice quality
138
Mutism
Most severe of psychogenic voice disorders
• Patient makes no attempt to phonate or articulate, or may
articulate without exhalation
• Selective mutism: does not speak in specific situations or
to specific people
• Characteristics:
• Indifference to the symptom
• Chronic stress
• Depression (mild to moderate)
• Suppressed anger
• Immaturity and dependency
139
Voice Therapy: General Goals
To rehabilitate the patient's voice to a level of function
that enables the patient to fulfill his or her daily voice
and/or speech communication needs
• To help patient produce a voice of best possible pitch,
loudness, and quality (in relation to age/gender, etc.)
• To reduce or eliminate the voice disorder
• To prevent recurrence of the voice disorder
Speech Science Exam 1
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