1
Q
- List and describe the biological functions of the voice
A
The primary biological function of the larynx is airway protection. It prevents foreign items from entering the trachea and blocking it, protecting the airway from water, food, etc that would damage the lungs
2
Q
- List and describe the emotional functions of the voice
A
The voice conveys to listeners information about the emotions the speaker is experiencing (ex: sadness, happiness, fear).
3
Q
- List and describe the linguistic functions of the larynx:
A
The larynx provides linguistic information both in the way the voice sounds (emotion) and based on how stress and varying pitch are applied throughout an utterance.
4
Q
- What are the main categories of voice disorders (described in the Boone et al. text book)?
A
- Functional
- Organic
- Neurogenic
5
Q
- Describe at least one difference between each of the main categories of voice disorders?
A
Functional voice disorders result from damage do to how the voice is being habitually used. Organic voice disorders, in contrast, result from structural deviation or disease affecting the structure, and neurogenic result from some type of neurological damage
6
Q
- What is the incidence and Prevalence of voice disorders in the general population?
A
Lifetime, 30%. At one point in time, 7%
7
Q
- What is the incidence and Prevalence of voice disorders in Children?
A
As low as 4%, as high as 20-30%.
8
Q
What is the incidence and Prevalence of voice disorders in the elderly?
A
20-30%
9
Q
What is the incidence and prevalence of voice disorders in professional voice uses?
A
4%-57.7%
10
Q
Who manages voice disorders professionally?
A
? Counselor/psychologist (in psychogenic voice disorders), ENT, respiratory therapist, surgeon.
11
Q
- Can emotions challenge the normal voice? If so, how
A
. The voice conveys to listeners information about the emotions the speaker is experiencing. In cases of fear, for instance, this can cause the larynx to be raised. This raised larynx alters the sound of the voice, making it crackly, strained, etc
12
Q
- Name 4 contributing factors that are involved with the onset, maintenance, and rehabilitation of a voice disorder:
A
Guess:. Vocal hygiene, vocal quality, respiration, environmental factors
13
Q
- What two things can increased circulation with exercise potentially cause?
A
a. Greater mental strength
b. Increased physiologic power
14
Q
- Define the terms intrinsic and extrinsic factors as they relate to health, and give an example of each. (guess)
A
a. Intrinsic—factors in the body such as genetics
b. Extrinsic—external factors in the environment, such as second hand smoke exposure
15
Q
- Identify the importance of the case history process:
A
a. Gathering case history information helps you get a more full picture of the issue and select which tests to administer. Without gathering a case history, you could miss vital information, which could lead to a misdiagnosis.
16
Q
- Voice recovery can vary dramatically from person to person. List 5 factors that may contribute to recovery time.
A
a. Ability to heal
b. State of mind
c. Previous level of vocal use
d. Current demands of vocal use
e. Compliance with lifestyle and therapy demands
f. Choice of therapy
17
Q
- As a clinician what should you explain to the patient about the inhalation of cigarette smoke?
A
a. Cigarette smoke irritates the lining of the nose, throat, and lower airway resulting in decreased mucus, which causes inflammation of the upper and lower respiratory tract. This could be causing or exacerbating your voice issue. It can also lead to cancer and is highly addictive.
18
Q
- Define the term diuretic and give a common example of one agent classified as a diuretic.
A
a. A diuretic causes the body to expel liquids more frequently, thus possibly leading to dehydration if enough water isn’t consumed in compensation.
b. Coffee is a diuretic
19
Q
- Name 3 symptoms of vocal fatigue, identify who is susceptible to it:
A
i. Dysphonia
ii. Periods of voice loss
iii. Odynophonia—soreness or pain in the throat following prolonged voice use
b. Professional voice users most vulnerable (especially if using lower than natural pitch)
20
Q
- If a patient increased their water intake, explain the effect it will have on their body.
A
a. Body wide-better brain function, higher energy.
b. More fluid vocal fold movement resulting in less effort when voicing, less lung pressure needed to initiate voicing.
21
Q
- Explain the difference between external and internal hydration and what can you tell your patient’s about how to increase their hydration.
A
a. Internal hydration is the state of water balance in an individual.
b. External hydration is the layer of fluid that covers the vocal folds outer surface
c. Drinking more water can improve internal hydration, and avoiding smoking, breathing through your mouth, and inhaling dry air can improve external hydration.
22
Q
Compare an assessment and a screening
A
A screening is a very brief, pass/fail procedure that simply tells about if there is a concern about a possible issue which should be further examined. An assessment is a much longer, more detailed procedure which includes both non-instrumental and possibly instrumental voice eval.
23
Q
- What should be included in the history and physical examination of a patient with a voice disorder? What are a few questions you may expect to ask in the history portion of your non-clinical assessment?
A
A case history should include a description of the problem and cause, the onset and duration of the problem, variability of the problem, description of vocal demands, as well as additional information such as family history and previous exposure to therapy.
24
Q
- What are the different laryngeal examination methods? What are the advantages and disadvantages? Do some appear more instrumental rather than non-instrumental?
A
Auditory perceptual ratings, which include: Voice handicap index, Consensus Auditory-Perceptual Evaluation of Voice, and the oral mech exam, which includes visual examination of the larynx through laryngoscopy, laryngeal stroboscopy, etc.
25
4. What does a laryngologist specialize in? What is their role as it relates to voice disorders?
Diagnosing laryngeal pathology. They look at the anatomical structure and refer to SLPs who then treat the voice disorder. Or, SLPs refer to them to look at the structure and make a diagnosis before SLPs continue with treatment.
26
5. What is the role of the speech language pathologist as it relates to voice disorders?
SLPs diagnose voice disorders along with the ENT? and do therapy to help improve the disorder.
27
6. Give 3 examples of professionals who would be on a voice care team?
* ENT
* SLP
* Primary Care Physician
28
Describe the importance of collecting a clinical case history
: The case history helps gather information which is valuable to identifying the issue and if it is functional in nature. It helps with narrowing down and forming a hypothesis about where the pathology may be.
29
8. Provide 5 examples of important items gathered during the data collection phase of the evaluation
a. Lung capacity
b. S/Z ratio
c. Maximum Phonation Tme
d. Vocal perturbation measures
e. Vocal Noise Measures
30
Are behavioral observations important? Why or why not.
Yes. They tell a lot about patients, including how they interact with others, if they have anxiety that may be impacting their voice, etc.
31
10. What is the purpose of an oral peripheral examination with a voice assessment?
To determine if there are any structural abnormalities or neurological deficits which may be responsible for the voice issue and need to be examined more closely by an ENT.
32
11. What should the clinician pay specific attention to during an oral peripheral examination?
Neck tension, movement of the larynx, appearance of the structures
33
12. What distinguishes an oral peripheral examination from a cranial nerve examination?
An oral peripheral examination is concerned with the surface anatomy and any deviations from it. However, it can often include elements of a cranial nerve exam inside of it (I think). A cranial nerve exam is focused specifically on testing the functioning of the various cranial nerves through very specific tasks. It often involves asking the client to do something or creating some sort of sensation and seeing if it is received. It can also test reflexes, such as the gag reflex.
34
Cranial nerves involved with voice and their description
```
Cranial Nerve Major Function
CN VII Facial Motor: Face
Sensory: ant. 2/3 of tongue
CN VIII Vestibulocohlear Special sensory: hearing
CN IX Glossopharyngeal Motor: Pharynx
Sensory: post. 1/3 of tongue, pharynx
CN X Vagus Motor: Larynx and pharynx
Sensory: larynx, viscera
CN XII Hypoglossal Motor: Tongue muscles
```
35
14. One tool for examining laryngeal function via the oral cavity is:
Laryngoscope
36
15. What joint statement was developed by the American Academy of Otolaryngology voice and Swallow Committee and the Special Interest Division on Voice and Voice Disorders of the American Speech-Language and Hearing Association?
It says that clinicians with special training in laryngoscopy are qualified to use it.
37
16. The most important considerations in the selection of any instrument used to evaluate voice are that they meet the criteria of being:
a. Reliable
| b. Valid
38
17. What is QOL measure that is reliable and valid?
Voice handicap index
39
18. What does the s/z ratio measure? What is the procedure?
The s/z ratio measures laryngeal airflow. The procedure is done by having the client produce /s/ and /z/ as long as possible through three different trials. This produces the ratio. If it is close to 1 it is a good sign. If it is further from 1, it suggests some type of issue.
40
19. Is it appropriate to do a non-instrumental examination prior to referring for an instrumental examination? Why or why not?
It is appropriate to do a non-instrumental examination beforehand, because it helps gather information and determine if an instrumental examination is actually needed.
41
20. Should Doctors orders be obtained to evaluate and treat a voice client? Is it always appropriate to do an instrumental evaluation before starting treatment with a voice patient?
Evaluation can sometimes be done to evaluate a voice client. However, an evaluation from a doctor should certainly be done before treating the client, in order to make certain there are no organic causes. An instrumental evaluation takes place when the results of a non-instrumental evaluation continue to indicate an issue.
42
1. What is the benefit of using a laryngoscopic procedure?
It improves the accuracy of diagnosis due to being able to physically the vocal structure. This leads to better treatment prognosis.
43
2. List 5 of the most routinely obtained acoustic measures and briefly describe each one:
a. Maximum Phonational Frequency Range—lowest to highest frequency the voice can do
b. Fundamental frequency—vocal fold’s rate of vibration
c. Average/habitual intensity—The average intensity used by the speaking in most vocalizations
d. Intensity variability—The range of intensities used in connected speech
e. Vocal perturbation (jitter and shimmer)—cycle to cycle vocal signal variability
44
3. Define Average fundamental frequency (F0):
The rate of vibration of the vocal folds expressed in Hz. Typically elicited with isolated vowels, and reading or connected speech.
45
4. What is the difference between average fundamental frequency and speaking fundamental frequency?
Speaking fundamental frequency is the average fundamental frequency when it is reported with connected speech.
46
5. What is frequency variability? What would you look for clinically?
Frequency variability is the changes in pitch which occur in a persons voice during typical conversation. Typically 25-30 Hz. Measured with standard deviation?
47
6. Define maximum phonation frequency range? What is an appropriate expectation of range for a young adult?
Maximum phonation frequency range measures that maximum variability in frequency a persons voice can do. It starts at the lowest frequency, and goes to the highest frequency. It can be measured by stepping or gliding from their lowest to their highest note. Average: 2.5 octaves
48
What is intensity? How is it measured objectively and subjectively? What is the difference between habitual loudness and intensity variability?
Intensity is the acoustic power of the voice. Subjectively, it is called loudness and it is measured
49
What is perturbation and how is measured?
Perturbation is the cycle to cycle variation in the vocal signal resulting from aperiodic vocal fold vibration. It includes jitter, which measures the variability in fundamental frequency, and shimmer, which measures the variability in amplitude. Typically in adults jitter of less than 1% and shimmer of less than .5 is normal. On its own can’t be used to diagnose.
50
9. What are the three basic types of breathing? Describe each one.
Clavicular—elevate shoulders when breathing. Shallow inspiration, inadequate respiratory support for speech. May increase laryngeal tension due to use of neck muscles
b. Thoracic—On inhalation, thorax expands and abdomen contracts. Used by most people. In some can result in shallow breath.
c. Diaphragmatic-abdominal breathing—On inspiration, abdomen and lower thorax expands, little upper body involvement. May be preferred method.
51
10. What is lung volume? What consequence does it have clinically?
The amount of air in the lungs at a given time and how much of it is used for various purposes. They are useful for diagnosing problems with pulmonary ventilation.
52
What is tidal volume?
The amount of air inspired and expired during a typical respiratory cycle
53
12. What is inspiratory reserve volume?
The maximum amount of air that can be inspired beyond the end of a tidal inspiration
54
13. What is expiratory reserve volume?
Maximum volume of air that can be expired beyond the end of a tidal expiration
55
14. What is residual volume?
Volume of air that remains in the lungs after a maximum inspiration
56
15. What are lung capacities? How do you determine them?
Add together the different volumes in different ways. Include Inspiratory capacity, vital capacity, and functional residual capacity
57
16. What are different air pressures necessary for speech?
Conversation speech=5 to 10 cmh20
58
17. What is airflow? Why is it important? How do we measure it?
Airflow is how much air passes through the glottis in a fixed period. It is important because voice quality is effected by the amount of airflow coming through the glottis. It is measured in cubic centimeters (cc) or milliliters (mL) per second.
59
18. If airflow is high, then
the voice quality is breathy.
60
19. What is the VisiPitch and what does it measure?:
A widely used clinical instrument for measuring habitual pitch and loudness, frequency, intensity variability, Maximum Phonational Frequency Range, and dynamic range.
61
20. What is the KayPentax phonatory aerodynamic system? What does it measure?
It is an instrument used to measure average phonatory flow rates, sound pressure level, fundamental frequency, vital capacity, subglottal pressure, glottal resistance, and vocal efficiency.
62
21. What type of data do you gain from using the VisiPitch? Subjective or Objective?
Objective data is gathered. A concrete number is given which has been measured by the software.
63
22. What is videostroboscopy? How does it work?
? It allows you to see the average vocal fold vibration pattern. It works through syncing with the fundamental frequency. Its value is limited in severely dysphonic patients because it needs a periodic voice signal.
64
23. What is the purpose of conducting an instrumental voice assessment?
To gather additional necessary data before diagnosis that supports the diagnosis and ensures no structural anomalies are missed.
65
24. Why would you use a keyboard during your voice evaluation?
A keyboard could be necessary when using software such as Visipitch.
66
25. What is electroglottography? What does it measure? How would performing this exam help you in your differential diagnosis of a voice disorder?
Electroglottography measures vocal fold contact patterns during phonation. An electrode is placed on both sides of the thyroid cartilage. Weak electrical current passes through it. This is able to measure if the vocal folds are open or closed due to a difference in resistance between the two states.
67
1. Define a functional voice disorder:
A voice disorder resulting from a lack of functional balance in the phonation system.
68
2. Define muscle tension dysphonia? Identify and describe three characteristics:
A functional voice disorder caused by excess tension in the larynx, and the resulting hyperfunctional vibratory patterns. Characteristics: Lack of space between hyoid bone and larynx (less than 1 finger), hoarseness, vocal fatigue
69
3. What is ventricular dysphonia? What are the characteristics?
A functional voice disorder involving excessive muscle tension that causes the false vocal folds to approximate in addition to/ instead of the true vocal folds. Characteristics: visually witnessing the ventricular folds being employed in phonation, “double” voice (diplophonia) due to both true and false VF vibrating. Low pitch, monopitch, hoarseness.
70
4. Why do vocal nodules form? Where do they form? Why are they considered a secondary characteristic of a functional voice disorder? What clinical signs would you perceive during a non-instrumental exam?
? Voice misuse and abuse. Form primarily on anterior middle third junction of VF. Typically bilateral. Considered a secondary characteristic of a functional voice disorder because they are caused as a result of the disorder and will often come back after surgical intervention if the vocal behaviors which caused them are not treated with therapy. Clinical signs: breathiness, voice gets worse with use, feeling of something in throat.
71
5. True/False. Vocal nodules typically form unilaterally.
False
72
6. True/False. Behavioral therapy is the general management approach for treating vocal nodules.
True
73
7. What is a vocal polyp? Are they typically bilateral or unilateral? How can you tell the difference between a vocal nodule and a vocal polyp? Why are they associated with functional disorders?
A vocal polyp is similar to a nodule but is deeper in to the superficial layer of the lamina propria. Typically unilateral with reactive lesion on opposite VF. Precipitated by single vocal event (ex: screaming)(vocal abuse). May be red or white, large or small.
74
8. Describe the difference between a sessile polyp and a pedunculated polyp
Sessile: broad based. Pedunculated: narrow-necked on a stem
75
9. What is Reinke’s Edema? Why does it form? Is it treatable?
Chronic diffuse swelling of the superficial lamina propria. AKA polypoid degeneration of the VF. Formed from exposure to inflammatory stimuli (ex: smoking) along with abnormal healing. Treatable: Yes, treatable with therapy and removal of irritating stimuli. Surgery if it remains.
76
10. True/False. In a patient with Reinke’s edema, visual assessment ALWAYS reveals bilateral swelling along the entire membranous length of the vocal fold.
False
77
11. Define Laryngitis
. A swelling of the vocal folds caused by some type of phonotrauma. It can be acute and last a few days, or if the phonotrauma continues, can become more chronic. Continued voice use with laryngitis may result in nodules, polyps, etc.
78
12. What is a perceptual sign of laryngitis?
Variably hoarse, breathy, harsh, strained, and low-pitched voice.
79
13. Define Diplophonia. How is it produced? Why is it considered a functional voice disorder?
Double voice. Occurs from irregular vocal fold vibration. One manner in which it is produced is when the ventricular folds are being engaged in phonation as we as the true VF. It is considered a functional voice disorder because it is a symptom of ventricular dysphonia, which negatively alters voice quality and is a sign of muscular tension.
80
14. Define phonation break
A sudden stopping of the voice in a portion of what is being said.
81
15. Define pitch break
Voice breaking to a higher pitch during speaking. Typically a result of puberty in males, or speaking in an inappropriate pitch (too low or high), or vocal fatigue.
82
16. What is the difference between a phonation break and a pitch break? Is there any significance in knowing the difference? Would it help differentially diagnose a voice issue?
A phonation break is the sound of the voice stopping, whereas a pitch break is the sound to the voice suddenly getting much higher or lower. ????
83
17. What is a psychogenic voice disorder?
A voice disorder that is tied into some psychological issue/ trauma.
84
18. Compare functional aphonic and functional dysphonia. Which is more severe? What are their characteristics?
Functional aphonia is more severe, resulting in complete loss of voice, or of voicing (only whisper).
85
19. What does a voice sound like when a functional voice disorder presents?
Hoarse, strained or effortful, breathy, aberrant pitch, possible diplophonia.
86
20. What does diplophonia sound like perceptually?
Two different pitches occurring at the same time when someone is talking.
87
21. What does ventricular phonation sound like perceptually?
The voice has a low pitch with a lack of pitch variability. It can also be hoarse and breathy due to the difficulty for the ventricular folds to approximate.
88
22. What are the three pillars we should be aware of and assess when a functional disorder is suspected?
Tension, use, visualization?
89
23. Write a smart goal that would target a functional voice disorder…have a rationale.
Client will maintain low laryngeal muscle tension during voicing at the sentence level for 8/10 trials over two sessions. (made it up, no idea if this is what she means)
90
2. Give two examples of structural pathologies of the vocal folds.
1. Reinke’s Edema
| 2. Cysts
91
3. Contact ulcers and granuloma are benign growths that can result from what cause? (choose all that apply)
1. Laryngopharyngeal reflux irritation
2. Intubation trauma
3. Phono trauma
92
4. List 5 factors that can contribute to acid reflux.
1. Exercising soon after eating
2. Drinking excess water right before bed
3. Eating spicy foods
4. Smoking
5. Doing activities that compress the abdomen
93
6. True/False. Granulomas are always located on the arytenoid complex.
True
94
7. What percentage of voice patients have laryngopharyngeal reflux?
4-10%
95
8. List two causes of a vocal cyst
1. Phonotraumatic behaviors
| 2. Blocking of ductal system of laryngeal mucous glands
96
9. Where can a vocal cyst be found? List three laryngeal areas
1. Inner margin of the VF
2. Superior surface of the VF
3. Ventricular folds
97
10. True/False. Phonosurgery of a cyst is the least common treatment choice.
. (unclear. Phonosurgery leaves scar and voice therapy should be tried first, but often needs surgery too. Don’t know if phonosurgery is least common)
98
11. Laryngeal papilloma is caused by exposure to the
Human Papilloma virus
99
12. True/False. The most common sites for papillomatosis are true vocal folds.
False. Couldn’t find anything stating this in the book or slides.
100
13. How does increased stiffness of the vocal fold change vocal fold vibration?
Increased stiffness of the vocal folds can create faster VF vibration, increasing the pitch of the speaking voice. If the increased stiffness is limiting the ability of the vocal folds to adduct, this could lead to a dysphonic voice with increased breathiness.
101
14. What are two symptoms associated with laryngeal web?
1. High pitched, rough sounding vibration
| 2. Shortness of breath
102
Which layer of the lamina propria does a sulcus vocalis affect?
? May be confined to the superficial layer of the lamina propria, or may penetrate deeper to vocalis muscle
103
16. List three perceived voice qualities associated with a sulcus vocalis
1. Breathiness
2. Hoarseness
3. Lack of loudness
104
17. Management of sulcus vocalis will often involve
speech therapy, surgery, or both. It is thought the acquired form may be partially due to vocal abuse. Techniques seeking balance among proper glottal closure, pitch and loudness can improve vocal quality without surgical intervention (Boone, 2010)
105
18. What does Leukoplakia look like? What causes it?
White patches, precancerous caused by the presence of irritants ex: smoking.
106
19. True/False. Endoscopically, the appearance of dysplasia and early vocal fold cancer is distinguishable from a malignancy.
False
107
20. The cause of laryngeal cancer is
1. Multifactorial
108
21. True/False. Smoking and heavy drinking of alcohol do not affect the risk of the developing laryngeal cancer.
False
109
22. List three symptoms of laryngeal cancer.
1. Airway inadequacy
2. Visually discernable growth
3. Possible voice disorder if on VF
110
23. Define subglottic stenosis
Subglottic stenosis is a condition in which there is a narrowed opening between the cricoid cartilage and the first tracheal ring. It can be congenital acquired, with 4 different grades of severity. Grades 3 or 4 often require surgical intervention.
111
24. Acquired subglottic stenosis is most commonly caused by
prolonged Intubation?
112
25. What is the common cause of inspiratory stridor in infancy?
Laryngomalacia
113
26. During flexible fiberoptic laryngoscopy in a patient with laryngomalacia, collapse of the laryngeal cartilages may be seen on:
Inspiration
114
27. Define sarcopenia.
Tissue loss with aging. This can affect the vocal folds, causing a condition know as Presbylarynges.
115
What are the three pillars of functional voice disorders?
Vocal hygiene, respiration, vocal quality
116
What are the 5 aspects that a typical voice is characterized by?
loudness, hygiene, pleasantness, flexibility, representation
Voice
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