Medical And Surgical Management Of Voice Disorders

Front 1

What are the five major groups for phonosurgeries?

Back 1

1.for removal of pathological tissue
2. surgical correction of VF shape, position or tension
3. alteration or restoration of laryngeal neuromuscular function
4. surgical reconstruction for partial loss or deformity of the larynx
5. surgical reconstruction for total larynx loss - laryngectomy

Front 2

What kind of benign lesions are removed during phonosurgery?

Back 2

1. chronic/hard nodules
2. large polyps
3. cysts
4. Reinke's edema

Front 3

Aside from benign lesions, what else is treated during phonosurgery?

Back 3

1. removal of VF Papilloma
2. Unilateral and Bilateral Vf Paresis
3. VF augmentation for incomplete glottic closure
4. laryngeal web
5. sulcus vocalis
6. removal of keratosis, hyperplasia and leukoplakia
7. removal of cancerous lesions

Front 4

T or F, the purpose of Endolaryngeal Microsurgery is to remove benign and cancerous lesion. The goal is to remove lesions by taking only as much VF tissue as necessary and preserving as much of the mucosa as possible.

Back 4

True

Front 5

What is the risk of using a CO2 laser in microsurgery, and what is a new replacement for it?

Back 5

Danger: might tether mucosa to the ligament.
New replacement: "smart laser", which only removes the lesion

Front 6

What is the goal of the mini microflap surgery?

Back 6

remove lesions while leaving the edge and smooth as possible and keeping as much of the mucosa as possible.

Front 7

T or F, Most VF surgeries are done under general anesthesia, except for injections, which use topical anesthesia.

Back 7

True

Front 8

T or F, surgery for Reinke's Edema is not performed very often. People just do vocal exercises and reduce/quit smoking. (It will go down if they quit smoking, but not all the way.)

Back 8

True

Front 9

T or F. Vf Cyst surgery is easier than other surgeries because it is separate from the VF structure.

Back 9

True

Front 10

T or F, some granulomas will heal of reflux symptoms are treated.

Back 10

True

Front 11

T or F. VF Papilloma is hard to fix surgically because it invades the superficial lamina and even the ligament.You wind up with a missing chunk of VF and also no more mucosa. Occasionally, tissue can grow back, but VFP likes to grow back on fresh tissue

Back 11

True

Front 12

T or F. Pre-Cancerous and Cancerous lesions cause a feeling of "fullness" due to pushing on cartilages and distorting the structure. If you don't do the surgery, it can keep growing and block the airway.

Back 12

True

Front 13

T or F. The two methods of VF medialization for unilaterate paralysis, bowing and glottic incompetency are:
1. intrafold injection
2. medialization surgery

Back 13

True

Front 14

What are the three surgeries for VF medialization?

Back 14

1. augementation
2. medial shift of thyroid cartilage
3. rotation of arytenoid cartilage

Front 15

Intrafold injection, what are the three substances which may be injected into the VFs?

Back 15

1. fat
2. collagen
3. hydroxylapetite (Radiesse)

Front 16

T or F, if you put someone under general anesthetic to scope them, it's called "direct" endoscopy.

Back 16

True

Front 17

What is the advantage of keeping someone awake while intrafold injection is being performed?

Back 17

they can phonate and you can see how well it works immediately

Front 18

T or F. Thyroid cartilage medialization is less common than intrafold injection, and is only used it VF is paralyzed and in a very open position. Once set, it is also much harder to fix.

Back 18

True

Front 19

T or F. Sometimes intrafold injection is performed through the outside of the neck.

Back 19

True

Front 20

T or F. Arytenoid rotation surgery is performed if the VF is paralyzed open, or if there is a bilateral paralysis, or to open the close the airway more. It is a little less invasive than Thyroid Cartilage medialization.

Back 20

True

Front 21

T or F. VT Tensing is sometimes used in the transgender population to make more tension on the folds, but it only has a 50-50 success rate.

Back 21

True

Front 22

T or F. Sometimes Drs. perform neuromuscular surgery for VF paralysis to reinnervate the RLN. However, nerves might grow in places that they shouldn't!

Back 22

True

Front 23

T or F, the gold standard for SD is Botox.

Back 23

True

Front 24

T or F. Surgeries for Sulcus Vocalis are often not very successful. The latest treatment is to inject stuff in rather than trying to remove it.

Back 24

True

Front 25

T or F. The laryngeal web is formed in the anterior part of the larynx.

Back 25

True.

Front 26

T or F. The Laryngeal web is sectioned or removed with a CO2 laser. Then a 'keel' or silicone plate' is inserted to prevent the VFs from post surgical union. (CO2 okay here, because there is nothing to tether. Plate stays in until wound heals.

Back 26

True

Front 27

T or F. An essential tremor is hard to treat with voice therapy.

Back 27

True

Front 28

What kinds of treatments are given to someone with an essential tremor?

Back 28

1. medication - Propranolol (beta blocker) and Primidone (anticonvulsant), but they have lots of side effects
2. crescendo exercises (soft to loud)
3. decrease negative compensatory strategies
4. try different pitch and loudness (speaking breathier and a little louder may help)
5. breath support

Front 29

T or F. The amplitude of the tremor can be decreased, but not the frequency.

Back 29

True

Front 30

T or F. The are surgical and medical treatments for VF Papilloma.

Back 30

True

Front 31

T or F. VF Papillomas are treated surgically with a pulse dye laser.

Back 31

True

Front 32

What medications are used to treat VF Papilloma (*all they can really do is reduce frequency of episodes)?

Back 32

1. Interferons - for agressive VFP
2. Indole 3 carbinol - alters growth pattern of VFP.
3. Cidofovir - antiviral injected into the papillomas
4. Methatrexate - chemotherapy, blocks growth of papillomas

Front 33

How often does SD need to be treated with Botox injections?

Back 33

every 3-6 months. Sometimes people become immune. In some people, this treatment doesn't work at all.

Front 34

RLN resection for Spasmodic Dysphonia is not successful because...

Back 34

the nerves sometimes grow into places they shouldn't. and VFs open when they're supposed to close!

Front 35

What is the voice therapy for people with SD?

Back 35

1. eliminated negative compensatory behaviors
2. improve breath support
3. decrease muscle tension in jaw, face, neck
(hard to treat. Best we can do is help them breathe better)

Front 36

What are the treatments for Paradoxical VF Motion? (happens to athletes a lot)

Back 36

1. teach diaphragmatic breathing
2. focus on exhalation
3. use "sniffing" as exaggerated inhalation
4. relaxed tongue posture
5. prolonged audible exhalation through pursed lips, or production of /s/.
4. used relaxed throat breathing during stridor
5. may also use general relaxation and digital manipulation
6. in depth self-awareness of breathing process

Front 37

What are the aspects of Lee Silverman Voice therapy?

Back 37

1. sustained loud /a/
2. pitch glides up and down
3. use of loud voice for functional phrases, sentences, paragraphs and conversation
4. take use of loud voice out of clinic and into public settings

Front 38

T of F. LSVT research says it helps increase glottic closure, louder voice and improved vocal quality, improved articulation and swallowing.

Back 38

True

Front 39

T or F. The SLP is usually first to identify Myasthenia Gravis, but we don't treat.

Back 39

True

Front 40

T or F. Myasthenia Gravis is not treated with SLP services. They take medication which delays the destruction of acetylcholine in NMJ.

Back 40

True

Front 41

T or F.Progressive neurological diseases such as ALS have poor prognosis and an AAC device is necessary.

Back 41

True

Front 42

Patients with TBI, Hyperkinetic Dysarthria and CP use the following voice treatments:

Back 42

1. breathing support - increase both inspiratory and expiratory volume
2. teach easy onsets to decrease excessive muscle activity
3. utilize aspiration i.e. air flow prior to voicing
4. use Lee Silverman Technique

Front 43

T or F. The exaggeration of LSVT helps people with TBI, hyperkinetic dysarthria, and CP overcome their spasticity.

Back 43

True

Front 44

What is the etiology of laryngeal cancer?

Back 44

smoking, environmental irritants, chemicals, smoking & alcohol, smoking & asbestos

Front 45

Who is the typical patient with laryngeal cancer?

Back 45

60 y/o male heave smoker with moderate alcohol intake

Front 46

T or F Laryngeal cancer accounts for 2-5% of all cancers.

Back 46

True

Front 47

T or F 1% of all cancer deaths are from laryngeal cancer.

Back 47

True

Front 48

T or F 50%-70% of all laryngeal cancer deaths are associated with smoking.

Back 48

True

Front 49

T or F. Male to Femal ratio of laryngeal cancer is 5:1 (in 1985) but decreasing

Back 49

True

Front 50

T or F Alcohol and smoking increase the risk of laryngeal cancer up to 8x.

Back 50

True

Front 51

T or F In cancer staging,

T = location/size of primary tumor
N = involvement of lymph node
M = distant metastasis

Back 51

True

For example, T1N1M0

T1 = tumor confined for VFs
N1 = a single small lymph node involved
M0 = no metastasis

Front 52

What are the signs and symptoms of layrngeal cancer?

Back 52

Primary Symptom = hoarseness

Additional Symptoms = stridor, difficulty breathing, pain, coughing, coughing up blood, swallowing problems, painful swallowing

Signs = lump in neck, tenderness in laryngeal area, lack of crepitation (crackling), fullness, in CT and TH membrane, presence of lumps, lesions on VFs

Front 53

Where does laryngeal cancer begin?

Back 53

in epithelium, usually squamous cell carcinoma

it invades tissue and destroys normally functioning cells

can invade layers of lamina propria and TA muscle

Front 54

How is laryngeal cancer diagnosed?

Back 54

biopsy and histiological anaylsis

Front 55

What does the VF vibration look like with laryngeal cancer?

Back 55

(depends on extent of lesion but..)
1. VFs appear stiff, immobile
2. decreased mucosal wave
3. decreased amplitude of vibration

Front 56

What are the acoustic signs of laryngeal cancer?

Back 56

1. increased frequency and intensity pertubations
2. increased noise levels

Front 57

What are the aerodynamic signs of laryngeal cancer?

Back 57

1. increased airflow
2. increased subglottal pressure (Ps)

Front 58

What are the treatment options for laryngeal cancer?

Back 58

1. radiation therapy
2. surgery
3. surgery and radiation
4. chemotherapy

Front 59

What is a laryngectomy?

Back 59

procedure in which all or part of the larynx is excised (can be total, hemi-, partial, or supraglottic)

extent depends on tumor size, location, invasiveness and spread

impacts communication, swallowing and body image

Front 60

What is the role of the speech pathologist for people who are getting laryngectomies?

Back 60

1. pre-op consult to educate patient regarding surgery, possible outcomes, communication options post surgery, address patient concerns, assess cognitive status, status of patient's hearing, hand writing, etc., and give support to patient and family

2. post-op consult - review pre-op discussion, assess voice, speech, swallowing, demo electronic speech aids, teach use of oral type instrument, discuss rehabilitation plans, schedule meeting with other laryngectomee patients

Front 61

What are the four types of alaryngeal speech?

Back 61

1. pneumatic devices
2. electronic
3. esophageal speech
4. tracheoesophageal speech

Front 62

T or F - in Pneumatic devices for alaryngeal spreech include a cup shaped piece to fit over the stoma, a small unit with a reed inside to provide sound. Tubing carries sound to mouth.

Back 62

True

Front 63

What are the advantages and disadvantages of pneumatic devices for alaryngeal speech?

Back 63

Advantage: It is natural sounding, easy to learn and inexpensive.

Disadvantage - bulky, requires access to stoma

Front 64

T or F, Two electronic speech aids are Cooper Rand Electronic Speech aid and Electric Larynx.

Back 64

True

Front 65

T or F, Cooper Rand Electronic Speech Aid has a vibrator that delivers vibration to a a tube which is placed in the mouth. Good post surgery when neck is healing

Back 65

True

Front 66

T or F, Electric Larynx is neck-held and easy to use. It can be used while learning esophageal speech.

Back 66

True

Front 67

How does esophageal speech work?

Back 67

1. air is injected from the mouth in esophagus via tongue and pharynx
2. as air is expelled, the PE segment vibrates, creating sound that is articulated in the mouth

Front 68

What are the advantages and disadvantages of esophageal speech?

Back 68

Advantage - no external devices, sounds more natural, pitch and loudness control, no batteries, both hands are free

Disadvantage - takes a long time to learn and master, must have great artic, not very loud in noise

Front 69

T or F, a tracheoesophageal puncture (TEP) is a surgical procedure in which a small puncture is made through tracheal wall into esophagus. Then a prosthesis is inserted that acts as a shunt to direct air into the esophagus. Air moves through PE segment, creating sound, and sounds travels into pharynx, oral and nasal cavities and is resonated and articulated.

Back 69

True

Front 70

What is head and neck cancer?

Back 70

Tumors that grown in the mouth, throat, voice box or neck

Front 71

How common is head and neck cancer?

Back 71

Approximately 400,000 new cases in the US every year. 50% have advanced cancers by the time they 1st see a doctor

Front 72

What are the risk factors for head and neck cancers?

Back 72

1. tobacco (90%)
2. alcohol
3. viruses - HPV
4. overexposure to the sun
5. chronic irritation
6. genetics

Front 73

How does risk of head and neck cancer increase if you are a smoker?

Back 73

15 times more likely than a nonsmoker
chew/dip increases risk 4 times

Front 74

T or F, more than 50% of tonsil and tongue based cancers are caused by HPV.

Back 74

True - they are young, nonsmokers, high risk strains are sexually transmitted, prevention is the key

Front 75

How is the infant vocal tract different than the adult?

Back 75

1. shorter VT
2. velum and epiglottis in close proximity
3. VFs have not developed a Vocal Ligament; there are no layers, thick cover, with more vascularity
4. arytenoids are disproportionately large
5. laryngeal position is high
6. hyoid bone and thyroid cartilage are contiguous

Front 76

What is the fundamental frequency in infancy?

Back 76

500 Hz, but lowers as children get older

Front 77

T or F, Children may have greater jitter, less vocal control (because neural system less fully developed)

Back 77

True

Front 78

T or F, Children have higher subglottal pressure and lower mean airflow than adults (shorter phonation times)

Back 78

True

Front 79

T or F, Laryngomalacia is a congenital anomaly where the soft cartilages collapse into the airway. Causes stridor. Surgery required if airway is obstructed. Without surgery, resolve on its own. Usually detected at birth

Back 79

True

Front 80

T or F, Subglottic stenosis is narrowing of the trachea. If it involves cartilage and airway is obstructed, surgery is necessary. If it involves soft tissue only, it may resolve spontaneously.

Back 80

True

Front 81

T or F, four other congenital anomalies are Laryngeal Paralyses, Laryngeal Web, Congenital Cysts and Vocal Fold Papilloma (which may be passed to child through birth canal)

Back 81

True

Front 82

What are some signs of laryngeal congenital anomalies?

Back 82

1. stridor
2. dysphonia
3. difficulty breathing
4. abnormal cry
5. coughing, choking

Front 83

Three acquired voice disorders in children are..

Back 83

1. VF nodules (most common - 50% of acquired disorders)
2. VF paralysis - from trauma to the RLN
3. laryngopharyngeal reflux (more common in boys than girls)

Front 84

T or F. Therapy for children with nodules consists of...
1. no surgery!
2. involving family and teacher
3. identifying and modifying causal behaviors
4. minimize inappropriate behaviors

Back 84

True

Front 85

T or F. Adults who had nodules as children seem to have a higher incidence of voice problems.

Back 85

True

Front 86

Why does a "geriatric voice" sound older in persons >65?

Back 86

1. cartilages calcify
2. blood flow decreases
3. lamina propria thickens; less elastin and collagen, more fibrotic tissue
4. atrophy of submucous glands (dry throat)
5. atrophy of muscle
6. decreased neural firing rates

Front 87

T or F, most "geriatric voice" problems are due to some other issue, such as a stroke.

Back 87

True

Front 88

What are the perceptual characteristics of geriatric voice?

Back 88

1. higher in males, lower in females
2. hoarseness
3. breathiness
4. decreased frequency and intensity ranges

Front 89

What are the acoustic characteristics of geriatric voice?

Back 89

1. greater fundamental frequency variability
2. jitter
3. decreased intensity variability
4. slower speaking rate

Front 90

What are the aerodynamic characteristics of geriatric voice?

Back 90

1. smaller vital capacity
2. decreased lung pressure
3. greater peak airflow and greater air leakage (incomplete glottic closure)
4. greater open quotient (because not closing all the way)
5. decreased MFDR (how fast VF are closing and MFDR going to zero)

Front 91

What does a geriatric voice look like when strobed?

Back 91

1. bowing, incomplete closure, posterior gap
2. atrophy and thinning of VFs
3. edema
4. decreased mucosal wave & amplitude of vibration
5. increased VF stiffness
6. increase aperiodicity

Front 92

What are the most common geriatric voice disorders for men and women?

Back 92

Men - laryngeal cancer
Women - VF paralysis

both get edema, nodules and polyps
many voice problems in elderly are not caused by aging (4%) but by disease