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42 Cards in this Set
- Front
- Back
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Organic:
Reflux |
According to research, about 50% of patients with voice disorders also have reflux (aka: Laryngo-Pharyngeal Reflux or GERD).
Reflux: back-flow of stomach acids/gases into the espohagus through LES Becomes LPR when it reaches the level of the VFS A common source of irritation in the larynx, and contributes to the growth of granulomas (benign growths) Fatty foods, chocolate, caffiene, alcohol, cigarette smoking, obesity, and pregnancy are all contributing factors. Signs and symptoms are highly variable in degree and between individuals: Morning hoarseness Sour taste in mouth Bad breath Frequent throat clearing/coughing Heart burn LPR specifically associated with voice problems: edema, contact ulsers, granulomas, laryngitis, subglottis stenosis (narrowing of the area beneath the VFs). Types of management: 1. Behavioral therapy: including vocal hygiene, things that the client can do to reduce reflux: elevate head and neck, especially during sleep. Remaining upright for about 60 mins after your meals; avoid spicy foods; don’t exercise after eating; reduce or eliminate caffeine, carbonated drinks, and alcohol from diet. Encourage loose clothing, especially around the waist. 2. Medications: anti-reflux meds, such as Priloseck. 3. Voice management: this is compensatory. Goal is not to reduce reflux; goal is to reduce and alleviate related vocal symptoms. Vocal facilitation Vocal hygiene Dietary hygiene |
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Organic:
Contact Ulcers/ Granulomas |
Description:
Etiology: often caused by intubation; and excessive contact Often found along the vocal processes. Contact ulcers: are raw sores occurring on the mucosal membranes of the arytenoids. The vocal processes are prone to trauma from impact stress; even more prone during loud speech and forceful phonation. Granulomas: tend to grow over the area of the contact ulcer, unless, the cause of the contact ulcer is addressed. Granulomas are soft and blood filled. They can exist without contact ulcers; HOWEVER, an untreated contact ulcer will lead directly to a granuloma on top. Symptoms: Bitter taste in the mouth Long voice warm up time Reduced pitch range Hoarseness Management: Intubations granuloma: Usually after tube has been removed, tx is not required Mucosal layer will heal, and granulomas will resolve themselves Contact ulcers due to excessive contact: functional behavior needs to be addressed in order to reduce symptoms. Phonotrauma: reduce impact stress |
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Organic:
Cysts |
- Description: a benign, mucous filled lesion, surrounded by a membrane. Located near the VF surface. Occurs right under the mucosal layer in the superficial layer of the Lamina Propria at the midline of the membranous glottis
- Etiology: phonotrauma, - Symptoms: voice issues can range from mild– severe based on size and shape of lesion Hoarseness Throat clearing Globus feeling Management: 1. vocal hygiene combined with vocal rest Reduces edema surrounding the cyst 2. voice therapy can help the voice somewhat, but cannot resolve the cyst. In this case surgery is needed to remove the cyst. What should you tell your client about this surgery? Even if surgery occurs, you need to address the underlying etiology so that it does not come back. |
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Organic:
Leukoplakia/Hyperkeratosis |
Description:
These two are very similar AKA: smoker’s voice Leukoplakia: a plack-like formation that occurs on the VF surface. Usually on the anterior portion of the VFs, but can in some cases extended all the way down between the arytenoid. Keratosis: a hardening tissue very similar to what is found in the fingernails and the deepest layers of the lamina propria. Both leukoplakia and keratosis are considered pre-cancerous; should always be biopsied. Etiology: chronic irritation of the VFs to due to cigarette smoking (worse than other types of smoking). Symptoms: These hardening lesions increase density of VFs, often lowering the pitch Reduced amplitude of VF vibration Increased stiffness Decreased pitch range Breathiness Managements: Biopsy required Surgical removal for both benign tumors If malignant, another set of circumstances comes up If benign- behavioral treatment; vocal hygiene, etc Following up to surgeries: should be followed closely by an SLP or ENT for 3-6 mos. |
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Organic:
Candida |
Description:
-Etiology: -cortico-steroids Diabetis Symptoms: Hoarse, harsh, breathy Management: Not usually treated with voice therapy Usually treated with medications SLP will provide vocal hygiene |
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Organic:
Infectious Laryngitis |
Description:
Occurs due to inflammation of the VFs Red, edema Can have ‘nasty’ lesions especially if viral Etiology: Viral and bacterial infections Symptoms: Hoarse voice Gets worse with prolonged use of voice (so functional laryngitis can emerge as an exacerbating factor) Acute phase: sore throat sensation; coughing; fever Management: Dependent on etiology Most often resolves itself with rest and TONS of liquids. Anti-biotics *vocal hygiene is crucial to prevent increase in severity |
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Organic:
Papilloma |
Description: viral based wart that can develop anywhere in the pharyngeal area. Also can develop on lungs, but this is rare.
Can be life threatening if it is very large and blocks the airway. Etiology: Viral Exposure to Human Papilloma Virus (HPV) Associated with peri-natal infection associated with sexually transmitted diseases Most often found in child under 5 yrs. Symptoms: Will interfere with VF closure Will interfere with frequency and amplitude of vibration Can lead to scarring on VFs Voice quality: rough, breathy (if it interferes with glottal closure) Chronic cough Globular feeling in throat Noise on inhalation Management: Care of the airway: takes precedent over quality of voice Surgery Drugs Viral nature often leads to frequent regrowths Voice therapy may be an option for children and adults, but only in a state of non-occurrence of papilloma Reduce inappropriate compensatory strategies |
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Organic:
Sulcus Vocalis |
Description:
A groove along edges of one or both VFs Etiology: Can be congenital or acquired Unknown! Acquired: seems to be associated with smoking Symptoms: Abnormal vibration of VFs Depth of groove: can be any where from superficial layers all the way to deep muscles Degree of dysphonia is associated with depth of sulcus Management: Surgery Resection of area of groove (sealing up of the separated parts) Possible injection of fatty tissues |
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Organic:
Webbing |
Description: thin membrane that covers glottis
Etiology: Failure of glottal webbing to separate in fetal development Acquired: a result of prolonged intubation Symptoms: Shortens usable length of VFs, increasing pitch of voice And can cause breathy voice due to incomplete closure of VFs Management: Immediate surgery Tracheotomy 6-8 weeks of vocal rest In some cases, ENT may recommend voice therapy to help achieve natural phonation |
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Organic:
Presbylaryngis (Aging Voice) |
-Description: associated with deterioration of thyro-arytenoid muscle
Etiology: Specifically due to aging Symptoms: Reduced vibration Weaker voice (reduced volume) Bowing of VFs Breathy voice Roughness/ hoarseness Management: Increase amount of medial compression This is somewhat counterintuitive, and doesn’t always work |
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Organic:
Vocal Fold Hemorrhage (Vascular) |
Description: really red, edema, veins are visible on surface of the tissues
Etiology: Singers are prone to this Symptoms: Areas of patchy redness on VF surface Increased VF mass Hoarseness Voice can range from extremely mild extremely severe, including aphonia Management: Surgery Don’t do therapy in acute phase . Need complete vocal rest Once surgery is over and VFs heal, there may be residual dysphonia due to scarring Voice therapy and other methods may be recommended (injections) |
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Organic:
Varix and Ecstasia (Vascular) |
Description:
Varix occurs on superficial layers of VFs A prominent vein that is enlarged and dilated Ecstasia: Blood vessels fuse Both usually occur on superficial layer of lamina propria Etiology: Usually caused by phonotrauma More common in women, and associated with female hormone cycles Symptoms: Red May or may not be signs of voice disorders, depending on amount of vascular damage Can have a hoarse voice and/or limited range esp. in higher frequencies Management: Vocal rest Surgery in extreme cases |
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Organic:
Dysplasia and Laryngeal Cancer |
Description:
White/red mass due to vascular displacement Can look like many different types of lesions Etiology: Precancerous tissues Multi-factorial : heavy smoking and drinking alcohol are risk factors Symptoms: Hoarse Lower pitch Management: Surgery, radiation, chemotherapy Partial or complete laryngectomy is sometimes necessary Counseling Swallowing and general voice management |
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Lower Motor Neuron Voice Disorders
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Etiology: Lesions to Lower Motor Neuron of PNS
General Symptoms: Muscle paresis (weakness) or paralysis (immobility) producing limited strength, speed and range of movement Types based on site of lesion: branches of Vagus Nerve: - Recurrent Laryngeal Nerve Paralysis - Superior Laryngeal Nerve Paralysis *often result from surgery trauma, not usually from phonotrauma There are medical/surgical interventions that take place to heal these issues Then, referred to a SLP for rehabilitation and beneficial compensatory strategies Very unlikely for voice to return to its original quality |
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Recurrent Laryngeal Nerve Paralysis
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Unilateral Recurrent Paralysis - hoarse, breathy voice, aphonia, or normal
Bilateral Recurrent –complete immobility -Abducted – aphonia or weak, fatigue -Paramedian – weakness, breathiness, some vibration, fatigue -Adducted – Total closure |
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Superior Laryngeal Nerve Paralysis (Cricothyroid Muscle)
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Weakness, breathy, hoarseness
Limitations in pitch range and variability |
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Lower Motor Neuron Disorder:
Myasthenia Gravis |
Description and Etiology: Autoimmune disease with reduced peripheral nerve neurotransmitters.
Can affect all lower motor neurons Severe muscle deterioration Voice Symptoms Inhalatory stridor, Breathy, hoarse voice Flutter, and tremor Decreased loudness and restricted pitch range Dysphagia, VPI, and hypernasality |
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Upper Motor Neuron Voice Disorders:
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Etiology: Unilateral or bilateral upper motor neuron damage, release of inhibition, hypertension, spacticity
General Symptoms: Rigidity, spacticity, involuntary rapid or slow movements, limited range of movement, tremor Hyperadduction of true and false cords Low-pitched voice with little variation in loudness or pitch Strained-strangled voice, periodic arrests Prolonged glottic closure, hyperactive supraglottic activity, retarded wave Types: Hyperkinetic: too much movement Spasmodic Dysphonia Essential Tremor Hypokinetic: not enough movement Parkinson’s Disease Ataxic Dysarthria (Cerebellar Lesions) |
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Hyperkinetic - Spastic Dysphonia
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Etiology: Uncertain – psychogenic (old) or neuromuscular (current)
Symptoms by Type: -Adductor Spastic Dysphonia (ADSD) most prevalent strained-strangled quality, periodic arrests -limited pitch and volume control -prolonged vocal fold closure and reduced amplitude of vibration Abductor Spastic Dysphonia (ABSD) 15% of cases: -Breathy and irregular voice Both: -Perceived stoppages of voice, delayed voice onset, reduced intelligibility Treatment: -Botox Injections -RLN Resection -Voice therapy |
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Hyperkinetic – Essential Tremor
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Description and Etiology: Common movement disorder effecting extremities including the head, arms and hands as well as larynx, tongue, velum and pharynx
*Unknown etiology -Tremors 4-7 per second Voice Symptoms: -Predominant involvement of TA muscle -Quavering or tremulous voice, -Pitch breaks and vocal arrests -most noticeable on vowel prolongation -Can be misdiagnosed as spastic dysphonia Management: -Not promising -Medication -Voice therapy to reduce loudness and force to reduce tremor |
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Hypokinetic – Parkinson’s Disease
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Description and Etiology:
-Degenerative disease - depletion of dopamine -Symptoms vary with time of day, medication, mood, age, gender, disease severity Voice Symptoms: -Reduced loudness, -Monopitch, -Breathy, rough, hoarse, tremorous voice -Slowed rate -Recruitment of ventricular folds not uncommon -Widespread hyper-tonicity and rigidity Management -Medications (LSVAT) – Dopamine -Questionable whether voice/speech therapy alone is effective |
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Ataxic Disorders
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Description and Etiologies:
-Lesions to cerebellum or pathways causing respiratory, phonatory and articulatory incoordination -Disease, vascular disorders, tumor, trauma Voice Symptoms: -Uncontrolled loudness and pitch outbursts/ variations -Hoarseness with mild to moderate tremors of laryngeal inlet during phonation -Normal focal folds -Uncoordinated respiration influences appropriate timing and breath groups |
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Mixed Neural Disorders
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Description and Etiologies
-Damage or disease to multiple subsystems -Multiple symptoms based on sites of lesion |
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Amyotrophic Lateral Sclerosis (ALS)
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-flaccid and spastic, depends on lesion
-dysphagia, airway obstruction -harsh quality, hyper-nasal, variable pitch -restricted intensity, breathy, stridor |
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Multiple Sclerosis – Progressive autoimmune and inflammatory disease
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-Demylinization and axon damage
-spastic and ataxic, mixed -impaired loudness control, harsh, breathy -inappropriate pitch and rate |
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General Treatment Protocols
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-Surgery
-Medications that treat motor symptoms -Speech therapy: behavioral treatment (rarely alone and used to minimize or compensate for sensory-motor problems -Augmentative or alternative communication devices |
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Symptoms for Functional Voice Disorders
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* these are pretty consistent across all functional voice disorders.
- hoarse voice - weak -breathy -strained |
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Muscle Tension Dysphonia
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Description: (MTD) A general disorder. A persistent disorder. No indication of structural abnormalities; can involve true and/or false VFs.
Scope will reveal excessive medial compression Etiology: can be caused by: Deviant body posture Misuse/ over tension of neck and shoulder muscles Excessive use of voice Persistent loud voice Excessive Psychological-emotional stress Differential diagnosis of cause is difficult because physical Management: *This is consistent across many of the functional VFs. Vocal hygiene Relaxation Laryngeal area massage General vocal rehabilitation Counseling for stress/emotional issues; referral if needed |
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Vocal Nodules (“kissing nodules")
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Description: unilateral/bilateral anterior 2/3rds of VFs. RARELY appear in the back of VFs. This is because the greatest amount of phonotrauma occurs anteriorally.
In acute stage: soft, gelatinous nodes Chronic stage: firm, callous-like, fixed to mucosal layers; larger too A form of callous Reactive nodular stage: a node that develops as a result of a previous disorder Etiology: Phonotrauma (abusive behaviors: talking too much; too loudly; etc.) Hyperfunction Symptoms: Abnormalities in voice become apparent during the later stages when they become larger/firmer *see general list Degree of symptoms varies with degree of phonotrauma. Management: SLP does vocal hygiene Analysis of abusive behaviors Modification/ rehabilitation of vocal uses Voice therapy is 1st manner of treatment ENT does surgery if they continue to grow, etc. This will not eliminate them forever…. Unless vocal behavior is changed. |
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Vocal Polyps
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Description: fluid filled bumps with their own blood supply
Can be pedunculated or sessile Etiology: Due to phonotrauma But CAN result from a SINGLE traumatic event (unlike nodules) Severity depends on size and shape Could feel globular sensation (which you don’t really feel with nodules) More blister-like instead of callous like Managements: ENT may perform surgery as 1st course of action |
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Generalized and Reinke’s Edema
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- Description: Swelling
Usually formed in superficial layer of VFs (Reinke’s space) Fluid fills those spaces Etiology: Phonotrauma Smoking GERD Symptoms: Hoarse Gravely voices Lower pitch More noticeable in women (because their voices tend to be higher, lighter) Management: Must stop what ever the cause is (e.g., smoking) General vocal hygiene Surgery is an option |
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Acute (Traumatic) Laryngitis
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Description: inflammation of vocal fold tissue associated with vocal strain; chronic coughing; vocal strain
Etiology: associated with phonotrauma Management: Vocal rest Don’t really need SLP HOWEVER…. Chronic laryngitis can develop on top of this if person doesn’t do vocal rest Complete vocal rest for about a week is necessary |
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Ventricular Dysphonia
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Description:
At rest: VFs look normal and not tense Adducted for phonation: abnormalities are visible Etiology: Latero-cricoarytneoid and thyro-arytenoid excessive tension Managemnet: Identify the capabilities of the true VFs… what’s stopping them from vibrating If they can use the VFs, relaxation and hygiene are necessary Botox injections are used in some cases In Many cases, compensatory strategies are used |
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Definition of Psychogenic Voice Disorders
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Conversion Reaction: “Any loss of voluntary control over normal striated muscle or over the general or special senses as a consequence of environmental stress or interpersonal conflict” (Aronson 2009).
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Common Psychoneurosis Etiologies
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Chronic anxiety
Stress Depression Intrapersonal and intrapersonal problems Trauma |
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Qualifications for Diagnosis (NOT diagnosed by SLP)
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One of the above conditions must be present
Voice must be affected fairly consistently No organic cause can account for the disorder |
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Classifications Psychogenic Voice Disorders (Note: “Hysterical” also used for “Conversion”)
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Conversion Aphonia
Conversion Dysphonia Conversion Muteness Puberphonia/Mutational Falsett |
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Conversion/Hysterical Aphonia and Dysphonia
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Conversion Aphonia: Involuntary whispering or no voice despite a normal larynx
Conversion Dysphonia - Unreliable Voice Unpredictable pitch, amplitude, quality changes Conversion Mutism – Most serious with no attempt to phonate or articulation (some try to articulate without sound) Common Treatments Counseling and/or psychotherapy Voice stimulation activities and expansion (see Boone et al DVD for excellent examples) |
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Puberphonia/Mutational Falsetto
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Characteristics
preadolescence voice to adolescence and adulthood voice Normal laryngeal function Capable of normal pitched voice during exam Etiology Physiological Psychological Voice Characteristics: High pitch and weak Thin Breathy Hoarse Monopitch Treatment Sharp attack Manual depression of larynx Depress tongue + manual lowering |
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Personality and Functional/Psychogenic Voice Disorders
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Link between personality traits and voice disorders has been established (e.g. Aronson, 1990, Roy 2000, 2009)
General Findings Muscle Tension Dysphonia and Conversion Disorders show Neuroticism (high anxiety and emotional stimulability) and Introversion Vocal Nodules – Neuroticism and extroversion |
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Identification of Psychogenic Voice Disorders
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Medical Examination: rule out any possible organic or neurologic cause for the disorder.
Endoscopic Examination: determine if vocal folds adduct during coughing, laughing, etc., but not during communicative speech. Patient Interview Let client know that stresses or conflict might may be affecting voice Ask if there’s anything happening in the client’s life that might be important for you to know Referrals Immediate mental health referral may not be most effective Client may reject referral to psychologist or psychiatrist SLP: Lead gradually to this area and educate the client regarding the need for professional counseling |
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Therapy Considerations
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Avoid telling the client, “You could talk if you wanted to!”
Instead, explain what is physically wrong “…keeping vocal folds apart…” Experiencing an inability to “get them started” Techniques Establish vegetative phonation and expand to progressively longer utterances Coughing, throat-clearing, laryngeal manipulation, etc. Prolongation to phonated vowels with cough Generalize All vowels Monosyllabic words Any word Simple phrases Oral reading Simple conversation Conversation with anyone about anything in the clinic setting Generalization to everyday communication |
