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151 Cards in this Set

  • Front
  • Back
What are the causes of vocal fold bilateral paralysis?
1. bilateral cerebral damage
2. bilateral damage to brainstem region of the CNX
3. neurological disease
4. intubation injury
5. (rarely) bilateral injury to RLN during thyroid surgery (3%)
6. viral infections
CVA (cerebrovascular accident) aka stroke may cause voice problems if they occur where?
in brainstem (lower bilateral regions)
What does a voice with vocal fold bilateral paralysis sound like?
strained/strangled, monotone, low pitched, low volume, hypernasal
T or F, Voice is seldom affected by a single unilateral cerebral lesion.
True
What is the most usual cause of bilateral vocal fold paralysis?
bilateral damage to central brainstem and descending tracts
What are the repercussions if VFs cannot adduct?
1. aphonia (often)
2. severe dysphagia
3. possible tongue, velum, pharyngeal weakness or paralysis
What is the primary versus secondary concern in bilateral VF paralysis?
1. respiratory safety and feeding
2. voice
What are possible treatments for bilateral VF paralysis?
1. tracheostomy
2. surgery
What causes 90% of unilateral vocal fold paralysis?
Unilateral Vagus Nerve (CNX) lesions
Other than unilateral vocal fold paralysis, what problems may be caused by Unilateral Vagus Nerve (CNX) lesions?
1. flaccidity
2. decreased tone
3. dysphagia
What is dysphagia?
difficulty swallowing
What is the voice quality of unilateral vocal fold paralysis?
breathy, decreased loudness and loudness range, hoarse, low-pitched, with decreased pitch range
Other than Unilateral Vagus Nerve (CN X) lesions, what else can cause unilateral vocal fold paralysis?
1. unilateral brainstem strokes
2. unilateral injury to RLN during thoracic or neck surgery
3. neck/laryngeal trauma
4. viral infections
What branch of the CN X is the usual cause of unilateral vocal fold paralysis/paresis?
the RLN (disease or trauma)
Which RLN is more common to be injured, left or right?
Left
In unilateral vocal fold paralysis, where is the affected VF usually set?
in the paramedian position (closer to the midline, but not closed)
How do VFs continue to vibrate when one fold is paralyzed?
1. VFs have some anterior approximation
2. healthy VF sometimes crosses midline to aid adduction
3. airflow sets affected fold into vibration
4. Bernoulli Effect aids in VF closure
When there is trauma to the RLN and unilateral VF paralysis, sometimes there is spontaneous recovery. How long might the VF take to recover?
8-9 months or up to a year (surgery not considered until after this time)
What technique is used to determine if there is nerve action in the VF?
electromyography
What vocal fold disorder is associated with presbylaryngis or presbyphonia?
vocal fold bowing
Other than in aging voices, vocal fold bowing can also be seen when...
there is increase laryngeal muscle tension
What causes the "hypotonicity" that is indicative of an aging voice?
atrophy of muscles due to subtle decrease in nerve input
When the VFs are bowed, what parts are adducting?
the anterior and posterior aspects of the VFs (usually bilaterally)
Other than laryngeal muscle tension and aging voices, what might cause VF bowing?
1. Parkinson's
2. other neurological probs
What is the most common cause of damage to the SLN?
1.thyroid surgery (unilateral or bilateral paralysis)
2. but also may be due to a virus
What muscle is paralyzed when the SLN is damaged?
CT muscle
What are the symptoms of a damaged SLN?
1. bowing and rotation of VF on affected side
2. decreased pitch range
3. breathiness due to bowing
Does the SLN usually recover spontaneously?
yes
What are the characteristics of VF bowing?
Perceptual: higher pitch, hoarse, breathy, strained/effortful, if compensating with increased muscle tension
Acoustic: decreased pitch and loudness ranges, increased noise in voice, possible vocal tremor
Aerodynamic: increased airflow
Patient complaints: vocal fatigue, trouble being heard/projecting voice, dislikes sound of voice, strain/effort
What is the cause of spasmodic dysphonia (SD)?
Unknown, thought to be neurological (NOT A MUSCLE TENSION ISSUE)
What is focal dystonia?
An abnormal movement in an isolated body part (in the case of Spasmodic Dysphonia, it is the VF abductors, adductors or both)
What happening during Spasmodic Dysphonia?
muscle or group of muscles contract spontaneously, irregularly and incontrollably
What is the gold standard treatment for Spasmodic Dysphonia?
botox
What are the three types of Spasmodic Dysphonia?
1.adductor
2. abductor
3. mixed
What happens in Adductor Spasmodic Dysphonia?
VF adductors (LCA, IA, TA) spasm periodically, causing undesired hyperadduction - harsh, strained, strangled sound with obvious effort.
What happens in abductor spasmodic dysphonia?
VF abductors (PCA) spasm and abduct VF, causing a breathy, hoarse, weak voice, decreased loudness
What is mixed spasmodic dysphonia?
A mixture of adductor and abductor SD
Who is most likely to get SD, and when?
Women, age of onset 30-50 yrs, after upper respiratory infection (URI), laryngeal trauma, vocal or emotional stress
What to conditions must spasmodic dysphonia be differentially diagnosed from?
1. muscle tension dysphonia
2. vocal tremor
What is another name for Essential Tremor of the Larynx?
Organic or Familial Tremor (there is a genetic component)
What other body parts can the essential tremor affect?
head, hands, tongue
What is the frequency of the essential tremor of the larynx?
4-7 hz, characterized by steady fluctuations in loudness and pitch
Is an essential tremor always present in sustained phonation?
Yes, and sometimes present in speech; quiet at rest but present during volitional movement
When is the onset of an essential tremor of the larynx?
middle to late middle age
What is Amyotrophic Lateral Sclerosis (ALS)?
1. progressive disease of unknown cause
2. affects upper and lower motor neurons (cortex, brainstem and spinal cord)
3. lack of innervation to muscles causes muscle wasting, muscle twitches, weakness, spasticity
4. artic problems, dysphagia
5. voice: hoarsness, harshness, strain/struggle, hypernal, breathy
What happens when there are lesions to the basal ganglia or other parts of the extrapyramidal system?
hyperkinesias
What are the three types of hyperkenesias?
1. Choreas - quick, jerky, purposeless movements; voice is irregular pitch/loudness, irregular respiration
2. Athetosis - hyperkinetic dystonia, voice is variable loudness, pitch, vocal quality
3. Huntington's Chorea (specific type) inherited from autosomal dom. Degenerative disease affecting basal ganglia. Onset = middle age. Voice is strained, strangled, harsh monopitch, variable loudness/pitch, irregular bursts of loud voice, sudden forced changes in breath control
What is the cause of Parkinson's Disease?
lack of dopamine in the substansia nigra, causing 'hypokinetic dysartrhia' (not enough movement)
What is the physical behavior of someone with Parkinson's Disease?
Slow rigid movements with decreased range of motion, resting tremor, difficulty initiating movement
How does Parkinson's Disease affect speech?
voice is breathy, weak, decreased loudness, monopitch, monoloudness, hoarse/harsh, sometimes tremor
What happens to the larynx with Parkinson's Disease?
vocal fold bowing or incomplete closure, with possible compensatory supraglottic squeezing, anterior-posterior compression, false vocal fold approximation
What is Multiple Sclerosis?
demylenating progressive disease that attacks the myelin sheath, causing breaks in the transmitting axons in white matter in peripheral nervous system (PNS) and central nervous system (CNS); damps or slows neuronal signal
What does the voice of someone with Multiple Sclerosis sound like?
impaired loudness control, harshness, hypernasality, decreased respiratory control, slow speech rate, impaired articulation
What is Myasthenia Gravis?
autoimmune disease, progressive failure to sustain maintained or repeated contraction of striated muscles. due to blockage of acetylcholine at NMJ which results in muscle flaccidity
When is the onset of Myasthenia Gravis?
women - 30's
men - 60's

occurs twice as often in women
What is the voice quality of someone with Myasthenia Gravis?
breathy, hypernasal, weak voice, decreased loudness, intermittent aphonia due to rapid fatigue
What happens to the vocal folds with Myasthenia Gravis?
incomplete adduciton of VFs with movement deteriorating with task reptitition. Patient fatigues rapidly
What are the 4 different types of voice disorders?
1. Functional - result of misuse or abuse of the vocal mechanism ('hyperfunctional')
2. Organic - result from a disease process, i.e. cancer, acid reflux, etc.
3. Psychogenic - result from an underlying psychological issue and have no identifiable vocal pathology
4. Neurological - result from damage to the nerves that supply the larynx or disease processes that affect these nerves
Name the functional voice disorders:
1. vocal fold nodules
2. vocal fold polyps
3. Reinke's Edema (vocal fold swelling)
4. traumatic laryngitis
5. ventricular phonation (false vocal fold phonation)
6. muscle tension dysphonia
7. *paradoxical vocal cord dysfunction*
What causes vocal fold nodules?
1. excessive yelling, loud talking, or screaming, especially if for prolonged periods of time
2. pervasive use of hard glottal attacks
3. excessive coughing or throat clearing
4. excessive laryngeal tension
5. incorrect singing technique
6. excessive strain, excessive use, especially during a period of vocal fold swelling, inflammation or other tissue changes
Are nodules usually unilateral or bilateral?
bilateral
Where do nodules occur?
In the Superior Lamina Propria (SLP), occur at juncture of anterior 1/3 and posterior 2/3 of vocal fold, characterized by by an 'hour glass' closure
Describe the original condition of the nodules versus an advanced condition
1. first, they are gelatinous
2. later, they harden and become fibrous
T or F, VF nodules add both mass and stiffness to the VF
True (and so it interferes with mucosal wave movement)
T or F, Nodules cause aperiodic vibration in the VF
True
Who is most susceptible getting nodules?
women more than men, but boys more than girls
What are the perceptual (voice) characteristics of nodules?
hoarseness, breathiness, decreased loudness, vocal strain or effort
What are the acoustic characteristics of nodules?
decreased pitch and loudness ranges, increased aperiodicity, increased noise levels, SOMETIMES lowered fundamental frequencies
What are the aerodynamic characteristics of nodules?
increased airflow rates, increase subglottal pressure
What are the complaints of a patient with nodules AND polyps?
vocal fatigue, sensation of something in throat, vocal effort/strain, pain due to muscle tension
What causes vocal fold polyps?
an isolated acute violent episode of vocal abuse, or a period of vocal abuse, such as...
1. screaming at a concert/sports event
2. a period of excessive yelling, screaming or shouting, loud singing
3. possibility of occurrence increases if vocal folds are already irritated, inflamed, swollen, etc.
What are VF polyps?
a soft fluid-filled outgrowth of tissue in the Superior Lamina Propria (SLP)
What do polyps look like?
usually unilateral, can be sessile (broad-based) or pedunculated (on a narrow stem or stalk)
Where do polyps occur?
Anywhere along the membranous VF, but typically in the same region as nodules (juncture of 1/3 anterior and posterior 2/3 of VF), closure is hour glass or irregular
T or F, Polyps can be glottic, supraglottic or sublottic.
True
What is inside a polyp?
1. fluid
2. serum
3. blood (hemorrhagic)
4. connective tissue (fibrous)
If a polyp is fluid-filled, it ______ mass but _______ stiffness.
adds, decreases
If a polyp is blood-filled, it ________ stiffness.
increases
The perceptual characteristics of polyps are...
hoarse, breathy, sometimes, diplophonia, strained
What are the acoustic characteristics of polyps?
decreased pitch and loudness ranges, aperiodicity, increase noise levels
What are the aerodynamic characteristics of polyps?
increased air flow and increased subglottal pressure
What does edema mean, in regard to VFs?
swelling, buildup of fluid in the superficial lamina propria layer (Reinke's space) of the vocal folds, it is bilateral
What causes edema?
is the reaction of laryngeal tissue to trauma or abuse
Who gets Reinke's edema?
smokers, more common in women
Reinke's edema ________ mass of VFs but _______ stiffness.
Increases (mass), decreases (stiffness)
Reinke's edema causes a(n) _________ mucosal wave and a(n) _______ vibration
increase (mucosal wave)
aperiodic (vibration)
How does edema affect the closure of the VFs?
closure is incomplete or irregular
What are the characteristics of Reinke's Edema?
1. Perceptual - low fundamental frequency, hoarseness, vocal effort
2. Acoustic - loss of high pitches, decreased pitch range
3. Aerodynamic - no date, but possibly decreased subglottic pressure as vocal folds are less stiff and thus require less air pressure to vibrate
What are thee complaints of a patient with Reinke's Edema?
vocal fatigue, dry throat, vocal effort
What causes traumatic laryngitis?
trauma to the VF tissue, usually excessive yelling, screaming or loud talking
How do VFs look and sound with traumatic laryngitis?
1. Look - erythemataous (red) and swollen
2. Sound - hoarse, low-pitched and breathy
How long does it take for traumatic laryngitis to resolve?
a few days to two weeks
Can traumatic laryngitis cause a vocal fold hemorrhage?
yes
What is chronic laryngitis caused by?
continued vocal abuse, particularly if patient with laryngitis is using more effort or straining to speak (using negative compensatory strategies)
What is ventricular phonation?
adduction of the false (ventricular) vocal folds
What type of patient displays ventricular phonation?
patients with a primary underlying vocal pathology, such as vocal fold papillomas, vocal fold paralysis, large vocal fold nodules, etc., which result in severely decreased glottic closure and reduced air flow
What are the negative compensatory strategies that cause ventricular phonation?
patient used increase laryngeal muscle tension to compensate for air wastage, inability to build sufficient subglottic pressure, and decreased loudness
Why is ventricular phonation a problem?
Adducted false vocal folds overlap true VFs and 'load' them, cause them to vibrate in an abnormal manner; if FVF vibrate, also causes diplophonia
What is the voice quality of people with using ventricular phonation?
hoarse, low pitched due to mass of FVF of combined mass of true and false folds, breathy, monotone, decreased pitch range
What are the complains of a person using ventricular phonation?
vocal effort/strain, possibly pain/discomfort
What is muscle tension dysphonia?
voice problems caused by excessive laryngeal muscle tension
What are the three types of muscle tension dsyphonia?
1. anterior-posterior compression
2. mediolateral compression (may involve FVF)
3. supraglottic squeezing (sphincter-like closer) with poster tongue carriage and contraction of pharyngeal constrictors
Can Muscle Tension Dysphonia (MTD) occur alone?
Yes, can occur along, or with other vocal fold pathologies such as nodules, polyps or vocal fold paralysis. If alone, there are no identifiable vocal fold lesions on pathologies
What are the clinical signs of Muscle Tension Dysphonia when palpating the larynx?
1. elevated laryngeal height
2. narrow, tense, thyrohyoid space
3. tension in suprahyoid muscles
4. tense, tight thyrohyoid muscles
5. inability to 'rock' layrynx left to right
What does Muscle Tension Dysphonia sound like? What are the patient complaints?
sounds - harsh, hoarse, or breathy; tense/tight pitch and/or phonation breaks; normal pitch, elevated pitch, or low pitch

patient complaints - vocal fatigue, tight, tense throat, laryngeal pain/discomfort
What is a psychogenic voice disorder?
A voice disorder with no underlying organic or physical cause, i.e. no identifiable disease or pathology, ranges from dysphonia to complete aphonia
What are the two types of psychogenic dysphonia?
1. puberphonia or mutational falsetto
2. psychogenic disphonia/hysterical dysphonia, can also be aphonia
Puberphonia is...
persistence of a child-like quality of voice after puberty (an ENT does bloodwork to make sure hormonic change did occur); diagnosis must include ruling out possible laryngeal structural defects or diseases that might affect the larynx.
What does puberphonia sound like?
high pitched, possibly hoarse and breathy; vocal pitch often lowers when they shout or do heavy lifting
What is psychogenic aphonia or dsyphonia?
complete loss of voice (aphonia) or dysphonic voice with no underlying physical cause; VFs appear healthy; non-speech/vegetative functions such as throat-clearning, coughing, laughing etc. show normal phonation
Psychogenic aphonia or dysphonia is often associate with...
fear, stress, traumatic event; onset is suddent or proceeded by periods of voice loss or dysphonia
What are the 10 different types of organic voice disorders?
1. paradoxical vocal cord movement
2. contact ulcers and granulomas
3. infectious laryngitis
4. gastrophageal reflux (GERD) or laryngealpharyngeal reflux (LPR)
5. vocal fold cysts
6. vocal fold papilomas
7. laryngeal webs
8. leukoplakia
9. sulcus vocalis
10. laryngeal cancer
What is Paradoxical Vocal Cord Movement (PVCM)?
1. adduction of VFS during quiet breathing.
2. causes stridor, shortness of breath.
3. learned behavior with no known cause (idiopathic) OR may be due to hyperactivity of the airway, a neurological problem, a psychological problem, or unspecified medical problem
4. often confused with asthma or exercised induced bronchospasms
T or F. The concerns of Paradoxical Vocal Cord Movement are non-vocal.
True. primary concern is ability to breath (occurs with a lot of athletes) - can be stopped using pursed lip breathing
What are the patient complaints with Paradoxical Vocal Cord Movement (PVCM)?
throat tightness, wheezing, shortness of breath, chest/lung tightness
What is the voice quality of patients with Paradoxical Vocal Cord Movement (PVCM)?
may be hoarse, weak, breathy
What are the 10 different types of organic voice disorders?
1. paradoxical vocal cord movement
2. contact ulcers and granulomas
3. infectious laryngitis
4. gastrophageal reflux (GERD) or laryngealpharyngeal reflux (LPR)
5. vocal fold cysts
6. vocal fold papilomas
7. laryngeal webs
8. leukoplakia
9. sulcus vocalis
10. laryngeal cancer
What is Paradoxical Vocal Cord Movement (PVCM)?
1. adduction of VFS during quiet breathing.
2. causes stridor, shortness of breath.
3. learned behavior with no known cause (idiopathic) OR may be due to hyperactivity of the airway, a neurological problem, a psychological problem, or unspecified medical problem
4. often confused with asthma or exercised induced bronchospasms
T or F. The concerns of Paradoxical Vocal Cord Movement are non-vocal.
True. primary concern is ability to breath (occurs with a lot of athletes) - can be stopped using pursed lip breathing
What are the patient complaints with Paradoxical Vocal Cord Movement (PVCM)?
throat tightness, wheezing, shortness of breath, chest/lung tightness
What is the voice quality of patients with Paradoxical Vocal Cord Movement (PVCM)?
may be hoarse, weak, breathy
Who gets Paradoxical Vocal Cord Movement (PVCM)?
athletes, more common in young women; may be linked to allergies, asthma, exercise, stress, or a psychogenic component
What are the three typical causes of contact ulcers and granulomas?
1. vocal misuse
2. GERD or LPR - if small and patient is compliant, they can go away on their own
3. intubation trauma
What are contact ulcers/granulomas?
inflammatory necrotic lesions (ulcers) that form on the medial aspect of the posterior third of the vocal folds (cartilaginous portion); can be unilateral or bilateral; may be complete or incomplete VF closure; mucosal wave may be decreased.
What are these contact ulcers/granulomas composed of?
lymphocytes and fibrotic connective tissue
Who gets contact ulcers and granulomas?
Dr. J has only seen this in men
Contact ulcers and granulomas caused by vocal misuse...
are caused by excessing slamming of the posterior glottis during low-pitched phonation, hard glottal attacks, increased loudness, throat clearing and coughing
Contact ulcers and granulomas caused by GERD/LPR...
affect the stomach acid and enzymes on VF tissue. Signs - heartburn, chronic hoarseness worse in AM, nocturnal coughing, excessing mucous, belching, sour/acid taste
Contact ulcers and granulomas caused by intubation...
trauma to VFs from prolonged intubation tube due to endotracheal tube rubbing VFs
Contact ulcers and granuloma characteristics and patient complaints:
1. may/may not be low-piched, hoarse, breathy
2. pain on phonation, voice worsens with prolonged use
What is infectious laryngitis?
inflammatory response of the larynx due to a viral infection (severe head or chest cold) - VF and layrngeal inlet appear red and swollen
What are symptoms and treatment of infectious laryngitis?
symptoms - total voice loss, hoarseness, breathiness, low pitch
treatment - VIRAL: voice rest, water, anti-inflammatory medications; non-mentholated lozenges, BACTERIAL: same as above by physician may prescribe antibiotics
Vocal Fold Cysts are...
sacs of tissue that contain either liquid (mucous) or a semisolid substance (epithelial cells)
What causes vocal fold cysts?
unknown. can be congenital or acquired in childhood; may be due to a blocked mucosal glandular duct.
Where are vocal fold cysts located, and what do they do?
located in SLP layer, are unilateral, absent mucosal wave, increased VF mass/stiffness of VF cover; irregular glottic closure; occur more in women (maybe because they have a higher FF and more bangs per second)
How are vocal fold cyst treated?
surgery, see an SLP afterward for 5-6 weeks to fix voice
What are the characteristics of VF cysts?
peceptual - hoarse, breathy, might be low-pitched, decreased loudness
acoustic - no date but probably similar to nodules, i.e. decrease pitch and loudness ranges, aperiodicity, increased noise levels
aerodynamic - no data but probably similar to that for nodules
patient complaints - hoarseness, vocal effort/strain, vocal fatigue
What are laryngeal papilloma?
wart-like growths caused by the human papilloma virus; found in VF, trachea and oropharynx
What are the two types of laryngeal papilloma?
1. early childhood onset
2. adult onset
How is laryngeal papilloma treated?
1. in children, surgically removed, but tend to re-occur until puberty, resulting in multiple surgeries; after surgery, most cases (80%) spontaneously resolve
2. in adults, surgery
How does larygneal papilloma affect the VFs?
1. incomplete glottic closure, absent mucosal wave
2. increase VF mass and stiffness
What are the characteristics of laryngeal papilloma?
1. perceptual - hoarse, breathy, strained
2. acoustic - no data available but probably decreased pitch/loudness ranges, decreased pitch
3. aerodynamic - no data available but due to increased stiffness or vocal fold subglottal pressure is likely increased
4. scarring due to repeated surgeries will further increase stiffness will decrease pitch range, increase aperiodicity, and decrease mucosal wave
5. patient complaints: trouble breathing, decreased pitch and loudness range, vocal effort/strain
laryngeal web is caused by...
1. congenital
2. acquired post-surgically
3. after laryngeal trauma (from a chemical burn of fire)
A laryngeal web is...
a band of tissue that forms in the anterior 1/3rd of glottis
Voice quality of laryngeal web...
1. in infants, inhalatory stridor may be present, shortness of breath, and high-pitched crying
2. voice is hoarse, high-pitched
what is leukoplakia and hyperkeratosis?
they are pre-cancerous lesions, ranging from flat and plaque-like whitish patches to warty lesions
What causes leukoplakia and hyperkeratosis?
constant irritation from smoking, alcohol ingestion, GERD or LPR, environmental pollutants, coughing/throat clearing
What does leukoplakia and hyperkeratosis look like and sound like?
1. can be unilateral or bilateral and VF edges are rough
2. increases VF mass and stiffness, decreases mucosal wave, irregular glottic closure, aperiodicty, VFs are asymmetric
3. voice is hoarse, breathy, low-pitched, decreased loudness
What is sulcus vocalis?
1. a longitudinal groove or indentation in the VF that parallels the free margins
2. is in the SLP layer
3. is usually congenital BUT may be from misuse/abuse or, if acquired, there may be a history of ruptured VF cyst
4. VF bowing, glottic incompetence, decreased mucosal wave, increased VF cover stiffness but decrease in mass of cover, incomplete glottic closure
5. voice is hoarse, breathy, decreased loudness, low pitched
What is larygneal cancer?
90% are malignant squamous cell carcinomas in the epithelial layer
What are symptoms of laryngeal cancer?
1. hoarse, dry, rough, low-pitched, breathy
2. globus sensation - 'full feeling' in throat, inhalatory stridor
3. throat pain, painful swallowing, problems swallowing, shortness of breath, foul breath