Epithelial Hyperplasia

Misuse/Abuse

Hyperfunctional voice

Chemical irritants

signs/symptoms:  hoarsness and roughness

Treatment:  surgerical removal/biopsy 

Nodules 

Misuse/ Abuse

Caused by phonotrauma, hyperfunction of VF

benign lesions on VF edge

Signs: hoarsness/breathiness

Treatment: Voice Therapy 

Polyp 

Misuse/abuse

period of vocal abuse or single incident

typically unilateral, looks like blood blister

Signs: hoarseness/roughness/breathiness

Treatment:  Surgical removal 

Edema & Reinke's Edema

Misuse/abuse

Build up of fluids in VFs, often assoc with smoking

Signs: low/rough/lower pitch 

Treatment:  Fix underlying cause/voice therapy 

Cyst

Can be Misuse/abuse  

Fluid filled oval sac

Signs:  hoarseness/roughness/breathiness 

Treatment:  Improved vocal habits and vocal rest 

Granuloma

Can be misuse/abuse

Often follow damage from tracheal intubation

or vocal abuse and reflux

Signs:  hoarseness, vocal fatique, globus

Treatment:  voice treatment/reflux regime 

Sulcus Vocalis

furrow or indentation in vocal fold

signs: harsh/reedy hoarseness/effortful voice production

treatment:  usually surgical 

Vocal Fold Scarring

usually post surgery

signs:  hoarseness/effortful voice production/difficulties with singing and pitch/vocal fatigue 

Treatment: voice therapy 

Carcinoma

Misuse/abuse

Smoking is number 1 risk factor/chemical etc

signs: hoarseness/sore throat

treatment: surgery/radiation/chemo 

Papilloma

Viral in nature

signs: hoarseness

treatment: surgery--lesions tend to reoccur 

Vocal Fold Web

fibrous band in larynx between VFs

Signs: weak hoarse cry, choking, aspiration

treatment: surgery 

Contact Ulcer

Misuse/abuse

Location is key to diagnosis

related to acid reflux/tube trauma

signs: low pitch, throat clearing and vocal fatigue 

Treatment: Treat GERD/vocal rest 

Laryngitis

Misuse/abuse

Inflammation of the larynx

signs: hoarseness/loss of voice

treatment: voice rest/antibiotics/fluids 

Trauma: blunt or thermal

some trauma to larynx

signs: swelling, stridor, hoarseness etc etc

treatemtn: reconstruction of damage 

Hemorrhage

Misuse/abuse

Usually a single episode of traumatic voice use or laryngeal trauma---bleeding 

signs: pain, hoarseness etc etc

treatment: vocal rest 

Anklyosis of Cricoarytenoid Joint

Fixation or stiffness caused by arthritis, trauma or joint disease

Signs:  hoarseness/breathiness/stridor

Treatment: ???? 

Vocal Fold Paralysis

Head/neck injury, tumors, disease, stroke---damage to the Vagus nerve

Signs:  hoarsenss/breathiness/limited pitch and loudness variation

treatment:  muscle nerve transplant, injection, voice therapy 

Voice with Increase Tension/Strain

1. hard glottal attack

2.  high laryngeal position

3.  anterior-post laryngeal squeezing 

Voice with Inappropriate Pitch Levels

1. Puberphonai

2.  Glottal Fry

3.  Monopitch 

Types of Voice Misuse

 1.  Voice produce with increased tension

2.  Voice produced at inappropriate pitch level 

3.  Excessive Talking

4.  Ventricular Phonation

5.  Aphonia/Dysphonia of Psychological Origin 

Abusive Behaviors

a. excessive, prolonged loudness

b.  strain and excess use during period of swelling, inflammation etc.

c.  excessive coughing and throat clearing

d.  the screamer or noisemaker

e.  sports and exercise enthusiast 

 Voice and Nervous System

• voice production is controlled in the CNS 

Neural-Based Voice Problem Etiologies

1. Lesions or disease of upper motor neurons
2. Lesions of lower motor neurons 

Upper Motor Neuron Lesions

Cause:

• CVA
• Disease Process
• Toxins
• Trauma

Lower Motor Neuron Lesions

Cause:

 Peripheral motor nerves running off CNS

May result in VF paralyis

• Iatrogenic (surgery trauma)
• Trauma of head, neck or chest
• Idiopathic (unknown, thought to be viral) 

Vagus Lesions Result in:

Flaccid Paralysis of abductor or adductor muscles 

Unilateral Adductor Paralysis

Failure to approximate VF 

Breathy/strained voice

Aspiration 

Bilateral Adductor Paralysis 

Vocal folds do no abduct

High airflow and air wastage

More severe symtoms than unilateral

Aspiration is a major problem 

Breathiness/strain/roughness 

Unilateral Abductor Paralysis

Not as serious as one fold is always near the midline

Can produce voice and protect the airway

No non-speech problems 

Bilateral Abductor Paralysis

Glottis is completely closed 

Can result in Dyspnea and air starvation---may need tracheotomy!

Medical Techniques

• Injections

• Medialization

•  Re-Inervation 

Non-Medical Techniques

• Facilitating Techniques
• Pushing Exercises

Spasmodic Dysphonia

Neurologically based

Abrupt voice breaks

greater number of aberrant acoustic evens

irregular wide spaced variations

some high freq spectral noise

increased stress since onset of symptoms

Not many instances of normal voice

pattern of phonemic variability

can have better voice in the A.M.

Does not respond well to voice therapy 

3 Types of Spasmodic Dysphonia

*can be accompanied by tremors and facial jerks!!! 

1. adductor-involuntary adduction of the VFs resulting in struggle and strain to talk, choked/tensed voice

Seen most often

2. Abductor-involuntary abduction of the folds  resulting in interruption that is breathy

3.  Mixed-both types are present 

Laryngoscopic Signs of SD

Appears normal at rest

hyperadduction or hyperabduction during phonation 

Pathophysiology of SD

Greater air pressures

More rapid open/closed phase 

Treatment for SD

Voice Therapy

Psychotherapy

Nerve Resection  (Dedo)

BT

Teaching to voice on exhalation 

Functional Voice Pathologies

1. Functional Aphonia

2.  Persistent Falsetto

3.  Paradoxical VF Motion

4.  Muscle Tension Dysphonia 

Functional Aphonia

(Conversion Aphonia) 

Consistent or Periodic absence of phonation during speech production  in the presence of a normal larynx

Usually middle aged woman

Can be psychological in origin (conversion aphonia), psychologial problem that manifest physically

Persistent Falsetto

(Puberphonia) 

Continued use by adolescent males of a high pitch register following development of the larynx.

Can persist to any age

Usually associated with young men 

May have a psychologic origin 

Paradoxical VF Motion

 Is an abnormal motion of the VFs--they move towards eachother during quiet breathing when they should remain abducted.

Results in irritation and cough

Often misdiagnosed as asthma

Treated with a program of respiratory retraining (behavioral modification, breathing exercises, relaxation) 

Muscle Tension Dysphonia

2 Types:

1.  Primary- a type of vocalizing or speaking in which the muscles in the neck are tense and when no other lesion or paralysis is seen.

2.  Secondary-  a compensatory method of vocalizing due either to a paralysis, paresis or muscular weakness causing the perosn to squeeze other parts of the larynx to help produce sound 

Muscle Tension Dysphonia

(vs. SD) 

Functionally based--no structural or neuro component

Signs of excessive muscle tnesion

No abrupt voice breaks

Less aberrant acoustic events

Excessive high freq spectral noise

Instances of normal voice

Do not vary phonemically

Consistent vocal tension, complaints of pain and tighness

Responds well to voice therapy 

Glottal Fry

Usually at the end of the sentance

End with lowest pitch range 

Ventricular phonation

Ventricular folds virbrate

Sometimes the source of diplophonia 

Drugs

Can have positve and negative effects on voice

Can cause mucosal damage---drying (inhalers)

Factors:

 1. individual response differences

2.  placebo effect

3.  Dose reactions

4.  Multiple effects 

Drug Categories

1. Coordination: proprioception, impacts the CNS

2.  Airflow:   

3.  Fluid Balance:

Drugs--Coordination

Proprioception---impact on CNS

Stimulants:  Caffeine, cocaine, amphetamines

Depressants:  Tranquilizers, alchohol

Anesthetics 

Drugs--Air Flow

Bronchodiliators--anti asthma meds, often have nervous side effect 

Drugs--Fluid Balance

 Diaretics-reduce edema and swelling

Decongestants

Steroids

anitspasmodics

codeine

anti psychotics

anti-depressants 

Drugs--Structure Change

androgens: male hormones--female to male transgender, increases risk for heart disease 

Drugs--Hearing (Ototoxins)

Auditory feedback change

Myosins, usually affect sensorineural hearing 

Malingerer

Pretends an illness that the patient knows is not present for often for gain

Always functional

Difficult to conclude 

Probes for Functional Disorders

Coughing

Falstto

Pair speaking with non speech (coughing)

Humming 

Negative Practice

Clinical return to previous voice use to alert patient that they are able to shift their voices---they are in control 

Misuse/Abuse

Misuse:  Less severe than abuse