Organic Disorders
What are organic voice disorders
CONTACT ULCERS/ GRANULOMAS
Vocal cord contact ulcers are usually caused by abusing the voice with forceful speech, particularly as a person starts to speak.
-These ulcers typically occur in singers, teachers, preachers, sales representatives, lawyers, and other people whose occupation requires them to talk or otherwise use their voice a lot.
-Backflow (gastroesophageal reflux[GERD]) of stomach acid also may cause or aggravate vocal cord contact ulcers.
-Endotracheal intubation (insertion of a plastic breathing tube through the mouth or nose into the windpipe [trachea]) may cause vocal cord contact ulcers if the tube is too big.
- Treatment involves resting the voice by talking as little as possible for at least 6 weeks so that the ulcers can heal. Whispering may cause further injury and must also be avoided.
BILATERAL VF PARALYSIS
most common cause of neonate stridor. Caused by lesions in the vegas nerve. May be both adductor or abductor type.
In bilateral adductor paralysis, neither vocal fold is capable of moving to midline, thus making phonation impossible and placing the individual at high risk for aspiration.
In abductor paralysis, the coal folds remain at the midline, causing serious respiratory problems.
DYSPHONIA/ APHONIA
PSYCHOGENIC
May be due to anxiety or emotional distress
is more common in women
VF tissue and movement are normal
during speech the VFs are held partially abducted, may hyper adduct or appear bowed, the voice may be intermittent or sporadic.
Voice treatment focuses on reestablishing voice utilizing various techniques.
TRAUMATIC LARYNGITIS
-Short term loss of voice with impaired vocal quality.
-Voice quality will be dysphonic and often described as rough, with increased spectral noise.
Phonational range is reduced; jitter and shimmer are increased. Patients may complain of dryness, under stroboscopy the folds move asymmetrically and aperiodically.
Treatment includes reduced phonotrauma and vocal hygiene
LARYNGOMALACIA
-soft larynx
-most common cause of stridor in infancy, in which the soft, immature cartilage of the upper larynx collapses inward during inhalation, causing airway obstruction.
-It can also be seen in older patients, especially those with neuromuscular conditions resulting in weakness of the muscles of the throat.
-In infantile laryngomalacia, the supraglottic larynx (the part above the vocal cords) is tightly curled, with a short band holding the cartilage shield in the front (the epiglottis) tightly to the mobile cartilage in the back of the larynx (the arytenoids).
-These bands are known as the aryepiglottic folds. The shortened aryepiglottic folds cause the epiglottis to be curled on itself. This is the well known "omega shaped" epiglottis in laryngomalacia.
-Laryngomalacia results in partial airway obstruction,
-most commonly causing a characteristic high-pitched squeaking noise on inhalation (inspiratory stridor). Some infants have feeding difficulties related to this problem.
-Rarely, children will have significant life-threatening airway obstruction. The vast majority, however, will only have stridor without other more serious symptoms such as dyspnea (difficulty breathing).
FUNCTIONAL DYSPHONIA
Functional dysphonia is poor voice quality without any obvious anatomical, neurological or other organic difficulties affecting the larynx or voice box.
-It is also referred to as functional voice difficulty.
-Functional dysphonia is more common in women over age 40.
Typical symptoms of functional dysphonia include: Breathy, hoarse or rough voice; Voice instability; Voice fatigue.
Treatment includes: Voice therapy; Visual and electromyographic biofeedback; Progressive relaxation; Laryngeal massage, which lowers the larynx and relaxes tense muscles
UNILATERAL VF PARALYSIS
when the RLN is compromised on one side, the laryngeal adductor muscles (particular the lateral circoarytenoid) are not able to perform their adductor role. This keeps the paralyzed fold fixed in the paramedian position.
The voice in UVFP is markedly dysphonic or aphonic. Perceptual characteristics include breathy, hoarse vocal quality, reduced phonation time, decreased loudness, monoloudness, dilophonia, and pitch breaks. Injections often help these people
PUBERPHONIA
PSYCHOGENIC
(Mutational falsetto)- typical during puberty; often occurs in males;
voice will be high pitch with neck tension evident; pitch breaks, phonation breaks, vocal fatigue and breathiness present.
Treatment focuses on the production and the establishment of a lower voice. Massage techniques or glottal attacks helps.
DIPLOPHONIA
-is a phenomenon in which a voice is perceived as being produced with two concurrent pitches.
Diplophonia is a result of vocal fold vibrations that are quasi-periodic in nature.
-It has been established that diplophonia can be caused by various vocal fold pathologies, such as vocal folds polyp, vocal fold nodule, recurrent laryngeal nerve paralysis or vestibular fold hypertrophy.
SUBGLOTTAL STENOSIS
-congenital or acquired narrowing of the subglottic airway.
-relatively rare, it is the third most common congenital airway problem (after laryngomalacia and vocal cord paralysis).
-Subglottic stenosis can present as a life-threatening airway emergency.
-Subglottic stenosis can affect both children and adults.
There are two types of functional dysphonia:
(1) Hypofunctional dysphonia — Results from an incomplete closure of the vocal cords or folds;
(2) Hyperfunctional dysphonia — Results from overuse of the laryngeal muscles and, occasionally, use of the false vocal folds (the upper two vocal folds that are not involved in vocalization).
SPASMODIC DYSPHONIA
there are three types of spasmodic dysphonia (add, ab, and mixed).
Adductor SD is most common. More common in women than men. Adductor is characterized by irregular, uncontrolled, random closing spasms of the VF during phonation the resulting voice is referred to as STRAINED and STRANGLED.
Abductor dysphonia experience irregular, random, uncontrolled opening movements of the VF and the voice is heard as more breathy. Voice quality normal during signing. More voice breaks. Behavioral treatment may be helpful.
VOCAL FOLD NODULES
MUSCLE TENSION DYSPHONIA
-Bilateral vocal fold nodules- Nodules typically form from long periods of phonotrauma, a buildup occurs on the lamina propria, the abnormal outgrowth (excrescence) usually forms at the junction of the anterior one-third posterior two- thirds of the VFs (i.e. the middle of the membranous VF).
-Appearace: start out as clear broad-based blister, become invaded by blood vessels and turn pinkish, become fibrous (hardened), finally are small white corns.
-The diagnostic characteristics include: Visual blisters on the VF; a hoarse, breathy, harsh, or raspy vocal quality with phonation breaks and vocal fold effort; quality decreases throughout the day
Treatment includes the reduction of phonotrauma during the day, nodules may have to be surgically removed.
-More common in women and children than men (2:1)
MUSCLE TENSION DYSPHONIA
(hyperfunctional dysphonia) is caused by chronic increased tension of the laryngeal musculature resulting in dysphonia that typically has multifactorial contribution etiologies.
-VF appearance is essentially normal although hyper- and hypo- adduction may be seen. Larynx may be held high in the neck.
-Dysphonia may range from mild to severe with a rough, strained quality. Voice breaks that re very short in duration.
Symptomatic voice treatment and Botox injections often help with these clients.
3 forms of subglottic stenosis include
-Subglottic stenosis can be of three forms, namely congenital subglottic stenosis, idiopathic subglottic stenosis (ISS) and acquired subglottic stenosis.
-As the name suggests, congenital subglottic stenosis is a birth defect.
-Idiopathic subglottic stenosis is a narrowing of the airway due to an unknown cause.
-Acquired subglottic stenosis generally follows as an after-effect of airway intubation, and in extremely rare cases as a result of gastroesophageal reflux disease (GERD).
ESSENTIAL TREMOR
Thought to result from a lesion in the extrapyramidal system of the CNS.
-Voice tremor may be accompanied by a resting tremor of the face, head, hands, or other muscles of the oral mechanisms.
-Characteristics include: Rhythmic oscillations of the larynx, the tremor may interfere with intelligibility, although complete voice breaks are not common.
Botox injections are the only treatment.
Unilateral paralysis of motor external branch of Superior Laryngeal Nerve
Unilateral Adductor Paralysis of Recurrent Laryngeal Nerve
Unilateral Abductor paralysis of Recurrent Laryngeal Nerve
VOCAL FOLD POLYPS
MUSCLE TENSION DYSPHONIA
-Phonotrauma resulting in hyper functional VF adduction result sin wound formation arising in the superficial layer of the lamina propria.
-Polys may result from one event or acute phono trauma.
Lesions may rise anywhere on the VFs. Polys are unilateral, some may be hemorrhagic.
-Pitch is typically lowered with increased jitter and shimmer, VF closure may be impaired, the patient may describe that there is something caught in their throat.
-Short term treatment focuses on improved vocal hygiene, most polyps require surgical treatment.
Etiology of vocal polyps-
VENTRICULAR DYSPHONIA
Adduction of the false VF. The voice quality is low in pitch and loudness, monotone, rough/harsh, often diplophonic and has a significant restricted pitch range.
Treatment focuses on reducing the Vocal fold dysfunction through various techniques.
ESOPHAGEAL ATRESIA
-Esophageal atresia (EA) is a congenital defect. This means it occurs before birth.
-There are several types. In most cases, the upper esophagus ends and does not connect with the lower esophagus and stomach.
-Most infants with EA have another defect called tracheoesophageal fistula (TEF). This is an abnormal connection between the esophagus and the windpipe (trachea). In addition, infants with EA/TEF often have tracheomalacia. This is a weakness and floppiness of the walls of the windpipe, which can cause breathing to sound high-pitched or noisy. Some babies with EA/TEF have other defects as well, most commonly heart defects.
Symptoms of EA may include: Bluish coloration to the skin (cyanosis) with attempted feeding; Coughing, gagging, and choking with attempted feeding; Drooling; Poor feeding. Exams and Tests include: Before birth, a mother's ultrasound may show too much amniotic fluid. This can be a sign of EA or other blockage of the baby's digestive tract. The disorder is usually detected shortly after birth when the infant tries to feed and then coughs, chokes, and turns blue. If EA is suspected, the health care provider will try to pass a small feeding tube through the infant’s mouth or nose into the stomach. If the feeding tube can’t pass all the way to the stomach, the infant will likely be diagnosed with EA.
An x-ray is then done and will show any of the following: An air-filled pouch in the esophagus; Air in the stomach and intestine.; If a feeding tube has been inserted before the x-ray, it will appear coiled in the upper esophagus
Treatment includes: EA is a surgical emergency. Surgery to repair the esophagus is done as soon as possible after birth so that the lungs are not damaged and the baby can be fed; Before the surgery, the baby is not fed by mouth and will need intravenous (IV) nutrition. Care is taken to prevent the baby from breathing secretions into the lungs.
CYSTS
a benign collection of material, typically on the superficial layer of the lamina propria, may be congenital or a result of phonotrauma, increased stiffness is note dint he folds, vocal fatigue and lowering habitual pitch may be perceptually noted.
-Surgery and emphasis on vocal hygiene
Bilateral Adductor paralysis of Recurrent Laryngeal Nerve
Bilateral Abductor paralysis of Recurrent Laryngeal Nerve
Bilateral superior laryngeal nerve paralysis
REINECKE’S EDEMA
MUSCLE TENSION DYSPHONIA
(polypoid degeneration)- most often seen in women, may be unilateral or bilateral.
-The edema causes a loose floppy appearance of the surface of the vocal folds, often pale in color.
FF is noticeably reduced with a reduced phonational range.
stroboscopy exam reveals decreased mucosal wave and decreased amplitude of vibration.
Treatment usually requires surgery then followed voice treatment with emphasis on vocal hygiene.
muscle tension dysphonia
a general term for an imbalance in the coordination of the muscles and breathing patterns needed to create voice.
This imbalance can be seen without any anatomical abnormality (primary MTD) or in the presence of an anatomical abnormality (secondary MTD). In the case of secondary MTD, the muscle tension is thought to be the body’s natural compensatory process to adjust for the vocal injury.