Nerves
Name the muscle(s) innervated by the RLN
Name the muscle(s) innervated by the SLN
RLN: PCA, IA, TA, LCA
SLN: CT
True or False
Clinicians encourage patients to work with the air loss rather than fight it
True
This is a type of compensatory pattern
Patients may start to change their behaviors by learning to accept shorter utterance length and use of a softer voice. This change can result in reduced strain and may ease vocal fatigue.
Define a neurologic voice disorder
Give an example
Directly caused by an interruption of the nervous innervation supplied to the larynx, including both central and peripheral insults
Some of these disorders are confined to voice and laryngeal manifestations, such as VF paralysis
Others include broader progressive neurologic diseases which cause deterioration of many central and peripheral motor control systems such as flaccid dysarthria
What is ILO?
Perceptual characterisitcs?
Etiology?
What is ELIO and Treatment?
Inappropriate adduction of VFs during inhalation
Perceptual characteristics: audible inhalation, stridor
Etiology: unclear but often associated with traumatic event and stress, anxiety
Sudden onset when exposed to a trigger
When stimulus/trigger is removed symptoms go away
Often misdiagnosed as asthma
Common triggers: LPR, Exercise/excursion (EILO), Cold air, Strong smells, Smoke, Can be cooccurring with CC or MTD or can occur on its on
Treatment: breathing exercises, goal of treatment is to improve control of glottal opening
Education about disorder (how we breath, what's happening, it's not a lung problem)
Biofeedback with laryngoscopy could be helpful
Relaxed/open throat breathing: (same as CHS but called different name)
Relax
Quick sniff in through nose (triggering abductor reflex to open glottis)
Diaphragmatic breath
Prolonged exhalation through pursed lips or small diameter straw
10 breaths, 4-5x/day and when feeling triggered
*same as CHS but called something different
ELIO: exercise induced, same treatment but with a few controlled breaths before
What are two purposes of acoustic measures?
What is the average fundamental frequency for females and males?
What is the average intensity for females and males?
What does CPP measure and what is the average
Provide indirect evidence of severity of voice problem, evaluate effects of treatment
Females: 170 - 225 hz , 60 - 106 dB
Males: 100 - 150 hz, 60 - 110 dB
CPP: general measure of breathiness and dysphonia severity. Values below 11.46 for vowel prolongation and below 6.11 for connected speech are strongly indicative of a voice disorder
What are the 3 branches of the vagus nerve?
1. SLN
2. RLN
3. Pharyngeal
*fun fact, the vagus nerve is the longest CN in the body and also called the wandering nerve
Define each:
Velopharyngeal dysfunction (VPD)
Velopharyngeal incompetence
Velopharyngeal insufficiency
Velopharyngeal mislearning
Velopharyngeal dysfunction (VPD)
General term for abnormal VP function
The port works (enough tissue) but it isn't working speech or feeding
Velopharyngeal incompetence: problem with the neurophysiology (movement)
Velopharyngeal insufficiency: problem with the anatomy (structure)
Velopharyngeal mislearning: a problem with function (articulation)
Articulation (learning) disorder
Will after surgery if person is still using the "old" way for producing a sound
Child has phoneme specific nasal emission
Describe perceptual characteristics of abductor, adductor and mixed SD
Is the onset gradual or sudden?
What is a hallmark of diagnostic certainty with SD?
What is the best treatment option for SD?
SD is a neurogenic dystonia (movement disorder)
Abductor: breathiness, aphonia, increased VOT, effortful, especially on unvoiced consonants
Adductor: Strain, effortful, pitch breaks, glottal stops especially on voiced consonants (Due to hypercontraction of muscles of adduction TA, LCA)
Mixed: Perceptually sounds like ADD but careful analysis will reveal a pattern of increased voice onset time. Intermittent, involuntary spasms of VF hyperadduction and sudden breathy bursts of involuntary abduction. Voice stoppage and breathy aphonia is inconsistent
Gradual onset
Hallmark: Resistance to any traditional medical or behavioral voice treatments is a hallmark of diagnostic certainty in SD
Treatment: Botox
What type of paralysis is this? what nerve is affected?
vocal fold paralyzed in a fully adducted or medial position
unilateral abductor paralysis
Name 3 vocally traumatic behaviors
Name 3 voice components that may be affected by a voice disorder
screaming, loud talking, throat clearing, coughing, vocal noises
Phonation, resonance, pitch, loudness, rate, respiration
Goal of GAVT
and targets that can be addressed in therapy
make voice and/or other aspects of communication congruent with gender identity or gender expression
Offering tools to help someone find congruence between their voice, communication style and gender
Targets that can be addressed in therapy
Pitch
Loudness
Rate
Intonation
Articulation
Prosody
Utterance length
Language
Body language
Describe three options for alaryngeal speech following a TL
What are some considerations for patients with each (pros and cons)
Bonus: what is the purpose of a HME?
1. Esophageal speech: "burping" bring air up into the esophagus and using that air to articulate words. Benefits is it doesnt require any extra materials.
2. Artificial larynx. Electrolarynx vibrates neck tissue which creates air movement in resonant cavities and can be shaped to produce words by over articulating. Voice comes out robotic and monotone (which is now changing with new technology) not hands free.
3. Voice prothesis. (TEP) tracheal esophageal puncher. fistula is created between the trachea and the esophagus, Occluding the stoma directs air into the voice prosthesis and sends it up the esophagus to resonant cavities to produce speech. Patient has to have good dexterity, eye site and hygiene in order to clean it everyday
HME: act like our nose airs, pharyngeal cavity, they warm and filter the air before it gets to our lungs
Describe a perceptual and visual characteristics of a vocal tremor
Whats the task for differential diagnosis between a vocal tremor and SD?
What treatment is used for tremor?
Movement disorder (CNS) characterized by rhythmic tremors that may involve the neck, head, arms, palate, tongue, face, larynx either in isolation or combination.
Perceptual: regular wavering of pitch and intensity during sustained phonation, prolonged vowels and connected speech. In severe cases causes voice breaks or complete stoppages similar to SD
Visual: rhythmic tremor of VF
Perceptual difference is evident during sustained vowels: SD will sound nearly normal except for brief intermittent spasms, VT will produce consistent rhythmic modulations
No uniformly successful treatment but botox injection is used with mixed results. Some research into deep brain stimulation for treatment of essential tremor- may be a future treatment. Voice therapy can be helpful- decrease perception of tremor by staccato production of vowels especially and treating secondary tension
What are treatments for VFP?
Medical:
Medialization laryngoplasty (injection)
Thyroplasty: permanent implant, typically done after repeated success with medialization injection
Voice therapy: The primary goal of voice therapy is to improve glottic closure, increase intrinsic muscle strength and agility, and develop abdominal support for breathing
Name what you can and cant do with rigid and flexible scope
Rigid: can do - vowel prolongation /i/, get bigger brighter picture
Cant do: connected speech
Flexible: can do - all speech tasks, see full pharyngeal cavity
Cant do -
Describe what both the extrinsic and intrinsic muscles do to alter the shape of the larynx and vocal folds.
Bonus is to name all the muscles
Extrinsic: Raise and lower the larynx, helpful for swallowing. Alter the shape and filtering characteristics of the supraglottic vocal track, which modifies vocal pitch, loudness and quality
(sternocleidomastoid, styohyoid, thyrohyoid)
Intrinsic: Alter shape and configuration of the glottis by modifying position, edge and tension of vocal folds Consist of adduction (closing) and abduction (opening) and modifications of length, tension and thickness
(PCA, IA, LCA, TA, CT)
What disorder is this? Age related changes that typically begin after age of 65 in the larynx/voice
Describe visual and perceptual characteristics
Name two treatment suggestions and the goal of each treatment
Presbylaryngis (structural) /presbyphonia(voice)
Visual: thinning of the vocalis muscle, bowed glottis, loss of elasticity
Perceptual: thin, muffled voiced quality, decreased loudness, increased breathiness, pitch instability and lack of vocal endurance and flexibility, reduced respiratory efficiency
Phorte: Goal is to improve the strength, quality and endurance of voice. Weekly sessions and daily practices concentrate on "loud and high" and "loud and low" voice productions practiced on functional phrases chosen by the patient which helps with generalization of voice techniques to conversational speech
Personal amplification: increase vocal loudness without creating fatigue, which can cause maladaptive behaviors
What is the function of the basil ganglia. What voice disorder is related to basil ganglia dysfunction?
Perceptual and visual voice characteristics of disorder
Treatment/treatment goals for disorder
What is happening in hypokinetic and hyperkinetic disorders in terms of dopamine?
Parkinsons: visual - rigidity, tremor, bowed glottis, asymetrical vibration, ventrical involvement, difficulty initiating and then inhibiting, masked face
Perceptual - Reduced ROM, Rapid, accelerated (“blurred”) speech, prosodic abnormalties, quiet, weak, breathy, fatigue, may be hoarse, rough, stutter
Treatment: LSVT Loud, intensive, emphasizes loud speech, which improves respiratory support, articulation and facial expression/animation
Initiation and inhibition of movement, Regulating muscle tone, Control postural adjustments during skilled movement (stabilize shoulder during writing), Scale force, amplitude, duration of movements, Adjust movements to environment (How far to through a ball)
Hypokinetic disorders = too much dampening
Reduced mobility and ROM
Bradykinesia or akinesia (no movement)
Hyperkinetic disorders = not enough dampening
Excessive activity of dopaminergic nerves which reduces the dampening effect on cortical signals
Involuntary movements
What is chronic cough?
What is cough hypersensitivity? and common tiggers
What is treatment? Show me the breathing technique
Cough that lasts 8+ weeks
natural reason (sickness, typically upper respiratory infection) for cough sensors to be dialed up and now that’s gone and they cough has turned into its own disorder
Triggers: talking, laughing, cold air, exercise, crumbly foods, odors/fumes
Cough is usually unproductive (dry)
Treatment: BCST Goal = override cough reflex to improve cough control and reduce cough sensitivity but still coughing when its needed
Relax
Quick sniff in through nose (triggering abductor reflex to open glottis)
Diaphragmatic breath
Prolonged exhalation through pursed lips or small diameter straw
10 breaths, 4-5x/day and when feeling triggered
Define a mucosal wave and disorders/factors that decrease the mucosal wave.
Reflects overall flexibility of VF during vibration
Absence of mucosal wave called nonvibrating portion, stiffness or adynamic segment can be described in terms of its location and extent of the VF
Conditions that stiffen the cover such as lesions and scarring tend to reduce the mucosal wave. Stiffening of the vocal fold cover also increases the phonation threshold pressure, which may be perceived by the patient as in-creased phonatory effort.
What nerve is a major contributer to Fundamental frequency control?
What nerve abducts the VF?
What nerve is the body of the VF?
What nerve is one of the strongest adductors, helpful with vegetive acts?
1. CT (Stretches, lengthens and creates longitudinal tension in VF, making them stiffer and decreasing vibratory wave)
2. PCA (Abducts fully for respiration and partially during quick glottal opening gestures to produce unvoiced sounds)
3. TA (Stiffen body and loosen cover, Contributes to lowering fundamental frequency, increasing loudness and tighter glottal closure )
4. LCA (Brings VF to midline, closes glottis which creates medial compression for loud voice and strong vegetative closure, as in coughing, grunting and throat clearing)
What fuses first during embryotic development?
What are the primary and secondary palates made up of?
Primary palate
Primary:
Secondary:
Paralysis
1. What will you hear if all branches of CNX are affected?
2. RLN unilateral types (4) and perpetual characteristics
3. RLN Bilateral risks for adductor and abductor
4. What does SLN paralyis look like?
1. hypernasality, VF(s) in intermediate position (position of rest), Weak and breathy voice, Risk of aspiration
2. Fully abducted (d) Severely breathy and aphonic, Impaired vegetative function: coughing, grunting, lifting, defecating
Median (a) Fairly normal vocal quality, Vocal instability, Slight weakness, Impaired loudness
Paramedian (b) – most common, Breathiness, Diplophonia, Impaired loudness, fatigue
Intermediate (c) - in between fully abducted and median
3. Adductor - risk of aspiration and lack of airway protection
Abductor - risk of not being able to breath
4. see normal vocal folds, but will see sudden twisting of larynx when they try and go up high, Usually unilateral, Highly idiopathic, not super debilitating for average human
1. Goal of breathing exercises
2. Goal of trills
3. Goal of circumlaryngeal massage
4. Goal of resonant voice therapy
5.Goal of relaxation techniques
1. Coordinate breathing with phonation. Targeting breath support and utterance length. Breathing should be a continuous, relaxed cycle with inhalation happening quickly and exhalation being extended during phonation.
2. Reducing laryngeal and extralaryngeal tension while promoting airflow and an increased sense of oral resonance. Once a patient can achieve trills consistently, they can shape these into vowels, words, and phrases in an attempt to maintain ease and quality of phonation from the trill to the spoken word.
3. Achieve neutral laryngeal positioning and release compensatory hyperfunction that may lead to fatigue or anterior neck discomfort. Patients with particular dysphagia-related complaints (e.g., food or pills feeling stuck in the throat) may also benefit from these techniques. Following laryngeal massage, patients often describe a sensation of openness in their throat, a smoother swallow, and increased ease of phonation.
4. The goal is to achieve easy phonation while experiencing energy or vibration of sound in the oral cavity. Maximizes resonance, which can result in more efficient vocal output with less effort
5. target secondary behaviors, Patients may benefit from stretching, progressive relaxation, meditation, and/or breathing exercises that work to release and refocus tension in the body.
A subjective perceptual measures of severity ____
This test looks at these 5 qualities ...
CAPE-V
1. roughness
2. breathiness
3. Strain
4. pitch
5. loudness