Voice Disorders

Voice Disorders

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Description: Voice disorders are distinct and evaluated differently than speech disorders. Voice is to vibration. Speech is to articulation.

Topics of Discussion in this report include: Mechanics of voice production, Pediatric Voice disorders, congenital, developmental, neurologic, Adult Voice Disorders, hyperkinetic, abuse, psychogenic, neurologic, chronologic, and cancer.

Author: David Witsell, MD, MHS (Fellow) | Visits: 1908 | Page Views: 1924
Domain:  Medicine Category: Therapy 
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Primer on Voice & Voice Disorders
David Witsell, MD, MHS Duke University Medical Center Division of Otolaryngology, HNS

Voice disorders are distinct and evaluated differently than speech disorders. Voice is to vibration Speech is to articulation

Topics of Discussion
Mechanics of voice production Pediatric Voice disorders
congenital, developmental, neurologic

Adult Voice Disorders
hyperkinetic, abuse, psychogenic, neurologic, chronologic, cancer

Mechanics of Voice Production-Sound
Nature of sound
condensations and rarefactions of air resulting in a rhythmic series of pressure changes 340 m/sec (travels about one mile in five seconds)

Modified by its surroundings Consists of energy

Mechanics of Voice Production-Sound
Activator or power source
airstream from the lungs

vocal cords, mucosal wave

upper airway principally, body as a whole, environment

Mechanics of Voice Production-Activator
Primary function is to exchange oxygen and carbon dioxide to sustain life Both a voluntary and involuntary activity Expansion of the thoracic cavity is active, recoil is both active and passive.
Greatest areas for expansion is lateral lung bases

Mechanics of Voice Production-Vibrator
Vocal folds within the boxlike structure of the larynx mucosa (squamous >>> pseudostratified columnar) superficial, intermediate, deep layer of the lamina propria
no true ligament, condensation of collagen and elastin, muscle

Mechanics of Voice Production-Vibrator
Attached to the inside of the laryngeal cartilage (Broile's ligament) Condenses on the arytenoids Lengthen, shorten, reposition
mucosal vibratory wave (HZ vibrations per second)

Mechanics of Voice Production-Resonator
Larynx Pharynx

Oral cavity

Head Body Environment

Mechanics of Voice Production-Resonator
Vocal tract vibrations are broken up by associated structures Fundamental frequency remains intact, notes outside the pitch range are dampened The resonators tune the vocal pitch to soprano, contralto, baritone Oral cavity and tongue create the "vowel formants"
"ah" "ee" "oo"

Mechanics of Voice Production-Resonator
Resonance is dependent on muscle relaxation Resonance is not an active process Falsetto Hearing provides the feedback necessary to fine tune pitch and resonance

Voice DisordersPediatric
Congenital Acquired/developmental Neurologic Infectious Traumatic Neoplastic

Voice DisordersPediatric
Vocal history begins at birth Perinatal events important to consider Genetic constitution Hearing

Voice DisordersPediatric
Prelinguistic vocalizations begin at 6-8 weeks of age
gliding pitch changes

Babbling repetitive syllables at 3 months
"ma-ma" "da-da"

Intonation patterns at 9 months
NO!!! Emotional linkage to voice production


Laryngeal web
May present at birth Can either produce a high pitched or raspy voice Typically diagnosed in adolescent males Usually anteriorly based

Laryngeal web

Average age of diagnosis is 2-3 years of age HPV types 6 and 11 most common HPV types 16 and 30 thought to predispose to SCCA Hoarseness and airway obstruction Spontaneous remission

Debulking procedures most common Carbon Dioxide Laser Cold knife Shaver Interferon Intra-lesional antiviral medication (Cidofovir)


Vocal Cord Nodules
Mucosal callus Screamers nodes Small capillary hemorrhage followed by edema Typically occur at the point of maximum excursion of the phonatory cycle

Disorders of Nasal Resistance
Nasal obstruction
Clarity and brilliance of voice decreases Work-up includes hearing assessment PE including endoscopy Speech therapy, medical and surgical

Disorders of Nasal Resistance
Nasal escape
Inadequate palatopharyngeal closure Plosive consonants (p,b,t,d,k) and fricatives (s,z,sh,ch) affected Work-up includes hearing assessment PE including endoscopy Speech therapy, medical and surgical

Neurologic disorders
Cerebral Palsy
mixed vocal disorder Hyper and hypotonicity of the vocal folds may co exist Vocalis and cricothyroid predominate Articulation palatal and VC paralysis need to be excluded

Voice Disorders-Adult
Congenital Acquired/psychogenic Neurologic Infectious Traumatic Neoplastic

Muscular Tension Dysphonia
Most common vocal disorder in adults
vocal fatigue poor projection neck pain voice worsens through the day

Muscular Tension Dysphonia
Complete ENT exam Flexible laryngoscopy
videostrobscopy to R/O mucosal lesions

Phonation alone may not yield dx Articulation shows AP contraction and plica ventricularis

Muscular Tension Dysphonia

Muscular Tension Dysphonia
Speech therapy Psychiatric assessment Reassurance Vocal hygiene

Vocal Abuse & Nodules
Usually bilateral - mucosal wave present Women>men Predisposes to muscular tension dysphonia Speech therapy Micro-surgical treatment for large or refractory nodules NO LASERS

Vocal Abuse & Nodules

Vocal Polyps
Usually unilateral - mucosal wave present Anterior off the subglottic surface of the vocal fold Superficial layer of the lamina propria ? Throat clearing or coughing Micro-surgical treatment Post-operative speech therapy

Vocal Fold Cysts
Unilateral anterior to mid-cord mucosal wave diminished Not mucosally based Bind mucosal surface to the deep layer of the lamina propria Hoarseness, loss of upper range Micro-surgical therapy indicated Long term rehab with speech therapy and vocal coach NO LASERS

Contact Ulcers
Bilateral in the posterior larynx, superior and involving the vocal processes Erythema, edema, obliteration of the ventricle Reflux related, probe for GE reflux sx Silent reflux Incidence related to language Medical treatment, SP

Psychogenic Vocal Disorders
Conversion disorders Secondary gain Emotional trauma Prolonged aphonia

Psychogenic Vocal Disorders
Sudden loss Intermittent periods of aphonia (not dysphonia) No indication of muscular tension dysphonia Cough normal Vowels normal Voicing is appropriate when distracted SPEECH THERAPY

Neurologic Disorders
recurrent nerve paralysis viral neuropathy myasthenia gravis

MS Parkinson's disease

Recurrent Nerve Paralysis / Paresis
Complete H&P Flexible laryngoscopy CXR / Neck CT / Chest CT Laryngeal EMG- prognosis Watchful waiting vs. implant

Laryngeal Nerve Paresis in Myasthenia Gravis
Progressive loss of projection with fatigue Increased breathiness with conversation Progressive articulation defects Nasality Tensilon Test Neurology referral, EMG

Vocal Disorders in Parkinson's Disease
Degeneration of the basal nuclei Voice is breathy and weak Loss of pitch variation Slowed rate of speech production (prosody of speech reduced) L-dopa dose not improve speech in 80% of patients Selected patients will improve with bilateral mid-cord augmentation

Other Adult Vocal Disorders
increased vocal edema associated with fluid balance and estrogen levels

atrophy of mucosa typically causes lowering of the fundamental frequency

Environmental irritants Aging

Vocal dysfunction associated with aging Pitch perturbation may increase Fundamental frequency changes Bowing of the vocal folds Activator Vibrator Resonator

Speech therapy Bilateral mid-cord augmentation Counseling Exercise

Discussed TopicsPrimer on Voice and Voice Disorders
Mechanics of voice production
begins with understanding the sound

Pediatric Voice disorders
principally organic in nature

Adult Voice Disorders
R/O functional causes and treat appropriately