Voice Disorders Exam 1

9 Cartilages of Phonation

Protects the airway by acting as a moveable leaf-shaped cover; prevents food or liquid from entering the trachea during swallowing.

Their rocking/sliding actions are responsible for moving the true vocal folds, which are attached posteriorly to the arytenoids' vocal processes.

Forms a protective shield in the front and sides of the larynx; the most anterior portion of the larynx; the thyroid eminence.

Forms the base of the larynx

Intrinsic Muscles of the larynx

Contraction of this muscle pulls the artenoid muscles forward causing anterior/posterior closure of the glottis.

Forms the vocal folds

Muscles that are responsible for abducting the vocal folds and thereby opening the glottis.

Muscles that are responsible for adducting the vocal folds...adduction is also aided by the interarytenoid muscles.

These muscles of the larynx stabilize the laryngeal neck posture and can raise/lower the larynx; sometimes referred to as the big strap muscles of the neck.

This structure of the larynx consists of 5 layers.

5 layers of vocal folds

3 Layers of lamina propria

layer of the lamina propria that appears loose and pliant; it is here that edema often develops

Layer of the lamina propria that is made up primarily of elastic fibers and helps make up the vocal ligament.

Layer of the lamina propria that is dense with mostly collagenous fibers and helps make up the vocal ligament.

The intermediate and deep layers of the lamina propria make up what structure in the vocal folds?

The cover of the vocal folds consists of this layer. Lesions invade the cover and affect mass and stiffness.

Term to describe structural resistance as opposed to compliance when a structure is displaced.

Layering of the folds result in complex vibratory patterns as the folds undulate and a ______ _______ can be observed moving across their surface.
This is like the "leading edge. and is unlike the vibration of a string or metal tuning fork.

What type of voice quality do lesions most often cause people to have?

This layer of the lamina propria is rich in fibroblasts and is significant because fibroblasts are responsible for scar formation.

Cysts (lesions) that occur in this layer of the lamina propria can usually be treated surgically without the risk of scar formation.

Space between the vocal folds

The point where the glottal space is widest during abduction of the folds and is the site of the biggest impact when the folds close and where lesions such as nodules occur.

Describes the pattern of oscillation that is created by a continual opening and closing of the two masses of the vocal fold cover during voicing.

Every opening and closing of the folds...opening from the bottom layer to the top and close in a similar fashion.
Open--from the back to the front
Close--from the front to the back

Initiation of sound produced as the folds begin to vibrate.

3 types of Voice Onset

Type of voice onset where air flows through the glottis BEFORE the focal folds are adducted and vibrating.

Type of voice onset where the air is flowing through the glottis AS vibration of the vocal folds and adduction begin and is the most natural way of speaking.

Type of voice onset where air flows through the glottis AFTER the vocal folds are adducted, and vibration begins with a jolt.

The kind of voice onset habitually used by a particular client can be ascertained through:

Vocal folds vibrate in a __________ manner.

Minor fluctuations in vocal fold vibration are found in _________ and _________.

Variation in FREQUENCY during vibratory cycles is called___________.

Variation in AMPLITUDE during the vibratory cyle is called ___________.

Vocal folds are the most complex and sophisticated __________ in the vocal tract.

______________ passes through two other valves before the sound waves are shaped by the articulatory mechanism and exit the body through the oral and nasal cavities.

________ folds are just above and parallel with the true folds. During swallowing and during physical effort, they close, but remain ___________ during normal phonation. When they are _________ and actually vibrate it is called ________ ___________.

Folds of connective tissue with some muscle fibers that form a sphincter to pull the epiglottis posteriorly to close the larynx entrance during swallowing.

Skeletal structures of the Respiratory System

Airway consists of...

Postural Muscles of Respiratory System

Breathing Muscles

Aerodigestive Tract

Bronchial Tree

Types of Breathing

Respiration type used to sustain life and involves little muscular movement. Only the diaphragm and external intercostals mosve appreciable during this type of inspiration.

This type of respiration is accomplished WITHOUT muscle involvement.

The number of breaths per minute is greater in an infant because of...

The amount of air inspired and expired during a TYPICAL respiratory cycle and is determined by the oxygen needs, not the speaking or singing needs of the individual.

The maximum volume of air that can be INSPIRED beyond the end of a tidal inspiration.

The maximume volume of air that can be EXPIRED beyon the end of a tidal expiration.

Volume of air that REMAINS in the lungs after a maximum expiration.

TOTAL amount of air that can be EXPIRED from the lungs and air passages following a maximum inhalation. It represents the total volumes of all the other lung volumes with the exception of residual volume (which cannot be expired). It's reasonable to expect a relationship between the relative size of an individual and this capacity. It also tends to decrease with age.

Represents the TOTAL VOLUME of air that can be HELD in the lungs and airways after a maximum inspiration.

This is determined by how many vibratory closings and openings (cycles) the vocal folds make in one second.

How humans perceive/hear fundamental frequency.

Short, thick vocal fold that vibrates at a slower rate producing a low pitch.

Long, thin vocal fold that vibrates at a higher rate producing a high pitch.

What are the primary derminants (factors) in the difference in vocal pitch?

What muscle when contracted, STRETCHES and THINS the vocal folds and therefore INCREASES the fundamental frequency/pitch?

What muscle when contracted, SHORTENS the vocal folds and therefore DECREASES the fundamental frequency/pitch?

2 ways of increasing perceived vocal loudness are to increase...

Subdivisions within the total range of pitches produced by the voice.

These result from faulty structure or function somewhere in the vocal tract, in the processes of respiration, phonation, articulation or resonance.

4 Types of Voice Disorders that are outiside of the normal range for the age, gender, or geographic background of the speaker.

Any alteration in normal phonation

Term meaning NO voice

This specialist is concerned with identifying the etiological (cause) and pathological aspects for the purposes of treatment.

This specialist uses imagery in an attempt to get the desired acoustical effect from a voice student.

This specialist has the laboratory interest of a physiologist or physicist.

This specialist uses the knowledge and vocabulary of all desciplines to bring about voice improvement through treatment of voice.

This specialist assesses the dynamics of voice production and uses whatever is necessary to get the best voice.

ASHA affirms within the scope of practice for SLPs the practice of visualization of the larynx by both otolaryngologists and speech-language pathologists.

Lip an intraoral cancers rarely contribute to changes in voice, but they may have negative effects on ________.

_________involving the tongue, sometimes requiring partial or total removal of the tongue (glossectomy), or palatal and velar cancer can seriously affect_______, _________, & _________.

What are some of the identified causes of oral cancer?

In what ways are oral cancer treated?

This cancer involves the most severe of vocal tract malignancies.

Laryngeal cancer comprises of approximately what percent of all malignancies diagnosed annually in the U.S.?

3 classifications of laryngeal cancers depending on the site of the legion

What's the treatment for small to moderate lesions of laryngeal cancer?

Extensive laryngeal cancer can require any of these types of laryngectomies:

Voice disorder that refers to the failure of cartilage to stiffen with development, resulting in an epiglottis that is too pliable and collapses into the airway. Symptoms are evident at birth or within the first few hours or days of life.

Laryngomalacia accounts for what percent of all congenital anomalies of the larynx and is the most prevalent cause of stridor (audible gulping inhalation) in the neonate.

Laryngomalacia is managed by a ________, who normally confirms the condition using ________ ________ laryngoscopy.

Children with laryngomalacia rarely present acute airway compromise, and it is common for children to outgrow laryngomalacia by ____months. Approximately what percent of cases require surgical intervention?

Voice disorder of narrowing of the subglottal space.

Subglottic Stenosis that results from an interruption of the cricoids cartilage or arrested development of the conus elasticus during embryonlogic development.

Subglottic Stenosis that occurs following endotracheal ingubation either related to lifesaving procedures or surgery.

If stenosis is severe and air is not being exchanged, what treatment may be necessary?

Openings that occur between the esophagus and trachea and is associated with vascular compromise to the developing esophagus.

Abnormal occlusion of the esophagus which the standard intervention is surgery followed by voice and feeding therapy by the SLP.

Small ulcerations that develop on the medial aspect of the vocal processes of the arytenoid cartilages due to irritation.

When granulated tissue forms over contact ulcers as a protective mechanism, these occur.

Contact ulcers are usually _________.

What are some typical symptoms of contact ulcers?

One of the causes of contact ulcers resulting from throat clearing or coughing which cause the excessive slamming together of the arytenoid cartilages during production of low pitched phonation and increased loudness. Speaker is usually a hard-driving person who speaks in a loud, controlling low pitch.

Another cause of contact ulcers where stomach acid is forced up the esophagus and exits the upper esophageal sphincter, thus irritating the area between the arytenoids or the vocal covering.

What are ways to treat Laryngopharyngeal Reflux (LPR)?

What's the terminology for when a physician places a tube down the pharynx into the airway, between open vocal folds, and on into the trachea?

In regard to endotracheal intubation, when is the patient at risk for trauma and who is at the highest risk?

No voice therapy should be initiated following endotracheal intubation trauma until what is completed?

If postsurgical ___________ are identified along the posterior glottis, medical-surgical treatment promotes healing and preserves the airway.

Sometimes surgery on the vocal folds will produce a _________ ________ ________ leading to the formation of granulomas.

What is the most common reactive lesion of the larynx?

Teflon injection is used to give greater bulk to the paralyzed fold in ____________ permitting better approximation of the normal fold with the paralyzed fold.

What are some other surgical traumas that have the possible side effect of the development of reactive tissue granuloma? How are they resolved?

Any ________ _________ of the larynx, such as TB, syphilis, or sarcoidosis, can lead to granulmatous tissue changes and may produce voice symptoms. How are these voice problems managed/treated?

The focus of voice therapy for patients with contact ulcers/granulomas is to take the _______ out of phonation.

What are some of the methods to take the effort out of phonation?

What percentage of total voice cases comprise from contact ulcers? (Hint: not common)

Lesions of the larynx that are usually unilateral, occuring on the vocal folds or on the ventricular folds. They are soft and pliable in contrast to a vocal nodule which is hard and fibrotic.

Cysts are ofted caused by an ______ _____ of the ductal system of _________ ___________ __________, but there are other causes. They can be congenital or acquired.

Depending on the site of lesion, the patient may or may not experience __________.

The SLP who identifies any kind of laryngeal lesion should refer the patient to an __________. This especially is true for cyst because their management requires surgical excision...Cysts rarely resolve spontaneously.

Voice therapy postsurgically from cysts usually is confined to helping the patient eliminate any _________ _________ (such as increased glottal attack) that may have been used to minimize negative effects caused by the cyst. This patient usually presents with a breathy/hoarse voice quality.

____________ changes often have a major impact on developing larynges and cause excesses in fundamental frequency, so that an individual's voice is either too low or too high in pitch.

In ___________ of the pituitary gland, laryngeal growth is retarded. A prebescent child will experience lack of secondary sexual characteristics and a continued high voice pitch. May be treated by endocrine trapy designed to stimulate normal pituitary function.

In ___________ of the pituitary gland caused by some tumors of the pituitary gland, precocious puberty and acromegaly results.

What's another name for hypofunctioning of the ADRENAL glands and can contribute to lack of secondary sexual characteristis, including a prepubescent voice in males?

_____________ of the adrenal glands can be caused by tumors in the adrenal system, producing adrenal hormone excesses. It results in virilization (masculization) and a deepening of the voice.

Insufficient secretion of thyroxin by the thyroid gland can produce increased mass of vocal folds, which lowers pitch. The symptoms of hoarse gravelly and excessively low pitch can usually be controlled by thyroid hormone therapy.

In this voice disorder resulting from excessive thyroid function, vocal symptoms are not severe and patients experience jumpiness and irritability which result in a breathy voice that may lack sufficient loudness (George & Barbara Bush).

__________ vocal syndrome is characterized by vocal fatigue, reduced pitch range, hypophonia, and loss of certain harmonics. This syndrome usually begins 4-5 days before menstruation in about ______% of women.

This is a time when some women may experience vocal changes, particularly a lowering of fundamental frequency because of the secretion of excessive androgenic hormones, the glottal membrane becomes thicker, increasing the size-mass of the folds, producing a lowering of pitch and sometimes vocal roughness.

These are similar to contact ulcers and granulomas, differing only in type of lesion. Whereas granuloma usually is a firm granulated sac, this is a soft pliable, blood-filled sac.

Like granulomas, hemangiomas often occur on the ________ glottis, frequently associated with what 3 causes?

A vocal hygiene program and voice therapy should be initiated after what treatment of a hemangioma?

Additive lesion in the pharynx or larynx that is a pinkish, rough, and nonmalignant growth that may be the precursor* of malignant tissue change therefore must be watch closely over time for any changes in appearance.

Common sites for hyperkeratoses include...

The primary etiologies of hyperkeratosis are chronic _________ to the oral and laryngeal membranes over time and their effect on voice can vary depending on the site and the extent of the lesion.

Most effective treatments of eliminating the sources of tissue irritation causing hyperkeratosis are...

This often develops in a patient who has had a cold, fever, headache, runny nose, sore throat, and coughing. Most cases are viral but may be caused by bacterial infections.

What is the treatment for Infectious Laryngitis and if not done can do permanent damage?

This is a treatment for a patient that has had their larynx comprised by disease such as laryngeal cancer or by trauma.

A ________ laryngectomy alters respiration, swallowing, and speech. To maintain an airway, an opening called a ________ is created in the trachea through which the patient (laryngectomee) breathes all pulmonary air in and out.

3 Methods of Alaryngeal communication...

Type of alaryngeal communication where air is either injected or inhaled by mouth into the pharyngoesophageal (PE) segment and immediately expelled, setting the PE segment into vibration. This type of speech is hardest to teach/learn and sounds like someone speaking while belching.

Type of alaryngeal communication where pulmonary air flows from the trachea through a prosthetic shunt into the esophagus, facilitating the production of esophageal "voice" without extensive special training. This device is implanted by the surgeion at the time of laryngectomy.

Type of alaryngeal communication where sound for speech is produced by placing the an instrument against the external throat or oral structures or inserting a tube into the mouth while speaking. Sound is produced by a vibratory voicing source and is highly intelligible but sound robotic.

Pathology that is common and is associated with whitish patches that are additive lesions to the surface membrane of mucosal tissue and often extend beneath the surface into the subepithelial space. Comon sites are under the tongue and on vocal folds and are considered to be precancerous.

It is impossible to distinguish between leukoplakia and ________ of the larynx by visual inspection alone.

The most common cause of leukoplakia is continuous ___________ .

Other than heavy smoking which is usually the cause of Leukoplakia, what have been other suggested causes?

Leukoplakia on vocal folds can dramatically alter voice. The added mass to folds lowers pitch and causes hoarseness and hypophonia (lower movement/tone; non-efficient voice). The additional mass may cause the vocal folds to be asymmetrical which results in ___________ as each fold vibrates at a different frequency.

Leukoplakia that occupy space on the _______ ________ may prevent normal approximation of the folds contributing to breathiness, reduced loudness, and overall dysphonia.

The treatment for leukoplakea is medical-surgical and voice therapy only contributes to developing ____________.

This pathology is the most common benign laryngeal neoplasm (tumor) in children and the most common cause of pediatric hoarseness.

Papillomas are ________ growths, viral in origin, that occur in dark moist caverns of the airway, frequently in the larynges of young children. Ohter sites are the oral cavity, trachea, and bronchi.

_____________ tend to reproduce quickly and can represent a serious threat to the airway, limiting the needed flow of air through the glottal opening.

The majority of papillomas occur in children under the age of _______. For this reason _________ &_________ in preschool children should be evaluated promptly. Most papillomas stop recurring about the time of ____________.

What percent of papillomas persist beyond puberty?

Tx for papillomas is medical-surgical. Treatment is considered _________ not curative because of the resiliency of the human papillomavirus.

Complications from continued surgical procedures for recurring papilloma include...

Injecting patients intramuscularly with ________ has proven effective with some papilloma patients.

___________ dysphonia and occasional _______ breaks can be experienced by boys during last year of puberty due to rapid laryngeal growth and dramatic change in vocal fundamental frequency. These are not cause for parental or clinical concern.

______________ disease is associated with the passage of gastric juices from the stomach into the esophagus.

___________ _________ occurs if the gastric juices move superiorly and exit the upper esophageal sphincter and the contents spill into the pharynx (throat)

What is considered the most definitive study of LPR/EER involving passing a thin catheter transnasally into the esophagus where a special sensor records each reflux incidence?

Other than 24 hr pH monitoring what are other diagnostic procedures to dx LPR/EER?

Reflux tx can be divided into what 3 categories?

Treatment for reflux involving following a vocal hygiene program: elevating head of bed, remaining upright for an hr after meals, avoiding spicy food, not exercising after eating, and cutting down on caffeined, carbonated drinks, alcohol, and excessive quantities of water right before bed.

Pharmacological tx for reflux involves taking a _____________ twice a day.

This voice disorder may be congenital or acquired and is of unknown etiology but vocal abuse and reflux may play a role in the acquired form.

This is a generic term that means furrow or indentation.

In sulcus vocalis, on endoscopy or stroboscopy, a furrowed _________ edge of the vocal fold is seen and is usually _________ symmetrical.

_____________ permits close examination by an SLP of the vocal folds to discover abnormalities associated with sulcus vocalis. In former years many of these abnormalities were missed by mirror examination only.

What are some of the dysphonia symptoms associated with sulcus vocalis?

Primary tx for sulcus vocalis is surgical followed by voice therapy. After surgery, _______ function needs reassessment by the SLP. Improved function may still require that _________ of the patient to be identified and corrected, particularly in reducing vocal _____________.

A __________ ______ grows across the glottis between the two vocal folds & inhibits normal vibration producing high-pitched rough sound and seriously compromises the open glottis. Approximately __________ of these cross the glottis.

A ___________ laryngeal web is detected at time of birth and is the result of the glottal membrane failing to separate in embryonic development. Depending on the size, the baby will produce stridor (inhalation noises), shortness of breath, and often a different high-pitched (squeal) cry.

Testing for ____________ deletion is suggested when congenital webbing is present as this may be associated with _____________ syndrome.

Presence of a congenital web requires immediate surgery, often followed by a __________ tracheostomy. Usually, and infant larynx will recover over a period of ___________ weeks.

__________ webs result from some kind of ___________ trauma of the ___________ edges of the vocal folds. Anything that might serve as an irritant to the __________ surface of the folds may be the initial cause of the webbing.

Any surface irritation associated with webbing due to prolonged _________ or __________ may cause the inner margings of the two fold surfaces to grow together.

One principle of plastic surgery is that when approximated together, _________ tissue surfaces will tend to grow and fuse together. This same principle explains why webbing occurs.

What are some examples of causes of acquired webbing to occur?

To prevent the surgically removed web from growing again a ________ _______ is placed between the two folds and kept there until complete healing has been achieved. The patient is on _______ _________ _________ as long as the keel is in place because its presence inhibits normal fold vibration.

When the keel is removed ________ weeks after web removal, the patient generally requires some voice therapy to restore normal ________. It may be impossible for the patient to ever have the same voice quality that they had prior to surgery. The __________ for voice recovery is highly individualized.

The primary function of the postnatal larynx is to __________.

At birth, the larynx is _____ the dimension of the adult laryx, is extremely soft and malleable, doesn't possess a vocal fold layer structure and shows no sex differentiation.

At birth the neonate's larynx occupies a position __________ in the neck than in adults. The epiglottis is in contact with the _______ allowing infants to carry out the functions of breathing and feeding simultaneously.

Almost immediately after birth, the larynx begins to descend in the neck. The evolutionary cause of the laryngeal descent is not clear but it is thought to have first evolved for _______ and secondarily for ___________.

Ossification of the hyoid bone begins by age ________. By age ________ nearly all of the laryngeal cartilage ossifies in males. The female larynx never completely ossifies.

The infant has a proportionately larger _________ than the adult.

4 Types of Infant Cries

The __________ characteristics of the cry from infants with various medical conditions deviate from typical cry characteristics. Voice is a reflection of the health of the body.

Universal fact about the larynx: the vocal folds respond differentially depending on __________ state.

The __________ cry is strained, tense, harsh, and forced owing to massive, tight, effortful closure of the entire laryngeal tract. By contrast, the _______ cry is more sonorous, lax, and devoid of strain or tension. Pain cries are longer in duration than _______ cries.

Research suggests that crying is a ___________ meant to communicate meaning. Infant cries serve to maintain proximity and elicit care from caregivers.

2 types of infant vocalizations

_________ Physiologic Basis for Intonation is used to segment speech.

Infants respond to intonation of voice before they are able to _________ language.

3 Intonational Stages in the development of language

In males _________ _________ drops 50% from the infant cry to childhood voice and another 50% from childhood voice to adulthood.

In females, the decrease in fundamental frequency is less dramatic but also reaches adult maturity during ___________.

Until puberty, the larynx is of equal size in male & female. At puberty, male laryngeal growth __________ the female's. Also, the greater the enlargement of the ________ in most males results in a more prominent increase in ___________ _________ than seen in females.

During puberty, the larynx continues to ____ in the neck, and the neck itself _________.

Onset of puberty occurs in _________ climates and with children who are __________ in weight.

In temperate climates, onset of females ranges from _______ and in males from ages __________. Near the Equator, onset is ___________ 1-2 years and near the poles it is ________ 1 year.

Onset of pubery in females can be delayed due to....

The average time from onset to completion of adolescent voice change is __________ and _________ at most.

__________ signs of puberty occur 3-4 months before its onset.

Pubertal voice change is divided into 3 time periods...

In females, the voice change is complete by ___________ and in males by age ________. Although the voice change occurs earlier in females, males & females complete the change at approximately the same age.

During puberty, the most marked drop in fundamental frequency occurs in boys and is thought to be related to the larygeal growth changes resulting from _______ _________. The male voice drops by approximately ________ octave.

This term refers to pervasive sudden voice breaks rom high to low pitch, or the reverse, or excessively husky or hoarse voice associated with adolescent voice change.

________ _________ can span an entire octave, transcending vocal registers from high-pitched falsetto to bass.

There is a high prevalence of ________ _______ (hoarse-husky voice quality) during adolescent voice change but most boys have uneventful voice change. Adolescent voice change does NOT constitute a ________ ________.

__________ voice may lower in some females around age 70 while male fundamental frequency may rise slightly.

Structural changes (respiratory system/vocal folds) due to aging process

Increase in the ________ of the vocal folds may be the cause for lowering of the fundamental frequency and roughness and hoarseness of voice in elderly women.

Older speakers have a tendency to ________ their voices.

_________ studies indicate listeners can identify older subjects by the sound of voice. Older persons in ________ ________ and those that participate in ________are more difficult to distinguish.

The primary biological function of the AIRWAY is...

The primary biological funtion of the LARYNX is...

The sound of our voice reflects our ___________ state. Also our voice is an important part of WHO we are so as SLPs we often in voice therapy must prepare to treat the _________ person.

How one feels affectively may be heard in the sound of the voice as well as in changes of the ________ rhythm patterns of vocalization. Such voicing is known as __________ phonation.

Voice pitch, loudness, and quality augment __________.

_________ as a group have been studied specific to voice disorders more than any other population showing much higher prevalance in this profession.

____% of school-age children experience continuing voice problems compared with _____% of the adult population.

4 Kinds of Voice Disorders

Kind of voice disorder that is caused by a structural problem or deviation (growth)that affects vocal fold vibration...something is physically wrong.

Kind of voice disorder that involves problems with the innervations of the laryngeal mechanism causing the vocal folds to function improperly.

Kind of functional voice disorder which is caused by psychosocial factors...nothing is physically wrong (Ex. Puberphonia)

Kind of functional voice disorder that is caused by too much laryngeal tension and effort...the most prevalant voice disorder in children and adults.

SLPs can evaluate/assess a voice disorder but NEVER treat a voice disorder without ________ _________ from a M.D. because the disorder could be cancer!

As SLPs, it's in our scope of practice to provide counseling, especially with patients with psychogenic voice problems, but couseling must be confined to the _________ ________ itself.

With _________ voice problems, the SLP may be the first health care professional to see a patient just beginning to experience voice symptoms.