Unit Seven Voice Disorders Copyright 2008 Delmar All

Chapter 27 Anatomy and Physiology of the Respiratory and Phonatory Systems Copyright © 2008

The Respiratory System • Driving support of voice production • Intricate balance between respiration

Supportive Structures of Respiration • Bones in the chest provide framework and protection of

Muscles of Respiration • Diaphragm – Primary muscle • Internal and external intercostals •

Trachea • Extends from larynx down to the lungs • Composed of cartilaginous rings

Respiratory Process • • • Diaphragm lowers and rib cage expands Space in thoracic

Phonation • Larynx is the organ of phonation • Sits at top of trachea

Framework of Larynx • • Cricoid cartilage Thyroid cartilage Two arytenoid cartilages Epiglottis 9

The Vocal Folds • Biological function – To prevent food/liquid entering the trachea •

Vocal Folds • Glottis – Space between open vocal folds • Posteriorly – Vocal

Vocal Fold Vibration • Vocal folds must open and close to produce voice •

Vocal Fold Vibration • To produce voice – Folds close • Air pressure beneath

Maximum Phonation Time (MPT) • Length of time a person can sustain a tone

Frequency • Frequency – Number of cycles of opening and closing the vocal folds

Pitch • Psychological sensation of the frequency of a sound • Pitch changes based

Loudness • Perceptual correlate of intensity of a sound – Intensity measured in decibels

Voice Quality • Judgments of voice quality are subjective • Quality is affected by:

Chapter 28 Voice Disorders in Children and Adults Copyright © 2008 Delmar. All rights

Voice Disorder • A deviation of loudness, pitch, or quality out of the range

Classification of Voice Disorders • Functional – Faulty use of mechanism • Neurological –

Functional Voice Disorders • Hyperfunctional – Excess tension or forcing in larynx • Hypofunctional

Laryngitis • Inflammation of vocal folds • Voice is associated with lowered pitch and

Chronic Laryngitis • Laryngitis lasting longer than 10 days • Causes may include: –

Vocal Nodules • Most common benign lesions in children and adults • Typically bilateral

Vocal Nodules • Caused by continuous abuse/misuse of voice – Screaming, coughing, singing in

Vocal Polyps • Benign vocal fold lesions • Frequently unilateral • Occur at juncture

Functional Dysphonia • May be hyperfunctional or hypofunctional • No medical or surgical treatment

Functional Aphonia • Hyperfunctional voice disorder • Voice is typically whispered • Most causes

Falsetto • High-pitched breathy voice • Produced by vibration of anterior onethird of the

Organic Voice Disorders • • Papillomas Contact ulcers Trauma Cancer 31 Copyright © 2008

Papillomas • Soft wart-like growths • Viral in origin • Occur mainly in children

Contact Ulcers • Small ulcers at juncture of middle and posterior one third of

Contact Ulcers • Voice quality is hoarseness • Voice therapy is usually successful 34

Traumas • Various traumas can compromise the airway and affect the larynx • Voice

Cancer • Requires surgical and medical treatment 36 Copyright © 2008 Delmar. All rights

Neurological Voice Disorders • Hypoadduction – Difficulty getting the vocal folds together – Vocal

Vocal Fold Paresis and Paralysis • Unilateral paralysis – Vocal quality is breathy –

Spasmodic Dysphonia • • Strained, strangled, harsh vocal quality Affects females more than male

Chapter 29 Voice Evaluation and Therapy Copyright © 2008 Delmar. All rights reserved.

Examination • Indirect laryngoscopy – Place a laryngeal mirror into back of mouth –

Examination • Endoscope placed intraorally or transnasally • Can be videotaped (videoendoscopy) – Or

Voice Screening • Screenings of voice will determine if a complete evaluation is needed

Voice Evaluation • Case history • Assessment of voice – Perceptual, acoustic, physiologic •

Instrumental Evaluations • • Aerodynamic Electroglottography Electromyographic assessment Photoglottography 45 Copyright © 2008 Delmar.

Voice Therapy • Multifaceted approach is required • Specific voice therapy will depend on

Hygienic Voice Therapy • First step in many therapy programs • Focus on instilling

Symptomatic Voice Therapy • Reduce/eliminate abuse and misuse of voice through facilitating techniques –

Psychogenic Voice Therapy • Identify and modify the emotional and psychosocial behavioral reasons that

Physiological Voice Therapy • Directly alter or modify the physiology of the vocal mechanism

Eclectic/Holistic Voice Therapy • Combination of any or all of the orientations and approaches

Laryngectomy • Surgical removal of the larynx • Surgical approach to treating laryngeal cancer

Before a Laryngectomy • Establish immediate means of communication after surgery • Discuss choices

Tracheoesophageal Puncture (TEP) • Incision made into trachea • Valve directs air from trachea

Esophageal Speech • Compressing air and injecting into esophagus • Expel air from esophagus

Electrolarynx • Neck devices with vibrating source that produces sound 56 Copyright © 2008

Chapter 30 Emotional and Social Effects of Voice Disorders Copyright © 2008 Delmar. All

Emotional and Social Effects • The voice reflects our personality • It is an

The Voice • The voice is the mirror of the person • The voice

Voice • In a social context, the voice will convey: – Semantic content –

Young Children • Many children are unaware or unconcerned with a hyperfunctional voice disorder

Children • As children get older, they become aware of their voice and are

Adolescents • Adolescents with chronic voice problems are typically motivated to participate in a

Adults • Twenty-five percent of adults are displeased with the sound of their voices

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Supportive Structures of Respiration • Bones in the chest provide framework and protection of the respiratory system • Thorax – Contains the lungs and the heart 4 Copyright © 2008 Delmar. All rights reserved.

Respiratory Process • • • Diaphragm lowers and rib cage expands Space in thoracic cavity increases Air pressure decreases in lungs Air flows down trachea into lungs Alveolar sacs and chest relax and air is forced from lungs 7 Copyright © 2008 Delmar. All rights reserved.

Vocal Fold Vibration • To produce voice – Folds close • Air pressure beneath the folds increases and forces folds to open • Elasticity and Bernoulli’s law causes folds to close • Subglottic air pressure builds up and forces folds to open again 13 Copyright © 2008 Delmar. All rights reserved.

Maximum Phonation Time (MPT) • Length of time a person can sustain a tone or sound on one expiration • Varies based on gender, age, physical characteristics, health 14 Copyright © 2008 Delmar. All rights reserved.

Frequency • Frequency – Number of cycles of opening and closing the vocal folds per second – Measured in Hertz (Hz) • Fundamental frequency – Rate of vocal fold vibration 15 Copyright © 2008 Delmar. All rights reserved.

Loudness • Perceptual correlate of intensity of a sound – Intensity measured in decibels (d. B) • Relates to the force with which vocal folds open and close and the amount of air that escapes 17 Copyright © 2008 Delmar. All rights reserved.

Voice Quality • Judgments of voice quality are subjective • Quality is affected by: – Adequate vocal fold closure – Efficient timing of closure – Amount of tonicity within the folds 18 Copyright © 2008 Delmar. All rights reserved.

Classification of Voice Disorders • Functional – Faulty use of mechanism • Neurological – Related to muscle control and innervation of muscles • Organic – Related to physical changes in larynx 21 Copyright © 2008 Delmar. All rights reserved.

Functional Voice Disorders • Hyperfunctional – Excess tension or forcing in larynx • Hypofunctional – Decreased or inadequate tension or reduced vocal capacity 22 Copyright © 2008 Delmar. All rights reserved.

Chronic Laryngitis • Laryngitis lasting longer than 10 days • Causes may include: – Traumatic laryngitis – Allergies – Singing excessively at damaging intensity levels – Smoking 24 Copyright © 2008 Delmar. All rights reserved.

Vocal Nodules • Most common benign lesions in children and adults • Typically bilateral • Occur at juncture of anterior and middle one third of vocal folds 25 Copyright © 2008 Delmar. All rights reserved.

Vocal Polyps • Benign vocal fold lesions • Frequently unilateral • Occur at juncture of anterior and middle one-third of vocal folds • Vocal quality is hoarseness 27 Copyright © 2008 Delmar. All rights reserved.

Functional Dysphonia • May be hyperfunctional or hypofunctional • No medical or surgical treatment • SLP works to improve intensity, pitch, quality • Psychological support may be beneficial 28 Copyright © 2008 Delmar. All rights reserved.

Papillomas • Soft wart-like growths • Viral in origin • Occur mainly in children – 4 -6 years • Vocal quality is hoarseness • Treatment is surgical removal 32 Copyright © 2008 Delmar. All rights reserved.

Contact Ulcers • Small ulcers at juncture of middle and posterior one third of folds • Can be caused by: – Persistent and excessive slamming of arytenoids and hard glottal attacks – Gastroesophageal reflux – Intubation for surgery 33 Copyright © 2008 Delmar. All rights reserved.

Traumas • Various traumas can compromise the airway and affect the larynx • Voice therapy will focus on helping clients achieve their most functional voice 35 Copyright © 2008 Delmar. All rights reserved.

Neurological Voice Disorders • Hypoadduction – Difficulty getting the vocal folds together – Vocal fold paralysis • Hyperadduction – Vocal folds close too tightly or for too long 37 Copyright © 2008 Delmar. All rights reserved.

Spasmodic Dysphonia • • Strained, strangled, harsh vocal quality Affects females more than male Onset on average at 45 years of age Treatment involves voice therapy and medical-surgical approach (Botox) 39 Copyright © 2008 Delmar. All rights reserved.

Voice Screening • Screenings of voice will determine if a complete evaluation is needed • Screening tasks include: – Count 1 to 10 – Conversation – Phonating vowels 43 Copyright © 2008 Delmar. All rights reserved.

Hygienic Voice Therapy • First step in many therapy programs • Focus on instilling healthy vocal behaviors in habitual speech patterns – Determine misuse – Become aware of these behaviors – Eliminate damaging behaviors 47 Copyright © 2008 Delmar. All rights reserved.

Symptomatic Voice Therapy • Reduce/eliminate abuse and misuse of voice through facilitating techniques – Auditory feedback – Change of loudness – Counseling 48 Copyright © 2008 Delmar. All rights reserved.

Before a Laryngectomy • Establish immediate means of communication after surgery • Discuss choices of voice production – Tracheoesophageal puncture (TEP) – Esophageal speech – Electrolarynx 53 Copyright © 2008 Delmar. All rights reserved.

Young Children • Many children are unaware or unconcerned with a hyperfunctional voice disorder • Voice therapy may not begin until kindergarten • Parents are counseled on how to encourage less abusive voice use by their children 61 Copyright © 2008 Delmar. All rights reserved.

Adolescents • Adolescents with chronic voice problems are typically motivated to participate in a voice therapy program • Adolescents with falsetto voices can experience significant social penalties – especially boys 63 Copyright © 2008 Delmar. All rights reserved.

Adults • Twenty-five percent of adults are displeased with the sound of their voices • A holistic approach to treatment views the whole person when determining the best therapy program for an adult with a voice disorder 64 Copyright © 2008 Delmar. All rights reserved.