Common Voice Disorders
Reference ON-LINE: GOOGLE “IOWA PROTOCOLS”
Resource: http://wiki.uiowa.edu/display/protocols/Home
Learning Objectives:
I. Understand the basis of voice and speech production with associated
terminology
II. Understand the significance of voice disorders
III. Understand the functions of the larynx and how disease impairs those
functions
IV. Learn how to evaluate a patient with a voice disorder
V. Identify common voice disorders
VI. Learn the management of common voice disorders
Henry T. Hoffman MD
Department of Otolaryngology—
Head and Neck Surgery
National Center for Voice and Speech
University of Iowa
Case Example – Audio then Visual
What is your diagnosis?
Link to video
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
A. Glottis = vocal cord area
B. Supraglottis= area of
larynx above vocal cords
(false vocal cords/
arytenoids/epiglottis)
C. Subglottis = area of
larynx immediately
below the vocal cords
Coronal section
D.
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
Cough
Voice = output from the lung
and larynx
video of normal videostrob
E. Speech = communication
resulting from modification of
voice by the articulators
(tongue/lips/palate/teeth)
video of dysarthria
F. The function of normal vocal cords
Voicing:
(a competent glottic valve)
‘Glottic valve’
converts the
convert DCDC current of air streaming
AC
upward from the lung into an AC current.
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
G. The most superficial layer of the vocal cord is fluid.
It overlies the mucosal surface of the vocal cord which
also contains muscle and ligament.
Normal voicing requires this fluid layer to be present –
underscoring key components to the treatment of
voice disorders: humidification and hydration.
Normal larynx
Vocal Folds - Complex Nature
Body - Underlying muscle + vocal ligament
Cover - Loosely attached epithelium
Overlying fluid
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
G. The combination of adequate breath support (lungs) and app
[VIDEO of patient with asthenic voice]
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
H. Impaired function of the glottic valve results in an
abnormal voice and can also impair swallowing
and breathing.
[VIDEO of bilateral vocal cord paralysis]
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
I. Passive vibration of the vocal cords rather than
active movement by muscle contraction results in voice –
this concept explains how a patient with
bilateral vocal cord paralysis may have a normal voice.
[VIDEO of bilateral vocal cord paralysis #2]
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
J. Phonation can also occur without vocal cords.
A man treated with removal (partial laryngectomy) of
cancerous vocal cords is able to produce a lung powered
sound (voice) by vibration of the arytenoid mucosa against
the base of the tongue.
[VIDEO of patient below]
10 year follow-up (video) of patient after supracricoid laryngectomy
Lung powered
sound:
Voice
without
vocal cords
Inspiration (glottis open)
Phonation
arytenoids
against
base of tongue
I. Basis of Voice and Speech Production –
Anatomy/Physiology/Terminology
K. More definitions:
Voice Disorders - Terminology
• Dysphonia = Hoarseness
Impaired laryngeal function
Impaired lung function
• Characterize GRBAS
G= overall grade
B -“Breathy” - poor glottic closure
R -“Rough” - irregularity of vocal fold
A - “Asthenic” = weak - poor breath support
S - “Strained” - tight glottic closure
II. The Significance of Voice Disorders
A. Dysphonia as a tipoff to another illness
Voice Disorders: Significance
Associated Disease
• Rough voice
• Laryngeal cancer
• Recurrent respiratory papillomatosis (RRP)
• Breathy voice- laryngeal paralysis
• Thyroid cancer
• Lung cancer
• Asthenia -weak voice
• Parkinson’s disease, ALS, Myasthenia gravis
• Poor breath support – pulmonary disease
• Strain
• Anxiety, stress, underlying psychiatric problem
II. The Significance of Voice Disorders
B. Voice Professional = singers, doctors, lawyers, teachers,
anyone using their voice to work
Voice Disorders - Significance
• Loss of Function
• 50% of teachers – vocal impairment
• 20% of teachers – loss of work due to dysphonia
• >1/3 the work force = ‘voice professionals’
III. Understand the functions of the larynx
and how disease impairs those functions
A. Impaired function of the glottic valve results in an
abnormal voice and can also impair swallowing and breathing.
Voice Disorders – Laryngeal Function
Airway: Breathing most important
Airway protection: Safe swallowing next most
important
Voice: Least important
III. Understand the functions of the larynx
and how disease impairs those functions
B. Impaired vocal cord/fold vibration results in dysphonia.
Common Voice Disorders
Impaired vocal fold vibration due to
• Vocal fold irregularities
Laryngitis infection/trauma/exposure to irritants
Nodules/Polyps/Cysts/ scar
Tumor papilloma/cancer
• Abnormal movement
• Paralysis
• Muscle tension
• Dystonia
– Action-induced muscle contraction abnormality
– Spasmodic dysphonia = laryngeal dystonia
» Ddx includes vocal tremor/muscle tension dysphonia/
»
compensation for incomplete glottic closure
III. Understand the functions of the larynx
and how disease impairs those functions
C. Example of dysphonia due to abnormal vocal cord vibration
a. Infection: viral/bacterial/fungal
b. Trauma: vocal overuse/intubation
c. Exposure to irritants: smoke/GE reflux/inhalants
Viral Laryngitis
• 41 yo female
• 7 days of
• Rhinorrhea
• Hoarseness
– Rough
– Breathy
IV. How to Evaluate a Patient with a Voice Disorder
A. Obtain a History
Voice Disorders - Evaluation
History - PPQRSTA
Provokes the hoarseness
Palliates the hoarseness
Quality of the hoarseness
Radiation of the pain (not applicable to voice)
Severity sufficient to impair work
Timing after a full day of talking
Associated symptoms pain,swallowing, breathing
IV. How to Evaluate a Patient with a Voice Disorder
B. Perform a physical examination
Voice Disorders - Evaluation
Physical Exam
Listen to the voice and breathing
Palpate the neck
Examine the vocal cords
Indirect mirror exam
Flexible fiberoptic (transnasal)
Rigid videostroboscopic exam
Direct laryngoscopy (in operating room)
IV. How to Evaluate a Patient with a Voice Disorder
C. Methods to image the larynx include:
Voice Disorders - Evaluation
Physical Exam
Examine the vocal cords
Indirect mirror exam
Flexible fiberoptic (transnasal)
Rigid videostroboscopic exam)
Direct laryngoscopy (in O.R)
IV. How to Evaluate a Patient with a Voice Disorder
C. Methods to image the larynx include:
flexible fiberoptic transnasal exam of the larynx,
[VIDEOS of exam]
V. Identify Common Voice Disorders
A. Important voice disorders include infectious,
neurogenic, traumatic, psychogenic, and neoplastic causes
Viral
ALS
Scarring
Trauma: nodule/polyp
Psychogenic
Neoplastic
V. Identify Common Voice Disorders
A. Important voice disorders include infectious,
neurogenic, traumatic, psychogenic, and neoplastic causes
Chronic hoarseness (> 2 weeks or ? >3 months)
Neoplastic
Glottic cancer: Harsh, breathy voice
Supraglottic cancer: “Silent”; muffled voice,
neck mass, airway obstruction
Subglottic: Airway obstruction
RRP (Recurrent respiratory papillomatosis)
V. Identify Common Voice Disorders
A. Important voice disorders include infectious,
neurogenic, traumatic, psychogenic, and neoplastic causes
Chronic hoarseness (> 2 weeks or ? >3 months)
Psychogenic
“Functional aphonia”
“Psychogenic aphonia”
Muscle tension dysphonia
VI. Management of common voice disorders
A. Voice disorders may be managed by physicians who are not capable of
examining the vocal cords when the presumptive diagnosis is laryngitis through
a. voice rest
b. humidification
c. hydration
d. management of associated symptoms (such as cough) and reflux.
Laryngitis
Laryngitis
General Treatment
Voice Rest
“arms length rule”
Humidification
Bedside vaporizer
Hydration
“urine pale”
Specific Tx - Infectious
Nasal decongestant
Anti-tussive
Steroids
Antibiotics
VI. Management of common voice disorders
B. Referral to an Otolaryngologist is indicated when
a. there is clinical suspicion that the voice disorder is not a self-limited
laryngitis
b. the voice problem persists longer than two to three weeks;
c. there are associated symptoms such as swallowing or breathing
impairment
VI. Management of common voice disorders
C. Medications with adverse effects on the voice include:
Drying effect (antihistamines, diuretics, tricyclic antidepressants)
Laryngeal irritants (inhaled propellants
Factors increasing bleeding risk (aspirin, anticoagulants)
Medications in Common Use Affecting Voice
(Attenuated List)
Adverse Effect
Dessication of Vocal Cords
- Antihistamines; Diurectics; Tricyclic antidepressants;
Other (many)
Alter Cord Substance
-Birth control pills (controversial); Androgens
Inflammation of Cord Surface
-Propellants in inhalants
Candida Laryngitis
- Steroid inhalants
Induce Intracordal Hemorrhage
-Aspirin; Anticoagulants
VI. Management of common voice disorders
D. Medications with favorable effects on the voice:
Antitussives: codeine/dextromethorphan/benzonatate (Tessalon perles)
Mucolytics: guaifenesin
Water: H20 (humidification and hydration)
Anti-reflux medications (H2 blockers e.g. Zantac /PPI e.g.
Prilosec/Omeprazole)
Medications in Common Use Affecting Voice
(Attenuated List)
Positive Effect
Mucolytics
- Iodinated glycerol; guaifenesin
Antitussives
- Dextromethorphan, codeine
Replacement Therapy
- Estrogen (menopause) controversial; Thyroxine (hypothyroid
states)
VI. Management of common voice disorders
E. Speech pathologists manage voice disorders by:
Assessing vocal behavior
Modifying vocal behavior
Maximizing vocal potential
Reference for "Common Voice Disorders“
ON-LINE: GOOGLE “IOWA PROTOCOLS”
Resource: http://wiki.uiowa.edu/display/protocols/Home
Voice
Protocols
Medical
Students
Reference for "Common Voice Disorders“
ON-LINE: GOOGLE “IOWA PROTOCOLS”
Resource: http://wiki.uiowa.edu/display/protocols/Home
Case Example – Audio then Visual
What is your diagnosis?
Link to video