Vocal Disored - PPT

Chapter 11:
Voice Disorders
Justice
Communication Sciences and Disorders: An
Introduction
Copyright 2006 by Pearson Education, Inc.

Upper Saddle River, New Jersey 07458
All rights reserved.
11.1
Focus Questions
What is a voice disorder?
How are voice disorders classified?
What are the defining characteristics of
voice disorders?
How are voice disorders identified?
How are voice disorders treated?
Justice
Introduction

11.2
Introduction A Brief History

16th century the larynx studied on human
cadavers did not permit to see larynx at work
1600 first book on laryngeal structures
18th century well-developed understanding
how the vocal folds produce the voice
1829 glottiscope: crude glimpses of the
laryngeal cavity
1854 laryngoscope: vast improvement in
technology to examine the larynx
Today, advanced technology (endoscopy,
stroboscopy) allow examination of the vocal
folds live in action
Justice
Introduction

11.3
Overview of Voice Disorders

Individuals vocal quality is in some way
compromised
For some, disorder is mild, transient, and
requires no treatment
For others, disorder is severe, persistent,
and requires ongoing treatment
Most serious cases, larynx is removed for
reasons such as cancer, and alternative
methods of producing voice are necessary
Justice
Introduction

11.4
Case Study #1: Kate

46-year old trauma surgeon and mother of
four
two years ago was in a car accident, suffered
a spinal cord injury and became a paraplegic
Unable to breathe and ventilator-dependent
Did not speak at all until a year after her

surgery, SLP has been working with her to
increase her speech output and set up a
voice-activated computer
Justice
Introduction

11.5
Case Study #1 Questions

What community activities might be
possible for Dr. Mitchell now that she uses
her voice?
How might Dr. Mitchell be involved with
her profession in the future as a
quadriplegic?
Justice
Introduction

11.6
Case Study #2: Anton

68-year old veteran diagnosed with
laryngeal cancer six years ago
Had his larynx removed two years ago,
tried unsuccessfully to learn esophageal
speech, now uses an artificial larynx
Is interested in helping other
laryngectomees
Is interested in possibility of a laryngeal
transplant
Justice
Introduction

11.7

Given that Anton already has a way to
produce speech via the artificial larynx,
why would he desire a laryngeal
transplant?
Antons hobby after his laryngectomy was
to counsel other laryngectomees. In what
ways might Antons counseling be superior
to that of a clinical professional, like a
psychologist?
Justice
Introduction

11.8
Case Study #3: Ms. Chin

42-year old television personality (coanchor of news show)
Experiencing intermittent problems with
her voice in which it seems to start and
stop and feels strangled
Went to otolaryngologist, who gave her a
preliminary diagnosis of spasmodic
dysphonia
Ms. Chins producer suggested she take
disability leave until her voice is resolved
Justice
Introduction

11.9

Do you agree with Ms. Chins producer
that she should be off the air until her
voice problems are resolved?
Ms. Chin has an appointment soon with an
SLP who may not be skilled in treating
spasmodic dysphonia. How important is it
to see a clinician who has worked with this
condition before?
What other professionals should be
involved with Ms. Chins voice treatment?
Justice
Introduction

11.10
I. What is Voice?
Vocal fold vibration that provides sound source

for spoken language
Phonation: humans set their vocal folds into a
vibratory pattern (say oooo)
Vocal folds are adducted (closed), air is exhaled
upwards and blows apart the vocal folds setting
them into a rapid vibratory pattern
Voice is further modified by the processes of

resonation and articulation
Three vocal characteristics: frequency,
intensity, and phonatory quality
Justice
Introduction

11.11
Frequency
Rate of vocal fold vibration (pitch)

Fundamental frequency (F0) basic
vibratory rate of the vocal folds (in Hertz)
Kindergarten girls and boys = 250 Hz
Adult women = 180 220 Hz
Adult men = 120 140 Hz
F0 relates to three characteristics:

Vocal fold length, mass, and tension
Fundamental frequency changes as we

age, especially between birth and puberty
Justice
Introduction

11.12
Intensity
Sound pressure reported in decibels

(loudness)
Relates to two features of vocal production:
Amount of airflow from the lungs
Amount of resistance to the airflow by the vocal
folds (which contributes to their excursion, or
how far apart the vocal folds move and come
back together)
Every person has a baseline intensity level

that characterizes his/her conversational
speech
Justice
Introduction

11.13
Phonatory Quality
How well the two vocal folds work together

during the vibratory cycle
If vocal folds work symmetrically and
harmoniously, voice is pleasant and clear
If compromised in some way (e.g., growth on
one of the folds), phonatory quality is affected
Also influenced by the resonation of the

voice into the oral and nasal cavities (e.g.,
nasal voice quality)
Justice
Introduction

11.14
What is a Voice Disorder?

Pitch, loudness, or phonatory quality
differs significantly from persons of a
similar age, gender, cultural background,
and racial and/or ethnic group, and
Vocal quality detracts from the ability to
function and achieve in society
Justice
Introduction

11.15
Describing Voice Quality
Dysphonia: umbrella term for a voice that

is disordered in some way
Aphonia: total loss or lack of voice
Many other, mostly subjective terms
Pitch and frequency: jitter or diplophonic
Loudness and intensity: pressed or strident
Resonance: nasal or ringing
Phonatory quality: flutter or creak
Justice
Introduction

11.16
Describing Vocal Fold Functioning

Hypofunction: vocal folds are underfunctioning and have inadequate tension,
so air escapes through
Breathiness or hoarseness, or no voice at all
Hyperfunction: vocal folds are overly tense

and compress too tightly together
Too loud, too high, and/or too strained
Sometimes spasticity of the voice
Diplophonia: vocal folds produce two

different pitches simultaneously
Justice
Introduction

11.17
Voice without a Larynx

Laryngectomy: surgically removing the
larynx
Two primary reasons:
laryngeal cancer: removed to stop spreading
laryngeal trauma: removed if too damaged to
protect respiratory system or impede
breathing
Alaryngeal communication: an alternative

way to produce speech
Justice
Introduction

11.18
Prevalence and Incidence:

Voice Disorders in Adults
Prevalence = 29%, Incidence = 6%

Higher prevalence for women, peak ages of 4060 years
Higher prevalence among people with frequent
allergies, asthma, colds, and sinus infections
Higher prevalence among professions reliant on
voice
Common causes: vocal nodules,
edema/swelling, polyps, carcinoma, and vocal
fold paralysis
Justice
Introduction

11.19
Prevalence and Incidence:

Voice Disorders in Children
25% of children exhibit significant vocal

problems, with 40% of these cases
ongoing, not transient, problems
For some it is a congenital problem, but
most cases result from overuse or misuse
of voice
Most common cause: vocal nodules that
impede smooth meeting of folds, resulting
in breathy or hoarse voice
Justice
Introduction

11.20
Prevalence and Treatment
Rate of voice disorders for both children

and adults is relatively high, but many
cases go undiagnosed and/or untreated
Several reasons for this:
Treatment access: e.g., disorder not
considered to impact educational
performance in school
Knowledge: e.g., person may believe that
voice problem will disappear spontaneously
Social perception: e.g., the disordered voice
(e.g., a breathy, hoarse voice) brings positive
social attention
Justice
Introduction

11.21
II. How are Voice Disorders

Classified?
Voice disorders are grouped based on

their cause, an etiological classification
Four different categories:
A. Vocal abuse
B. Neurogenic disorders
C. Psychogenic disorders
D. Alaryngeal communication
Justice
Introduction

11.22
A. Vocal Abuse
Chronic or intermittent overuse or misuse

of the vocal apparatus
Vocally abusive behaviors:
Talking in noisy environments
Frequent coughing or clearing of the throat
Using caffeine products
Yelling, screaming, and cheering
Giving speeches or lectures
Spending time in smoky environments
Two common conditions: vocal nodules

and contact ulcers and granuloma
Justice
Introduction

11.23
Vocal Nodules
Small bilateral protuberances or calloused
growths on the inner edge of the vocal
folds
Acute nodules are similar to bruises on the
vocal folds, but these can harden and
thicken over time, which becomes a
chronic condition
Most prevalent in children and adults who
engage in vocal misuse and abuse
Additional factors: temperament and
general health
Justice
Introduction

11.24
Contact Ulcers and Granuloma

Contact ulcers: inflamed lesions that
develop on the cartilage in the larynx
Granuloma: a mass of tissue generated by
the bodys healing process at the site of
the contact ulcer
Mostly results from vocal abuse, but also
from acidic irritation due to chronic reflux
or tubal intubation (during surgery)
Low, breathy voice quality
Justice
Introduction

11.25
B. Neurogenic Disorders
Result from illness, damage, or disease to

the neurological systems associated with
voice production
One of the most important nerves: vagus
nerve in peripheral nervous system
runs from cranium down around the heart, but
has several branches that innervate the
pharynx and larynx
Pharyngeal nerve
Superior laryngeal nerve
Recurrent laryngeal nerve
If any of these nerves are disrupted, a

voice disorder may result
Justice
Introduction

11.26
Vagus Nerve Lesions
Can occur due to surgical damage, trauma,

and viral infections
Most serious outcome: vocal fold paralysis
Mostly unilateral paralysis:
Abduction paralysis: one of the vocal folds cannot
open, voice is not usually affected, but breathing
may be difficult
Adduction paralysis: one of the vocal folds cannot
close, so they cannot meet together, causing
hoarse or breathy voice quality
Complete paralysis: both vocal folds

paralyzed, completely blocking airway
tracheostomy is necessary
Justice
Introduction

11.27
Spasmodic Dysphonia
Affects motor control of larynx, results in

intermittent voice stoppages
Jerky, grunting, squeezed, groaning, and
stuttering-like voice quality
Ranges from mild to severe
Adductor type: most common, voice is
strangled, strained, and squeezing
Abductor type: less common, voice is
breathy and open
Justice
Introduction

11.28
Amyotrophic Lateral Sclerosis
Also called Lou Gehrigs Disease

progressive, degenerative, neuromuscular
disease
Cause is unknown, impact is significant, and
most survive less than 10 year after
diagnosis
Voice is soft, breathy, low in pitch and
loudness, limited variability, and hypernasal
Difficulty clearly articulating speech sounds
because cannot strongly coordinate motor
processes
Justice
Introduction

11.29
Parkinsons Disease
Progressive, degenerative neurological
disease caused by depletion of dopamine
Unable to produce a strong voice because
of a weakened respiratory system
Rigid muscular tone restricting movements
of larynx; produces hoarseness and a
monotonic pitch
Lee Silverman Voice Treatment program
effective for improving voices of persons
with Parkinsons
Justice
Introduction

11.30
C. Psychogenic Disorders
Nonorganic disorders, resulting from

emotional or psychological characteristics
Our voices carry messages about our
emotional or psychological state
The voices of individuals who experience
significant personality or psychological
health disorders may be negatively
impacted
Justice
Introduction

11.31
Psychological or Emotional
Triggers
After someone recovers from a vocal

injury because of overuse or misuse of the
voice, may experience a sense of
vulnerability and anxiety about using voice
Other traumatic experiences, like cancer,
being robbed or raped, and having surgery
of the throat, can have the same effect
Justice
Introduction

11.32
Psychopathology
1. Stress, Anxiety, and Depression
Acute stress disorder: within one month of
having a traumatic experience,
exaggerated startle responses, motor
restlessness; can be reflected in the voice
Generalized anxiety and anxiety disorder:
muscle tension, trembling, twitching; may
lead to vocal tremors and voice breakages
Justice
Introduction

11.33
2. Conversion Disorder
Physical symptoms or deficits result from
severe anxiety or stress
Can result in a loss or disordered voice as
one variety of conversion disorder
3. Vocal tics and Tourettes Disorder
Vocal tics produce sudden, rapid,
recurrent vocalizations
Tourettes: vocal tics occuring
simultaneously with other motor tics
affecting the head, torso, and extremities
Justice
Introduction

11.34
Mutational Falsetto and

Juvenile Voice
Vocal characteristics are not consistent

with age and gender
Mutational falsetto: male child or
adolescent exhibits inappropriately high
voice
Voice therapy and medical treatment are
effective
Juvenile voice: female companion to

mutational falsetto, women maintain a
child-like voice into adulthood
Justice
Introduction

11.35
D. Alaryngeal Communication
Producing voice without a larynx
Two most common reasons:
Larynx is not available because of a
tracheostomy
Larynx has been completely removed in a
larnygectomy
Justice
Introduction

11.36
Trachestomy
When respiratory system is compromised,
mechanical ventilation and respiration is
needed
tracheostomy tube is inserted through the
neck to direct air into the lungs
Unable to talk because air is not going

over vocal folds
Passy-Muir Tracheostomy Speaking
Valve: allows adults and children to speak
even while ventilated
Justice
Introduction

11.37
Laryngectomy
Etiology: Laryngeal cancer is linked to tobacco

and alcohol use, nutritional inadequacies and
occupational exposures; affects African-American
older males at the highest rates
Symptoms: most consistent symptom is
hoarseness
Any person exhibiting hoarseness should seek medical
attention if persists for more than two weeks
Treatment: Rid the body of the malignancy

most oncologists use conservation approaches, and
prefer to only remove part of the larynx if possible
Justice
Introduction

11.38
III. Defining Characteristics of

Voice Disorders
Voice disorders impact one or more of the
following perceptual characteristics of
voice:
A. Resonance
B. Loudness and pitch
C. Phonatory quality
Justice
Introduction

11.39
A. Resonance
Velopharyngeal port controls the extent to

which exhaled air enters the nasal and
oral cavities
The port typically rests in an open
position, but when we speak, it is almost
always closed (airflow channeled into the
oral cavity)
Voice disorders of resonance result from
problems with control of port, called
velopharyngeal inadequacy
Justice
Introduction

11.40
Velopharyngeal Inadequacy
Common causes:
Cleft palate and cranio-facial abnormalities
Iatrogenic (problems resulting from surgery)
Allergies
Neuromuscular impairment
Results in either:
Hypernasality: port remains open to allow too
much resonance and nasal emissions during
speech
Hyponasality: too little nasal resonance, voice
may sound stuffy and congested
Justice
Introduction

11.41
B. Pitch and Loudness

Pitch: frequency
Loudness: intensity
Too much or too little tension in voice
production can cause abnormal pitch or
loudness
Of pitch and loudness, pitch changes are
more common symptoms of voice
disorders
Justice
Introduction

11.42
Pitch
Important concepts:
Habitual pitch: pitch one uses normally
Optimal pitch: best pitch voice can produce
Basal pitch: lowest pitch one can produce
Ceiling pitch: highest pitch one can produce
Vocal range: difference between basal and
ceiling
Disordered pitch:
Habitual pitch differs significantly from optimal
Extremely limited vocal range
Justice
Introduction

11.43
Loudness
Over-loudness: air pressure builds up
under vocal folds and produces wide
excursion of folds
Under-loudness: lack of respiratory force
because of
Neurological injury and disease
Social or psychogenic factors
Justice
Introduction

11.44
C. Phonatory Quality
When vocal folds do not work
harmoniously, impairment in general
quality of the voice
Common types of impaired phonation:
Hard glottal attack
Glottal fry
Breathy phonation
Spasticity
Hoarseness
Justice
Introduction

11.45
IV. How are Voice Disorders

Identified?
A. The Voice Care Team

Close collaboration of a variety of
professionals
Medical professionals: primary care
physician (PCP), otolayrngologist
Allied health professionals: speechlanguage pathologist, psychologist or
psychiatrist
Possibly educators or voice coaches also
Justice
Introduction

11.46
B. The Assessment Process

Identification of warning signs
Assessment Protocol:
Case history and interview
Oral-motor examination
Clinical voice observation
Instrumental voice observation
Justice
Introduction

11.47
Warning Signs for Voice Disorders

Children and adolescents:
Vocally abusive behaviors
Underlying medical condition
Psychological well-being
Adults:
Change in phonatory quality for more than two
weeks, consult physician
Referrals: PCP will likely make at least two

referrals:
Otolaryngologist
Speech-language pathologist
Justice
Introduction

11.48
Assessment Protocol
Speech-language pathologists goals:
Characterize the general features of the voice
Establish if any of these features differ from
the norm
If disorder is present:
Identify cause
Identify intervention approach that will be the most
beneficial to improving the voice
Justice
Introduction

11.49
Case History and Interview

Interview with the client to learn more
about:
Medical history
Chronological history of problem
Symptoms and possible etiology of problem
Way in which client uses voice for daily living
activities
Clients motivation for seeking help
Justice
Introduction

11.50
Oral-Motor Examination
Identify conditions of structures involved
with producing voice
Study amount of tension and sensation
involved in speech and voicing
Examine possible swallowing problems
Study the appearance and functioning of
the velum
Justice
Introduction

11.51
Clinical Observation
Perceptual observation of characteristics
of voice during a variety of speaking and
vocal activities
Example activities: counting from 1 to 40
softly then loudly, sustaining a vowel
sound for as long as possible, engaging in
normal conversation
Also studies systems that support vocal
production, like respiration
Relies heavily on the listener, so need to
be properly trained and experienced
Justice
Introduction

11.52
Instrumental Observation
Objective measures of vocal functioning:
Acoustic assessment: measures frequency,
intensity, and resonance characteristics
Aerodynamic assessment: measures airflow,
air pressure, and vocal fold resistance
Electroglottography: measures vocal fold
contact during voicing
Videostroboscopy: examines laryngeal
system and measures vocal fold movement
Justice
Introduction

11.53
V. How are Voice Disorders

Treated?
Elimination of the cause of the disorder (e.g.,

vocally abusive behavior)
Compensation for a disorder (cause cannot
be eliminated)
Three possible goals:
Teach a vocal behavior that is absent
Substitute vocal behavior for inappropriate one
Strengthen vocal behaviors that are weak or
inconsistent
Justice
Introduction

11.54
A. Treatment for Vocal Abuse
Several options:
Surgery (e.g., removal of vocal nodules)

Vocal hygiene programs
Voice therapies
Computer programs
Justice
Introduction

11.55
B. Treatment for Neurogenic

Disorders
Combination of medical interventions and

voice therapies
Medical interventions:
Phonosurgery: improvement, alteration, or
restoration of the voice (e.g., thyroplasty)
Injections into the vocal folds (e.g., Teflon,
botox)
Voice therapies:
e.g., Lee Silverman Voice Treatment program
Justice
Introduction

11.56
C. Treatment of Psychogenic
Disorders
Multidisciplinary approach including

speech-language pathologist and mental
health professionals
Goal: determine emotional or psychosocial
cause of voice disturbance
Therapy usually focus on reducing
tension, counseling, and eliminating any
voice abuses or misuses
Justice
Introduction

11.57
D. Treatment of Alaryngeal
Communication
Communication counseling: explore all

alternative options for producing voice
Artificial larynx: vibrating power source placed
against the neck, often mechanical sounding
voice
Esophageal speech: learn to trap air in the
esophagus and then use that for voice, often
very difficult for most people
Tracheoesophageal speech: surgical puncture
between the trachea and esophagus provides
an air source for speaking
Justice
Introduction


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Chapter 11:

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Introduction A Brief History

Copyright 2006 by Pearson Education, Inc.

Overview of Voice Disorders

Copyright 2006 by Pearson Education, Inc.

Case Study #1: Kate

Did not speak at all until a year after her

Copyright 2006 by Pearson Education, Inc.

Case Study #1 Questions

Copyright 2006 by Pearson Education, Inc.

Case Study #2: Anton

Copyright 2006 by Pearson Education, Inc.

Case Study #2 Questions

Copyright 2006 by Pearson Education, Inc.

Case Study #3: Ms. Chin

Copyright 2006 by Pearson Education, Inc.

Case Study #3 Questions

Copyright 2006 by Pearson Education, Inc.

Vocal fold vibration that provides sound source

Voice is further modified by the processes of

Copyright 2006 by Pearson Education, Inc.

Rate of vocal fold vibration (pitch)

F0 relates to three characteristics:

Fundamental frequency changes as we

Copyright 2006 by Pearson Education, Inc.

Sound pressure reported in decibels

Every person has a baseline intensity level

Copyright 2006 by Pearson Education, Inc.

How well the two vocal folds work together

Also influenced by the resonation of the

Copyright 2006 by Pearson Education, Inc.

What is a Voice Disorder?

Copyright 2006 by Pearson Education, Inc.

Describing Voice Quality

Dysphonia: umbrella term for a voice that

Copyright 2006 by Pearson Education, Inc.

Describing Vocal Fold Functioning

Hyperfunction: vocal folds are overly tense

Diplophonia: vocal folds produce two

Copyright 2006 by Pearson Education, Inc.

Voice without a Larynx

Alaryngeal communication: an alternative

Copyright 2006 by Pearson Education, Inc.

Prevalence and Incidence:

Prevalence = 29%, Incidence = 6%

Copyright 2006 by Pearson Education, Inc.

Prevalence and Incidence:

25% of children exhibit significant vocal

Copyright 2006 by Pearson Education, Inc.

Prevalence and Treatment

Rate of voice disorders for both children

Copyright 2006 by Pearson Education, Inc.

II. How are Voice Disorders

Voice disorders are grouped based on

Copyright 2006 by Pearson Education, Inc.

Chronic or intermittent overuse or misuse

Two common conditions: vocal nodules

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Contact Ulcers and Granuloma