Voice Disorders Final Study Guide

what of voice therapy

- Biomechanics - How we do the exercises - The approach to the voice exercise - How to do SOVT, what is the rationale, how does it fit the physiology

____________ (50 %) and _____________________ (50 %) layers of the vocal fold form the vocal ligament.

Intermediate lamina propria and deep lamina propria

Indicate a difference between laryngeal surgery and phonomicrosurgery.

Laryngeal surgery is the grafting of new and desirable tissues. This surgery improves all the functions of the larynx which includes respiration, phonation, and swallowing. Phonosurgery is the removal of additional and undesirable tissue. This procedure will specifically improve the patient's phonation.

A 57 year-old female comes in to your clinic with a breathy voice following a heart surgery. On videostroboscopic analysis, the left vocal fold is immobile. Which nerve may be impacted in this client?

Left RLN

A 23 yr-old female presents to your clinic with a high-pitched squeaky voice, effort to produce voice, vocal fatigue and difficulty swallowing her own saliva. Her voice issues started following an URI. On palpation, you identify a tight thyrohyoid space. What is your first diagnosis given the client's complaints?

Muscle Tension Dysphonia

A 17-yr old male is referred to your clinic for voice therapy. His voice has not changed following puberty and people mistake him for a female on the phone. What is an approach that you can use to help with the client's vocal issue?

digital manipulation

True/ FalseIntrinsic muscles of the larynx repeatedly contract during the maintenance stage of phonation

false

The space between the true vocal folds is called the

glottis

A 35 yr old female self-refers to your clinic with increased effort to produce her voice, something stuck in her throat sensation and constant need to clear her throat. Videostroboscopic analysis revealed increased mucus between the free edges of the vocal folds. Her subglottic pressure is likely to be increased.

true

In individuals with PVFM, the usual onset of symptoms is less than 5 minutes after beginning of exercise, the recovery period is 5-10 minutes and the area of constriction is in the throat.

true

Thyroarytenoid is a tensor when it co-contracts with the cricothyroid muscle.

true

True/ False:Hyolaryngeal elevation is an important process during initiation of swallow

true

Resonant frequency is defined as the lowest component frequency with which a body vibrates freely.

False

The only intrinsic muscle supplied by the SLN is the cricothyroid, a muscle that aids in vocal fold shortening.

False

You can assess running speech (i.e., conversational speaking) using a rigid videostroboscopy.

False

A 55 year old male is referred to your clinic with a diagnosis of ADDuctor spasmodic dysphonia. Botox in the PCA muscle will relieve the vocal symptoms. True/ False?

False - PCA is only for ABductor - ADDuctor would have botox target the LCA and TA

True or False:Cricothyroid is a tensor and is supplied by the RLN

False- the CT is a tensor but it is supplied by the SLN- only intrinsic muscle that i supplied by the motor branch of the SLN

You are a SLP in a school system. A colleague approaches you and is curious to know why female teachers tend to have more vocal issues than male teachers. How would you explain this to your colleague in terms of physiology of vocal fold vibration and protein composition of the vocal folds?

Females tend to have more vocal issues when compared to males due to the fact that women have less hyaluronic acid than men do. Hyaluronic acid prevents lesions on the vocal folds. As males get older, they produce more hyaluronic acid; however, as women get older, their hyaluronic acid levels are reduced. Also, females tend to have more vocal issues due to the fact that they have a higher frequency than males.

List the main factors responsible for the maintenance of phonation.

First, The vf have to adducted then the subglottic pressure is needed to abduct the vocal folds. Next, the vocal folds will come back together for medial compression from negative pressure (Bernoulli Effect). Then there is an elastic recoil of muscles.

A 45-yr old female teacher is presenting to your clinic with vocal fold lesions. You initiate voice therapy and notice that your client presents with a hard glottal onset during SOVT and RV exercises. What is the first therapeutic approach that comes to your mind to decrease the hard glottal onset to improve airflow?

Flow phonation

Possible symptoms associated with allergen laryngitis include

Globus sensation Coughing Hoarseness

A prospective client is described as a man in his forties, who is under chronic stress. He uses his voice extensively in daily life, has a hard driving personality, and exhibits glottal fry. The client has the classic profile of a person at high risk for

Granuloma

A 23 year old soccer mom comes in to your clinic for a voice evaluation. She indicated that she was cheering for her son's team and all of a sudden her voice quality changed and fluctuated between hoarseness to no voice. She indicated a weird taste in her mouth. What is your hypothesis about her voice diagnosis and what is your immediate recommendation for this mom?

I hypothesize her voice diagnosis will be vocal fold hemorrhage and my immediate recommendation for her would be vocal rest.

In a falsetto register, the vocal folds are stretched and there is lower than average airflow.

True

A 26 year-old female comes in to your clinic with a complaint of loss of her higher pitch range. Videostroboscopic examination reveals decreased or no stretching of the vocal folds. Specify exactly the cranial nerve and the branch that might be impacted.

Vagus Nerve- CN X; Superior Laryngeal Nerve- Branch

If of voice therapy

- Compliance of the pt - If the pt needs surgery - If voice therapy is going to work with pt - The buy in : Rapport is very important : Make sure the pt trusts you - Establish a good relationship bw therapist and client - Attitude toward voice therapy - If they seek treatment - If they have been compliant with other behavior or medical suggestions - Voice therapy will only work IF they are compliant and ready to change - How severe is the voice problem - If is not bad and they can live with it then good - Impact on social and professional life - This indicates their IF will be much better - Ensure they know the expectation from therapy - Vf paralysis- telling them that this will not bulk up their vf or make them move

For pediatric therapy you want to:

- Create motivation - Awareness : Good voce, bad voice, front voice, throat voice, push the box and talk, hold the breath and feel what it feels like for the throat, feel the throat when they are using throat sound and face for the mouth sound - Once they are aware you focus on.. - Implementation : Actually doing : How do you get them to do it : Doing negative practice helps - We need to make it fun, motivating, provide the buy in, and rewarding

How of voice therapy

- If you miss these two then the what is not going to make a difference - How do you teach the exercises - Depends mainly on: 1. Law of practice - When to give feedback - Simple to hierarchy? - Use the same target? Or vary target - How do we give feedback : Is it verbal, gestural, tactile, etc. - When to give feedback - Vary when to give feedback - Vary the complexity of the tasks : Do the negative practice 2. Locus of attention a) External- outside of our body - SOVT example : Make the bubbles go up half an inch above the water, pucker the lips, drop your jaw - Biomechanics - Instruction of the exercises b) internal- inside the body - SOVT example : Watch me and do what I do - Give visual cues - Constantly doing the watch me, see me, do what I do - Focus on modeling - Vary the targets to get them to what they can do - Exploration of the exercises so they can learn what it feels like - LSVT is an internal approach - It is easier to do the internal than external - Internal is away from biomechanics

Key thing for pediatric patients

- Know the anatomy and physiology - What is the difference in the boys and girls with their structures and the layers of the VF - Advocate for the child to the ENT to alleviate their opinion of the surgical therapy for the unilateral lesions - Negative perceptual with the child with the voice problem- perceived as the mean child and wont get called on to answer - Things that are going to intrinsically influence the child

Are control variables independent of each other?

- NO - they are dependent of each other (lower note= lower loudness) - this is how normal people do it because we don't have the training to do it the right way - in a professional singer who wants intrinsity of their voice, you them the control variables to be independent of each other to maintain volume as they get higher/ lower note - this is what ours should be but we are dependent of each other

Things to consider for pediatric patients:

- No list of do's and don'ts - No don't make animal noise, no car noise, no outside voice during recess - No telling them to rest their voice : This will make them have more problems with sociall acceptance and just give them alternate strategies - Do give them alternative strategies and collaborate with the teacher - Provide individualized care to give them the why this is important - What is voice therapy going to do for them - How to make voice therapy fun : Bubbles - with the RV during the oooo : Who can feel more vibrations in the front : Who can stay within the safe voice zone the most

Control Variables in Phonation

- control variables usually described in perceptual terms - something that we hear and can measure - Classic variables of control variables are: 1. pitch - measure in frequency ~Fo 2. Loudness - measure in ~Intensity 3. Timbre - voice quality - measured in terms of hearing quality with auditory perceptual tool - measured in terms of a spectrum

Tensor definition

- stretches VF to change pitch

Average airflow for healthy vocal folds is in the order of _______________

100-200ml/sec

Identify a behavioral/non-instrumental measure to obtain information on minimal flow to infer the mucosal status/ function and what is the expected norm for this measure?

A behavioral/ non-instrumental measure that obtains information on minimal flow to infer the mucosal status/ function is the S:Z Ratio. The expected norm for this measure would be an s:z ratio that is less than or equal to 1.= .99-1.0

A 43-yr-old woman complains of a gradual onset, over the past 2 yr, of her voice "catching" and "giving way." She says that she feels like she is running out of breath when she talks. However, she is able to sing fluently in her church choir. She says that she now avoids social situations and talking in public because of the problem. Although she had a bit of a cold the first time she noticed the problem, she has not had any real upper respiratory tract infections that she is aware since that time. Assuming that you do not have any other information about the patient, what is the first condition that you would want to test for?

Abductory spasmodic dysphonia

Paired Cartilages of the Larynx

1. Arytenoid Cartilages 2. Corniculate Cartilages 3. Cuneiform Cartilages

A 35yr old elementary school teacher comes to your clinic with a c/o inability to project her voice in her class. she indicates that it takes a lot of effort and work to project her voice and experiences vocal fatigue and sore throat with increased volume. Given her occupation, her goal is to be able to project her voice without having to push her voice. What would be the choice/s to help her achieve her goal?

1. Manipulate vocal tract 2. Decrease medial compression

List two differences between asthma and PVFM. In other words, compare and contrast asthma and PVFM.

1. Patients with PVFM will have tightness in their throat while patients with asthma will have tightness in their chest.2. Patients with PVFM will have abnormal inspiratory adduction patterns while patients with asthma will have breathing difficulties during exhalation.

Therapy techniques that work with children

1. SOVT - Blowing bubbles - Blowing into the glove - Lip trills - Using bubble stands - Focus on airflow 2. RV - Use a vibratory toothbrush to understand what the buzzing in the mouth should feel like - Leslie Kessler- developed the buzzy child 3. Flow phonation - Using the Kleenex for biofeedback

Unpaired Cartilages of the Larynx

1. Thyroid Cartilage 2. Cricoid Cartilage 3. Epiglottis

Non- speech laryngeal functions of the larynx

1. breathing 2. swallowing 3. protecting airway 4. abdominal fixation

List two issues that might interfere with inter-rater reliability (i.e., accuracy of identification of deviance in vocal parameters) during an auditory-perceptual evaluation

1. previous experience with voice/ memory load 2. voice just heard-listening context/ difficulty isolating parameters

Voice therapy principles:

1. what of voice therapy 2. how of voice therapy 3. if of voice therapy

As vocal fold elongation increases, impact stress also increases linearly.

False

List one effect of an antihistamine on the vocal folds.

Antihistamine creates dryness of the mucosa.

A 25 year-old football player comes to your clinic with significant pain in his neck and voice complaints including change in quality of his voice, specifically breathiness, vocal fatigue, and shortness of breath. He has a weird sensation of something moving in his neck when trying to speak. The problem started 3 days ago when during practice; he received a punch in his neck. Given the symptoms, what is your first impression on what could be causing his vocal impairment?

Arytenoid dislocation

Breathiness is characterized by irregularly modulated airflow.

False

A 77 year old male comes to your clinic with a complaint of slightly higher pitch, weak, breathy voice with an inability to project voice. It is impacting his ability to complete his teaching job as an adjunct professor. Based on this information, what is potentially the underlying voice disorder and which layer of the vocal fold is affected by this pathology?

Atrophy of muscle/ vocalis

Increased caffeine intake results in a decreased viscosity and decreases PTP

False

Intrinsic laryngeal muscles contract during the maintenance phase of phonation.

False

The minimum subglottic pressure required to initiate phonation is

3-5 cm h2o - 5-7 cm h2o maintains phonation

The minimum subglottic pressure required to initiate phonation is ___________ (no unit, no credit)

3-5cmH20

8 year old boy is referred to you for hoarse vocal quality and pitch breaks. Evaluation indicated mild dysphonia, characterized by moderate breathiness, mild roughness, mild strain, mildly decreased pitch with pitch breaks, and moderately increased loudness. Video strobe revealed bilateral symmetrical lesions in the anterior 1/3 mid membranous portion of the TVF. Increased mucus between the vocal folds, an hour glass glottal closure, phase asymmetry, edema of the arytenoids, and pachydermia of the post cricoid area. Client's functional goal as determined by mom is to improve vocal quality and not have pitch breaks. Client is not specifically aware of his voice issues. Choose the most appropriate activity to help improve his awareness of his voice use to discriminate appropriate and inappropriate voice use. 1. educate the client on the anatomy and physiology of the vocal folds 2. instruct the client to stop shouting 3. provide tactile and visual feedback with negative practice on easy and tight voice 4. educate the client to go on voice rest during lunch breaks and games

3. provide tactile and visual feedback with negative practice on easy and tight voice

28 year old female comes to your clinic with complaint of globus sensation, swallowing difficulty with dry foods, and pain and tightness in the neck with voice use. Palpation of the neck revealed minimal thyrohyoid space and tenderness in the area. What would be a technique that would help this client with all symptoms? 1. Full body stretch to release tension 2. lip trills for to improve vocal oscilation 3. tongue stretch and CLM to release hyolaryngeal tension 4. increased hydration to improve dehydration and decrease mucus

3. tongue stretch and CLM to release hyolaryngeal tension

A 71 year old male a professor in college is referred to you for inconsistent vocal quality and difficulty projecting his voice. Auditory perceptual Evaluation indicated mild dysphonia, moderate roughness, mild to moderate breathiness, mildly increased pitch, mildly decreased loudness, and moderate strain. Videostrobe revealed adequate bilateral arytenoid symmetry, thinning of the TVF, spindle shaped glottal closure, supraglottic compression (hypofunction) prominent on the left side skewing the view of the TVF. Mild pacadermia of the post cricoid area. Client's functional goals is to have a consistent vocal quality, and be able to project his voice. Indicate the appropriate therapy approach based on his presenting symptoms, visual and perceptual evaluation, and EBP. 1. Flow phonation 2. LSVT 3. PhorTE 4. Vocal Function Exercises

4. Vocal function exercises - justified by the supraglottic compression - if he did not have compression or strain then you would do phorte - VFE will release the tension then you would Phorte - phorte you want them to get loud but since he has supraglottic compression phorte would only make it worse

28 year old female that is referred to you for episodes of aphonia or loss of voice. Evaluation indicated a moderately severe dysphonia characterized by moderate breathiness, high pitch squeaky voice, periods of aphonia, moderately decreased loudness, and asthenia. Video strobe revealed incomplete glottal closure with stretched or elongated vocal folds. Increased vascularity of the TVF. The client's functional goal is to be able to produce a voice that is not squeaky and not lose her voice. An immediate approach to unload the tension would be.... 1. Shorten the vf with simetra (injection used to plump up the VF) 2. shorten the vf with high to low pitch glides 3. lowering the larynx by digital manipulation 4. lowering the larynx by doing the SOVT exercises

4. lowering the larynx by doing the SOVT exercises

A 62-yr old female is referred to your clinic for voice therapy. Client has a diagnosis of unilateral VFP- onset about 4 months ago following an anterior disc fusion surgery. You complete a videostroboscopic evaluation on your first session to understand the anatomy and physiology of vocal fold function. On the video stroboscopic evaluation, you see that the right VF is immobile in the lateral position and the client has a significant glottal gap and some supraglottic compression prominent on the left. Please indicate what you might expect to see in auditory perceptual evaluation (indicate parameters as assessed by CAPE-V-). Additionally, indicate what therapeutic options might be beneficial to this client at this time (behavioral vs medical intervention).

Auditory Perceptual Evaluation: Auditory perceptual measures indicate moderate dysphonia characterized by moderate breathiness, mild to moderate roughness, mild strain, mildly incresaed pitch, mild to moderately decreased loudness. All parameters were consistent across all vocal tasks with periods of aphonia noted on pitch glides. Behavioral: SOVT to unload hyperfunction. Medical intervention: The medical intervention that I would suggest to this client would be to partake in collagen injections to the right true vocal fold to bulk it up in order to better the vocal fold closure.

are two parameters of the glottal waveform that provide information about glottal closure/glottal incompetence.

Average airflow and minimum airflow

Indicate the benefits of the HME system. Check all that apply.

Better hygiene Better pulmonary function

A 35-yr old female comes to clinic with c/o loss of voice that started about a month ago. She has a previous experience of voice loss, but her voice returned within 6 weeks. Auditory-perceptual evaluation revealed aphonia and a strained whisper. What would you expect in terms of acoustic measures including F0, and intensity?

Cannot obtain the acoustic measures of fundamental frequency and intensity.

You are asked to consult a patient in the hospital setting for swallowing and breathing difficulties. When you probe through the history, client was admitted to the hospital following a laryngospasm where she passed out and could not breathe. She has experienced 3-4 such episodes in the past that is triggered by chemical odors, where she has difficulty catching her breath and has tried to take asthma medication to relieve the symptoms with minimal relief. Based on the given information, what is your diagnosis?

Chemical laryngeal hypersensitivity/ Irritable larynx

A 61yr old male presents to your clinic with a complaint of a strained, strangled vocal quality and reports of an ease with singing voice. During assessment, client is able to produce voiceless sounds with ease compared to voiced sounds. Client presents with a diagnosis of abductor spasmodic dysphonia (ABSD).

False

A 16-yr-old female singer comes to you distraught because, in auditions for roles that are important to her, she keeps "sharping" her high notes (i.e. producing a frequency that is slightly too high with some strain). Comments from the adjudicators indicate that this is the primary reason she is failing to get the roles. Her voice is otherwise good, and her larynx appears healthy based on the ENT exam. Which manipulations might you attempt to help this young lady stop sharping?

Decrease her typical subglottic pressure on high notes

A client presents to your clinic with ADSD. He has been recommended voice therapy. Voice therapy is an appropriate treatment choice to help with his medical diagnosis.

False

A 45 year old female is referred to your clinic for voice quality issues following thyroidectomy. She reports of increased breathiness in her voice and inability to project her voice. On video stroboscopic evaluation, you identify that the left vocal fold is immobilized in the lateral position. What would you expect to see in terms of minimum airflow, average airflow and subglottic pressure (Ps) for this client and what do these correlate with in what you hear.

Due to the immobilization of the left vocal fold in the lateral position, one would expect the minimum and average airflow to be increased due to the incomplete glottal closure. Also, the subglottic pressure will be low from the glottal closure being incomplete. One would expect to hear breathiness and a decrease in loudness from the incomplete glottal closure. Moreover, one would expect to hear no strain or roughness since there is no adduction of the vocal folds. Lastly, there would be no change in the pitch due to no lesion adding mass to the vocal folds.

Anatomical studies of the human vocal folds and detailed observation of mucosal behavior during phonation has led to the current "cover-body" characterization of the vocal fold. Which of the following is included in the vocal fold cover?

Epithelium and superficial lamina propria

A 32 year-old female comes in to your clinic with a compliant of loss of her higher pitch range following thyroid surgery. Videostroboscopic examination reveals decreased or no stretching of the vocal folds. Specify exactly the nerve and the branch that might be impacted.

Nerve: Vagus NerveBranch: Superior Laryngeal Nerve

Identify the voice disorder from the images.

Nodules

A patient is referred to you with a breathy strained voice following an intubation procedure 4 weeks ago. As you listen to her history, you begin to wonder if the client is experiencing the symptoms due to an immobile vocal fold or is she experiencing a functional dysphonia/aphonia. What is one task that you might ask the client to complete to indicate one diagnosis or the other?

One could ask the client to cough to assess the vocal fold adduction which will indicate the diagnosis.

A 13 yr-old female is referred to your clinic with symptoms of dyspnea on exertion, tightness in throat and poor recovery of symptoms with asthma medication. She is presenting with a diagnosis of

PVFM

A 13-yr old female presents with c/o tightness in throat and dyspnea with exertion when playing soccer. What is her diagnosis and the appropriate treatment approach?

PVFM and respiratory retraining strategies

A 55 year-old male is referred to your clinic for a voice evaluation. His wife's primary complaints include the husband's weak voice, inability to be hear him in background noise, although the husband says he speaks quite loud. On observation, you notice minimal inflections in speech and an occasional fast rate of speech. Acoustic measures revealed intensity at 58dBSPL and physiologic measures revealed subglottic pressure at 4.8cmH20, average airflow of 280ml/sec and a laryngeal DDK rate of 12 in 5 sec with moderately poor consistency and strength. Visual analysis reveals spindle shaped glottal (bowed) closure. Given this information, what do you think is possibly going on with this client?

Parkinson's Disease

A 65-yr old male is presenting to your clinic for vocal quality issues. His wife indicates that she has a hard time hearing him and people have difficulty hearing him and understanding him. Client however indicates that his voice is loud. Your observations indicate a fast rate of speech, monotone and monopitch. What is your primary diagnosis and what is an evidence-based approach for his diagnosis?

Parkinson's Disease, LSVT

A 73-yr old male is referred to you for voice therapy with a primary medical diagnosis of atrophy and secondary MTD. His primary complaints include weak voice, an inability to project voice, vocal effort and vocal fatigue. Choose all that apply to relieve the client's symptoms.

PhoRTE SOVT

Indicate the control variables in phonation and for each provide it's acoustic correlate.

Pitch: Fundamental Loudness: Intensity Timbre/ quality: Spectrum

Name the intrinsic muscles responsible for abduction of the vocal folds

Posterior Criarytenoid Muscle (PCA)

List all the pros and cons of indwelling and non-indwelling TEP.

Pros of non- indwelling: - the patient is able to insert the voice prosthesis meaning that the patient is not dependent on the professional to replace it- this is less expensive Cons of non- indwelling: - the patient could incorrectly place the voice prosthesis- the retention strap must be tapedPros of indwelling: - the patient is not responsible for removal and insertion of the voice prosthesis- requires less therapy time- often produces a louder and more natural sounding speechCons of indwelling: - patient is dependent on the professional to replace the voice prosthesis- more costly

A 19-yr old college student comes to your clinic with c/o high-pitched weak voice. On further probing, you understand that the client never had a change in voice after puberty. What is the first thing that comes to your mind?

Puberphonia

What nerve is responsible for the motor supply to the intrinsic laryngeal muscles?

Recurrent Laryngeal Nerves (RLN)= 1. Lateral Cricoid Arytenoid (LCA)- ADDuctor 2. Intra Arytenoid (IA)- ADDuctor- (transverse and oblique arytenoid muscles) 3. Thyroid Arytenoid (TA)- ADDuctor 4. Posterior Cricoid Arytenoid (PCA) ABductor Superior Laryngeal Nerve (SLN)= 1. Cricothyroid

Identify the voice disorder from the image.

Recurrent laryngeal Papillomatosis

A 43 year -old female clerk is referred to you for a voice evaluation. Her primary complaints include intermittent dysphonia, a deep voice, an effort to produce her voice, and shortness of breath during exertion. In addition, she is constantly asked by other people "What's wrong with your voice?" On the telephone, people mistake her for a male. On further probing, she revealed a constant need to clear her throat. The patient recently quit smoking, but used to smoke half a pack for 20 years. No other significant medical history reported. Given this information, what is your possible medical diagnosis?

Reinke's edema

You work for a home health agency and see a total laryngectomy patient who had the surgery 3 months ago. She is using a TrueTone Electrolarynx and indicates difficulty communicating and people have difficulty understanding her. What are some recommendations? Check all that is appropriate.

Suggest intraoral tubing Check placement of the electrolarynx Emphasize the overrarticulation

List the layer of the vocal fold that is primary in voice production

Superficial Lamina Propria- has highest impact of phono trauma

___________ layer of the vocal fold is primary and the most important layer in voice production in the five layer scheme.

Superficial lamina propria

List the group of muscles that is involved with laryngeal elevation

Suprahyoid muscles: 1. Digastric- CN V- elevates hyoid, depresses jaw 2. Mylohyoid- CN V- elevates tongue and floor of mouth while depressing the mandible 3. Geniohyoid- C1 and C2, CN XII- pulls hyoid forward and depresses jaw 4. Stylohyoid- CN VII- Elevates hyoid and tongue base

The frequency of VF vibration is directly proportional to ________ and inversely proportional to ____________

Tension and length mass

A 31 yr-old male self-refers to your voice clinic with complaints of hoarse voice, significant effort to produce voice and vocal fatigue. He smokes about a pack of cigarettes a day and drinks 2-3 beers a day. On videostroboscopic examination, white plaque-like lesions are observed along his vocal folds, which do not seem to be impacting the vocal fold vibration. In addition, thickening of the posterior cricoid space and pachydermia is observed. Based on this information, what is your medical diagnosis(es)?

The medical diagnoses for this patient would be leukoplakia and laryngopharyngeal reflux.

A 57 year-old female comes in to your clinic with a breathy voice following a heart surgery. On videostroboscopic analysis, the left vocal fold is immobile. Which cranial nerve, and which branch, may be impacted in this client?

Vagus nerve- CN X; Recurrent Laryngeal Nerve- Branch

Describe the role of SLP in the education of the laryngectomee patient in pre-operative care/counseling.

The role of the SLP in preoperative counceling for a laryngectomee patient is to first be a professional. This includes educating the patient and family on the anatomical and physiological changes that will result from the laryngectomy. It is beneficial to use visuals at this time to provide a clear explanation of the procedure's affect to the patient's anatomy and physiology. Also, the SLP can reduce the anxieties about communication by eliminating any misunderstandings the patient or family might have regarding the patient's communication and swallowing after surgery. At this time, the SLP can provide information and education about communication options that the patient will have to undergo after the surgery. Lastly, SLP's role in prepoerative counseling is to be a resource to the client and family. He/ she should provide the opportunity for the patient and family to ask any questions or discuss any concerns they might have. The SLP should also provide the client and family their phone number in case they might have any further questions or concerns after the meeting.

Thyrovocalis originates in the _______________ and inserts into the _____________.

Thyroid notch Vocal process of the arytenoid

The structure inferior to the larynx is the __________ and superior to the larynx is___________

Trachea Hyoid

According to the author of the approach, Vocal function exercises (VFE) can increase the mass and strength of the vocal folds.

True

Confidential voice is recommended post phonomicrosurgery to ensure decreased impact stress.

True

During voice therapy, pitch is targeted as an outcome measure/ goal in patients presenting with granuloma.

True

Higher pitch and a weak voice are typical symptoms of vocal fold atrophy.

True

A 42-yr old male is referred to you for voice therapy. C/o "raspy" voice, increased effort to produce voice, constant need to clear his throat. H/o acid reflux (is not on any medication) and seasonal allergies- takes antihistamines everyday. Hydration- 30oz, caffeine 45oz, smoking- 6 cigarettes a day, 2 beers a night. Indicate what you might see on videostroboscopic evaluation (list in order of assessment- from arytenoids to true vocal fold vibratory characteristics, and other parameters). Indicate plan of care both direct and indirect. Please be detailed.

Videostroboscopic Evaluation: Videostroboscopic evaluation revealed adequate bilateral arytenoid symmetry, bilateral lesions on the anterior 1/3 of the free edge of the true vocal folds, mucus on the true vocal folds, hour glass glottal closure, phase asymmetry, diminished to no mucosal wave, edema and erythema of the arytenoids, pachydermia of the post cricoid area. A- P compression and supraglottic compression. White plaque like lesions given the smoking and alcohol situation Plan of care: Client was educated on acid reflux and the impact it has on the voice. It was recommended that the client manage symptoms behaviorally by elevating his head at night, keeping a food log, and eating 2-3 hours before bedtime. It was also recommended that he manage his acid reflux symptoms medically by initiating over the counter acid reflux medicaiton. Client was educated on the impact caffeine and alcohol have on the voice. It was recommended that the client increase his hydration with water and decrease caffeine and alcohol intake. Client was also educated on the impact that smoking has on the voice and was encouraged to decrease the number of cigarettes a day. It was also recommended that the client undergo voice therapy with Semi- Occluded Vocal Tract exercises to improve his overall vocal quality and vocal efficiency. Alternate throat clear strategies and antihistamines

You are working as an SLP in a Senior High school district. The school's music teacher refers a 15-yr old female choir singer to you with complaints of significant hoarseness and increased phonatory effort when speaking and singing. You refer her to an otolaryngologist, who provides a diagnosis of mid-membranous lesions, which are probably bilateral nodules. The nodules interfere with complete vocal fold closure during phonation. Based on the physician's report, the lesions appear limited to which layer of the vocal fold.

Vocal fold mucosa

You are working as an SLP in a Senior High school district. The school's music teacher refers a 15-yr old female choir singer to you with complaints of significant hoarseness, pitch breaks in higher register and increased phonatory effort when speaking and singing. You refer her to an otolaryngologist, who provides a diagnosis of mid-membranous lesions, which are probably bilateral nodules. The nodules interfere with complete vocal fold closure during phonation. Based on the physician's report, the lesions appear limited to which layer of the vocal fold?

Vocal fold mucosa

A 45 yr old male comes to your clinic with c/o hoarse, deep voice. Problems started following a period of violent coughing during bronchitis. During videostroboscopic evaluation, you notice granuloma. To which part of the vocal fold is this lesion is usually localized to?

Vocal process

A 26 yr old female teacher comes to your clinic with a complaint of significant effort to produce her voice, pitch breaks at high notes, and a breathy voice quality. On visual examination, you notice bilateral vocal fold lesions depicting an hour glass glottal closure. What would you expect to see for average airflow and subglottic pressure? Justify your answer

With a patient who has an hourglass glottal closure, you would expect to see an increase in average airflow and a decrease in the subglottic pressure due to the incomplete glottal closure. However, due to the fact that this client is a teacher, she could be compensating for the lesion to project her voice by using supraglottic compression which may increase the subglottic pressure or keep it the same.

A 50 year old male is referred to your clinic with a weak voice and inability to project his voice. Videostroboscopic examination reveals bilateral atrophy of the vocal folds. What trend would you expect for the following? a) Fundamental frequency (F0), b) intensity, c) subglottic pressure?

a) Increased Fundamental Frequency. b) Decreased Intensity c) Decreased Subglottic Pressure.

In working with a patient to limit vocal fold impact stress, which of the following variables are linearly related that you are likely manipulate?

a) Vocal fold adduction b) Subglottic pressure

A 30 year old female is referred to your clinic with bilateral vocal fold lesions. Auditory perceptual evaluation reveals a moderate breathy voice quality with mild strain and decreased pitch. Videostroboscopic evaluation revealed bilateral lesions and an hour glass glottal closure pattern. Indicate what you would expect for this client on a) F0, b) average airflow, c) minimum airflow, and d) Noise to Harmonics Ratio (type of voice).

a) decreased Fundamental Frequency. b) increased average airflow. c) increased minimum airflow. d) increased Noise to Harmonics Ratio with a type 2 voice (some amount of noise).

An otolarngologist examines a 47-yr-old male whose voice went south when he had a cold 1 year ago. The patient's voice never recovered. Physical examination shows that the patient's left vocal fold does not come to midline on adduction. The examination also reveals a moderate-sized tissue bridge across the vocal folds at the anterior commissure. Further questioning of the patient reveals that his voice was never "entirely normal", even from childhood. What is your possible diagnosis? Pick the most appropriate answer.

a-left vocal fold paresis or paralysis b-congenital web

An eight-yr old male was referred to your clinic for a voice evaluation. Mom reported that he has a high-pitched hoarse voice and a weak voice that she has noticed since age of three following an emergent endotracheal intubation during a hospital visit. He also has dyspnea on exertion (specifically heavy physical activity). Additionally, the kid likes to use a lot of animal and vehicle noises during play and drinks about 2 cups of soda a day and 2 cups of water. On videostroboscopic evaluation, you notice a tissue bridge in the anterior aspect of the vocal folds. What is your diagnosis based on this?

acquired anterior glottic web

The two possible non-neurological conditions leading to voice problems in individuals secondary to intubation injury is _________&_____________.

arytenoid dislocation and granuloma

A 37-yr old teacher comes to your clinic with a diagnosis of bilateral true vocal fold lesions. On visual perceptual analysis, you notice that there is an hour glass glottal closure pattern with an anterior and posterior chink, no supraglottic compression and some aperiodicity (flutter) of the true vocal folds. What would you expect to find based on this information. Pick the most appropriate answer.

breathy voice, rough voice, increased airflow, decreased F0

Of all layers of the vocal fold, _____________ layer forms the bulk of the vocal fold.

muscle/ vocalis

_________ is the frequency of VF vibration that is most appropriate and comfortable for an individual's system

optimal frequency

You meet a 17-yr-old male at a company party. When you tell him you are a speech-language pathologist, he tells you that you might be interested he has had 24 surgeries on his larynx, since he was 3 years old. His voice is very hoarse. He says that he has to go back in for laryngeal surgery now every 6 months to 1 yr. Otherwise he is healthy. You ask him what the name of his condition is, but he doesn't remember what it's called. What is your first guess?

recurrent laryngeal papillomatosis

You are at a broadway performance show. During the show, the lead female performer experiences a sudden break in her voice and then experiences hoarseness. The show is temporarily halted and a substitute performer comes in to complete the rest of the show. Out of curiosity and being related to the profession, you go back stage and ask the performer some questions. You find out that the client has been experiencing a cold and was on steroids. She said as soon as her voice cracked, she could taste blood. What is the first condition that comes to your mind with such a sudden onset of voice problem?

vocal fold hemorrhage