Voice Disorders - Midterm Exam

Abdominal muscles image

**See image

Another view of extrinsic muscles

**See image

"SUPRALARYNGEAL" NARROWING

**See image - not only do you see the aryepiglottic fold becoming active... you also see

Major muscles for inhalation

**see image

▪ Discuss potential pathologic conditions that can modify the rate of VF vibrations... (4 pts)

- Growths on the VFs - Changes in the mucosa - Changes in the composition of the VFs - Changes in the muscle function

Laryngeal cancer - warning signs (8 pts)

- Lump in the neck - Broadening of the larynx, felt on palpation - Tenderness in the neck - Hoarseness - Dysphagia - Odynophagia - Dyspnea - Earache More Info ▪ Dysplagia - refers to (8:00) ▪ leukoplakia = white spots on the VFs ▪ pachydermia = patches on the VFs?

Acoustic and Physiologic signs of polyp: (7 pts)

Acoustic signs are similar to those of a nodule ▪ Increased (↑) Jitter and shimmer, spectral noise ▪ Deceased (↓) Phonation range, dynamic range ▪ Little effect on f0 Physiologic signs similar to those of a nodule ▪ Average to increased (↑) airflow ▪ Decreased (↓) VF closure time

Sections to include (3 pts)

Background info: ▪ Medical History: How long has problem been going on, any other medical conditions that might be related, what does patient report? Any medications? ▪ Vocal History: how much does she/he use voice, any misuse or abuse? Vocal hygiene? Smoker? Singer? Teacher? Occupation? Etc.

Polyps generally interfere with ______________.

Closure

Cuneiforms

Rod-shaped cartilages within the aryepiglottic fold

GLOTTAL FRY WITH AND WITHOUT FVF (2 pts)

See video: https://www.youtube.com/watch?v=DvEMsrC80ls&list=UUb4ihHoftUZGxPmDZtRqPAg&index=18 ▪ when you hear fry AND it's tight, then it's concerning - patients w/ vocal fold paresis actually have a hard time producing a fry

What is a good goal for circumlaryngeal massage?

client will use appropriate pitch x amount of time using the _____ technique.

Sulcus Vocalis - physiologic signs

increased airflow

Intracordal cysts - Acoustic & Physiologic Signs

no actual data but would expect findings to be similar to nodules; not always easy to identify with endoscopy

Aphonia

no voice

Sentence V "My mama makes lemon jam."

could be used to assess nasality → this sentence would be good to detect if the person had hyponasality because those nasal sounds would be distorted

Misuse vs. Abuse

degree would be a little big harsher for abuse behaviors

Sentence VI "Peter will keep at the peak"

doesn't contain any nasal sounds so you could use it to assess hypernasality

Sentence IV "We eat eggs every Easter."

good to see if there's hard glottal attack

PALATOPHARYNGEUS/ARYEPIGLOTTIC MUSCLE RELATIONSHI

see image ***

Ataxic

significant disorganization with irregular and varying depths of respiration

Vocal Behaviors Characterized as MISUSE:

voice production behaviors that distort the normal propensity of the phonatory mechanism to work effectively and efficiently More Info ▪ any type of deviation from normal propensity would be considered misuse behavior ▪ what is the normal propensity?

Asthenia

voice weakness

Vocal Fatigue

when the Pt feels really tired after talking

If there is a lesion on the upper motor neuron for CN X , what will you see?

you might see paresis or possibly even normal function because it's bilateral

Acoustic signs of Voice Problems (4 pts)

▪ "Imperfect mirrors" of the underlying vocal fold physiology ▪ Acoustic measures are some of the easiest measures to obtain and analyze ▪ Many of the acoustic signs are associated with more than one laryngeal pathology - although probable pathology can sometimes be assumed, a diagnosis cannot be made on the basis of a particular acoustic sign More info: ▪ we just observed a 200 Hz fundamental frequency for a male speaker ▪ what does it tell you? NOTHING ▪ you can't really guess what's going on from this info alone ▪ acoustic measures are easy to obtain/access, but still based on one acoustic measure we can't diagnose

Clients perform three specific vocal tasks for CAPE-V, and their speech tasks should be recorded: 2. Sentences (7 pts)

▪ "Please read the following sentences one at a time, as you were speaking to somebody in a real conversation (the clinician can model the task)." I. The blue spot is on the key again. II. How hard did he hit him? III. We were away a year ago. IV. We eat eggs every Easter. V. My mama makes lemon jam.; and VI. Peter will keep at the peak. More Info: ▪ there are certain purposes that each sentence is actually aiming for ▪ some make sense, some don't

3. Running Speech

▪ "Tell me about your voice problem." ▪ "Tell me how your voice is functioning." - The clinician should elicit at least 20 seconds of natural conversational speech from the client. More Info

Vibratory Cycle - Return of folds to the midline (4 pts)

▪ 2 forces: elasticity and Bernoulli force ▪ Tissue elasticity returns folds back to midline ▪ Also, aerodynamic force (Bernoulli); velocity of air is greater b/w the folds than above or below when the puff of air escapes ▪ Therefore the pressure is also less b/w the folds (negative pressure) and the folds are sucked together - Bernoulli effect

GMA/Sandwich Muscles (5 pts)

▪ Anterior belly of digastric runs most superficially ▪ Underneth is mylohyoid ▪ Most interior is the geniohyoid ▪ all three are important for swallowing ▪ they elevate the larynx up and forward towards the epiglottis so that there can be a good closure for swallowing

Case history continued

▪ Ask about the nature of the problem that brought the patient to the clinic ▪ This provides you with initial impressions - which can be changed over time ▪ You learn how astute the patient is regarding his problem ▪ How articulate he is in describing the problem ▪ How concerned or motivated he is ▪ Ask open ended questions ▪ Try to determine if the patient understands the cause of his problem ▪ Does he really understand why he was sent to you? More Info:

Reactions to voice disorder (7 pts)

▪ Ask the patient to describe other people's reactions to the voice disorder ▪ If the patient coworkers, or family do not see this as a problem, the motivation to change may be limited ▪ Some persons are in denial, interview carefully before accepting the patient's attitude that his/her voice is no problem ▪ Has the problem had any impact on the patient's personal life ▪ Scale 1 to 5 ▪ What does the patient believe to be the cause of the voice problem? - this can be very insightful - Self assessment of how voice problems affecting daily functions, psychosocial well being, self concept/image, etc. (Voice Handicap Index: read Jacobson et al., 1997) More Info ▪ you definitely want to ask if the patient's voice change has been noticed by others. ▪ if noticed, the patient probably has greater motivation ▪ VHI (voice handicap index) value is often reported

Exhalation (4 pts)

▪ Assisted by non-muscular forces including - Gravity - Elasticity (recoil force of lungs, rib cartilage torque, and diaphragm and abdominal content relaxation) ▪ Major muscles (abdominal muscles) working toward decreasing thoracic cavity volume My Notes: ▪ exhalation may be achieved without any muscle contraction - if you want to, you can include some muscle involvement ▪ gravity pulls things downward ▪ when the rib cage is elevated it's inhalation ▪ the gravitational pull is downward so rib cage goes back down ▪ ab muscles are important exhalation muscles

Spasmodic dysphonia (5 pts)

▪ Associated with CNS impairment; location of the insult not clear yet ▪ A focal dystonia affecting laryngeal muscle control during speech ▪ Occurs equally in men and women ▪ Onset is usually, but NOT always, in middle age ▪ Variable onset More Info: ▪ struggled voice may have something to do with spasm ▪ it is a task-specific, action-induced problem - dystonia is something related to the CNS, when you have involuntary, uncontrollable movement taking place... it can affect any part of the body, including vocal folds

Physiologic signs of nodules (2 pts)

▪ Average to increased (↑) airflow ▪ Decreased (↓) VF closure time

Clinical Impressions

▪ Based on what you found from your assessment, what are your thoughts and clinical impressions? More Info ▪ exam question: how would you come up with your clinical diagnosis - you would have to review all of the previous info and your evidence should support your clinical diagnosis

Recommendation (5 pts)

▪ Based on your results, what do you recommend? ▪ Recommend therapy ▪ No recommendations at this time ▪ Make referral for further evaluation ▪ Sometimes may even list how long therapy should be and what goals should be focused on (good thing to add if you can)

Vocal fold granuloma (4 pts)

▪ Benign growth of lymphoid or epithelial tissues due to irritation or trauma - Intubation granuloma - Contact granuloma - Result of gastroesophageal reflux More Info: ▪ this mass develops towards the back of the VFs typically in the vocal process region ▪ the mass growth rubs on the other side too and the constant rubbing irritates the other side too ▪ the membranous portion of the VFs are ok with this type of pathology ▪ a lot of times patients may experience pain during swallowing = odynophagia

Possible neurologic signs often co-occur (5 pts)

▪ Blepharospasm ▪ Jaw or facial jerks ▪ Limb or hand tremor ▪ Neck twisting ▪ Writer's cramps More Info ▪ it is not necessary that individuals with spasmodic dysphonia may have these symptoms.... ▪ it can kinda be thought of as a cramp - when you're trying to write and you have a spasm in your wrist ▪ you will hear people talking about spasmodic torticollis = neck spasm

Other types of trauma (6 pts)

▪ Blunt or penetrating trauma can fracture or severely damage the larynx ▪ Inhalation and thermal trauma - When these events occur, the individual is often at risk of mortality. ▪ Aspiration of foreign bodies in children ▪ Can occur on a congenital or developmental basis ▪ In some cases, can be surgically corrected

Intrinsic muscles: (2 pts)

▪ Both attachments within the larynx. ▪ Regulate mutual positions of the laryngeal cartilages, directly affecting vocal fold behaviors.

PHONATION TASKS (5 pts)

▪ PITCH GLIDES AND SUSTAINED VOWELS - HOW???? - "THICK" VERSUS "STIFF" FOLDS - CONSTRICTED VERSUS NOT CONSTRICTED FALSE FOLDS - CONSTRICTION/SUPRAGLOTTIC COMPRESSION WITH AND WITHOUT TVF CLOSURE

Arytenoid cartilages (4 pts)

▪ Paired, located on the posterior/superior surface of cricoid ▪ Pyramidal-shaped, four surfaces ▪ Base, apex, vocal process (anterior-medial-inferior), muscular process (posterior-lateral-inferior) ▪ Anterior/medial movement vs. posterior/lateral (outward) movement

Where does resonance voice therapy fit in? (5 pts)

▪ some hygienic but really physiologic level ▪ cost: how much does it cost to have a clinician certified for resonant voice therapy - the workshop itself was nearly 700$ in addition to certification - theoretically, you can actually have a similar program of your own knowledge base ▪ goals: you could do % of time using forward focus in the therapy session

Webbing Video #2

▪ some redness going on right on top of the VFs ▪ maybe because of the webbing condition the patient might have overused ▪ there is some asymmetry in terms of the vocal folds

Student Lectures - Voice Disorder Tx Summaries

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LECTURE 3 - Functional Voice Problems - Disorders of voice use

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Lecture 5 - Voice Problems Associated with Nervous Systems

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Lecture 6 - Voice Assessment

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Lecture 7 - Voice Therapy

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Laryngoscopic signs that can be observed without a strobe unit (7 pts)

- Vocal fold approximation - Vocal fold gross movement - Tissue changes in the VF area - Changes in pyriform sinus, ventricular folds, etc. - Anatomical malformations and congenital anomalies - Appropriate VF lengthening/shortening - Involuntary laryngeal activity More info: ▪ bowed glottal configuration ▪ bowing of the vocal folds, they bow outwards ... common for older larynx .. .presbylaryngis ▪ it can sometimes mean that they can never get a full closure ▪ caused by atrophy of the vocalis muscle

Stroboscopic findings (require the use of stroboscopy) (8 pts)

- complete/incomplete closure - glottal configurations: - Posterior chink, anterior chink, bowed, hourglass configuration, etc. - mucosal wave - condition and closure of ventricular folds - symmetry of closure - amplitude of vibration - vibratory behaviors

Functional vs. Organic (4 pts)

- organic = you can ID the lesion - functional = can't ID the lesion ▪ misuse behavior and abuse are two categories - photrauma is a term that people use over abuse bc abuse sort of blames the speaker More Info ▪ this has to do with vocal use ▪ functional voice problems , you can't really identify particular lesions in the larynx but you will still see voice problems present

▪ so before the vagus nerve actually separates into different branches , and the entire LMN got severed how is this going to affect the person's movement?

- right side VF = paralyzed - right side palate = paralyzed (uvula would be deviated towards the stronger side) - could potentially affect swallowing function because of the lack of sensory info in that area ▪ unlike the larynx, the lower quadrants of your face receive only contralateral cortical input ▪ the tongue (hypoglossal - CN XII) , actually only carries motor function and receives contralateral cortical input only ▪ if any injury takes place at the cortical level that can actually damage motor function - the tongue will deviate towards the weak side... the tongue will actually push out on the strong side and go towards the weak side that cannot push out as much

VHI (voice handicap index) (11 pts)

- there are 30 questions that the patients answer using a 5 point scale - never (0) , almost never, sometimes, almost always, always (5) ▪ there are three subscales under VHI - F = functional (10 statements) - P = physical (10 statements) - E = emotional (10 statements) ▪ the type of questions falls under one of these subscales ▪ functional: "my voice makes it difficult for people to hear me ▪ physical: "i run out of air when i talk" ▪ emotional: "i am tense when talking with others because of my voice" - you can use VHI to really assess how the voice issue affects the patient

▪ if someone had a legion on the left motor cortex how would that affect them? (5 pts)

- there would be reduced movement (paresis) in the VFs, but it's still innervated from the other side so they will still have some functioning left ▪ when you see vocal fold paralysis, typically 90% of the cases have to do with LMN ▪ if there's a legion in the LMN, there is potential for paralysis ... ▪ it is important to know which level the legion took place at ▪ depending on the superior, pharyngeal, recurrent branch ....

Lee Silverman Voice Treatment (LSVT) for persons with Parkinson's Disease (Ramig, L. Many articles are available)

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"ARYEPIGLOTTIC" NARROWING VS VENTRICULAR FOLD COMPRESSION

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*CAPE-V (image 1)

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CAPE-V (see image 2)

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CAPE-V (see image 4)

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CAPE-V (see image 6)

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CN image

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DO NOT CONFUSE "TWANG" AND "NASAL"

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GUEST LECTURE: VOCAL TRACT PHYSIOLOGY: CONTRIBUTIONS TO VOICE QUALITY

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LARYNX, POSTERIOR OBLIQUE VIEW

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LARYNX, SUPERIOR VIEW

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LECTURE 4 - Structural Voice Problems

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Lecture 2 - Differential Diagnosis

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MORE NARROWING/"TWANG"

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Manual Laryngeal Musculoskeletal Reduction Technique (MLMRT) (Aronson, A. E. (1990). Clinical voice disorders (3rd ed.). New York: Thieme Stratton.)

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Resonant Voice therapy (RVT) (Verdolini, K. (1998). National Center for Voice and Speech Guide to Vocology. Iowa City.)

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UMN , LMN image

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VELUM - ACOUSTIC CONSEQUENCES

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VENTRICULAR FOLDS

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VENTRICULAR FOLDS - ACOUSTIC CONSEQUENCES

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VERTICAL LARYNX POSITION

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Voice therapy can be classified as: Psychogenic

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VELUM (5 pts)

... ▪ left → posterior pharyngeal wall ▪ right → velum ▪ when you lower the larynx you can see how much longer the larynx gets ▪ as you go up in pitch , you have less "wiggle room" option ▪ pitch change is not as simple as the relationship of TA and CT

CAPE-V (see image 3)

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CAPE-V (see image 5)

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CN image 2

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Clients perform three specific vocal tasks for CAPE-V, and their speech tasks should be recorded: 1. Sustained vowel production (3 pts)

1. "The first task is to say the sound /a/. Hold it as steady as you can, in your typical voice, until I ask you to stop (the clinician can model the task)." 2. Perform the task three times for 3-5 seconds each 3. Repeat the same task with the sound /i/. More Info ▪ you use both a low and a high vowel ▪ you want the production of the vowel to be repeated at least three times ▪ you definitely want to record these kinds of sessions

Six quality features to be evaluated (6 pts)

1. Overall severity. Global, integrated impression of voice deviance 2. Roughness. Perceived irregularity in the voicing source 3. Breathiness. Audible air escape in the voice 4. Strain. Perception of excessive vocal effort (hyperfunction) 5. Pitch. Perceptual correlate of f0 6. Loudness. Perceptual correlate of sound intensity More Info ▪ be able to define these terms ▪ use the term roughness, not hoarseness ▪ if someone has aphonia, they will not have a roughness value bc it has to do with voicing ▪ breathiness → audible air in voicing ▪ strain →

Impedance is ____(1)____ when the VFs are adducted, and thus generating ____(2)____ EGG signals.

1.) Low 2.) Stronger

Short MPT reflects inefficiency of ____________or _____________.

1.) maybe the person has insufficient breath support 2.) valving is not really effective (too much air escaping at the larynx)

Physiological signs include features affecting (3 pts)

1. aerodynamics 2. vocal fold vibratory behavior 3. muscle contractile properties

NARROWING - ACOUSTIC CONSEQUENCES

1800 - 4200 are the "singer's formant" - see image

Average sound pressure level or intensity (in dB)

80 dB

Case Study Examples: ▪ 30 y/o female who presented w/ dysphonia ... ▪ f0 = 175 Hz, jitter of .89%, shimmer of .50 dB and harmonic to noise ratio of 2.3 dB ▪ persistent small chink in the posterior glottis during phonatory efforts was noted due to bilateral polypoid degeneration of the vocal folds - Before phonosurgery (7 pts) & after phonosurgery (6 pts)

Before phonosurgery: ▪ there is slightly compromised MPT ▪ roughness ▪ rated as moderate ▪ low pitched vocal quality ▪ consistent use of vocal fry ▪ you can hear some mild strain, not all the time but intermittently ▪ jitter and shimmer is slightly higher which may go along with her vocal instability After phonosurgery: ▪ roughness still there ▪ pitch is much higher, speaking fundamental is not significantly higher ▪ mild roughness.. improved the most, from moderate to mild ▪ breathiness is still present ▪ not only irregular but there is still audible air ▪ volume rate of airflow = probably low resistance (13:30) More Info harmonics to noise ratio = typically 15 dB is an OK value

How does the vagus nerve CN X receive input?

Bilaterally --> from both sides ▪ so the soft palate actually receives input from the contralateral and ipsilateral side ▪ to assess this have them say "Ahhhhhh" or "ah ah ah ah" ▪ you should see the soft palate rise

Corniculates

Cone-shaped cartilages forming the apex of the arytenoids

Image of different VF positions: (5 pts)

Position A.) folds are adducted achieved by adductor muscles - they're creating resistance Position B.) if pressure blow the folds increases the folds will get sucked together Position C.) the folds will be blown apart Position D.) the folds come back to the midline

M1:

Distant metastasis

Mx:

Distant metastasis cannot be assessed

How can we assess muscle activity?

EMG

What is "flexibility" referring to when talking about vocal quality?

Flexibility = not monotone

Sulcus Vocalis - location

Generally bilateral

Note about pitch and loudness

In general, pitch changes are controlled primarily by laryngeal activity and loudness changes are controlled primarily by respiratory activity.

Intracordal cysts - Mass & Stiffness

Increased mass and stiffness

Vocal Fold Granuloma - Location

Located at the vocal process of the arytenoids or on the lateral wall of the posterior glottis

Sulcus Vocalis - Mass & Stiffness

Mass of the cover is reduced and stiffness is increased

N3:

Metastasis in a lymph node more than 6cm in greatest dimension

N1:

Metastasis in a single ipsilateral lymph node, 3cm or less in greatest dimension

Vocal Fold Granuloma - Population

More common in females

Where do Motor & Sensory fibers decussate ?

Most motor and sensory fibers cross the midline (decussate) in the caudal medulla of brainstem (contralateral sensorimotor control) More Info: ▪ There are CNs that receive bilateral input from both sides of the cortex ▪ CNs with bilateral cortical input ▪ Unilateral cortical lesion? ▪ Bilateral cortical lesion? ▪ After a LMN lesion? ▪ CNs with unilateral cortical input ▪ e.g., Lower facial muscles (VII), tongue muscles (XII)

Other neurologic disorders

Neurologic disorders affecting the larynx do not occur in isolation - voice impairment is likely accompanied by other disordered motor speech functions (respiration, articulation, resonance, prosody, etc.)

M0:

No distant metastasis

N0:

No regional lymph node metastasis

What kind of polyp might have no effect at all on the vibratory pattern?

Pedunculated Polyp

Sample recordings

Recording sample #1 ▪ some roughness, some breathiness ▪ some hard glottal attack ▪ some mild strain quality ▪ vocal fry ▪ overall her pitch level was really low resonance was fine Recording sample #2 ▪ roughness ▪ breathiness ▪ ABductor spasmodic dysphonia → this is the kind when they have difficulty transitioning from opening to close (bc the ABductors are stuck open) ▪ maybe conversion dysphonia that happens because of the trauma ?? ▪ refer patient for psychological testing ▪ if that's ruled out, spasmodic dysphonia would be the final diagnosis Recording sample #3 ▪ rough/breathy ▪ a little strained quality because of the spasm? ▪ spontaneous speech was much better than the other tasks ▪ moderate - she has dysphonia BUT can we identify what is causing her dysphonic features - we would need imaging (refer to ENT) - we might need a neurologist

Sulcus Vocalis - Acoustic signs

Reduced maximum phontation time and phonational range

Nx

Regional lymph nodes cannot be assessed

Excessive talking

Results in vocal fatigue; the excessive talker may use other forms of misuse in order to keep the voice going More Info ▪ excessive talkers don't always develop a laryngeal pathology - this may result in increased tension but that doesn't all the time result in voice disorders

Cast Study #3 ▪ middle aged male ▪ f0 = 109 Hz , MPT within normal limits ▪ shimmer = 0.63% (RAP) , jitter ( (6 pts)

Sulcus vocalis voice sample: ▪ he has some sort of vocal demands in his life ▪ there was maybe some breathiness ▪ very mild level of breathiness ▪ irregular roughness , maybe some gurgly quality ▪ very mild case ▪ it sounds like he may have had some sort of cold, which sounds like a little bit of hyponasality

LSVT Loud - Summary (3 pts) - Category (1 Pt) - Pros (3 pts) - Cons (2 pts)

Summary - "Gold standard" for speech treatment for individuals with Parkinson's disease (and other neurological conditions) - Trains individuals to use their voice at a more typical loudness level - Training focuses on recalibrating their perceptions of how loud they sound to other people Category -Symptomatic -Psychogenic Pros - backed by LOTS of research and considered the "gold standard" - can have positive effects on other speech characteristics other than loudness, such as intelligibility, speech rate, facial expressions - progress is seen relatively quickly Cons - expensive (for clinicians to be certified and for patients to pay for) - very intense program

Resonant Voice Therapy - Summary (8 pts) - Category (2 Pts) - Pros (3 pts) - Cons (2 pts)

Summary - 7 stages - First three start with hum this, speak with a sing-song voice, speak naturally - Last few are generalization [try in stressful settings; pick your own phrase; try emotional topics] - First stage is all voiced sounds - The second stage is mix of voice/voiceless - Third stage is pick your own phrase - Work on forward focus of voice - Facial bone vibrations Category - Physiologic - symptomatic Pros - Can DIY for free but training is expensive - Mind-body model [not abstract concepts, actually feel the facial bones vibrate] - Functional endgame Cons - Training is expensive - Takes a long time - Lots of homework

Hygienic Voice Therapy - Summary (4 pts) - Category (1 Pt) - Pros (2 pts) - Cons (2 pts)

Summary - Modify/eliminate harmful voice behaviors related to voice misuse/abuse - No management of physiological function - only changing behaviors - Should only be used in conjunction with other therapies - Stay hydrated, avoid situations with yelling, decrease alcohol intake, management of GERD, reduce smoking, management of allergy medication, etc. Category -Hygienic voice therapy Pros - Education that supplements another voice therapy and further improves voice use - Proven to have an effect on professionals who excessively talk Cons - Should not be used in isolation - Need to think of creative ways to ensure the patient is utilizing the education tips (journaling, managing coughs during sessions)

Prevention Program 1-Schools - Summary (5 pts) - Category (2 Pts) - Pros (3 pts) - Cons (2 pts)

Summary - Modify/eliminate harmful voice behaviors related to voice misuse/abuse - Stay hydrated, avoid situations with yelling - Use indoor voice - Sit up tall - Jacobsens Techniques (relaxing whole body to relax laryngeal muscles Category - Hygienic (Main) - Psychogenic Pros - Doesn't cost money - Easy to implement - Positive effects are shown Cons - Child must have motivation in order to have this work - Teachers are also prone to voice disorders so may be a poor model for students

Vocal Function Exercises - Summary (3 pts) - Category (2 Pt) - Pros (2 pts) - Cons (2 pts)

Summary - Strengthen and balance laryngeal musculature - Four steps: Warm-up, stretching, contracting, power - Traditional dosage: 2x/day, 6-8 weeks Category -Physiologic -symptomatic Pros - Can be used by healthy/pathologic voice users - Attends to all three subsystems of voice Cons - Least effective with low dosage/inconsistent use - Pt. must be highly motivated for tx to be effective

Facilitation Techniques - Summary (7 pts) - Category (2 Pts) - Pros (3 pts) - Cons (2 pts)

Summary - There are many, many types - Some target pitch loudness and quality altogether - 4 that we covered: - Change of loudness (↑ or ↓ loudness) - Chewing (increase jaw movement) - Focus (adjusting resonance, move from deep in the throat to high in the head) - Glottal Fry (reduces hyperfunction Category - Symptomatic - Hygienic Pros - Easy to use and apply - Low to no cost - Easily modified to the patient Cons - Not a lot of research - Doesn't directly address physiologic problems

Manual Laryngeal Musculoskeletal Tension Reduction Techniques - Summary (3 pts) - Category (1 Pt) - Pros (3 pts) - Cons

Summary - Used for people with hyperfunction and increased laryngeal tension or VF paralysis - Two types: digital manipulation and laryngeal massage - Types of digital manipulation: Digital pressure to lower pitch, monitoring vertical movement of larynx, and unilateral digital pressure Category - Physiologic - Symptomatic Pros - research to prove effectiveness - can be used for many different populations - can have immediate effect Cons - ?

Confidential Voice Therapy - Summary (3 pts) - Category (2 Pts) - Pros (3 pts) - Cons (2 pts)

Summary -Reduce tension on the voice by speaking with a low intensity/low effort voice (confidential voice) -not the same as a whisper (using phonation, just reduced) -used for patients who have undergone phonotrauma or need to reduce hyperfunctional voice characteristics Category -Physiologic -hygienic Pros -good to use as a time for the voice to recover (after surgery, vocal nodules etc) -easy to implement -can help reduce vocal lesions Cons -not a long term strategy -requires self monitoring to be successful

Prevention Program 2-Professional Voice Users - Summary (13 pts) - Category (2 Pts) - Pros (2 pts) - Cons (2 pts)

Summary ▪ Implemented to increase awareness of potentially damaging vocal behaviors ▪ Effective for improving vocal fatigue and vocal endurance for speakers and singers ▪ Components: -Vocal Hygiene -Vocal Stress -Vocal Health -Vocal Exercises ▪ Vocal Warm-Up Exercises - Traditional - Physiological ▪ Vocal Cool-Down Exercises ▪ Exercises used for vocal warm-up can work for cool downs - 2 studies were reviewed for effectiveness of vocal warm ups and cool downs Category - Originates from Hygienic Approach, - Considered mostly symptomatic Pros - Proven in research to be effective for speakers and professional voice users - Cost effective, non-invasive, low-risk approach to improving vocal efficiency and quality Cons - Patient must be highly motivated for tx to be effective - Further evidence needs to be done to ensure appropriate amount of time spent on exercises for most effective vocal outcomes, without leading to vocal overuse

Intrinsic muscles on a digram - Interartynoids (4 pts) - PCA (3 pts) - CT (6 pts) - LCA (6 pts) - TA (5 pts)

Top left: ▪ you can see the posterior view of the epiglottis ▪ you can see the cricoid cartilage Bottom left: ▪ angled view with part of the thyroid cartilage removed Interarytenoids: ▪ the muscle that runs between the two arytenoids - there are two parts - transverse part deeper - oblique part = superficial Posterior Cricoarytenoid (PCA) ▪ the only ABductor in the larynx ▪ goes from the cricoid cartilage and the two muscular processes of the arytenoids ▪ when this muscle contracts the arytenoids would be pulled backwards and laterally Cricothyroid (CT) muscle ▪ runs between the cricoid cartilage and the thyroid cartilage ▪ the muscle is somewhat anterolaterally positioned within the larynx ▪ when the muscle contracts, the distance between the two cartilages would be decreasing (either cricoid up, or thyroid down) ▪ when the CT muscle contracts, the vocal folds would be stretched ▪ when the vocal folds are stretched, it created higher pitch ▪ this is the major muscle known for pitch-control Lateral Cricoarytenoid (LCA) ▪ runs between the cricoid and muscular processes of arytenoids on the lateral section? ▪ an important ADductor ▪ best candidate to exert medial compression ▪ exerting medial compression controls the amount of mass present for vocal fold vibration ▪ when you exert medial compression, only a limited amount of vocal fold mass can participate in vibration ... this can also be used as a method of increasing pitch ▪ medial compression (especially excessive medial compression) can be thought of as poor vocal behavior Thryoarytenoid (TA) ▪ two parts ▪ first part is more medially located → that's called the "thyrovocalis" or "vocalis" ▪ on the lateral part you will see the thyromuscularis running as well ▪ when this muscle is not opposed by any other muscle...you can easily picture shortening of the muscle will shorten the vocal folds ▪ if CT muscle is already contracted what happens if TA muscle contracts, it will make the tension increase

T2

Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal fold mobility

T4

Tumor invades through the thyroid cartilage and/or to other tissues beyond the larynx (e.g., trachea, soft tissues of neck, including thyroid, pharynx)

T3

Tumor limited to the larynx with vocal fold fixation

T1

Tumor limited to vocal fold(s) (may involve anterior or posterior commissure) with normal mobility More Info ▪ these are like the stages of cancer ▪ if someone has stage 3 laryngeal cancer that would be T3

Mixed

UMN and LMN involvement

Vocal Fold Granuloma - Vibratory Pattern

Usually does not affect the vibratory pattern unless very large

Aerodynamic Principle: (4 pts)

V = ∆P/R ▪ V = volume rate of airflow (ml/sec) ▪ ∆P = pressure drop (cmH2O) ▪ R = resistance (cmH2O·sec/ml) More Info: ▪ v = volume rate of airflow within a given time amount - it is inversely related to airway resistance ▪ if there's a person who has one vf paralyzed in the medial position ... which position emits a lot of air ? - the paralyzed one? ▪ volume rate of airflow would be greater in this paralyzed condition with very very low resistance considering that the person has a normal respiratory system? (28:00) ▪ in adductor spasmodic dysphonia, because of the increased pressure/resistance towards the middle from the adductor muscle, volume rate of airflow will be lower ? (29:00) ▪ if someone had V = 500 ml/sec, then 400 ml/sec, then 300 ml, sec... this would tell you that the person gained more closure (33:00)

Pathophysiologies of nodules (3 pts)

Vary depending on: ▪ Changes in mass and stiffness over time ▪ VF closure and vibratory patterns

Ventricular phonation

When it occurs in the absence of laryngeal pathology, the condition is considered to be due to vocal misuse More Info ▪ sometimes you may really see the false vocal folds making medial approximation and literally vibrate ▪ when the false vocal folds come to the midline too excessively, that's considered misuse ▪ when false vocal folds come to the midline it will obscure the view of the view of the true VFs ▪ false VFs come to the midline bc of excessive adduction movement ▪ this girl in the example video has a high fundamental frequency

Semi Occluded Vocal Tract (SOVT) exercise

an easy thing to incorporate for voice clients

Average amplitude variability (SD)

about 3-5 dB

Sentence III "We were away a year ago."

all vocalic sounds , good for adductor spasmodic dysphonia ... if someone has any voice stoppage kind of thing

lower motor neuron lesion

both upper and lower face will be paralyzed on one side

Voice Symptoms of Polyps

hoarseness and breathiness

Papilloma (4 pts)

▪ A benign tumor thought to be caused by a virus ▪ Wartlike appearance ▪ Originates in the epithelium but can invade the entire cover and the muscle ▪ Can be anywhere in the glottal, supraglottal, or subglottal levels More Info: ▪ recurrent respiratory papillomatosis ▪ there are multiple types, types 6 & 11 are the types that can manifest as recurrent papillomatosis ▪ these can grow from the tip of the nose all the way down to the lungs ▪ it can be a problem if it blocks the airway ▪ these can be surgically removed , but they can also grow back

Essential tremor (5 pts)

▪ A disorder to the CNS that may result in tremor in the head, limbs, tongue, palate, and larynx. Usually starts in the hands ▪ Typically absent at rest, ▪ Somewhat reduced during movement, ▪ Present at the termination of movement, ▪ And maximal during maintenance of posture More Info ▪ typical = 4-7 Hz

Epiglottis (2 pts)

▪ A leaf-shaped cartilage attached on the thyroid ▪ Important for swallowing by directing food and liquids down to the esophagus and protecting the airway (Green part on the image)

The final result of the complete evaluation includes several factors (3 pts)

▪ A listing of specific etiologic factors ▪ A baseline description of the voice ▪ An outline of the management plan

Carcinoma (6 pts)

▪ A malignant neoplasm ▪ Squamous cell carcinoma is the most likely type of laryngeal cancer (SCCa) ▪ Lesions originate in the epithelium and gradually invade the deeper structures ▪ Usually unilateral but can grow and eventually invade the entire larynx ▪ 2-5% of all cancers are laryngeal cancers ▪ 50-70% of all oral and laryngeal cancer deaths are associated with smoking! More Info: ▪ squamous cell is the epithelial layer that's the most common type of cancer you'll see within laryngeal cancer ▪ you'll see the malignant condition actually invades into the deeper layers

PROMPTS FOR TWANG (8 pts)

▪ ANIMAL SOUNDS - SHEEP - ANGRY CAT - COW ▪ ROBOT ▪ BUZZER/WRONG ANSWER ▪ THE "NANNY" ▪ ETC....

HOW CAN I ELICIT/PROBE TVF CLOSURE? (11 pts)

▪ ASK FOR QUIET, MEDIUM, AND LOUD "NO" OR OTHER WORD - SHOUT OR "THINK LOUD" ▪ LIGHT BREATH HOLD ▪ LIGHT "MINI-COUGHS" ▪ LARYNGEAL DIADOCHOKINESIS OR GLOTTAL STOPS - /IIII/ VS /HIHIHIHI/ - "HEY" VS "EY" - UH-OH ▪ THROAT-CLEAR ▪ REGULAR COUGH ▪ FRY

Vocal fold paralysis

▪ About 10% result from damage to the CNS; the remaining 90% are due to damage to the PNS More Info ▪ in a lot of cases, especially the PNS damage, probably thyroidectomy or other sorts of trauma like open heart surgery causes VF paralysis ▪ over ⅓ of the cases actually have ⅓ idiopathic etiology ▪ the top branch is the pharyngeal branch that innervates the palatal region ▪ the second branch is the superior laryngeal branch - it goes into Thyrohyoid membrane and picks up info from the supraglottic region ▪ external branch goes into the CT muscle ▪ vagus nerve on the right side wraps around the subclavian artery ▪ left vagus nerve goes around the big aorta - You see cases on the left side more because of the longggg path ▪ in some cases you will see ALL branches damaged ▪ if someone would have an injury on the recurrent branch only? - probably AD and ABductory function would be compromised ▪ Worst case scenario: - if the legion starts up high in the left branch then everything underneath it will be affected

Can the patient describe the onset and the course of the voice problem? (7 pts)

▪ Abrupt onsets often are more disturbing to the patient ▪ Abrupt onsets are most likely due to - Neurologic problem with CN X involvement - Bacterial or viral infection with laryngitis - Trauma - Sudden, severe abuse - Psychological causes

Acoustic & Physiologic signs of spasmodic dysphonia (2 pts)

▪ Acoustic signs: limited intensity, low-frequency voice tremor ▪ Physiological signs: high subglottal pressure with increased glottal resistance, low volume rate of airflow

Lateral cricoarytenoid (3 pts)

▪ Adductor ▪ Paired muscles ▪ Upon contraction, the muscular processes of the arytenoids (on the lateral side) are pulled anteriorly and medially

Interarytenoid (5 pts)

▪ Adductor ▪ Treated as an unpaired muscle ▪ b/w two arytenoid cartilages ▪ Transverse (deep): pulling the bases of the arytenoids toward each other ▪ Oblique (superficial): pulling the tips of the arytenoids together

Inappropriate pitch level (4 pts)

▪ Almost always a sign of a problem rather than the cause of the problem - Puberphonia (aka adolescent falsetto, pubescent falsetto, mutational falsetto..etc.) - Persistent glottal fry - Lack of pitch variability More info: ▪ puberphonia - high pitched voice persists beyond the age of when it should actually drop - probably isn't that easy to come to a diagnosis - need to make sure there are no anatomic abnormalities going on ▪ persistent glottal fry - glottal fry itself is not a problem until it becomes persistent - glottal fry promotes the medial movement of vocal folds (22:00) ▪ lack of pitch variability - if somebody has any type of neurogenic ongoing problem - monopitch is an ongoing problem ▪ if you know a patient has some neurological things going on (i.e., Parkinson's) then it's not functional because you know the origin ▪ if someone had an injury to the neck and now the person can't vary their pitch much then it's an organic problem because you can identify the legion

Reinke's edema (5 pts)

▪ Also called polypoid degeneration, chronic polypoid corditis, chronic edmatous hypertrophy, or polypoid vocal fold ▪ Fold is edematous along its entire length ▪ Edema is bilateral in the superficial layer of the lamina propria ▪ Folds usually close ▪ Increased mass and decreased stiffness More Info: ▪ fluid layer along the whole length of VFs ▪ usually patients can make full closure with this ▪ roughness, strained ▪ even if they have a full closure, voice could still be rough because of the uneven amounts of mass on each side ▪ roughness or spectral noise is typically talking about the noise that's created at the medial edge of the vocal folds (59:00) ▪ low pitch is commonly assocaited with this condition bc the extra mass from the fluid slows down the rate of vibration (aka polypoid degeneration)

Efficient Use of Voice (2 pts)

▪ An efficient system produces the best results with a minimal effort ▪ From misuse to abuse is simply a continuum of behavior with abusive behavior being harsher than those of misuse More Info ▪ minimal level of effort at the level of the larynx ▪ in terms of extent, abuse may be associated with more harsh behaviors ▪ misuse/abuse are along a continuum - abuse harsher than misuse ▪ normal vs. misuse? - is there a clean boundary? - not really - this is very shady in terms of boundaries

CAPE-V (9 pts)

▪ CAPE-V was created by a combination of voice specialists ▪ under CAPE-V a patient's voice would be rated between 6 categories: 1.) overall severity - overall grade, degree of abnormality 2.) roughness - irregularity of voicing 3.) breathiness - audible air perceived in voice 4.) strain - extra muscular effort, extra tension 5.) pitch 6.) loudness ▪ cape V also brings up additional dysphonic features like coughing & vocal try More Info ▪ when you open up the CAPE-V rating form , you will see a piece of paper with all of these different qualities ▪ CAPE-V is used quite often in our field

Abnormal voice quality may be a sign or symptom of illness, which can be: (6 pts)

▪ Cancer ▪ Some neurological disease ▪ psychological disturbances ▪ simple inflammation ▪ viral infection - We cannot really tell/identify unless we assess the vocal quality more in depth

Components of the diagnostic workup (3 pts)

▪ Case history ▪ Medical and social history (surgeries, chronic diseases/disorders, medications), daily habits related to vocal hygiene ▪ Patient's complaints (symptoms) More Info: ▪ chronic diseases/disorders - someone who complains of hoarse voice, can't reach a certain pitch anymore - if the person has reflux and doesn't actually want to take medication, you can try to change the lifestyle/diet, but that's really all you can do ▪ highly acidic foods - tomatoes, fries, chocolate, alcohol ▪ you can tell the person to avoid those foods, eat maybe ¾ hours before you go to bed ▪ stay somewhat elevated while sleeping ▪ sleep on the left side

Inhalation (4 pts)

▪ Considered an active process accompanied by muscle contraction to increase thoracic cavity volume. ▪ Major inhalation muscles (diaphragm and external intercostals) routinely active for quiet inhalation (including speech). - the central tendon of diaphragm gets pulled downward which gives greater vertical dimensions of the thoracic cavity ▪ Accessory inhalation muscles may assist when a greater air intake is necessary. ****My notes: ▪ this is considered an active process bc the beginning starts with contraction of a muscle ▪ diaphragm separates thoracic and abdominal cavities ▪ when your lungs (thoracic cavity) get larger (volume) density goes down ▪ Diaphragm and external intercostals are MAJOR inhalation muscles bc they're very important for the expanding of the thoracic cavity - some people may rely on other accessory muscles (like people who breathe and raise their shoulders/tighten their neck) known as "shallow breathers"

Vocal Fold Granuloma - Symtoms (3 pts)

▪ Constant throat clearing ▪ vocal fatigue ▪ odynophagia reported

Vocal fold scar (3 pts)

▪ Dense collagenous scar tissues developed due to surgery, vocal trauma, burns, or inflammation ▪ Mass varies depending on the scar, the layer that is involved has increased stiffness ▪ Glottis often does not close completely during phonation More Info Kissing Nodules Video #1 ▪ potentially more jitter shimmer ▪ increased rate of glottal airflow Scarring ▪ scarring can actually affect deeper layers as well (lamina propria)

Sulcus vocalis (3 pts)

▪ Description: a dip or furrow along the upper, medial edge of the vocal folds ▪ Often considered part of an aged larynx, but a congenital sulcus seen in the young children ▪ The edge of the epithelium is bowed and sometimes thickened More Info: ▪ sulcus vocalis can be a type of condition that you may see that resulting from scarring ▪ a lot of time people may just simply describe the glottal shape as bowing of the vocal folds presbylarynx or presbylaryngis → "aged larynx" ▪ one of the typical features of aging is typically the bowing aspect of the larynx ▪ possible loss in range in terms of frequency and dynamic range as well (26:00) ▪ harmonics to noise ratio would potentially be going down

Spasmodic dysphonia

▪ Direct Botox injection into the vocal fold musculature

Direct approaches (Dworkin & Meleca, 1997) (2 pts)

▪ Direct manipulations of the respiratory/phontory/resonantory systems ▪ Muscle relaxation, breath support exercises, pitch adjustment, easy voice onset, biofeedback, mManual compression and stabilization, phonatory VF valving exercises

Vocal Fold Granuloma - Tension/stiffness (2 pts)

▪ Does not affect tension or stiffness of the cover ▪ if continued tissue damage affects the tissue attributes it may get stiffer ... you will see fibrosis (4:24)

Laryngomalacia - characteristics (4 pts)

▪ During inspiration, the epiglottis and the aryepiglottic folds collapse into the airway ▪ Results in a loud staccato repetitive crowing noise when the child inhales ▪ Breathing is easier when the child is prone (face down), but aggravated when recumbent ▪ Usually disappear between 12 and 18 months of age More Info: ▪ why is breathing easier when the baby is in the prone position - bc gravity pulls the epiglottis towards the front rather than towards the back

Does the patient have any associated symptoms or sensations? (14 pts)

▪ Dysphagia ▪ Heartburn ▪ Nasal regurgitation ▪ Gradual weakness of eyes, face, limbs ▪ General fatigue ▪ Excessive coughing* ▪ Slurred speech* ▪ Hypernasality* ▪ Runny nose* ▪ Sensation of a lump in the throat ▪ Odynophagia ▪ Throat pain ▪ Unexplained weight loss ▪ * observed by the clinician More Info ▪ if someone comes in with trouble in terms of swallowing: - aspiration could be a concern - some neurologic origin ▪ heartburn - reflux - can a patient with voice problems also have some heartburn issue? ▪ runny nose/nasal regurgitation - post nasal drip, excessive mucus ▪ slurred speech - dysarthria ▪ hypernasality can go with slurred speech - bc weak muscles for VP closure - nasal regurgitation = when food or liquids come out of the nose

Is thyrohyoid intrinsic or extrinsic? (2 pts)

▪ EXTRINSIC , but WHY?? - bc it doesn't have any function on the vocal fold behaviors

Chronic laryngitis (4 pts)

▪ Generally caused by irritants over time ▪ Description: long standing inflammation of the laryngeal mucosa, generally resulting from exposure to noxious agents, environmental agents, or abuse; can also result from purulent drainage from sinusitis ▪ Pathophysiology: increased stiffness in the cover, little effect on the mass ▪ Voice: roughness, hoarseness, lower pitch, often fatigue More Info: ▪ typically VFs become very strained, stiffness increases ▪ a lot of times when people have rough , hoarse voice, it's generally perceived as having lower pitch; HOWEVER, when you go to actually measure it, the fundamental frequency isn't actually that low

Increased tension/strain (5 pts)

▪ Edema and/or erythema without any presence of lesions ▪ Hard glottal attack ▪ High laryngeal position ▪ Excessive medial compression - may include ventricular phonation More Info: ▪ the first big item of misuse behavior is increased tension/strain ▪ you will often see some swelling/redness present in the VF region without having any identifiable legion ▪ increased tension/strain often result in using hard glottal attack - hard glottal attack= really loud onset ▪ you can already feel the tension before you actually let the sound go out ▪ before you begin phonation your VFs are slamming into each other ▪ you make a very excessive adductory gesture even before voice onset - an easy onset would be produced by combining an h sound followed by a vowel ▪ high laryngeal position - when you touch the neck you can feel the thyroid prominence go up when the larynx is elevated the length of the vocal tract is shorter - all the fromants would go up - vocal folds would be a lot stiffer ... fundamental frequency would go up too (19:00) - if you use extra adductory gesture that could also result in ventricular phonation

Strained and excessive use during a period of swelling, inflammation, or other tissue change (5 pts)

▪ Edema can result from infection, allergic reaction, or noxious environment agents ▪ Increased vulnerability of the mucosa can occur as a result of - Chronic sinusitis and gastroesophageal or laryngopharyngeal reflux - Dryness from drugs (e.g., decongestants) or excessive alcohol consumption - Dry heat in homes or buildings More Info: ▪ when you're using excessive voice on top of inflammation - like when you have some sort of sickness and you have to have prolonged use of voice ▪ there a variety of drugs that can affect the vocal fold tissue ▪ if a singer takes an aspirin which is a blood thinner, the vocal folds could bleed during their performance

Secondary Objectives (4 pts)

▪ Education and motivation of the patient - The more he understands, the more helpful the patient can be in communicating pertinent information and the greater the patient's motivation ▪ Establishment of the credibility and trust in the speech pathologist must occur early ▪ Casual but confident More Info: - the more the patient understands the more the patient would be motivated to implement strategies at home

Laryngeal Imaging (4 pts)

▪ Endoscopy "videolaryngoendoscopy" - flexible (through the nose) - Rigid (oral, provides better visuals) - often combined with stroboscopy "videolaryngostroboscopy" More info: (50:00 min) ▪ stroboscopy → flashing light so that we can slow down the motion of the vocal folds and so we can actually visualize the super fast motion of the vocal folds ▪ flexible scope is often used for the nasopharynx , but rigid scope can be used orally for better visuals of the larynx ▪ if you're just using endoscopy, without the strobe you can't appreciate individual vocal fold vibrations ▪ with the strobe unit on, you can really tell whether the folds are making a full closure, you can see the mucosal wave and appreciate individual vibratory cycle ▪ if the folds are closed you can also provide additional info about the glottal configuration ▪ posterior chink - a gap in the back of VF closure - a lot of females tend to have an open spot in the back of the vocal folds ... not uncommon ... not always pathological ▪ anterior chink - a gap towards the front of VF closure ▪ if there's a polyp in the middle, you will only see contact at the polyp, there will be an hourglass glottal configuration... a little gap and above and below the polyp

Is the problem constant or episodic? (6 pts)

▪ Episodic problems are more likely to be due to tension or psychological origin ▪ Is the person under any stress? - Family or personal relationships - Stress can trigger a neurologic problem as well as be indicative of a possible psychological origin - "Tell me about your family? Do you have a significant other in your life?" - Tell me about your job and the people you work with"

Respiration (3 pts)

▪ Exchange of Co2 for O2 ▪ Respiratory passage: Nasal/oral cavities, pharynx, larynx, trachea, bronchi, bronchioles, lungs ▪ Boyles Law: Thoracic volume and lung pressure inversely related

Control of the f_0 (fundamental frequency) within a given speaker: (3 pts)

▪ F_0 increases as the VFs are lengthened ▪ F_0 increases as VF tension increases ▪ F_0 decreases as the VF mass/area increases

False Vocal Folds (3 pts)

▪ False vocal folds = ventricular folds ▪ just above true VFs (same anterior and posterior attachments, but more superiolaterally) ▪ don't normally participate in phonation

Muscle tension dysphonia (4 pts)

▪ First described in 1990s (Morrison and Rammage, 1994) ▪ Variable voice disruption symptoms accompanied by observable tension of the neck, jaw, shoulders, and throat ▪ Pain commonly reported ▪ High incidence of concomitant psychosocial stress or other interpersonal conflicts More Info ▪ MTD = became more popular in mid 90s ▪ core symptom = extra tension in larynx ▪ in the example video you can see that even the arytenoids are moving extremely far forward

Medical/Surgical Treatments for Polyps (2 pts)

▪ Fresh and small polyps are first given a period of trial therapy, if no response, then surgery is appropriate ▪ With large or old polyps, surgery is followed by voice therapy More Info ▪ surgery can fix the problem and you will see immediate improvement of vocal quality BUT if the person doesn't immediately change their lifestyle pattern then the person will most likely develop the problem again

Acoustic measures of frequency: (6 pts)

▪ Fundamental frequency (f0) - Average speaking f0 - frequency variability (pitch SD) - (maximum) phonation range - frequency perturbation (jitter)* ----*norms vary depending on the method of how jitter is calculated

Structural anomalies: Laryngeal Webs (7 pts)

▪ Generally a congenital disorder ▪ Most are situated anteriorly, involving a variable length of the vocal fold; ▪ often thick and fibrotic ▪ may cause severe stridor and airway obstruction ▪ Can be supraglottic, glottic, subglottic - 75% are sited in the glottis, the remaining 25% at the levels above and below the glottis ▪ Can range from a small anterior web to complete glottal closure which is incompatible with life More Info: ▪ think about a baby that has this webbing - webbing that occurs towards the anterior region, they should still be able to breathe - if webbing covers the entire area, then that's not compatible with life - webbing can occur in any place around the larynx... a majority of the places usually on the vocal folds ▪ webbing is a particular condition ▪ stenosis - narrowing (this is more of a broader term) ▪ at birth sometimes webbing condition may not be detected, but as child gets older and their pitch doesn't descend this could be a possibility that they have anterior webbing too

Glottis (8 pts)

▪ Glottis = area between ▪ anterior 3/5 = membranous glottis (from the anterior commissure of VFs to the vocal processes of arytenoids ▪ posterior 2/5 = cartilaginous glottis (bounded by medial surfaces of arytenoids) ▪ at rest, width of the glottis b/w vocal processes equals about 8mm in the adult male; during forced inhalation, the width may be almost doubled - adduction = glottis closed - toward midline - abduction = glottis open - away from midline ▪ above = supraglottal ▪ below = subglottal My Notes: Glottis= The space between the two true vocal folds Question: the space between the TRUE vocal folds only, not also the FALSE vocal folds?

WHAT DO WE KNOW ABOUT THE VOCAL TRACT? (4 pts)

▪ HOW DOES THE VOICE GET LOUDER/SOFTER? ▪ HOW DOES THE SOUND GET BRIGHTER/DARKER? ▪ WHAT MAKES THE VOICE STRAINED/"OPEN"? ▪ WHAT MAKES A SOUND "FORWARD" VERSUS "BACK"?

Major symptoms of voice problems (9 pts)

▪ Hoarseness ▪ Vocal fatigue ▪ Breathy voice ▪ Reduced phonational range ▪ Aphonia ▪ Pitch breaks or inappropriately high pitch ▪ Strain/struggle voice ▪ Tremor ▪ Pain and other physical sensations More Info: ▪ symptom = a complaint that the patient has - they aren't going to come to the clinic and use these terms - they will use different terms but eventually what they describe will fit these terms ▪ signs = things that you can observe and test

Max Phonation Range (2 pts)

▪ How low can you go and how high can you go - a lot of clinicians just simply ask if they can go from their lowest to their highest.... a lot of people won't actually start at their lowest point

Principle behind EGG: (3 pts)

▪ Human tissue as a good conductor of electricity ▪ Pairs of electrodes placed externally on each side of the lamina of the thyroid cartilage ▪ A low level, high frequency electrical voltage is "sent" through" the neck

Voice therapy can be classified as: Hygenic

▪ Identification and subsequent elimination of poor vocal behaviors followed by the development of proper vocal behaviors

Acoustic signs of nodules include: (3 pts)

▪ Increased (↑) Jitter and shimmer, spectral noise ▪ Deceased (↓) Phonation range, dynamic range ▪ Little effect on f0 More Info ▪ all these signs are potential signs, not absolute signs that you would see every time a person has nodules ▪ nodules could be asymptomatic

Pathophysiology of polyps (2 pts)

▪ Increased (↑) VF mass ▪ Stiffness may vary

Voice Characteristics of structural anomalies (3 pts)

▪ Infant: hoarse, weak, or absent cry, sometimes difficulty breathing ▪ Older children: pitch is high and does not descend ▪ Can occur in the adult after vocal fold surgery, pitch is high

Holistic voice therapies (3 pts)

▪ Integrate all of the voice subsystems - respiration, phonation, and resonance ▪ Is a comprehensive approach ▪ May be applied to both hyperfunctional and hypofunctional disorders

Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V, Kempster et al., 2009)

▪ Intended to become a standardized protocol, useful to clinicians and researchers for best practices in assessing perceived abnormal vocal quality

Major Signs of Voice Problems (5 pts)

▪ Interrelated signs in the perceptual, acoustic, and physiologic domains ▪ Signs that can be assessed by an SLP fall into three categories - Perceptual signs - Acoustic signs - Physiologic signs More Info ▪ it's often difficult to find 1 to 1 correspondence ▪ the three domains are somewhat interconnected

Intrinsic muscles (2 pts)

▪ Intrinsic = both attachments in larynx - help to regulate the vocal folds

What is the most common neurologic problem from & why? (2 pts)

▪ LMN damage ▪ if you see a patient who had a thyroidectomy and you look in and see the right VF has stopped moving, this is a clear case of lower motor neuron lesion especially CN X recurrent damage

Thyroid Cartilage (5 pts)

▪ Largest cartilage of the larynx - anterior and lateral walls of the larynx ▪ Parts: - Thyroid laminae, thyroid notch, thyroid prominence (Adam's apple): more acute angle for males - Oblique line; inferiorly and medially on external surface of laminae, muscle insertion site - Superior horn (cornua), inferior horn (cornua)

Vibratory frequency of the VFs is determined by: (3 pts)

▪ Length - Greater length = higher frequency ▪ Tension - Greater tension = higher frequency ▪ Mass/area - Greater mass = lower frequency

Medical/Surgical Treatments for Nodules (2 pts)

▪ Limited need for surgery because nodules in children generally disappear by the end of adolescence ▪ In adults they respond to behavior modification unless they are old nodules

Larynx (4 pts)

▪ Located between trachea and pharynx anterior to esophagus; cartilage calcifies with age ▪ Biologic function (bidirectional valving) - Prevent foreign objects from entering lungs (cough reflex), important during swallowing - Prevent air from escaping the lungs (to stabilize torso for lifting heavy objects)

Loudness (5 pts)

▪ Loudness = perceptual correlate of intensity ▪ Vocal intensity strongly related to subglottal air pressure ▪ Control of subglottal pressure - Increase exhalatory muscle force - Increase laryngeal adductory muscle force

Cricothyroid (2 pts)

▪ Main muscle for pitch control; raises pitch by rocking the cricoid upward or thyroid downward, resulting in a stretched and elongated vocal folds - vertical part more towards thyroid prominence, oblique part more towards thyroid angle

Abdominal muscles (5 pts)

▪ Major exhalation muscles - rectus abdominis - external oblique abdominis - internal oblique abdominis (deep to external oblique) - transverse abdominis (Deepest) **See image

How can you make a hygienic goal? (5 pts)

▪ Make a goal about water intake ▪ Monitor loudness control ▪ Maybe have them rate perception of their use ▪ can count their frequency of throat clearing behavior within a session ▪ have them keep a log, educate them so that they know the importance →

s/z ratio (Boone & McFarlane, 1988)

▪ Maximum sustained time of /s/ divided by the maximum sustained phonation time of /z/ - normal: the ratio approximates 1 - pathologic conditions > 1.4 More info: ▪ s/z ratio was widely used into the late 90s ▪ initial assumption → think about the production of s and z.... one is voiced , one is voiceless - if someone has any vocal pathology, maybe they will not be able to produce the z sound correctly ▪ this was countered because /z/ is often produced louder than /s/ - it was originally thought that voicing was the only difference - the initial idea was not really supported by later subsequent studies ▪ this might still be an OK ratio for comparing people with vocal pathology to normal patients - they MAY have excessively high value compared to the normal group ▪ it's OK... BUT the value assigned to this measure still needs to be further studied - this 1.4 would be a very gross number - for example, if someone has 1.2 , this person still may exhibit a low ratio?

Ankylosis of the cricoarytenoid joint (3 pts)

▪ May be a result of arthritis or other joint disease or trauma ▪ Patient may complain of pain on swallowing or talking which helps to differentiate it from vocal fold paralysis ▪ Voice symptoms: hoarseness More Info ankylosis - fixation

Neurogenic dysphonia:

▪ May need to target "functionally" useful voices More Info - how motivated are the patients to fix their vocal use ?

N2: (3 pts)

▪ Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6cm in greatest dimension ▪ or in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension ▪ or in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension

Pitch and Musical Scale - Middle C (3 pts)

▪ Middle C = C4 ▪ beginning of the 4th octave ▪ C4 = 261.63 Hz

Slow onsets are generally associated with (6 pts)

▪ Misuse or abuse ▪ Neurologic causes often with coexisting signs such as - Dysphagia - Nasal regurgitation - Hypernasality - Gradual weakness of the eyes, face, limbs, general fatigue, slurred speech

Voice therapy can be classified as: Symptomatic

▪ Modification and correction of vocal, respiratory, and resonance symptoms would lead to improvement in the voice condition

Hypokinetic (extrapyramidal tract: Parkinson's disease) (5 pts)

▪ Monopitch ▪ monoloudness ▪ hypernasality ▪ weak phonation ▪ limited vocal endurance

Problems can be of adductor type or abductor type ( 3 pts)

▪ Most common type: unilateral adductory paralysis ▪ Most common causes of PNS paralysis are trauma and surgical injury during thyroidectomy ▪ Approximately 1/3 are of unknown origin and may be due to a virus More Info: ▪ exam question: two endoscopic images, then you will be asked what went wrong Video ▪ left side arytenoid is stuck in medial position ▪ there is a difference in VF thickness, the paralyzed side probably already went through atrophy Video #2 ▪ It's hard to distinguish if it's completely stuck adducted or abducted ▪ Right side unilateral ADDuctor = bc the person cannot phonate - the consequences here are really affecting phonatory gesture not breathing - ADDuctor is the most common - if you want to call it ABductor, you will want to identify that it's completely in the midline and affects breathing more

How are musical scales organized? (6 pts)

▪ Musical scales organized into octaves. - An octave increase: frequency ratio of 2 to 1 ▪ An octave has 6 tones (5 full- and 2 semi-tones) with 8 notes. - A tone increase: frequency ratio of 1.122 to 1 ▪ Each tone is divided into 2 semi-tones. - A semi-tone increase: frequency ratio of 1.059 to 1

What does "Myo" mean? (5 pts)

▪ Myo = muscle ▪ when you're breathing in and out folds need to be open ▪ PCA needs to be activated so folds can stay open ▪ in order for the vocal folds to begin vibration adductor muscles need to be on - TA, IA, LCA, sometimes CT

NARROWING/TWANG: CLINICAL SIGNIFICANCE (9 pts)

▪ NOT TO BE CONFUSED WITH "NASAL" ▪ INCREASES LOUDNESS BY MODIFYING SHAPE OF THE VOCAL TRACT, NOT NECESSARILY BY INCREASING RESPIRATORY EFFORT OR ACTIVE TVF ADDUCTION - ACOUSTIC EFFICIENCY IN UPPER FREQUENCIES ▪ NON-LINEAR THEORY OF VOICE PRODUCTION - HAVE A POSSIBLE "THICKENING EFFECT" ON TVFS TO ENCOURAGE CLOSURE! - WHAT PATIENTS MIGHT NEED THIS? - CAN ALSO ENCOURAGE UNDESIRABLE FVF ACTIVITY ▪ "TWANG THERAPY" AND ITS CLINICAL BENEFITS FOR VOICE HAVE BEEN REPORTED (LOMBARD & STEINHAUER, 2007) ▪ DOES TWANG HELP SWALLOWING? - THE PHYSIOLOGY IS SOMEWHAT SIMILAR TO THE EFFORTFUL PITCH GLIDE (MILORO ET AL, 2014) More info: ▪ nasality is different from ring or twang ▪ anecdotally: people who have swallowing difficulties often can't twang

Advantages of EGG: (4 pts)

▪ Non-invasive ▪ good for measuring f0 ▪ visual feedback ▪ direct information concerning the closed portion of the VF cycle

Voice registers: 3 registers generally recognized in speech literature (3 pts)

▪ Normal = modal ▪ Falsetto (higher than normal); VFs tightly in back, no posterior vibration; extremely contracted vocalis ▪ Vocal fry, glottal fry, pulse register (lower than normal); very slow cycles/sec

CN X (Vagus) - Sensory (7 pts)

▪ One branch of sensory = Taste from epiglottis ▪ Another branch - general sensation ▪ Under "General sensation" ▪ [PB]: mucosa of superior and middle pharyngeal constrictors, levator veli palatini ▪ [SLIB]: mucosa of laryngopharynx (especially above the VFs) ▪ [RLB]: mucosa of esophagus, inferior pharyngeal constrictor (below the VFs) ▪ [EB]: mucosa of esophagus More Info ▪ if someone has a brain injury in the head typically it's not JUST affecting the vagus nerve, especially 9,10, and 11 bc they all run through this cranial foramen all together ▪ when we picture cranial nerves think about it going from the brain stem down to the muscle level

Posterior Cricoarytenoid (PCA) (2 pts)

▪ Only intrinsic abductor ▪ Upon contraction, the muscular process pulled posteriorly, and thus opening the VFs

Sources of referral (6 pts)

▪ Otolaryngologists (ENTs) ▪ Neurologists ▪ Family physicians ▪ Other SLPs ▪ Teachers ▪ The patient More Info: ▪ if the patient was referred by ENT, you would typically have access to the imaging - what would your role be: - behavioral components (misuse/abuse) - if someone was actually referred by neurologist, they would probably also have seen the ENT ▪ other SLPs who do not do specialties in the voice area may make referrals ▪ in any case, you definitely want to work closely with the ENT ... ▪ laryngeal exam needs to be done before you begin any type of treatment

Papilloma - characteristics (3 pts)

▪ Pathophysiology: increased mass, increased stiffness ▪ Voice: hoarseness is the most common; can also result in aphonia and in dyspnea and stridor ▪ Speech therapy of little effect; may help with producing best voice during periods of remission More Info HPV Video ▪ the presence of the wart actually obstructs closure in the middle ▪ repeated surgery can potentially damage the vocal folds Case #67 ▪ diagnosis: infectious laryngitis ▪ breathy ▪ roughness ▪ strained (not as high) ▪ loudness limited ▪ intermittent aphonia - lots of phonation breaks ▪ MPT - decreased ▪ harmonics to noise ratio decreased? dynamic range limited

Indirect approaches (2 pts)

▪ Patient education and counseling ▪ Short course, vocal hygiene education, logging pt's responses to therapy, involvement of family members, diet modification, etc.

Auditory-Perceptual signs (6 pts)

▪ Perceptual characteristics are considered to be subjective, but some can be assessed through certain scaling techniques (CAPE-V and GRBAS) ▪ Characteristics that are perceived by the listener - pitch - loudness - vocal quality - non-phonatory behaviors More Info ▪ signs are something that you can test/pbserve ▪ perceptual seems at least to some extent subjective

How do we make perceptual signs a bit more objective? (13 pts)

▪ Perceptual rating CAPE-C and GRBAS - with CAPE-V you're using a rating scale of 100 - if someone experiences sudden pitch breaks or maybe voice cracks that could indicate some loss of neurological control ▪ we can also think about underlying problems that explain loudness - some people have excessive loudness, some people who may have too quiet of a voice - too quiet could be someone who doesn't have a good air support, maybe someone who has vocal fold paralysis ▪ with paralysis it could be breathy, it may be aphonic (not able to hear the voice) ▪ what if someone's vocal fold is paralyzed straight on in the middle ? - the muscle is going to lose it's tone when it's paralyzed - atrophy is very common - the tissue health itself is going to be compromised the person will be able to phonate but the quality may not be as good/normal ▪ when someone's vocal fold is paralyzed in the open position, this person's biggest issue is going to swallowing - this will put the person at a higher risk of aspiration (20:44)

Excessive prolonged loudness (3 pts)

▪ Persons who habitually use a loud voice or react with loud voice use ▪ Those who have to talk above a noisy background ▪ Professional voice users such as auctioneers, aerobics instructors, coaches, preachers, teachers, actors, singers, etc. More Info: ▪ factory workers are also professional voice users

GERD (2 pts)

▪ Pharmacologic as the first line tx ▪ Voice therapy with a modified diet recommended

Site of lesion affects the extent of impairment (3 pts)

▪ Pharyngeal - Affects the ability to eat safely ▪ SLN - Affects sensation of the larynx and the CT ▪ RLN - All intrinsic muscles of the larynx except CT More Info: ▪ Glottal closure? - Status of the paralyzed VF? - especially tone, atrophy, etc.

Ankylosis of the cricoarytenoid - characteristics (4 pts)

▪ Physiologic signs would depend on whether it is unilateral or bilateral and in what position the folds are fixed ▪ With vocal fold paralysis, the muscle is affected, that is not the case with ankylosis (EMG can differentiate) ▪ With ankylosis resulting from arthritis, edema and erythema can be present on the folds ▪ Speech therapy of no use, the patient needs surgery

Disadvantages of EGG: (3 pts)

▪ Placement is critical and easiest for thin necks with prominent thyroid angles - Anything b/w the electrodes affecting impedance can influence the EGG signal (e.g., contraction of the extrinsic laryngeal muscles) ▪ Less information on the open phase of VF vibration

Normal Voice (4 pts)

▪ Pleasant quality ▪ Adequate pitch level based on age and sex ▪ Appropriate loudness for environment ▪ Adequate flexibility My Notes: - unpleasant voice quality is probably not very uncommon for younger boys

Performing a diagnostic voice evaluation (9 pts)

▪ Primary objectives ▪ To discover the etiological factors specific to the development of the voice problem (e.g., the cause) ▪ Use our knowledge of - Laryngeal anatomy and physiology - Pathologies of the laryngeal mechanism - Common etiologic factors -> Do this in a systematic fashion in order to determine the specific causes ▪ To describe the present vocal properties ▪ To develop an individualized management program

LSVT Loud (2 pts)

▪ Psychogenic as well as symptomatic ? - because it focuses on the person's thoughts but also their symptoms

Adductor spasmodic dysphonia (6 pts)

▪ Quick hyperadduction of folds ▪ Strained strangled quality ▪ Squeezing, choking sounds, tension ▪ Voice stoppages/interruptions especially for vowel productions ▪ Pitch and loudness variations ▪ Non-communicative vocalization often not affected More Info ▪ these patients actually go through years of searches trying to figure out what's wrong with their voice ▪ dystonia = involuntary movement disorder ▪ spasmodic dysphonia is actually induced by speaking (task-specific) - so when these individuals are singing , they might sound a lot better - when they try to use a pitch level that's very unusual for them, they sound a lot better ▪ abductor type spasmodic dysphonia = common feature is breathy ▪ adductor type = the most prominent feature that you will hear is strained/strangled quality

Sections to include (11 pts)

▪ Test Results and Observations: - Oral-peripheral Examination - Hearing Screening / Speech-Language Screening - Perceptual Voice Analysis ▪ Report what scale you used, speech sample that was assessed (vowel prolongation, sentence, conversation, etc) ▪ Consensus Auditory-Perceptual Evaluation of Voice ▪ Report your rating for each major section ▪ Acoustic Voice Analysis - Report the use of instrumentation such as PRAAT ▪ Physiologic Voice Analysis - Aerodynamic features, muscle activity, imaging More Info - if there's a hearing issue then they might not be able to hear feedback of their own voice

Intracordal cysts (3 pts)

▪ small spheres on the margins of the vocal folds within the lamina propria ▪ caused by a blockage of a glandular duct with retention of mucus ▪ typically requires surgical removal More Info: ▪ hard to determine cysts from polyps just visually ▪ not a lot of data with a strong consensus about the perceptual/acoustic/physiological characteristics - potentially if the growth is big enough it could block complete closure which will cause breathiness

Polyps (8 pts) - what are polyps caused by? (2 pts)

▪ Reddish or whitish, large or small and described as one of four types ▪ Pedunculated - Attached by a thin stalk of tissue ▪ Sessile - Well attached to a portion of the mucosa ▪ Hemorrhagic - Look like a blood blister ▪ Polypoid degeneration / Reinke's edema: - Covering at least half of a vocal fold - Usually around the vocal edge at the middle of the membranous fold - In the superficial layer ▪ polyps are caused by constant irritation of the VF region ▪ they are structural changes secondary to misuse/abuse More Info: ▪ polyp is typically more vascular, more inflammatory and larger than nodules ▪ often times they can develop unilaterally ▪ how would it affect the vibratory gesture? - may potentially interfere with the complete vocal folds - increased volume rate of airflow - in terms of VF closure time, closure time would probably be decreased - potentially harmonics to noise ratio would go down - depending on how large/stiff the legion is they might not be able to build up sufficient subglottal air pressure - acoustically it may cause increased jitter and shimmer - max phonation time might be shorter because more air is coming out and you have larger amount of wasted air - you would hear breathiness, possibly pitch lowering if the mass is really big, roughness, loudness might be reduced if the person experiences difficulties building up subglottal air pressure ▪ Rainke's Edema - affects the entire length of the VFs - the superficial layer of the lamina propria (also known as Reinke's space) (35:00)

Vocal rehabilitation (3 pts)

▪ Requires a full understanding of the anatomy and physiology of the phonatory and respiratory systems ▪ Accurate diagnosis critical to treatment planning ▪ With knowledge comes the ability to take responsibility for making changes More Info ▪ Drug induced won't be on the exam ▪ First ⅓ of exam will be released at 8:00 am on friday ! ▪ Student presentations will be on the exam ▪ slightly over ~30 questions ▪ some multiple choice, some short answer, some fill-in the blank ▪ most of the written part will be on our early-released exam ▪ really wants core content only for when it asks you to LIST

In Summary (lecture 1): (2 pts)

▪ Respiratory system - power source ▪ Phonatory system - sound source

NARROWING/"TWANG" SUMMARY (7 pts)

▪ SOME AUTHORS SUPPORT "PHARYNGEAL NARROWING" - ECHTERNACH ET AL, 2014 - THIS ACTUALLY GOES AS FAR BACK AT 1930 ▪ SOME AUTHORS SUPPORT "ARYEPIGLOTTIC NARROWING" - YANAGISAWA ET AL, 1989 ▪ MOST AUTHORS DISCUSS "EPILARYNGEAL NARROWING" - DÖLLINGER ET AL, 2006; SAMLAN & KREIMAN, 2014

Can the patient rate the severity of his problem? (3 pts)

▪ Scale of 1-5 or by comparing to an audiotape of different severities ▪ Does the patient have any other symptoms or problems that are annoying to him/her or causing any distress ▪ Listen, listen, listen and watch the patient throughout the interview

Scoring (3 pts)

▪ Score on the CAPE-V form after the client performs all the tasks. ▪ When a discrepancy in performance across tasks is noted, multiple tick marks can be used to label different tasks. ▪ Measure ratings from each scale; use both mm measures and descriptive labels

Laryngeal framework (5 pts)

▪ Several cartilages, membranes, and one bone - Major cartilages of the larynx: thyroid, cricoid, and arytenoids - Other cartilages: corniculates and cuneiforms ▪ Intrinsic laryngeal muscles ▪ Internal surfaces of the larynx

Cricoid Cartilage (2 pts)

▪ Sits on top of the trachea ▪ Articulates with arytenoids on the posterolateral surfaces (purple part on image)

Acoustic measures of amplitude (3 pts)

▪ Sound pressure level ▪ amplitude perturbation (shimmer)* - *norms vary depending on the method of how shimmer is calculated

Major laryngeal depressors (3 pts)

▪ Sternothyroid ▪ Sternohyoid ▪ Omohyoid

Functional voice problems:

▪ Success in therapy depends on patients' efforts (e.g., adopting coordinated efforts to modify stress factors and adjusting their lifestyles)

Hyoid Bone (8 pts)

▪ Supports the root of the tongue as well as the larynx ▪ Free floating, not attached to any other bone ▪ Horseshoe-shaped ▪ approximately at the level of C3 ▪ Parts - Central body (corpus) - Posteriorly/laterally directed greater horns (cornua) - Superiorly directed lesser horns (cornua)

For abnormal growths or lesions including large, fibrotic nodules, polyps, cysts, granulomas, webs, papillomas, etc., (3 pts)

▪ Surgical removal necessary prior to behavioral therapy program ▪ Behavioral therapy usually begins 2 wks postoperatively ▪ Recurrence of pathologic conditions often occurs: significant improvements with good surgical results are short-lived with pts having functional problems

Facilitating Techniques

▪ Symptomatic → these focus on the changing the symptoms rather than the underlying physiology

Classification of glottal tumors (3 pts)

▪ T refers to the site of the primary tumor ▪ N refers to the involvement of lymph nodes ▪ M to the spread to other parts of the body (metastasis) More Info ▪ if a tumor grows below the region of the glottis, potentially breathing would be the primary concern ▪ if a tumor grows above the region of the glottis this could potentially affect swallowing and resonance factors

ACTIVITIES THAT AFFECT SUPRAGLOTTIC ACTIVITY (9 pts)

▪ TIGHT BREATH HOLD VS LIGHT BREATH HOLD ▪ PUSHING/LIFTING - "PULL UP ON YOUR CHAIR AND VOCALIZE" ▪ SEMI-OCCLUDED VOCAL TRACT (SOVT) TASKS - HUMMING/RESONANT VOICE THERAPY (RVT) - STRAW PHONATION - LAX VOX (STRAW IN WATER) - VOICED CONTINUANTS V, Z, ETC - LIP TRILL

Essential Tremor - Characteristics (6 pts)

▪ Tends to run in families ▪ Occurs more frequently with advanced age ▪ Mean of onset has been reported at 48 and 57 years for men ▪ Voice: tremor, strained strangled quality ▪ Acoustic signs: variation in intensity and frequency ▪ Low frequency tremor More Info: ▪ essential tremor = organic tremor ▪ how would you reduce the involuntary spasm ? ▪ botox injection in the VF - it can potentially/temporarily reduce the movement - it temporarily kills the muscle function ▪ in adductor spasmodic dysphonia, one of the adductor muscles would receive the injection ▪ in Abductor SD the PCA would receive an injection

LMN Impairment (5 pts)

▪ e.g., myasthenia gravis ▪ Flaccid dysarthria ▪ VF hypoadduction ▪ weak, breathy voice ▪ hypernasality/nasal air emission

Hirano Body-Cover Theory (1974): (6 pts)

▪ The cover and transition slide over body producing a mucosal wavelike progression ▪ Three-mass model including cover, lamina propria, and body - Anatomically demonstrated the vocal fold structures - Different properties of the layers differentially contribute to the vocal fold vibrations!! ▪ remember: body = vocalis muscle ▪ the mucosal layer (or cover) is what participates in vibration More Info: ▪ the vocalis is the main muscle (body) , the rest of the mucosal layer is called the cover - you might have heard the "mucosal wave" because you can actually see it waving during phonation ▪ The image is the patient's left vocal fold - the most superficial layer is the epithelial layer - the deepest layer is the muscle (body) - between these two layers is a connective tissue later (lamina propria) ▪ the mucosal layer has multiple components

VFs opening and closing regulated by: (4 pts)

▪ The degree of tension in the VFs (myoelastic) ▪ Aerodynamic events (aerodynamic) ▪ Bernoulli effect: increased velocity of air molecules generates negative air pressure. ▪ Positive pressure below the VFs: open the VFs to repeat the vibratory cycles.

How does the hyoid bone move during swallows? (2 pts)

▪ The hyoid bone moves forward and up in every single swallow - the "sandwich/GMA" muscles under the chin help to accomplish this

Maximum phonation time (MPT)

▪ The maximum time a subject can sustain a tone on one breath ▪ males--about 20 seconds ▪ females--about 15 seconds ▪ children--about 10 seconds - differential diagnosis must be performed before therapy can begin more info: ▪ think about what should be considered as ok ranges ▪ let's say someone came into clinic and wasn't able to sustain longer than 5 seconds? - why would this happen? - excessively short max phonation times indicates two things: 1.) maybe the person has insufficient breath support 2.) valving is not really effective (too much air escaping at the larynx) ▪ if there is incomplete closure at the level of the vocal folds, there will be wasted air that will shorten the MPT

Laryngomalacia (3 pts)

▪ The most common congenital laryngeal disorder ▪ Caused by an immature development of cartilaginous structures of the larynx ▪ this is an omega shaped epiglottis http://www.youtube.com/watch?v=DIA2YCn_CSI More Info: ▪ what structure is in the picture? ▪ because this is due to immature develop, a lot of time typically babies actually grow out of this condition ▪ aryepiglottic folds are collapsing (58:00) ▪ aryepiglottic folds are located superiorly to the false vocal folds

Lower Motor Neuron (LMN) (2 pts)

▪ The motor pathways that begin at the brainstem or spinal cord and terminates at the neuromuscular junction (connecting CNS with PNS) ▪ Cranial Nerves V, VII, IX, X, XI, & XII

Clinical Examination (2 pts)

▪ There is absolutely no separation between history taking and the initial stage of voice exam ▪ Listen to the voice while interviewing the patient

Major laryngeal elevators (6 pts)

▪ These muscles are important for swallowing: - Digastric (anterior belly & posterior belly) - Mylohyoid - Geniohyoid - Stylohyoid - Thyrohyoid

Laryngeal musculature: Extrinsic muscles (5 pts)

▪ These muscles position the entire larynx. - upon contraction of an extrinsic muscle that is situated higher, the larynx will be pulled upward ... - if there's a contraction b/w an extrinsic muscle that is lower (like from the chest)... the larynx will be pulled downward ▪ Important for swallowing. ▪ May also be important for singing, especially to lower the larynx and thus to enlarge the lower pharyngeal cavity My notes: ▪ when you sing, your larynx goes up when you actually elevate your pitch (but probably not for a trained singer)

Goals of voice therapy (3 pts)

▪ To identify and eliminate behaviors that constitute misuse or abuse and to replace them with acceptable patterns of voice production ▪ To restore the mucosa to a healthy condition ▪ To regain clear and full vocal function More Info ▪ this probably works best for patients who have disordered vocal use ▪ is it really going to be a good goal for patients who have compromised VF function

4 different views

▪ Top left = PCA ▪ Top right = Thyroarytenoid - vocalis is medial - muscularis is lateral portion - another adductor ▪ bottom left you can see LCA contracting and brining vocal processes to midline ▪ bottom right = interarytenoid muscle

Sections to include (5 pts)

▪ Top of page: include where eval was done, name of patient, address, phone, who made referral, date of evaluation, DOB, Age ▪ Statement of problem: - Name of client, age, and why they are being seen. - What are their complaints - Do they have any diagnoses already made?

Aphonia or dysphonia of psychological origin (2 pts)

▪ Total aphonia / dysphonia with episodic bursts of explosive vocalization (hard attack) alternating with extreme hoarseness / dysphonia with hyperadducted vocal folds (possibly the false vocal folds involved as well) ▪ SLPs may be the ones who first identify a possible psychological cause but are not the ones to treat the patient - refer to the appropriate source More Info ▪ Considered functional ▪ can have someone with conversion dysphonia - sounded like spasmodic dysphonia - a lot of time conversion disorders occur with some disturbance of emotional anxiety/stress ▪ if the etiology is not due to any abnormal structures then the next step is probably to refer them on to the next specialist - look at anatomy and consult with neurologist - this is often the last conclusion after going through all of the other diagnoses ▪ this is an unconsciously developed behavior

Reinke's edema

▪ Treated with surgery and counseling to eliminate smoking or exposure to other environmental unpleasantness.

Thyroarytenoid (TA) (8 pts)

▪ Two parts ▪ Vocalis: medial portion - origin: thyroid, insertion: arytenoid/vocal ligament - main mass of VFs - upon contraction, it tenses the VFs (may raise pitch) ▪ Thyromuscularis: lateral portion - origin: thyroid, insertion: arytenoid (muscular process) - Probably pulls arytenoids toward thyroid angle (anteriorly) to shorten VFs

Vestibule

▪ entrance to larynx from above; i.e., area immediately above false VFs

Vibratory Cycle- subglottal air pressure builds up (2 pts)

▪ eventually the folds are blown apart (the glottis need not be completely closed for this to occur) mainly laterally somewhat superiorly ▪ This releases a puff of air into the pharynx

Primary Tumor (T) (3 pts)

▪ Tx: Primary tumor cannot be assessed ▪ T0: No evidence of primary tumor ▪ Tis: Carcinoma in situ - carcinoma is still in the primary location where it began More Info: ▪ what would be the case if the tumor could not be assessed? ▪ what's the difference between tx and t0? - tx case: a patient came into the clinic and some abnormal tissue was found. - doctor ordered a biopsy and the type of cancer cell was not really a common type of cancer that occurs in the larynx - there are certain types of organs, where certain types of cancer grow - maybe it was actually spread from cancer that originated in a different place - the patient would actually be sent to an imaging or radiology suite to get an entire PET scan ▪ Tis: (check 24:00)

Upper Motor Neruon (UMN)

▪ UMN function begins at the cerebral cortex and ends in the brainstem or spinal cord (within CNS)

Principles of EMG (3 pts)

▪ Used to study muscle contraction ▪ Used to investigate respiration, phonation, and articulation - activities underlying movements ▪ Provides information about muscular forces by recording muscle action potentials (the electrical activity that accompanies each muscle contraction) More info: ▪ surface EMG and inserted EMG ▪ inserted EMG is actually positioned with a needle that goes into the skin - among the three physiological signs including aerodynamic, vf motion, and muscle activity, probably muscle activity would be less frequently done clinically ▪ when one vf doesn't move, it's not always paralysis - this could be someone who has a joint problem at the CT joint... this could be due to something like rheumatoid arthritis - if there IS muscle activity on the EMG it might be a joint issue - if there is NO muscle activity, then it's probably paralysis

Carcinoma - characteristics (4 pts)

▪ Usually impedes closure ▪ Mass and stiffness increase in the cover ▪ The mass and stiffness of the body increase when the tumor invades the muscle ▪ Vibratory pattern affected

THE LARYNX AS A SERIES OF VALVES: (5 pts)

▪ VALVE 1 - TRUE VOCAL FOLDS ▪ VALVE 2 - FALSE VOCAL FOLDS ▪ VALVE 3 - ARYEPIGLOTTIC REGION ▪ WHAT BIOLOGICAL FUNCTIONS ARE ASSOCIATED WITH THE LARYNX? ▪ WHAT VALVING ACTIONS ARE IDEAL FOR VOICE VERSUS SWALLOWING? More Info ▪ True vocal folds ▪ false vocal folds ▪ aryepiglottic folds ▪ breathing and swallowing are the two most important biological functions ▪ the whole vocal tract is designed to shut and close

Vibratory Cycle - VFs at rest vs. phonation (4 pts)

▪ VFs abducted during rest breathing ▪ The arytenoids are brought together by the adductor muscles (any or all of the intrinsics except the PCA) in preparation for phonation - VFs are thereby adducted - The arytenoids held firmly together

Glottal tone initiation (3 pts)

▪ VFs approximation in the phonatory position ▪ VFs properly tensed and elongated ▪ Airflow supply from the lungs

Vocal fold vibratory behavior (5 pts)

▪ VFs difficult to assess - Located inside the neck - Location is dark - Rapid vibration ▪ Laryngeal imaging allows for visualization of the vocal folds

NON-LINEAR THEORY OF VOICE PRODUCTION ( 7 pts)

▪ VOICE IS PRODUCED VIA AERODYNAMIC AND ACOUSTIC POWER ▪ THE LARYNX CONVERTS AERODYNAMIC POWER (I.E. AIR FROM THE LUNGS) TO ACOUSTIC POWER (I.E. VOICE QUALITY) VIA VOCAL FOLD VIBRATIONS ▪ SOME SOUNDS ARE PRODUCED IN A LINEAR FASHION - I.E. FIRMLY ADDUCTED VOCAL FOLDS AND A WIDE EPILARYNX (LARYNGEAL VESTIBULE REGION) - SOUND IS ONLY DETERMINED BY AERODYNAMICS WITHOUT INFLUENCE FROM THE UPPER VOCAL TRACT ▪ IN NON-LINEAR PRODUCTIONS, THE SHAPE OF THE EPILARYNX AND VOCAL TRACT CHANGE TO MATCH THE LEVEL OF RESISTANCE AT THE VOCAL FOLDS - THIS IS ACCOMPLISHED BY CHANGING THE DEGREE OF VOCAL FOLD ADDUCTION More Info ▪ your voice is organized into respiratory system (aka power) ▪ vibration in larynx is phonation (source) ▪ shape and size of your vocal tract = resonance (filter) ▪ Nonlinear voice means that if you change something in your filter (length of tongue, narrowing of mouth) that can then have a downstream effect on what the vocal folds are doing ▪ it's important to listen to their voice bc it clue you in that they're going to have some trouble swallowing - like someone who has a paralyzed VF ▪ /IIIIII/ is glottal onset vs. /HIHIHIHI/ aspirate onset? (check 14:00)

Ventricle (3 pts)

▪ Ventricle = ventricular sinus = ventricle of morgagni ▪ groove b/w the true and false folds. ▪ Channel for the flow of mucous to lubricate the folds

Bony Framework supporting the respiratory mechanism: (4 pts)

▪ Vertebral column - supports the trunk and head ▪ Rib cage - cases the lungs ▪ Pectoral girdle - contains lots of accessory muscles for breathing ▪ Pelvic girdle - serves as a floor for abdominal content

Recurrent laryngeal nerve (3 pts)

▪ Vital to the abductory-adductory function of the larynx ▪ Innervates the epiglottis and all intrinsic laryngeal muscles except for the CT ▪ sensory info assigned for the recurrent is anything BELOW the level of the true VFs More Info ▪ this is probably the most important branch bc it has to do with AB and ADduction ▪ it innervates ALL the ab and adductor muscles (except CT) ▪ subglottic region and sensation would be primarily done by this recurrent laryngeal nerve ▪ interarytenoid (IA), thyroarytenoid (TA) , LCA, PCA

Provides (4 pts)

▪ Vocal hygiene ▪ Counseling, emotional support ▪ Attention to vocal symptoms ▪ And direct physical exercise through manipulation of respiration, phonation, and resonance

Voice Mutations (3 pts)

▪ Voice change due to rapid growth of the larynx during puberty - Usually an octave decrease in males - Usually 2-3 tone decreases in females

The relationships between the signs (2 pts)

▪ Voice signs are not independent of one another ▪ Movement of the vocal folds (physiology) creates pressure disturbances in the air (acoustics) that are received by the ear and processed (perception). More info: - look at sample voice eval on carmen for examples of similar case studies to exam - 32-45 cm H2O/l/s is considered normal

HOW MANY PAIRS OF MUSCLES ADDUCT THE FOLD FOLDS? (12 pts)

▪ WHAT ARE THEY? ▪ HOW COULD THIS AFFECT CLOSURE? ▪ the VFs are white bc there is mucosa over it ▪ Three Adductor Muscles - Thyroarytenoid - lateral cricoarytenoid - Interarytenoid ▪ picture on the far right is clapping (thick) ▪ the one in the middle would be like putting the sides of your hands together facing down (thin) ▪ the far left would be like barely touching your hands together, palms facing down (stiff) ▪ the one on the far right is better to do with the one on the right (thick) - easier to do high pitch with the one's on the left

Excessive coughing, throat clearing (7 pts)

▪ We normally cough in response to - A local irritation - An infection - To guard the airway from the entry of foreign objects - To expel an unwanted object that may have entered the airway - To remove a collection of mucus on the folds ▪ Throat clearing and coughing are violent reactions More Info ▪ true and false VFs crash together during a cough/throat clearing ▪ silent cough has an "h" sound ▪ For pateitns who have dysphonia, typically silent cough is not very satisfying - when you need to cough it's because you want to get stuff out of your throat ▪ hard/dry swallow followed by water may help? (55:00) ▪ when you cough, persistent coughing actually makes your larynx more vulnerable/sensitive to any type of small irritants

Identification of patient's needs that require other forms of attention and appropriate referral (2 pts)

▪ When voice therapy is the secondary (adjunct) treatment modality ▪ Depends upon the health and laryngeal condition of each patient

Identification and elimination of all abusive behavior

▪ When voice therapy is the treatment modality of choice and there are mucosal and vocal changes

Vocal abuse while observing or participating in a sporting event or performing heavy labor (3 pts)

▪ Whenever it is necessary to build up thoracic pressure, it is necessary to effortfully close off the glottis ▪ Weight lifting, aerobics instruction, heavy labor ▪ Cheering at ball games, time spent at loud parties, etc. (not necessary to be effortful, but our patients often are)

Vocal nodules (5 pts)

▪ White, tiny bumps, usually bilateral, made up of edematous tissue and/or collagenous fibers - Site of lesion: middle or front 1/3 of the membranous fold and usually bilateral - Shape: usually round - typically nodules are in the epithelial layer, with some edema - when they become older they become very fibrous and be hard to remove More Info: ▪ typically nodules develop in the anterior ⅓ or ½ of the membranous VFs - maybe a little bit of an irregular edge can be the beginning of a nodule formation

Vibratory pattern with increased intensity (3 pts)

▪ With increased intensity, closure duration is longer (i.e., open quotient is shorter) ▪ Produces shorter pulses of energy leading to overall greater intensity ▪ Trained singers also may use shorter open quotient, thereby using the vocal mechanism more efficiently (perhaps not wasting as much air)

CAPE-V (3 pts)

▪ You should have copies of - Sample voice evaluation form - Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) form

Screaming, making strange noises (2 pts)

▪ Young children are the primary offenders ▪ Incidence of vocal nodules higher for boys than girls More Info ▪ nodules would be part of the organic problem ▪ when nodules are young , they're very soft , still pliable and respond pretty well to voice therapy ▪ old nodules can be fibrous and only surgery may work to get rid of them

CN X (Vagus) - Motor

▪ [PB]: superior and middle pharyngeal constrictors, levator veli palatini, (palatoglossus, palatopharyngeus, salpingopharyngeus) ▪ [SLEB]: inferior pharyngeal constrictor, cricothyroid (CT) ▪ [RLB]: all intrinsic except for CT

EGG (4 pts)

▪ a lot of times scoping is done in combo with EGG = electroglottography ▪ when folds are together, the electric signal will pass through the neck and you will get a strong signal... when folds are apart you will have a weaker signal ▪ if a person is aphonic, you can't use an EGG... EGG NEEDS vocal fold contact otherwise you will not get any signal ▪ When VFs abducted, the impedance is high (i.e., greater open space of the glottis, longer distance to traverse, greater resistance) More Info ▪ Refer to current flow at various VF positions, taken from: Baken, R. J. (1987). Clinical Measurement of Speech and Voice.

Abductor spasmodic dysphonia (4 pts)

▪ a.k.a. intermittent breathy dysphonia/ intermittent abductory dysphonia ▪ Perceptually there is a break in phonation, voice becomes weak and breathy, voice onset following a voiceless consonant is delayed, general difficulty with transitions especially from voiceless consonants to vowels ▪ Acoustic: due to the short VF closure, acoustic noise observable, low intensity ▪ Physiologic: low subglottal pressure with decreased glottal resistance, high volume rate of airflow more info ▪ if you think about a single syllable production like "pah" , these people would have difficulty bringing the folds together to set them into vibration ▪ you will likely see difficulty building up the subglottal air pressure level

Reduced phonation range (3 pts)

▪ aka maximum phonation range - common complaint from singers - used to be able to hit a high note and can no longer and they don't know why

Air pressure (P_s)

▪ also called subglottal pressure, alveolar pressure or lung pressure ▪ conversational speech level: 0.2 and 0.9 kPa (1kPa equals to 10cm H2O) ▪ peak intraoral pressures during the production of a voiceless bilabial plosive reflect the value of the tracheal pressure More info: ▪ pressure drop OR pressure difference → think about a circuit - the current goes through and changes all of the different registers ▪ How can you measure someone's subglottal air pressure? (40:00) - if you are going to say "p" ... the pressure is going to build up until you actually release the 'p' sound - before you release it, you can get the lung pressure info ▪ if you say "ah" with the pressure catheter in the lips, this is not going to be equal to the lung pressure - this will give you the atmospheric pressure - the difference is the pressure drop ▪ typically the range is about 2 -10 cm/H2O

Strain/Struggled/Strangled voice (2 pts)

▪ associated with increased laryngeal tension ▪ perceived as very effortful phonation

video

▪ asymmetry ▪ left arytenoid is moving laterally more, and the left VF is thicker than the right one ▪ the right false VF looks swollen ▪ there is small tumor just under the anterior point of closure of the two VFs

Breathy voice (5 pts)

▪ audible air - it's like a whisper but we still differentiate between a whisper and breathy voice - there is some presence of phonation,.. BUT in a whisper there is no phonatory component - person with breathy voice also runs out of breath quickly - with a whisper you would probably run out even quicker bc there's no valving

Coronal Cross Section and sagittal view (10 pts)

▪ below the true VFs are the trachea ▪ base of the larynx is cricoid cartilage ▪ right above that you would see the thyroid cartilage - you would anticipate to see the arytenoids on top of the cricoid cartilage and medially (white drawings) ▪ you can see a section of the lateral cricoarytenoid and also the cricothyroid muscle more superficially (circled in dark blue) right image ▪ you can see epiglottis behind tongue ▪ space between epiglottis and tongue is valleculae ▪ true vocal folds inferior and more medial ▪ false = superior and lateral ▪ between the true and false is the ventricle

Acoustic Frequency: (Maximum) Phonation Range (7 pts)

▪ best way to ellicist someones lowest to highest frequency - start from the middle, go all the way up - start from the middle, go all the way down - males = 80 - 700 (about 3 octaves) - female - 140 - 1100 (this is about a 3 octave range) (41:00) ▪ typically the max range is 2.5 - 3 octaves (this range is probably a bit high) ▪ when we do max phonation range we typically do not include vocal fry range

Sulcus Vocalis - Voice (2 pts)

▪ breathiness ▪ hoarseness

TVF CLOSURE - ACOUSTIC CONSEQUENCES

▪ breathiness looks like "snow" or aperiodic static in that signal

CASE STUDY 2 PERCEPTUAL DESCRIPTORS? PHYSIOLOGIC DESCRIPTORS TVF CLOSURE PATTERN FALSE VOCAL FOLDS ARYEPIGLOTTIC NARROWING WHAT DO YOU THINK IS WRONG WITH THIS PATIENT?

▪ breathy , rough, strained, low pitch , aphonic at times ▪ TVF closure → incomplete ▪ FVF closure → some medially ▪ aryepiglottic narrowing → no ▪ what's wrong → added mass on the vocal folds ▪ This is a type of dystonia this is a spasmodic dysphonia that has developed a severe muscle tension dysphonia on top of that

Nodule Video #2: (10 pts)

▪ breathy, rough, strained - roughness = irregularity of voicing - strain = extra muscle tension/effort - when false VFs make a medial approximation then that's gotta be done by extra muscular effort ▪ you would anticipate to see extra jitter, shimmer, probably a lower HTN ratio ▪ glottal configuration is hour class shape ▪ no complete closure, resulting in increased transglottal airflow (glottal rate of air flow) - nodules are usually one on each side but there can be multiple along the whole length of the VFs ▪ nodules are usually bilateral ▪ thinking about the size of the nodules, nodules can actually change over time... if they are new, they can cange and get better, if they are old and fibrous they can leave a gap along the medial edge

CASE STUDY 1 PERCEPTUAL DESCRIPTORS? PHYSIOLOGIC DESCRIPTORS TVF CLOSURE PATTERN FALSE VOCAL FOLDS ARYEPIGLOTTIC/EPILARYNGEAL NARROWING (TWANG) WHAT DO YOU THINK IS WRONG WITH THIS PATIENT?

▪ breathy, rough, strained, diplophonia - TVF closure → incomplete closure - False VF → open ▪ twang → no ▪ bilateral adductor paralysis ▪ what was wrong ▪ unilateral left adductor paralysis

Changes in muscle composition (3 pts)

▪ case: patient had a micro surgery that resulted in VF burns ▪ if a patient has scar tissue on the VFs (from burns) you would hear a strained vocal quality bc it's not as easy for the VFs to move together - the actual vibration is only done by smaller amount of tissue = higher pitch

What can closure be good for at the level of the larynx ? (2 pts)

▪ closure is good for lifting heavy objects (or going to the bathroom) - person with laryngectomy may have difficulties going to the bathroom bc they can't have that closure to stabilize the torso

Sentence I "The blue spot is on the key again." (3 pts)

▪ corner vowels in different consonant contexts (10:00) ▪ why do you use sustained vowels? - you can really focus on the vocal aspects without any coarticulatory features

Average amplitude perturbation (shimmer*) (5 pts)

▪ cycle to cycle amplitude variation ▪ similar to jitter, shimmer calculation methods vary ▪ shimmer local % = typically 3.8% or higher is considered pathologic ▪ local dB = .34 dB or greater = pathologic - the person might have higher rates but we're not going to say that they have a voice disorder if they sound perceptually fine More info - jitter/shimmer can be used as supplemental evidence for what you hear - they aren't going to be used to determine final diagnosis - there's no perceptual correspondence right away - this is like "program speech" from the computer

Frequency Perturbation (Jitter) (7 pts)

▪ cycle to cycle variation in frequency ▪ generally speaking , if someone has really irregular vocal quality , they tend to have increased abnormal jitter/shimmer balance, but there's no 1:1 correspondence right away ▪ doesn't have a clean/clear relationship to the perceptual domain? - it is related to roughness, but in reality ,... when someone has high jitter value it doesn't necessarily = roughness and vice versa ▪ RAP = relative average perturbation of .68 or greater would be determined as pathologic ▪ you will also see "jitt" or "local %" as another way to calculate this jitter ▪ local % - higher than 1% is abnormal More Info - tremor is OBVIOUSLY perceivable, whereas jitter is not ▪ one cycle within the period might take so long, but then the next one so short

Vocal History Form

▪ description of voice problem ▪ how would you rate your voice problem: mild/moderate/severe ▪ description of onset - sudden onset = trauma, nerve damage, choking that caused damage, hemorrhage - gradual onset = smoking/lifestyle, abuse misuse, neurological disorders ▪ has the problem increased/decreased since the onset? ▪ does voice problem interfere with work/school? - this is asking the patient's perception ▪ does voice quality vary ? → seasons, time of day - a lot of people complain about voice issues due to seasonal allergies - tells you where the patient is at, how educated they are? ▪ talking for long period of times? singing? ▪ how motivated are you? ▪ how much water do you drink? ▪ how much caffeine? ▪ smoking?

Voice therapy can be classified as: Physiologic

▪ direct management toward modifying the inappropriate physiologic activity

Most measures are made from: (3 pts)

▪ duration of steady-state vowel ▪ running speech sample ▪ duration of steady-state /s/ and /z/

Average dynamic range (4 pts)

▪ dynamic range kinda similar to maximum phonation range - it's like the amplitude version - from the softest to the loudest - typically between 50 dB to over 100dB

UMN diseases (5 pts)

▪ e.g., dystonia, CVA-induced, TBI-induced types ▪ Spastic dysarthria ▪ VF hyperadduction ▪ strained-strangled ▪ effortful/harsh phonation

Growths on the VFs (6 pts)

▪ extra mass could affect pitch - great example VF polyp - the extra mass would lower the pitch /slow down the rate of vibration ▪ if someone's entire superficial layer (lamina propria) is filled with fluid - a lot of patients who smoke have reinke's edema, where the most superficial layer is filled with fluid - reinke's edema = most common among smokers More info: endoscopic view: ▪ you can see the extra mass on the vocal fold ▪ rough vocal quality ▪ wet/gurgly voice ▪ pitch = lower - physiologic explanation = increased mass - you can see the arytenoids sitting in the back and the lateral bumps which are the cuneiforms - you can see one arytenoid doing extra medial movement - it's moving a lot more forward and more medially ▪ you will also see a little bit of bulging on the false vocal folds as well ▪ the interarytenoid space = between the two artnoids - when people have reflux you will see this area red/swollen ▪ right behind that space you would anticipate to see the esophagus - changes in the mucosa = extra fluid

Upper motor neuron lesion on facial nerve (5 pts)

▪ facial nerve innervates upper face and lower face ▪ a legion could have different effects ▪ upper face receives innervation contralateral AND ipsilateral (opposite side and SAME side) ▪ BUT lower face receives innervation ONLY contralaterally - this is called ( central VII ) when the lower face loses its innervation

Bidirectional Valving (2 pts)

▪ false and true vocal fold closure are so you don't breathe in foreign objects - i.e, when you don't have complete closure during swallows, the liquid goes into the "wrong pipe" and you cough

Webbing Video

▪ false vocal folds made massive medial approximation obscuring the view of the true vocal folds underneath ▪ if the webbing condition is having respiratory effects or effects of the

VENTRICULAR FOLDS (FALSE VOCAL FOLDS) (2 pts)

▪ for swallowing you want everything closed so you don't get things down in your lungs ▪ muscle tension dysphonia → when the med team scopes you, you look like you have a normal larynx but you have some sort of voice problem like muscular fatigue

**See image

▪ green one starts in the cerebrum ▪ little circles are the thalamus ▪ the second green dot is in the brain stem ▪ the light green dot/line is the upper motor neuron... ▪ this really stays in the central nervous system ▪ lower motor neuron starts in the brain stem and goes out to what it's moving ▪ decasation (crossover) starts within the upper motor neuron ▪ certain parts of our body only receive information from one side, while other parts of our body recieve info from both sides ▪ the red arrow starts at a random point outside of the brain stem ▪ info goes to the brainstem ▪ decasation takes place at the thalamus and information goes to cortex

Voice Symptoms of nodules: (2 pts)

▪ hoarseness ▪ breathiness

Intracordal Cysts: Voice Symptoms (2 pts)

▪ hoarseness ▪ possible lower f0

Bilateral ABductor paralysis (5 pts)

▪ if the VFs are closed at rest, we call this bilateral ABductor VF paralysis - during breathing when you anticipate to see abductory gesture, this person's abductors are stuck closed - the main problem = you can't breathe ! - for cases like this, the patient would probably need to go through tracheostomy right away to establish breathing - if they have trachs, they will not be able to phonate

Compensation (8 pts)

▪ if the right side overcompensates and makes adduction of the VFs, it will be asymmetrical - you might hear some stridor with this person - this person will still be able to have a safe swallow - you will see muscle atrophy, decreased tone, flaccidity, bowing on the side of the VF that is stuck - this is only the case when the paralysis of one VF is ore towards the medial position ▪ if one VF were stuck open ... - that person would not be able to phonate - that person would not have a safe swallow

Video 2 - Pedunculated Polyp

▪ if they don't fix their vocal behaviors the polyps will come back

Bilateral ADductor paralysis (6 pts)

▪ if vocal folds are stuck open during phonation, we would call this bilateral ADDuctor VF paralysis - in this case the ADDuctory gesture was paralyzed - in this case, the airway is fine and the person can breathe in and out, but the biggest problem would be airway protection - it wouldn't be safe for this person to eat - tube feeding would probably be recommended - the epiglottis wouldn't be enough to protect the airway

Boyle's Law (3 pts)

▪ if you have a jar of air (high density) and the air around it is low density .... as soon as you open that jar the high density of air molecules will rush to the low density area ▪ When the inhalation muscles contract , the volume of the thoracic cavity gets bigger and the density decreases ▪ Size change is accomplished by muscle contraction

Another View for the Body-Cover Theory (5 pts) - what are the intermediate and deep layers of the lamina propria?

▪ imagine the top of the screen is more towards the midline ▪ what you're actually looking at in that view is the epithelium - the intermediate and deep layers of the lamina propria are actually the vocal ligaments - one of the most frequent laryngeal cancer is squamous cell epithelioma ▪ it's hard to picture in an endoscopic video, but remember that there are various layers that make up the mucosa

Pitch breaks (2 pts)

▪ inappropriate high pitch ▪ common for children going through puberty

CNXII (4 pts)

▪ interesting bc it only receives contralateral cranial input - the right side of tongue receives cortical input from the left side only and vice versa ▪ if this patient actually had some cortical lesion on the left motor cortex, we could potentially think right side loss of tongue function ▪ if this person had an UMN legion OR a LMN legion, they would both effect the right side of tongue ? **check** ▪ lower quadrants actually recieve contralteral cortical input

Polyp video #1: (4 pts)

▪ sessile polyp ▪ breathy, roughness, a little strained ▪ the left arytenoid is asymmetrical maybe because the polyp is on that side and it's trying to get the VF to close ▪ HTN ratio = down , potentially increased jitter shimmer, maybe decreased dynamic range, MPR probably very limited too

Tremor (3 pts)

▪ shaky voice/wobbly voice ▪ different from vibrato - intentionally creating fluctuation of pitch and loudness ▪ tremor is NOT intentional

CN X - Superior Laryngeal Nerve (2 pts)

▪ internal branch- sensory innervation to the mucous membrane at the base of the tongue and to the mucous membrane of the supraglottic larynx ▪ external branch - motor innervation to part of the lower pharyngeal constrictor and to the CT muscle More info ▪ when you think about the sensory info , it talks about the supraglottal region - this is covered particularly by the superior laryngeal nerve particularly internal branch CT muscle = main muscle for tensing of the vocal fold ! ▪ pharyngeal branch - responsible for upper pharynx and soft palate innervation ▪ will be important for resonance and swallowing but not necessarily voice per say bc it has nothing to do with the VFs ▪ superior laryngeal nerve ▪ external = motor - inferior pharyngeal constrictor - CT muscle ▪ Internal = sensory info ABOVE the level of the true VFs

Webbing Video #3

▪ irregular medial edges ▪ VFs aren't having regular nice shape

What does the respiratory system provide for voice production? (9 pts)

▪ it's the power source.. without the power, you can not set your vocal folds into vibration ▪ example: blow a raspberry - air flow is moving outward - need to have the appropriate tension ▪ vocal folds come to the midline by adductor muscles ▪ they need some pressure difference to set themselves into vibration ▪ if there's no pressure difference then they cannot be set into vibration - there may be cases where the patient may not have that level of subglottal air pressure to blow the vocal folds apart ▪ a person who doesn't have appropriate respiratory function wouldn't be able to sustain a sound for a long time

Polyp vs. nodule

▪ larger, more vascular, more edematous, more inflammatory than a nodule; usually unilateral

Pain & Other Physical Sensation (6 pts)

▪ lump in the throat , lump in the neck ▪ some people may complain that when they breathe random noise comes out ▪ noisy breathing suggests that the abductors aren't making full abduction ▪ it would likely be some sort of airway obstruction - it can be at the level of the vocal folds or somewhere else ▪ there are many different types of noisy breathing... stridor is a specific type accompanied by high pitched noise

Hyperkinetic (extrapyramidal tract) involvement: (4 pts)

▪ multiple sclerosis, Huntington's chorea) ▪ Vocal dystonia ▪ respiratory/phonatory irregularities resulting in random and sudden changes in pitch & loudness ▪ tremor

Additional acoustic measures: Signal to Noise Ratio

▪ noise source at or near the VFs (e.g., air rushing against the open VFs) ▪ aperiodicity of vocal fold vibration ▪ typically 15:20 dB is what you would want to see - anything that's lower would be considered pathologic

If the VFs receive bilateral cortical input, an UMN lesion would result in ...

▪ paresis or maybe OK function

Pediatric Nodules Video (6 pts)

▪ perceptual - strained, breathy, rough component all present ▪ incomplete closure in the back ▪ continuously mucus actually builds up on where the nodules developed ▪ there was a pinhole opening in the front and a larger opening towards the backside ▪ airflow rate would likely be higher with this child ▪ harmonics to noise ratio: extra acoustic noise may be embedded, HTN ratio would potentially be lower amplitude may be a little bit lower than normal

Pitch (2 pts)

▪ perceptual phenomenon; related to the rate at which VFs vibrate (the glottis opens and closes) - fundamental frequency is physical correlate of pitch More Info: ▪ physiological basis = rate of VF vibration - a hummingbird's wings flap slower than the rate of male's VFs

Samples

▪ perceptual, acoustic, and psychological signs are all somewhat interconnected ▪ acoustic features ▪ we all heard really high pitched voice ... this would be represented by excessive high fundamental frequency ▪ weak voice would be represented as lower intensity ▪ breathy quality = audible noise - when you look at the production of vowels - energy occurs at the fundamental frequency and subsequent harmonics - in this case we also heard additional noise later on we're going to learn about harmonics to noise ratio (like signal to noise concept) ▪ typically you won't want much noise embedded in the voice

CN X - has sensory & motor function (6 pts)

▪ pharyngeal branch = picks up all of the sensory info in the upper pharynx/palatal region (sensory function) ▪ innervates muscles within the palate (motor function) ▪ superior laryngeal nerve = sensory info from above the level of the true VFs (supraglottal) ▪ motor: innervates the CT muscle , also innervates inferior pharyngeal constrictor muscle ▪ recurrent branch - innervates all of the ____ laryngeal muscles and picks up all sensory information below the level of the larynx ▪ from the motor cortex, info comes down , decasates , goes down to the medulla

Vocal Attributes (4 pts)

▪ pitch ▪ loudness ▪ quality - perceptual phenomena with physical correlates

Posterior and Anterior Chink (3 pts)

▪ posterior chink - a gap in the back of VF closure - a lot of females tend to have an open spot in the back of the vocal folds ... not uncommon ... not always pathological ▪ anterior chink - a gap towards the front of VF closure

True Vocal Folds (6 ts)

▪ posterior surface of the thyroid lamina near the angle and below the notch ▪ diverge posteriorly to attach to antero-lateral surface (vocal process) of arytenoid cartilages ▪ medial boundary = vocal ligament ▪ at rest, vocal fold (VF) length equals about 15-20mm in adult males and 9-13mm in adult females ▪ if cartilaginous part included, glottal length is about 29mm for adult males and 21 mm for adult females. ▪ folds longer at rest than during phonation because of the path of the arytenoids

Hoarseness (2 pt)

▪ raspy voice, rough, scratchy - hoarseness is an umbrella category that may be defined with various categories together

What could a breakdown in the respiratory system result in (with regards to voice?) (2 pts)

▪ reduced volume ▪ more breaks for inhalation

Video #3: (2 Pts)

▪ reinke's edema → looks like a lot of movement in addition to the tumor ▪ probably a condition that started out as reinke's edema which then developed into cancer

CN X (VAGUS) - Pharyngeal Branch

▪ sensory and motor branches supplying the mucous membrane and selected muscles of the pharynx and soft palate More Info ▪ responsible for motor/sensory innervation in the pharynx/soft palate

In- Class Case Study Examples

▪ strained ▪ very shaky - you can hear a very rhythmic, involuntary tremor in her voice Patient #11 ▪ it wasn't rhythmic ▪ you were able to hear some voice stoppage ▪ strained/strangled - maybe some breathy component - this is a compensatory maneuver that a lot of patients with spasmodic dysphonia do - instead of actually using their voice, they try to communicate with all voiceless speech sounds, which has better intelligibility Patient #18 - female Abductor SD ▪ extremely breathy ▪ not able to identify a tone ▪ in this particular vocal quality, you could add strained quality too ▪ connected speech is a lot better than sustained phonation in terms of vocal quality tremor ▪ essential tremor is typicaly between 4-7 Hz

Confidential Voice Therapy Colton, R. & Casper, J. (textbook). (3 pts)

▪ take a look at Thomas & Stimple reading on carmen? ▪ often times you might hear people say that whispering is bad for you... - it probably depends on what kind of whisper mode or strategy that you're using

Anterior Commissure

▪ the conversion point of the vocal folds is actually the thyroid, typically called the anterior commissure

More on Extrinsic Muscles (4 pts)

▪ the name of these muscles depend a lot on the origin and insertion ▪ the omohyoid is a laryngeal depressor because it pulls the hyoid downward - it depends on which location is more fixed - the more fixed location will be the direction it pulls toward

Physiological vs. Perceptual Aspects (1 pts)

▪ the perceptual aspects don't really give us any ideological info about what's going on - because he sounds so breathy he can't achieve good closure - he might have some sort of obstruction like a polyp that isn't causing the good closure - one could be paralyzed open - what does the high pitch mean ? ▪ very limited length of the vocal folds ▪ maybe there's only a limited amount of soft tissue ▪ the person has unilateral vocal paralysis - had a few strokes and coronary bypass surgery during the surgery he ended up with paralysis

Phonation threshold pressure (5 pts)

▪ the pressure level that would be needed to begin phonation ▪ typically b/w 2-3 cm/H2O - you will also see pascal as the unit - 0.2 kPa is roughly equal to 2 cm/H2O , and 0.9 is roughly equal to 9 cm/H2O ▪ cm/H2O is preferred for this class

Average speaking fundamental frequency (7 pts)

▪ the range and the mean value may change depending on the different task ▪ this is not obtained during a sustained vowel production , instead it is during a passage reading or conversational speech - average speaking f0 for males is about 100 - 120 Hz ▪ this means that their VFs vibrate 100 - 120 times per second ▪ when they read a passage or are producing spontaneous speech , their SD/variability is about 2-3 semitones ▪ average speaking f0 for females is about 200 - 225 Hz - variability is a little greater than males , typically about 3-4 semitone deviations

How does the length of the vocal folds change? (4 pts)

▪ the vocal folds diverge posteriorly and attach to the vocal processes ▪ for adult males including the cartilaginous portion is about an inch long, females shorter, kids even shorter - when folds are medially approximating they are shorter..WHY ? - the arytenoids move forward and medially

Airflow (4 pts)

▪ the volume rate of air flow from the lungs ▪ during speech the range is between 50 and 200 ml/s - males have a higher flow rate than females ▪ think about the flow rate for individuals w/ vocal pathologic conditions More info ▪ 1 liter = 1000 ml ▪ 50 - 200 ml/sec → typically considered as the range ▪ used for speech ▪ .05 ~ .2 liter/sec

Vocal Function Exercises (Stemple, J. C. (1993). Voice therapy: Clinical studies. St. Louis, MO: Mosby Year Book)

▪ there are a lot of similarities across these techniques .... think about this and voice resonance therapy, forward focus, and even semi-occluded vocal tract therapy

Does a child with dysphonia qualify for services? (2 pts)

▪ they should qualify but WHY ▪ how is it going to affect the child's communication abilities and school performance

When you think of mucosal wave propagation, which way direction does it propagate?

▪ think of the mucosal wave propagation from the bottom to the top

GRBAS Rating Scale (4 pts)

▪ this scale has a longer history than CAPE-V - this one is from Hirano (body-cover theory) ▪ G= grade (overall hoarseness grade) , R = roughness, B = breathiness, A= Asthenia (weakness) , S= strain ▪ this system only has 4 grades to score: ▪ 0 = normal , 1 = mildly abnormal , 2 = moderately abnormal , 3 = severely abnormal More Info ▪ for the rater it's probably a lot easier for the evaluator

Cartilages of the larynx: (10 pts)

▪ thyroid cartilage/prominence may be important spot to look at during swallowing exam ▪ arytenoid cartilage - anterior movement = medial vocal cord movement - posterior movement = lateral vocal cord movement ▪ cricoid cartilage - small in front, bigger in the back - arytenoids sit on top of the cricoid cartilage in the back - the processes that you can see in the back are called the muscular processes - the anterior medial processes that you can see in the center image are called the vocal processes ▪ the most superior point on the arytenoids are called the corniculate or cuneiform cartilage

*See image

▪ top left pic = nodules - we don't have to ID what these pathologies are, but we should be able to describe how the presence of this type of growth would affect the VF vibratory behaviors - we should be able to describe perceptual, acoustic and physiologic descriptors

Sentence II "How hard did he hit him?"

▪ transitioning from voiceless to voice sounds, can be used to look at spasms like in spasmodic dysphonia, this would be a way to see if the patient can actually produce soft glottal attack, or easy onset

REVIEW: 1. HOW DOES THE VOICE GET LOUDER/SOFTER? 2. HOW DOES THE SOUND GET BRIGHTER/DARKER? 3. WHAT MAKES THE VOICE STRAINED/"OPEN"? 4. WHAT MAKES A SOUND "FORWARD" VERSUS "BACK"?

▪ two things that could make the voice louder - amount of VF closure - twang ▪ what does brighter/darker mean? - that has to do with the length of the vocal tract - when formants are down, that's a lower sound - when formants are up, that's a bright sound ▪ some of these are subjective, may be influenced by psychoacoustics ▪ strain → has to do with false VFs ▪ when you twang , that seems like extremely forward ▪ when you do a low voice that's more back

What VF paralysis would be the most common? (8 pts)

▪ unilateral , left , ADDuctor VF paralysis - adductor VF paralysis is when it can't close → the difficulty is on the adductor muscles ▪ when CT muscle contracts, it elongates the VFs - if one side of the CT muscle doesn't work, when you see the VFs during action what would it look like? - one side of the VF stretched, the other side not stretched - superior laryngeal nerve paralysis is not common but it is somewhat superficially located so if someone has a big trauma on the outside of their neck it could potentially be damaged ▪ when CT muscle contracts, the thyroid cartilage gets pulled down, which stretches the VFs - when only one side contracts, it'll give an oblique, asymmetric position of the VFs

Normal Larynx (3 pts)

▪ vocal folds at rest = open ▪ during phonation = nice complete closure closure - this is what you anticipate to see when you see a normal larynx

what are some conditions where you would see excessive airflow ? (5 pts)

▪ vocal paralysis ▪ dysarthria ▪ any kind of polyp or nodule ▪ burn on the vocal folds ▪ when people get laryngitis --> the vocal folds may be so slowly that they cannot get sent into a nice vibration motion

Case study #2 ▪ 27 y/o female who presented w/ 2 year history of papillomas involving the true VFs. Underwent surgical procedure ~2 years ago during which right-sided... ▪ MPT = 7 seconds ▪ f0 = 232 Hz, jitter = 4.6% (RAP) , shimmer at 0.61 (local, dB), and H to N ratio of 0.6 dB ▪ no complete glottal closure

▪ volume rate of airflow = ▪ this will probably be very noisy with a breathy quality ▪ rough, some breathiness, strained quality (but not as strong as rough or breathy) After surgery ▪ more severe breathy quality ▪ more severe strain

Changes in muscle function (5 pts)

▪ we can think of VF paralysis ▪ CT muscle innervated by superior laryngeal nerve ▪ a patient who has injury on SL nerve may have compromised pitch control ▪ not uncommon bc this nerve is very superiorly located - if someone gets hit in the neck by a big ball

What does "aerodynamic" mean? (4 pts)

▪ when folds are brought together you're exhalation is still ongoing ▪ subglottal air pressure builds up and a puff of air is emitted ▪ the folds get blown apart ▪ but the folds are sucked back to the midline bc of bernoulli effect (negative glottal air pressure) and tissue elasticity

LARYNX - ACOUSTIC CONSEQUENCES (2 pts)

▪ when the vocal tract gets longer you're going to lower all the formants ▪ when the vocal tract gets shorter you're gonig to elevate all of the fromants

Endoscopic View - VF Closure patterns (3 pts)

▪ when they transitioned from stiff to thick the voice got louder ▪ fry and thick folds don't look that different , the main difference is the amount of airflow - thick folds requires a little bit more air flow and breath pressure

FALSE VOCAL FOLDS (2 pts)

▪ with muscle tension dysphonia you can see their musculature go from squeezed to not squeezed - spasmodic dysphonia is different bc it has to do with spasms on the TA specifically

if someone has a legion on the LMN ... what will you see? (3 pts)

▪ you will see that one side during the production of "ahhhhhhhh" ▪ the levator veli palatini raises the palate ▪ if the left side is intact and the right side is paralyzed (aka right side has a legion) you will see that the uvula would be deviated towards the intact side

ARYEPIGLOTTIC/EPILARYNGEAL NARROWING (3 pts)

▪ you would THINK that you would want it to look more open , HOWEVER the upper filter adjusts and narrows in order to amplify a sound ▪ when you pinch and create some sort of narrowing, that serves as whey they call an impedance matching - it's a way of amplifying the sound without excess breath pressure? (26:00)