Voice Disorders Final

PT has a broken hyoid bone due to blunt force trauma from a baseball accident. How will his voice be impacted?

Because the hyoid bone is a point of attachment for many of the tongue muscles, this patient's articulation and vocal quality will be negatively affected. The hyoid bone also serves as a point of attachment for the larynx which will also cause his vocal quality to decrease when the laryngeal muscles cannot function properly.

To keep subglottal pressure consistent so we don't end up dropping off at the ends of our phrases, we use these muscles: (check all that apply)

Diaphragm, external intercostals

Which muscles contract with active inhalation?

Diaphragm, external intercostals

The biomechanics of speech breathing relies on a constant interplay between active and passive forces. An active force would be the muscles that counter relaxation pressure. A passive force would be:

Elastic recoil

The glottis is the space between the hyoid bone and thyroid cartilage

False

The lateral cricoarytenoid functions to abduct the vocal folds

False

When producing a long sustained note, the diaphragm contracts and pushes air out of the lungs

False

In the biomechanical 3-layer system, the "vocal ligament" consists of:

Intermediate and deep lamina propia

Which of the following are short term effects of radiation?

Hoarseness, Odynophonia, copious secretions, inflammation, dry mouth, swelling

This diagnosis is due to a faulty laryngeal gatekeeper (check all that apply)

Laryngospasms, chronic cough, irritable larynx syndrome

Which laryngeal muscles are the primary muscles of vocal fold adduction?

Lateral cricoarytenoids, interarytenoids

When the vocal folds aren't opening, resulting in an obstructed airway, which intrinsic laryngeal muscles could be involved (check all that apply)?

Lateral cricoarytenoids, posterior cricoarytenoids, interarytenoids

Dry, non-productive cough that lasts more than 3 weeks. Usually starts as a tickle of sensation in the throat.

Chronic cough

The sternohyoid functions to pull the hyoid bone down

True

The superior laryngeal nerve provides the majority of sensation to the laryngeal mucosa

True

The transverse oblique interarytenoid muscle is the only unpaired intrinsic laryngeal muscle

True

The way we shape our vocal tract can influence the efficiency of vocal fold vibration

True

Voice is abnormally high pitched, breathy , and quiet

Puberphonia

Describe two disadvantages of placing the TE prosthesis into the TE tract at the time of the initial laryngectomy surgery?

Two disadvantages of of placing the TE prosthesis into the TE tract as the time of the initial laryngectomy surgery is that the patient must be fed by NG tube or PEG due to swallowing difficulties and that there are high rates of complications due to the amount of radiated tissue.

The interarytenoid muscles are innervated by the:

Recurrent laryngeal nerve

The vocal folds themselves are innervated by the

Recurrent laryngeal nerve

If a patient is unable to perform an upward pitch glide, there may be a problem with which of the following (click all that apply)?

Recurrent laryngeal nerve, regulating sub glottal pressure, cricothyroid muscle, superior laryngeal nerve

Sac-like collection of fluid in the sub-epithelial space or ligament that requires surgery

VF cyst

Which of the following voice disorders can be congenital?

VF cyst, sub glottal stenosis, laryngeal web

A bleed in the subepithelial space caused by a phonotraumatic incident

VF hemorrhage

Symmetric, bilateral lesions of the epithelium that respond well to voice therapy

VF nodules

Translucent or hemorrhagic lesions in the sub-epithelial space that requires surgery

VF polyp

Stiff, disorganized tissue that significantly reduces mucosal waveforms

VF scar

The primary and most basic biological function of the larynx is

airway protection

Which muscle is the primary regulator of pitch?

cricothyroid

Increasing subglottic press while keeping all other laryngeal function the same...

increases volume

The cricoarytenoid joint allows for

opening the vocal folds, closing the vocal folds

The "pitch changing muscles" is innervated by the

superior laryngeal nerve

the best exercise for swallowing is

swallowing

A deviation in pitch is automatically considered a voice disorder

false

The external intercostals are associated with active exhalation

false

Vocal misuse is the key underlying cause of phonotraumatic lesions

false

A vocal nodule that isn't impacting a patient's vocal function is considered a voice disorder

fasle

This type of vocal pathology can occur as a result of prolonged intubation or untreated reflux and is commonly seen at the medial aspect of the arytenoid cartilage

granuloma

The extrinsic infrahyoid muscles are innervated by which cranial nerve?

hypoglossal

Other than phonation, the larynx plays a role in (check all that apply)

Airway protection, respiratory modulation, postural stability

These voice disorders are progressive and degenerative

Amyotropic lateral sclerosis, Parkinson's

Lengthening and stiffening the vocal folds results in

An increase in frequency and pitch

The posterior aspect of the vocal folds attach to which cartilage?

Arytenoid

Which of these joints allow movement of the vocal folds?

Cricoarytenoid, cricothyroid

No voice, incomplete glottal closure with voicing attempts. Nonphonatory movements are usually normal

Conversion aphonia

Leukoplakia on the true vocal fold typically requires a laryngectomy

False

At the very top of our breath, we need to use checking action in order to sustain ongoing phonation. Which muscles would be involved in this action? (check all that apply)

External intercostals, diaphragm

A resident who has had a laryngectomy is admitted to your skilled nursing facility. You do not see a TE puncture. You should be worried that this is impacting their hyolaryngeal excursion.

False

Adductor spasmodic dysphonia involved intermittently breathy vocal quality

False

Functional voice disorders are all caused by psychological stress

False

The supraglottic laryngeal cavity extends from the laryngeal vestibule/ventricles to the inferior aspect of the vocal folds

False; extends from the laryngeal vestibule/ventricles to the SUPERIOR aspect of the vocal folds

You have a 36 year old female patient whose main complaint is vocal tension. You notice that the muscles in her neck are unusually large.What muscles are likely to be impacted and why are they bulging?

Her extrinsic laryngeal muscles are most likely to be the ones impacted. Because she is complaining of tension when vocalizing, she is most likely tensing up all of the muscles in her neck while talking. Because of the over tensing of her neck, her neck muscles have become larger/bulging.

Mary is a 65-year old female who comes to you complaining mainly of shortness of breath with speaking and "wheezing" with exercise. She notes a sudden onset approximately 3 months ago followed by unilateral complete thyroidectomy. Her Ear, Nose, and Throat (ENT) evaluation revealed a paralyzed vocal fold in medial position. Explain to Mary what a "paralyzed vocal fold in medial position" means and how it relates to her shortness of breath and noisy breathing.

Hi Mary. The ENT evaluation showed that you have what's called a paralyzed vocal fold in the medial position and I'm going to explain to you what that means and why it's causing you to feel short of breath and wheezy when you exercise. We have two vocal folds which are commonly known as vocal chords. When we breathe, they pull apart and stay wide open. When we speak, they come together and vibrate. Because you have a paralyzed vocal fold, it does not pull apart from the middle space known as the glottis. Therefore, it is blocking airflow from getting in and getting out when you breathe. This is causing you to feel like you're short of breath. Because the glottis is narrowed from your paralyzed vocal fold, it would make sense that you're wheezing while exercising when you're breathing harder and trying to take in more air.

Difficulty raising pitch directly following thyroid surgery might suggest the following as a main diagnosis

Injured superior laryngeal nerve

Describe 2 downsides to auditory perceptual analysis

It can be subjective, meaning that one person's perception of someone's voice may not be exactly the same of someone else's perception of the same voice. There are also many different methods for auditory perceptual analysis - therefore uniformity can be hard to achieve when using different methods.

What is it about "shouting" that contributes to mucosal irritation of the vocal folds?

It increases collision forces of the vocal folds

Describe 2 benefits of the CAPE-V over the FITQ and GRBAS

It was created in order to create some form of standardization for voice analysis, something that had been lacking from other methods. And the sentences allow hypothesis of physiologic correlates.

A patient comes to your clinic with complaint of severe muscle pain between the trachea and sternal notch. The laryngologist wants to do an SLN (superior laryngeal nerve) block, which includes injecting a combination of anesthetics and steroids into the superior laryngeal nerve to relieve the pain. Would this intervention help alleviate the patient's pain? Why or why not?

It would not because pain is not located in a region where the RLN or SLN would innervate

Increased vocal effort and discomfort or pain in the perilaryngeal region; may be accompanied by excessive supraglottic compression and hoarseness

Muscle tension dysphonia

Which extrinsic laryngeal muscle is NOT innervated by the hypoglossal nerve?

Mylohyoid

Which muscles elevate the larynx? (check all that apply)

Mylohyoid, geniohyoid, digastric (NOT the sternohyoid)

Dyspnea with laryngeal constriction or obstruction

Paradoxical vocal fold motion disorder

During quiet breathing, exhalation occurs via

Passive elastic recoil of the thorax and lung tissue

In a variant of spasmodic dysphonia, the vocal folds uncontrollably spasm open during speech. Botox treatment temporarily paralyzes the offending muscle. Which muscle should the doctor inject to get the best outcome?

Posterior cricoarytenoid muscles

Which muscles open the vocal folds?

Posterior cricoarytenoids

Which muscle courses in the same direction as the stylohyoid?

Posterior digastric

A classic presentation of this disorder is vocal fold blowing

Presbylarynges

Why should surgeons hold off on inserting a prosthesis (do a TEP) at the time of the initial laryngectomy?

Radiated tissue with surgery causes prolonged tissue healing which can further lead to fistulas and other long-term consequences with immediate TEP

What are two issues of contemporary management of laryngeal cancer?

Radiation first, followed by surgery to remove the larynx causes long-term issues and tissue sparing commonly leads to re-occurance and subsequent consequences

Which of the following, when severe, can pose risk to a patient's airway? (check all that apply)

Reinke's edema, paradoxical vocal fold motion disorder, vocal fold papilloma/RRP

The phenomenon in which the efficiency of vocal fold vibration can improve under the influence of the vocal tract resonance is called

Source-filter theory

The cricothyroid muscle is innervated by which nerve?

Superior laryngeal nerve

You are evaluating a patient that has just had surgery and are suspicious that the SLN (superior laryngeal nerve) of CN X has been impaired. What is the easiest way to test this on the spot?

The easiest way to test this would be to have the patient try to raise their pitch on an elongated phonation. The SLN innervates the cricothyroid muscle which modulates pitch. Therefore, evaluating whether or not the patient can raise their pitch is a good test.

You receive an Modified Barium Swallow report from the local hospital for a patient who has had a laryngectomy. The report states that the patient has reduced hyolaryngeal excursion. What is the issue with this statement?

The issue with this statement is that reduced hyolaryngeal excursion is a side effect of radiation for someone who has a larynx. This patient has had a laryngectomy, therefore it is impossible that they would have reduced hylolaryngeal excursion when their larynx has already been removed.

The mucosal waveform of the vocal folds is generated by

The out-of-phase motion of the upper and lower lip of the vocal folds

What are two reasons why the posterior cricoarytenoid muscles are needed for speech?

The posterior cricoarytenoids are needed for speech because they are the only muscles that abduct (open) the vocal folds. Without opening the vocal folds, the airway would be blocked and an individual would not be able to breathe in air needed for speech. The posterior cricoarytenoids open the vocal folds to obtain air needed to create subglottic pressure for phonation. Additionally, when more air needs to be released during speech, the posterior cricoarytenoids come to action, opening the glottis as needed. (In addition to speech breathing mentioned, also voicing offsets, voiceless phonemes, suprasegmental prosody in conjunction with CT muscle)

What is the purpose of the CAPE-V sentence "We were away a year ago"?

The sentence targets the ability to maintain constant voicing

In 2-3 sentences, describe the functional differences between the thyromuscularis and thyrovocalis vocal fold muscles.

The thyromuscularis and thyrovocalis together make the thyroarytenoid. The thyrovocalis is a vocal fold tensor and serves as the main source of vocal fold vibration. Comparatively, the thyromuscularis is the more lateral portion of the thyroarytenoid and serves to increase the mass of the vocal folds by pulling the arytenoids anteriorly. Together they cause pitch change.

What happens when the cricothyroid muscle contracts? (check all that apply)

The vocal folds lengthen

A patient is admitted to the acute care unit following a heart attack. During his visit to the hospital he undergoes heart surgery. During his recovery his family notices changes to his vocal quality. As the SLP on the unit, you are called to do a consult. Explain to the patient and his family the possible correlation between his surgery and the noticeable changes to his voice.

There is a nerve called the recurrent laryngeal nerve , and this nerve controls most of the muscles that help us to speak. The thing about this nerve is that it actually wraps around part of the heart (might explain how it wraps under the aorta depending on the family members' understanding of the heart surgery/anatomy). This nerve may have been affected during his heart surgery which is what most likely has caused some change to the quality of his speech.

Name two reasons laryngeal breathing disorders are difficult to diagnose?

They are acute and triggered by environmental systemic stimuli that is not always reproducible in the clinic

What are 2 reasons why giving a patient a medical diagnosis after hearing their vocal quality is inappropriate?

This is inappropriate because there can be multiple etiologies that produce the same type of vocal quality. Additionally, diagnosing a vocal disorder is not under our scope of practice as SLP's.

You get a referral from an Ear, Nose, and Throat doctor to do voice therapy for a patient with a vocal fold nodule. The following image came with the evaluation documentation. (picture has a bump on only one nodule)

This is not VF nodules

Which laryngeal muscles regulate pitch?

Thyroarytenoids, cricothyroid

Which extrinsic laryngeal muscle decreases the distance between the hyoid and the thyroid cartilage?

Thyrohyoid

Which cartilage "houses" the vocal folds?

Thyroid cartilage

Blood vessels enter the larynx through the:

Thyroid membrane

"Breathiness" is used to describe the sound of increased airflow through the vocal tract while "asthenia" describes a weak vocal quality.

True

Damage to the recurrent laryngeal nerve may cause difficulty in ab/adducting the vocal folds

True

Damage to the vagus nerve can impact both voice and swallowing

True

Enhancing vocal resonance can improve the function of the larynx

True

Which is the only intrinsic laryngeal muscle that you can feel from the outside of your throat?

You can't directly feel the intrinsic laryngeal muscles

The pharyngeal nerve innervates each of the following: (check all that apply)

pharyngeal muscles, soft palate

When moving from a low to high pitch, the vocal folds (check all that apply)

vibrate faster, decrease in mass