Voice Midterm

The Spaces and Openings in the Larynx

-Aditus ad laryngis (opening to the larynx) -Vestibule (upper laryngeal space) -Laryngeal ventricle (or sinus), laryngeal saccule (anteriorly) -Glottis (rima glottidis) Atrium (or sub glottal space)

What are the three layers of the vocal folds?

-Ary-epiglottic folds (epiglottis) -Ventricular (/false) folds -Vocal (/true) folds

Inappropriate Use of Vocal Components/Systems: Resonance

-Hypernasality (rhinolalia aperta) -Hyponasality or denasality (rhinolalia clausa) -Cul-de-Sac, or Mixta -Assimilative nasality -Retracted tongue, and elevated larynx

Intrinsic Laryngeal Muscles

-LCA (Laterial Crico Arytenoid) -PCA (Posterior Crico Arytenoid) -IA (Inter Arytenoid) -TA (Thyro Arytenoid) -CT (Crico Thyroid

Extrinsic Laryngeal Muscles: Infra-hyoid or Laryngeal Depressors

-Sternohyoid muscles -Sternothyroid muscles (high pitch) -Thyrohyoid muscles (low pitch) -Omohyoid muscles

What are the five disorder groups?

-Structural changes in the vocal folds -Neurogenic voice disorders -Systemic disease influences on larynx and voice -Disorders of voice use -Idiopathic Voice Disorders

Biological Functions of the Larynx

-To prevent foods and liquids from entering the airways -To take part in swallowing behaviors -To keep air in and develop abdominal strength/firmness -To expel mucus -To laugh -Phonation is called an "overlaid function" relative to the biological functions of the larynx.

Etiologies of Vocal Misuse

-Vocal Abuse -Inappropriate Use of vocal components and systems

Parameters of phonation

1. Degree of vocal fold approximation 2. Pitch 3. Loudness 4. Mode 5. Prosody

What are the causes to some neurogenic voice disorders?

1. Faulty innervation of respiratory components 2. Deficiency in adducting the vocal folds 3. Incoordination of vocal tract components 4. Velopharyngeal insufficiency

Inappropriate Use of Vocal Components/Systems: Phonation

1. Glottal attacks: -coup de glottes -breathy/aspirate attacks -even/static attacks; 2. Glottal fry: or pulse register; 3. Loft, or falsetto; 4. Modal register

Voice Therapy (Stemple)

1. Hygienic voice therapy (identify behavioral/chemical causes and modify/eliminate them) 2. Symptomatic voice therapy (modify identified behavioral symptoms) 3. Psychogenic voice therapy (work on emotional and psychosocial status of a client) 4. Physiologic voice therapy (modifying aspects of respiration, phonation, and resonance) 5. Eclectic voice therapy (combinations of the above)

What is the fundamental frequency of phonation affected by?

1. Length/size of vocal folds at rest 2. Mass/thickness along the edges of the vocal fold 3. Elasticity 4. Rigidity of compliance of the vocal fold tissues

Why do vocal folds vibrate during phonation?

1. Myo-Elastic Aerodynamic Theory -The Bernoulli Effect 2. The Body-Cover Theory (Two Mass Theory)

What are the 2 types of neurogenic voice disorder conditions?

1. Neurogenic problems with vocal fold adduction and approximation 2. More general voice problems associated with neurological diseases

Parameter of Voice

1. Phonation (frequency, intensity, quality, mode) 2. Prosody (intonation, stress, emphasis, rate, rhythm) 3. Resonance (hyper, hypo nasality; oral or guttural and other forms of resonance) 4. Style (parallels the term dialect in a language)

Neurogenic Voice Disorder: Bilateral Vocal Fold Paralysis

A bilateral vocal fold paralysis can be explained merely by some impairment to the central brainstem where the tracts to both vocal folds are physically close. It is usually accompanied by other symptoms, such as weakness and paralysis of the tongue, pharynx, or velum. Voice may not be the primary concern, as there are difficulties with swallowing as well as breathing With bilateral abductor paralysis there is a concern for enough opening for breathing and surgery is considered to manipulate at least one of the arytenoids to ensure opening. A tracheostomy may by necessary in severe cases. Bilateral adductor paralysis causes a concern for too much opening (problems with swallowing), while the chances for voice are strongly reduced. AAC devices are likely necessary: electrolarynx, or speech amplifiers.

What part does respiration play for phonation?

A normal voice quality is dependent on sufficient respiratory support: -sufficient volume -sufficient subglottic pressure -effective coordination (of abdominal and thoracic breathing)

Chronic Illnesses and Disorders: Endocrine Dysfunctions

A variety of endocrine dysfunctions may lead to voice problems (e.g., hypo-/hyper thyroidism; hyperpituitarism, as well as minor hormonal changes associated with menstruation can lead to voice symptoms or even disorders such as hoarseness, vocal fatigue, pitch changes, loss of range, breathiness, reduced loudness, and pitch breaks.)

Chronic Illnesses and Disorders: Allergies

Allergies, while directly affecting many mucous membrane areas (histamine production which leads to swelling, dilation of blood vessels, and increased production of mucus) and thus lead to irritations, or an increased chance of infection, will also lead to use of antihistamines and cortico-steroids, which have the effect of drying the mucosal surfaces to some extent. This dryness also exposes the client to increased risk for infection. It is important for mucous membrane to be adequately hydrated in order to stay healthy. Some common cough suppressant medications have the same drying effect.

Crico-Arytenoid joints

Allow for sliding of the arytenoids (toward and away from each other) and rocking (most important movement). Some hypothesize a rotation at this point as well. All these movements contribute to vocal fold approximation (adduction and abduction).

Crico-Thyroid joints

Allow the thyroid to rock forward (vocal process down and to the middle) and backward (vocal process up and to the side) relative to the cricoid cartilage (this motion represents our primary pitch change mechanism).

Optimal Valving

An efficient relationship between the vocal folds during phonation, as to cause a clear musical harmonic tone produced with a minimal amount of energy, or air volume, to produce an optimal loudness maintaining an acceptable quality. There is an efficient balance between the open and closed phases of the vocal fold oscillation.

Epiglottis

An unpaired leaf-like structure of elastin cartilage which arises from the inner surface of the angle of the thyroid cartilage. It can be moved to cover the laryngeal opening, which occurs during swallowing.

Chronic Illnesses and Disorders: Arthritis

Arthritis could implicate the crico-arytenoid joints and produce either hoarseness or pain sensations in these joints; and in severe cases these joints could become locked up (ankylosis) and produce a condition that has similar results for one's voice as vocal fold paralysis.

Posterior Crico Arytenoid Muscle (PCA)

Back border of cricoid (medial line) to the muscular processes of the arytenoids. Function: mainly abduction of the vocal folds; also, stabilizes the arytenoids in case of strong longitudinal tension in the vocal folds due to high pitch levels, or increased loudness.

Inappropriate Use of Vocal Components/Systems: Pitch

Can be a cause of strain; optimal pitch can only be determined if it involves a functional problem, organically caused pitch abnormalities reduce the ability to determine one's optimal pitch

Chronic Illnesses and Disorders: Cardiac and Blood Circulation Problems

Cardiac and blood circulation problems may be associated with a variety of voice disorders (surgery could possibly lead to damage to one of the recurrent laryngeal nerves; medications may be directly or indirectly responsible for dehydration and resulting irritation of the mucous membranes including the vocal folds).

Primary Disorder Etiologies: Cleft Palate

Cleft palate and other organic velopharyngeal insufficiency produce hypernasality. Individuals who are deaf may present with relatively high pitch levels, and a pharyngeal resonance ("guttural", "back in the throat").

Indirect Consequences of Surgery: Hysterectomies

Complete hysterectomies may present with another surgery related consequence, that is, a lowering of pitch (temporarily or permanently) due to changes in hormone levels.

Voice Pathologist

Completes the evaluation and management of voice disorders. This role focuses on three major goals: 1. Evaluation of laryngeal function using the following identification techniques: a. perceptual b. acoustic c. aerodynamic d. visual 2. Identification, modification, or elimination of the functional causes that have led to the development of the voice disorder 3. Developing a therapy plan that will remediate the voice disorder and return the voice to improved function.

Thyro Arytenoid Muscle (TA)

Connect antero-lateral surfaces of the arytenoids to the inside angle of the thyroid. There are two parts: (1) Thyro muscularis (main muscular body of vocal folds; located lateral to the thyrovocalis muscle); Function: relaxing of the vocal fold tissues; medial portions of the folds 'shrivel' and become relaxed for low pitch levels (contains slow acting muscle fibers) (2) (Thyro-)Vocalis muscle (most medial muscle of the vocal folds, which connects mostly to the lateral sides of the vocal process and the tips; has fast acting muscle fibers); Function: fine-tuning of longitudinal tension in the cords (works as team mate for the CT muscle). By increasing tension in the cords these muscles contribute to adduction as well.

Lateral Crico Arytenoid Muscle (LCA)

Connects muscular process to annulus of cricoid (somewhat anteriorly). Function: mainly contributes to adduction of the vocal folds (in addition to the adduction produced by action of the inter-arytenoid muscles); the vocal processes move forward, down, and medially; a secondary function of the LCA is to regulate medial compression of the vocal folds (especially where they vibrate!).

Parameters of phonation (Degree of vocal fold approximation)

Continuum of vocal fold approximation: -abductory aphonia (vocal fold too far apart; no voice) -whisper (breathy only noise) -hypo-adduction (too much space/breathy/quieter voice) -optimal valving (preferred approximation) -hyper-adduction (touch/vibrate too much/loud voice from pressure buildup) -adductory aphonia (closed folds/no voice)

Structural Changes of the Vocal Folds

Differences in mass, size, stiffness, flexibility, and tension affect vocal fold vibration; closure patterns are affected as well. These differences cause variable changes in pitch, loudness and quality. Often, fairly non-distinct forms of dysphonia result (= breathiness, roughness, effort and strain, intermittent voice breaks or even aphonia).

Primary Disorder Etiologies: Direct Trauma

Direct trauma to the larynx is of course also possible: penetrations, dislocations, fractures, lacerations. Trauma to the larynx can be caused by a great variety of accidents: car accidents, acts of violence, fires and chemical fumes, intubation during hospitalization. Primary concern in these cases is to preserve an open airway.

Medically-Related Etiologies

Direct/Indirect consequences of surgery Chronic Illnesses and Disorders

Structural Changes of the Vocal Folds: Hyperkeratosis

Etiology: A non-malignant (but pre-cancerous) pinkish rough-looking lesion anywhere in the pharynx or larynx. Usually as a result of continued tissue irritation (e.g., excessive smoking). They occur under the tongue, on the vocal folds either at the anterior commissure, or at the arytenoid prominences. The swelling appears as a layered structure, and the text book describes a "leaf like" appearance. Symptoms: Variable depending on site and extent of the lesion. Intervention and management: Eliminate the cause of the irritation, possibly surgical removal and voice therapy as needed.

Structural Changes of the Vocal Folds: Presbylaryngeus

Etiology: A voice disorder because of normal processes of laryngeal aging (respiratory, changes in the vocal folds, cartilage and its joints). Vocal folds may present with a slightly bowed gap. Symptoms: Decreased (1) loudness, (2) pitch (in-)stability and range, and (3) voice quality. Intervention and management: Voice therapy may improve voice quality.

Structural Changes of the Vocal Folds: Leukoplakia

Etiology: Benign tumors, but they are pre-cancerous. They occur under the tongue and on the vocal folds. Look like "white plaque" in diffuse patches. They are difficult to distinguish visually from cancer. Cause: continuous irritation of the membranes (heavy smoking usually, or related to alcohol use). Symptoms: May lower pitch, increase hoarseness, breathiness, and sometimes: weak volume. Intervention and management: Medical/surgical, and voice therapy added later to find the best voice despite the consequences of the surgery.

Structural Changes of the Vocal Folds: Sulcus Vocalis

Etiology: Congenital, acquired (vocal abuse may affect it), or unknown Symptoms: A long oval shaped glottal opening during adduction, or a line/groove running longitudinally, parallel to the glottis down one, or both folds. Voice sounds soft, breathy and hoarse. The groove is difficult to identify visually. Intervention and management: Adjust a balance between proper glottal closure (increased vocal efficiency without creating excessive strain), pitch, and loudness (pitch shifts, loudness changes, lateral digital pressure, and experimentation with firmer glottal closure. Some consider teflon injections, but others recommend primarily voice therapy.

Structural Changes of the Vocal Folds: Congenital and Acquired Cysts

Etiology: Fluid filled, sessile growths, congenitally present or acquired later in life. No clearly known etiology. Can occur anywhere; they aren't specifically related to vocal fold behaviors. Occur below the epithelium as an oval whitish swelling. The effect on phonation is primarily stiffness of a vocal fold segment. May lead to secondary changes (e.g., bilaterally). Symptoms: Mild to moderate (a-)(dys)phonia depending on the location and size of the swelling. Intervention and management: Medical/surgery mostly as cysts do not respond to behavioral changes.

Structural Changes of the Vocal Folds: Reinke's Edema

Etiology: Same as vocal fold thickening. Despite similarity with "polypoid degeneration" in Reinke's edema the swelling is more "watery and fluid filled", the tissue appears to stick briefly upon abduction (endoscopy). Symptoms: Husky hoarseness and low pitch; some breathy escape; because of failure of the vocal folds to close completely; often associated hyperfunction as compensation. Intervention and management: Medical- remove the cause of irritation or even surgery; SLP: removal of excess use of the larynx (abuse)

Structural Changes of the Vocal Folds: Contact Granuloma

Etiology: The granuloma looks like a firm sac. Often on the posterior glottis (on vocal process). May be looking "pushed in". Generally along the posterior one third (cartilaginous portion) of the vocal folds. May look like little craters. Usually unilateral. Throat clearing common. The text book discusses granulomas and contact ulcers as related, and in the same diagnostic category. Medical: Intubation during surgery, or gastric reflux disease (GERD). Vocal abuse: excessive slamming of the vocal folds (hard glottal attacks, low pitched voice, increased loudness, coughing, throat clearing) Symptoms: Hoarseness, breathiness, the need to clear the throat frequently. Deterioration of voice following prolonged vocalization (vocal fatigue), pain in the laryngeal area is common, or sometimes lateralizing to one ear). Intervention and management: If caused by hiatal hernia (and associated gastric reflux): antacids, diet management, raise head of the bed, reduce meals before sleeping, and voice therapy. If caused by intubation (and they don't go away: surgery). Otherwise: take the effort out of phonation. Some success with vitamin C and E.

Structural Changes of the Vocal Folds: Carcinoma

Etiology: Tissue in the laryngeal area becomes cancerous (extremely variable in form). Smoking (particularly pipe), smokeless tobacco, chronic infections, herpes, repeated trauma, leukoplakia or hyperkeratosis (see earlier). With regard to voice quality, cancers may also affect the tongue, pharynx, velopharyngeal area, lips and thus affect resonance (among others) or swallowing! Symptoms: Usually a persistent hoarseness, and pain (may refer to ear), and various other impacts on phonation and resonance depending on the particular nature of the growth. Intervention and management: Surgery (micro-, or laryngotomy and laryngectomy) or radiation. Site and extent of surgery depends on the lesion and are variable. The voice therapist prepares client and family for possible consequences of the surgery and takes place in the various forms of laryngeal voice rehabilitation or other new sources for phonation.

Structural Changes of the Vocal Folds: Laryngitis

Etiology: Usually in response to a cold, or related URI (Upper Respiratory Tract Infection). May be viral or bacterial. Acute: the vocal folds swell usually as result of the infection. There is an associated irritation and increased blood accumulation. (Very) Young children may experience "croup" which results in a narrowing of the airways producing an inhalatory stridor and severe coughing. Chronic laryngitis: is a condition of long standing laryngeal mucosal inflammation, viscous mucus, and epithelial thickening that is associated with infection. Possibly there are repeated episodes of acute laryngitis, vocal misuse and abuse, smoking and poor laryngeal hydration. Air pollutants, airborne allergies, the use of dehydrating medications, gastro-esophageal reflux disease, and repeated vomiting associated with bulimia (periodic binge eating, followed by vomiting to get rid of the food) have also been implicated as etiological factors. Symptoms: Hoarseness, mild to severe dysphonia, with lowered pitch and intermittent phonation breaks. In severe cases aphonia may result. Other symptoms include laryngeal fatigue and non-productive coughing, and throat clearing, but local pain is seldom present. Intervention and management: If viral- needs to run its course; if bacterial: antibiotics should lead to dramatic improvements. Internal and external hydration, antibiotics if prescribed, and rest. Occasionally, cough suppressants may be prescribed. In cases of chronic laryngitis, the cause may be identified and eliminated. Voice Therapy: voice rest (no speech, no whisper either) of 2 to 3 days, and ensure sufficient hydration. Avoid excessive coughing, sneezing, or throat clearing.

Structural Changes of the Vocal Folds: Papilloma

Etiology: Virally induced (theory), wart-like growths that originate in the epithelium but invade to deeper layers, often deep into the upper respiratory tracts of young children. Papillomas may spread to other parts of the respiratory system and pose a threat to breathing if severe. They may recur, and decline in frequency beyond puberty. Symptoms: Shortness of breath in children under the age of six (usually), and hoarseness if the papillomas affect the vocal folds (cause stiffness and obstruction). The condition may become dangerous if not treated. Intervention and management: Medical/surgery mostly (if airway is affected): laser beam, or excision; radiation, or interferon. Some evidence that voice therapy may reduce the risk of recurrence. Voice therapy will be needed also following surgery. (Boone:) Some hope for use of: Indole-3-carbinol (in certain vegetables, or as approved food supplement). Repeat surgery should be avoided if possible because of the risk of scarring and development of webbing.

Structural Changes of the Vocal Folds: Polyps

Etiology: A local swelling (soft watery), response to a small internal bleeding, on the inside margin (anterior 1/3) of the vocal folds (often unilateral). Polyps can be sessile (broad-based) or pedunculated (have a stem). Usually following a (one-time) excessive vocal abuse, mostly seen in adults. Symptoms: Hoarseness; some breathy escape; because of failure of the vocal folds to connect completely; often associated hyper-function as compensation Intervention and management: -Medical: remove the cause of irritation; often surgery; -SLP: removal of excess use of the larynx (abuse). Combination of surgery and voice therapy.

Structural Changes of the Vocal Folds: Vascular Lesions (Vocal Hemorrhage, Hematoma, and Varix)

Etiology: Hemangioma/hematoma: a "soft-pliable blood-filled sac", often on the posterior glottis. They have a tendency of recurring. A bleeding into Reinke's space, caused by hyperfunction, hyperacidity, or intubation. Varix occurs when a number of capillaries together produce what looks like a "blood blister". Sataloff suggested: may be caused in premenstrual women who are taking aspirin. Symptoms: Result in vocal fold stiffness where the blood, or blood plaque is present. Voice change is likely similar to for example granulomas and other obstructions: hoarseness, breathiness, the need to clear the throat frequently. Intervention and management: Healing of the hematoma first (vocal rest), followed by a vocal hygiene program and some voice therapy. Sometimes, steroids; and in case of a varix microsurgery using laser.

Neurogenic Voice Disorder: Unilateral Vocal Fold Paralysis

Etiology: Nerve damage to peripheral nerves that innervate intrinsic muscles of the larynx. Most typical: right vocal fold paralysis (left nerve damage) due to thyroid or heart surgery. Other possibilities are: viral infection, trauma. There are two basic problems: incomplete adduction and atrophy. Symptoms: A breathy and hoarse voice quality; low pitch and low intensity. Vocal fold not fully abducted or adducted. Intervention and management: Medical: teflon injections; muscle nerve re-innervation surgery Voice therapy: respiration training, pushing approach, ear training, and promoting hard glottal attack. Recently, Boone et al have begun to favor the "head turning" and "lateral digital pressure" approaches (reduce air waste) over pushing/pulling and hard glottal attacks which, if successful, still lead to unacceptably rough voices.

Structural Changes of the Vocal Folds: Congenital and Acquired Webs

Etiology: Growing across the glottis (usually at the anterior commissure). May be congenital, or acquired (due to bilateral lesions), or infections. Symptoms: A high pitched rough sound (dysphonia), possibly stridor (audible breathing). "Cri du chat" syndrome. Intervention and management: Immediate surgery, followed by placement of a keel. Often followed by temporary tracheostomy. Voice therapy for finding one's optimal capabilities.

Structural Changes of the Vocal Folds: Laryngectomy

Etiology: If much of the laryngeal area is cancerous, or when surgery would compromise the valving functioning of the larynx (3 valves: vocal folds, ventricular folds, and aryepiglottic folds): total laryngectomy (removal of the larynx) may be necessary, and the creation of an alternate way to breathe: a stoma (result of tracheostomy). Symptoms: Natural voice not available anymore Intervention and management: Placement of a esophageal shunt (Singer and Blom) for relatively easy esophageal phonation, artificial larynx (electronic buzzing device to be held up to the neck area); on the discussion list currently there is an issue about the efficacy of using "UltraVoice"; or teach the client to use esophageal speech. The SLP assists in learning to use either of these methods effectively.

Psychological Etiologies: Identity Conflict

Examples: -Maintaining a high pitched voice by adolescent males -Trans-gender related voice conversions Especially the latter may present some clinicians with unique conflicts. You may not agree with the wish of your client to make the transgender conversion, and be uncomfortable about which ethical standards to follow in these cases (yours or your client's). Another issue is, of course, if a client wishes to use a pitch that is unnatural to the biological nature of the larynx, which would affect voice quality and the amount of effort needed for producing a naturally sounding voice. There are other qualities that may help suggest the opposite sex which aren't as abusive or effortful to the larynx.

Voice Disorder

Exists when a person's voice quality, pitch and loudness differ from those of similar age, gender, cultural background, and geographic location. In other words, when the perceptual properties of voice are so different that they draw attention the speaker, a voice disorder may be present.

Structure of the Vocal Folds

Five layers of tissue -First layer: squamous epithelium (part of mucosal lining) thinnest, forms a pliable capsule. Has little mass, needs a thin layer of slippery mucous lubrication to vibrate best. -Next 3 layers (superficial, intermediate and deep) combined are called the lamina propria. The layers of the lamina propria provide for different stretch qualities in the vocal folds. The first and most superficial of these layers is Reinke's space, and is very loose and flexible, almost like "lubrication for the surrounding capsule". It certainly contributes to the so-called "mucosal wave" visible on endoscopic exams. The "vocal ligament" is formed by layers 2 and 3 of the lamina propria and form a two step transition to the bulk of the mass of the vocal folds -Fifth and deepest layer of the VF edges: (thyro-)vocalis muscle Below the vocalis is found the Thyro-Muscularis muscle.

Extrinsic Laryngeal Muscles: Supra-Hyoid or Laryngeal Elevators

Function: for the larynx: adjust position (height, somewhat forward, and thus tension; obviously related to swallowing!) -Digastricus anterior and posterior -Stylohyoid muscles -Mylohyoid muscles Tongue Related: -Geniohyoid muscles -Genioglossus muscles -Hyoglossus muscles

Chronic Illnesses and Disorders: GERD

GERD, or Gastro-Esophageal Reflux Disease is responsible for voice problems in that it may deposit stomach acids in the larynx, and especially in between the arytenoids (which may contribute to 'contact ulcers or granulomas', edema and granulation, and when untreated may even cause hyperkeratosis and carcinoma of the larynx. Chronic throat clearing is typical with this condition and of course may lead to additional voice symptoms.

Indirect Consequences of Surgery: General Anesthesia

General anesthesia requires the use of tubes ("intubation") to ensure a free airway for the patient. These tubes may inflict "intubation injuries" to the vocal folds, with possible consequences for voice quality. The damage is apparently close to the vocal processes of the arytenoids, which may heal irregularly and need surgical correction followed by voice therapy.

Vocal Abuse

Hyperfunction, or too strenuous or frequent use of the vocal organ, may lead to inflammatory changes in the vocal fold edges. Examples: -Shouting and loud talking, for sustained periods of time -Screaming -Produce vocal noises -Frequent throat clearing (common sensations: dryness, tickling, burning, aching, "lump in the throat", or a "thickness" sensation; Globus Sensation). -Coughing (either due to a respiratory infection, but also possibly due to gastro-esophageal reflux disorder or GERD in which case it does NOT relate to vocal abuse that could be under voluntary control).

Optimal Pitch

Ideal pitch level that is theoretically healthy, efficient, and well-sounding. Clinicians can only estimate one's optimal pitch range from the results of a voice evaluation involving the client and clinician as participants to cover the perceptual aspects of this concepts.

Myo-Elastic Aerodynamic Theory

If an airway with flowing air becomes constricted, there will be (1) a pressure drop around the constriction and (2) an increased flow around the edges of the constriction. This causes a negative pressure at the walls. This is an example of the Bernoulli Effect.

Direct Consequences of Surgery

In most cases these surgeries are necessary to remove malignant tumors. These surgeries are urgent, and are conducted often without having the opportunity to carefully consider consequences for phonation or resonance.

Inter Arytenoid Muscle (IA)

Interconnect the back borders of the arytenoids. Function: Adduction of the vocal folds; arytenoids slide toward each other; may contribute to medial compression at the posterior ends of the vocal folds.

Linguistic Function of the Voice

It is not always what we say that carries the message, but how we say it. Supra-segmental variations (e.g., pitch, loudness, intonation, phrasing, pauses etc) often affect the meanings of spoken utterances. Because of all of the aforementioned functions, it is easy to see how handicapping voice disorders can be for communication.

Arytenoids

Located on sloping back-borders of cricoid lamina; they appear as three-sided pyramids with one base. A fairly long vocal process points forward into the vocal fold; a muscular process hangs over the back border and is point of attachment for several intrinsic laryngeal muscles (up from here we find the corniculate and cuneiform cartilages).

Chronic Illnesses and Disorders: Lung Cancer

Lung cancer and its treatments may be responsible for voice problems in multiple ways: -vocal fold paralysis, if the cancer/surgery affects one of the Vagus nerves. -radiation, chemotherapy, and lung surgery can do further damage in that they affect the nervous supply to the vocal folds as well as mucous secretion and internal hydration. Lung surgery furthermore, may reduce available air for phonation.

Voice

May range from simple concept (perception of speech in its entirety), to very specific (vibrations of the vocal folds, of phonation). What we will use is those physio-acoustic parameter of speech that are not related to phonemic distinctions. In other words voice in a broader perspective pertains to how we say things rather than what we are saying. Suprasegmental features are always superimposed upon the basic spoken speech elements and affect or fine tune intended meaning.

The Body-Cover Theory

Mucosal Wave: fluid wave like movements Transition (vocal ligament) Body (muscle): provides stability Three types of movement can be distinguished in each glottal cycle: 1. horizontal 2. longitudinal (zipper like) 3. vertically (also zipper like) The first two of these can be seen during endoscopy. The vibration results in pulses of air ("pressure bubbles") to be released into the vocal tract.

Structural Changes of the Vocal Folds: Nodules

One of the most common benign vocal fold lesions. Inflammatory degeneration of the superficial layer of the lamina propria. Vary in number, and size from a "pinhead" to a "pea". Etiology: Acute or Chronic abuse of the vocal folds, excessive use of voice in certain professional settings (teachers, actors, singers). Often nodules are bilateral (because of the impact of the vocal folds: usually at the anterior 1/3). The swelling is somewhat harder than for example a polyp, or edema. The surface can even become callous, which makes nodules permanent if not detected in time and require surgery. Nodules respond to voice therapy usually (especially if small and new). Most common in children (girls and boys) and adult females. Symptoms: Hoarseness and roughness; some breathy escape; because of failure of the vocal folds to close completely; often associated hyperfunction as compensation. Intervention and management: Voice therapy in most cases, surgery in extreme cases (sometimes scarring results or vascular related abnormalities). 1. identifying the abuses/misuses 2. reducing the occurrence of these abuses 3. find a treatment with the client that produces "easy optimal" voice production

Types of Voice Disorders

Organic Voice Disorders:(structural deviations, or diseased tissues) Primary treatment: medical, dental, surgical. Neurogenic Voice Disorders: Damage to peripheral nerves, or CNS structures Functional Voice Disorders: -Psychogenic Voice Disorders -Muscle Tension Dysphonia

Emotional Function of the Larynx

Our voice presents one of the primary means for expressing emotions. Also, emotional states often affect voice quality. Because emotionality and voice are so closely linked, voice therapy often needs to address emotions, and a person as a whole, not just the voice problem component. Finally, it is not uncommon to find emotional/psychological resistance to certain recommended voice changes.

Crico Thyroid Muscle (CT)

Pars recta: from the annulus of cricoid straight up to the lower inside border of the thyroid lamina; Pars oblique: from the annulus of cricoid back and up to the inferior horns, and lower, inside, border of thyroid. Function: pull the Thyroid cartilage forward and down in a rocking fashion; the vocal folds are stretched and longitudinal tension is increased for raising one's pitch. Our main mechanism for regulating pitch; by increasing tension in the cords these muscles contribute to adduction as well. When the thyroid is pulled forward and down, the anterior part of the cricoid has the tendency to move upward, this movement is restricted by the crico-pharyngeus muscle (lower part of the inferior pharyngeal constrictor).

Primary Disorder Etiologies: Cerebral Palsy

Persons who have forms of cerebral palsy could have the voice differences typical of almost any possible form of dysarthria. We may encounter: "labored, monotonous, strained phonation", other differences relate to a lack of controlling loudness, or meeting the respiratory conditions for a normally sounding voice. It doesn't seem to make any sense to treat the dysarthrias as a group separately from cerebral palsy. Most of the dysarthrias represent the same conditions as found under CP but specific to the speech system. In general where speech is affected by CNS or PNS damage, voice symptoms are also expected, and are of course consistent with the other speech related impairments.

Modal Pitch

Pitch used most often in speech. It manifests itself as a frequency used pitch baseline from where intonation takes off. The range of such intonation jumps is not very big, usually a few whole tones on a scale at the max. This pitch can be best estimated from Visipitch, or by comparing one's speech with the keys on an electronic keyboard.

Hyoid Bone

Point of support for the extrinsic tongue muscles and the laryngeal structure below. Parts: body, greater and lesser horns.

Inappropriate Use of Vocal Components/Systems: Respiration

Pressure between 3-7cm H2O; flow between 50-200 ml/sec. and a sufficient volume to support such flow

Psychological Etiologies: Conversion Behaviors

Previously called "hysteria"; when stress or a conflict raises to a level where it can't be consciously accepted, it may be avoided through unconscious substitution with a somatic symptom (either sensory or motor in nature). The exact nature of symptoms cannot be specifically predicted or completely described but may take on the form of muteness, whispering, or some form of dysphonia when it involves the voice system. They would simply be the conversion symptoms as they may express themselves in the voice system, but overall this would make up a small proportion of the possible manifestions.

Innervation of the Larynx

Provided by the Vagus Nerve The Superior Laryngeal (SLN) branch provides sensory feedback and the External branch of the SLN only goes to the CT muscle. The Recurrent Laryngeal nerve supplies all intrinsic muscles besides the CT muscle. If damaged it could cause vocal fold paralysis, but this is mostly one sided.

Inappropriate Use of Vocal Components/Systems: Rate

Rapid speech may be associated with vocal hyper-function and poor breath support.

Chronic Illnesses and Disorders: COPD

Relatively chronic respiratory illnesses, such as asthma, chronic obstructive pulmonary disease (COPD), and lung cancer may directly or indirectly lead to voice symptoms. Hoarseness could result from coughing and poor respiratory support related to wheezing and dyspnea (difficult, labored, uncomfortable breathing), or the medications to treat these conditions. Bronchodilators (e. g., albuterol) may lead to tremors and nervousness, while corticosteroid inhalers, with prolonged use, may lead to "vocal fold bowing" and elevation of fundamental frequency.

Cricoid Cartilage

Shaped like a signet ring. The arytenoids are positioned over the back border, and can produce a sliding (toward/away from midline), rocking/tipping (forward backward), and rotation-wise (some) movements.

Thyroid Cartilage

Shaped like a visor. Contains the vocal folds; thyroid gland is directly anterior to it. Note the thyroid angle (130◦) in newborns; angle becomes more acute during development; end result differs for men (90◦) and women (110◦)); laryngeal prominence (Adams Apple). It, like most other cartilages (except the epiglottis), is composed of hyaline cartilage which ossifies and limits flexibility with age. Also, note the laminae, and the thyroid notch.

Chronic Illnesses and Disorders: Sinusitis and Upper Respiratory Infections

Sinusitis and upper respiratory infections produce drainage problems, however, it is coughing and throat clearing related to this condition that is technically responsible for the resulting hoarseness as the drainage naturally flows to the esophagus.

Chronic Illnesses and Disorders: Smoking, Alcohol Abuse, and illicit Drug use

Smoking, alcohol abuse, and illicit drug use may have negative effects on the vocal mechanism. Smoking: hot air related to smoking, when inhaled can lead to erythema (reddening), edema, and generalized inflammation. Moreover, prolonged exposure to the chemicals related to smoking can produce growths of various forms of severity: polyps, leukoplakia and hyperkeratosis (the last two of which are known pre-cancerous conditions) and carcinoma.

Psychological Etiologies: Environmental Stress

Some dysphonias may result directly from stress, and do not show evidence of other etiologies typical for the symptoms. A case history typically confirms this.

Chronic Illnesses and Disorders: Emotional Disorders

Some emotional disorders (tension, depression etc.), also, may be responsible for multiple complications affecting one's voice: (1) laryngeal area tension, (2) poor respiratory support, and (3) whole body fatigue from poor sleep habits. Associated medications here too can have drying affects on the mucosal linings of the larynx.

Chronic Illnesses and Disorders: Lower Intestinal Disorders

Some lower intestinal disorders, furthermore, require prescriptions which work as 'drying agents' and of course may lead to dehydration in the vocal folds.

Vocal Tract Resonance

Sound waves created by the vocal folds ("Source Function") may excite air molecules in the supra-glottic spaces (Resonance: "Filter function"). Fant described the "linear source-filter theory" of speech production. Vocal fold oscillation at the level of the folds is nothing more than a "buzz" (with a certain pitch and loudness). The "filter" creates the perceptual attributes of phonation (quality, resonance).

The Bernoulli Effect

The Bernoulli Effect (1) is the aerodynamic aspect of a set of forces that produce, and sustain, vocal fold vibration. In addition to the Bernoulli Effect there are: (2) sub- glottic pressure, and (3) elastic forces within the vocal folds when they are drawn apart. Combined these forces are described in the Myo-Elastic Aero-Dynamic theory of vocal fold vibration.

Neurogenic Voice Disorder: Cricothyroid Muscle Paralysis

The Superior Laryngeal Nerve is not frequently affected by trauma. The most likely cause of SLN damage is virus infection. This leads to paralysis that affects the left, right or both vocal folds. Upon examination: slight rotation of the involved vocal fold to the normal side, as well as a slight bowing (because of atrophy, or a reduction in muscle tissue) of the vocal fold on the involved side. VOICE SYMPTOMS: inability to elevate pitch and some breathiness.

Parameters of phonation (Mode)

The manner of the vocal fold oscillation. Relevant terms: normal phonation, falsetto, glottal fry, laryngeal whistle Mode: a range of frequencies with the same type of oscillations. Modes typically overlap in frequency. Register: a range of frequencies with the same Phonatory Quality. A pitch break is a term reserved for a sudden switch in mode of phonation (e.g., "yodeling").

Parameters of phonation (Loudness)

The perception of vocal fold oscillation intensity. This is mostly determined by an individual's sub-glottic pressure.

Parameters of phonation (Pitch)

The perception of vocal fold oscillation/vibration rate (fundamental frequency) Optimal pitch range Modal or habitual pitch There is a range of tones optimal for speech production, and it normally starts at the low end about two whole tones from the lowest possible tone with normal phonation and up. Finding best pitch is difficult because it is not based on a simple mathematic rule.

Who is on the voice pathologists team and what is a crucial skill they need to have and be knowledgeable of?

The team includes a laryngologist, and maybe other relevant medical specialists, counselor/psychologist/psychiatrist, vocal coaches, and singing instructors. A voice pathologist needs to have good counseling skills to know how to deal with the emotional component of many voice problems, and to know when to make referrals. A voice pathologist needs to be knowledgeable about: -Normal anatomy and physiology -Laryngeal pathologies -Etiologies -Diagnostic methods including: -Perceptual assessment -Vocal acoustics -Vocal aerodynamics -Laryngeal imaging techniques -Therapy methods

Indirect Laryngoscopy

The use of a dental mirror and light to see the vocal folds. Inventor is Manuel de Garcia (1854) who was a Parisian singing teacher.

Voice Disorders in the Normal Population

To determine norms for voice problems in the general population is difficult. The voice may be affected by colds, allergies, temporary needs to use the voice a lot. Others have voice problems of a more permanent nature, or have professions that require a lot of speech or voice production. The population incidence of voice problems elsewhere is described as about 3% (adults) and 7% among children. Looking at specific professional populations this number is much higher (20% among teachers, the highest incidence is among cheerleaders).

Inappropriate Use of Vocal Components/Systems: Loudness

Too soft, too loud, lack of variability); vocal intensity is determined by the lateral excursion of the vocal folds and the speed with which they approximate??, as dictated by subglottic pressure, and the resultant airflow

Parameters of phonation (Prosody)

Variations in: pitch, loudness, completeness/ deliberateness of production, (speech sound/syllable) duration, and rate. Terms: intonation, stress, emphasis, punctuation, rate and rhythm.

Indirect Consequences of Surgery

Voice changes due to surgery may be due to indirect effects of surgery on parts of the body not normally involved in phonation or speech production: heart surgery or thyroid surgery for example. The more typical case scenario is damage to the recurrent laryngeal nerve, which has a relatively unpredictable course. This type of damage results in varying degrees of paralysis (usually of one vocal fold, or the loss of sensation in its mucosal lining).

Real-life Examples of the Bernoulli Effect

Wings of an airplane; cars passing at different speeds and as a result move toward each other. When vocal folds approximate, the glottis narrows. Because of this, airflow between the folds increases while a medial pressure in the cords builds up pushing the tissue into the air stream. The vocal folds are drawn to each other until closure stops the airflow and sub-glottic air pressure takes over and pushes them apart.