copyright © 2008 delmar. all rights reserved. unit seven voice disorders
TRANSCRIPT
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Unit Seven
Voice Disorders
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Chapter 27
Anatomy and Physiology
of the Respiratory
and Phonatory Systems
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3
The Respiratory System
• Driving support of voice production
• Intricate balance between respiration (inhalation and exhalation) and phonation
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4
Supportive Structures of Respiration
• Bones in the chest provide framework and protection of the respiratory system
• Thorax– Contains the lungs and the heart
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5
Muscles of Respiration
• Diaphragm– Primary muscle
• Internal and external intercostals
• Pectoralis major and minor muscles
• Rectus abdominis muscles
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Trachea
• Extends from larynx down to the lungs
• Composed of cartilaginous rings
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Respiratory Process
• Diaphragm lowers and rib cage expands
• Space in thoracic cavity increases
• Air pressure decreases in lungs
• Air flows down trachea into lungs
• Alveolar sacs and chest relax and air is forced from lungs
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Phonation
• Larynx is the organ of phonation
• Sits at top of trachea and below root of tongue
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Framework of Larynx
• Cricoid cartilage
• Thyroid cartilage
• Two arytenoid cartilages
• Epiglottis
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The Vocal Folds
• Biological function– To prevent food/liquid entering the trachea
• Overlaid function of true vocal folds is to produce voice
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11
Vocal Folds
• Glottis– Space between open vocal folds
• Posteriorly– Vocal folds attach to the arytenoids
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12
Vocal Fold Vibration
• Vocal folds must open and close to produce voice
• Vocal folds are open when breathing
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Vocal Fold Vibration
• To produce voice– Folds close
• Air pressure beneath the folds increases and forces folds to open
• Elasticity and Bernoulli’s law causes folds to close
• Subglottic air pressure builds up and forces folds to open again
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Maximum Phonation Time (MPT)
• Length of time a person can sustain a tone or sound on one expiration
• Varies based on gender, age, physical characteristics, health
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Frequency
• Frequency – Number of cycles of opening and closing
the vocal folds per second– Measured in Hertz (Hz)
• Fundamental frequency – Rate of vocal fold vibration
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Pitch
• Psychological sensation of the frequency of a sound
• Pitch changes based on vocal fold:– Tension– Mass– Length
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Loudness
• Perceptual correlate of intensity of a sound– Intensity measured in decibels (dB)
• Relates to the force with which vocal folds open and close and the amount of air that escapes
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Voice Quality
• Judgments of voice quality are subjective
• Quality is affected by:– Adequate vocal fold closure– Efficient timing of closure– Amount of tonicity within the folds
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Chapter 28
Voice Disorders
in Children and Adults
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Voice Disorder
• A deviation of loudness, pitch, or quality out of the range of a person’s age, gender, or geographical background
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Classification of Voice Disorders
• Functional – Faulty use of mechanism
• Neurological– Related to muscle control and innervation
of muscles
• Organic – Related to physical changes in larynx
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Functional Voice Disorders
• Hyperfunctional – Excess tension or forcing in larynx
• Hypofunctional– Decreased or inadequate tension or
reduced vocal capacity
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Laryngitis
• Inflammation of vocal folds
• Voice is associated with lowered pitch and phonation breaks
• Vocal quality is hoarseness
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Chronic Laryngitis
• Laryngitis lasting longer than 10 days
• Causes may include:– Traumatic laryngitis– Allergies– Singing excessively at damaging intensity
levels– Smoking
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Vocal Nodules
• Most common benign lesions in children and adults
• Typically bilateral
• Occur at juncture of anterior and middle one third of vocal folds
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Vocal Nodules
• Caused by continuous abuse/misuse of voice– Screaming, coughing, singing in abusive
manner
• Voice quality is hoarseness
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Vocal Polyps
• Benign vocal fold lesions
• Frequently unilateral
• Occur at juncture of anterior and middle one-third of vocal folds
• Vocal quality is hoarseness
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Functional Dysphonia
• May be hyperfunctional or hypofunctional
• No medical or surgical treatment
• SLP works to improve intensity, pitch, quality
• Psychological support may be beneficial
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Functional Aphonia
• Hyperfunctional voice disorder
• Voice is typically whispered
• Most causes are psychological
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Falsetto
• High-pitched breathy voice
• Produced by vibration of anterior one-third of the vocal folds
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Organic Voice Disorders
• Papillomas
• Contact ulcers
• Trauma
• Cancer
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Papillomas
• Soft wart-like growths
• Viral in origin
• Occur mainly in children– 4-6 years
• Vocal quality is hoarseness
• Treatment is surgical removal
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Contact Ulcers
• Small ulcers at juncture of middle and posterior one third of folds
• Can be caused by:– Persistent and excessive slamming of
arytenoids and hard glottal attacks– Gastroesophageal reflux– Intubation for surgery
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Contact Ulcers
• Voice quality is hoarseness
• Voice therapy is usually successful
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Traumas
• Various traumas can compromise the airway and affect the larynx
• Voice therapy will focus on helping clients achieve their most functional voice
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Cancer
• Requires surgical and medical treatment
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Neurological Voice Disorders
• Hypoadduction– Difficulty getting the vocal folds together– Vocal fold paralysis
• Hyperadduction– Vocal folds close too tightly or for too long
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Vocal Fold Paresis and Paralysis
• Unilateral paralysis – Vocal quality is breathy– Has low intensity– Diplophonia
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Spasmodic Dysphonia
• Strained, strangled, harsh vocal quality
• Affects females more than male
• Onset on average at 45 years of age
• Treatment involves voice therapy and medical-surgical approach (Botox)
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Chapter 29
Voice
Evaluation and Therapy
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Examination
• Indirect laryngoscopy– Place a laryngeal mirror into back of mouth– Direct light onto mirror to shine on the
vocal folds
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Examination
• Endoscope placed intraorally or transnasally
• Can be videotaped (videoendoscopy)– Or observed with a strobe light
(videostroboscopy)
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Voice Screening
• Screenings of voice will determine if a complete evaluation is needed
• Screening tasks include:– Count 1 to 10– Conversation– Phonating vowels
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Voice Evaluation
• Case history
• Assessment of voice– Perceptual, acoustic, physiologic
• Instrumental evaluations
• Self-perception
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Instrumental Evaluations
• Aerodynamic
• Electroglottography
• Electromyographic assessment
• Photoglottography
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Voice Therapy
• Multifaceted approach is required
• Specific voice therapy will depend on age of client, type, and severity of disorder
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Hygienic Voice Therapy
• First step in many therapy programs
• Focus on instilling healthy vocal behaviors in habitual speech patterns– Determine misuse– Become aware of these behaviors– Eliminate damaging behaviors
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Symptomatic Voice Therapy
• Reduce/eliminate abuse and misuse of voice through facilitating techniques– Auditory feedback– Change of loudness– Counseling
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Psychogenic Voice Therapy
• Identify and modify the emotional and psychosocial behavioral reasons that cause a voice disorder
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Physiological Voice Therapy
• Directly alter or modify the physiology of the vocal mechanism
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Eclectic/Holistic Voice Therapy
• Combination of any or all of the orientations and approaches of voice therapy
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Laryngectomy
• Surgical removal of the larynx
• Surgical approach to treating laryngeal cancer
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Before a Laryngectomy
• Establish immediate means of communication after surgery
• Discuss choices of voice production– Tracheoesophageal puncture (TEP)– Esophageal speech– Electrolarynx
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Tracheoesophageal Puncture (TEP)
• Incision made into trachea
• Valve directs air from trachea into esophagus
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Esophageal Speech
• Compressing air and injecting into esophagus
• Expel air from esophagus causing it to vibrate upper esophageal valve
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Electrolarynx
• Neck devices with vibrating source that produces sound
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Chapter 30
Emotional and Social
Effects of Voice Disorders
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Emotional and Social Effects
• The voice reflects our personality
• It is an indicator of emotions and attitudes
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The Voice
• The voice is the mirror of the person
• The voice reflects our personality
• The voice is an indicator of emotions and attitudes
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Voice
• In a social context, the voice will convey:– Semantic content– Emotional state– Personality characteristics
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Young Children
• Many children are unaware or unconcerned with a hyperfunctional voice disorder
• Voice therapy may not begin until kindergarten
• Parents are counseled on how to encourage less abusive voice use by their children
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Children
• As children get older, they become aware of their voice and are better candidates to participate in voice therapy
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Adolescents
• Adolescents with chronic voice problems are typically motivated to participate in a voice therapy program
• Adolescents with falsetto voices can experience significant social penalties – especially boys
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Adults
• Twenty-five percent of adults are displeased with the sound of their voices
• A holistic approach to treatment views the whole person when determining the best therapy program for an adult with a voice disorder