12/7/2010

VOICE DISORDERS

AIISH | Project

injurious inhalation. Also one or more aspects of voice (loudness. vocal abuse and misuse. CVA. Quality & Loudness. A voice is termed "disordered" when the vocal quality of an individual is altered/changed in such a way that it is thought to be abnormal to the listener. given an individual¶s age &/or sex (ASHA). For e. Voice disorders result from faulty structure or function somewhere in the vocal tract.V oice is the laryngeal modification of pulmonary air stream which is further modified by the configuration of the vocal tract (Brackett. Degenerative neurologic disease. and chronic allergies may characterize slow onset." Examples of characteristics of sudden onset may be: trauma. conversion reaction. An important part of assessment of a patient is the determination of which of these four conditions are present. The production of voice is dependent on four primary factors. pitch. The voice conveys information about the speaking individual. phonation. infection. Voice disorders are characterized by the abnormal production &/or absence of vocal quality.g. i) Pulmonary air pressure. . gender. a vocal fold polyp (structural /neoplastic cause) may arise as a result of primary muscle tension imbalance as a result of voice abuse (shouting when suffering from a viral upper respiratory tract infection/inflammation). Voice problems can be broadly classified into four main categories: structural/neoplastic. neuromuscular. or geographical background of the speaker. Pitch. pitch. resonance. in the processes of respiration. growths of folds. The onset and development of these disorders can be "sudden" or "slow. physiological & social characteristics to the world. gastro-esophageal reflux. & muscle tension imbalance. There are mainly three attributes of voice. or resonance. quality. or a severe allergic reaction. inflammatory. or resonance) are outside of normal range of age. which are primary & which are secondary. Many patients will have evidence of more than one of these conditions contributing to their voice condition & this may change at different phases in the chronology of the condition. ii) Vocal fold vibrations. intubation. iii) Transfer function of vocal tract. 1971). musculo-skeletal tension. loudness. The presence of polyp can in turn cause secondary physical trauma to the vocal folds & a muscle tension imbalance to compensate for the alteration in the biomechanical properties of vocal folds. & the voice quality serves as a primary means by which speakers project their physical. & which are actually contributing to the patient¶s voice complaint. &/or duration. and iv) Central nervous system.

dryness. Adults: 3-9% of the population Classification of Voice Disorders Based on Perceptual Signs  Disorders of Pitch  Disorders of Loudness  Disorders of Quality  Disorders of Non-phonatory behaviors  Aphonia Based on Etiology  Functional  Organic  Psychological . discomfort.  Difficulties or restrictions in the use of voice at different times of the day or related to specific daily. social or occupational related tasks. mucus) particularly related to voice use. hoarseness & breathiness  A deeper or higher pitched voice that is not appropriate for the age & sex  Problems controlling the voice described as pitch breaks.  Difficulty making oneself heard in a noisy environment or in raising the voice.  Effort in producing voice.  Reduced stamina of the voice or one that tires with use. Incidence Children: 3-6% of the population.  The consequent emotional.  Difficulty in singing. psychological effects caused by the above.  Throat-related symptoms (soreness.The common voice complaints / symptoms are:  Change in voice quality (harshness.  A reduced ability to communicate effectively. aching. squeaky voice or the voice cutting out.

Functional Voice Disorders Functional disorders encompass all disorders that result in physical change. and breathy voice with some hoarseness accompanied by discomfort or even stabbing pain ii) Vocal Nodules: Definition: localized benign growths on the vocal folds that are usually thought to be a result of vocal abuse. hoarseness. Etiology: due to vocal abuse when the tissues are under constant stress induced by frequent. 1. other than hyperfunctional). however we are also subcategorizing them as Voice Disorders Resulting from Abuse (i. vocal fatigue.. Voice Disorders with No Indication of Pathology. but do not have a known cause. sensation of something in throat. Psychogenic Voice Disorders. abuse or misuse). They are typically hyperfunctional voice disorders (e. and Manifestations of Voice Disorders. Laryngoscopically. (2) constant throat clearing that is secondary to irritation of mucosa due to gastroesophageal reflux or regurgitation of peptic acid. Symptoms: constant throat clearing. and breathiness iii) Vocal Polyps: Definition: soft fluid filled bulges located at the front region of the vocal fold Etiology: vocal abuse . Hyperfunctional Voice Disorders i) Contact Ulcers: Definition: A small ulceration that develops on the medial surface of the vocal processes of the arytenoid cartilages.g. Etiology: (1) predominantly in males average age of 50 who engage in a great deal of aggressive speaking or so called type A personality.e. hard oppositional movement of vocal folds Symptoms: soreness or pain in neck.. a contact ulcer will be visible as a buildup of pink or pinkish-white tissue on one of the vocal processes of the arytenoids.

Psychogenic Voice Disorders i) Functional Aphonia: Definition: absence of voice Etiology: (1) acute stress to vocal folds (2) laryngeal pathology or other disease Symptoms: no voice present 4. audible inhalation 2. Etiology: Chronic smoking or tobacco use. alcohol use. A precancerous lesion develops on the tongue or the inside of the cheek as a response to chronic irritation.e. Voice Disorders with No Indication of Pathology i) Ventricular Dysphonia: Definition: a condition in which the false vocal folds. other than hyperfunctional) i) Hyperkeratosis: Definition: a mass of accumulated keratin (a scleroproteinous pigmented spot or covering) which may grow on the inner glottal margins which may occasionally develop into malignancy Etiology: smoking.Symptoms: hoarseness. Voice Disorders Resulting from Abuse (i. environmental pollution and other factors Symptoms: pronounced hoarseness ii) Leukoplakia (Keratosis): Definition: a disease characterized by a whitish patchy thickening of the epithelium of a mucous membrane. roughness 3. the ventricular bands adduct together over the true vocal folds below Etiology: (1) pathology may be unknown (2) may occur due to true vocal fold disease Symptoms: monotonous voice. low pitched . shortness of breath. Symptoms: hoarseness..

reduced maximal phonation time iii) Thickening of Vocal Folds: Definition: a disorder that occurs when vocal folds become too thick or massive Etiology: unknown.5. Manifestations of Voice Disorders i) Phonation Breaks: Definition: temporary but complete cessation of phonation Etiology: occurs after prolonged hyperfunction Symptoms: breaks in phonation. restricted phonation range. Traumatic / Surgical Voice Disorders. alcohol/smoking may contribute. complains of vocal fatigue and need to increase vocal effort to speak ii) Pitch Breaks: Definition: unexpected and uncontrolled sudden shifts of pitch in either an upward or downward direction are readily perceived even by an untrained listener Etiology: (1) frequently associated with the changing voice of the adolescent male. . and is usually a temporary stage that changes with time (2) may occur as a result of laryngeal pathology or as an accompaniment to conditions that involve some loss of neural control of phonation Symptoms: inappropriate pitch level.. Viral / Bacterial / Infectious Voice Disorders. and Other Voice Disorders (i. those with no determined etiology). pitch breaks. GERD Symptoms: abnormal vibratory patterns of vocal folds Organic Voice Disorders Organic voice disorders are those disorders that do have a known cause.e. increased fundamental frequency. We are subcategorizing them into four categories: Neurological Voice Disorders.

movement range. breathiness. harsh vocal quality. voice tremor. resonance disorders. vocal noise. Neurological Voice Disorders i) Flaccid Dysarthria: Definition: A perceptually distinguishable motor speech disorder produced by injury or malfunction of one or more of the cranial or spinal nerves. slow rate. PICK's) (2) stroke (3) trauma (4) inflammation (5) tumor (6) drug toxicity (7) normal pressure hydrocephalus Symptoms: monopitch.1. axons. mild hypernasality iv) Ataxic Dysarthria: Definition: a motor speech disorder caused by a widespread disturbances in timing. and coordinated and alternating forcing functions of the muscles of the speech and respiratory mechanism . imprecise consonants. resonatory and articulatory components of speech and reflects problems in the nuclei. nasal emissions. speed. audible inspiration. voice stoppage. control of dysmetria. monopitch. low pitch. short phrases. synergy. phonatory. hypernasality iii) Hypokinetic Dysarthria: Definition: a motor speech disorder caused by damage to the basal ganglia Etiology: (1) degenerative diseases (Parkinson's. inappropriate interruption of phonation. breathy voice. variable rate. monoloudness. or neuromuscular junctions that make up the motor units of the final common pathway Etiology: (1) surgery (2) trauma from accidents (3) muscle disease (4) tumor (5) stroke (6) infections (7) degenerative and demyelinating diseases (8) anatomic malformations Symptoms: hypernasality. reduced stress. harsh voice. harsh voice. Alzheimer's. strained voice. It may be manifested in any or all of the respiratory. monoloudness ii) Hyperkinetic Dysarthria: Definition: a motor speech disorder where involuntary movements and variable muscle tone are present as a result of damage to basal ganglia Etiology: (1) Huntington's Disease (2) vascular trauma (3) infections (4) neoplastic and metabolic factors Symptoms: inappropriate loudness.

bronchi. and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6) birth trauma (7) central nervous system disease Symptoms: breathiness. diplophonia. monopitch. hoarseness. and dysphonia . low pitch voice vi) Vocal fold paralysis: Definition: a unilateral or bilateral paralysis of the vocal folds occurs when conduction of nerve impulses is temporary blocked. Acquired web result from injury to the vocal folds. monoloudness. Bacterial and Infectious Voice Disorders i) Laryngeal Webbing: Definition: a band of tissue varying in size that extends across the glottis between the two vocal folds. Etiology: prolonged infection or trauma Symptoms: varying degrees of breathing problems.Etiology: (1) stroke (2) tumor (3) infection (4) ataxic cerebral palsy Symptoms: hoarse breathy coarse voice with tremors. diplophonia. and aphonia 2. Etiology: (1) peripheral lesions of Vagus nerve (2) neuritis (3) neoplasm's in neck. Congenital webs results as the glottal membrane fails to separate in the embryonic development. the axons of the nerve section. and explosive pitch outburst v) Spastic Dysarthria: Definition: a disorder resulting from disturbances in muscular control over the speech mechanism due to damage of the central (brain) or peripheral (spinal cord) nervous system Etiology: (1) stroke (2) accident/trauma (3) tumor Symptoms: harsh vocal quality. or the nerve fibers are entirely cut which disturbs glottal closure due to lack of adduction of the affected vocal fold. Viral.

and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6) birth trauma (7) central nervous system disease Symptoms: breathiness. hoarseness. Traumatic/Surgical Voice Disorders i) Granuloma: Definition: area of thickened irregular tissue on vocal folds caused by irritation Etiology: (1) complication of intubation (2) contact (3) gastroesophageal reflux Symptoms: breathiness. hoarseness. Etiology: (1) peripheral lesions of Vagus nerve (2) neuritis (3) neoplasm's in neck. or the nerve fibers are entirely cut which disturbs glottal closure due to lack of adduction of the affected vocal fold. bronchi. diplophonia. swallowing difficulty (rare).ii) Papilloma: Definition: is a common benign tumor that starts in the epithelium that interfere with glottal closure depending on the extent of the lesion which causes increased stiffness Etiology: caused by a virus of the papovavirus group Symptoms: low pitch level iii) Traumatic Laryngitis: Definition: a minor inflammation of the larynx and surrounding tissues causing temporary hoarseness. sore throat. slight fever. the axons of the nerve section. phonation breaks ii) Vocal fold paralysis: Definition: a unilateral or bilateral paralysis of the vocal folds occurs when conduction of nerve impulses is temporary blocked. Etiology: (1) viruses (2) bacteria (3) Allergies (4) excessive use of voice (5) electrolyte disturbances (6) tumors (7) changes in production of hormones by endocrine glands Symptoms: hoarseness or loss of voice. and aphonia . tiredness 3. sensation of lump in throat.

Acquired web result from injury to the vocal folds. diplophonia. alcohol/smoking may contribute. and failure to maintain voice. Other Voice Disorders i) Puberphonia: Definition: a high-pitched adolescent voice that occurs passed the age of puberty in males Etiology: difficult to determine the physical or psychological factors Symptoms: high pitch ii) Spasmodic Dysphonia: Definition: a disorder described as both functional/organic basis that is a rare condition with a neurological basis Etiology: (1) psychological influence (2) unknown cause Symptoms: strained struggled effortful voice which is hoarse with tremors. pharynx. GERD Symptoms: abnormal vibratory patterns of vocal folds iv) Carcinoma: Definition: cancer is a disease that may affect the structures of the oral cavity. and dysphonia 4. intermittent voice breaks. Etiology: prolonged infection or trauma Symptoms: varying degrees of breathing problems.iii) Laryngeal Webbing: Definition: a band of tissue varying in size that extends across the glottis between the two vocal folds. iii) Thickening of Vocal Folds: Definition: a disorder that occurs when vocal folds become too thick or massive Etiology: unknown. and larynx. breathy spasms. The lesion . hypernasality. Congenital webs results as the glottal membrane fails to separate in the embryonic development. Most carcinomas of the vocal fold are squamous cell carcinomas. jerky voice onset.

excessive coughing. Pitch breaks & Pitch tremors.Assessment of pitch includes ascertaining pitch disturbances & quantifying the disturbances using rating scales.This usually involves analyzing the psycho-acoustic / perceptual correlates of voice ± pitch. It is the most common benign tumor in infants Etiology: unknown Symptoms: inspiratory stridors. Etiology: (1) smoking (2) environmental irritants (3) chemical or other contaminants (3) metabolic disturbances (4) unknown causes Symptoms: hoarseness.begins unilateral. lump in neck. broadening of larynx. Consensus Auditory ± Perceptual Evaluation of Voice (CAPE-V) etc are some of the tools used for perceptually evaluating the voice. the relevance of defects & their impact on the subject¶s ability to communicate. The mass and the stiffness of the cover are increased. but can extend to the contralateral side. and dysphagia Assessment Procedures Based on state of the art technology. Includes assessing Habitual Pitch. Perceptual evaluation ± Perceptual evaluation is the fundamental in assessing voice quality. The Voice Profile Analysis Protocol. Voice Assessment Protocol for Children & Adults. . This evaluation usually involves the rating scale. The vocal fold tissue is asymmetrical and glottic closure is usually bothered. assessment of voice disorders can be performed in a non-intrusive way. Buffalo Voice Profile. tenderness in neck v) Hemangioma: Definition: a blood sac that usually occurs in the head and neck region. Qualitative Assessment . and many treatment plans are successful. The GRABS scale. Pitch stability. hoarseness. quality & loudness. Total Pitch Range. Assessment of Pitch .

Breathy. Highest F0.Hz). Smoothed Pitch Period Perturbation Quotient (sPPQ %). c) perturbation measures of frequency & amplitude. Amplitude / Intensity & its related measures . to determine variation from established norms.Habitual loudness. Speed of Fluctuation in Fundamental Frequency (Hz/sec). Coefficient of Amplitude Variation (vAm %). Amplitude Perturbation Quotient (APQ %). F0-tremor frequency (fftr .Vocal quality is the perceptual correlate of harmonics. Variation in F0 (vF0 %).Acoustic analysis uses a computer to analyze the patient's voice. standard deviation of F0. Amplitude Perturbation measures . Fall time (ms). Lowest F0. Relative Average Perturbation (%). Rise time (ms). Extent of Fluctuations in Fundamental Frequency (Hz). Pitch Period Perturbation Quotient (%). Intensity range (dB). Quantitative Assessment / Acoustic Analysis . & hoarse are the three main disorders of voice quality. . Frequency Perturbation Measures ± comprise of Absolute Jitter (µ sec). Amplitude Tremor Frequency (ATRI %). Smoothed Amplitude Perturbation Quotient (sAPQ %).consist of Mean intensity (dB). b) amplitude / intensity & related measures. and d) other measures such as tremors & soft phonation index. Frequency of Amplitude Tremor (Fatr).- Assessment of Loudness . F0 Tremor Frequency (Fftr Hz). Jitter Percent (%). harsh. Loudness range & Loudness variability are assessed. Shimmer Percent (%). Acoustic analysis involves the extraction of a) fundamental frequency & related measures.involves Shimmer (Sh dB). Fundamental frequency & its related measures . Characterization of voice quality is one of the key facets of perceptual assessment & an integral part of any voice evaluation.includes Fundamental Frequency (Average F0). resonance & symmetry of vocal fold vibrations. - Assessment of Vocal Quality . Extent of Fluctuation in Intensity (dB) Speed of Fluctuation of Intensity (dB/sec). Frequency range in Phonation & Speech (in Hz). Frequency Tremor Index (FTRI %).

open & speed quotients. EGG basically demonstrates vocal fold contact area based on motion-induced changes in electrical impedance. Praat. . subglottic pressure.g. stroboscopy is necessary for correct diagnosis. Vaghmi. MDVP (Multi Dimensional Voice Program). For e. Nasalance etc. F0 & its deviations. Acoustic analysis of the voice is one part of the complete examination of voice. volume.- Other perturbation measures ± Normalized Noise Energy (NNE dB). Degree of Voice Break (DVB %). Harmonic to Noise Ratio (HNR). etc. etc are derived. For e. There are different tools / softwares which help in the acoustic analysis. The quantitative analysis of resonance include obtaining measures such as TONAR (The Oral & Nasal Airflow Ratio). More than 33 different aspects of voice are analyzed from a single vocalization (in MDVP). and phonation time. Various functional vocal fold vibration parameters such as closed & open durations. & tremor measurements could also be derived from the electroglottogram at greater accuracy than from microphone signal. Electroglottography (EGG) . Phonatory Function Analysis . Signal to Noise Ratio (SNR)." Stroboscopy can reveal laryngeal diseases early in their development. Noise to Harmonic Ratio (NHR). speed index. Helios. Nasal view¶ is a tool for obtaining such measures. These changes in the electrical impedance when both the vocal folds vibrate is obtained & graphically represented. Voice Turbulence Index (VTI).EGG is a non-invasive technique of drawing inferences about certain aspects of vocal fold vibration & therefore is very helpful in assessing laryngeal function. Dr. peak airflow. Videostroboscopy . Capturing the examination on videotape allows the examiner and physician to review the film following completion of the examination (videostroboscopy). Speech.g.Measurement of aerodynamic function consists of measurements of airflow. airflow rate. Stroboscopy allows the examiner to observe the movement of the vocal folds in a type of "slow motion. "Stroboscopy" refers to using flashes of light to observe movement. Soft Phonation Index (SPI).Videostroboscopy is one of the most practical techniques for clinical examination of the larynx and vocal folds. In many cases. Visi Pitch.

there are so many techniques to raise or lower the baseline F0: Confidential Voice Therapy. Approaches To Elicit True Vocal Fold Vibrations . Accurate diagnosis of voice disorders is critical to treatment planning. to facilitate or to elicit true vocal fold vibration. Such patients produce their faulty voice in different ways such as poor breathing pattern. However. Respiration training. Hence. Masking Approach. vegetative & Reflexive Techniques. inappropriate use of vocal fold & usage of false vocal folds. Resonant Voice Therapy. The Lee Silverman Voice Treatment Program (LSVT). Methods of achieving correct F0 . speaking with hard glottal attack.Professional voice users learn techniques to help avoid problems. & Pushing. the goal of voice therapy is to restore the best voice possible. many approaches are there like Inhalation Phonation. Voice therapy must by root in and derived from an understanding of laryngeal anatomy and phonatory physiology. Circumlaryngeal Massage. Treatments and Therapies Voice therapy ± The specific goal of voice therapy will vary from patient to patient. producing functional dysphonia. The Accent Method.most of the voice disorders are related to misusing the vocal mechanism. It is important to remember that no one specific therapy approach is facilitative for all the patients with the same voice problem. Open mouth approach. .Voice Training . in general. It is also important to recognize that there are differing approaches implemented for various disorders based on their own individual assumption concerning the disorder. There are varieties of voice therapy techniques for which each disorder has a specific therapy technique. etc. Pulling & Isometric Approach. Baseline measurements taken when the voice is healthy can pinpoint voice problems should they develop later. The manner in which therapeutic techniques are used will vary from clinician to clinician with the awareness that one particular treatment may possible contribute to hyperfunctional problems. a voice that will be functional for purpose of employment and general communication.

Chewing Technique. Post-laryngectomy rehabilitation .  Try your best to maintain good general health . A speech/language pathologist determines the most appropriate method of voice rehabilitation through an evaluation. A paralyzed vocal cord often will prevent closure of the vocal cords. strangled voice. Whisper Phonation Method. Thyroplasty is a surgical technique that moves the paralyzed vocal cord closer to the normal.Drink 7-9 glasses of water per day. & can produce an array of voice defects: aphonia. The most useful techniques in reducing laryngeal tension are: Digital Laryngeal Manipulation.Phonosurgery is designed to alter voice quality and the ability to produce voice. - Methods to Improve Voice Quality .When the larynx is removed. hoarseness. or botox.the life stress elevates general muscle tension. or excessively high pitch.- Approaches to Decrease Laryngeal Tension . Yawn-Sigh & Half Swallow Boom Technique. Head Positioning.includes Chant-Talk Method. usually for extensive cancer. Repeat injections are usually needed. or speech using artificial larynx. breathiness. Phonosurgery can raise or lower the pitch of a voice to a more desirable range. Phonosurgery . Voice Care To improve vocal hygiene:  Drink lots of fluids . including that of the laryngeal muscles.Exercise regularly. The botoxin weakens the muscles of the larynx so that voice can be produced with much less effort. This may include training esophageal speech. Altered Tongue Position. more robust vocal cord. Botoxin injections . TEP (Tracheo-eosophageal Puncture) speech. rehabilitation of the voice is a main concern.Botoxin. . is a toxin that is injected into specific muscles of the larynx for spasmodic dysphonia which is characterized by a tight. also good are herbal tea and chicken soup. The results last for 3-5 months on average. strained. etc.

 Less is more if we think of vocal longevity. fruits and whole grain foods.  Do not eat late at night .  Use a humidifier to assist with hydration. Try taking vocal naps. Chloraseptic Œ is one example.  Avoid use of local anesthetic over-the-counter medications for throats. lungs and vocal tract.They are bad for the heart. The medications how they can affect the voice:  Avoid taking antihistamines. artificial interior climates. Avoid speaking too much.  Reduce the caffeine and alcohol intake . Avoid smoking cigarettes .If you eat a late meal and you have trouble with acid reflux. avoid lengthy telephone conversations and wisely use natural pausing in conversation (avoid vocalized pauses). They may make the female voice deeper.  Medications that help liquefy thick mucus and increase the output of thin respiratory tract secretions are helpful.Caffeinated and alcoholic drinks pull water out of your system and deplete vocal cord hydration.  Take antacid for acid reflux .May have problems when stomach acid backs up on the vocal cords.They dry out the membranes in the throat.  Avoid dry. . and take an antacid at bedtime.Include vegetables.  Eat a balanced diet . raise the head of your bed. How to use the voice:  Learn to use your voice with as little effort and tension as is necessary. decongestants and antidepressants . Examples are RobitussinŒ and GuaifenesinŒ.  Question the use of progesterone dominant birth control pills.

 Take advantage of amplification devices. Before singing or using the voice in unusual ways. cars. such as microphones. screaming. airplanes).  Use non-vocal sounds such as clapping. always do vocal warm-ups. Face the person(s) with whom you are speaking.  Avoid making strange vocal noises and sounds.  Avoid shouting. . loud laughter and heavy throat clearing.it is worse than speaking because whispering strains the laryngeal muscles. as needed. bells or other things to gain the listener's attention.  Move close to those with whom you are speaking. Do not whisper .  Be aware of noise in the environment and do not compete with it (parties.

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