12/7/2010

VOICE DISORDERS

AIISH | Project

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

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

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

roughness 3. 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. alcohol use.e. low pitched . A precancerous lesion develops on the tongue or the inside of the cheek as a response to chronic irritation. 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. Voice Disorders Resulting from Abuse (i. Voice Disorders with No Indication of Pathology i) Ventricular Dysphonia: Definition: a condition in which the false vocal folds. 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. Symptoms: hoarseness.Symptoms: hoarseness. Etiology: Chronic smoking or tobacco use. shortness of breath. 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.. audible inhalation 2.

. those with no determined etiology). restricted phonation range. alcohol/smoking may contribute. reduced maximal phonation time iii) Thickening of Vocal Folds: Definition: a disorder that occurs when vocal folds become too thick or massive Etiology: unknown. pitch breaks. Viral / Bacterial / Infectious Voice Disorders.e. and Other Voice Disorders (i. Traumatic / Surgical Voice Disorders. GERD Symptoms: abnormal vibratory patterns of vocal folds Organic Voice Disorders Organic voice disorders are those disorders that do have a known cause.. Manifestations of Voice Disorders i) Phonation Breaks: Definition: temporary but complete cessation of phonation Etiology: occurs after prolonged hyperfunction Symptoms: breaks in phonation. We are subcategorizing them into four categories: Neurological Voice Disorders. increased fundamental frequency.5. 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.

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. variable rate. strained voice. 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. monopitch. resonatory and articulatory components of speech and reflects problems in the nuclei. short phrases. speed. breathiness. voice tremor. harsh vocal quality. harsh voice. and coordinated and alternating forcing functions of the muscles of the speech and respiratory mechanism . low pitch. nasal emissions. breathy voice. vocal noise. PICK's) (2) stroke (3) trauma (4) inflammation (5) tumor (6) drug toxicity (7) normal pressure hydrocephalus Symptoms: monopitch. reduced stress. 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. inappropriate interruption of phonation.1. monoloudness. movement range. hypernasality iii) Hypokinetic Dysarthria: Definition: a motor speech disorder caused by damage to the basal ganglia Etiology: (1) degenerative diseases (Parkinson's. Alzheimer's. imprecise consonants. audible inspiration. voice stoppage. mild hypernasality iv) Ataxic Dysarthria: Definition: a motor speech disorder caused by a widespread disturbances in timing. It may be manifested in any or all of the respiratory. control of dysmetria. axons. synergy. phonatory. harsh voice. resonance disorders.

the axons of the nerve section. Acquired web result from injury to the vocal folds. diplophonia. 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. or the nerve fibers are entirely cut which disturbs glottal closure due to lack of adduction of the affected vocal fold. bronchi. Viral. 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. hoarseness. diplophonia. and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6) birth trauma (7) central nervous system disease Symptoms: breathiness.Etiology: (1) stroke (2) tumor (3) infection (4) ataxic cerebral palsy Symptoms: hoarse breathy coarse voice with tremors. 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. 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. monopitch. monoloudness. and dysphonia . and aphonia 2. Etiology: prolonged infection or trauma Symptoms: varying degrees of breathing problems.

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. and aphonia .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. hoarseness. hoarseness. and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6) birth trauma (7) central nervous system disease Symptoms: breathiness. sensation of lump in throat. the axons of the nerve section. slight fever. tiredness 3. swallowing difficulty (rare). 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) peripheral lesions of Vagus nerve (2) neuritis (3) neoplasm's in neck. diplophonia. bronchi. 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. or the nerve fibers are entirely cut which disturbs glottal closure due to lack of adduction of the affected vocal fold. sore throat.

pharynx. iii) Thickening of Vocal Folds: Definition: a disorder that occurs when vocal folds become too thick or massive Etiology: unknown. alcohol/smoking may contribute. and dysphonia 4. and failure to maintain voice. Most carcinomas of the vocal fold are squamous cell carcinomas. 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. and larynx. hypernasality. GERD Symptoms: abnormal vibratory patterns of vocal folds iv) Carcinoma: Definition: cancer is a disease that may affect the structures of the oral cavity. diplophonia. Congenital webs results as the glottal membrane fails to separate in the embryonic development. jerky voice onset. Acquired web result from injury to the vocal folds. breathy spasms. intermittent voice breaks. Etiology: prolonged infection or trauma Symptoms: varying degrees of breathing problems. The lesion .iii) Laryngeal Webbing: Definition: a band of tissue varying in size that extends across the glottis between the two vocal folds.

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

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

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

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

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

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

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