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Chapter 11:

Voice Disorders

Justice

Communication Sciences and Disorders: AnIntroduction

Copyright ©2006 by Pearson Education, Inc.

Upper Saddle Rier, !e" #ersey 0$%&' (ll rights resered.


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)ocus *uestions

+ hat is a oice disorder-

+ o" are oice disorders classi/ied-

+ hat are the de/ining characteristics o/oice disorders-

+ o" are oice disorders identi/ied-

+ o" are oice disorders treated-

.

Justice





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Introduction 1 ( rie/ istory+ 6th century 1 the laryn3 studied on hu4an

cadaers 1 did not per4it to see laryn3 at "or5

+ 600 1 /irst boo5 on laryngeal structures

+ 'th century 1 "elldeeloped understanding

ho" the ocal /olds produce the oice+ '27 1 glottiscope8 crude gli4pses o/ the

laryngeal caity

+ '&% 1 laryngoscope8 ast i4proe4ent in

technology to e3a4ine the laryn3+ 9oday, adanced technology :endoscopy,

stroboscopy ; allo" e3a4ination o/ the ocal/olds lie in action

.2

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Case Study *uestions

+ hat co44unity actiities 4ight be

possible /or >r. Aitchell no" that she uses

her oice-

+ o" 4ight >r. Aitchell be inoled "ith

her pro/ession in the /uture as a

@uadriplegic-

.&

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Case Study 28 (nton+ 6'year old eteran diagnosed "ith

laryngeal cancer si3 years ago

+ ad his laryn3 re4oed t"o years ago,

tried unsuccess/ully to learn esophageal

speech, no" uses an arti/icial laryn3

+ Is interested in helping other

laryngecto4ees

+ Is interested in possibility o/ a laryngeal

transplant

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Case Study 2 *uestions

+ Gien that (nton already has a "ay to

produce speech ia the arti/icial laryn3,

"hy "ould he desire a laryngeal

transplant-+ (nton?s hobby a/ter his laryngecto4y "as

to counsel other laryngecto4ees. In "hat

"ays 4ight (nton?s counseling be superiorto that o/ a clinical pro/essional, li5e a

psychologist-

.$

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Case Study B8 As. Chin+ %2year old teleision personality :co

anchor o/ ne"s sho";

+ E3periencing inter4ittent proble4s "ith

her oice in "hich it see4s to start and

stop and /eels strangled

+ ent to otolaryngologist, "ho gae her a

preli4inary diagnosis o/ spas4odic

dysphonia

+ As. Chin?s producer suggested she ta5e

disability leae until her oice is resoled

.'

Justice





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Case Study B *uestions

+ >o you agree "ith As. Chin?s producerthat she should be Ho// the air until heroice proble4s are resoled-

+ As. Chin has an appoint4ent soon "ith anSFP "ho 4ay not be s5illed in treatingspas4odic dysphonia. o" i4portant is it

to see a clinician "ho has "or5ed "ith thiscondition be/ore-

+ hat other pro/essionals should beinoled "ith As. Chin?s oice treat4ent-

.7

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I. hat is =oice-+ =ocal /old ibration that proides sound source

/or spo5en language

+ Phonation8 hu4ans set their ocal /olds into a

ibratory pattern :say Hoooo;

1 =ocal /olds are adducted :closed;, air is e3haledup"ards and blo"s apart the ocal /olds setting

the4 into a rapid ibratory pattern

+ =oice is /urther 4odi/ied by the processes o/resonation and articulation

+ 9hree ocal characteristics8 frequency,

intensity, and phonatory quality

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)re@uency+ Rate o/ ocal /old ibration :pitch;

+ )unda4ental /re@uency :)0; 1 basic

ibratory rate o/ the ocal /olds :in Hertz ;

1 Dindergarten girls and boys J 2&0 K

1 (dult "o4en J '0 1 220 K

1 (dult 4en J 20 1 %0 K

+ )0 relates to three characteristics8

1 =ocal /old length, 4ass, and tension

+ )unda4ental /re@uency changes as "e

age, especially bet"een birth and puberty

.

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Intensity+ Sound pressure reported in decibels

:loudness;

+ Relates to t"o /eatures o/ ocal production8

1 (4ount o/ air/lo" /ro4 the lungs

1 (4ount o/ resistance to the air/lo" by the ocal

/olds :"hich contributes to their e3cursion, or

ho" /ar apart the ocal /olds 4oe and co4e

bac5 together;+ Eery person has a baseline intensity leel

that characteriKes hisLher conersational

speech

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Phonatory *uality

+ o" "ell the t"o ocal /olds "or5 togetherduring the ibratory cycle

1 I/ ocal /olds "or5 sy44etrically and

har4oniously, oice is pleasant and clear

1 I/ co4pro4ised in so4e "ay :e.g., gro"th on

one o/ the /olds;, phonatory @uality is a//ected

+ (lso in/luenced by the resonation o/ the

oice into the oral and nasal caities :e.g.,nasal oice @uality;

.B

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hat is a =oice >isorder-

+ Pitch, loudness, or phonatory @ualitydi//ers signi/icantly /ro4 persons o/ a

si4ilar age, gender, cultural bac5ground,

and racial andLor ethnic group, and+ =ocal @uality detracts /ro4 the ability to

/unction and achiee in society

.%

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>escribing =oice *uality

+ >ysphonia8 u4brella ter4 /or a oice thatis disordered in so4e "ay

+ (phonia8 total loss or lac5 o/ oice

+ Aany other, 4ostly subectie ter4sM 1 Pitch and /re@uency8 jitter or diplophonic

1 Foudness and intensity8 pressed or strident

1 Resonance8 nasal or ringing 1 Phonatory @uality8 flutter or crea

.&

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>escribing =ocal )old )unctioning+ Hypofunction8 ocal /olds are under

/unctioning and hae inade@uate tension,

so air escapes through

1 reathiness or hoarseness, or no oice at all

+ Hyperfunction8 ocal /olds are oerly tense

and co4press too tightly together

1 9oo loud, too high, andLor too strained

1 So4eti4es spasticity o/ the oice

+ Diplophonia8 ocal /olds produce t"o

di//erent pitches si4ultaneously

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=oice "ithout a Faryn3

+ !aryngectomy 8 surgically re4oing thelaryn3

+ 9"o pri4ary reasons8

1 laryngeal cancer8 re4oed to stop spreading 1 laryngeal trau4a8 re4oed i/ too da4aged to

protect respiratory syste4 or i4pede

breathing

+ Alaryngeal communication8 an alternatie

"ay to produce speech

.$

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Prealence and Incidence8

=oice >isorders in (dults+ Prealence J 27N, Incidence J 6N

+ igher prealence /or "o4en, pea5 ages o/ %0

60 years

+ igher prealence a4ong people "ith /re@uentallergies, asth4a, colds, and sinus in/ections

+ igher prealence a4ong pro/essions reliant on

oice+ Co44on causes8 ocal nodules,

ede4aLs"elling, polyps, carcino4a, and ocal

/old paralysis

.'

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Prealence and Incidence8

=oice >isorders in Children+ 2&N o/ children e3hibit signi/icant ocal

proble4s, "ith %0N o/ these cases

ongoing, not transient, proble4s

+ )or so4e it is a congenital proble4, but

4ost cases result /ro4 oeruse or 4isuse

o/ oice

+ Aost co44on cause8 "ocal nodules that

i4pede s4ooth 4eeting o/ /olds, resulting

in breathy or hoarse oice

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Prealence and 9reat4ent

+ Rate o/ oice disorders /or both childrenand adults is relatiely high, but 4anycases go undiagnosed andLor untreated

+ Seeral reasons /or this8

1 #reatment access8 e.g., disorder notconsidered to i4pact educationalper/or4ance in school

1 $no%ledge8 e.g., person 4ay beliee that

oice proble4 "ill disappear spontaneously 1 Social perception8 e.g., the disordered oice

:e.g., a breathy, hoarse oice; brings positiesocial attention

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II. o" are =oice >isorders

Classi/ied-

+ =oice disorders are grouped based on

their cause, an etiological classi/ication

+ )our di//erent categories8 (. =ocal abuse

. !eurogenic disorders

C. Psychogenic disorders>. (laryngeal co44unication

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(. =ocal (buse+ Chronic or inter4ittent oeruse or 4isuse

o/ the ocal apparatus+ =ocally abusie behaiors8

1 9al5ing in noisy eniron4ents

1 )re@uent coughing or clearing o/ the throat 1 Using ca//eine products

1 Oelling, screa4ing, and cheering

1 Giing speeches or lectures 1 Spending ti4e in s4o5y eniron4ents

+ 9"o co44on conditions8 "ocal nodules and contact ulcers and granuloma

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=ocal !odules

+ S4all bilateral protuberances or callousedgro"ths on the inner edge o/ the ocal/olds

+ Acute nodules are si4ilar to bruises on theocal /olds, but these can harden andthic5en oer ti4e, "hich beco4es achronic condition

+ Aost prealent in children and adults "hoengage in ocal 4isuse and abuse

+ (dditional /actors8 te4pera4ent and

general health

.2B

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Contact Ulcers and Granulo4a

+ Contact ulcers8 in/la4ed lesions thatdeelop on the cartilage in the laryn3

+ Granulo4a8 a 4ass o/ tissue generated by

the body?s healing process at the site o/the contact ulcer

+ Aostly results /ro4 ocal abuse, but also

/ro4 acidic irritation due to chronic re/lu3or tubal intubation :during surgery;

+ Fo", breathy oice @uality

.2%

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. !eurogenic >isorders+ Result /ro4 illness, da4age, or disease to

the neurological syste4s associated "ithoice production

+


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=agus !ere Fesions+ Can occur due to surgical da4age, trau4a,

and iral in/ections+ Aost serious outco4e8 ocal /old paralysis

+ Aostly unilateral paralysis8

1 Abduction paralysis8 one o/ the ocal /olds cannotopen, oice is not usually a//ected, but breathing4ay be di//icult

1 Adduction paralysis8 one o/ the ocal /olds cannotclose, so they cannot 4eet together, causinghoarse or breathy oice @uality

+ Co4plete paralysis8 both ocal /oldsparalyKed, co4pletely bloc5ing air"ay 1

tracheosto4y is necessary

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Spas4odic >ysphonia

+ (//ects 4otor control o/ laryn3, results in

inter4ittent oice stoppages

+ #er5y, grunting, s@ueeKed, groaning, and

stutteringli5e oice @uality

+ Ranges /ro4 4ild to seere

+ (dductor type8 4ost co44on, oice is

strangled, strained, and s@ueeKing

+ (bductor type8 less co44on, oice is

breathy and open

.2$

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(4yotrophic Fateral Sclerosis

+ (lso called Fou Gehrig?s >isease 1progressie, degeneratie, neuro4usculardisease

+ Cause is un5no"n, i4pact is signi/icant, and

4ost surie less than 0 year a/terdiagnosis

+ =oice is so/t, breathy, lo" in pitch and

loudness, li4ited ariability, and hypernasal+ >i//iculty clearly articulating speech soundsbecause cannot strongly coordinate 4otorprocesses

.2'

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Par5inson?s >isease

+ Progressie, degeneratie neurologicaldisease caused by depletion o/ dopa4ine

+ Unable to produce a strong oice because

o/ a "ea5ened respiratory syste4

+ Rigid 4uscular tone restricting 4oe4ents

o/ laryn3 produces hoarseness and a

4onotonic pitch

+ !ee Sil"erman &oice #reatment program 1

e//ectie /or i4proing oices o/ persons

"ith Par5inson?s

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C. Psychogenic >isorders

+ !onorganic disorders, resulting /ro4

e4otional or psychological characteristics

+


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Psychological or E4otional

9riggers

+ (/ter so4eone recoers /ro4 a ocal

inury because o/ oeruse or 4isuse o/ the

oice, 4ay e3perience a sense o/

ulnerability and an3iety about using oice

+


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Psychopathology

'( Stress, An)iety, and Depression+ (cute stress disorder8 "ithin one 4onth o/

haing a trau4atic e3perience,

e3aggerated startle responses, 4otorrestlessness can be re/lected in the oice

+ GeneraliKed an3iety and an3iety disorder8

4uscle tension, tre4bling, t"itching 4aylead to ocal tre4ors and oice brea5ages

.B2

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*( Con"ersion Disorder

+ Physical sy4pto4s or de/icits result /ro4

seere an3iety or stress+ Can result in a loss or disordered oice as

one ariety o/ conersion disorder

+( &ocal tics and #ourettes Disorder

+ =ocal tics produce sudden, rapid,

recurrent ocaliKations

+ 9ourette?s8 ocal tics occuring

si4ultaneously "ith other 4otor tics

a//ecting the head, torso, and e3tre4ities

.BB

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Autational )alsetto and

#uenile =oice

+ =ocal characteristics are not consistent"ith age and gender

+ -utational falsetto8 4ale child oradolescent e3hibits inappropriately highoice 1 =oice therapy and 4edical treat4ent are

e//ectie+ .u"enile "oice8 /e4ale co4panion to

4utational /alsetto, "o4en 4aintain achildli5e oice into adulthood

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>. (laryngeal Co44unication

+ Producing oice "ithout a laryn3

+ 9"o 4ost co44on reasons8

1 Faryn3 is not aailable because o/ atracheosto4y

1 Faryn3 has been co4pletely re4oed in a

larnygecto4y

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9rachesto4y

+ hen respiratory syste4 is co4pro4ised,4echanical entilation and respiration isneeded 1 tracheosto4y tube is inserted through the

nec5 to direct air into the lungs+ Unable to tal5 because air is not going

oer ocal /olds

+ PassyAuir 9racheosto4y Spea5ing=ale8 allo"s adults and children to spea5een "hile entilated

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.B$


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Faryngecto4y+ /tiology: Faryngeal cancer is lin5ed to tobacco

and alcohol use, nutritional inade@uacies andoccupational e3posures a//ects (/rican(4erican

older 4ales at the highest rates

+ Symptoms: 4ost consistent sy4pto4 ishoarseness

1 (ny person e3hibiting hoarseness should see5 4edical

attention i/ persists /or 4ore than t"o "ee5s

+ #reatment 8 Rid the body o/ the 4alignancy 1 4ost oncologists use conseration approaches, and

pre/er to only re4oe part o/ the laryn3 i/ possible

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.B'


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III. >e/ining Characteristics o/

=oice >isorders+ =oice disorders i4pact one or 4ore o/ the/ollo"ing perceptual characteristics o/

oice8

(. Resonance

. Foudness and pitch

C. Phonatory @uality

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(. Resonance

+ &elopharyngeal port controls the e3tent to

"hich e3haled air enters the nasal andoral caities

+ 9he port typically rests in an open

position, but "hen "e spea5, it is al4ostal"ays closed :air/lo" channeled into the

oral caity;

+ =oice disorders o/ resonance result /ro4proble4s "ith control o/ port, called

"elopharyngeal inadequacy Justice




.%0


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=elopharyngeal Inade@uacy+ Co44on causes8

1 Cle/t palate and cranio/acial abnor4alities 1 Iatrogenic :proble4s resulting /ro4 surgery;

1 (llergies

1 !euro4uscular i4pair4ent+ Results in either8

1 Hypernasality 8 port re4ains open to allo" too

4uch resonance and nasal e4issions duringspeech

1 Hyponasality 8 too little nasal resonance, oice

4ay sound stu//y and congestedJustice




.%


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. Pitch and Foudness

+ Pitch8 /re@uency+ Foudness8 intensity

+ 9oo 4uch or too little tension in oice

production can cause abnor4al pitch orloudness

+


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Pitch

+ I4portant concepts8

1 abitual pitch8 pitch one uses nor4ally

1 isordered pitch8

1 abitual pitch di//ers signi/icantly /ro4 opti4al

1 E3tre4ely li4ited ocal rangeJustice



Upper Saddle Rier, !e" #ersey 0$%&'

(ll rights resered.

.%B


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Foudness

+


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C. Phonatory *uality

+ hen ocal /olds do not "or5har4oniously, i4pair4ent in general

@uality o/ the oice

+ Co44on types o/ i4paired phonation8 1 ard glottal attac5

1 Glottal /ry

1 reathy phonation 1 Spasticity

1 oarseness

Justice

Communication Sciences and Disorders: An

Introduction



(ll rights resered.

I= = i >i d.%&


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I=. o" are =oice >isorders

Identi/ied-

(. 9he =oice Care 9ea4

+ Close collaboration o/ a ariety o/

pro/essionals

+ Aedical pro/essionals8 pri4ary care

physician :PCP;, otolayrngologist

+ (llied health pro/essionals8 speech

language pathologist, psychologist orpsychiatrist

+ Possibly educators or oice coaches alsoJustice


Introduction



(ll rights resered.

.%6


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. 9he (ssess4ent Process

+ Identi/ication o/ "arning signs

+ (ssess4ent Protocol8

1 Case history and interie"

1


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arning Signs /or =oice >isorders+ Children and adolescents8

1 =ocally abusie behaiors

1 Underlying 4edical condition

1 Psychological "ellbeing

+ (dults8 1 Change in phonatory @uality /or 4ore than t"o

"ee5s, consult physician

+ Re/errals8 PCP "ill li5ely 4a5e at least t"ore/errals8

1


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(ssess4ent Protocol

+ Speechlanguage pathologist?s goals8 1 CharacteriKe the general /eatures o/ the oice

1 Establish i/ any o/ these /eatures di//er /ro4

the nor4

1 I/ disorder is present8

+ Identi/y cause

+ Identi/y interention approach that "ill be the 4ost

bene/icial to i4proing the oice

Justice


Introduction



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.%7


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Case istory and Interie"

+ Interie" "ith the client to learn 4oreabout8

1 Aedical history

1 Chronological history o/ proble4

1 Sy4pto4s and possible etiology o/ proble4

1 ay in "hich client uses oice /or daily liing

actiities

1 Client?s 4otiation /or see5ing help

Justice


Introduction



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Clinical


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Instru4ental


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=. o" are =oice >isorders

9reated-+ Eli4ination o/ the cause o/ the disorder :e.g.,

ocally abusie behaior;

+ Co4pensation /or a disorder :cause cannot

be eli4inated;

+ 9hree possible goals8

1 9each a ocal behaior that is absent

1 Substitute ocal behaior /or inappropriate one

1 Strengthen ocal behaiors that are "ea5 or

inconsistentJustice


Introduction



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( 9 t t / = l (b.&%


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(. 9reat4ent /or =ocal (buse

Seeral options8

+ Surgery :e.g., re4oal o/ ocal nodules;

+ =ocal hygiene progra4s

+ =oice therapies

+ Co4puter progra4s

Justice


Introduction



(ll rights resered.

9 t t / ! i.&&


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. 9reat4ent /or !eurogenic

>isorders

+ Co4bination o/ 4edical interentions and

oice therapies

+ Aedical interentions8

1 Phonosurgery8 i4proe4ent, alteration, or

restoration o/ the oice :e.g., thyroplasty;

1 Inections into the ocal /olds :e.g., 9e/lon,

boto3;

+ =oice therapies8

1 e.g., Fee Siler4an =oice 9reat4ent progra4Justice


Introduction



(ll rights resered.

C 9reat4ent o/ Ps chogenic.&6


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C. 9reat4ent o/ Psychogenic

>isorders

+ Aultidisciplinary approach including

speechlanguage pathologist and 4ental

health pro/essionals

+ Goal8 deter4ine e4otional or psychosocial

cause o/ oice disturbance

+ 9herapy usually /ocus on reducing

tension, counseling, and eli4inating any

oice abuses or 4isuses

Justice


Introduction



(ll rights resered.

> 9reat4ent o/ (laryngeal.&$


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>. 9reat4ent o/ (laryngeal

Co44unication

+ Co44unication counseling8 e3plore allalternatie options /or producing oice 1 (rti/icial laryn38 ibrating po"er source placed

against the nec5, o/ten 4echanical soundingoice

1 Esophageal speech8 learn to trap air in theesophagus and then use that /or oice, o/ten

ery di//icult /or 4ost people 1 9racheoesophageal speech8 surgical puncture

bet"een the trachea and esophagus proidesan air source /or spea5ingJustice Copyright ©2006 by Pearson Education, Inc.

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