Functional voice disorders
Fn voice disorders
Voice disorders associated w phonotrauma, psychogenic voice disorders
How phonotrauma develops?
Periods of increased tension
Greater than usual demands on voice
Episode of laryngitis
Periods of voice difficulty that resolved on their own
More episodes of voice difficulty
Change vocal behaviour, not aware of change
Features of phonotrauma
Increased tension, strain
Hard glottal attack (adduction of VF before phonation)
High laryngeal position
A-P laryngeal squeezing- epiglottis, arytenoids approach each other
Inappropriate pitch lvl
Puberphonia
Persistent glottal fry (lowest F0, very tense)
Lack of pitch variability
Excessive prolonged loudness
Strained, excess voice use when swelling, inflammation, tissue changes
Excess coughing, throat clearing-abusive when habitual. VF come together quite forcefully. Analogy: Clap hands until red
Screaming
Over-enthusiasm in sports, exercise eg. parents, coaches
Symptoms, signs of phonotrauma
Harsh, strident, hoarse, breathy, hard glottal attack, vocal fatigue
High vocal vol. pitch breaks
Freq throat clearing
Tissue changes, laryngeal pain
Vocal fold nodules
Aetiology
Frictional trauma of VF
Excessive laryngeal tension
Pathophysio
White, greyish protuberance on edge of VF
Junction of anterior 1/3, posterior 2/3 of VF
Usually bilateral, symmetrical
Pre-nodule swelling
Early stages (acute)-localised capillary haemorrhage, swelling & redness
Shiny glistening material
Late stage (chronic)- fibrosis of epithelium, rough, semicircular, nodule--> Increases mass, stiffness of VF, VFs cannot completely adduct due to hard nodule
Features: large nodules, vocal fold oedema, subglottic erythma (redness)--> laryngopharyngeal reflux
Perceptual, physiological signs
Hoarse, breathy voice which fatigues over time
Loss of vocal range, endurance
Habitual cough, throat cleaning--> non-productive--> friction--> nodules
Airflow may be increased
Increased subglottal pressure, harder for person to get air out
Pt Characteristics
More common in young male children, female adults
Certain occupations
Incessant talker, socially aggressive
Stressed & loud
Mgm
Nodules at early stage--> vocal therapy + vocal hygiene
Nodules at later stage--> surgical removal + vocal hygiene + voice therapy w/o behavioural voice therapy, nodular formation may reform bcos of same phonotraumatic behaviour
Vocal fold polyps
Aetiology
VF trauma bcos of acute vocal trauma, phonotraumatic behaviours
Secondary rxn to allergies, URTI, excess smoking
Pathophysio
Types: 1) sessile(broad based), pedunculated (mushroom like growths)
Usually unilateral
Junction anterior 2/3 & posterior 1/3 of VF bcos greatest frictional force
Perceptual, physiological signs
Depends on size, location of polyp, interference w VF closure (alot/little bit)
Diplophonia, sudden voice breaks, hoarseness, roughness, breathiness
Increased airflow, increased subglottal pressure to overcome glottal incompetence (alot more effort to get voice out)
Management
Vocal hygiene, voice therapy, surgical removal: Pedunculated, large sessile-
Vocal hygiene, voice therapy: Small sessile
2- 6months before impv in voice quality
Reinke's oedema
What?
Build up of fluid in superficial lamina propria (Reinke's space)
Aetiology
VF trauma, misuse
Exposure to irritants eg. smoking, LP reflux
Hormonal changes eg. hypothyroidism (under-active thyroid)
Pathophysiology
VF full of fluid, swollen, heavy
Oedema full length of VF bilaterally
Swelling disturbs elasticity of VF--> decreased stiffness
Perceptual, physiological signs
Low pitch, hoarseness, shortness of breath
Increased airflow-need more effort to speak
Chronic laryngitis
Mgm
If bcos smoking, initial treatment QUIT
Advanced cases eg. surgical intervention eg. longitudinal incision, removal of swelling by suction, resect healthy VF mucosa --> form healthy VF margin
What?
Aetiology
Inflammation of laryngeal mucosa secondary to phonotrauma
Result from any long term irritation to larynx. Smoking most common
Phonotrauma-coughing, throat clearing (productive, non-productive)
Overuse mouthwash-high alcohol content-irritation to mucosa
LP reflux
Pathophysiology
VF red, irregular, thick, rounded cf. sharp
Small dilated blood vessels on surface
Swollen supraglottic area
Perceptual, physiological signs
Hoarseness
Low, high pitch
Non-productive throat clearing
Sore throat
Increased air flow, subglottal pressure
Mgm
Medical
Antibiotics
Removal of causative irritant
Surgical stripping of inflamed area if therapy X successful
Therapy
Program to reduce phonotruama
Rest
Hydrate
Muscle tension dysphonia
Aetiology
Excessive musculoskeletal tension of head, neck
Intrinsic, extrinsic laryngeal muscles sensitive to emotional stress (impt bcos tool that conveys emotion), clients complain of stress, anxiety, depression, high vocal demand, emotionally overloaded
Perceptual, signs, symptoms
Aphonia, dysphonia
Breathiness
Hoarseness
Excessive high pitch, increased effort, high vocal tension
Pain in laryngeal area
Referred pain to ears, chest
Can dev. VF nodules where vocal tract closes on itself
Sensation of lump, tightness in larynx, pharynx (globus)
Pathophysiology
Larynx usually appears normal at rest
During phonation
Excessive glottic, supraglottic medial contraction
AP contraction-squeeze of supraglottal musculature (arytenoids, epiglottis, false VFs)
Secondary mucosal changes may occur
Mgm
Behavioural voice therapy using range of vocal techniques
Biofeedback
Muscular relaxation, stretching
Resonant voice therapy
Manual circumlaryngeal massage
Accent method
Ventricular dysphonia
What? Vibration of false/ventricular VF during voicing +/- true VF
Aetiology
Excessive muscle tension
May be subst voice in case of severe true VF dysfunction
Pathophysiology
False VF approx, begin to vibrate
Increased VF mass--> X vibrate quickly--> low pitch
Perceptual, physiological signs
Low pitch, diplophonia, very hoarse
Decreased pitch variability
Decreased loudness
Vocal fatigue
Globus sensation
Referred pain to ears, chest
Decreased air flow
Mgm
Therapy
Medical
Generally not used unless bcos primary VF defect
Pharmaco therapy (botox)
surgical- excision, laser surgery
If capable of true VF phonation-retrain them to stop using false VF
If compensation, improve age, gender appropriate chars, ventricular phonation eg. pitch, loudness
increase VF mass, stiff