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Voice Disorders Flowchart - Coggle Diagram
Voice Disorders Flowchart
Organic Voice Disorders
Nonorganic/Functional Voice Disorders
Psychogenic Dysphonia (PVD)
Voice problems can occur as a behavioral response to emotional distress, anxiety, or stress. The voice problem is a conversion reaction, the translating of the emotional distress into a different set of symptoms. (It is not a conscious attempt to be dysphonic. The patient believes there is a physical etiology of the voice problem.)
Sometimes called conversion dysphonia or (perhaps) aphonia.
The therapist should remember that this is not a structural disorder—the folds are capable of appropriate movement.
Patients who have PVD may exhibit some of the following:
Intact vegetative functions of the voice.
Onset described as sudden or the result of something else (eg., URI).
Differentiation of the vocal symptoms from any other medical condition.
Paradoxical Vocal Fold Motion (PVFM)
Characterized by spasmodic vocal fold adduction during the inhalation phase.
Most often observed in females (3:1) and more common in adults than children or adolescents.
Unknown etiology but may be multiple. It is often misdiagnosed as asthma or exercise-induced broncho-spasm.
May be related to a hypersensitivity of the larynx to stimuli that causes a reflexive closure of the VF.
Related to psychoemotional factors in some patients and would be considered a conversion disorder.
Reflux may be a significant etiology.
Typical symptoms are stridor and dyspnea.
Irritant-Induced PVFM
Onset of symptoms after exposure to gas, smoke, fume, vapors, mist, dust, etc.
Exercise-Induced PVFM
Symptoms triggered by competition, practice, or strenuous activity
Symptoms resolve quickly
Treatment
Aimed at relieving the airway obstruction
Behavioral voice therapy
Pharmacologic therapy
Respiratory
Ventricular Dysphonia
This condition is observed when the false vocal folds are adducted and vibrate. This may occur in the absence of true vocal fold vibration or in conjunction with TVF vibration (achieving diplophonia).
This phenomena may occur in the cases of TVF paralysis (as a compensatory technique) or when there is extreme hyperfunction of the head/neck.
Puberphonia
Sometimes called mutational falsetto. It is considered a continuation of a child-like, high-pitched voice when it is not age appropriate. May be seen in females but is more common in males. Technically, the term falsetto is not appropriate.
This is seen in the absence of anatomical deviations of the larynx (and should be ruled out).
Voice weak, often breathy or raspy, unable to increase intensity or shout.
Etiology poorly understood, but proposed causes include…
Resistance to puberty,
Feminine self-identification,
Desire to maintain a competent childhood soprano singing voice,
Embarrassment when voice lowers dramatically earlier than one’s peers.
Behavioral voice therapy is usually effective.
Juvenile Voice
Post-adolescent females with higher than normal pitch, breathy voice, child-like speech distortions and prosody, and high tongue carriage.
Etiology unknown, but hypothesized…
Women who resisted transition into adulthood or,
Habituated the altered laryngeal and vocal tract posture
Presbyphonia (Presbylaryngeus)
Voice disorder presumably related to processes of laryngeal aging.
An “older” sounding voice…
Thin, muffled voice quality,
Decreased loudness,
Increased breathiness,
Pitch instability,
Lack of vocal endurance and flexibility.
Classic laryngeal appearance is a slightly bowed glottic configuration presumably related to “thinned or atrophic” VFs.
Voice rehabilitative therapy, especially Vocal Function Exercises (VFEs) can be effective.
Vocal Misuse and Abuse
Behaviors of Misuse
Increased tension or strain. Observable signs:
Hard glottal attack.
Manner of initiating vowels, where there is a rapid and complete adduction of the folds and with considerable muscular tension and subglottal tension needed to overcome medial compression.
High laryngeal position
If a speaker consistently speaks in this position, excessive tension is typically noted as well as higher medial compression of the folds.
A-P laryngeal squeezing
This disorder is such that the arytenoids and epiglottis approach each other in a “squeezing” motion (to a greater degree than a low back vowel.
Inadequate breath support for speech.
Other Potential Behaviors of Abuse.
Excessive, prolonged loudness.
Strained and excessive use during periods of tissue changes.
Excessive coughing, laughing, and throat clearing.
The screamer and noise maker.
The sports and exercise enthusiast.
Inappropriate pitch level
This notion suggests that there is an “optimal” pitch.
persistent glottal fry.
lack of pitch variability. This behavior tends to be fatiguing.
too low or high pitch.
Excessive talking
Varying from person to person, a larynx may have a physiological limit. This limit can vary within a person based on the context of their health, etc. Vocal fatigue is typical.
Muscle Tension Dysphonia (MTD).
Dysphonia that results from hypercontraction of the instrinsic and extrinsic laryngeal muscles as well as possible other muscles in the head and neck. Tension is typically noticeable.
Patient may often report pain secondary to excessive effort and vocal fatigue.
MTD is typically primary and related to:
Psychologic and personality factors
Poor vocal technique
Compensatory related to glottal insufficiency (e.g., paralysis, tumor, etc.)
Excessive occupational and social use of the voice. Sometimes may be secondary (organic in nature).
Symptoms:
Pain and or discomfort on phonation
Hard glottal attacks
Poor breath support
Obvious neck tension
Vocal qualities: breathiness, hoarseness, strain, effortful phonation, fatigue, pitch break, reduction in range
Videolaryngoscopy is helpful is diagnosing MTD through observation of
squeezing of tissues
laryngeal pathology
medial compression of folds
Digital laryngeal manipulation that is not with ease may indicate suprahyoid muscle tension.
Gentle digital downward pressure on the thyroid cartilage with improved immediate quality may indicate MTD (from high carriage of larynx).
Effects of Drugs on the Voice.
Coordination and proprioception
CNS stimulants or depressants will negatively affect speech and voice.
Airflow
Drugs that dilate or constrict the bronchioles will affect the movement of air through the larynx.
Fluid balance and secretions of the upper respiratory tract.
Diuretics (including caffeine)
Decongestants
Antihistamines
antitussive meds
certain HTN meds
H2 blockers and antacids
certain psychotropic agents
Corticosteroids
Changes in structures of the vocal folds.
Typically used in the treatment of hormone imbalance disorders, these can increase the mass of the folds. Aspirin and anticoagulants increases the likelihood of submucosal hemorrhage.
Irritation of the vocal mucosa.
Drugs and foods are often thought to lower LES pressures and increase the likelihood of the GERD.
Caffeine, fat, alcohol, spicy and acidic foods and drinks, and several medications.
Smoking (first hand or second hand).
Each disorder should have a brief description (name, possible cause/etiology, location where it can be found in the larynx, visual description if applicable, possible voice qualities, etc.)