1 organic voice disorders. 2 organic lesions mass lesions of v.f.’s cause the following changes:...

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Organic Voice Disorders

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Organic Lesions

• Mass lesions of v.f.’s cause the following changes:

1. Increase mass of the v.f.’s

2. Alter shape of the folds

3. Restrict mobility

4. Change tension

5. Modify size & shape of glottic, supraglottic airway

6. Prevent approximation along the a-p margin

7. Excessive tightening of approximation

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Benign Laryngeal Pathologies

• Category 1:

– Abnormal growths or lesions secondary to aggressive (hyperfunctional-abuse) vocal fold behaviors

• Nodules

• Polyps

• Contact Ulcerations

• Submucosal cysts

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• Category 2:– Voice difficulties due to abnormal growths & lesions, tissue

degeneration, joint immobility, or fractures caused by:

• intubation, gastro-esophageal reflux, chronic cigarette smoking inhalation, presbylaryngis, thyroid gland disease, upper respiratory infection, cervical rheumatoid arthritis, & external laryngeal trauma

– Granulomas

– Webs

– Pacydermia laryngis

– Hyperplastic-leukoplakic lesions

– Cricoarytenoid joint fixation

– Bowing

– Infectious laryngitis

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• Category 3:

– Patients who exhibit neurogenic dysphonias,

laryngeal neuromuscular impairments:

central or peripheral nervous system.

• Bowed secondary to aging

• Flaccid paralysis

• Vocal fold paralysis

• Superior laryngeal nerve dysfunction

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Category 1

Vocal Pathologies Secondary to Vocal Abuse & Misuse

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Nodules

• Description/Etiology:– Localized benign growths

– Reaction of the tissue to constant stress induced by frequent, hard oppositional movement of the vocal folds

• Early- – Edema on vocal fold edge

– Fairly soft & pliable, reddish in appearance

– Remainder of fold edematous

– Nodule may only be evident on one side

• Later-– Tissue undergoes hyalinization & fibrous

– Nodule becomes firm

– Chronic- Hard, white, thick & fibrosed (bilateral)

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Nodules

• Perceptual Signs & Symptoms:

– Hoarseness & breathiness

– Soreness & pain in the neck lateral to

larynx

– Sensation of something in the throat

– Difficulty in producing pitches in upper

third of range

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Nodules

• Acoustic Signs:

– Increased frequency & amplitude perturbation

(Jitter -2.61%; Shimmer- 1.87%)

– Fundamental frequency in normal range

– Phonational range decreased

– Reduced ability to produce loud SPL

– s/z ratio of 1.65

– Spectrum analysis will show noise

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Nodules• Aerodynamic Signs:

– Airflow- Equal or slightly higher than normal

• 275 ml/sec (.275 l/sec)

• Normal (Women)-

• Normal (men)- 125 ml/sec (.125 l/sec)

– Subglottal pressure- Slightly higher than normal

• 7.45 cm H20

• Normal (women)- 5 cm H20

• Normal (men)- 6 cm H20

– EGG- Decreased closing times & irregular closing pattern

– EMG- Normal or elevated if laryngeal tension is present

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Nodules• Observable Physiological Signs:

– Laryngoscopy:

• Benign lesions at the anterior 1/3 of the vocal folds

– Force of the vibratory cycle is greatest

• Incomplete closure

– Near nodule & chink

• Edema (where increased vascularity)

– Stroboscopy:

• Normal symmetry & periodicity but reduced amplitudes & mucosal waves at nodule site

• Reduced glottal closure

• Absence of mucosal wave where the nodule area when mass is firm but not edematous

• Glottal closure- hourglass configuration

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Video, Case Examples

Nodules

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Case 42; CD 2 (Track 9): Bilateral Vocal Fold Nodules

• History:

– 39 year old female

– Complaint of progressive hoarseness over

the last 3 months

– Increased voice use-Choir practice

– Chronic throat clearing

– 16 pack per year smoking habit

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Preoperative: Bilateral Nodules

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Bilateral Vocal Fold Nodules• Examination findings:

– Perceptually- Moderately hoarse-breathy, low pitch

– Maximum phonation time-normal

– Fundamental frequency- 173 Hz

– Jitter (.77%)

– Shimmer (.23 dB)

– Harmonic to noise ratio (12.5 dB)

– Aerodynamics:• Transglottal airflow during phonation- .282 l/sec (3x higher than

normal)

• Subglottal pressure- 6.5 cm H20

• Glottal resistance- 17.7 cm H20/lps (1/2 of normal value)

• Hypofunctioning

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Bilateral Vocal Fold Nodules• Videostroboscopy:

– Multiple nodule formations on free edge

– Closure: hourglass

– Interruption of complete closure

– Mild irregularities of mucosal wave

• Treatment Recommendations:

– Multiple bilateral nodules

– Surgical removal

– Followed by speech therapy

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Bilateral Vocal Fold Nodules• Treatment Results:

– Surgical excision of nodules

– Voice therapy:• Vocal hygiene

• Pitch, loudness & breath support regulation using visipitch

• 8 week treatment cycle

– Laryngeal study before discharge:• Perceptual improvement: mild dysphonia, higher pitch

• Maximum phonation time-normal

• Fundamental- 238 Hz

• Jitter- 1.72%; Shimmer- .12 dB

• Aerodynamics:– Mean airflow- .469 l/sec

– Subglottal pressure- 5.3 cm H20

– Glottal resistance- 12 cm H20/lps

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Postoperative: Bilateral Vocal Fold Nodules

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Discussion

• Vocal nodules secondary to vocal abuse

• Disrupt mucosal wave

• Incomplete glottic closure

• Surgical excision recommended followed

by therapy

• Therapy aids in likelihood of not

reoccurring

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Case 26, CD #1 (track 26): Bilateral Vocal Fold Nodules

• History:

– 45 year old non English speaking female

– 18 month history of dysphonia

– One year ago- Vocal fold nodulectomy

– Severe hoarseness reoccurred within 2 months post

surgery

– Avid cigarette smoker (20 years)

– Struggled daily with coughing, throat clearing,

gastric reflux

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Bilateral Vocal Fold Nodules • Examination Findings:

– Head & neck exam- Unremarkable

– Perceptually- Moderately hoarse-breathy, low pitch & volume

– Videostroboscopy-• Large nodular-like mass lesions on the

anterior third of the left cord – caused deformation on the opposite cord &

chink in the glottis during phonation– Amplitude of vibration was interrupted

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Bilateral Vocal Fold Nodules

• Treatment Recommendation:

– Bilateral excision, microflap approach

– Followed by voice therapy

– Dietary lifestyle modification

– Antireflux medication

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Bilateral Vocal Fold Nodules • Treatment Results:

– Bilateral vocal fold stripping, instead of microflap– 10 days of voice rest– Reevaluation in the voice lab 6 weeks postop– No antireflux was prescribed

• She complained her coughing, throat clearing & indigestion had not abated

– Perceptually her voice was hoarse & breathy– Disappointing surgical outcome

• jitter (2.6%)

• Shimmer (.92 dB)

• Mean airflow rate (.831 l/sec)

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Bilateral Vocal Fold Nodules

• Treatment Results cont.:

– Maximum phonation time was less than 10

seconds

– Videostroboscopy results (photos)

• Prominent chink throughout length

• Divot formation on right fold

• No complete closure

• Intensive voice therapy prescribed, but patient

failed to follow through

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Discussion

• Early detection- Respond to therapy as pretreatment

• Resolve with appropriate vocal hygiene & behavioral modification techniques

• Cessation of chronic throat clearing & vocal abuse

• Vocal exercises

• Diet modification

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Problems

• Chronic voice abuse– Never modified before or after surgery

• Surgery was recommended first– No postoperative voice therapy to learn how to

protect her larynx

• Nodules were progressed; therapy alone would not have helped– Unfortunately her larygologist stripped her folds

rather than using the mucosal saving technique of microflap

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Polyps• Description/Etiology:

– Many forms-

• Localized pedunculated (attached by slim stalk)

• Sessile (closely adhered to mucosa)

• Hemorrhagic (blood blister)

– Diffuse- covers one half or two thirds of the entire length of the vocal fold

– Result from a period of vocal abuse, single traumatic incident (e.g. yelling at a basketball game)

– Polyps & nodules same etiology only to a different degree)

– Polyp is larger, more vascular, edematous, & inflammatory

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Polyps

• Perceptual Signs:

– Hoarseness, roughness or breathiness

– Sensation of something in their throat

• Acoustic Signs:

– Increased jitter & shimmer

– Reduced phonational ranges & dynamic

range

– Increased spectral noise

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Polyps

• Measurable Physiological Signs:

– Increased airflow if polyp interferes with glottal closure- Unilateral: .162 -.247 l/sec, Bilateral: .256-.359 l/sec

– Subglottal pressure increases to produce phonation in the presence of a leaky glottis

– EGG- Decreased closing times

– EMG- normal, unless excessive tension

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Polyps• Observable Physiological Signs:

– Laryngoscopy• Large masses on one fold, sometimes broad based

• Translucent

• May appear reddish if filled with blood

– Stroboscopy• Asymmetry of motion

• Increased aperiodicity

• Distinct phase differences between the folds

• Amplitude reduced

• Glottal closure effected

• Little or no mucosal wave

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Polyps


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Case 29; CD 1 (Track 29): Bilateral Vocal Fold Polyps

• History:

– 23 year old male

– Acute onset of hoarseness while shouting at a music concert

– Voice remained unchanged during the following 6 months

– Medical history was significant for allergy-induced rhinosinusitis, chronic cough 7 throat clearing

– Smoked one pack of cigarettes per day (2 years)

– Voice abuse at work

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Bilateral Vocal Fold Polyps• Examination Findings:

– Perceptually- moderately to severely hoarse, reduced volume and pitch control

– Maximum phonation time- 10 seconds

– Acoustic:• Fundamental frequency- 137 Hz

• Jitter- .81%

• Shimmer- .34 dB

• Harmonic-to-noise ratio- 16 dB

• Moderately abnormal

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Bilateral Vocal Fold Polyps• Stroboscopy-

– Pronounced polyp on the middle third of the right true

vocal fold

– Compresses opposite fold & reduces glottal competency

across the glottal inlet

– Reactive polyp evolved over left true vocal fold

– Mucosal wave is restricted bilaterally

– Glottal incompetence at midline

– Diagnosis: Bilateral vocal fold polyps secondary to vocal

abuse

– Recommendation: Surgical removal recommended followed

by voice therapy

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Preoperative: Vocal Fold Polyps

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Bilateral Vocal Fold Polyps• Treatment Results:

– Surgical excision of the bilateral polyps– Post op the patient was placed on H2 blocker

therapy & oral antibiotics– Voice rest for 10 days– One month post surgery his voice was a good

quality with normal pitch and loudness– Persistent edema– Chink in posterior glottis during closed phase of

vibration– Voice therapy concentrating on limiting voice

abuse behaviors

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Postoperative: Vocal Fold Polyps

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Discussion• Acute onset of hoarseness associated with vocal abuse

may result in submucosal hemorrhage caused by forceful & traumatic closure

• Hoarse breathy voice ensues

• Treatment on voice abuse behaviors may reverse mild mucosal changes

• Surgery indicated for larger masses– Removal of large polyp will resolve the opposite cord

without surgery

• Postoperative therapy

• Psychological consolation

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Intracordal Cysts• Description/Etiology:

– Small spheres on the margins of the vocal folds

– May be mistaken for early nodules

– Predominately unilateral

– may occur along with vocal nodules

– Cause blockage of a granular duct in which mucous is retained (retention cyst)

• Perceptual Signs:– Hoarseness, lowered pitch

– “Tired” voice

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Intracordal Cysts

• Acoustic Signs:

– not available

– Data similar for nodules

• Measurable Physiologic Signs:

– Few data available

– Higher flows & peak flows

– EGG- Slower closing phase

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Intracordal Cysts• Observable Physiologic Signs:

– Laryngoscopy• 10% obvious cysts on initial exam

• Capillary dilation raises suspicion of a cyst in 55% of cases

– Stroboscopy• Absence of mucosal wave in area over the cyst

• Greater aperiodicity & reduced glottal closure

• Vibration of both folds is asymmetric over cyst area

• Cyst increases mass & stiffness of the cover whereas the transition layers & body are unaffected

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Intracordial Cysts

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Case 38; CD 2 (Track 5): Vocal Fold Cyst

• History:

– 38 year old male

– Chief complaint of persistent hoarse vocal quality

for the past 6 months

– Nonsmoker, complained of excessive postnasal

mucous secretions, chronic cough, throat clearing

& gastric reflux

– Admitted to voice abuse patterns at work

– Singer in a local band

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Vocal Fold Cyst• Examination Findings:

– Perceptually- Moderately hoarse-breathy quality, limitations in pitch & volume range

– Maximum phonation time- normal– Acoustic:

• Fundamental frequency- 165 Hz

• Jitter- .63%

• Shimmer- .13 dB

• Harmonic to noise ratio- 16.0 dB

• Mildly abnormal

• Instability of cycle to cycle vibratory characteristics

• Mildly elevated pitch

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Vocal Fold Cyst• Stroboscopy-

– Presence of large submucosal cyst over middle 1/3 of left vocal fold

– Hampers vibratory activities of involved fold & compresses the opposing fold

– Inhibits full glottic closure– Anterior & posterior glottal gap

• Recommendations:– Microflap surgery– Postoperative speech therapy

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Preoperative: Intracordial Cyst

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Vocal Fold Cyst• Treatment Results:

– Microflap excision of the left vocal fold– Postoperatively placed on H2 blocker to lesson

likelihood of acid regurgitation onto healing vocal folds

– Refrain from voice use for 2 weeks postop– Laryngeal Study 2 weeks postop-

• Mild hoarseness

• Fundamental frequency- 148 Hz

• Jitter- .53%

• Shimmer- .22 dB

• Harmonic to noise ratio- 8 dB

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Vocal Fold Cyst• Videostroboscopic Findings postop:

– Mild edema of left fold

– Free margins clean

– Small amounts of mucous beading which

caused throat clearing

• Instructed on importance of hydration to thin

secretions & provide better vibratory

environment

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Postoperative: Intracordial Cyst

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Discussion

• Vocal fold cysts- Most often mucous

retention

• Typically diagnosed through hoarse voice

and absence of mucosal wave

• Voice therapy is the treatment option

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Treatment of Post Surgical Laryngeal Pathology

• Preoperative Considerations:

-Inservice training- medical staff, physicians, residents

-Referral information: SLP visit before therapy, description of laryngeal condition

-Counseling: case history interview, analysis of voice characteristics, postoperative problems, return of growth, need for surgery, present possible voice therapy approaches not requiring surgery, audio tape /a/

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• Postoperative considerations:

-Surgical report: healing time

-Voice session post op: analysis of voice, program for recovery of voice, counseling on vocal hygiene for those with normal outcomes

-Scheduling: 1-2 hour sessions once or twice per week for 1st 2 weeks, discuss difficulties, control of vocal abuses

-Diary of voice use: verbal patterns in daily life, speaking time log, provides a good look at the client’s overall voice use

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Reading

• Colton & Casper Ch. 6

• Additional sources:

• Daniel Boone & Stephen C. Mcfarlane, The Voice and Voice Therapy, Prentice Hall, 1994, Ch. 3

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Directed Reading

• Colton, R.H., Woo, P., Brewer, D.W., Griffen, B. & Casper, J. (1995). Stroboscopic Signs Associated with Benign Lesions of the Vocal Folds. Journal of Voice, 9 (3), 312-325.

• Due 9/30/99

1 organic voice disorders. 2 organic lesions mass lesions of v.f.’s cause the following changes:...

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