Disorders of voiceDr .Sithananda kumar @ venkatesan . RAssistant ProfessorDepartment of ENTMGMC&RI

Definition

•Vocalization means producing sound, preferably on an emotional level

•Phonation is sound production with the aim of communicating by speech or singing

•Voice production involves interaction between the respiratory system, larynx, vocal tract, articulatory organs, and cerebral coordination

Components of phonatory apparatus

• Activator( power source) - lungs and respiratory muscles

• Generator ( of voice)– vocal cords

• Resonator – vocal tract( supraglottic , pharyngeal passages)

• Articulator – palate , tongue , lips , teeth

• The coordination of phonation originates in two centers in the brain—the limbic system and the primary motor area of cortex

Functions of larynx• Lower Airway protection

• Respiration

• Phonation

Mechanism of vocal fold vibration•Aerodynamic myo-elastic theory

•Body cover hypotheses

•Source filter hypotheses

Aerodynamic myo-elastic theory

Body cover hypotheses

Source filter model

Classification of Speech and Language Disorders

• Speech Disorders:

• Language Disorders:

Speech Disorders:• A. Fluency Disorders

• 1.Stuttering Slow Rate of Speech

• 2.Cluttering Fast Rate of Speech

B. Articulation Disorders:

• Substitution eg: Soap - Thoap

• Omission Soap- oap

• Distortion soap- soarp

C. Voice Disorders•1.Picth Disorders

•2.Quality Disorders

•3.Loudnes Disorders

Language Disorders1.Aphasia:

Fluent Aphasia: Broca’s Aphasia

Non Fluent Aphasia: Wernicke's Aphasia

Global Aphasia

Hoarseness • Any change in voice quality from harsh, rough or raspy voice to

weak voice is usually referred as hoarseness

• Hoarseness results from variations of periodicity and/or intensity of consecutive sound waves

• For production of normal voice, vocal cords should: a. Be able to approximate properly with each other. b. Have a proper size and stiffness. c. Have an ability to vibrate regularly in response to air column.

Causes of hoarsenessLoss of approximation

Increase / decrease in size/ thickness of the cord

Increase / decrease in Stiffness

Evaluation • History

• Indirect laryngoscopy

• Video laryngoscopy

• Stroboscopy

Dysphonia Plica ventricularis• voice production by ventricular folds (false cords)

• False cords take over the function of true cords

• Voice is rough, low-pitched and unpleasant

• Ventricular voice may be secondary to impaired function of the true cord such as paralysis, fixation, surgical excision or tumors

• Ventricular bands in these situations try to compensate or assume phonatory function of true cords.

• Functional type of ventricular dysphonia occurs in normal larynx

• psychogenic

• In this type, voice begins normally but soon becomes rough when false cords usurp the function of true cords

• Treatment – speech therapy

Puberphonia• Also called mutational falsetto voice

• Failure in the change of childhood high-pitched voice to low- pitched male voice after puberty in boys is called puberphonia

• The boy’s physical and sexual development is normal

• Seen in boys who are emotionally immature, feel insecure and show excessive fixation to their mother

• Until puberty, the larynx of male and female have identical dimensions

• Childhood voice has higher pitch.

• After puberty, male larynx grows rapidly with increase in length of Rima glottides

• The vocal cords lengthen which brings change in character of male voice (voice becomes lower pitch).

• Gutzmann’s pressure test-Pressing the thyroid prominence in a backward and downward direction relaxes the overstretched cords and low tone voice can be produced

• Treatment – speech therapy

Phonaesthenia • Weakness of voice

• Fatigue of phonatory muscles

• Thyroarytenoid and interarytenoids or both may be affected

• Seen in abuse or misuse of voice or following laryngitis. Patient complains of easy fatigability of voice

Indirect laryngoscopy

Functional aphonia• Also called hysterical aphonia

• Functional disorder is usually seen in emotionally labile young females.

• Sudden onset aphonia

• Not associated with other laryngeal symptoms.

• Patient is usually able to whisper

• Vocal cords are seen in abducted position and fail to adduct on phonation

• Adduction of vocal cords can be seen on coughing, indicating normal adductor function

• Sound of cough is good

• Treatment given is to reassure the patient of normal laryngeal function and psychotherapy

Spasmodic dysphonia• Neurologic disorder of unknown origin that causes vocal fold spasms during speech

• The spasms result in either excessive glottal closure or prolonged lateralization of the vocal folds, causing vocal breaks

• The disease was first described by Traube in 1871

• Three types-adductor, abductor and mixed

• Spasmodic dysphonia are focal dystonia that affects laryngeal muscle control during speech

• Dystonia refers to a syndrome of sustained muscle contraction

• Focal dystonia involve abnormal activity in only a few localized muscles

• More common in females

• Common between 2nd to 9th decade

• The typical age at onset is 39 to 45 years

• Adductor SD occurs in 82%of patients, whereas 17%have abductor SD

• Stuttering can be prevented by proper education of the parents, not to overreact to child’s dysfluency in early stages of speech development

• Treatment of an established stutterer is speech therapy and psychotherapy to improve his image as a speaker and reduce his fear of dysfluency.

Adductor spasmodic dysphonia• Voice breaks are due to spasmodic hyper adduction of the vocal folds that interrupt phonation

• Vocal fold closure interrupts phonation, causing a strained or strangled vocal quality with intermittent vocal break

• In adductor SD, the Thyroarytenoid and lateral cricoarytenoid muscle spasm predominate

Abductor spasmodic dysphonia• Voice breaks are due to spasmodic hyper abduction of the vocal folds that interrupt phonation

• Patients have prolonged breathy voiceless breaks

• Pitch changes and uncontrolled rises in vowel fundamental frequency may make them sound as if they are on the verge of crying

• In abductor SD, the posterior cricoarytenoid muscles predominate

Evaluation • Detailed history

• Video laryngoscopy

• Stroboscopy

• Electromyography

Treatment • Botulinum toxin injections are the current treatment of choice

• Their effect is temporary ( onset of action in 72hrs)and injections must be repeated approximately every 3 months

• Contra indicated in pregnancy , along with aminoglycosides and neurological disorders like myasthenia gravis

• Botulinum toxin is produced by Clostridium Botulinum

• Causes a chemical denervation by splicing fusion proteins (SNAP [soluble NSF attachment protein]-25, syntaxin, synaptobrevin) and blocking the release of acetylcholine at the synaptic junction

• Botulinum toxin must be injected directly into the muscle, the Thyroarytenoid for adductor SD and the posterior cricoarytenoid for abductor SD

STUTTERING

• Disorder of fluency of speech

• Consists of hesitation to start, repetitions, prolongations or blocks in the flow of speech

• Stutterer may develop secondary mannerisms such as facial grimacing, eye blink and abnormal head movements

• Normally, most of the children have dysfluency of speech between 2 and 4 years

Rhinolalia clausa• Hyponasal voice

• Lack of nasal resonance for words which are resonated in the nasal cavity, e.g. m, n, ng

• Due to blockage of the nose or nasopharynx

Rhinolalia aperta• Hyper nasal voice

• words which have little nasal resonance are resonated through nose

• The defect is in failure of the nasopharynx to cut off from oropharynx or abnormal communication between the oral and nasal cavities.

Hot potato voice• Also called muffed voice

• Due to obstruction in the glottal tract above the level of vocal cords

• Peritonsillitis/ abscess• Hypertrophied lingual tonsil / lingual thyroid

• Growth posterior one third of tongue• Vallecular cyst• Acute epiglottitis / epiglottic malignancy• Retropharyngeal abscess

Mogiphonia • Phonic spasm

• Professional neuroses seen in singers ,teachers and clergyman

• Initially the voice is normal but soon the vocal cords get adducted and the person cannot speak

• The treatment is vocal rest, speech therapy

• Treatment of the underlying psychoneurotic problem.