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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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Benign Laryngeal Pathologies
• 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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Benign Laryngeal Pathologies
• 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
Video, Case Examples
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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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Video, Case Examples
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