VOICE AND SPEECH DISORDERS

Hoarseness

  Roughness of voice from variations of  periodicity and/or intensity of sound waves.

  For  production of normal voice, vocal cords should:

1. Be able to ap proximate properly

2. Have a proper size and stiffness3. Have an ability to vibrate regularly in response to air column

  Any condition that interferes with above functions causes hoarseness:

(a) Loss of approximation: in VC paralysis/fixation/tumour in between VC(b) Size of the cord: increases in oedema VC/tumour; decreases in surgical excision/fibrosis(c) Stiffness: decreases in par alysis, increases in spastic dysphonia(d) Cords not be able to vi br ate properly: in congestion, submucosal haemorrhages, nodule/ polyp

AetiologyCauses of hoarseness

1 . Idiopathic/ F unctional : Hysterical aphonia2. Congenital: Laryngeal web, cyst, laryngocele

3. Trauma: Submucosal hgge, laryngeal trauma4. Inflammations:

   Acute: cold, inf luenza, laryngo-tracheo-bronchitis, diphtheria 

  Chronic:(i) Specific: TB, syphilis, scleroma, fungal infn(ii) N on-spec ific: Chronic laryngitis, atrophic laryngitis

5. Neoplasms:

Benign: Papilloma, haemangioma, chondr oma, fibroma, leukoplakia

  Malignant: Carcinoma 

Tumor like masses: VC nodule, polyp, cyst, amyloid tumour 6. Neurologic : RLN &/or SLN palsy 7. Miscellaneous: Dysphonia plica ventricul aris, fixation of cricoarytenoid ioints, myxoedema

Investigations1.  History:

  Onset, Duration , pt's occupation, habits and assoc complaints.

   Any hoar  seness persisting >3 wks deserves examn of larynx.

   Malignancy should be excluded  in pts > 40 yrs.

2. IDL: for local laryngeal causes 3. Examn of  neck, chest, CVS and CNS to find cause for lar yngeal paralysis4. Lab and r adiol inv as per  cause sus pected on clinical examn 

5. DLscopy and MLscopy : for  detailed examn, biopsy and assessment of the mobility of cricoarytenoid joints

6.+/- Br onchoscopy and oeso phagoscopy

Dysphonia Plica Ventricularis (Ventricular Dysphonia)

  Voice by ventricular folds (false cords) which have taken over the function of true cords (e.g. in paralysis, fixation,surgical excision, or tumour s) 

  False cords in these situations try to compensate fn of true cords.

  Voice is rough, low-pitched and unpleasant.

  Ventricular dysphonia secondary to laryngeal disorder is difficult to treat.

  Functional type of ventricular dysphonia occurs in normal lar ynx . Here cause is psychogenic. In this type,

voice begins normally but soon becomes rough when false cords take over . Treatment: voice therapy and psychologicalcounselling.

  Diagnosis on IDL: false cords seen to ap proximate and obscur e the view of true cords on phonation

Functional Aphonia (Hysterical Aphonia)

  Functional disorder 

  In emotionally labile females 

  Age group: 15-30yrs.

  Aphonia is usually sudden without any laryngeal symptoms. 

  O/E: VC abducted and fail to adduct on phonation; however adduction possible on coughing. Even though patient is

aphonic, sound of cough is good.

 

  Treatment: Reassure the pt and psychotherapy.

Puberphonia (Mutational Falsetto Voice)

   Normally, child has higher  pitch. At puberty, VC lengthen, and voice becomes low pitch (a feature exclusive to males)

  Failure of  this, leads to persistence of childhood high-pitched voice k/a puber  phonia. 

  Seen in boys who are emotionally immature, feel insecur e and show excessive fixation to their mother.

  Treatment: training to produce low-pitched voice (Gutzmann's pressure test: Pressing the thyroid prominence in a

 backward and downward direction relaxes the over stretched cords and giving a low tone voice & then pt tr ains himself to produce syllables, words and number s).

  Prognosis is good.

Phonasthenia

  Weakness of voice due to fatigue of phonatory muscles (Thyroarytenoid and interarytenoids). Patient complains of 

easy fatiguability of voice.

  Seen in a buse or misuse of voice or f ollowing laryngitis 

  Indirect lar yngoscopy shows three characteristic findings:

(i) Elliptical space (weakness of thyroarytenoid)

(ii) Triangular ga p (weakness of interaryteno id)(iii) K ey-hole appearance (weakness of thyroarytenoid + interarytenoids)

  Treatment: voice rest and vocal hygiene 

Hyponasality (Rhinolalia Clausa)

  Lack of nasal resonance f or words r esonated in nasal cav ity (e.g. m, n, ng) due to blockage of  nose or naso phar ynx

  Important causes:

o  Common cold, Nasal allergy, Nasal growth or polyp o  Nasopharyngeal mass/Adenoidso  Familial/ Habitual speech pattern

Hypernasality (Rhinolalia Aperta)

  When certain words with little nasa l r esonance ar e resonated through nose.

  The defect is in f ailure of the nasopharynx to cut of f from oropharynx. 

  Important causes:

o  Velopharyngeal insufficiency, Large nasopharynx/ Post-adenoidectomy o  Paralysis of soft palate, Cleft of soft palate o  Familial/ Habitual speech pattern

Stuttering

  Disor der of fluency ( hesitation to start, repetitions, pr olongations or  blocks in the flow of speech).

  When well-established, a stutterer develops secondary mannerisms such as facia l grimacing, eye blink and a bnormalhead movements.

   Normally, children have dysfluency b/w 2-4 year s. 

  If reprimanded this behaviour becomes fixed and child develops into adult stutterer.

  Prevented by parent education not to overreact in early stages. 

  Treatment: speech therapy and psychother apy to reduce his fear of dysfluency & increase confidence.