Chapter 6 Phonation: Clinical Applications Perry C. Hanavan, Au.D.

Cultures The Jimi Hendrix of Mongolia Incredible Human Machine Steven Tyler Wall of Sound Naturally 7 Dr. Patricia Kuhl: Linguist Genius of Babies

Question What is meant by phonation? Whispered speech sound Voiced speech sound Produce a nasal sound Use your lips to produce sound I don’t know

Practice Labeling

Review

Question Which non-speech function is helpful for lifting or pushing heavy objects? Coughing Abdominal fixation Throat clearing Swallowing reflex All the above

Larynx: Non-Speech Functions Coughing Abdominal fixation Throat clearing Swallowing reflex

The Cough

The Cough Can voluntarily cough Reflex triggered when irritant stimulates one or more cough receptors Receptors transmit message to cough center in brain, telling body to cough Cough begins with deep inhalation, at which point opening between vocal cords at upper part of larynx (glottis) shuts, trapping air in lungs As diaphragm and other muscles press against lungs, vocal folds suddenly abduct, producing explosive outflow of air at speeds exceeding 100 miles per hour

Nonspeech Laryngeal Function Cough Reflex Visceral afferent branch of Vagus Nerve Response to irritant of tissue of respiratory passageway to irritant or foreign object Widely abducted vocal folds followed by tight adduction of vocal folds and elevation of larynx Smokers less sensitive to cough-inducing irritants (which may have important medical implications) Reflex cough test reliably evaluated the laryngeal cough reflex and the associated risk of developing aspiration pneumonia in stroke patients. Testing the laryngeal cough reflex may significantly reduce morbidity, mortality, and costs in stroke patients. (Addington et al 1999)

Clearing Throat

Swallowing Reflex Bolus of food triggers reflex as it passes tongue above larynx Larynx elevates Epiglottis drops down to cover aditus (opening to larynx from pharynx) Tight adduction of folds

Vocal Fold Functions

Laryngeal Structures Aryepiglottic folds The most superior of laryngeal folds Run from the sides of epiglottis to apex of each arytenoid cartilage

Laryngeal Structures False vocal folds Ventricular folds lie inferior to aryepiglottic folds and just superior and parallel to true vocal folds

Laryngeal Structures True vocal folds Most complex of laryngeal valves Consist of five layers, including thyroarytenoid muscle, three layers of mucous membrane surrounding muscle, and layer of epithelium

True Vocal Folds

Laryngeal Structures Laryngeal ventricle Separates false from true vocal folds Small space between true and false folds

Laryngeal Function for Speech Attack Simultaneous Breathy Glottal Termination Sustained phonation Vocal register Whispering

Laryngeal Function for Speech Attack - process of bringing folds together for phonation, requires muscles (three types): Simultaneous - adduction and onset of exhalation occurs together Breathy - airflow begins before phonation “hope”, Breathy phonation - failure to completely close folds Glottal- used when word begins with stressed vowel, normal process (Hard glottal attack – damaging) Termination - process of fold retraction (abduction) Sustained phonation - requires maintenance of tonic (sustained tensing) of musculature (actual phonation does not require repeated adduction and abduction)

Speech Function

Vocal Folds Phonation Fundamental Harmonics Habitual pitch Optimal pitch Average fundamental frequency

Question Register or pattern of phonation used in daily conversations: Falsetto Whistle Modal Vocal fry Whisper

Vocal Register Vocal register - differences in mode of vibration of vocal folds Modal register - pattern of phonation used in daily conversations Glottal fry - (rough voice) vibrating portion flaccid, lateral portion tensed resulting in strong medial compression with short, thick folds and low glottal pressure Falsetto - long and extremely thin folds Whistle register - turbulence on edge of vocal folds Whispering - not actually phonatory because no voicing partially adducted and tensed to produce turbulence, strenuous and fatiguing

Modal Register Modal register or modal phonation refers to the pattern of phonation used in daily conversation Example

Vocal Fry

Glottal Fry Also known as pulse register or Strohbass (straw bass) Vocal folds vibrate between 30 and 90 Hz Frying pan sound of eggs frying Low subglottal pressure Tension of the vocalis is significantly reduced relative to modal vibration, so that the vibrating margin is flaccid and thick. The lateral portion of folds is tensed creating thick folds Example

Glottal Fry Vocal Fry

Falsetto A singing technique that produces sounds that are pitched higher than the singer's normal range Vocal folds lengthened and become extremely thin expansion and separation of vocal cords, in which case, only the edges of the vocal cord vibrate, not the entire vocal cord used by male countertenors to sing in the alto range, before women sang in choirs. It is a very common technique in soul music, and has also been made popular in heavy metal How to sing falsetto Falsetto Voice Phrases

Whistle Register Register above falsetto (flageolet register) is the highest register of the human voice Up to 2500 Hz in females Product of turbulence on the edge of the vocal fold Not considered a mode of vibration as product of turbulence Mariah Carey

Whispering Not a phonatory mode Voicing removed Mariah Carey

Question Maintaining childhood pitch despite having passed through puberty… Aphonia Puberphonia Phonia fear Non-phonia

Puberphonia Maintenance of the childhood pitch despite having passed through puberty Puberphonia Other voice disorders

Gender & Age

Vocal Length Change with Age

Fundamental Frequency & Age

Vocal Intensity vs. Vocal Fold Vibration

2 Vocal Fold Intensities

Prosodic Feature of Question Form

Aging Voice Voice quality of the aging voice and disease (cancer of larynx) have similar characteristics Hoarse, shaky, breathy, weak, & altered pitch Voice changes in elderly likely influenced by disease rather than physiologic aging Woo (1992) study of 64 patients aged 65 and older found that only 11 had functional problems related to aging others had lesions, cancer, or inflammatory problems

Normal Changes in the Aging Voice Decrease in breath support thus weakened voice try to compensate by sphyncterically contracting larynx during phonation, producing a strained quality leading to muscular tension dysphonia Laryngeal changes ossification of laryngeal cartilages and joints may cause “bowing” of the vocal folds which may be most common benign aging pathology loss of vocal fold mass decreasing ability to adduct vocal folds - thus weak, breathy voice

Young vs. Aged Vocal Folds Young (healthy) Aged

Normal vs. Cancerous Normal Cancer (beginning stage)

Normal Changes Con’t Other changes… changes in the cricoarytenoid due to aging may account for some of the pitch variability men, beginning in 60’s and each decade after- vocal cords become thin and atrophied resulting in a higher pitched conversational voice women, pitch seems to lower through life— vocal cords may become more polypoid after menapause due to estrogen deprivation which causes substantial changes in mucous membranes lining vocal tract

Presbylaryngis Age related structural changes of vocal folds may cause glottal gap during voice production Woo states: “presbylaryngis is not a common disorder and should be a diagnosis of exclusion made only after careful medical and speech evaluation”

Aging Larynx Gender Differences Nature of Aging Change Progressive in males until 70, declines thereafter Progressive in females after 70 Thickening Epithelium In males - limited data in females Atrophy Intrinsic muscles More evident in males General deterioration Cricoarytenoid joint More extensive, earlier onset in males Ossification & calcification Cartilages Gender Differences Nature of Aging Change Laryngeal Structure From Linville, Vocal Aging

Perceptual Age-related changes X Slow rate Breathy Hoarseness Pitch changes Classify into age groups Determine age from voice sample Female Male

Acoustic Age-related Changes of Voice Smaller Intensity range Variability of Intensity Slower Speaking rate Avg Intensity level Fo range Greater Freq Pertubation Fo variability Lower Higher Avg Fund Freq Female Male

Aging Pathological Conditions Infections of viral, bacterial, or fungal origin Inflammatory autoimmune disease Neoplasms (benign or malignant) Vocal cord paralysis Thyroid function problems Functional and psychogenic disorders Patients who have undergone surgical procedures or emergent intubation will have pathological changes in larynx for weeks, months, or permanently

Laryngeal Stridor

Voice Disorders Voice Doctor Voice Disorders Functional Voice Disorder Disorders of the Larynx Cancer of the Larynx

Vocal Cords Phonation Vocal cords (variables) Length Mass (thickness) Tension Normal Vocal Cord Images/Videos

Question Who has the longer vocal folds? Men Women Young boys Young girls Cats

Question Whose pitch rises as they age? Men Women Young boys Young girls Cats

Question When does the most dramatic change in phonation occur? Childhood Pubescence Adulthood Elderly Infancy

VC Fundamental Frequency Fo (fundamental of vocal fold vibrations) Vocal folds/chords generate a fundamental and harmonics Fundamental is not audible due to vocal tract resonance Although Fo not audible, the listener perceives the audible harmonics as the Fo (perceptually as pitch) SFF = speaking fundamental frequency Average Fo of an individual during normal conversation or during oral reading

VC Fundamental Frequency SFF variations: Age Gender Emotions Sentence type Disease Medications

SFF and Age Infants 350-500 Hz Children 270-300 Hz Pubescence 120 Hz - males; 220 Hz - females Seniors 162 Hz - males; 177 Hz - females

Gender Pubescence Seniors More dramatic change in males than females SFF Seniors SFF increases in males SFF decreases in females

Adult Gender Differences Male vocal folds: 17 mm and 25 mm (0.67" to 1.0") in length. Female vocal folds: 12.5 mm and 17.5 mm (0.5" to 0.7") in length.

Frequency Variables Stress and accent of sounds in speech Prosody features of speech Measured by: FoSD Normal conversation 20-35 Hz Varies by age, gender, emotions Semitones=pitch sigma (2-4 semitones) Range – difference between highest and lowest Fo in sample of speech

Question Whose voice has the greatest frequency variation? Infants Children Adolescents Adults Seniors

Range of Freq. Variability Infants greatest range -1202 Hz Children 150-190 Hz Adolescents 64-95 Hz Seniors 78-101 Hz

Question What can influence our voice intensity? Prosody of speech Emotions Social situations Health All the above

Amplitude Normal 65-85 dB SPL Prosody of speech Emotions Social situations Health

Medications Adversely Affecting Voice Antidepressants Muscle relaxants Diuretics Antihypertensives (blood pressure medication) Antihistamines (allergy medications) Anticholinergics (asthma medications) High-dose Vitamin C (greater than five grams per day)   Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a cough or excessive throat clearing. Pill may cause edema in the vocal cords due to estrogen. Estrogen replacement therapy post-menopause may have effect. Low level of thyroid replacement medication in patients with hypothyroidism. Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp formation in response to trauma.

Medical Conditions Affecting Voice Poor health Laryngitis Laryngopharyngeal Reflux Disease (LPRD) Voice misuse and overuse Benign vocal cord nodules Vocal Cord Hemorrhage Vocal Cord Paralysis and Paresis Neurologic related Laryngeal cancer

Voice Disorders Diplophonia Neurologic Spasmodic disphonia Muscle Tension Dysphonia (MTD) is a general term to describe excessive and unnecessary tension of laryngeal muscles during voicing.  MTD is often referred to by many different names including - hyperfunction, functional dysphonia, ventricular or false vocal fold compression, etc.  MTD is thought to be a compensatory mechanism in the presence of underlying laryngeal pathology.  Symptoms often include a sensation of excessive laryngeal tension and strain, vocal fatigue, and hoarseness. Neurologic Spasmodic disphonia