Common Voice Disorders Reference ON-LINE: GOOGLE “IOWA PROTOCOLS” Resource: https://medicine.uiowa.edu/iowaprotocols/ https://medicine.uiowa.edu/iowaprotocols/ Learning Objectives: I. Understand the basis of voice and speech production with associated terminology II. Understand the significance of voice disorders III. Understand the functions of the larynx and how disease impairs those functions IV. Learn how to evaluate a patient with a voice disorder V. Identify common voice disorders VI. Learn the management of common voice disorders Henry T. Hoffman MD Department of Otolaryngology— Head and Neck Surgery National Center for Voice and Speech University of Iowa

Case Example – Audio then Visual What is your diagnosis? https://medicine.uiowa.edu/iowaprotocols/slide-01-common-voice-disorders-dysphonia-what-your-diagnosis

Case Example – Audio then Visual What is your diagnosis? https://medicine.uiowa.edu/iowaprotocols/slide-01-common-voice-disorders-dysphonia-what-your-diagnosis Answer: https://medicine.uiowa.edu/iowaprotocols/slide-02-common-voice-disorders-diagnosis-and-treatment https://medicine.uiowa.edu/iowaprotocols/slide-03-common-voice-disorders-postop

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology A. Glottis = vocal cord area B. Supraglottis= area of larynx above vocal cords (false vocal cords/ arytenoids/epiglottis) C. Subglottis = area of larynx immediately below the vocal cords

Coronal section

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology Cough D. Voice = output from the lung and larynx video of normal videostrob E. Speech = communication resulting from modification of voice by the articulators (tongue/lips/palate/teeth) video of dysarthria F. The function of normal vocal cords (a competent glottic valve) converts the DC current of air streaming upward from the lung into an AC current. Voicing: ‘Glottic valve’ convert DC-AC

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology G. The most superficial layer of the vocal cord is fluid. It overlies the mucosal surface of the vocal cord which also contains muscle and ligament. Normal voicing requires this fluid layer to be present – underscoring key components to the treatment of voice disorders: humidification and hydration.

Normal larynx Vocal Folds - Complex Nature Body - Underlying muscle + vocal ligament Cover - Loosely attached epithelium Overlying fluid

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology G. The combination of adequate breath support (lungs) and appropriate vocal cord vibration are needed for normal phonation. [VIDEO of patient with asthenic voice]

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology H. Impaired function of the glottic valve results in an abnormal voice and can also impair swallowing and breathing. [VIDEO of bilateral vocal cord paralysis]

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology I. Passive vibration of the vocal cords rather than active movement by muscle contraction results in voice – this concept explains how a patient with bilateral vocal cord paralysis may have a normal voice. [VIDEO of bilateral vocal cord paralysis #2]

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology J. Phonation can also occur without vocal cords. A man treated with removal (partial laryngectomy) of cancerous vocal cords is able to produce a lung powered sound (voice) by vibration of the arytenoid mucosa against the base of the tongue. [VIDEO of patient below]

I. Basis of Voice and Speech Production – Anatomy/Physiology/Terminology K. More definitions:

II. The Significance of Voice Disorders A. Dysphonia as a tipoff to another illness

II. The Significance of Voice Disorders B. Voice Professional = singers, doctors, lawyers, teachers, anyone using their voice to work

III. Understand the functions of the larynx and how disease impairs those functions A. Impaired function of the glottic valve results in an abnormal voice and can also impair swallowing and breathing.

III. Understand the functions of the larynx and how disease impairs those functions B. Impaired vocal cord/fold vibration results in dysphonia.

III. Understand the functions of the larynx and how disease impairs those functions C. Example of dysphonia due to abnormal vocal cord vibration from laryngitis. Laryngitis is inflammation of the larynx and can be caused by a. Infection: viral/bacterial/fungal b. Trauma: vocal overuse/intubation c. Exposure to irritants: smoke/GE reflux/inhalants Video of Viral laryngitis

IV. How to Evaluate a Patient with a Voice Disorder A. Obtain a History

IV. How to Evaluate a Patient with a Voice Disorder B. Perform a physical examination

IV. How to Evaluate a Patient with a Voice Disorder C. Methods to image the larynx include:

IV. How to Evaluate a Patient with a Voice Disorder C. Methods to image the larynx include: flexible fiberoptic transnasal exam of the larynx, [VIDEOS of exam]

V. Identify Common Voice Disorders A. infectious, neurogenic, traumatic, psychogenic, and neoplastic Fungal - https://medicine.uiowa.edu/iowaprotocols/slide-07-common-voice-disorders-fungal-laryngitis Paralysis - https://medicine.uiowa.edu/iowaprotocols/slide-08-common-voice-disorders-laryngeal-paralysis ALS Scarring Trauma: nodule/polyp Psychogenic Muscle Tension Dysphonia - https://medicine.uiowa.edu/iowaprotocols/slide-09-common-voice-disorders-muscle-tension-dysphonia Neoplastic

V. Identify Common Voice Disorders A. Important voice disorders include infectious, neurogenic, traumatic, psychogenic, and neoplastic causes Chronic hoarseness (> 2 weeks or ? >3 months) Neoplastic Glottic cancer: Harsh, breathy voice Supraglottic cancer: “Silent”; muffled voice, neck mass, airway obstruction Subglottic: Airway obstruction RRP (Recurrent respiratory papillomatosis)

V. Identify Common Voice Disorders A. Important voice disorders include infectious, neurogenic, traumatic, psychogenic, and neoplastic causes Chronic hoarseness (> 2 weeks or ? >3 months) Psychogenic “Functional aphonia” “Psychogenic aphonia” Muscle tension dysphonia

VI. Management of common voice disorders A. Voice disorders may be managed by physicians who are not capable of examining the vocal cords when the presumptive diagnosis is laryngitis through a. voice rest b. humidification c. hydration d. management of associated symptoms (such as cough) and reflux.

VI. Management of common voice disorders B. Referral to an Otolaryngologist is indicated when a. there is clinical suspicion that the voice disorder is not a self-limited laryngitis b. the voice problem persists longer than two to three weeks; c. there are associated symptoms such as swallowing or breathing impairment

VI. Management of common voice disorders C. Medications with adverse effects on the voice include: Drying effect (antihistamines, diuretics, tricyclic antidepressants) Laryngeal irritants (inhaled propellants Factors increasing bleeding risk (aspirin, anticoagulants)

VI. Management of common voice disorders D. Medications with favorable effects on the voice: Antitussives: codeine/dextromethorphan/benzonatate (Tessalon perles) Mucolytics: guaifenesin Water: H20 (humidification and hydration) Anti-reflux medications (H2 blockers e.g. Zantac /PPI e.g. Prilosec/Omeprazole)

VI. Management of common voice disorders E. Speech pathologists manage voice disorders by: Assessing vocal behavior Modifying vocal behavior Maximizing vocal potential

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Case Example – Audio then Visual What is your diagnosis? Link to video