1 Organic Voice Disorders

2 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

3 Benign Laryngeal Pathologies Category 1: –Abnormal growths or lesions secondary to aggressive (hyperfunctional-abuse) vocal fold behaviors Nodules Polyps Contact Ulcerations Submucosal cysts

4 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

5 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

6 Category 1 Vocal Pathologies Secondary to Vocal Abuse & Misuse

7 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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9 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

10 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

11 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 H 2 0 Normal (women)- 5 cm H 2 0 Normal (men)- 6 cm H 2 0 –EGG- Decreased closing times & irregular closing pattern –EMG- Normal or elevated if laryngeal tension is present

12 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

13 Video, Case Examples Nodules

14 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

15 Preoperative: Bilateral Nodules

16 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 H 2 0 Glottal resistance cm H 2 0/lps (1/2 of normal value) Hypofunctioning

17 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

18 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 H 2 0 –Glottal resistance- 12 cm H 2 0/lps

19 Postoperative: Bilateral Vocal Fold Nodules

20 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

21 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

22 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

23 Bilateral Vocal Fold Nodules Treatment Recommendation: –Bilateral excision, microflap approach –Followed by voice therapy –Dietary lifestyle modification –Antireflux medication

24 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)

25 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

26 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

27 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

28 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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31 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

32 Polyps Measurable Physiological Signs: –Increased airflow if polyp interferes with glottal closure- Unilateral: l/sec, Bilateral: l/sec –Subglottal pressure increases to produce phonation in the presence of a leaky glottis –EGG- Decreased closing times –EMG- normal, unless excessive tension

33 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

34 Polyps Video, Case Examples

35 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

36 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

37 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

38 Preoperative: Vocal Fold Polyps

39 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

40 Postoperative: Vocal Fold Polyps

41 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

42 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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44 Intracordal Cysts Acoustic Signs: –not available –Data similar for nodules Measurable Physiologic Signs: –Few data available –Higher flows & peak flows –EGG- Slower closing phase

45 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

46 Video, Case Examples Intracordial Cysts

47 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

48 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 dB Mildly abnormal Instability of cycle to cycle vibratory characteristics Mildly elevated pitch

49 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

50 Preoperative: Intracordial Cyst

51 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

52 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

53 Postoperative: Intracordial Cyst

54 Discussion Vocal fold cysts- Most often mucous retention Typically diagnosed through hoarse voice and absence of mucosal wave Voice therapy is the treatment option

55 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/

56 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

57 Reading Colton & Casper Ch. 6 Additional sources: Daniel Boone & Stephen C. Mcfarlane, The Voice and Voice Therapy, Prentice Hall, 1994, Ch. 3

58 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), Due 9/30/99