1. Lecture 5 Voice Disorders Part 2: Organic Disorders (Aronson and Bless, 2009; Colton et al., 2011;2013; Sapienza & Hoffman-Ruddy 2014) CD661OL
1. Lecture 5 Voice Disorders Part 2: Organic and Neurological Voice Disorders

2. Organic Voice Disorders
Disease
1. Contact ulcers & Granulomas
2. Infectious laryngitis
3. Gastroesophageal reflux and
laryngealpharyngeal reflux
4. Vocal fold papilloma
5. Candida
6. Leukoplakia and Hyperkeratosis
7. Sulcus Vocalis
8. Laryngeal Cancer
Congenital & Trauma
1. Laryngeal web
2. Laryngeal Cleft
3. Subglottic stenosis
4. Laryngomalacia
2. Organic voice disorders are disorders that are congenital or result from disease processes. This slide lists the various disorders.

3. Contact Ulcers and Granulomas
Three typical causes:
1. GERD or LPR
2. Phonotrauma
3. Intubation trauma
Form on the medial aspect of the posterior third of the vocal folds (cartilaginous portion)
Granulomas are comprised of lymphocytes and fibrotic connective tissue
Usually unilateral but can be bilateral
Variable glottic closure – complete to incomplete
Mucosal wave may be decreased
3. There are 3 possible causes of contact ulcers and granulomas; gastroesophageal reflux and laryngopharyngeal relfux, GERD or LPR for short, vocal abuse/misuse and intubation injury. Contact ulcers are raw sores occurring in the mucus membrane of the AC processes. Granulomas tend to grow over the contact ulcer. Glottic closure will depend on the size of the granuloma. The mucosal wave may be decreased if the VFs are also edemic due to reflux.

4. Causes of Contact Ulcers and Granulomas
Phonotrauma– excessive medial compression of posterior glottis during low pitched phonation, hard glottal attacks, increased loudness, throat clearing and coughing
GERD/LPR – affects of stomach acid and enzymes on VF tissue. Signs are heartburn, chronic hoarseness worse in a.m., nocturnal coughing, excessive mucous, belching, sour/acid taste, burning in throat
Intubation – trauma to VFs from prolonged intubation due to endotracheal tube rubbing VFs
4. There is strong evidence that LPR contributes significantly to the formation of Granulomas. When stomach acid flows into the laryngopharynx, it damages the laryngeal tissues. LPR signs are typically in the posterior larynx. Impact stress from shouting or repetitive arytenoid contact during loud talking an cause mucosal irritation to the vocal processes and also cause ulcers and granulomas. These behaviors, especially in the presence of uncontrolled LPR, increase the likelihood of ulcer and granuloma formation. Granuloma formation due to intubation is rare but can occur when the intubation tube lays against the arytenoid processes and causes irritation to the tissue. A granular tissue then forms. Granulomas from intubation can quickly resolve one the tube is remove. Granulomas due to phonotrauma and LPR can also resolve once the source of irritation is removed. Contact ulcers and granulomas due to phonotrauma and reflux are typically managed with behavioral voice therapy, and if reflux is present, anti-reflux medication such as acid blockers (Zantac) or proton pump inhibitors (Nexium) and dietary and lifestyle changes.

5. Contact Ulcers and Granulomas
5. Both of these videostills show VF granulomas. Note that on the right, you can see that the R vocal process is becoming red and irritated from the impact of the granuloma during VF closure. Also note the extra band of tissue in the posterior commissure. This is called posterior tissue mounding or pachydermia and is directly related to reflux and is the result of chronic irritation from the acid.
Posterior commissure tissue mounding from reflux

6. 6. A very large granuloma.

7. Contact Ulcers and Granulomas
Perceptual characteristics –low pitch, vocal fry, hoarse, breathy
Acoustic – low habitual pitch, increased frequency and intensity perturbations if granuloma is large and if reflux is present.
Patient complaints: vocal fatigue, sensation of something in the throat, pain on phonation, voice worsens with prolonged use
7. Perceptually, the voice may sound low in pitch, and possibly hoarse and breathy. Vocal quality will depend on glottic closure and whether there is edema and irritation of the membranous VFs as well.

8. Reflux Laryngitis: GERD & LPR
GERD – GastroEsophageal Reflux Disease
LPR – LaryngealPharyngeal Reflux
Both may cause voice problems
Regurgitation of acid and stomach enzymes are irritants to the VFs
Cause VF edema, erythema, arytenoid and posterior commissure hypertrophy, pachydermia (thickening of tissue between the arytenoids)
8. Reflux laryngitis can result from either GERD or LPR. Stomach acid and digestive enzymes are irritants to the VFs and are highly corrosive the laryngeal tissue causing edema, erythema (redness), arytenoid and posterior commissure hypertrophy and posterior commissure tissue mounding.

9. Symptoms of GERD and LPR
Heartburn
Rapid vocal fatigue
Sore, burny throat
Globus sensation in the throat
Excessive throat mucus
Increased throat clearing
Chronic ,dry cough or tickle
Waking up choking or coughing
Acid taste in the mouth,
Regurgitation
9. These are all possible symptoms of GERD and LPR. However, People with LPR seldom experience heartburn. Their primary symptoms are laryngeal, sore, burny sore, hoarseness, and vocal fatigue. People with GERD may experience any or all of these symptoms.

10. Reflux Laryngitis: GERD & LPR
Perceptual signs: hoarseness, breathiness, decreased Fo.
Acoustic: Increased noise levels, increased frequency and intensity perturbations
10. Perceptual characteristics of reflux laryngitis include hoarseness, breathiness and possibly decreased habitual pitch. Reflux laryngitis is managed with dietary changes, lifestyle changes, and anti-reflux medications. If poor compensatory vocal habits have developed, behavioral voice therapy may also be indicated.

11. Infectious Laryngitis
Inflammatory response of the larynx due to a viral or bacterial infection
Vocal folds and laryngeal inlet appear red and swollen
Symptoms – total or partial voice loss, hoarseness, breathiness, low pitch
Treatment – Viral: voice rest, water, anti-inflammatory medications, non-mentholated lozenges
Bacterial: same as above but physician may prescribe antibiotics
11. Infectious laryngitis is due to either a bacterial or viral infection. The VFs and laryngeal inlet will appear red and swollen. If the cause is a virus, then voice rest, increased hydration, anti-inflammatory medications and non-mentholated lozenges are appropriate. If the cause is bacterial, the physician may prescribe an antibiotic. Care should must be taken during speech and behaviors such as yelling, loud talking and singing should be avoided until the laryngitis resolves and the voice returns to normal. Whenever the VFs are already irritated and inflamed, they are more susceptible to injury from any behavior that could cause phonotrauma.

12. Laryngeal Papilloma Cause: Human papilloma virus (HPV)
Are wart-like growths
Two types: Juvenile onset and Adult onset
Can also be found in trachea and oropharyx
In children VFP are surgically removed but tend to re-occur til puberty resulting in multiple surgeries
Some juvevnile cases (20%-40%) then spontaneously resolve
Adults – surgery
12. Previously termed Recurrent Respiratory Papilloma, laryngeal papillomatosis is a devastating voice disorder. The most common sites for papillomatosis are the true VFs, the trachea, the bronchi, palate, and nasopharynx. Juvenile papillomatosis typically occurs in the first 1-5 years of life and is passed from mother to the infant. The infection is perinatal. While juvenile onset papillomatosis is rare, children born to mothers carrying the HPV virus are at risk for development of the disease. The papilloma are wart or raspberry shaped and, in children, tend to cluster and form in multiple areas. They grow rapidly and sometimes recur every 2-4 weeks after surgical removal. Surgery is needed to minimize risks to the airway. The impact on voice quality is high due to the numerous surgeries and resultant scarring of the VFs. Adult onset papillomatosis has a much slower rate of recurrence and the papilloma tend to be more localized and single as opposed to multiple lesions. Several studies have shown that, in some children, the disease goes into remission. Ruparelia et al. (2003) reported that likelihood of remission appeared to be positively correlated to age of onset and number of surgeries; older age of onset and fewer surgeries correlated to higher chance of remission.

13. Laryngeal Papilloma Perceptual: Hoarseness, breathiness, strained
Acoustic: no data
Aerodynamic: no data available BUT due to increased stiffness of vocal fold subglottal pressure is likely increased
Endoscopic: Incomplete glottic closure, absent mucosal wave, increased VF mass and stiffness
Scarring due to repeated surgeries will further increase stiffness and decrease mucosal wave
Patient complaints: trouble breathing, decreased pitch and loudness range, vocal effort/strain
13. Pre- and post- surgery, vocal quality is frequently hoarse, rough, breathy and often strained. Stridor may be heard if the airway is compromised. The papilloma cause increased VF mass and stiffness, incomplete glottic closure, and decreased mucosal wave. Post-surgery there is often scar tissue and, depending on how much tissue was excised, incomplete closure. Thus, post-surgery, the voice is also hoarse and may be breathy and strained.
While the primary treatment approach remains surgery, many drugs are being used and tested with hopes of decreasing the severity and rate of recurrence of the disease. More on this when we get to treatment. We see these clients for voice therapy post-surgery to help them maximize whatever vocal ability they have and eliminate or prevent secondary laryngeal muscle tension as a compensatory strategy.

14. 14. On the bottom right, we see a real cross-section of a normal adult VF as well as an illustration. On the top left is a cross-section of a VF with papilloma. Note how the layers of the lamina are obliterated.

15. Laryngeal Papilloma
15. VF papilloma on the RVF, anterior commissure and anterior portion of LVF.

16. 16. Multiple papilloma in a child.

17. 17. Multiple papilloma on both VFs, on the FVFs, and in subglottic area.

18. Laryngeal Web
Cause: Congenital or acquired post-surgery or after laryngeal trauma
The web is a band of tissue that forms in the anterior 1/3 of glottis
Inhalatory stridor may be present, shortness of breath, and high pitched crying (infants)
75% of webs are congenital
Voice is hoarse, possibly high pitched and there may be problems sustaining phonation
18. Laryngeal webs cab be acquired thru trauma to the VFs, occur post-surgery or they may be congenital. Webs, although typically anterior, can block up to 75% of the airway. Any infant with inspiratory stridor, high pitched crying or problems breathing should be evaluated for presence of laryngeal web. Acquired laryngeal webs can occur due to laryngeal trauma, surgery, or intubation. I have also treated a patient who acquired a laryngeal web after breathing caustic chemical fumes. Laryngeal webs are managed via surgical resection of the web using either a scalpel or laser. A keel is typically placed between the VF edges to prevent the web from growing back after surgery.

19. Laryngeal Web
19. A severe laryngeal web running the entire length of the VFs.

20. Congenital Disorders
Laryngomalacia – Soft laryngeal cartilages . May collapse into airway on inhalation. Resolves with maturation.
Most common cause of infant inspiratory stridor
10-20% require surgical intervention (pg. 244)
Endoscopic signs:
collapse of laryngeal cartilages in inspiration
enlarged/floppy arytenoid cartilages
excessive AC mucosa
20. Laryngomalacia is a congenital disorder of unknown etiology and is the most common cause of infant inspiratory stridor. It results in very soft laryngeal cartilages that collapse into the airway on inhalation. It usually resolves with maturation but 10-20% of cases require surgical intervention.

21. Congenital Disorders
Laryngeal Cleft - may be related to an autosomal dominant pattern of inheritance
Cleft on posterior portion of cricoid cartilage causes narrowing of airway.
Symptoms and problems:
Inspiratory & expiratory stridor
Dyspnea
Aspiration
Feeding difficulties
Managed surgically
21. Laryngeal cleft is an extremely rare disorder occurring in 1 out of 20,000 births and is more common in boys than girls. It is diagnosed via microlaryngoscopy and managed surgically. Benjamin and Inglis (1989), presented a classification system in which 4 types of clefts can be described. Types 3 and 4 are most severe. This classification system is outlined nicely in your text on pages

22. Congenital Disorders
Subglottic Stenosis - can be congenital or acquired (trauma/disease)
Is any narrowing of the tissue below the level of the glottis
Third most common congenital condition
Symptoms:
Inspiratory and expiratory stridor, dyspnea, low pitch cough, nostril flaring, excessive chest wall movement
Managed surgically
22. Congenital subglottic stenosis is associated w/ a malformed cricoid cartilage (CC) that occurs in utero and causes the CC to be smaller than normal with a thicker underlying mucosal layer. Acquired subglottic stenosis is usually due to prolonged intubation. Symptoms include inspiratory and expiratory stridor, low pitch cough, dyspnea and significant nostril flaring and chest wall movement indicative of effortful ventilation. Myer et al. (1994) developed a grading system for degree of stenosis which is included in your text reading assignment on page Subglottic stenosis is managed surgically. Advances in the treatment of upper airway disorders have greatly improved surgical outcomes in the management of these disorders resulting in decannulation (removal of trach tube) in 85-90% of patients.

23. Leukoplakia and Hyperkeratosis
Pre-cancerous lesions – range from flat plaque-like whitish patches (leukoplakia) to warty lesions (keratosis). Arise from epithelium.
Causes: Constant irritation to VFs from Smoking, Alcohol ingestion, GERD or LPR, environmental pollutants, coughing/throat clearing
Can be unilateral or bilateral and VF edges may be rough
Increases VF mass and stiffness, decreases mucosal wave and amplitude, irregular glottic closure, aperiodicity , VFs are asymmetric
Voice is hoarse and rough
23. Leukoplakia and hyperkeratosis are pre-cancerous lesions due to constant irritation of the VFs from smoking, reflux, alcohol etc. The majority of the cases I have seen have been due to smoking or reflux. Management involves a biopsy for histopathological analysis. If the cells are not atypical or cancerous, then voice therapy involves vocal hygiene counseling, cessation of smoking and / or reflux management. Post excision, these patients are typically followed for at least 3-6 months to monitor for recurrence and/or malignant transformation. Voice quality depends on the extent and severity of the lesions.

24. Leukoplakia and Hyperkeratosis
24. Examples of leukoplakia and hyperkeratosis
Hyperkeratosis
Leukoplakia

25. 25. Leukoplakia

26. Sulcus vocalis
A longitudinal groove or indentation in the upper edge of the VFs that parallels the free margins
In the SLP layer – causes a loss of VF tissue
Etiology is undefined BUT may be
1. Congenital
2. Related to phonotrauma
3. Related to smoking
4. Due to a ruptured VF cyst
26. Sulcus vocalis is a longitudinal groove that runs the entire length of the VF. It typically occurs in the SLP but can include the vocal ligament and TA muscle. The cause of sulcus vocalis is unknown but there are several theories as to the etiology. They are outlined in your text and listed in this slide.

27. Sulcus Vocalis Ford Sulcus Classification (1996)
Type I – entire VF length into SLP only
Type 2a – entire VF length includes SLP up to the VL. Causes moderate dysphonia
Type 2b – entire SLP and VL and may involve TA muscle. Causes severe dysphonia.
27. Ford (1996) has classified sulcus vocalis by the depth of the sulcus. Type I includes only the SLP layer and causes only minimal dysphonia. However, the degree of handicap varies by individual. I had a professional opera singer client diagnosed mid career with a Type 1 sulcus who reported the sulcus caused phonatory instability, faster than normal vocal fatigue and problems with high notes. For him, the sulcus caused moderate dysphonia and a moderate handicap to his singing. He reported that his speaking voice was unaffected. The sulcus was found when he went to the ENT for an exam to find out why he was having singing problems! We always need to remember that the degree of vocal handicap perceived by our client may not always match the degree of dysphonia we perceive !

28. Sulcus Vocalis Perceptual: Hoarse, breathy, sometimes effortful
Complains of vocal fatigue
Unilateral or bilateral
Endoscopy:
Incomplete glottic closure which is sometimes spindle shaped
Decreased mucosal wave & amplitude of vibration
Increased VF stiffness but decreased mass
28. On endoscopy, the closure is typically incomplete and may be spindle shaped. The sulcus causes increased stiffness so the mucosal wave and amplitude of vibration are usually decreased.

29. Sulcus vocalis Colton & Casper 1994
29. This slide shows a VF cross-section with sulcus (on R) as well as an illustration of a VF with sulcus (on L). In the illustration, A = epithelium and SLP, B= vocal ligament, C = TA and D = the sulcus.
Colton & Casper 1994

30. Sulcus vocalis
30. Severe bilateral sulcus

31. 31. Sulcus seen with an operating microscope
31. Sulcus seen with an operating microscope. Management of sulcus often involves resection of the abnormal mucosa from the surface of the VF. Unfortunately, this typically results in a glottic gap. Augmentation via injection of collagen, fascia or fat has been used to increase and improve glottic closure.

32. Laryngeal Cancer
90% are malignant squamous cell carcinomas & can be supraglottic, glottic and/or subglottic
Voice quality - Hoarse, dry, rough, low pitched, breathy
Globus sensation – ‘full feeling’ in throat
May observe inhalatory stridor
Throat pain, painful swallowing, problems swallowing, shortness of breath, halitosis
32. Laryngeal cancer is an organic disorder that we will cover in a separate lecture. However, we briefly mention it here for completeness.

33. Laryngeal Cancer
Risk Factors – smoking, alcohol, smoking & alcohol, environmental irritants, chemicals, smoking & asbestos
Typical pt. – y/o male heavy smoker w/mod alcohol intake
H & N cancers accounts for 2% - 5% of all cancers
1% of all cancer deaths are from laryngeal cancer
50% - 70% of all laryngeal cancer deaths are associated w/ smoking
Alcohol & smoking increase risk up to 22x’s !!!!
Male to female ratio 5 to 1 (1985) – but is increasing
33. Most laryngeal cancer is related to smoking or smoking and drinking. Alcohol and smoking increase the risk 22 times ! The male to female ratio in 1985 as 5 to 1 but is increasing.

34. Laryngeal Cancer
Perceptual signs: Chronic hoarseness, lump in the neck, swallowing problems, neck tenderness, pain during swallowing
Acoustic: Depends on extent/severity. Increased frequency/intensity perturbations, decreased pitch range, possibly increased fundamental frequency, increased noise levels.
Aerodynamic: Incr. airflow rates (little data)
34. Perceptual signs include chronic hoarseness, lump in the neck, neck tenderness and difficulty or pain during swallowing. There is little aerodynamic data.

35. 35. On the right, is the normal VF cross-section and illustration
35. On the right, is the normal VF cross-section and illustration. On the left, is a cross-section of a VF with a cancerous lesion. Note how the VF layers are obliterated.

36. Laryngeal Cancer
36. Videostills of VF cancers.