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

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

3. 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

4. Practice Labeling

5. Review

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

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

8. The Cough

9. 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

10. 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)

11. Clearing Throat

12. 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

13. Vocal Fold Functions

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

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

16. 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

17. True Vocal Folds

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

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

20. 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)

21. Speech Function

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

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

24. 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

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

26. Vocal Fry

27. 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

28. Glottal Fry
Vocal Fry

29. 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

30. 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

31. Whispering
Not a phonatory mode
Voicing removed
Mariah Carey

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

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

34. Gender & Age

35. Vocal Length Change with Age

36. Fundamental Frequency & Age

37. Vocal Intensity vs. Vocal Fold Vibration

38. 2 Vocal Fold Intensities

39. Prosodic Feature of Question Form

40. 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

41. 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

42. Young vs. Aged Vocal Folds
Young (healthy)
Aged

43. Normal vs. Cancerous
Normal
Cancer (beginning stage)

44. 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

45. 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”

46. 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

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

48. 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

49. 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

50. Laryngeal Stridor

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

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

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

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

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

56. 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

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

58. 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

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

60. 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.

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

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

63. Range of Freq. Variability
Infants greatest range Hz
Children Hz
Adolescents Hz
Seniors Hz

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

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

66. 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.

67. 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

68. 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