1. Chapter 11: Voice Disorders
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

2. Focus Questions What is a voice disorder?
11.1
Focus Questions
What is a voice disorder?
How are voice disorders classified?
What are the defining characteristics of voice disorders?
How are voice disorders identified?
How are voice disorders treated?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

3. Introduction – A Brief History
11.2
Introduction – A Brief History
16th century – the larynx studied on human cadavers – did not permit to see larynx at work
1600 – first book on laryngeal structures
18th century – well-developed understanding how the vocal folds produce the voice
1829 – glottiscope: crude glimpses of the laryngeal cavity
1854 – laryngoscope: vast improvement in technology to examine the larynx
Today, advanced technology (endoscopy, stroboscopy) allow examination of the vocal folds live in action
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

4. Overview of Voice Disorders
11.3
Overview of Voice Disorders
Individual’s vocal quality is in some way compromised
For some, disorder is mild, transient, and requires no treatment
For others, disorder is severe, persistent, and requires ongoing treatment
Most serious cases, larynx is removed for reasons such as cancer, and alternative methods of producing voice are necessary
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

5. Case Study #1: Kate 46-year old trauma surgeon and mother of four
11.4
Case Study #1: Kate
46-year old trauma surgeon and mother of four
two years ago was in a car accident, suffered a spinal cord injury and became a paraplegic
Unable to breathe and ventilator-dependent
Did not speak at all until a year after her surgery, SLP has been working with her to increase her speech output and set up a voice-activated computer
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

6. 11.5
Case Study #1 Questions
What community activities might be possible for Dr. Mitchell now that she uses her voice?
How might Dr. Mitchell be involved with her profession in the future as a quadriplegic?
Justice Communication Sciences and Disorders: An Introduction
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7. 11.6
Case Study #2: Anton
68-year old veteran diagnosed with laryngeal cancer six years ago
Had his larynx removed two years ago, tried unsuccessfully to learn esophageal speech, now uses an artificial larynx
Is interested in helping other laryngectomees
Is interested in possibility of a laryngeal transplant
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

8. 11.7
Case Study #2 Questions
Given that Anton already has a way to produce speech via the artificial larynx, why would he desire a laryngeal transplant?
Anton’s hobby after his laryngectomy was to counsel other laryngectomees. In what ways might Anton’s counseling be superior to that of a clinical professional, like a psychologist?
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

9. 11.8
Case Study #3: Ms. Chin
42-year old television personality (co-anchor of news show)
Experiencing intermittent problems with her voice in which it seems to start and stop and feels strangled
Went to otolaryngologist, who gave her a preliminary diagnosis of spasmodic dysphonia
Ms. Chin’s producer suggested she take disability leave until her voice is resolved
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

10. 11.9
Case Study #3 Questions
Do you agree with Ms. Chin’s producer that she should be “off the air” until her voice problems are resolved?
Ms. Chin has an appointment soon with an SLP who may not be skilled in treating spasmodic dysphonia. How important is it to see a clinician who has worked with this condition before?
What other professionals should be involved with Ms. Chin’s voice treatment?
Justice Communication Sciences and Disorders: An Introduction
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11. 11.10
I. What is Voice?
Vocal fold vibration that provides sound source for spoken language
Phonation: humans set their vocal folds into a vibratory pattern (say “oooo”)
Vocal folds are adducted (closed), air is exhaled upwards and blows apart the vocal folds setting them into a rapid vibratory pattern
Voice is further modified by the processes of resonation and articulation
Three vocal characteristics: frequency, intensity, and phonatory quality
Justice Communication Sciences and Disorders: An Introduction
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12. Frequency Rate of vocal fold vibration (pitch)
11.11
Frequency
Rate of vocal fold vibration (pitch)
Fundamental frequency (F0) – basic vibratory rate of the vocal folds (in Hertz)
Kindergarten girls and boys = 250 Hz
Adult women = 180 – 220 Hz
Adult men = 120 – 140 Hz
F0 relates to three characteristics:
Vocal fold length, mass, and tension
Fundamental frequency changes as we age, especially between birth and puberty
Justice Communication Sciences and Disorders: An Introduction
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13. Intensity Sound pressure reported in decibels (loudness)
11.12
Intensity
Sound pressure reported in decibels (loudness)
Relates to two features of vocal production:
Amount of airflow from the lungs
Amount of resistance to the airflow by the vocal folds (which contributes to their excursion, or how far apart the vocal folds move and come back together)
Every person has a baseline intensity level that characterizes his/her conversational speech
Justice Communication Sciences and Disorders: An Introduction
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14. 11.13
Phonatory Quality
How well the two vocal folds work together during the vibratory cycle
If vocal folds work symmetrically and harmoniously, voice is pleasant and clear
If compromised in some way (e.g., growth on one of the folds), phonatory quality is affected
Also influenced by the resonation of the voice into the oral and nasal cavities (e.g., nasal voice quality)
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

15. What is a Voice Disorder?
11.14
What is a Voice Disorder?
Pitch, loudness, or phonatory quality differs significantly from persons of a similar age, gender, cultural background, and racial and/or ethnic group, and
Vocal quality detracts from the ability to function and achieve in society
Justice Communication Sciences and Disorders: An Introduction
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16. Describing Voice Quality
11.15
Describing Voice Quality
Dysphonia: umbrella term for a voice that is disordered in some way
Aphonia: total loss or lack of voice
Many other, mostly subjective terms…
Pitch and frequency: jitter or diplophonic
Loudness and intensity: pressed or strident
Resonance: nasal or ringing
Phonatory quality: flutter or creak
Justice Communication Sciences and Disorders: An Introduction
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17. Describing Vocal Fold Functioning
11.16
Describing Vocal Fold Functioning
Hypofunction: vocal folds are under-functioning and have inadequate tension, so air escapes through
Breathiness or hoarseness, or no voice at all
Hyperfunction: vocal folds are overly tense and compress too tightly together
Too loud, too high, and/or too strained
Sometimes spasticity of the voice
Diplophonia: vocal folds produce two different pitches simultaneously
Justice Communication Sciences and Disorders: An Introduction
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18. Voice without a Larynx Laryngectomy: surgically removing the larynx
11.17
Voice without a Larynx
Laryngectomy: surgically removing the larynx
Two primary reasons:
laryngeal cancer: removed to stop spreading
laryngeal trauma: removed if too damaged to protect respiratory system or impede breathing
Alaryngeal communication: an alternative way to produce speech
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

19. Prevalence and Incidence: Voice Disorders in Adults
11.18
Prevalence and Incidence: Voice Disorders in Adults
Prevalence = 29%, Incidence = 6%
Higher prevalence for women, peak ages of years
Higher prevalence among people with frequent allergies, asthma, colds, and sinus infections
Higher prevalence among professions reliant on voice
Common causes: vocal nodules, edema/swelling, polyps, carcinoma, and vocal fold paralysis
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

20. Prevalence and Incidence: Voice Disorders in Children
11.19
Prevalence and Incidence: Voice Disorders in Children
25% of children exhibit significant vocal problems, with 40% of these cases ongoing, not transient, problems
For some it is a congenital problem, but most cases result from overuse or misuse of voice
Most common cause: vocal nodules that impede smooth meeting of folds, resulting in breathy or hoarse voice
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

21. Prevalence and Treatment
11.20
Prevalence and Treatment
Rate of voice disorders for both children and adults is relatively high, but many cases go undiagnosed and/or untreated
Several reasons for this:
Treatment access: e.g., disorder not considered to impact educational performance in school
Knowledge: e.g., person may believe that voice problem will disappear spontaneously
Social perception: e.g., the disordered voice (e.g., a breathy, hoarse voice) brings positive social attention
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

22. II. How are Voice Disorders Classified?
11.21
II. How are Voice Disorders Classified?
Voice disorders are grouped based on their cause, an etiological classification
Four different categories:
A. Vocal abuse
B. Neurogenic disorders
C. Psychogenic disorders
D. Alaryngeal communication
Justice Communication Sciences and Disorders: An Introduction
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23. 11.22
A. Vocal Abuse
Chronic or intermittent overuse or misuse of the vocal apparatus
Vocally abusive behaviors:
Talking in noisy environments
Frequent coughing or clearing of the throat
Using caffeine products
Yelling, screaming, and cheering
Giving speeches or lectures
Spending time in smoky environments
Two common conditions: vocal nodules and contact ulcers and granuloma
Justice Communication Sciences and Disorders: An Introduction
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24. 11.23
Vocal Nodules
Small bilateral protuberances or calloused growths on the inner edge of the vocal folds
Acute nodules are similar to bruises on the vocal folds, but these can harden and thicken over time, which becomes a chronic condition
Most prevalent in children and adults who engage in vocal misuse and abuse
Additional factors: temperament and general health
Justice Communication Sciences and Disorders: An Introduction
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25. Contact Ulcers and Granuloma
11.24
Contact Ulcers and Granuloma
Contact ulcers: inflamed lesions that develop on the cartilage in the larynx
Granuloma: a mass of tissue generated by the body’s healing process at the site of the contact ulcer
Mostly results from vocal abuse, but also from acidic irritation due to chronic reflux or tubal intubation (during surgery)
Low, breathy voice quality
Justice Communication Sciences and Disorders: An Introduction
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26. B. Neurogenic Disorders
11.25
B. Neurogenic Disorders
Result from illness, damage, or disease to the neurological systems associated with voice production
One of the most important nerves: vagus nerve in peripheral nervous system
runs from cranium down around the heart, but has several branches that innervate the pharynx and larynx
Pharyngeal nerve
Superior laryngeal nerve
Recurrent laryngeal nerve
If any of these nerves are disrupted, a voice disorder may result
Justice Communication Sciences and Disorders: An Introduction
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27. 11.26
Vagus Nerve Lesions
Can occur due to surgical damage, trauma, and viral infections
Most serious outcome: vocal fold paralysis
Mostly unilateral paralysis:
Abduction paralysis: one of the vocal folds cannot open, voice is not usually affected, but breathing may be difficult
Adduction paralysis: one of the vocal folds cannot close, so they cannot meet together, causing hoarse or breathy voice quality
Complete paralysis: both vocal folds paralyzed, completely blocking airway – tracheostomy is necessary
Justice Communication Sciences and Disorders: An Introduction
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28. 11.27
Spasmodic Dysphonia
Affects motor control of larynx, results in intermittent voice stoppages
Jerky, grunting, squeezed, groaning, and stuttering-like voice quality
Ranges from mild to severe
Adductor type: most common, voice is strangled, strained, and squeezing
Abductor type: less common, voice is breathy and open
Justice Communication Sciences and Disorders: An Introduction
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29. Amyotrophic Lateral Sclerosis
11.28
Amyotrophic Lateral Sclerosis
Also called Lou Gehrig’s Disease – progressive, degenerative, neuromuscular disease
Cause is unknown, impact is significant, and most survive less than 10 year after diagnosis
Voice is soft, breathy, low in pitch and loudness, limited variability, and hypernasal
Difficulty clearly articulating speech sounds because cannot strongly coordinate motor processes
Justice Communication Sciences and Disorders: An Introduction
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30. 11.29
Parkinson’s Disease
Progressive, degenerative neurological disease caused by depletion of dopamine
Unable to produce a strong voice because of a weakened respiratory system
Rigid muscular tone restricting movements of larynx; produces hoarseness and a monotonic pitch
Lee Silverman Voice Treatment program – effective for improving voices of persons with Parkinson’s
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

31. C. Psychogenic Disorders
11.30
C. Psychogenic Disorders
Nonorganic disorders, resulting from emotional or psychological characteristics
Our voices carry messages about our emotional or psychological state
The voices of individuals who experience significant personality or psychological health disorders may be negatively impacted
Justice Communication Sciences and Disorders: An Introduction
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32. Psychological or Emotional Triggers
11.31
Psychological or Emotional Triggers
After someone recovers from a vocal injury because of overuse or misuse of the voice, may experience a sense of vulnerability and anxiety about using voice
Other traumatic experiences, like cancer, being robbed or raped, and having surgery of the throat, can have the same effect
Justice Communication Sciences and Disorders: An Introduction
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33. Psychopathology 1. Stress, Anxiety, and Depression
11.32
Psychopathology
1. Stress, Anxiety, and Depression
Acute stress disorder: within one month of having a traumatic experience, exaggerated startle responses, motor restlessness; can be reflected in the voice
Generalized anxiety and anxiety disorder: muscle tension, trembling, twitching; may lead to vocal tremors and voice breakages
Justice Communication Sciences and Disorders: An Introduction
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34. Physical symptoms or deficits result from severe anxiety or stress
11.33
2. Conversion Disorder
Physical symptoms or deficits result from severe anxiety or stress
Can result in a loss or disordered voice as one variety of conversion disorder
3. Vocal tics and Tourette’s Disorder
Vocal tics produce sudden, rapid, recurrent vocalizations
Tourette’s: vocal tics occuring simultaneously with other motor tics affecting the head, torso, and extremities
Justice Communication Sciences and Disorders: An Introduction
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35. Mutational Falsetto and Juvenile Voice
11.34
Mutational Falsetto and Juvenile Voice
Vocal characteristics are not consistent with age and gender
Mutational falsetto: male child or adolescent exhibits inappropriately high voice
Voice therapy and medical treatment are effective
Juvenile voice: female companion to mutational falsetto, women maintain a child-like voice into adulthood
Justice Communication Sciences and Disorders: An Introduction
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36. D. Alaryngeal Communication
11.35
D. Alaryngeal Communication
Producing voice without a larynx
Two most common reasons:
Larynx is not available because of a tracheostomy
Larynx has been completely removed in a larnygectomy
Justice Communication Sciences and Disorders: An Introduction
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37. 11.36
Trachestomy
When respiratory system is compromised, mechanical ventilation and respiration is needed
tracheostomy tube is inserted through the neck to direct air into the lungs
Unable to talk because air is not going over vocal folds
Passy-Muir Tracheostomy Speaking Valve: allows adults and children to speak even while ventilated
Justice Communication Sciences and Disorders: An Introduction
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38. 11.37
Laryngectomy
Etiology: Laryngeal cancer is linked to tobacco and alcohol use, nutritional inadequacies and occupational exposures; affects African-American older males at the highest rates
Symptoms: most consistent symptom is hoarseness
Any person exhibiting hoarseness should seek medical attention if persists for more than two weeks
Treatment: Rid the body of the malignancy
most oncologists use conservation approaches, and prefer to only remove part of the larynx if possible
Justice Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.

39. III. Defining Characteristics of Voice Disorders
11.38
III. Defining Characteristics of Voice Disorders
Voice disorders impact one or more of the following perceptual characteristics of voice:
A. Resonance
B. Loudness and pitch
C. Phonatory quality
Justice Communication Sciences and Disorders: An Introduction
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40. 11.39
A. Resonance
Velopharyngeal port controls the extent to which exhaled air enters the nasal and oral cavities
The port typically rests in an open position, but when we speak, it is almost always closed (airflow channeled into the oral cavity)
Voice disorders of resonance result from problems with control of port, called velopharyngeal inadequacy
Justice Communication Sciences and Disorders: An Introduction
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41. Velopharyngeal Inadequacy
11.40
Velopharyngeal Inadequacy
Common causes:
Cleft palate and cranio-facial abnormalities
Iatrogenic (problems resulting from surgery)
Allergies
Neuromuscular impairment
Results in either:
Hypernasality: port remains open to allow too much resonance and nasal emissions during speech
Hyponasality: too little nasal resonance, voice may sound stuffy and congested
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42. B. Pitch and Loudness Pitch: frequency Loudness: intensity
11.41
B. Pitch and Loudness
Pitch: frequency
Loudness: intensity
Too much or too little tension in voice production can cause abnormal pitch or loudness
Of pitch and loudness, pitch changes are more common symptoms of voice disorders
Justice Communication Sciences and Disorders: An Introduction
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43. Pitch Important concepts: Disordered pitch:
11.42
Pitch
Important concepts:
Habitual pitch: pitch one uses normally
Optimal pitch: best pitch voice can produce
Basal pitch: lowest pitch one can produce
Ceiling pitch: highest pitch one can produce
Vocal range: difference between basal and ceiling
Disordered pitch:
Habitual pitch differs significantly from optimal
Extremely limited vocal range
Justice Communication Sciences and Disorders: An Introduction
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44. 11.43
Loudness
Over-loudness: air pressure builds up under vocal folds and produces wide excursion of folds
Under-loudness: lack of respiratory force because of…
Neurological injury and disease
Social or psychogenic factors
Justice Communication Sciences and Disorders: An Introduction
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45. 11.44
C. Phonatory Quality
When vocal folds do not work harmoniously, impairment in general quality of the voice
Common types of impaired phonation:
Hard glottal attack
Glottal fry
Breathy phonation
Spasticity
Hoarseness
Justice Communication Sciences and Disorders: An Introduction
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46. IV. How are Voice Disorders Identified?
11.45
IV. How are Voice Disorders Identified?
The Voice Care Team
Close collaboration of a variety of professionals
Medical professionals: primary care physician (PCP), otolayrngologist
Allied health professionals: speech-language pathologist, psychologist or psychiatrist
Possibly educators or voice coaches also
Justice Communication Sciences and Disorders: An Introduction
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47. B. The Assessment Process
11.46
B. The Assessment Process
Identification of warning signs
Assessment Protocol:
Case history and interview
Oral-motor examination
Clinical voice observation
Instrumental voice observation
Justice Communication Sciences and Disorders: An Introduction
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48. Warning Signs for Voice Disorders
11.47
Warning Signs for Voice Disorders
Children and adolescents:
Vocally abusive behaviors
Underlying medical condition
Psychological well-being
Adults:
Change in phonatory quality for more than two weeks, consult physician
Referrals: PCP will likely make at least two referrals:
Otolaryngologist
Speech-language pathologist
Justice Communication Sciences and Disorders: An Introduction
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49. Assessment Protocol Speech-language pathologist’s goals:
11.48
Assessment Protocol
Speech-language pathologist’s goals:
Characterize the general features of the voice
Establish if any of these features differ from the norm
If disorder is present:
Identify cause
Identify intervention approach that will be the most beneficial to improving the voice
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50. Case History and Interview
11.49
Case History and Interview
Interview with the client to learn more about:
Medical history
Chronological history of problem
Symptoms and possible etiology of problem
Way in which client uses voice for daily living activities
Client’s motivation for seeking help
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51. Oral-Motor Examination
11.50
Oral-Motor Examination
Identify conditions of structures involved with producing voice
Study amount of tension and sensation involved in speech and voicing
Examine possible swallowing problems
Study the appearance and functioning of the velum
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52. 11.51
Clinical Observation
Perceptual observation of characteristics of voice during a variety of speaking and vocal activities
Example activities: counting from 1 to 40 softly then loudly, sustaining a vowel sound for as long as possible, engaging in normal conversation
Also studies systems that support vocal production, like respiration
Relies heavily on the listener, so need to be properly trained and experienced
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53. Instrumental Observation
11.52
Instrumental Observation
Objective measures of vocal functioning:
Acoustic assessment: measures frequency, intensity, and resonance characteristics
Aerodynamic assessment: measures airflow, air pressure, and vocal fold resistance
Electroglottography: measures vocal fold contact during voicing
Videostroboscopy: examines laryngeal system and measures vocal fold movement
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54. V. How are Voice Disorders Treated?
11.53
V. How are Voice Disorders Treated?
Elimination of the cause of the disorder (e.g., vocally abusive behavior)
Compensation for a disorder (cause cannot be eliminated)
Three possible goals:
Teach a vocal behavior that is absent
Substitute vocal behavior for inappropriate one
Strengthen vocal behaviors that are weak or inconsistent
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55. A. Treatment for Vocal Abuse
11.54
A. Treatment for Vocal Abuse
Several options:
Surgery (e.g., removal of vocal nodules)
Vocal hygiene programs
Voice therapies
Computer programs
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56. B. Treatment for Neurogenic Disorders
11.55
B. Treatment for Neurogenic Disorders
Combination of medical interventions and voice therapies
Medical interventions:
Phonosurgery: improvement, alteration, or restoration of the voice (e.g., thyroplasty)
Injections into the vocal folds (e.g., Teflon, botox)
Voice therapies:
e.g., Lee Silverman Voice Treatment program
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57. C. Treatment of Psychogenic Disorders
11.56
C. Treatment of Psychogenic Disorders
Multidisciplinary approach including speech-language pathologist and mental health professionals
Goal: determine emotional or psychosocial cause of voice disturbance
Therapy usually focus on reducing tension, counseling, and eliminating any voice abuses or misuses
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58. D. Treatment of Alaryngeal Communication
11.57
D. Treatment of Alaryngeal Communication
Communication counseling: explore all alternative options for producing voice
Artificial larynx: vibrating power source placed against the neck, often mechanical sounding voice
Esophageal speech: learn to trap air in the esophagus and then use that for voice, often very difficult for most people
Tracheoesophageal speech: surgical puncture between the trachea and esophagus provides an air source for speaking
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