1. Unit Seven
Voice Disorders

2. Anatomy and Physiology of the Respiratory and Phonatory Systems
Chapter 27
Anatomy and Physiology
of the Respiratory
and Phonatory Systems

3. The Respiratory System
Driving support of voice production
Intricate balance between respiration (inhalation and exhalation) and phonation

4. Supportive Structures of Respiration
Bones in the chest provide framework and protection of the respiratory system
Thorax
Contains the lungs and the heart
See figure 27-1.

5. Muscles of Respiration
Diaphragm
Primary muscle
Internal and external intercostals
Pectoralis major and minor muscles
Rectus abdominis muscles
Refer to figures 27-1 and 27-2.

6. Trachea Extends from larynx down to the lungs
Composed of cartilaginous rings
See figure 27-4.

7. Respiratory Process Diaphragm lowers and rib cage expands
Space in thoracic cavity increases
Air pressure decreases in lungs
Air flows down trachea into lungs
Alveolar sacs and chest relax and air is forced from lungs

8. Phonation Larynx is the organ of phonation
Sits at top of trachea and below root of tongue

9. Framework of Larynx Cricoid cartilage Thyroid cartilage
Two arytenoid cartilages
Epiglottis
Figure 27-6 displays these structures

10. The Vocal Folds Biological function
To prevent food/liquid entering the trachea
Overlaid function of true vocal folds is to produce voice
See figure 27-7

11. Vocal Folds Glottis Posteriorly Space between open vocal folds
Vocal folds attach to the arytenoids

12. Vocal Fold Vibration Vocal folds must open and close to produce voice
Vocal folds are open when breathing

13. Vocal Fold Vibration To produce voice
Folds close
Air pressure beneath the folds increases and forces folds to open
Elasticity and Bernoulli’s law causes folds to close
Subglottic air pressure builds up and forces folds to open again
Description given of Bernoulli’s law in text. Students may be able to come up with other ways to describe this principle.

14. Maximum Phonation Time (MPT)
Length of time a person can sustain a tone or sound on one expiration
Varies based on gender, age, physical characteristics, health
See Table 27-1

15. Frequency Frequency Fundamental frequency
Number of cycles of opening and closing the vocal folds per second
Measured in Hertz (Hz)
Fundamental frequency
Rate of vocal fold vibration
Average Fo based on gender and age is provided in Table 27-2

16. Pitch Psychological sensation of the frequency of a sound
Pitch changes based on vocal fold:
Tension
Mass
Length

17. Loudness Perceptual correlate of intensity of a sound
Intensity measured in decibels (dB)
Relates to the force with which vocal folds open and close and the amount of air that escapes

18. Voice Quality Judgments of voice quality are subjective
Quality is affected by:
Adequate vocal fold closure
Efficient timing of closure
Amount of tonicity within the folds

19. Voice Disorders in Children and Adults
Chapter 28
Voice Disorders
in Children and Adults

20. Voice Disorder
A deviation of loudness, pitch, or quality out of the range of a person’s age, gender, or geographical background

21. Classification of Voice Disorders
Functional
Faulty use of mechanism
Neurological
Related to muscle control and innervation of muscles
Organic
Related to physical changes in larynx
Table 28-1 lists different types of voice disorder organized by this classification system.

22. Functional Voice Disorders
Hyperfunctional
Excess tension or forcing in larynx
Hypofunctional
Decreased or inadequate tension or reduced vocal capacity

23. Laryngitis Inflammation of vocal folds
Voice is associated with lowered pitch and phonation breaks
Vocal quality is hoarseness
Photos in Figure 28-3 and 28-4 of larynx.

24. Chronic Laryngitis Laryngitis lasting longer than 10 days
Causes may include:
Traumatic laryngitis
Allergies
Singing excessively at damaging intensity levels
Smoking

25. Vocal Nodules Most common benign lesions in children and adults
Typically bilateral
Occur at juncture of anterior and middle one third of vocal folds
See Figure 28-5.
Case Study of Beverly is presented in the text

26. Vocal Nodules Caused by continuous abuse/misuse of voice
Screaming, coughing, singing in abusive manner
Voice quality is hoarseness

27. Vocal Polyps Benign vocal fold lesions Frequently unilateral
Occur at juncture of anterior and middle one-third of vocal folds
Vocal quality is hoarseness
See figure 28-6.

28. Functional Dysphonia May be hyperfunctional or hypofunctional
No medical or surgical treatment
SLP works to improve intensity, pitch, quality
Psychological support may be beneficial
Case study of Margaret is presented in the text.

29. Functional Aphonia Hyperfunctional voice disorder
Voice is typically whispered
Most causes are psychological
See Case study of Irene who has functional aphonia.

30. Falsetto High-pitched breathy voice
Produced by vibration of anterior one-third of the vocal folds
Case study of Jason, a 17 year old adolescent, is discussed.

31. Organic Voice Disorders
Papillomas
Contact ulcers
Trauma
Cancer

32. Papillomas Soft wart-like growths Viral in origin
Occur mainly in children
4-6 years
Vocal quality is hoarseness
Treatment is surgical removal
See figure 28-7

33. Contact Ulcers
Small ulcers at juncture of middle and posterior one third of folds
Can be caused by:
Persistent and excessive slamming of arytenoids and hard glottal attacks
Gastroesophageal reflux
Intubation for surgery
See Figure 28-8.

34. Contact Ulcers Voice quality is hoarseness
Voice therapy is usually successful

35. Traumas
Various traumas can compromise the airway and affect the larynx
Voice therapy will focus on helping clients achieve their most functional voice

36. Cancer
Requires surgical and medical treatment
See figure 28-9.

37. Neurological Voice Disorders
Hypoadduction
Difficulty getting the vocal folds together
Vocal fold paralysis
Hyperadduction
Vocal folds close too tightly or for too long

38. Vocal Fold Paresis and Paralysis
Unilateral paralysis
Vocal quality is breathy
Has low intensity
Diplophonia

39. Spasmodic Dysphonia Strained, strangled, harsh vocal quality
Affects females more than male
Onset on average at 45 years of age
Treatment involves voice therapy and medical-surgical approach (Botox)

40. Voice Evaluation and Therapy
Chapter 29
Voice
Evaluation and Therapy

41. Examination Indirect laryngoscopy
Place a laryngeal mirror into back of mouth
Direct light onto mirror to shine on the vocal folds
See Figure 29-1

42. Examination Endoscope placed intraorally or transnasally
Can be videotaped (videoendoscopy)
Or observed with a strobe light (videostroboscopy)
See Figure 29-2

43. Voice Screening
Screenings of voice will determine if a complete evaluation is needed
Screening tasks include:
Count 1 to 10
Conversation
Phonating vowels

44. Voice Evaluation Case history Assessment of voice
Perceptual, acoustic, physiologic
Instrumental evaluations
Self-perception

45. Instrumental Evaluations
Aerodynamic
Electroglottography
Electromyographic assessment
Photoglottography

46. Voice Therapy Multifaceted approach is required
Specific voice therapy will depend on age of client, type, and severity of disorder

47. Hygienic Voice Therapy
First step in many therapy programs
Focus on instilling healthy vocal behaviors in habitual speech patterns
Determine misuse
Become aware of these behaviors
Eliminate damaging behaviors

48. Symptomatic Voice Therapy
Reduce/eliminate abuse and misuse of voice through facilitating techniques
Auditory feedback
Change of loudness
Counseling
See case study of Mathew and Mark

49. Psychogenic Voice Therapy
Identify and modify the emotional and psychosocial behavioral reasons that cause a voice disorder

50. Physiological Voice Therapy
Directly alter or modify the physiology of the vocal mechanism

51. Eclectic/Holistic Voice Therapy
Combination of any or all of the orientations and approaches of voice therapy

52. Laryngectomy Surgical removal of the larynx
Surgical approach to treating laryngeal cancer
See figures 29-5 of before and after laryngectomy

53. Before a Laryngectomy
Establish immediate means of communication after surgery
Discuss choices of voice production
Tracheoesophageal puncture (TEP)
Esophageal speech
Electrolarynx

54. Tracheoesophageal Puncture (TEP)
Incision made into trachea
Valve directs air from trachea into esophagus
See figure 29-5

55. Esophageal Speech Compressing air and injecting into esophagus
Expel air from esophagus causing it to vibrate upper esophageal valve
See figure 29-6

56. Electrolarynx Neck devices with vibrating source that produces sound
See figures 29-7 and 29-8

57. Emotional and Social Effects of Voice Disorders
Chapter 30
Emotional and Social
Effects of Voice Disorders

58. Emotional and Social Effects
The voice reflects our personality
It is an indicator of emotions and attitudes

59. The Voice The voice is the mirror of the person
The voice reflects our personality
The voice is an indicator of emotions and attitudes

60. Voice In a social context, the voice will convey: Semantic content
Emotional state
Personality characteristics

61. Young Children
Many children are unaware or unconcerned with a hyperfunctional voice disorder
Voice therapy may not begin until kindergarten
Parents are counseled on how to encourage less abusive voice use by their children

62. Children
As children get older, they become aware of their voice and are better candidates to participate in voice therapy

63. Adolescents
Adolescents with chronic voice problems are typically motivated to participate in a voice therapy program
Adolescents with falsetto voices can experience significant social penalties – especially boys

64. Adults
Twenty-five percent of adults are displeased with the sound of their voices
A holistic approach to treatment views the whole person when determining the best therapy program for an adult with a voice disorder