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Structure and Function of Larynx

Structure and Function of Larynx. Some questions. What is a voice disorder? How does it differ from speech disorder? How does if differ from a resonance disorder? How common are voice disorders? Who gets a voice disorder? Why might someone have a voice disorder?

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Structure and Function of Larynx

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  1. Structure and Function of Larynx SPPA 6400 Voice Disorders

  2. SPPA 6400 Voice Disorders

  3. Some questions • What is a voice disorder? • How does it differ from speech disorder? • How does if differ from a resonance disorder? • How common are voice disorders? • Who gets a voice disorder? • Why might someone have a voice disorder? • How do you know if someone has a voice disorder? SPPA 6400 Voice Disorders

  4. Voice Disorders: Simple Taxonomy • Organic • Neurogenic • Functional SPPA 6400 Voice Disorders

  5. Prevalence vs. Incidence Source: Manitoba Centre for Health Policy SPPA 6400 Voice Disorders

  6. Epidemiology From Roy et. al (2004) JSLHR 47 281-93. SPPA 6400 Voice Disorders

  7. Epidemiology From Roy et. al (2004) JSLHR 47 281-93. SPPA 6400 Voice Disorders

  8. From Roy et. al (2004) JSLHR 47 281-93. SPPA 6400 Voice Disorders

  9. Epidemiology SPPA 6400 Voice Disorders From Roy et. al (2004) JSLHR 47 281-93.

  10. Voice/laryngeal disorders is often a multidisciplinary effort • Speech Language Pathology • Otolaryngology • Voice Scientists • Vocal Instructors • Neurology • Gastroenterology • Pulmonology • Psychology SPPA 6400 Voice Disorders

  11. Assessment What are the goals of assessment? SPPA 6400 Voice Disorders

  12. Assessment: Aims • Etiology • Diagnosis • Prognosis • Planning SPPA 6400 Voice Disorders

  13. Signs vs. Symptoms SPPA 6400 Voice Disorders

  14. Common Voice Symptoms (Table 2.1) • Hoarseness • Vocal fatigue • Breathy voice • Reduced phonational range • Aphonia or voice loss • Pitch breaks/inappropriately high pitch • Strain/struggle • Tremor • Pain & other physical sensations SPPA 6400 Voice Disorders

  15. Primary components of Assessment • Chart Review • Case History • Clinical Evaluation • Non-instrumented evaluation • Instrumented evaluation • Quality of life Indicators • Experimental/diagnostic therapy SPPA 6400 Voice Disorders

  16. Case History • Voice Symptom History • Voice Use History • Health History • Social/Vocational History • Psychosocial History SPPA 6400 Voice Disorders

  17. Voice Symptom History • The Voice Problem • Effect of the Voice Problem • History of the Voice Problem SPPA 6400 Voice Disorders

  18. Voice Use History • Establish voice use patterns • On the job • At home • In social settings • Look for, • Environmental factors (noise, air quality) SPPA 6400 Voice Disorders

  19. Health/Medical History • Current health problems & past history • Specific areas to probe • Respiratory problems • Gastrointestinal problems • Neurological problems • Allergies • Head and neck trauma, surgery, disease • Prescription and OTC drugs • Substance use: alcohol, tobacco, drugs, caffeine • Exercise/diet considerations SPPA 6400 Voice Disorders

  20. Social/Vocational History SPPA 6400 Voice Disorders

  21. Psychosocial Interview • “The voice is often a sensitive to our emotional well being…” • Ask about, • Stress/emotional problems • Chronic or episodic • Hx of counseling SPPA 6400 Voice Disorders

  22. Clinical Evaluation • Non-instrumented evaluation • Auditory perceptual evaluation of voice • Maximal effort tasks • Assessment of laryngeal musculoskeletal tension • Instrumented evaluation • Videolaryngostroboscopy • Acoustic evaluation • Other selected instruments • Quality of life indicators • Voice Handicap Index SPPA 6400 Voice Disorders

  23. Critical listening during history • How do signs match symptoms? • Signs of other communication impairment • Variability in signs as a function of • Duration of session (change over time) • Periods of improvement/resolution • Automatic behaviors (e.g. cough, throat clear, laugh) • Conversational content • Atypical vocal signs such as stridor (noise during respiration), tics, grunts, barks SPPA 6400 Voice Disorders

  24. Critical observation during history • Signs of pain/discomfort • Signs of tension/strain • Respiratory patterns (“clavicular breathing”) • Level of comfort (or anxiety) over the course of the interview • Signs of tremor, unusual movements of the body SPPA 6400 Voice Disorders

  25. Auditory Perceptual Evaluation • Standardized to clinic/profession • Standardized with respect to • Data collection procedures (e.g. Alvin Clinic) • Data evaluation procedures (e.g. CAPE-V) • Data reporting procedures (be consistent) SPPA 6400 Voice Disorders

  26. GET HIGH QUALITY RECORDINGS OF VOICE!!! You need High quality recording device High quality microphone Easy access to recordings SPPA 6400 Voice Disorders

  27. Auditory Perceptual Signs • Pitch • Loudness • Quality • Aphonia • Other Behaviors SPPA 6400 Voice Disorders

  28. Pitch • Monopitch • Inappropriate pitch • Pitch breaks • Diplophonia • Reduced pitch range Females Male SPPA 6400 Voice Disorders

  29. Loudness • Monoloudness • Excessive loudness variation • Reduced loudness range SPPA 6400 Voice Disorders

  30. Quality • Roughness • Breathiness • Strain/struggle/tension • Tremor • Sudden interruption of voicing (voice break) • Hoarseness SPPA 6400 Voice Disorders

  31. Aphonia • Aphonia vs. dysphonia • Consistent vs. intermittent/episodic SPPA 6400 Voice Disorders

  32. Other Behaviors • Stridor • Excessive throat clearing/coughing SPPA 6400 Voice Disorders

  33. Scaling perceptual features of voice SPPA 6400 Voice Disorders

  34. Scaling perceptual features of voice Definitions of Vocal Attributes: OVERALL SEVERITY: Global, integrated impression of voice deviance. Roughness: Perceived irregularity in the voicing source. Breathiness: Audible air escape in the voice. Strain: Perception of excessive vocal effort (hyperfunction). Pitch: Perceptual correlate of fundamental frequency. This scale rates whether the individual's pitch deviates from normal for that person's gender, age, and referent culture. The direction of deviance (high or low) should be indicated in the blank provided above the scale. Loudness: Perceptual correlate of sound intensity. This scale indicates whether the individual's loudness deviates from normal for that person's gender, age, and referent culture. The direction of deviance (soft or loud) should be indicated in the blank provided above the scale. From ASHA Consensus on Auditory Perceptual Evaluation of Voice (CAPE-V) SPPA 6400 Voice Disorders

  35. Other Tasks • Phonational frequency range • Loudness range • Maximum phonation time • repeat 3 times, take largest value • S/Z ratio • repeat 3 times, take largest value • Laryngeal diadochokinesis (quickly repeated /a/ and/or /ha/) • Voluntary cough SPPA 6400 Voice Disorders

  36. Assessment of Laryngeal Musculoskeletal Tension “All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990) SPPA 6400 Voice Disorders

  37. Instrumented Evaluation • Videolaryngostroboscopy • Acoustic Evaluation • Selected Instruments SPPA 6400 Voice Disorders

  38. Laryngoscopy • Direct • Indirect • Mirror examination • Rigid laryngeal endoscopy • Constant light • Stroboscopy • Flexible fiberoptic laryngeal endoscopy • Constant light • Stroboscopy SPPA 6400 Voice Disorders

  39. Components • Endoscope (rigid or flexible) • Light source (constant or strobe) • Camera • Recording device (VHS, computer) • If strobe light is used, a neck mounted microphone (or electroglottograph) is used for tracking Fo SPPA 6400 Voice Disorders

  40. Constant light vs. strobe light • Constant light source allows viewing of basic structure and function • Identify lesions • Identify abnormalities in ab/adduction • Identify supraglottic activity • Strobe light source allows a view of “simulated” vibration • allows assessment of the vibratory function of the vocal folds • May reveal structural abnormalities not seen during constant light endoscopy SPPA 6400 Voice Disorders

  41. Videolaryngostroboscopy (VLS) • Why do it? SPPA 6400 Voice Disorders

  42. VLS Examination • Evaluate structural integrity • Evaluate gross mobility of structures • Evaluate (inferred) vibratory patterns SPPA 6400 Voice Disorders

  43. VLS Examination Relevant structures • True vocal folds • Ventricular folds • Arytenoids • Interarytenoid area • Epiglottis • Glottic closure SPPA 6400 Voice Disorders

  44. Typical VLS Examination A task list • Normal, loud and soft phonation • Pitch glide (glissando) • Cough • Normal & deep breathing SPPA 6400 Voice Disorders

  45. Glottal closure patterns (Hirano & Bless,1993) SPPA 6400 Voice Disorders

  46. Stroboscopic observations Parameters for evaluating the stroboscopic image • Symmetry of VF motion • Periodicity • Glottal closure configuration • Horizontal excursion of the VFs • Mucosal wave • Phase closure • Vocal fold edge • Vibratory behavior SPPA 6400 Voice Disorders

  47. Example of a VLS evaluation form SPPA 6400 Voice Disorders

  48. Poburka BJ, Bless DM (1998) A multi-media, computer-based method for stroboscopy rating training JOURNAL OF VOICE 12 (4): 513-526 Methods of training individuals to rate stroboscopic examinations vary widely … Consequently, problems occur in both inter- and intrajudge agreement … This study attempted to determine if CAI could train individuals to make accurate and reliable visuo-perceptual judgments of stroboscopy… Following 4 to 5 hours of CAI training, the subjects with no previous experience demonstrated improved interjudge agreement with a panel of expert raters. The training was not effective for the experienced group. Regardless of the rater's experience, the parameters that required evaluation of movement were more difficult to rate than those requiring only an assessment of structure. SPPA 6400 Voice Disorders

  49. VLS Considerations • Level of training (ASHA, 2004) • Cleaning/Universal precautions • Use of topical anesthetic SPPA 6400 Voice Disorders

  50. “Typical” acoustic measures • Fundamental frequency and variability • mean Fo F 210 Hz M 110 Hz • SDFo ~ 2-4 semitones • Vocal intensity and variability • Mean 60-80 dB • SD 10 dB • Perturbation measures (many ways to measure) • Analysis must be limited to a phonated segment • Jitter (0.2-1 %) • Shimmer (0.5 dB – norms not well established) • Harmonic to noise ratio (> 15) NOTE: these are ballpark figures. Always check actual tables for normative values. SPPA 6400 Voice Disorders

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