Chapter 6 Phonation: Clinical Applications

1. Chapter 6Phonation: 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 • 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 • 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 Laryngeal Structure Nature of Aging Change Gender Differences Cartilages Ossification & calcification More extensive, earlier onset in males Cricoarytenoid joint General deterioration More evident in males Intrinsic muscles Atrophy In males - limited data in females Epithelium Thickening Progressive in males until 70, declines thereafter Progressive in females after 70 From Linville, Vocal Aging

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

48. Acoustic Age-related Changes of Voice Male Female Avg Fund Freq Higher Lower Fo variability Greater Greater Freq Pertubation Greater Greater Fo range Smaller Smaller Avg Intensity level Smaller Smaller Variability of Intensity Smaller Smaller Intensity range Smaller Smaller Speaking rate Slower Slower

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