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Current Diagnosis and Treatment of Voice Disorders

Internal Medicine Grand Rounds: February 28 th , 2007. Current Diagnosis and Treatment of Voice Disorders. Seth H. Dailey, MD Assistant Professor University of Wisconsin Hospital and Clinics University of Wisconsin School of Medicine. Cartilaginous skeleton. Intrinsic Musculature.

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Current Diagnosis and Treatment of Voice Disorders

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  1. Internal Medicine Grand Rounds: February 28th, 2007 Current Diagnosis and Treatment of Voice Disorders Seth H. Dailey, MD Assistant Professor University of Wisconsin Hospital and Clinics University of Wisconsin School of Medicine

  2. Cartilaginous skeleton

  3. Intrinsic Musculature • Abductors • Adductors • Tensors

  4. Intrinsic Musculature

  5. Innervation

  6. Abduction

  7. Adduction

  8. Tension

  9. Vocal Fold Anatomy

  10. Laryngeal Anatomy • Three surrounding structures- pharynx, trachea and esophagus • Three levels - supraglottis, glottis and subglottis • Three fixed structures - hyoid, thyroid and cricoid • Three mobile structures -epiglottis, false vocal cords and true vocal cords (folds)

  11. LaryngealAnatomy

  12. LaryngealAnatomy

  13. Mucosal wave/Phase delay

  14. Body-Cover Theory • Changes to mucosal wave • Stiffness • tension

  15. Mucosal wave • Velocity increases • Increased airflow • Increased subglottic pressure

  16. Laryngeal Physiology • Three main functions - airway, swallowing and voice • Three criteria for voice- generator, vibrator resonator • Three components for high quality glottic voice - closure, pliability and symmetry

  17. Indirect mirror examination • Advantages • Quick • Inexpensive • Little equipment • Disadvantages • Gag • Anatomic features • nonphysiologic

  18. Flexible laryngoscopy • Advantages • Well tolerated • Complete examination • Video documentation • Disadvantages • More time • Expensive

  19. Rigid laryngoscopy • Advantages • Best images • Magnification • Video documentation • Disadvantages • Expensive • Nonphysiologic • Gag • Anatomic features

  20. Common disorders affect the “magic three” • Closure - neuromuscular, joint, vocal fold • Pliability - “golden layer” - mass, scar • Symmetry - tension and viscoelasticity • VOICE DISORDERS ARISE FROM A COMBINATION OF THESE ELEMENTS

  21. Differential Diagnosis of Hoarseness • Vocal quality- determined by: • distance between vocal cords, • tenseness of the cords • how rapid cords vibrate • Hoarseness is caused by

  22. Differential Diagnosis of HoarsenessTypes of voice • Breathy- vocal cords do not approximate so air escapes. • Raspy- harsh voice. Cord thickening due to edema or inflammation. Voice is low in pitch and poor quality

  23. Differential Diagnosis of HoarsenessTypes of voice • Muffled voice- painful dysphagia and dyspnea • Shaky- high pitch or low soft. • Elderly • debilitated

  24. Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis • Laryngeal mucous membrane infection, usually viral (adenovirus/ influenza, RSV, coxsackie, rhinovirus) • Also can be due to trauma to throat, vocal abuse, toxic exposure, GI complications, smoking, allergy

  25. Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis • Hoarseness • Cough • Sore throat • Fever • Vesicles on soft palate • Lymphadenopathy

  26. Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis • Diagnostics: Laryngoscopy if suspect mass, infection, vocal cord dysfunction • Management: Voice rest, smoking/alcohol cessation, hydration

  27. Evaluation of Hoarseness • History is paramount • Projection - tired, breathy and low volume • Quality - ”hoarse”, “gruff”, “raspy” • Range - high, middle and low

  28. Evaluation of Hoarseness • Physical Exam • Speaking voice • Range profile • Fundamental Frequency – F0 • Maximum Phonation Time • Standard Reading Passages • Singing if appropriate – local, regional, bodywide • Voice Lab – Acoustics and Aerodynamics

  29. Evaluation of Hoarseness • Endoscopic exam – • mirror, flexible endoscope, rigid endoscope • Digital archiving essential for documentation

  30. Evaluation of Hoarseness • Studies • CT scan – evaluation of course of RLN • EMG – Is there an nerve to muscle problem? • Double pH probe – What is the severity of Laryngopharyngeal reflux (LPR)? • Microlaryngoscopy – some lesions missed in the office.

  31. Evaluation of Hoarseness • Studies – the future…. • Aerodynamics and acoustics – Chaos theory and mathematical modeling • Vocal cord motion – gross arytenoid motion being evaluated endoscopically • Vocal cord pliability – endoscopic rheometers and vocal fold oscillators • Ocular Coherence Tomography/Ultrasound

  32. Normal Stroboscopy

  33. NeuromuscularDisorders • Vocal cord paralysis • Vocal cord paresis • Cricoarytenoid joint dysmobility • Presbylaryngis (aging larynx) • Muscle Tension Dysphonia (Hyperfunction)

  34. Vocal Cord Paralysis • Thoracic, thyroid surgery, “Bell’s” palsy of the larynx • Closure and symmetry • Swallowing and voice • Static Repair - Watch and wait, temporary procedure, permanent procedure (Laryngoplasty). • Dynamic repair Nerve Muscle Transosition

  35. Vocal Cord Paresis

  36. Vocal Cord Paralysis 2

  37. Videostroboscopy

  38. Radiographic studies • MRI • CT

  39. Laryngeal EMG • Myopathy – normal frequency of firing but decreased amplitude • Neuropathy – decreased frequency but occasional normal amplitudes • Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun

  40. Laryngeal EMG

  41. Differential • Congenital • Inflammatory • Neoplastic • Traumatic • Neurologic • Endocrine • Iatrogenic • Local factors

  42. Vocal Cysts

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