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Understanding Vocal Problems

Understanding Vocal Problems. Created for the 7 th c students Taishan Medical University. Healthy Vocal Cords. Healthy vocal cords have smooth straight edges and are pearly white in color. . These pictures of normal, healthy vocal cords give another view of their

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Understanding Vocal Problems

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  1. Understanding Vocal Problems Created for the 7th c students Taishan Medical University

  2. Healthy Vocal Cords • Healthy vocal cords have smooth straight edges and are pearly white in color.

  3. These pictures of normal, healthy vocal cords give another view of their pearly-white color in contrast to the pinkish surrounding tissue.

  4. BENIGN TUMOURS OF LARYNX • NON NEOPLASTIC • Vocal nodules • Vocal polyp • Reinke’soedema • Contact ulcer • Intubation granuloma • Leukoplakia • Amyloidtumours • Laryngocele • Ductal cysts • Saccular cysts • NEOPLASTIC • Squamouspapilloma • Chondroma • Haemangioma • Granular cell tumours • Glandular tumour • Rhabdomyoma • Lipoma • fibroma

  5. Vocal Nodules Vocal nodules are non-cancerous growths that normally occur bilaterally. Nodes keep the cords from closing properly.

  6. The most common symptom of nodes is hoarseness. • Vocal production will take effort and depending upon the size of the nodes, production may be painful. • Vocal fatigue on prolonged phonation , are other common symptoms.

  7. Nodules usually occur because of vocal misuse or overuse. This causes vocal irritation and inflammation. With continued misuse, the tissue becomes fibrotic and hardened.

  8. EARLY CASES Nodes are treated with voice therapy that teaches techniques to reduce the vocal force on the cords as well as behaviors to avoid. Educating people for proper use of voice Certain medical conditions such as allergies and reflux may maintain the nodules. LATE STAGE / LARGE NODES Surgery is required , excision with precision under operating microscope avoiding any trauma to the underlying vocal ligament.

  9. PREVENTION • Speech therapy and re-education in voice production are essential to prevent their recurrence.

  10. Polyps • Polyps are non-cancerous lesions. • They occur usually in males.

  11. Symptoms of Polyps • Polyps cause a hoarse, breathy voice that tires easily. • Feeling of “something in the throat”

  12. Causes of Polyps • Vocal abuse and misuse • Often associated with a single traumatic event such as yelling at a sporting event.

  13. TRETMENT Surgical excision under operating microscope followed by speech therapy

  14. REINKE’S OEDEMA • Collection of oedema fluid in the subepithelial space of Reinke. • The most superficial layer of the lamina propria is called Reinke's space and consists of a very loose material that allows the cover of the fold to vibrate over the more rigid deeper strucutres •  Fluid can occur in response to chronic inflammation. Fluid collection in the body is called edema, so this fluid build-up is called Reinke's edema. • Cause same – vocal abuse • Alcohol & smoking

  15. TREATMENT • Vocal cord stripping, preserving enough mucosa for epithelialisation. • Only one cord operated 1 time . • Patient re-education in production and cessation of smoking are essential to prevent recurrence.

  16. The photo to the left shows example of Reinke's edema. (The front of the vocal folds is at the top of the photo.) • This disorder is quite typical in heavy smokers, and can produce a low pitched voice. • It is not premaligant, though smokers certainly are at risk for developing laryngeal cancer (as well as heart disease, emphysema, lung cancer, and a variety of other problems.) • As the edema becomes more gelatinous, it may eventually turn into actual vocal fold polyps.

  17. Reinke's edema can be treated surgically by making an incision in the lateral portion of the vocal folds and carefully removing the thick gelatinous fluid in Reinke's space. • If there is a lot of excess mucosa (the covering of the vocal fold), this excess mucosa can be trimmed. • The photo to the left shows a post-operative view of the folds of the above patient immediately after evacuation of the edema. • The goal in this surgery is to preserve the healthy lower layers of the vocal folds and to avoid excessive removal of vocal fold mucosa.

  18. This view shows the same patient in the office about three weeks later. • This photo was taken through a flexible fiberoptic scope with a different light source, so the colors are slightly different. • The folds had already started to vibrate fairly well and the voice was significantly improved. • It usually takes 4-6 weeks for all the swelling from the surgery to resolve.

  19. Vocal Fold Cysts • The image to the left shows a vocal fold cysts in a person who had significant hoarseness. This picture was taken with a stroboscopic light source through a flexible fiberoptic scope. • The vocal folds are therefore "frozen" in time at the point of closure. • Note that the folds cannot close completely due to the cyst. • This cyst was removed surgically and the voice returned to normal

  20. This image shows a close up view of a larger cyst in a different individual. This photograph was taken at the time of surgery for removal of the cyst. • Notice that the left vocal fold is slightly thickened immediately opposite the cyst. • This thickening has developed in response to the cyst, and should resolve spontaneously after removal of the cyst.

  21. The to the the left shows bilateral cysts on vocal folds that may have developed at the site of previous nodules. • The cyst on the right is more solid in appearance but did contain fluid. • The cyst on the left has a little dark red dot showing where there has been bleeding into the cyst.

  22. Laryngitis Sicca Laryngistis sicca is caused by inadequate hydration. The protective mucus normally needed for the vocal cords becomes too thick and they cannot open or close properly.

  23. Acid Reflux • Acid reflux affects singers in that the stomach acid can flow past the esophagus into the throat. • Small amounts of reflux can cause considerable damage.

  24. The left picture is damage from acid reflux. Notice how the vocal cords are mostly red instead of white. The right picture is the same vocal cords after successful treatment. Another result of acid reflux. Grandulomas

  25. Symptoms • Hoarseness • Bad/bitter taste in mouth (especially in morning) • Chronic (on-going) cough • Asthma-like symptoms • Frequent throat clearing

  26. Referred ear pain • Pain or sensation in throat • Post-nasal drip • Feeling of "lump" in throat • Singing: Difficulty hitting high notes • Problems while swallowing

  27. Hemorrhage A vocal hemorrhage is actually a ruptured blood vessel on the true vocal cord, and bleeding into the tissues of the fold. It is a rare occurrence caused by aggressive use of the vocal cords (e.g. cheerleading)

  28. Common Signs of Vocal Abuse • Throat is tender to the touch after use. • Voice is hoarse at the end of singing. • Throat is very dry, with a noticeable “tickle” that is persistent. Check dehydration. • Inability to produce your highest notes at pianissimo volume. • Persistent hoarseness or an inability to sing with a clear voice after 24-48 hours of vocal rest.

  29. Chronic Laryngitis • Divided into:- • Chroinc laryngitis without hyperplasia( chronic hyperaemic laryngitis) • Chronic hypertrophic laryngitis ( chronic hyperplastic laryngitis)

  30. CHRONIC LARYNGITIS • It is diffuse inflammatory condition symmetrically involving the whole larynx, i.e. true cords, ventricular bands, interarytenoid region and root of the epiglottis.

  31. AETIOLOGY • It may follow incompletely resolved acute simple laryngitis or its recurrent attacks. • Presence of chronic infection in paranasal sinus, teeth and tonsils and the chest are important contributory causes. • Occupational factors, e.g. exposure to dust and fumes such as in miners, strokers, gold or iron smiths and workers in chemical industries. • Smoking and alcohol. • Persistent trauma of cough as in chronic lung diseases.

  32. Clinical feature • Hoarseness • Constant hawking • Discomfort in the throat • Cough dry and irritating

  33. On examination • There is hyperaemia of laryngeal structures. • Vocal cords appear dull red and rounded. • Flecks of viscid mucus are seen on the vocal cords and interarytenoid region.

  34. Treatment for chronic laryngitis: • Same as acute laryngitis HOWEVER • If symptoms last for longer than 2 weeks, seek medical attention. • Avoidance of irritating factors, e.g. smoking, alcohol, or polluted enviromnment , dust and fumes • Voice rest and speech therapy • Steam inhalations • expectorants

  35. Chronic hypertrophic laryngitis • May be either a diffuse and symmetrical process or a localised one, the latter appearing like a tumour of the larynx. • Localised variety presents as dysphoniaplicaventricularis, vocal nodules, vocal polyp, reinke’soedema and contact ulcer.

  36. Aetiology • SAME AS BEFORE • CLINICAL FEATURES • MOSTLY AFFECTS MALE (8:1) IN THE AGE GROUP OF 30-50 YEARS • HOARSENESS, CONSTANT DESIRE TO CLEAR THE THROAT DRY COUGH , TIREDNESS OF VOICE HAS BEEN USED FOR AN EXTENDED PERIOD OF TIME, ARE THE COMMON PRESENTING SYMPTOMS

  37. On examination: • Laryngeal mucosa , in general , is dusky red and thickened. • Vocal cords appear red and swollen. Their edges lose sharp demarcation and appear rounded. • In later stages, cords become bulky and irregular giving nodular appearance. • Ventricular bands appear red and swollen and may be mistaken for prolapse or eversion of the ventricle. • Mobility of cords gets impaired due to oedema and infiltration , and later due to muscular atrophy or arthritis of the cricoarytenoid joint.

  38. PBL • A 3 year old child was referred to an ENT specialist because of cough, difficulty of respiration and temperature 39.5 C of few hours duration. • The child was admitted to hospital for observation and medical treatment. 6 hours later, the physician decided an immediate tracheostomy. • After the surgery the child was relieved from the respiratory distress for 24 hours then he became dyspnic again. • The physician carried out a minor procedure that was necessary to relieve the child from the dyspnea. • Few days later the tracheostomy tube was removed and the child discharged from the hospital.

  39. A 4 year old child was referred to an ENT specialist by a pediatrician because of repeated attacks of severe chest infection (three in number) during the last month that usually resolved by antibiotics, expectorants and mucolytics, but the last attack did not resolve. • On examination the lower right lobe of the lung showed no air entry and a lot of wheezes all over the chest by auscultation. • A chest x-ray revealed an opacified lower right lobe. • Temperature 38 C, pulse 120/min and respiration rate 35/min.

  40. Ohh !! Guys it’s time for pneumonics

  41. D/D OF ACUTE TONSILLITISMADI LoVe MAT • Quote: • M-membranous tosillitisA-agranulocytosisD-diphtheriaI-infectious mononucleosisL-ludwig's anginaV-vincent's anginaM-malignancyA-aphthous ulcerT-tonsillar cleft • D/D of membrane over the tonsilWe Mainly Discuss At Length About Membrane In Tonsil • Quote: • We - Vincent's anginaMainly - MalignancyDiscuss - DiptheriaAt - AgranulocytosisLength - LeukemiaAbout - Apthous ulcersMembrane - Membranous TonsillitisIn - Infectious mononucleosisTonsil - Traumatic ulcer

  42. Little's area: Arteries •  " LEGS " • L - superior Labial artery • E - anterior Ethmoidal artery • G - Greater palatine artery • S - Sphenopalatine artery

  43. Voice box component "There are 3 Vs in your  Voice box" The structures as they appear in the sagittal section are • Vestibular fold • Ventricle • Vocal fold

  44. Tonsils in ENT • "PPL (people) have tonsils" • Pharyngeal • Palatine • Lingual

  45. Types of DNS (Deviated Nasal Septum) •  'SCAN your nose' • S -shaped deformity • C -shaped deformity • Anterior dislocation • Nasal spur

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