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Transcript of Voice Disorders
What are Voice Disorders?
Types of Voice Disorders
Vocal fold lesions
Vocal fold lesions are abnormal growths within or on the covering of the vocal cord.
Article: Voice Disorders in Children Require a Team Approach
Author: by Mary Beth Nierengarten
Today, Febrauary 2012
Although voice disorders in children are not new, recognition of the need to address and treat these disorders in many children is increasing.
A 2008 study found that chronic dysphonia in children negatively affected their lives by inviting negative attention and limiting their participation in important events (J Voice. 22(2):197-209).
“In the past, practitioners have downplayed pediatric voice disorders because they believed that children would grow out of it, or if they would just stop yelling on the playground the hoarseness would go away,” said Shannon M. Theis, PhD, CCC-SLP, clinical assistant professor of communicative disorders at the University of Wisconsin School of Medicine and Public Health–Voice and Swallowing Clinics in Madison, Wis. “Now, we understand that pediatric voice disorders can have a significant effect on a child’s school performance, self-esteem and communicative effectiveness.”
Dr. Verdolini Abbott also emphasized the ineffectiveness of traditional voice therapy that focuses on telling children “not to abuse their voice.” She and her colleagues have developed a voice therapy program based on research they’ve done on the biomechanics of phonation, learning and compliance in children. Called “Adventures in Voice,” the game-based program is geared for children between the ages of four and 11 and uses video games and other technology to teach them how to produce a normal and loud voice safely rather than restricting their phonation.
Nodules are blister-like or callous-like swellings that form just below the epithelial surface of the vocal folds.
Nodules form symmetrically on both vocal folds at the midpoint and look like small bumps. They can create a space between the 2 folds resulting in the escape of air and the disruption of normal vibration.
Nodules can stiffen mucosal tissue leading to irregular vibration and a rougher sound.
abnormal voice quality, limited pitch/volume, vocal fatigue, and discomfort after extensive voice use
Nodules usually happen in people who use their voice intensely for an extensive time. They form as a natural response to trauma.
Functional voice therapy reduces trauma and resolves nodules; surgery is rarely required
Polyps are growths arising from the vocal cord mucosa which are solid or fluid filled and can become large in size. Polyps can affect vibration depending on its size and location.
abnormal voice quality, vocal fatigue, discomfort after extensive talking, a sense of something irritating in the throat that needs to be cleared or coughed away, and problems with breathing (if the polyp is very large)
Can arise for unknown reasons; may be caused by trauma to the vocal cords; smokers polyps occur due to smoking and its impact on the vocal fold mucosa which results in the “smoker’s voice”
can be resolved by itself with vocal therapy; usually surgical removal is required; smoker’s polyps are not to be removed unless the person quits smoking otherwise the polyps will form again
Pitch, loudness, or voice( phonatory) quality differs significantly from persons of a similar age, gender, cultural background, and racial and/or ethnic group.
Vocal quality detracts from the ability to function and achieve in society.
For some, disorder is mild, transient, and requires no treatment.
For others, disorder is severe, persistent, and requires ongoing treatment.
Most serious cases, larynx is removed for reasons such as cancer, and alternative methods of producing voice are necessary.
Vocal Cord/fold Paralysis
What is Voice?
There are 2 vocal cords, or elastic bands of muscle tissue, located in the larynx, also known as the voice box, that vibrate during speech to produce the sound of our voice.
Vocal cord paralysis occurs when one or both of these cords are unable to move. The paralyzed vocal cords may stay open causing the air passageway and lungs to be left unprotected. This can result in voice, breathing, or swallowing problems. Food and liquid could possibly enter the trachea and lungs causing serious health issues.
Vocal fold vibration that provides sound source for spoken language
Phonation: humans set their vocal folds into a vibratory pattern (say “oooo”)
Vocal folds are adducted (closed), air is exhaled upwards and blows apart the vocal folds setting them into a rapid vibratory pattern
Voice is further modified by the processes of resonation and articulation
Three vocal characteristics: frequency, intensity, and phonatory quality
: Laryngeal cancer is linked to tobacco and alcohol use, nutritional inadequacies and occupational exposures.
: most consistent symptom is hoarseness that does not get better in 1 - 2 weeks, abnormal (high-pitched) breathing sounds, cough, coughing up blood, difficulty swallowing, neck pain, sore throat that does not get better in 1 - 2 weeks, even with antibiotics, swelling or lumps in the neck, unintentional weight loss.
Diagnostic instruments used for assessment:
Direct (flexible) laryngoscopy: For this exam, the doctor inserts a fiber-optic laryngoscope a thin, flexible, lighted tube through the mouth or nose to look at the larynx and nearby areas.
Indirect laryngoscopy: In this exam, the doctor uses special small mirrors to view the larynx and nearby areas.
Prognosis for the future:
Throat cancers can be cured in 90% of patients if detected early. If the cancer has spread to surrounding tissues or lymph nodes in the neck, 50 - 60% of patients can be cured. If the cancer has spread (metastasized) to parts of the body outside the head and neck, the cancer is not curable and treatment is aimed at prolonging and improving quality of life.
Communication counseling: explore all alternative options for producing voice.
Artificial larynx: vibrating power source placed against the neck, often mechanical sounding voice
Esophageal speech: learn to trap air in the esophagus and then use that for voice, often very difficult for most people.
After treatment, patients generally need therapy to help with speech and swallowing. A small percentage of patients (5%) will not be able to swallow and will need to be fed through a feeding tube.
Stress, Anxiety, and Depression
Acute stress disorder: within one month of having a traumatic experience, exaggerated startle responses, motor restlessness; can be reflected in the voice.
:Generalized anxiety and anxiety disorder: muscle tension, trembling, twitching; may lead to vocal tremors and voice breakages
Diagnostic instruments used for assessment:
A complete medical examination should be completed to rule out any possible organic or neurologic cause for the disorder.
Flexible endoscopic evaluation to reveal if vocal folds adduct during coughing, laughing, etc., but possibly not during communicative speech.
Evaluation consisting of parent and teacher assessment forms such as the Selective Mutism Comprehensive Diagnostic Questionnaire (SM-CDQ) and the SM School Evaluation Form©.
Prognosis for the future:
The prognosis for mutism is good. Sometimes it disappears suddenly on its own. The negative impact on learning and school activities may, however, persist into adult life.
Multidisciplinary approach including speech-language pathologist and mental health professionals
Goal: determine emotional or psychosocial cause of voice disturbance
Therapy usually focus on reducing tension, counseling, and eliminating any voice abuses or misuses.
The SLP may create a behavioral treatment program, focus on specific speech and language problems, and/or work in the child's classroom with teachers.
A behavioral treatment program may include the following:
Stimulus fading: involve the child in a relaxed situation with someone they talk to freely, and then very gradually introduce a new person into the room.
Shaping: use a structured approach to reinforce all efforts by the child to communicate, (e.g., gestures, mouthing or whispering) until audible speech is achieved.
Self-modeling technique: have child watch videotapes of himself or herself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry over this behavior into the classroom or setting where mutism occurs.
Injury to the head, neck, or chest
Tumors of the skull base, neck, or chest
Neurological conditions (multiple sclerosis/Parkinson’s disease)
Anterior spinal fusion, thyroid, cardiac, or pulmonary surgeries
Damage to the nerves that go from the brain to larynx
Recurrent laryngeal nerve: comes out of the brain stem and descends all the way down to wrap around the aorta (the main artery leading out of the heart) on the left side. It then comes back up and attaches to the larynx.
Second Language Learner
Difficulty breathing- shortness of breath/noisy breath
inability to speak loudly
limited pitch and loudness variations
voicing that lasts only for a very short time (around 1 second)
Swallowing issues- choking or coughing while eating
possible pneumonia due to food and liquid being aspirated into the lungs (the vocal cords cannot close adequately to protect the airway while swallowing)
Comprehensive voice evaluation is done by a otolaryngologist- ear, nose, and throat doctor
Endoscope: a device with a light that shows the cords and movement patterns during phonation (sound production) and at rest; inserted through the nose or mouth.
Laryngeal electromyography: measures the electrical impulses of the nerves in the larynx to identify the paralyzed areas
Avoid eating large amounts of food two to three hours before bedtime. This recommendation can be difficult for families who have children in extracurricular evening activities. Families should be strongly encouraged to give the child a very small, nonfat meal if the child is eating close to bedtime.
Sleep with the head of the bed elevated.
Reduce intake of known acid producers, such as citrus- or tomato-based products, caffeinated or carbonated beverages, onions, garlic, high-fat foods and chocolate.
Maintain an appropriate weight.
Wear clothing that fits loosely around the waist.
Cysts are growth that develops under the surface layer of the vocal fold mucosa.
Cysts can create a space between the 2 folds preventing normal vibration. They can also cause part of the vocal cord mucosa to stiffen resulting in disruption of normal vibration as well.
abnormal voice quality, vocal fatigue, and discomfort after extensive talking
the exact cause is unknown; excessive voice use/abuse
can resolve on its own by reducing vocal cord impact for some time; often requires surgical removal; pre and post voice therapy improves the surgical result.
- some voices are able to recover naturally during the first year after diagnosis. As a result, doctors delay surgery for at least a year and have patients see a SLP for voice therapy.
Exercises to strengthen vocal cords and improve breath control
Techniques to use your voice differently (ex. Opening wider/slower speaking)
- depends whether one or two vocal cords are paralyzed.
Common surgical procedures include changing the position of the vocal cord by inserting a structural implant or stitches to bring the vocal cords closer together. The surgery results in a stronger voice and is followed by voice therapy to adjust the voice.
When 2 of the cords are paralyzed a tracheotomy may be needed to improve breathing. A cut is made at the front of the neck and a breathing tube is inserted into the trachea. After the surgery, voice therapy with a SLP teaches the patient how to use voice and care for the breathing tube.
Small adjustments can really help a student with a speech or language impairment.
Seat the student near you, which will help with questions and instructions.
Include a system of signals that lets the student ask for help or indicate confusion without causing disruption.
Visual aids and clear, written instructions also help
Talk privately with the student and get his or her input on what’s helpful and what’s not.
Work closely with the speech pathologist and special educators in your school to get tips and strategies for supporting the student, including ways to adapt the curriculum and how to address the student’s IEP goals in your classroom.
Work together with the student’s parents to create and implement an educational plan tailored to meet the student’s needs. Regularly exchange information with parents about how the student is doing at home and at school.
ESL students can have speech or language impairments, although it may be difficult to distinguish the impairment from the language learning. If you suspect that one of your ELLs has a speech or language impairment, refer the student for assessment by a bilingual speech pathologist. Otherwise, the student’s speech or language impairment may be attributed to cultural or linguistic differences.
• Teach students about vocal hygiene and address issues such as screaming, talking loudly, making vocal noises, and clearing the throat excessively.
• Have the school SLP come in and observe the students to spot any voice abnormalities or vocal misuse.
• Model good vocal habits in the classroom.
Introduce games and activities to educate students about voice disorders
Go to the school with your child before or after school when few people are there.
Allow your child to speak to you or anyone else s/he might wish to talk to in the language s/he is most comfortable with.
Initially, what is important is helping your child see him or herself as a “speaker” in school.
Once the child is speaking to you in your native language within the school environment, encourage English.
If your child is reluctant, offer some positive reinforcement, such as stickers or tokens.
Since your child is already speaking to you in the school, the reluctance is due to insecurity, continue speaking English as much as possible at home and other places (stores, malls, etc).
If your child is still very reluctant to speak English…negotiate! You might suggest that two days a week you will speak English together in the school and the other three days you will speak your native language. This tactic has the benefit of giving the child some control in establishing treatment goals.
Let Your Child be the Teacher
It has been said that there is no better way to learn something than to teach it! Encourage your child to teach you better English Skills. Get workbooks, tapes, games, etc.
In school, spend time alone with the teacher. The point here is to build comfort with the teacher without any additional social pressures. Since the SM child feels confident with their native language, spending alone time with the teacher, where the SM child begins to TEACH the teacher the new language is a very successful tactic that has worked with many bilingual children.
On play dates, encourage your child to teach the other child simple words (colors, numbers, songs, etc.) in your native language. It would be helpful if this child could be a child the teacher is pairing your child with for activities in the classroom. Since your child is confident and secure with his/her native language, teaching other children and feeling in control is often very effective.