Manner of Phonation:

Muscle Tension Dysphonia

Anatomic Changes

• None

Etiology

• Effortful manner of phonation • Idiopathic •Counterproductive compensation

Voice Symptoms

• Extraneous muscle activity in head, neck, and thorax • Excessive or limited breath control • Inappropriate loudness • Pressed phonation • Abrupt initiation of phonation • Roughness • Breathiness • Stridency • Intermittent aphonia

Manner of Phonation:

Edema/Swelling

Anatomic Changes

• Swelling and stiffening of medial edge of membranous portion of vocal folds

Etiology

• Effortful manner of phonation

Vocal Symptoms

• Roughness • Breathiness • Voice and pitch breaks • Reduced pitch and loudness range(s)

Manner of Phonation :

Hyperemia or Hemorrhage

Anatomic Changes

• Collection of blood under skin • May stiffen cover

Etiology

• Effortful manner of phonation

Vocal Symptoms

• Roughness • Breathiness • Intermittent aphonia • Reduced pitch and loudness range • Pain

Manner of Phonation:

Vocal Fold Nodule

Anatomic Changes

• Benign callous-like, fibrous mass • Primary striking zone • Starts as soft, unilateral swollen area • Long term is well-defined, callous-like mass

Etiology

• Effortful manner of phonation

Vocal Symptoms

• Roughness • Breathiness • Stridency • Abrupt initiation of phonation • Pressed phonation • Intermittent aphonia • Reduced pitch and loudness range(s) • Deterioration of voice quality with prolonged 

Manner of Phonation :

Sessile or Pedunculated Polyp

Anatomic Changes

• Fluid-filled sac on medial edge midmembranous portion of vocal folds • Sessile (broad-based sac) • Pedunculated (a thin stem)

Etiology

• Effortful manner of phonation • May develop into Reinke’s edema

Vocal Symptoms

• Roughness • Breathiness • Intermittent aphonia • Reduced pitch and loudness range(s) • Voice breaks

Manner of Phonation:

Vocal Fold Cyst

Anatomic Changes

• Fluid or semisolid material in a sac • May protrude into vibratory margin • Increase vocal fold stiffness • If membrane forms, it becomes difficult to reabsorb

Etiology

• Effortful manner of phonation • Reflux • Upper respiratory infection • Congenital or acquired

Vocal Symptoms

• Roughness/breathiness • Vocal fatigue • Intermittent aphonia • Reduced pitch range

Manner of Phonation:

Reinke’s Edema

Anatomic Changes

• Translucent, gelatinous lesion • Length of membranous portion

Etiology

• Effortful manner of phonation • Smoking • Gastroesophageal reflux • Hormonal changes (hypothyroidism)

Vocal Symptoms

• Lowered pitch • Roughness • Breathiness • Stridency • Intermittent aphonia • Reduced pitch range

Idiopathic and Manner of Phonation:

Sulcus Vocalis 

Anatomic Changes

• Unilateral or bilateral furrow • Stiffening

Etiology

• Unclear • Congenital • Develop when a cyst ruptures • Following a hemorrhage • Effortful manner of phonation Voice Symptoms

• Roughness • Breathiness • Intermittent aphonia • Higher than normal pitch

Neurological Problem and Manner of Phonation:

Vocal Fold Bowing

Changes in Physiology

• Low tone • Weakness in membranous portion • Muscular atrophy

Etiology

• Parkinson’s disease • Aging • Effortful manner of phonation

Vocal Symptoms

• Roughness • Breathiness • Stridency • Intermittent aphonia • Monopitch/monoloudness

Neurological Problem:

Paresis or Paralysis

Anatomic Changes

• Reduced adduction and abduction of vocal fold(s) • Vocal fold(s) flaccidity

Etiology

• Damage to recurrent laryngeal nerve • Nerve may regenerate • Viral infection, stroke

Voice Symptoms

• Roughness • Breathiness • Intermittent aphonia • Reduced pitch and loudness range(s) • Shortness of breath • Weak, ineffective cough • Difficulty protecting airway

Neurological Problem :

Spasmodic Dysphonia

Changes in Physiology

• Involuntary adduction or abduction of VF during speech Etiology

• Idiopathic • Trauma • Genetic

Symptoms

• Short-term variations in severity • Overall severity stabilizes • Action induced • Symptoms diminish with sensory tricks

Pathology • Irregular thickening and cancerous overgrowth • Squamous cell carcinomas • Can be glottal, subglottal, or supraglottal • Tumors may invade deep structures

Etiology

• Smoking • Alcohol • Genetics

Vocal Symptoms

• Inhalatory/exhalatory stridor • Shortness of breath • Intermittent aphonia • Roughness • Breathiness • Stridency • Reduced vocal pitch and loudness range(s) • Dysphagia

Anatomic Changes

• Adduction VF during inhalation • Posterior, diamond-shaped chink

Etiology

• Idiopathic • Reflux • Exercise • Irritants • Effortful manner of phonation • Misdiagnosed as asthma

Symptoms

• Dyspnea • Wheezing on inhalation/Inhalatory stridor • Tightness in throat • Cough • Occurs during sports

A state of equilibrium exists in the respiratory system at approximately 38% of vital capacity due to the coupling of the chest wall-lung unit

Also called resting lung volume (RLV)

An increase in air pressure above the vocal folds due to narrowing of the vocal tract

Increase in back pressure facilitate self oscillation of the membranous portion of the vocal folds, reducing impact stress

Reveals attitudes regarding need for voice rehabilitation

• Indirectly indicates motivation to make changes

• Suggests level of motivation to adhere to recommendations

• Reveals the patient’s knowledge about the problem

Examples:

• “I can’t project my voice.” • “My voice gets tired.” • “People ask me to repeat.” • “My voice cuts out on me.” • “I have a break in the passaggio.” • “My pitch range is limited.” • “I have developed a nodule.” •

Children ~10 seconds*

• Adults ~20 seconds*

• Females ~25.7 seconds*

• Males ~34.6 seconds* 

• noise in the signal; ratio of harmonic sound to noise
• Sustained vowels
• Higher numbers = greater periodic sound
• Lower number = greater aperiodic (noise) sound, greater roughness 

Structure and Function of the Speech Mechanism

• Hearing • Cognition and Language • Articulation and Fluency • Swallowing Screenings

Patient’s needs are met

• Patient and clinician agree that rehabilitation is maximized

• Has a physical problem that interferes with production of voice, and voice will never be normal

• Clinician has no more rehabilitation hypotheses to test

• It may be appropriate to refer this patient to another clinician

• Patient does not practice and refuses to change behaviors such as drinking or drug abuse

• It may be appropriate to refer this patient to another clinician

• Easy manner of phonation

• Efficient voice production

• Effective communication

 suggests that a task is performed without undue effort or difficulty

 The voice works without effort— spontaneously and easily

• Minimize changes in configuration of vocal tract so that patient can focus on one change at a time

• Gradually, as patient becomes consistent in simple exercises, he will be ready to move on to more complex, speech-like utterances

• Structured tasks
  • e.g. /mhm/ develop awareness of what it feels like to produce speech with decreased effort
• less structured tasks (random practice)
  • Voiceless phoneme (/h/, /s/, /f/, etc.) and nasals (/m/, /n/) initiation with short phrase that is totally or mostly voiced (e.g., /hu ar ju/) 
• Semi-structured Tasks With Increased Cognitive Load
  • Patient chooses his own words but must decide upon them before he inhales
• unstructured tasks
  • Brief conversations of one minute
  •  Gradually lengthen conversations and introduce controversial topics or topics of special interest to patient

Suprahyoid muscles

• cranial nerve V, VII, XII

Infrahyoid muscle

• cranial nerve XII