classification of voice disorders

INTRODUCTION

A NORMAL VOICE:

          In order to evaluate a person’s voice it is necessary to know the essential elements of a normal voice incontrast to the characteristics of a problem voice.  It’s more difficult to define normal voice than any other speech or language component because by nature, voice variety is limitless, and standards for voice adequacy are broad (Moore 7f)A normal voice is essential for efficient speech communication.

          According to West Ansburry and Care in 1955, a normal voice should be,

1.       Of adequate loudness

2.       Should be clear

3.       Appropriate pitch for age, and gender

4.       Should have constant inflections

5.       should implicate the meaning of what is spoken

          Though these authors tried to analyze a normal voice from different perspective, their description of the normal voice is ambiguous and subjective when they explained about pitch or loudness in terms of clearness, adequate and appropriate and have indirect connotations.

According to Wilson  D.E'87  a good voice  should have  the following characteristics:

1. Pleasing voice quality

2. Proper balance of oral and nasal resonance

3. Appropriate loudness

4. A speaking fundamental frequency level suitable for age, size and sex,

5. Appropriate voice inflection involving pitch and loudness. The rate of speaking should be such that it does not interfere with the five essential characteristics of a normal voice; this basic definition of a normal voice must be broad enough to allow a wide range of variation in any one or more of the essential positive characteristics.

Johnson et al'56 gave the following criteria for defining normal voice,

1.   Quality must be pleasant. This criterion implies the presence of a certain musical quality and absence of noise/atonality.

2.   Pitch level must be adequate. The pitch level must be appropriate to the age and sex of the speaker.

3.   Loudness must be appropriate. The voice must not be so weak that it cannot be heard under ordinary speaking conditions, nor it should be so loud that it calls undesirable attention to itself.

4.  Flexibility must be adequate. Flexibility/variety refers to variations in pitch and loudness that aids in the expression of emphasis, meaning or subtleties indicating the feelings of individual.

Perkins (1971) lists 5 kinds of information that can be extracted from the voice. It is an indicator of the speakers: 1) Physical health, 2) emotional health, 3) Personality, 4) Identity and 5) aesthetic orientation. It is also a carrier of connotative and denotative content. This list is important in that it tells us that voice has many meanings for both speaker and clinician and is a rich storehouse of clues to understanding the individual. It is usually seen that we are prejudged by our voices regardless of the content of our speech.

PROBLEM VOICE

A voice disorders exists quality, pitch, Loudness or flexibility differs from the voices of others of similar age, sex, and cultural group. However, no fixed, uniform standard of abnormal voice exists, just as no absolute criterion for normal voice can be established.

An abnormal voice can be described as 1) A Sign of illness, or 2) A Symptom of illness or 3) As a disorder of communication.

Abnormal voice as a sign of illness.

Faced with someone whose voice sounds abnormal, the clinican's chief concern should be whether or not the abnormal voice signifies illness. Communicative or aesthetic considerations are, for the moment, secondary. The cause or causes of the abnormal voices needs to be established, if at all possible. Once the reasons for the voice disorder is known and has been eliminated from the physical health of the individual, the communicative significance of the voice can then be considered.

Abnormal voice as a symptom of illness.

Symptom refers to the patient's subjective complaint, real or imagined; whether or not the clinicians think the voice is abnormal is independent of the patient's beliefs. Three variations on this can be observed clinically:

1. The voice is judged by both clinician and patient, and both advocate a need for its investigations and its therapy.

2. The Clinician is convinced of a_need for voice investigation and Therapy. but the patient is not This situations arises from either (a) the clinicians unrealistic, or over determined definition of abnormal voice and overemphasis on voice improvement or, (b) the patient's indifference to a genuine problem.

3. The Patient's conviction that a voice disorder exists despite the fact that clinician believes the problem to be trivial or Nonexistent.  Such ^conflict is usually a sign of patient Overreaction, and frequently seen during recovery from laryngologic disease or laryngeal surgery.

Abnormal Voice as a disorder of communication

In addition to abnormal voice as an index of health or illness, it is also valued as an instrument of communication. Within this framework, the following questions are pertinent:

1.       Is the voice adequate to carry language intelligibility to the listener?

2.       Are its acoustic properties aesthetically acceptable?

3.       Does it satisfy its own occupational and social requirements?

To define a problem voice the five characteristics of a normal voice can be listed as negative characteristic, making the answer to the question "What is a problem voice?   fall quite easily into place.   A child has a voice problem if his voice shows one or more of the following characteristics:

1.       Disturbed voice quality caused by laryngeal dysfunction and characterized by hoarseness, harshness or breathiness.

2.       Hypernasality,  hyponasality  or culde-sac resonance caused  by

improper balance of oral and nasal resonance.

3.       A voice too soft to be heard easily or so loud it is unpleasant.

4.     A speaking fundamental frequency level too high/too low for age, size

& sex.

5.       Inappropriate prosody involving primarily stress and intonation

patterns. Rate, if too fast or too slow, may interfere with adequate voice production. A problem voice may be distracting or unpleasant to the listener and it may be severe enough to interface with communication (ASHA, 1964; Peterson, 1946).

Seymour (1975) found that among the 130 days in his study, between the ages of 6 and 8 yrs, those judged as having less acceptable voices^ Characteristically had lower pitch voices, softer voices, and slower speaking rates. Careful listening can pinpoint voice abnormalities as described by Maragos (1984). Therefore Vaughan stated a vocal disability should be defined only as a vocal activity or a characteristic that interferes with specific person's voice requirements.

CLASSIFICATION OF VOICE DISORDERS

I. Classification based on acoustic phenomena:

Wilson (1979) has observed that voice problems are traditionally classified under the aspect of voice affected (quality, loudness and pitch problems).  While this is useful and apparently simple form of classification; we are immediately faced with the fact that in the majority of dysphonic patients aspects of voice production are affected. As Van Riper & Irwin (1958) observe seldom does the abnormal voice is weak in intensity, restricted in pitch and hoarse or husky in quality. While we may encounter conditions where a single feature of voice is affected such as the level of intensity in the early stages of Parkinson's disease, these cases are relatively uncommon, furthermore such a classification does not tell us all we need to know about the causes underlying the disturbed acoustic features.

II. THE FUNCTIONAL VERSUS ORGANIC DICHOTOMY:

The Classical approach to classification is the broad one of a functional versus organic dichotomy, but as van Riper and Trisin (1958) comment both organic and functional factors are often present and it is difficult or impossible to weigh their influence properly. Aronson (1980) described organic as caused by structural (anatomic) /physiologic disease, either a disease in the larynx itself or remote systematic illness which impairs laryngeal structure / function. As Wilson 71 says the continuum (between organic and functional) is a 2 way path because a pathology can result in a poorly functioning mechanism or a poorly functioning mechanisms can results in organic changes or an organic conditions.

Brackett (1971) says that functional applies to the physiology or use of structures in attaining particular objectives. Murphy (1964) reported that functional/organic dichotomy is not an entirely satisfactory form of classification and they represent an 'untenable' dichotomy. Voice pathologies are characterized by interaction of various etiological factors which includes psychogenic factors. Organic condition and misuse and abuse of voice.

Greene and Mathieson (1989) have proposed an interesting and useful alternative to the organic/functional dichotomy by classifying voice disorders under behavioral and organic. Changes in the laryngeal mucousa resulting from hyperfunctional voice use are grouped within behavioral categorie Organic conditions are grouped under structural abnormalities, neurological, conditions, endocrine disorders, and laryngeal disease Authors stress, however, that whilst the classification is conveniently tidy, the clinical reality is likely to be more complex. Nonetheless their classification is appealingly simple for the voice clinician.

III. HYPER FUNCTIONAL AND HYPOUNCTIONAL VOICE USE:

Some attempts have been made to classify voice on a continuum of over adduction or under adduction. Greene (1980) prefers the term hyperkinetic which she equates with vocal strain. Brackett (1971) introduced the concept of hypovalvular and hypervalvular phonation. which can clearly be used synonymously with hyper functional and hypo functional and hyperkinetic and hypokinetic Luchsinger and Arnold (1965)   use   the  term   hypokinetic to  describe   inefficient  laryngeal movements and hyperkinetic to excessive laryngeal movements. Aronson (1980) uses the term kinesiologic for this form of classification and comments that although this idea is not without merit, if used exclusively, it oversimplifies the complexities of the laryngeal pathologies placing excess emphasis on the degree of appropriation of the vocal edges rather than on the multiple causes of such approximation defects.

IV. Etiological classification:

According to Aronson (1980J a classification that looks at the cause of voice disorders encourages the deepest understanding of dysphonia/Aphonia Luchsinger and Arnold (1965) give the following system of classification.

1.       plastic dysphonia: voice disorders of constitutional origin

2.       Vocal nodules, polyps .'Primary dysphonia and secondary laryngitis.

3.       Endocrine disphonia : vocal disorders of endocrine origin

4.       Paralytic dysphonia : Vocal disorders from laryngeal paralysis.

5.       Dysarthric dysphonia : Vocal disorders of central origin.

6.       Myopathic dysphonia ;vocal disorders of myopathic origin.

7.       The influence of neurovegetative system on the voice (contact ulcers, vasomotor monochorditis)

8.       Traumatic dysphonia : Vocal disorders following laryngeal injury

9.       Alaryngeal dysphonia

10.     Habitual dysphonia 11. Psychogenic dynsphonia

Simpson in 1971 gave the following classification which took into account the luchsingers classification.

1.       Dysplastic Dysphonia

2.        traumatic dysphonia

3.       Mechanical dyspohonia

4.       Inflammatory dysphonia

5.       Vasomotor dysphonia

6.       Endocrine dysphonia

7.       Functional dysphonia

8.       Paralytic laryngeal dysphonia

9.       Dysarthric dysphonia

10.     Arthritic dysphonia

11.     Neoplastic dysphonia

12.     Dysarthric dysphonia

13.     Alaryngeal dysphonia

          Aronson (1980) gave his classification under following 3 headings: organic psychogenic and those of indeterminate etiology.  The etiological classification attempts to locate the precise areas of breakdown in the vocal mechanism, and the cause of that breakdown.  It is the most essential aspect of assessment of vocal dysfunction, since we may find that there is a condition which requires medical and surgical treatment.

V.               Classification by sokolof (1966), broad’r Nitz (1959) and Boone (1971):

Divided into three categories:

1.       Phonotary disorders, because of the hyperfunction of the laryngeal system.

Eg: Spastic dysphonia, vocal nodule etc.

2.       Phonotary disorder because of hypofunction of the laryngeal system

Eg: Breathiness

3.       Phonotary disorder due to abnormal resonance hypo+hyper nasality.

Disadvantage:

It is purely based on quality of voice and not with the laryngeal system, i.e. no. organic cause.

VI. Classification by Van riper (1966) and Murphy (1966):

Divided voice disorder into 2 categories based on the etiology of voice disorder. 1.Organic eg: Carcinoma, V.C.Paralysis, Laryngeal web 2.Functional voice - disorder eg- hysterical aphonia, Spastic dysphonia.

Disadvantages:

1.       It is a very broad category. All organic disorder will have some

functional symptoms like stress, anxiety etc. So it is difficult to group those disorders.

2.        It is medical classification which may not suit the paramedical

profession.

3.       There are some voice disorders which will not come into this category

i.e. puberphonia.

VII. By van riper 1966 and categories: Divided into three categories,

1.       Pitch disorder e.g. Puberphonia.

2.       Intensity disorder e.g. Hyperfunctional voice disorders (vocal nodule).

3.       Quality disorder e.g. Hoarseness, Breathiness as in vocal cord

paralysis.

Each category is further divided into number of categories for e.g. high pitch, low pitch voice etc. Disadvantage:

1.       It does not give us the idea of what is the cause of voice disorder.

2.       They are totally dependent like if a person has a pitch disorder then

he will also have problems in intensity.

VIII. Boone (1988) classification:

Divided 26 voice related problems under functional and organic changes,

these are:

Functional voice disorders:

•         Contact ulcers

•         Diplophonia

•         Functional Dysphonia

•         Spastic Dysphonia

•         Thickening Vocal Fold

•         Traumatic Laryngitis

•         Ventricular Dysphonia

•         Vocal nodule

•         Vocal Polyp

Organic Voice Disorder:

•        Cancer

•         Vocal Card Paralysis

•         Pubertal Changes

•         Dysarthria

•         Endocrinal Changes

•         Granuloma

•         Laryngectomy

Disadvantage

1.       Very   limited   classification, and   difficult   to   place   voice

disorders caused by structural and neurogenic disruption.

2.       Not  clearly classified with respect to  etiology and voice parameters.

IX. By Arnold (1990)

He grossly divided the voice disorder into 2 main groups.

(a).        Behavioral

(b).         Organic These two are subdivided as (a).

Behavioral:               

1.       Excessive muscular tension. No Change in muscular mucousa.

Spasmodic dysphonia.

2.       Excessive muscular tension. Change in excessive muscular mucousa.

Vocal nodule. Chronic laryngitis. Edema. Polyp. Contact ulcers.

3. Psychogenic

        Anxiety State

        Neurosis

        Delayed Pubertal voice Change (puberphonia).

        Transexual conflict

(b). Organic

1 . In structural abnormalities

•         Laryngeal web

•         Cleft palate

•         Nasal Obstruction

•        Trauma

2. Neurological conditions

Recurrent Laryngealnerveparalysis

Psedudobulbar Palsy

bulbar Palsy

Cerebella Ataxia

Tremor

Parkinsonism Chorea Athetosis

Apraxia

Multiple lesions

3.        Endocrinological disorders

        Thyrotoxicosis

        Myxedema

        Male Sexual mutational retardation.

        Female verification due to adverse hormone therapy.

        Adverse drug therapy.

4.  Laryngeal disease

Tumor - benign / malignant.

*Hyperkeratosis

*Papillomatosis

*Cyst       

*Laryngitis acute/ chronic

*Cricoarytenoid arthritis

*Granuloma

*Fungal infection Disadvantages

Disadvantages:

•        Ediopathic voice disorders cannot be grouped under this category.

•        Classified only based on etiology not included other parameters of

voice (pitch, quality and loudness).

VI By Mysak (1966)

Divided Voice disorders into 3 categories.

1.       Phonatory and resonatory disorder of infraglottal region (below the

larynx) e.g. Carcinoma produces weak and soft voice

2.       Phonatory and resonatory disorder of glottal region.e.g. vocal nodule,

polyp, vocal cord paralysis.

3.       Phonatory and resonatory disorder of supra glottal region e.g. cleft

palate, velopharangeal inadequacy

Disadvantage:

1.       Functional causes are not constituted.

2.       Does not consider the parameter of voice.

(pitch, quality and loudness) only organic cause.

COGNENITAL ANOMALIES

CONGENITAL SUBGLOTTIC HEMANGIOMAS

This appears in children as large, purplish  red, sessile tumors, which tend to be sub glottic.. These lesions are relatively rare, but when they do occur, they are usually curable. The presence of congenital hemangioms in the trachea may cause episodes of airway obstruction in infants. These tumors may also, upon occasion, extend submucosally into other region of the larynx. Although hemangiomas are congenital, symptoms may not appear until 2 to 3 months following birth, often following the infant's first upper respiratory tract infection.

ETIOLOGY & PATHOGENESIS

Subglottic Hemangiomas result from vascular malformations derived from Mesenchymal rests of vasoactive tissue in the subglottis.

SYMPTOMS

Some infants with subglottic hemangiomas are asymptomatic because the lesion does not effect vocal fold vibration and does not obstruct the airway in other cases. Some of the Symptoms exhibited includes.

                    

a)       Inspiratory stridor,  sometimes becoming biphasic, is the most

common presenting problem.

b)      Dyspnea and cyanosis may occur if airway obstruction becomes

more severe.     

c)       Hoarseness may appear-occasionally, but since the vocal folds are

usually not involved the cry is usually normal,

d)      Excessive coughing is common,

e)       Dysphagia may occur.

VOICE CHARACTERISTICS

The voice is altered to varying degrees, dependent on the involvement of the larynx, Altered Cry, Hoarseness Barking Cough, and failure to thrive are the most frequently noted symptoms.

VOICE THERAPY MANAGEMENT

Voice therapy is usually not indicated as a primary treatment for patients with hemangiomas, but voice therapy procedures may be required, to persistent hoarseness following medico surgical removal of tumor.

LARYNGEAL PAPPILOMA

Congenital laryngeal papilloma is the most common laryngeal growth found in children (although) it is rare within the entire spectrum of  laryngeal disease).   Although laryngeal papilloma has been found in the neonate, the most common age range of children who present with  the tumor is 6 months to 6 years.Congenial laryngeal papilloma appears be hormonally dependent  because  the juvenile form  of the  disease usually resolves as the patient approaches puberty; with an even further decrease in recurrence of the tumor following puberty;

The juvenile form of laryngeal papilloma usually begins as a benign epithelial tumor that appears at the anterior portion of the vocal folds and then spreads across the laryngeal epithelium to include, singly or in combination with the aryepiglottic folds, the ventricular folds, and various subglottic regions. Although papillomas can be removed by medicosurgical methods, they frequently reoccur after being removed.

ETIOLOGY

This wart like growth of the larynx and tracheobronchial tree is through to be caused by a DNA virus of the papova group. This virus tends to be specific to the laryngeal region and appears to be unrelated to other types of papilloma that are found in the nose, mouth, and paranasal sinuses.

SYMPTOMS

Voice quality is hoarse if the papilloma involves the vocal folds. Aphonia may result if vocal fold involvement is severe.

Respiratory stridor is common

Dyspnea may occur.

LARYNGOSCOPIC FINDINGS

Laryngeal papillomas arise from the anterior part of the larynx and may spread to involve supraglottic and/or subglottic regions. The lesions rarely arise from the posterior part of the larynx. Looks sessile or peduculated shape. be hormonally dependent because the juvenile form of the disease usually resolves as the patient approaches puberty; with an even further decrease in recurrence of the tumor following puberty;

The juvenile form of laryngeal papilloma usually begins as a benign epithelial tumor that appears at the anterior portion of {he vocal folds and then spreads across the laryngeal epithelium to include, singly or in combination with the aryepiglottic folds, the ventricular folds, and various subglottic regions. Although papillomas can be removed by medicosurgical methods, they frequently reoccur after being removed.

ETIOLOGY

This wart like growth of the larynx and tracheobronchial tree is through to be caused by a DNA virus of the papova group. This virus tends to be specific to the laryngeal region and appears to be unrelated to other types of papilloma that are found in the nose, mouth, and paranasal sinuses.

SYMPTOMS

Voice quality is hoarse if the papilloma involves the vocal folds. Aphonia may result if vocal fold involvement is severe. Respiratory stridor is common Dyspnea may occur.

LARYNGOSCOPIC FINDINGS

Laryngeal papillomas arise from the anterior part of the laryftx and may spread to involve supraglottic and/or subglottic regions. Ttte lesions rarely arise from the posterior part of the larynx. Looks sessile or peduculated shape.

VOICE THERAPY MANAGEMENT

Since the primary treatment of laryngeal papilloma is medicosurgical voice therapy is indicated only if hoarseness persists following surgery, which occurs in approximately 20 percent of cases .

CONGENITAL STRUCTURAL ANOMALIES OF THE LARYNX

LARYGOMALACIA

Laryngomalacia is the most common congenital laryngeal anomaly in

which symptoms appear during infancy and is the cause of 75% of cases of congenital stridor. It is characterized by excessive flaccidity of the supraglottic larynx, which is accompanied by inspiratory stridor.

ETIOLOGY

Laryngomalacia is caused by insufficient or delayed calcium deposition in infants, which results in excessive flaccidity of the  cartilaginous superstructure of the larynx. The lack of calcium provides inadequate support for the cartilaginous epiglottis, which consequently collapses over the glottis during inspiration. A reduction of calcium may also be present in the tracheal cartilages. There are other theories which states that it's the abnormal development of the cartilaginous structures and  I immaturity of neuromuscular control.

SYMPTOMS

The following are the symptoms associated with this congenital laryngeal anomaly.

`The Primary symptom is a noisy inspiration stridor that sounds like crowing.  In extreme cases. Inspiration may sound like a stridorous staccato flutter. Stridor may be accomplished by suprasternal and intercostal retraction during inspiration. Muffled voice will also be seen.

LARYNGOSCOPIC FINDINGS.

If laryngoscopy is performed however, examination will reveals an omega shaped epiglottis that is collapsed over the glottis during inspiration.

The aryeplglottic folds are in close approximation to each other and are usually sucked into the glottis during inspiration and blown away from the glottis during expiration.

VOICE THERAPY MANAGEMENT.

Because the vocal folds are unaffected by laryngomalacia, the voice is asymptomatic and requires no voice therapy management. In severe cases tracheostomy will be done to release from airway obstruction.

VOCAL FOLD PARALYSIS

Epidemiology

According to Cotton & Prescott vocal fold paralysis is the second most congenital anomaly of the larynx. It represents 15% of all congenital laryngeal anomalies.

Etiology & Pathogenesis

Overall the most common cause of bilateral vocal fold paralysis is Arnold Chiari Malformation followed by birth trauma causing excessive strain on the cervical spine; one - third of the cases are idiopathic. Birth induced   vocal   fold   paralysis   can   be   bilateral  or   unilateral   and   is responsible for approximately 20% of the cases. Other acquired cases of bilateral vocal fold paralysis may be secondary to central neuromuscular immaturity, cerebral   palsy,   hydrocephalous,   spinal   bifida, hypoxia hemorrhage or infection, tumor .cardiac surgery complication.

CLINICAL PRESENTATION

Bilateral vocal fold paralysis presents in children with near normal phonation and progressive airway obstruction, manifesting as biphasic or inspiratory stridor at rest exacerbated by agitation. Aspiration is common with bilateral vocal^ fold paralysis, often resulting in recurrent chest infections.

The most common symptoms are a hoarse, breathy cry. Feeding difficulties and signs of aspiration may also be present.

CONGENITAL LARYNGEAL WEBS & LARYNGEAL ATRESIA

Congenital laryngeal webs and laryngeal atresia represent varying degrees of laryngeal occlusion that are caused by weds of connective issue in subglottic, glottic, and supraglottic regions. If the webbed tissue completely occludes the larynx at birth (congenital laryngeal atresia), immediate action must be taken to provide an airway or the infant will die.

ETIOLOGY.

Laryngeal atresia/webs result from a failure of the vocal fold primordial (embryologic tissue) to partially or completely separate during the first trimester of embryologic development.

SYMPTOMS

Associated with laryngeal webs very depending upon the location and the extent of the opening in the web. The  following   phonatory   and   respiratory   symptoms   are  typically associated.

a.       Phonatory symptoms

1)      The voice may be asymptomatic if the web is not located at the level of the glottis.

2)      The effect that an interglottic laryngeal web has on vocal pitch varies with the extent of the web. Small webs located at the anterior commissure will have little effect on vocal pitch. Larger webs Which involve greater degrees of the vocal folds, can cause vocal pitch elevation. Elevation of pitch occurs because the effective vibration portion of the vocal folds is shortened due to the presence of the web.

Some infants present a high - pitched cry at birth, which generally indicates laryngeal webbing.

3)      If the web causes asynchronous vocal fold vibration,  the voice may be hoarse.

4)      Aphonia will result if the web is extensive.   Aphonia is always accompanied by severe stridor and dyspnea.

b. Respiratory symptoms

1) Stridor

2) Cyanosis

3) Restlessness or other signs of respiratory distress in the infant.

Laryngoscopic findings.

Inspection of the larynx reveals a web of connective tissue that pi occludes the larynx. Laryngeal webs at the level of the glottis are i at the anterior commissure and grow posteriorly.

Voice therapy management

If medicosurgical management leaves the patient with a roughened free margin on the vocal folds, voice therapy for the elimination of any post surgical breathiness and hoarseness should then be initiated.

Congenital subglottic stenosis

Congenital subglottic stenosis refers to a narrowing of the airway between the glottis and the first tracheal ring. Subglottic stenosis is the third most common congenital disorder of the larynx.

Etiology

Subglottic stenosis can result from:

 a.   Thickening of subglottic tissue and occasionally, the vocal folds g^        b.  Cartilaginous   narrowing   of  the   cricoid   cartilage   in   an   anterior  to posterior direction, leaving a small posterior opening.

SYMPTOMS:

          Symptoms of congenital subglottic stenosis may b e intermittent and are as follows:

a.                 Inhalatory and exhalatory stridor, with of without an accompanying cyanosis, is present ins everecases.

b.                 B. Less severe cases of stenosis may occur as recurrent episodes of croup.

c.                  Phonation is generally normal although it may be reduced in intensity if the stenosis limits airflow.

Laryngoscopic findings:

          The following may be observed in the subglottic region of the larynx.

a.       Soft tissue stenosis appearing as concentric narrowing or bilateral subglottic swelling.

b.       Cartilaginous   stenosis   appearing   anteriorly   with   a   small  

posterior opening.

Voice therapy management.

The voice is usually unaffected by congenital subglottic stenosis because the vocal folds are not involved.

LARYNGOCELE (CONGENITAL)

A.      Laryngocele is an air - filled or fluid - filled dilation or hemiation of the anterior appendix of the laryngeal ventricle, the space between the false and true vocal folds. The laryngocele sac has a small opening directly into the interior of the larynx, which allows the laryngocele to become inflated.

There are three types of laryngoceles, which are described by their extent of dilation: (1) Internal type, in which the inflated sac remains entirely within the thyroid cartilage; (2) external type in which the sac protrudes above the thyroid cartilage, and (3) a combination type, which has features of both the internal and external types.

Etiology

Laryngoceles result from a congenitally enlarged laryngeal ventricle that is

further enlarged by activates that is further enlarged by activities that

increase.

A. Straining

B. Coughing

C. Vocal abuse

D. Playing wind instruments

E. Glassblowing

Symptoms

Laryngoceles are usually asymptomatic in infancy symoptoms normally appear in adulthood, almost exclusively in males, usually in their fifties. Comon symptoms of laryngoceles include the following.

a.                 Hoarse voice or cry if the internal type of laryngocele is present and is affecting vibrationof the true vocal folds.

b.                 Inspiratory stridor.

c.                  Dysphagia may occur if the laryngocele is sufficiently large.

Laryngoscopic findings

          The larynx may appear normal if there is only external component to the larygocels. However external components are frequently accompanied by an internal componenet that appears as marked swelling of the false folds and the arypiglottic folds.

Voice therapy management

          External type is treated by applying direct pressure to the bulge on the neck internal type is treated with surgical techniques.

Congenital laryngeal cysts

Congenital laryngeal cysts are small fluid – filled sacs that are found in the larynx primarily I the ventricle. Congenital laryngeal cysts are related to congenital laryngoceles and have a similar origin. The primary difference between a cyst and laryngocele is that cyst does not have an opening directly into the interior of the larynx

Etiolgoy

          A laryngeal cyst result from a congenital saccule tht progressively enlarged due to an accumulation of secretion from glands in the submucosa of the saccule.

Symptoms

          Laryngeal cysts may be asymptomatic unless they enlarge sufficiently to displace the true and false vocal folds and obstruct the supraglottic region of the larynx enlarged laryngeal cysts will result in

a.                 Hoarseness if the vocal folds are displaced

b.                 Inspiratory stridor if sufficient airway obstruction occurs.

Laryngoscopic finding.

          Laryngeal cysts are located primary in the ventricle and appear as marked swellings of the false vocal folds, aryepiglottic folds; or arytenoids.

Medicosurgial Management

          Laryngolgistrs find that aspiration of laryngeal of laryngeal cysts is useful only for the purpose of diagnosis. Surgical removal of the cyst wall is generally required for cure.

Laryngeal clefts

A laryngeal cleft is a vertical opening between the (cricoid Cartilage) and the esophagus.The cleft may be limited to the region of the larynx or it may from a complete laryngotracheoesophagela cleft.

Etiolgoy

          A laryngeal cleft results from failure of dorsal fusion of the cricoid lamina (signet portion)

Symptoms.

          Symptoms appear shortly after  birth, when the infant chokes and perhaps aspirates during he first feeding other symptoms include

a.                 Respiration obstruction

b.                 Weak cry or aphonia

c.                  Repeated pneumonia

Laryngoscopic finding

          A laryngel cleft appears as an obvious vertical located between the arytenoids and extending into the lamina of the cricoid cartilage.

Medico surgical management

          A laryngeal cleft is usually closed surgically as soon as possible through a lateral pharyngotomy.

Voice therapy management

          The extent voice therapy depends depends upon the structural adequacy of the laryngeal mechanism for phonation following surgical, repair.

         

LLARYNGEAL TRAUMA

Dysphonia caused by vocal abuse and Misuse

          The two related forms of autogenous tram to the larynx, and particularly to the vocal folds, are chronic; abuse and misuse of the voice producing mechanism.  The primary characteristics of both abuse and misuse us a condition of hyper adduction of both intrinsic land extrinsic laryngeal musculature, which is frequently accompanied by excessive and often, violent, vocal fold vibration.  The dysphonia that result from these vocal fold changes is characterized as hoarse, breathy and/or low.

Local Abuse:

          Vocal abuse is defined as poor vocal hygiene, which includes any vocal habit that can have a traumatic effect on the vocal folds.  The following are the common examples of abusive vocal behaviors.

1.       Yelling, Screaming and Cheering

2.       Strained Vocalizations

3.       Excessive talking

4.       Frequent use of hard glottal attack

5.       Excessive throat clearing and coughing

6.       Singing Speaking

Vocal misuse:

          Vocal misuse is defined as incorrect use to pitch or loudness aspects of voice production.  If a person misuses his voice by speaking to loudly or at too high a habitual pitch on a constant or intermittent but frequent basis, damage to the vocal mechanism can result.

1.       One cause of elevated vocal loudness is talking in situations with high back ground noise.

a.       Talking while riding in moving automobiles that have high background noise levels.

b.       Talking while using motorized sports equipment, such as motorcycles, snow mobiles, jet skis etc.

c.       Talking while listening to live rock music or while listening ;to very loud rock music through stereo headphones.

2.       Elevated pitch levels tend to occur as a consequence of elevated loudness.

3.       Elevated vocal loudness and pitch can occur for various reasons.

Voice problems of the hearing impaired young adults

          The speaker characteristics of hearing impaired people are different from those of speakers who are able to use their auditory sense to monitor their production of speech. Voice problems may be associated with all types and extent of hearing loss.  A child with a mild to moderate loss may only have difficult with oral nasal reasonance balance while a child with a more extensive hearing loss may not only have resonance problems but other problems involving, pitch, loudness, laryngeal tone, and rate and rhythm of talking.

          Levitt and Nye (1971) reported the most noticeable features; of the voice of the severity hearing impaired are a too high or too low modal pitch level, breathness, harshness and resonance problems.  An important observation of Levitt and Nye is that although voice use may have a secondary effect on meaning, an unpleasant/abnormal voice may nevertheless be an important psychologic impediment to communication.

          Stark (1972) studied localization of young (preverbal) deaf children and one of her observation was that young deaf children did not acquire control over voicing or pitch and intensity variations as did hearing children.

VOICE PROBLEMS IN MENTALLY RETARDED CHILDREN

          The number of voice problems in retarded children is very high.  More than 40% of the retarded have voice defect.  Pathologic – Physiologic; causes.  Particularly aberrant motor intervention produces a large share of quality loudness and pitch defects. Personality problems are frequent among these children and as expected to cause a great deal of malfunctioning of phonatory apparatus.

          West kennedy and carr (1949) reported that these individuals have hoarse voices which is loud and inflectionless.

          Benda (1949) states that these children have deep raucous low pitch voice land sounds masculine and mature.

Novak stated that children with down syndrome revealed their voices to be harsh rough and characterized by vocal strain.

Laryngeal Features ion Children with cerebral palsy

Children with cerebral palsy may have a variety of voice problems depending on the type and severity of the condition

Mysak (1971)

                   Noted few voice features in CP children:

1.                 Intermittent voicing and phonation on inhalation

2.                 Difficulty with pitch control and stability

3.                 Low pitch and breathy voice

Their voice is also characterized by uncontrollable variations in tensions of laryngeal muscles. These variations leads to undesirable shifts in pitch, intensity or quality.