Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 5th Edition

CHAPTER 8: Voice and Resonance Disorders Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 5th Edition Owens, Farinella, & Metz Developed by Sarah A. Dachtyl, Ph.D., CCC/SLP Chapter Learning Goals Explain the normal process of phonation and resonance Describe the perceptual signs of voice and resonance disorders Describe voice disorders that are associated with vocal misuse or abuse, medical or physical conditions, and psychological or stress conditions Describe the primary components of a voice and resonance evaluation Describe the major goals of voice and resonance treatment, and effective voice and resonance treatment approaches and techniques Outline Normal Voice and Resonance Production Voice Disorders Resonance Disorders Evaluation and Management of Voice and Resonance Disorders Voice and Resonance Disorders Voice is our primary means of expression and an essential feature of speech Resonance is the quality of the voice that is produced from sound vibrations in the pharyngeal, oral, and nasal cavities Failure to separate the oral and nasal cavities is called velopharyngeal inadequacy (VPI) Will discuss a variety of concepts, including disorders of resonance related to craniofacial anomalies Normal Voice and Resonance Production Vocal Pitch Perceptual correlate of F0, measured in Hertz (Hz) F0 for men is around 125 Hz Women are around 250 Hz Children are up to 500 Hz Infant larynx is high in the neck and descends after birth Frequency varies constantly during speech production Monotone voice Varying pitch has linguistic consequences Modifications in length and tension of vocal folds changes pitch Normal Voice and Resonance Production Vocal Loudness Perceptual correlate of intensity Measured in decibels (dB) Loudness of conversational speech averages 60dB Changes in vocal intensity requires the vocal folds to stay together longer Alveolar pressure is the major determinant Normal Voice and Resonance Production Resonance Largely determined by velopharyngeal structures and the adequacy of their function Structures include the velum, lateral pharyngeal walls, posterior pharyngeal wall Velopharyngeal port remains open most of the time but most close for production of oral speech sounds Voice Disorders Deviations may be in voice quality, pitch, loudness, and flexibility 3-6% of school-age children and 3-9% of adults in the U.S. have a voice disorder Voice disorders in children are usually related to vocal misuse/abuse Perceptual signs and case history are initial benchmarks Voice Disorders Disorders of Vocal Pitch Monopitch: Lacks normal inflectional variation and sometimes the ability to change pitch May be a sign of neurological impairment, psychiatric disability, or personality Inappropriate pitch: A voice that is judged outside the normal range for age and/or sex Too high: may indicate underdevelopment of the larynx Too low: May be related to endocrinological problems Pitch breaks: Sudden uncontrolled upward or downward changes in pitch Common in males going through puberty Laryngeal pathologies and/or neurological conditions Voice Disorders Disorders of Vocal Loudness Monoloudness: Lacks normal variations in intensity or ability to change vocal loudness May reflect neurological impairment, psychiatric disability, or personality Loudness variations: Extreme variations in vocal intensity Loss of neural control of the respiratory/laryngeal mechanism or psychological problems Voice Disorders Disorders of Vocal Quality Hoarseness/roughness: Lacks clarity and the voice is noisy Can be due to pathologies that affect vocal fold vibration Can be temporary; minor misuse/abuse produces edema Breathiness: The perception of audible air escaping through the glottis during phonation May be a lesion that prevents closure of a neurological impairment Vocal tremor: Variations in pitch and loudness that are not under voluntary control Usually loss of CNS control over the laryngeal mechanism Strain and struggle: Related to difficulties initiating and maintaining voice Related to neurological impairments or psychological problems Voice Disorders Nonphonatory Vocal Disorders Stridor: Noisy breathing or involuntary sound that accompanies inspiration and expiration Indicative of narrowing somewhere in the airway and is always abnormal and serious Excessive throat clearing Consistent aphonia: Persistent absence of voice; perceived as whispering May be related to vocal fold paralysis, disorders of the CNS, or psychological problems Episodic aphonia: Uncontrolled, unpredictable breaks CNS disorders and psychological problems can contribute Voice Disorders Vocal misuse and abuse Contribute to structural damage; abuse is harsher Vocal nodules: Localized growths resulting from frequent, hard vocal fold collisions Generally bilateral Nodules are soft and pliable but can become hard and fibrous Most common in women between 20 and 50 years old Children (mostly boys) prone to excessive loud talking or screaming The primary perceptual voice symptoms are hoarseness or breathiness Sore throat or inability to use the upper third of the pitch range Newly formed nodules are often treated with vocal rest Voice therapy and education is usually recommended Longstanding nodules may require surgical removal Voice Disorders Vocal Misuse and Abuse Contact ulcers: Reddened ulcerations on posterior surface of the vocal folds near the arytenoid cartilages Usually bilateral Can be painful, can radiate to the ear Occur predominantly in men older than 40 years Predisposing condition: Gastric reflux during sleep Primary voice symptoms are hoarseness and breathiness Throat clearing and vocal fatigue Treatment efficacy is questionable Frequently reappear after removal, so managing gastric reflux prior to surgery has been suggested Voice Disorders Vocal Misuse and Abuse Vocal Polyps: Fluid filled lesions that develop when blood vessels in rupture and swell Unilateral, larger than nodules, vascular, prone to hemorrhage Can result from a single traumatic incident Sessile: Closely adhere to vocal folds and can cover two-thirds of the vocal fold Pedunculated: Appears to be attached by means of a stalk Hoarseness, breathiness, and roughness are the typical vocal symptoms There may be the sensation of something in the throat Surgical removal and voice therapy is effective Voice Disorders Vocal Misuse and Abuse Acute and chronic laryngitis: Inflammation of the vocal folds that can result from exposure to noxious agents, allergies, or vocal abuse Acute laryngitis: Temporary swelling; hoarseness Chronic laryngitis: Vocal abuse during acute laryngitis; can lead to serious deterioration of vocal fold tissue Folds are thickened, swollen, and reddened If it persists, folds can atrophy Folds are dry and sticky; persistent cough and sore throat Voice symptoms range from mild hoarseness to near aphonia Surgery and voice therapy are usually both necessary Voice Disorders Voice Disorders Associated with Medical or Physical Conditions Disorders of the CNS can result in speech and voice disorders characterized by muscle weakness, discoordination, tremor, or paralysis Generally called dysarthrias, most involve generalized neurological damage resulting in complex patterns of speech and voice symptoms CNS disorders either result in hypoadduction or hyperadduction Voice Disorders Voice Disorders Associated with Hypoadduction Parkinson disease Monopitch, monoloudness, harshness, breathiness Intensive therapy that improves adduction improves loudness and intelligibility Unilateral and bilateral vocal fold paralysis Caused by damage to the recurrent branch of CN X Hoarse, weak, and breathy voice Diplophonia Collagen or Teflon injections to build up mass Voice therapy after surgery (vf implantation) Voice Disorders Voice Disorders Associated with Hyperadduction Spastic dysarthrias Bilateral damage to the brain Great difficulty speaking and swallowing, lability Harshness, pitch breaks, strained/strangled quality Spasmodic dysphonia Abnormal adductor laryngospasm that causes a strained, effortful, tight voice, and intermittent voice stoppages Voice tremor Can be neurological, psychogenic, or idiopathic Botulism toxin injection for neurological or idiopathic Voice Disorders Other Conditions that Affect Voice Production Laryngeal papillomas: Small, wart-like growths of the vocal folds and interior of the larynx Caused by papovavirus; common in children under 6 years Noncancerous but can obstruct airway Stridor, may be aphonic Must be surgically removed, but tend to reappear; repeated surgery can damage tissue Congenital laryngeal webbing: Form anteriorly and can interfere with breathing Must be surgically removed Webs produce a high-pitched, hoarse voice quality Voice Disorders Other Conditions that Affect Voice Production Laryngeal Cancer Persistent hoarseness in the absence of colds or allergies Frequently necessary to remove the entire larynx Trachea is repositioned to form a stoma for breathing Removal of the larynx requires alternate methods of producing voice Esophageal speech Electrolarynx Tracheo-esophageal puncture or shunt Voice Disorders Other Conditions That Affect Voice Production Granuloma: Ruptured capillaries covered with epithelial tissue, associated with intubation Severity is directly related to tube size and length of time it is in place Treatment is surgical removal followed by voice therapy Voice Disorders Voice Disorders Associated with Psychological or Stress Conditions Strong emotions, when suppressed, can cause psychogenic voice disorders Conversion disorders: Psychogenic voice disorders that result from emotional suppression The vocal folds are structurally normal and function normally for nonspeech behaviors Conversion aphonia: Individuals whisper even though they are capable of phonation. May be avoidance of personal conflict or unpleasant situation May require psychotherapy or psychiatric treatment Resonance Disorders Result when there is any disruption to the normal balance of oral and nasal resonance Can be caused by a number of structural abnormalities Cleft: An abnormal opening in an anatomical structure caused by failure of the structures to fuse or merge correctly early in embryonic development May also be due to a blockage in the nasopharynx that impedes sound energy from traveling through the nose for production of nasal sounds Resonance Disorders Hypernasality: Occurs when the velopharyngeal mechanism fails to decouple the oral and nasal cavities Audible nasal emission: When an individual with VPI attempts to build up the necessary air pressure in the oral cavity for production of high-pressure sounds, the air pressure subsequently escapes through the nasal cavity, causing a nasal rustle or nasal turbulence Hyponasality: When there is an insufficient amount of nasal resonance; occurs when there is a blockage somewhere in the nasopharynx or oral cavity Evaluation and Management of Voice and Resonance Disorders The Voice Evaluation Otolaryngologist evaluation first Endoscopic evaluation Biopsy if laryngeal cancer suspected SLP Case history Nature of disorder, how it affects individual, developmental history and duration, social/vocational use of voice, overall physical and psychological condition Perceptual evaluation Pitch, loudness, voice characteristics Evaluation and Management of Voice and Resonance Disorders The Resonance Evaluation Standardized rating scales Non-instrumental procedures – mirror test and nostril-pinching test Nasometer: Measures simultaneously the relative amplitude of acoustic energy being emitted through the nose and mouth during phonation A nasalance score is computed Multi-view videofluoroscopy: A motion picture X-ray recorded on DVD that permits the imaging of velopharyngeal function from three perspectives Evaluation and Management of Voice and Resonance Disorders Intervention for Misuse/Abuse Behavioral voice intervention, surgical intervention, psychological/psychiatric counseling, drug treatments When voice therapy is the primary intervention: Restore the voice tissue to a healthy condition Regain clear and full vocal function Identify and eliminate behaviors that are abusive Establish improved vocal habits (vocal hygiene) When voice therapy is a secondary treatment method: Restore healthy vocal function Help the individual discover the “best” voice Make environmental changes Evaluation and Management of Voice and Resonance Disorders Intervention for Medical/Physical Conditions Best or alternative voice Assess effects of medication or surgery Voice therapy has limited effectiveness Intervention for Voice Disorders Associated with Psychological or Stress Conditions Treatment can be effective if the individual is convinced there is nothing physically wrong via specific voicing techniques The voice can return to normal in minutes or over several sessions Psychiatric referral is often not needed Evaluation and Management of Voice and Resonance Disorders Elective Voice Intervention for Transgender/Transsexual Clients For females transitioning to males, hormone replacement often serves to lower pitch Individuals transitioning from male to female often need assistance in raising pitch For biological males to be perceived as female, they must raise F0 to 155-165 Hz or as high as 180 Hz SLPs can train individuals to place their tongue more anteriorly when speaking, achieving a more “forward” resonance associated with the female voice Evaluation and Management of Voice and Resonance Disorders Treatment of Resonance Disorders Medical Management Treatment of hypernasality secondary to VPI in individuals with cleft palate typically begins with surgical intervention Children born with palatal clefts undergo surgical closure of the cleft between 9 and 12 months of age Surgery to repair a cleft lip occurs before 3 months Prosthetic Management Palatal obturator Speech bulb obturator Palatal lift Evaluation and Management of Voice and Resonance Disorders Behavioral Management In individuals with VPI resulting in a mild degree of hypernasality following surgical repair of a cleft palate, behavioral management may be appropriate Continuous positive airway pressure (CPAP) can be used to strengthen the muscles of the velum CPAP is based on the exercise physiology principle of progressive resistance training Evaluation and Management of Voice and Resonance Disorders Treatment of Articulation Disorders Secondary to VPI Direct intervention for speech sound development should begin prior to the first palatal surgery, and as early as 5-6 months of age Should increase consonant inventory, especially pressure consonants, and increase oral airflow Teach difference between oral and nasal sounds Electropalatography (EPG) Can help learn correct placement of articulators Evaluation and Management of Voice and Resonance Disorders Efficacy of Voice and Resonance Treatment Treatment is reasonably effective for: Vocal misuse and abuse Voice disorders with structural tissue damage Voice disorders associated with psychological or stress conditions Individuals with cleft palate who receive medical and behavioral management earlier in their life generally speak normally by adolescence Changing habituated behaviors that contribute to vocal misuse or abuse is hard work and takes time Summary The human voice reflects personality, health and age, and emotional condition Vocal tract is a filter Closure of the velopharyngeal mechanism is necessary to produce most speech sounds Inadequate closure due to structural abnormalities such as cleft palate results in hypernasality Voice and resonance disorders vary in etiology and severity Effective and ethical management requires a team approach Online Resources National Center for Voice & Speech: www.ncvs.org Smiles: www.cleft.org Voice disorders: http://www.asha.org/public/speech/disorders/voice.htm Lauder, the electrolarynx company: http://www.electrolarynx.com/ National Parkinson Foundation: http://www.parkinson.org/Page.aspx?pid=201 Cleft Palate Foundation: http://www.cleftline.org/ Operation Smile: http://www.operationsmile.org/ National Craniofacial Association: http://www.faces-cranio.org/