Understanding Voice Disorders in Children and Adults

VOICE DISORDERS IN CHILDREN AND ADULTS Chapter 13

Outline I. Introduction II. Causes and Classification of Voice Disorders III. Voice Disorders Related to Functional Etiologies and Faulty Usage IV. Voice Disorders Related to Organic Etiologies V. Voice Disorders Related to Neurological Etiologies VI. Medical Assessment of Voice VII. SLP Assessment of Voice VIII. Treatment for Voice Disorders IX. Laryngectomy X. Transgender Voice

Reflection An 85-year old man comes to you wanting to sound younger. In at least 2 sentences, what advice would you give him?

This is an excellent chapter but very technicalhere is the information you don t need to read: P. 316 acute laryngitis P. 319 contact ulcers, vocal fold cysts P. 320 muscle tension dysphonia P. 322 mutational falsetto P. 323 papillomas P. 330 instrumental evaluation Pp. 334-337 laryngectomy

I. INTRODUCTION** A voice disorder is a deviation of loudness, pitch, or quality that is outside of the normal range for the person s age, gender, or geographical and cultural background and that interferes with communication or adversely affects the speaker and/or listener For me as a clinician, it is entirely up to the client not me or the outside world! to decide if they are unhappy with their voice. It s very subjective.

Terms you might hear to describe a person with a voice disorder:

Here are a few examples: https://www.youtube.com/watch?v=SqzfsKMaLqk Spasmodic Dysphonia Voice Samples

A common cause of voice problems is gastroesophageal reflux disease (GERD):** It mostly occurs at night when a person is in bed and frequently happens after a large meal The lower esophageal valve relaxes, letting gastric acids from the stomach seep into the esophagus and travel upwards If acid spills over into the larynx and onto the vocal folds, causing coughing and severe irritation

We try to recommend to patients:

Teachers are the most likely people to have voice disorders** They may have hoarseness, pain, discomfort, and increased effort when talking They may get tired and their voice quality worsens We recommend amplification for them

II. CAUSES AND CLASSIFICATION OF VOICE DISORDERS** Functional voice disorders are caused by faulty use of a normal vocal mechanism e.g. too much cheering or shouting Neurological voice disorders are related to muscle tone and control of the muscles of respiration and phonation e.g. in Parkinson s disease Organic voice disorders are related to some physical abnormality in the larynx

Parkinson voice project Start at 58 seconds https://www.youtube.com/watch?v=xlKK6WJDk64

Common causes of voice disorders:

Some patients have voice disorders with both functional and organic components** For example, vocal abuse behaviors like screaming and yelling are functional behaviors that create vocal nodules Vocal nodules are the organic component of the voice disorder

Smoking

Vocal hyperfunction

Vocal hypofunction

III. VOICE DISORDERS RELATED TO FUNCTIONAL ETIOLOGIES AND FAULTY USAGE** A. Vocal Nodules Most common benign lesion in adults and children Bilateral Causes include yelling and screaming, singing in an abusive way, coughing, hard glottal attacks, excessive throat clearing, speaking in noisy environments

The patient with vocal nodules:

B. Laryngitis** Acute or chronic voice disorder due to vocal abuse or bacterial or viral infections Vocal fold mucosa become inflamed Patient may have phonation breaks and lower pitch

C. Vocal Polyps

D. Functional Aphonia** Conversion reaction associated with emotional conflicts or psychological stressors Though patients can t talk, they can often hum, cough, and clear their throat

E. Functional Dysphonia

IV. VOICE DISORDERS RELATED TO ORGANIC ETIOLOGIES** A. Presbyphonia Age-related dysphonia Multiple causes: normal physical aging, medical conditions, depression and loneliness

B. Carcinoma or Cancer** Laryngeal cancer is life threatening Patients usually need both surgery and voice therapy Symptoms: patient is often hoarse, has a persistent cough, sore throat, difficulty swallowing and breathing, possible weight loss

V. VOICE DISORDERS RELATED TO NEUROLOGICAL ETIOLOGIES A. Hyperfunction Vocal Fold Problems

B. Spasmodic Dysphonia

Spasmodic dysphonia voice samples: https://www.youtube.com/watch?v=SqzfsKMaLqk&t=49s

C. Hypoadduction Vocal Fold Problems** Difficulty making the vocal folds close strongly enough and long enough to produce normal phonation Voice is weak and breathy, deteriorating throughout the day Usually related to neurological disorders like Parkinson s, muscular dystrophy

Vocal fold weakness and paralysis

YouTube video--Diplophonia https://www.youtube.com/shorts/ZKAs2SnN05Q What is diplophonia in the voice?

Bilateral vocal fold paralysis** Damage to brainstem due to stroke, tumor, trauma If vocal folds are paralyzed in the adducted or closed position, respiration is a big concern can t breathe adequately If vocal folds are paralyzed in the abducted or open position, there is a danger of choking on food or liquid because the vocal folds aren t closed during swallowing

VI. MEDICAL ASSESSMENT OF THE VOICE** A. Otolaryngologist Examination (ENT) This is absolutely a foundation before SLPs see patients In the schools, it is illegal to see a student for voice therapy without an ENT letter--documentation

1. Indirect Laryngoscopy

2. Endoscopy** A rigid scope can be used where the scope is passed through the oral cavity with the tip of the scope reaching near the posterior pharyngeal wall A flexible scope can be passed through the nose and down to the level of the epiglottis to view the vocal folds and pharyngeal area

The patient phonates and a video recording is made with strobe lights** This is the best way to accurately evaluate a patient s vocal folds and detect any pathologies

3. Direct laryngoscopy

VII. SLP ASSESSMENT OF THE VOICE** A. Case History Interview patient to ascertain nature of the problem What do they think caused it? What is making the problem continue? Are they on any medications? Smoking? Drinking? Eating late at night resulting in GERD?

B. Hearing Screening

C. Quantification of the Voice** You do not have to know instrumental evaluations on p . 330 We use listening and published voice evaluations to evaluate loudness, pitch, and quality

We will look at the case report of J.H.not on exam: I evaluated him on a scale totally subjective judgment What was objective was the number of seconds he could do tasks

VIII. TREATMENT FOR VOICE DISORDERS** A. Foundational Principles Both children and adults may experience social penalties for dysphonic voices E.g., bullied or teased Often the cause is at least partially emotional, so counseling may be needed

B. Children** With preschoolers who are yelling and screaming, work primarily with the parents Hoarseness is usually the problem caused by vocal abuse For elementary-aged children, use direct therapy where we explain the consequences of vocal behaviors and work towards modifying those behaviors

Boone Voice Therapy Program for Children

C. Adolescents and Adults** Help client id easy vs. effortful phonation record and listen back Vocal hygiene therapy help person avoid yelling, hard glottal attacks, talking too much, speaking with inadequate respiratory support Hydration is critical!

IX. LARYNGECTOMY** You don t need to read pages 334-337 For the exam, please know what is on these slides

In cases of laryngeal cancer

Video of a patient using an electrolarynx: https://www.youtube.com/watch?v=riHLUOXt1Aw Speaking with an electrolarynx Mr. Albert Brooks

X. TRANSGENDER VOICE