voice disorders AmmanAnatomy and P .pptx

Anatomy and Physiology of the Respiratory Tract.pptx

1. Clinical Evaluation of Voice Disorders Dr. Salah Attili, MD ENT Consultant Rhinoplasty Consultant

2. Anatomy

3. Patterns of glottal closure during phonation

4. (a) Complete closure: complete closure is considered normal. (b) Spindle gap : vocal fold bowing with incomplete closure: sulcus vocalis, vocal fold paralysis or presbylarynges . (c) Hourglass gap : there is contact only in the midmembranous portion of the vocal folds, which is seen when vocal nodules or vocal polyp are present. (d) Anterior gap : there is a gap between the anterior membranous vocal folds, which is sometimes seen in the presbylarynge s.

5. (e) Posterior gap : there is a triangular chink between the vocal processes or extension to involve portions of the membranous vocal folds. The posterior gap is seen commonly in muscle tension dysphonia, vocal fold paralysis or paresis , or is a normal variation in many females and seldom males . (f) Irregular closure :. Masses of the vocal fold is the most common cause of irregular closure. Irregular closure can also be present when the vocal fold is not straight due to vocal fold scar . (g) Incomplete closure : incomplete closure is present when vocal folds never contact along the entire length during maximal closure. Usually, the gap is large and the gap extends across the span of the glottis. The causes of incomplete closure are often caused by vocal fold paralysis and an absence of vocal fold tissue due to laryngeal trauma, cordectomy or partial laryngectomy .

6. Voice disorders that are characterized as dysphonia in the setting of normal vocal fold anatomy and movement. Puts too much effort” into his or her voice as a result of physical or emotional stress or as a compensation for laryngitis. Muscle tension dysphonia Psychogenic voice disorders Functional voice disorder

7. Functional voice disorders Organic voice disorders Neurogenic voice disorders Voice disorders

8. Functional voice disorders

9. Persistent dysphonia Results from excessive laryngeal and related musculoskeletal tension and associated hyperfunctional true and/or false vocal fold vibratory patterns The larynx is often elevated in the neck Decreased space between the hyoid bone and larynx Increased extrinsic laryngeal muscle tone Pain is often reported in the neck, jaw, and shoulders Other symptoms: variable Muscle Tension Dysphonia (MTD)

10. Deviant body posture and misuse of neck and shoulder muscles High stress levels Excessive voice use Persistently loud voice use Laryngopharyngeal reflux disease Significant emotional stress or conflict Factors may contribute to the development of MTD

11. Laryngeal examination: Excessive laryngeal or supralaryngeal constriction Anterior-posterior compression Medial compression An open posterior glottic chink during phonation شق/ صدع

12. Dysphonia plicae طية ventricularis Phonation using false vocal fold vibration rather than true vocal fold vibration. MTD most commonly Occasionally may be an appropriate compensation for profound true vocal fold dysfunction. Ventricular dysphonia Low-pitch طبقة منخفضة Monotonous على وتيرة واحدة Quite hoarse and may also be breathy. مبحوح وهوائي Diplophonia اكثر من طبقة

13. Inappropriate persistence of higher-pitched prepubertal voice long after puberty and normal voice change. Males Unknown etiology Emotional stress Delayed development of secondary sexual characters Psychogenic Puberphonia (mutational falsetto)

14. Patient speaks in a whisper but continues speaking with the same rhythm and prosody of normal speech. Vocal cords movement with: Ah Cough Swallowing Functional Aphonia اختفاء كامل للصوت

15. Inspiration phonation cough

16. Organic voice disorders

17. Vocal Fold Nodules Bilateral Whitish protuberances on the glottal margin of each vocal fold, located at the anterior-middle third junction. An open glottal chink anterior and posterior to the nodule contact point, which results in a glottal hourglass figure Breathiness in the voice and air wastage They need to clear their throat continually and often Perceive that they have excessive mucus or something on the vocal folds. They may start the day with fairly good voices that become increasingly dysphonic with continuous vocal usage. More common in boys/voice abuse/ vocal overuse/ teachers… Inspiration Phonation

18. Vocal fold polyp Unilateral Sudden onset of hoarseness After single episode of voice abuse Polyp may be sessile or pedunculated Treatment: usually surgery

19. Vocal cord granuloma الورم الحبيبي

20. Reinke’s Edema

21. Heartburn Role of pepsin Symptoms: FOSIT , hoarseness, frequent throat clearing, sudden coughing or chocking spasm at night GERD & LPR (Silent reflux)

22. 1. Swelling ( oedema ) at the back of the larynx 2. Reddening (erythema) around structures at the back of the larynx

23. Sulcus Vocalis Depression along the edge of one or both vocal folds In most patients, the symptoms of sulcus vocalis include persistent hoarseness since puberty with breathiness, vocal fatigue and vocal weakness. Spindle-shaped chink with glottal incompetence during phonation

24. Vocal fold cyst An hourglass glottic closure configuration was seen during phonation

25. Ventricular fold cyst This patient complained of pharyngeal foreign body sensation for 2 months, with a history of paroxysmal laryngospasm.

26. Tuberculosis of vocal folds التدرن/ السلّ Hoarseness without fever or night sweats. Irregular ulcerative depressions The movements of bilateral vocal folds remained normal Usually unilateral congested left vocal fold

27. Papilloma الأورام الحليمية

28. Has a malignant transformation tendency Symptoms: Hoarseness Throat discomfort Sore throat Irritating cough The vocal fold leukoplakia/ erythroplakia اللطاخ الأبيض

29. Laryngeal cancer

30. Carcinoma and granuloma of the left vocal fold.

31. Neurogeni c voice disorders

32. Spasmodic dysphonia Vocal cord paralysis/ paresis Stroke Traumatic brain injury Parkinson, multiple sclerosis, mysthenia gravis,…. Neurogenic voice disorders

33. The muscles of the larynx involuntarily spasm and interfere with the voice. Adductor vs. abductor Adductor : Most common 90% The vocal cords are pressed together excessively, intermittently breaking the voice. The voice: constant strangled quality Abductor : The vocal cords are abruptly and momentarily pulled apart while talking, causing the voice to drop out completely or down to a whispery, breathy sound. Mixed Treatment : periodic injections of Botox™ (botulinum toxin type A) into the muscles of the larynx Spasmodic dysphonia

34. Causes ? Arytenoid fixation Left VC paralysis: more common Unilateral vocal cord paralysis Breathy, hoarse vocal quality, reduced phonation time and diplophonia VOCAL CORD PARALYSIS Bilateral vocal cord paralysis Bilateral abductor vocal fold paralysis Most common Severe dyspnea and laryngeal stridor Bilateral adductor vocal fold paralysis Hoarseness and aspiration.

35. Bilateral abductor vocal fold paralysis

36. Quiz left/ right

37. Trauma: Iatrogenic Intubation NG tube External coughing, sneezing It is hard to distinguish arytenoid dislocation from vocal fold paralysis by symptoms and laryngoscopic signs Closed arytenoid reduction is the optimal choice Arytenoid dislocation

38. Who should be referred to otolaryngologist ?

39. Thank you