DISORDERS OF VOICE

1. Disorders of voice
Dr. Humra shamim
JNMCH ,AMU,ALIGARH

2. • Human speech requires coordinated interaction of the mouth,
pharynx, larynx, lungs, diaphragm, and abdominal and neck
muscles.
• The three fundamental components in the process are
phonation, resonance, and articulation:
1. Phonation is the generation of sound by vibration of the
vocal folds,
2. Resonance is the induction of vibration in the rest of the
vocal tract to modulate laryngeal output, and
3. Articulation is the shaping of the voice into words.

3. Laryngeal mucosa develops from the endoderm of the cephalic part of foregut.
Laryngeal cartilages and muscles develop from the mesenchyme of the fourth and
fifth branchial arches.
Development of other structures is as follows:
STRUCTURE DERIVED FROM
Epiglottis Hypobranchial Eminence
Upper part of thyroid cartilage,
Lower part of thyroid cartilage,
Cricoid cartilage,
Corniculate cartilage,
Cuneiform cartilage,
Intrinsic muscles of larynx
4th Arch
Upper part of body of hyoid bone,
Lesser cornua of hyoid bone,
Stylohyoid ligament
6th arch
Lower part of body of hyoid bone and
greater cornua
2nd arch
EMBRYOLOGY

4. The laryngo-tracheal groove
appears as a vertical slit on the
floor of the primitive foregut. The
laryngo-tracheal diverticulum
develops from this groove and
rapidly gets separated from the
foregut by the formation of the
tracheoesophageal septum.
The ventral portion develops into
the larynx and the lower
respiratory tracts.
Development of the tracheobronchial
diverticulum and oesophagus. (a)
Laryngotracheal groove appears in the ventral
aspect of the foregut. (b) The edges of
the groove close in to form the
oesophagotracheal septum. 1,foregut; 2,
laryngotracheal groove; 3, oesophagotracheal
septum; 4, trachea; 5, lung bud; 6, stomach

5. • The human larynx is composed of three single and three
paired cartilages held together with ligaments,membranes
and intrinsic muscles of the larynx.
• This unique arrangement allows movements and variations of
shape and volume of the supraglottic vocal tract
• This is essential for regulation of the acoustic characteristics
of human voice
• The thyroid, cricoid and paired arytenoid cartilages are the
most important structures of the larynx in relation to the
vocal function

6. • Thyroid cartilage is formed from two rectangular laminae
fused at the midline. The angle between these two laminae is
90degree in males and 120degree in females, resulting in
variation of the anteroposterior length of the laryngeal cavity.
• Vocal folds are, therefore, longer in males (17.5 mm–25 mm).
Female vocal fold length is approximately 12.5 mm–17.5 mm.

7. Anatomy
• The larynx consists of
four basic components:
 A cartilaginous
skeleton
 Membranes and
ligaments
 Intrinsic and
extrinsic muscles
 Mucosal lining

8. • The cartilaginous
skeleton is comprised
of :
 Single Cartilages:
 Thyroid
 Cricoid
 Epiglottis
 Paired Cartilages:
 Arytenoid
 Corniculate
 Cuneiform

9. • Laryynx two laminae, which meet in
the midline and form a prominent
angle, called laryngeal prominence
(Adam’s apple) and the superior
thyroid notch at the rostral margin.
• The posterior border of each lamina
forms superior & inferior cornu
(horns)
• Outer surface of each lamina shows
an oblique line which gives
attachment to thyrohyoid,
sternothyroid & inferior constrictor of
the pharynx
• The superior border gives
attachment to the thyrohyoid
membrane

10. Cricoid Cartilage
• Lies below the thyroid cartilage
Forms a complete ring
• Has a narrow anterior arch & a
broad posterior lamina
• Has an articular facet on its:
• Lateral surface for articulation
with inferior cornu of the thyroid
cartilage (hinge like synovial
joints that create a “bucket
handle” structure )
• Upper border for articulation
with base of arytenoid cartilage
(shallow ball-and-socket joints )

11. Arytenoid Cartilages
• Small, pyramidal in shape
• Situated at the back of the larynx
Has:
• A base articulating with the upper border
of the cricoid cartilage
• An apex supporting the corniculate
cartilage
• A vocal process projecting forward, gives
attachment to the vocal ligament
• A muscular process projecting laterally,
gives attachment to muscles

12. Corniculate Cartilages
• Small nodules
• Articulate with the apices
of arytenoid cartilages
Cuneiform Cartilages
• Small rod shaped, placed
in each aryepiglottic fold,
producing a small
elevation
• Do not articulate with any
other cartilage
• CO
CO

13. Epiglottis
• Leaf shaped, situated behind the root
of the tongue
• Connected:
 In front to the body of hyoid bone
by the hyoepiglottic ligament
 By its stalk to the back of thyroid
cartilage by the thyroepiglottic
ligament
• Upper edge is free.
• Laterally gives attachment to
aryepiglottic fold
• Anteriorly mucosa is reflected onto the
tongue forming three glossoepiglottic
folds & valleculae

14. INTRINSIC MUSCLES OF THE LARYNX
Abductor
• The posterior crico-arytenoid (PCA)
muscle,pulls the muscular process of
the arytenoid posteriorly and caudally
.The structure of the cricoarytenoid
joint prevents the entire arytenoid
from being pulled along this vector.
Instead, the arytenoid rotates, which
displaces the vocal process upward
and laterally and thereby abducts the
vocal fold

15. • Segmental compartmentalization within muscles
increases the possibilities for fine control. The
human PCA muscle is divided into two
compartments supplied by separate nerve
branches; they differ in fiber type and insert on
opposite sides of the muscular process .
• The human thyroarytenoid muscle is also
compartmentalized, and it has long been
regarded to have a separate medial
compartment, the vocalis.

16. Adductors
• The adductor muscles include
the lateral cricoarytenoi(LCA),
inter-arytenoid (IA) and
thyroarytenoid (TA).
• Vocal folds need to be in the
adducted position, allowing
intimate contact of the
contralateral mucosal surfaces
to initiate the rise in subglottic
pressure in part of the
vibratory cycle of phonation.

17. • In contrast to other intrinsic
laryngeal muscles, the cricothyroid
muscle does not insert on the
arytenoid cartilage and therefore
has no direct action on arytenoid
motion.
• Instead, the cricothyroid muscle
connects the anterior edges of the
thyroid and cricoid cartilages.
Contraction of this muscle pulls the
two cartilages closer together, which
increases the distance between the
anterior commissure and the cricoid.
• The result is a stretching of the
vocal fold and an increase in its
length and tension .Vocal folds insert
on the anterior commissure,
contraction of either cricothyroid
muscle affects both ipsilateral and
contralateral vocal folds.
• Contraction of both right and left
cricothyroid muscles results in
maximal anterior traction

18. EXTRINSIC MUSCLES OF THE LARYNX

19. The sternohyoid, thyrohyoid,
and omohyoid muscles are
innervated by the ansa cervicalis
and exert caudal traction on the
larynx.
This action, as well as downward
traction on the trachea during
inspiration, causes abduction of
the vocal folds.

21. Muscles that exert a cephalad force
include the geniohyoid, anterior
belly of the digastric, mylohyoid,
and stylohyoid muscles. In patients
with hyperfunctional dysphonia,
excess activity can usually be
palpated in the extrinsic laryngeal
muscles.

22. Vocal fold
• The vocal fold is a trilaminar musculomembranous structure
that extends from the vocal process of the arytenoid cartilage
to the anterior commissure, where it meets its counterpart
and is anchored into the lamina of the thyroid cartilage by the
ligament of Broyle.
• Vocal folds are made up of five distinct layers; the rigidity of
the tissue increases with its depth.
• The anterior two-thirds of the vocal fold contributes mainly
to phonatory function, while the posterior one-third
contributes to respiratory function.

24. SURFACE MUCOSA
• The mucosal lining is approximately 0.05 to 0.1 mm in thickness and is
composed of nonkeratinizing squamous epithelium.
• This layer of tissue can tolerate a minimal degree of stretching.A transition
layer between the surface mucosa and the lamina propria is described as
the basement membrane zone.
• It has two subdivisions:lamina lucida and lamina densa. These layers are
held together by collagen IV and fibronectin.
• Anchoring fibres, composed of collagen VII, bind the lamina densa to the
superficial layer of lamina propria (SLLP). There is a significantly high
concentration of these fibres in the middle third of the vocal folds, thus
providing increased integrity and tensile strength to this layer.

25. LAMINA PROPRIA
• The lamina propria is composed of three
histologically and somewhat functionally
distinct layers of tissues. It is made up of
extracellular matrix (ECM). Collagen, elastin,
fibronectin, fibromodulin,decorin and
hyaluronic acid variably constitute the body of
the ECM.

26. Superficial layer of lamina propria
• The SLLP is a very thin (0.5
mm) elastin-rich layer with
sparse collagen fibres
embedded in
mucopolysaccharideand
mucoprotein matrix. The SLLP
also contains macrophages,
decorin, fibronectin and
myofibrils with high healing
potential. This layer is also
described as Reinke’s space.
This is a highly deformable,
isotropic and resilient layer
with innate structural integrity
to support the generation of
mucosal waves.

27. Intermediate layer of lamina propria
The intermediate layer of
lamina propria (ILLP) is
characterized by the highest
concentration of strongly
hydrophilic glycose amino
glycan (GAG) molecules.
There is also an abundance of
elastin fibres along with the
presence of fibronectin and
fibromodulin. A
predominance of elastin fibre
at the anterior and posterior
parts of the vocal ligament
may have a function in
dissipation of any tension.

28. Deep layer of lamina propria
• This layer is
predominantly made of
longitudinally arranged
collagen fibres. There is
also fibroblast, elastin,
hyaluronic acid and
fibronectin in the ECM.

29. MUSCULAR LAYER
• Fibres of the vocalis muscle form the body of
the vocal fold and add bulk and rigidity to it.
The fibres nearest to the vocal ligament are
densely innervated of slow-twitch type while
the fibres at the muscularis part are of fast-
twitch type in function

30. • The length, mass, tension and volume of the vocal folds will
determine the fundamental physical characteristics of the
voice. The resonance of the voice is determined by the
resonating chambers of the SGVT and their natural resonance
frequency.
• Loudness of the voice increases with any increase in the
amplitude of vibration,while the pitch of the voice increases
with an increase in the frequency of vocal fold vibrations.

31. Physiology of larynx
• Swallowing (deglutition)
During swallowing, the primary function of the larynx is to
prevent food and liquid entering the airway. This is
achieved by means of the sphincteric action of the
aryepiglottic folds and the true and false vocal folds which
occurs simultaneously with elevation of the larynx.
• Coughing
Coughing is the process by which material is expelled from
the airway. It is preceded by rapid inspiration, followed by
forceful closure of both the vocal and vestibular folds. Air
pressure is then built up below the adducted folds as the
diaphragm ascends spasmodically until the folds separate
explosively and mucus or foreign material is expelled.

32. • Effort closure
During any form of exertion involving use of the arms, the vocal
folds are firmly adducted preventing expulsion of air and collapse of
the chest walls, thus providing a fixed origin for the arm and
shoulder muscles. This fact is clinically important in that those who
have undergone laryngectomy or who have paralysis of one or both
vocal folds, for example, may have difficulty with weightbearing
activities because of their inability to close the glottis effectively.
Trauma to the vocal fold mucosa can occur or be aggravated by
forceful, prolonged vocal fold adduction during some types of
physical training, such as working with weights.
Effort closure of the larynx also occurs during childbirth and
defaecation as the abdominal contents are compressed by the
abdominal muscles in order to achieve expulsion

33. The biomechanics of phonation
• INITIATION OF VOICE
Immediately before phonation, the vocal folds rapidly
abduct to allow the intake of air. This is termed this the
‘prephonatory inspiratory phase’. Subsequently,the vocal
folds are adducted by the contraction of the lateral
cricoarytenoid muscles. The vocal note is generated by
pulmonic air (air from the lungs) as it is exhaled between
the adducted vocal folds.
The vocal folds working together, therefore, constitute a
vibrator which is activated by the excitor, the exhaled air.
The production of the vocal note at this point is the result
of the repeated vibratory movement of the vocal folds,
known as vocal fold oscillation.

34. • The vocal folds, in common with all vibrators, have a degree of
inertia which has to be overcome in order for phonation to
occur. The amount of air pressure required to begin voicing is
known as the ‘phonation threshold pressure’.

35. THE VIBRATORY CYCLE
• Each vibratory cycle of
the vocal folds consists
of three phases:
• Adduction
• Aerodynamic
separation
• Recoil

36. • Vocal fold gets blown upwards by increasing
subglottic pressure
• Undulating wave moves on the medial margin
from the lower part to upper part.

37. • After the width of the glottis reaches the
maximum, subglottic air pressure reduces and
elastic recoil of vocal folds draw them towards
midline. Closure occurs from below upwards
• The lower lip of vocal folds close first followed
by the upper

38. • Glottis closes completely when the upper lip
of both vocal folds come together.
• This phase lasts till the subglottic pressure
overcomes the glottic closure

39. • The “body-cover” concept of phonation is that
vibration of the mucosa does not correspond
directly to that of the rest of the vocal fold.
Instead, the “body” of the vocal fold is
relatively static, whereas the wave is
propagated in the mucosal “cover.”
• This mucosal wave begins on the inferomedial
aspect of the vocal fold and moves rostrally

40. • Normal phonation requires that five conditions be
satisfied;
1.Adequate breath support
2. Approximation of vocal folds
3. Favorable vibratory properties
4. Favorable vocal fold shape
5. Control of length and tension

41. • The frequency of vibrations varies among adult
males (100–120 Hz), adult females (180–220 Hz) and
children (250–300 Hz).
• At puberty, in boys, the bulk of the TA muscle
increases significantly under the action of
testosterone.
• Increase in the bulk of the vocal fold brings about the
lowering of the fundamental frequency, adding more
bass to the voice.
• In girls the vocal pitch drops as well, thus adding
more maturity to the voice of a women.

42. DISORDERS OF VOICE

43. • A disordered voice can be defined as one that has one
or more of the following characteristics:
• it is not audible, clear or stable in a wide range of
acoustic settings;
• it is not appropriate for the gender and age of the
speaker;
• it is not capable of fulfilling its linguistic and
paralinguistic functions;
• it fatigues easily;
• it is associated with discomfort and pain on phonation.

44. • Voice disorders are often multifactorial in aetiology
and to complicate matters patients may develop
compensatory vocal behaviours in order to be able to
communicate effectively. This may mask the true
underlying or primary disorder, for example muscle
tension imbalance secondaryto extraoesophageal
(laryngopharyngeal) reflux
• More often than not patients will have more than one
condition contributing to their voice disorder. For
example, a patient with vocal fold nodules may well
have a degree of muscle tension imbalance and
extraoesophagealreflux.

45. Pathological Processes Causing Voice
Problems
• There are four main
pathological processes that
can contribute to the voice
becoming disordered
• It is essential that the
presence or absence of
these four processes is
checked for systematically,
particularly as voice
disorders tend to be
multifactorial .
• This also reduces the
chances of overlooking
pathologies

46. • Each pathological process can affect any part of the
three essential elements of voice production, that is,
breath control, vocal fold vibration, and resonance.
This is determined by careful history and examination,
occasional specialist assessments, and probe therapy or
empirical treatment.
• By looking for evidence for each of the four etiologic
factors individually, target the treatment more
precisely.

47. PATIENT ASSESSMENT
The patient should be assessed in a voice clinic
where a voice therapist and a laryngologist are
present.
The laryngologist’s role in the initial assessment of
the patient is to formulate a diagnosis or
differential diagnosis, exclude serious underlying
causes, determine the impact of the condition on
the quality of life and provide information about
treatment options and prognosis.

48. History
• Nature & chronicity
• Exacerbating / releiving factors
• Life style / dietary / hydration issues
• Medical conditions / trt effects
• Pts voice use / voice requirements
• Impact on quality of life
• Pts expectations

49. complaints
• Voice quality changes - (hoarseness, roughness and
breathiness)
• Inappropriate pitch - age and sex
• Poor voice control (break in pitch)
• Inability to raise voice to be heard in noisy environment
• Difficulty in singing
• Voice tiring
• Throat related symptoms
• Reduced ability to communicate
• Difficulties in using voice at different times of the day
• Emotional effects due to voice changes

50. Examination
• Oral cavity
• Oropharynx
• Nasal cavity
• Lower cranial nerves
• Cervical adenopathy
• Signs of increased muscle tension
• Laryngeal position
• Breathing pattern

51. Direct laryngoscopy
• Small view
• Brief duration of
visibility
• Mucosal wave cannot
be appreciated (100
cycles / sec. Retina can
perceive only 5 cycles /
sec)

52. Stroboscopy
A stroboscopic light source brightly illuminates the
vocal folds across multiple vibratory cycles, and a
series of images are captured that highlight the
vocal folds at successive phases of the cycle.
When the images are presented to the viewer at
the proper rate, the vocal folds appear to be
moving and create smooth cycles of the vocal
folds separating and returning to midline.

53. • Perceptual judgements of the stroboscopic images can
include:
1. Symmetry, or the degree to which the two vocal folds
provide mirror images of each other
2. Periodicity, or the regularity of apparent successive
cycles of vocal fold vibration
3. Amplitude, or the extent of horizontal excursion of the
vocal folds
4. Presence of stiffness or adynamic
(nonvibratory)segments on the vocal fold
5. Pattern of closure.

54. • It is the extent of vocal fold movement in the
horizontal plane
• Usually it is one half of the width of the visible
part of the vocal fold
• Amplitude decreases when the pitch increases
• Amplitude increases with increasing loudness
of phonation
Amplitude of vibration

55. Decreased vocal fold vibration
amplitude
• Vocal fold stiffness
• Reduced subglottic pressure
• Sulcus vocalis increases stiffness of the vocal
folds
• Tight glottic closure - Hyperfunctional
dysphonia

56. Increased amplitude of vocal fold
vibration
• Reinke's odemea - There is a consious increase
of subglottic pressure in these patients to
move the increasingly bulky cord
• Decreased laryngeal muscular tone - vocal fold
paralysis (appears like flag fluttering in the
wind)

57. Mucosal wave
• This is a normal wavy motion of vocal fold mucosa
travelling both in vertical and horizontal planes
• Normally it travels across in the vertical plane of the
vocal folds and then rolls laterally across atleast 50%
of the width of the visible part of vocal fold
• It is affected by the mucosa and the underlying
muscle layers
• Normally it decreases with rising pitch of phonation
• It increases with increasing loudness of phonation

58. Decreased mucosal wave - causes
• Increased stiffness due to mucosal changes -
Polyp, sulcus vocalis and vocal fold dysplasia
• Increased muscle tension leading to tight
glottic closure (Hyperfunctional dysphonia; it
leaves a long closed phase)
• Decreased muscle tone causes weak glottic
closure pattern (Hypofunctional dysphonia
with long open and short closed phase)

59. Mucosal wave absence
• Stroboscopic fixation (synonym)
• Malignant neoplasm
• Vocal fold scarring
• Recurrent laryngeal nerve paralysis

60. Increased mucosal wave
• Reinke's oedem
This is due to elevated subglottic pressure

61. VIDEOKYMOGRAPHY
• Videokymography analyzes the high-
speed images of oscillation at one
specific horizontal position on the
vocal fold. It produces a
spatiotemporal image of the
vibration of the medial edge of the
vocal fold in that area and plots this
along the vertical axis against time.
• Asymmetry of vibration or pathologic
changes are particularly well seen
with this technique.The endoscope
must be perpendicular to the fold,
and for true comparison exactly the
same segment must be used, which
does provide some technical
challenges

62. NARROW BAND IMAGING
• Narrow band imaging (NBI) is a
technique for imaging the
mucosal surfaces with selected
portions of the light spectrum –
usually blue (400 nm) or green
(540 nm). Haemoglobin will
preferentially absorb these, so
that early cancers with increased
vasculature give a dark signal
when viewed with NBI
techniques. Early studies suggest
that it may also have a role in
early detection of laryngeal
cancer and in guidance regarding
the limits and location of biopsies

63. LARYNGOGRAPHY
• Laryngography is a quantitative assessment of laryngeal function.
The electrolaryngograph consists of two electrodes placed on either
side of the thyroid cartilage at the level of the vocal cords.
• A high-frequency current (3 MHz) is applied between the
electrodes. The change in conductance correlates to the change in
contact area between thevocal folds during vibration.
• This gives an assessment of the laryngeal component of voice and is
not affected by any change in the vocal tract (resonance) that is
present when using a microphone to analyze the voice at the
mouth.

64. ELECTROMYOGRAPHY
• Electromyography (EMG) measures electrical activity of
muscle. This gives a visual signal of electrical activity and is
usually coupled to a speaker to produce an audible output.
There are three different types of electrical potential:
spontaneous,insertional and volitional
• Differentiating laryngeal paralysis from mechanical fixation
• Diagnosing neurological diseases such as myasthenia gravis
and amyotrophic lateral sclerosis, and distinguishing
between upper and lower motor neuron conditions
• Estimating the degree and prognosis (recovery) of
paralysis/paresis

65. Specific voice disorders
The most common voice disorders are:
• Muscle tension dysphonia;
• Laryngitis/muscle tension dysphonia secondary to
poor vocal hygiene, dietary and lifestyle issues;
• Extraoesophageal reflux
• Vocal fold nodules
• Vocal fold polyps
• Vocal fold cyst
• Vocal fold palsy and paresis
• Arytenoid granulomas.

66. Less frequently seen conditions
include:
• Sulci and mucosal bridges;
• Spasmodic dysphonia;
• Papillomatosis;
• Microvascular lesions;
• laryngeal trauma, including post-surgical causes;
• Other neuromuscular causes hyperkeratosis,
dysplasia and carcinoma;
• Endocrine causes;
• amyloid;

67. Functional voice disorders
• Muscle tension dysphonia (MTD) is the most common
type of functional voice disorder. It is described in
patients with significant vocal demand living in
stressful situations.
• Increased and sustained tension of the laryngeal
muscles leads to abnormal laryngeal movement during
phonation with consequent dysphonia.
• The primary form is seen predominantly in females (up
to 40 %)
• Primary MTD is diagnosed in absence of any organic
pathology of the vocal fold, or psychiatric or
neurological pathology

68. • Secondary MTD has an
established association
with underlying organic
pathology.
• It still remains
undecided whether
MTD is the cause or the
effect in the secondary
variety

69. MTD classification
• MTD Type 1: Hypertonic state of the posterior crico-
arytenoid muscle causing posterior open chink and
laryngeal isometric contraction
• MTD Type 2: Supraglottic contraction with adducted
ventricular folds
• MTD Type 3: Anterior-posterior contraction with
approximation of the epiglottis with the arytenoids;
posterior migration or placement of the tongue base
• MTD Type 4: Extreme anterior-posterior
contraction;supraglottic squeeze. Difficult to view the
entire larynx with the flexible endoscope positioned in
the mid-oropharyngeal level.

70. • The underlying factors predisposing and/or
perpetuating MTD can be psychological
conditions,misuse/abuse of the voice, organic
pathology (local/systemic) or changes (aging)
where vocal compensationis needed.
• Respiratory infections associated with prolonged
frequent coughing, deafness,chronic snoring and
laryngopharyngeal reflux(LPR) may also
predispose an individual to MTD.

71. Management of MTD
• Voice therapy :This is the mainstay of treatment for muscle
tension dysphonia (MTD)
1. vocal exercises with the aim of targetting and
strengthening specific muscle groups and improving
glottal closure and efficiency;
2. increasing awareness of and reducing excessive tension in
the muscles around the larynx, neck and shoulders;
3. advice on posture and improving breathing during
speech;
4. laryngeal massage;
5. general relaxation exercises and stress management;
6. psychological counselling

72. • Hyperfunctional disorders include dystonia,
myoclonus, essential tremor, stuttering, and
muscle tension dysphonia
• Hypofunctional disorders include focal
disorders, such as vocal fold paresis and
paralysis, Parkinson disease, multiple sclerosis,
neuromuscular junction disorders,
poliomyelitis, myopathies

73. SPASMODIC DYSPHONIA
• Spasmodic dysphonia (SD) is a neuropathology of focal dystonia
affecting muscle groups of the larynx supplied by the RLN.
• The central pathology is thought to be at the basal ganglia of the
midbrain and its connections. The incidence is 1 in 50 000–100 000.
Adductor spasmodic dysphonia (ADSD)is the most common variety
and is characterized by strained and strangulated voice. Symptoms
of ADSD are more intensified during voiced reading (reading the
Rainbow Passage).
• Abductors spasmodic dysphonia (ABSD) constitutes approximately
15 per cent of laryngeal dystonia. Combined varieties of SDs are
very rare. SD may present with generalized dystonia. Public
speaking, speaking to a stranger and telephone conversations are
knownto trigger symptoms of SD.

74. VOICE THERAPY FOR DYSPHONIA
• The voice therapy technique used varies
based on patient strengths and needs and
clinician strengths and training.
• No gold standard technique or “recipe” for
voice therapy works for all patients and
clinicians, even within a diagnosis, and
patients respond to different types and levels
of feedback and instruction.

75. Vocal hygiene, lifestyle and dietary
advice
The areas covered may include:
1. The links between lifestyle, phonatory and nonphonatory vocal activities
and stress on voice disorders;
2. The potentially traumatic effects to the vocal folds of‘vocally abusive
behaviours’, such as talking or singing too loudly, talking too fast,
shouting, throat clearing and harsh coughing;
3. Communicating without raising or straining the voice, for example using
a whistle in the school playground or using amplification devices where
practical
4. The importance of adequate hydration for vocal fold function, i.e. by
drinking water, use of steam inhalations and avoiding excessive amounts
of drinks containing caffeine, i.e. coffee, tea and colas;
5. Smoking cessation, reducing alcohol and social drug consumption
(particularly spirits, cannabis andcocaine)
6. Avoiding exposure to fumes, dust and dry air;
7. Avoiding eating late at night, large or fatty meals.

76. INFLAMMATORY DISORDERS
LARYNGITIS
• This is a common short-lasting acute inflammation of
the laryngeal mucosa of multifactorial aetiology.
• Upper respiratory tract infections, viral infections,
physical and chemical injury (coughing, voice
misuse,smoking, alcohol abuse) and sometimes
bacterial infection can cause laryngitis.
• Most patients will recover spontaneously. Voice rest,
rehydration and inhalation of steam (without any
additive) are effective in resolution of acute laryngitis,
when toxic causes are avoided.

77. • When symptoms continue beyond 3 weeks, it is then
considered to be chronic laryngitis. Laryngopharyngeal
reflux, smoking, heavy alcohol ingestion, severe snoring
and inhalers for asthma (if not administered correctly with
precautions) may frequently predispose individuals to
recurrent and chronic laryngitis
• Dietary and lifestyle strategies are most effective in the
management of this category of laryngitis, along with voice
therapy.
• Some rare systemic diseases (Wegener’s granuloma,
sarcoidosis, rheumatoid arthritis) may be associated with
chronic inflammation of the laryngeal mucosa and present
with hoarse voice and/or variable intensity of respiratory
distress

78. SPECIFIC INFLAMMATORY
CONDITIONS
Arytenoid granuloma
Arytenoid granulomas are benign
inflammatory lesions that arise from
the medial surface of the arytenoid
Cartilages and in particular the vocal
processes. Other terms for them
include:
• contact ulcer or granuloma;
• vocal process granuloma;
• intubation granuloma;
• contact pachydermia;
• peptic granuloma.

79. These consist of a proliferation of granulation tissue with
epithelial hyperplasia.
They result from injury to the thin mucoperichondrium over the
vocal processes from mechanical trauma, either following
intubation or repeated high velocity impact of the vocal
processes against each other from throat clearing, coughing
or talking in a habitually low pitched, creaky,
hyperfunctional manner.
Men tend to develop granulomas secondary to hyperfunction,
while women develop them more commonly as a result of
intubation.
Extraoesophageal reflux is an important aetiological factor
either contributing to the symptoms leading to the
mechanical trauma or preventing healing of the damaged
mucosa.

80. • Presentation with a change in the voice and/or vocal
fatigue, a constant tickling sensation, discomfort or pain
localized to the posterosuperior aspect of the larynx which
is worse on phonation, coughing and throat clearing ,
radiation to the ear. In addition, there may be symptoms
associated with extraoesophageal reflux, including choking
episodes and, in severe cases, stridor.
• These symptoms may come on insidiously, after intubation,
an infection or a period of stress.
• They may be unilateral or bilateral and range from a
nodular, diffuse thickening over the vocal process to large
pedunculated, exophytic masses obscuring the posterior
glottis

81. Treatment include reducing the effects of laryngeal irritants,
i.e. stopping smoking,improving vocal hygiene, treating any respiratory tract
infections, allergies and extraoesophageal reflux.
Voice therapy ,raising awareness of and reducing hyperfunctional and vocally abusive
behaviour and psychological counselling where necessary.
Surgery when used in isolation, does not usually cure arytenoid granulomas as there is
a high rate of recurrence. It is useful in
• confirming the diagnosis histologically,
• excluding a carcinoma
• in debulking large lesions.
There is no good evidence in support of use of antibiotics steroids in general.
• Botulinum toxin injections into the thyroarytenoid muscle is useful in resistant
cases
The vocal fold paresis created by the action of the Botulinum toxin allows for
forced voice rest with adequate time for healing over the vocal process.

82. Recurrent respiratory papillomatosis
• Human papilloma virus (HPV) types 6
and 11 are the frequently identified
pathogens.
• Endoscopic removal of papillomas
with a microdebrider is the preferred
surgical option.
• Recalcitrant cases need concomitant
local treatment with Mitomycin or
cidofovir or α-interferon.
• Hemoangiolytic lasers such as 585-
nm pulse dye laser and potassium
titanyl phosphate (KTP) laser are
especially useful in the management
of this vascular lesion.
• recurrence is rampant due to the
presence of the virus in the
neighboring normal tissue

83. Structural or neoplastic lesions

84. Vocal fold polyps
• A true vocal polyp is a
benign swelling of greater
than 3mm that arises from
the free edge of the vocal
fold .It is usually solitary,
but can occasionally affect
both vocal cords.
• Most common structural
abnormality that cause
hoarseness and they affect
men more than
women.They are most
frequently seen in smokers

85. • Polyps can shrink spontaneously or even be
coughed up.
• Voice therapy may provide the patient with
coping strategies, preventative advice and may
help ease symptoms, but is unlikely to result in
resolution of the polyp. Any concomitant
inflammatory conditions should be treated.
• Most polyps need removal under a general
anaesthetic.The aim is to restore the smooth
edge of the vocal cord allowing them to close
fully and vibrate normally.

86. Vocal fold nodules
• Vocal fold nodules are manifestations of
repetitive trauma due to misuse of the
voice with overactive intrinsic muscle
action. These nodules are a frequent cause
of hoarseness in children who are naturally
excitable and vocal.
• When seen in singers,the condition is called
‘singer’s nodules’.
• Vocal nodules are bilateral, small swellings
(less than 3mm in diameter) that develop
on the free edge of the vocal fold at
approximately the midmembranous
portion.In singers, they may be smaller,
more pointed and white in colour reflecting
a more superficial response to trauma. They
are of variable size and are characterized
histologically by thickening of the
epithelium with a variable degree of
underlying inflammation

87. • Mainstay of treatment for persistent vocal nodules is voice therapy
• Significant number of nodules recur if surgery is performed without
voice therapy either pre- or postoperatively.
• The centre of the nodule is held with grasping forceps and pulled
medially towards the opposite cord.Microscissors are then used to
cut the mucosa close to its base, thus preserving normal mucosa,
keeping a straight vibratory edge and preventing secondary
notching. Theopposite nodule can then be removed in a similar
fashion, taking care not to damage the mucosa of the anterior
commissure.
• Postoperative voice rest for 48 hours is recommended and correct
technique of voice productionis essential to prevent recurrence.

88. MUCOSAL INFLAMMATORY PATHOLOGY (EXUDATIVE PATHOLOGY)
Cysts
• Cysts are usually associated with
laryngitis, vocal trauma or
laryngopharyngeal reflux.
• The two distinct varieties are
epidermoid cysts, which are
pearly in appearance and found
buried in submucosa, and
greyish-yellow .Ductal mucus
retention cysts, which are often
found under the free edge of the
focal fold in its middle third.
• Histologically, epidermoid cysts
show keratinized stratified
squamous epithelium, while
retention cysts show columnar
epithelium

89. • A mucus retention cyst is thought to arise
from a blocked minor salivary gland, possibly
secondary to phonotrauma or inflammation.
• It is lined by cuboidal or low columnar
epithelium and can be associated with
oedema and fibrosis in Reinke’s space.It is
usually unilateral and is found on the free
edge of the vocal fold or can arise in the
ventricular fold (false cord).
• Patients with vocal fold cysts should be given
a trial of voice therapy, particularly when
symptoms are relatively mild. Many will
require surgery but this must be done
precisely preserving the overlying mucosa as
much as possible. It is important to avoid
leaving part of the wall behind which will
result in a recurrence or causing localized
scarring and poor voice results
• Postoperative voice therapy helps patients to
restore vocal function and improvement may
continue for up to nine months.
• Complete sharp dissection of the cyst with
microlaryngoscopy instruments or with the
laser is the treatment of choice.

90. Polypoid degenerations (Reinke’s oedema)
• Reinke’s oedema is a term used to
describe the vocal folds when they
become chronically and irreversibly
swollen
• Reinke’s oedema is often bilateral at
presentation but can be a unilateral
finding.
• Most commonly found in smokers,
polyploidal degeneration of the vocal
fold can also be found in presence of
severe laryngopharyngeal reflux.
• Hypothyroidism may be found as a
concomitant feature
• Increased bulk of the vocal cord causes
masculinization of the voice, producing
predominantly bass notes like the
thicker cords in the guitar.
• Lateral cordotomy (mucosa-sparing
approach) with the removal of viscous
fluid from Reinke’s space is effective in
restoring voice function. If the
precipitating noxious agent (smoking in
most cases) for oedema is not removed,
recurrence is almost inevitable.

91. GRADING

92. Surgical treatment should be considered when:
• Leukoplakia is present and a histological
diagnosis is required;
• Gross Reinke’s oedema is present causing
choking episodes or airway compromise;
• Pitch elevation of the voice is the main
requirement of treatment.

93. The principles of surgery for Reinke’s oedema include:
• Reducing the bulk of the mucosa (mass per unitlength) of the vocal
fold
• Obtaining a straight mucosal edge, i.e. avoidingleaving small
deposits of the myxoematous material behind;
• Avoiding damage to and exposure of the underlying ligament,
thereby reducing the chances of scarring and web formation.
• ‘Reduction glottoplasties’ can be performed with phonosurgical
instruments or new generation of microspot lasers. The
myxoematous material from the superficial lamina propria layer is
aspirated, removed with forceps or vaporized and the epithelial
edges apposed following excision of redundant mucosa as
necessary.

94. Sulcus vocalis
• A congenital absence or idiopathic loss of lamina propria
results in a sulcus vocalis . Most sulci are congenital and
run through the entire length of the membranous vocal
fold, referred to as linear vergeture
• It has been classified into three types depending on the
depth of the sulcus and its shape.
• Type I is superficial and is not associated with any voice
abnormality.
• Types IIa and IIb cause moderate and severe dysphonia,
respectively.
• Management is challenging. A small epithelial
cordotomy with elevation of epithelium over the sulcus
with fat implantation is preferred .This is followed by a
long course of voice therapy with the patient counseled
regarding postoperative voice improvement expected at
6 to 8 weeks

95. NEUROMUSCULAR CAUSES
UNILATERAL VOCAL CORD PARALYSIS
• Malignancy (20 to 40%)
• Surgical trauma (22 to 44%)
• Nonsurgical trauma (9 to 10%)
• Neurological causes (2 to 3%)
• Inflammatory and infectious causes (2 to 3%)
• BILATERAL VOCAL CORD PARALYSIS
• Iatrogenic (57%), ( thyroidectomy, pneumonectomy, and posterior fossa surgery)
• Trauma( postintubation or whiplash injury.)
• Neurological 21%( encephalitis, syringobulbia, multiple sclerosis, and progressive
bulbar palsy)
• Malignancies.
• Infections (thyroiditis, syphilis, and viral diseases)
• IDIOPATHIC

97. Management of VFP

98. IDIOPATHIC VOCAL FOLD PARALYSIS
• Twenty to forty per cent of patients with
idiopathic vocal fold paralysis show
spontaneous recovery.
It might take up to 12 months to show signs of
recovery; some patients get partial recovery
with an acceptable quality of voice

99. MANAGEMENT OF BILATERAL VFP
The basic aims of management are as follows:
• Achieve a safe and stable airway.
• Preserve speech and voice quality.
• Allow safe swallowing without aspiration

100. Tracheostomy is done in management of most patients with bilateral VFP
Vocal Fold Lateralization
• There are several techniques to widen the glottal opening.
• Surgical intervention is performed about a year following the paralysis to
permit any spontaneous reinnervation to occur.
1. Arytenoidectomy: This entails removing part or whole of the arytenoid
cartilage and may be done endoscopically with the laser or
microsurgically or externally via a lateral neck approach (Woodman
procedure).
2. Arytenoidopexy: involves displacement of vocal fold and arytenoid by
means of suture passed around the vocal process of the arytenoid and
secured laterally. This procedure has a relatively high failure rate.
3. Cordectomy: This consists of carbon dioxide laser (or cold steel) removal
of a C-shaped wedge from posterior edge of one true vocal fold
(posterior partial cordectomy) with or without additional removal of part
of the false fold and arytenoidectomy.

101. JOINT PATHOLOGY
• Cricothyroid joint and crico-arytenoid joint
involvement by trauma or systemic disease
may present with the symptom of dysphonia.
Intubation trauma can dislocate the crico-
arytenoid joint causing immobility of the vocal
fold and resultant marked hoarse voice.
• Closed reduction is the most effective
treatment in this situation.

102. THANK YOU