Voice Disorder

Introduction The voice box (larynx) consists of cartilage, muscle and mucous membranes situated at the top of the windpipe (trachea) and the base of the tongue. Sound is produced when nerves signal the vocal folds to move toward each other and close; as air leaves the lungs, mucous membrane lining the vocal folds vibrate. The vocal cords are also responsible for helping to close the voice box during swallowing to prevent aspiration. The quality of the voice depends on the condition and function of the vocal folds. If the vocal folds become inflamed, develop growths or become paralyzed, they cannot function properly. This can result in a voice disorder.

Definition “One of a group of problems involving abnormal pitch, loudness, or quality of the sounds produced by the larynx (the voice box).” (http://www.medterms.com/script/main/art.asp?articlekey=13305)

Types of voice disorders: Voice disorders fall into three main categories: organic, functional, or a combination of the two. Organic voice disorders fall into two groups: structural and neurogenic. Structural disorders involve something physically wrong with the mechanism, often involving tissue or fluids of the vocal folds. Neurogenic disorders are caused by a problem in the nervous system. A functional disorder means the physical structure is normal, but the vocal mechanism is being used improperly or inefficiently. The tricky part with categorizing voice disorders is that often times, different types of disorders will interact. For instance: •

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Individuals with a neurogenic or structural disorder may develop a functional (relating to use of the muscles) component as they attempt to compensate for their voice disorder. Individuals with poor muscle function may develop a structural lesion (growth).

On the other hand, there are some ways in which voice disorders don't interact, but do cause other unhealthy factors to arise.

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Individuals with any voice disorder may develop a psychogenic, or emotional component, because the voice disorder can be so emotionally devastating. However, we do not consider this to be a psychogenic voice disorder. Individuals with a psychogenic disorder may develop an additional structural or functional component. Poor muscle function can become habitual, but it will not cause a permanent problem in the nervous system.

ORGANIC STRUCTURAL: Structural disorders are caused by some lesion (physical abnormality) of the larynx.

NEUROGENIC: Neurogenic Voice Disorders are caused by some problem in the nervous system as it interacts with the larynx. Briefly, two nerves come from the brain to the larynx and control the movement of the larynx. The most important of the two nerves, the recurrent laryngeal nerve, comes down and wraps around the aorta before going back up to attach to the larynx on the left side. Because of this position in the neck, the recurrent laryngeal is vulnerable to damage during cardiac, pulmonary, spinal and thyroid surgeries. When the nerve is damaged, it causes a paresis (weakness) or paralysis (complete lack of movement) in the vocal fold of the affected side. Other neurogenic voice disorders are related to other kinds of problems in the central nervous system.

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Contact Ulcers Cysts Granuloma Hemorrhage Hyperkeratosis Laryngitis Leukoplakia Nodules (nodes) Papilloma Polyps Trauma

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Miscellaneous growths . Paralysis/Paresis Spasmodic Dysphonia (Laryngeal Dystonia) Tremor (Benign Essential Tremor)

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Voice problem caused by another neurological disorder (e.g. Parkinson's disease, myasthenia gravis, ALS/Lou Gherig's Disease)

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Muscle tension dysphonia (general) Anterior-posterior constriction HyperABduction HyperADduction Pharyngeal constriction

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FUNCTIONAL: Functional disorders are caused by poor muscle functioning. All functional disorders fall under the category of muscle tension dysphonia.

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PSYCHOGENIC: Psychogenic disorders exist

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Ventricular phonation

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Vocal fold bowing

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Conversion dysphonia or aphonia

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Puberphonia (mutational falsetto)

because it is possible for the voice to be disturbed for psychological reasons. In this case, there is no structural reason for the voice disorder, and there may or may not be some pattern of muscle tension. While it is quite common for a psychogenic component to exist in a voice disorder, voice disorders that are caused by a psychological disorder are relatively rare. The two most common types of psychogenic disorders are listed on the right.

Structural Disorders: Contact Ulcers The Lesion and Effect on Vibration

A contact ulcer is a sore on the mucosal tissue of the posterior part of the larynx, usually on the arytenoid cartilage or very posterior portion of the vocal fold (also called the vocal cord; refer to our explanation of this terminology). It appears similar to a canker sore in the mouth. A contact ulcer can be quite painful. Contact ulcers are very similar in cause and treatment to granulomas.

Cysts The Lesion and effects on vibration A cyst is a growth that forms beneath the surface layer of the vocal fold mucosa. It causes a gap between the two vocal folds (also called vocal cords; refer to our explanation of this terminology) and prevents normal vibration.

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Sound of Voice The voice may have a range of sound from normal to breathy to very rough and hoarse.

Complaints May include: • • •

abnormal voice quality vocal fatigue discomfort after extensive talking

Cause The exact cause of any cyst is usually unknown. It often can occur with minute bleeding (hemorrhage) in the mucosa of the vocal fold. The bleeding resolves, but leaves a tiny bit of scar tissue, and the cyst forms around it. The cyst may be solid, filled with fluid, or even filled with blood. The initial bleed may be caused by a relatively short period of intense vocal fold vibration, such as severe coughing or screaming. However this is not always the case. Contributing factors may include taking medication to reduce platelet function (aspirin and non-steroidal anti-inflammatory drugs). Another contributing factor may be menstruation, which makes a woman slightly more vulnerable to hemorrhage. Cysts are typically found on one vocal fold, but can be found on both. It is also common for a nodule to form on the opposite vocal fold (vocal cord) in response to the additional pressure from the cyst. Treatment Cysts may resolve by simply reducing vocal fold impact for a time. However, they often require surgical removal. Pre- and post-surgical functional voice therapy usually improves the surgical result.

Granuloma The Lesion and Effects on Vibration A granuloma is a benign growth that typically occurs in the posterior (back) part of the larynx, either directly on the vocal fold (also called vocal cord; see the explanation of this terminology), or on one of the mucosal surfaces nearby. The growth may prevent glottic closure, causing vibration to be weak or non-existent. This could cause a weak or breathy

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voice, or frequent "breaks" in the voice. Or the lesion may interfere with vibration, causing a rough, irregular sound. The voice may fatigue easily and become worse sounding with continued use. A lesion that is not directly on the vocal fold may not interfere with voice quality, but can be very irritating and even painful. A large enough lesion may obstruct the airway.

Sound of Voice Ranges from normal to breathy to extremely rough and hoarse. Often worsens with increased voice use.

Complaints May include: • • • • •

abnormal voice quality vocal fatigue discomfort or pain associated with increased talking interference with breathing a sense of something irritating in the throat that needs to be cleared or coughed away

Cause The granuloma is actually one of the body's ways of healing or protecting itself from an inflammatory or infectious process. It is believed to be related to an infectious process within the cartilage of the larynx. Granulomas can occur in a number of ways, but most are related to some acute or chronic injury, such as: • • • •

trauma from intubation during surgery an extended bout of coughing or other vocal trauma chronic reflux (see our explanation of GERD/LPRD) chronic mild trauma such as frequent throat-clearing

Granulomas may occur from any single or combination of the above, but it is often difficult to determine an exact cause. Whatever the initial cause, vocal fold trauma or impact will usually make the granuloma worse. Loud or excessive talking, throat-clearing, coughing, grunting, and effortful vocal production can all cause the granuloma to grow larger.

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Treatment Treatment for granuloma can be frustrating, as the lesion can be quite tenacious. Many surgeons prefer to remove the lesion immediately, but recurrence is common. At the Lions Voice Clinic, the first line of treatment for granulomas is medical and functional: •

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Anti-reflux medications are prescribed to eliminate any burning from acid reflux. Also, the patient is counseled about dietary precautions to alleviate GERD/LPRD. A short course of steroids is prescribed to reduce the inflammation and, hopefully, the size of the granuloma. Antibiotics are given to alleviate any infectious process. Speech therapy is initiated to help identify sources of high vocal fold impact, and to teach techniques to reduce the impact while talking.

The above treatment may be enough to cause the granuloma to resolve. However, sometimes surgery is required to remove the lesion.

Surgery Medical and functional therapy may be enough to cause the granuloma to resolve. However, sometimes surgery is required to remove the lesion. Some things you should know about surgery:

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It is done under general anesthesia. The area is often injected with steroids immediately after removal of granuloma. Total voice rest is prescribed for 3-5 days after surgery. Voice use is minimal at first, with a very gradual return to complete voice use (1-4 months, depending on extent and type of voice use required). Functional treatment is continued, voice use is monitored, and medical treatment may be used again.

Granulomas are known for recurring, which can be frustrating to the patient, and patients frequently come to the Lions Voice Clinic after multiple surgeries. These patients are usually frustrated and looking for another answer. However, they're often surprised to hear that another surgery may just aggravate an already inflamed area, and that speech therapy is an important part of the treatment process. Fortunately, this treatment program turns out to be successful in the vast majority of cases.

Hemorrhage The Lesion and Effects on Vibration

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A hemorrhage occurs when a tiny blood vessel within the vocal fold (also called vocal cord; see the explanation of this terminology) bursts, creating a bleed into the mucosal covering. The accumulation of blood under the surface of the vocal fold makes the fold stiff, which makes vibration more difficult. The amount of the bleed can vary greatly, and so can the effect on the voice, but often it is large enough to prevent vibration of the affected vocal fold altogether. Sound of Voice A hemorrhage is typically an acute (sudden) event, and the voice may suddenly "cut out" or become very weak, breathy, or rough. A person experiencing a hemorrhage may suddenly find themselves unable to produce a sound. This resolves over time as the blood accumulation subsides. Complaints May include: • • • •

sudden decrease in voice quality loss of pitch range loss of volume loss of vocal control

Cause A hemorrhage occurs when there is sudden high impact, or prolonged impact to the vocal folds, and is more likely to occur when the blood vessels in general are already more susceptible to hemorrhage. This may happen when some anticoagulant, such as aspirin products, or some vasodilator, such as alcohol products, are used. It is also more common in women during their menstrual period. Therefore, we caution women suffering from menstrual cramps not to take aspirin, have a drink, then go out on stage and scream! Treatment A person with a very recent hemorrhage is advised to undergo several days of total voice rest. This is one of the few times when we advise no voice use at all. After a maximum 5 days of silence, there should be enough resolution of the hemorrhage to resume voice use gradually. The extent of vocal decrement can very greatly, as can the demands of the voice user. Professional voice users with a hemorrhage are generally advised to undergo some voice therapy and/or monitoring during the first month or two following the incident, in order to prevent further damage. Sometimes the bleed becomes encapsulated into a cyst or polyp. This may still resolve on its own, but the likelihood is greater that it will have to be surgically removed. At the Lions Voice Clinic, we prefer to try several months of intensive voice therapy before resorting to surgical removal. In

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therapy, techniques are taught that will promote safe voice use for the postoperative period, should surgery be necessary.

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Nodules (a.k.a. "Singer's Nodes") The Lesion and Effects on Vibration Nodules are blister-like or callous-like swellings that form just below the epithelial surface of the vocal folds (also called vocal cords; see the explanation of this terminology). They occur on both vocal folds and are symmetrical. The nodules appear as small bumps along the mid portion of the vocal folds, where the vocal folds come into contact with each other. The nodules may create a gap between the two vocal folds allowing air to escape and prevent normal vibration. They may also stiffen the mucosal tissue, causing irregular vibration and a rougher sound. Sound of Voice May range from normal to breathy to very hoarse and strained. The inability to sing high, soft notes is one of the hallmarks of nodules. When the individual tries to sing high and soft, there is a delay in the onset of the sound, with an audible air escape, and then the sound starts abruptly. Complaints May include: • • • •

abnormal voice quality limited pitch and volume vocal fatigue discomfort after extensive voice use

Cause Nodules typically occur in people who use their voice in an intense manner over an extended period of time. The nodules appear as small bumps along the mid portion and are a result of the thickening of the surface layer of the vocal folds. The nodules are a natural response to increased trauma, similar to calluses on the hands.

Treatment

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When the trauma is reduced through functional voice therapy, the nodules nearly always resolve. Surgery is rarely needed and is usually contraindicated if the individual has not learned to reduce the trauma. This would likely cause the nodules to recur.

Polyps The Lesion and Effect on Vibration Polyps are similar to cysts in that they are growths arising from the vocal fold (also called vocal cord; see the explanation of this terminology) mucosa. They may be solid or fluid filled, and can become quite large (see the multimedia gallery for pictures). Their effects on vibration depend on their size and their location on the vocal folds. Sound of Voice May vary from normal to severely dysphonic (very poor voice quality). Complaints May include: • • •

abnormal voice quality vocal fatigue discomfort after extensive talking

Cause Like cysts, polyps may result from some sort of trauma or impact to the vocal folds, or arise for some unknown reason. Although polyps tend to more associated with sudden, acute trauma, smokers polyps are a reaction of the vocal fold mucosa to the chronic insult of smoking. They cause the well-known "smoker's voice." Treatment Like cysts, polyps may resolve on their own with improved vocal hygiene, but are more likely to require surgical removal. At the Lions Voice Clinic, surgical removal of polyps is done after a course of functional voice therapy to optimize surgical results. Smoker's polyps are not likely to be removed unless the individual stops smoking, because continued smoking almost ensures that the polyps will return.

Functional Disorders: 9

Muscle Tension Dysphonia One of the most common voice disorders we treat is muscle tension dysphonia (MTD). The root word phon means "sound". Phonation refers to the sound made by the voice. The term dysphonia means there is something wrong with the voice. However, muscle tension dysphonia can also refer to a voice that sounds normal, but causes pain, discomfort, or fatigue to the voice user. MTD is known as a functional disorder; that is, there is nothing structurally wrong with the voice. There are no nodules, polyps, paralysis, etc.. Rather, the muscles do not function properly, which causes poor sound, discomfort, or a sensation of increased effort.

Symptoms of Muscle Tension Dysphonia Different individuals may have very different symptoms of MTD. In fact, MTD can mimic most structural voice disorders.

Possible voice characteristics of MTD • • • • • • • • • •

rough, hoarse, gravely, raspy, coarse weak, breathy, airy, leaky, backward, hollow strained, pressed, squeezed, tight, tense, choked, effortful jerky, shaky, halting, suddenly cutting out, squeezing shut, breaking off, changing pitch, or fading away giving out gradually, or becoming weaker or more tense as voice use continues excessively high or low pitch inability to produce a loud voice inability to produce a clear voice inability to sing notes that used to be easy

Possible sensations of MTD

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pain or discomfort anywhere in the throat area associated with voice use a tight choking sensation associated with voice use a sensation of fatigue or effort that increases with voice use some area of the neck is tender to the touch a feeling of the need to clear the throat frequently a feeling of a lump in the throat

Causes of Muscle Tension Dysphonia There are many specific, individual reasons why use of the vocal mechanism becomes abnormal. Some general causes are very common:

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prolonged illness prolonged overuse prolonged underuse (such as after a surgery) trauma, such as an injury, chemical exposure, or emotionally traumatic event

These may lead to an abnormal vocal response, causing the individual to compensate by using extra effort while talking. The onset of MTD can be very subtle. The individual is usually unaware of the extra effort, But this extra effort typically recruits muscles that are not part of the larynx itself. The result may or may not be a stronger voice, but it usually starts a vicious cycle where more and more effort is required. This cycle may continue for months or even years before the individual becomes aware that his or her voice is abnormal. The reason why some individuals adapt one style of muscle tension over another is unknown.

Treatment of Muscle Tension Dysphonia Functional therapy is usually the only treatment available. BUT: • • • •

should only be done after a thorough evaluation by ENT physician should be done with a certified speech language pathologist who specializes in voice disorders may require only a few sessions, or may take many months for complete relief, but generally some relief is gained within the first 4 to 6 sessions in the case of emotional stress, some counseling or stress management may be very helpful or even necessary

Occasionally, medical or surgical treatments may be tried.

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Botox injections may be useful in severe cases Surgery to reduce the size of ventricular folds has been tried but is not done at the Lions Voice Clinic Muscle relaxants are NOT useful for muscle tension dysphonia - the action of the drugs is not localized to the vocal mechanism, so in order to provide enough relaxation for the vocal mechanism, the individual is often unable to function for day to day living

Types of Muscle Tension Dysphonia Muscle tension in the vocal mechanism can exhibit itself in many ways. Each individual is different. But here are a few common patterns:

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Anterior-Posterior Constriction Hyper Abduction 11

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Hyper Adduction Pharyngeal Constriction Ventricular Phonation Vocal fold (vocal cord) Bowing

Functional Disorders Specific Patterns of Muscle Tension Dysphonia:

Anterior-Posterior Constriction Muscle tension pattern

The arytenoid cartilages bend forward during voice use, and/or the epiglottis bends backwards, causing the larynx to squeeze from front to back (anterior to posterior). As effort increases, the squeezing continues, causing a vicious cycle. The squeezing in a front-to-back direction may put pressure on the vocal folds such that they bow ( Vocal Fold Bowing), causing poor vibration. In extreme cases, especially in children, the arytenoids may actually vibrate against the epiglottis. Sound of Voice Ranges from normal to extremely squeezed and tight sounding. The voice may sound rough if the squeezing causes irregular vibration of the vocal folds. "Froggy" sound if arytenoids and epiglottis vibrate. Complaints May include: • • •

discomfort pain that increases with voice use but may be constant even during rest fatigue and decline of voice quality with voice use

Cause Prolonged voice overuse, or continued voice use while vocal mechanism is impaired, or prolonged use of a tense style of speaking. Sometimes related to emotional stress. Treatment:

Functional therapy. Hyper abduction

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Muscle tension pattern The vocal folds (also called vocal cords; see the explanation of this terminology) do not come together to produce voice. They may appear to be pulled apart as the person phonates. Sound of Voice Weak, breathy, airy, very soft, hollow, breaks in voicing, Complaints Effort and fatigue from voice use; voice is ineffective Cause Sometimes abnormality in vocal mechanism causes pain, leading to protective avoidance of voicing. Emotional or stress component is common. Treatment Functional therapy, often combined with psychotherapy. Occasionally, Botox injections are helpful.

Hyperadduction Muscle tension pattern The vocal folds (also called vocal cords; see the explanation of this terminology) adduct (come together) very tightly, producing a valve that restricts airflow. The larynx may look normal on exam, but the sound and sensation are not. Sound of Voice Ranges from normal to extremely tight, pressed, squeezed, strangled, forced or effortful. Tension may be irregular, causing a stopping/starting or shaking effect. Complaints May include: •

effort and fatigue, usually increasing with continued voice use

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pain discomfort

Cause Prolonged overuse or continued voice use when the vocal mechanism is impaired. Tense style of voice use can cause this pattern of muscle tension dysphonia to become habitual over time. Emotional component may be present. Treatment Functional therapy. Occasionally Botox injections are helpful.

Pharyngeal Constriction Muscle tension pattern Muscle of the pharynx (throat) contract excessively while talking, leaving the throat very constricted. Sound of Voice Ranges from normal to very tight or squeezed, may be tremulous, or may be backward and throaty sounding. Complaints May include: • • • •

discomfort pain that increases with voice use but may be constant even during rest fatigue decline of voice quality with voice use

Cause Prolonged voice overuse, or continued use while vocal mechanism is impaired, or prolonged use of a tense style of speaking. Sometimes emotional stress. Treatment Functional therapy

Ventricular Phonation 14

Also called plica ventricularis, ventricular dysphonia, or false cord phonation. Muscle tension pattern The ventricular folds come together and vibrate instead of, or along with, the vocal folds (also called vocal cords; see the explanation of this terminology). The ventricular folds, also known as the false vocal cords, are mounds of fleshy tissue just above the true vocal folds (see About the Voice). Though the ventricular folds are not muscular, they can be brought together and vibrated. However, they were not meant to vibrate, so they can't vibrate very fast (for high pitches) or very strongly (for loud sounds). Pressure from the ventricular folds is usually strong enough to keep the true vocal folds from vibrating. Sound of voice The voice sounds very rough and strained, sometimes not quite human, limited in pitch and volume. Complaints May include: • • •

fatigue, especially with attempts at loud voice use pain or dryness with voice use sometimes no discomfort at all

Cause Most often, continued use of voice while true vocal folds (vocal cords) are impaired. Sometimes, extreme strain in response to a trauma. Treatment In extreme cases, medical or surgical treatments may be tried, but only after functional therapy has failed. In some cases, ventricular phonation is the best alternative if the true vocal folds will always be too impaired to vibrate.

Vocal fold (Vocal Cord) Bowing Muscle tension pattern

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Vocal folds (also called vocal cords; see the explanation of this terminology) don't come together to vibrate. Sound of Voice Weak, breathy, hollow, backward, sometimes rough or scratchy. Complaints Fatigue from voice use, undependable voice, sense of effort when talking, poor volume, voice gets weaker with continued talking. Cause Usually over exertion, sometimes when individual is in poor condition (vocal fold bowing is sometimes referred to as presbylarynges, which means "the laryngeal status of old age"). This assumes that the vocal folds are bowed because the muscle in the vocal folds has atrophied (wasted away) due to old age. Senior citizens are often told that they must accept their voice quality as a natural part of getting old. Other times, surgery is offered to "plump up" the vocal folds in order to get them to come together again. In the Lions Voice Clinic, we see many individuals of all ages with vocal fold bowing. Also, the senior citizens we see with vocal fold bowing range in voice use from minimal to very heavy voice use. This suggests to us that bowing is not just caused by wasting away of the muscles. We believe it is more often caused by compensatory muscle tension, usually in the anterior-posterior direction, which squeezes the vocal folds apart. Treatment

In the Lions Voice Clinic, we treat bowing successfully with functional therapy, in a wide variety of individuals. We rarely find that surgery is necessary.

Neurogenic Disorders: Paralysis/Paresis Abnormal Movement Pattern One or both vocal folds (also called vocal cords; see the explanation of this terminology) do not move, often causing a gap between the two vocal folds, which allows air to leak through and disrupts vibration. Typically, there is some nerve regrowth into the paralyzed vocal fold but movement may or may not return if the nerve regrowth is random. If the damage is permanent and there is no movement at all to the vocal fold, it is considered a paralysis. If there is some movement but movement is reduced, it is called a paresis, which means "weakness." 16

Sound of the voice May be weak, breathy, rough, diplophonic (two pitches occurring at the same time), or just a whisper. Complaints May include • • • • • •

Lack of volume Lack of vocal strength Vocal fatigue, which increases with voice use Poor voice quality Shortness of breath Swallowing problems

Cause Damage to one of the two nerves that go from the brain to the larynx, most commonly the recurrent laryngeal nerve paralysis can result from surgeries such as anterior spinal fusion, and thyroid, cardiac, and pulmonary surgeries. It is also possible for a virus to cause damage to the nerve, often without any other symptoms of the virus.

Treatment In people with mild voice impairment and moderate vocal demands, functional voice therapy is often effective. However, multiple surgical options are also available to people who do not obtain a satisfactory result with speech therapy. The principal goal of surgical treatment for paralysis is to move the vocal fold into a position so that it can effectively be used by the mobile vocal fold on the other side to produce vibration. Injections: Moving the immobile vocal fold (vocal cord) can be done by injecting it with a substance to bulk it up and move it toward the center. The material can be temporary (Cymetra is used at the Lions Voice Clinic. It is a foamy substance

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that usually lasts about 6 months.) or permanent (Teflon, which is rarely used in the Lions Voice Clinic because it is known to migrate). Injection of a small amount fat from elsewhere on the body can also be performed which can give a permanent result. However, the results vary as far as how well the grafted fat survives. Injections are performed through the mouth and typically in the operating room. The person can usually go home the same day as the injection. In select situations, injections can be performed in our clinic. Implants: Another option for a bothersome immobile vocal fold (vocal cord) is a procedure called a thyroplasty. In a thyroplasty, a solid piece of material is placed through a window made in the cartilage of the larynx. The larynx is approached through a small incision in the neck. A window is made in the thyroid cartilage and the material is placed in the immobile vocal fold to move it toward the middle. The procedure is performed with the person awake so that the voice can be tested and the implant modified as needed. Different surgeons use different materials (Silastic blocks, hydroxadhesive or goretex). All of these materials produce good results. At the Lions Voice Clinic, we use silastic implants. Reinnervation: A third option for unilateral vocal fold immobility due to nerve dysfunction is reinnervation. In this procedure, a nerve is "borrowed" from one of the neck muscles and "hooked into" the recurrent laryngeal nerve. In our clinic, we see the most consistent high quality voice with this procedure. A disadvantage is that 6 to 12 months are needed for the nerve to start functioning to provide substantial voice improvement. Because of this, a vocal fold injection is used to temporarily move the vocal fold to the middle. Following a reinnervation, the vocal fold will not actually move, but will have excellent position, bulk and muscle tone so that is can meet the other vocal fold at the midline.

Spasmodic Dysphonia (SD) a.k.a. Laryngeal Dystonia (LD) The Disorder and Effects on Vibration

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Spasmodic Dysphonia (SD) is the common name for laryngeal dystonia. Dystonia is a neurologic movement disorder, caused by a problem in the nervous system. Dystonias can affect many parts of the body, and when a dystonia affects the larynx, it is called Laryngeal Dystonia or Spasmodic Dysphonia. The vocal folds (also called vocal cords; see the explanation of this terminology) vibrate normally, but they spasm intermittently during speech. Spasmodic Dysphonia was called spastic dysphonia until about 10 years ago. Spasmodic Dysphonia or Laryngeal Dystonia are more correct terms. There are two kinds of laryngeal spasms, creating three kinds of Spasmodic Dysphonia

Adductor Spasmodic Dysphonia This is the most common type of SD. The thyroarytenoid muscle (the muscle that lies within each vocal fold) contracts strongly and suddenly as in a muscle spasm. This causes the vocal folds to suddenly squeeze together very tightly. The result is a sudden breaking, stopping, or strangling of the voice.

Abductor Spasmodic Dysphonia This less common form of SD causes the posterior cricoarytenoid muscle (the muscle that draws the vocal folds apart) to contract suddenly, causing the vocal folds to pull apart suddenly. The result is a sudden "blowing out" or breathiness of the voice.

Mixed Spasmodic Dysphonia This is the most rare form of SD, in which both adductor and abductor spasms are present during speech.

Sound of voice • •

Adductor SD: the voice sounds tense, tight, strained, strangled, with sudden stoppages of the voice. Abductor SD: the voice sounds breathy, weak, leaky, with sudden blowouts

Complaints

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May include • • •

Poor voice quality, may be so severe that speech is unintelligible Loss of control of the voice Fatigue, strain, and effort associated with voice use

Cause Though we know that Spasmodic Dysphonia is a neurologic disorder, the exact cause is unknown; for more discussion, we recommend the web sites of the National Spasmodic Dysphonia Association or the Dystonia Medical Research Foundation.

Treatment There is no cure for SD. However, treatment using Botox injections is often very helpful, especially for Adductor SD. Botox is the nickname for Botulinum Toxin, which is a strain of botulism, a powerful poison. When small amounts of Botox are injected into the vocal folds, the muscle is weakened, and the spasms are reduced or eliminated. The injections cause weakness or breathiness to the voice for the first few weeks, but then the voice strengthens and is without spasms for an average of three months. The spasms gradually return, and more Botox must be injected. In the case of abductor SD, the Botox is injected into the posterior cricoarytenoid muscle (the abductor muscle) to reduce abductor spasms. At the Lions Voice Clinic, you will be evaluated jointly by Drs. Goding and Michael for Spasmodic Dysphonia. If you are diagnosed with SD, you will be offered Botox injections and functional therapy. The majority of patients find that a combination of therapies is best; the Botox reduces the muscle spasms, and the functional therapy reduces habits of effortful overcompensation that make speech even worse.

Botox Treatment and the Nervous System When a nerve gets the signal from the brain to fire, chemicals called neurotransmitters are released from the nerve into the muscle fibers, causing the muscle to contract. Botox works by preventing the release of the neurotransmitters. This prevents the contraction of the muscle. Actually, the Botox is injected in such small amounts that it only affects the muscle fibers near the injection site, not the entire muscle. Therefore, the muscle contraction is weakened, but not entirely eliminated. We talk about the Botox wearing off, but that is not quite what happens. The tiny ends of the nerve fibers near the injection site eventually die off from the Botox. However, new nerve endings grow, much like the roots of a plant. The regrowth of active nerve endings allows the release of neurotransmitters again, so that the muscle contraction is no longer weakened. The gradual strengthening of muscle contraction makes it feel as if the Botox effect is wearing off.

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Botox can be used to treat other voice disorders in addition to SD. These include Benign Essential Tremor and severe Muscle Tension Dysphonia.

To receive Botox injections... How long does it take? The injection process will only take a few minutes. Then we'll ask you to wait a few minutes after your injection, to make sure you feel OK. Does it hurt? Most people say it's a little painful for a short time, like getting a tetanus shot. No anesthesia is used, because most people prefer avoiding additional injection. It's helpful if you relax, just like that tetanus shot. It's fine if you want to have someone come with you and hold your hand. How do we know the needle is in the right muscle? At the Lions Voice Clinic, we use EMG (electromyographic) guidance. That means the needle is attached to a tiny wire that sends a signal to the electromyograph machine, which in turns gives a signal about the activity of the muscle. When the needle is in place, we will have you activate the muscle by performing a specific task such as saying "eee" or sniffing. Electrical energy caused by the contraction is sent through the wire to the electromyograph, and a "crackling" sound confirms that the needle is in the correct muscle. Before your injection, round disks called electrodes will be applied to your clavicle. These provide grounding and reference for the electrical signal. Typically, there will be two injections, one for each side. How soon does the injection take effect? Usually in the next three days. Sometimes people can feel a difference the next morning, but more often it takes a day or two. If you don't feel any effect within a week, call us. Sometimes the strongest effect is felt first, and other times the effect builds over the first week. Individual reactions are hard to predict. What are the side effects? Side effects are minimal, because the amount of Botox is so small, and the area it affects is very small. Both side effects are related to the intended purpose of the Botox, to weaken the vocal folds. In the first week, a few people notice choking or coughing when they drink thin liquids like water. It is the same effect when you get water "down the wrong pipe." To avoid this, sip carefully; don't chug-a-lug. Many people cough a little when they first take a drink

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after the injection takes effect, and then they remember to sip more slowly. It is rarely a problem, and rarely lasts more than a week. The other, more common side effect is that your voice may become weak and breathy for some period of time after the injection. This is because the vocal folds are weak and cannot come together strongly to provide a strong vibration. This is what prevents the spasm. In time the breathiness resolves and the voice becomes stronger, but still does not spasm. The degree of breathiness and the length of time the voice stays breathy are related to the dose of Botox, and to the individual reaction. In general, the larger the dose, the longer the voice stays breathy, but also, the longer the spasms are prevented after the breathiness resolves. Some people cannot tolerate any breathiness or weakness in their voice, and therefore they have frequent, small doses of Botox. Others can tolerate several weeks of breathiness, but in exchange they get more months of improved voice quality. It may take a few injections before you know your best dose and timing schedule.

How will I know when I should get another injection? The spasms will return gradually, and at first they will not be as strong as they were before the injection. Spasms typically get worse over a period of weeks or months. During that time, techniques you learned in voice therapy are the most helpful. Because injections are only given once a month, typically on the fourth Tuesday of the month, you should make your appointment for your next injection accordingly. If the spasms start coming back during the third week of the month, you can probably wait another month. But if they come back early in the month, you may want to make your appointment for the end of the month. One thing is certain: no one ever wants to wait so long they get back to the level of spasms they had before their first injection!

Tremor (Benign Essential Tremor) The Disorder and Effects on Vibration Benign Essential Tremor is a disorder that causes shaking of the voice. Benign means that the disorder will not harm your health. Essential means that the tremor is not associated with any other disease state, such as the tremor associated with Parkinson's Disease. When Benign Essential Tremor affects the voice, vocal fold vibration is normal, but the entire larynx shakes slightly, causing an extra vibration, or tremor, at about 5-7 cycles per second. Sometimes the larynx can be seen to tremor even at rest, but usually the tremor begins when the person begins to speak. Benign Essential Tremor tends to occur in older persons, though persons in their 50's may also be afflicted. 22

Sound of voice A steady shaking or wobbling of the voice, ranging from gentle and continuous to a staccato, almost hiccuping sound. The easily-recognized sound of Katherine Hepburn is a famous example of Benign Essential Tremor. The tremor is rhythmic and steady, at 5-7 cycles per second, and it occurs in all speech contexts. It may vary in intensity with changes in pitch or volume, and, like all voice disorders, tends to get worse in stressful situations. Complaints May include: • • •

Poor voice quality, with "old-sounding" characteristics Vocal weakness and low volume Vocal fatigue increasing with voice use

Cause Tremor is caused by a central nervous system problem that can also cause tremor of the hand, head, or other extremities. Tremor may be hereditary. Benign Essential Tremor sometimes occurs along with Spasmodic Dysphonia, so that there are vocal fold spasms as well as continuous shaking. The reason for this is unknown. Treatment There is no treatment that will eliminate the tremor. Often, the individual with tremor tries to stop the tremor while talking, but ends up creating more tension and making the tremor worse. Functional voice therapy can help reduce this effortful compensation, improve voice quality, and make speech easier. When the tremor is severe and causes voice breaks, Botox injections may help reduce the severity and the strain, though they will not eliminate the tremor altogether. At the Lions Voce Clinic, many patients with tremor have found a short course of functional therapy to be helpful, but only a few have found Botox to be helpful enough to continue getting injections every few months. There are also a number of pharmacological (drug) treatments that are helpful for some people. There are several classes of drugs that may be helpful, including beta-blockers, anti-seizure medications, and psychotropic drugs. We encourage individuals who are diagnosed with Benign Essential Tremor to see a neurologist, to confirm the diagnosis, rule out other neurologic problems, and discuss a course of drug treatment. Some of the drugs that are helpful in reducing tremor have unwanted side effects, or may be conflict with drugs the individual is already taking. Therefore it is important to coordinate this treatment between the neurologist and primary care physician.

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Botox Treatment for Benign Essential Tremor Botox is the nickname for Botulinum Toxin, which is a strain of botulism, a powerful poison. When a minute amount of Botox is injected into a muscle, it weakens the muscle contraction. In the case of Tremor, it does not stop the tremor, but weakens the severity of the tremor. The Botox is injected into the thyroarytenoid muscle within the vocal fold. The thyroarytenoid muscle is responsible for the strength of the staccato, hiccuping effect of the tremor. How does Dr. Goding know the needle is in the right muscle? At the Lions Voice Clinic, Dr. Goding uses EMG (electromyographic) guidance. That means the needle is attached to a tiny wire that sends a signal to the electromyograph machine, which in turns gives a signal about the activity of the muscle. When the needle is in place, Dr. Goding will have you say "eeee," which will cause the muscle to contract. Electrical energy caused by the contraction is send through the wire to the electromyograph, and Dr. Goding can hear the "crackling" sound that tells him the needle is in the correct muscle. Before your injection, Dr. Goding or the nurse will apply round disks called electrodes to your clavicle. These provide grounding for the electrical signal. It sounds scary, but you won't feel a thing, and it's not at all dangerous. There will be two injections, one for each side. How long does it take? The injection process will only take a few minutes. Then we'll ask you to wait about 15 minutes after your injection, to make sure you feel OK. You only have to wait after your first injection. Does it hurt? Most people say it's a little painful for a short time, like getting a tetanus shot. No anesthesia is used, because that would hurt more! Sometimes the first injection hurts the most, because people are the most nervous, and more likely to tense their muscles. It's helpful if you relax, just like that tetanus shot. It's fine if you want to have someone come with you and hold your hand. By your second injection, you won't bat an eye. How soon does the injection take effect? Usually in the next three days. Sometimes people can feel a difference the next morning, but more often it takes a day or two. If you don't feel any effect within a week, call us. Sometimes the strongest effect is felt first, and other times the effect builds over the first week. Individual reactions are hard to predict. What are the side effects?

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Side effects are minimal, because the amount of Botox is so small, and the area it affects is very small. Both side effects are related to the intended purpose of the Botox, which is to weaken the vocal folds. In the first week, you may notice some choking or coughing when you drink thin liquids like water. It is the same effect when you get water "down the wrong pipe." To avoid this, sip carefully; don't chug-a-lug. Many people cough a little when they first take a drink after the injection takes effect, and then they remember to sip more slowly. It is rarely a problem, and rarely lasts more than a week. The other side effect is that your voice may become weak and breathy for some period of time after the injection. This is because the vocal folds are weak and cannot come together strongly to provide a strong vibration. This is what reduces the staccato, hiccuping sound of the tremor. The tremor will still be there, but should be more gentle. With less interference from the tremor, it is easier to talk and make yourself understood. The degree of breathiness and the length of time the voice stays breathy are related to the dose of Botox, and to the individual reaction. In general, the larger the dose, the longer the voice stays breathy, but also, the longer the tremor is reduced after the breathiness resolves. Some people cannot tolerate any breathiness or weakness in their voice, and therefore they have frequent, small doses of Botox. Others can tolerate several weeks of breathiness, but in exchange they get more months of the optimal effect. It will take several injections before you know your best dose and timing schedule. How will I know when I should get another injection? The tremor gradually becomes stronger over a period of weeks or months. During that time, techniques you learned in voice therapy are the most helpful. Because injections are only given once a month, on the fourth Tuesday of the month, you should make your appointment for your next injection accordingly.

Other Neurogenic Disorders The voice may be impaired in persons with other neurologic diseases such as: • • •

Parkinson's Disease Myasthenia Gravis Amyotrophic Lateral Sclerosis (ALS, a.k.a. Lou Gherig's disease)

The voice may also be impaired in persons who suffer a stroke or other brain injury and have damage to any part of the speech system. When there is damage to the brain causing some impairment of the speech system, including the voice, it is termed dysarthria. In the case of these neurogenic disorders, there is rarely any medical treatment that will help the voice, over and above the medical treatment given for the primary disease. Botox injections (see Spasmodic Dysphonia) may be helpful if there is extreme tension in the larynx. A surgical procedure to bring the vocal folds into closer contact (see 25

Paralysis/Paresis) if there is extreme weakness of the vocal folds. Functional voice therapy may be useful to teach techniques for efficient compensation.

Psychogenic Disorders: Conversion Dysphonia/Aphonia This disorder exists when there is psychological trauma that is manifested physically. In the case of conversion dysphonia or aphonia (complete loss of voice), there may be a single traumatic event such as an accident, death, or psychologically damaging event, and there is change of voice within a short time. Or, there may be a long term psychologically damaging circumstance, such as sexual abuse, that may be manifested soon or many years later. In the case of conversion disorder, the individual may undergo functional voice therapy to gain control over his or her voice, but in most cases the voice disorder will not resolve unless there is also psychotherapy to address the underlying problem.

Juvenile Voice/Mutational Falsetto/Puberphonia This disorder exists when there is some psychological reason for an individual to resist the maturing and lowering pitch of the adult voice, and maintains the higher pitch of preadolescent. This disorder is much more common in adolescent males, but can also exist in females. The voice therapist may be able to elicit a normally low-pitched voice by engaging the individual in certain vocal tasks, but if the psychological resistance is strong, psychotherapy may be necessary to maintain the more adult voice quality. It is also possible that the post-pubertal voice does not develop because there is some physical problem with the voice at the time of the pubertal voice change, such as a prolonged upper respiratory infection or intubation. In that case, the disorder is not considered psychogenic and usually responds quickly and easily to functional therapy.

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Case History History 29 year old male Complaints • • • • • • • •

Lifelong hoarse voice quality that has gradually worsened. Noted to be a fairly significant problem ten years ago. He can’t yell very well. He cannot be heard and he is unable to complete long sentences in one breath. His voice is hoarse in quality and soft-spoken. His voice is generally better in the morning, though the voice sometimes improves with continued use. Previously diagnosed with nodules - speech therapy did not help at that time

Medical history • • •

Singing: none Smoking: none Fluids: o Water: 5 cup per day o Caffeine: 2 caffeinated beverages/day 27

o

Alcohol: 0 glass per month

Character • • •

Talkativeness: 3 on a scale of 7 (1 quiet, 7 talkative) Loudness: 3 on a scale of 7 (1 is soft, 7 is loud) Vocal commitments at Work: 2 hours per workday

Vocal capabilities See Vocal capabilities testing (annexure B)guidelines for explanations • • • • • • • • • •

Reading pitch: Forced with harmonics and overtones Anchor pitch: A3 (falsetto like or female pitch) Range: G3 – E4 (very abbreviated range) Max phonation: >20 seconds @ B3 Loudness: excellent Swelling tests: negative, though he sounds like he has a gap throughout his range Neurogenicity: none Psychogenicity: none Valving: fair Respiration: normal

Stroboscopic Examination of the Larynx

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Evaluation

Rigid endoscopy

During breathing, the vocal folds open widely and the furrow on the inside or medial margin is visible as a groove (arrows).

The prephonatory gap is the instant just before the vocal cords begin vibrating. There is bowing with the large central gap present. In addition the false vocal folds are squeezed quite tightly together as the patient attempts to close the vocal cords as much as possible.

Closed phase during stroboscopy. The vocal folds do not even meet in the midline so a lot of air escapes while making a sound. The pitch is E3, a normal speaking pitch for a male. The left vocal fold is vibrating at a harmonic with a central musical node of vibration suggesting a source for the overtones in his voice. Again the false vocal folds are squeezed tightly almost covering the true vocal folds.

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Evaluation

Flexible endoscopy

Intralaryngeal view demonstrates wispiness of vocal folds with very capacious or sunken in laryngeal ventricles (arrows). The vocal cord muscle (thryoarytenoid) is very atrophic.

Closed phase during stroboscopy for the lower lip of the vocal fold with a central air gap.

Open phase during stroboscopy. The left vocal fold seems weaker than the right and here is buckling out or fluttering in the wind, compared to the more subdued vibrations on the right. It is as if the left vocal cord lacks the tension present in the right.

Treatment 1. My protocal has been to try voice building (see annexure A) initially, since the visible bowing may represent muscular atrophy. 2. I wondered in this case if there was a loss of innervation or nerve supply to the very bowed vocal muscle (thyroarytenoid) and performed an EMG. There was a normal hookup of the nerve to the vocal muscle. 3. If voice building fails (after a three to six week trial), then I inject collagen or place laryngeal implants to improve the bulk of the vocal folds and bring the edges closer together. 4. The furrow may represent an adhesion of the lining of the vocal fold mucosa to the underlying muscle. The normal vocal fold is three layers with a lubricating layer in between the mucosa and the muscle.

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Reference: Web links   

http://www.voicedoctor.net/therapy/underdoer.html http://www.mayoclinic.org/voice-disorders/index.html More information about this topic can be found at the International Tremor Foundation web site at: www.essentialtremor.org. Another good site is www.diseasesexplained.com/EssentialTremor/index.html. This is provided as a link at the first site.

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Annexure A

Weak voices and Voice Building Information for patients with problems affecting the muscles the vocal folds. This is commonly termed vocal fold bowing. • • • • • • •

Causes of a vocal weakness Symptoms of a vocal weakness What does my voice box look like? Results of voice building The voice building program Benefits of voice building Alternatives when voice building fails

Causes •

• • • •

Underuse o Insufficient voice use or insufficient vocal vigor can play a role. These are people who might be termed vocal underdoers. For example, an individual might have an unusually taciturn personality, live alone and work at a job that requires very little talking. Aging o The general physical changes that accompany aging may cause a loss of strength, elasticity and bulk to the vocal folds. Paralysis o Thyroid or chest surgery may leave a person with a paralyzed vocal fold. o This may also occur spontaneously, after a cold or from unknown causes as well. Loss o Partial loss of a vocal fold. Surgery, such as to remove a tumor may leave one vocal fold smaller. Scarring o Scar injuries to the voice box may occur after a breathing tube has been in for a prolonged period. o Surgery on the vocal fold may leave scarring that stiffens the vocal fold. o Cricothyroidotomy  This special tracheotomy is placed into the voicebox in an emergency situation.

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•

Congenital o One may be born with or genetically determined - to have or develop - relatively thin vocal folds, just like there are all types of bodies, there are all sizes of vocal cords.

Symptoms •

• • • •

Trouble speaking in noisy environments. o This includes trouble being heard by others as well as unusually rapid fatigue or wearing out of the voice when used in a noisy area. Some people may even complain of lightheadedness after speaking in a noisy environment. A whispery quality to the voice. o There is a lot of air escaping. A coarse quality to the voice. o One is speaking using the false vocal folds. Reduced vocal endurance. o The voice fades or becomes foggy. It may sound hoarse after use. Breathing more often. o When speaking, fewer words than normal may be produced on each breath and more breaths are required than before to complete a sentence.

Appearance of the vocal folds • • • • • • •

The vocal folds may be bowed, thinned and/or convex, rather than straight. There is a noticeable gap in the center that results in air loss during speaking. One or both vocal folds may have decreased mobility. Primarily, or only, the false vocal folds are being used to phonate. The vocal folds may not be able to reach each other or touch. The vocal folds may move but fail to vibrate from stiffness and/or scarring. The vocal folds may have an irregular edge or even scar bands connecting the vocal folds.

Results of voice building 1.

Strength

o

2.

Vigorous usage over several weeks can increase the strength and bulk of the vocal muscles. Both of these changes can lead to improved closure of the vocal folds with a stronger voice. There will also be a more efficient use of the air passing between the vocal folds. This can also lead to increased endurance Flexibility o Loosening up scarred, stiffened vocal folds can actually start them vibrating again, even after severe scarring or a prolonged loss of voice.

Voice building program 1. 2. 3. 4. 5.

To benefit the most, adopt the following program under the supervision of a speech pathologist (voice therapist) Schedule 2 or 3 practice sessions per day on your own, each lasting about 10 minutes. Use your voice in a robust fashion during each session. Do not yell or scream, rather, use your "voice of authority" or "opera singer voice". Pretend you are speaking to an audience in a large room without a microphone... "Four score and seven years ago..." You may read the newspaper or a book out loud for something to say. Many people have exercised their voice on their daily commute in the car. To passers by, they appear to be talking on a car phone. Content is not important, robustness is. Some have just

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6.

described the surroundings out loud. "I see a two story, red brick house! There goes a green minivan!..." Visit the entire range of the voice, both high and low. Robust hooted "oooo" sounds can be very helpful. Vocalizations may be produced when breathing in as well. This has been particularly helpful with scarring.

Benefits 1.

2.

A high percentage of people with the above problems will see an improvement in their voice and its capabilities. It is impossible to know if you will benefit until you have followed this treatment on a disciplined basis for at least three weeks. You should have a follow up examination after this time to evaluate your progress. If you do notice a benefit, you should continue on this regime until there is no further improvement. Like athletes in training, most people will not be at there maximum improvement in three weeks. When a maximum improvement has been attained, the benefit to the voice can usually be maintained with regular, but perhaps less extensive voice use.

Annexure B

Vocal Capability Battery This portion of the exam actually starts during the history interview as many cues can be picked up during conversation with the patient. Then a series of vocal behaviors are elicited from the patient and recorded. The reason for performing these tasks are that they are a vocal stress test. Like the more familiar cardiac stress test, many problems show up under exercise. The speaking voice is typically near the lowest end of the patient’s pitch range and using the speaking voice could be likened to measuring the hearts ability to pump while sitting down at rest. Asking the patient to phonate throughout their range then would be like exercising. A generalization is that most voice disorders cause problems with stiffening the vocal fold and are most detectable at high pitch when extra physiologic stiffness is being applied to the vocal folds. Neuromuscular problems are typically best detected at lower pitches when the additional physiologic flaccidity augments any preexisting muscular problem. This portion of the exam is audio recorded for documentation and later review.

• • • • • • •

Speaking voice Maximum phonation time (MPT) Speaking loudly Yelling Pitch Range Sustained pitch Swelling tests

Speaking voice 34

Anchor pitch is the lowest common pitch during a given task. We use a reading task. The patient states his/her name and reads a paragraph. In our clinic the paragraph «Mans First Boat» is utilized. It is approximately a 4th grade level of reading. There are other phonetically balanced paragraphs in use as well. It is probably most important to be internally consistent by using the same text each time. When the patient cannot read or cannot speak English we resort to counting in the patients own language. While the patient is reading we match their most obvious lowest pitch and note this as their anchor/speaking pitch. This should be considered their fundamental frequency (Fo). A typical Fo for men is about C3 or 100 Hz. A typical Fo for women is about G3 or 200Hz. See a discussion on measuring pitch.

Maximum phonation time (MPT) We ask the patient to say /i/ (which can be translated as a prolonged eeeeee sound) at their anchor pitch. Typically they will need to be reminded that it is low in their voice. We try to use their anchor pitch to make the maximum phonation time as consistent as possible between exams, at least for a given patient. They are asked to breathe in fully and hold /i/ at anchor pitch for as long as possible. This is a very imprecise measure because variables other than pitch, such as degree of loudness or pressed phonation, can drastically affect the MPT. However, it is a useful measure in a given patient when measured before and after treatment, particularly when dealing with air wasting disorders.

Speaking loudly The patient rereads the paragraph in their loudest possible voice. Some coaching is necessary since some patients will be hesitant to embarrass themselves since they know their voice is limited and may not sound well to others. Non organic patients will have difficulty with this unexpected task. Underdoers may have a restrained quality.

Yelling We ask the patient to say Hey! as if they had an emergency and had to get someone’s attention. Disorders which cause a flaccidity of the vocal fold, such as paralysis or atrophy will lack an edge to the sound or, if more severe, have the characteristics of a leaky valve. The harder the vocal fold is driven, the louder will be a luffing or fluttering sound. This sound will be apparent, especially at low pitch, since the additional energy imparted to the vocal fold combined with its flaccidity will cause the fold to buckle out rather than to draw in. At higher pitches this luffing may disappear as tensioning of the vocal folds increases the ability of a flaccid vocal fold to recoil. Non organic disorders will typically demonstrate an unusual pattern such as the voice getting softer instead of louder during a yell.

Pitch Range Pitch range determinations almost always require coaching since singers with voice problems are embarrassed when they cannot get their voice to perform properly, perhaps even threatening their career. The rest of the world, who are shower or car radio singers only, are sometimes quite reluctant to sing in front of an audience, even as small as one person - the examiner. To confirm range we listen for characteristics of a vocal ceiling and vocal floor to determine overall pitch range. A muscular ceiling has a tight, strained quality. A mucosal ceiling has a breathy quality. A rapport ceiling has a

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completely normal sound. Ceilings tend to be the same for different vocal tasks so when several tasks reveal the same pitch, the upper range has been determined. For the ceiling, the patient is asked to sing /i/ repeating the pitch of the examiner. Often we try working up the scale by intervals such as Do Mi Sol Do. Another method is to have the patient make a sound like a siren striving to reach the highest note possible. Above C5 we may switch to /a/ or if the patient is having difficulty we switch to /oo/. We verify the ceiling by asking the patient to sing the first phrase of Happy Birthday, again working up the scale until a ceiling is reached. A staccato task is also useful for confirming the pitch ceiling. To determine the floor of the pitch range, the patient is asked to lower their pitch in a stepwise fashion. We ask them to keep going until we hear vocal fry (a popping sound like grease in a frying pan), they can’t move lower or the sound becomes breathy. Then they are asked to try to reach their lowest note by gliding down in pitch from a mid-range starting point.. In some pathology the anchor pitch is often right at the bottom of the pitch range. The normal recoil position of the vocal folds should be 5 to 6 semitones higher. Much pathology is revealed in the upper pitch range so this is an extremely important part of the vocal exam. The accuracy of the examiner is increased by having the patient perform multiple tasks and verifying that the extremes are the same in each task. We utilize musical notation to describe pitch range. Middle C on the piano is called C4 (the beginning of the fourth octave on the piano). One advantage to using musical measures is the ease of communication with singers. See swelling tests below. It is possible to use Hertz as well.

Sustained pitch The patient is asked to match a pitch and hold a prolonged phonation. Voice quality and steadiness can be observed. Characteristics may differ at different pitches. Note may be made of pitch variability, including its regularity of variation. Tremor and spasmodic dysphonia are differentiated by this test. Scarring or stiffness may also be suggested by loss of phonation throughout some portion of the pitch range.

Swelling tests (1) Vocal fold swellings cause a very characteristic ceiling effect. Two sung phrases are utilized in our clinic. The first phrase of Happy Birthday and a staccato passage (Fig 2). These are sung by the patient in a pianissimo boy soprano style. As pitch is increased, a ceiling will be reached. A mucosal ceiling will be characterized by onset delays (air escape prior to phonation) and ability to overcome the ceiling by driving the voice or increasing the volume. A muscular ceiling will be evident by a slight flatting or straining of the pitch Observing the patients voice at high pitch is essential for finding disorders that cause stiffness of the vocal fold. Physiologically pitch is increased by stretching the vocal fold and this physiologic stiffness adds to any lesion induced stiffness to stop or distort vocal fold vibrations. Thus, a lesion with minimal stiffness will show up as a loss of high, soft singing. As the lesional stiffness increases, the voice becomes pathologic at lower and lower pitches. Since the speaking voice is typically at the bottom end of a patients pitch range, it takes a significant amount of stiffness to cause a disordered speaking voice.

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Swelling tests can be taught to patients and can be essential in preventing recurrence of nodules and polyps. The patient is taught to use the tests as a monitoring device. If they use the tests daily, they can catch swelling and alter their behavior before the swelling becomes chronic and permanent.

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