Voice Disorders

DYSPHONIA PLICA VENTRICULARIS
  • Ventricular dysphonia
  • Voice is produced by ventricular folds (false cords)
  • Voice is rough, low pitched and unpleasant.
  • Ventricular voice may be secondary to impaired function of the true cord such as paralysis, fixation, surgical excision, or tumours.
  • Ventricular bands in these situations try to compensate or assume phonatory function of true cords.
  • Functional type of ventricular dysphonia occurs in normal larynx . Here cause is psychogenic.
  • Diagnosis is made on indirect laryngoscopy; the false cords are seen to
  • approximate partially or completely and obscure the view of true cords on phonation.
  • Ventricular dysphonia secondary to laryngeal disorders is difficult to treat but the functional type can be helped through voice therapy and psychological counselling. 
FUNCTIONAL APHONIA or HYSTERICAL APHONIA
  • Seen in emotionally labile females in the agbe group 15 – 30.
  • Does not occur due to vocal cord paralysis.
  • Usually sudden
  • Patient communicates with whisper
  • O/E – vocal cords are seen in abducted position and fail to adduct on phonation
  • Adduction of cords are seen on coughing, which indicates normal adductor function
  • Sound of cough is good
  • Treatment – reassurance and psychotherapy.Speech therapy has no role in it.
PUBERPHONIA or MUTATIONAL FALSETTO VOICE
  • Childhood voice has a higher pitch
  • When the larynx matures at puberty, vocal cords lengthen and voice changes to lower pitch in males
  • Failure of this change is called puberphonia.
  • Voice break may also refer to the deepening of the voice during puberty, known as the voice change.
  • Young man whose voice has not broken is called Puberphonia.
  • Seen in boys who are emotionally immature, feel insecure and show excessive fixation to their mother
  • Physical and sexual development are normal
  • Gutzmann's pressure test – pressing the thyroid prominence in a backward and downward direction relaxes the overstretched cords and low pitch voice can be produced.
  • Treatment
  • Mostly conservative:Training the body to produce low pitched voice with the help of a speech therapist.
  • Surgery might be needed in few cases:Lengthening of vocal cord i.e.Thyroplasty type III
PHONASTHENIA
  • Weakness of voice due to fatigue of phonatory muscles
  • Thyroarytenoid and interarytenoids are affected
  • Seen in voice abuse or misuse
  • Indirect laryngoscopy shows
  1. Elliptical space between the cords in weakness of thyroarytenoid
  2. Triangular gap near the posterior commissure in weakness of interarytenoid
  3. Key-hole appearance of glottis when both are involved.
  4. Voice therapy may help.
HABITUAL DYSPHONIA
  • When a person always uses a poor voice in normal circumstances, is called habitual dysphonia.
  • It is not related to stressful events and seems to be a habit.
  • Treatment is Vocal exercise and reassurance.
SPASMODIC DYSPHONIA
Spasmodic dysphonia (or laryngeal dystonia) is a neurological voice disorder characterized by involuntary movements or spasms of one or more muscles of the larynx (vocal folds or voice box) during speech
. Spasmodic dysphonia is not a local laryngeal disorder but a neurolgical disorder and is often associated with other dystonias, e. g. blepharospasm, oromandibular dystonias.
The three types of spasmodic dysphonia :
Adductor spasmodic dysphonia
  • Sudden involuntary muscle movements or spasms cause the vocal cords to slam together and stiffen.These spasms make it difficult for the vocal folds to vibrate and produce 
  • voice. Words are often cut off or are difficult to start because of the muscle spasms.
  • The voice of an individual with adductor spasmodic dysphonia is commonly described as strained or strangled and full of effort.
  • Stress,often makes the muscle spasms more severe.
Abductor spasmodic dysphonia
  • In abductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal folds to open.
  • The vocal folds cannot vibrate when they are open.
  • The open position of the vocal folds also allows air to escape from the lungs during speech. As a result, the voices of these individuals often sound weak, quiet and breathy or whispery.
Mixed spasmodic dysphonia
  • Mixed spasmodic dysphonia involves both muscles that open the vocal folds and those that close them and therefore has features of both adductor and abductor spasmodic dysphonia.
Treatment :
  • Botox injection:The most common treatment for spasmodic dysphonia is the injection of very small amounts of botulinum toxin directly into the affected muscles of the larynx.
  • The toxin weakens muscles by blocking the nerve impulse to the muscle.
  • Surgery:Type 2 Thyroplasty in a case of Adductor Spasmodic Dysphonia.
  • Lateralization thyroplasty is intended to prevent this tight closure of the glottis at the terminal stage of phonation by lateralizing the position of the vocal cord
  • Behavioral therapy :it may work to reduce symptoms in mild cases.
  • Other people may benefit from psychological counseling to help them accept and live with their voice problem.
HYPONASALITY or RHINOLALIA CLAUSA
  • Due to blockage of the nose or nasopharynx 
  • Common cold
  • Nasal allergy
  • Nasal polypi
  • Nasal growth
  • Adenoids
  • Nasopharyngeal mass
  • Familial speech pattern
  • Habitual
HYPERNASALITY or RHINOLALIA APERTA
  • Failure of nasopharynx to cut off from oropharynx or abnormal communication between oral and nasal cavities
  • Velopharyngeal insufficiency
  • Congenitally short soft palate
  • Submucous palate
  • Large nasopharynx'
  • Cleft on soft palate
  • Paralysis of soft palate
  • Post-adenoidectomy
  • Oro-nasal fistula
  • Familial/habitual
Exam Question
  • Rhinolalia clausa is associated with Allergic rhinitis , Adenoids, Nasal polyps.
  • Rhinolalia clausa is associated with Palatal paralysis.
  • In dysphonia plica ventricularis, sound is produced by False vocal cords.
  • Functional Aphonia is seen commonly in females.
  • Functional aphonia is not due to vocal cord paralysis.
  • In a case of functional aphonia,the patient is able to cough.
  • Habitual dysphonia is characterized by poor voice in normal environment .
  • Treatment of Habitual Dysphonia is Vocal exercise and reassurance.
  • Young man whose voice has not broken is called Puberphonia.
  • Patient with the adductor type of Spasmodic dysphonia have strained and stran­gled voice.
  • Botulinum toxin is the standard treatment for Spasmodic dysphonia.
  • Spasmodic dysphonia may be associated with other focal dysphonia.
  • Type -III Thyroplasty is the surgical treatment of Puperphonia.

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