physiology of voice production

1. Physiology Of Voice Production Its
Disorders And Management
Kunal ranjan
Pgt 3rd year
E. N.T , GMCH

2. Introduction
Even before we are born, we are listening for voices.
Research has shown that a child in the womb shows a
discernible preference for a mother's voice. Hearing that
voice, and mother's heartbeat, is one of the few sensory
perceptions accessible in the womb.
Voices are highly unique and individual. Marilyn Monroe
had a breathy, come-hither voice. Alfred Hitchcock had a
stilted, caught-in-the-throat sound that complemented his
theatrical thrillers. Martin Luther King Jr. spoke with
command and charisma in a smooth deep voice that
captivated listeners.
To understand, the physiology of voice production is essential
for the proper diagnosis and treatment of voice disorders.

3. Definitions
• Voice
A more precise definition of voice is the acoustic output from the vocal tract that is
characterised by their dependance on vocal fold vibratory input
Voice (or vocalization) is the sound produced by humans and other vertebrates using
the lungs and the vocal folds in the larynx, or voice box. Voice is not always
produced as speech, however. Infants babble and coo; animals bark, moo, whinny,
growl, and meow; and adult humans laugh, sing, and cry.
• Speech
Humans express thoughts, feelings, and ideas orally to one another through a
series of complex movements that alter and mold the basic tone created by voice
into specific, decodable sounds. Speech is produced by precisely coordinated
muscle actions in the head, neck, chest, and abdomen. Speech development is a
gradual process that requires years of practice. During this process, a child learns
how to regulate these muscles to produce understandable speech.
• Language
Language is the expression of human communication through which knowledge,
belief, and behavior can be experienced, explained, and shared
• Whispering is an unvoiced mode of phonation in which the vocal folds (vocal
cords) are adducted so that they do not vibrate; air passes between the arytenoid
cartilages to create audible turbulence during speech

4. Relevant Anatomy
Vocal ligament:
• Also known as the true vocal cord is responsible for the
generation of voice.
• This is attached just below the level of vestibular
ligament. This ligament raises a mucosal fold known as
known as vocal fold.
• Infact this ligament has been considered to be the
thickened superior portion of the cricothyroid
ligament.
• The vocal ligament gets arises from the vocal process
of the arytenoid cartilage and gets attached to the
thryoid angle

5. Vestibular ligament:
• Also known as the false vocal cord.
• This ligament raises a thick fold of mucous
membrane known as the vestibular fold.
• This ligament constitues the upper border of
the ventricle of the larynx.

9. Nerve supply:
• The larynx is supplied by branches of vagus nerve
i.e. superior and recurrent laryngeal nerves.
• Superior laryngeal nerve: arises from the inferior
vagal ganglion.
• Divides into a small external laryngeal branch and
a larger internal laryngeal nerve branch.
• The external laryngeal nerve provides motor
supply to the cricothyroid muscle,
• while the internal laryngeal nerve pierces the
thyrohyoid membrane above the entrance of the
superior laryngeal artery and divides into sensori
and secretomotor branches.

10. Comparative anatomy and
evolutionary changes for production
of voice
• The unique morphological features of the human
larynx lie not in the internal structure of the larynx, but
in the fact that the larynx, hyoid bone, and lower
jawbone move apart together and are interlocked via
the muscles, while pulled into a vertical position from
the cranium.
• This positional relationship was formed because
humans stand upright on two legs, breathe through the
diaphragm (particularly indrawn breath) stably and
with efficiency, and masticate efficiently using the
lower jaw, formed by membranous ossification (a
characteristic of mammals).

11. • Animals other than humans also use a wide range of vocal
communication methods, such as the frog’s croaking, the
bird’s chirping, the wolf’s howling, and the whale’s calls.
• However, only some reptiles and mammals produce sound
from their vocal cords. The majority of other reptiles and
amphibians do not vocalize.
• Frogs generate sound from tracheal ridges in their tracheae
and
• Birds produce sound from the syrinx right above the
tracheal bifurcation.
• But the muscles that control these movements are
primarily controlled by the hypoglossal nerve. This is
different from the larynx of humans and other mammals

12. • This historical background shows that the larynx was
differentiated as a branchial organ to store air in the
lungs, and even during the biological evolution
resulting from the subsequent shift to land, the larynx
was simply differentiated to take in air.
• However, in mammals, once the diaphragm—the
muscle dedicated to respiration —was differentiated
from the parietal muscles of the neck region, the larynx
became engaged in regulating respiration. This laid the
groundwork for vocal movement.

13. • Once humans began to walk upright on two legs and the cervical
region and the mouth cavity/nasal cavity sat at right angles to the
cranium, the larynx moved downward and the pharyngeal cavity
lengthened.
• It is often asserted that this led to the birth of language.
• However, the physical relationship of the lower jawbone, hyoid
bone, and larynx is almost vertical and they are connected to each
other in gorillas, which are partly bipedal.
• The current physical relationship of them was likely acquired by
upright humans over millions of years.
• This can be easily understood by the human’s growth process.
• The larynx is just below the soft palate after birth, but begins to
descend when the infant begins to hold up his/her neck.

14. Neuroanatomy of phonation
• Phonation is dependent upon the integrated functioning of
many elements of the CNS and PNS.
• Cortical loci is associated with voluntary phonation and
subcortical representation is responsible for reflex laryngeal
function and involuntary phonation.
• PET scan has shown that PAG( periaqueductal grey matter a
region of midbrain, is a crucial site for voice production.
• The motor activity for vocalization appears to be integrated
through a projection from PAG to column of neurons
known as nucleus retroambigualis (NRA)
• NRA plays an important role in generating respiratory
pressure and laryngeal adduction.

15. • Pyramidal and extrapyramidal system controls the
phonation
• Extrapyramidal system inhibts the pyramidal system
thereby controlling the force, speed and range of
movement.
• Mechanoreceptors present over the larynx play an
important role in phonation.
• It ensures that vocal folds are stablised and return to
normal following displacement by forceful aexpiratory
air stream
• Mechanoreceptor system is in connection with other
systems

16. • 3 main areas of brain controlling phonation are-
a. Precentral and post central gyrus
b. Brocas area
c. Supplementary motor area
d. Motor cortex has number of connections to
thalamus, hypothalamus
e. Thalamus has number of connections to
cerebellum and mid brain
f. Ventral nucleus of thalamus controlls initiation
of speech, rate, pitch and articulation

17. The Biomechanics of phonation
• On quite respiration vocal cords abduct on
inspiration and adduct on expiration.
• The larynx descends on inspiration and ascends
on expiration.
Biomechanics of phonation can be divided into –
Initiation of voice
The vibratory cycle
Vocal registers: characteristics of vocal fold
adduction and vibration

18. The requirements of normal phonation are as
follows:
1. Active respiratory support
2. Adequate glottic closure
3. Normal mucosal covering of the vocal cord
4. Adequate control of vocal fold length and
tension.

19. Three Voice Subsystems
Subsystem Voice organ Role in sound production
Air pressure system Diaphragm, chest, abdomen,ribs Provides and regulates air
pressure to cause vocal
folds to vibrate
Vibratory system Voice box (larynx)Vocal
folds
Vocal folds vibrate,
changing air pressure to
sound waves producing
“voiced sound,” frequently
described as a “buzzy
sound”Varies pitch of
sound
Resonating system Vocal tract: throat
(pharynx), oral cavity, nasal
passages
Changes the “buzzy sound”
into a person’s
recognizable voice

20. INITIATION OF VOICE:
• Vocal folds rapidly abduct before phonation to allow
intake of air.
• Wyke termed it as the prephonatory inspiratory phase.
• Subsequently vocal folds are adducted by the
contraction of lateral cricoarytenoid muscles.
• Vocal note is generated by pulmonic air as it is exhaled
between adducted vocal cords.
• Vocal note is produced due to vocal fold osscillation.
• The amount of air pressure required to begin voicing
known as phonation threshold pressure.

21. THE VIBRATORY CYCLE:
• Three phases- adduction, aerodynamic separation and recoil.
• Subglottic air pressure overcomes the adducted vocal cord ,
the vocal folds peel apart at inferior border.
• Vocal folds separate at their superior margin
• Puff of air released
• Negative pressure at glottis caused by Bernoulli effect, leading
inferior vocal margins closing first.
• Each cycle of adduction, separation and recoil is the
manifestation of mucosal wave travelling from inferior to
superior margin of vocal fold.
• Cover / body theory – vocalis muscle provides firm body of the
vocal fold over which mucous membrane cover of vocal fold is
blown by expiratory air stream

22. MUCOSAL WAVE
• One important physiologic parameter which must
be noted during phonation is the mucosal wave.
• The mucosal wave is an undulation which occur
over the vocal fold mucosa.
• This wave travels in an infero superior direction.
• The speed of mucosal wave ranges from 0.5 - 1
m/sec. The symmetry of these mocosal waves
must also be taken into consideration while
studying the physiology of voice production.
• Any mild assymetry between the two vocal folds
must be considered as pathological.

23. VIBRATORY CYCLE:
phase description
closing The vocal fold begins to close rapidly from
their lower margin
closed The medial edges of the vocal folds are in
full contact
opening The vocal folds begin to separate from
their lower margin and gradually peel
apart. The superior margin remains in
contact until end of this phase
open Vocal folds are separated , the longest part
of normal vibratory cycle

24. VOCAL REGISTERS: Characteristics of vocal fold
adduction and vibration
• A vocal register is a range of tones in the human
voice produced by a particular vibratory pattern
of the vocal fold
• Registers have been regarded as the distinct
regions of vocal quality over certain ranges of
pitch and loudness.
• Registers are governed by degree of contraction
of vocalis muscles.

25. LOFT REGISTER-
• Also known as falsetto
• Covers the highest frequencies of the voice
• Vocal folds are lengthened, extremely tense and
thinned so that there is minimal vibration
• Subglottic air pressure is high
• During the production of these high frequencies
the larynx is raised by suprahyoid musclesand
pharynx shortened

26. Modal register-
• Encompasses range of frequencies usually
employed in speech and singing
• Membranous portion of vocal folds are
adducted
• In cross section the vocal folds are triangular
in shape

27. Pulse register-
• Also known as glottal fry or vocal fry or creaky
voice
• Occurs in lowest vocal frequencies
• Feature of normal speech
• Long closed phase in each vibratory cycle

28. VOCAL REGISTERS
REGISTER EQUIVALENT TERM VOCAL FOLDS FREQUENCY
RANGE
LOFT REGISTER FALSETTO THIN ,TENSE,
LENGTHENED,
MINIMAL
VIBRATION
275- 1100
MODAL REGISTER CHEST, HEAD,
MIDDLE VOICE
COMPLETE
ADDUCTION
100- 300
PULSE REGISTER VOCAL FRY,
GLOTTAL FRY,
CREAKY VOICE
LONG CLOSED
PHASE
20- 60

29. THEORIES OF MECHANISM OF VOCAL
CORD VIBRATION
• Vibrating string theory
• Myoelastic theory
• Aerodynamic theory
• Neurochronaxic theory
• Two mass theory of vocal fold vibration
• Cover body theory of Hirano

31. MYELOELASTIC -AERODYNAMIC
THEORY
• Based on the Bernoulli energy law in fluids.
• Propagated by Van den berg and colleagues in 1957.
• Bernoulli forces (negative pressure) cause the vocal folds to be sucked together,
creating a closed airspace below the glottis. Continued air pressure from the lungs
builds up underneath the closed folds. Once this pressure becomes high enough,
the folds are blown outward, thus opening the glottis and releasing a single 'puff'
of air.
• The theory states that when a stream of breath is flowing through the glottis while
the arytenoid cartilages are held together by the action of the interarytenoid
muscles
• A push-pull effect is created on the vocal fold tissues that maintains self-sustained
oscillation.
• The push occurs during glottal opening, when the glottis is convergent, whereas
the pull occurs during glottal closing, when the glottis is divergent.
• This is most acceptable theory of phonation.
• According to this theory , the vocal cords vibrate transversely under the pressure
of tracheobronchial bellows , which acts like a wedge separating the vocal cords,
their elasticity bringing them together again.

35. Neurochronaxic theory
• Was propagated by Husson 1950
• Rapidly contraction and relaxation of muscles
• This theory states that the frequency of the vocal fold vibration is
determined by the chronaxy of the recurrent nerve, and not by breath
pressure or muscular tension.
• Advocates of this theory thought that every single vibration of the vocal
folds was due to an impulse from the recurrent laryngeal nerves.
• And that the acoustic center in the brain regulated the speed of vocal fold
vibration.
• Speech and voice scientists have long since left this theory as the muscles
have been shown to not be able to contract fast enough to accomplish the
vibration.
• In addition, persons with paralyzed vocal folds can produce phonation,
which would not be possible according to this theory.
• Phonation occurring in excised larynges would also not be possible
according to this theory.

36. TWO MASS THEORY OF VOCAL FOLD
VIBRATION
• By Ischizaka and Flangang in 1972.
• Both upper and lower part of vocal fold
demonstrate closing and opening movement
but they are not in same phase.
• Upper part of the vocal fold follows behind
the lower part

37. BODY COVER THEORY
• Propagated by Hirano in 1974
• A two-layer body-cover model of the vocal fold, as suggested
by Hirano (1974), is used to investigate the influence of the stiffness
of vocal fold body and cover and vocal fold geometry on phonation
threshold pressure, phonation onset frequency, vocal fold vibration,
and sound production efficiency.
• Myeloelastic and aerodynamic theory can’t explain all details of
vocal cord vibration
• Outer edges of vocal cord consists of different kind of tissues
together form viscous surface
• The cover layer consists of the epithelium, and the superficial and
intermediate layers of the lamina propria, which have no contractile
properties and are generally more pliable than the body layer
(Hirano, 1974)
• Surface reacts different to the airstream than the deeper muscle
layer
• Surface flutters when vocal cord vibrates due to airstream

40. Mechanism of Vocal Frequency change
• Determined by length, tension and mass
• Total mass not important but the mass
vibrating is more important
• Amount of mass set into vibration depends
upon fundamental frequency, intensity and
mode of vibration and length of the vocal cord
• As the band is stretched the thickness of the
band decreases

41. Relationship between vocal cord
length and frequency

42. VOCAL FOLD TENSION AND
FUNDAMENTAL FREQUENCY
• As tension increases the frequency increases
• Difficult to measure
• Tension is not the only determinant but mass
per unit length has a pronounced influenceon
fundamental frequency of vibration
• In the modal register the mass is an important
factor however , in falsetto register tension is
a determinant factor

43. Vocal
frequency
decreases as
mass
increases

44. MECHANISM OF LOUDNESS CHANGE
• Vocal loudness is the perceptual correlate of
amplitude- the size of the oscillation of vocal
folds
• Amplitude determined by the force of
transglottal airflow
• Increasing both the airflow through the larynx
and vocal resistance increases vocal loudness

45. Voice Types Different voices can be described in different
ways. These adjectives can be used to describe someone's
voice.
• Breathy- A breathy voice is one that has lots of breathing noises
throughout speaking.
• Croaky- Describes a voice that is low and sounds as if the person is sick.
• Gruff- If you have a gruff voice you have a low and rough sound when
you speak.
• Flat- A flat voice can also be described as a monotone voice. There is
very little change in how you sound when speaking.
• Gravelly- Similar to gruff; low and rough with an unhealthy sound.
• Hoarse- When someone speaks in a low and rough voice because their
throat is sore
• Penetrating- A voice so high pitched that it is uncomfortable to listen to.
• Smoky- A gravelly voice that smokers often have.
• Throaty- Comes from deep down in the throat.
• Wheezy- Sounds as if the person is having difficulty breathing while they
speak.

46. Male And Female Voice
• Adult male voices are usually lower-pitched and have larger folds.
• The male vocal folds are between 17 mm and 25 mm in length.
• The female vocal folds are between 12.5 mm and 17.5 mm in
length.
• The difference in vocal folds size between men and women means
that they have differently pitched voices.
• Additionally, genetics also causes variances amongst the same sex,
with men's and women's singing voices being categorized into
types.
• For example, among men, there
are bass, baritone, tenor and countertenor.
• and among women, contralto, mezzo-soprano and soprano

47. OBJECTIVE EVALUATION OF VOICE
• Perceptual evaluation of voice- e. hoarseness,
roughness, breathiness. It refers to process of assessing
the qualities of voice by an expert or trained listener
• Acoustic analysis- using a microphone placed near
mouth to evaluate various factors like fundamental
frequency, intensity, perturbation measures
• Electrolaryngography – measuring high frequency
electrical conductance placed over skin over thyroid
cartilage
• Visual assesssment – using endoscopic laryngoscopy
including stroboscopy, high speed digital
cinematography

48. • Aerodynamic measures – indirect measure of
subglottic presssure and airflow
• Quality of life measures- generic
questionnaires to evaluate impact of voice
condition on quality of life
• Voice accumulator and tests of vocal loading-
sampling the voice or vocal function over a
prolonged period of time or after vocal stress
test

49. Stroboscopy-
• Stroboscopy is a special method of examination of a vibrating or fast
moving object, such as the vocal folds.
• A bright flashing light lasting a fraction of a second (10µs) is used to
illuminate the vocal folds.
• This flash 'freezes' the movement of the vibrating vocal folds.
• The flashes of light from the stroboscope are synchronized to the
frequency of vocal fold vibration with a slight time delay added for each
flash. If the flash takes place in time with the fundamental frequency the
vocal folds would appear not to move. The slight time delay means that
the vocal folds are illuminated at a slightly later point in the vibratory
cycle.
• The pattern of light traveling from mediolaterally along the superior
surface of the vocal fold during vibration under illumination is referred to
as the mucosal wave.
• It is a correlate of the pliable cover (epithelium and superficial lamina
propria) of the vocal fold being displaced relative to the body of the vocal
fold (vocalis muscle).
• Focal abnormalities of mucosal wave help to localize pathology in the
vocal fold.

50. Vocal cord movement noted during
stroboscopy

51. VOICE DISORDERS
Patients complain of:
• Hoarseness
• Huskiness
• Reduced pitch
• Loss of part of range of voice
• Pitch instability
• An increased effort to speak
• Vocal fatigue
• Throat symptoms like- irritation, globus sensation,
dryness, throat clearing or chronic cough

52. 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 wide range of
acoustic settings
• Not appropriate for gender and age of the speaker
• Not capable of fulfilling its linguistic and paralinguistic
functions
• It fatigues easily
• Associated with discomfort and pain on phonation

53. ETIOLOGIES OF VOICE DISORDERS
 Inflammatory disorders-
a. Acute laryngitis
b. Chronic laryngitis
c. Specific inflammatory conditions e.g- arytenoid granuloma
 Specific structural or nodular lesions-
a. Vocal fold polyp
b. Vocal fold nodule
c. Pseudocysts
d. Reinke’s oedema
e. Mucous retention cyst
f. Epidermoid cyst
g. Sulcus vocalis
h. Sulcus vergeture
i. Mucosal bridge
 Neuromuscular causes-
a. Parkinson’s disease
b. Motor neuron disease
c. Multiple sclerosis
d. Myasthenia gravis
e. Vocal cord paralysis

54.  Hormonal disorders-
a. Hypothyroidism
b. Sex hormone abnormalities
 Muscle tension dysphonia or functional dysphonia
 Specific muscle tension dysphonias-
a. Puberphonia or mutational falsetto
b. Presbylaryngis
 Microvascular lesions
a. Varices or capillary ectasis
 Vocal use and misuse
 Others
a. Foreign accent syndrome
b. Bogart–Bacall syndrome
c. Intubation
d. Chronic allergies
e. CVA

55. GENERAL MANAGEMENT OF VOICE
DISORDERS
PROPER HISTORY- A detailed history is needed
• The nature and chronology of voice problem
• Exacerbating and relieving factors
• Lifestyle, dietary and hydration issue
• Contibuting medical conditions
• Patient’s voice use and requirements
• Social and psychological well being
• Their expectations for outcome of the
consultation and treatment

56. GENERAL EXAMINATION-
• Examination of oral cavity
• Examination of nasal cavity
• Lower cranial nerves
• Neck for lymphadenopathy
• Masses and signs of increased muscle tension
• External laryngeal skeleton
• Posture
• Breathing pattern
• General affect

57.  SPECIFIC EXAMINATION-
• Posterior rhinoscopy
• Indirect laryngoscopy
INVESTIGATIONS
• Flexible laryngoscopy
• Videolaryngostroboscopy

58. FURTHER ASSESSMENT
If the diagnosis is not clear from the initial assessment , the
patient may undergo one of the following options
• Laryngeal electromyography
• Objective voice measurements
• Twenty –four hour Ph monitoring
• Impedance testing
• oesophagoscopy
• Exploring psychological issue
• Referral to another voice disorders team or professional for
second opinion e.g clinical psychologist, neurologist,
respiratory physician , gastroenterologist

59. TREATMENT OVERVIEW
If treatment is required , it will consist of one or
more of the following options depending on
patient’s symptoms, vocal requirement and
clinical findings:
• Vocal hygiene, lifestyle and dietary advice
• Voice therapy
• Specialist therapy
• Medical treatment
• phonosurgery

60.  Vocal hygiene, lifestyle and dietary advice
• An explanation of how voice works
• The links between lifestyle, phonatory and non- phonatory activities
and stress on voice disorders
• Communicating effectively without raising or straining voice, for
example using a whistle in school playground or using amplification
devices
• Importance of adequate hydration for vocal fold function i.e.
drinking water, use of steam inhalations and avoiding excessive
amounts of drinks containing caffeine, i.e coffee., tea, and colas
• Smoking cessation, reducing alcohol, cannabis
• Avoiding exposure to dry air, fumes, dust
• Diet and reflux reduction, for example avoiding eating late at night,
large or fatty meals

61. VOICE THERAPY
• This is the mainstay treatment for muscle
tension dysphonia
• The main aims of voice therapy are
a. To help patient find a better voice quality
b. To make better use of vocal resonance and
tonal quality
c. To increase the stamina of voice

62. • Various techniques used are
a. Vocal exercise with aim of targetting and
strengthing specific muscle groups
b. Advice on posture and improving breathing
during speech
c. Laryngeal massage
d. General relaxation exercise and stress
management
e. Psychological councelling
f. Remedial singing lessons

63. MEDICAL TREATMENT
• Mainly includes treatment for acid reflux
• Upper respiratory tract infection treatment
• Allergy treatment
• Use of botulinum toxin into laryngeal muscles
used in case of spasmodic dysphonia and
arytenoid granuloma

64.  PHONOSURGERY
 Microlaryngoscopic surgery-
• The vocal folds or occasionally false cords are inspected and lesions
removed using microscope and endoscope
• Attempt to restore normal surface contour and layered structure of vocal
fold
 Laryngeal injection techniques
• Several synthetic, biological and autologus materials are usually injected
• To augment the vocal cord
• Materials for deep augmentation injection are typically described as
temporary, and permanent/long lasting.
• Long lasting, and sometimes, permanent injectable materials include
autologous fat, calcium hydroxylapatite (Radiesse™),
polydimethylsiloxane (PDMS or particulate silicone), and polytef paste
(Teflon™).
• Temporary injection materials include bovine gelatin (Gelfoam™,
Surgifoam™), collagen-based products (Cymetra™, Zyplast™,
Cosmoplast/Cosmoderm™), hyaluronic acid (Restylane™, Hyalaform™),
and carboxymethylcellulose (Radiesse Voice Gel™).
• The materials vary in the duration of integration and are thought to vary
in their specific viscoelastic properties and biocompatibility.

65. LARYNGEAL FRAMEWORK SURGERY
• Transcutaneous surgery performed on
cartilaginous skeleton of larynx
• Laryngoplasty
• Arytenoid adduction
• Cricothyroid approximaqtion
NERVE – MUSCLE PEDICLE GRAFT TECHNIQUE
REINNERVATION AND ELECTRODE PACING
TECHNIQUES

66. DISCUSSION OF VARIOUS VOICE
DISORDERS

67. VOCALABUSE
Poor vocal habit that can have
traumatic effect on the vocal folds.
Examples for vocal abuse
• children who mimic the sounds of
vehicles and machinery
• yelling, screaming, and cheering
• Professional voice users such as
teachers, street vendors, singers

68. VOCAL MISUSE
Incorrect use of pitch and loudness during
voice production.
• elevated vocal loudness
• elevated pitch levels

69. Etiology:
Predominantly in males, who engage in a great deal
of aggressive speaking.
Constant throat clearing
Symptoms:
vocal fatigue
breathy voice

70. VOCAL FOLD POLYP
• Benign swelling of greater than 3mm that arises from the
free edge of vocal fold
• Usually solitary, but can affect both cords
• More common in males and in smokers and between 30 to
50 years of age
• Etiology is phonotrauma leading to disruption to vascular
basement membrane, capillary proliferation, thrombosis
and haemorrhage and fibrin exudation
• Hoarse voice, lower in pitch
• Voice therapy , treatment of concomittant inflammatory
condition and phonosurgery

71. VOCAL FOLD NODULE
• Bilateral small swellings less than 3mm
• Develop at free edge of vocal fold at
midmembranous portion
• Voice abuse
• More common in boys than girls and in adults
more common in women
• Husky , breathy voice
• Voice therapy, phonosurgery in fail voice therapy
cases

72. Reinke’s oedema
• Also known as polypoid vocal cord, pseudomyxoma or
pseudomyxomatous laryngitis, smoker’s larynx
• Edema of Reinke’s space(superficial lamina propria)
• Smoking, voice strain, GERD
• Effortful smoking, choking episodes, deepening of the
pitch of voice
• Reduction glottoplasties with phonosurgical instrument

73. CONTACT ULCER
A hickened irregular tissue on vocal folds caused by irritation
Etiology:
 complication of intubation
 gastroesophageal reflux
• Ulceration and granuloma at the posterior commissure
• Hoarseness and foreign body sensation
• Voice modification
• Antireflux treatment
• Steroid inhalation
• Microlaryngeal excision

74. SULCUS VOCALIS
• Localized invagination of the mucosa of vocal cord of
varying depth
• Sulcus vocalis may be congenital or secondary to vocal
trauma, infection, degeneration of benign lesions, or
surgery.
• In addition, Bouchayer et al proposed a relationship with
ruptured congenital epidermoid cysts and also suggested
that the disorder may demonstrate familial patterns.
• Most clinicians agree that presentation of sulcus vocalis is
hoarseness, vocal fatigue, voice weakness, and increased
effort

75. MICROVASCULAR LESIONS
• Varices or capillary ectasias
• Superior or medial aspect of midmembranous
portion of vocal cord
• Professional vocalists, repetitive trauma
• Voice therapy, precise vaporization or point
diathermy of feeding vessel

76. PUBERPHONIA
• Mutational falsetto
• The persistence of adolescent voice even after puberty in the absence of
organic cause is known as Puberphonia.
• This condition is commonly seen in males.
• This is uncommon in females because laryngeal growth spurt occurs
commonly only in males
• In infants the laryngotracheal complex lies at a higher level. It gradually
descends. During puberty in males this descent is rapid, the larynx
becoming larger. In puberphonia larynx tends to be high in the neck.
Cricothyroid muscle remains contracted
Etiology: include
1. Emotional stress
2. Delayed development of secondary sexual characters
3. Psychogenic
4. Excessive maternal protection
5. Non fusion of thyroid laminae
Speech therapy, injection of botulinum toxin into cricothyroid muscle
Laryngeal framework surgery is contraindicated

77. DYSPHONIA PLICA VENTRICULARIS
• False cord voice
• Oppsition of false cord during voice
• Psychogenic conditions and vocal cord disability
• Harsh voice, low pitch, crackling and rumbling
voice
• Hypertrophy of false cord
• Videostroboscopy is helpful
• Speech therapy, psychotherapy, laser excision

78. FUNCTIONAL APHONIA
• Abrupt onset of loss of voice
• Following emotional crisis
• Associated with psychological conditions
• Young females
• Laughing, crying, coughing not affected
• Failure of vocal cords to oppose on phonation
• Cough is normal
• Speech therapy
• psychotherapy

79. PHONASTHENIA
• Functional weakness of voice
• Normal vocal organ
• Faulty use of voice
• These patients talk more
• Professionals like doctors, teachers are more
prone
• Speech therapy
• Psychological councelling

80. MUSCLE TENSION DYSPHONIA
• Muscle tension dysphonia (MTD) is one of the most common voice
disorders.
• Imbalance of synergistic and antagonistic muscle affecting the vocal fold
• There are two types of MTD:
Primary MTD — In this type, the muscles in neck are tense when we use
our voice but there is no abnormality in the larynx (voice box).
Secondary MTD — In this type, there is an abnormality in the voice box
that causes us to over-use other muscles to help produce voice.
• Stress , anxiety and depression, conversion disorders, poor oral hygiene,
smoking, talking in poor acoustic enviornment for prolonged period
• Voice therapy — This is the most common treatment for MTD. It may
include resonant voice techniques and massage.
• Botox injections — Botox is sometimes used along with voice therapy to
get the voice box to stop spasms.

81. SPASMODIC DYSPHONIA
A condition in which there is irregular spasmodic
movements in the vocal folds which interferes with the
adduction and abduction phase of phonation
Etiology:
(a) Psychological influence
(b) Neurological influence
(c) unknown cause
Symptoms: strained and jerky voice, breathy spasms,
hyper nasality, failure to maintain voice.

82. THICKENING OF VOCAL FOLDS
A disorder that occurs when vocal folds become too
thick or massive
 Etiology: unknown; alcohol/smoking may contribute;
GERD
 Symptoms: abnormal vibratory patterns of vocal
folds.

83. PITCH BREAKS
Unexpected and uncontrolled sudden shifts of pitch
Etiology:
 may occur as a result of laryngeal pathology
Symptoms:
 inappropriate pitch level
 pitch breaks
 restricted phonation range

84. Presbylaryngis
• Aging voice
• Mean fundamental frequency rises after age of
50 in males
• Voice is often high pitched, thin reedy
• In females fundamental frequency tends to fall
• Ossification of laryngeal skeleton, arthritic
changes in cricothyroid and cricoarytenoid joint

85. Vocal cord palsy
• It is a sign of disease and not a diagnosis
• Semon’s law and Wagner Grossman theory
• Lesion of vagal trunk above the nodose ganglion-
combined abductor paralysis( cadaveric position)
• Vagus nerve below the nodose ganglion-
recurrent laryngeal nerve palsy ( paramedian
cord position)
• Superior laryngeal nerve alone- bowing of the
cord

86. Superior laryngeal nerve paralysis
• Thyroid surgery, viral neuritis, neck dissection
• Weakness of voice, monotonus voice
• Bowing of affected cord
• Chest x ray, ct scan, endoscopy
• Speech therapy, surgery
• Teflon injection into vocal cords
• Arytenoid adduction procedure

87. Recurrent laryngeal nerve paralysis( unilateral)
• Severe voice disturbance including hoarseness
or temporary aphonia
• Trauma, iatrogenic cause, neoplasm
• Later voice improves over a period of time as
compensation from normal cord and
paralysed cord move to paramedian position
• Cord is paramedian or median position

88. Recurrent laryngeal nerve paralysis ( bilateral)
• Surgical trauma
• Inspiratory stridor, dyspnea
• Xray chest, ct scan, direct laryngoscopy,
panendoscopy
• Tracheostomy, arytenoidectomy and
lateralization procedure

89. THYROPLASTY
• Isshiki divided thyroplasty into four categories
• Type 1- medial displacement of cord , teflon injection
• Type 2- lateral displacement of cord, used to improve
airway
• Type 3- shorten the vocal cord, relaxation of vocal cord,
used in gender transformation from female to male
• Type 4- to lengthen the vocal cord and to raise the
pitch, male to female voice, also used in lax vocal cord
in aging process or trauma

90. Laryngeal reinnervation
• A segment of anterior belly of omohyoid
muscle , carrying its nerve (ansa hypoglossi)
and vessels is implanted into the
thyroarytenoid muscle after making a window
in thyroid cartilage
• It is supposed to innervate the paralysed
thyroarytenoid muscle.

91. VOCAL HYGIENE
• There are good habits – things we can do to take care
of our voice
• Don’t smoke.
• Eliminate habitual and frequent throat clearing
• Drink lots of water
• Control and limit vocal loudness
• Humidify the environment
• Symptoms of laryngopharyngeal reflux disease
• Use caution with medications (over-the-counter and
prescription)

92. Voice therapy
• Accent Method: This program uses rhythmic exercises to facilitate the
coordination of minimally-constricted vocal fold vibration with appropriate air
pressure and air flow.
• Confidential Voice: Confidential voice is a light voice. It is an easy, breathy, low
airflow style of phonation. It is a softly-produced voice, and therefore not
functional for many communicative needs
• Digital Laryngeal Manipulation: Also called laryngeal massage, the focus of this
technique is to decrease excessive contraction of the muscles of the larynx
• Vocal Function Exercises: This approach is a three-component program of warm
up, pitch glides (high to low and low to high) and sustained vowel phonation at
selected pitches.
• Chewing: helpful in reducing vocal hyper function
• Chant talk technique -The patient is taught to reduce hard glottal attack by
using a phonatory style that sounds like a religious chant.
•

93. THANK YOU