This audio lecture corresponds with chapter three in your textbook titled “Organic Voice Disorders.” Here I will be discussing some of the most prevalent types of organic disorders, though you should make sure that you thoroughly read your textbook so that you understand the other, perhaps less common, types of voice disorders. Before we get started, remember that by organic voice disorders we mean those disorders which are related to structural deviations within the speech mechanism as well as diseases which affect specific structures within the vocal tract.
Laryngeal reflux is a disorder that can contribute to many of the organic voice disorders that we will discuss in this unit. That’s why, even though your authors introduce this topic toward the end of your chapter, I wanted to talk about it right away. You’ve probably seen the ads on TV for Prilosec and other acid reflux medications, and a lot of people are diagnosed with reflux. What we call reflux is the coursing of acid from the stomach, where it helps to digest food, to areas where it shouldn’t be, such as the esophagus and/or the larynx. When the stomach acid travels up to the esophagus, it is known as GERD, or gastroesophageal reflux. And when this same acid travels further up, into the larynx, it is known as LPR, or laryngopharyngeal reflux. While some people with reflux don’t experience any symptoms, other symptoms can have an effect on the voice. In particular, the voice may be hoarse or raspy, especially in the morning, as acid is more likely to travel up toward the larynx after lying down. Some people have a burning feeling in their throat, and a sour taste in their mouth. My own mother, and I hope she’ll forgive me for sharing this, was diagnosed with acid reflux after a chief complaint of bad breath which had no other causes. She went in for a barium swallow study, which included her esophagus. The radiology department was able to visibly seen the liquid barium reflux up her esophagus and into the larynx immediately after she had swallowed. Another symptom is of LPR or GERD is a globus sensation, or a feeling like there’s something in the throat. This is because the acid is irritating the throat, and it can cause throat clearing. We usually divide treatment for reflux into three types: behavioral, in which lifestyle and diet changes are made; pharmacological, where medications are prescribed by a physician (not an SLP); and surgical. For more information about the surgery for LPR and GERD, you can click the hyperlink in the PowerPoint document to see a WebMD web page on this topic.
There are a number of conditions which are largely congenital, meaning that the disorder is present from birth. One of these conditions, laryngomalacia, is a disorder in which there is a delay in the stiffening of the laryngeal cartilages, including the epiglottis and/or the arytenoid cartillages. In the first picture shown on your PowerPoint slide, you can see how the epiglottis is curled in on itself and prevents adequate air intake on inspiration. Laryngomalacia results in stridor, or a high pitched wheeze upon inhalation. Usually this is not a life threatening disorder, though the deviation in laryngeal structures may contribute to GERD or feeding problems in severe cases. By age two, the cartilages seem to stiffen, and the stridor goes away. Another disorder, subglottal stenosis, is a narrowing of the subglottal space. This disorder, shown as the second picture on the PowerPoint slide, may be congenital but can also be caused by difficulties following surgical intubation. A relatively new system has been developed to grade the severity of the stenosis. Usually SLPs do not need to intervene if the narrowing is less than 75%, but if it is greater than 75%, the patient may need to have surgical intervention with voice therapy follow-up. Finally, two conditions, called tracheoesophageal fistulas and esophageal atresia, may require surgical intervention with subsequent voice and feeding therapy by SLPs. Tracheoesophageal fistulas are small holes between the trachea and esophagus. Esophageal atresia is a blockage to the esophagus.
The larynx is susceptible to ulcers, as are other parts of the body. Contact ulcers within the larynx affect the medial portion of the arytenoid cartilages and have three usual causes. One of these causes is GERD or LPR. That acid reflux should cause ulcers is perhaps not surprising if we consider how ulcers can develop in the stomach as a result of excess stomach acid. Also, many people use hard glottal attacks which sound like this: (demonstrates a forceful slamming together of the vfs). Unfortunately using such a voice, along with frequent throat clearing, brings the arytenoids forcefully together and can cause ulcers to develop. And finally, sometimes people who undergo surgery, particularly emergency surgery, must be intubated. Often surgical tubing may be a little too large for the airway, and abraids the surface of the arytenoids. The small ulcerations are typically accompanied by swelling, known as edema. Eventually these ulcerations can be covered by a thick covering of epithelial tissue, known as granuloma. This is especially true in the case of contact ulcers caused by surgical intubation. You can see the large round blobs of tissue covering the arytenoid cartilages on the PowerPoint picture and in your textbook. Obviously voice quality is not good with such an obstruction in the larynx, and pain, hoarseness, throat clearing, and vocal fatigue are symptoms. For contact ulcers in general, without much granular tissue, voice therapy focusing on good vocal hygiene is usually recommended. Surgery tends to be ineffective except in the case of larger granulomas which will not resolve on their own.
Leukoplakia is characterized by whitish lesions on the vocal folds and other mucosal surfaces within the body. In the first picture on the Powerpoint, you can see leukoplakia on the vocal folds, and in the second picture you can see it on the tongue. Leukoplakia of the vocal folds can interfere with vocal quality and can result in a hoarse, effortful voice due to the additional weight on the vocal folds. While technically a benign condition, leukoplakia looks identical to cancer. A biopsy has to be performed by an ENT to determine whether the whitish lesions are benign or cancerous. Smoking and reflux are considered to be the primary causes. Next we’ll talk about laryngeal cancer. Brace yourself for some graphic pictures on the next slide!
As you can see from the pictures on this slide, cancerous lesions in the vocal folds usually appear as white patches, or as a tumor. Like many voice disorders, a hoarse, breathy voice quality with decreased intensity is a major symptom. So it’s really important that SLPs do not assume that someone has nodules when they may have cancer instead. Reflux, alcohol and smoking, and repeated infections can cause cancer. It’s absolutely necessary that an ENT evaluate, diagnose, and treat patients with laryngeal cancer, and surgery is necessary to remove the cancer so that it doesn’t spread. We will talk more toward the end of the term about laryngectomy, or the surgical procedure of having all or part of the larynx removed.
Finally, let’s talk about sulcus vocalis. This is a disorder which can be congenital, acquired, or idiopathic, meaning we’re not sure what causes it for a particular individual. Sulcus vocalis can be caused by reflux, but also by vocal abuse and misuse. The term sulcus refers to the depression, or vertical line, that runs along the length of one or both of the vocal folds. Sometimes it looks like a small chunk is missing out of the lateral edge of the vocal fold, or that there is a grove in the vocal fold tissue. This is because the mucosal cover is scarred down to the underlying vocal ligament. This impairs vibration of the vocal folds, resulting in a voice that is breathy, hoarse, and quiet.
One disorder that tends to affect children and can be potentially life threatening is referred to as papilloma. In juvenile cases, children who are typically under the age of 6 develop wart-like growths in the larynx. These growths spread across the vocal folds, limiting air supply and necessitating surgery. Unfortunately, the papilloma tends to recur, meaning that multiple surgeries are often required. Laser surgeries tend to have the best results, but even so, children with histories of repeat surgeries may have hoarse voices due to vocal fold scaring. There are some newer therapies, including injections and vitamins, which may help the prevent recurrence. The SLPs job, however, is to help the child develop functional communication. This may include teaching a child with a tracheostomy how to speak to the best of their ability and to use good vocal hygiene strategies. It is important to note that papilloma usually resolves itself around adolescence, though adults with no prior history can develop the disorder too.
In summary, I’ve only touched on some of the more common types of organic voice disorders, but there are many others, such as cysts, hyperkeratosis, and laryngitis, as well as those disorders which can be caused by changes in puberty and to the endocrine system. Do be sure to read up on these disorders in your textbook. Also, recall from our discussion on the first night of class that while SLPs can evaluate clients for a voice disorder, they can’t begin treatment until they have permission from a medical doctor to do so. Preferably this individual is an ENT who has evaluated the client via laryngoscopy to visualize the vocal folds. And while we can counsel patients on their options, we can only do so within our scope of practice. This means that we can’t make recommendations for specific medications or surgeries, though we can educate patients and help them to better discuss these issues with their doctors and other relevant health care providers. See you next time!
Unit 3: Organic Voice Disorders
Organic Voice Disorders
Laryngeal Reflux <ul><li>Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR). </li></ul><ul><li>Acid irritates the larynx and can contribute to cancer and pre-cancerous conditions. </li></ul><ul><li>Voice may be hoarse or raspy; may have low-grade burning or globus sensation in throat, often with throat clearing. </li></ul><ul><li>Treatment is typically behavioral or pharmacological, but can also involve surgery . </li></ul>
Congenital Abnormalities <ul><li>Laryngomalacia – epiglottis and/or arytenoids do not stiffen with development and threaten the airway. </li></ul><ul><li>Subglottal Stenosis – narrowing of the space below the VFs. Can be congenital or acquired after intubation. Results in dysphonia and difficulty breathing which may ultimately require tracheostomy. </li></ul>
Contact Ulcers and Granuloma <ul><li>May result from slamming arytenoids together in hard glottal attacks or frequent throat clearing; GERD/LPR; and intubation. </li></ul><ul><li>Are formed on the medial aspect of the vocal processes of the arytenoid cartilages. </li></ul><ul><li>The small ulcerations are typically accompanied by edema and can become covered by granulated tissue (granuloma), particularly in the case of intubation. </li></ul><ul><li>Symptoms are vocal fatigue after prolonged use, pain in larynx, throat clearing, hoarse voice </li></ul><ul><li>Voice therapy recommended, surgery usually ineffective except in the case of large granulomas. </li></ul>
Leukoplakia <ul><li>Whitish lesions on the vocal folds </li></ul><ul><li>Is technically a benign condition, but also a pre-cancerous one </li></ul><ul><li>Smoking and reflux are considered primary causes </li></ul><ul><li>Adds to the mass of the VFs (hoarseness, decreased pitch) and may inhibit VF adduction (breathy voice) </li></ul><ul><li>Must do a biopsy to tell if it is leukoplakia or cancer!! </li></ul>
Cancer (carcinoma) <ul><li>Can be caused by smoking, excessive alcohol, tobacco, reflux, infections. </li></ul><ul><li>Surgery is necessary to remove cancerous portions of the laryngeal mechanism. </li></ul><ul><li>Sometimes a laryngectomy may be warranted. </li></ul><ul><li>The voice will sound hoarse, possibly breathy, and can have decreased intensity. </li></ul><ul><li>Note that oral cancer can interfere with articulation and resonance, and laryngeal cancer may occur subglottally, supraglottaly, or at the level of the glottis (VFs) </li></ul>
Sulcus Vocalis <ul><li>Can be congenital, acquired, or idiopathic </li></ul><ul><li>May be related to reflux and abuse/misuse </li></ul><ul><li>Breathy, hoarse, quiet voice </li></ul><ul><li>May be seen as a longitudinal line (depression) running along the length of one or both VFs. </li></ul><ul><li>Along the sulcus, the mucosal cover is scarred down to the underlying vocal ligament and impairs vibration. </li></ul>
Papilloma <ul><li>Wartlike growths that are a form of HPV </li></ul><ul><li>Most often occurs in children under age six (juvenile papilloma) </li></ul><ul><li>Symptoms include hoarse, breathy voice </li></ul><ul><li>Can be a severe threat to respiration and multiple surgeries are often required, as the papilloma may reoccur until the child reaches puberty. </li></ul><ul><li>Newer therapies including injections and vitamins may help the papilloma from returning. </li></ul>
Summary <ul><li>Be sure to read your textbook chapter thoroughly! </li></ul><ul><li>SLPs must work closely with medical doctors in order to treat organic voice disorders. </li></ul><ul><li>We can counsel patients on their options, but only within our scope of practice. </li></ul>