a seminar on phonosurgery and speech therapy

1. Dr Utpal

2. Def’n
 Any surgery designed primarily for the improvement
or restoration of the voice.

3. Assessment
 Video laryngoscopy
 Stroboscopy
 Laryngeal electromyography

4.  Microlaryngoscopic surgery
 Vocal fold injection
 Laryngeal framework surgery
 Nerve grafting
 Neuromuscular surgery

5. Laryngoscopy
 Manuel Garcia first described mirror indirect
laryngoscopy.
 Bozzini described the first ILS for surgey on the vocal
folds.
 Horace Green described the first direct laryngeal
surgical case, which was removal of laryngeal polyp in
a 11 yr old girl.

6. Anatomy

7.  THE LARYNGEAL MUSCULATURE •
 Intrinsic Muscles •
 Abductor – Posterior Cricoarytenoid (PCA) •
 Adductors – Lateral Cricoarytenoid (LCA) Interarytenoid
(IA) Thyroarytenoid (TA) •
 Tensors – Cricothyroid (CT) , Vocalis (internal part of TA) •
 Openers – Thyroepiglottic (part of TA) •
 Closers - Interarytenoid – oblique part (IA) Aryepiglottic –
(AE)

9. Histology of the Vocal Folds
 Respiratory epithelium (pseudostratified squamous)
on the superior and inferior aspects of the fold and
non keratinizing squamous epithelium on the medial
contact surface.
 The subepithelial tissues are composed of a three-
layered lamina propria .
 Deep to the lamina propria is the thyroarytenoid (or
vocalis) muscle.

11. Surgical principles:
 Benign disease:usually located in the mucosal layer or superficial
part of lamina propria.
 Surgery should therefore be superficial staying out of the vocal
ligament with limited mucosal excision only.
 No role for stripping of the mucosa of the vocal fold for benign
disease.
 Use the largest laryngoscope possible.
 Position:A flexed neck and extended atlanto-occipital joint.
 External laryngeal counterpressure will also improve exposure of
the vocal fold.

12. Advantage of microlaryngoscopy
 Binocular vision
 Magnification
 Better illumination
 Ablility to use bimanual instrumentation.
 Ablility to use carbon di oxide laser

13. Laser vs alternative dissecting
instrumentation
 Precise.
 Better healing rates.
 However surgeon must have an understanding on spot size,
wattage, mode, and their soft tissue interaction .
 Limit lasers to vascular lesion or those that bleed on
removal such as papillomatosis or granulomas,or to the
removal of cartilage and when excising large areas of tissue.

14. Disadvantage:
 Laser plume in the management of papilloma can be
considered a potential risk of infection to both surgeon and
hospital staff and there is a theoretical risk of seeding of
laryngeal disease further into the tracheobronchial tree
during jet ventilation.
 Use of laryngeal microdebrider eliminates many risks of
laser(lesss post op pain and quicker return to a usable
speaking voice)

15.  Laser and cold instruments should be considered as
synergestic tools rather than in direct opposition.

16. Anaesthesia
 Mostly done under G.A.
 Ventilation can either be via ET tube, which may be laser
proof or via jet ventilation.
 Jet ventilation gives the best exposure but drawbacks
include damage to the subglottis while lasering and
vibration of the free edge of the vocal folds during jetting

17. Voice rest
 48 hrs of absolute voice rest following a phonosurgical
procedure is essential.
 Followed by 10 days of relative voice rest.

18. Vocal Nodules

19. Vocal Nodules
 Mostly B/L lesions.
 Arises on the edges of vocal folds at the junction of anterior
third and posterior two-third of the vocal fold.
 Confined to superficial squamos epithelium.
 Stroboscope can be useful in distinguishing between hard
and soft nodule.

20.  Hard nodules usually require surgery.
 The centre of the nodule is held with a grasping
forceps and pulled medially towards the opposite cord.
 Microscissors are then used to cut the mucosa close to
its base,thus preserving normal mucosa.

21. Polyps

22. Vocal Polyp
 A polyp is well differentiated ,hyperplastic benign
pathological structure of the mucous membrane.
 U/L localised area of oedematous tissue.
 Gentle steady traction is applied by grasping forceps
towards the opposite cord and base of the polyp is cut with
microscissors.
 Post op voice rest.

23. Reinke’s oedema

24. Reinke’s oedema
 b/l diffuse condition where there is a collection of fluid in the
superficial layer of lamina propria.
 Seen after laryngitis and in chronic smoker.
 A cordotomy incision is made on the lateral aspect of the superior
surface of the vocal fold with an arrow headed knife or laser.
 Mucosa is then elevated with a blunt dissector and myxomatous
contents either aspirated or removed with cupped forceps.
 Mucosal flap is replaced and any excess epithelium trimmed with
microscissors.

25. Intracordal cyst

26. Intracordal cyst
 May be mucosal retention or epidermoid cyst.
 Arise halfway along the membranous part of vocal fold
cover.
 Mucosal retention cyst can be removed with cold
instruments or with laser.
 An epidermoid submucosal cyst can be approached via
lateral microflap technique where an incision is made on
the superior surface of the vocal fold away from its medial
edge.The flap is then elevated from lateral to medial ,the
lesion excised and the flap replaced.

27. Vocal fold varices

28. Vocal fold varices
 If lying in longitudinal orientation,can be left and treated
conservatively.
 The presence of vessels lying at 90 degree or different
orientation may indicate underlying disease and require
further investigation.
 Recurrent hemorrage from these vessels can be dealt with
either lasering the blood vessel or needle cautery to ablate
the vessels.

29. Laryngeal web

30. Anterior webs
 It is a band of connective tissue which joins the two vocal
folds at the anterior commisure.
 May be congenital or acquired.
 c/f:cyanosis/stridor/dysphonia/feeding problem/weak
phonation.
 Can be divided either with a laser or with cold steel.
 Thick webs with recurrence may require insertion of a keel,
either endoscopically or via an open approach

31. Granulomas

32. Granulomas
 Located on the vocal process of the arytenoid cartilage and
are usually u/l,sessile,bi lobed.
 Low pitch,monotonous,vocal creak.
 Causes:intubation,GERD,hyperfunctional voice disorder.
 t/t modalities: surgery/treat GERD/steroids/oral
prostaglandin/speech therapy/osteopathy/botulinum toxin
injection into lateral cricoarytenoid muscle.
 It is preferred to use a local mucosal rotation flap at the
time of laser excision to cover the exposed cartilage.

33. Papilloma

34. Papilloma
 HPV 6 and 11
 Site-upper aerodigestive tract.;mostly U/L.
 Mostly reported in children between 2 to 4 yrs old, mostly
recur. Prognosis improves with age.
 T/t of choice-CO2 laser excision.
 Settings:4 watts on super pulsed laser(0.1 sec),with a spot
size of 0.3mm.

35.  Single papilloma-grasp gently and laser is used to excise
the base.
 Multiple papilloma-Inj saline submucosally(+/- adr) and
excise the mucosa en bloc.
 Adjuvant T/t:Retinoids ,alpha interferon,ribavirin,cox2
inhibitor,cidofovir.
 Photodynamic therapy is in experimental stage.

36. Sulcus vocalis

37. Vocal sulcus
 Physiological(pseudosulcus)/ sulcus vergeture/sulcus vocalis.
 Might be a sequel to ruptured congenital cyst.
 c/f:persistent dysphonia following puberty
 T/t modalities: excising the sulcus, injecting collagen or fat.
 Pontes advocated a technique involving parallel mucosal
incisions of varying length running in cephalad to caudal
direction to break up the linear scar of vocal fold

38. Vocal fold injection
 Brunings in 1911 first described injection of vocal folds using
paraffin.
 Arnold in 1962 popularised this technique with the
introduction of teflon.
 Materials commonly used are:
 Teflon
 Fat
 Glycerine
 Collagen
 Silicone

39. IDEAL INJECTION MATERIAL
 Readily available
 Inexpensive
 Inert
 Easy to use
 Completely biocompatible

40. Indications
 Temporary correction in cases of u/l vocal cord palsy
when prognosis for recovery is uncertain.
 Immediate improvement of voice required.
 Permanent correction of glottic insufficiency .
 Vocal fold atrophy
 Adjunctive augmentation after prior surgery
 Trial basis

41.  All can ideally be carried out under L.A in the normal
anatomic position with the patient sitting up by injecting
through the cricothyroid membrane.
 Reversibility(Glycerine>fat>teflon).
 All carry the potential complication of over injection,airway
compromise and under injection but silicon carries the
additional risk of misplacement and migration ,while teflon
also has the risk of granuloma formation.
 Cost is not a major issue in deciding which to use.

42. VOCAL CORD INJECTION
TECHNIQUES
 It may be done under GA or LA through following routes:
a)Peroral b)Percutaneous c)Laryngoscopic
 Peroral : performed in selected patients.
 topical 4% LA applied on laryngeal and pharyngeal
mucosa. •
 Curved inj. device in clinical setting; under indirect
visualization of larynx by holding the tongue forward.
 Bevelled end directed away from midline to minimize risk
of intramucosal injection.

43. Percutaneous technique
 can be performed under sedation or LA
 Visualization is with a flexible fibreoptic
nasopharyngoscope with digital imaging system.
 For optimum results needle is placed just anterior and
lateral to vocal process on a plane level with the lower
border of medial edge.

45. Routes of administration
 1. Translaryngeal – through inferior half of thyroid
cartilage.
 performed through lateral appraoch.
 level of vocal fold determined by palapting thyroid notch
and inferior border of thyroid cartilage.
2. CT membrane puncture – becoming popular method.
performed through anterior approach.
 vocal folds approached from below.
3. TH membrane puncture: usually not done routinely.
danger of injection into Reinke’s space.

46. translaryngeal
CT
membrane
puncture
TH
membrane
puncture

47. Laryngoscopic Injection(telescopic
visualization):
 Indications:
 1. Patients who do not tolerate flexible fibreoptic examination.
 2. During ablative procedures where RLN or Vagal nerve resection is
anticipated.This provides temporary medialization decresing immidiate
post operative symptoms.
 Position: Supine
 Anaesthesia: GA or LA.
 Instruments:
1. 0/30 degree 5mm laryngeal telescope
2. Digital video system
3. 23-gauge butterfly needle for Cymetra ,
Injection gun(Bruning’s syringe) for Autologus fat

48.  Needle is inserted anterior and lateral to vocal process
appr. 2 mm deep or at the plane level with the lower
margin of the true folds. After injection massage is
done over vocal fold to distribute the material.

49. COMPLICATIONS
 1. Under injection requiring repeat procedures
 2. Over injection causing airway compromise –Immediate
m/n is to incise mucosa and remove excess materialwith
suction.
 Late m/n :CO2 laser or cupped forcep removal or
thyrotomy.
 3. Improper placement causing subglottal extension and
stenosis.
 4. If given in Reinke’s space – cause granuloma formation
leading to impaired VC vibrations.

50. Laryngeal framework surgery
 Payr in 1951 first described laryngeal framework
surgery.
 Isshiki was the first to describe using an alloplastic
material(sialistic) and also to stress the benefits of
carrying out the procedure under a local anaesthetic
using the patient’s voice for feedback.

51. Isshiki classification of thyroplasty
 Type 1 thyroplasty(medialisation thyroplasty)
 Type 2 thyroplasty(lateralisation thyroplasty)
 2a-lateral approach
 2b-medial approach
 Type 3 thyroplasty(relaxation thyroplasty)
 Type 4 thyroplasty(tensioning thyroplasty)
 4a-cricoid approximation.
 4b-tensioning by lateral approach.

52. classification
 1. Approximation Laryngoplasty
 Medialization thyroplasty (Type I)
 Arytenoid Adduction
 Roatation (pull) technique (Lateral cricoarytenoid pull
technique)
 Fixation technique (Adduction arytenopexy)
 2.Expansion laryngoplasty
 Laterlization Thyroplasty
 Lateral approach (Thyroplasty type II a)
 Medial approach (Type II b) or Midline lateralization thyroplasty.
 Vocal fold abduction
 Suture technique.
 Resection Technique. (Thyroarytenoid myectomy)

53.  3. Relaxation Laryngoplasty
 Shortening Thyroplasty
Lateral approach (Type III)
Medial approach ( Anterior commissure retrusion)
4.Tensioning Laryngoplasty
 Cricoid Approximation (Type IV a)
Elongation Thyroplasty
- Lateral approach (Type IV b)
- Medial approach (Springboard advancement or Anterior
commissure advancement)

54. Type 1/medialisation thyroplasty
 Can be done in any patient with U/L v.c palsy.
 Waiting for 12 months in idiopatic cases is recommended.
 It can also be done in case of u/l or b/l bowed vocal cords
caused by ageing and may be useful to correct defects in the
vocal fold as a result of previous surgery.

55. Indications:
 Symptomatic glottic insufficiency (dysphonia, aspiration).
 U/L vocal fold paralysis.
 Vocal fold atrophy, including age related atrophy.
 Vocal fold bowing d/t ageing and cricothyroid joint
fixation.
 Sulcus vocalis
 Soft tissue defect resulting from excision of pathological
masses

56. Contraindications:
 Malignant disease overlying laryngotracheal complex.
 Poor abduction of C/L vocal fold.
 h/o radiation therapy to larynx.

57. technique
 Involves medialisation of the vocal cord by its inward
displacement with an implant placed through a window in
the thyroid cartilage.
 Many authors believe it is likely that the inner
perichondrium is torn while inserting the implant and as a
result some authors advocate incising the inner
perichondrium and preserving the thyroarytenoid fascia.
 It allows the fold to vibrate and a mucosal wave to be seen.

58. MANUAL COMPRESSION TESTthis test results in a preoperative improvement in voice
suggest that
surgery will be successful

59. Materials currently used in
medialisation thyroplasty
material
sialistic
hydroxyapatite
gortex
cost
low
high
moderate
Surgical
skill
moderate
high
low

60. Insertion of sialastic prosthesis for
medial displacement of paralysed
vocal cord.

61.  Skin incision.
 Sternohyoid muscle is elevated off the thyroid cartilage.
 The muscle is retracted posterior to thyroid lamina; a cautery template
marks the fenestra (6 × 10 mm), and the superior aspect of the window is
at the vocal fold level.
 The outer perichondrium is incised and removed.
 A cutting bur, followed by a diamond bur, is used to remove cartilage and
protect underlying periochondrium; a small Kerrison punch may
facilitate removal of cartilage from the fenestra.
 The inner perichondrium is circumferentially elevated with a blunt
dissector.
 A template or appropriately sized prosthesis is placed in the most
effective position

62. Alternative procedure
 Isshiki described an arytenoid adduction procedure for
patients where there is a large posterior gap and the
paralysed cord is at a different vertical level
.
 Modification of this technique –arytenoid fixation and
cricothyroid subluxation was described by Zeitels.

63.  With an extended incision ,the arytenoid cartilage is
exposed,its attached muscles divided and the
arytenoid cartilage is fixed in a midline position.
 Tension of the paralysed cord is obtained by a suture
between the inferior horn of the thyroid cartilage and
the cricoid cartilage anteriorly

64. Suture gives tension to the
paralysed vocal cord with the arytenoid cartilage
fixed medially.

65.  In patients with atrophied vocal cord(post rt
patients),it is easy to perforate the laryngeal mucosa
when lifting the inner perichondrium due thin/non
existent muscle bulk.
 Use of local sternothyroid strap muscle flap to insert
healthy tissue and prevent the implant from extruding
inwards.

66. TYPE I THYROPLASTY:
COMPLICATIONS
 Penetration of endolaryngeal mucosa - assess air leak before
placement of implant in window. If air leak is present , then
terminate the procedure.
 Wound infection
 Chondritis
 Airway obstruction – most danger – overnight
monitoring is required.
 Implant extrusion
 Can become displaced and even extrude into the airway,
more commonly with Gore-Tex and with implants without
outer phalanges

67. TYPE I THYROPLASTY: PITFALLS
 Window is too high.
Then implant is too high, false VF is medialized and
voice is poor.
 Implant is too big or too small.
Makes voice either pressed or breathy.

68. Type I I thyroplasty
 Lateral displacement of vocal cord and is used to
improve the airway.
 Vocal folds are displaced laterally away from the
midline under local anaesthesia.
 Management of adductor spasmodic dysphonia
(AdSD)

69. Type II a :
 Lateralization thyroplasty by lateral approach -
 Two paramedian vertical incisions and interpose the
anterior segment beneath the lateral segments.
Type II b:
 LateralizationThyroplasty By medialapproach a/k/a (
Midline Lateralization Thyroplasty )
 A vertical incision in the thyroid cartilage and lateralizing the
posterior segment over the anterior one.

72. Advantages:
 Optimal glottal closure can be adjusted and readjusted
 No damage of physiologic function
 Reversible
Disadvantages:
 Technically difficult
 Does not relieve cause of
SpasmodicDysphonia(neuromuscular ,parkinson’s , MND
, MS)

73. Vocal Cord Abduction by
1. Suture Method-
Arytenoidopexy:
 Displacing the vocal fold and arytenoid without surgical
removal of any tissue.
 Suture passed around the vocal process of the arytenoid
and secured laterally.
 Relatively high failure rate.

75. 2.Resection Method-
(Arytenoidectomy).
 Removal of some or all of the arytenoid cartilage.
Endoscopically by Microsurgical technique-Thornell
procedure
with Laser surgery- Jako’s procedure
 With Thyrotomy approach- Scheer’s approach)
 By lateral neck approach (Woodman’s) – Most popular
approach.

76. Woodman procedure –
 Lateral neck incision.
 Exposure of the arytenoid cartilage posteriorly with
removal of the majority of the cartilage, sparing the vocal
process.
 Suture is then placed into the remnant of vocal process and
fixed to the lateral thyroid ala.
 Cause less voice deficit.

77. Type 3 thyroplasty
 Used to shorten (relax) the vocal cord .
 Relaxation of vocal cord lowers the pitch .
 This procedure is done in mutational falsetto or in
those who have undergone gender transformation
from female to male.

78. TYPE III
THYROPLASTY
Lateral approach :
( Type III)
Thyroid ala is incised
at about junction of
anterior and middle
one third, and 2-5 mm
cartilage strip is
excised.

79. Medial approach:
( Anterior commissure
retrusion)
Retrusion of the middle
portion of the thyroid
cartilage and leads to
reduction in the length of
vocal folds results in normal
adult voice
 Vertical incision are
made either side of the
midline of the thyroid
cartilage.

80. Middle portion of the cartilage
pushed posteriorly Free edges of the
* thyroid cartilage
reapproximated with 2-0 vicryl

81. Type 4 thyroplasty
 This procedure is used to lengthen (tighten) the vocal
cord and elevate the pitch .
indications:
 It converts male character of voice to female and has
been used in gender transformation.
 It is also used when vocal cord is lax and bowing due to
aging process(presbyphonia) or trauma.
 Androphonia (Abnormally low pitched voice in
female.

82. Cricothyroid
Approximation
•Increases vocal pitch by
simulating the contraction of
cricothyroid muscle with
sutures.
• The cricoid and thyroid
cartilage is approximated as
closely as possible because
postoperative reversion
towards a lower pitch to
some extent is inevitable.

83. •4 nonabsorbable
monophilic sutures are
placed to draw the cricoid
and thyroid cartilages
together.

84. Advantages:
 No surgery on the vocal cords themselves.
 Theoretically reversible if the patient is dissatisfied.
Disadvantages:
 Requires neck incision.
 prolonged healing process.
 long-term results are inconsistent.

85. Cricothyroid Subluxation : By
Steve Zeitels
Indications :
 U/L vocal fold paralysis with vocal fold shortening with
resultant reduced pitch range.
 Poor pitch range after adequate implant positioning in
medialization laryngoplasty.
 Contraindications :
 Present or impending laryngeal fracture of thyroid ala from
associated medialization laryngoplasty.

86.  To lengthen the vocal fold by increasing the
distancefrom the cricoarytenoid joint (cricoid ) to the
anterior commissure (thyroid cartilage) by subluxating
the cricothyroid joint.
 Results in rotation of anterior commissure away from
midline in a direction C/L to unilateral vocal fold
paralysis

87. Elongation Thyroplasty:
- Lateral Approach (Type IV
b)
•Vertical incision is taken at
the junction of anterior and
middle one-third of ala and
silastic implant is fixed
between cartilage edges by
two mattress sutures.
•-If pitch elevation is
insufficient, the same
procedure may also be
performed on the
contralateral side.

88. Medial Approach:
By Le Jeune as “springboard
advancement”
Indication : Breathy voice due to
bowed vocal folds.
After exposure of anterior portion
of thyroid cartilage, an inferiorly
based carilage flap is formed so
as to include the anterior
commissure. The upper end of
flap is held in position by a
tantalum shim.
- Tucker modified this technique
by reversing the pedicle and
called it “anterior commissure
advancement”.

89. Reinnervation procedures
 RLN anastomosis was initially described in 1909 by Horsley
and further work suggested that this was successful
technique but with no objective evidence.
 Recently Crumley has popularised the technique of ansa
cervicalis to RLN anastomosis.
 Muscle nerve pedicle reinnervation has also been described
using a block of omohyoid with its branch from ansa
cervicalis.

90.  There is currently no convincing clinical or scientific
evidence that the reinnervation techniques give better
or equal results to either injection,medialisation,or
laryngeal framework surgery in the management of a
unilateral vocal cord paralysis.

91. Speech therapy
 Abnormal voice is described as:
 Redued in volume,to a level where normal hearing listeners
would have difficulty in hearing.
 Excessively loud
 At a pitch level that is deemed to be incongruent for age and sex
of the speaker.
 Lacking in flexibility to alter pitch and loudness.
 Characterised by a a quality that draws attention in an
unpleasant manner.

92.  There is no internationally accepted classification of vocal
problem.
 Traditional approach:functional vs organic dysphonia.
 Newer classification:(based on etiology and symptom)
 Discreet mass lesion
 Distributed tissue changes.
 Organic movement disorders
 Non organic disorders.

93. Non organic
dysphonia:infections,chronic cond’n
 M.C associated conditions:LPRD(55%),chronic tobacco
use(25%),URTI(15%).
 Acute laryngitis may be caused by either viral or bacterial
agents and the voice is often affected.
 Causes of chronic laryngitis include:LPRD,allergic
rhinitis,trauma,vocal abuse,smoking,thermal,chemical or
caustic irritation,drying medication and rhinosinustis.
 Common symptoms:hoarseness,reduced voice
quality,dysphagia,chronic throat clearing and cough.

94.  Speech therapy is directed towards alleviating
symptoms(such as throat clearing,coughing,excessive
dryness or excessive mucus production) and improving
signs(hoarse,husky voice,excessive and strained
vocalisation).
 If hyperfunction is noted, then a behavioural programme
may be instigated to reduce vocal fold contact,to reduce
laryngeal and pharyngeal muscle tension to change vocal
pattern

95. Effectiveness of speech therapy
 RCT have shown that symptomatic/behavioural voice
therapy is effective in perceptually improving voice ,in
patients who present with non organic dysphonia.

96. Vocal hygeine
 Vocal hygeine is an encompassing term to describe techniques
which are routinely incorporated into most voice therapy
programmes.
 It includes:
 Reducing the amount of talking.
 Reducing loud,effortful talking
 Eliminating vocal abuse
 Manipulating the environment to be optimal for voice
production.

97. Vocal nodules
 Patient presents with restricted pitch range and voice
breaks.
 Arises due to combination of overuse and incorrect use.
 t/t of choice is: suitable training programme that
motivates the patient to practice outside the clinic to
change faulty vocal habits and eliminate vocal misuse and
abuse.
 Unless the incorrect vocal habits that led to the nodules
are addressed ,then there is a high probability that the
nodules will recur.

98. Cysts of vocal fold.
 Usually removed surgically ,and afterwards a period of
voice therapy may be necessary to correct any faulty
vocal habits.
 However there have no published studies examining
the efficacy of voice therapy with this population.

99. Granulomas
 Treat the underlying cause(GERD)
 Speech therapy is appropriate in order to eliminate
laryngeal abusive behaviours.

100. PAPILLOMATOSIS OF LARYNX
 Surgical treatment needs to ensure the damage to the
growing larynx is avoided and that subepithelial layers
are preserved.
 Voice therapy in children ,teaching non traumatic use of
voice, may be important .

101. Vocal fold oedema and polyp
 Voice therapy to assure good vocal habits and to
eliminate misuse and abuse of the larynx is strongly
advised in order to prevent recurrence.
 A vocal fold polyp never resolves with therapy alone
and should be surgically removed.

104. Conditions Requiring Performance
Cancellation
 Submucosal hemorrhage
 Enlarging vocal fold varix
 Break in vocal fold mucosa
 Significant systemic illness
 Severe laryngitis

105. Indications for Systemic
Corticosteroid Therapy in
the Professional Voice Patient
 Edema from episodic abuse
 Mild to moderate laryngitis
 Allergic vocal fold edema
 Vocal fold hemorrhage

106. Spasmodic dysphonia
 Middle age.
 M=F
 Neurological/psychological origin.
 c/f:Addductor spasmodic dysphonia :struggle/strain in
talking,marked intermittent stoppage of
voice/hoarseness/harshness/vocal tremor.
 Abductor spasmodic dysphonia: intermittent episodes of
breathy dysphonia, drop in pitch and vowel prolongation.

107.  Mgmt: counselling/hypnosis/biofeedback/surgery.
 Only few studies have demonstrated voice therapy as
being effective.

108. Parkinson’s disease
 Monotonous,low pitch and harsh voice.
 Lee Silverman voice programme is designed
specifically for this disease to increase vocal cord
adduction.
 Intensive therapy(16 daily sessions per month),using
high phonatory effort exercises to increase vocal
adduction ,maximize pitch range and respiratory
support.

109. Hyperfunctional voice disorders
 Hyper function occurs when glottis closes too firmly, or
when there is excess ventricular fold or pharyngeal level
constriction.
 Hyper function might be viewed as a continuum of voice
abuse /misuse leading to pathological change.
 Therapy includes approaches to reduce vocal fold tension,
to reduce muscle tension in the laryngeal and pharyngeal
regions and to restore normal tone to speech muscles

110.  3 most common techniques which offer levels of
scientific evidence to validate their use are:
 Accent method
 EMG biofeedback training
 Stemple’s vocal function exercise programme.

111.  Accent method of voice therapy employs:
Rhythm and intonation(accent)
Abdomino-diaphragmatic breathing exercises
Body and arm movements

112. EMG biofeedback training
 It is a technique that uses a physiological signal to control
the amplitude ,frequency and duration of a feed back signal
that is presented to the subject either acoustically or
visually.
 EMG activity is recorded from the laryngeal area using
bipolar surface electrodes placed on the cricothyroid
region,1cm each side of the midline of the larynx,with a
third electrode on the ear lobe.
 Visual and auditory feedback may be given together.

113. Stemple’s voice function exercise
programme.
 It is series of voice manipulations designed to
strengthen and balance airflow to muscular effort and
balance laryngeal musculature.
 No study has used subjects with laryngeal disease or a
history of voice disorder,so this procedure has yet to be
demonstrated on patients with dysphonia or laryngeal
disease

114. Psychogenic disorder
 A psychogenic voice disorder occours when vocal
control over pitch,loudness,quality or resonance is
disrupted sufficiently to impede communication
because of psychological disequilibrium.
 Mgmt:speech therapy+Psychotherapy

115. Pitch disorders
 Puberophonia
 Transexual voice.

116. puberophonia
 Unusually high pitched voice persisting beyond
puberty.
 Problem specific to men .
 3 mutational disorder:
Mutational falsetto voice
Prolonged mutation
Incomplete mutation
Abnormal use of voice during puberty may contribute to
incomplete mutation.

117.  Therapy for incomplete mutation may involve many
months training.
 Prolonged mutation and mutational falsetto voice may be
treated effectively in one or two sessions.
 Therapy involves manipulation of the position of larynx
and thus lowering the pitch by applying pressure on the
Adam’s apple while the patient phonates.

118. Transexual voice
 For female transexual ,this is an irreversible effect,so
the person must be certain they do ,indeed wish to
change gender as,once applied the vocal deepening
doesnot revert if there is a change of mind and
testosterone intake is ceased.
 It is often the male transexual that presents to a speech
pathologist,as they find their voice unacceptable to
their new female body/persona

119.  No high level evidence is available showing that
surgery gives a better outcome than therapy nor vice
versa.
 Transexual undergoing phonosurgery for pitch
change(thyroplasty) will usually need voice therapy
post operatively to optimize the surgical result.

120. Rehabilitation of voice after total
laryngectomy
 A laryngectomised patient is left with 3 options of
rehabilitating voice after surgery:
 1)Using a tracheo oesophageal puncture(TEP)
 2)Oesophageal speech
 3)Artificial larynges

121. Tracheo oesophageal
Puncture(TEP)
 Done at the time of T.L or some months later.
 Can restore near normal speech in terms of loudness
and fluency,but can be slightly restricted in vocal pitch
range.
 Reversible .
 Successful use of TEP speech demands a tonic PE
segment.

122. Oesophageal speech
 Patient is taught to semi swallow(or inject) air into
upper oesophagus and regurgitate this to produce a
burp like speech.
 May provide a fluent,hands free mode of
communication,but is limited in range and loudness.

123. Artificial larynges
 Types:A)Electronic
 B)Pneumatic
 Easy to use
 Provide intelligible speech
 Perceived monotonous and always demand the use of
one hand

124. Physiological pre requisite for
acquiring a laryngeal speech
 Pharyngo-oesophageal (P.E) opening pressure is a key
factor in success or failure to acquire both oesophageal
and TEP voice.

125. chart

126. Thank you……..