| February 4, 2016






Voice Disorder

The phrase hoarseness is an independent word utilized to explain irregular vocal quality. Nevertheless, the existence of hoarseness does not certainly suggest a particular etiology. Vocal generation is a sophisticated communicative performance engaging interaction between the mechanism of respiration, phonation, and expression that are each, affected a person’s vocal style and emotional condition.  The last vocal outcome mirrors three varied but connected acts. The general incidence of voice disorders is not understood.  Practical explanations of a vocal disturbance are ambiguous, and prevalent research has not been completed.  Three mechanisms comprise the vocal tools: the respiratory system, the larynx, and the supraglottic vocal tract. In essence, these sophisticated mechanisms are incorporated to generate high vocal quality (Grillone et al., 2004). The respiratory system plays a compressor role by offering a persistent and stable flow of air via a compact glottis by way if the Bernoulli effect. After inhalation, the belly muscles smoothly contract to create room for a steady supply of air via the glottis. Irregular breathing style might impact the vocal control, which is particular essential for singers. The larynx comprises fold-looking muscles and is enclosed by mucous membranes. The space among the vocal folds is known as the glottis (Hixon, 2011). The presence of pathology along the course of alternating laryngeal nerve can alter vocal fold motion on the ipsilateral side and result in hoarseness. Sound is produced at the level of the vocal folds and then goes via the supraglottic vocal tract. At this point sound is changed by numerous oral pharyngeal structures. Lesions of the vocal folds quite frequently generate vocal symptoms of progressive onset (Fritzell et al., 2003).

Laryngeal dystonia is a speech abnormalities illustrated by involuntary contraction of the laryngeal muscles responsible for speech generating activity.  Even if in the past they were regarded as psychosomatic disorders, currently we understand that laryngeal dystonia or spasmodic dysphonia (SD) as central-motor processing neurological abnormality.  Laryngeal dystonia is classified in four types (adductor, abductor, mixed or respiratory). For almost 100 years since it was discovered, SD was perceived as psychogenic disorder. Normally manifested in anxious people and marked by limited aggression over the stresses and losses of middle age. For a long time, SD has been re-categorized as a kind of focal dystonia affecting laryngeal muscles at the time of speech. Adductor-class SD (ADSD) is hallmarked by hasty, inconsistent, and intense spasms of the vocal folds during regular phonation, recurrently blocking the glottis and generating a hint of effortful phonation. The adductor variety might be further split in four sub-varieties depending on the position (glotti, supraglottic) and the presence of tremor. In the glotti sub-variety, only those muscles responsible for vocal cord adduction experience this intermittent contraction, and in the supraglottic, vocal folds, ventricular folds alongside other supraglottic structures are responsible for action, and speech articulation is most impacted in this subtype.  Abductor dystonia SD (ABSD) does not occur frequently and has far-reaching effects from Botulin Toxin treatment. It takes place when abductor muscles coordination fails and is displayed by pitch changes and intermittent periods of excessive breathiness when giving a speech (Grillone et al., 2004).

Vocal cord nodules are noncancerous tumors on both vocal cords. Vocal nodules are analogous to lumps of the vocal cords. They appear on both vocal cords parallel to each other at the position of utmost wear and tear and are normally treated with voice therapy. The voice is generated in the voice box that is situated in the neck. Phonation itself is generated by the vibration of the vocal cords that are situated in the larynx. During this production of voice, the vocal cords shut and are vibrated by air emanating from the lungs. The diagnosis of voice nodules is made chiefly by patient history. Its etiology is linked to vocal abuse.  Vocal abuse can make the vocal cords to shut with severe force. As this takes place, a minor appears on the edge if the vocal cord. Swelling alongside the edge of the cord then follows. Eventually, a definite nodule forms on the front of the vocal cord- a point on which great vibration takes place. The chief symptom of vocal cord nodules is breathless and husky voice. These grazes interrupt the glottic closure and permit escape of air during voice production. Essentially glottal airflow is an important gauge that gathers the quantity of air passing via the vocal folds at the time of voice production. Raised air supply is normally characterized with partial glottic closure. The patient normally shows signs of husky voice.  Nodules show great response to speech therapy (Srirompotong et al., 2001).

In order to carry out further information gathering and assessment for the first client, Mrs. Irene Jones:  I will evaluate her voice behavior and the perceptive-auditory voice analysis. The speech material will consist of a constant utterance of the vowels, for instance vowel ‘e.” In this case, voice quality is expected to change and become more manifest than in attached speech, if the client is going to hide voice quality and the deviation of voice transformations. This voice assessment task will take place during the time in which the client will be admitted to the hospital.  Because I am a practiced speech specialist at a major center that receives patients from various distant regions, I therefore have a significant series. However I expect the whole process with the first patient to be a total success. As for the second patient, Miss Jennifer Smart I will chose a lesion that has been diagnosed as vocal fold nodules. It will be important for me to collect paraffin block of this lesion from the pathology laboratory, and consequently place it on a glass slide. The slides will be evaluated between me and a pathologist via a light microscope connected to a TV screen, with prior insight concerning the ENT diagnosis. It will be important for the pathologist to determine the last histological diagnosis of the variety of lesion. Finally I will compare and contrast the pathological diagnosis with that of ENT diagnosis and classify it as either concordant or discordant (Holmberg and Hammarberg et al., 2001)

Treatment plan for patient B: Miss Jennifer Smart

Many voice disorders are multifaceted in etiology and are connected to irritation from likely reflux, vocal abuse. A key part of voice therapy for Miss Smart will include educating her on the basic anatomy and physiology of the vocal phonation system. My patient will have to understand the relationship between her particular voice disorder and any causative factors.  This understanding will facilitate collaboration with therapeutic procedures. It will be important too for my client to be counseled regarding the techniques of vocal conservation. Complete voice rest will not be an option. While voice rest permits edematous tissues to recover, voice advancement is most probably short-lived and the vocal nodules might return. Minimizing evident sources of vocal abuse is the only component of the program. Work noise cannot be evaded, my patient (a primary school teacher who must raise her voice to get the attention of young pupils) might use a noise maker to achieve the same purpose without injury her voice.  My patient might have to use corticosteroids although conservatively since she has an important speaking engagement. Corticosteroids function by lowering edema at the glottic region therefore reduce hoarseness.  Corticosteroids must be prescribed for not more than 4 to 5 days alongside voice conservation. The function of surgical intervention relies upon the cause of the patient’s huskiness. If my patient will need surgical intervention, it will be important to start voice therapy preoperatively to reduce vocal abuse and secondary trauma in the postoperative stage. The phonosurgical methods for removal of benign lesions concentrate on the protection of usual mucosa whilst eliminating the affected region only (McCrory, 2001).

Treatment plan for patient A

Etiology of larynx dystonia remains unknown. In essence, this abnormality has been regarded psychogenic in nature but contemporary hypothesis includes a neurologic cause. Diagnosis is founded upon history and keen evaluation of the glottis round laryngeal tasks. Treatment is normally implemented via intramuscular injection of Botulin toxin (BXT) affected muscle regions, and will be directed by endoscopy. The recommended dose will be 0.1-10U4.  Treatment with this toxin amounts in lowering of voice breaks normally by 48 hours post treatment. Treatment will last an average of 3-4 months before the patient starts to experience recurrence of symptoms. I’ll explain to my patient the side-effects of the treatment that include breathiness. There are various benefits involved with using BXT: it’s less aggressive technique than surgery, no long-term damage to laryngeal structures; it’s widely accessible. The other treatment intervention will be voice therapy. It might assist to prevent a psychogenic disorder and might be utilized to offer support to those who are allergic to Botox.  For instance, lowered speech force and laryngeal manipulation are the methods focused on lowering laryngeal pull. Therapy may as well use relaxation and respiration coaching to assist in obtaining of knowledge and regulation of laryngeal tension. The present surgical techniques available include recurring laryngeal nerve denervation and reinnervation, amid others (Blitzer, Brin and Stewart, 2008).


  1. Fritzell, B. Hammarberg, H. Schiratzki, S. Haglund, E. Knutsson and A. Martensson. (2003). “Long-term results of recurrent laryngeal nerve resection for adduction spasmodic dysphonia,” Journal of Voice 7(2), 172–178.

Blitzer A, Brin M.F, Stewart C.F. (2008). “Botulinum toxin management of spasmodic     dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients.” Laryngoscope, 108(10):1435-41.

Carding P.N., Horsley I.A., Docherty G.J. (2009). “The effectiveness of voice therapy for            patients with non-organic dysphonia,” Clinical Otolaryngology Allied Science, 23(3)10–        8.

  1. Boutsen, M.P. Cannito, M. Taylor and B. Bender. (2002). “Botox treatment in adductor spasmodic dysphonia: a meta-analysis,” Journal of Speech, Language, and Hearing Research 45(3), 469–481.

Grillone G.A, Blitzer A, Brin M.F., Annino D.J. Jr, Saint-Hilaire M.H. (2004). “Treatment of        adductor laryngeal breathing dystonia with Botulinum toxin type A.” Laryngoscope,    104(23) 30-32.

Hixon T. (2011). Respiratory function in speech. In Normal Aspects of Speech, Hearing, and         Language. Englewood Cliffs, NJ: Prentice-Hall.

Holmberg EB, Hillman RE, Hammarberg B, et al. (2001) “Efficacy of a behaviorally based voice             therapy protocol for vocal nodules,” Journal of Voice, 15:395– 412.

McCrory E. (2001). “Voice therapy outcomes in vocal fold nodules: a retrospective audit.” In       Journal of Communication Disorder, 36:19 –24.

Srirompotong S., Saeseow P., Vatanasapt P. (2004). “Small vocal cord polyps: completely            resolved with conservative treatment,” Southeast Asian Journal of Tropical Medical                     Public Health, 35(1):169-71.

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