VOICE AND SPEECH DISORDERS

VOICE AND SPEECH DISORDERS

Hoarseness

Hoarseness is defined as roughness of voice resulting from variation of periodically and/or intensity of consecutive sound waves.

For production of normal  voice, vocal cords should:

1. Be able to approximate properly with each other.
2. Have a proper size and stiffness
3. Have an ability to vibrate regularly in response to air column

Any condition that interferes with the above function causes hoarseness.

(a)    Loss of approximation may be seen in vocal cord paralysis or fixation or a tumour coming in between the vocal cords.

(b)   Size of the cord may increase in oedema of the cord or a tumour; there is a decrease in partial surgical excision or fibrosis.

(c)    Stiffness may decrease in paralysis, increase in spastic dysphonia or fibrosis.

Cord may not be able to vibrate properly in the presence of congestion, submucosal haemorrhages, nodule or a polyp.

Aetiology

Hoarseness is a symptom and not a disease per se.

Causes of hoarseness

1. Inflammations

Acute: Acute laryngitis usually following cold, influenza, exanthematous fever, laryngo-tracheo-bronchitis, diphtheria

Chronic: (1)Specific. Tuberculosis, syphilis, scleroma, fungal infections

               (2)Non-specific. Chronic laryngitis

2. Tumours

Benign: Papilloma (solitary and multiple), haemangioma, chondroma, fibroma,leukopalkia

Malignant:Carcinoma

Tumour-like masses: Vocal nodule, vocal polyp, angiofibroma, amyloid tumour, contact ulcer, cysts, laryngocele

3. Trauma: Submucosal haemorrhage, laryngeal trauma(blunt and sharp), foreign bodies, intubation
4. Paralysis: Paralysis of recurrent, superior laryngeal or both nerves
5. Fixation of cords: Arthritis or fixation of cricoarytenoid joints
6. Congenital: Laryngeal web, cyst, laryngocele
7. Miscellaneous: Dysphonia plica ventricularis, myxoedema, gout
8. Functional: Hysterical aphonia

Investigations

1. History. Mode of onset and duration of illness, patients occupation, habits and associated complaints are important and would often help to elucidate the cause. Any hoarseness persisting for more than three weeks deserves examinations of larynx, Malignancy should be excluded in patient above 40 years.
2. Indirect laryngoscopy. Many of the local laryngeal causes can be diagnosed.
3. Examination of neck, chest, cardiovascular and neurological system would help to find cause for laryngeal paralysis.
4. Laboratory investigations and radiological examination should be done as per dictates of the cause suspected on clinical examination.
5. Direct laryngoscopy and microlaryngoscopy help in detailed examination, biopsy of the lesions and assessment of the mobility of cricoarytenoid joints.
6. Bronchoscopy and oesophagoscopy may be required in cases of paralytic lesions of the cord to exclude malignancy.

Dysphonia plica ventricularis

(Ventricular Dysphonia)

Here vice is produced by ventricular folds(false cords) which have taken over the function of true 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. In this type , voice begins normally but soon becomes rough when false cords usurp the function of true cords. 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 counseling.

Functional Aphonia(Hysterical Aphonia)

It is a functional disorder mostly seen in emotionally labile females in the age group of 15-30. Aphonia is usually sudden and unaccompanied by other laryngeal symptoms. Patient communicates with whisper. On examination, vocal cords are seen in abducted position and fail to adduct on phonation; however adduction of vocal cords can be seen on coughing, indicating normal adductor function. Even though patient is aphonic, sound of cough is good. Treatment given is to reassure the patient of normal laryngeal function and psychotherapy.

Puberphonia (Mutational Falsetto Voice)

Normally, childhood voice has a higher pitch. When the larynx matures at puberty, vocal cords lengthen. And the voice changes to one of lower pitch. This is a feature exclusive to males. Failure of this change leads to persistence of childhood high-pitched voice and is called puberphonia. It is seen in boys who are emotionally immature, feel insecure and show excessive fixation to their mother. Psychologically, they shun to assume male responsibilities though their physical and sexual development is normal. Treatment is training the body to produce low-pitched voice. Pressing the thyroid prominence in a backward and downward direction relaxes the overstretched cords and low tone voice can be produced (Gutzmann’s pressure test). The patient pressing on his larynx learn to produce low tone voice and then trains himself to produce syllables, words and numbers. Prognosis is good.

Phonasthenia

It is weakness of voice due to fatigue of phonatory muscles. Thyroarytenoid and interarytenoids or both may be affected. It is seen in abuse or misuse of voice or following laryngitis. Patient complains of easy-fatiguability of voice. Indirect laryngoscopy show three characteristic findings:

(i)                 Elliptical space between the cords in weakness of Thyroarytenoid

(ii)               Triangular gap near the posterior commissure in weakness of interarytenoid.

(iii)             Key-hole appearance of glottis when both Thyroarytenoid and interarytenoids are involved.

Treatment is voice rest and vocal hygiene, emphasizing on periods of voice rest after excessive use of voice.

Hyponasality

It is lack of nasal resonance for words which are resonated in the nasal cavity, e.g. m,m,ng. It is due to blockage of the nose or nasopharynx.

Causes of Hyponasality

Common cold

Nasal allergy

Nasal polypi

Nasal Growth

Adenoids

Nasopharyngeal mass

Familial speech pattern

Habitual

Causes of hypernasality

Velopharyngeal insufficiency

Congenitally short soft palate

Submucous palate

Large nasopharynx

Cleft or soft palate

Paralysis of  soft palate

Post-adenoidectomy

Oronasal fistula

Familial speech pattern

Habitual speech pattern

Hypernasality (Rhinolalia Aperta)

It is seen when certain words which have little nasal resonance are resonated through nose. The defect is in failure of the nasopharynx to cut off from Oropharynx or abnormal communication between the oral and nasal cavities.

Stuttering

It is disorder of fluency of speech and consist of hesitation to start, repetitions, prolongations or blocks in the flow of speech. When well established, a stutterer may develop secondary mannerisms such as facial grimacing, eye blink and abnormal head movements. Normally most of the children have dysfluence of speech between 2-4 years. If too much attention is given or child reprimanded by parents and peers, this behavior pattern may become fixed and child may develop into an adult stutterer. Stuttering can be prevented by proper education of the parents, not to overreact to child’s dysfluency in early stages of speech development. Treatment of an established stutterer is speech therapy and psychotherapy to improve his image as a speaker and reduce his fear of dysfluency.