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Physiology of Phonation and

Approach to a patient with


Hoarseness of voice

Presenter: Dr. Arun


Moderator: Dr. Vinaybabu

Relevant Anatomy
Fundamental components of speech
Theories of phonation
Glottic cycle
Factors affecting phonation

Objective evaluation of voice-Approach to


a patient with Hoarseness of voice

Larynx
Situated at the upper end
of trachea
Opposite 3rd 6th cervical
vertebrae (males)
Higher in women and
children
Infants smaller, narrow
lumen, funnel-shaped,
cartilages softer &
collapse easily

Framework
Cartilages:
Thyroid cartilage
Cricoid cartilage
Aryetenoid cartilage
Corniculate and Cuneform
Vocal folds
Muscle
Intrinsic
Extrinsic
Nerve supply

THYROID CARTILAGE
Shield shaped cartilage
Fused at midline Thyroid
notch ( 90* /120*)
Superiorly fusion absentThyroid notch
Posteriorly each ala has
superior and inferior horn

Inferior horn articulates with


facet on cricoid cartilageCricothyroid joint

Anterior commissure at the midpoint of line


connecting thyroid notch to inferior border of thyroid
cartilage.
Thyroid cartilage is lined by a thick layer of
perichondrium on all surfaces except- at Ant
commissure 5 ligaments attached:
Median Thyroepiglottic ligament Median thyrohyoid
fold
B/L Vestibular ligaments Vestibular or false cords
B/L Vocal ligaments Vocal folds

Cricoid Cartilage
Complete signet ring cartilage.
On post surface, post
cricoarytenoid muscles are
attached in depressions which
are separated by a midline
vertical ridge.
Paired arytenoid cartilages are
attached onto superior surface
of Posterior cricoid lamina

Arytenoid cartilage
Paired catilages
Roughly Pyramidal in
shape
Antero-lateral surface
has vestibular
ligament,
thyroaryetenoid and
vocalis muscle.
Posterior surfacemuscular attachments

Corniculate cartilage:
cartilage of Santorini
Cuneform cartilage:
cartilage of Wrisberg
Are small paired
fibroelastic cartilages
Adds rigidity to
aryepiglottic fold.

Extrinsic muscles
Elevators: elevates and displaces larynx
anteriorly during swallowing

Thyrohyoid
Stylohyoid
Digastric
Geniohyoid
Mylohyoid
Stylopharyngeus

Extrinsic muscles
Depressors: displaces larynx downward during
inspiration
Omohyoid
Sternohyoid
Sternothyroid

Intrinsic muscles
Muscles anatomically
restricted to larynx
Abductors:
Posterior cricoarytenoid

Adductors:
Cricothyroid

Lateral cricoarytenoid
Interarytenoid

Cricothyroid
2 bellies:

Pars recta- attached to lateral


portion of Ant arch of cartilage
to inf border of thyroid cartilage.
Pars obliqua- attached to
anterolateral border of cricoid
arch travels obliquely upward to
insert on Ant portion of inferior
cornu.

It lowers , stretches and thins


vocal folds while bringing them to
para median position.

Posterior Cricoarytenoid
Attached to a depression on
posterior surface of cricoid lamina
and its fibers run obliquely superior and
lateral and attach to muscular process of
arytenoid.
Contraction: abducts, elongates and
thins vocal fold.
Brings muscular process medially,
posterior and inferior while laterally
rotating and elevating vocal process.
Role in high pitch singing

Lateral Cricoarytenoid
Attaches along the superior border of cricoid
cartilage and inserts to the Ant portion of
muscular process.
Contraction: brings muscular process
anterolaterally
Adducts, elongates and thins the vocal cord.

Interarytenoid
Transverse and oblique fibres
Transverse fibres pass from posterior surface of one
arytenoid to the other
Contraction: brings together the arytenoid cartilages.

Assist closing post portion of glottis


Only muscle having dual innervation from Both RLN

Thyroarytenoid
T. internus
Contract - brings vocal process and
Ant commissure closer to
each other
adducts true and false
vocal folds

T. externus
adducts, shorten
thickens and
lowers
the vocal fold

Vocal cord
Antoine Ferrein coined the term
Located within larynx attached antthyroid cartilage and post-arytenoid
cartilage
Male vocal folds -17.5 mm to
25 mm
Female vocal folds -12.5 mm and
17.5 mm
3-5 mm thickness
Folds are pearly white in color more white in women than in men.

Vocal Fold
Vocal fold consists of five
layers:
1. Squamous epithelium layerVery thin helps to hold the
shape of vocal cord.
2. Superficial layer of the lamina
propria-loose fibres and matrix
aka Reinkes space
3. Intermediate layer-elastic &
collagenous fibres but more
than superficial layer
4. Deep layer-high concentration
of collagen bundles.
5. Vocalis: Main mass of the
vocal cord

Nerve Supply
Motor
Vagus

SLN
RLN

Ext

Cricothyroid Muscle

Int
Thyroarytenoid, Lateral cricoarytenoid,
Posterior cricoarytenoid, Interarytenoid

Sensory
Internal laryngeal nerve: supraglottis and the glottis
Recurrent laryngeal nerve: upper trachea and subglottis

Theories of Nerve innervation


Semons law

Wagner & Grossman Theory


Modern theory

Semons Law
Rosenbach (1880) & Semon (1881)
In all progressive organic lesions, abductor fibres of
recurrent laryngeal nerve, which are phylogenetically
newer, are more susceptible and thus first to be
paralyzed compared to adductor fibres.

1st stage: only abductor fibres damaged; vocal folds


approximate in midline; adduction still possible
(paramedian position)
2nd stage: contracture of adductors; vocal folds
immobilized in median position
3rd stage: adductors become paralyzed; vocal fold
assumes cadaveric position

Abductors affected first ??


Nerve fibres supplying abductors are in periphery of
recurrent laryngeal nerve
Muscle bulk for the abductors is less, more
susceptible
Phylogenetically, larynxs main function is
protection, so adductor functions are maintained

Wagner & Grossman Theory


In isolated paralysis of recurrent laryngeal nerve,

cricothyroid muscle (innervated by SLN) keeps


vocal cord in paramedian position due to adductor
function
In both RLN and SLN palsy, cord lies in
intermediate (cadaveric) position.

Modern theory
Final position of paralyses vocal cord is not static & is
decided by:
Degree of paralyzed muscle atrophy & fibrosis
Degree of re-innervation following injury

Extent of synkinesis (mass movement) of all intrinsic


muscles
Fibrosis & ankylosis of crico-arytenoid joint

Position of
vocal cord
Median

Distance
from centre
Midline

Healthy

Diseased

Phonation

Paramedian

1.5 mm

Intermediate
(Cadaveric)

3.5 mm

Strong
Whisper
Neutral
position

Gentle
abduction

7 mm

Quiet
respiration

RLN
Paralysis
RLN
Paralysis
Paralysis of
both RLN &
SLN
Paralysis of
adductors

Full
abduction

9.5 mm

Deep
Inspiration

--

Fundamental components of Speech


Phonation Generation of sound by vibration of the
vocal folds
Resonance Induction of vibration in the rest of the
vocal tract to modulate laryngeal output ( The throat,
mouth cavity, and nasal passages)
Articulation Shaping of the voice into words.( The
tongue, soft palate, and lips)

Subsystem

Voice Organs

Role in Sound Production

Air Pressure System

Diaphragm, chest muscles, Provides and regulates air


ribs, abdominal muscles
pressure to cause vocal
folds to vibrate
Lungs

Vibratory System

Voice box (larynx)


Vocal folds

Vocal folds vibrate,


changing air pressure to
sound waves producing
"voiced sound," which is
frequently described as a
"buzzy sound"

Varies pitch of sound


Resonating System

Vocal tract: throat


Changes the "buzzy sound"
(pharynx), oral cavity, nasal into a person's recognizable
passages
voice

Sound is produced when aerodynamic phenomena


cause vocal folds to vibrate rapidly in a sequence of
vibratory cycles with a speed of about:
110 cycles per second or Hz (men) = Low pitch
180 to 220 Hz (women) = Medium pitch
300 Hz (children) = Higher pitch

PHONATION:
Physical act of sound production by means of
passive vocal fold interaction with the exhaled air stream.

Prerequisites:

Adequate respiratory support.


Appropriate glottal closure.
Favourable vibratory properties.
Favourable vocal fold shape.
Control of vocal fold length and tension are required.

THEORIES OF PHONATION
I.

Neuromuscular theory / Clonic Theory /


Neurochronaxic Theory of Husson, 1953

II. Myoelastic Aerodynamic Theory of Van den Berg,


1958

III. Body- Cover theory/Two Mass Model

Neurochronaxic Theory
Each vibratory cycle initiated by nerve impulse to
Vocalis muscle via Recurrent laryngeal nerve/ Vagus
nerve
Frequency of voice dependent upon rate of impulses
delivered.
Each vibratory cycle caused by a separate neural
impulse.
Invalid theory.

Myoelastic Aerodynamic Theory

Widely accepted theory- Van den berg


AERO - air pressure and flow
DYNAMIC - movement and change
MYO - muscular involvement
ELASTIC - ability to return to original state
States that interaction of
aerodynamic forces and
mechanical properties of the laryngeal tissues are
responsible for inducing vocal fold vibration and
generating vocal sound.

Body- Cover theory


Hirano
According to this, the vocal folds
consist of a multi-layered
vibrator with increasing stiffness
from the cover to the body.
The cover is responsible for most
of the vibratory action of the
vocal folds
Theory can be applied only in
modal register but not in high or
lower pitch

Air is moved out of the lungs and towards the vocal folds.

Vocal fold vibration sequence of Vibratory cycles/Glottic


cycles

The nose, pharynx and mouth amplify and modify sound,


allowing it to take on the distinctive qualities of voice

Glottic Cycle
Adduction of Vocal Folds by voice box muscles, and
cartilage.
Expiration of air from lungs Subglottic pressure.
Air pressure increases below the glottis until folds forced
apart.

Subglottic pressure more than vocal fold resistance.


Air flow passes through narrowed glottis.

1 Column of air
pressure moves
upwards towards
vocal folds in
"closed" position.
2, 3 Column of air
pressure opens
bottom of vibrating
layers of vocal folds;
body of vocal folds
stay in place.

4, 5 Column of air
pressure continues
to move upwards,
now towards the top
of vocal folds and
opens the top.

6 10 The low
Pressure created behind
the fast-moving air
column produces a
"Bernoulli effect"
which causes the
bottom to close,
followed by the top.

10 Closure of the vocal


folds cuts off the air
column and releases a
pulse of air

Factors causing return of Vocal folds to


midline
1. Air travels faster through the glottis when it is
narrow. This causes a local drop in air pressure
(Bernoulli effect) which causes the folds to be
sucked towards each other.
2. Elastic forces in vocal folds.
3. Transglottal pressure
4. Subglottic pressure

CHARACTERISTICS OF SOUND
SOURCE or GLOTTIC SIGNAL
Quality
Frequency
Amplitude

Quality
Depends on:
Nature of vocal cords adduction during phonation.
Regularity of mucosal waves of lamina propria.
1. Incomplete adduction Breathy voice
2. Insufficient vocal cord adduction for vibration but sufficient
to produce audible turbulent air Whisper
3. Irregular mucosal waveform vibration Hoarse
4. Vocal cords strongly adducted + raised subglottal air
pressure Pressed or Strained voice

Frequency
Number of vibratory cycles/ sec (measured in Hertz)
Frequency with:
Length of vocal cord
Thinning and stiffening of vocalis muscle
Jitter or Pitch perturbation short term variance in
frequency of vocal cord vibration

Amplitude
It is the size of oscillation of the vocal folds.
Perceived as loudness or sound intensity

Largely determined by the force of the transglottal


airflow.
Shimmer or amplitude perturbation short term
variance in intensity of vocal signal

Pitch
Frequency, intensity and spectral properties of sound
interact in very complex ways to lead to a given Pitch
perception.
Registers : Describe the vibratory pattern of the vocal
cords and the acoustic parameters being produced.
There are three pitch registers:
Loft (or falsetto) register
Modal (or middle) register
Pulse (or chest) register

LOFT REGISTER
Aka Falsetto
Highest vocal frequency ( F0 275 to 1100Hz)
Vocal folds Thinned, tensed, lengthened

Minimal vibration of vocal cord


Subglottic air pressure high.
Larynx raised ; Pharynx shortened

MODAL REGISTER
Aka Heavy voice
Speech and singing frequency (F0100 to 300Hz)
Vocal folds complete adduction, triangular in cross
section
Larynx pulled down; Pharynx Normal
Vibration slowly and whole length.

PULSE REGISTER
Aka Glottal fry, Vocal fry or Creaky voice
Reflects pulsatile nature of laryngeal sound generated
Occurs during lowest frequency (F0 20 to 60Hz)

Feature of normal speech


Larynx normal; Pharynx normal
Vocal cord long closed phase

Modification of Glottic signal


Raw Glottic Signal Modified into speech by

RESONANCE

ARTICULATION

VOCAL RESONANCE
TYPES

ORAL RESONANCE
AFFECTED BY:
1. Degree of jaw movt.
2. Mouth opening
3. Tongue raising
4. Pharygeal
constriction

NASAL RESONANCE
AFFECTED BY:
Velopharyngeal sphincter

ARTICULATION
Synchronized movements of the organs of articulation (e.g.
Palate, Tongue, Lips) to change Glottal sound Recognizable
speech
Described by SOURCE FILTER MODEL
SOURCE LARYNX
FILTERS Lips , Tongue, Palate ,Pharynx
( Forms Consonants and Vowels)

Articulatory movement are of two types Vowels and Consonants

VOWELS
These are sounds in which
there is no obstruction to
flow of air as it passes
from larynx to lips.
Eg : A, E, I, O, U
Different vowels are
produced by :

Height of tongue
raising in mouth
Part of tongue raised
Position of lips (spread or
rounded)

CONSONANTS
Sounds produced when there is more definitive
obstruction to air by one or more articulator in the
oral tract
Eg : P, B, M, W, F, T, S, Z, R
Different consonants are produced by :
- Place of articulation
- Manner of articulation
- State of larynx

CONSONANTS
Bilabial
Labiodental
Dental
Based on place
of articulation

Alveolar
Palatal
Velar
Glottal

CONSONANTS BASED ON PLACE OF


ARTICULATION
BILABIAL

Articulation
between Upper
and lower lip

P, B, M,W

CONSONANTS BASED ON PLACE OF


ARTICULATION
LABIODENTAL
Top teeth and lower
lip
F, V

CONSONANTS BASED ON PLACE OF


ARTICULATION
DENTAL
Tongue tip and top
teeth occlusion
th in th ink

th in th at

CONSONANTS BASED ON PLACE OF


ARTICULATION
ALVEOLAR
Tongue tip touching ridge
behind the teeth

T, D, N, S, Z, R, ch, dj

CONSONANTS BASED ON PLACE OF


ARTICULATION
PALATAL
Articulation of
middle tongue with
hard palate
Y

CONSONANTS BASED ON PLACE OF


ARTICULATION
VELAR

Articulation of
posterior tongue and
soft palate
K, G, ng

CONSONANTS BASED ON MANNER OF


ARTICULATION
Refers to how air flow is obstructed in oral tract

PLOSIVES
: P, B, T, D, K, G
FRICATIVES
: F, V, S, Z, th
AFFRICATIVES : ch, dj
NASAL
: M, N, ng
APPROXIMANT : W, Y, L, R, H

CONSONANTS BASED ON STATE


OF LARYNX
Consonants are paired- here only difference is whether their
articulation is accompanied by voicing or not.
Eg: p and b, t and d, k and g, s and z
Can be either:
Voiced b, d, g, z
Voicelessp , t, k, s, h no vibration of vocal cords
h does not have a voiced twin so in connected speech,
vocalization is not continuous.
Phonation is switched on and off to signal voiceless
consonants.

HOARSENESS
The perceived breathiness quality of the voice (Bailey)
A rough or noisy quality of voice (Dorland)
A rough, harsh voice quality (Stedman)

Hoarseness is described as having difficulty producing


sound when trying to speak, or a change in the pitch or
quality of the voice.

Workup

HOARSENESS
ANY PATIENT WITH HOARSENESS OF TWO
WEEKS DURATION OR LONGER MUST
UNDERGO VISUALIZATION OF THE VOCAL
CORDS
EVALUATION OF A PATIENT WITH
HOARSENESS INCLUDES THE FOLLOWING:- History
- Clinical examination
- Investigations

History

Duration
Character of onset ( Sudden / gradually progressive)
Constant or intermittent Vocal nodule/ Chr. laryngitis
Associated symptoms:
Cough/ dyspnoea/ dyphagia/ fever
Diurnal variation:
Chronic laryngitis-worse in morning
Malignancy- worse in evening

Potential triggering factors (Vocal abuse, URTI,


Change in medications, Exposure to known allergens)

Exacerbating and ameliorating factors, such as


improvement with voice rest, or fatigue with use
Other head and neck symptoms (eg, dysphagia,
otalgia, odynophagia)

History
Past H/o:
History of past surgery involving the neck (especially
thyroid, carotid, and cervical spine), base of skull, or chest
History of trauma or endotracheal intubation
History of reflux or sinonasal disease
Medical comorbidities which may affect voice (eg,
rheumatoid arthritis or tremor)
Psychological stress

Personal H/o:
History of smoking and alcohol use
H/o weight loss.
Occupation, hobbies, and habits impacting voice use

Voice quality

Differential diagnosis

Breathy

Vocal cord paralysis


Abductor spasmodic dysphonia
Functional dysphonia

Hoarse

Vocal cord lesion


Muscle tension dysphonia
Reflux laryngitis

Low-pitched

Reinke's edema
Vocal abuse
Reflux laryngitis
Vocal cord paralysis
Muscle tension dysphonia

Differential diagnosis of hoarseness

Voice quality
Strained

Differential diagnosis
Adductor spasmodic dysphonia
Muscle tension dysphonia
Reflux laryngitis

Differential diagnosis of hoarseness


Tremor

Parkinson disease
Essential tremor of the head and neck
Spasmodic dysphonia
Muscle tension dysphonia

Vocal fatigue

Muscle tension dysphonia


Vocal cord paralysis
Reflux laryngitis
Vocal abuse

Examination of the nose for patency, obstructing


lesions, foreign body, or evidence of allergy
Examination of the oral cavity for mass lesions,
mucosal abnormalities, tonsil size, and motor
function of the palate and tongue
Palpation of the neck for mass lesions

LARYNGEAL EXAMINATION

INDIRECT LARYNGOSCOPY

FLEXIBLE LARYNGOSCOPY

RIGID LARYNGOSCOPY

INDIRECT LARYNGOSCOPY
Advantages
Quick
Inexpensive
Minimum
Equipment
Disadvantages
Gag
Non physiologic
No permanent
image capability

DIRECT LARYNGOSCOPY
70 or 90-degree
telescope.
Advantages:
Best optic image
Magnifies image
Video documentation
Disadvantages:
Gag,
Non physiologic
Expensive

FLEXIBLE LARYNGOSCOPY
Advantages:
Well tolerated
Physiologic
Video documentation
possible
Disadvantages:
Time consuming
Expensive
Resolution limited by
fiberoptics

RIGID LARYNGOSCOPY
Advantages:
Best images
Video
documentation
Disadvantages:
Expensive
Nonphysiologic
Gag
Requirement of
General Anaesthesia

VIDEOSTROBOSCOPY
Done to evaluate the vibratory patterns of the vocal folds that
occur too rapidly to be visualized by the unaided human eye.
Is an illusion of slow motion
Light source - flashing Xenon tube
Permits accurate visualization of epithelial abnormalities which
are missed out on IDL due to fast vibrations
Evaluation criteria include:
1. Symmetry
2. Amplitude
3. Periodicity
4. Mucosal wave propagation
5. Glottal closure.

Advantages:
Allows apparent slow
motion assessment of
mucosal vibratory
dynamics
Video documentation.
Disadvantages:
Time consuming
Expensive

OTHER TESTS
LABS: TFT

PLAIN FILMS: Chest xray, Lateral Neck, Foreign body r/o.


CT SCAN: Cancer, Unknown diagnosis, Persistent or
recurrent pain and hoarseness, trauma.
MRI : R/o Multiple cranial neuropathies- Evaluate skull base
and brainstem.

LARYNGEAL EMG
One of the most specific and sensitive test to determine the presence
of vocal fold paralysis.
Differentiate Bilateral vocal fold fixation and Neurogenic Vocal fold
paralysis
To confirm the presence of dystonia and in identifying which muscles
are most involved.
Myogenic Normal frequency of firing but decreased amplitude (A)
Neurogenic Decreased frequency but occasional normal amplitudes
(B)

PANENDOSCOPY
INDICATIONS
To do biopsy of suspicious lesions
Laryngeal cancer Tumour extend, any secondaries

Hoarseness patients without any diagnosis at the end of all


routine investigations.
Persistent or recurrent vocal symptoms
Patients with malignancies with new onset of hoarsenss.

References

Ballengers 16th edition


Scott brown 7th edition
Cummings 5th edition
OCNA 40 (2007) 991-1001
NCVS.org-national centre for voice and speech.
Voiceproblem.org ( Washington voice consortium)

Thankyou