Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

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Abdominal Distention of R-CPD Including Before and After Botox Injection

One of the primary symptoms of R-CPD (inability to burp) is bloating. Bloating is often accompanied by actual abdominal distention due to excess air in both stomach and intestines. Since the person is unable to burp, air must now pass through the entire GI tract and be dispelled as flatulence.


Abductor spasmodic dysphonia

A variant of spasmodic dysphonia in which the spasms pull the vocal cords apart, causing the voice to drop out or sound weak and breathy. Abductor spasmodic dysphonia (AB-SD) is an uncommon variant of spasmodic dysphonia, comprising only about 10% of the cases. It is to be distinguished from adductor spasmodic dysphonia (AD-SD), a much more common variant in which the spasms push the vocal cords together.

In its classic variant, the abductory spasms of abductor spasmodic dysphonia are intermittent, each time pulling the vocal cords apart momentarily, so that a person’s voice drops out intermittently to a whisper or breathy sound. Hence, this classic variant of abductor spasmodic dysphonia is sometimes called intermittent whisper phonation. In its tonic variant, the abductory spasms are more constant and sustained than intermittent, so that instead of interrupting the person’s speech, the spasms produce a more constant breathy quality to the voice.

Occasionally, a person has both abductory and adductory spasms; this is called mixed AB-AD spasmodic dysphonia. For more about spasmodic dysphonia in general and the treatment options for it, see our main entry.

Photos of abductor spasmodic dysphonia:


Absent swallow reflex

When a person’s automatic swallow reflex—which normally kicks in when liquid or chewed food in the mouth reaches the base of the tongue—is entirely absent. In such cases, saliva, food, or liquid in the mouth can slip back to the base of the tongue and then downward to fill the lower part of the throat and flow into the airway without a swallow reflex ever being triggered. Such an individual should not be allowed to swallow by mouth, for fear of incurring aspiration pneumonia. He or she would require an alternate method of feeding, such as a gastrostomy tube. Compare this disorder with delayed swallow reflex.


Achalasia

Achalasia is the failure of a ring of muscle, such as the lower esophageal sphincter (LES), to relax appropriately at the moment that food arrives at the end of its journey down the esophagus. This muscular non-relaxation creates a functional obstruction, interfering with normal passage of food into the stomach. This term is most commonly used in relation to the LES, but may also be used in reference to the upper esophageal sphincter (UES) or even anus.


Acid reflux

The backward flow (reflux) of acid from stomach up into the esophagus or, even further up, to the level of the laryngopharynx. Symptoms may be esophageal, laryngopharyngeal, or both. Esophageal symptoms include heartburn, indigestion, and acid belching. Laryngopharynx symptoms tend to include dry throat, husky (especially morning) voice, frequent morning throat clearing, excessive mucus, and mildly sore throat.

Sometimes acid reflux is diagnosed when it isn’t the real problem. The do-it-yourself trials in this downloadable article can help a person and his or her personal physician verify if acid reflux is the appropriate diagnosis: When Acid Reflux Treatment Takes You Down a Rabbit Trail.¹

See also: gastroesophageal reflux disease and laryngopharynx acid reflux disease.

1. Originally published in Classical Singer, April 2009. Posted with permission.

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Acoustic analysis of voice

The measurement or graphing of acoustic (sound) information about the voice. This acoustic analysis includes such voice measures as fundamental frequency, formant pattern and energies, decibel level (a physical measure of sound pressure level that roughly correlates to perception of loudness), signal-to-noise ratio, jitter, and shimmer.

At present it is difficult to find unique diagnostic information from any set of acoustic measures. Hence, acoustic analysis is arguably justified for now in the realm of voice research and when used as a feedback tool in the therapy room. Although this may change in the future, at present acoustic analysis is superfluous to the diagnostic process, and specifically to the integrative diagnostic model.


Addition of loudness

Refers to the ability to increase the loudness of the voice. An individual may, either apparently or due to physical limitation, be unable to add loudness because of vocal cord paralysis, a nonorganic disorder, or vocal cord bowing – though when three individuals representing these three diagnoses try to add loudness, the phenomenology observed differs markedly.


Adductor spasmodic dysphonia

A variant of spasmodic dysphonia in which the spasms push the vocal cords together, choking off or straining the voice. Adductor spasmodic dysphonia (AD-SD), also called strain-strangle phonation, is the most common variant of spasmodic dysphonia, comprising about 90% of the cases. It is to be distinguished from abductor spasmodic dysphonia (AB-SD), a variant in which the spasms pull the vocal cords apart.

In its classic variant, the adductory spasms of adductor spasmodic dysphonia are intermittent, each time clamping the vocal cords together momentarily, so that words or syllables in a person’s speech are intermittently choked out. In its tonic variant, the adductory spasms are more constant and sustained than intermittent, so that instead of interrupting the person’s speech, the spasms cause a constant strained or “tight” vocal quality.

Occasionally, a person has both abductory and adductory spasms; this is called mixed AB-AD spasmodic dysphonia. For more about spasmodic dysphonia in general and the treatment options for it, see our main entry.

Photos:

Audio:

Pure AD-SD tonic only, moderate severity:


Aerodynamic analysis of voice

Instrument analysis of the power supply for voice pulmonary air. Aerodynamic analysis of voice can include spirometry, which assesses various capacities and capabilities of the respiratory system, apart from phonation. It also allows determination of the pressure and flow through the vocal folds during phonation.

Our clinicians believe that aerodynamic analysis of voice has yet to earn a place as part of the routine diagnostic workup (see the integrative diagnostic model). Aerodynamic analysis of voice, however, may be of interest for voice research, and when the equipment is used as a biofeedback tool in the therapy room.


Air-wasting dysphonia

Air-wasting dysphonia is a kind of hoarseness that refers to the breathiness (see breathy dysphonia) that one is hearing. Typically, the length of time a person can sustain voice without taking a new breath (maximum phonation time) is decreased. The voice may be described as whispery or foggy or fuzzy. Among other things, possible causes include vocal fold paralysis or paresis, vocal fold bowing and atrophy, or functional (especially nonorganic) voice problems.


Amyloidosis

A condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells. In some cases, the cause of amyloidosis is a systemic disorder in which the body over-produces proteins–for example, multiple myeloma, a blood disease; in these cases, the amyloid deposits can be dispersed widely across the body. In other cases, the amyloid deposits do not seem to reflect systemic disease, and in such cases, the amyloid deposits can be more organ-specific.

Amyloidosis in the larynx:

In laryngeal amyloidosis, the deposits seem to be localized either just to the larynx, or to the larynx and pharynx. One sees what looks like yellowish candle wax within the tissues. The amyloid deposits are quite firm, and when biopsied, there is little bleeding.

Treatment for laryngeal amyloidosis:

Because of their infiltrative nature, amyloid deposits typically cannot all be dissected out of the larynx; instead, then, an operating physician will aim to debulk the deposits in areas where they impair breathing or the voice. That is, when deposits are widespread in the larynx, there does not seem to be any point in removing them except in locations where removal will improve function. Often, repeated procedures are required over many years’ time, though occasionally the condition seems to stop progressing.

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Videos:

Amyloidosis
This video gives an example of amyloidosis, which is a condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells.

Ankylosis

Immobility and fusion of a joint due to disease, injury, or a surgical procedure. Ankylosis of the cricoarytenoid joint may be seen after traumatic dislocation, or in rare instances of the disease rheumatoid arthritis.

Photos of Ankylosis:


Anterior

Toward the front side of a person’s body. For example: the toes are anterior to the heel. The opposite of posterior.


Anterior commissure

The point at which the vocal cords are joined together, which is at the most anterior end of each cord. Compare this with the posterior commissure.


Anterior commissure microweb

A tiny webbing between the vocal cords at the anterior commissure, where the two cords meet. Some think that an anterior commissure microweb can help to cause vocal nodules, but we do not see any such relationship.

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Aryepiglottic cord

The aryepiglottic cord is the membranous sheet of tissue that stretches from the lateral edge of the epiglottis to the arytenoid cartilage. The upper edge of the aryepiglottic cord is like the gunwale of a boat, so that liquid or saliva can pool in the pyriform sinus without immediately spilling over into the laryngeal entrance.


Arytenoid Cartilages

A pair of small triangular cartilages in the larynx that help to move the vocal cords. The arytenoid cartilages sit on the upper surface of the cricoid cartilage ring’s posterior section. Each arytenoid has a body, apex, muscular process, and vocal process. The vocal process is the only part of the arytenoid cartilage that is sometimes clearly visible when viewing the larynx endoscopically, such as in the photos provided on this site (see the photo below), since the vocal process projects into the posterior part of the vocal cord with thin enough soft tissue covering it that it may “shine through.”

Attachments of the arytenoid cartilages:

The arytenoid cartilages help to move the vocal cords because the vocal cords are attached to them and because several muscles also attach to the arytenoids and can move them around. The joint capsule (tiny ligaments and fibrous tissue) attaches the arytenoid cartilage to the cricoid cartilage; the vocal cord (comprised mostly of the thyroarytenoid, or TA, muscle) attaches to the arytenoid cartilage at its vocal process. The PCA and LCA muscles attach to the arytenoid at what is called the muscular process, which points more laterally, at 90 degrees from the vocal process. The interarytenoid muscle (IA) attaches to the arytenoid on the concave posterior surface of each arytenoid’s body; the IA muscle also connects the arytenoids to each other.

Movement of the arytenoid cartilages:

The IA muscle pulls the arytenoid cartilages together for coughing, voicing, and so forth. The PCA muscles move the arytenoids apart simultaneously to open the larynx widely for breathing. The LCA muscles can move the arytenoids, and especially the vocal processes, toward each other, and can also rock the arytenoids anteriorly.

As the arytenoids move in all these different ways, the vocal cords—being attached to the arytenoids—move along with them. Thus, via the arytenoid cartilages, these muscles cause the vocal cords to separate (abduct) for breathing or come together (adduct) for voicing, throat clearing, coughing, and so forth. There are also other muscles that affect the vocal cords, but apart from the involvement of the arytenoids: the TA muscle that makes up most of the bulk of each cord can isometrically contract and affect the tension of the cords, for varying the quality and (somewhat) the pitch of the voice, and an external muscle, the cricothyroid, has a major role for creating high pitches.

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Arytenoid chondritis / perichondritis

An infectious or inflammatory response with ongoing ulceration or granulation on the superstructure of the arytenoid cartilage. Here we are talking of the arytenoid cartilage and/ or its thin “envelope” of fibrous tissue called perichondrium. The root chondr- refers to cartilage.

A similar and much more common disorder, contact granuloma or contact ulcer, occurs on the medial surface of the arytenoid cartilage, but low and at the level of the vocal process. When arytenoid chondritis or perichondritis occurs, it causes significant chronic pain (in contrast to contact granuloma, which can be pain-free or bring only minor discomfort). We have never diagnosed the underlying cause. Treatment tends to require definitive removal of the area of cartilage involved (not the entire arytenoid, of course), and then typically the area will heal, though often only after a time of re-granulation.

Photos:

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Aspiration

The entry of foreign material, such as saliva, ingested liquid or food, or gastric contents refluxed up to the level of the throat, into the airway below the vocal cords. If this foreign material only enters the laryngeal vestibule but does not descend below the vocal cords, this is not considered aspiration, but instead laryngeal penetration. Significant or recurring aspiration puts a person at risk of pneumonia; laryngeal penetration alone does not, though a person with laryngeal penetration is more likely to aspirate trace amounts than is the person with completely normal swallowing function.

Aspiration can occur before, during, or after the act of swallowing. Aspiration before the swallow means that liquid or food in the mouth dribbles or spills down into the larynx and beyond before the swallow is initiated.  This is seen most commonly when there is a neurological disorder, such as after a cerebrovascular accident (stroke).

Aspiration during swallowing happens when, as the swallowed material travels from the base of the tongue toward the entrance to the esophagus (in the pharyngeal phase of swallowing), some of that material drops into the larynx and straight down through it to enter the airway. This kind of aspiration can happen because a person’s vocal cords don’t close properly, due to paralysis, paresis, or tissue loss such as after a partial laryngectomy.

Aspiration after swallowing happens when some of the ingested liquid or solid remains pooled in the lower throat after the swallow is complete, and when the patient takes the first post-swallow breath, it enters the airway. To try to prevent aspiration after swallowing, the supraglottic swallow technique can help.

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Aspiration pneumonia

Pneumonia, or an infection of the lungs, that has resulted from aspiration—that is, from passage of food, liquid, saliva, or vomited stomach contents down into the larynx, trachea, and air sacs of the lungs. Aspiration pneumonia can occur in individuals who have chronic swallowing deficits (e.g., presbyphagia), or can be a result of intoxication, seizure, loss of consciousness, etc.


Atypical spasmodic dysphonia

A benign neurological voice disorder caused by laryngeal dystonia. Atypical cases of spasmodic dysphonia (SD) may be challenging to diagnose, even by clinicians with some experience with the disorder. Examples of reasons that this may be so: In the atypical case, contrary to what is usually seen, singing may be more affected than talking; falsetto/head voice may be more affected than chest voice, and so forth. There may also be no phonatory arrests in the less common tonic variant spasmodic dysphonia.


Auditory perceptual evaluation of voice

The sense of hearing applied to assessment of the voice. In some locations, auditory perceptual evaluation of voice refers primarily to characteristics of the patient’s spontaneous speaking voice, and sometimes very basic additional elicitations.

However, in clinics where the integrative diagnostic model has been mastered, the clinician’s auditory perception has been informed by extensive knowledge and experience of normal and abnormal vocal capabilities and vocal limitations. This knowledge, along with his or her own voice used for modeling and elicitation, are the tools used when conducting the vocal capability battery. It is auditory perceptual evaluation of elicited vocalizations at the extremes of normal capability that provide powerful diagnostic information about the voice, as distinct from the larynx.


Auto-immune laryngitis

Inflammation of the vocal cords, especially of the layer just beneath the mucosa, caused by an auto-immune disorder. Auto-immune disorders that can potentially cause laryngitis (albeit infrequently) include rheumatoid arthritis, lupus erythematosus, Wegener’s granulomatosis, and combined auto-immune disorder. Some individuals develop an inflammatory picture of capillary prominence and mucosal edema which is unrelated to vibratory trauma; that is, these individuals do not have the profile of the “vocal overdoer.” Others form rheumatoid nodules of the vocal cords, aka “bamboo nodes.”


Average/anchor frequency

Average/anchor frequency is a term used at our practice to designate the pitch (and by extension, fundamental frequency) that an individual is using during spontaneous, running speech, as determined via auditory perception. We use both “average” and “anchor” together, because some persons speak in a perceptually monotone voice, at which point we consider the pitch extracted via auditory perception to be virtually synonymous with “average” fundamental frequency (proven to be the case in informal study comparing Fo extracted by auditory perception vs. by machine measures).

Other individuals speak with a great deal of pitch inflection. In these cases, we listen for the lowest common pitch to which the voice seems to be “anchored.” When highly inflected speakers become generally fatigued or “depressed,” they tend to default to this pitch, which then becomes more of an “average” pitch for them. Of course, using machine measures of fundamental frequency (primarily using equipment for acoustic analysis), a formal average fundamental frequency can be determined. The ability to determine average/anchor pitch via auditory perception during the vocal capability battery can be learned by clinicians with good pitch perception.


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