1. Disorders Associated with Vocal Misuse/Abuse

• Majority are related to under- or over-adduction of vocal folds
• Examples of misuse include:
• Increased tension or strain
• Consistent use of inappropriate pitch
• Excessive talking
• Psychogenic aphonia/dysphonia
• Examples of abuse include:
• Excessive prolonged loudness
• Excessive use during edema, inflammation, etc.
• Excessive coughing/throat clearing

• Broader-based lesion often covering entire membranous glottal margin
• Two-types
•  Swelling in response to vocal fold trauma; often precursor to nodules or polyps
•  Tissue changes associated with prolonged or chronic irritation
•  Etiology is the same as for nodules - abuse & misuse
•  Other causes (Andrews, 1996)

3. Reinke's Edema & Polypoid Degeneration

• Reinke's edema
•  Build-up of fluid in superficial layer of lamina propria
•  Often associated with smoking especially in females who are long-term smokers
•  Polypoid degeneration
•  Advanced tissue reaction to prolonged laryngeal abuse
•  Fluid under vocal fold cover is thicker/gel-like
•  Symptoms include reduced pitch, hoarseness, shortness of breath, loss of pitch range and increased effort to speak

4.  Vocal Nodules

• Benign growths along glottal margin
• Location - bilateral, junction of anterior and middle 1/3 of glottal edge
• Pathogenesis
• Predisposing conditions
• Perceptual/acoustic/physiological signs

5. Vocal Polyps

• Benign, soft, often fluid-filled growth along inner(lower) margin of vocal folds
• Location - unilateral, same site as nodules
• Can result from single traumatic event
• 2 types
• Broad-based (sessile-type)
• Narrow-necked (pedunculated)
• Perceptual/acoustic/physiological signs

6. Other Functional Disorders

• Puberphonia/mutational falsetto
• Functional aphonia/dysphonia
• Muscle Tension Dysphonia (MTD)
• Ventricular dysphonia (plicae ventricularis)
• Phonation breaks, pitch breaks & diplophonia

7.  Contact Ulcers

• Etiology may be one of three causes
• Hard glottal attack
• Irritation as result of gastric reflux
• Intubation for surgery
• Symptoms
• Hoarseness/roughness of voice
• Laryngeal pain or pain lateralizing to ear
• Vocal fatigue
• Excessive throat-clearing
• Tissue changes
• Bilateral ulcerations eventually showing granulation tissue around arytenoids
• Pachydermia

• Both often occur on posterior glottis as result of either:
• GERD (hyperacidity)
• Intubation injury/irritation
• Vocal hyperfunction
• Granuloma - firm granulated sac
• Hemangioma - soft, pliable, blood-filled sac
• Also related to contact ulcer; similar symptoms

• Congenital or acquired
• Acquired form may be associated with vocal abuse
• Identified by furrow along upper medial edge of vocal folds; most often bilateral
• Voice may be low in intensity breathy and hoarse
• Incomplete glottal closure, reduced phonation time, interrupted mucosal wave

• Benign lesions of the epithelial layer that are red( or pink) and wart-like in appearance
• Result of accumulation of keratin
• Etiology - chronic irritation:
• Inhalation of dust and noxious fumes (cigarette smoke)
• Excessive use of alcohol
• Chronic infection of sinuses & pharynx
• Chronic laryngitis
• Radiation injury
• Symptoms are hoarseness and lowered pitch

• White patches of plaque-like cells on mucous membranes of the larynx
• Classified as benign but may be precancerous
• Etiologies include chronic irritation with most common cause heavy smoking
• Voice symptoms include:
• chronic hoarseness & lowered pitch
• Less often diplophonia, breathiness, reduced loudness

• Etiology is infection - most often viral but may be bacterial
• Symptoms may be aphonia or severe to moderate hoarseness with sore throat, nonproductive cough
• Talking increases discomfort
• Treatment of choice is complete voice rest, humidification, hydration, reduced physical activity, & analgesics

• Fluid-filled lesions with epithilial case or shell; encapsulated
• Usually unilateral; more common in women esp. professional voice users
• May be congenital or result of poor lymphatic drainage
• Symptoms include low pitch, hoarseness, complaints of "tired" voice
• Increase mass and stiffness of vocal fold resulting in changes in mucosal wave
• Surgical removal usually indicated

• Wart-like growths, viral in nature
• Majority appear in children under age 6
• Can be serious threat to airway
• Can be removed surgically, but often reappear in as little as 2 weeks
• Voice quality is hoarse, respiratory stridor and shortness of breath also common

• May be congenital or acquired
• Connective tissue grows across subglottic, glottic or supraglottic spaces
• Only interglottic webs affect voice
•  Large webs result in elevation of pitch
•  Voice may be hoarse from asynchronous movement
•  Aphonia if webbing is extensive; will also have respiratory signs

• Endocrine changes
• Congenital structural anomalies
• Laryngomalacia
• Cri-du-chat syndrome
• Congenital subglottic stenosis
• Laryngocele & congenital laryngeal cysts

17.  Vocal Fold Paralysis

• Etiology - damage to SLN or RLN
• Infections
• Tumors
• Stretching/compression/severing of nerve during surgery
• Damage to SLN causes paralysis to CT muscle with inability to change pitch
• Most common is unilateral adductor paralysis
• Bilateral vocal fold paralysis

• Classified as a focal dystonia
• Movement disorder caused by forceful, inappropriate contraction of muscle groups
• Result of disrupted function, possibly in basal ganglia
• Two primary types
• Adductor spasmodic dysphonia
• Abductor spasmodic dysphonia
• Symptoms only appear during speaking; not present during vegetative functions or in speech not requiring phonation

• Also called vocal cord dysfunction
• Airway obstruction due to vocal fold closure during inhalation
• Mistaken for asthma and exercise-induced bronchospasm
• Etiology unknown - may be several forms
• Symptoms include breathy weak phonation, wheezing, stridor

• Results from rhythmical contraction of vocal muscles
• May be isolated to voice or occur in conjunction with tremor of head, tongue, jaw
• Appears during volitional movement
• Symptoms include steady fluctuations of pitch and loudness (frequency of 4-7 HZ)
• May be familial or related to aging