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Relevant Anatomy
Fundamental components of speech
Theories of phonation
Glottic cycle
Factors affecting phonation
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
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:
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.
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
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.
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
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
--
Subsystem
Voice Organs
Vibratory System
PHONATION:
Physical act of sound production by means of
passive vocal fold interaction with the exhaled air stream.
Prerequisites:
THEORIES OF PHONATION
I.
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.
Air is moved out of the lungs and towards the vocal folds.
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.
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.
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
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
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)
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)
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
Articulation
between Upper
and lower lip
P, B, M,W
th in th at
T, D, N, S, Z, R, ch, dj
Articulation of
posterior tongue and
soft palate
K, G, ng
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
HOARSENESS
The perceived breathiness quality of the voice (Bailey)
A rough or noisy quality of voice (Dorland)
A rough, harsh voice quality (Stedman)
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
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
Hoarse
Low-pitched
Reinke's edema
Vocal abuse
Reflux laryngitis
Vocal cord paralysis
Muscle tension dysphonia
Voice quality
Strained
Differential diagnosis
Adductor spasmodic dysphonia
Muscle tension dysphonia
Reflux laryngitis
Parkinson disease
Essential tremor of the head and neck
Spasmodic dysphonia
Muscle tension dysphonia
Vocal fatigue
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
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
References
Thankyou