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Neurologic Disorders of the Larynx and Videostroboscopy Stephanie Cordes, MD Anna Pou, MD April 1998.

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Presentation on theme: "Neurologic Disorders of the Larynx and Videostroboscopy Stephanie Cordes, MD Anna Pou, MD April 1998."— Presentation transcript:

1 Neurologic Disorders of the Larynx and Videostroboscopy Stephanie Cordes, MD Anna Pou, MD April 1998

2 Introduction ä scientific and technological advancements ä improvements in diagnosis of voice disorders ä better understanding of laryngeal function ä laryngeal mechanism subject to highly complex, extensive neural control ä mostly a neglected topic

3 Anatomy of Phonation ä functions as biological valve for phonation, respiration, and swallowing ä lies between the 3rd and 6th cervical vertebra ä arises from paired branchial arches III, IV, and VI ä development begins during third week of embryonic growth

4 Anatomy of Phonation ä unpaired cartilages :thyroid, cricoid, and epiglottis ä paired cartilages :arytenoids, corniculates, and cuneiforms ä intrinsic muscles :cricothyroids, posterior cricoarytenoids, lateral cricoarytenoids, transverse arytenoid, oblique arytenoids, and thyroarytenoids ä extrinsic muscles :strap muscles

5 Anatomy of Phonation ä innervation by vagus ä superior laryngeal nerve :internal and external branches ä recurrent laryngeal nerve :anterior and posterior branch ä blood supply :superior and inferior laryngeal artery ä vocal fold arrangement - mucosal wave

6 Physiology of Phonation ä begins in cerebral cortex ä precentral gyrus to motor nuclei then coordinated activity ä phonatory cycle : ä vocal folds approximated ä infraglottic pressure builds up ä pressure opens folds from bottom up ä upper portion with strong elastic properties

7 Parameters of Voice ä quality, loudness, and pitch ä quality :depends on symmetrical vibration at the midline of the glottis ä loudness :influenced by subglottic pressure, glottic resistance, transglottic air flow, and amplitude of vibration ä pitch :alterations in length, tension, and cross- section mass of folds

8 Patient Evaluation ä review of history and comprehensive exam ä history to include -”I MADE A SPEECH” ä Impressions of Dysphonia ä Medical /Surgical History ä Abusive Voice Patterns/Allergies ä Dysphagia/Aspiration ä Esophageal Reflux

9 Patient Evaluation ä “I MADE A SPEECH” ä Auditory Acuity ä Shortness of Breath/Stridor/Speech Difficulties ä Patient’s Perceptions of Voice Difficulty ä Emotional Status of Patient ä ETOH Consumption and Tobacco Use ä Clearing the Throat and Coughing ä History of Voice Difficulty

10 Patient Examination ä ears - hearing acuity ä conjunctiva - allergies, anemia, jaundice ä nose - obstruction ä oral cavity - dental patterns, xerostomia, enamel ä neck - thyroid and muscle tension ä cranial nerve - gag reflex, palatal deviation ä laryngeal exam - IDL

11 Videostroboscopy ä allows routine, slow-motion evaluation ä detect vibratory asymmetries, structural abnormalities, submucosal scars ä illuminates different points on consecutive vocal folds ä desynchronize light and frequency of vocal fold vibration

12 Neurologic Voice Disorders ä Flaccid neural ä Spastic neural ä Ataxic neural ä Hypokinetic neural ä Hyperkinetic neural ä Mixed neural ä Vocal tremors ä Spastic Dysphonia

13 Flaccid Neural Disorders ä damage or disease to component of motor unit causing laryngeal muscle paralysis ä type and extent depends on lesion site ä bilateral complete - total weakness, aphonic ä bilateral incomplete - partial, SOB, fatigue ä bilateral recurrent - abductor paralysis, median ä unilateral recurrent - hoarse, breathy voice ä Myasthenia Gravis

14 Myasthenia Gravis ä autoimmune disease with reduced availability of Ach receptors ä severe muscle deterioration ä inhalatory stridor, breathy voice, hoarseness, flutter, and tremor ä decreased loudness ä restriction in pitch range ä dysphagia, VPI, hypernasality

15 Spastic Neural Disorders ä unilateral or bilateral upper motor neuron damage, release of inhibition ä hyperadduction of true and false cords ä low-pitched voice with little variation in loudness or pitch ä strained-strangled voice, periodic arrests ä prolonged glottic closure, hyperactive supraglottic activity, retarded wave

16 Ataxic Neural Disorders ä follows cerebellar damage ä typically struggle with uncontrolled loudness and pitch outbursts ä mild to moderate tremors of laryngeal inlet during phonation ä vocal folds without anatomic abnormalities ä usually has accompanied dysarthria ä Friedreich’s Ataxia

17 Hypokinetic Neural Disorders ä related to Parkinson’s Disease ä depletion of dopamine in substantia nigra ä reduced loudness, monopitch, breathy, rough, hoarse, tremorous ä widespread hypertonicity and rigidity ä recruitment of ventricular folds not uncommon

18 Hyperkinetic Neural Disorders ä associated with EPS, Huntington’s Chorea ä loss of neurons in caudate nucleus ä irregular pitch alterations and voice arrests ä hypotonic limbs and respiratory muscle incoordination ä inappropriate loudness variations ä harsh, strained-strangled quality

19 Mixed Neural Disorders ä damage or disease to multiple subsystems ä ALS -flaccid and spastic, depends on lesion ä dysphagia, airway obstruction ä harsh quality, hypernasal, variable pitch ä restricted intensity, breathy, stridor ä MS - spastic and ataxic ä impaired loudness control, harsh, breathy ä inappropriate pitch and rate

20 Vocal Tremors ä essential tremor most common disorder ä head and hands involved, +/- voice ä cause unknown ä quavering or tremulous speech, most noticeable on vowel prolongation ä pitch breaks and voice arrests ä larynx moves at rest and during phonation ä predominant involvement of TA muscles

21 Spastic Dysphonia ä unknown cause - psychogenic or neuromuscular ä three forms - adductor, abductor, mixed ä adductor most prevalent ä strained-strangled quality, periodic arrests ä limited pitch and volume control ä prolonged vocal fold closure and reduced amplitude of vibration

22 Treatment ä surgical :NSGY or laryngeal surgery ä medical :drugs that treat the motor symptoms ä speech pathology :behavioral treatment ä use of augmentative or alternative communication devices

23 Case Report ä 72 y/o male with 12 mo. h/o progressive dysphonia ä signs and symptoms of Parkinson’s ä referred by neurology for speech difficulties and occasional aspiration of thin liquids

24 Case Report ä 38 y/o female with 6 mo h/o strained-strangled voice, worse over past two months ä 20 pack year history of smoking ä h/o heroine and cocaine addiction ä intermittent arrests in phonation, lapsed into whispered speech patterns

25 Case Report ä 55 y/o female with h/o CVA 18 mo ago that resulted in dysarthria w/o apraxia or aphasia ä CT - hypodense lesion in internal capsule ä MRI - infarct in right anterior corona radiatum ä speech unintelligible ä imprecision, hypernasal, strained-strangled

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