1. SH 598- Voice Disorders

2. Syllabus
Office hours: T; TH 2-4 PM and 9-10 AM (Friday); by appointment.
Phone:
Teaching Assistant: Donna Eduardo
Required Text: Understanding Voice Problems- Colton & Casper.

3. Instructional Methods
lecture
case studies
objective exam
individual project & presentation
essay exam
directed readings
class activities

4. Grading
Scale
Critiques
Grade postings

5. IMPORTANT!!
Missing exams- Illness
Office Hours
Clinic office hours

6. Anatomy and Physiology of Voice Production

7. What is voice? The acoustic result of the interaction between:
muscle groups
cartilage's and
the aerodynamic system.
Three major subsystem to be concerned about:
Respiratory
Phonatory
Supraglottal

8. Anatomy of the Larynx Review:
-Anatomical structures of the larynx, including the primary cartilage's and intrinsic and extrinsic musculature.
-The function of the individual muscles should become a second language to you...at least until the semester ends!

9. Structural Support of the Larynx
Larynx suspended by a single bone: hyoid bone.
6 laryngeal cartilage's: 3 paired and 3 unpaired: Provide structural support

10. Laryngeal Cartilage's Epiglottis:
-Shaped like a long leaf,
-Base attached to inner portion thyroid cartilage,
-Folds down over airway to protect during swallowing.
-Composed of elastic cartilage (does not ossify with age).

11. -Anterior attachment of true vocal folds,
Thyroid Cartilage:
-Angled saddle-shaped,
-Anterior attachment of true vocal folds,
-Posteriorly there are 2 superior cornu and 2 inferior cornu,
-Composed of hyaline cartilage- ossifies & limits flexibility with age,
-Lateral walls are laminae and attach to midline of notch.

12. Cricoid Cartilage: -2 sets of paired faces: Connects to other joints,
-Signet ring shaped,
-2 sets of paired faces: Connects to other joints,
-Cricothyroid joint: Connects the cricoid to inferior cornu of the thyroid cartilage.

13. Arytenoid, Corniculate & Cuneiform Cartilage's:
-Hyaline,
-Pyramid shaped with 3 surfaces, anterior angle forms the vocal process,
-Lateral angle: muscular process, attaches to intrinsic muscles,
-Corniculate attached to superior tips of arytenoid cartilage,
-Cuneiform embedded in muscular complex, superior to corniculate: Provide no clear function, add stability for abduction.

14. Laryngeal Cartilage's 3 Unpaired Cartilage's -Thyroid -Cricoid
-Epiglottis
-Thyroid
-Cricoid

15. 3 Paired Cartilage's
-Cuneiform
-Corniculate
-Arytenoid

16. Extrinsic Laryngeal Muscles
Three Main Purposes:
1) Fixation (primary role)
2) Elevation (move larynx up)
3) Depression (move larynx down)
Two major groups: Suprahyoid & Infrahyoid
Anatomical position:
Suprahyoid- Attachment lies above hyoid bone.
Infrahyoid- Attachment lies below hyoid bone.

17. Extrinsic Laryngeal Muscles
Suprahyoid Muscles:
1) Digastricus
2) Geniohyoid
3) Hyoglossus
4) Mylohyoid
5) Stylohyoid
Function: Raise hyoid bone & indirectly raise larynx.

18. Infrahyoid Muscles:
1) Omohyoid & Sternohyoid:
Function: Lowers the hyoid bone & indirectly lowers larynx.
2) Sternothyroid:
Function: Lowers thyroid cartilage & lowers larynx.
3) Thyrohyoid:
Function: Raises thyroid cartilage & raises larynx, or with thyroid fixed lowers hyoid.

19. Extrinsic laryngeal Muscles
Mastoid Tip
Mylohyoid
Hyoid Bone
Sternohyoid
Omohyoid
Sternum
Mandible
Ant. Digastric
Post.
Digastric
Stylohyoid
Thyrohyoid
Sternothyroid

20. Intrinsic Laryngeal Muscles
Functions:
1) Abduction of vocal folds for respiration,
2) Fine discrete movements during voice production & closure of vocal folds and,
3) Protection of trachea,

21. More Specifically... Change degree of abduction/ adduction
Change mass characteristics of folds
Change tension of folds
Change length characteristics of folds
React during swallowing- closure of folds
Assist in muscular mechanical advantage

22. Intrinsic Muscles Pars recta
Action of
Cricothyriod
Pars oblique
Pars recta
Cricothyroid: fan-shaped, 2 divisions, Lengthens & tenses vocal folds.

23. Intrinsic Muscles Vocal Ligament
Thyroarytenoid
Thyrovocalis
Thyromuscularis
Thyroarytenoid: muscle making up true vocal folds, 2 parts: thyrovocalis (bound to vocal ligament) & thyromuscularis (lateral to arytenoids).

24. Thyroarytenoid Functions
Decreases distance between the thyroid & arytenoid cartilage's,
Shortens folds,
Decreases tension
Decreases pitch of the voice,
Active contraction lowers pitch of voice.

25. Intrinsic Muscles Posterior Cricoarytenoid Action of Post.
Posterior Cricoarytenoid: Abducts the vocal folds, actively contracted at the end of phonation & any speech sound not requiring v.f. vibration.

26. Intrinsic Muscles
Action of Lat.
Cricoarytenoid
Lateral
Cricoarytenoid
Lateral Cricoarytenoid: lies on upper surface of cricoid cartilage, adducts vocal processes of arytenoids closing membranous portion of v.f.’s.

27. Intrinsic Muscles
Transverse
Interarytenoids
Oblique
Interarytenoids
Interarytenoids (transverse & oblique): Unpaired, 2 part muscle, adducts v.f.’s in cartilaginous portion by pulling arytenoid tips together.

28. The Glottis Glottis Glottis is an open space between vocal folds.
Size is dependent on what position the v.f.’s are in.
Not a muscle or cartilage.
Abduction- open v.f.’s; Adduction- closed v.f.’s

29. Ventricular Folds False Folds, Superior & lateral to true vocal folds,
Their role in phonation?
-No role in voicing
Consist of muscle, but doesn’t have innervation for discrete movements,
Hyperfunctional voice?

30. Neuroanatomy of Vocal Mechanism
Volitional control of laryngeal muscles: Resides in brain.
Connecting points in brain having a role in control of phonation: cortex, subcortical areas, midbrain & medulla.
Next slides will briefly review phonation neuroanatomy & neurophysiology.

31. Cortical Mechanisms of Phonatory Control
The cerebral cortex is responsible for conceptualization, planning, and execution of the speech act (phonation).
Three major areas of cortex responsible for vocalization:
a) Precentral & postcentral gyrus,
b) Anterior (Broca’s) area, and
c) Supplementary motor area.

32. Cortical Areas Involved in Speech Movement Control
Primary Motor Cortex
Premotor & Supplementary
Cortex
Somatosensory
Cortex
Broca’s Area
1. Stimulation of these areas can initiate, stop or distort vocalization.
2. These behaviors occur in dominant & nondominant hemispheres.

33. Speech and Phonation are Complex Motor Acts
Involves simultaneous activation and control of many muscles.
Control of these motor acts occurs in cortex.
Control of individual muscles occurs lower in brain.
No evidence that cortical stimulation produces a response in a muscle.
Higher brain function = idealization of an event, integration of sensory information, feedback control, and coordination of various muscles.

34. Subcortical Mechanisms
Motor cortex:connections to Thalamus, a major portion of diencephalon or interbrain.
Parts of diencephalon: a) hypothalamus, b) metathalumus, c) epithalumus, d) subthalamus, and, e) third ventricle.
Thalamus has major pathways to motor cortex & Broca’s area.
Thalamus also connects to midbrain, cerebellum and other structures in diencephalon.

35. Nuclei in the thalamus that project to parts of cerebral cortex
Motor area receives projections from ventrolateral nucleus.
1971- Found that ventrolateral nucleus was responsible for initiation of speech movements & control of loudness, pitch, rate & articulation.
Broca’s area- receives connections from dorsomedian & centromedian nuclei.
to & from
Sup. Parietal Lobule
to & from
Parietal Lobe
Massa
Intermedia
to & from Prenucleus
Lateral
Dorsal
Dorsal
Median
Ventral posterior
Lateral
Ventral
Lateral

36. Thalamus: What Does it Do?
Projections to Cerebral Cortex
Acts as relay for impulses in lower brain.
integrates emotion into complex motor act.
Plays a major role in:
coordinate outgoing information:cortex
integrating incoming sensory information and,
adding emotion to speech.
Thalamus
Midbrain
Projections
to Cerebellar
Cortex
Diencephalon
Pons

37. Midbrain Structures Midbrain (mesencephalon) lies beneath thalamus.
Cerebral peduncles lie on anterior surface of midbrain and connect cerebrum with brainstem and spinal cord.
Posterior side has four colliculi: Superior (visual function), inferior (audition).
Within midbrain lies cerebral aqueduct of Sylvius, surrounded by periaqueductal gray.

38. Periaqueductal Gray: What does it do?
Stimulation of dorsal and ventrolateral areas of periaqueductal gray = activity in some laryngeal muscles.
1985- Larson reported cells in ventrolateral area stimulate muscle activity, whereas some suppress activity.
Periaqueductal gray is an intermediate area between recognition of a stimulus and production of motor act.

39. Brainstem
Bilateral structures in brainstem implicated in neural control of phonation:
Nucleus ambiguus
Nucleus tractus solitarii
Nucleus parabrachialis
How do we know these structures are involved in phonation?

40. Cerebellum Structure lying posterior to midbrain area.
Control of movement.
Three main portions: a) Vermis, b) Pars Intermedia, c) Hemispheres
Consists of traverse folia- increases surface area.
Fissura prima- fissure separating anterior & posterior lobes.

41. Peripheral Connections: The Vagus Nerve
Major nerve that supplies larynx.
Provides sensory fibers in larynx & fibers to control muscles of larynx.
Cell bodies of vagus located in nucleus ambiguus.
Laryngeal muscles controlled by cells in caudal portions of nucleus.
Vagus emerges from surface of medulla between cerebellum peduncle and inferior olives in midbrain.
Vagus exits skull through jugular foramen.

42. Distribution of Vagus (X) Nerve
Nucleus Ambiguus
Pharyngeal Nerve
Nucleus
ambiguus
chief part
vagal accessory
Vagus (X) nerve
Jugular foramen
Vagus (X)
Nerve
Superior
Laryngeal Nerve
Pharyngeal nerve
Superior laryngeal nerve
Jugular
Foramen
Cricothyroid
muscle
Recurrent
Laryngeal Nerve

43. Vagus innervation of larynx
Nodose ganglion
Pharyngeal branch
Hyoid bone
Sup. laryngeal
nerve
Thyroid memb.
Internal SLN
External SLN
Thyroid gland
Cricothyroid memb.
Right recurrent
laryngeal nerve
Common carotid
artery
Left recurrent
laryngeal nerve
Vagus nerve

44. What nerve innervates the intrinsic laryngeal muscles?
Intrinsic laryngeal muscles are innervated by branches of vagus (X) nerve
The vagus nerve splits into several branches:
1. Recurrent laryngeal nerve,
2. Superior laryngeal nerve,
3. Pharyngeal nerve.

45. Recurrent Laryngeal nerve of Vagus
Courses along laryngeal branch of inferior thyroid artery.
It passes under caudal border of inferior constrictor muscle.
Divides into a motor & sensory branch prior to entry into larynx.
Innervates int. muscles that control abduction/adduction of vocal folds

46. RLN & SLN Inferior Recurrent Laryngeal Branch:
Thyroarytenoid
Lateral Cricoarytenoid
Posterior Cricoarytenoid
Interarytenoids
Superior Laryngeal Branch:
Cricothyroid

47. SLN & RLN
Ensure ability of intrinsic muscles to move quickly & fine motor control
High conduction velocity
Rapid contractions
Low innervation per motor unit ratio.

48. Conclusion Neurology of larynx is specific and finely tuned
More is known about peripheral connections
Less known about higher brain centers
Coordination of respiratory, phonatory & supraglottal areas must occur for adequate speech production.

49. Readings & Directed Reading Assignment
For lecture - Chs. 10 & 11 in Colton & Casper.
Directed Reading assignment- Hoit, J.D.(1995). Influence of body position on breathing and its implications for the evaluation and treatment of speech and voice disorders. Journal of Voice, vol.9 (4):

50. Activity
1) With you mouth open, hold your breath, then abruptly release it with a vocal tone. What physiologic events occur at the glottis?
2) Produce an /h/ sound alone. What is the status of the glottis? How did it get there?
3) Produce an /h/ sound, then slide into phonation. What muscles are contracting to affect what conditions in the glottis?

51. More questions...
1) Place your finger on the laryngeal prominence, alternate between high and low pitched tones. Can you identify a change in the position of the larynx and describe the prime movers?
2) Can you phonate while inhaling? What are the physiological differences?