voice disorders in neuro diseases

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Neurogenic Voice Disorders

Celia R. Hooper, Ph.D., CCC-SLP, Lecture

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NEUROGENIC VOICE DISORDERS . . . use C + C organization, but see attached

info from Hartman. . .uses Darley, Aronson and Brown organization.

Good sources: Colton and Casper, Understanding Voice Problems; and Blitzer

et al., Neuroloqic Diseases of the Larynx.

I. Introductory Comments re: the nervous system

A. Nervous system dysfunction

B. Nervous sys and phonation/ " dysarthrophonia "

C. Nervous sys and pathology

Darley Aronson and Brown, focus on the efferent system (motor system)

II. Common disorders: voice symptom, description/pathology, etiology,

perceptual signs and symptoms, objective measurements, suggested treatment

I will say a sentence or two about the following, especially related to tx:

1. supra- or pseudobulbar palsy-harsh . . .use relaxation if possible .

.. . easy onset

2. Parkinsonism. . .Ramig, L.--mono pitch, poor control of

loudness--therapy from whole word to conversation, using a pushing approach

is recommended by L. Ramig

3. Shy-Drager Syndrome--harshness at first, but general whole-nervous

system deterioration. rapid, usually less than five years to death.

Augmentative communication is the way to go, no voice tx indicated.

4. Amyotrophic lateral sclerosis, ALS--roughness. Same as above, but

occasionally can be misdiagnosed as vocal abuse. Thus, reiterates the fact

that we need to return patients to physicians if they do not respond to tx.

Most ALS patients, however, do not show voice signs first. During 5 years of

seeing 60% of my caseload as voice patient, I saw only one ALS patient who

had voice as the first complaint.

5. Huntington's chorea-roughness--genetic basis, basal ganglia, jerky

movements of larynx--can adduct or abduct too quickly during speech. Not

responsive to voice tx--aug comm as long as possible.

6. Ataxic dysphonia--roughness. A cerebellar lesion. Stress and

intonation a problem. Like some other motor speech disorders, early on

relaxation techniques may help, but this is very controversial. Some

patients can keep oral speech, although impaired. Others are unintelligible

and need aug comm.

7. Arnold--Chiari Malformation--congenital anomaly of

hindbrain--brainstem and cerebellum are squeezed. Can appear as vocal fold

paralysis, but never compensates. May want to teach pushing exercises to get

louder voice, but this person can sound like cerebellar ataxia and be

unintelligible, thus aug comm. Very rare...you will probably not ever see,

so relax.

8. Lower motor neuron diseases Spasmodic dysphonia/spasmodic dysphonia

Abductor and Adductor

Essential tremor

Misc. medulla syndromes (rare)

9. Gilles de la Tourette syndrome. Can have many varieties and degrees

of severity, some not including voice. Will discuss. Treated by medication.

Voice therapy usually not indicated since the vocalizations, which may be

abusive, are reduced or eliminated by medication (haloperidol).

10. Multiple sclerosis--general cns deterioration...scarring of the

white matter. 20% seek ENT help due to speech/dysarthria problems. Will

discuss. See page 130, Table 5.6 in C + C for speech signs in MS. Not a big

problem--usually other problems are more important . If there is a prob it

is usually loudness and " scanning speech. "

11. Myasthenia gravis--breathiness (voice quality). Slowly progressing

weakening of muscles which are innervated by cranial nerves. Very rare, more

in females. Sometimes voice the first symptom...either breathiness or

hypernasality, but usually patient reports general fatigue in upper body

first. The symptoms can vary due to general body fatigue which leads to a

misdiagnosis of vocal abuse. These folks have breathy, rough voices and

early on respond best to use of a portable microphone. Pushing, relaxation

not so effective--will discuss.

12. Peripheral Nerve Lesions. . .C and C use this to describe vocal fold

paralysis, abductor or adductor. A lesion can occur anywhere in the SLN or

RLN and result in paralysis. The more muscles involved, the higher the

lesion--in higher neck area or brainstem. These referrals come from an ENT

or neurologist and this has been figured out for you! Cannot tell from

behavior. Treatment in first 3-6 months includes breathing, adductor

exercises for abductor paralysis, but compensation takes place without tx .

.. .it only speeds it along. Surgery sometimes recommended as discussed in

class already.

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Hartman Neurogenic Dysphonia

NEUROMUSCULAR PHONATORY RESONATORY SIGNS AND NASOLOGY OF MOTOR SPEECH

DISORDERS Motor Speech Disorder Neuromuscular Signs Phonatory/Resonatory

Signs Nasology

Apraxia of speech Essentially normal to mildly weak Incoordination for

speech; difficulty with voice initiations Broach's area lesion

Dysarthria - Spastic Hyperactive gag; hyperadduction of vocal folds,

weakness Strain-strangle " wall: " variable hypernasality, nasal emission

Bilateral corticobulbar tract lesion

Dysarthira- Hypokinetic Rigidity, dyskinesia particularly of

laryngeal-extralaryngeal musculature Monopitch, monoloudneess, breathiness,

hoarseness, resonance changes uncommon Parkinson's disease, parkinsonism

Dysarthria- Hyperkinetic Essentially normal to adventitious irregular or

regular movements, vocal fold hyperadduction, laryngospasm Variable pitch

and loudness, harshness, strain-strangle quality, voice arrests, tremor,

variable breathiness, variable resonance changes Huntington's chorea,,

focal -diffuse dystonias, dyskinesias, palatopharyngolaryngeal myoclonus,

essential tremor, Tourette Syndrome

Dysarthria- Ataxic Essentially normal Mono- to variable pitch, harness,

coarse changes in volume; resonance changes uncommon Cerebellar disease,

Friedreich's ataxia

Dysarthria- Flaccid Absent/reduced gag, hypotonicity, weakness,

fasciculations, incomplete adduction or abduction of vocal folds,

aspiration, reduced cough, asymmetrical velopharynx-glottis Mild to severe

continuous " wet " hoarseness, reduced loudness, and pitch variation,

" fluttering " prolonged /a/, inhalatory stridor; mild to severe continuous

hypernasality, nasal emission Myasthenia gravis, myopathies, myelopathies,

neuropathies (i.e., IX, X)

Dysarthria- Mixed Various combination of preceding signs Various combination

of preceding signs Shy-Drager syndrome, amyotrophic lateral sclerosis,

multiple sclerosis, 's disease, diffuse central-peripheral nervous

system disease.

Chart source from the Department of Neorology, Gundersen Clinic, Ltd. and

the Gundersen Medical Foundation, La Crosse, Wisconsin