Core Curriculum Syllabus: Disorders of Speech and Swallowing

Speech

• Normal Mechanisms
  • Phonation-the production of sound by the larynx
    • Requirements
      • Approximation of vocal folds
      • Forced expiration (adequate breath support)
      • Passive vibration of free mucosal edge of vocal fold
    • Pitch determined by the fundamental frequency of vocal fold vibration
      • Dependent on vocal fold length and tension
      • Controlled by "pre-phonatory tuning" and auditory feedback
    • Intensity is dependent on subglottic pressure, which is related to:
      • Expiratory flow
      • Glottic aperture area
  • Resonance-the modulation of sound by passage through body tissues. This can be voluntarily modified by movements of the tongue, palate and pharynx, as well as by changing the position and shape of the larynx. It may also be altered by pathology.
  • Articulation-the formation of words is accomplished by voluntary movements of the upper aerodigestive tract (lips, teeth, tongue, palate, etc.) to produce:
    • Unvoiced consonants
    • The "shaping" of phonation into vocalizations
• Speech Disorders
  Speech disorders may result from disruption of phonation (hoarseness), articulation (dysarthria), resonance, or prosody. A speech disorder is a symptom or sign - not a diagnosis. It cannot be properly treated if the etiology is unknown. Further, it can be a manifestation of a serious underlying disorder. Hence a thorough diagnostic evaluation is always indicated for persistent speech disorders.
  • Hoarseness-abnormal vocal fold vibration-coarseness or raspiness of the voice. Most commonly, hoarseness is due to either infectious laryngitis or vocal abuse and will resolve with voice rest. However, a patient with hoarseness which persists more than two weeks should be referred for laryngeal exam.
    • Structural changes in larynx
      • Laryngitis
        • Diffuse edema of the larynx
        • Etiology: infection, allergy, acute or chronic gastroesophageal reflux, trauma, or vocal abuse.
        • Therapy
          • Voice rest!
          • Specific management of causative factors
      • Reinke's edema
        • Isolated edema of the mucosal edge of the vocal fold
        • Etiology
          • Usually due to hormonal changes (menopause, hypothyroidism, etc.) but may also be seen in allergy, vocal abuse, or secondary to URI
        • Therapy
          • Voice rest, speech therapy, medical management of endocrine problems. If persistent, stripping of vocal fold mucosa may be indicated.
      • Vocal nodules
        • Thickened area on vocal cord, usually bilateral, at junction of anterior and middle thirds.
        • Etiology
          • Analogous to a callus. Develops with vocal abuse.
        • Therapy
          • Voice therapy in adults and older children. Mature nodules in adults are excised. Nodules in children frequently regress in puberty.
      • Vocal polyps
        • Sessile or pedunculated, on vocal fold
        • Etiology - most commonly results from traumatic hemorrhage into vocal fold with stretching of mucosa and loss of elasticity.
        • Therapy
          • Excision
      • Contact granuloma
        • Hyperplasia and granulation of mucosa overlying the vocal process of the arytenoid, seen more commonly in males.
        • Etiology
          • Traumatic irritation (intubation)
          • GE reflux, chronic throat clearing or cough, vocal abuse may also be implicated.
        • Therapy
          • Voice rest, voice therapy, anti-reflux regimen and cough suppression.
          • May need biopsy to rule out cancer or surgical removal.
      • Hyperkeratosis
        • White plaques on vocal fold
        • Etiology - smoking, other chemical agents
        • Biopsy to rule out carcinoma, discontinue smoking, stripping of mucosa
      • Papillomas
        • Warts on vocal folds. Most often in children. Airway obstruction can be life threatening.
        • Etiology
          • Human papilloma virus subtype HPV6, HPV11.
          • Relationship with maternal condylomas has been suggested
        • Therapy
          • Surgical removal by cup forceps or CO2 laser. Usually requires multiple repeat excisions because of recurrence.
          • May spontaneously resolve
      • Carcinoma of the larynx
        • See section on Head and Neck Cancer. Laryngeal lesion requires direct laryngoscopy and biopsy for diagnosis and staging
        • Etiology - patient almost invariably smokes heavily and may drink
        • Therapy
          • Radiation, surgery, or combination
      • Laryngeal paralysis
        • Unilateral vocal fold paralysis
          • Symptoms are determined by position of the cord, which correlates to specific neural lesion.

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Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
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Last modified: Jan. 23, 2006