Clinical Voice

Pathology
Theory and Management

Sixth Edition
 Clinical Voice
Pathology
Theory and Management

Sixth Edition

Joseph C. Stemple, PhD, CCC-SLP, ASHAF

Nelson Roy, PhD, CCC-SLP, ASHAF
Bernice K. Klaben, PhD, CCC-SLP, BCS-S
5521 Ruffin Road
San Diego, CA 92123

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Library of Congress Cataloging-in-Publication Data:

Names: Stemple, Joseph C., author. | Roy, Nelson, author. | Klaben, Bernice,
author.
Title: Clinical voice pathology : theory and management / Joseph C. Stemple,
Nelson Roy, Bernice K. Klaben.
Description: Sixth edition. | San Diego, CA : Plural Publishing, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2018029068| ISBN 9781635500288 (alk. paper) | ISBN
1635500281 (alk. paper)
Subjects: | MESH: Voice Disorders
Classification: LCC RF510 | NLM WV 500 | DDC 616.2/2 — dc23
LC record available at https://lccn.loc.gov/2018029068
 Contents

Preface xiii
Contributors xvii

1 Voice: A Historical Perspective 1

Introduction 1
Definition of a Voice Disorder 2
Role and Skills of the Speech-Language Pathologist 2
Ancient History 3
Folklore Remedies 3
Egyptian Papyri 3
Hindu Writings 4
Hippocrates 4
Aristotle 4
Claudius Galenus 5
The Renaissance 6
The 17th to 19th Centuries 7
The Laryngeal Mirror 7
Further Advancements 8
Voice Therapy 9
Clinical Voice Pathology 11
Artistic and Scientific Ingredients of Voice Pathology 11
Summary and Concluding Remarks 12
References 13

2 Anatomy and Physiology 15

Anatomy 15
The Laryngeal Valve 17
Respiration for Phonation 19
Vocal Tract Resonance 21
Structural Support for the Larynx 21
Hyoid Bone 21
Laryngeal Cartilages 22
Muscles 27
Muscles for Respiration: Inspiration and Exhalation 27
Laryngeal Muscles 29
True Folds, Ventricular (False) Folds, and Ventricle 39

v
 vi Clinical Voice Pathology:  Theory and Management

Vocal Fold Microstructure 41

Epithelium 41
Basement Membrane Zone 42
Lamina Propria 42
Vocalis Muscle 45
Blood Supply and Secretions 46
Neurologic Supply 46
Central Nervous System Control 46
Peripheral Innervation 47
Laryngeal Reflexes 49
Developmental Changes 50
Geriatric Vocal Folds 51
DNA Microarray Gene Expression Analysis 52
Physiology of Phonation 53
Theories of Vibration 53
Fundamental Frequency Control 56
Intensity Control 57
Phonation Modes and Voice Quality Control 57
Summary 58
References 58

3 Etiologies of Voice Disorders 63

Etiologies of Phonotrauma 63
Phonotrauma 64
Inappropriate Vocal Components 65
Medically Related Etiologies 69
Direct Surgery 70
Indirect Surgery 70
Chronic Illnesses and Disorders 70
Primary Disorder Etiologies 74
Personality-Related Etiologies 75
Environmental/Life Stress 75
Identity Conflict 76
Summary 77
References 77

4 Pathologies of the Laryngeal Mechanism 83

Prevalence of Voice Disorders 84
Pathology Classifications 85
Structural Pathologies of the Vocal Fold 86
Congenital and Maturational Changes Affecting Voice 99
Inflammatory Conditions of the Larynx 101
Trauma or Injury of the Larynx 104
 vii
Contents

Systemic Conditions Affecting Voice 105

Allergies 107
Nonlaryngeal Aerodigestive Disorders Affecting Voice 108
Psychiatric and Psychological Disorders Affecting Voice 111
Neurologic Disorders Affecting Voice 115
Movement Disorders Affecting the Larynx 123
Central Neurologic Disorders Affecting Voice 126
Other Disorders of Voice Use 129
Summary 132
References 133

5 The Diagnostic Voice Evaluation 141

The Management Team 142
Patient Profile 143
Referral Sources 144
Medical Evaluation 145
Voice Pathology Evaluation 147
Diagnostic Voice Evaluation 148
Referral 148
Reason for the Referral 148
History of the Problem 150
Oral-Peripheral Examination 153
Auditory-Perceptual Voice Assessment 153
Diagnostic Probes (Stimulability) 156
Focal Palpation of the Paralaryngeal Region 157
Patient Self-Assessment of the Voice Disorder 158
Impressions 159
Prognosis 159
Recommendations 160
Additional Considerations 160
Summary 160
References 161
Appendix 5–A. Sample Report 164
Appendix 5–B. Consensus Auditory-Perceptual Evaluation of 167
Voice (CAPE-V)
Appendix 5–C. The Rainbow Passage 172
Appendix 5–D. Vocal Component Checklist 173
Appendix 5–E. Voice Handicap Index (VHI) 174

6 Instrumental Measurement of Voice 177

Clinical Utility 178
Basics of Technical Instruments 181
Microphones and Recording Environment 181
 viii Clinical Voice Pathology:  Theory and Management

Digital Signal Processing 182

Acoustic Measures 183
Pitch Detection Algorithm 185
Fundamental Frequency 185
Intensity 186
Voice Range Profile, Phonetogram, and Physiologic Frequency 188
Range of Phonation
Perturbation Measures 189
Signal (or Harmonic)-to-Noise Ratios 190
Spectral Analysis 191
Aerodynamic Measures 194
Calibration 196
Pressure, Flow, Resistance, and Ohm’s Law 196
Airflow Equipment 197
Flow Measurement 198
Subglottal Air Pressure Measurement 198
Phonation Threshold Pressure 199
Laryngeal Resistance 201
Inverse Filter 201
Laryngeal Imaging 202
Endoscopy 204
Stroboscopy 206
High-Speed Digital Imaging 208
Kymography 210
Criteria for Laryngeal Imaging 213
Endoscopic Imaging Techniques 214
Recording Protocol 215
Visual Perceptual Judgments 216
Electroglottography (EGG) 218
Laryngeal Electromyography (LEMG) 219
Normative Information 219
Electrical Safety 221
Hygienic Safety 222
The Clinical Voice Laboratory 223
Caveats and Additional Considerations 224
Glossary 225
Acoustics 225
Aerodynamics 226
Imaging 227
References 228
Appendix 6–A. Joint Statement:  ASHA and AAO-HNS 234
Appendix 6–B. Vocal Tract Visualization and Imaging: 235
Position Statement
 ix
Contents

7 Survey of Voice Management 237

Voice Therapy Orientations 237
Hygienic Voice Therapy 237
Symptomatic Voice Therapy 242
Psychogenic Voice Therapy 244
Physiologic Voice Therapy 245
Eclectic Voice Therapy 246
Case Study 1:  Representing Voice Therapy Orientations 247
Hygienic Voice Therapy 251
Treatment Strategies for Vocally Traumatic Behavior 251
Vocal Hygiene Therapy Approaches 251
Case Study 2:  The Homemaker 252
Case Study 3:  The Noisy Job Environment 253
Case Study 4:  The Public Speaker 254
Case Study 5:  Phonotrauma in Children 255
Case Study 6:  Can We Always Expect Success? 260
Hydration 261
Confidential Voice 262
Symptomatic Voice Therapy 263
Therapy Approaches for Respiration 263
Therapy Approaches for Phonation 266
Therapy Approaches for Resonance 268
Therapy Approaches for Pitch 273
Case Study 7:  The Pseudoauthoritative Voice 274
Case Study 8:  The Voice Saver 275
Case Study 9:  Emotional Voice Changes 276
Voice and Communication Modification for Gender Diverse People 277
Therapy Approaches for Loudness Modification 278
Therapy Approaches for Rate Modification 279
Treatment Approaches for Laryngeal Area Muscle Tension 279
Case Study 10:  Ventricular Phonation 281
Psychogenic Voice Therapy 282
Functional Aphonia/Dysphonia 283
Functional Falsetto 292
Vocal Cord Dysfunction (VCD) 297
Physiologic Voice Therapy 298
Case Study 11:  Laryngeal Muscle Imbalance 298
Case Study 12:  The Postsurgical Patient 299
Case Study 13:  The Aging Voice 300
The Semi-Occluded Vocal Tract 301
Speech-Based SOVT Therapy 309
Accent Method of Voice Therapy 313
Flow Phonation 315
 x Clinical Voice Pathology:  Theory and Management

Lee Silverman Voice Treatment (LSVT)™ 316

Phonation Resistance Training Exercise (PhoRTE™) 317
Conversation Training Therapy (CTT) 318
Team Management of Specific Laryngeal Pathologies 320
Vocal Fold Cover Lesions 320
Laryngopharyngeal Reflux (LPR) and Gastroesophageal 321
Reflux Disease (GERD)
Unilateral Vocal Fold Paralysis 323
Case Study 14:  Unilateral Vocal Fold Paralysis 328
Spasmodic Dysphonia 329
Organic (Essential) Tremor 334
Successful Voice Therapy 335
References 337
Appendix 7–A. Phrases and Sentences Graduated in Length 350

8 The Professional Voice 369

Overview 369
The Professional Voice User 370
History 370
The “At-Risk” Status 373
Professional Roles 374
The Otolaryngologist 375
The Voice Pathologist 376
The Producer 377
The Agent or Manager 378
Clinical Pathways 378
Otolaryngology-Voice Pathology-Voice Pedagogy 378
Voice Pedagogy-Otolaryngologist-Voice Pathology 379
Voice Pedagogy-Voice Pathology-Otolaryngology 379
Otolaryngology-Voice Pedagogy 381
Voice Pathologist-Voice Pedagogy 381
Vocal Types and Vocal Range 381
Categories of Singers 383
Vocal Registers 383
Common Etiology Factor 384
Personality Factor 384
Phonotrauma 384
Drugs 386
Hydration 387
Common Pathologies 388
Acute and Chronic Noninfectious Laryngitis 388
Vocal Nodules 389
 xi
Contents

Contact Ulcers and Granulomas 390

Gastroesophageal Reflux Disease/Laryngopharyngeal Reflux 390
Voice Fatigue 392
Vocal Fold Hemorrhage and Vascular Pathologies 393
Clinical Assessment of the Vocal Performer 395
Supportive Training and Techniques 396
Alexander Technique 397
The Linklater Method 398
The Feldenkrais Method 398
The Lessac System 399
Estill Voice Training 399
Summary 400
Glossary of Terms Used in Singing 400
References 402

9 Rehabilitation of the Laryngectomized Patient 409

Overview 409
Incidence of Laryngeal Cancer 409
Etiology 410
Symptoms of Laryngeal Cancer 411
Medical Evaluation 412
Staging and Tumor-Node-Metastasis Classifications 413
Lymph Node Distribution 419
Treatment Options 421
Conservation 421
Combined Treatments 422
Radiation Therapy 422
Surgery 424
Concurrent Chemoradiotherapy 425
Methods of Reconstruction 428
Need for Follow-up Treatment 429
Multidisciplinary Rehabilitation Team 430
Special Concerns of the Laryngectomized Patient 435
Communication 435
Physical Concerns 436
Psychosocial Concerns 445
Speech Rehabilitation 446
Artificial Larynges 447
Esophageal Speech 453
Surgical Prosthetics 458
Role of the Speech-Language Pathologist and Surgical Prosthetics 463
Patient Evaluation 463
 xii Clinical Voice Pathology:  Theory and Management

Patient Fitting 465

Independent Care 469
Maximizing Communication 472
Hands-Free Speaking Valve 473
Summary 475
Helpful Websites on Head and Neck Cancers 476
References 478

10 Artificial Airway and Mechanical Ventilation 491

Introduction 491
Artificial Airway 492
Nasopharyngeal Airway 492
Oropharyngeal Airway 492
Laryngeal Mask Airway 493
Endotracheal Intubation 493
Tracheotomy 497
Tracheostomy Complications 499
Communication Options for Patients with a Tracheostomy 500
Mechanical Ventilation 506
Mechanical Ventilation Terminology 507
Strategies for Restoring Verbal Communication for Ventilator 508
Dependent Patients
Noninvasive Ventilation Speech Challenges 508
Invasive Ventilation Speech Challenges 510
Summary 511
References 512

Index 515
 Preface

With each new edition of Clinical Voice enhance learning and understanding
Pathology: Theory and Management comes of the material as well as a companion
change, including societal, professional, website with additional content, includ-
and educational; this sixth edition is ing videos of laryngeal pathologies and
no exception. This is a clinical text- instructional PowerPoint lectures. In
book meant to lay the groundwork for addition to updated references through-
speech-language pathology students to out the text to reflect the current state
eventually become competent providers of clinical research in evaluation and
for the care and management of patients treatment of voice disorders, we intro-
with voice disorders. As technology duce a new chapter describing the SLP’s
rapidly changes, so does our profes- responsibilities with artificial airways
sion evolve: necessary skills are modi- and mechanical ventilation, and an
fied and expanded, and research dem- expanded voice therapy chapter, which
onstrates new and better methods for includes new evidence-based manage-
evaluation and treatment. Technology ment approaches.
has also impacted how students acquire The advances in our field in the
and retain information, and as a result, past thirty-five years have been extraor-
our teaching approaches must also be dinary. However, when one studies the
modified. To meet these changes, the history of our specialty, it is remarkable
6th edition of this text has also been mod- how much of our past remains constant
ified to take advantage of technology in terms of assessment and treatment.
that will assist both speech-language As an example, with all the available
pathology students and their instructors technology to aid in voice evaluation,
to build the foundational knowledge we would submit that the skilled patient
necessary to evaluate and treat voice interview remains the most important
disorders. This knowledge includes the part of the voice assessment. In the same
history and common causes of voice vein, many of the therapy techniques
disorders, the anatomy and physiol- that we currently use maintain their
ogy of voice production, pathologies of foundations in skills that were practiced
the vocal mechanism, and an extensive centuries ago to enhance the singing and
array of evaluation and management speaking voices. The advances in our
approaches. knowledge have significantly enhanced
Changes made to this edition focus the diagnostic process and have helped
on enhancements to instruction and confirm whether our chosen treatments
learning, including use of “Call Out” are truly effective.
boxes throughout the text to highlight The authors of this text have been
cases, encourage additional thought, privileged to provide clinical services
and suggest additional readings. There to those with voice disorders, and to
are full color figures and illustrations to contribute to the research for the many

xiii
 xiv Clinical Voice Pathology:  Theory and Management

aspects of voice production. While we geal mechanism is an essential basis

have had the opportunity to work in for evaluating phonatory function, for
interdisciplinary clinical voice centers, examining the larynx and vocal folds,
side-by-side with our laryngology part- for recognizing the impact of abnormal
ners, we fully understand that voice changes or adaptations on voice pro-
therapy is needed and provided in prac- duction, and for sharing information
tically every setting in which speech- with our physician partners-in-care.
language pathologists work. This text is Using enhanced illustrations, this sixth
designed to help prepare all clinicians to edition updates the descriptions of the
evaluate and treat voice disorders, and three subsystems of voice production,
is not limited to only those who special- respiration, phonation, and resonance,
ize in the area of voice. This unique and and expands the discussion of vocal
eclectic population of patients encom- fold histology and DNA microarray
passes all ages, across the lifespan, and gene expression analysis.
represents etiologies arising from medi- Chapter 3 provides a thorough up-
cal, environmental, social, psychologi- date on the common etiologies of voice
cal, and occupational threats to vocal disorders, including behavioral, medi-
health. Our patients may include typical cal, and personality-related etiologies.
voice users, occupational voice users, Common factors associated with the
elite vocal performers, individuals with cause and maintenance of voice disor-
head and neck cancer, and others who ders are discussed in order to understand
suffer with upper airway symptoms. best options for treatment planning.
Each patient provides us with a unique Chapter 4 presents the pathologies
diagnostic dilemma: How do we best of the laryngeal mechanism, which are
return the voice to optimal condition? organized according to the Classification
This text is organized to system- Manual for Voice Disorders-I developed
atically build the knowledge base and by Special Interest Division 3 (Voice
clinical skills necessary to successfully and Voice Disorders) of the American
answer this question. We seek to orga- Speech-Language-Hearing Association
nize, explain, and illustrate the com- (2006). The pathologies are presented
prehensive hierarchy of knowledge in eight major groups: (1) Structural
necessary to manage the many types of pathologies; (2) Inflammatory condi-
voice disorders. Chapter 1 begins with tions; (3) Trauma or injury; (4) Systemic
an entertaining history of voice disor- conditions affecting voice; (5) Aerodi-
ders from its ancient foundations to the gestive conditions affective voice; (6)
present. This information clarifies the Psychiatric or psychological disorders
role speech-language pathologists play affecting voice; (7) Neurologic voice dis-
in the care of voice-disordered patients orders and; (8) Other disorders of voice.
and introduces the interdisciplinary Many of the pathologies are illustrated
background that has permeated our his- with color plates.
tory of successful voice therapy. Chapters 5 and 6 discuss the objec-
The progressive development of tives and procedures of a systematic
essential clinical knowledge areas begins diagnostic voice evaluation. Chapter 5
in Chapter 2, the anatomy and physiol- introduces traditional evaluation tech-
ogy of voice production. Understanding niques, including the patient interview,
the structure and function of the laryn- audio-perceptual judgments, patient
 xv
Preface

self-assessment, determining the cause(s) perament, performance routines and

and maintaining factor(s) of the voice schedule, and other special consider-
disorder, and educating the patient ations needed for their care and treat-
about these findings to establish a col- ment. The chapter defines the roles of
laborative management plan based on the expanded interdisciplinary team
these clinical data. Chapter 6 provides a and identifies the affiliate organizations
state-of-the-art overview of the instru- that represent and support voice per-
mental measures that comprise a com- formers. In addition to traditional voice
prehensive voice assessment, including therapy considerations, the chapter also
the scientific principles that underlie discusses nontraditional alternative
their development, application, and treatments that are popular with this
interpretation. In addition to standard population.
measures of acoustics, aerodynamics, Chapter 9, “Rehabilitation of the
electromyography, and stroboscopy, Laryngectomized Patient,” serves as a
this edition explains the utility of high- stand-alone manual on the management
speed digital imaging and videoky- of this special patient population. This
mography tools. The appendix includes chapter reflects the current “best prac-
instrumental measurement norms and a tice” in voice rehabilitation or restora-
helpful glossary of terms. tion in head and neck cancer patients.
Knowledge of anatomy and physi- By outlining the complementary roles of
ology, pathologies, etiologies, and the the interdisciplinary treatment team, we
diagnostic process have prepared the understand the multiple management
reader for Chapter 7, which explores goals: cure the disease, select optimal
an array of voice therapy approaches communication methods, ensure safe
following the orientations of hygienic, swallowing, and address any associated
symptomatic, psychogenic, physiologic, physical, social, and emotional changes
and eclectic treatments. Using frequent that affect each patient. The chapter also
patient cases to illustrate major insights contains photographs of the latest com-
about voice treatment that we have munication and airway management
each gathered from our 30-plus years devices currently on the market.
of clinical experience, we orient the Finally, new to this text is Chap-
reader to the theories, selection criteria, ter 10, written by Tammy Wigginton
and clinical methods for specific voice and Mark Finfrock titled, ”Artificial Air-
management principles. This treatment way and Mechanical Ventilation.” It has
framework is appropriate for common, been our experience that our colleagues
yet diverse, voice complaints due to a who teach voice disorders are often
variety of laryngeal pathologies and tasked with also teaching information
vocal dysfunctions. Finally, we high- related to the speech-language patholo-
light the current clinical evidence that gist’s role in treating tracheostomy and
supports popular treatments used in ventilator-dependent patients. With the
voice therapy. knowledge that there are limited teach-
Because of the exceptional concerns ing resources related to this area for our
of voice performers, Chapter 8 intro- field, these authors, a speech-language
duces the factors that influence clinical pathologist and a respiratory therapist
management approaches for this artistic respectively, have prepared an excel-
population, such as personalities, tem- lent chapter that provides an overview
 xvi Clinical Voice Pathology:  Theory and Management

of the basics of the artificial airway, and Text development requires a team,
the dynamics of mechanical ventilation, and we are deeply indebted to our team,
as it applies to the practice of speech- Angie Singh, Kalie Koscielak, and Val-
language pathology. erie Johns, for encouraging and sup-
Over the past four decades, our cho- porting this sixth edition, and to Linda
sen specialty of clinical voice pathology Shapiro, Lori Asbury, and Jessica Bris-
has expanded greatly within the field tow on the production side of the text
of communication disorders. Nonethe- preparation. In addition, we wish to
less, this sixth edition of our text retains thank our students and colleagues who
its original purpose: to provide students have suggested ways to improve the
and clinicians with a strong foundation of text with each new writing. As always,
basic voice science infused with a deep clini- we are most appreciative for the support
cal understanding of the best methods for of our families. Finally, it is our patients
assessing and treating voice disorders. We who have taught us so much about what
hope that you, the reader, will find this is important in the care of their voices,
text clear, informative, and a worthwhile and to whom we are greatly indebted.
addition to your professional library.

Joseph C. Stemple,
Nelson Roy, and
Bernice K. Klaben
 Contributors

Mark R. Finfrock, RRT-NPS

Registered Respiratory Therapist
Neonatal Pediatric Specialist
University of Kentucky
Children’s Hospital
Lexington, Kentucky
Chapter 10

Tammy L. Wigginton, MS, CCC-SLP, BCS-S

Senior Clinical Speech Language Pathologist
Specialist in Swallowing Disorders
University of Kentucky
Voice and Swallow Clinic
Lexington, Kentucky
Chapter 10

xvii
 2
Anatomy and Physiology

Knowledge of the anatomy and physi- power supply, the laryngeal valve, and
ology of the laryngeal mechanism is the supraglottic vocal tract resonator.
paramount to understanding voice dis- When considering the “vocal mecha-
orders, and is a foundation for examin- nism,” it is common to emphasize the
ing the larynx, evaluating phonatory complex and intricate structures of the
function, and recognizing the impact larynx and vocal folds, but this limited
of abnormal changes or adaptations on perspective is flawed if it fails to include
voice production. A solid understand- the broader contributions of subglottic
ing of the normal structure and function breath support and supraglottic vocal
of the larynx is the basis for interpret- tract resonance. Indeed, vocal function
ing evaluative findings and developing of the larynx relies heavily on the inte-
appropriate voice treatment plans. gration of this three-part system: respi-
ration, phonation, and vocal tract reso-
nance (Figure 2–1).
The lungs function as the power
Anatomy supply by providing aerodynamic (sub-
glottal) tracheal pressure that blows the
vocal folds apart and sets them into
The larynx is essentially a cartilaginous vibration. This vocal fold oscillation
tube that connects inferiorly to the respi- provides the sound source for phona-
ratory system, (trachea and lungs), and tion. As the tissues open and close in
superiorly to the vocal tract and oral repeated cycles, the vocal folds modu-
cavity. This orientation in the body is late subglottal pressure and transglottal
important because it exploits the inter- flow as short pulses of sound energy.
active relationship between these three The vocal tract serves as the resonat-
subsystems of speech: the pulmonary ing cavity, which shapes and filters the

15
 16 Clinical Voice Pathology:  Theory and Management

resonance

vocal tract

larynx phonation

lungs respiration

Figure 2–1.  Orientation of the larynx in the body, at the juncture between the subglottic
trachea and lungs and the supraglottic pharyngeal and oral cavities. These structures form
the three subsystems of voice: respiration, phonation, and resonance.

acoustic energy to produce the sound or compromised lung capacity may be

we recognize as human voice.1–7 unable to generate sufficient subglottal
Differential diagnosis of voice dis- pressure required to produce normal
orders requires careful assessment of vocal loudness or quality. Similarly,
these three components. Obviously, altering the shape and size of the vocal
laryngeal health and vocal function will tract can either improve or diminish
influence the quality of voice produc- vocal resonance by enhancing or con-
tion, but respiratory support and supra- stricting the phonatory sound source
glottic resonance will also affect the generated by the vocal folds. The loss of
speech product. For example, adequate either of the subglottal or supraglottal
or insufficient lung pressure can either contributions could violate the potential
maximize or limit vocal fold vibra- for normal voice quality.6–7 Indeed, the
tion, respectively. A patient with weak resulting voice product radiated from
 2.  Anatomy and Physiology 17

the lips is a truly interactive result of When the epiglottis cartilage folds
these subsystems: respiration, phona- posteriorly and inferiorly over the
tion, and resonance. laryngeal vestibule, it separates the
pharynx from the larynx and offers
the first line of defense for preserv-
The Laryngeal Valve ing the airway.1,2,8,9
2. Ventricular (or false) folds lie supe-
The larynx consists of a complex arrange- rior and parallel to the true vocal
ment of cartilages, muscles, connective folds just above the ventricles. The
tissues, and mucosa that allows wide ventricular folds form the second
degrees of variation in position, move- sphincter. They are not normally
ment, and tension to support three basic active during phonation but may
functions: airway preservation (open- become hyperfunctional or more
ing) for ventilation, airway protection prominent during effortful speech
(closing) to block or repel environmen- production, or extreme vegetative
tal infiltrates, and phonation (vocal fold closure. The ventricular folds are
vibration) for communication and sing- directly superior to the ventricles,
ing. The laryngeal valve achieves these which function as variable pock-
three functions through three levels of ets of space above the true vocal
“folds” that are best appreciated from folds. The ventricular folds form a
an endoscopic view of the larynx (Fig- “double layer” of medial closure, if
ure 2–2). Endoscopy permits visualiza- needed. The principal function of
tion of internal structures from outside this sphincter is to increase intra-
of the body, and it is this view of the lar- thoracic pressure by blocking the
ynx that often forms the basis of clinical outflow of air from the lungs. For
judgments related to the normalcy of example, the ventricular folds com-
anatomical structure and physiological press tightly during rapid contrac-
function. This view of the endolarynx tion of the thoracic muscles (eg,
(and surrounding anatomy) shows the coughing or sneezing) or for longer
vocal folds in their fully open position durations when building up sub-
(A) or closed position (B), and also illus- glottic pressure to stabilize the tho-
trates the location of each of the three rax during certain physical tasks
sets of folds (from most superior to most (eg, lifting, emesis, childbirth, or
inferior): defecation). The ventricular folds
also assist in airway protection dur-
1. Aryepiglottic folds connect the ing swallowing.1,2,8,9
anterior attachment of the epiglot- 3. True vocal folds open for breathing,
tis cartilage to the arytenoid carti- close for airway protection, and
lages to form the superior border vibrate to produce sound. The third
of the circular laryngeal column and final layer of this folding mech-
(Figure 2–3). The upper rim of the anism is the true vocal folds. For
larynx is formed by the aryepiglot- speech communication, the vocal
tic folds, which are strong fibrous folds provide a vibrating source for
membranes that connect the lateral phonation. They also close tightly
walls of the epiglottis to the left and for nonspeech and vegetative tasks,
right arytenoid cartilage complexes. such as coughing, throat clearing,
 18 Clinical Voice Pathology:  Theory and Management

B
Figure 2–2.  Endoscopic view of the larynx and sur-
rounding structures as observed from above with the
vocal folds in the fully open (A), and closed (B) posi-
tions. R = right, L = left.

and grunting, by functioning as a ing actions, and providing resis-

variable valve, modulating airflow tance to increased abdominal pres-
as it passes through the vibrating sure during effortful activities. The
vocal folds during phonation, clos- angles of true vocal fold closure are
ing off the trachea and lungs from multidimensional and include the
foods and liquids during swallow- potential for valving in both hori-
 2.  Anatomy and Physiology 19

superior cornu of thyroid aryepiglottic fold

epiglottis

thyroid cartilage

arytenoid cartilages

interarytenoid muscles

posterior cricoarytenoid inferior cornu of

muscles thyroid (hidden)
cricoid cartilage
tracheal rings

Figure 2–3.  Oblique view of the larynx.

zontal and vertical planes, depend- sion, and position to accomplish these
ing on the variable shape, tension, communicative and vegetative func-
and compression of the medial edge. tions in the body. Together, these three
Communicative maneuvers include levels of airway preservation and pro-
narrow and rapid opening and clos- tection perform constant adjustments in
ing gestures to produce momentary the airway aperture (Figure 2–4).
phonetic contrasts for voiced and
voiceless speech sounds, as well as
sustained vocal fold closing to pro- Respiration for Phonation
duce vibration for phonation.1,2,8,9
Vocal fold vibration is the sound source
All three of these folding structures — the that produces phonation and provides
epiglottis, ventricular folds, and true the speech signal. Phonation relies on
vocal folds — exhibit variable shape, ten- the pulmonary respiratory power, sup-
 20 Clinical Voice Pathology:  Theory and Management

vocal tract

ventricular
(false) fold

ventricle
thyroid cartilage

vocal ligament
true vocal fold

conus elasticus

trachea
cricoid cartilage

Figure 2–4.  Coronal view of the ventricular and true vocal folds. (insert: Coronal plane
of Figure 2–5).

ported by the abdominal and thoracic attached to the top of the diaphragm
musculature. The lungs are housed by a double-walled pleural lining. Dur-
within the rib cage in the thorax and ing inhalation, the diaphragm contracts
separated from the viscera (digestive (flattening downward in the body),
organs in the abdomen) by a large, compressing the viscera, and simulta-
dome-shaped muscle called the dia- neously pulling the lungs downward,
phragm. The bottoms of the lungs are thereby expanding the lung volume. As
 2.  Anatomy and Physiology 21

this lung volume expands, air is drawn characteristics (articulatory gestures)

passively into the lungs. During exha- is the basis for Fant’s Acoustic Theory of
lation, the diaphragm relaxes and rises Speech Production.15 This theory under-
back up to its resting position, as passive lies our understanding of the three com-
elastic recoil pushes air out of the lungs ponents of the acoustic speech product:
and upward through the vocal folds and glottal sound source provided by the
vocal tract. During quiet exhalation, the vibrating vocal folds, coupled with the
vocal folds are abducted (opened) in the supraglottic contributions of vocal tract
paramedian position (approximately filtering, and resonant characteristics.15,16
60% of the full glottal aperture), so no The fluctuating dimensions of the
sound is generated. To exhale for speech, vocal tract cross-sectional area, cavity
however, the vocal folds adduct (close) at shape, and points of articulatory con-
midline, constricting the airflow stream tact (eg, tongue, teeth, and lips), each
as it exits the lungs. This aerodynamic have a direct influence on the quality
breath stream builds up pressure below and strength of the acoustic product
the adducted vocal folds until they are radiated from the lips, and perceived by
blown apart and set into oscillation, listeners. The sound of vocal fold vibra-
creating the vibratory sound source of tion without the supraglottic resonating
phonation.10–12 Without this airflow, no cavity (for example, in intraoperative
sustained phonatory sound source can conditions or in excised larynx studies)
be achieved. The interactive relation- reveals a flat, atonal buzz, devoid of any
ship between the subglottal air pressure “ring” and completely unrecognizable
buildup and transglottal airflow rate as human voice. The contribution of
passing through the vibrating vocal fold this resonating filter is essential to cre-
valve influences the overall pitch, loud- ating the perceptual attributes of voice,
ness, and quality of phonation.4,5,10–14 including pitch, loudness, nasality, and
quality. Manipulating resonance char-
acteristics by changing the vocal tract
shape and oral posturing has been the
Vocal Tract
study of vocal pedagogues, actors, and
Resonance singers for several centuries.5,7,11,13–16
Modifying resonance has also been
As sound waves generated by the vocal applied directly to voice treatment
folds travel through the supraglottic methods for disordered speakers and
air column into the pharynx, oral and professional voice users.17–20
nasal cavities, and across articulatory
structures such as the velum, hard pal-
ate, tongue, and teeth, the excitation of
Structural Support
air molecules within this space creates
a phenomenon called resonance. Reso-
for the Larynx
nance occurs when sound is reinforced
or prolonged as acoustic waveforms
reflect off another structure. The model Hyoid Bone
of acoustic energy (phonation) traveling
through a filter (vocal tract) modified in The larynx is composed of a complex
variable shape, size, and constriction system of mucosa, connective tissues,
 22 Clinical Voice Pathology:  Theory and Management

muscles, and cartilages, all suspended tioning and monitor vocal tension in
from a single semicircular bone, the patients or performers (Figure 2–5).1,2,9,10
hyoid. The hyoid bone marks the supe-
rior border of the laryngeal complex of
muscles and cartilage. It articulates with Laryngeal Cartilages
the superior cornu of the thyroid carti-
lage and attaches to the thyroid through There are nine laryngeal cartilages that
the thyrohyoid membrane. Although extend from just below the hyoid bone
the hyoid serves as the muscular attach- superiorly to the first tracheal ring infe-
ment for many extrinsic muscles of the riorly. Together, these cartilages attach
larynx, it is notable as the sole bone in to muscles and connective tissues to
the body that does not articulate with form the surrounding columnar hous-
any other bone. This has an important ing for the vocal folds. The three larg-
benefit clinically because chronic ele- est cartilages are (from most superior
vation of the hyoid can reflect exces- to inferior) the epiglottis, thyroid, and
sive tension of the muscular sling that cricoid. Additionally, there are three
supports the larynx. Speech-language smaller pairs of cartilages that form the
pathologists and vocal pedagogues may posterior wall of the laryngeal column;
palpate the neck to assess hyoid posi- they are (from most inferior to superior)

hyoid bone

epiglottis
thyrohyoid membrane

thyroid notch
thyroid cartilage

cricothyroid space
cricoid

tracheal ring

Figure 2–5.  Anterior view of the hyoid bone and laryngeal cartilages.
 2.  Anatomy and Physiology 23

the arytenoid, corniculate, and cunei- forms the top level of the three tiers of a
form cartilages. sphincteric folding mechanism to divert
particles of food or liquid away from
Epiglottis the glottis during swallowing. Unlike
other laryngeal cartilages, the epiglot-
The epiglottis cartilage is shaped like tis is composed of elastic cartilage and,
a long leaf, with its narrow base (peti- therefore, does not ossify, or harden,
ole) attached to the inner portion of the with age. This composition is important
anterior rim of the thyroid cartilage. because this structure must remain flex-
This attachment allows the blade of ible throughout life to allow a pliable
the epiglottis cartilage to fold along its free edge to assist in closing the airway
midline and move forward and back, (Figures 2–6 and 2–7).1,2,9,10
closing down inferiorly and posteriorly
over the laryngeal vestibule. Although Thyroid
the position of the epiglottis may influ-
ence vocal tract resonant properties, the The thyroid cartilage is a three-sided
epiglottis normally has no direct role saddle-shaped curve that creates the
in phonation or communication. Its anterior border of the airway column.
primary role is airway protection, as it The thyroid cartilage attaches the true

epiglottis

hyoid bone

thyrohyoid muscle
superior cornu of thyroid cartilage

aryepiglottic muscle
thyroid cartilage

thyroarytenoid muscle

posterior cricoarytenoid muscle

lateral cricoarytenoid muscle
cricothyroid joint

cricothyroid muscle cricothyroid muscle

(pars oblique-cut) (pars recta-cut)

tracheal rings

Figure 2–6.  Lateral view of the larynx.

 24 Clinical Voice Pathology:  Theory and Management

hyoid bone

thyrohyoid muscle
epiglottis

thyroid cartilage

oblique interarytenoid muscle transverse interarytenoid

posterior cricoarytenoid muscle

cricoid cartilage

tracheal rings

Figure 2–7.  Posterior view of the larynx.

vocal folds to the internal rim of the ante- thyroid notch can be seen or palpated
rior curve. Posteriorly are two superior at the front of the neck. Clinically, mal-
cornu, or “horns” that extend upward to position or aberrant movement of the
articulate with the hyoid bone, and two thyroid notch can signal extrinsic laryn-
inferior cornu that articulate with the geal muscle hyperfunction, or voice
cricoid cartilage below it.1,2,9,10 The thy- misuse.18–20
roid is composed of hyaline cartilage
that ossifies and limits flexibility with Cricoid
age.21 The lateral walls form quadrilat-
eral plates, called laminae, that attach at Below the thyroid cartilage is the cri-
the anterior midline in a thyroid notch coid, another hyaline cartilage. It is the
or prominence. In newborns, these lami- only circular cartilage and its shape is
nae form a curve of about 130°, and the described as a “signet ring,” with a nar-
angle becomes more acute with age. row anterior curve and broad posterior
A fully matured thyroid angle will be back.
more acute for adult males (90°) than The cricoid sits above the first tra-
for adult females (110°).9 In males, the cheal ring and provides a stable round
thyroid notch will become more promi- entry to the pulmonary airway. The cri-
nent anteriorly, resulting in the char- coid has two sets of paired facets, or flat
acteristic male “Adam’s apple.” This surfaces that articulate with the thyroid
 2.  Anatomy and Physiology 25

and lymph tissue. Both articular joint

Call-Out Box 2–1 surfaces and the synovial joint mem-
In clinical circles, it is quite common branes do display normal age-related
for patients to complain of pain and/ deterioration, although no gender differ-
or discomfort in specific regions of ences have been noted (Figure 2–8).21–22
the laryngeal framework. This pain
is often a symptom of overactivity Arytenoids, Corniculates,
of the extrinsic laryngeal muscles. and Cuneiforms
This overactivity may be causal,
concomitant, or a consequence of The three-paired cartilages are the ary-
the persistent dysphonia. In fact, tenoid, corniculate, and cuneiform car-
during the diagnostic session, many tilages. The arytenoid cartilages are
clinicians will palpate the larynx pyramid-shaped, with three quasitri-
to identify the location and extent angular surfaces: the anterior, lateral,
of muscle tenderness and pain (see and medial sides. The arytenoids have
Chapter 5). These sites typically a pointed apex on top and a concave
include the major horns of the hyoid base. The anterior points of the aryte-
bone (bilaterally), within the thyro- noid base project farther forward than
hyoid space, and over the superior the lateral and median sides to form the
cornu of the thyroid cartilage. Try to vocal processes. The bilateral vocal pro-
identify these sites on your own lar- cesses form the cartilaginous portions
ynx, and then recruit some of your of the vocal fold, and are the posterior
fellow students, (or friends) and see points of attachment for the membra-
if you can identify these anatomical nous left and right true vocal folds. The
landmarks/sites across a variety of arytenoids are composed of hyaline car-
larynges. This exercise will help you tilage, except for these vocal processes,
to appreciate the variation in laryn- which have elastin cartilage at their tips.
ges across people of different gen- The lateral arytenoid angles are called
ders and body types. the muscular processes because two
different intrinsic laryngeal muscles
attach in separate locations. When these
and arytenoid cartilages. The cricothy- muscles contract, they move the bilat-
roid joints connect the lateral facets of eral vocal processes laterally, to open
the cricoid to the inferior cornu of the (abduct), or medially to close (adduct),
thyroid cartilage above it, thus allow- the vocal folds. The medial arytenoid
ing the thyroid cartilage to rock forward angle faces its arytenoid pair, forming
from its vertical position. The convex an even surface for midline glottic clo-
facets on top of the posterior cricoid rim sure (Figure 2–9).1,2,9,10
are where the concave pyramidal bases The base of the arytenoid cartilage
of the paired arytenoid cartilages rest to is a concave cylinder, allowing it to
form the cricoarytenoid joint.1,2,9,10 Both articulate smoothly with the convex
the cricothyroid and cricoarytenoid superior surface of the posterior cri-
joints are lined with a synovial mem- coid cartilage. The arytenoid base fits
brane, which provides a connective tis- neatly over the posterior cricoid similar
sue cushion supplied with secretions for to an empty half cylinder resting over
lubrication, blood supply, adipose cells, a rounded bar. The movement of the