72 Chapter 4
are damaged, ataxia occurs in which vocal movements are poorly coordinated. “ Whether or not
dysphonia is pres ent may depend upon the severity of the ataxia. The dysphonia may take one
of several forms: sudden bursts of loudness, irregular increases in pitch and loudness or coarse
voice tremor” (Aronson, 1990, p. 100). Flaccid dysphonia results from damage to cranial nerve X.
Usually in f laccid vocal cord paralysis, the voice quality is breathy. In addition, damage at vari ous
levels of the neurological system causes laryngeal tremors, uncontrolled jerks, spasms, and voice
arrest. The treatment for laryngeal paralysis depends on the type of paralytic dysfunction and
may include exercises for forcing the unimpaired vocal cord across the midline, improving range
of motion, and strengthening laryngeal muscles. Voice quality, loudness, and pitch modulation are
also addressed. According to the American Speech-Language-Hearing Association (2015), behav-
ioral therapies provided by a speech- language pathologist may be the only treatments necessary
for vocal cord paralysis.
Cancer of the Larynx
Laryngeal growths can be benign or malignant. Benign growths are nodules or polyps result-
ing from vocal strain and abuse (see the section Voice Disorders Related to Vocal Strain and
Abuse). Malignant (cancerous) growths tend to worsen if not destroyed by chemical or radiation
therapy or surgically removed. Malignant growths also destroy other tissue and can metastasize,
or spread, to other parts of the body. De cades of research have linked cigarette smoking and the
use of other tobacco products to oral and laryngeal cancer.
Improved radiation therapy and chemotherapy for laryngeal cancer have reduced, but not
eliminated, the necessity for complete laryngectomy, the removal of the entire larynx. In addition,
metastasis of the cancer to adjacent tissue may require a radical neck dissection, involving removal
of lymph nodes and other tissue. Partial laryngectomy involves removal of one vocal cord or part
of it. Laryngectomies are extremely disfiguring surgeries, and loss of voice is a major quality- of-
life consideration many patients must face. In fact, MacNeil, Weischselbaum, and Pauker (1981),
in a study of laryngeal cancer and treatment options, found that most subjects would be willing to
reduce their life expectancy to retain the ability to speak. Byrne, Walsh, Farrelly, and O’Driscoll
(1993) found an association between depression and poor communication skills in laryngecto-
mized patients.
There are three methods of alaryngeal speech. First, the Passy- Muir Valve can direct the air
through the speech mechanism by plugging the stoma (an opening through the neck). Second, the
patient with a laryngectomy can use an electronic larynx (electrolarynx), which provides a vibrat-
ing source placed on the patient’s neck; the energy is directed upward through the oral and nasal
cavities, and the patient “mouths” the words. Third, esophageal speech, or belch talking, allows the
patient to produce near- normal speech by partially swallowing a small amount of air and talking
while gradually expelling it. Depending on the laryngectomy patient’s capabilities and preferences,
these methods can be used to produce speech. However, some patients prefer to write and gesture
rather than to learn these methods.
Other Diseases Affecting the Voice
In progressive neuromuscular disorders, the first indication of the disorder may consist of
speech difficulties, particularly laryngeal functioning. Patients report unusual pitch changes,
vocal tremor, voice quality aberrations, difficulty controlling loudness, and so forth. As the disor-
der progresses, these symptoms often increase in frequency and severity. Many diseases can cause
dysphonia or aphonia. Rather than listing the many diseases affecting laryngeal functioning, it
is con ve nient to categorize them relative to the damaged neurological pathways (Aronson, 1990;
Darley, Aronson, & Brown, 1975). Damage to the cerebellum, extrapyramidal system, and upper
and lower motor neurons can cause clusters of voice symptoms unique to each neurological level.