In women, the vocal folds are shorter. vocal folds

The most characteristic for this form of dysarthria are: 1) weakness of the articulatory and respiratory muscles, especially the diaphragm, hypokinesia of the laryngeal muscles; 2) pareticity of the lingual, labial muscles, soft palate.

With the spastic-rigid form of dysarthria, there is a significant change in muscle tone along with the phenomena of spastic paresis. When attempting arbitrary speech, muscle tone sharply increases in the articulatory, respiratory and vocal apparatus.

The most characteristic signs of this form of dysarthria are: 1) tension of the respiratory muscles; 2) hyperkinesia of the larynx; 3) spastic paresis in the lingual, labial muscles, soft palate, which leads to monotony, nasalization of the voice.

Thus, in the spastic-rigid form of dysarthria, the rhythmic-melodic-intonation side of speech suffers due to asynchrony in the activity of the articulatory, respiratory and vocal apparatus, which is associated with the tension of the phonator muscles.

In the spastic-hyperkinetic form of dysarthria, the phenomena of spastic paresis are combined with athetoid and choreic hyperkinesis. Articulatory movements are disordered, chaotic, non-localized, arrhythmic.

Voice disorders in extrapyramidal disorders were described by M. Zeeman, calling them extrapyramidal phonatory syndrome. M. Zeeman notes a characteristic violation of breathing, voice and all melodic coloring of speech in this syndrome. So, breathing, usually shortened, with affective state the patient accelerates, asynchrony appears between the chest and abdominal respiratory movements (reminiscent of breathing during stuttering). The voice changes in strength and duration of sound due to hyperkinesia or hypokinesia of the larynx, respiratory failure. There is a noticeable reduction in the phonatory period - the voice fades after 3-5 s, the patient takes frequent breaths. The timbre of the voice acquires a nasal sound due to the retraction of the raised soft palate from the posterior pharyngeal wall. But, as M. Zeeman notes, rhinophony is not permanent, it increases towards the end of a phrase or towards the end of phonation. Such speech is characterized by monotony, monodynamism and tempo disturbances (its acceleration or deceleration), therefore, in order to avoid diagnostic errors, differential diagnosis with stuttering is necessary. In addition, the voice may be aphonic or dysphonic with laryngeal hyperfunction, muffled, excessively loud, difficult to control. These children usually do not have a singing voice, they cannot sing.

The most characteristic signs of the spastic-hyperkinetic form of dysarthria are:

• 1) hyperkinesis of the respiratory muscles, which cause its tension or, conversely, weakness, lethargy; the consequence of this phenomenon is a weak, quiet voice, constantly exhausted, intermittent;
• 2) dyskinesia of the larynx, which causes, on the one hand, squeezing of the voice, and on the other hand, its trembling and vibration;
• 3) spastic paresis of the lingual, labial muscles in combination with hyperkinesis, which gives the voice a monotonous tone with cries and an increase in voice; the phonetic side of speech usually suffers slightly.

Thus, in the spastic-hyperkinetic form of dysarthria, the potential for voice formation is much higher than their implementation in the speech stream. In the process of arbitrary phonation, hyperkinesis intensifies, in connection with which the sonority of the voice is reduced, its strength is depleted and speech intelligibility decreases. The melodic-intonational side of speech suffers to a large extent and is difficult to correct.

With atactic form of dysarthria, articulatory movements lose their accuracy and coordination. Against the background of a decrease (hypotension) of muscle tone, its increase can be observed. Speech is slurred and somewhat slow. The voice is monotonous, unmodulated, intermittent, hoarse. Pitch modulations and changes in strength are not available, with non-speech phonation the voice is strong, sonorous.

So, dysphonia in various forms of dysarthria in children is characterized by a peculiar and complex violation of the pitch, strength and timbre of the voice with many neurodynamic layers. The characteristic of dysarthria is complicated clinical syndromes children's cerebral palsy. The main cause of the voice disorder in some cases is asynchrony in the activity of the articulatory, respiratory and vocal apparatus, and in others - the paresis of the movements of the vocal folds and articulatory motility. The study of voice disorders can be an important diagnostic sign for determining the form of dysarthria in children.

To the peripheral organic disorders voices include voice disorders associated with pathoanatomical changes in the larynx, extension tube and hearing loss.

With pathoanatomical changes in the extension tube, rhinolalia and rhinophony are observed. Differential diagnosis of rhinolalia and rhinophony does not present a significant difficulty. Rhinolalia is a pathological change in the timbre of the voice and a distorted pronunciation of speech sounds; rhinophonia - a change in tone, voice timbre, due to a violation of the relationship between the nasal cavity and the oropharyngeal resonator during phonation without articulation and pronunciation disorders.

Rhinolalia and rhinophony take place in speech pathology and are manifested by a peculiar violation of the timbre of the voice and the phonetic side of speech.

Many speech therapists in the study of patients with open rhinolalia after uranoplasty surgery reveal a significant impairment of their voice function. The voice is deaf, unmodulated, with a sharp nasal tone. As a result of air leakage during speech through the nose, rhinolalics delay it not in places of normal articulation (labial closure when pronouncing sounds p, b, lingo-palatine with t, d, k, d), but on the vocal folds, which gives the speech a guttural character.

Rhinolaliks, embarrassed by their speech, try to speak more quietly, as a result of which the voice becomes monotonous, weak, muffled. M. Zeeman calls voice disorders during cleft palate dysphonia palatina or palatophonia, in contrast to articulatory disorders, i.e. palatolalia. The author points to two causes of palatophony: laryngeal hyperfunction and abnormal vocal resonance. “The voice arises with strong expiratory pressure on the glottis and increased tension of the vocal cords. At the same time, the larynx rises strongly and the extension tube contracts ... The voice is formed primitively and squeezed ... ”M. Zeeman connects the change in the timbre of vowels with a number of anatomical and resonator reasons, as well as with incorrect movement of the tongue and larynx. And what older child, the more noticeable and unpleasant is the palatophony.

The Polish logotherapist A. Mitrinovich-Modrzeevska notes that rhinophony can be accompanied by rhinolalia in the following cases: 1) if acquired factors (for example, degenerative changes sensitive and trophic nerve fibers pharynx, dysfunction of the muscular system of the respiratory, phonation and articulatory muscles) begin to exert their influence in the first years of a child's life, when the articulatory mechanisms are not yet fully formed; 2) if there is also a hearing impairment; 3) if there are also violations of articulation of central origin.

The method of X-ray cinematography confirmed the assumptions of A. Mitrinovich-Modrzeevska: in rhinolalia, the function of the vocal folds is characterized by asymmetry and asynchrony. There are also functional disorders of the respiratory muscles, and especially the diaphragm, their lethargy, lack of coordination with phonation and articulation. The sound of vowels changes relatively little, fricative and occlusive-fricative consonants are most distorted. The height and intensity of the frequencies that make up the spectrum of a given sound changes with rhinolalia: the sound goes down, its intensity decreases. Even after a successful operation and phoniatric treatment, the voice of these patients is characterized by vocal inferiority, they are not able to produce vocal efforts.

T.N. Vorontsova notes a violation of the height, strength and timbre of the voice with rhinolalia. The voice is deaf, with a sharp nasal tone, monotonous, unmodulated, weak. When determining the degree of nasality, the author uses the following terms: sharply nasalized speech and speech with slight nasalization. Investigating the voice function in these patients using the analysis method, T.N. Vorontsova revealed a sharp decrease in the envelope of the spectrum in the range of 2000-3000 Hz. All format areas, except for the main tone, are not clearly expressed.

The voice disorder is largely determined by the functional impairment of the respiratory function in rhinolalia. These patients are characterized by a short superficial breath, a small volume of inhaled air and a large loss of exhaled air through the nasal passages.

The soft palate is involved in the formation of the closing pharyngeal ring (or palatopharyngeal closure) - it moves back and up until it contacts the Rassavant roller, while the muscles of the lateral walls of the pharynx on both sides close the pharyngeal ring. The uvula rises and creates a complete isolation of the nasopharynx from the oropharynx. With insufficient functioning of the muscles involved in the formation of the pharyngeal ring, most of air enters into nasal cavity, since the distance between the back wall of the pharynx and the soft palate exceeds 5-6 mm. The main value is the length of the soft palate, and to a lesser extent - its mobility. The function of the palatopharyngeal closure is also influenced by the degree of mouth opening and the position mandible, which changes the shape and size of the oropharyngeal resonator, and, consequently, its acoustic tuning and the pitch of formant vowels.

There is a close functional relationship between the soft palate and the larynx, and between the pharynx and larynx. The slightest change in the position of the soft palate causes a change in the position of the vocal folds. Irritations of the receptors of the nasal cavity and especially the mucous membrane of the soft palate affect the voice-forming apparatus. The receptors of the soft palate (especially the uvula) transmit impulses to the central nervous system, as a result of which the system of the oronasopharyngeal resonator associated with it is aligned with the function of the soft palate (the reverse afferentation mechanism operates).

In addition, there is a relationship between the muscles of the closing pharyngeal ring and the respiratory muscles (especially the diaphragm), which make up a single motor system during phonation. With tension of the vocal folds and the respiratory system, the soft palate is inactive; with uniform respiratory movements, lightness, sonority of the voice, the fluctuations of the vocal folds are uniform and the soft palate is mobile.

Thus, dysfunction of the soft palate (regardless of the causes that cause it) leads to a violation of coordination in the activity of the energy, generator and resonator systems and to a decrease in the regulatory role of the central nervous system. There is a fixation of the pathological reflex of voice formation, which complicates speech therapy work even with favorable anatomical and physiological data (i.e., after the elimination of the causes that caused nasalization).

Nasalized phonation can be attributed to dysphonic disorders of voice formation, violation of the pitch, strength and timbre of the voice. But hallmark disphonia palatina is a predominant violation of the timbre of the voice. Nasalization deprives the timbre of pleasant modulations, pitch changes, sonority and flight of the voice. In addition, there is a weakness of the voice, a tendency to its excessive increase, a clamped, stifled sound, sometimes hoarse and hoarse. The muffled, dull, dead sound of the voice impoverishes the natural intonations, the melody of speech, and reduces its expressiveness. The patient finds it difficult to convey the main intotones - questions, statements, exclamations, surprise, amazement (emotional intonations), commands, beliefs, requests (volitional intonations), narrative, enumeration, indifference (logical intonations). Raising and lowering the tone, amplifying and weakening the sound are almost inaccessible to children suffering from rhinophony.

Thus, with rhinophony, the main link of speech expressiveness is violated - voice modulations, which leads to a disorder of the melodic-intonation side of the child's speech.

There are two types of rhinophonia - open (rhinophonia aperta, hiperrhinophonia) and closed (rhinophonia clausa, huporhinophonia) (see Table 3 on p. 40).

Open rhinophony is due to organic (congenital and acquired) and functional causes.

Organic congenital open rhinophony occurs with congenital shortening of the soft palate, which is a sign of a malformation - the ratio of the lengths of the hard and soft palate is 3:1 or even 4:1 (instead of the normal 2:1).

Organic congenital open rhinophony may be the result of open rhinolalia resulting from splitting of the hard and soft palate. In this case, open rhinophony is manifested only by a violation of the timbre of the voice without phonetic defects.

Thus, the involvement of a conscious-arbitrary level of regulation of speech activity improves the child's intonation capabilities. But speech is highly automated motor function, so it is important to translate voluntary control into unconscious-involuntary.

Acquired organic open rhinophony occurs with acquired paresis and paralysis of the soft palate, myasthenia gravis, perforations, fistulas of the hard or soft palate caused by injury, tuberculosis, syphilis. Open rhinophony can be an unpleasant consequence of tonsillectomy when postoperative scars tighten the soft palate and limit its mobility. Unfortunately, such an undesirable postoperative effect is quite common.

An unsuccessful operation can cause open rhinophony associated with scarring of the soft palate. Sometimes the function of the soft palate is restored spontaneously, but the rhinophony is preserved due to the prevailing pathological reflex of voice formation (transforms into a functional habitual form). In this case, you also need speech therapy classes to eliminate nasalization.

The most common cause of open rhinophony is peripheral and central paresis and paralysis of the soft palate. Peripheral paralysis and paresis occur after diphtheria, influenza, with damage to the motor branches of the glossopharyngeal and vagus nerves, with injury or pressure of the tumor. At the same time, hoarseness and aphonia are also observed due to dysfunction of the internal muscles of the larynx.

Central paralysis or paresis of the soft palate is relatively rare. It should be distinguished from peripheral paralysis: in peripheral paralysis, the soft palate is motionless, not only phonation is disturbed, but also swallowing, fluid passes into the nose; with central paralysis, the mobility of the soft palate is limited during phonation, but its reflex movements during swallowing are preserved. Pseudobulbar palsy can be accompanied by both peripheral and central (with erased forms) paralysis of the soft palate (congenital and acquired).

Rhinophony manifests itself in a peculiar way in diseases of the extrapyramidal system: rhinophony is not permanent - stronger towards the end of phonation or towards the end of a phrase, sometimes turns into a closed one, which again turns into an open one. Extrapyramidal rhinophony is not associated with a violation of the innervation of the soft palate. This is due to the retraction of the raised and tense soft palate from the posterior pharyngeal wall. During phonation, not only the muscles that raise the palate work, but also their antagonists. Depending on the tension of the muscle that raises or lowers the palate, hyperrhinophonia or hyporhinophonia (extrapyramidal phonator syndrome) occurs.

Functional open rhinophonia occurs for a number of reasons. Sometimes it appears in weak, asthenic children with sluggish articulation, in which the soft palate does not reach the back of the pharynx. Functional open rhinophony may be the result of hysterical reactions that appear as a result of mental trauma, fright, fear. The resulting hysterical muscle paresis, and, accordingly, rhinophony, are transient. Habitual functional open rhinophony is observed after the past post-diphtheria paralysis of the palate, removal of adenoids, choanal polyps, tumors of the nasopharynx, peritonsillar abscess, etc. Such a violation occurs as a result of forgetting the idea of ​​movement, the loss of the kinesthetic support of movement (in this case, the soft palate) or due to the creation of new physiological conditions for the formation of speech sounds. So, after extirpation of tumors of the nasopharynx, due to insufficient differentiation of oral and nasal exhalation, the air stream begins to penetrate into the nasal cavity when pronouncing not only nasal, but also oral sounds.

Functional unstable open rhinophony is observed with hearing loss. Its appearance is associated with inaccurate articulation, including inaccurate palatopharyngeal closure.

The voice with open rhinophony is disturbed to varying degrees, depending on the reasons that caused it, and most importantly, on the usefulness of the function of the soft palate, its mobility and length. The specific acoustic features of a nasalized voice sound are explained by the amplification of the fundamental tone and low tones.

Occupational diseases of the vocal apparatus (chronic laryngitis; nodules of the vocal folds) - diseases of the larynx that develop in persons of voice-speech professions when performing professional voice functions or during prolonged (without rest) voice activity, as a result of inept use of phonation breathing, modulation of pitch and volume of sound , incorrect articulation, etc.

Vocal fold nodules, also called "singing nodules" or hyperplastic nodules, are small paired nodules, symmetrically located on the edges of the vocal folds at the border of their lateral and middle thirds, of a very small size (pinhead), consisting of fibrous tissue. Sometimes they take diffuse form and spread over a large surface of the folds, causing significant disturbances in the timbre of the voice.

ICD-10 code

J37.0 Chronic laryngitis

Epidemiology

Prevalence occupational diseases pharynx and larynx among people of voice-speech professions is high and reaches 34% in some professional groups (teachers, educators). moreover, there is a clear dependence on the experience, the incidence is higher in groups examined with an experience of more than 10 years.

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Causes of vocal cord nodules

Occupational diseases of the vocal apparatus develop in teachers, kindergarten teachers, vocalists, drama artists, announcers, guides, guides, etc. Of particular importance is the work on foreign language when errors in speech technique cause a sharp tension in the neck muscles, and insufficiently good respiratory support leads to a significant displacement of the larynx forward, which reduces the tone of the vocal folds.

In addition to the main etiological moment (overstrain of the vocal apparatus), in the development of occupational diseases of the vocal apparatus, the specifics of working conditions are important (nervous-emotional stress, increased intensity of ambient background noise, poor room acoustics, changes in ambient temperature, increased dryness and dustiness of the air, uncomfortable working posture). etc.). Non-compliance with voice hygiene (smoking, alcohol) and inflammatory diseases of the nasal cavity and pharynx contribute to the development of occupational diseases of the larynx. An important role is played by the allergization of the body with the development hypersensitivity to such irritants as dust, scree of colors from the scenery, makeup, as well as fatigue and psychogenic trauma.

It is also suggested that the etiological factor of vocal fold nodules can be submucosal microhematomas, which are formed during superstrong vocal load, after the resorption of which fibrous proliferation occurs. connective tissue with the formation of nodules. However, this assumption is rejected by Ch.Jackson (1958), who believes that hematomas of the vocal folds underlie the formation of polyps.

Pathogenesis

These nodules are not tumors in the morphological sense of the term, but look like growths of the vocal fold's own connective tissue. Usually these formations occur when they are overstrained during screaming, singing, reciting in a loud voice, especially, according to a number of foreign phoniatric studies, in cases where high register sounds are used in voice formation, therefore singing nodules are found in soprano, coloratura soprano, tenors and countertenors and very rarely in contraltos, baritones and basses.

During stroboscopic studies, it was found that at the level at which singing nodules appear, with phonation of high tones, the vocal folds take on a more convex shape and thereby more closely and for a longer time adjoin each other. As a result, first, a bilateral limited focus of inflammation appears at the indicated place, followed by hyperplasia of connective tissue fibers, which are most sensitive to mechanical and inflammatory irritations, with continued voice loads.

Symptoms of vocal cord nodules

The main complaints of people using in professional activity voice apparatus, are quick fatigue of the voice, sounding of the voice in an incomplete range (the voice "sits down"), a feeling of discomfort in the throat, dryness, perspiration. Among workers with experience in the profession from 3 to 10 years, there are voice disorders (dysphonia) up to complete hoarseness (aphonia), pain in the throat and in the neck when performing voice-speech functions.

The initial period of the disease is characterized by the development of functional disorders in the vocal apparatus, most often manifested as phonasthenia. Phonasthenia (from the Greek phone - sound and asteneia - weakness) is the most typical functional disorder that occurs mainly in voice-speech professions with unstable nervous system. The main reason for its occurrence is an increased voice load in combination with various adverse situations that cause disorders of the nervous system. Patients with phonasthenia are characterized by complaints of rapid fatigue of the voice; paresthesia in the neck and pharynx; perspiration, soreness, tickling, burning; a feeling of heaviness, tension, pain, spasm in the throat, dryness, or, conversely, increased mucus production. Quite typical for this pathology are the abundance of complaints and their careful detailing to patients. AT initial stage disease, the voice usually sounds normal, and endoscopic examination larynx does not reveal any abnormalities.

Often the appearance of nodules of the vocal folds is preceded by catarrhal laryngitis and long-term current phonasthenia. The latter forces the patient to strain the vocal apparatus, and the former contributes to proliferative processes, the result of which can be not only nodules, but also others. benign tumors larynx. In the initial period of the formation of nodules, patients feel slight fatigue of the vocal apparatus and inadequate formation of singing sounds during the piano (quiet sounds), especially at high tones. Then there is a deformation of the voice with any sounds: a feeling of “split” of the voice, an admixture of vibratory sounds is created, while loud speech requires a significant tension of the vocal apparatus. This is due to the fact that during phonation the nodules prevent the complete closure of the vocal folds, due to which the resulting gap causes an increased air flow, the subglottic air support decreases, and the strength of the voice cannot reach the desired level. Laryngoscopy reveals changes.

In children, nodules of the vocal folds are observed most often at the age of 6-12 years, more often in boys, whose vocal apparatus in the stage of hormonal development is more susceptible to alteration during vocal loads. It should be borne in mind that children's games at this age are invariably accompanied by appropriate cries. It has been noted that the formation of vocal fold nodules in children is often accompanied by secondary catarrhal laryngitis due to the presence of adenoids and impaired nasal breathing. Removal of adenoids in such children, as a rule, leads to spontaneous disappearance of vocal cord nodules.

Diagnosis of vocal cord nodules

Diagnosis of nodules of the vocal folds usually does not cause difficulties. The main distinguishing feature is the symmetry of the location of the nodules, the absence of other pathological endolaryngeal signs and anamnesis data. Sometimes, a young laryngologist, inexperienced in the pathology of the larynx, can mistake the vocal processes of the arytenoid cartilages for singing nodules, which, with individual characteristics, protrude into the glottis, but during phonation, their functional purpose and their absence between the vocal folds, which are completely closed, become obvious. To verify this, it is enough to conduct a stroboscopic examination of the larynx.

The diagnosis of phonasthenia requires mandatory application modern methods research functional state larynx - laryngostroboscopy and microlaryngostroboscopy. Characteristic findings during laryngostroboscopy in these patients are unstable and "variegated" stroboscopic picture, asynchronism of vocal fold oscillations, their small amplitude, frequent or moderate tempo. Typical is the absence of “stroboscopic comfort”, that is, when creating conditions for absolute synchronization of the frequency of pulsed light and vibrations of the vocal folds, instead of motionless vocal folds (as is normal), contractions or twitches are visible in their individual areas, resembling trembling or flickering. With long-term severe forms of phonesthesia, leading to organic changes in the vocal folds, the absence of the phenomenon of displacement of the mucous membrane in the region of their anterior margin is typical.

Of the organic dysphonias, the most common occupational diseases are chronic laryngitis and "singers' nodules". Quite rarely among the "professionals of the voice" there are contact ulcers of the vocal folds. The endoscopic picture of the listed diseases is typical. It should be noted that professional diseases include not only the above-mentioned diseases of the voice and speech apparatus, but also their complications and direct consequences.

So, the idea of ​​general otorhinolaryngology about chronic laryngitis as a precancerous process gives grounds in some cases to consider a neoplasm of the larynx (in the absence of other etiological factors) as a professional one, if it has developed in a patient - a "professional voice" who had a history of chronic inflammation vocal folds.

It should be noted that so far there are no specific objective criteria for the professional affiliation of diseases of the vocal apparatus, which sometimes leads to diagnostic errors and incorrect resolution of expert issues. In this regard, to determine the professional nature of the disease of the larynx, a thorough study of the anamnesis is necessary (excluding the impact of other etiological factors, primarily smoking, alcohol intake, injuries, etc.; frequent visits to healthcare facilities for acute inflammatory diseases larynx or pharynx). Of decisive importance is the study of the sanitary and hygienic characteristics of working conditions in order to determine the degree of voice load. Accepted allowable rate of voice load for voice-speaking professions - 20 hours per week. In addition, it is necessary to take into account the potentiating effect of the accompanying factors of the working environment and the labor process. Objective criteria are the data of dynamic monitoring of the state of the upper respiratory tract, and first of all the larynx, using methods for determining the functional state of the larynx.

Treatment of vocal cord nodules

Treatment of patients with occupational diseases of the vocal apparatus is based on the principles of treatment of non-occupational inflammatory diseases of the larynx. In all cases of dysphonia, it is necessary to observe the voice mode and personal hygiene of the voice (no smoking, drinking alcohol), hypothermia should be avoided. Sanitation of foci of chronic infection is necessary.

Medical treatment

In organic diseases of the larynx, anti-inflammatory therapy, antihistamines, and instillation of oils into the larynx are indicated. Good for vasomotor changes healing effect renders the installation of oils to the larynx in combination with a suspension of hydrocortisone, ascorbic acid. In subatrophic processes, alkaline inhalations with vitamins, various biostimulants are useful; with hypertrophic forms - with zinc, tannin; with vasomotor - with a suspension of hydrocortisone, procaine. Physiotherapeutic procedures are widely used: electrophoresis on the larynx with potassium iodide, potassium chloride, vitamin E. With phonasthenia, the use of additional sedative therapy is indicated (tranquilizers: diazepam, chlordiazepoxide, oxazepam, etc.). To increase the vitality of these individuals, it is recommended to use an extract of red deer antlers, an extract of ginseng, eleutherococcus. From physiotherapy procedures for phonasthenia good effect have hydroprocedures (rubbing with water, pine baths), gargling with infusion of sage, chamomile. To prevent recurrence of phonasthenia, voice strain should be avoided, various situations that negatively affect the nervous system.

Working capacity examination

Examination of both temporary and permanent disability due to occupational diseases of the vocal apparatus requires a special approach. We are talking about a temporary disability in voice-speech professions when the pathological process that has arisen in the larynx is not long-term, reversible, and after a short period of time, the ability to work is fully restored. This can be with phonasthenia, injuries and hemorrhages in the vocal folds, that is, with the initial forms of an occupational disease.

Temporary disability in people with voice-speaking professions is complete. This means that the employee is unfit for professional work for a short period, since any violation of the voice mode (silence mode) can aggravate the course of his illness.

Persistent disability in people with voice-speaking professions also occurs more often with exacerbations of chronic laryngitis, recurrent phonasthenia, monochorditis and other diseases of the larynx. In these cases, the patient needs a long-term inpatient treatment. In the absence of a positive clinical effect from the treatment, depending on the severity of the process and the functional state of the larynx, the patient is referred to MSEC to determine the degree of disability. Such patients need observation by a phoniatrist and an otorhinolaryngologist and active treatment.

Prevention

Prevention of occupational diseases of the larynx should be based, first of all, on the correct professional selection, teaching young professionals and students the technique of speech, instilling voice hygiene skills. During professional selection, it is advisable to conduct a preliminary conversation with a neuropsychiatrist. Applicants must be emotional enough, able to quickly respond to the situation. The presence of foci of chronic infections in the upper respiratory tract is undesirable, after sanitation of which it is necessary to re-solve issues of professional suitability.

Absolute contraindications for work in voice-speech professions are acute and chronic diseases of the larynx: chronic diseases pharynx of a dystrophic (especially subatrophic) nature, vasomotor and allergic reactions of the mucous membrane of the upper respiratory tract. Preliminary and periodic medical examinations are a necessary condition for prevention.

Treatment of acute catarrhal laryngitis is carried out in outpatient settings. All patients with edematous laryngitis, epiglottitis and abscesses of the epiglottis, complicated forms of the disease (infiltrative and abscessing) with the threat of developing laryngeal stenosis and injuries are subject to hospitalization in the hospital.

Furrow is a linear recess or gutter. There are various definitions of the groove of the vocal fold (sulcus vocalis). This term describes several diseases at once, one of the main features of which is the presence of a linear depression on the medial surface of the fold. The causes of the condition can vary from a local deficiency of the surface layer of the lamina propria to invagination of the epithelium into the vocal cord.

If a furrow does not affect the oscillation of the fold, it is considered physiological. Sometimes the furrows can be congenital, in which case they are most often localized on both folds at once. In some cases, the furrow may be a consequence of the surgical intervention, for example, removal of the formation of the vocal fold with a postoperative local defect in the surface layer of the lamina propria. Theoretically, a sulcus may occur after a vocal cord cyst ruptures.

According to Ford classifications, three types of such deformations can be distinguished:

Type I: physiological furrows, these include congenital furrows that do not affect the condition, as well as furrows that appear due to atrophy of the fold; mucous wave is normal or slightly disturbed.

Type II: sulcus stria or sulcus vergeture, is a depressed strip along the medial edge of the fold, along which the epithelium is soldered to the intermediate and deep layers of the lamina propria; the mucous wave is significantly reduced or absent.

Type III: focus of compaction pressed into the thickness of the vocal fold; this condition is accompanied by severe dysphonia. The voice of such patients is usually thin and high, patients complain of rapid fatigue of the voice, the inability to pronounce loud sounds.

a) natural flow. After the formation of the groove of the vocal fold does not progress in any way. In trying to adjust the voice to the presence of the sulcus, patients often develop abnormal vocal habits.

b) Possible Complications . There are no reports of any consequences other than voice impairments.

The vocal cords are controlled by the recurrent nerve, the 10th of the 12 cranial nerves. The recurrent laryngeal nerve and the superior laryngeal nerve, which are part of vagus nerve, control the muscles of the larynx and vocal folds so that they move in harmony, which promotes voice production, breathing and preventing food from entering the trachea.

However, when the nerves are damaged, the vocal folds remain immobile and the glottis remains open so that air flows through the vocal folds without causing them to vibrate, causing the voice to become hoarse. Because the vocal folds cannot close when swallowing, food often enters the trachea, causing choking.

When diagnosing vocal fold paresis, it is very important to remember that vocal fold immobility can be for another reason than vocal fold paresis. There are others pathological conditions that can cause these symptoms. For example, a neoplasm in the larynx, dislocation of the arytenoid cartilages as a result of trauma, fixation of the thyroid cartilage, congenital pathology, inflammation, infection of the larynx, scarring of the vocal folds, etc. Therefore, it is very important to differential diagnosis to identify the exact cause of the disease.

The recurrent nerve that controls the movement of the vocal folds is one of the laryngeal nerves. It has a different origin on the right and left. The left recurrent laryngeal nerve begins at the level of the aortic arch and, having rounded it from below, rises vertically upwards in the groove between the esophagus and trachea. The right recurrent laryngeal nerve departs from the vagus nerve at the level of the right subclavian artery, bends around it from below and also in the posterior direction, and rises up lateral surface trachea. Since the recurrent nerve goes around important organs, damage to any of them can lead to deviations in the functioning of the nerve.

Examination for paresis of vocal cords

Since vocal cord paresis can occur for various reasons, it is important to find out the exact cause of the disease, the degree of paralysis, the possibility of nerve recovery, and if recovery is possible, how long it will take. Depending on the cause and degree of the disease, the diagnosis and method of treatment may differ, so a number of investigations are necessary. If necessary, an MRI or computed tomography of the brain is performed to exclude a possible tumor or disorder of the central and peripheral nervous system. A CT scan of the neck is used to detect tumors in the neck or pathology of the nerves of the neck, and sometimes a functional test and ultrasound are also required. thyroid gland. In order to detect congenital pathology of the larynx, inflammation or functional disorders, fibrolaryngoscopy or stroboscopy of the larynx is performed.

CT scan

Electromyogram of the larynx

Fibrolaryngoscopy

Stroboscopy of the larynx

The treatment of unilateral vocal cord paresis has a rich history. So, in 1911, Wilhelm Brunings was the first to use paraffin injections into the vocal cord muscle on the side of the injury. This method was widely practiced until the 1970s, but it was discontinued due to the high risk of granuloma formation.

In 1915, Dr. Erwin Paire developed and pioneered the operation of the thyroid cartilage plasty method. Thereafter, there was no definite systematic theory until the 1950s, and a large number no operations were performed. In 1974, Dr. Isshiki introduced thyroplasty, after which this method began to be used everywhere.

Another treatment for vocal cord paralysis is arytenoid cartilage adduction, first performed on 12 patients by Drs. Slavit and Maragos in 1992. Since then, both methods have been used in parallel.

In 1977, Dr. Tucker attempted to replace the paralyzed recurrent laryngeal nerve by partially transecting the scapulohyoid muscle, which is innervated by the hypoglossal nerve, and implanting that part into the thyrocynoid muscle. In other words, it was a way to replace the damaged vocal cord nerve with a healthy one. However, this method has not found wide application for the reason that it took too long to restore the function of the vocal fold.

Later, in 1984, Dr. Ford pioneered the injection of collagen into the vocal fold, and in 1991, Dr. Michelian introduced a method based on fat grafting.

An advanced and now widely used method is EMG-guided percutaneous injection laryngoplasty (electromyogram), developed and presented at domestic and international conferences by Dr. Kim Hyun-tae, Associate Professor of Medicine at the Catholic University, and now the chief physician of the Yesong Voice Restoration Center. This method consists in the high-precision introduction of a biological filler into the vocal fold, helping to restore the voice.

The larynx occupies a middle position in a person in the anterior region of the neck, where its thyroid cartilage forms a protrusion, although in children and women there is no such an angular protrusion as in adult men (Adam's apple, or Adam's apple). The larynx is located in the middle of the respiratory tract: above it are the upper respiratory tract, the lower ones begin from the larynx.

In an adult, the larynx is located at the level of the IV-VI cervical vertebrae, in children it is one vertebra higher, in old age- one vertebra below. On the sides of the larynx are large blood vessels neck, and in front the larynx is covered with muscles below the hyoid bone, and upper parts lateral lobes of the thyroid gland. At the bottom, the larynx passes into the windpipe (trachea).

The structure of the larynx reflects the performance of its respiratory function, the function of a generator of sounds and a regulator that separates the respiratory system and the esophagus.

The human larynx is made up of cartilage various shapes connected by ligaments and joints set in motion by muscles. At its base is the cricoid cartilage. The thyroid cartilage rises arched in front and from the sides above it, and behind it there are two arytenoid cartilages. The epiglottis is attached to the inner surface of the thyroid cartilage. During swallowing movements, the larynx rises, the epiglottis closes the entrance to the larynx and the food, as if on a bridge, rolls over the epiglottis into the esophagus. The action of the epiglottis is automatically controlled by the central nervous system, but sometimes it fails, and then the liquid or pieces of food go "in the wrong throat."

The cavity of the larynx is lined with a mucous membrane that forms the vocal folds (it is often said: vocal cords). The cartilages of the larynx form a series of joints that determine their mobility and, consequently, a change in the tension of the vocal fold.

The structure of the human larynx: vocal folds.

The main structural feature of the human larynx is the vocal folds with their unique capabilities. Between the arc of the cricoid cartilage and the edge of the thyroid cartilage, a strong cricoid-thyroid ligament, consisting of elastic fibers, stretches along the midline. The fibers of this ligament, starting from the upper edge of the cricoid cartilage, deviate and connect behind with other ligaments and form an elastic cone tapering upward, the upper free edge of which is the vocal fold. This is where the voice is born.

The vocal fold is made up of highly elastic fibers of muscle and connective tissue. Two vocal folds are located on the right and left sides of the human larynx and are stretched from front to back at an angle to each other. Moving apart, the folds form the glottis. During normal breathing, the glottis is wide open and has the shape of an isosceles triangle, the base of which is turned back, and the top is forward (toward the thyroid cartilage). Inhaled and exhaled air at the same time silently passes through a wide glottis. During a conversation or singing, the vocal folds are stretched, approaching, and when the exhaled air passes, they vibrate, producing a sound.

The length of the vocal folds in adults ranges from 20 to 24 mm in men, 18 to 20 mm in women, and 12 to 15 mm in children. Male vocal folds are thicker and more massive than female ones. The pitch of the voice depends on the size and shape of the vocal folds.

The human larynx is a mobile organ that actively moves up and down during voice formation and swallowing. During swallowing, the larynx first rises up and then falls down. If you want to pronounce a high sound, then move the larynx up, if it is low, lower it down. You can move the larynx to the sides.

Among the muscles of the larynx there are those that expand the glottis and narrow it. Between the lower horns of the thyroid and cricoid cartilage, a paired combined joint is formed, with a transverse axis of rotation. The thyroid cartilage in this joint moves back and forth, as a result of which the fibers of the vocal fold either stretch (when the thyroid cartilage is tilted forward), or relax.

The vocal folds are also involved in protecting the lower respiratory tract from foreign bodies. This pair of folds is called the true vocal folds. Slightly above them in the larynx is another pair of folds that are not involved in the formation of the voice. However, they are used in so-called guttural singing.