Voice Disorders Test 2
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Changes in speech can be the first or only manifestation of _________ _______.
The CNS and PNS coordinate all _______ operations from the elevation of the larynx for swallowing.
What term is used for closure involving true vocal folds, ventricular folds, and aryepiglottic folds required for cough, to the delicate nuance sung by operatic lyric soprano?
Triple Valving Closure
Composed of the brain and spinal cord and is housed in the bony, protective structures of the cranium and vertebral column.
The motor cortex for _______ ______is in the _______ and ______ aspects of the motor cortex and primary motor strip.
- Laryngeal Control
- Inferior and Lateral
The third frontal convolution, or _______ _______ in the left hemisphere, has much to do with __________ a motor speech act, including voice response.
Medial to the temporal lobe, plays an active role in motor planning for voice and speech.
Provide cortical imput for audition.
Area of the brain associated with Language Comprehension.
The _________ tract regulates the voluntary and reflex activity of muscles.
The _________ tract regulates muscle movement and posture.
Enzymes which facilitate the transmission of neural impulses between neurons.
Many of the diseases of the CNS cause _________ or ________ of neurotransmitters.
Inhibition or Overproduction
Functions as the great regulator of the extrapyramidal tract, coordinating sensory information with coordinated motor response.
Which dysarthria is associated with lesions to the cerebellum from trauma or disease that causes speech symptoms of incoordination.
Cerebellar lesions produce what type of voice-speech symptoms?
- Prosodic slowdown (scanning speech)
- Resonance changes
- Inarticulate speech
- (Sounds like person is INTOXICATED)
What type of lesion produces symptoms of spasticity?
Upper Motor lesion
In a stroke victim, the patient may experience _________ which is one-sided spastic paralysis of the extremities.
A lower motor lesion such as the cutting of the __________ ___________ nerve, causes _________ vocal fold flaccid paralysis.
- Recurrent Laryngeal nerve
Upper motor neuron function begins at the _________ _______ and ends at the ________ _______.
- Cerebral Cortex
- Nucleus Ambiguous
Lower motor neuron function begins at the ________ _______ and travels down the spinal cord, ending at the lowest _______ _______ _________.
- Nucleus Ambiguous
- Lowest Spinal Nucleus
IX Glossopharyngeal functions include taste in the _________ third of the tongue and sensation to the fauces, tonsils, pharyns, and soft palate. Its innervations is to the _________.
- Posterior third of the tongue
X Vagus nerve has two important branches that innervate the larynx, the ________________ and the _____________.
- Superior Laryngeal Nerve (SLN)
- Recurrent Laryngeal Nerve (RLN)
Innervations of the velum
Base of the tongue
Autonomic ganglia of the thorax
are all __________ ________ affecting voice.
___________ is a motor nerve that has innervations of the neck accessory muscles as its primary function; lesions to this nerve can cause obvious problems of __________ and in the contribution of neck accessory muscles to respiration.
- XI Spinal Accessory
___________ is a Cranial nerve that has much to do with positioning of the larynx, that is, depression or elevation of the total laryngeal body, and is essential for all ________ movements of the tongue. Its primary impact on voice is _________ and _________.
- XII Hypoglossal
- Intrinsic movements
- Resonance and Quality
This nerve branches off the vagus at about the level of the carotid sinuses in the neck and angles medially toward the superior larynx.
Superior Laryngeal Nerve (SLN)
The Superior Laryngeal Nerve (SLN) divides into the two branches of _________ and _________.
- Internal branch
- External branch
The ___________ branch of the SLN provides sensory innervations to the mucous membrane at the base of the tongue and to the mucous membrane of the supraglottal larynx.
The __________ branch of the SLN provides motor innervations to part of the lower pharyngeal constrictor and to the cricothyroid muscles.
These muscles are paired; lesions to these muscles are rare and seldom due to trauma but more often are related to some form of viral neurophathy.
Cricothyroid (CT) muscles
What is the primary symptom of disease or trauma to CT muscles?
Inability to Elevate Vocal Pitch
In the case of __________ CT paralysis, there may be also be extreme hoarseness and occasional diplophonia (double voic) because of the disparate tension of the two vocal folds.
This nerve branches off the vagus below the larynx at the level of the trachea. Of some relevance to its frequent accidental cutting during surgery is its precarious location in the neck, ascending to the larynx in a groove between the trachea and the esophagus.
Recurrent Laryngeal Nerve (RLN)
The RLN is vital to the __________/__________ function of the larynx as it innervates the five intrinsic mucles of the larynx.
This muscle is the main mass of the vocal fold.
Thyroarytenoid muscle (TA)
___________ paralysis of this muscle resulting from cutting or trauma to the RLN will in time lead to vocal fold atrophy resulting in weakness in vocal fold approximation, midfold bowing, and dysphonia; subtle changes of pitch variation will also be compromised.
Paired; lone ABDUCTOR muscle of the vocal folds.
Posterior Cricoarytenoid muscle (PCA)
What's the primary symptom of PCA paralysis?
Inability to open the glottis on involved side...creating unilateral abductor paralysis (one vocal fold paralyzed)
Paired; Primary ADDUCTOR muscle of the vocal folds (antagonist to PCA).
Lateral Cricoarytenoid muscle (LCA)
What's the primary symptom of LCA paralysis?
Vocal Fold paralysis in the fixed, abducted paramedian position
These muscles contribute to vocal fold ADDUCTION. A RLN lesion may produce weakness or paralysis not only in these muscles function but in other adductory muscles as well.
These muscles as do the transverse arytenoids contribute to vocal fold ADDUCTION. If unilaterally paralyzed from lack of RLN innervations, this further contributes to unilateral adductor paralysis.
Motor speech disorder whose main symptom is dysphonia.
__________ ________ is the most common cause of SLN involvement, unilateral or bilateral, causing paralysis of left or right (or both) ___________ muscles.
- Viral Infection
What are the primary voice symptoms of Cricothyroid Muscle Paralysis?
- Inability to elevate or lower pitch
- Breathiness (due to bowing).
Virally caused cricothyroid paralysis is usually temporary, with patient responding well to what treatments?
- Antiviral Agents
For those with longer lasting cricothyroid muscle paralysis, promising results have been obtained with __________ _________ of the cricothyroid muscle.
This paralysis is usually the result of lesions in the vagus nerve and include tumors at the base of the skull, carcinoma, and trauma.
Bilateral Vocal Fold Paralysis
In the case of children, bilateral vocal fold paralysis is a common cause of _______ _______. Most pediatric cases are associated with intracranial pathology such as _________ or _________.
- Neonatal Stridor
- Hydrocephalus or Malformation
Bilateral vocal fold paralysis may be of the abductory or adductory type. Both are _______ ________. Voice is of secondary concern to ________ _______ and _________.
- Life threatening
- Respiratory control and Feeding
In Bilateral ________ paralysis, neither vocal fold is capable of moving to the midline, thus making phonation impossible and placing the individual at risk for aspiration.
In Bilateral _________ paralysis, the vocal folds remain at the midline, causing serious respiratory problems for which most patients will need a tracheostomy.
Disease or trauma to the _______ _______ ________ on one side is the most common form of laryngeal paralysis and is called what?
- Recurrent Laryngeal Nerve (RLN)
- Unilateral Vocal Fold Paralysis (UVFP)
________ RLN appears to be more prone to traumatic or surgical injury than the _____ RLN. _______ ______ is the most common etiology, followed by viral and unknown (idiopathic) causes.
When the RLN is compromised on one side, the laryngeal adductor muscles, particularly the _______ _______ are not able to perform their adductory role. This keeps the paralyzed fold fixed in the _______ position (1/2 open, 1/2 closed) for bothe inspiration and expiration. The paralyzed fold remains abducted as the normal fold moves to the midline.
- Lateral Cricoarytenoid
- Paramedian position
Perceptual characteristics of this type of paralysis include breathy, hoarse vocal quality, reduced phonation time, decreased loudness, monoloudness, diplophonia, and pitch breaks.
Unilateral Vocal Fold Paralysis (UVFP)
Excessive _________ ________ (hyperfunction) may contribute to the perception of hoarseness in Unilateral Vocal Fold Paralysis (UVFP).
Because many traumatic vocal fold paralysis have spontaneous recovery within the first ____ to ____ months postonset, permanent corrective procedures should be delayed until _______ _________ has been tried.
- 9 to 12 months
- Voice therapy
In many cases, what 2 treatments result in very good voice quality and surgery is unncecessary in Unilateral Vocal Fold Paralysis (UVFP)?
- Strengthening the vocal muscles
- Improving speaking technique
Rather than Teflon injections, greater use today are vocal fold injections using various ____________ and __________.
- Soft Tissue Fillers
- Medialization Thyroplasty
_____________ is a surgical approach to medialization of the paralyzed fold, using a free-moving wedge to move the paralyzed fold to midline...can produce excellent results.
Another procedure other than thyroplasty for unilateral paralysis involves reinnervating the paralyzed muscles by ______ _______.
Some patients, after injection or surgery, continue to display the hyperfunctional vocal behaviors they were using before treatment. _____ _______ ______ usually can reduce such problems.
Direct Symptom Modification
Direct symptom modification usually can reduce such problems as:
- Squeezing the words out
- Using Pushing behaviors
- Using excessive Glottal Attack
Following injection or surgical forms of medialization, the SLP may help the patient by what efforts?
- Reestablish normal voice
- Breath support
- Phonation free of effort
- Voice focus
- Adequate loudness
Fairly common dysarthria with an incidence of 1 in 10,000; patients experience problems of severe voice fatigue with associated problems in adequate breath support.
Myasthenia Gravis is an _________ disease resulting in extreme muscle fatigue. Muscles innervated by the cranial nerves in the ________ and ______ are particularly vulnerable to the disease.
______ ________ occurs twice as often in women over men with females reporting onset in their ________ and men reporting onsets in their _______.
- Myasthenia Gravis
- 30's--onset in women
- 60's--onset in men
This type of dysarthria patient experience vocal change to a breathy, weak, barely audible voice. With a few minutes of complete voice rest, the voice will be restored, but after a few minutes of usage, the weak voice will return. In severe cases, the patient will report difficulty swallowing with occasional ________ ________.
- Myasthenia Gravis
- Nasal Regurgitation
Treatment of Myasthenia Gravis (MG) is primarily _________. Because receptors are blocked, drugs that increase the presence of __________ (neurotransmitter) in the neuromuscular junction are useful.
What's often the primary role of the SLP in regard to Myasthenia Gravis?
Discovering the disease
What are some of the complaints patients present to an SLP that have Myasthenia Gravis and what specialist should the patient be referred to?
- Deteriorating voice after usage
- Drooping eyelid (ptosis)
- New problems in swallowingNeurologist
At the evaluation, SLP should give the Myasthenia Gravis patient ________ ______ ______ tasks.
Sustained Oral Reading tasks (detemination should be made of how long oral reading must continue before vocal-speech deterioration is heard.
SLP's role in Myasthenia Gravis is discovery and comparison of _________ ________ ________ over time, not providing voice therapy. W/ acetylcholine levels achieved through medication, speech and voice competence will usually return to what they had before the onset of symptoms.
Motor Response Data
Disorder of unknown cause, but is frequently preceeded by viral infection. It involves the focal demyelinization of spianl and cranial nerves.
Guillain-Barre (GB) often is expressed in _____ and _______. Disease process usually begins symmetrically in the ________ __________ and advances ______, but some researchers have sugeested that facial, oral-pharyngeal, and ocular muscles occasionally are affected first.
- Dysphonia and Dyshagia
- Lower extremities
What are parts of Guillain-Barre medical interventions?
- Intravenous Immunoglobulin
What percent of individuals recover from GB while the remainder are left with _______ dysarthria and altered function in psychosocial situations.
Dysarthria caused by a unilateral lesion to the CNS, involving both the pyramidal and extrapyrmidal tracts; often observed in patients who have experienced a cerebrovascular accident (CVA), a stroke, but it could be caused by other etiologies, such as a tumor or trauma.
Unilateral Upper Motor Neuron Dysarthria (UUMND)
What are the 3 different types of strokes?
Most common obstruction causing stroke which is a clot that forms within an artery obstructing the flow of blood.
Traveling blood clot that lodges within an artery preventing the flow of blood.
Stroke occurring from blood flowing out of a break in an arterial wall.
Blood supply to each of the 2 cerebral hemispheres is _________. A stroke in the ________ hemisphere will produce a right-sided weakness or paralysis. A _________ hemisphere stroke will involve the left side of the body.
Imprecise _________ due to unilateral facial and lingual weakness is a primary deviant characteristic of UUMND. There is also a high incidence of _________ and is associated with _________. These sensory-motor disturbances usually are mild and transient.
Dysarthria caused by 2 or more neurogenic events that result in bilateral cerebral lesions may produce severe voice symptoms from lesions to the pyramidal and extrapyramidal tracts bilaterally.
Common neuromuscular symptoms of spastic dysarthria are:
- Paresis (weakness, partial lack of movement)
- Bilateral weakness of various speech and voice muscle groups
Voice symptoms chracteristic of a spastic dysarthria, also known as _______ ______ may be strained and strangled, brief phonation time, low in pitch, and monopitch with variable loudness...sometimes hypernasality.
Symptomatic of patients with bilateral pyramidal and extrapyramidal tract damage is ________ ________ which may severely influence voice quality and resonance...patient will laugh or cry easily, inappropriately to the intensity of the stimulus.
Voice therapy for patients with spastic dysarthria is highly __________, depending on the speech subsystems that are compromised.
Dysarthria associated with a depletion of or functional reduction in the effect of the neurotransmitter dopamine on the activities of the basal ganglia.
Clinical features underlying basal ganglia pathology are:
- Slow movement (bradykinesia)
- Limited ROM
- Resting tremor (ameliorated through intentional movement)
What is known as the prototypical hypokinetic dysarthria and what percent of hypokinetic dyarthrias are of this type?
Parkinson's patient exhibits a hypokinetic dysarthria characterized by what symptoms?
- Reduced loudness
- Breathy voice
- Monotony of pitch
- Intermittent rapid rushes of speech
- Soft production of consonants
Most effective voice therapy approach for Parkinson's is a ________ one, finding that to exaggerate one component helps improve function in all other components.
Speaking with intent can improve unintelligible speech in a Parkinson's patient. Following the ________ __ _____ used in physical therapy for gait training works to improve speech.
Model of Intention
What are techniques that SLPs use when having patients speak with intent?
- Use an accent
- Different pitch
- Speak slower
- Speak louder
Recent in-clinic trials have found that instructing patients to deliberately pronounce the ______ sound of each word has yielded increases in vocal loudness and intelligiblity.
The main goal of the _____________ program is to increase vocal fold adduction and respiratory effort, which, in turn, is intended to increase loudness, vocal quality, and intelligibility.
Lee Silverman Voice Treatment Program
Therapy that has ahd mixed results with Parkinson's patients; it's an instrumental procedure that feeds an individual's speech back to the patient via earphones at a delayed rate. The effect is to jslow speech rate, increase vocal loudness, and increase articulatory accuracy.
Delayed Auditory Feedback Therapy (DAF)
Dx of Parkinson's and it's medical management belong to the _________.
Over a period of continued dopamine drug therapy, relief of symptoms becomes shorter requiring what?
- New medication protocols
- Neurosurgical approaches to reduce tremor
Dysarthria associated with damage to the basal ganglia or an imbalance of neurotransmitters (acetylcholine and dopamine). Hyperkinetic--involuntary & uncontrolled movements, may manifest in any or all subsystems of speech.
Rare hyperkinetic dysarthria; exhibits strangled, harsh voice w/observable effort in pushing air out during voicing...sounds like someone is choking them because of the hyperadduction of the true vocal folds...resembles stuttering
Most common type of spasmodic dysphonia related to tight laryngeal adduction.
Adductor Spasmodic Dysphonia (ADSD)
Dysphonia where patients exhibit normal or dysphonic voices that suddenly are interrupted by temporary involuntary abduction of the vocal folds resulting in fleeting aphonia (glottic chink); triggered by unvoiced consonant sounds. Can be treated as a phonation break.
Abductor Spasmodic Dysphonia (ABSD)
Spasmodic dysphonia is a form of focal _______, a neurological dysfunction of motor movements (larynx)
Site in the brain where lesion might occur in Spasmodic dysponia is not known; only the ________ (vocal fold) has abnormal muscle activation during voicing. No environmental/hereditary patterns in etiology.
The majority of Spasmodic Dysphonia patients are of what gender?
The ________________ offers the SLP a standardized way of asking for speech-voice responses and a seven-point rating scale for evaluating SD voice parameters (severity, quality, initiation, arrests, loudness, tremor, effort, rate, intelligibility, grimaces).
Unified Spasmodic Dysphonia Rating Scale
Surgical resection of RLN
Surgical modification of vocal folds are all tx options for what dysphonia?
________ ________ as the sole tx for SD is seldom successful. _______ _______ is one of the symptoms of this disorder.
- Voice therapy
- Poor Prognosis
What's the best therapeutic management for spasmodic dysphonia?
- Voice therapy coupled with:
- Surgery or
- Botox injections
What was the first widely used surgical procedure for spasmodic dysphonia?
Recurrent Laryngeal Nerve (RLN) sectioning
Postoperatively, SD patients may persist in _________ __________ ________ such as pushing/working hard, grimacing, marked reduction in normal prosody; most of these are unlearned with voice therapy: elevation of pitch, ear training, head positioning, digit manipulation.
Maladaptive Hyperfunctional Postures
What is the primary approach today for treating spasmodic disorder?
- Botox injections in one or both vocal folds (aspiration and breathiness are temporary)
- Maintain good functional voice 4-6 months
Most common of movement disorders hyperkinetic dysarthria of tremor; considered a ________ ______ ______ condition with variable penetrance.
- Essential Tremor
- Benign Autosomal Dominant condition
Which gender does essential tremor affect more?
Female (Katherine Hepburn)
Tremor may appear present in the tongue, velar, pharyngeal, and laryngeal structures, producing a vocal tremor in the ___________ range.
4-7 per second
_________ tremor is a common form of essential tremor (approx. 50% of cases) often beginning in early adulthood.
Essential tremor is aggravated by _______ & ___________ and can be reduced in some patients by the administration of mild sedatives or alcohol.
Activity and emotion
Essential tremor is an __________ tremor that appears to exist independently of other neurogenic conditions. The dx is best made by asking pt to sustain production of ________ in isolation.
Voice clinicians offer 3 therapy approaches that seem to minimize voice symptoms what are they?
- Reducing voice intensity
- Elevating pitch a 1/2 note
- Shortening vowel durationAlso producing an "Easy /h/" at the beginnings of vowel initial words such as /h/apples to reduce amplitude of tremor
Very serious inherited progressive autosomal dominant degenerative neurological terminal disease; onset is middle age (40-50 years old). Each child of an affected parent has a 50% chance of inhering the disease.
Huntington's Disease (HD)--Woodie Guthrie
Huntington's Disease (HD) is an __________ disorder of the basal ganglia, characterized by an __________ of dopamine resulting in occasional jerks or spasms in either the extremities or more centrally in speech and voice progressing into chorea, athetosis and mental deterioration.
What are typical voice symptoms associated with Huntington's Disease (HD)?
- Jerky, Irregular bursts of loud voice
- Obvious interruptions of prosody
- Strained/strangled voice quality
- Excessive loudness variations
- Equal stress on ordinarily unstressed words
- Sudden forced changes in breath control
What techniques are used with HD patients?
- Work on easy, forward prosody (150 syllables per minute)
- Delayed Auditory Feedback
- Metronomic pacer (to control rate)
- Yawn-sigh (opens vocal tract)
- Speaking with greater intent
As HD progresses, with death occurring _________ years after onset, the patient usually begins experiencing some _________ decline...then attempts of speech and voice therapy are no longer successful.
Extreme ________ interruptions of airflow and flailing _______ movements make speech intelligibility impossible in Huntington's disease patients.
The hyperkinetic movements that interrupt respiration, voice, and articulation in HD are the same that underlie the severe_________ that patients experience in the moderate to severe stages of the disease process.
Dysarthria that is a CNS disturbance caused by damage to the cerebellum that makes patient sound inebriated; from degenerative disease, vascular disorders, tumors, and trauma.
What are the symptoms associated with Ataxic Dysarthria?
- Hoarse phonation
- Mildly tremorous overlay & respiratory function
- Dyscoordinated inhalatory/exhalatory exchanges
What are tx techniques used with Ataxic Dysarthria?
- Breath support experimentation
- Companion technique--final "boom" at the end of each breath group
- Pacing to regulate amplitude & pitch--tactile & auditory
Condition that's a mixture of dysarthrias characterized by 2 or more types and caused by multiple lesion sites w/in the nervous system.
Progressive degenerative disease of unknown etiology often called motor neuron disease usually leads to complete paralysis needing dysphagia tx in later stage; retains good cognition.
- Amyotrophic Lateral Sclerosis (ALS)
- Lou Gehrig's disease
Early symptoms of ALS
- Articulation difficulty in rapid speech
- Fasciculations (wavelike muscle tremors) on surface of tongue
As ALS progresses, pt may experience _________ atrophy of extremities rather than distal.
Of life-thretening concern in ALS is the growing inability to ___________. More clinical focus will be given to swallowing/coughing than to speech/voice.
Clear the throat
In early stages of ALS, SLPs address respiratory, phonatory, and resonance support for speech which may involve building a ______ ______ for pts who present with weak or spastic _________ function.
What are some tx techniques used with ALS patients?
- Renew breath more often
- Develop High-Front voice focus
- Increase rate (metronome pacing)
- Diet modification
- Swallowing techniques
Since ALS patients retain cognitive ablities but motor function is affected, eventually the patient may require some kind of __________ __________ _____.
Augmentative Communication aid
Most common demyelinating disease causing breaks in tranmitting axons; is progressive.
Multiple Sclerosis (MS)
What are the 3 most popular theories of causation for MS?
- Autoimmune basis
- Genetic predisposition
Depending on the site of involvement, the symptoms will vary...what are some of these physical symptoms for MS?
- Sensory deficits
- Motor deficits
- Both--(more commonly)
What are voice symptoms associated with MS?
- Impaired loudness control
- Harsh quality
- Sameness of prosody & pitch control
- Decreased breath control
What are some tx techniques used in MS patients?
- Changing rate will help loudness & harshness
- Reducing the # of words on 1 expiratory breath
- Good postural habits--Neutral postural set before speech initiation
In the advanced stages of MS, natural speech/voice may not be possible. Alternative communication has obstacles due to ataxia, spasticity, and tremor; the patient may have severe _________ problems as well.
Disorder caused by external forces acting on the head and most are caused by car accidents, falls, assaults, and explosion injuries causing focal or diffuse lesions, axonal shearing, & hypoxia secondary to vascular or tissue damage.
Traumatic Brain Injury (TBI)
Dysarthria associated with TBI may be temporary or chronic, mild or severe, and accompanied or not by other language and cognitive disorders. Most dysarthrias are of the _________ type.
Many individuals with TBI have lower _______ ________ than nondisabled speakers. Some have problems coordinating actions of the __________ and ________ during speech. This results in replenishing breaths at __________ ______ ______ .
- Vital Capacities
- Ribcage and Abdomen
- Inappropriate Phrase Junctures
Large number of voice disorders have no organic or neurogenic causative origin and appear to be wholly ___________.
Some continued functional behaviors may eventually cause ___________ tissue changes, such as nodules or polyps.
What are the 2 functional voice disorder categories/causes?
- Excessive Muscle Tension
High register voice produced primarily by adolescent/adult male who's completed physical changes to postpubertal male (can occur in females).
How are falsetto clients treated?
- Cough & Extend phonation
- Record and use auditory feedback model
- Brief word list
- Light digital pressure on anterior thyroid cartilage
- Using glottal fry
- 3-4 wk follow up
Dysphonia where pt speaks in a whisper with the same rhythm and prosody of normal speech but the larynx often appears to elevate excessively near the hyoid bone & is difficult to move manually.
Onset of functional aphonia can occur in what ways?
- Gradually /Sporadically
- Emotional situations
- Laryngeal pathology/severy systemic disease
- Edema from infection and retain aphonia after infection is gone
- Communicate well by gesture, whisper, or high-pitched, shrill-sounding weak voice
Embarrassed and frustrated by lack of voice, aphonic patients generally _______ and completely recover their normal voice usually in the ________ session of therapy and have excellent prognoses.
How is functional aphonia treated?
- Use nonspeech phonations (coughing-throat clearing)
- Redirecting phonation while singing or humming-kazoo
- Masking noise while reading aloud
- Immediate Auditory Feedback from being recorded
- Increase Loudness
- Produce voice interactively
Physiologic imbalance produced in part by psychological needs of the patient having no physical or organic cause.
Dysphonia that should be referred for an extensive medical workup and psychiatric evaluation/treatment.
Somatization Dysphonia (Briquet's Dysphonia)
Prevalence of somatization dysphonia is much greater in women than men by a ratio estimated as high as _____ to ___.
10 to 1
Somatization dysphonia is a ________ _______ disorder, and management appears possible only with successful identification and reduction of emotional and psychological factors.
True Conversion disorder
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