Download Voice Disorders in Children and

4/7/16
1
Voice Disorders in Children and Adults:
A Case-Based Approach to Discussing the Role of the SpeechLanguage Pathologist from Prevention to Treatment
2
Who Am I?
3
4
What is a voice disorder?
5
Many ways to define:
´From the clinician’s perspective
´Voice that draws attention to itself due to unusual pitch, quality,
loudness typically resulting from anatomic, physiologic, or
psychogenic causes
´
´From the patient’s perspective:
´Voice complaints about vocal pain, vocal fatigue, or that one’s
voice is not meeting job or social demands**
´
6
Voice disorders are fairly common based on epidemiological
studies
´Children
´6-9% to as high as 40% in school age children with few receiving
treatment
´(Dejonckere, 1999; Mortenson, Schaberg, & Woo, 2010;
Bhattacharyya, 2014)
´
´Adults (Roy, Merrill, Gray, & Smith, 2006)
´~7% or 20 million people in the US at any given time
´~30% life time prevalence in US adults
´Self-reported by telephone
´Elderly (Golub, Chen, Otto, Hapner, & Johns, 2006)
´20% prevalence with half of those indicating compromised quality
of life
´Self-reported by survey measure within independent living
facility
´
7
Voice Disorders are Particularly Problematic in Professional
Voice Disorders….
´Teachers
´Clergy
´Singers
´Actors
´Litigators
1
´20% prevalence with half of those indicating compromised quality
of life
´Self-reported by survey measure within independent living
facility
´
7
Voice Disorders are Particularly Problematic in Professional
Voice Disorders….
´Teachers
´Clergy
´Singers
´Actors
´Litigators
´Call Center Workers
´
8
Ripped from the Headlines…
9
Laryngeal Anatomy and Physiology Review
10
4/7/16
The Larynx does not exist in a Vacuum…
2 ´Resonation
´Phonation
´Respiration
11
Laryngeal framework
12
Intrinsic Laryngeal Muscles & Vocal Fold Structure
13
Extrinsic Laryngeal Muscles
14
When we think about the larynx does….
´Layers of protection
´Airway valving
´Assistance in swallowing
´Thoracic fixation
´Phonation
15
The Vocal Folds In Action
16
The Vocal Folds in Action
17
´An undulation or oscillation of the cover
´Tissue deformation and elastic recoil in:
´Horizontal (medial-lateral)
´Longitudinal (anterior-posterior)
´Vertical phase (inferior –superior)
18
The viscoelastic properties of the vocal folds allow vibration to
happen..
19
20
Vocal lesions also compromise mucosal wave
´Vibration 20-3000 times per second
´Excessive phonatory stress=inflammation
2
´An undulation or oscillation of the cover
´Tissue deformation and elastic recoil in:
´Horizontal (medial-lateral)
´Longitudinal (anterior-posterior)
´Vertical phase (inferior –superior)
18
4/7/16
The viscoelastic properties of the vocal folds allow vibration to
happen..
19
20
Vocal lesions also compromise mucosal wave
´Vibration 20-3000 times per second
´Excessive phonatory stress=inflammation
(Li, Heris, and Mongeau, 2013)
21
Laryngeal Innervation
22
Unilateral and Bilateral Vocal Fold Paralysis
23
A few things to remember….
24
At the vocal folds aerodynamic energy becomes acoustic energy
25
Aerodynamic and resonatodry properties are created by both
upstream and downstream influences
26
Infant Larynx:
Not just a tiny version of the Adult’s
´Larynx is higher in the neck
´Vocal folds are only a few millimeters in length at birth
´Tongue is large
´Velum contacts the epiglottis
´Laryngeal framework is floppy and soft
´Undifferentiated layer structure
´Biomechanical stress leads to cell differentiation (Li, Heris, and
Mongeau, 2013)
´No vocal ligament until age 4
´No differentiation in divisions of lamina propria until age 16
´Arytenoids cartilages (posterior vocal folds) are large
27
28
29
The soft tissues of the pediatric larynx can result in voice
disorders that do not occur in the adult population
30
Adolescent Larynx: Big Changes Happening Quickly
´Males (vs Females)
´A larger thyroid lamina
´A more acute thyroid angle, giving prominence to the thyroid
notch or “Adam’s apple”
´Thicker, longer vocal folds
´Vocal fold length differences
3
28
29
The soft tissues of the pediatric larynx can result in voice
disorders that do not occur in the adult population
30
Adolescent Larynx: Big Changes Happening Quickly
´Males (vs Females)
´A larger thyroid lamina
´A more acute thyroid angle, giving prominence to the thyroid
notch or “Adam’s apple”
´Thicker, longer vocal folds
´Vocal fold length differences
´17-21 mm in adult males and 11-15 mm in adult females
31
Puberphonia or Mutational Falsetto
´Some boys (and girls) do not easily make transition to new “adult”
voice
32
Adolescent Singers
´New anatomy can be difficult to manipulate across the pitch range…
33
4/7/16
Voice Disorders Occur in Post-Adolescent Females more than
Post-Adolescent Males
1 ´Impact stress
´Closure pattern
´Contents of lamina propria
´Hyaluronic acid
34
Laryngeal Aging (Vocal Folds)
´Stiffening of lamina propria
´Vocal fold bowing
´Muscle atrophy of thyroarytenoid muscle
´Decrease in muscle bulk and strength
´Decreased vocal fold elasticity, increased vocal fold viscosity
´Dehydration of epithelium
´Edema
´
35
Presbylaryngis
36
37
Assessment: Considerations by Setting
38
Voice Assessment can be Tricky….
39
What is the role of the SLP in assessment & screening of voice
disorders?
´Model of voice assessment and treatment is multidisciplinary
´Ear nose and throat physician (otolaryngologist/laryngologist)
´Medical diagnoses & assessment
´Speech-language pathologist
´Functional diagnoses
´Functional Voice Assessment
40
Other Members of the Team
4
38
Voice Assessment can be Tricky….
39
What is the role of the SLP in assessment & screening of voice
disorders?
´Model of voice assessment and treatment is multidisciplinary
´Ear nose and throat physician (otolaryngologist/laryngologist)
´Medical diagnoses & assessment
´Speech-language pathologist
´Functional diagnoses
´Functional Voice Assessment
40
Other Members of the Team
´Singing Voice Specialist
´Neurologist
´Psychologist
´Nurse
´Physician assistant
41
Multidisciplinary Voice Assessment in Specialized Settings
´Private or university hospital
´Inpatient
´Outpatient
´Specialty Clinic/National voice center
´
´Stand-alone private outpatient voice clinic
42
What are you, the SLP, trying to find out during assessment?
´Was there a referral?
´Does the patient understand their disorder/problem?
´What caused the problem?
´How bad is it?
´When did it start and how has it evolved over time?
´What is the likely response to treatment?
´
43
How do you find these things out?
´Listen
´
´Look
´
44
LISTEN to their case history…..
´Determine:
´Chronological history of problem
´Etiological factors
´Patient motivation
´In addition to history of problem discuss:
´Medical History
´Social History
´
´
4/7/16
5
44
LISTEN to their case history…..
´Determine:
´Chronological history of problem
´Etiological factors
´Patient motivation
4/7/16
´In addition to history of problem discuss:
´Medical History
´Social History
´
´
45
LISTEN through the structured interview
´Clinician: So Mario what brings you in to the clinic today? You are
new to us I believe.
´Mario: Yup, that’s right. Well, I lost my voice completely about 6
days ago. It happened suddenly. One minute it was there and the
next minute it was gone.
´Clinician: Any particular way you were using your voice around that
time?
´Mario: Well, I was at a football game at the time and I know I was
straining my voice by yelling; but I always strain my voice at football
games. I’m usually hoarse for a few days afterwards, but it’s no big
deal. My voice always returns. But this time, it was weird…I got
really worked up during this one play and started yelling even louder
than usual. Right before I lost my voice, I felt a little pain and like,
this strange popping sensation. I don’t know how else to describe it
really. After that, my voice was gone.
´Clinician: So when did your voice return?
´Mario: Well, my voice was gone for three days. I was writing on a
white board to communicate.
´Clinician: How would you describe your voice today? Is it back to
normal in your opinion?
46
LISTEN through the patient-centered measures
´Why do these measures matter? What can they tell us?
´
´Two most common statistically validated tools in US are:
´Voice handicap index (VHI) (Full 30 , 10, singer, pediatric)
´Full VHI
´Functional-Impact of voice disorder on patient’s life
´Emotional-Affective response to voice disorder
´Physical-Laryngeal discomfort and voice output
characteristics
´Voice-Related Quality of Life (V-RQOL)
´Also a pediatric version
´
´
47
Voice Handicap Index (VHI)
6
´Two most common statistically validated tools in US are:
´Voice handicap index (VHI) (Full 30 , 10, singer, pediatric)
´Full VHI
´Functional-Impact of voice disorder on patient’s life
´Emotional-Affective response to voice disorder
´Physical-Laryngeal discomfort and voice output
characteristics
´Voice-Related Quality of Life (V-RQOL)
´Also a pediatric version
´
´
47
Voice Handicap Index (VHI)
Jacobson (1997)
48
Reflux Severity Index (RSI)
49
Voice-Related Quality of Life (VR-QOL)
50
Singing VHI
51
General Anxiety Disorder (GAD) 7 Item Scale
52
LISTEN to measure voice quality through auditory-perceptual
measure
´Rate present vocal components
´What components are present? Which ones are not?
53
LISTEN to and LOOK at Resonance
´In voice, the term resonance often takes on a special meaning
´Tone focus
´Place in the pharynx where primary sound transmission is
taking place
´May be the place where vibration is felt/sensed, but ONLY
identified via non-standardized auditory perceptual methods
´
´
´Location of amplified sound transmission in upper aerodigestive
tract
´Sound quality that is influenced by the shape of vocal tract
´Hypernasal, hyponasal, etc.
´Often can be identified by visual imaging as well as well as
auditory-perceptual method
´
´
54
LISTEN to and LOOK at Respiration
´Conversational breathing
´Clavicular, thoracic, diaphragmatic patterns
´Breath holding
´Coordination of voice and speech
´
´
55
LISTEN to pitch range and fundamental frequency
4/7/16
7
´Often can be identified by visual imaging as well as well as
auditory-perceptual method
´
4/7/16
´
54
LISTEN to and LOOK at Respiration
´Conversational breathing
´Clavicular, thoracic, diaphragmatic patterns
´Breath holding
´Coordination of voice and speech
´
´
55
LISTEN to pitch range and fundamental frequency
´Typically tested by singing up and down scale
´Midrange to highest and lowest pitches
´Note by note or on a glide
´May be place along scale were pitches drop out or the patient
must phonate especially loud or with greater effort
´If patient reverts to louder sound at higher notes, ask patient
to produce the same notes more softly
56
LISTEN to Loudness
´Assess ability to build up subglottic pressure
´Shouting/coughing
´Sometimes dysphonic voice will improve with increases in vocal
intensity
´Ability to override dysphonia with intensity, may indicate
quicker remediation
´What does the ability to increase vocal intensity indicate
about vocal function?
´Soft voice
´If voice cannot be produced softly may be a result of tissue
pliability issue
57
BUT WAIT…....
58
Assumptions
59
60
Examples: Standardized Auditory-Perceptual Measures of Voice
Quality
´Consensus-auditory perceptual evaluation of voice (CAPE-V)**
´Created by ASHA Voice SIG committee
´GRBAS scale
´Grade, Roughness, Breathy, Asthenic, Strained
´0=normal
´1=slight
´2=moderate
´3=extreme
61
CAPE-V Task 1: Sustained vowels
8
60
Examples: Standardized Auditory-Perceptual Measures of Voice
Quality
´Consensus-auditory perceptual evaluation of voice (CAPE-V)**
´Created by ASHA Voice SIG committee
´GRBAS scale
´Grade, Roughness, Breathy, Asthenic, Strained
´0=normal
´1=slight
´2=moderate
´3=extreme
61
CAPE-V Task 1: Sustained vowels
The clinician should say to the individual, “The first task is to say the
sound, /a/. Hold it as steady as you can, in your typical voice, until I
ask you to stop.” (The clinician may provide a model of this task, if
necessary) The individual performs this task three times for 3-5 sec
each.
“Next, say the sound, /i/. Hold it as steady as you can, in your typical
voice, until I ask you to stop.” The individual performs this task three
times for 3-5 sec each.
62
CAPE-V Task 2: Sentences
The clinician says, “Please read the following sentences one at a
time, as if you were speaking to somebody in a real conversation.”
(a)The blue spot is on the key again
(b)How hard did he hit him?
(c)We were away a year ago
(d)We eat eggs every Easter
(e)My mama makes lemon jam
(f)Peter will keep at the peak.
63
CAPE-V Task 3: Running speech
´The clinician should elicit at least 20 seconds of natural
conversational speech using standard interview questions such as,
“Tell me about your voice problem." or "Tell me how your voice is
functioning."
64
Severity
— Normal: no signs, symptoms, or functional limitations
— Mild: Limited signs, symptoms, or functional limitations
— Moderate: Signs, symptoms, functional limitations between mild and
severe
— Severe: Significant signs, symptoms, or functional limitations
4/7/16
Verdolini et al. Classification Manual for Voice Disorders, 2006.
65
66
Roughness: Muscle Tension Dysphonia
67
Breathiness: Bowed Vocal Folds
68
Hoarseness: Polyp
9
— Mild: Limited signs, symptoms, or functional limitations
— Moderate: Signs, symptoms, functional limitations between mild and
severe
— Severe: Significant signs, symptoms, or functional limitations
4/7/16
Verdolini et al. Classification Manual for Voice Disorders, 2006.
65
66
Roughness: Muscle Tension Dysphonia
67
Breathiness: Bowed Vocal Folds
68
Hoarseness: Polyp
69
Pitch: Reinke’s Edema
70
Visual analog scale (VAS)
71
Measurement CAPE-V
72
CAPE-V Reporting
Moderate to severe degree of overall dysphonia (78/100), severe
roughness (78/100), moderate to severe breathiness (65/100) and
strain (62/100) were noted. Modal pitch (35/100) was judged to be
moderately low for the person’s age/gender, while loudness (0/100)
was judged to be normal. All voice attributes were judged as
consistently present in this assessment.
73
Examples: Auditory-Perceptual Screener
´S to Z ration
´Sustain S x 3
´Sustain Z x 3
´Is the ratio of the longest S divided by the longest Z greater
than 1.4?
´
74
Examples: Auditory-Perceptual Screener
´Maximum Phonation Time (MPT)
´What is this?
´How do we elicit a representative MPT?
´
75
LOOK
76
LOOK through a Physical exam (Look)
´Full head/neck exam should be performed by ENT
´
´SLP evaluation may include oral mechanism exam
´View oral mechanism
´Observe upper body for tension
´Rock thyroid back and forth
´Laryngeal sensations
´Swallow function
´
77
LOOK Endoscopically under halogen and stroboscopic light
10
76
LOOK through a Physical exam (Look)
´Full head/neck exam should be performed by ENT
´
´SLP evaluation may include oral mechanism exam
´View oral mechanism
´Observe upper body for tension
´Rock thyroid back and forth
´Laryngeal sensations
´Swallow function
´
77
LOOK Endoscopically under halogen and stroboscopic light
78
What do we look for on exam?
• Glottal closure
• Supraglottic activity
• Vocal fold edge
• Vocal fold mobility
• Mucosal wave
• Periodicity
• Phase closure
• Overall laryngeal function
•
•
79
Endoscopic Exam Reporting
80
Other Instrumental Measures
81
Acoustic Measurement
82
What if you work outside the voice clinic?
´Public School System
´Generalized Outpatient Rehabilitation Clinic
´Skilled Nursing Facility
´Government Agency
´Home health
83
Just you…..
´May not have access to a multidisciplinary team, visual imaging,
and other instrumental measurement, but can still complete;
´History interview/patient-centered measures
´Auditory-perceptual evaluation
´Low-tech and freely available computer-based voice measures
´
´
84
Low Tech Measures
´Maximum phonation time
´S to Z ratio
´Consensus Auditory Perceptual Evaluation of Voice
´Where’s the air?
´Resonance, respiration, pitch, loudness
´Laryngeal palpation
4/7/16
11
´History interview/patient-centered measures
´Auditory-perceptual evaluation
´Low-tech and freely available computer-based voice measures
´
4/7/16
´
84
Low Tech Measures
´Maximum phonation time
´S to Z ratio
´Consensus Auditory Perceptual Evaluation of Voice
´Where’s the air?
´Resonance, respiration, pitch, loudness
´Laryngeal palpation
´
85
Computer Based Measures: Present & Future
´Freeware
´Praat
´http://www.fon.hum.uva.nl/praat/
´Wavesurfer
´https://sourceforge.net/projects/wavesurfer/
´
´There’s an app for that
´Voice Test
´https://itunes.apple.com/us/app/voice-test/id437811882?mt=8
´Pitch Analyzer
´https://itunes.apple.com/us/app/pitchanalyzer/id571243369?mt=8
´Cepstral peak prominence (upcoming)
´(van Leer, Pfister, & Zhou, 2016)
´
86
Referral
´Behavioral treatment without visualization and medical evaluation
and diagnosis by an otolaryngologist/laryngologist should NEVER be
initiated.
´If your clinical impression leads you to believe that a voice disorder
is present, establish relationship with an otolaryngologist with
specialized knowledge of the voice.
87
88
Common Voice Disorders
89
Pathology Classifications
´Classification Manual of Voice Disorders
´Structural pathologies*
´Inflammatory conditions*
´Trauma or injury
´Systemic conditions
´Aerodigestive conditions
´Congenital and Age-related*
´Psychiatric/psychological*
12
87
88
Common Voice Disorders
89
Pathology Classifications
´Classification Manual of Voice Disorders
´Structural pathologies*
´Inflammatory conditions*
´Trauma or injury
´Systemic conditions
´Aerodigestive conditions
´Congenital and Age-related*
´Psychiatric/psychological*
´Neurologic*
´Other*
´
90
Structural Pathologies
´Alterations in histological (tissue) structure of vocal fold
´Affect mass, size, stiffness, flexibility, and tension of vibrating
mechanism
´Affect closure
´
91
Structural Pathologies and Auditory-Perceptual Features
´Tremendous variation
´Dependent on:
´Habitual voice use
´Compensation!!!
´Productive
´Improved breath support, better use of vocal tract for
resonance, appropriate loudness/pitch changes
´Maladaptive
´Effortful phonation, inappropriate pitch/loudness, poor tone
focus
´Unlikely that distinctive features can discriminate
especially due to inconsistent terms
4/7/16
92
93
Vocal Nodules (Structural)
´Inflammatory degeneration of lamina propria
´Edema and fibrosis
´
´Bilateral, symmetric
´Large variations in size
´
´Arise at point of greatest amplitude (impact stress)
´Midmembranous
´
´Two types
´Acute
13
93
Vocal Nodules (Structural)
´Inflammatory degeneration of lamina propria
´Edema and fibrosis
´
´Bilateral, symmetric
´Large variations in size
´
´Arise at point of greatest amplitude (impact stress)
´Midmembranous
´
´Two types
´Acute
´Gelatinous/floppy (normal epithelial layer)
´Chronic
´Harder and more fixed (thickened epithelial layer)
´Cover of vocal folds stiffens
´
4/7/16
94
95
Scarring (Structural)
´Scar
´Permanent tissue changes in cellular structure of LP
´May be due to lesion, chronic tissue irritation, or surgery
´
´Increases stiffness and reduces mucosal wave during vibration
´Adynamic segment can limit closure of vocal folds
´
´Auditory perceptual correlates
´Roughness, strain, reduced flexibility in pitch, loudness,
enduracne
´
´Treatment: behavioral
´Not always very effective
´
96
97
Vocal fold Hemorrhage (Structural)
´Trauma to vocal folds’ blood vessels
´Excessive coughing, crying, screaming
´More frequent among premenstrual women taking aspirin
´Hemorrhage
´Abrupt rupture of small capillary on surface of vocal fold lamina
propriaAuditory-perceptual
´Severe dysphonia at time of bleed and typically after
98
99
Polyps (Structural)
´Fluid filled lesion in the superficial lamina propria
´Typically unilateral and arise above the tissue with active blood
14
´Trauma to vocal folds’ blood vessels
´Excessive coughing, crying, screaming
´More frequent among premenstrual women taking aspirin
´Hemorrhage
´Abrupt rupture of small capillary on surface of vocal fold lamina
propriaAuditory-perceptual
´Severe dysphonia at time of bleed and typically after
4/7/16
98
99
Polyps (Structural)
´Fluid filled lesion in the superficial lamina propria
´Typically unilateral and arise above the tissue with active blood
supply
´Sessile (blisterlike) or pedunculated (attached via stalk)
´
´Cause
´Thought to be trauma/misuse
´
´Effects
´Depend on if connected to vibratory edge and if obstruct glottis
´Increase mass/stiffness of vocal fold
´
100
101
Reinke’s Edema and Polypoid Degeneration (Structural)
´When enter superficial lamina propria fills with thick gelatinous fluid
´Look like enlarge fluid filled balloons
´Increased mass and stiffness of vocal fold cover
´Most extreme cases called polypoid degeneration
´Most common in smokers, but may be a result of vocal misuse or
hypothyroidism also
´Low pitch and husky dysphonic voice
102
103
Granuloma (Structural)
´Usually develop on medial surface of arytenoids
´Inflammatory reaction to tissue irritation in posterior larynx
´
´Painful, often involve complaints of sore throat, referred pain to ear,
and voice disturbances (sometimes)
´Causes
´Endotracheal tube pressure on arytenoid mucosa
´Acid reflux
´Persistent voice misuse
´Pressed, low-pitched
104
105
Laryngeal Cancer
15
´
´Painful, often involve complaints of sore throat, referred pain to ear,
and voice disturbances (sometimes)
4/7/16
´Causes
´Endotracheal tube pressure on arytenoid mucosa
´Acid reflux
´Persistent voice misuse
´Pressed, low-pitched
104
105
Laryngeal Cancer
´Often called squamous cell carcinoma
´Referring to cancer in epithelial layer
´Can affect muscle and deep layers of LP
´Mass/stiffness implications
´
´Symptoms
´Persistent hoarseness
´Mild to severe depending on tumor location
´Difficulty breathing
´Airway compromise/swallowing issues
´Laryngeal pain/referred pain in ear
´
´Causes
´Chronic irritation to larynx at true vocal folds or other sites
´
106
Congenital and Age-Related Conditions
107
108
Laryngeal Web (Congenital and Age-related)
´Webs
´Tissue bridge between two vocal folds at anterior commissure
´Congenital type
´When vocal folds fail to separate during 10th week of
embryonic development
´May even have complete web from anterior to posterior
glottis compromising airway
´Most commonly web is at anterior glottis resulting in some
stridor or dyspnea
´
109
Puberphonia/Mutational Falsetto (Congenital and Age-related)
´Male voices lower approximately 1 octave and female lower 2 -3
semitones (~half an octave) at puberty
´Puberphonia when this change does not take place despite
normal maturation
´Mutational falsetto
´Males speaking in falsetto or top of modal
´Childlike voice/Juvenile resonance disorder
16
glottis compromising airway
´Most commonly web is at anterior glottis resulting in some
stridor or dyspnea
´
109
4/7/16
Puberphonia/Mutational Falsetto (Congenital and Age-related)
´Male voices lower approximately 1 octave and female lower 2 -3
semitones (~half an octave) at puberty
´Puberphonia when this change does not take place despite
normal maturation
´Mutational falsetto
´Males speaking in falsetto or top of modal
´Childlike voice/Juvenile resonance disorder
´Females speaking in falsetto or top of modal
´Not recognized as much as in men (less aberrant)
´
´https://www.youtube.com/watch?v=bQnEdgZX9es
´https://www.youtube.com/watch?v=D_vAsZk-wRI
´
110
´Possible causes
´Difficulty using new “adult” mechanism
´Resistance to puberty
´Embarrassment over voice change
´Feminine self-identification
´Auditory-perceptual
´High pitch, low intensity, cul-de-sac nasality, breathiness
´Physiological components
´High larynx and tongue
´Hyperfunction of CT
111
112
Presbyphonia/Presbylaryngis (Congenital and Age Related)
´Normal voice changes related to aging
´Typically in ages 65+
´Professionally trained, vocally active may be more resistant
´Features
´Reduced respiratory efficiency
´Loss of elasticity in vocal fold cover
´Decrease in muscle bulk of TA
´Ossification of hyaline cartilages
´Bowed vocal folds
´Due to decrease elasticity in cover and loss of muscle bulk in
body
´
113
´Auditory-perceptual
17
´Features
´Reduced respiratory efficiency
´Loss of elasticity in vocal fold cover
´Decrease in muscle bulk of TA
´Ossification of hyaline cartilages
´Bowed vocal folds
´Due to decrease elasticity in cover and loss of muscle bulk in
body
´
4/7/16
113
´Auditory-perceptual
´Thin, muffled voice
´Decreased intensity
´Increased breathiness
´Pitch instability
´Lack of vocal enduranc
114
Inflammatory Conditions
115
116
Acute Laryngitis (Inflammatory)
´Inflammation of vocal folds (typically epithelium)
´Usually associated with URI or behavioral trauma
´
´Vocal fold appearance
´Edematous and erythematous
´Treatment
´Hydration, antibiotics, rest
*When occurs for weeks/months other conditions should be ruled
out*
´
´
117
Laryngopharyngeal Reflux (Inflammatory)
´When gastric fluid from upper esophageal sphincter leak into
pharynx/larynx resulting in in irritation and inflammation to epithelium
´Symptoms
´Dysphonia
´Excessive mucus
´Coughing
´Throat pain
´Globus
´Swallowing problems
118
Chemical Sensitivity (Inflammatory)
´When consistent and repeated sensitivity to chemical exposures
that trigger abnormal airway/voice changes
18
pharynx/larynx resulting in in irritation and inflammation to epithelium
´Symptoms
´Dysphonia
´Excessive mucus
´Coughing
´Throat pain
´Globus
´Swallowing problems
118
Chemical Sensitivity (Inflammatory)
´When consistent and repeated sensitivity to chemical exposures
that trigger abnormal airway/voice changes
´Dysphonia
´Weak voice
´Vocal fatigue
´
´Chemical causes
´Smoke, pollution, perfume, aerosals, etc.
´
´Irritable Larynx Syndrome
´Cluster of symptoms often reported in patients with chemical
sensitivity
´
119
Functional/Psychological Conditions
120
Functional Dysphonia/Aphonia (Functional/Psychological)
´Functional Dysphonia/Aphonia (FA/FD)
´No visible structural/neurological laryngeal pathology exists in
conjunction with partial or complete voice loss
´Terms
´Hysterical, psychogenic, hyperkinetic, conversion,
psychosomatic, muscle misuse, muscle tension dysphonia
´Reflection of clinician bias/preference
4/7/16
*Typically occurs in women, but can also occur in men/children*
´
´
121
122
Functional Dysphonia/Aphonia (Funtional/Psychological)
´Before labeling this condition as psychogenic
´Symptom psychogenecity
´Time of onset, course, and severity linked to psychological
event/conflict
´Symptom incongruity
´Vocal symptoms not compatible with potential function
´Whispered voice but normal vegetative/non-speech phonatory
tasks (throat clear, laugh, cough, sigh, grunt, hum)
19
121
122
Functional Dysphonia/Aphonia (Funtional/Psychological)
4/7/16
´Before labeling this condition as psychogenic
´Symptom psychogenecity
´Time of onset, course, and severity linked to psychological
event/conflict
´Symptom incongruity
´Vocal symptoms not compatible with potential function
´Whispered voice but normal vegetative/non-speech phonatory
tasks (throat clear, laugh, cough, sigh, grunt, hum)
´Symptom reversibility
´Rapid reversal of condition with voice therapy and/or
psychological counseling
´Sometimes 1-2 sessions
´Maintenance of voice after treatment requires little patient
effort
123
124
125
126
Functional Voice Disorders
´Muscle Tension Dysphonia (Primary and Secondary)
´Primary MTD and FD are the same thing
´Secondary MTD
´Maladaptive compensation for laryngeal pathology
´Ventricular Phonation (Plica ventricularis)
´Ventricular fold vibration when drawn into midline
´Can be compensation for scarring, paralysis, or other VF
deficits
´Therapy if true vocal fold vibration possible
´Auditory-perceptual
´Moderate-severe roughness, strain, decreased intensity, low
pitch
´Other symptoms
´Vocal fatigue
´
´
https://www.youtube.com/watch?v=8y3EuL6kIds
´
´
127
´Paradoxical vocal fold motion (PVFM) or vocal cord dysfunction
(VCD)
´Vocal fold adduction during inspiration
20
´Other symptoms
´Vocal fatigue
´
´
https://www.youtube.com/watch?v=8y3EuL6kIds
´
4/7/16
´
127
´Paradoxical vocal fold motion (PVFM) or vocal cord dysfunction
(VCD)
´Vocal fold adduction during inspiration
´Symptoms/signs
´Inspiratory stridor, dyspnea
´Triggered by
´Stress, laryngopharyngeal reflux, exercise
´Common in
´Athlete, healthcare workers, high achievers, adolescents,
asthma sufferers
https://www.youtube.com/watch?v=gmNwpJf1zUQ
*Respiratory condition that can be effectively treated by SLP*
128
Neurologic Conditions
129
Vocal Fold Paralysis & Paresis (Neurologic)
´Damage to RLN or SLN of Vagus nerve
´Causes
´Surgical trauma,
´Anterior cervical fusion, Malignant tumors, thyroid surgery
´Idiopathic
´Often following viral infection
´Neurologic disease
´Accidental trauma
´http://www.entusa.com/larynx_videos_flash/Larynx_paralysis_2
0031120/superior-laryngeal-nerve_flv1.htm
´
´
130
Unilateral RLN Vocal Fold Paralysis (Neurologic)
´Recurrent Laryngeal Nerve Paralysis (unilateral)
´Auditory-perceptual symptoms
´Mild to severe breathiness, decreased intensity, diplophonia
´Visual exam
´Inadequate vocal fold closure
´Loss of vocal fold muscle tone
´Bowing, weakness, flaccidity
´Aperiodic, asymmetric, and incomplete vocal fold vibration
´Vertical asymmetry between vocal folds
´
21
130
Unilateral RLN Vocal Fold Paralysis (Neurologic)
´Recurrent Laryngeal Nerve Paralysis (unilateral)
´Auditory-perceptual symptoms
´Mild to severe breathiness, decreased intensity, diplophonia
´Visual exam
´Inadequate vocal fold closure
´Loss of vocal fold muscle tone
´Bowing, weakness, flaccidity
´Aperiodic, asymmetric, and incomplete vocal fold vibration
´Vertical asymmetry between vocal folds
´
4/7/16
131
132
133
Bilateral (RLN)Vocal Fold Paralysis (Neurologic)
´Serious if occurs in the medial position!!
´Airway threat
´Surgery to reestablish adequate airway and tracheostomy
´Arytenoidectomy, lateralization of arytenoid, cordotomy
´Paramedian or lateral position
´Airway protection and phonatory compromise
´Gastrostomy tube
´AAC
´May not be permanently necessary
134
Paresis (RLN; Neurologic)
´RLN paresis
´Partial injury to nerve
´RLN paresis presumed by appearance of reduced VF
movement/tone
´Sluggish adduction/abduction
´Mild breathiness, decreased pitch range, reduced intensity,
vocal fatigue
-Diagnosis verified by electromyogra
135
136
Spasmodic Dysphonia (Neurologic Movement Disorder)
´Focal, action induced dystonia only during phonation for speech
´Abductor Spasmodic Dysphonia
´Adductor Spasmodic Dysphonia
´Mixed Spasmodic Dysphonia
´
´Involuntary phonatory adductory/abductory spasms affecting about
15,000 people at any given time
´No evidence of spasms on vegetative vocal tasks
´
´Onset often in middle adulthood
´Often intermittent symptoms that gradually progress over period
of time and plateau
22
´Focal, action induced dystonia only during phonation for speech
´Abductor Spasmodic Dysphonia
´Adductor Spasmodic Dysphonia
´Mixed Spasmodic Dysphonia
´
´Involuntary phonatory adductory/abductory spasms affecting about
15,000 people at any given time
´No evidence of spasms on vegetative vocal tasks
´
´Onset often in middle adulthood
´Often intermittent symptoms that gradually progress over period
of time and plateau
´Symptoms may worsen with heavy stress
4/7/16
137
138
Essential Voice Tremor (Neurologic Movement Disorders)
´Essential voice tremor
´Often related to SD
´Rhythmic vocal tremors 4-7 Hz
´More frequent in females
´Gradual onset in 50’s or 60’s typical
´How might we differentiate from SD just by listening?
139
Essential Voice Tremor
140
141
Voice Therapy and Commonly Uttered Words
142
Voice Treatment: Specific approaches & Demos
143
Voice Therapy is a Highly Individualized
Process
´Different etiologic factors
´Background history
´Certain voice demands
´Medical complexities
´Occupational and social issues
´Motivation
144
Goal of Voice Therapy
´Restore the best voice possible, one that focuses on functional
outcomes (for purposes of employment and recreational
opportunities), social interactions, and activities of daily living
´Program needs to re-educate the patient on how to most effectively
and efficiently use the voice and eliminate the re-formation of the
voice disorder/pathology
145
How does a voice therapy session begin?
´Describe :
–Normal anatomy and physiology
23
144
Goal of Voice Therapy
´Restore the best voice possible, one that focuses on functional
outcomes (for purposes of employment and recreational
opportunities), social interactions, and activities of daily living
4/7/16
´Program needs to re-educate the patient on how to most effectively
and efficiently use the voice and eliminate the re-formation of the
voice disorder/pathology
145
How does a voice therapy session begin?
´Describe :
–Normal anatomy and physiology
–Etiologic factors
–Correlate etiology and vocal symptoms
–Impact on vocal fold function
´Measure motivation for therapy
´Discuss a timeline
´Home practice materials
–
146
When do you terminate therapy?
´Resolution of the vocal pathology
´
´Patient satisfaction with voice outcome
´
´Reimbursement issue
147
Factors Contributing to a Successful Therapy Outcome
´Agreement/comfort with the therapy process
´Willingness to change
´Elimination of other medical problems
´Development of realistic expectations
´Consideration of other health problems
´Development of a trusting rapport between clinician and patient
148
Voice Work: Requires Attention & Cognitive Load
´Move voice from subconscious to consciousness and back to
subconscious
´
´Involves motor learning (repetition, knowledge, and attention)
´Skill acquisition
´Learner acquires ability to perform behavior in optimal
circumstances
´Habit formation
´Acquiring the ability to produce behavior with limited attentional
resources
´Dual task loading to test this
´Habit change
´Old habitual behavior inhibited and replaced with newly
acquired behavio
24
´Skill acquisition
´Learner acquires ability to perform behavior in optimal
circumstances
4/7/16
´Habit formation
´Acquiring the ability to produce behavior with limited attentional
resources
´Dual task loading to test this
´Habit change
´Old habitual behavior inhibited and replaced with newly
acquired behavio
149
Therapy Orientations
´Hygienic Voice Therapy (HVT)
´Symptomatic Voice Therapy (SVT)
´Psychogenic Voice Therapy (PSVT)
´Physiologic Voice Therapy (PVT)
´Eclectic Therapy
´
150
Vocal Hygiene (VH) Therapy
151
Vocal Hygiene Counseling
´Make patient aware of effects of trauma to vocal folds
´Discuss A and P
´Video/images
´Patient’s own exam
´ *Buy-in*
´Determine when/why patient engages in phonotraumatic behavior
to design treatment plan
´Your concern for a patient’s voice may not always match up to
their own concern?
´Social/vocal behaviors may be more important for patient to
maintain than improving vocal health
152
Vocal Hygiene Treatment Planning
´Identify traumatic behaviors and describe their effects
´Define specific occurrences
´Eliminate traumatic behaviors that can be eliminated
´Modify traumatic behaviors that cannot be eliminated
´Manipulate environment to improve conditions for voicing
´
153
VH: Common Phonotrauma by Occupation/Condition
´The mother who reprimands her kids
´Find alternatives to:
25
´Identify traumatic behaviors and describe their effects
´Define specific occurrences
´Eliminate traumatic behaviors that can be eliminated
´Modify traumatic behaviors that cannot be eliminated
´Manipulate environment to improve conditions for voicing
4/7/16
´
153
VH: Common Phonotrauma by Occupation/Condition
´The mother who reprimands her kids
´Find alternatives to:
´Calling/reprimanding children
´Shouting from one room to other
´Talking to someone with poor hearing
´Speaking over loud media
´Alternatives to all of these are possible
´
154
VH: Common Phonotrauma by Occupation/Condition
´Factory worker
´Reduce speaking over noise
´Determine if social vs. essential to job
´Move away from noise source
´Mask noise with ear protection
´Do not strain to have others hear you
´Make them strain to hear you
´Amplification system
´Change jobs
´
155
VH: Common Phonotrauma by Occupation/Condition
´Public Speaker (actors, singers, teachers, lecturers, politicians,
clergy)
´Consider space where speaking occurs
´Room’s acoustic and size
´Size of audience
´Use of amplification
´Seating arrangement
´Length of public speaking
´Timing breaks
´Subject matter
´Reduce amount of talking
´Improve vocal technique
´Decrease vocal inconsistencies and perception of vocal fatigue
´Stronger voice in morning than afternoon
*Phonotrauma not always evident in diagnostic evaluation for this
group and obtaining recording of public speaking voice
recommended*
156
VH: Common Phonotrauma by Occupation/Condition
26
´Length of public speaking
´Timing breaks
´Subject matter
´Reduce amount of talking
´Improve vocal technique
´Decrease vocal inconsistencies and perception of vocal fatigue
´Stronger voice in morning than afternoon
4/7/16
*Phonotrauma not always evident in diagnostic evaluation for this
group and obtaining recording of public speaking voice
recommended*
156
VH: Common Phonotrauma by Occupation/Condition
´Children
´Decrease shouting, loud talking vocal noise, throat clearing
´Chart occurrences on daily basis and reward child when
reductions occur
´Traditional approach not adequate for all children
´Additional considerations:
´How does child shout?
´All shouting is not created equal so “teach the child to
shout”
´Low-pitched voice with improved breath support and
forward focus
´WHY would you do this physiologically???
157
VH: Habitual Throat Clearing
´Significant trauma to vocal folds
´
´Common with cold, flu, allergies, LPR (globus)
´May continue after resolution of any of these because of the
presence of edema and irritation that was caused by initial throat
clearing
´May develop secondary to pathology
´“I feel something in my throat” OR “I didn’t know I was doing it”
´Substitute throat clear with non-phonotraumatic behavior that can
still clear mucus
´Hard swallow
´Silent cough
´Modified Valsalva
´
´Use family and friends to help point out instances of throat clear and
help facilitate self-monitoring
´
158
VH: Hydration
´Increase hydration by:
´Drinking 64 oz of water/day OR drink ½ body weight (60 oz for
120 pounds)
´Gradual increase to target amount
´Decreasing caffeine and alcohol intake
27
´Silent cough
´Modified Valsalva
´
´Use family and friends to help point out instances of throat clear and
help facilitate self-monitoring
´
158
4/7/16
VH: Hydration
´Increase hydration by:
´Drinking 64 oz of water/day OR drink ½ body weight (60 oz for
120 pounds)
´Gradual increase to target amount
´Decreasing caffeine and alcohol intake
´When whole body hydrated secretory glands on ventricles and
located below vocal folds lubricate vocal folds
´Thick mucus on vocal folds during dehydration often assumed to be
result of allergies
´May result in antihistamine use and throat clearing
(counterproductive)
*Decrease PTP to decrease vocal effort*
159
Symptomatic Voice Therapy (SVT)
160
SVT: Respiratory Approaches
´DEBATE: Should we train respiratory control for voice production or
should it just be considered an automatic behavior?
´Whether direct or indirect most voice therapy techniques impact
pressure and flows to improve vocal production
´SVT respiratory approaches are direct
´Limited Breath support
´Talking following expiration or limited inspiration leads to reliance
on muscle tension
´To reduce:
´Identify problem for patient, and describe effects using visuals/A
&P
´Train patient to recognize difference with ear training
´Count until end of airsteam prior to onset of vocal strain/fry
´Use breath marks in paragraph
´Have patient self-monitor during specific times
´
´
161
SVT: Respiratory Approaches
´Types of respiration (box analogy)
´Clavicular
´Raising the top of the box leads to little air inhalation
´Thoracic
´Raise the side of the box supportive of conversational speech
´ Can result in chest/neck tension, but is typically still sufficient
for supporting speech
´Abdominal/diaphragmatic
28
´
´
161
4/7/16
SVT: Respiratory Approaches
´Types of respiration (box analogy)
´Clavicular
´Raising the top of the box leads to little air inhalation
´Thoracic
´Raise the side of the box supportive of conversational speech
´ Can result in chest/neck tension, but is typically still sufficient
for supporting speech
´Abdominal/diaphragmatic
´Downward expansion of bottom of box
´Greater airflow into lungs/less tension
´Patient practice without phonation first and then practice
with vowels, words, phrases, paragraphs, and spontaneous
speech
Why to you think diaphragmatic breathing is often thought of as best
practice?
162
SVT: Phonatory Approaches
´Hard glottal attack
´Build up of subglottic air pressure is greatly increased just before
utterance beginning with vowel
´Vocal folds squeezed together tightly
´When air pressure released, vocal folds bang together
´To prevent, teach easy onsets
´/h/ faciliates easy onset initially and is then eliminated
´Negative practice facilitates awareness
´
´Glottal fry phonation
´May lead to vocal dysfunction, but we don’t really know;)
´To prevent, train increase in pitch and loudness (WHY?)
´
´
163
Listen, Do, and Discuss
164
SVT: Phonatory Approaches
´Breathy phonation
´Habitually speaking in falsetto and disengaging TA may lead to
dysfunction
´Symptomatic approaches to remediate
´Use plosives /p/, /t/, and /k/ to facilitate firm productions
´Increase vocal intensity
´Ear training and negative practice
´Use of hard glottal attacks
´Pushing exercises
29
163
Listen, Do, and Discuss
164
SVT: Phonatory Approaches
´Breathy phonation
´Habitually speaking in falsetto and disengaging TA may lead to
dysfunction
´Symptomatic approaches to remediate
´Use plosives /p/, /t/, and /k/ to facilitate firm productions
´Increase vocal intensity
´Ear training and negative practice
´Use of hard glottal attacks
´Pushing exercises
´Isometric pushing of arms during vocal fold adduction
´Increase muscular tension and tightness of vocal fold
adduction
´Controversial!!
165
SVT: Resonatory Approaches
´Before treating, ensure resonance issue is functional and not
organic
´Organic
´Structural issues with VP complex
´Treated primarily with surgery and prosthetics possibly followed
by behavioral therapy
´Craniofacial team includes SLP, audiologist, orthodontist,
prosthodontist, ENT, and oral/plastic surgeons
´Functional
´Resonance of voice may be shaped by characteristics of region
in which one lives, changes in anatomical structures, or
unconsciously learned habits
´Client may want to modify resonance when moves into a new
area
´Changes in oral-pharyngeal structure after
tonsillectomy/adenoidectomy
166
SVT: Resonatory Approaches
´Modifying functional hypernasality
´Articulation therapy
´Increase:
´Precision of articulation
´Excursion of articulators
´Modify pitch and loudness
´Increased intensity and decreased pitch
´Nonspeech phonation
´Work from nonspeech sounds that are produced with decreased
nasality
´Metaphor use
´Speak as if you have a cold
´Negative practice
4/7/16
30
´Articulation therapy
´Increase:
´Precision of articulation
´Excursion of articulators
´Modify pitch and loudness
´Increased intensity and decreased pitch
´Nonspeech phonation
´Work from nonspeech sounds that are produced with decreased
nasality
´Metaphor use
´Speak as if you have a cold
´Negative practice
´After production of normal resonance, produce hypernasal
voice to contrast and feel difference
´Often ability acquired prior to discharge in therapy
´Instrumental feedback
´Nasometer
167
SVT: Resonatory Approaches
´Denasality
´May occur functionally when nasal obstruction removed
´Auditory/kinesthetic feedback system doesn’t adjust
´To modify
´Determine ability to produce /m/, /n/, /ng/ and expand
successful productions into gradually more complex stimuli
´Humming
´Lip closure forces more nasal resonance which can
gradually be manipulated into open mouth gestures like
/ma/
´Eventually hum can be eliminated and more complex
stimuli can be attempted starting from a properly nasalized
/m/
´Have patient produce hypernasal voice
´Negative practice
168
SVT: Resonatory Approaches
´Tone Focus
´Resonance of the voice in the supraglottic vocal tract
´Constriction of supraglottic airway at any point changes focus
´Backward tone focus
´Elevation of larynx, constriction of pharynx, laryngeal
pathology resulting in compensation, tone retraction
´Common with edema, mass lesions, glottal
incompetence, ADSD, muscle tension
´Forward focus is optimal
´Relaxed and open supraglottic structures to allow for
maximal resonation
´
169
SVT: Resonatory Approaches
´To Modify Tone Focus:
4/7/16
31
´Constriction of supraglottic airway at any point changes focus
´Backward tone focus
´Elevation of larynx, constriction of pharynx, laryngeal
pathology resulting in compensation, tone retraction
´Common with edema, mass lesions, glottal
incompetence, ADSD, muscle tension
´Forward focus is optimal
´Relaxed and open supraglottic structures to allow for
maximal resonation
´
169
4/7/16
SVT: Resonatory Approaches
´To Modify Tone Focus:
´Educate patient about resonance
´Negative practice with backward tone focus is contrasted with
exaggerated, nasal forward focus
´Chant phrases with exaggerated nasal & vowel sounds
´OH NO, OH ME, OH MY, etc.
´Direct patient to sensation of the tone on lips and in nose
´Use negative practice and ear training
´Introduce intensity, rate, and pitch variations into chant
´Move from chant to normal speaking
´Finally, eliminate chant, but maintain forward focus in phrases,
sentences, paragraph reading, and conversational speech
*Might also use lip or tongue trill*
170
SVT: Loudness Modification
´Refer for hearing evaluation first and rule out hearing impairment
´Educate patient about abnormally loud/soft intensity
´Help patient monitor reactions to voice and use as cues to change
intensity
´Have patient use a variety of vocal intensities, record, and use for
ear training
´Use sound level meter to stabilize appropriate intensity
´Starting at sounds and moving to conversation at end of
treatment
171
SVT: Rate Modification
´Unusual that will cause voice problem on its own
´If does, usually rate that is too fast resulting in hyperfunction
´After educating patient and making them aware of problem,
help patient exaggerate/prolong vowel sounds in phrases
followed by song lyrics, poetry, paragraph reading, prose, and
finally conversational speech
´Better than them prolonging pauses
172
SVT: Tension Reduction for Primary or Secondary MTD
´Progressive relaxation
´Help patients feel different between tense and relaxed muscles by
alternatively tensing/relaxing
32
´If does, usually rate that is too fast resulting in hyperfunction
´After educating patient and making them aware of problem,
help patient exaggerate/prolong vowel sounds in phrases
followed by song lyrics, poetry, paragraph reading, prose, and
finally conversational speech
´Better than them prolonging pauses
172
SVT: Tension Reduction for Primary or Secondary MTD
´Progressive relaxation
´Help patients feel different between tense and relaxed muscles by
alternatively tensing/relaxing
´Chewing exercises
´Based on idea that phonation during vegetative chewing will relax
structures necessary for voicing
´Have patient imagine and act as if they are chewing food using
wide jaw/tongue movement
´Add in vowel sound, then words, and then phrases
´Take out chewing but maintain relaxed phonation in more
advanced stimuli (conversational speech)
´Yawn-sigh
´YAWN: Expand pharynx and stretches/relaxes extrinsic laryngeal
muscles
´Lowers larynx, places tongue forward
´SIGH: Produced with less tension due to priming by yawn
´Paired with vowels and expanded into gradually more complex
stimuli
´Biofeedback
´Surface electromyography (supported by efficacy data)
´
173
Psychogenic Voice Therapy (PSVT)
174
PSVT
´Typically use this mode of therapy with patients who have MTD, FD,
or mutational falsetto/juvenile voice
´
´Counseling will typically come after a variety of techniques to elicit
the voice, but explanation of problem should always be nonjudgmental and encouraging
´
´After return of normal voice must explore/probe cause of functional
disorder (counseling and rapport is key)
175
PSVT: Other Techniques
´Non-speech phonatory tasks
´Falsetto Voice Technique
´Visual Biofeedback
´Falsetto Voice Technique
´Respiratory Retraining
´Circumlaryngeal massage and reposturing
176
PSVT/PT: Laryngeal Relaxation with Circumlaryngeal Massage
4/7/16
33
judgmental and encouraging
´
´After return of normal voice must explore/probe cause of functional
disorder (counseling and rapport is key)
175
PSVT: Other Techniques
´Non-speech phonatory tasks
´Falsetto Voice Technique
´Visual Biofeedback
´Falsetto Voice Technique
´Respiratory Retraining
´Circumlaryngeal massage and reposturing
176
PSVT/PT: Laryngeal Relaxation with Circumlaryngeal Massage
and Re-Posturing Technique
Steps of the Technique:
1.From the thyroid notch, move superiorly finding the hyoid bone
and place direct pressure on the two major cornu of the hyoid
bone
2.From the thyroid notch move just superiorly, finding the superior
cornu of the thyroid notch and apply pressure
3.From the thyroid notch move laterally to feel along the anterior
side of the sternocleidomastoid muscle, then move up to palpate
the submandibular muscles
177
PSVT/PT: Laryngeal Relaxation with Circumlaryngeal Massage
and Re-Posturing Technique cont’d
4/7/16
4. Find the thyroid notch and apply “traction,” pulling the larynx down
during vocalization to determine if there is an improvement in
voice quality. If voice quality significantly improves then laryngeal
repositioning may be a key factor in remediating the patient’s
dysphonia
5. Apply manual tension reduction using the clinician’s or the
patient’s fingers
6. Pressure is applied in a circular motion with downward pressure
´
178
Physiological Voice Therapy (PVT)
179
PVT
´Organic, neurologic, and functional voice problems affect
physiological balance of respiration, phonation, and resonation
´Compensation of one subsystem for another
´i.e. tight larynx to compensate for decreased respiratory support
´Maintenance of poor vocal technique after phonosurgery
´
´Repair imbalance in the systems
´Respiration, phonation, resonance
´Consider physiologic explanations for why therapy will work
´Programmatic, holistic, and direct
34
179
PVT
´Organic, neurologic, and functional voice problems affect
physiological balance of respiration, phonation, and resonation
´Compensation of one subsystem for another
´i.e. tight larynx to compensate for decreased respiratory support
´Maintenance of poor vocal technique after phonosurgery
´
´Repair imbalance in the systems
´Respiration, phonation, resonance
´Consider physiologic explanations for why therapy will work
´Programmatic, holistic, and direct
´Strong focus on sensory/kinesthetic awareness
´
´
´
180
Vocal Function Exercises
´Used to help patients with hyper- or hypo-functional voice disorders
´Based on assumption that the system can be strengthened and that
muscles of the larynx are similar to others
´This has not been proven especially not for the vocal folds
´So what do these exercises really do?
´Balance and coordinate subsystems
´Decrease maladaptive behaviors
´Commonly completed after phonosurgery just like PT after limb
surgery
–
181
Vocal Function Exercises
´Four exercises to be performed twice daily
(1)Warm-up
(2)Stretching
(3)Contraction
(4)Power
4/7/16
182
183
Confidential Voice
´Vocal conservation technique by Colton and Casper
´Easy, quiet breathy voice
´Small vocal fold amplitudes=less forceful impact
´Typically used temporarily before attempting other techniques
´Use is tailored to individual
´This has been considered both a symptomatic and a
physiologic technique
´
184
Flow Phonation
´Sometimes called stretch and flow or Casper-based confidential
flow therapy.
35
´Vocal conservation technique by Colton and Casper
´Easy, quiet breathy voice
´Small vocal fold amplitudes=less forceful impact
´Typically used temporarily before attempting other techniques
´Use is tailored to individual
´This has been considered both a symptomatic and a
physiologic technique
´
184
Flow Phonation
´Sometimes called stretch and flow or Casper-based confidential
flow therapy.
´Increase airflow management, ease of phonation, and oral
resonance through focus on balanced airflow
´
185
Lessac-Madsen Resonant Voice Therapy (LMRVT)
´Used to help adolescent and adult voice patients with hypo- and
hyperfunctional voice disorders
´Target: for the patient to use the least amount of respiratory effort
and impact stress on the vocal folds by achieving oral vibratory
sensations
´Semi-occluded vocal tract
´Back pressure assists in vocal fold vibration and decreases
impact force
´
186
Lee Silverman Voice Treatment
´Certification is required
´Goal: Increase loudness by increasing effort and coordination
during speech production
–Relies on memory, learning and reliance on self-cuing and selfregulating
´Intensive protocol: 4 times a week for 4 weeks, for a 1 hr session
´Used with primarily with Parkinson’s disease
187
ACTIVITY
´What are some appropriate goals/treatment approaches for the
following patients:
´35 year old male accountant with a vocal polyp. Laryngologist and
you agree to trial therapy before surgical excision. Patient has LPR
and is currently on PPI medication. He produces voice with back
focus and also engages in a lot of screaming and yelling during
football games on the weekend. You also notice that he breathes
clavicularly and is persistently throat clearing.
188
ACTIVITY
´What are some appropriate goals/treatment approaches for the
following patients:
´32 year old female with vocal nodules works at a call center and
talks for approximately 4-5 hours per day. Decreased airflow and
increased subglottal pressures were noted. Back-focused
resonance and tendency to lower modal pitch and increase vocal
intensity.
4/7/16
36
you agree to trial therapy before surgical excision. Patient has LPR
and is currently on PPI medication. He produces voice with back
focus and also engages in a lot of screaming and yelling during
football games on the weekend. You also notice that he breathes
clavicularly and is persistently throat clearing.
188
ACTIVITY
´What are some appropriate goals/treatment approaches for the
following patients:
´32 year old female with vocal nodules works at a call center and
talks for approximately 4-5 hours per day. Decreased airflow and
increased subglottal pressures were noted. Back-focused
resonance and tendency to lower modal pitch and increase vocal
intensity.
189
ACTIVITY
´What are some appropriate goals/treatment approaches for the
following patients:
´15 year old male with puberphonia. Patient exhibits a great deal
of extrinsic laryngeal tension and his larynx is situated in an
elevated position. His vocal pitch is at 220 Hz and vocal quality is
also very breathy.
190
ACTIVITY
´What are some appropriate goals/treatment approaches for the
following patients:
´22 year old females with functional aphonia with onset following
death of parent. Severe laryngeal muscle tension. Elevated
laryngeal position. You noticed some normal non-speech
phonatory tasks.
191
Team Management
192
Vocal Fold Cover Lesions
´Phonosurgery may be necessary to excise non-malignant mucosal
lesions (laser
´SURGICAL GOAL: Reserve vocal fold mucosa, restore vocal fold
edge
4/7/16
´Voice pathologist’s role in phonosurgery
´Perform videostroboscopy
´Conduct preoperative counseling
´Vocal hygiene
´Will ONLY conduct direct voice therapy if for some reason voice
therapy cannot be initiated for several weeks/months
´Prepare patient for postoperative voice rest/use
´Complete voice rest often a few days to a week
´Modified voice rest following that time
´
´Perform postsurgical videostroboscopy 7-10 days post-surgery
´Initiate voice therapy when healing is sufficient
37
´Conduct preoperative counseling
´Vocal hygiene
´Will ONLY conduct direct voice therapy if for some reason voice
therapy cannot be initiated for several weeks/months
´Prepare patient for postoperative voice rest/use
´Complete voice rest often a few days to a week
´Modified voice rest following that time
´
´Perform postsurgical videostroboscopy 7-10 days post-surgery
4/7/16
´Initiate voice therapy when healing is sufficient
*What lesions might benefit from surgery?*
193
194
195
Treatment Plan Considerations
´Do you need to speak with the MD about surgery prior to therapy?
´When/why would surgery be a consideration prior to initiating
behavioral therapy?
´Atrophy
´VF paralysis
´Lesions such as polyps and cysts
´When would behavioral therapy be a consideration prior to
initiating surgery?
´Nodules
´Polyps (possibly)
´Granulomas
´Atrophy and paralysis (only under certain conditions)
´
Why????
´
´
´
´
196
LPR/GERD
´Only 18% of patients with upper esophageal dysfunction (LPR)
have heartburn
´Identification of signs/symptoms of LPR can be controversial
´Self-report measures and visual examination is not reliable
´Gastroenterology consult and PH probe monitoring is necessary
´Treatment
´May include over-the-counter prescription medications, surgery,
and life-style modification Dietary and lifestyle changes and overthe-counter medications
´Voice pathologist is supportive of management of antireflux
regime, meds schedule, decreasing coughing/throat clearing,
and initiating new vocal behaviors
38
´Only 18% of patients with upper esophageal dysfunction (LPR)
have heartburn
´Identification of signs/symptoms of LPR can be controversial
´Self-report measures and visual examination is not reliable
´Gastroenterology consult and PH probe monitoring is necessary
´Treatment
´May include over-the-counter prescription medications, surgery,
and life-style modification Dietary and lifestyle changes and overthe-counter medications
´Voice pathologist is supportive of management of antireflux
regime, meds schedule, decreasing coughing/throat clearing,
and initiating new vocal behaviors
´
197
4/7/16
Unilateral Vocal Fold Paralysis
´Treatment specific to circumstances of paralysis
´Idiopathic and/or unknown if function will return
´Temporary injection of material into lateral aspect of paralyzed
vocal fold that will reabsorb, but temporarily medialize vocal fold
´Gelfoam, collagen, calcium hydroxylapatite, hyaluronic acid,
Alloderm
´Follow-up with voice therapy to maximize positive effects of
medialization and decompensate maladaptive vocal behaviors
´Watch and wait to see if recovery occurs in 6-12 months and
prevent development of maladaptive vocal behaviors in mean time
´If paralysis is permanent and/or cause is known, permanent
surgical treatment followed by voice therapy initiated
´
´
198
199
Unilateral Vocal Fold Paralysis
200
Unilateral Vocal Fold Paralysis
´Goal of behavioral treatment:Improve glottic closure without
hyperfunction
´Pushing exercise
´Hard glottal attack
´Lateral Digital Manipulation
´Unless some closure present with UVFP, unlikely that behavioral
voice therapy of any kind will be effective without surgery
´Vocal function exercises may be most appropriate in cases where
some closure is possible
201
Spasmodic Dysphonia
´Historical treatment
´Unilateral recurrent laryngeal nerve section
´Decreased spasming at midline
´Fallen out of favor due to symptom recurrence
´Modern treatment
´Botox
39
´Unless some closure present with UVFP, unlikely that behavioral
voice therapy of any kind will be effective without surgery
´Vocal function exercises may be most appropriate in cases where
some closure is possible
201
4/7/16
Spasmodic Dysphonia
´Historical treatment
´Unilateral recurrent laryngeal nerve section
´Decreased spasming at midline
´Fallen out of favor due to symptom recurrence
´Modern treatment
´Botox
´In Adductory type, into TA
´Decreased spasm 3-6 months typically
´In Abductory type, into PCA (unilaterally)
´Less predictable success
202
203
Voice Treatment: General Principles & Considerations
204
Voice Therapy
´New technique**
• Resonant, frontward focus
• Spend more air
• Decrease muscular tension
´Health behaviors
• Smoking
• Water intake
´
205
Voice Therapy Success
´Voice pathologist
´Is expert in:
´A&P
´Assessment
´Etiological factors
´Laryngeal pathology
´Psychodynamics of voice prodcution
´Has strong ability to:
´Educate, counsel, apply management techniques skillfully
´
206
Voice Therapy Success (continued)
´Patient:
´Is motivated
´Agrees that there is a problem
´Is willing to shed vocal image, recognize negative behaviors, and
put forth necessary effort to modify those behaviors
´Shares information
40
´Has strong ability to:
´Educate, counsel, apply management techniques skillfully
4/7/16
´
206
Voice Therapy Success (continued)
´Patient:
´Is motivated
´Agrees that there is a problem
´Is willing to shed vocal image, recognize negative behaviors, and
put forth necessary effort to modify those behaviors
´Shares information
´
´Patient and voice pathologist will negotiate over success
´Manage expectations
´Define what is realistic
´
207
Why is finding success in voice therapy so hard?
208
209
Self-regulation
´Effort exerted by the self to modify or control cognitions, emotions,
or outward behavior (Vohs & Baumeister, 2004)
210
Problems with self-regulation
211
212
Depletion is likely to cause two overall problems for voice
patients like Sonya:
213
Self-regulation may be optimized
(Tyler and Burns, 2008)
´Replenishment of previously depleted self-regulatory resources
through interventions like rest or relaxation.
´Automatic self-regulation
´Implementation intentions
214
Other Factors to Consider
´Adherance
´Self-efficacy
´Therapeutic Alliance
´Motivational Interviewing
215
VocaHealth and Disorder Prevention
(Direnzo, Tanner, & Thibeault, 2016)
216
What is the role of the SLP in promoting vocal health and voice
disorder prevention?
217
Vocal Overuse or Misuse: What does the Science Say?
´TYPICAL PRACTICE
41
´Self-efficacy
´Therapeutic Alliance
´Motivational Interviewing
215
4/7/16
VocaHealth and Disorder Prevention
(Direnzo, Tanner, & Thibeault, 2016)
216
What is the role of the SLP in promoting vocal health and voice
disorder prevention?
217
Vocal Overuse or Misuse: What does the Science Say?
´TYPICAL PRACTICE
´Tell patients at risk for voice disorders to reduce vocal use and
practice good vocal technique
´
´ACTUAL EVIDENCE IS GENERALLY SUPPORTIVE:
´Animals and humans who use voice with increased duration and
intensity will typically experience inflammation in the outer vocal
fold layers and potentially pathology
´Consistent with the high presence of disorders in populations at
risk for voice disorders
´That being said, voice use via monitoring devices and objective
acoustic measurements have found that vocal intensity, pitch, and
amount of voice use does not differ between those with and
without vocal fold lesions (Van Stan et al., 2015)
218
Caffeine & Hydration: What does the Science Say?
´TYPICAL PRACTICE
´Conventionally have recommended patients drink 6-8 glasses of
water per day, minimize use of diuretics such as caffeine, and
inhale steam to deliver surface hydration to the vocal folds.
´
´ACTUAL EVIDENCE
´Body is relatively good at maintaining systemic internal hydration
in individuals who are healthy, even with fluctuations in fluid intake
´Inconsistent studies as to how vocal fold vibration is affected by
decreased fluid intake and decreased humidity in the environment.
219
Vocal Rest: What does the Science Say?
´TYPICAL PRACTICE:
´Often patients who go through vocal fold surgery are prescribed 7
days of voice rest.ACTUAL EVIDENCE
´Lack of evidence to support complete voice rest likely after 2-3
days post-surgery
´In animal models:
´Fibroblasts or the cells that build new healthy tissue in the
lamina propria appear at around day 3
220
Other Factors
´Strengthening vocal fold muscles/Exercise
´Presbylaryngis and vocal fold paralysis
´Smoking
42
´Often patients who go through vocal fold surgery are prescribed 7
days of voice rest.ACTUAL EVIDENCE
´Lack of evidence to support complete voice rest likely after 2-3
days post-surgery
´In animal models:
´Fibroblasts or the cells that build new healthy tissue in the
lamina propria appear at around day 3
220
Other Factors
´Strengthening vocal fold muscles/Exercise
´Presbylaryngis and vocal fold paralysis
´Smoking
´E-cigarettes?
´Laryngopharyngeal reflux
´Sleep Deprivation
´Warm-ups
221
Conclusions
222
Final Thoughts in a Nutshell
´Voice disorders come in many shapes and sizes
´Must understand vocal anatomy and physiology to effectively
facilitate treatment and assess for disorder
´
´Assessment may vary by setting, but visual examination +
perceptual and clinical judgment is a must
´
´Voice treatment is highly individualized and approaches can be
classified by theoretical orientation
´
´Vocal health recommendations are important, but the science is still
pending on a lot of conventional wisdom
´
223
Questions….
´What questions do you have about assessing and treating voice
disorders from your own practical experience, classroom learning,
clinical practica, etc?
´
224
Opportunities to Learn More
´Interactive atlas of laryngeal anatomy by Ahmet Sinav
´https://www1.columbia.edu/sec/itc/hs/medical/anatomy_resources
/anatomy/larynx/
´ASHA’s Special Interest Group (SIG 3) on Voice and Voice
Disorders
´http://www.asha.org/SIG/03/
´National Center for Voice and Speech
´http://ncvs.org
´Summer Vocology Institute
´http://ncvs.org/svi_infous.html
´Voice Science Works
´http://www.voicescienceworks.org
4/7/16
43
´Interactive atlas of laryngeal anatomy by Ahmet Sinav
´https://www1.columbia.edu/sec/itc/hs/medical/anatomy_resources
/anatomy/larynx/
´ASHA’s Special Interest Group (SIG 3) on Voice and Voice
Disorders
´http://www.asha.org/SIG/03/
´National Center for Voice and Speech
´http://ncvs.org
´Summer Vocology Institute
´http://ncvs.org/svi_infous.html
´Voice Science Works
´http://www.voicescienceworks.org
´
´
4/7/16
44