Therapy

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J O S E P HC . S T E MP L E E D I ER . H A P N E R

Voice Therapy Clinical Case Studies Fourth Edition

Voice Therapy Clinical Case Studies Fourth Edition

Joseph C. Stemple, PhD, CCC-SLP, ASHAF Edie R. Hapner, PhD, CCC-SLP

5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Website: http://www.pluralpublishing.com

Copyright © by Plural Publishing, Inc. 2014 Typeset in 11/13 Palatino by Flanagan’s Publishing Services, Inc. Printed in the United States of America by McNaughton & Gunn, Inc. All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity.

Library of Congress Cataloging-in-Publication Data Voice therapy : clinical case studies / [edited by] Joseph C. Stemple, Edie R. Hapner. -- Fourth edition. Proudly sourced and uploaded by [StormRG] p. ; cm. Kickass Torrents | TPB | ET | h33t Includes bibliographical references and index. ISBN 978-1-59756-558-5 (alk. paper) — ISBN 1-59756-558-X (alk. paper) I. Stemple, Joseph C., editor of compilation. II. Hapner, Edie R., editor of compilation. [DNLM: 1. Voice Disorders — therapy — Case Reports. WV 500] RF510 616.85'5606 — dc23 2014000154

Contents Preface xiii Contributors xvii

1

Principles of Voice Therapy

1

Joseph C. Stemple Introduction 1 Historical Perspective 2 Hygienic Voice Therapy 3 Symptomatic Voice Therapy 4 Psychogenic Voice Therapy 5 Physiologic Voice Therapy 5 Eclectic Voice Therapy 6 Case Study: Patient A 6 Voice Care Professionals 10 References 10

2

Comments on Voice Evaluation

13

Joseph C. Stemple Introduction 13 Management Team 14 Medical Examination 15 Voice Pathology Evaluation 15 Instrumental Voice Assessment 23 Hearing Screening 23 Impressions 23 Prognosis 24 Recommendations 24 Summary 24 References 24

3

Primary and Secondary Muscle Tension Dysphonia

27

Introduction: Muscle Tension Dysphonia: An Overview Nelson Roy Case Study 1. Behavioral Shaping in Primary MTD Masquerading as Elective Mutism in a 10-Year-Old Boy R. E. Stone Jr and Kimberly Coker

27 29

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Voice Therapy: Clinical Case Studies

Case Study 2. Management of Primary MTD in a 13-Year-Old Using Falsetto Voice to Modify Phonation Joseph C. Stemple Case Study 3. Use of Laryngeal Massage and Resonant Therapy in Primary MTD in an Adolescent Susan Baker Brehm Case Study 4. Flow Phonation in a Teenager with Primary Muscle Tension Aphonia Jackie Gartner-Schmidt Case Study 5. Manual Circumlaryngeal Techniques in the Assessment and Treatment of Primary MTD in a 55-Year-Old Woman Nelson Roy Case Study 6. Management of Primary MTD Initially Masquerading as a Paralytic Dysphonia in a 39-Year-Old Woman Using an Enabling Approach Claudio Milstein Case Study 7. Use of Patient-Family Education and Behavior Modification to Treat MTD Secondary to Vocal Nodules Leslie Glaze Case Study 8. Eclectic Voice Therapy for Secondary MTD in a 10-Year-Old With a Vocal Fold Cyst Carissa Portone-Maira Case Study 9. Using a Psychosocial Management Approach in the Therapy of a Child With Midmembranous Lesions and Secondary MTD Moya Andrews Case Study 10. Treatment of Secondary MTD in a Child With Early Bilateral Lesions: A Telehealth Approach Lisa N. Kelchner Case Study 11. Treating a Child With MTD Secondary to Vocal Nodules Using Concepts From Adventures in Voice Rita Hersan Case Study 12. Pediatric Vocal Fold Nodules and Secondary MTD Treated in Conjunction With a School-Based SLP Rebecca Hancock Case Study 13. Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD Joseph C. Stemple Case Study 14. Accent Method in the Treatment of Secondary MTD Sara Harris Case Study 15. Voice Therapy Boot Camp in the Treatment of Secondary MTD in an Adult Rita Patel

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Contents vii

Case Study 16. Medical and Therapeutic Management of Laryngopharyngeal Reflux With Resulting Secondary MTD Sandra A. Schwartz

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Case Study 17. Management of Secondary MTD Associated With Vocal Process Granulomas Heather Starmer

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Case Study 18. Lessac-Madsen Resonant Voice Therapy in the Treatment of Secondary MTD Diana M. Orbelo, Nicole Yee-Key Li, and Katherine Verdolini Abbott

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Case Study 19. Use of Ambulatory Biofeedback to Supplement Traditional Voice Therapy for Treating Primary MTD in an Adult Female Tara Stadelman-Cohen, Jarrad Van Stan, and Robert E. Hillman

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Case Study 20. Use of Glottal Attack in the Treatment of Primary MTD 164 in an Adult Female Presenting With Persistent Falsetto Joseph C. Stemple Case Study 21. The Use of a Multi-Approach Therapy in a Female Professional Voice Speaker Presenting With a Primary MTD Marked With Habitual Falsetto Phonation Mara Behlau and Glaucya Madazio

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Case Study 22. Use of Hard Glottal Attack as Laryngeal Manipulation to Modify Mutational Voice in a 16-Year-Old Male Lisa Fry

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References 179

4

Management of Glottal Incompetence

189

Introduction 189 Case Study 1. Treatment Strategies Used for Unilateral Vocal Fold Paralysis in a Case With a Complex Medical History Stephen C. McFarlane and Shelley Von Berg

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Case Study 2. Use of Physiologic Therapy Approaches to Treat Unilateral Vocal Fold Paralysis Following Complications From a Total Thyroidectomy Mara Behlau, Gisele Oliveria, and Osíris do Brasil

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Case Study 3. Treatment of Glottal Incompetence With Secondary Muscle Tension Dysphonia in a Patient With Unilateral Vocal Fold Paralysis Maria Dietrich

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Case Study 4. Use of Semi-Occluded Vocal Tract Methods and Resonant Voice Therapy to Treat Unilateral Vocal Fold Paralysis Julie Barkmeier-Kraemer

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Case Study 5. Use of Expiratory Muscle Strength Training in a Case of 222 Unilateral Vocal Fold Paralysis 4 Years Post Chemotherapy/Radiation Bari Hoffman Ruddy, Christine M. Sapienza, Erin Silverman, and Henry Ho Case Study 6. Brief Discussion and Case Presentation of Treatment for 226 Superior Laryngeal Nerve Paralysis Using Medical, Surgical, and Behavioral Interventions Bruce J. Poburka Case Study 7. Use of Phonation Resistance Training Exercises (PhoRTE) 233 in a Part-Time Cooking Instructor With Presbyphonia Aaron Ziegler and Edie R. Hapner Case Study 8. Use of Vocal Function Exercises in an Elderly Man With 240 Presbyphonia Stephen Gorman Case Study 9. Treatment of Glottal Incompetence Caused by Sulcus 245 Vocalis: Evidence of a Team Approach for Vocal Rehabilitation Amanda I. Gillespie and Clark A. Rosen Case Study 10. Improvement of Vocal Fold Closure in a Patient With 250 Voice Fatigue Joseph C. Stemple Case Study 11. An Eclectic Approach in the Management of an 255 Individual With Vocal Fatigue Chaya Nanjundeswaran References 262

5

Dystonia, Essential Tremor, and Other Neurogenic Disorders

269

Spasmodic Dysphonia 269 Case Study 1. Functional Voice Therapy for Spasmodic Dysphonia 271 Joseph C. Stemple Case Study 2. Medical and Behavioral Management of Adductor 273 Spasmodic Dysphonia Edie R. Hapner and Michael M. Johns Case Study 3. Combined Laryngeal Injection of Botulinum Toxin and 281 Voice Therapy for Treatment of Adductor Spasmodic Dysphonia Eileen M. Finnegan Case Study 4. Use of Reduced Voicing Duration to Treat Vocal Tremor 287 Julie Barkmeier-Kraemer 298 Case Study 5. Use of LSVT® LOUD (Lee Silverman Voice Treatment) in the Care of a Patient With Parkinson Disease Lorraine Ramig and Cynthia Fox Case Study 6. Use of Telehealth Technology to Provide Voice Therapy 303 Lyn Tindall Covert References 307

Contents ix

6

Irritable Larynx Syndrome, Paradoxical Vocal Fold Dysfunction, and Chronic Cough

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Introduction to Irritable Larynx Syndrome Linda Rammage

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Case Study 1. A Case of ILS Managed by a Comprehensive Approach to Multiple Central Sensitivity Syndrome Triggers Linda Rammage

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Case Study 2. Multimodality Behavioral Treatment of Long-Standing Chronic Cough in an Adult Marc Haxer

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Case Study 3. Failed Voice Therapy With Successful Use of Central Nervous System Inhibitors in Chronic Cough Madeleine Pethan and Laureano Giraldez-Rodriguez

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Paradoxical Vocal Fold Motion: An Introduction Mary J. Sandage

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Case Study 4. Treatment of PVCD in a Collegiate Swimmer Mary J. Sandage

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Case Study 5. Management of PVCD: An Adolescent Athlete With Exercise-Induced Dyspnea Michael D. Trudeau, Jennifer Thompson, and Christin Ray

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Case Study 6. Treatment of Paradoxical Vocal Fold Motion Disorder in a 9-Year-Old Athlete Maia Braden

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Case Study 7. Paradoxical Vocal Fold Movement (PVFM): A Case of 355 the Young Athlete With Associated Psychosocial Contributions Mary V. Andrianopoulos References 368

7

Management of the Professional, Avocational, and Occupational Voice

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Introduction 376 Marina Gilman Case Study 1. Management of Vocal Fold Nodules in a Female Prepubescent Singer Patricia Doyle and Starr Cookman

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Case Study 2. The Developing Performer Barbara Jacobson

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Case Study 3. 19-Year-Old Talented Male Singer, Presenting With Soft Bilateral Vocal Fold Lesions Marina Gilman

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Case Study 4. Therapeutic Modalities for the Touring Musical Theater 400 Vocal Athlete Wendy D. LeBorgne Case Study 5. Voice Intervention for a Touring Broadway Singer 405 Shirley Gherson Case Study 6. The High-Risk Vocal Performer 412 Bari Hoffman Ruddy, Jeffrey Lehman, and Christine M. Sapienza Case Study 7. Semi-Occluded Vocal Tract Exercises and Resonant 422 Voice Therapy in the Perioperative Management of a Professional Actor and Singer With a Vocal Fold Cyst Sarah L. Schneider and Mark S. Courey Case Study 8. Treating Vocal Injury in a Physically and Vocally 435 Demanding Performer Wendy D. LeBorgne Case Study 9. Voice Recalibration With the Cup Bubble Technique for 442 a Country Singer Jennifer C. Muckala and Brienne Ruel Case Study 10. Praise and Worship Leader Preremoval and 452 Postremoval of Bilateral Vocal Fold Lesions Marina Gilman Case Study 11. Use of Voice Therapy in Conjunction With Minimal 458 Injection Medialization in the Longitudinal Treatment of Dysphonia in an Elite Operatic Singer Brian E. Petty and Miriam van Mersbergen Case Study 12. Voice Therapy in a 28-Year-Old Theater Actor 463 Kate DeVore Case Study 13. Conversational Voice Therapy: A Case Describing 469 Application of Public Speaking Techniques to Voice Disorders Alison Behrman References 474

8 Successful Voice Therapy

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Introduction 479 Joseph C. Stemple Interview and Counseling Skills 480 Clinical Understanding of the Problem 481 Misapplied Management Techniques 482 Lack of Patient Education or Understanding of the Problem 482 Recognition of One Philosophical Orientation or One Etiologic Factor 483 Premature Discontinuation of Therapy 483 The Clinical Ear 484

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Patient Realities 484 Can All Voices Be Improved? 488 Case Study 1. The Role of Self-Efficacy on Voice Therapy Adherence 488 Amanda I. Gillespie Case Study 2. Using iPod Apps to Improve Voice Therapy Adherence 493 Between Sessions: A Social-Cognitive Approach Eva van Leer Case Study 3. There’s an App for That: Use of Portable Electronic 497 Software Applications to Facilitate Home Practice of Voice Exercises in a Lawyer With Vocal Fold Nodules Bryn Olson and Carissa Portone-Maira Case Study 4. Threat of Being Fired From Therapy Improved a Vocal 503 Overdoer’s Adherence Carissa Portone-Maira References 510 Appendix 8–A. Selected Applications Useful in Voice Therapy 513 Index 521

Preface The fourth edition of Voice Therapy: Clinical Case Studies marks the 20-year anniversary of this text. We are excited to introduce Edie Hapner as co-editor of this fourth edition. Hapner’s clinical and research contributions to the field of voice pathology are recognized nationally and internationally. She is a master clinician and a teacher and mentor to a generation of voice clinicians. We are pleased to have Edie on board and know that her contributions will enhance the quality of the learning experience for voice students and professionals alike. Since its initiation, the purpose of this text has remained the same: . . . to provide both the student and the working clinician with a broad sampling of management strategies as presented by master voice clinicians, laryngologists, and other voice care professionals. The text is meant to serve as a practical adjunct to the more didactic publications.

As the knowledge of voice production continues to expand, so, too, have the publications dedicated to describing this knowledge. There are currently excellent texts and journals dedicated to the scientific understanding of voice. Other publications are available to help prepare students to evaluate and manage clinical voice disorders. By necessity, these texts must include great quantities of didactic information so that the student learns not only “how” but “why.” To utilize a management approach without understanding the underlying basis of the approach is inappropriate.

Nonetheless, because of the breadth of material necessary in these texts, therapeutic methods for voice disorders are often given only a cursory and generalized discussion. This text is meant to bridge that gap. In over 60 case studies involving a wide variety of voice disorders with various pathologies and etiologies, master clinicians have provided detailed descriptions of management approaches and techniques. It is our hope that the expertise offered in these pages will serve the reader well in guiding clinical practice. Utilizing the format of actual case studies, complete descriptions of diagnostic and therapeutic methods are provided for a full array of voice disorders. Chapter 1 includes information on the various philosophies of treatment. With the maturation of the voice care specialty, different schools of thought have evolved regarding treatment designs. These philosophical orientations include hygienic, symptomatic, psychogenic, physiologic, and eclectic orientations. Each orientation is discussed and illustrated with a representative case study. Chapter 2 comments on various voice evaluation techniques. These techniques include the formal questionnaire, the patient interview, perceptual voice analysis, patient self-assessment, and instrumental assessment of voice production. The role of the evaluation process as a part of the overall management plan is also discussed. Chapter 3 discusses treatment approaches for the most common type

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of voice disorder, muscle tension dysphonia (MTD). Following an overview of MTD by Nelson Roy, management approaches for both children and adults including hygiene programs, symptomatic modifications, attention to psychosocial issues, and direct physiologic manipulation and exercises are presented in illustrative case studies of both primary and secondary MTD. Treatments for various etiologies of glottal incompetence are described in Chapter 4. Management for voice fatigue, bowed vocal folds, senile laryngis, and vocal fold paralysis are described, including direct voice therapies, surgical intervention, and a combination of these approaches. Many techniques including voice facilitating techniques, semi-occluded vocal tract, expiratory muscle strength training, and phonation resistance training are discussed. Chapter 5 presents management strategies for laryngeal dystonia, essential tremor, and other neurologic voice disorders. These strategies include behavioral and medical management of spasmodic dysphonia, voice therapy for essential tremor, and face-to-face and remote treatment of voice and speech symptoms related to Parkinson disease. Because of the speech-language pathologist’s unique blend of knowledge regarding upper respiratory anatomy and physiology and behavioral therapy, we have become the caregivers for complex respiratory and laryngeal disorders. Chapter 6 provides several detailed case studies regarding the various etiologies, patient profiles, and evaluation and treatment approaches used with those diagnosed with irritable larynx syndrome. Included in this category are chronic cough and vocal cord dysfunction (VCD). These cases

include treatments for laryngopharyngeal reflux and VCD in the young child, young athlete, and elite athlete. The consequences of a voice disorder may impact the quality of life and threaten the livelihood of individuals dependent upon a healthy voice. Chapter 7 presents case studies for those dependent upon their voice such as the elite vocal performer, the occupational voice user, and those whose avocational voice use is related to their quality of life. The final chapter, Chapter 8, is devoted to a discussion of successful voice therapy and patient adherence. What makes therapy successful or unsuccessful? This chapter looks at both the therapist and the patient and describes the pitfalls that may influence the ultimate goal of therapy: improved vocal function. As with the first three editions of Voice Therapy: Clinical Case Studies, the most exciting element in the preparation of this text was the support received by the master clinicians who graciously and generously submitted the case studies. What a wonderful opportunity it is to learn from those who are in the trenches, those experts who embody not only superior clinical skills, but wonderful insight as to why they do what they do. We are deeply indebted to all of them and proudly offer their collective expertise. We are certain that the reader will benefit from their vast clinical experiences. Text preparations are extremely time-consuming and require many hours of tedious work. Checking and preparing references, organizing tables, figures, and their legends, reading and re-reading in an attempt to make the intent clear to those we are trying to reach are only a few of the tasks involved. We were so very fortunate in the prepara-

Preface xv

tion of this text to have the invaluable editorial assistance of the Plural Publishing professionals. We are indebted to Angie Singh, Megan Carter, Milgem Rabanera, and Mckenna Bailey for encouraging and supporting this fourth

edition. In addition, we wish to thank our students and colleagues who have suggested ways to improve the text with each new writing. Finally, as usual, we are most appreciative for the support of our families. — Joseph C. Stemple Edie R. Hapner

Contributors Moya L. Andrews, EdD Professor Emerita Department of Speech and Hearing Sciences Indiana University Bloomington, Indiana Chapter 3 Mary V. Andrianopoulos, PhD Associate Professor Clinical Consultant Department of Communication Disorders Center for Language, Speech, and Hearing University of Massachusetts-Amherst Amherst, Massachusetts Chapter 6 Susan Baker Brehm, PhD Associate Professor and Chair Department of Speech Pathology and Audiology Miami University Oxford, Ohio Chapter 3 Julie Barkmeier-Kraemer, PhD Professor Department of Otolaryngology University of California, Davis Sacramento, California Chapters 4 and 5 Mara Behlau, PhD Permanent Professor Graduate Program in Human Communication Disorders Director Specialization Course in Voice

Universidade Federal de São Paulo UNIFESP and Centro de Estudos da Voz-CEV São Paulo, SP, Brazil Chapters 3 and 4 Alison Behrman, PhD, CCC-SLP Associate Professor Department of Speech-LanguageHearing Sciences Lehman College/City University of New York Bronx, New York Chapter 7 Maia Braden, MS Speech-Language Pathologist University of Wisconsin-Madison Voice and Swallow Clinics American Family Children’s Hospital Madison, Wisconsin Chapter 6 Kimberly Coker, MS Speech-Language Pathologist North Texas Voice Center Dallas, Texas Chapter 3 Starr Cookman, MA Assistant Professor Clinical Faculty University of Connecticut Health Center Farmington, Connecticut Chapter 7 Mark S. Courey, MD Professor Otolaryngology-Head & Neck Surgery

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Director Division of Laryngology University of California, San Francisco San Francisco, California Chapter 7 Kate DeVore, MA Speech-Language Pathologist Total Voice, Inc. Chicago, Illinois Chapter 7

Lisa Fry, PhD Adjunct Faculty Department of Communication Disorders Marshall University Huntington, West Virginia Chapter 3

Maria Dietrich, PhD Assistant Professor Department of Communication Disorders University of Missouri Columbia, Missouri Chapter 4

Jackie Gartner-Schmidt, PhD Associate Professor Otolaryngology Associate Director UPMC Voice Center Director of Speech Pathology-Voice Division University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Chapter 3

Osíris do Brasil, MD Centro de Estudos da Voz CEV, São Paulo, SP Associate Professor São Paulo, Brazil Chapter 4

Shirley Gherson, MA Clinical Specialist-Voice Disorders NYU Langone Medical Center Rusk Rehabilitation New York, New York Chapter 7

Patricia B. Doyle, MA Instructor University of Connecticut Health Center Farmington, Connecticut Chapter 7

Amanda I. Gillespie, PhD Assistant Professor University of Pittsburgh UPMC Voice Center Pittsburgh, PA Chapters 4 and 8

Eileen M. Finnegan, PhD Associate Professor University of Iowa Iowa City, Iowa Chapter 5

Marina Gilman, MM, MA, CCC-SLP Speech-Language Pathologist Emory Voice Center Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 7

Cynthia Fox, PhD Research Associate National Center for Voice and Speech University of Colorado-Boulder Denver, Colorado Chapter 5

Laureano A. Giraldez-Rodriguez, MD Fellow Head and Neck Cancer Surgery– Microvascular Reconstruction

Contributors xix

Department of Otolaryngology-Head & Neck Surgery Mount Sinai School of Medicine New York, New York 2013 Fellow Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 6 Leslie E. Glaze, PhD Speech-Language Pathologist Minneapolis, Minnesota Tucson, Arizona Chapter 3 Stephen Gorman, PhD Voice Pathologist Blaine Block Institute for Voice Analysis and Rehabilitation Dayton, Ohio Professional Voice Center of Greater Cincinnati Cincinnati, Ohio Chapter 4 Rebecca L. Hancock, MEd Senior Speech Pathologist University of Kentucky Voice and Swallow Clinic Lexington, Kentucky Chapter 3 Edie R. Hapner, PhD, CCC-SLP Associate Professor Department of Otolaryngology-Head & Neck Surgery Emory University School of Medicine Director Speech-Language Pathology Emory Voice Center Atlanta, Georgia Chapters 4 and 5

Sara Harris, FRCSLT Speech-Language Pathologist Lewisham Hospital Voice Disorders Unit London, United Kingdom Chapter 3 Marc Haxer, MA Clinical Senior Speech Pathologist Departments of OtolaryngologyHead & Neck Surgery and SpeechLanguage Pathology University of Michigan Health System Ann Arbor, Michigan Chapter 6 Rita Hersan, MS Speech-Language Pathologist Voice Clinician University of Pittsburgh Voice Center Pittsburgh, Pennsylvania Chapter 3 Robert E. Hillman, PhD Co-Director Research Director Center for Laryngeal Surgery and Voice Rehabilitation Massachusetts General Hospital Director Research Programs MGH Institute of Health Professions Professor of Surgery Harvard Medical School Boston, Massachusetts Chapter 3 Henry Ho, MD, FACS Director Head and Neck Program The Florida Hospital Cancer Institute Orlando, Florida Chapter 4 Bari Hoffman Ruddy, PhD Associate Professor

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Department of Communication Sciences and Disorders University of Central Florida Orlando, Florida Chapters 4 and 7 Barbara Jacobson, PhD Assistant Professor Associate Director Medical Speech-Language Pathology Department of Hearing & Speech Sciences Vanderbilt University Nashville, Tennessee Chapter 7 Michael M. Johns, MD, FRCS Associate Professor Otolaryngology Director Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 5 Lisa N. Kelchner, PhD, BCS-S Associate Professor Director of Graduate Studies Department of Communication Sciences and Disorders University of Cincinnati Cincinnati, Ohio Chapter 3 Wendy D. LeBorgne, PhD, CCC-SLP Voice Pathologist Singing Voice Specialist Clinical Director The Blaine Block Institute of Voice Analysis and Rehabilitation Provoice Center of Cincinnati CollegeConservatory of Music Dayton and Cincinnati, Ohio Chapter 7

Jeffrey Lehman, MD, FACS Clinical Professor College of Health and Public Affairs University of Central Florida Medical Director The Voice Care Center Winter Park, Florida Chapter 7 Glaucya Madazio, PhD Fonoaudiologa Especialista em Voz Consultora em Comunicacao Humana Sao Paulo, SP, Brazil Chapter 3 Stephen C. McFarlane, PhD Foundation Professor/Professor Emeritus Speech Pathology Department University of Nevada, School of Medicine Reno, Nevada Chapter 4 Claudio F. Milstein, PhD Director The Voice Center Cleveland Clinic Associate Professor Otolaryngology Cleveland Clinic Lerner College of Medicine Cleveland, Ohio Chapter 3 Jennifer C. Muckala, MA, CCC-SLP Senior Speech Pathologist Singing Voice Specialist Vanderbilt Voice Center Nashville, Tennessee Chapter 7 Chayadevie Nanjundeswaran, PhD Assistant Professor Department of Audiology and SpeechLanguage Pathology

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East Tennessee State University Johnson City, Tennessee Chapter 4 Gisele Oliveria, PhD Associate Professor CEV–Centro de Estudos da Voz Sao Paulo, SP, Brazil Assistant Professor Touro College Brooklyn, New York Chapter 4 Bryn Olson, MS Speech-Language Pathologist The Communication Development Center Madison, Wisconsin Chapter 8 Diana M. Orbelo, PhD Assistant Professor Mayo Clinic College of Medicine Rochester, Minnesota Chapter 3 Rita R. Patel, PhD Assistant Professor Department of Hearing and Speech Sciences Indiana University Bloomington, Indiana Chapter 3 Madeleine Pethan, MA Speech-Language Pathologist Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapter 6 Brian E. Petty, MA, MA Speech-Language Pathologist Emory Voice Center

Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapter 7 Bruce J. Poburka, PhD Professor Communication Disorders Minnesota State University, Mankato Mankato, Minnesota Chapter 4 Carissa Portone-Maira, MS Lead Speech-Language Pathologist Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapters 3 and 8 Lorraine Ramig, PhD Professor University of Colorado-Boulder Senior Scientist National Center for Voice and Speech-Denver Adjunct Professor Columbia University New York, New York Chapter 5 Linda Rammage, PhD, RSLP Director Provincial Voice Care Resource Program, UBC Vancouver, BC, Canada Chapter 6 Christin Ray, MA (ABD) Doctoral Candidate Department of Speech and Hearing Science The Ohio State University Columbus, Ohio Chapter 6

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Clark A. Rosen, MD, FACS Professor Department of Otolaryngology University of Pittsburgh School of Medicine Director University of Pittsburgh Voice Center Pittsburgh, Pennsylvania Chapter 4 Nelson Roy, PhD, CCC-SLP, ASHAF Professor Department of Communication Sciences and Disorders Division of Otolaryngology-Head & Neck Surgery Department of Surgery, School of Medicine University of Utah Salt Lake City, Utah Chapter 3 Brienne Ruel, MA Speech-Language Pathologist UW Voice and Swallow Clinics, Department of Surgery Madison, Wisconsin Chapter 7 Mary J. Sandage, PhD Assistant Professor Auburn University Auburn, Alabama Chapter 6 Christine M. Sapienza, PhD Program Director Speech Pathology Associate Dean College of Health Sciences Jacksonville University Jacksonville, Florida Research Career Scientist BRRC Malcolm Randall VA Gainesville, Florida Chapters 4 and 7

Sarah L. Schneider, MS Director Speech-Language Pathology UCSF Voice and Swallowing Center University of California, San Francisco San Francisco, California Chapter 7 Sandra A. Schwartz, MS Clinical Faculty/Instructor Duquesne University Pittsburgh, Pennsylvania Chapter 3 Erin Silverman, PhD Research Assistant Professor University of Florida Gainesville, Florida Chapter 4 Tara Stadelman-Cohen, BM, MS Senior Voice Pathologist Center for Laryngeal Surgery and Voice Rehabilitation Massachusetts General Hospital Adjunct Clinical Instructor School of Health and Rehabilitation Sciences MGH Institute of Health Professions Part-time Faculty Boston Conservatory Boston, Massachusetts Chapter 3 Heather Starmer, MA Assistant Professor Department of Otolaryngology-Head & Neck Surgery Johns Hopkins University Baltimore, Maryland Chapter 3 Joseph C. Stemple, PhD, CCC-SLP, ASHAF Professor Communication Sciences and Disorders

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College of Health Sciences University of Kentucky Lexington, Kentucky Chapters 1, 2, 3, 4, 5, and 8 R.E. Stone Jr, PhD Retired Director of Speech-Language Pathology Vanderbilt Voice Center Vanderbilt Bill Wilkerson Department of Communication Sciences and Disorders Nashville, Tennessee Chapter 3 Jennifer Thompson, MA Clinical Voice Pathologist Clinical Instructor James Care Voice and Swallowing Disorders Clinic The Ohio State University Columbus, Ohio Chapter 6 Lyn Tindall Covert, PhD Speech-Language Pathologist Department of Veterans Affairs Medical Center Lexington, Kentucky Chapter 5 Michael D. Trudeau, PhD Emeritus Associate Professor The Ohio State University Columbus, Ohio Chapter 6 Eva van Leer, PhD, MFA Assistant Professor Department of Education Psychology, Special Education, and Communication Disorders College of Education Georgia State University Atlanta, Georgia Chapter 8

Miriam van Mersbergen, PhD Assistant Professor Speech-Language Pathology Northern Illinois University DeKalb, Illinois Chapter 7 Jarrad Van Stan, MA, BRS-S Senior Clinical Research Coordinator Speech-Language Pathologist MGH Center for Laryngeal Surgery and Voice Rehabilitation PhD Student MGH Institute of Health Professions Boston, Massachusetts Chapter 3 Katherine Verdolini Abbott, PhD Professor Department of Communication Science and Disorders, Otolaryngology McGowan Institute for Regenerative Medicine University of Pittsburgh Center for the Neural Basis of Cognition Carnegie-Mellon University and University of Pittsburgh Pittsburgh, Pennsylvania Chapter 3 Shelley Von Berg, PhD Associate Professor Communication Sciences and Disorders California State University, Chico Chico, California Chapter 4 Nicole Yee-Key Li, PhD, M.Phil. Assistant Professor University of Maryland-College Park College Park, Maryland Chapter 3

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Aaron Ziegler, MA (ABD) Doctoral Candidate University of Pittsburgh Pittsburgh, Pennsylvania Chapter 4

1 Principles of Voice Therapy

Introduction In preparing the fourth edition of this text, it was necessary to review almost 80 years of history related to voice therapy techniques and approaches. It is a rich and interesting history that gives an excellent understanding of how the treatment of voice disorders has grown and evolved to our present practice. Some of the therapy approaches developed by early speech pathologists continue to be used successfully in the remediation of voice disorders to this day. Because of the growth in our knowledge and understanding of voice production, other therapy approaches once commonly used were proven to be ineffective. The past 30 years have yielded tremendous growth in our knowledge and understanding of vocal function. Computer models of phonation,1–6 histologic studies of the vocal folds,7–10 analysis of the vocal fold cover and tissue engineering,11–19 and genetic issues

associated with voice disorders20–23 are but a few of the many advances in voice science. Furthermore, consider the rapidly evolving ability to measure and describe normal and pathologic voice function objectively through sophisticated acoustic and aerodynamic instrumentation, as well as the ability to observe vocal fold vibration. All of these scientific advancements have provided voice clinicians with the tools to confirm the efficacy of their approaches. The number of traditional therapy approaches that continue to be used in voice therapy today is a strong statement of appreciation and admiration for the voice pedagogues, clinicians, and scientists of earlier days. The accuracy of their practical observations regarding voice function has proved to be uncanny. The efficacy of many of these traditional voice therapy techniques is now being tested through systematic outcomes research.24 Proof of the usefulness of many of these techniques, however, has been well established by

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the clinical results of skilled speechlanguage pathologists. The major difference in voice therapy today compared with even 20 to 25 years ago is the ability to diagnose a problem quickly and accurately and to confirm the efficacy of our management approaches through objective measures. These objective measures may also be used as patient feedback during the therapeutic process. Although our management approaches have changed over the years, voice therapy remains a blend of science and art. The scientific nature of voice therapy involves the clinician’s knowledge of several important areas of study. These areas include the anatomy and physiology of normal and pathologic voice production; the nuances of laryngeal pathologic conditions; the acoustics and aerodynamics of voice production; and the etiologic correlates of voice disorders, including patient behaviors, medical causes, and psychological contributions: n When considering the voice, we are

considering the most widely used instrument on earth. n To understand the voice disorder, we must understand the instrument’s physical structure and functional components. n We must have the skills to measure these components objectively and to relate these measures to our management choices. n In addition, we must possess a broad knowledge of the common causes of voice disorders and the nuances of laryngeal pathologic conditions. The artistic nature of voice therapy is dependent on the human interaction skills of the clinician. Compassion,

understanding, empathy, and projection of credibility, together with listening, counseling, and motivational skills are essential attributes of the successful voice clinician. Philosophically, we might make these statements about the artistic nature of voice: n When considering the voice, we must

consider the whole person. n To examine a voice disorder is to examine a unique individual. n The feelings of that individual, both physical and emotional, may be directly reflected in the voice. n To remediate a voice disorder, we must have the skills to counsel and motivate the patient and empower readiness for change. The successful voice clinician will combine attributes of the artistic approaches toward voice therapy with the objective scientific bases to identify the problem and then plan and carry out appropriate management strategies. Nonetheless, possession of a solid base of didactic information augments experience. Experience continues to teach even the masters. It is hoped that the experiences of others provided in this text will prove helpful in the development of superior voice clinicians.

Historical Perspective In examining the evolution of the treatment of voice disorders, we find it was not until around 1930 that a few laryngologists, singing teachers, instructors in the speech arts, and a fledgling group of speech correctionists became interested in retraining individuals with voice disorders. This group used drills

and exercises borrowed from voice and diction manuals designed for the normal voice in an attempt to modify disordered voice production. Many of these rehabilitation techniques were and remain creative and effective, but they were not necessarily based on scientific principles. The “artistic” portion of voice treatment was the strong point of early clinicians. Out of this artistic approach came the general treatment suggestions of: (1) ear training, (2) breathing exercises, (3) relaxation training, (4) articulatory compensations, (5) emotional retraining, and (6) special drills for cleft palate and velopharyngeal insufficiency.25,26 These treatment suggestions became the foundation of vocal rehabilitation. Several general management philosophies have arisen from the early foundations of voice rehabilitation. These philosophical orientations are based primarily on the clinician’s mindset and previous training regarding voice disorders that directs the management focus. For the sake of discussion, we classify these management philosophies as: n hygienic voice therapy n symptomatic voice therapy n psychogenic voice therapy n physiologic voice therapy n eclectic voice therapy

In short, hygienic voice therapy focuses on identifying inappropriate vocal hygiene behaviors, which then are modified or eliminated. Once modified, voice production has the opportunity to improve or return to normal. Symptomatic voice therapy focuses on modification of the deviant vocal symptoms identified by the speech-language pathologist, such as breathiness, low pitch, glottal


attacks, and so on. The focus of psychogenic voice therapy is on the emotional and psychosocial status of the patient that led to and maintains the voice disorder. The physiologic orientation of voice therapy focuses on directly modifying and improving the balance of laryngeal muscle effort to the supportive airflow, as well as the correct focus of the laryngeal tone. Finally, the eclectic approach of voice therapy is the combination of any and all of the previous voice therapy orientations.27 None of these philosophical orientations are pure. Much overlap is present, often leading to the use of an eclectic approach. With this introduction, let us examine the orientations of voice therapy in greater detail.

Hygienic Voice Therapy Hygienic voice therapy often is the first step in many voice therapy programs. Many etiological factors contribute to the development of voice disorders. Poor vocal hygiene may be a major developmental factor. Some examples of behaviors that constitute poor vocal hygiene include shouting, talking loudly over noise, screaming, vocal noises, coughing, throat clearing, and poor hydration. When the inappropriate vocal behaviors are identified, then appropriate treatments can be devised for modifying or eliminating them. Once modified, voice production has the opportunity to improve or return to normal. Poor vocal hygiene may also include the habitual use of inappropriate pitch or loudness, reduced respiratory support, poor phonatory habits (glottal attacks, fry), or inappropriate resonance. Functional inappropriate use of

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these voice components may contribute to the development and maintenance of a voice disorder. Hygienic voice therapy presumes that many voice disorders have a direct behavioral cause. This therapy strives to instill healthy vocal behaviors in the patient’s habitual speech patterns. Good vocal hygiene also focuses on maintaining the health of the vocal fold cover through adequate internal hydration and diet. Once identified, poor vocal hygiene habits can be modified or eliminated leading to improved voice production.

Symptomatic Voice Therapy Symptomatic voice therapy was a term first introduced by Daniel Boone.28 This voice management approach is based on the premise that modifying the symptoms of voice production including pitch, loudness, respiration, and so on, will improve the voice disorder. Once identified, the misuses of these various voice components are modified or reduced using voice therapy facilitating techniques. In the voice clinician’s attempt to aid the patient in finding and using his best voice production, it is necessary to probe continually within the patient’s existing repertoire to find the best one voice which sounds “good” and which he is able to produce with relatively little effort. A voice therapy facilitating technique is that technique which, when used by a particular patient, enables him easily to produce a good voice. Once discovered, the facilitating technique and resulting phonation become the symptomatic focus of voice therapy . . . This use of a facilitating technique to produce a

good phonation is the core of what we do in symptomatic voice therapy for the reduction of hyperfunctional voice disorders.28(p11)

Boone’s original facilitating approaches included: 1. altering of tongue position 2. change of loudness 3. chewing exercises 4. digital manipulation 5. ear training 6. elimination of abuses 7. elimination of hard glottal attack 8. establishment of a new pitch 9. explanation of the problem 10. feedback 11. hierarchy analysis 12. negative practice 13. open mouth exercises 14. pitch inflections 15. pushing approach 16. relaxation 17. respiration training 18. target voice models 19. voice rest 20. yawn-sigh approach Many if not all of these facilitators remain useful and popular in the treatment of voice disorders and are described in greater detail in cases throughout this text. The main focus of symptomatic voice therapy is direct modification of vocal symptoms. For example, if the patient presents with a voice quality characterized by low pitch, breathiness, and hard glottal attacks, then the main focus of therapy is to directly modify the symptoms. The facilitating approaches used to modify these symptoms might include explanation of the problem, ear training, elimination of hard glot-


tal attack, and respiration training. The speech-language pathologist constantly probes for the “best” voice and attempts to stabilize that voice with the various, appropriate facilitating techniques. Symptomatic voice therapy assumes voice improvement through direct symptom modification.

Psychogenic Voice Therapy Early in the study of voice disorders, the relationship of emotions to voice production was well recognized. As early as the mid-1800s, journal articles discussed hysteric aphonia.29,30 West, Kennedy, and Carr26 and Van Riper25 discussed the need for emotional retraining in voice therapy. Murphy31 presented an excellent discussion of the psychodynamics of voice. Friedrich Brodnitz,32 as an otolaryngologist, was uniquely sensitive to the relationship of emotions to voice. These early readings are most interesting and remain informative to those treating voice disorders. Our understanding of psychogenic voice therapy was further expanded by Aronson,33 Case,34 Stemple,35 and Colton and Casper.36 These authors discussed the need for determining the emotional dynamics of the voice disturbance. Psychogenic voice therapy focuses on identification and modification of the emotional and psychosocial disturbances associated with the onset and maintenance of the voice problem. Pure psychogenic voice therapy is based on the assumption of underlying emotional causes. Voice clinicians, therefore, must develop and possess superior interview skills, counseling skills, and the skill to know when the treatment

for the emotional or psychosocial problem is beyond the realm of their skills. A referral system of support professionals must be readily available.

Physiologic Voice Therapy Physiologic voice therapy includes voice therapy programs that have been devised to directly alter or modify the physiology of the vocal mechanism. Normal voice production is dependent on a balance among airflow, supplied by the respiratory system; laryngeal muscle balance, coordination, and stamina; and coordination among these and the supraglottic resonatory structures (pharynx, oral cavity, and nasal cavity). Any disturbance in the physiologic balance of these vocal subsystems may lead to a voice disturbance.37 These disturbances may be in respiratory volume, power, pressure, and flow. Disturbances also may manifest in vocal fold tone, mass, stiffness, flexibility, and approximation. Finally, the coupling of the supraglottic resonators and the placement of the laryngeal tone may cause or may be perceived as a voice disorder. The overall causes may be mechanical, neurologic, or psychological. Whatever the cause, the management approach is direct modification of the inappropriate physiologic activity through exercise and manipulation. Inherent in physiologic voice therapy is a holistic approach to the treatment of voice disorders. They are therapies that strive to at once balance the three subsystems of voice production as opposed to working directly on single voice components, such as pitch or loudness. Examples of physiologic voice

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therapy include Vocal Function Exercises,38 Resonant Voice Therapy,39 and the Accent Method of Voice Therapy,40 all of which are presented in this text.

Eclectic Voice Therapy Adherence to one philosophical orientation of voice therapy would not be advisable. Successful voice therapy depends on utilization of an approach that happens to work for the therapist and the individual patient. The more management approaches are understood and mastered by the clinician, the greater the likelihood for success. Management techniques that prove successful for one patient may not be successful for a similar patient. The clinician, therefore, must possess the knowledge to adjust the management approach. Some techniques that work well for one therapist may prove to be difficult for another. In whatever management approach you choose, you must have supreme confidence in your understanding of the technique and your ability to make that approach work successfully. Your confidence is one factor that will determine the success or failure of therapy. Using a typical case, let us examine how each therapy orientation might be used to treat the vocal difficulties of this composite patient.

Case Study: Patient A Patient A, a 52-year-old woman, was referred by her laryngologist to the voice center for postsurgical evaluation and treatment. Large, bilateral, draping polyps were first identified by an anes-

thesiologist while intubating the patient for a laminectomy 6 months prior to her voice evaluation. Because of the large polyps, intubation had been difficult. The problem was reported to her family physician, who in turn referred the patient to an otolaryngologist for a laryngeal examination. Indirect mirror examination revealed bilateral polypoid degeneration, worse on the left than the right. Audible inspiratory stridor was noted by the physician, and the patient reported shortness of breath during even limited physical exertion. Therefore, two surgeries (one for each vocal fold) were scheduled 6 weeks apart for aspiration of fluid and laser vaporization of redundant tissue. The surgeries were performed without complication, and the patient was seen for voice evaluation following appropriate healing.

History of the Problem The patient reported that she had always had a “deep” voice, which had lowered even more over the past several years. Her presurgical voice quality had not been a concern to her, however. Instead, it was the shortness of breath that led her to agree to surgery. She reported that voice quality following the first surgery (left fold) was a little “hazy” but returned to “normal” within 1 week. The second surgery left her with significant, bothersome hoarseness that made her “wish I had never had surgery.”

Medical History The patient reported undergoing two previous surgeries: removal of her gall bladder 10 years earlier and the lami-

nectomy performed earlier this year. Even with the difficult intubation and the risk of vocal fold paralysis inherent in laminectomy, her presurgical voice quality was maintained. In addition to surgeries, she had been hospitalized 3 years before for 3 weeks and treated for chronic depression. Chronic medical disorders included frequent upper respiratory infections including bronchitis, high blood pressure, circulatory problems in her legs, elevated blood sugar, and chronic neck and back pain. Daily medications were taken for blood pressure, chronic pain, depression, and sleep. She continued a 30-year history of smoking 1½ to 2 packs of cigarettes per day. Her liquid intake consisted mostly of 6 cups of caffeinated coffee per day. Chronic throat clearing and a persistent cough were noted throughout the evaluation.

Social History Patient A had been married for 12 years to her second husband, following a first marriage of 18 years and divorce. She had two adult children from her previous marriage. Her elderly mother-inlaw lived with her and her husband, a situation that often caused friction and conflict with her husband. She was not shy in reporting her unhappiness with her marital relationship. This unhappiness was said to be a major factor in her history of depression. Both the patient and her husband were employed by the local automobile assembly plant. She had worked as an assembler for 14 years in an environment described as “noisy, dusty, and full of fumes” and was on a temporary medical disability because her back problems precluded her working in the


plant. Present activities included shopping with her daughter, talking on the telephone, caring for her home (back permitting), watching daytime television “talk” shows, and bowling two nights per week in two different leagues.

Voice Evaluation Perceptually, the patient’s voice quality was described as moderately dysphonic, characterized by low pitch, inappropriate loudness, strained raspiness, and intermittent glottal fry phonation. Acoustic and aerodynamic analyses revealed a low fundamental frequency (150 Hz), limited frequency range (118–290 Hz), increased habitual intensity (76 dB), normal airflow volume (2300 mL H2O), reduced airflow rate (<80 mL H2O/s), and reduced maximum phonation time (<12 s). Laryngeal videostroboscopic observation revealed mild-to-moderate bilateral true vocal fold edema and erythema. Glottic closure demonstrated an irregular glottal chink with a moderate ventricular fold compression. The edges of the vocal folds were rough and irregular, worse on the left than on the right. The amplitude of vibration was severely decreased bilaterally. The mucosal waves were barely perceptible. The closed phase of the vibratory cycle was strongly dominant, whereas the symmetry of vibration was generally irregular. No mass lesions, paresis, or paralysis was evident. In short, the patient had an edematous, stiff, hyperfunctioning vocal fold system.

Impressions Patient A presented with a voice disorder that derived from the following possible causal factors:

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n cigarette smoking n harsh employment environment n talking over noise at work n large caffeine intake n frequent upper respiratory infections n prescription medications n coughing and throat clearing n emotional instability n talking too loudly (suggesting pos-

sible hearing loss, which later proved not to be present) n using a low pitch n laryngeal muscle tension n postsurgical vocal fold mucosal changes

Recommendations Hygienic Voice Therapy The general focus would be to identify the primary and secondary vocal misuses and then to modify or eliminate these nonhygienic behaviors. The primary etiologic correlates include: n Smoking n Laryngeal dehydration from caffeine

and drugs

n Voice abuse, such as coughing, throat

clearing, and talking loudly over noise at work

Secondary precipitating factors that result from the pathologic condition include: n Laryngeal area muscle tension and

hyperfunction caused by vocal fold stiffness n Low pitch caused by increased mass n Increased loudness caused by the effort used to force stiff vocal folds to vibrate Therapy would focus on modification or elimination of the primary

causes. The patient would be aided in her attempt to stop smoking, encouraged to begin a hydration program, and given vocal hygiene counseling to aid in elimination or reduction of the vocally abusive behaviors. The secondary causes most likely would improve spontaneously as the primary causes were modified and the vocal fold condition improved. Symptomatic Voice Therapy The general focus would include use of facilitating techniques to: n raise pitch n reduce loudness n reduce laryngeal area tension and

effort

This direct symptom modification would follow an explanation of the problem and would run concurrently with modification of vocally abusive behaviors, including: n smoking n caffeine intake n coughing and throat clearing

Psychogenic Voice Therapy The general focus would be to explore the psychodynamics of the voice disorder. Techniques would include: n Detailed interview with the patient

to determine the cause and effects of depression n Determination of the relationship of emotional problems and voice problem n Counseling of the patient regarding the effects of emotions on voice production

n Reduction of the musculoskeletal

tension with the use of laryngeal manipulation/laryngeal massage n Referral for marital counseling as deemed appropriate. The secondary focus would deal with modification or elimination of the abusive behaviors, including: n smoking n caffeine and medications n coughing and throat clearing

Inappropriate use of pitch and loudness would most likely be viewed as obvious symptoms of the problem. These symptoms would likely improve as the psychodynamics were improved. Physiologic Voice Therapy The general focus would be on evaluating the present physiologic condition of the patient’s voice production and developing direct physical exercises to improve that condition. We know that the patient presented with extreme laryngeal tension. Irregular vocal fold edges caused a glottal chink. In addition, her vocal folds were extremely stiff, both in amplitude and mucosal wave. Normal voicing is dependent on near total closure of the vocal folds, permitting air pressure to build below the folds. As the pressure builds, it eventually overcomes the resistance of the approximated folds, permitting the release of one puff of air. As the air rushes between the vocal folds, subglottal, supraglottal, and intraglottal pressures, along with the static position of the vocal folds, draw them back together to complete one vibratory cycle. Air gaps, or glottal chinks, change the physical dynamics of vocal


fold vibration, requiring an increased subglottic pressure. Patients such as this woman often make physical compensations in an attempt to push out the “best” voice by hyperfunctioning the supraglottic structures. Add vocal fold muscular and mucosal stiffness to this mix, and the patient presents with a significant muscle tension dysphonia with associated respiratory, laryngeal, and resonance dysfunctions. Direct physiologic voice therapy would focus on exercises designed to rebalance the three subsystems of voice production: respiration, phonation, and resonance. Therapy methods chosen to accomplish this task might include Vocal Function Exercises, Resonant Voice Therapy, or the Accent Method of Voice Therapy. (All methods are described in subsequent chapters.) Eclectic Voice Therapy In this review of philosophical orientations of voice therapy, you have seen the various strengths of each management orientation, as well as the difficulty in subscribing to any one philosophy. All patients will be treated best by a speechlanguage pathologist with knowledge and understanding of all possible management strategies and alternatives. As you read and study the many case presentations of this text, it is beneficial to evaluate the philosophy behind the treatment approach as a means of better understanding the reasons for the approach. The successful speechlanguage pathologist is both an artist and a scientist with an eclectic point of view. Therapy for Patient A should focus on: n vocal hygiene counseling n symptom modification

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n attention to the psychodynamics of

the problem n direct physiologic vocal exercise

Voice Care Professionals Thus far, we have discussed the treatment of voice disorders in terms of direct voice therapy. Voice care, however, is a shared province, with contributions from the primary care physician, laryngologist, speech-language pathologist, neurologist, allergist, gastroenterologist, pulmonologist, psychologist, vocal coach, singing instructor, and others. Case studies presented in all chapters of this text describe the unique interdisciplinary and complementary relationships of each of these professionals with the others and with their patients.

References 1. Alipour F, Berry DA, Titze IR. A finite element model of vocal-fold vibration. J Acoust Soc Am. 2000;108(6):3003–3012. 2. Hunter EJ, Titze IR, Alipour F. A threedimensional model of vocal fold abduction/adduction. J Acoust Soc Am. 2004; 115(4):1747–1759. 3. Story BH, Titze IR. Voice simulation with a body-cover model of the vocal folds. J Acoust Soc Am. 1995;97(2):1249–1260. 4. Titze IR. The human vocal cords: a mathematical model. I. Phonetica. 1973;28(3): 129–170. 5. Titze IR. The human vocal cords: a mathematical model. II. Phonetica. 1974;29(1): 1–21. 6. Titze IR, Hunter EJ. A two-dimensional biomechanical model of vocal fold posturing. J Acoust Soc Am. 2007;121(4): 2254–2260.

7. Kersing W, Jennekens FG. Age-related changes in human thyroarytenoid muscles: a histological and histochemical study. Eur Arch Otorhinolaryngol. 2004; 261(7):386–392. 8. Kahane JC. Histologic structure and properties of the human vocal folds. Ear Nose Throat J. 1988;67(5):322, 324–325, 329–330. 9. Hirano M. Morphological structure of the vocal cord as a vibrator and its variations. Folia Phoniatr (Basel). 1974;26(2):89–94. 10. Gray SD, Titze IR, Alipour F, Hammond TH. Biomechanical and histologic observations of vocal fold fibrous proteins. Ann Otol Rhinol Laryngol. 2000;109(1): 77–85. 11. Duflo S, Thibeault SL, Li W, Shu XZ, Prestwich GD. Vocal fold tissue repair in vivo using a synthetic extracellular matrix. Tissue Eng. 2006;12(8):2171–2180. 12. Hansen JK, Thibeault SL. Current understanding and review of the literature: vocal fold scarring. J Voice. 2006; 20(1):110–120. 13. Hansen JK, Thibeault SL, Walsh JF, Shu XZ, Prestwich GD. In vivo engineering of the vocal fold extracellular matrix with injectable hyaluronic acid hydrogels: early effects on tissue repair and biomechanics in a rabbit model. Ann Otol Rhinol Laryngol. 2005;114(9):662–670. 14. Chen X, Thibeault SL. Novel isolation and biochemical characterization of immortalized fibroblasts for tissue engineering vocal fold lamina propria. Tissue Eng Part C Methods. 2009;15(2):201–212. 15. Schweinfurth JM, Thibeault SL. Does hyaluronic acid distribution in the larynx relate to the newborn’s capacity for crying? Laryngoscope. 2008;118(9): 1692–1699. 16. Thibeault SL, Duflo S. Inflammatory cytokine responses to synthetic extracellular matrix injection to the vocal fold lamina propria. Ann Otol Rhinol Laryngol. 2008;117(3):221–226. 17. Thibeault SL, Klemuk SA, Smith ME, Leugers C, Prestwich G. In vivo compar-

ison of biomimetic approaches for tissue regeneration of the scarred vocal fold. Tissue Eng Part A. 2009;15(7):1481–1487. 18. Hirschi SD, Gray SD, Thibeault SL. Fibronectin: an interesting vocal fold protein. J Voice. 2002;16(3):310–316. 19. Ward PD, Thibeault SL, Gray SD. Hyaluronic acid: its role in voice. J Voice. 2002;16(3):303–309. 20. Duflo SM, Thibeault SL, Li W, Smith ME, Schade G, Hess MM. Differential gene expression profiling of vocal fold polyps and Reinke’s edema by complementary DNA microarray. Ann Otol Rhinol Laryngol. 2006;115(9):703–714. 21. Rousseau B, Ge PJ, Ohno T, French LC, Thibeault SL. Extracellular matrix gene expression after vocal fold injury in a rabbit model. Ann Otol Rhinol Laryngol. 2008;117(8):598–603. 22. Thibeault SL, Hirschi SD, Gray SD. DNA microarray gene expression analysis of a vocal fold polyp and granuloma. J Speech Lang Hear Res. 2003;46(2):491–502. 23. Thibeault SL, Smith ME, Peterson K, Ylitalo-Moller R. Gene expression changes of inflammatory mediators in posterior laryngitis due to laryngopharyngeal reflux and evolution with PPI treatment: a preliminary study. Laryngoscope. 2007;117(11):2050–2056. 24. Thomas L, Stemple J. Voice therapy: does science support the art? Comm Disord Rev. 2007;1(1):51–79. 25. Van Riper C. Speech Correction Principles and Methods. Englewood Cliffs, NJ: Prentice Hall; 1939. 26. West R, Kennedy L, Carr A. The Rehabilitation of Speech. New York, NY: Harper & Brothers; 1937. 27. Stemple J, Glaze L, Klaben B. Clinical


Voice Pathology: Theory and Management. 3rd ed. San Diego, CA: Singular; 2000. 28. Boone D. The Voice and Voice Therapy. Englewood Cliffs, NJ: Prentice Hall; 1971. 29. Goss F. Hysterical aphonia. Boston Med Surg J. 1878;99:215–222. 30. Russell J. A case of hysterical aphonia. Brit Med J. 1864;8:619–621. 31. Murphy A. Functional Voice Disorders. Englewood Cliffs, NJ: Prentice Hall; 1964. 32. Brodnitz F. Vocal Rehabilitation. Rochester, NY: American Academy of Ophthalmology and Otolaryngology; 1971. 33. Aronson A. Clinical Voice Disorders: An Interdisciplinary Approach. New York, NY: Brian C. Decker; 1980. 34. Case J. Clinical Management of Voice Disorders. 3rd ed. Austin, TX: Pro-Ed; 1996. 35. Stemple J. Clinical Voice Pathology: Theory and Management. Columbus, OH: Charles E. Merrill; 1984. 36. Colton R, Casper J. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. Baltimore, MD: Williams & Wilkins; 1996. 37. Stemple JC, Glaze L, Klaben BG. Clinical Voice Pathology: Theory and Management. San Diego, CA: Singular; 2000. 38. Stemple JC, Lee L, D’Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice. 1994;8(3):271–278. 39. Verdolini K. Resonant Voice Therapy. Iowa City, IA: National Center for Voice and Speech; 1998. 40. Kotby MN, Shiromoto O, Hirano M. The accent method of voice therapy: effect of accentuations on F0, SPL, and airflow. J Voice. 1993;7(4):319–325.

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2 Comments on Voice Evaluation

Introduction Voice clinicians use a variety of tools to evaluate and document voice disorders. Traditional components of the voice evaluation have included the medical examination to diagnose the disorder, systematic interviewing of the patient to determine causes, and a perceptual voice evaluation to describe the vocal symptoms. Other tools include acoustic and aerodynamic measures of voice production, along with observation of vocal fold vibration through laryngeal videostroboscopy,1 kymography,2,3 and high-speed digital imaging.4–7 Information gathered through these evaluation tools will provide: n An understanding of the perceptual

symptoms n A means of systematically describing the vocal condition

n Pretreatment and post-treatment

measures used to describe the efficacy of intervention n Patient education and feedback. Many of the case studies presented in this text use instrumental measures of voice production. Although instrumental measures are an important adjunct to the traditional components of voice evaluation, they are not meant to replace any other component. The eyes and ears of the physician and the clinician cannot be replaced. The most important aspect of the diagnostic voice evaluation is the ability to talk to one’s patients — that is, to conduct a patient interview that will yield the necessary diagnostic information. If only one evaluation component was available to me, the patient interview would be my choice. Another important aspect of the evaluation process is gaining an understanding of the functional impact of

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the voice disorder on the individual in daily life. Those in clinical practice know that individual patients will perceive similar voice disorders differently. For example, a professional voice user with vocal nodules may be devastated by the effect that nodules have on the voice, whereas a computer programmer may not consider the mild hoarseness to be a problem. One method of gaining this functional measure is through the use of validated tools that measure the patient’s self-assessment of the voice disorder.8,9 The primary objective of the voice evaluation is to uncover etiologic, physiologic, or behavioral factors specific to the development and persistence of the voice disorder. Voice pathologists will use all of their scientific acumen and artistic skill in a systematic evaluation to determine these specific causes. In addition, a detailed analysis of the vocal symptoms, both subjective and objective, will be completed. A systematic management approach will be the result. Secondary objectives of the diagnostic evaluation include education and motivation of the patient and the establishing of credibility and trust in the voice pathologist. Most patients have little knowledge or understanding of the normal voice, to say nothing of their own voice disorders. During the voice evaluation, the speech-language pathologist (SLP) may find it useful to explain, in simple terms, normal voicing and how it relates to the patient’s current problem. Videostroboscopy, when available, is invaluable as a patient educator and often encourages patients to become partners in their own care. The better understanding patients have of their voice disorders, the more helpful they can be in answering questions designed to discover the causes of their

voice disorders. In addition, the wellinformed patient may better understand the therapy process and therefore is ready to adhere to the therapy process and change behavior. It is essential that the credibility of the SLP be established early during the evaluation. Many probing questions regarding the patient’s personal life must be asked in seeking etiologic factors. The patient must trust the voice pathologist’s intent to use this information appropriately. The voice pathologist who projects a casual yet professional demeanor may develop credibility and trust at the initial patient contact. This type of relaxed demeanor will reduce anxieties and establish an atmosphere for easy discussion. Once the primary etiologic factors have been discovered, the vocal symptoms have been subjectively and objectively described, the impact of the disorder has been determined, the patient has been educated, and the clinician has established credibility, the management plan can be outlined. When patients understand the causes of the problem and are presented with a systematic management approach, along with a reasonable estimated time for completion, a positive therapeutic attitude usually is developed.

Management Team Evaluation and management of patients with voice disorders increasingly have been accomplished through the teamwork of several professionals. The two primary professionals are laryngologists and SLPs. SLPs who specialize in the treatment of voice disorders are sometimes called voice pathologists. You will


notice that both terms, SLP and voice pathologist, are used by case study contributors in this text. Other medical specialists who might contribute to the care of patients with voice disorders include allergists, pulmonologists, gastroenterologists, and neurologists, among others. In addition, speech/voice trainers and singing teachers or coaches may be part of the team. The laryngologist is trained to examine the laryngeal mechanism and to determine the need for medical, surgical, or behavioral intervention. The voice pathologist is trained to identify the precipitating and persisting functional causes of the voice problem, evaluate the vocal symptoms, and establish improved vocal function through various therapeutic methods. The speech/ voice trainer or singing teacher judges the efficiency and correctness of performance technique and suggests modifications as deemed necessary. This complementary professional relationship has significantly improved the care of the voice-disordered population.

viewed on a monitor. A laryngeal stroboscope also may be used with the digital video equipment and endoscopes to provide a simulated, slow-motion view of vocal fold vibration. The vocal folds also may be viewed directly through direct laryngoscopy performed in the operating room. During this surgical procedure, the patient receives general anesthesia, and a magnifying laryngoscope is placed into the oral cavity and pharynx to yield a direct view of the larynx. Biopsies and surgical excisions also may be performed through the laryngoscope. This procedure is generally limited to patients requiring surgical intervention or exploration and is not a routine diagnostic test of vocal health. The medical examination also may include special radiographs of the head and neck, as well as blood analysis and swallow studies. The final result of the medical examination is a diagnosis of the problem and recommendations for treatment including medical, surgical, voice evaluation, and voice therapy, or any combination thereof.

Medical Examination A laryngologic examination involves examination of the entire head and neck region, as well as a detailed medical history. It includes otoscopic examination of the ears; observation of the oral and nasal cavities; palpation of the salivary glands, lymph nodes, and thyroid gland; and a visual examination of the larynx. The visual examination of the larynx may be performed in the office using indirect mirror observation, a fiber-optic nasal endoscope, or a rigid oral endoscope. The fiber-optic or rigid scopes may be attached to a digital camera, permitting the vocal folds to be

Voice Pathology Evaluation The evaluation format presented here may be classified as semistructured. The basic questions remain the same from patient to patient, but the answers given by individual patients dictate the direction in which the questioning will proceed and the order in which each diagnostic section is reviewed. This format favors the more experienced voice pathologist. The beginning clinician may feel the need for a more structured format. As experience is gained, the structured formats may prove limiting, and

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the semistructured method is often the method of choice. Some voice pathologists also feel most comfortable audio or video recording the entire diagnostic session for later review. This may help in determining the exact vocal components produced during the evaluation and serves as a record of the baseline voice quality. Even if the entire diagnostic session is not recorded, recording of a standard speech sample is necessary for later comparison. It is not unusual for the voice pathologist and the patient to forget the actual severity of the baseline quality. Audio recordings serve as an objective reminder and should be used liberally. When referral is made for a diagnostic voice evaluation, the four major objectives of the voice pathologist are to do the following: 1. Uncover etiologic, physiologic, or behavioral factors specific to the development and persistence of the voice disorder. 2. Describe the aberrant respiratory, phonatory, resonatory, and articulatory components in the voice. 3. Determine prognosis for treatment through trial therapy. 4. Develop an individualized treatment plan. Various methods have been used to identify the precipitating and persisting behavioral causes of the voice disorder and those that might impact optimal surgical outcomes. These methods include the formal interview with the patient or a predeveloped case history form to be completed either by the patient or by the patient and clinician together. This author finds prepared forms to be restrictive and prefers to use the patient interview format. Beginning clinicians may find prepared question-

naires useful, however. The following interview procedure (reprinted from Stemple, Glaze, and Klaben10) describes specific goals for each component of the patient interview, as well as pertinent areas of investigation.

Referral The primary referral source will be the otolaryngologist, but referrals may also come from other physician specialties like pulmonology, gastroenterology, allergy, and neurology. Speech-language pathologists, singing teachers, and voice coaches are referral sources as are the patient’s relatives and friends, or the patient may be self-referred.

Reason for the Referral The goals are to: n establish the exact reasons for patient

referral

n establish patient understanding of

the referral

n develop the patient’s knowledge of

his or her voice disorder

n establish the credibility of examiner.

It is important to have adequate information regarding the exact reason the patient was referred. When a physician refers a patient, the specific medical diagnosis should be reported along with the physician’s expectations. There are many reasons for patient referrals. These may include preoperative objective measures of voice, evaluation without management, baseline description of present voice, preoperative trial therapy, postoperative follow-up therapy, or a complete diagnostic voice evaluation with appropriate vocal manage-


ment. Understanding the physician’s expectations will avoid confusion and help maintain the necessary working relationships. Voice therapy suffers from poor patient adherence, and several studies have documented a high dropout rate from therapy.11,12 The literature documents that there is an improved likelihood that the patient may follow through with the recommendation for voice therapy if these three key elements occur: (1) communication between the physician, speech-language pathologist, and patient is open and optimized; (2) the expected outcome from therapy is discussed prior to the initiation of therapy; and (3) the patient’s readiness for change is determined and addressed early in the therapy process. Chapter 8 presents detailed descriptions of cases whereby adherence was a problem, and solutions suggested result in improved adherence to the treatment plan. There are differing opinions regarding explanation of diagnosis and treatment processes. Some believe in cognitive simplification of therapy, motor learning, and increased self-awareness through vocal work with little explanation of the actual therapy process (ERH). This author (JCS) believes it is also desirable at this time to establish the patient’s understanding of the referral for “speech therapy.” A typical dialogue between a patient (PT) and voice pathologist (VP) might be as follows: VP: “Do you understand why the doctor referred you here?” PT: “Not really. The doctor just said I needed speech therapy, but I really don’t understand what it is all about. My speech is OK; I’m just hoarse.” This is an excellent opportunity for the voice pathologist to explain in some

detail the three major goals he or she intends to accomplish during the evaluation. The more patients understand the procedures, the more reliable they will be in communicating pertinent information to the clinician throughout the evaluation. It also is helpful to establish and develop the patient’s knowledge of the voice disorder before proceeding. This may be accomplished by explaining briefly how the normal laryngeal mechanism works and how it is affected by the disorder. With this information, patients will better understand where certain questions are leading and may be able to give more reliable information. Some patients even volunteer pertinent information following this discussion and before other questions are asked. For example: VP: “Do you understand what vocal nodules are?” PT: “They’re some kind of growths on my vocal cords, aren’t they?” VP: “Something like that. Do you know what your vocal cords look like?” PT: “No, not really.” VP: “Well, when the doctor looked down your throat at your vocal folds, she or he was essentially looking at two solid shelves of muscle tissue, one on each side. (Draw a diagram, show pictures, or use a video.) Those shelves are the vocal folds, or cords, and we’re looking down on top of them. The point here where they meet is your Adam’s apple. Can you feel yours? (Give patient spatial orientation.) Now, the space between the vocal folds is the airway where air travels to the lungs as we breathe.

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“Attached to the back of each vocal fold we have two cartilages: one here, and one here. The reason we have these cartilages is so that other muscles that work the vocal folds may have a place on which to attach. Some muscles separate the folds, whereas other muscles draw them together. This is certainly a simplified explanation, but I think it will give you the basic idea of how the system works. “To move the vocal folds together, we have muscles attached to each cartilage pulling in opposite directions. These pull the vocal folds to the middle where they vibrate, giving us our voices. “If these muscles pull too hard, such as when we shout, talk loudly for a long time, or clear our throats, this excessive pull will cause the vocal folds to rub and bang together. (Demonstrate with clapping hands.) If this rubbing and banging occur too frequently, they eventually will cause some swelling of the tissues that usually causes temporary hoarseness. The hoarseness may go away after a day or so, but if whatever caused the swelling persists, the folds will remain swollen and eventually attempt to protect themselves from further damage. In your case, they’ve done this by developing, layer by layer, small, callouslike structures, which are called vocal nodules. “As you’ve experienced, the nodules cause a change in your voice. Because of the swelling and the nodules, your voice is deeper in pitch; because the nodules are holding your folds apart when you try to vibrate them, your voice is breathy. You’ve also probably

noticed that when you do a lot of talking your voice fatigues, and it becomes quite an effort just to talk. Sometimes by the end of the day, you may be worn out from the effort, and you simply don’t feel like talking anymore. “One final point. Vocal nodules are not cancer, are not related to cancer, and do not lead to cancer. Many people do not understand this, and I think it’s important to mention. So do you now understand basically what the vocal folds are like and what vocal nodules are?” PT: “Yes, now I do. I’m glad you mentioned cancer. I was worried about that. But what do you think caused the nodules? I don’t raise my voice very much.” VP: “That’s what we’re here today to find out. I’m going to ask you many questions. I need to get to know who you are and how you use your voice. From that information, we will try to determine what specifically has caused your nodules. Any questions?” It also should be noted that this type of discussion goes far in developing your credibility as an “expert” in this area. You usually will have managed to develop a high level of trust before you begin questions regarding the history of the problem.

History of the Problem The goals are as follows: n Establish the chronologic history of

the problem.

n Seek etiologic factors associated with

the history. n Determine patient motivation.

This section of the evaluation is designed to yield a chronological history of the voice disorder from the onset of vocal difficulties, through the development of the problem over time, and ending with the patient’s present vocal experiences. All questions are designed to yield information regarding the causes of vocal difficulties. Finally, the patient’s motivation for seeking vocal improvement is determined. A list of appropriate questions may include the following: n When did you first notice you were

having some difficulties with your voice? n Was this the first time you ever experienced vocal difficulties? n How did the problem progress from there? n What finally made you decide to see your doctor about it? n How did the doctor treat the problem? n Did your family doctor refer you to the otolaryngologist? n Has anyone else in your family ever had voice problems? n Is your voice better in the morning than in the evening or vice versa? n Have you ever totally lost your voice? n Do you have any occasion at all to raise your voice, to shout, or to talk loudly over noise? n Do you talk often to anyone who is hard of hearing? n Do you have a pet? n Not knowing you prior to your vocal difficulties, I don’t know what your normal voice is like. I have a scale of 0 to 5. How hoarse are you right now if 0 is normal and 5 is very hoarse?


n The effort to talk is sometimes a real

problem for people. On a scale of 0 to 7 with 0 being no effort and 7 being extreme effort to talk, how much effort does it take you to make your voice work throughout the day? n How much does this problem actually bother you? n Are you interested in doing something about it?

Medical History The goals are as follows: n Seek medically related etiologic factors. n Help establish awareness of the pa-

tient’s basic personality.

Taking the medical history is the process of seeking out any medically related etiologic factors regarding the presenting disorder. Questions are asked regarding past surgeries and hospitalizations. Chronic disorders are probed, along with the use of medications. Smoking history and alcohol and drug use are explored. The patient’s hydration habits also are discussed. The medical history also helps to establish in the clinician’s mind how patients “feel” about their physical and emotional well-being. Asking patients whether, on a day-to-day basis, they feel “excellent, good, fair, or poor” may accomplish this task. The response to this question will provide the voice pathologist with insight into how patients feel about themselves. Some patients report lengthy medical histories with many chronic disorders, but they indicate that they feel “good” on a day-to-day basis. Other patients with unremarkable medical histories may report feeling “fair” or “poor.” This information is helpful in learning patients’ basic personalities.

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Social History The goals are as follows: n Know the patient’s work, home, and

recreational environments.

n Discover emotional, social, and fam-

ily difficulties.

n Seek more etiologic factors for the

disorder.

The social history finalizes in the clinician’s mind a perception of the patient. It yields information regarding work, home, recreational, and social lifestyles and whether these lifestyles contributed to the development of laryngeal disorders. All questions probe for answers to possible etiologic factors. For example:

know who they are and what they do to find the causes for their vocal difficulties. You want patients to “excuse” you if some of the questions seem personal. This questioning is necessary to discover all possible causes. Do not be surprised when patients open up to you with many personal, family, social, marital, or work problems. If you have developed your credibility and gained their trust, you often will be entrusted with this important information.

Oral-Peripheral Examination The goals are as follows: n Determine the physical condition of

oral mechanisms.

n Are you married, single, divorced, or

n Observe areas of the upper body for

As you begin the social history questions, it often is helpful to explain to patients that you need to get to

A routine oral-peripheral examination also should be conducted to determine the condition of the oral mechanism in its relation to the patient’s speech and voice production. Also included is observation of the patient’s laryngeal area tension utilizing visual observation of posture and neck muscle tension, as well as digital manipulation of the thyroid cartilage. The patient should be asked whether any swallowing difficulties are present to determine whether this function has been affected by or is affecting vocal production. Finally, the patient should be asked whether any laryngeal sensations are present. The laryngeal sensations most often associated with voice disorders include ach-

widowed? n How long have you been (married, divorced, widowed)? n Do you have children? n What are their ages? n How many are still at home? n Does anyone else live in your home? Parents? Others? n Do you work? Where? How long? n Specifically, what do you do in your work? n How much talking is required? n What is the work environment? n Does your husband or wife work? Where? How long? What shift? n When you’re not working, what do you enjoy doing? (Include clubs, groups, hobbies, organizations, and so forth.)

tension during breathing, speaking, and at rest. n Check for swallowing difficulties. n Check for laryngeal sensations.

ing, dryness, tickling, burning, and a feeling of a “lump in the throat.”

Voice Evaluation The goals are as follows: n Describe the present vocal compo-

nents. n Examine inappropriate use of the vocal components.

Following the patient interview, the perceptual and instrumental voice evaluations are conducted. Several formal voice rating scales have been developed and utilized for perceptually judging voice quality.13 In an attempt to improve the perceptual evaluation of voice, a committee of the American SpeechLanguage-Hearing Association Special Interest Group 3, Voice and Voice Disorders, developed the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).14,15 The CAPE-V uses a 100mm visual analog scale to assess voice quality at the vowel, sentence, and conversational speech levels. The parameters of voice assessed include overall severity, roughness, breathiness, strain, pitch, and loudness. Areas for describing additional features such as diplophonia, fry, falsetto, asthenia, aphonia, pitch instability, tremor, wet/gurgly, or other relevant terms are provided. The perceptual voice evaluation is conducted to describe the current condition of voice production and to determine whether any vocal components — such as pitch, loudness, breathiness, and so on — are inappropriate to the degree of contributing to the development or maintenance of the disorder. Beyond the formal scales described


above, each vocal component may be examined separately as follows. Respiration This includes a description of: n conversational breathing patterns, in-

cluding supportive or nonsupportive

n locus of respiration such as clavicu-

lar, thoracic, or abdominal-diaphragmatic breathing n breath holding or shallow breathing n coordination of respiration and phonation. Phonation Subjective observations regarding vocal function are made through critical listening and are well documented on validated flexible tools like the CAPE-V. The presence of hard glottal attacks, glottal fry, diplophonia, tremor, spasm, etc, can be added to the validated form and judged on a 100-mm visual analog scale providing a rating metric. These vocal characteristics should be observed in prolonged vowels, phonemically loaded sentences, standard reading passages, and conversational speech. In addition, the voice pathologist is guided to listen throughout the evaluation for changes in quality when the patient is not responding to formal testing requests. Resonance The term resonance refers to the location of amplified sound transmission in the upper aerodigestive tract. Terms like hypernasal and assimilative nasality are used when describing the quality of sound as a result of the extent of sound

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transmission in the nasal cavity and are most often used in reference to persons with velopharyngeal incompetence or insufficiency. Cul de sac resonance may occur when the tongue is held in a posterior fashion, and the sound is primarily focused in the oral pharyngeal port. This type of resonance is most often associated with hearing loss, velopharyngeal incompetence, and has been noted in patients with significant compensatory posterior tongue carriage in the absence of a pathological cause. Hyponasality is the sound associated with an upper respiratory infection and stuffy nose. Often called denasal, the patient with hyponasality should be referred to the otolaryngologist for follow-up of the presence of nasal obstruction. Finally, the term resonance in voice often means the place in the hypopharynx for primary sound transmission, or what people refer to as focus of the voice. There remains no standardized method to identify tone focus/resonance of voice transmission. The evaluation of resonance is auditory perceptual. Many voice pathologists believe that resonance is sensed as the place where the voice emanates or where the patient senses vibration of sound. Pitch Pitch range is tested by having the patient sing up a scale from the lowest note to the highest note and from highest to lowest note while matching the extremes to a pitch pipe or a keyboard. Many patients are embarrassed to produce pitch range. Another method to assess range of phonation is the use of a functional phonatory task one might do when riding a rollercoaster or a sled, the “whee” sound from lowest to highest pitch. One additional method that,

while time consuming, is an excellent method to assess the pitch and loudness capabilities of the vocal mechanism is the use of a phonetogram (also known as a Voice Range Profile). The phonetogram is a graphic picture of the limits of the vocal system. The patient is asked to produce the lowest pitch and the highest pitch at softest and loudest phonation that are graphed on a chart with pitch on the horizontal axis and loudness on the vertical axis. Finally, a thorough assessment of pitch should include examining the use of inflection and pitch variability in a conversational context. Loudness The appropriateness of the patient’s speaking loudness level during the evaluation is described. It is also important to test the patient’s ability to increase subglottic air pressure. This may be accomplished by asking the patient to shout “hey.” The ability to produce a more solid phonation during a shout is a good indicator of the severity of the problem. If the patient is able to override the dysphonia with increased loudness (which is determined by the ability of the folds to approximate tightly to increase subglottic air pressure), the disorder is perhaps not as severe as when a patient cannot easily increase loudness. If there is a vocal fold tissue pliability issue, the patient may complain that there are places in the vocal range that require greater loudness/effort to produce the sound. One simple task is to ask the patient to sing up the scale while maintaining a steady-state loudness. If the patient reverts to a louder sound at the higher notes, ask the patient to produce the same notes cueing them with “softer, softer, softer.” If the patient is unable to produce sound softly, there is


likelihood that an adynamic area is present on the vocal folds (an area that does not vibrate) requiring greater subglottal pressures to initiate and maintain vocal fold vibration.

n maximum phonation time n subglottic air pressure n glottal efficiency n phonation threshold pressure n laryngeal airway resistance

Rate

Laryngeal videostroboscopy demonstrates a simulated, slow-motion view of the vocal fold vibration. This view provides much additional diagnostic information, including:

The rate of the patient’s speech may contribute to the development of the vocal disorders. This is especially true for the individual who speaks with an exceptionally fast rate. During the diagnostic work-up, the rate of conversational speech is described as normal, fast, or slow.

Instrumental Voice Assessment Instrumental measures of vocal function, sometimes called laryngeal function studies or phonatory function tests, may be conducted if the appropriate instrumentation is available. Acoustic, aerodynamic, and laryngeal imaging analyses are used to objectively describe vocal function. Common acoustic measures include: n fundamental frequency n frequency range n frequency perturbations (jitter) n habitual intensity n intensity range (maximum/minimum) n intensity perturbations (shimmer) n signal-to-noise ratio n spectral analyses n cepstral peak

Useful aerodynamic measures include: n airflow volume n airflow rate

n configuration of glottic closure n degree of supraglottic activity n vertical level approximation of the

vocal folds

n condition of the vocal fold edge n amplitude of vibration n integrity of the mucosal wave n nonvibrating areas of the vocal folds n phase and symmetry of the vibratory

pattern of the vocal folds

Hearing Screening The American Speech-Language-Hearing Association mandates that patients who undergo speech, voice, and language evaluations must have a current hearing screening. Audiometric evaluation is important for the patient with a voice disorder. The inability to monitor one’s voice may result in the use of inappropriate vocal components. Severe voice disorders are often observed in hard-ofhearing and deaf populations.

Impressions The goal is to summarize the etiologic factors associated with the development and maintenance of the individual’s

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voice disorder. This section of the diagnostic procedure is used as a summary for the causes of the voice disorder discovered throughout the evaluation. These causes are listed in order of perceived importance, relating first to the initiation of the problem and second to the maintenance of the problem. Remember that the precipitating factor may not be the maintenance factor.

Summary

The goal is to analyze the probability of improvement through voice therapy. The prognosis for improving many voice disorders through voice therapy is generally good. Nonetheless, many factors influence prognosis (see Chapter 8), including the motivation, interest, and time of the patient; ability of the patient to follow instructions; the physical and emotional conditions of the patient; and the general condition of the vocal folds. The prognosis section permits the voice pathologist to give a subjective opinion regarding the chances for successful remediation based on the diagnostic information. A reasonable time frame for expected completion of the management program also should be stated.

Successful voice therapy is totally dependent on an in-depth and accurate diagnostic evaluation. This author views the voice evaluation as a primary therapy tool. The evaluation determines the causes for the disorder, teaches the patient about the disorder, and describes the vocal function that must be modified for voice improvement to occur. The remainder of this text is devoted to management techniques for voice disorders. You will realize in studying the many case presentations that selecting the appropriate treatments depends on the multidisciplinary cooperation and management by the voice team members. The chapters are organized to describe management strategies for disorders of primary and secondary muscle tension dysphonia (MTD), glottal incompetence, irritable larynx/cough/ paradoxical vocal fold dysfunction, neurogenic voice disorders, and professional voice. Many crossovers in management approaches are evident and useful for the various disorders. All successful voice therapy, however, begins with accurate diagnosis and planning through the medical examination and voice evaluation.

Recommendations

References

The management plan should be outlined based on the etiologic, physiologic, and behavioral factors that precipitated the voice disorder and that cause it to persist which were discovered during the evaluation. The plan includes the therapy approaches to be used, results of trial therapy, prognosis, and additional referrals suggested.

1. Hirano M, Bless, D. Videostroboscopic Examination of the Larynx. San Diego, CA: Singular; 1993. 2. Larsson H, Hertegard S, Lindestad PA, Hammarberg B. Vocal fold vibrations: high-speed imaging, kymography, and acoustic analysis: a preliminary report. Laryngoscope. 2000;110(12):2117–2122. 3. Wittenberg T, Tigges M, Mergell P, Eysholdt U. Functional imaging of vocal

Prognosis

fold vibration: digital multislice highspeed kymography. J Voice. 2000;14(3): 422–442. 4. Patel R, Dailey S, Bless D. Comparison of high-speed digital imaging with stroboscopy for laryngeal imaging of glottal disorders. Ann Otol Rhinol Laryngol. 2008;117(6):413–424. 5. Bonilha HS, Aikman A, Hines K, Deliyski DD. Vocal fold mucus aggregation in vocally normal speakers. Logoped Phoniatr Vocol. 2008;33(3):136–142. 6. Deliyski DD, Petrushev PP, Bonilha HS, Gerlach TT, Martin-Harris B, Hillman RE. Clinical implementation of laryngeal high-speed videoendoscopy: challenges and evolution. Folia Phoniatr Logop. 2008;60(1):33–44. 7. George NA, de Mul FF, Qiu Q, Rakhorst G, Schutte HK. New laryngoscope for quantitative high-speed imaging of human vocal folds vibration in the horizontal and vertical direction. J Biomed Opt. 2008;13(6):064024. 8. Hogikyan ND, Wodchis WP, Terrell JE, Bradford CR, Esclamado RM. Voicerelated quality of life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis. J Voice. 2000;14(3): 378–386.


9. Jacobson B, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–70. 10. Stemple JC, Glaze L, Klaben B. Clinical Voice Pathology: Theory and Management. 4th ed. San Diego, CA: Plural; 2009. 11. Portone C, Johns M, Hapner E. A review of patient adherence to the recommendation for voice therapy. J Voice. 2008; 22(2):192–196. 12. Portone C, Johns M, Hapner E. Correlation of the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL). J Voice. 2007;21(6): 723–727. 13. Hirano M. Clinical Examination of Voice. New York, NY: Springer-Verlag; 1981. 14. American Speech-Language-Hearing Association. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) Purpose and Applications. Retrieved from http:// www.asha.org. 15. Kempster GB, Gerratt BR, Verdolini Abbott K, Barkmeier-Kraemer J, Hillman RE. Consensus Auditory-Perceptual Evaluation of Voice: development of a standardized clinical protocol. Am J Speech Lang Pathol. 2009;18(2):124–132.

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3 Primary and Secondary Muscle Tension Dysphonia

Introduction: Muscle Tension Dysphonia: An Overview Nelson Roy Poorly regulated activity of the perilaryngeal muscles affects phonatory function and contributes to a class of disorders known as hyperfunctional or musculoskeletal tension voice disorders.1 Several characterizations of laryngeal hyperfunction exist, but a recurrent feature in almost all descriptions includes excessive laryngeal musculoskeletal activity, force, or tension. More recently, muscle tension dysphonia (MTD) has become the preferred diagnostic label for such hyperfunctional syndromes,2,3 with some clinicians preferring the term primary MTD, to refer to a voice disturbance that exists in the absence of structural or neurological pathology.4 Primary emphasizes the principal role of dysregulated muscle

activity as the proximal cause of the dysphonia and distinguishes it from secondary MTD, wherein the hyperfunctional muscle activity is interpreted to either coexist with or compensate for some underlying mucosal disease and/ or glottic insufficiency.4–7 In primary MTD, the origin of abnormal muscle activity is not fully elucidated, but it has been attributed to a variety of potentially overlapping sources, including: (1) psychological and/or personality factors that tend to induce elevated perilaryngeal tension and/or muscular laryngeal inhibition,8–12 (2) technical misuses of the vocal mechanism in the context of extraordinary voice demands,13–16 (3) learned adaptations following upper respiratory tract infection,17 and (4) increased pharyngolaryngeal tone secondary to the laryngopharyngeal reflux reflex.18 Despite uncertainty surrounding the source(s) of muscle tension, these tension-based disorders often represent

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the most perceptually abnormal voices encountered clinically.8 Furthermore, most clinicians agree that recognizing the untoward effects of abnormal musculoskeletal tension is an important component of the diagnostic process, and restoring normal laryngeal muscular balance is an essential part of successful voice therapy. Muscle tension voice disorders often leave the impression that the speaker is expending considerable physical effort to produce voice, and there is a decidedly laryngeal/perilaryngeal focus to this effort.18–21 Perilaryngeal tension refers to excess tension primarily in the extrinsic and intrinsic laryngeal muscles, but this tension may also extend to include the pharyngeal constrictor muscles and the deep muscles of the neck. The putative effect of such excess tension is foreshortening and stiffening of muscles which interfere directly or indirectly with normal voice production.20 Because excess perilaryngeal tension tends to restrict vocal flexibility, most patients are described as pitch and loudness locked, often displaying a markedly reduced dynamic range in both speaking and singing. Vocal fatigue is a frequent concomitant.13,20 Voice quality symptoms can vary in severity and type, ranging from severely pressed to extreme breathiness with myriad combinations depending on the muscle groups involved.18 Many dysphonia types are observed including hoarseness, pressed voice, glottal fry, breathiness, high-pitched falsetto, diplophonia, as well as voice and pitch breaks that vary in consistency and severity.19,22 In the absence of mucosal, structural, or neurological pathology, however, these myriad voice effects can only be explained on the basis of the deleterious effects of abnormal musculoskeletal pat-

terns on laryngeal and extralaryngeal structures. That is, the disordered voice reflects the cumulative effects of abnormal tensions affecting both the source and the filter (ie, the entire vocal tract). In cases where excess perilaryngeal tension has persisted for some time, additional features may be present. Patients commonly report a dull to severe ache and tightness of the anterior neck, larynx, and shoulder regions that is accompanied by increased vocal effort and fatigue with all symptoms intensifying with extended voice use.18–21 According to Morrison, the inferior bellies of the omohyoid muscles where they cross the supraclavicular fossae are often tense and prominent during speech. General body posture may be rigid with the jaw jutting forward.23 Jaw, tongue, and respiratory movements can be restricted, reflecting the held nature of the voice and articulatory system.18,24 Boone and McFarlane25 observed “we see too many people with vocal hyperfunction who appear to speak through clenched teeth, with very little mandibular or labial movement.”25(p177) Similarly, Sapir26 recognized the complex effects of laryngeal tension on both voice and articulation. He noted “articulatory movements may induce or exacerbate, via mechanical or neural coupling, the phonatory abnormalities.”26(p49) Although muscle tension dysphonia (MTD) is properly regarded as a “voice” disorder, excessive tension in the perilaryngeal muscles could also constrain articulatory movements and vocal tract dynamics, by virtue of the mechanical linkage of the articulators to the hyolaryngeal complex, central nervous system influences (eg, heightened muscle tension in the jaw muscles), orolaryngeal sensorimotor interactions, or a combination of these.26–29 Recent research suggests that

successful treatment of MTD appears to positively affect vocal tract dynamics with acoustic evidence of vowel space expansion to suggest improved articulatory movements after treatment.27,30 Dysregulated laryngeal and perilaryngeal muscle tension can often be observed laryngoscopically. In this regard, a variety of glottic and supraglottic contraction patterns have been associated with primary MTD, and several classification systems have been offered to describe these laryngoscopic features.2,17,18 Often-cited laryngeal manifestations of dysregulated laryngeal muscle tension include tight mediolateral glottic and/or supraglottic contraction, anteroposterior glottic and/or supraglottic compression, incomplete glottic closure, posterior glottic chink, and bowing of the vocal folds.2,31 It should be noted, however, that researchers have recently challenged the existence of specific laryngoscopic clusters/features believed to uniquely and reliably distinguish MTD from nondysphonic speakers, and other voice disorder types including spasmodic dysphonia (SD).32–35 According to these investigators, many of the laryngoscopic patterns used to classify MTD such as supraglottic mediolateral and/or anterior-posterior compression, are frequently observed in individuals with normal voices and spasmodic dysphonia, and thus fail to distinguish such individuals from patients with MTD. Given the likely involvement of a variety of intrinsic and extrinsic laryngeal muscles — in diverse states of relaxation and contraction — myriad laryngeal configurations may be present in MTD. So, although no single laryngoscopic pattern should be uniquely and definitively identified with musculoskeletal tension voice disorders, observing certain glot-


tic and supraglottic contraction patterns should raise the suspicion of a tensionbased voice disorder. Despite some controversy surrounding causal mechanisms and nosological imprecision, the clinical voice literature is replete with evidence that symptomatic voice therapy for hyperfunctional voice disorders like MTD can often result in rapid and dramatic voice improvement. Because there are few studies directly comparing the effectiveness of specific therapy techniques, not much is known whether one therapy approach for MTD is superior to another. In the following section, case examples serve to illustrate the various approaches used to manage MTD.

Case Study 1 R.E. Stone Jr with comments by Kimberly Coker Behavioral Shaping in Primary MTD Masquerading as Elective Mutism in a 10-Year-Old Boy It is truly an honor to contribute to the work of my mentor, Dr R.E. “Ed” Stone. Dr Stone has influenced and mentored so many in our field through his ideas and demonstrations of superior clinical skill. The term master clinician is often used but not better represented than by this gentleman. This timeless case study gives us a glimpse of him at his best. I have always felt Dr Stone’s talents were shown most brightly when the patients could not complete the first step of traditional therapy approaches. He makes us feel confident in trusting our skills and meeting the patient where he/she is. Enjoy . . .

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Case History History of the Problem Patient Y was only 10 years old but represented one of the greatest intervention challenges I have encountered in nearly 30 years of clinical practice. At the mother’s telephone contact for an appointment, I learned that patient Y came home from school one day with extreme dysphonia after attending a soccer game. She thought that he had developed laryngitis. When supper was over, he produced no voice and indicated that he couldn’t talk. Professional help from various disciplines over a 7-week period was unproductive in restoring normal voice and communication. A history provided to the clinician (C) by the mother (M) follows: C: “Tell us a little bit about when patient Y started talking with a really tight voice.” M: “OK. He came home from school hoarse. They had a soccer game; he had some voice, but it sounded like he had been screaming a lot. Within maybe 2 hours, the voice was completely gone.” C: “All he could do, then, was produce this sound?” M: “He did not even do that; there was just nothing.” C: “Did he mouth his words, or did he stop talking altogether?” M: “He stopped talking, and when I would ask him to try, he would just make indications that there was nothing there.” C: “How long after that was it before he started pushing air

through the larynx a little bit” (strained sounding voice-making that vocal-fry kind of voice)? M: “I would say it was like a week. He went to a pediatrician the following day, and he thought it was laryngitis, so he told him not to try to talk. So he made no attempt of any kind to talk for a week until he went to a throat specialist who then got him to make that vocal-fry noise. That was when he started with . . . ” C: “So he kind of learned to produce the sound then, huh?” M: “Yes, I think so, yes.” Medical History Dr Stone continued his history inquiring about the patient’s prior treatment. The patient’s medical history was unremarkable. C: “What other things has he done in trying to get voice back again? You have been to the pediatrician and to an ear, nose, and throat specialist.” M: “And he was hospitalized for a week and was treated then by a psychologist, a throat specialist, and a physical therapist. All who were trying to make him relax enough to be able to make his vocal cords work. They said they were too tight.” C: “What kinds of things did they do for relaxation?” M: “They did hypnotic suggestion, they put him in whirlpool baths, they played games with him, and they just talked to him about other things, anything that was unrelated to his being unable to talk.”


C: “You spent a great deal of money pursuing this then, haven’t you?” M: “Yes, about $7000.” This would be roughly $16 000.00 today. Unfortunately, this occurrence continues today with patients subjected to multiple doctors and tests that in many instances are unnecessary. Social History Patient Y was adopted during infancy into a home of two older female siblings. The family life seemed healthy. The parents were well educated, and the father was a vice president of a large company in a large metropolitan Midwestern city. Both parents were energetic and had outgoing personalities. They did not give the impression of being overbearing or unreasonably demanding of their children.

Instrumental Assessment Visual Imaging. Previously completed during visits to an ear, nose, and throat specialist and was found to be within normal limits. Acoustics and Aerodynamics. Not completed in this case due to the patient’s limited vocalizations.

Patient Self-Assessment There were no indications that the patient could reliably provide a self-assessment at the time of the evaluation. Additionally, this case study occurred prior to the common use of validated and reliable self-assessment tools. Today, we might have had the mother fill out a Pediatric Voice Handicap Index.

Voice Therapy Specific Types of Therapy

Voice Evaluation Audio-Perceptual When we met, patient Y’s only vocalizations were utterances of vocal fry but with no accompanying lip, jaw, or tongue movements needed for word formation. These movements were not elicited even when the boy was asked to whisper. If it weren’t for the vocal fry productions, he might have been thought to show elective mutism. One got the impression that his talking was reduced to a series of vocal-fry grunts that may have showed syllabification, thought pauses, and interphrase silences. Additionally, the pitch and loudness of the grunts varied within restricted limits but seemed to suggest his attempts at prosody.

Stretch ’n flow,36 gargle, general shaping of voice production, and negative practice37 were all used to achieve desired target. Rationale for Using the Therapy The clinician is charged with identifying behaviors present, deficits present, and determining the next step/behavior the patient is capable of. The clinician must trust his/her knowledge of the voice-producing mechanism and engage in a dynamic assessment of the patient’s abilities. This patient was unable to utilize traditional facilitative techniques; thus, Dr Stone began with increasing patient awareness and control of the respiratory system progressing to articulated airflow in hierarchical speech tasks while building patient

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confidence. With neuromuscular reeducation already begun, Dr Stone then used gargle to engage the vocal folds followed by successive approximations toward normal phonation. Once this was completed, Dr Stone engaged in negative practice to confirm the patient was volitionally able to control the voice-producing subsystems. He was able to discuss the patient’s progress with the patient and his family and found them to be pleased with the patient’s progress and prepared should the patient have difficulty in the future. Therapy Goal and Expected Outcome Return to within normal limits sound production to meet all vocal needs. Complete Description of How to Do the Therapy We will now return to Dr Stone’s account of the rationale and description of therapy. My involvement with patient Y was governed by a model I have called erg. In physics, an erg is a unit for measuring work. It involves moving a mass through a certain distance in a given unit of time. Applied to the therapeutic setting, one might consider taking a patient (mass) from one point of behavior to another (distance) within an individual therapy session (or segment of it) divided into three parts: 1. Evaluation of behavior or skill that is needed or (needs to be abandoned) to bring the person closer to normal 2. Recommendation of desirable behavior through verbal instruction and modeling

3. Getting on with developing the use of the desired skill (or absence of the undesired behavior) in a hierarchy of speaking situations After the patient achieves success criterion at one level of the hierarchy, the erg is repeated at another level. Each recycling would involve a new bit of behavior. The bits are designed to shape the individual’s eventual performance into the use of normal physiology for phonation, finally in normal proposition communication.38 The child’s potential for voice production using a variety of facilitative techniques,39 including inspiratory voice, yawn-sigh, humming, throat clearing, coughing, and chewing was unproductively probed. Evaluating patient Y, initially, I sought to recognize those behaviors he brought to the task of communication that obviated normal voice production. Hollien40 has reviewed the characteristics of vocal fry (pulse register) productions, suggesting there is increased glottal resistance and decreased airflow. Patient Y consequently needed to reduce muscle effort and increase airflow to the task of voice production. Teaching muscular relaxation41 of the interarytenoid, lateral cricoarytenoid, and thyroarytenoid muscles to a 10-year-old child within 1 or 2 days (before he and his parents returned home several hundreds of miles away) seemed an unrealistic clinical undertaking. Recommendation, therefore, deemphasized formal relaxation training and focused on increasing airflow. I learned quickly that asking patient Y to change behavior during speech-like activities led to failure. When a patient fails at a task that I recommend, I am obligated to

assume the responsibility for the error in asking something that is too difficult or in not adequately communicating what I want of the person. Because failure tends to foster undesirable thoughts in a patient and unproductive consequences of my guidance, I must present requests that the individual can understand and accomplish. Teaching increased airflow, at what task could I expect patient Y to succeed? Finally, I merely asked him to blow against his upheld index finger as if he were blowing out a match. This was nonpropositional use of airflow and was a request of a behavior with which he had previous experience. It was behavior that easily could be molded by later instruction and was a task with a simplicity that anyone with normal anatomy could do. The component or partial behaviors to which patient Y’s attention was drawn through verbal instruction included unimpeded inspiration, no holding of the breath between inspiration and expiration, and lack of work (muscular action) in the neck area (and consequently in the larynx) on exhalation. These partial behaviors were adopted, then, as the recommended behaviors to be employed repetitively (that is, practiced, which constitutes “getting on with the behavior”) in a variety of tasks one might consider as constituting a speaking-situations hierarchy. Lowest on the hierarchical ladder was purposeful flow of air through the untensed speech mechanism. Next, patient Y practiced flow of air while his mouth and lips were placed in various static positions. This was done by asking that he produce a relaxed flow of air with his mouth open, then somewhat closed with the corners of the lips pulled back, then with lips rounded, and so


forth. (These positions resulted in the production of different whispered vowels; however, this fact was not pointed out to patient Y because of the need to avoid the chance of failure that might have accompanied a request to “whisper /i/, whisper /a/,” for example.) After the boy successfully produced multiple events, meeting at least 80% success in the desired partial behaviors while instruction (discriminative stimulus) and positive feedback were withheld, it was pointed out that he indeed produced many tokens of various vowels. He then was asked to practice production of airflow (no voice) on vowels that he read from flash cards. (This represented another level of the hierarchy: purposeful vowel production with flow of air through an untensed mechanism.) The use of unvoiced flow of air through a relatively relaxed speech mechanism was eventually shaped through carefully graded increments of a speaking hierarchy into employment for propositional speech. At this point, after approximately 1 hour of intervention, patient Y was whispering normally. Mouth, lip, and tongue movements had become reestablished communication behaviors along with unimpeded flow of air. Not only had an erg been accomplished, but the idea of elective mutism as a diagnostic label no longer was an appropriate consideration. The second session began with an evaluation of what behavior was needed to bring patient Y a step closer to normal communication. Even the uninitiated clinician would recognize the patient’s need for vocal fold activity superimposed on the flow of air through a relatively relaxed speech mechanism. But how could vocal fold activity be recommended without a statement such as,

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“OK, now produce the airflow like you did last hour, but this time with voice?” The reader also may ask, “What’s wrong with asking for voice?” Maybe nothing would be wrong, but I submit that it would have risked the patient adopting behaviors similar to those he demonstrated when he first entered therapy (which was vocal fry). Guarding against this possibility, I was compelled not to refer to “voicing.” Also, I did not want to ask the patient to do any of the activities previously requested because he failed at them. What could I do that might rely on referents that the child knew, that were not requests “to produce voice” (because he “knew” he couldn’t produce voice), and that would ensure success? I decided to approach voice production by recommending gargling. Unvoiced gargling really wasn’t much different from the activity patient Y had engaged in during the previous hour. The recommendation proceeded as follows, where C is the clinician and P is the patient. C: “I know you can let air flow out of your mouth. This time I’d like you to do so while gargling a small mouthful of water.” (Clinician models, tilting the head backward and gargling with voice.) “Now you do it.” P: The patient tried. He produced the bubbling sound, but no voice. C: “Okay, you kept the air flowing out all the time. That’s a good thing, too! If you hadn’t, you’d have done a lot of choking. Keeping the air going is pretty important. Now, this time let’s have you gargle like your Dad might do — with a lot of sound.” (Clinician models vocalized gargling.) “Now, you do it.”

P: The patient tried. He produced the bubbling sound louder than before, but still no voice. After he swallowed the mouthful of water, he gave a little laugh with one short period in which the voice was produced in a high-pitched squeal sound. C: Immediately, the clinician remarked, “Hey, did you notice that part of your laugh had some voice to it? Here, gargle another sip of water and make that little squeak sound as you gargle.” P: Patient Y succeeded. C: “Do that again, but this time make the sound longer.” P: Again, patient Y succeeded. C: “This time, make your gargle sound bigger, like your Dad might sound.” P: Again, patient Y succeeded. C: “Okay, this time make that sound, but without using a sip of water.” P: Again, the patient succeeded. Voice was produced, and the gurgling sound probably resulted from interruption of the voice airstream by repetitive action of the uvula against and away from the base of the tongue. Practice followed until the patient and the clinician both felt assured that this behavior could be repeated any time the patient wished. The next evaluation established the need to alter the boy’s head position to an upright posture. Accomplishing this was done in three trials in which gradual increments of head position change minimized the potential for failure that might have

accompanied moving the head in a single trial to a position more suitable for communication. Next, the evaluation established the need to alter the gurgling of sound to a continuous voice production by eliminating the tongue-uvula vibration. The recommendation to the patient was a simple instruction to open the mouth widely (separating the tongue from the uvula) accompanied by providing a mode of sustained /a/. Five trials were done before the patient indicated that he felt able to do this consistently whenever he wanted. The next intervention step needed to establish patient Y’s ability to maintain continuous voice while moving parts of the speech mechanism without triggering his dysphonic behaviors conditioned to the act of speaking. The recommendations involved leading the boy, by modeling, through a sequence of behaviors starting with opening and closing the mouth (vowel productions) with continuous voice. Next, vowel-like utterances were made individually rather than the continuous vowel series. Following this, individual vowel productions each were terminated with an articulatory valving; then, vowels were initiated and terminated with consonants. Even though patient Y was producing nonsense and finally meaningful syllables at this time, the fact that he merely was copying the model set by the clinician seemed to keep him from recognizing that he was using voice in speech-like units. Finally, after the boy had produced several CVC units that would have resulted in meaningful words if they had been uttered in reverse, it was pointed out that the patient had been saying words backward. For example, “tube” said backward would be “boot.” “You have been


speaking backward, let’s now say some words forward,” was the recommendation used to elicit meaningful words. Use of words to form phrases and sentences was based on increasing the length of utterance, word for word, and then finally uttering the entire unit. For example C: “Say ‘I’.” P: “I.” C: “Say, ‘I want’.” P: “I want.” C: “Say, ‘I want some’.” P: “I want some.” (etc, etc) P: “I want some eggs for breakfast.” By the end of this session (2 hours), patient Y was able to engage in dialogue, maintaining voice that was different from that with which he presented initially and was closer to normal. The voice still had a falsetto-like quality and was produced with guarded participation. I decided to accompany patient Y and his parents to lunch and observe the degree to which the boy maintained his present skill outside the clinical setting. He did admirably. Not once did he lapse into vocal fry, and during lunch he even seemed to modify voice production to be more normal. After lunch, intervention resumed and constituted a review of the processes the boy had used in reacquiring use of voice. With a trend during lunch for him to improve voice toward normal, formal activities focusing on voice normalization were deferred until the next day. Patient Y returned the next day, and his parents vouched for the accuracy of his contention that he had maintained use of the improved vocal function

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established during the previous afternoon and evening. Although he presented this morning with normal voice, I was uncertain of his awareness of the clinical processes and goals. To test this, I asked the boy to demonstrate the way he talked before we started intervention. He did. Then, he successfully switched at will between normal voice and that which he used previously. One last evaluation seemed necessary. Because patient Y lived nearly 300 miles away, and he could not conveniently return to the clinic, I needed satisfaction that he knew what to do to reestablish normal voice if he ever began speaking with his pre-intervention behaviors. Notice the absence of the term remission. Within a behavioral model of intervention, the use of medical terms such as remission, exacerbation, and cure tend to be used in ways that do not foster a patient’s development of the awareness that the behavior brought to the task of speaking is the responsibility of the patient. I was seeking indication that this patient had become his own clinician and that he had an appropriate plan of approach to solving future problems of voice of a similar nature should he exhibit them. Patient Y reiterated and successfully demonstrated the intervention steps he used to reestablish normal voice. Because his parents participated in the therapy sessions, it seemed important to sample the parents’ understanding of how their son implemented a change to normal and the implications of this change. This was assessed on the second morning through an interview at the end of the patient’s hour-long session. C: “What thoughts went through your mind as you and the family were experiencing this?”

M: “Well, we were told that our son’s problem was purely psychological, that until he could learn to cope with a lot of the fears and things that were going on inside of him he would not be able to produce a voice that his subconscious would not allow him to speak. So we went through a whole lot of guilt and embarrassment. I think that each one of us wondered . . . were we the ones who caused that kind of trauma and what have we done when we thought that we had a typical, normal family. You know there was a lot of self-doubt and wondering if he would ever get over this.” C: “Pretty spooky!” M: “Yes, it was very scary, yup.” C: “Do you have any concerns or questions now that you know he is producing voice again?” M: “No, I don’t think so; I guess, if he comes down with laryngitis I will be very nervous. I think I am really satisfied with the psychological end of it and . . . C: “Explain what you mean.” M: “Well, I guess I worried about a lot of deep-seated problems and, you know, I don’t think I am worried about that anymore. In the beginning, I would have said if he had gotten his voice back maybe there would be another time when if a traumatic experience occurred, he would lose it again. I see it now more as a physical thing that he can deal with and we can help him if he, you know, if it would come to a point where there was a problem


with voice, I think we would know how to handle it.” Frequency and Duration of Treatment Patient Y was seen for approximately 5 hours across 2 days. Dr Stone additionally accompanied the family to lunch. This was consistent with how patients were often treated when I was employed with Dr Stone at the Vanderbilt Voice Center. We often saw patients for multiple, consecutive sessions over several days due to distances patients had traveled or lack of qualified resources near their homes. We found this type of treatment to be very effective. Recently, the University of Wisconsin has written about a similar intensive program they refer to as “boot camp” which has initially promising results. It should be noted that an important aspect of boot camp, which differs from this account, involves use of multiple therapists.42 (See Case Study 15 by Rita Patel, Voice Therapy Boot Camp, presented later in this chapter, for more information.)

Therapy Outcomes Audio-Perceptual Within normal limits voicing. Patient Self-Assessment Patient Y demonstrated volitional control, coordination, and responsibility for his voice returning to baseline voice. He also reported confidence that he knew what to do if any voice difficulty recurred.

Summary and Concluding Remarks The above case study represents an eclectic management approach to remediation.

Dr Stone demonstrates how to synthesize knowledge of anatomy and physiology, combined with keen observational skills, knowledge of learning styles, and psychology to treat a functional voice disorder. In real time, he completes task analysis for voicing and determines the patient cannot coordinate all vocal subsystems and is not readily able to produce typical stimulability tasks. A bridge step is created, reducing the complexity of the task and utilizing demonstrated skills. With a specific goal in mind, he confidently and patiently explores coupling airflow and articulation in the absence of voicing for over an hour, increasing the patient’s body awareness, creating behavioral change, building rapport, building confidence, and relaxing the upper body. All the while, he assessed for understanding and checked for a shift from an external to an internal locus of control, an optimistic attitude, and accurate placement of responsibility required to ensure success. Dr Stone further demonstrates the essential skill of pacing and timing sessions, introducing voicing via nontraditional methods, and continuing to shape skills with successive approximations toward the ultimate goal. He modifies his plan after observing the patient with his family and progresses him accordingly. The patient tests or evaluates whether he has brought under voluntary control the behavior that had previously been involuntary. Finally, the patient demonstrates awareness of behaviors involved in speaking, positive attitude regarding performance, understanding of how to proceed following therapy, and a within normal limits voice. Muscle tension dysphonia may occur across all ages. In the following case, Joe Stemple describes using a falsetto voice to disrupt the inappropriate voice production pattern of a 13-year-old.

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Case Study 2 Joseph C. Stemple Management of Primary MTD in a 13-Year-Old Using Falsetto Voice to Modify Phonation

Patient History Patient X, a 13-year-old, eighth-grade student, was referred with a 4-week history of “voice loss.” The patient and her mother were interviewed together, and then the interview was continued when the mother was asked to leave the examination room. As is the case with many functional voice problems, the onset of whispering was associated with a cold. The patient’s mother reported that her daughter had developed “laryngitis” 4 weeks prior to this examination and then “lost her voice totally” 2 days later. The cold quickly resolved, but the patient’s voice had not yet returned. The patient was reported to be a rather shy child who succeeded reasonably well in her academic activities. Socially, she had two “best” friends and participated in the school choir, library club, and 4-H activities. Her medical history was unremarkable as related to this problem. Although she had never experienced vocal difficulties before, her mother reported that the girl had experienced a “chronic cough” 1 year earlier for which no diagnosis could be found. Following several weeks of excessive coughing, the behavior suddenly stopped. The child’s mother was hoping the voice would come back in the same manner.

Assessment Laryngeal videostroboscopy was performed at this point of the evaluation as a means of educating the patient about the anatomy and physiology of the laryngeal mechanism and vocal folds. Patient X presented with normalappearing vocal folds. The whisper, of course, did not permit slow-motion observation of fold vibration, but the folds were shown to adduct toward the midline, only to stop in an incomplete closure. The lack of approximation of the folds was pointed out to the patient with an explanation similar to the following: Your vocal folds look very good and healthy. For some reason, the muscles that pull them together are simply not pulling the way that they should. Therefore, the vocal folds are not closing all the way. When they do not close all the way, they do not vibrate, and we hear whispered speech. Our goal in therapy, therefore, is to do whatever is necessary to encourage those muscles to pull hard enough to make the vocal folds come together.

With this approach, the voice pathologist has given the patient a nonthreatening explanation as to why phonation is not occurring. No comment is yet made regarding the patient’s inherent ability to phonate. In fact, the “blame” for lack of phonation has been removed from the patient and placed squarely on the faulty mechanism.

Management Traditional management approaches then might examine the patient’s ability to phonate during nonspeech phona-

tory behaviors such as coughing, throat clearing, laughing, crying, or sighing. When clear phonation is identified during one of these behaviors, it is then shaped into vowel sounds, nonsense syllables, words, and short phrases. The voice pathologist must demonstrate patience at this time. Most patients have not phonated for several weeks. The possibility of proceeding too quickly and frightening the patient away from phonation is present. Once good, consistent phonation is established under practice conditions, the voice pathologist begins to insist gently that it be used during the therapy conversations. Some claim that, when voice is regained in this manner, it is seldom lost again, and patients do not substitute other symptoms. Long-term studies are needed to substantiate this claim. Another technique that we have found useful is the use of direct visual feedback using laryngeal videoendoscopy. While the patient is being scoped, with either a rigid or flexible endoscope, an explanation is given related to the positioning of the vocal folds and how that positioning relates to the present vocal problem. The patient is able to monitor the video over the voice pathologist’s shoulder. The patient is then instructed in various manipulations of the vocal folds, such as deep breathing, light throat clearing, laughing, and attempts to produce tones of various loudness levels and pitches. We have had surprising success in the quick return of normal voicing using these visual biofeedback procedures. A different management strategy was used with patient X — that is, the use of falsetto voice as a facilitator of normal voicing. It was explained to the patient that we were going to manipulate her


vocal folds in a manner that would encourage her muscles to pull the folds together. The therapist then produced a high-pitched falsetto tone on the vowel /ai/. The patient was told, in a matterof-fact manner, that, by stretching the vocal folds for this high pitch, the folds are more closely approximated. Everyone, even those with vocal problems, can produce this tone. The falsetto again was demonstrated, and the patient was told to produce the same sound. Following several unsuccessful attempts, the patient produced a highpitched squeak. This was promptly reinforced with praise and repeated several times. As the falsetto voice strengthened and the sound became clearer, other vowel sounds were introduced and stabilized at this pitch level. It was explained to patient X that we were going to use the muscle tension created by producing the falsetto tone to encourage the vocal folds to pull together normally. The patient was given a list of 150 two-syllable phrases and asked to read them in the falsetto voice. During this exercise, she was constantly encouraged to read swiftly and loudly. After the voice stabilized in a relatively strong falsetto, the patient was halted and asked to match the clinician when singing down the scale about 3 to 4 notes from the original falsetto tone. The patient was then asked to continue reading the phrases at this new pitch level. The same procedure was repeated 2 to 3 more times until the young woman’s pitch closely approximated a normal pitch level. She was continually encouraged to produce these phrases louder and faster until her voice eventually “broke” into normal phonation. Occasionally, the patient will approximate normal phonation but then

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hesitate as if somewhat reluctant to produce normal voice. When this occurs, the patient is asked to “drop way down” and produce a guttural voice quality while reading the phrases. This will “produce more appropriate muscle pull.” After a few minutes, the patient is taken back to the falsetto voice with the break into normal phonation usually occurring soon after. It is extremely important for the voice pathologist to be patient when utilizing this technique. The normal time frame from aphonia to normal voice is approximately 30 to 45 minutes. The voice pathologist must not only be patient but also must present a very matter-of-fact, confident manner. Voice pathologists are not cheerleaders. They are simply presenting a technique that they know will work. Why do these techniques work? n The patient is ready for change. n The voice pathologist has given a

reasonable explanation for what the vocal folds are doing. n The voice pathologist has demonstrated confidence in the therapeutic techniques. Following return of voice, it is necessary to explore the actual cause for the voice disorder. It is desirable to do this in a direct manner. For example, the voice pathologist could say the following: I’m very pleased that the muscles are all functioning well now and that your voice has returned to normal. It sounds really good. The thing that still puzzles me somewhat is why the muscles stopped closing the folds in the first place. I can tell you quite frankly that with a lot of other patients we have seen with the same problem, the cause has been something that has happened that was very upsetting or emo-

tionally draining. Can you think of anything that has been going on lately that has been upsetting to you?

By this time, it is hoped that the patient has developed strong confidence in the voice pathologist and will “open up a floodgate” of information about deaths, family problems, work problems, and the like. In discussing these problems, the voice pathologist attempts to accomplish two major objectives: (1) Give the patient total and final control over the laryngeal mechanism and (2) determine the patient’s general emotional state to decide the need for further professional counseling. Up to this point, the voice pathologist has been manipulating the voice. The patient now must understand that despite the ultimate cause of the aphonia, he or she is in total control of the voice and does not need to permit the problem to recur. If it does, the patient knows how to regain control of the voice. Finally, just because the need for the functional reaction no longer may be present, this does not mean that formal family, psychiatric, or psychological counseling would not be helpful. If the voice pathologist feels the problem is not resolved and further counseling is in order, the suggestion should be discussed with the patient, and appropriate referrals should be made. In discussing the problem with the patient’s mother, it became evident that patient X had experienced other episodes of possible functional behaviors, most notably several long-term coughing spells. Patient X was shy and she lacked confidence. Physically, she was overweight and had, in the past year, become sensitive about her appearance. Her mother reported that around the onset of this voice problem, her daugh-


ter had come home from school very upset about being teased by some classmates about her weight. Like many children in this age group, she was sensitive to comment by her peers and was struggling to find her own identity. Suggestions were made for further counseling. In a follow-up voice therapy session, patient X had maintained normal voicing. As a matter of fact, she was looking forward to singing with her school choir in a concert that week. Her ability to control her voice production was reinforced. She was told that if she felt the whisper returning, all she needed to do was produce the falsetto tone and most likely her voice would return to normal. That was our last contact with this patient. Many therapy techniques have been used successfully to remediate MTD. In the following case study, Susan Baker Brehm describes the use of laryngeal massage and resonant voice therapy with an adolescent presenting with MTD.

Case Study 3 Susan Baker Brehm Use of Laryngeal Massage and Resonant Therapy in Primary MTD in an Adolescent

Case History Patient X, a 14-year-old female, was referred for a voice evaluation at a pediatric hospital–based voice clinic. Approximately 2 months prior to her evaluation, she had an upper respira-

tory illness that lasted for about 2 weeks. During this illness, she coughed and cleared her throat frequently. About 1 week into the illness she became aphonic. Her pediatrician referred her to a general practice otolaryngologist who completed an indirect laryngoscopy. Patient X was told that her vocal folds did not “meet in the middle” during phonation. She was then referred to the specialized hospital-based voice clinic. At the beginning of her evaluation, a case history was obtained through completion of a medical history form by the patient’s mother and an interview conducted by the evaluating clinician (speech-language pathologist). Her medical history revealed no current or past significant illness or disease. All aspects of development (motor, speech, cognition) were normal. The interview with the patient and her mother revealed several sources of stress and anxiety for patient X over the past 3 to 4 months. She was a high school freshman and her transition to her new school had been challenging. Her parents separated 1 month prior to the start of the school year. The patient was moved to a new school district as her mother was required to relocate. She was having trouble making new friends and was struggling academically in several classes. When she was sick 2 months ago with the respiratory illness, she missed school for several days prior to an Algebra test. She took the test when she returned to school and performed very poorly. Her mother revealed that the complete loss of voice began the night after she took the test. She had become very hoarse during that day from crying and was completely aphonic by the evening. The onset and consequences of the aphonia appeared to be stressful for all

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of the family members. Throughout the interview, the clinician began to understand that patient X was spending a lot of time with both of her parents through many of the doctor appointments. She was also getting some additional attention at school from her peers as she was not able to participate in her school choir of which she was a member.

Voice Evaluation A formal perceptual assessment of voice quality such as the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) or grade, roughness, breathiness, asthenia, strain (GRBAS) scale was not completed because the patient was aphonic. In her written evaluation report, the patient’s voice was described as severely breathy characterized by significant strain observed in the entire upper body (particularly in the neck region) during attempts at phonation. Acoustic and aerodynamic measures were also not obtained with this patient due to her aphonia. A rigid videostroboscopic examination was performed with this patient by the evaluating clinician. She tolerated the examination well and all laryngeal structures appeared normal. When asked to sustain the vowel /i/, she had incomplete closure with mild anteriorposterior and lateral compression of the supraglottic structures. Abduction of the vocal folds was normal during quiet breathing and sniffing tasks. The patient was asked to clear her throat to remove excessive mucus off the vocal folds during the examination, and she was able to achieve closure of the vocal folds during this event. She was also observed to have a typical sounding laugh during

the rigid examination. No evidence of laryngeal irritation or edema from gastroesophageal reflux was observed. The pediatric otolaryngologist on the team was present for the examination as well. The otolaryngologist assured the patient and her mother that the larynx looked healthy and that she had a condition called muscle tension dysphonia. The speech-language pathologist used the recorded examination to show the patient and her mother the incomplete closure of the vocal folds during phonation and discussed how the vocal folds are normally configured during phonation. The patient and her mother appeared to understand why the voice sounded so breathy but then began to question why the onset of aphonia occurred with this particular respiratory illness. The evaluating team discussed the excessive tension that can occur in the larynx due to illness and excessive use of the voice (eg, excessive coughing). The team also briefly mentioned how stress and anxiety leading to tension in the neck region can lead to excess tension in the larynx. The patient’s parents were asked to complete the Pediatric Voice Handicap Index.43 This assessment tool is a validated modification of the Voice Handicap Index (VHI). The format is similar; however, the statements are focused more to children and adolescents and it is completed by parent-proxy. Due to the age of the patient, the evaluating clinician encouraged the patient to provide input regarding the responses. The following are the subset scores: Functional = 20 (out of 28); Physical = 30 (out of 36); Emotional = 20 (out of 28). The total score was 70 (out of 92). The scores on this index indicated that the patient was experiencing a high level

of impact on her daily activities related to her voice impairment and a related emotional impact.

Voice Therapy Diagnostic Therapy Once the formal evaluation with the team was completed, the clinician initiated a brief (10 minute) diagnostic therapy session. The patient was exhibiting a significant amount of tension in her neck and shoulders and upon palpation of the larynx, demonstrated significant tension in the thyrohyoid space. Circumlaryngeal massage was initiated as described by Roy and colleagues,3 and patient X was able to produce a relatively “normal” voice during this procedure. [For more information on circumlaryngeal massage, see case study 5 by Nelson Roy, Manual Circumlaryngeal Techniques in the Assessment and Treatment of Primary Muscle Tension Dysphonia (MTD) in a 55-year-old woman, later in this chapter.] However, when the clinician removed her hands from the laryngeal area, the patient was immediately aphonic. Based on this initial therapy session, the clinician felt that the patient’s prognosis was good and that she could benefit from circumlaryngeal massage techniques paired with exercises that promote the use of easy, front-focused phonation utilizing resonant voice activities. The success of circumlaryngeal massage has been demonstrated in patients with functional voice disorders exhibiting excessive tension of the extrinsic and intrinsic laryngeal muscles.44,45 When using this technique with an adolescent, the clinician must be


aware (as should the clinician be with all patient populations) of the location of the carotid arteries in the neck and not provide any compression in this area. Resonant therapy techniques were chosen as well to provide a means of reducing tension at the larynx and moving the tension to the face and lips during phonation. Session 1 Because of the nature of the disorder, the next therapy session was scheduled as soon as possible. Patient X was able to return the next day for a half-hour therapy session. Both of her parents were present at the appointment. The clinician felt that more progress might be made in the session if the parents did not join the session and remained in the waiting room. The clinician began with having the patient perform unvoiced lip buzzes/ trills with as little effort and tension as possible. The patient completed these unvoiced lip buzzes 10 times (duration was about 2 s each). Next, phonation/ voicing was added to the lip buzz. The exercise was also completed 10 times. For the next exercise, the clinician had the patient perform the voiced lip buzzes at her pitch extremes. She performed 5 lip buzzes (approximately 3 to 4 s) at a high pitch and 5 lip buzzes (approximately 3 to 4 s) at a low pitch. The clinician had the patient perform these exercises again with added laryngeal massage at the pitch extremes, and she was able to sustain phonation for approximately 4 to 5 s. From there, the clinician had the patient use the lip buzz and perform glides from her pitch extremes. So, lip buzzing with phonation from her highest

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pitch down to comfort pitch 5 times and then from her lowest pitch up to comfort pitch 5 times. This exercise was used to assist the patient in gaining more ease and flexibility with the front-focused voicing pattern. Following this exercise with some additional laryngeal massage, the patient was now able to phonate for approximately 5 to 6 s. Next the goal was to extend the voiced lip buzz into phrases. The clinician modeled the first exercises as a lip buzz extended into a “mmm” (eg, voiced buzz — mmmm). This was performed at a comfortable pitch 5 times. Then the lip buzz was extended into m-vowel combinations (eg, voiced buzz — ma-ma-ma-ma . . . voiced buzz — mimi-mi-mi, etc). This exercise was performed 5 times. Finally, the lip buzz was extended into /m/ initial sentences (eg, voiced buzz — Mary made me mad . . . voiced buzz — My mother made marmalade, etc). This exercise was completed 5 times. At the conclusion of the session, the patient reported that she felt fatigue, but she seemed encouraged about the progress that had been made. She demonstrated her ability to phonate during the phrase exercises for her parents when they were invited into the therapy room at the end of the session. The clinician provided a written instruction sheet outlining the exercises performed in the session and asked the patient to perform each of the exercises in two separate sessions throughout the day for the next several days. Session 2 Again, due to the nature of this disorder, the treating clinician felt it was important to continue the success obtained in the first session relatively soon. The cli-

nician felt that the less time the patient had to move back into excessive tension and poor voicing patterns, the more rapidly she would be able to use a “normal” voice consistently. Fortunately, the patient and her family were motivated to continue, and session 2 was scheduled 3 days after session 1. Patient X entered the therapy room for this session using a nearly “normal” voice. The voice was mildly breathy. The clinician led patient X through voice lip buzz into phrase exercises used in the previous session to reestablish frontal focus. The clinician then advanced the patient to using front-focused chanting for m-initial sentences (eg, Mary made me mad). After frontal focus was established, the clinician had the patient overinflect the sentences and then speak them. After the completion of 10 sentences using the chanting, overinflection then speaking sequence, the patient was able to able to self-monitor the appropriate use of frontal focus about 90% of the time. The same pattern of chanting, overinflecting, and speaking was then used for voiced and unvoiced sentences (eg, Mom may move Polly’s movie to 10). Again, after the completion of the 10 voiced/unvoiced sentences, the patient was able to self-monitor and correct errors in frontal focus about 90% of the time. The clinician then had the patient say sentences of increasing length (voiced and unvoiced) while selfmonitoring for frontal focus. Approximately midway through this session, when this stable, essentially normal voice was reestablished, the clinician invited the patient’s parents into the therapy room. The clinician began a more significant discussion of how stress and anxiety can create tension during speaking and interfere with normal laryngeal function. The parents

were very pleased with the outcome of therapy; however, all parties agreed that the onset of the aphonia was a sign that patient X would benefit from speaking with a counselor or psychologist to discuss some of her current life stressors. From this session, patient X was discharged. She was encouraged to continue the exercises at home for another week and to call if she had any problems.


that you can help the patient obtain his or her “old” voice again is often a key to success. Flow phonation is another therapy approach often used to remediate MTD. In the next case, Jackie Gartner-Schmidt gives a detailed description of the use of this technique with a teenager presenting with MTD.

Therapy Outcome The clinician called patient X 2 weeks after her final session. The patient demonstrated a “normal” voice over the phone and reported no further difficulties with the voice. Patient X indicated that she was going to start counseling sessions the following week.

Summary and Concluding Remarks Primary muscle tension dysphonia is not a common diagnosis observed in children and adolescents; however, those patients who present with this disorder can be difficult to treat. Sensing sources of stress, how much to push the patient forward in the exercises, and the timing of the push are all complex aspects of treating these patients. Additionally, the clinician must sense from the patient when it is appropriate to discuss that stress, anxiety, and tension may have played a large role in the onset of the disorder and that psychotherapy may be recommended. There is not a “one-size-fits-all” approach with this patient population; however, generally getting the point across that the laryngeal structures are healthy and that you as the clinician feel confident

Case Study 4 Jackie Gartner-Schmidt Flow Phonation in a Teenager with Primary Muscle Tension Aphonia This case is presented to illustrate the use and concepts of flow phonation. The therapeutic concept was introduced by Stone and Casteel46 and later instrumentally examined by Gauffin and Sundberg,47 who coined the term flow phonation based on their work with flow glottograms. Flow phonation is a modification of stretch and flow phonation.46,48–50

Case History Patient J, a 17-year-old female high school student, reported a sudden onset of total voice loss approximately 3 months prior to her clinical visit. This loss was precipitated by heavy voice use while playing high school basketball, although “nothing out of the ordinary.” Patient J’s chief complaints were total voice loss, extreme vocal fatigue, and severe throat constriction when talking. She did not have any prior history of voice loss before this episode. Patient J

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was a product of a split family, although her mother and father were still married. She admitted to being afraid of her father but denied physical abuse. Her father was very competitive when it came to his daughter’s basketball playing and was at the game the night she lost her voice. Patient J denied her father’s presence as the trigger, given that he often attended her games. However, she admitted that “She did not like him.” She divulged that she had been admitted to the hospital for vomiting and dehydration months before her current voice problem; she and the physicians believed that the episode was probably due to stress. In fact, patient J described herself as always “very stressed.” She had never been evaluated by a mental health professional. Other than this information, the patient’s medical and speech history were unremarkable. She was a healthy teenager who drank over 1920 mL (64 fl oz) of water a day.

Voice Evaluation The following noninstrumental and instrumental measures were taken: Auditory-perceptual evaluation using a modified version of the CAPE-V51 revealed a Visual Analogue Scale measure of 95/100 for overall severity of voice quality. The following audio-perceptual descriptions of voice were rated with an ordinal scale as done with the GRBAS52: roughness (0); breathiness (0); strain (3); pitch — high (2); pitch — low (0); loudness — loud (0); loudness — soft (2); hoarseness (3); and aphonic. It is important to note that the pitch rating was probably due to resonating frequencies of the vocal tract (ie, formant frequencies) as she was aphonic. Patient

J’s assessment of her overall voice problem was “severe” based on an ordinal scale (none, mild, mild-moderate, moderate, moderate-severe, severe), and her chief complaint included both the sound and feel of her voice. She also described herself as an extremely talkative person. To quantify the effect of patient J’s perception of her voice handicap, the VHI-1053 was used. Patient J’s score was 36/40, which is above the normative value of 11.54 In addition, because stress reactivity may be an etiologic factor in laryngopharyngeal reflux (LPR),55the Reflux Symptom Index56 was given to patient J and her score was 10/45, which is within normal limits. Patients J’s assessment of her overall vocal effort as measured via a Direct Magnitude Estimation Scale57–59 was 1 000 000. An example of how we have modified the original DME for vocal effort is as follows: If I told you that 100 represents an easy amount of vocal effort and 200 is twice that amount and 450 is 4.5 times that amount and 1200 is 12 times . . . there is no ceiling. Pick a number in the hundreds that best indicates how much vocal effort it takes you to voice when you are having a bad day.

Patient J described her feeling of vocal effort as 10 000 times that of “an easy amount of vocal effort.” Unfortunately, frequency measures were not valid as the patient had a type III Signal Typing 60,61 defined as no apparent fundamental frequency as obtained from the Multi-Dimensional Voice Program (MDVP) (KayPENTAX, 2008). Aerodynamic measures were recorded using the Phonatory Aerodynamic System (PAS, KayPENTAX, 2006), and mean airflow for the center 3/pa/ tokens of a 5-token repetition showed 50

mL/s with subglottal air pressure estimates of 17.3 H2O at her most comfortable pitch and loudness (MCPL). These measures were interpreted to mean that perhaps she was holding back her airflow (as demonstrated by low flow measures) and using increased thyroarytenoid and lateral cricoarytenoid muscle tension to spike high, indirect, subglottal air pressure measures.62 This appeared to corroborate the speech-language pathologist’s audio-perceptual assessment of “severe breath holding.” Phonatory mean airflow rate for a spoken sentence (“Peter picked a pound of pickled peppers”) was 40 mL/s. Hence, both of the decreased airflow measures could perhaps be indicative of severe pressed phonation [eg, muscle tension dysphonia (MTD)]. Her intensity range was 11 dB SPL, which is below the norm, perhaps due to the limited vocal agility of her mechanism due to muscle tension. The laryngologist visualized the larynx using a chip-tip flexible endoscope and reported no lesions and normal bilateral vocal fold motion. Flexible endoscopy versus rigid endoscopy is routinely used in the clinic for the diagnosis of MTD because it allows visualization of speech during the exam. Two sentences are used which are phonetically different to elicit specific laryngeal articulatory gestures: “We eat eels every day” and “She speaks pleasingly.”63 No evidence of LPR was found on endoscopy corroborating the RSI result. The patient was diagnosed with “severe” primary muscle tension dysphonia (MTD-1).

Voice Therapy After her initial evaluation, patient J received 2 voice therapy sessions back-


to-back with a 20-minute rest between sessions. At the time, insurance companies were reimbursing 2 voice therapy sessions on the same day; unfortunately, currently, they only reimburse 1 a day. Presented in Figure 3–1 is a summary of the basic skills of flow phonation and a conceptual diagram of the hierarchical steps of flow phonation. Patients are asked to become aware of frontal energy/airflow while feeling no throat tightness. Patients go through the hierarchy, but if problems recur, they go “down a step” until they reach functional performance. It is important to note that patients do not have to go through all the steps in order. Also, patients can go back and forth between the “steps” as much as necessary, and because vocal balance is the ultimate goal, it does not matter if each step is used. Finally, this is not a programmatic approach to voice therapy64; many times the reader will see the words “et cetera” because the reader is encouraged to invent new stimuli based on the concepts of flow phonation.65 The examples given are in no way exhaustive.

Skill Levels of Flow Phonation (Table 3–1) Skill 1: Airflow Release — Unarticulated Airflow Gargling Technique: Patient J was first asked to do the gargle technique. Patient J was given a glass of water. The SLP modeled the gesture, and patient J was asked to produce plenty of “bubbles” with the water. Patient J was able to gargle well, which represented the first step toward flow phonation, as gargling is merely airflow in a nonspeech task. Having a patient gargle initiates airflow

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(Examples)

Articulatory Precision: No reduction in rate

Airflow PLUS voicing: (Either breathy / flow phonation)

No overenunciation

Gargling

Crispness of articulation

Lip bubbles

Conversational Speech

Establish Airflow Release:

Prolonged fricatives:

Gargling

/z, v, j/

/u/ prolongation

/u/ prolongation – kazoo sound

Lip bubbles

Whistling

Prolonged fricatives:

Words, phrases

/s, f, sh/

Etc

Whistling Other voiceless phonemes Words, phrases, etc

Figure 3–1. Hierarchical steps of flow phonation. Table 3–1. Skill Levels of Flow Phonation Skill 1: Airflow Release

Skill 2: Breathy Phonation

Skill 3: Flow Phonation

Skill 4: Articulatory Precision

1. Unarticulated airflow

1. Unarticulated breathy phonation

1. Unarticulated flow phonation

Conversational speech

2. Articulated airflow

2. Articulated breathy phonation

2. Articulated flow phonation 48

release without the maladaptive habits of extralaryngeal/intralaryngeal tensions. The head, chin, and elongated neck posture characteristic of a gargling posture dissuaded patient J from raising her larynx higher than it was. In a gargling posture, a patient cannot make the hyolaryngeal sling tighter than it often already is. The posture also stretches the extrinsic laryngeal strap muscle. The next instruction to patient J was to add the gargle “sound” to the air bubbles, being careful not to use the word “voicing” so as not to introduce any anxiety ridden verbiage. Patient J again was successful. The final step in the gargling technique was to have the patient slowly lower her chin while still gargling with sound. With some patients, once phonation is established with this technique, shaping the sustained gargle into speech is all that is needed. In general, whenever a SLP feels that a patient can “jump” right to conversational speech in the therapeutic process, the sooner the patient tries, the better.66 Unfortunately, patient J was unable to transfer the voiced gargle to phonemes, words, and phrases. /u/ Prolongation: The next instruction I gave patient J was to produce a /u/ without voicing. A strip of facial tissue was held between her index and third fingers, approximately 5 cm (2 in) from her nose. The reason a voiceless /u/ is used is because the lip contour for /u/ directs the airflow in a column from the lips, and it is easy to move the tissue and hear a steady airflow stream. The cycle of inhalation followed by exhalation on a voiceless /u/ should be produced smoothly and without hesitation resulting in a consistently uplifted tissue. The goal is to achieve the task with minimal throat effort and a feeling of airflow “energy” at the lips. Patient J


was asked to take a breath and immediately exhale a sigh on a /u/. At first, the tissue moved only with the initial exhalation, but then the patient appeared to hold back her airflow; the tissue did not move. She did an audible semi-Valsalva as she stopped the airflow. The instruction was given again, and this time the patient released the exhalation for a longer duration but the exhalatory airflow sounds were “jerky” and not consistent. Often the SLP will use the following verbiage to instruct the patient: “I want you to pretend that you have had a long day and that you are just letting out a nice, relaxed sigh but on the letter /u/.” She performed much better this time. Lip Bubbles: Wanting to capitalize on her success thus far, I moved on to another airflow-inducing technique. I asked her to do an easy voiced lip bubble. Patient J could lip bubble with the aid of placing her 2 index fingers on the corners of her lips. She lip bubbled for long and short durations, producing high-pitched and low-pitched sirens. All the while, patient J was asked if she could feel “airflow energy” at her lips and if her throat felt relaxed. Some patients find this very difficult to do; if so, they are asked to move to the next exercise. Skill 1: Airflow Release — Articulated Airflow Voiceless Phonemes: Now that airflow was being released, she was informed that she could produce approximately 31% of the sounds of the alphabet; out of 26 letters, she produced 7 without a problem, which were all the voiceless consonants (f, h, k, p, q, s, t). I immediately advanced to prolonging the voiceless fricatives /s, f, sh/. Once she could prolong them, she was asked to do pitch

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(ie, formant frequencies) glides, sirens, and be loud and soft with the fricatives. All the while, patient J was asked if she could feel “airflow energy” at her lips and if her throat felt relaxed. Voiceless Phrases/Conversation: When it was apparent that patient J could easily release unvoiced airflow, she was asked to articulate around the airflow done in an easy, breathy unvoiced whisper. First, I wanted to model articulated airflow (ie, efficient whisper) and second, I did not want patient J to reinforce the old strained whisper in between all her successful trials to establish airflow release done so far. This is a very important instruction to a patient that should be said as follows: “I want you to move your tongue and lips around this steady stream of airflow that you have done so far.” Having patients concentrate on airflow versus speech articulation may disentangle the possible maladaptive habits found in speech. The concept of airflow always must be front and center with this therapy. So, keeping the facial tissue in the same position as was done for the voiceless /u/, patient J was asked to produce phrases with just airflow. The tissue should move with the airflow. Within each phrase, patient J was asked to connect each of the syllables or words together, so that no separation or pausing occurs. Examples of phrases that direct the airflow to easily uplift the tissue are “Poo-loo-poo-loopoo-loo” and “Who is Lou? Who is Sue? Who are you?” At this juncture in the therapy, communications between patient J and I were done in an easy, breathy, unvoiced whisper. During this stage of therapy, often it is a good time to interrupt the structured tasks of therapy and just “talk.” This can be an opportunity for the SLP to discover any psychosocial

issues if the SLP thinks that the voice problem may be secondary to stressreactivity-personality profiles and/or psychosocial trait or states.12,67–70 Furthermore, all patients are asked to adopt this easy unstrained whispering in between sessions (eg, at home) if voice reinstatement is not achieved within the first few sessions. Skill 2: Breathy Phonation — Unarticulated /u/ Prolongation: Patient J was asked to make voice while continuing to use the tissue as feedback. Patient J was told that the most important part of the exercise was to see and hear the airflow versus produce voice. Patient J was asked to take a breath and exhale on a breathy /u/ in a downward glide like a sigh. The tissue should move with the airflow. The sound she produced was breathy but unsteady, and at the end, she cut off her airflow. I asked her to do the /u/ on just airflow alone to reestablish the easy feel and see/feel the airflow on the tissue. Then I asked her to try again with sound, and this time she was more successful. Voiced Lip Bubbles: Patient J was educated about coordination of airflow with sound and told that these exercises were merely coordinating her airflow with her sound generator. Next she did voiced lip bubbles and was very stimulable, producing a wonderful voice. Skill 2: Breathy Phonation — Articulated Voiceless to Voiced Fricatives: Patient J was now asked to do a true vocal balancing technique; that is, to prolong an /s/ and seamlessly add voicing into the cognate /z/. Patient J was asked to pay

attention to how little effort was needed to make voice. She was asked to do an /f/ into a /v/ and back and forth, as well as voiceless [th] to voiced [th] and [sh] to [dz]. Phrases/Conversation: This is the very short section of flow phonation, which is to ask patients to actually converse in breathy phonation. This is very much like Confidential Voice,71 but because we know that breathy phonation actually takes more effort than efficient voicing,72 this part of therapy is meant only to gradually introduce the patient to voicing with lots of airflow. Patient J was told that she might need more breaths per phrases because of the breathiness. The same sentences were used as before, but with added voice this time. Patient J was again reminded to feel “airflow energy” at her lips and see that her throat felt relaxed. She was asked to say: “Poo-loo-poo-loo-pooloo” and “Who are you? Who is Lou? Who is Sue?”


back.” Then she was asked to produce /u/ using flow phonation, allowing the tissue to move but without the breathy voice quality. She also was asked to contrast the sensation and degree of effort for the different modes of phonation: breathy, flow, and pressed.47

Flow Phonation — Articulated. Voiceless to Voiced Fricatives: Patient J was asked to get louder when doing the seamless transition from the voiceless cognates into the voiced cognates, and to do them on pitch glides. For example, on a siren, patient J produced /s/→/z/ →/s/→/z/, and so forth. This was done on the other fricative cognates. This can be a difficult step for some patients as different pitches, different articulatory postures, and transitions from voiceless to voiced sounds are being introduced. Patient J, with some practice, did well. Phrases/Conversation: Patient J was then asked to say the following phrases in flow phonation and contrast that to pressed phonation (explained as Flow Phonation — Unarticulated. /u/ holding back all the airflow): “Poo-looProlongation and the Kazoo Sound: poo-loo-poo-loo” and “Who are you? Patient J was asked to prolong an /u/ Who is Lou? Who is Sue?” just like in breathy phonation but to Patient J did very well and discrimimake the sound louder and not sound nated not only between the difference in breathy. In other words, produce a non- the 2 sounds (pitch lower and rougher breathy sound yet achieve the same for pressed phonation) but between the movement of the tissue (flow phona- differences in feeling in the throat (contion). Often, the only instruction a stricted for pressed and “open” for flow patient needs to go from breathy to phonation). flow phonation is to get louder. Patient Articulatory Precision: An easy J was fairly successful in making the technique that seems to link cognition transition to flow phonation but needed to flow phonation in speech is having much time simply doing pitch glides patients concentrate on articulatory preand sirens on /u/. She was then asked cision in their speech. The final key to to contrast pressed and flow phonation using flow phonation in conversational styles on /u/. First, she was asked to speech is to allow articulation to faciliproduce the /u/ again but not to allow tate the sensation of airflow energy at any airflow to move the tissue. She was the front of the mouth. Practice using simply instructed to “hold her breath flow phonation while maintaining

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awareness of articulatory activity first with sentences that include many phonemes generated in the front of the mouth. Patient J was asked to pretend that she was “speaking clearly”73,74 to a person who was hard of hearing while she said the following sentences that were loaded with voiceless/voiced consonants and, in particular, voiceless fricatives. Here are examples: n “Fat Freddy prefers French fries.” n “See Sammy slither in the grass.”

Finally, patient J and the voice therapist had a conversation about a topic chosen by patient J. The only thing patient J was asked to do was to use articulatory precision monitoring airflow energy at the lips without any throat constriction. Although the area in the brain that governs speech (speech motor cortex) is different from the area of the brain that governs vocalization, the periaqueductal gray (PAG),75 the patient was asked to feel the energy of articulation and not be concerned with feeling any constriction in the throat. If not, patients can be very precise in articulation but aphonic at the same time. The patient must produce airflow energy at the mouth without throat constriction. Patient J did well at using articulatory precision at the beginnings of her phrases, but she often let her airflow drop at the end of linguistic strings, once again engaging in pressed phonation. This is a common trait in North American English because of decreased pitch intonation contours at the ends of linguistic strings. To counter this, she was asked to end every phrase with a voiceless /p/ to offset phonation with abducted vocal folds versus tightly adducted vocal folds. Patient J thought this was “very weird” but seemed to understand the rationale and was suc-

cessful in monitoring lack of flow at the ends of linguistic strings. At the end of the session, patient J’s mother was invited into the session. As a rule, the SLP usually dissuades parents or caregivers coming to the voice therapy sessions. The SLP likes to invite parents or caregivers after the session and have patients explain to them what they did in therapy. It is not important that patient J understood how she did something,76 but rather that she was aware of the effects of different sensations and how they related to the sound and feel of voicing. Patient J nicely demonstrated the difference between breathy, flow and pressed phonation. She was skeptically happy that her “voice came back.” However, when she made that remark, I quickly intervened with “voice production came back.” It was important for patient J to think of herself as an active participant in voicing and not just a victim of “her voice.” This is a key point in any type of therapy.

Therapy Outcome Patient J was fully speaking after being aphonic for 3 months. As is common with many muscle tension aphonic patients, the patient unfortunately did not return for follow-up. Although this was the first time the patient had lost her voice production, her history and conversations led me to believe that perhaps her aphonia may have been related to stress reactivity. The patient certainly had other known forms of stress-related illnesses, and she described herself as being “always stressed.” It is hoped that she will not relapse, but as the literature indicates, 60% of patients are prone to relapse.67 For now, flow phonation seemed to reestablish vocal balance and give her a conceptual framework


for understanding how she could again reinstate her voice if needed. Manual manipulation of the larynx has proven to be a technique that modifies maladaptive phonatory patterns. In the next case, Nelson Roy describes the use of manual circumlaryngeal techniques to remediate MTD in an adult woman.

Case Study 5 Nelson Roy Manual Circumlaryngeal Techniques in the Assessment and Treatment of Primary MTD in a 55-Year-Old Woman Without exception, contemporary voice texts cite excessive or poorly regulated activity of the intrinsic and extrinsic laryngeal muscles as important causal considerations in a variety of voice disorders.2,19,77–80 This “imbalanced” laryngeal and paralaryngeal muscle activity seems to be the common denominator behind a class of voice disorders referred to as hyperfunctional or musculoskeletal tension voice disorders.1 In this regard, manual circumlaryngeal techniques recently have received attention in the clinical voice literature as potentially valuable diagnostic and treatment tools. This case study illustrates the use of these manual laryngeal techniques and highlights important procedural considerations.

Voice and Medical History Patient XX, a 55-year-old “paralegal,” presented with a 6-month history of

chronic mild-to-moderate dysphonia with sporadic acute exacerbations. These acute episodes, which bordered on aphonia, persisted for less than a week and resolved gradually. The patient indicated that she seemed to be gradually “losing the full force of her voice.” She reported a persistent ache and tightness of the anterior neck, larynx, and shoulder regions. She had also noticed episodic neck swellings that she labeled as “swollen glands.” According to the patient, these “lumps” would worsen according to her amount of voice use, and the degree of perceived laryngeal tension, fatigue, and effort. She added that the swellings coincided with the acute dysphonic exacerbations and that their appearance was not accompanied or preceded by symptoms of an upper respiratory infection (URI). The patient reported no change in health status and occupational or social voice use preceding the onset of vocal symptoms. Her recent medical history included treatment for asthma, allergies, hypertension, depression, tension headaches, gastroesophageal reflux disease (GERD), and temporomandibular joint dysfunction. Her current medications included Altace (antihypertensive), Prozac (antidepressant), Cimetidine (antacid), and Premarin (estrogen replacement). She had received psychological treatment for clinical depression 4 years previously, but she was not currently consulting a mental health professional.

Psychosocial Interview During the psychosocial interview, patient XX reported numerous workrelated stresses. She indicated that just prior to the onset of her voice difficulties, “her workload at the firm had become horrendous and had doubled following

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a company takeover.” Patient XX explained, “I found every single day stressful at work, and that’s when some of this started. . . . Every day I went into work to put out the fires, rather than doing something fresh — it was constant pressure.” She admitted feeling overwhelmed and exhausted. Patient XX indicated that 2 months earlier, she had missed work for 1 week with “chronic fatigue” accompanied by complete voice loss. Although she was frustrated by the increased workload and the limited support offered by her superiors, she had not expressed this dissatisfaction to her manager and was reluctant to do so. Her employer had hired additional office help recently, but she was solely responsible for training that individual. Consequently, she was forced to neglect some of her own duties in the process, only adding to the burden. In addition to the work-related stresses, the patient admitted to a long-standing communication breakdown with her only daughter. She had not communicated with her daughter over the past several years. Despite probing by the clinician, patient XX denied knowing the precise cause of the communication breakdown, but she confessed to thinking about the unresolved conflict on a daily basis.

Voice Evaluation Perceptually, her connected speech was characterized by a mildly pressed, tight vocal quality, which worsened over the course of the assessment period. By the end of the interview, patient XX was in glottal fry 80% of the time. Repeated readings of a standard passage produced further deterioration in voice. Sustained vowel production was somewhat superior in quality when compared with connected speech. She

displayed reduced pitch range and experienced noticeable phonatory disintegration early during upward pitch glides. She seemed to be functioning toward the bottom of her phonatory frequency range. Rigid videolaryngostroboscopy revealed no evidence of structural or neurological pathology. Both vocal folds moved symmetrically and were free of mucosal disease. Mild mediolateral supraglottic compression was noted. Vocal fold vibratory characteristics, including mucosal wave and amplitude of vibration, were essentially within normal limits; however, the closed phase dominated the vibratory cycle.

Treatment Focal Laryngeal Palpation: At rest, musculoskeletal tension was appraised manually by palpation of the laryngeal area to assess the degree, nature, and location of focal tenderness, muscle tautness, muscle nodularity, or pain. Care was taken to avoid sustained carotid artery compression during these maneuvers. With the occiput gently supported in a neutral position, pressure was directed: (1) over the major horns of the hyoid bone, (2) over the superior cornu of the thyroid cartilage, (3) within the thyrohyoid space, (4) within the suprahyoid region, and (5) along the anterior border of the sternocleidomastoid muscle. During palpation, the degree of compression applied was roughly equal to the pressure required to cause the thumbnail tip to blanch when pressed against a firm surface. When this amount of pressure was used, focal sites of tension evoked discomfort and pain. The patient winced, withdrew, and vocalized her discomfort when tender points were specifically identified. These sites

of tenderness were over the major horns of the hyoid and the superior cornu of the thyroid cartilage. The patient confirmed that these sites were the location of her episodic laryngeal swellings. The discomfort was more pronounced on the left than on the right and radiated to both ears. This severe tenderness in response to pressure in the laryngeal region, along with extreme muscle tautness, was considered abnormal and highly suggestive of excess laryngeal musculoskeletal tension. The extent of laryngeal elevation was examined by palpating within the suprahyoid region and the thyrohyoid space from the posterior border of the hyoid bone to the thyroid notch.8 Noticeable muscle tautness was appreciated in the suprahyoid region. The patient also demonstrated a narrowed thyrohyoid space that caused the larynx and hyoid to be suspended high in the neck. This finding was also highly suggestive of excess muscle tension. Attempting to maneuver the larynx from side to side along the horizontal plane tested its mobility. Ample resistance to lateral movement indicated generalized extralaryngeal tension. Voice Stimulability Testing Using Manual Techniques With the index finger and thumb situated within the thyrohyoid space, the clinician applied gentle downward traction over the superior border of the thyroid lamina while the patient vocalized a sustained “ah” vowel. The voice improvement associated with such laryngeal lowering (reposturing) was immediate and audible to both the patient and the clinician. Such a positive response to laryngeal reposturing and stimulability testing was informative regarding the patient’s potential


for normal voice and was suggestive of muscular tension and laryngeal elevation as possible causal mechanisms. (Other manual reposturing techniques, including pressure in a posterior direction over the inferior aspect of the hyoid bone, did not produce noticeable improvement in voice quality.) Before proceeding with manual circumlaryngeal therapy, the diagnosis of muscle tension dysphonia was explained to the patient, and she was educated regarding the negative effects of excessive musculoskeletal tension on voice and the possibility that such tensions may be responsible, solely or in part, for her voice disorder. In addition, the results of the laryngoscopic examination were reviewed, emphasizing the absence of vocal fold pathology sufficient to account for the severity and fluctuating nature of her voice symptoms. Once she appeared to understand the relationship between muscle dysregulation, stress, and voice, the manual therapy procedure was outlined, and the positive outlook for recovery was explained. She was warned that the technique may produce some initial discomfort but that with continued kneading of the musculature, the pain gradually would remit. She was also encouraged to attend carefully to any voice improvement and the laryngeal sensation accompanying such improvement. Circumlaryngeal Massage Rationale. Once the assessment procedures were completed and the results were explained to the patient, the manual tension reduction technique (ie, circumlaryngeal massage) was undertaken according to the description of Aronson.19 Skillfully applied, systematic kneading of the extralaryngeal region is postulated to stretch muscle tissue and

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fascia, promote local circulation with removal of metabolic wastes, relax tense muscles, and relieve pain and discomfort associated with muscle spasms.81 The putative physical effect of such massage is reduced laryngeal height and stiffness and increased mobility.82 Once the larynx is “released” and range of motion is normalized, an improvement in vocal effort, quality, and dynamic range should follow. Focal palpation and massage help patients become more aware of where they are holding tension. By being conscious of these laryngeal “trouble spots,” the patient can begin to focus on relaxing them during self-massage, which can be undertaken on a daily basis. In a series of articles, Roy and others have evaluated the clinical utility of manual techniques with a variety of voice disorders.3,7,27,30,44,45,83–85 The results of these investigations suggest that the majority of patients studied derived noticeable voice improvement within a single treatment session using manual circumlaryngeal therapy. Description of the Technique The hyoid bone was encircled with the thumb and index finger, which were then worked posteriorly into the tips of the major horns of the hyoid bone. Pressure was applied in a circular motion over the tips of the hyoid bone. The procedure was repeated within the thyrohyoid space, beginning from the thyroid notch and working posteriorly. The posterior borders of the thyroid cartilage medial to the sternocleidomastoid muscles were located, and the procedure was repeated there. With the fingers over the superior border of the thyroid cartilage, the larynx was stretched downward and, at times, moved later-

ally. Sites of focal tenderness, nodularity, or tautness were deliberately given more attention. Gentle kneading or sustained pressure was focused over these sites and then released. The procedure began superficially, and the depth of massage was increased according to the degree of tension encountered and the tolerance of the patient. The clinician extended the technique into the medial and lateral suprahyoid musculature, because excess tension and pain were encountered over those sites. The patient was encouraged by the clinician to “unhinge her jaw and assume a more relaxed jaw position.” The immediate effects of massage were noticeable on the skin. A slight reddening and warming of the skin accompanied friction and circular stroking movements. During the above procedures, patient XX was asked to sustain vowels while both the clinician and the patient noted changes in vocal quality. The patient, as an active participant in the therapy process, was encouraged to continually self-monitor the type and manner of voice produced. Given her marked sensitivity to pressure in the laryngeal region, some discomfort during the procedure was unavoidable. Nonetheless, the clinician’s goal was to achieve sufficient tension reduction without inducing reactive-reflexive muscle tensing because of pain. Improvement in voice was noted almost immediately and was combined with reductions in pain and laryngeal height. Such changes were suggestive of a relief of tension. The patient commented, “Even though it hurts, it still feels good.” Over the course of approximately 20 minutes, the improved voice was extended from vowels to words (automatic serial speech, ie, counting, days of the week), to short phrases loaded with nasals (eg,

“many men in the Moon,” “one Monday morning”), to sentences and paragraph recitations, and then to conversation. Once sufficient tension was released and the patient assumed a more normal laryngeal posture, progress was swift, with complete amelioration of the dysphonia. Following the procedure, patient XX commented that the voice felt free of tension and effort. On repeated laryngeal palpation, the sites of most severe tenderness were no longer apparent. Pain no longer radiated to the ears. The patient was warned that she could experience some mild laryngeal discomfort over the next 24 to 48 hours as a consequence of the intense massage but that this should resolve. Patient XX was instructed in selflaryngeal massage techniques and encouraged to perform them twice daily and whenever she experienced any tightness or fatigue in the laryngeal region. She was scheduled for a followup visit in 1 month to assess progress and determine future management. Patient XX was instructed to contact the clinician should she experience any acute exacerbations. In the interim, the patient was encouraged to make modifications to her work schedule to alleviate some of the situational stresses and to explore psychological counseling to acquire relaxation skills.

Recurrence and Relapse Patient XX contacted the clinician 2 weeks later with a severe strained dysphonia (with frequent aphonic breaks) that had suddenly begun a day earlier, which was Sunday. Until this exacerbation, the patient reported symptom-free voice for the 2-week post-treatment period. She indicated that her recent attempts


at self-laryngeal massage were completely unsuccessful in modifying the voice. She denied any new situational conflicts, stresses, or voice-use patterns that may have contributed to the onset but had not pursued counseling. Rigid and flexible videolaryngo stroboscopy revealed an extraordinary sequence of laryngeal movements, most obvious during laryngeal ddks (rapid abduction and adduction of vocal folds). The laryngeal movement pattern was characterized by prephonatory supraglottic compression with complete obliteration of the view of true vocal folds by the overadducted ventricular folds. Phonatory initiation was preceded by abduction of the left arytenoid complex while the right arytenoid remained adducted, producing an irregular-shaped posterior glottic and supraglottic chink (Figure 3–2).

Figure 3–2. Pretreatment rigid video laryn goscopy obtained during sustained phonation illustrates the asymmetric appear ance of the arytenoids, combined with mediolateral and anteroposterior supraglot tic constriction that was sufficient to obscure the view of the true vocal folds. An irregularshaped, posterior glottic and supraglottic chink was created by the partially abducted left arytenoid complex.

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This paradoxical movement of the left arytenoid during phonatory initiation appeared to represent a decoupling of conjugate vocal fold movements. The dysphonia was interpreted by the clinician to be a more severe manifestation of the original muscle tension disorder. Manual circumlaryngeal therapy again was undertaken according to the previous description. In spite of paralaryngeal tension and pain that were judged to be more severe than the original visit, normal voice quality was again rapidly reestablished within a single treatment session. This time, the patient transitioned through several stages of decreasing vocal severity until normal voice was restored. One intermediate stage of dysphonia was quite reminiscent of her original dysphonia. Post-treatment rigid videolaryngostroboscopy (same session) showed no evidence of the atypical and asymmetric arytenoid movement pattern and confirmed normal vibratory characteristics (Figure 3–3). The pretreatment and post-treatment sustained vowel acoustic analyses are shown in Figures 3–4A and 3–4B, respectively. Her severely disturbed voice in the pretreatment analysis is replaced by a normal post-treatment voice. All results are based on samples obtained within the same assessment and treatment session. Once the voice was restored, a frank discussion ensued regarding the complex interplay of laryngeal muscle tension, life stresses, situational conflicts, and her apparently ineffectual coping strategies. She agreed that she needed to develop more pragmatic coping skills and that long-term maintenance of voice improvement probably would require supportive psychological coun-

Figure 3–3. Videolaryngoscopy com pleted immediately following successful manual circumlaryngeal therapy (same ses sion) confirmed normal glottic and supra glottic symmetry and function. All vibratory parameters, as assessed by stroboscopy, returned to within normal limits. seling. Arrangements were made for her to return to her counselor.

Short-Term and Long-Term Follow-Up The patient was reevaluated in the voice clinic at 3 and 6 months’ post-treatment. On each occasion, she reported no further relapse. Initially post-treatment, patient XX completed self-laryngeal massage on a daily basis, then weekly, and eventually as needed. She returned to her psychologist for relaxation training and short-term cognitive-behavioral therapy. By 6 months post-treatment, she had discontinued counseling and selflaryngeal massage, and had made many positive life and work adjustments. Contact by telephone approximately 2 years’ post-treatment confirmed maintenance of therapy gains without any evidence of partial or complete relapse.

A


B

Figure 3–4. Acoustic analysis before (A) and after (B) manual circumlaryngeal therapy for the acute exacerbation (ie, recurrence). Each figure illustrates the middle 1-second segment extracted from the pretreatment and post-treatment sustained vowel /a/ produc tions, sampled at 25 kHz, and acoustically analyzed using the Computerized Speech Lab (CSL Model 4300B, Kay Elemetrics Corp., Lincoln Park, NJ). A: Sound pressure waveform. B: Narrow-band spectrogram of the preemphasized downsampled (12.5 kHz) waveform generated using a 36 Hz analyzing filter. C: FFT (power spectrum) at the cursor location. D: Cepstrum power spectrum. The time axis is frequency and shows the dominant energy corresponding to the harmonic peaks in the spectrum. A prominent peak in the cepstrum is called the dominant harmonic, and its amplitude reflects the harmonic structure of the voice signal. Visual inspection of the pretreatment and post-treatment acoustic analyses confirms substantial improvement in spectral and cepstral characteristics following manual circumlaryn geal therapy. Improvement in harmonic intensity and structure following treatment is apparent in the post-treatment narrowband spectrogram (B) and power spectrum (C). The presence and amplitude of the dominant harmonic in the post-treatment cepstrum (D) substantiates these improvements.

Comparisons With Existing Research Patient XX’s positive response to manual circumlaryngeal therapy and her subsequent relapse and exacerbation are compatible with the results of an investigation of 25 patients with functional dysphonia (FD) conducted by

Roy and colleagues.44 All patients with FD received a single treatment session of manual circumlaryngeal massage. Although the majority of patients improved across perceptual and acoustic indices of vocal function, interviews during the follow-up phase revealed that over two-thirds of the patients who had initially responded favorably

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reported infrequent, partial, and selflimiting recurrences early in the followup phase (ie, less than 2 months posttreatment). It appears, then, that the case presented here is not exceptional from a treatment-and-relapse perspective. Roy et al44 advised that, for some patients, superior long-term results might be found when manual laryngeal techniques are combined with supportive counseling, more frequent clinical support, or both. Certainly, patient XX’s eventual sustained voice improvement following manual circumlaryngeal therapy and short-term psychological counseling seems to support this contention. During the second treatment, patient XX progressed through stages of decreasing dysphonia and laryngeal discomfort until voice symptoms gradually remitted. These findings are also consistent with Aronson’s 19(p315) accounts and the reports of Roy, Bless, et al44 Whether this gradual remission of dysphonia and laryngeal pain during treatment represents a steady reduction in laryngeal tension, as Aronson maintained, remains open for debate.

Conclusion It is apparent from this case study that voice and musculoskeletal symptoms can be consequences of specific environmental triggers and stressors combined with individual differences in coping style.10,86 Understanding the contribution of laryngeal and extralaryngeal muscle dysregulation to these disorders, therefore, is critical to proper diagnosis and selection of appropriate treatments. Manual techniques, including focal palpation, laryngeal reposturing maneuvers, and circumlaryngeal massage, are

valuable tools that augment the voice practitioner’s diagnostic and treatment armamentarium. Voice disorders often are complex in nature and challenging to fully define at the time of the initial evaluation. Consequently, clinicians may find themselves reconsidering their initial impressions as they walk with patients through the therapeutic process and observe the patients’ response to various methods. The following case of primary muscle tension dysphonia by Claudio Milstein highlights the importance of approaching clients with an open mind and a flexible treatment plan.

Case Study 6 Claudio Milstein Management of Primary MTD Initially Masquerading as a Paralytic Dysphonia in a 39-Year-Old Woman Using an Enabling Approach

Case History The patient is a 39-year-old woman who was referred by her ear, nose, and throat physician (ENT) for a 3-month history sudden onset of hoarseness following a total thyroidectomy. She is a trained singer and has worked as an elementary school music teacher (kindergarten through grade 6) for the last 10 years. She had a 4-year history of formal classical voice training in college, and over the years continued to take individual voice lessons for short periods to “tune-

up” her voice. Her teaching technique consisted of demonstrating the songs to her students, and then singing with them throughout the entire class. Therefore, over the course of an 8-hour working day, she estimated singing for about 4 to 5 hours. Prior to this event, she has not had a voice problem in the past and was able to complete her working days with no vocal fatigue. Her past medical history was significant for occasional sinus problems. Otherwise, she was a healthy woman. Her history was negative for smoking. She rarely consumed alcohol, drank about one serving of caffeine daily, and reportedly drank “lots of water.” Medications included thyroid hormone replacement therapy and birth control pills. She stated that she was very protective of her voice, has been well aware of vocal hygiene guidelines, and did not engage in any vocal behaviors that “would put my voice at risk.” Prior to undergoing a total thyroidectomy, her surgeon explained the potential risks of damage to laryngeal nerves, and stated that she would probably experience some hoarseness after the procedure. She had a noneventful postoperative period and was sent home the same day. She experienced minimal pain during the following 2 days. She noticed a change in her voice quality with some hoarseness immediately following the surgery but was not concerned about it initially, as she had expected to have some temporary voice changes, as explained by her doctor. However, after a month of hoarseness, she started worrying about possible vocal fold nerve damage. She consulted with her surgeon, who indicated that the laryngeal nerves were monitored during the operation, and that, as far as


he could tell, there had been no nerve trauma as a result of the procedure. She was referred to her local ENT physician, who confirmed that both vocal folds were mobile. He found generalized laryngeal edema and erythema and prescribed antireflux medication. The patient discontinued this medication after 3 weeks due to lack of improvement. On her next ENT follow-up visit, she was urged to comply with the reflux management recommendations. After 3 months of medical treatment with no improvement, the ENT physician referred the patient to our clinic for what he described as a “frustrating lack of progress.” During her first evaluation, the patient reported that she had returned to work full time but was having significant difficulties performing her job. She was unable to sing and was experiencing extreme vocal fatigue at end of the day. She had started using a microphone at school when teaching, but this was not helping much. She appeared quite anxious about the future of her voice and indicated that this was catastrophic for her career both as a music teacher and a singer. She described her symptoms as follows: n Consistent hoarseness n Straining to speak n Significant drop in her speaking fun-

damental frequency, resulting in a “very deep voice” n Significant drop in her singing pitch range with a 1½ octave loss in the upper range n Inability to increase loudness beyond a quiet voice n Pain described as “cramping” localized to the lateral aspect of the larynx, hyoid, and submandibular area

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bilaterally, particularly when attempting to sing at high pitches n Voice fatigue that increased with voice use n Increased shoulder/neck tension with voice use n Globus sensation with difficulty swallowing. She indicated that her thyroid hormone levels were balanced, as per her endocrinologist. On the weekends, when she rested and maintained a selfimposed complete voice rest, her energy levels were good. She attributed the fatigue during the week days to the constant effort required for speaking.

Voice Evaluation Trauma to the laryngeal branches of the vagus nerve following thyroid surgery is a known potential risk of this procedure. The nerves may be stretched, bruised, or severed, resulting in unilateral neuropathy, and more rarely in bilateral involvement.87 In some patients, the damage is permanent, whereas others experience spontaneous recovery up to 9 months after the nerve insult. Trauma to the recurrent laryngeal nerve may result in unilateral vocal fold paralysis or paresis, causing hoarseness and sometimes dysphagia. Superior laryngeal nerve (SLN) transient or permanent injuries are relatively frequent and are often underestimated.88,89 Deeper voices and a loss of the upper part of the register are not infrequent in these cases. Based on this patient’s case history and symptomatology, trauma to the SLN was considered. On initial evaluation, her voice quality was judged to be consistently mildly hoarse and low pitched, with

a consistently low loudness level. Her average speaking F0 was 165 Hz, which was considered low for her age and gender. During testing for voice range, she had an inability to increase either pitch or loudness. When asked to perform a pitch glide toward higher pitch levels, the patient reported throat pain starting consistently at around 250 Hz. She was unable to go any higher than 260 Hz. This, for a classically trained soprano, was devastating. Palpation of the neck musculature during upward pitch glides revealed sudden and severe tightening of the laryngeal and paralaryngeal musculature. When prompted to increase volume, her voice remained soft and weak, despite clear efforts from the patient to do the task correctly. Videostroboscopic evaluation revealed essentially a normal larynx. There were no lesions, tumor, masses, ulcerations, or areas of leukoplakia identified. Mobility of the vocal folds was within normal limits bilaterally. There was no edema or erythema. The vocal folds appeared with good color and straight edges. During phonation at a comfortable pitch level, the pattern of glottal closure was complete. Phase symmetry of vocal fold vibration was regular. Amplitude of vibration and mucosal waves were within normal limits bilaterally. The only significant finding from the videostroboscopic examination was an odd laryngeal posturing when the patient attempted to phonate above 250 Hz. There was noticeable narrowing of the posterior pharyngeal wall, and supraglottic constriction, with significant tilting forward of the arytenoids. In other words, laryngeal posturing was normal below 250 Hz, and a severe constriction with an odd posturing was observed as soon as that pitch level was

reached. This was confirmed with multiple pitch glide repetitions, in which constriction was elicited exactly at the same pitch level every trial. When the patient was asked to produce a louder voice, she simply could not do it, despite perception of a legitimate attempt to do so. After the initial evaluation, several therapeutic probes, which included digital laryngeal manipulation and neck and shoulders stretching exercises, were implemented. Following this brief treatment, the patient was able to raise pitch slightly higher than before, up to 300 Hz, but not any higher. She could not increase loudness level. Based on the results of this evaluation, nerve trauma was suspected. The deepening of her conversational voice, together with the inability to produce higher pitches, and the odd laryngeal posturing seen during endoscopy were thought to be secondary to insult to the superior laryngeal nerve. In addition, musculoskeletal tension was observed. Although the decrease in pitch range could be attributed to SLN neuropathy, there was no physiological explanation for the inability to go beyond a soft voice. The comprehensive evaluation did not reveal any physiological impediment for increasing loudness, as her respiratory system, ability to produce large subglottic pressures, and laryngeal mechanism and valving appeared to be intact. Treatment recommendations included an electromyographic (EMG) study to evaluate the status of laryngeal nerves and the initiation of an individual course of voice therapy to address musculoskeletal tension. The patient refused to undergo a diagnostic EMG examination for fear of needles and the invasive nature of the procedure. She agreed to initiate voice therapy.


Voice Therapy Even if a neuropathy was confirmed at a later time, it was believed that a therapeutic approach would be beneficial to decrease the hyperfunctional component. Therefore, the goals of therapy were established as follows: (1) decrease muscular tension during voicing, (2) increase pitch range and loudness levels while maintaining a relaxed voicing mechanism, and (3) achieve effortless and relaxed sound. Prognosis for voice improvement was deemed good based on the initial positive response to therapeutic intervention during her evaluation. The patient initially presented for 2 therapy sessions where several therapeutic techniques were tried. These included: n laryngeal repositioning maneuvers n digital laryngeal manipulation n head-neck-shoulders relaxation n coordination of respiratory and pho-

natory behaviors n breath support for increased loudness n phonation through semi-occluded vocal tract configurations n pitch glides with lip and tongue trills n voice placement with forward focus

All of these techniques failed to improve pitch or loudness ranges. Even though she had responded well to digital laryngeal manipulation during the initial evaluation, further improvement was not achieved with therapy. It appeared as if there was a threshold for both pitch and loudness above which the patient could not operate. Phonation below that threshold could be achieved in a relaxed manner, with no hoarseness or discomfort, but above it, severe tension was elicited.

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Based on the clinician’s belief that there was no physiologic impediment for producing louder voice, by mutual agreement, a third session was scheduled to focus exclusively on vocal loudness. The intent was to encourage and motivate the patient to overcome the loudness threshold and achieve louder phonation. An overview of the therapeutic approach follows. The process occurred within a 30-minute time frame: Clinician: “We are going to focus on the volume of your voice today, and try to get very loud. I want you to look out of the window and try to yell, “Hey you!” loud enough to get that person’s attention.” Patient: “I don’t think I can do that.” C: “Just try.” P: Patient initiates a series of “Hey You!” productions, trying to increase loudness after each trial as prompted by the clinician. Her willingness to do the required task was evident; however, the more she tried to get loud, her voice would become breathier and more strained but not any louder. C: As the patient would stop and “think” between trials, the clinician prompted her to: “Just do it — don’t think about it — just do the task!” The more the patient tries, the more frustrated she gets by her inability to get louder, and she becomes emotional and tearful. The emotional display did not stop the unrelenting prompts by the clinician to continue to try to yell. P: “I’m exhausted, I can’t do anymore, this is not going to work.”

C: “Keep trying, as loud as you can!” “Yell now!” “One more time!” After approximately 15 more trials, her voice got increasingly louder. Eventually, she was able to produce a very loud voice. Encouraged, she tried a couple more times, actually yelling, and this elicited an emotional catharsis. Evaluation of her voice quality after this sequence of events revealed a normal voice, with normal loudness level, and ability to voluntarily increase volume as desired. Voice quality during loud productions was judged to be within normal limits, with no evidence of the prior hoarse and breathy voice she had at the onset of the voice therapy session. Moreover, and this was surprising to both the patient and the clinician, once loudness range was reestablished, her average fundamental frequency during conversational speech was noticeably higher. Immediate evaluation of her pitch range revealed complete recovery of her pitch range without further intervention. The patient was able to produce pitch glides up to 1050 Hz without effort or discomfort. This appeared to be a simultaneous benefit of the breakthrough with loudness.

Therapy Outcomes A 1-week over-the-phone follow-up revealed that she had maintained a normal voice quality, with an increase in her overall fundamental frequency for speech, ability to phonate at normal and loud voice levels, and recovery of her normal pitch range. She was able to stop using a microphone at work and was able to teach all day without discomfort. She also reported a significant improvement in her singing voice. Posttherapy videostroboscopic examination was deemed unnecessary.

Summary and Concluding Remarks This case demonstrates the use of an enabling voice therapy technique in a patient who had developed an inability to phonate above a specific threshold. It appeared that the patient had acquired maladaptive strategies in an attempt to “protect” her voice after surgery, as if she was “holding back” for fear of further damage. Even though some of the symptoms appeared consistent with postoperative SLN injury, this was a unique manifestation of what turned out to be a case of functional dysphonia, or musculoskeletal tension. Muscle tension disrupted two parameters of vocal function, creating a “ceiling-effect” beyond which the patient could not operate. Below those levels, physiologic parameters of voice production were intact. Once the patient regained access to volume control, it appeared to recalibrate the entire system, with immediate restoration of full pitch range. The clinical relevance of this case lies in the therapeutic approach. As demonstrated, at times, coaching of this patient required gentle guidance, and at other times coaching needed to be more assertive and harsh. The approach was met with resistance, in terms of the patient believing she could not perform the required tasks. The actual dialogue was neither sophisticated nor particularly varied. It was a relentless, continued urging of the patient to get louder, louder, louder, followed by additional prompts such as: “You can do this,” “You need to push yourself,” “It doesn’t matter how it feels, just do it,” and so on. This focused on only one goal, to force the patient to overcome her limitation. Not surprisingly, there was signifi-


cant emotional catharsis manifested in crying, not only during the process, but after the breakthrough. The patient’s reflection was that it was really hard, and she was convinced she could not do it. She genuinely believed she was physically unable to get louder. She was grateful that the clinician pushed her beyond levels that she did not think possible. The reader should understand that sometimes “tough love” is required in therapy. We cannot use the patient’s words, or emotional reaction of resistance, to be the indicators of the end point of the therapeutic approach. In order to allow the patient to push through an emotional and physiologic limit, sometimes the guidance has to be done in an encouraging but strict manner. Voice improvement in this case was not a slow, gradual response to therapy to obtain a normal voice. In the treatment of patients with functional dysphonia, often there is little or no evidence of success during the therapeutic process, until the patient reaches a breakthrough moment, after which recovery is achieved quite rapidly. In these cases, the clinician’s persistence is paramount to success. It appears as if, once the patients reach a level of tiredness (mental or physical) during the therapeutic process, their physical or mental blocks go down, and they are not able to continue to hold on to the maladaptive patterns of vocal function that resulted in dysphonic voices. In the following case study, Leslie Glaze advocates for supplemental patient-family involvement to support traditional treatment strategies, including voice conservation and a vocal exercise regimen, in the case of a 7-year-old child with MTD secondary to vocal nodules.

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Case Study 7 Leslie Glaze Use of Patient-Family Education and Behavior Modification to Treat MTD Secondary to Vocal Nodules

Patient History Patient D, a 7-year-old girl, was referred for voice evaluation and treatment by the otolaryngologist, who had diagnosed bilateral vocal fold nodules. Her mother described her daughter as active, energetic, and frequently “difficult,” based on “temper tantrums” and episodes of yelling and screaming with her younger brother. Her second-grade schoolwork was average and she did not pose behavior problems at school. Her parents divorced 2 years ago, and the patient lived primarily with her mother, but spent extended summer vacations at her father ’s home. Patient D, her mother, and her brother were receiving family counseling sessions weekly to resolve problems with discipline and communication at home. The patient reported that her favorite activities were watching videos, playing outside with neighbor friends, riding her bicycle, and Scouts. She was also active in a summer softball league, spring gymnastics team, and a winter hockey league. Patient D had a normal, healthy medical history, with very infrequent middle ear infections during the first 4 years of life. She had no history of allergies, postnasal drip, chronic colds, sinus infections, or other upper respiratory infections. She had not had any injury to the throat, nose, or neck, and had no evidence of hearing loss. She had

never been hospitalized and was not on any medication. The patient reported that she drank approximately 3 cans of caffeinated soda per day and drank milk with meals, but consumed little or no water regularly. Her favorite foods were spaghetti, pizza, and “McDonald’s.” She denied any symptoms of burping, “hot spit-up,” burning throat, or stomachaches.

History of the Problem Initially, patient D’s first-grade and second-grade teachers noticed that she had frequent hoarseness with approximately 4 episodes per year of complete voice loss. The patient had no evidence of other speech or language problems, but they reported this concern to patient D’s mother, the school speech-language pathologist, and the school nurse. The child did not qualify for school services, but the school nurse asked the family to seek a medical evaluation and treatment for the voice problem. The otolaryngologist examined her larynx with a mirror and observed “soft-appearing, moderate-sized, bilateral vocal fold nodules.” The remainder of the head and neck examination was negative, including normal appearing ears, nose, mouth, pharynx, and neck. The patient’s mother reported that she believed her daughter’s voice had worsened gradually over about a 3-year period, beginning during the time when she and her ex-husband were separating. Patient D and her younger brother were upset about the transition and the mother reported a general increase in vocal arguments, crying, and tantrum behavior by both children during that time. However, her mother also noted that in 2 consecutive summers,

her daughter’s voice had improved following vacations with her father. Her mother believed this improvement was attributable to the fact that the patient’s father is a psychologist who manages the children’s behavior differently, such that fewer tantrums or vocally abusive episodes occur. In fact, the principal goal of the ongoing family counseling sessions was to learn different behavior management styles, to create a calmer, more communicative home environment.

Evaluation Procedures Patient D received a standard battery of vocal function testing in the voice laboratory. These assessments included: 1. Visual-perceptual. A stroboscopic examination was conducted using a rigid 70-degree endoscope without need for topical anesthesia. The recording revealed moderatesized, bilateral vocal fold nodules at the anterior two-thirds junction of the vocal folds with no evidence of edema or hemorrhage. Mucus stranding between the vocal nodules was persistent. The nodules appeared to vibrate with the vocal folds, although mucosal wave and amplitude were reduced at the midline bilaterally, presumably as a result of stiffness at the lesion sites. Phase symmetry and periodicity were always irregular. Supraglottic hyperfunction was evident throughout sustained vowel productions because of a mild, but consistent, medial compression and “bulging” of the ventricular folds. There was no evidence of tissue irregularity or irritation anywhere else on the vocal folds or in the posterior larynx.


2. Acoustic analysis. Patient D’s recorded mean fundamental frequency was 237 Hz during sustained vowel /i/, following the elicitation cue, “start counting and when you get to 3, hold out the ‘ee’ sound.” Following cues for pitch glide on /i/ from lowest to highest sounds, patient D produced a range from 157 to 314 Hz. Perturbation values were also obtained during sustained vowel /i/ using the CSL software program (KayPENTAX), with results for jitter measuring 1.68% (normal = <1.0%); shimmer 0.56 dB (normal = <0.35 dB); and signal-to-noise ratio of 14 dB (normal = 20 dB or greater). All of these measures represented subnormal performance based on the expected acoustic measures for a 7-year-old girl. Patient D produced a maximum loudness of 87 dB SPL following the cue to “yell ‘Hey!’ as loudly as possible.” Her minimum loudness was 62 dB SPL on a sustained /a/ produced “as quietly as possible.” Her habitual loudness was 70 dB SPL, measured during conversational speech. All of patient D’s loudness productions were within typical expectations. 3. Aerodynamic measures. Airflow measures were taken during sustained vowel productions; intraoral pressure measures were estimated from repeated productions of /pi/. Mean airflow rate was 270 cc/s, which exceeds the normal range of approximately 120 to 200 cc/s, suggesting “air leak” through the laryngeal valving mechanism. Intraoral pressure was measured at 8.3 cm H2O, which is also greater than the expected norm of approximately 5 cm H2O. 4. Audio-perceptual. Patient D’s voice quality was judged perceptually by

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the voice pathologist during informal conversation and sentence productions, using the CAPE-V protocol and form developed by Special Interest Division 3 of the American Speech-Language-Hearing Association. On the day of the evaluation, patient D exhibited consistently moderate vocal roughness (55 mm) and strain (42 mm) with a mild amount of intermittent breathiness (23 mm) and intermittent aphonia of 1-syllable to 2-syllable duration occurring about once each sentence. Her habitual loudness level was appropriate, and she did not exhibit any signs of hard glottal attack during casual conversation. She also sang “Happy Birthday to You” to assess pitch-changing ability in song and demonstrated 5 pitch breaks.

Description and Rationale for Therapy Approach The patient’s history, medical diagnosis of bilateral nodules, and evaluative findings all corroborated the clinical impression that patient D has developed a hyperfunctional voice disorder due to her frequent phonotraumatic behaviors, aggravated by chronic, ongoing stress in the family setting. Accordingly, the initial treatment need was to eliminate the vocal behaviors that contribute to vocal nodules and modify the communicative environment that produced stressful or aggressive communications. To address these concerns comprehensively, both patient D and her mother agreed to work together to identify, then reduce or eliminate aggressive vocal behaviors in each other that injure vocal fold tissue, such as crying, screaming, and speak-

ing with excessive tension or loudness. This shared approach to detecting and modifying faulty voice patterns was designed to increase mutual awareness and responsibility for establishing healthy vocal communication patterns. Because some arguments occurred between patient D and her mother, the family counselor also supported patient D and her mother in this aspect of voice therapy. Counseling emphasized the need to resolve conflicts at home without screaming, arguing, and yelling, thereby avoiding further vocal damage. In working together on this challenge, patient D and her mother strengthened their mutual support for voice goals. The treatment program involved both voice conservation strategies, to maximize vocal fold tissue health, and active therapy exercises, to restore and stabilize improved voice quality. Five specific treatment goals were established for the patient, focusing on patient and family education, eliminating vocal abuse, increasing hydration, achieving healthy voice through active vocal exercises, and increasing patient D’s vocal self-awareness and personal responsibility for voice quality. Goal 1 Patient D, her mother, and her brother learned about the origin and recovery patterns for vocal nodules, including the effects of vocally abusive behaviors on vocal fold structure and function and the risks of future tissue deterioration with prolonged vocally aggressive behaviors. Rationale. Teaching children and families about the pathologic impact of problem vocal behaviors is essential to ensure compliance with a conserva-

tion component of voice therapy. When children develop a proprietary sense of responsibility for the voice problem, it can motivate the child to control behaviors that influence vocal health. Visual aids and other demonstrations help convey this information to children. For patient D, viewing the videostroboscopy recordings of her larynx was particularly illustrative. Another example of vocal fold injury was simulated by having the patient and her brother rub their hands together for a 3-minute period so that they could feel how tired and hot their hands were after clapping hard together for that time. Pictures of just a few other benign structural pathologies (eg, hemorrhagic nodules, polyps, and cysts) sparked her further interest in vocal fold tissue health. From session to session, the voice pathologist asked patient D to answer a game-show-style question we called “Treatment Knowledge Check,” such as, “For 5 stickers, patient D, please describe how drinking more water might help your vocal folds get better!” or “Why is it helpful to rest your voice after speaking loudly?” Patient D appeared to enjoy displaying her new knowledge, as the voice pathologist reinforced the cause-and-effect relationship between voice behaviors and the rehabilitation plan. Goal 2 Patient D and her mother participated in a home program designed to identify and reduce their instances of vocal abuse and to provide “recovery” time for each occurrence. Patient D and her mother monitored and recorded every vocally abusive production on a chart at home, including screaming, yelling, excessive crying, and “tantrum” behavior. Each time, patient D (or her mother)


agreed to be silent for a 10-minute recovery period, spent in a pleasant, relaxed, quiet activity, such as reading or taking a walk. Each week, patient D and the voice pathologist predetermined a target maximum of vocally abusive episodes, for example, no more than twice per day. If, at the end of the week, patient D stayed at or below the weekly target, she earned a specific reward, such as a video rental or a trip to the park. Rationale. Home programming allows the greatest potential for treatment success and generalization, especially when the goal is to reduce vocally aggressive behaviors. In my experience, without home compliance, the prognosis for improvement with therapy is limited. Moreover, home programming is family therapy; if other family members exhibit vocally aggressive behaviors (as in the case of patient D’s mother), these members must also participate in treatment, if possible. To clarify the incidence and severity of problem behaviors, it is helpful to implement a token charting system, to reinforce self-awareness and motivate patients to change. When vocally aggressive behaviors occur, patients can experience success and control by applying a defined alternative response, such as a 10-minute silent recovery time, immediately afterward. This recovery time is never intended to be punitive; rather, it provides a specific reminder that tissue damage requires a recovery period. For patient D, it was especially important that her mother participate, so that both were able to distinguish their voice program responsibilities from their other work, school obligations, household chores, and disciplinary events. As patient D developed increasing compliance, she successfully

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reduced vocal abuse incidents in 5 out of 7 regular treatment sessions. Goal 3 Patient D eliminated all colas and caffeinated beverages from her diet and drank a minimum of five 240-mL (8 fl oz) glasses of water per day. Rationale. Evidence of mucus stranding and reports of patient D’s typical caffeine consumption raise questions about sufficient vocal fold hydration. By increasing water intake and avoiding caffeine, she increased the possibility of adequate hydration, without modifying her age-appropriate milk consumption. Because caffeine also can be associated with hyperactive behavior and laryngeal reflux, minimizing or eliminating caffeine is a useful adjunct to most voice care routines for children.

Goal 4 In conjunction with her family therapy, patient D kept a daily journal of pictures, drawings, or written material describing her voice use that day, based on feelings and events that created opportunities for positive or negative voice use. Rationale. The family counselor began this journal project earlier with the patient and her brother to encourage greater self-awareness of their feelings. With the counselor’s permission, a voice use component was added for the patient to allow her to relate everyday stress responses to her vocally abusive behaviors. She made schematic drawings of the nodules in her throat, drew pictures for her room to remind her not to yell (such as a drawing of a lion

“roaring” with a big X over the mouth), and wrote large signs to use instead of yelling (eg, “LEAVE ME ALONE”). Her journal contained pictures she drew or cut from magazines to describe her feelings whenever she was sad, angry, or upset. Initially, patient D received a small reward (eg, a quarter or sticker) every time she used these graphic cues instead of a vocally aggressive response. Quickly, these rewards ceased as she learned to describe her feelings in conversational exchanges with her mother. Moreover, patient D’s mother reported that as the frequency of aggressive vocal behavior lessened, the overall level of household calmness, behavioral cooperation, and positive communication increased. Goal 5 Patient D and her mother both attended voice therapy sessions, where they learned to perform a series of direct vocal exercises, including a warm-up routine and Stemple’s vocal function exercises. They received a 10-minute CD recording of home practice cues to allow them to practice therapy tasks twice daily. The warm-up consisted of “vocal play” cues for relaxed breathing, gentle sighs and pitch glides, humming nursery rhymes and other simple tunes, and short conversational phrases. The vocal function exercise segment contained pitch cues for sustained resonant tones, according to that protocol. Rationale. Besides learning about voice care and addressing the psychosocial contributors to the patient’s voice problems, it is essential for patients and their families to learn to produce healthy voice independently, outside the treatment room. Audio-recorded exercises

conducted at home are a useful adjunct to therapy time, because they create opportunities for consistent and accurate vocal practice. For patient D, the home exercises provided a fun and relaxing opportunity for her and her mother to talk, sing, and play quietly using audio cues to progress through the warm-up and vocal function exercise routine.

Results of Therapy Patient D received 7 sessions of voice therapy over the course of 3 months and attended 2 follow-up sessions at 1 and 3 months following treatment. At the final session (approximately 6 months from initial diagnosis), we collected post-treatment data. Visual-Perceptual Patient D’s vocal fold nodules resolved as judged by the patient and her voice pathologist from visual records of her pretreatment and post-treatment stroboscopic recordings. The otolaryngologist confirmed this judgment during a follow-up indirect mirror examination that revealed no evidence of any midline vocal fold lesion or supraglottic hyperfunction. Under stroboscopic light, vibratory movement exhibited normal phase closure, with normal mucosal wave and amplitude. Phase symmetry and periodicity were still irregular. Acoustic Analysis Using the same sustained vowel /i/ protocol measured at pretesting, patient D reduced jitter to 0.89% and shimmer to 0.31 dB. She also increased signal-tonoise ratio to 25 dB SPL. Her maximum


pitch increased to 547 Hz. All of these post-test acoustic measures were within expected norms for her age. Habitual pitch and loudness tasks did not change. Aerodynamic Measures Mean airflow rate decreased to a final mean rate of 150 cc/s, which was within expected normal limits. Mean intraoral pressure was measured at 5.7 cm H2O, which is also decreased from initial measures and within expected limits. Audio-Perceptual Patient D’s voice quality improved markedly as judged perceptually by the patient, her mother, and the voice pathologist. She eliminated pitch breaks and intermittent aphonia entirely during a repeat perceptual assessment using the CAPE-V. Both the patient and therapist rated conversational voice productions as normal overall with only mild, intermittent evidence of roughness (11 mm), and no evidence of breathiness, or strain. She sang “Happy Birthday to You” again without any pitch breaks. The positive outcome of this treatment plan is attributable to the patient and family compliance with the home programming effort. The concurrent family counseling process undoubtedly assisted with creative problem-solving strategies to mitigate angry or emotional vocal outbursts. During the course of voice treatment, patient D developed a sense of self-awareness and responsibility toward her voice problem, as evidenced by her willingness to report her weekly progress and to display some of her creative journal entries when she came to therapy. The behavioral modification program of effort and reward did seem to reinforce her “control” over

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vocally abusive behaviors. Certainly, not all children can eliminate vocally aggressive behaviors. Fortunately, patient D enjoyed the positive attention and support she received from her mother and brother for her compliance with vocal exercises and voice conservation strategies. Thus, her decisions about good voice use were motivated by her own sense of self-determination and satisfaction, and the entire household benefitted from improved communication patterns. Both she and her mother were pleased with the outcome. In the following case of a 10-year-old with MTD secondary to a vocal fold cyst, Carissa Portone-Maira uses vocal hygiene counseling, vocal function exercises, and resonant voice therapy to improve vocal function.

Case Study 8 Carissa Portone-Maira Eclectic Voice Therapy for Secondary MTD in a 10-Year-Old With a Vocal Fold Cyst

Case History History of the Problem GG presented as a pleasant 10-year-old boy who was a good fourth-grade student and had recently become interested in acting. His mother reported that over the past 3 years, GG had developed progressively worsening vocal difficulties. The specific complaints were a rough and breathy voice, decreased vocal stamina, decreased pitch flexibility, decreased

loudness, inability to project his voice, and voice loss after attempts to raise the voice (such as calling across the football field). GG reported that he had to repeat himself frequently to be understood, and he agreed that he had problems with losing his voice. Medical History GG underwent adenotonsillectomy in 2010. He had asthma and seasonal allergies but otherwise was a healthy boy. He used an Asmanex inhaler and Nasonex for allergy management. He was a fullterm infant, and there were no reported hospitalizations. He had seen a generalpractice otolaryngologist, who diagnosed him with vocal fold nodules. Social History GG lived with his mother, father, and younger sister (age 4). He attended a public elementary school and was auditioning for roles in commercials and local community theatre productions. There was no tobacco exposure in the home. He had no history of speech therapy in early childhood, and he was not receiving speech therapy services at school.

Voice Evaluation Audio-Perceptual Assessment The CAPE-V,90 a 100-mm visual analog scale, was utilized to assess overall severity of voice quality and to quantify aberrant perceptual features identified in the voice. The overall severity score was 72/100, indicating a moderatesevere dysphonia. The aberrant perceptual features identified in the voice were

moderate breathiness, moderate roughness, and severe strain. GG frequently spoke with excessive hard glottal attacks, but overall vocal intensity was reduced. There was a low laryngeal tone focus. Locus of respiration was primarily thoracic. Vocal pitch and prosody were normal for age and gender. Articulation and language skills were within the normal range for age and gender. Instrumental Assessment Laryngeal Imaging. Multidisciplinary voice evaluation was conducted. Laryngeal videostroboscopy was performed transorally with a 70-degree endoscope. Arytenoid motion was brisk and symmetric. There was a right-sided subepithelial lesion that led to moderate reduction in mucosal wave. There was also a contralateral softer reactive lesion that did not impact mucosal wave. The larger right vocal fold lesion fit into the left lesion with a cup-andsaucer appearance. Glottic closure was incomplete with an hourglass superior configuration. This was particularly prominent in higher pitches. There was normal amplitude of vibration on the left, but reduced amplitude on the right side. This led to consistent phase asymmetry. Vibration was frequently aperiodic, but periodic cycles were observed. There were no vascular abnormalities, and no other lesions noted in his pharynx or the remainder of his larynx. The laryngologist’s diagnosis was rightsided subepithelial cyst with a reactive lesion on the contralateral (left) vocal fold. The laryngologist referred GG for voice therapy but stated that if there were ongoing limitations after completing voice therapy, he would likely require surgical excision of the rightsided cyst.


Aerodynamic Measures. Maximum phonation times were as follows: /a/ = 6.8 seconds, /s/ = 12.6 seconds, /z/ = 7.5 seconds. The s/z ratio was 1.68, indicative of glottal incompetence. Instrumental aerodynamic assessment was conducted with the KayPENTAX Phonatory Aerodynamic System. Mean flow rate on sustained vowels was 0.17 L/s, on the highest end of the normal range. Mean peak air pressure on the voicing efficiency task (an estimate of subglottic pressure) was 11.45 cm H2O, on the high end of the normal range. Phonation threshold pressure was elevated at 6.93 cm H2O, consistent with the perceptual assessment of hard glottal attacks. Acoustic Measures. Laryngeal function studies were completed utilizing the KayPENTAX Computerized Speech Lab. A headset microphone was placed at a 45-degree angle at 2 cm from the mouth for data acquisition. Speaking fundamental frequency (SF0) was within the normal range at 260.57 Hz with a standard deviation of 28.41 Hz. Physiological pitch range was 204 to 655 Hz, with a midrange gap from 350 to 500 Hz. When asked to produce a pitch glide with reduced loudness, highest F0 was limited to 400 Hz. Fundamental frequency on sustained vowels was 249.845 Hz. Vocal instability was evidenced by elevated pitch perturbation (jitter) of 3.593% and intensity perturbation (shimmer) of 10.352%. An elevated noise-to-harmonic ratio (0.321%) was consistent with the perceptual assessment of roughness.

Patient Self-Assessment Pediatric Voice Handicap Index score was 60/120. When asked to rate his

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voice on a scale from 1 to 10 (10 = best), GG rated his voice as a 3/10. At its best, he would rate it at 7.5. At worst, he would rate it a 1. On a self-rating scale of 1 to 7 for talkativeness and loudness (1 = quiet and introspective; 7 = loud and talkative), GG rated his innate talkativeness as 5/7 and loudness as 5/7.

Voice Therapy Therapy was planned for 6 weekly sessions. The primary goal of therapy was to improve the efficiency of vocal mechanics sufficient to enable GG to participate fully in his normal activities, including sports and acting, without voice loss. A secondary goal was to avoid the need for surgical remediation. GG agreed at the time of the initial evaluation to refrain from yelling or raising his voice until he was taught methods for healthy vocal projection in voice therapy. One of his parents was present for the entire evaluation and for all therapy sessions to promote carryover of therapy techniques to the home environment. Therapy targeted vocal hygiene education, forward-focused resonance to improve the efficiency of vocal tract posturing, and coordination of abdominal respiration with phonation to improve vocal quality and efficiency and reduce hard glottal attacks. Resonant voice therapy91 and Vocal Function Exercises92 were the primary treatment paradigms used in order to balance the 3 subsystems of voice (respiration, phonation, and resonance). Semi-occluded vocal tract exercises93 were incorporated into Vocal Function Exercises to reduce phonatory impact during practice and facilitate optimal vocal tract configura-

tion. During the evaluation, there was a notable improvement in GG’s perceptual voice assessment as well as normalization of perturbation measures with cues for forward-focused resonance and increased transglottal airflow. GG’s age and stimulability to improvement with forward focus would support use of the Adventures in Voice program94 (for more information on Adventures in Voice, see Hersan’s Treating a Child with Secondary MTD using concepts from Adventures in Voice, Chapter 3). However, GG’s high maturity level did not necessitate full immersion into Adventures in Voice, which creates a make-believe adventure for the voice patient, complete with passport to travel to “lands” where various skills are mastered. Still, some specific therapy tasks from the program were used advantageously. The first treatment session introduced coordination of respiration with phonation specifically targeting reduction of hard glottal attacks. Forwardfocused resonance was introduced as well. Both concepts were incorporated into a semi-occluded vocal tract exercise: GG phonated into a drinking straw placed within a cup of water. Using this exercise, he was able to avoid a hard glottal attack (sudden splash of water in the face). He increased his awareness of forward focus versus vocal tract straining by attending to sensations. During the session, he was able to identify effortful versus easy phonation in his mother’s voice as well as the clinician’s voice. He was able to demonstrate introductory awareness of the same in his own voice by the end of the session. Vocal hygiene recommendations from the evaluation session were reviewed, and he was able to independently recall recommendations for hydration and elimination of coughing/throat clearing.

At the second voice therapy session, GG reported daily homework practice between visits. He expressed low confidence in his ability to identify target versus nontarget voice during his practice, but his mother stated that she thought his voice already sounded better. GG described tension in his upper back, a new complaint. Because tension in the upper back could refer and create tension within the vocal tract, therapy began with stretches for the back of the neck/upper back to promote more relaxed postures of the laryngeal mechanism. Attention was then turned to coordination of abdominal respiration with phonation. Elimination of high chest breathing was easily established simply by cueing “easy inhalation” and shifting the focus to exhalation rather than inspiration. Ideal transglottal air flow (flow phonation)95 was established on sustained and pulsed /S/ and /m/. The nasal sound /m/ was then generalized to “m-hm” for use as a selfcueing mechanism (carrier phrase) to achieve forward focus in conversation. The use of self-cueing on “m-hm” was incorporated into a game of Memory with m-initial words. Negative practice was contrasted with the target to increase awareness. GG noted a sensation of reduced laryngeal effort using the techniques as compared to negative practice, and he expressed increased confidence in his awareness of target versus nontarget vocal quality. To promote ease of home practice, GG was advanced from phonation into a straw within a cup of water to phonation into a straw without water. Modified Vocal Function Exercises (VFEs) were introduced. The VFE tasks were performed as described by Stemple (for more information on Vocal Function Exercises, see Case Study 13 by Joseph Stemple, Use


of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD, later in this chapter), but the sound used for all tasks was phonation into a straw, as GG was already familiar with straw phonation. Unfortunately, at this point, GG did not return for over 1 month. When he returned for his third therapy session, he reported inconsistent homework practice. He cited after-school activities and overload of academic homework as the causes for his lack of practice. Therefore, therapy began with identifying a motivator to practice, and we agreed that he would receive a prize of chocolate if he practiced every day before his next session. Stretches for the back of the neck/ upper back were reviewed. Awareness and production of forward focus without vocal tract straining were targeted at the sentence level during a game of 20 Questions. Chanting and negative practice were incorporated on a limited basis as needed to achieve target voice and to ensure a contrast between habitual voice versus forward focus. GG noted a sensation of reduced laryngeal effort using the techniques. Vocal Function Exercises (modified with straw phonation) were reviewed, and considerable time and attention were paid to ensure there was no vocal tract straining during the exercises. The fourth treatment session was 1 week later. GG reported consistent daily homework practice and was rewarded with a chocolate bar as promised. Awareness and production of forward focus without vocal tract straining were targeted at the paragraph level during story reading. Semi-occluded vocal tract techniques between paragraphs were helpful as a facilitating technique. Forward focus was also targeted at an increased loudness level.

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Phonation into a very narrow straw (coffee stirrer) was helpful to internalize the amount of breath needed to phonate loudly without strain during a game of “Mother, May I?” in the clinic hallway. When acting as the “mother,” GG would reply to requests with either “m-hm, Yes you may” or “m-mm, No you may not.” Asking GG to base his answer of yes or no on whether or not the opposing player utilized forwardfocused resonance simultaneously targeted awareness of forward focus. The clinician intermittently demonstrated laryngeal tone focus as a foil to ensure GG’s awareness. When acting as a player rather than the “mother,” GG had the option of producing target voice with increased loudness to make his request or to engage in negative practice followed by self-correction. Phonating into the coffee stirrer intermittently through the game promoted increased success in performance. Modified Vocal Function Exercises were reviewed and were continued with phonation into a straw as in the previous session. GG was encouraged to produce one production of each VFE exercise into the coffee stirrer and one into a standard straw. We agreed that chocolate reinforcement would again be provided if homework was completed each day prior to the next session. GG again did not return for 1 month between sessions. When he arrived for his fifth therapy session, he reported inconsistent homework practice. Voice recording was compared to the initial pretreatment recording. Hearing the improvement in his voice led to immediate stated motivation to return to more consistent practice. Awareness and production of forward focus without vocal tract straining were reviewed

in modified Vocal Function Exercises, on carrier phrase (m-hm), and in sentences. GG was successful in implementing target voice independently at these levels but still questioned his own awareness. Awareness and production were targeted in a monologue being prepared for audition, at conversational and stage/projected loudness levels. After each sentence, GG was asked for a self-assessment of forward versus laryngeal tone focus, and his confidence in his awareness improved. Vocal Function Exercises were advanced to the standard protocol to help generalize therapy skills to new sounds. Standard nasal /i/ was used for the warm-up sound and kazoo buzz for the stretch, contraction, and power phase. Care was taken to avoid straining with the new sounds. GG agreed to follow through with practicing Vocal Function Exercises twice daily. He expressed understanding that he needed to begin paying attention to speaking with forward focus, and he elected to begin by using forward focus when speaking with his parents. Note that both parents had attended sufficient therapy sessions to be aware of forward versus laryngeal tone focus in GG’s speech. At the sixth therapy session, 2 weeks later, GG reported consistent twice daily homework practice; however, he was not sure if he was using target voice when attempting to do so. After ensuring Vocal Function Exercises were being performed accurately, the remainder of the session was spent targeting awareness of forward focus without vocal tract straining. GG was consistently able to produce target voice, despite his reservations. Given the repeated failure to maintain awareness between treatment sessions, a new approach was needed.

Awareness was targeted via recording and playing back the voice in a “quiz” format. Grant would mark each production as “+,” “−,” or “±,” while the clinician did the same. We then compared scores, and GG was in agreement with the clinician over 80% of the time. His confidence improved as he saw the answers on his quiz being graded as correct consistently. His real-time selfassessment was then targeted by first judging the clinician’s voice in real time, then his own voice in a slow counting task, then a sentence-level reading task, still using the quiz format. Awareness remained accurate with greater than 80% success. The session improved GG’s confidence in identification and production of target voice during playback and in real time to such a degree that only one final discharge session was planned for the next week.


closure with an hourglass superior configuration, reduction in mucosal wave on the right, and intermittent phase asymmetry. Vibration was consistently periodic, however. Acoustic and Aerodynamic Measures. Instrumental aerodynamic measures were not repeated. Maximum phonation time on /a/ was 10.4 seconds, a substantial increase from the initial assessment. Brief acoustic assessment demonstrated slight increase in mean speaking F0 to 275 Hz. Pitch range was 200 to 650 Hz at a moderate loudness level, and the midrange gap was eliminated. In soft phonation, pitch range was 210 to 507 Hz. Perturbation measures (jitter and shimmer) reduced to 1.98% and 5.54%, respectively. Noiseto-harmonic ratio improved to 0.134%.

Patient Self-Assessment

Therapy Outcomes Audio-Perceptual At the seventh treatment visit, GG presented with a mild dysphonia characterized by mild breathiness, intermittent mild roughness, and occasional laryngeal tone focus. His overall score on the CAPE-V was 12/100. Instrumental Assessment Laryngeal Imaging. Follow-up videostroboscopy demonstrated resolution of the left vocal fold reaction change and slight reduction in the right vocal fold lesion, attributed to reduction of superimposed vocal fold edema. The subepithelial cyst remained present and continued to result in incomplete glottic

GG reported consistent homework practice and confidence in his awareness and use of target voice. He no longer had difficulties with losing his voice in any situation. His hoarseness was largely resolved. He was able to project his voice loudly without strain.

Follow-Up Plan GG was encouraged to continue oncedaily practice of Vocal Function Exercises and additional semi-occluded vocal tract exercises with straw phonation as a warm-up prior to auditions and rehearsals. He expressed understanding that he would need to maintain attention to speaking with forward focus consistently for several weeks to establish his new voice as a habit. His mother

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telephoned 2 months later as requested to report that GG was maintaining his new voice and had not had return of his previous difficulties.

Summary and Concluding Remarks GG presented with a subepithelial cyst not likely to be remediated by voice therapy. However, his laryngologist recommended voice therapy as an initial conservative approach with the understanding that he would likely need surgery to fully resolve his complaints. GG was able to improve his vocal efficiency using resonant voicing techniques and Vocal Function Exercises incorporating flow phonation and semi-occluded vocal tract postures. The behavioral modifications, including changes in vocal technique and vocal hygiene, resulted in reduction in the overall edema overlying his vocal fold cyst and elimination of the contralateral reaction change to such a degree that surgery was not warranted. The voice remained slightly impaired, but functional for GG’s needs, including sports participation and acting voice demands. On two occasions during his course of therapy, GG had a 1-month lapse between treatment sessions, during which time he did not practice consistently. Each lapse resulted in a setback from the previous session, but not to baseline status. Motivation to practice was a continuing challenge. Extrinsic motivation with a prize was effective in the short term but not in the long term. Lasting motivation was achieved with demonstration of treatment effect and building confidence in the accuracy of self-assessment.

At times, children manipulate their environments with their voices, sometimes leading to vocal pathology. In the following case study, Moya Andrews explores the psychosocial aspects of a child’s behavior related to the development of a voice disorder and introduces voice-facilitating techniques including storytelling, role-playing, and others.

Case Study 9 Moya Andrews Using a Psychosocial Management Approach in the Therapy of a Child With Midmembranous Lesions and Secondary MTD

Patient History Patient C, aged 4 years and 6 months, was referred to the otolaryngologist by her teacher at a Montessori preschool because of “hoarseness, loud talking, and frequent attention-getting behaviors in class.” The otolaryngologist imaged the child and reported bilateral midmembranous lesions with secondary MTD. She was brought to the speech and hearing clinic by her mother, who had taken the patient from school in time for their 11 AM appointment. The mother apologized for the fact that the child insisted she needed to bring a large, “fast-food” milkshake into the diagnostic room with her. “She always has to have a shake,” said the mother with a shrug, while the little girl smiled complacently and toyed with her straw. When the speech pathologist suggested that patient C should sit in the waiting

room until she had finished her shake, the mother looked distressed and said, “Oh no, she wouldn’t like that at all.” The patient’s smile widened, she tossed her head, did a little dance around the room, and spilled some of the shake on the floor. “Oh dear,” said the mother helplessly, “she’s just so full of energy.” During the interview, the mother reported that patient C was the youngest of 3 children. Her older brothers, aged 14 and 16 years, attended the local high school. The mother, a homemaker, said that the patient had been born in Germany during the time that her husband had been in the US military service. The father was currently employed at a local hospital. “My husband always wanted a daughter, so I suppose we spoil her,” said her mother. Patient C presented with a mildmoderate dysphonia characterized by roughness, breathiness, and the use of intermittent glottal fry at the end of breath groups. She was noted to demonstrate many of the classic behaviors associated with vocal abuse: inefficient respiratory pattern; tension in the shoulder, neck, and jaw; phonation breaks; hard glottal attacks; loud conversational level; rough and breathy vocal quality; laryngeal resonance; limited vocal variety; and frequent throat clearing. She could prolong a vowel for only 3 seconds and exhibited hearing sensitivity within normal limits bilaterally. The results of an examination of her peripheral speech mechanism were unremarkable. The school psychologist’s report noted above-average intelligence, frequent temper tantrums and episodes of crying, and use of manipulative interpersonal strategies. The child was involved in after-school programs such as ballet, swimming, an art class, and a neighborhood playgroup.


The mother characterized her daughter’s behavior in the following way: “She is quite a handful at times, but she’s intelligent and has had more opportunities than other children her age because we lived abroad. Also, she has had to be assertive or her brothers ignore her. She is a live wire and can be difficult, but she is so cute and talented that we can never stay angry with her for long.” It appeared that the psychodynamics in the patient’s family merited further attention. Further questions resulted in the information that when the patient’s vocal behavior was loud and forceful, she usually got what she wanted at home. The patient’s teacher reported that the child’s interpersonal strategies did not help her succeed in her school environment, however. Rather, she needed to develop more effective interpersonal and vocal strategies to establish satisfying relationships with her peers and teachers. Therefore, the therapy program was designed to include work on relevant psychosocial issues, as well as modification of abusive vocal behaviors.

General Awareness Phase Voice therapy programs for children usually begin with a general awareness phase. During this phase, the child is oriented to the general area of voice and taught basic concepts and the background information that are necessary before the clinician targets specific symptoms. For example, patient C needed a general awareness of respiration because it was an area of her behavior that needed to be modified. The clinician used a “science project” format to teach the girl general information about

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breathing. Activities were designed to achieve 2 sets of goals. 1. I can talk about breathing. n I can describe some different ways people and animals breathe. n I can describe how air is used (to sustain life, to make sound, to pant, and so forth). n I can label the body parts used during breathing (such as lungs and windpipe). n I can tell my teacher how to breathe in without tensing her shoulders and neck. n I can time the number of seconds it takes for my teacher to breathe out air. 2. I can talk about what happened in stories my teacher reads to me. Another general awareness goal for patient C was for her to develop an understanding of psychosocial factors relevant to vocal communication. The clinician used a “story format” to teach the patient some general principles of communication. The following activities were designed to achieve this: n I can guess what might happen when

storybook characters act in certain ways (utilization of cause and effect). n I can make up different endings to some stories (analysis of choices). n I can explain why some things go wrong for some children in our stories (identification of unproductive strategies). n I can suggest some other ways the characters may handle situations (problem solving). Sample Stories 1. Jennifer and Mary were both doing puzzles at preschool. Mary finished

her puzzle and started to watch Jennifer, who was having trouble with hers. Mary picked up 2 of the pieces of Jennifer’s puzzle, shrieked loudly, and ran across the room. Jennifer ran after Mary and tried to grab the pieces from her, but Mary quickly threw them under a storage cabinet. It took Jennifer a long time to crawl under the low cabinet and find them. Answer these questions: n

How did Mary feel? How did Jennifer feel? n Why do you think Mary threw the pieces away? n What would you suggest Mary should do next? n Does Mary like Jennifer? Explain why or why not? n What would you do if you were the teacher? n

2. Ann told Cathy that she was mean and no one wanted to play with her anymore. Cathy felt very bad, but she didn’t want Ann to know, so she knocked over the glue and then screamed loudly that Ann had knocked the glue over on purpose and ruined Cathy’s work. Cathy screamed so much she got red in the face, and the teacher had to tell her to have a drink of water to calm down. The teacher also told Ann to go and work on the other side of the room. Cathy felt she had paid Ann back. Answer these questions: n

What do you think the other children in the class were thinking during the uproar? n Why do you think Ann said Cathy was mean?

Primary and Secondary Muscle Tension Dysphonia n How

do you think Cathy could have solved the problem differently? n What would Cathy wish Ann had said instead? 3. During recess, Emily was playing by herself. A new girl named Lindy stood nearby. Emily asked Lindy if she wanted to play with her in the sandbox. Lindy was pleased when Emily quietly asked her about her family and where she lived. Lindy thought Emily was a really friendly girl. Answer these questions: n

Why did Lindy think Emily was friendly to her? n Why didn’t Emily talk more about herself? n Describe how it feels on the first day at a new school. n What advice would you give to someone who wanted to make friends? 4. Mrs. Brown’s class was having a discussion about different ways to talk. They had 2 boxes. One box was labeled “loud talking,” and one box was labeled “soft talking.” The children had to think of times when they talked in loud or soft voices. The teacher wrote their ideas on pieces of paper, and they put them in the correct box. Here are some of their ideas. You decide which box they go in. In the library; at a ball game; telling secrets; visiting a sick relative; calling the dog; saying goodnight; fighting with my brother; making friends; calling for help; calming a frightened animal; when I’m not getting my fair share; when my mom has a headache.

Specific Awareness Phase During the specific awareness phase of therapy, the child is taught to focus on specific behaviors, discriminate between behaviors, and describe pertinent behavioral characteristics. This creates a perceptual and linguistic framework that prepares the child to modify critical behaviors during the subsequent production phase of therapy. Four goals for patient C included: n Identification of abusive vocal behav-

iors exhibited by others n Description of the salient characteristics of vocal behaviors n Discrimination of differences between appropriate and inappropriate behaviors n Explanation of ways inappropriate behaviors can be avoided or changed Targets Respiration n Use lower chest breathing n Use more replenishing breaths n Eliminate unnecessary upper torso

movement.

Phonation n Use easy onsets n Use easy breathy quality (clear qual-

ity is not realistic until the nodules are resolved) n Decrease tension n Decrease loudness level in conversational speech n Employ vocal variety (not only increased loudness). Interpersonal n Increase question asking n Improve listening-to-talking ratio

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n Use “other” referenced statements in

addition to “self” referenced ones.

Resonance n Improve resonance n Increase articulatory precision.

Because patient C needed to modify a number of different behaviors subsumed under 4 different areas, the clinician decided to present the behaviors as a set or a gestalt. Consequently, the appropriate behaviors were associated with one storybook character and the inappropriate behaviors with another. The “beautiful ballerina’s” voice was relaxed and “airy” and her lips danced when she used them. She made music by a humming on the front of her face, and the music was carried over into the voice as she chanted words. The ballerina voice was characterized by appropriate breathing patterns, easy onsets, resonance, and lack of laryngeal tension. The voice was light and musical and easy to listen to. Listeners felt relaxed and pleased when they heard it. In contrast, laryngeal effort, hard glottal attacks, excessive loudness, and inefficient breathing patterns characterized “tense Tessie’s” voice. Patient C was given ample opportunity to identify the 2 patterns and their effects on listeners during discussion of stories. Sample Stories 1. The beautiful ballerina came onto the stage wearing a frothy white tutu. She breathed deeply and her lower chest swelled with the air. She stood with her lovely head, neck, and shoulders relaxed and poised. The audience admired her patient,

restful posture and relaxed expression. As she began to dance she hummed to the music and the bones of her face vibrated. “Hmmmm” she hummed as she glided smoothly across the flower-strewn stage under the glittering chandelier. Answer these questions: n

Describe how the ballerina breathes. n How does she hum? n Explain how she keeps her body relaxed. 2. Tense Tessie tightens her jaw and neck and raises her shoulders when she breathes in. She pushes hard with her throat and makes a little click or grunt on phrases such as I’m always eager. But everywhere I go. I jerk instead of glide. I feel all stiff, you know! Answer these questions: n

Can you tell Tessie what she must do to breathe more efficiently? n How can she relax her neck? n Can you tell which words Tessie makes with a hard start? Sample Activity When your teacher tells you an action, do it the way tense Tessie would do it and then do it the way the beautiful ballerina does it. Explain the difference.

Production Phase During the production phase of therapy, patient C learned to produce and

monitor target vocal behaviors in structured and controlled situations. Initially, cues and monitoring were provided by the clinician. Gradually, however, the patient learned to assume more and more of this responsibility. For this patient, the production goals were sequenced as follows: 1. Produce each target behavior correctly (in isolation): n with instructions, cues, and presentation of the model n with instructions and cues n with instructions n spontaneously 2. Prolong and repeat the target behavior. 3. Stop and start the target behavior at will. 4. Demonstrate both the appropriate and inappropriate forms of the behavior (negative practice). 5. Produce the target behavior, varying length of utterance: n isolated sounds n syllables n words n phrases n sentences 6. Produce the target behavior, varying the complexity of processing: n imitation n automatic responses n limited repertoire of responses n simple self-generated responses n complex self-generated responses 7. Produce the target behavior, varying the timing of the response: n predictable response time n unpredictable response time


8. Describe the characteristics of one’s own production in terms of the following: n preparatory set n strategies used n reactions of self n reactions of others 9. Monitor one’s own production: n when cued verbally n when cued nonverbally n after practicing aloud n after thinking about it first n spontaneously Sample Materials Facilitating Techniques

Yawn-sigh Humming Chanting Facilitating Contexts n Minimal pairs to teach breathy onset.

“Think” the [h] in the second word of the following pairs: whose ooze hear ear hair air has as his is how ow ha ah hoe oh heel eel high eye hobo oboe

n Words and phrases containing only vow

els and voiced continuant consonants

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for continuity of tone and maximum vibration of facial structures: /z/ /l/ /m/ zulus lovely Maisie zoo lazy Molly Zoro long mowing Zelma lions money zero lying Moses /v/ /th/ Vivian them violin those Vera there vision these Volvo then n Sentences

Mow the lawn. Move the Volvo. Vivian is lazy. The lions were lying in the zoo. Molly loves violins. My mom never loses money. Noses are nozzles. I was living in Germany then. Zionsville is near there. Nellie is never nosy. n Words, phrases, and sentences loaded

with “front” sounds to promote articulatory movement and forward tone focus: Words: 1. whirl 2. bounce 3. jump 4. wobble 5. tap 6. tumble

7. topple 8. toddle 9. pretty 10. dainty Sentences: 1. Pop goes the weasel. 2. Pitter patter water splatters. 3. Fit as a fiddle. 4. Tap with your toes. 5. Pearl buttons to button up. 6. Touch Tilly’s white tulle tutu. 7. Leap up and down. 8. Tiptoe through the tulips. 9. Puppies snap and yip and yap. 10. You yell at little lizards. Sample Activities 1. Be the dancing teacher and “sing” as you count for the ballerinas to practice at the bar: “One and two and three and four.” 2. Play “singing Simon says,” and sing the instructions for dance movements. 3. Look at this stack of cards with the names of foods (ie, eggs, apples, onions). Use the carrier phrase “I eat” and make a sentence with each card in the stack. You get 1 point for each word you say with an easy onset. Try lengthening the vowel sound. 4. Find the sounds that will help you vibrate your voice on the front of your face. (“I’ll say some words, and you tell me which sounds helped you when you repeated the words.”)

The Carryover Phase The clinician arranged with the teacher for patient C to present some of her “sci-

ence projects” in her school classroom. Patient C enjoyed the opportunities for attention as she explained and demonstrated some of the information she had learned about respiration. The teacher also implemented a unit on “voice pictures” into her classroom curriculum and provided opportunities for patient C to be the “expert” on how to make pictures with her voice without talking loudly or in a tense manner. The patient demonstrated “high jumps,” and “broad jumps,” and “long worms,” and “soft fur” using vocal variety, and she served as the judge when the teacher organized a “voice-picture” competition. The patient also starred in another classroom activity where picture cards were used. For example, 2 cards, one with a bird (blue jay) and one with a letter (blue J), were held up. The listeners had to identify to which card patient C was referring. The patient’s mother routinely observed therapy sessions and observed the ways in which the clinician insisted on mature, direct interpersonal interactions. The mother also met for several sessions alone with the clinician and the school psychologist so that she could talk about ways to help the patient at home. The teacher and the parents agreed to give the patient lots of attention and praise when she used mature, nonabusive vocal strategies. Patient C’s father agreed to read stories with his daughter each evening before bedtime and to reinforce appropriate voice use. For example, he used phrases such as, “I really like these times when we talk quietly together. You make me see the pictures in my head, and the stories come alive for me,” and “you have the prettiest ‘quiet voice’ I know.” The parents set up rules during mealtimes to ensure that everyone had a


turn to talk and that loud interruptions and shouting down other siblings was not reinforced. When patient C lapsed into her immature, manipulative patterns of interacting, the parents calmly said, “Let’s replay that in a more grownup way.” Fortunately, patient C’s parents understood the importance of addressing the psychosocial issues underlying their daughter’s vocal behavior. Their commitment to change and, not coincidentally, patient C’s progress were remarkable. From the outset, their interest in their daughter’s well-being was reinforced, and the clinician served as a facilitator encouraging them to expand their range of parenting skills. Patient C attended therapy for 2 years, twice weekly for 45-minute sessions. After she was dismissed from therapy, she was followed for 1 year to ensure that gains were maintained. When travel distance required to receive voice therapy is prohibitive or there is lack of local professional speechlanguage pathology services, remote treatment may be a solution. In the following case, Lisa Kelchner describes the use of a telehealth approach in treating a child with MTD secondary to early bilateral vocal fold lesions.

Case Study 10 Lisa N. Kelchner Treatment of Secondary MTD in a Child With Early Bilateral Lesions: A Telehealth Approach

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Case History A 10-year-old male “Sam” was referred to a pediatric voice center after being seen by his pediatrician. This was Sam’s second referral to the center in 2 years. Sam has a history of intermittent hoarseness secondary to vocal exuberance in the form of loud talking and forceful yelling. The previous laryngeal exam of 2 years ago revealed mild bilateral vocal fold edema, erythema, and mild evidence of LPR. At that time, vocal hygiene education was provided, but the recommendations for therapy were not heeded. During this exam Sam’s parents report his hoarseness was getting worse as was his throat clearing and coughing. In the time since his first visit Sam has been placed on Ritalin for management of his recently diagnosed attentiondeficit/hyperactivity disorder (ADHD). Although he is now on the proper therapeutic dosage, there was a period of 3 months when he was demonstrating chronic throat clearing and vocal tics, a known side effect of Ritalin. The vocal tics have mostly subsided after his developmental pediatrician adjusted (down) the dose. Sam also suffers periodic upper and lower respiratory infections and has a known allergy to cats. This allergy is treated with over-the-counter medications as needed and environmental controls. Sam’s hearing and vision were within normal limits. There were no other major medical concerns.

enjoys math, computers, and gaming. He is on grade level and his mother reports the Ritalin is helping with overall behavior management and performance in school. He does have a long history of vocal exuberance with lots of yelling and shouting in the home and during play. Without the Ritalin, Sam has frequent episodes of upset and outbursts. He also has a pattern of excessive loud talking. Sam is one of 3 children (2 boys, 1 girl), all of who are within 2 years of each other. Mom described their household as noisy. On the day of his exam, Sam was generally cooperative although he was more interested in playing games on his mother’s iPhone. He had undergone a full evaluation before, so he was not fearful about the exam. Sam was quite inquisitive about the equipment used for the evaluation and wanted to know about all the controls.

Voice Evaluation During this visit, Sam underwent a full voice and laryngeal examination. After the initial interview, Sam’s mother was asked to fill out a pVHI and answer questions related to voice use and reflux symptoms. Sam was taken into the sound-treated booth where the following data were gathered using the Real Time Pitch Program of the CSL and the Phonatory Aerodynamic System. Audio-Perceptual

Social and Educational History Sam has a history of hyperactivity and difficulty concentrating during sustained tasks. He experiences some challenges with completing schoolwork but

Sam was administered the CAPE-V. The expert rating of the perceptual parameters generated the following scores: overall severity: 63/100 (consistent moderate-severe dysphonia), intelligibility of his connected speech (separate

analysis) was informally judged to be moderately affected by the presence of dysphonia; roughness: 45/100; breathiness: 58/100; strain: 45/100 (during connected speech samples); pitch: 21/100 (low); and loudness: 32/100 (inconsistent; loud and soft). Instrumental Assessment Acoustic. Inspection of the harmonics during sustained vowel production via a narrow band spectrogram revealed dominance of a type 2 signal. His average fundamental frequency (F0) was 180 Hz; His highest F0 was 267 Hz and his lowest was 155 Hz. Glides up and down the scale were marked by phonation breaks. Fundamental frequency during counting was 78 dB/SPL. Sam was able to get louder (90 dB/SPL), but he was unable to lower his volume. Aerodynamics. Measures of average airflow, estimated subglottic pressure and maximum sustained phonation were measured. The values are as follows: average airflow: 120 cc/s; estimated subglottal pressure: 9 cm/H2O); MPT: 10 seconds. Imaging. Using both rigid and flexible endoscopy, direct light images of the larynx and segments of simulated slow-motion stroboscopy during sustained phonation and connected speech were captured. This exam revealed symmetric, bilateral true vocal fold lesions at the juncture of the anterior one-third and posterior two-thirds vocal fold edge resulting in a large posterior gap configuration during glottic closure. The anterior segments of the folds did make full contact during phonation and the lesions appeared “soft” and compressible. Both CA joints were fully mobile.


There was mild posterior commissure hypertrophy and erythema suggestive of acid irritation and moderate lateromedial compression of the ventricular folds during phonatory segments. Sustained views during phonation adequate for interpretation of discreet vibratory parameters revealed mildmoderate decrease in mucosal wave and amplitude of vibration. Phase symmetry was inconsistent, but it did appear that phase closure was dominated by prolongation of the closed phase of the vibratory cycle. The overall impression was one of laryngeal hyperfunction. Patient Self-Assessment Sam reported that he frequently felt he had to push his voice and that his voice became tired by the end of the day. When asked if he gives his voice a break when it felt tired, he responded he didn’t know. Scores on the Pediatric Voice Handicap (pVHI)43 (as filled out by his mother) were physical (15), functional (15), and emotional (5). Sam and his parents agreed he was “pretty hoarse” and that sometimes he cannot be understood when on the playground, at baseball, and in the classroom.

Impressions and Recommendations It was the consensus opinion of the voice team (SLP and ENT) that Sam demonstrated bilateral prenodular-type thickness and laryngeal hyperfunction due to his chronic coughing and periods of voice overuse. Vocal hygiene counseling, reflux precautions, and voice therapy were recommended. At the time of this evaluation, receiving voice therapy via telehealth was an option.

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Given Sam’s proclivity for technology, the family’s in-home technology setup and access to broadband along with the family’s reluctance to travel weekly to the urban medical center for treatment, an 8-session over 10-week program of voice therapy to be delivered by synchronous teleconferencing and an interactive website was arranged. The intention was to make gains using private therapy and to transfer information and care (as needed) to the school SLP, as possible. Use of telehealth for delivery of behavioral-based therapies to children is relatively new but supportive data exist in the treatment of adult voice and other pediatric communication disorders to warrant its use in this application.

Telehealth Setup The patient was dispensed a desktop for dedicated TH use. Software requirements and operating systems permitted uploading and downloading of acoustic and video images; speakers; and headphone microphones (with increased acoustic sensitivity, high definition, and low interference). In addition, compatibility specifications were cross-referenced on all components to include the patient web-portal, video client, and standard antivirus requirements. Cisco Telepresence Movi 4.2 was the teleconferencing software. To provide ample in-home Internet connectivity, the household was required to have the following minimum high-speed broadband requirements: high-speed cable or DSL with download and upload speeds of 1.5 Mbps or greater. At the start of therapy, Sam and his parents were provided an orientation and instructional session to learn how

to use the Web-based home program portal and instructions for providing us Web-based feedback. The structure of the Telehealth Session: Therapy via the telehealth model used included weekly half-hour synchronous hospital to home sessions. The sessions were scheduled to flex with the family and therapist’s availability. The family attempted to secure a relatively quiet space and time for the sessions, although this did not always happen. Use of a departmental computer was the model of TH used at the time of this therapy due to security, privacy, and configuration reasons. A relatively small desktop rather than a laptop was used for durability reasons. Each session was started by affirming that the audio and video connections were clear and stable. Camera and audio adjustments were made as needed. “Eye contact” between Sam and the clinician was encouraged by having both look at the “camera art”— a visual cue to look up at the camera versus at the screen (although Sam frequently liked to look at himself on the small insert). Each screen had both the clinician and Sam on it. The clinician also viewed the room or asked Sam and his parent to inform her of any guests in the treatment session. Pop-in visits by curious siblings were more common in the first few sessions. Sam kept his headset mic and headphones on most of the time. Each session started with a review of the previous week’s home program results that Sam and his parents entered on the interactive website. Successes and challenges with vocal hygiene and vocal behaviors and any important events from the previous week were discussed. The remainder of the time was spent on the direct therapy approaches.

Any technical issues with either the synchronous or Web home program sessions were discussed with parents and Sam at the end of the session.

Voice Therapy Sam’s voice therapy program was initiated with the standard long-term goals of improving vocal hygiene and reducing laryngeal irritability, and improving voice quality and connected speech intelligibility. Indirect strategies for accomplishing LT Goal 1 included the following: Provide patient and parent education regarding vocal function and voice care in order to identify ways to avoid vocally harsh behaviors and situations that provoke laryngeal hyperfunction; identify substitute behaviors for harsh vocal behaviors (eg, sip water and long, hard swallow, turning down background noise/volumes; walk to listener); drink more water and reduce carbonated, caffeinated drinks; model and teach easy onset shout; use ear plugs to lower volume; and take voice naps during other activity (homework, game playing). Specific strategies to manage reflux included providing a basic description of what reflux is and how it can impact laryngeal health. They were also provided a list of foods and behaviors that are known to aggravate reflux. The dose and timing of the prescribed PPIs were also reviewed. The family was under the impression Sam should take the medication only if he was symptomatic. Taking the medication 30 minutes prior to the selected meals was emphasized. Of note, we did not ask Sam to eliminate all potential reflux triggers but rather pace and proportion such foods (eg, pizza) and to avoid late-night snacks.


Instead of charting all specific behaviors, Sam was asked to answer questions related to his vocal health and behavior on his daily Web homework session. That website had highinterest graphics and a series of yes/ no questions that reinforced an understanding of why the behaviors should be used (or avoided). Positive feedback was provided at the end of the website question session. Information regarding voice care guidelines was also conveyed to Sam’s elementary school personnel including his classroom teacher, school nurse, school SLP, music teacher, and PE teacher. Direct Therapy: Modification of Vocal Function Exercises and Resonant Voice were used to accomplish the second LT goal. Initially Sam had difficulty producing the desired semioccluded vocal tract gestures to achieve easy vibration and frontal focus during vocal tasks. This issue was addressed by having Sam do lip and tongue trills, sustained labiodental “vv” sounds, and “whistle with voice.” This whistle technique makes use of a long, plastic whistle that can act like a kazoo (which also could have been used). After 2 weeks of (2 live and daily Web) sessions (meaning Sam uploaded an audio/video sample during Web practice), Sam was able to achieve the appropriate gesture. It is important to note that we did demonstrate this with some hands-on cues during the initial voice evaluation. We also worked on him finding the tense spot in his belly while he sustained the sound, rather than “pushing” from the neck area. Maintaining the gesture while switching back and forth from high and tense to low and relaxed vowel sounds was also a practice task. With the semi-occluded “focused” gesture in place, work on modified Vocal

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Function Exercises (VFEs) and Resonant Voice Therapy (RVT) started (for more information, see Case Study 13, by Joseph Stemple, Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD, later in this chapter). Sam started by using the warm-up exercises and 3 within-range, comfortable pitch levels (low, medium, and high). His initial times averaged 9 seconds for lower and midpitch (CDE) notes and increased to 17 by the end of therapy. Averages for high notes (FG) started at 7 seconds. Glides up were especially hard for him, and we needed to use a lip trill to avoid significant voice breaks. Sam was able to progress to the fully differentiated scale of 5 notes by the end of the 10 weeks and remained working on them in the form of a home program. We tended to use the vowel sound “oo” as in hoot (owl) for the power exercises. Average times for the highest notes improved to 15 seconds but never exceeded the low and mid note times. Modified Resonant Voice Therapy (RVT) was used in conjunction with the VFEs to reinforce easy vocal fold vibration and distribution of physical energy for voicing in connected speech. Admittedly, Sam was rather shy at joining in with some of the chanting and voiced/ voiceless syllable, phrase, and sentence practice. Initially more time was making him comfortable with the series of exercises and a lot of time was spent on natural melodic contour humming and easy chanting coordinated with ease of respiratory support. During this task, it was useful for the treating clinician to have Sam’s parents pay attention to the degree of tension throughout his chest, neck, and face area. To reinforce the use and practice of the modified RVT, we uploaded videos (with permission) of other children who had excellent tech-

nique. We also were able to record and upload Sam’s practice and point out some subtle differences. Both Sam’s and the sample videos were available to him on the website.

Therapy Outcomes At the end of the 10 weeks, Sam and his parents returned for an interval voice evaluation. At that time we were able to document a number of positive changes related to Sam’s vocal health. Audio-Perceptual CAPE-V expert ratings revealed the following: overall severity: 48 (mild-moderate dysphonia; and moderate improvement in intelligibility); roughness: 36; breathiness: 32; strain: 13; pitch: 12 (low); and loudness: 5 (stable). The acoustic values revealed a more stable type I signal, elevated F0 (210 Hz), and greater range (155 to 330 Hz). Improvement in aerodynamic function was evident in changes in average airflow (145 cc/s) and estimated subglottal pressure (5 cm/H2O ). Repeat laryngeal digital stroboscopy revealed mild improvement in the size of the bilateral lesions with the adjacent edema and erythema resolved; improved glottic closure characterized by a reduction in the posterior gap and apparent size of the bilateral lesions. The posterior commissure hypertrophy remained but erythema was resolved. Simulated slow-motion images revealed that mucosal wave and amplitude of vibration were greater, phase closure was more equal, and the symmetry of vibration was normal. Parent proxy ratings on the PVI revealed perceived improvements in both the functional (7) and physical domains (8), dropping by 8 and 7 points, respectively. Recall that the emotional

domain was not particularly elevated at the start of treatment (4). When discussing the results directly with Sam, he agreed that he was aware he did not have to force his voice like he did at the start of treatment. Both Sam and his parents agreed that his voice was clearer and “less hoarse.” Intermittent raspiness persisted. Importantly, Sam’s laryngeal irritability quieted. He was doing much less throat clearing and definitely was able to self-cue to talk at a lower volume in key school and home situations. He remained on his Ritalin with no vocal side effects.

Summary and Concluding Remarks Sam, his family, and the treating clinician experienced success. Use of the interactive website for homework proved quite successful with a demonstrated 85% participation rate. The hospital bioinformatics department had to reset and refresh a small number of practice sessions where Sam had let the sessions time out as opposed to log out. Everyone was pleased with the ability to check practice of gestures through the uploading and downloading of samples in the file share format. Manipulating the rather simple technology aspects of the therapy appealed to Sam. In general the family and clinician reported that using teleconferencing helped maintain Sam’s attention, that he enjoyed the website graphics, and liked the uploaded images that helped remind them of specific therapeutic gestures. He especially enjoyed recording his own voice and uploading the recordings on the website message board so the clinician could monitor progress


between synchronous sessions. Likewise, the clinician felt she was more an active participant in the home program and only had to make minor adjustments to her usual instructions. There was some burden on the family to appear organized to have the clinician “come to their home” via telehealth, but after the first couple of synchronous sessions the family and siblings relaxed. One advantage to the synchronous sessions was that the clinician was able to gauge the family’s natural communicative style, and she often spontaneously invited siblings into the therapy session, in part to satisfy their curiosity. Children often need to be able to use their voices strongly, while avoiding damage, and to promote healing of existing vocal injury. In the following case, Rita Hersan describes a therapeutic approach called Adventures in Voice to treat a child with MTD Secondary to Vocal Nodules.

Case Study 11 Rita Hersan Treating a Child With MTD Secondary to Vocal Nodules Using Concepts From Adventures in Voice

Case History History of the Problem Patient M, an 8-year-old boy, came to the voice center accompanied by his parents who described a gradual but noticeable change in the patient’s voice quality

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over the preceding 9 months approximately. Initially, the voice problem was considered transient and did not seem to bother M or impact his communication or activities at school. M’s parents reported frequent periods of hoarseness that they considered “normal” during this period, until hoarseness worsened and persisted after M attended a summer camp. His parents decided to have M’s voice evaluated, once he expressed frustration saying his voice “was not working right.” M’s teacher had also noticed M’s worsening of voice, but she reassured the parents that no negative comments had been made about it by M’s classmates. Medical History Parents described M as a healthy boy with normal developmental history. M had tympanostomy tubes placed when he was 3 years old. His mother reported that M had been “aggressively” clearing his throat, unrelated to eating or drinking, and she was concerned about this “habit.” His medical history revealed no evidence of allergy or acid reflux symptoms. Social History Patient M was the oldest of 3 children; his younger brothers were 6 and 3 years old. The parents considered M a socially and academically well-adjusted, secondgrade student who had special interest in music, singing, and soccer. Both parents were professional classical musicians. The home environment was characterized as moderately noisy because M’s mother taught piano lessons at home. The patient and his brothers had the assistance of a babysitter for afterschool activities, but M liked to assume leadership in keeping his brothers enter-

tained while his mother taught piano lessons. The parents described M as not aggressive but a “natural captain,” especially with his soccer team and brothers. He strained his voice while playing and occasionally imitated monsters’ voices. The parents reported that M had always showed mature behaviors compared to his peers.

Voice Evaluation The patient was evaluated by a voice team that consisted of a speech-language pathologist, audiologist, and otolaryngologist. Hearing was within normal limits. Audio-Perceptual The audio-perceptual evaluation used a modified ordinal GRBAS96 scale, evaluating overall grade, roughness, breathiness, asthenia, strain, adding pitch, and loudness variables. Overall grade (G) was scored based on the CAPE-V90 procedures. For that parameter, on a visual analog scale of 100 mm, the overall “G” score for M was 52/100. For remaining voice quality parameters, using an ordinal scale on which 0 = normal, 1 = mild, 2 = moderate, and 3 = severe, the following results were obtained: roughness: 1; breathiness: 2; asthenia: 0; strain: 1; pitch: 1 (low); and loudness: 0. An additional note was that intermittent phonation breaks were perceived during all the assessment tasks. Patient Self-Assessment The parental proxy Pediatric Voice Handicapped Index (pVHI)43 was administered to quantify the effects of the voice problem. The score was 45/92. Additionally, M answered verbally the following


3 questions to self-assess the impact of the voice problem:

Voice Therapy: Using Concepts of Adventures in Voice

n “How much does your voice problem

Adventures in Voice (AIV) was developed by Verdolini, Hersan, Hammer, and Reed to teach children to use their voices strongly, when needed, while avoiding damage and promoting healing to existent vocal injury.99,100 The program is founded on a framework grounded in basic science on: (1) the biomechanics and biology of voice production, (2) perceptual-motor learning, and (3) factors affecting patient compliance. Throughout the program, all therapy exercises are based on 3 principles of perceptual-motor learning that are particularly relevant for children, summarized in the acronym APT as follows:

bother you?” “It bothers you a little bit (mildly), quite a bit (moderately), or a lot (severely)?” He answered “a lot!” n “Do you think the problem is just the way the voice sounds, just the way the voice feels, or both?” He answered, “both!” n “How is your voice today?” Using a chart representing 10 steps (1 = the worst voice to 10 = the best voice), the patient pointed to step 4. Instrumental Videolaryngostroboscopy revealed a bilateral symmetric midsubepithelial lesion of true vocal folds with normal mucosal wave and slightly reduced amplitude of vibration bilaterally. Glottic closure revealed an hourglass configuration. Acoustic measures revealed a speaking fundamental frequency of 238 Hz in connected speech, based on the allvoiced sentence, “We were away a year ago,” and 226 Hz taken on sustained “ah” at comfortable loudness. A fundamental frequency of 250 Hz was expected for his age on sustained “ah” at comfortable loudness.97,98 Frequency range varied from 178 to 295 Hz on sustained “ah.” Mean intensity was 68 dB SPL measured during connected speech, and the dynamic intensity range was 65 to 86 dB SPL on sustained “ah.” Patient M’s loudness measures were within normal range. Aerodynamic measures based on repeated syllable trains of /pa/ showed a high mean airflow of 250 mL/s at comfortable pitch and loudness, and estimated subglottal pressure at 8.5 cm H2O, which was expected for his age.97

Active This refers to the concept of the child as an active participant in the learning process, in evaluating different modalities of voice use, and in discovering how to produce different voice exemplars without explicit biomechanical instructions. Some voice clinicians may argue that children are not aware of the voice problem, and consequently have no motivation to engage on a therapeutic program such as Adventures in Voice. In fact, in challenge situations, motivation is also addressed by keeping the child actively involved as co-creator of the tasks in all phases of the program. Moreover, the attention required to learn a new motor task is continually encouraged by requiring the child’s participation. Perception and Production This refers to the constant alternation between perceiving and producing the target vocal pattern. Biomechanically, the target pattern involves vocal folds

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barely touching or barely separated, which the child will learn to identify as “easy vibration voice” or simply “easy voice” associated with vibrations in the anterior oral cavity.72 The child and the voice clinician (also known as the Adventure Guide) are continually engaged in activities that promote perception and production aimed at voice outcomes, not the biomechanics of voice production. Therapeutic This refers to the principle that the activities should be structured to be different from events likely occurring outside the clinic. Specifically, therapy activities emphasize functionality (having a practical application, or serving a useful purpose), salience, repetition, and variability of practice.

Rationale for Using Adventures in Voice Many children use their voices extensively and vigorously, placing them at risk for phonotrauma. Noisy playgrounds, sports events, and parties are typical environments sought by this population, and yelling, cheering, and loud singing represent common vocal behaviors in children. The traditional therapy approach for children, which focuses on voice conservation by encouraging them to reduce or eliminate “phonotraumatic behaviors” (historically referred to as vocal “abuse” and “misuse”), seems pragmatically hopeless from the outset. It usually provides patients with long lists of dos and don’ts, lacking a cohesive framework, and ultimately potentially promoting fear of talking, coughing, singing, and even laughing.

Adventures in Voice 101 promotes targeting and tailoring individualized vocal care activities, which may have a greater likelihood of benefiting the child, as compared to generic programs that may be overwhelming and irrelevant to the patient. The broad goal of the program is for the child to acquire a healthy vocal pattern in a variety of contexts, including background noise and emotional situations. Biomechanically, this vocal pattern involves barely adducted or abducted vocal folds, perceptually corresponding to “resonant voice,” or “easy” voice associated with perceptible anterior oral vibrations.72

Therapy Goals and Expected Outcomes The long-term therapy goal for the patient was to maximize his vocal output relative to the existing laryngeal disorder. It was expected that the patient would be able to produce clear and strong voice with minimal vocal fold impact stress,101 and to integrate target vocal behaviors in a variety of contexts.

Description of How to Do the Therapy Are You Ready for This Adventure With Your Voice? The patient heard a simple story about how “hurt voices and healing voices”100 may happen to a lot of people (children and adults) because we all use our voice frequently and not always in the best conditions. He learned about facts that can cause hurt voices: not drinking enough water; talking loudly with

background noise; irritation caused by throat clearing, yelling, and screaming in different situations; and talking a lot while feeling sick. When asked about what he thought could have caused his “hurting” voice, the patient responded “maybe I yelled a lot at the soccer games and didn’t drink much water!” His mother added “too much throat clearing!” The Adventures in Voice for this particular patient was called “A Journey to Discover My Easy Voice.” Most of the activities were planned using the patient’s own ideas, supported by his mother throughout the therapy sessions. The map of the journey was prepared by the patient. The voice clinician, also known as the journey guide, proposed a visit to 8 different “towns” and asked, “We will start our journey, how is your voice today?” The patient confirmed “not good!” For each session, the patient was asked to self-assess his voice using the same representation of steps that was used on the initial evaluation. The patient had in mind that his voice could improve as he progressed on the journey. The patient received materials that he needed before going on the journey: a bottle of water, a backpack, a journey diary, and a passport. The patient immediately understood that he would need to drink water more frequently. The patient was told that he could help his voice by taking sips of water and eating watery fruits to increase vocal fold hydration. Patient M was asked if he knew why clearing the throat frequently and yelling at the soccer game were not helping the voice. He felt the difference by way of example in the force and friction while clapping, rubbing, and gently vibrating one hand against the other. These demonstrations were suffi-


cient for him to understand the negative impact of throat clearing and screaming. It was explained to the patient that he could face some challenges during the journey but certainly he would have lots of fun. He could always get a stamp on his passport for following the directions well. The patient was encouraged to invite other people to go on the journey with him. His father and a special friend were suggested as special “journey partners” for his therapy program. He would need to show his journey map, and to participate in some activities with them. Taking into account the patient’s interest in music and singing, the journey guide suggested that the first stop would be at the “Wind Town.” To enter Wind Town, all the visitors were requested to produce special sounds. Pictures of some of the wind family instruments of an orchestra were shown, and the target sounds /v/, /z/, and /Z/ were introduced. Initially, the patient felt easy vibrations on his lips using a straw and colored water; he made bubbles while producing a kazoo-like sound. To incorporate the activity into something meaningful, the patient selected cards with written words and pictures from a small backpack. As he took the cards out, the journey guide produced “extremely” vibrating sounds on words, such as zebra, vase, viola, measure, very, zero, television, voice, zoo, and treasure. Patient M heard the difference when the journey guide alternated easy vibrating voice and voice without easy vibrations on words beginning with /f/, /s/, and /S/, such as sea, fifth, shop, fat, ship, soup, shoe, feet, shelf, soap, face (that is voiceless-initial consonants as opposed to voiced-initial consonants, which involve a “semi-occluded vocal tract” during phonation, and consequently

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facilitate vocal fold vibration). The journey guide asked if the patient would like to practice “very vibrating” sounds before playing a game. After consistent response (80% accuracy), the patient was invited to play a game: each player got 3 points if a word with /v/, /z/, or /Z/ was pulled out from the backpack and produced with a tickle (that is, easy oral vibrations), and only 1 point for a word with /f/, /s/, or /S/ and no tickle. Patient M and the journey guide then prepared together a home program called “Tracking my Voice” that used a charting and added personalized vocal care and vocal activities. The Journey Continues The journey guide pretended to play string instruments while producing easy vibrations on /m/, /n/, and /ŋ/, and immediately patient M guessed that he was going to visit “String Town” on the second session. The patient was asked to cover his mouth and nose to feel the vibrations on the palm of his hands. Once he was able to feel them, he was asked to keep his lips very tight while producing /m/ or the tongue very pressed while producing /n/. Once again, the patient recognized the difference between easy vibrations and no vibration. The patient was told that in String Town everyone enjoyed humming; they were called Humming People because they liked to prolong sounds. Humming People were very smart because they loved to feel a tickle inside the mouth, around the lips, or behind the teeth to make sure they were using their easy voice. Patient M and the journey guide played a game filling in blanks on sentences using words beginning with /m/, /n/, and /ŋ/ while “humming” (chanting). For

example: Many men on the . . . (moon), My nanny made . . . (lemonade), String Land is . . . (fun), My Mom is a . . . (musician), I love lemon . . . (muffins), Manny and Lenny are . . . (twins), Monna made me . . . (mad), No one found the . . . (money), Noah is mowing the . . . (lawn), May I know your . . . (name). The patient produced more “humming” words while playing bingo; all the Wind Town and String Town target sounds were combined: van, music, dozen, vision, news, visit, museum, nose, violin, television, navy, eleven, venture, and zombie. To transition from humming (chanting) to more natural voice production, the patient, his mother, and the journey guide had to answer 10 questions each using “mhmm” for “yes” or “nnno,” gliding the voice and focusing on easy vibrations. The patient heard a story about “Tony, a telephone that enjoyed very much ringing all day and listening to conversations, until the day that nobody was at home to answer him. After hours of constant ringing, Tony felt exhausted and had no energy to produce a ringing sound.” The story reinforced the idea that Tony “recovered his ringing sound” after some rest and care. Patient M prepared his version of the story using the “Story Kit”, an iPad app, and he added tongue trills to produce Tony’s ringing sound. Where Are We Going Now? The third session was a visit to “Brass Town,” and the target sounds /l/ and /r/ were introduced, with emphasis on pitch glides and “humming” (chanting) on rhymes. For pitch glides the patient and journey guide prepared a road template using curves, going up and down through the mountains, and cre-

ating a “scene” for animated repetitions of /l/ and /r/ in different emotional situations. The patient was asked to find pictures of animals, objects, and people that he would like to include on the scene, and he created a story using suggested words with target sounds: red, car, rock, rain, rainbow, parrot, yellow, tire, run, long river, lizard, rolling, Lori, Rosie, Larry, Liz, and Ryan. He called it: “The Road to Brass Town.” Patient M learned “voice release” strategies such as sigh, lip trills, stretches, and yawn associated with body movement and embedded on different emotional situations associated with the story. Examples of emotional situations included the following: The car run out of gas à journey guide felt upset and said “arrr” (with tight /r/). Then, to “release the voice,” she used “ahh” (like a sigh). A flat tire à patient expressed frustration with a tight “uhh”; and then, he released the voice with lip trills and shoulder shrug. Feeling exhausted by driving à patient stopped at the gas station, sipped water, and stretched the body with a big yawn! For chanting, the patient enjoyed: “Rain, rain, go away/come again another day/little Johnny wants to play.” We Are Halfway There Another series of target sounds /b/, /d/, and /g/ were introduced for the particular work on loudness variation associated with precise articulation. The fourth session was the visit to “Percussion Town.” Initially, patient M and the journey guide used gestures and body movement associated with a variety of rhythmic patterns and loudness on syllable trains, such as: bambambambambam; bombombom BOMBOM bombombom; dindindindindindin;


gaingaingaingain; dundun dun dun dun dun [dn]. To engage the patient in the functional use of loudness variations, he used different sizes of fake pebbles made of cardboard to build a trail on the floor. Patient M was shown how to vary the voice loudness while stepping on the pebbles: the bigger the pebble, the louder is the voice. Several target sounds were included in greeting expressions and short sentences, and the patient was asked to add names. Here are some examples: Bye-bye Ben! Hello Dan! Come here, Ross! Hi Sammuel! No, Bryan! Let’s go Mom! Stop Jimmy! Bring a Partner to the Journey It was arranged with the patient’s mother that on the fifth therapy session M could invite a friend to participate in the journey. This strategy was particularly important to engage the patient in activities that were more representative of his habitual behavior. The journey guide asked the patient to show the journey map to his friend, including all the towns he had visited, and the most special characteristics of each town. M felt really excited to share with his friend what he had done on the journey to discover his easy voice. To work on loud and safe voice, the patient and his friend used a soundlevel meter to monitor the loudness of their voices while playing a video game. Afterward, an activity was suggested which prompted the use of soft, normal, and loud voice associated with different situations. For example, M went to the library, and he needed to ask for a book (soft voice). The space rocket was about to launch, and M’s friend had to count “5, 4, 3, 2, 1” (loud voice). Dad was taking a nap but M wanted to

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play (soft voice). The soccer coach was teaching the team how to dribble (loud voice). M wanted to invite his friend to play (normal voice). Mom was asking her kids to come for dinner (loud voice). When Loud Is Too Loud The sixth therapy session introduced the experience of background noise and loud talking. It was reported that the home environment was moderately noisy. Since patient M had started therapy, his mother had been always present in the therapy and very supportive. She had already made arrangements for her children to play distant from the piano room while she taught at home. Patient M read a story about Zeca, “a boy who yelled frequently at soccer games. Zeca finally realized that it was not his loud voice that helped him to score a goal, but rather his strong legs and good skills. Yelling was just causing confusion among the other players and affecting Zeca’s voice to the point, he had almost no voice after the soccer games.” Loud background noise with headphones was played during reading activity. Patient M.’s voice was recorded and played back after his reading. Both patient and mother were impressed by the effect of background noise on voice loudness. Using the “Story Kit,” an iPad app, patient M wrote his version of Zeca’s story, adding drawings and voice recordings. Let’s Vibrate the Voice The two last therapy sessions were less structured and basically a review of all concepts of healthy voice use through stories and games. They focused on applying target sounds to spontane-

ous conversation and challenging the patient to recognize risky situations.

Frequency and Duration of Treatment The patient attended a total of eight 45-minute voice therapy sessions over a 10-week period. The initial 6 sessions were scheduled once a week, and the last 2 sessions every 2 weeks.

Therapy Outcomes Audio-Perceptual The overall severity of voice quality that was considered “moderate” (52/100) at the initial evaluation indicated a marked improvement (15/100) at 1 month post therapy reevaluation. The patient did not have phonation breaks in any of the tasks. Perceptually, his voice showed no evidence of breathiness, or strain, and only mild, intermittent roughness. The pitch of his voice was considered normal. Instrumental Videolaryngostroboscopy revealed mild edema of true vocal folds with considerable reduction of bilateral subepithelial lesions, normal mucosal wave and amplitude of vibration, and a small posterior glottic gap. Acoustic measures revealed a speaking fundamental frequency of 250 Hz in connected speech and 246 Hz on sustained “ah.” The frequency range was 178 to 385 Hz. The mean intensity was 69 dB SPL in connected speech and the dynamic range was 62 to 98 dB SPL. Aerodynamic measures based on 5 syllable trains of /pa/ showed mean

airflow of 160 mL/s and estimated subglottal pressure of 7.5 cm H2O. Both measures were considered normal for his age. Patient Self-Assessment Using the Pediatric Voice Handicapped Index (pVHI), score was 12/92 at the 1-month post therapy follow-up visit. With regard to self-assessment, M reported that his voice was not bothering him anymore, and he had no problems with the way it sounded or effort to produce the voice.

Summary and Concluding Remarks Children require frequent and tangible evidence of progress across time. Visual charts assume great importance in analyzing the child’s progress. The notion of getting better is translated by going higher on numbers using a chart representing steps. This idea is very beneficial for motivation, helping the patient to quantify his progress, and to understand the long-term goals. Patient M perceived a significant improvement after the third and fourth session, jumping to steps 6 and 7 in his self-evaluation of voice (on a scale of 10), in his self-assessment chart. Then he went back 1 point in session 5, most likely because he had a cold. He reached a plateau on step 7 and remained there for 2 consecutive sessions, and he finished on step 9 at the last session. He expressed great satisfaction with his progress. Home practice should be part of real life, not time out from it. In the case of patient M, family participation was remarkable, but even with their incred-


ible support, the voice clinician was attentive to not overload the parents with too many tasks. Based on the progress noted in each therapy session, only 2 or 3 voice activities were selected each week for the home program, besides “vocal care” (voice hygiene) recommendations. The use of CDs recorded during the therapy sessions, the journey diary containing a summary of all the activities worked in therapy, and the chart “Tracking my Voice” assisted the child and his parents in adhering to the therapy process. The voice clinician reviewed the chart at the beginning of each therapy session. She suggested specific times for home practice, accordingly to the family availability. A family activity was also recommended as M’s parents were very interested and asked for other materials (see list of recommended family activities). These activities were only suggestions, and not considered essential for the therapy outcome. Informational feedback was present throughout the therapy process to reflect how well the patient was doing (emphasis on positive aspects). In addition, motivational feedback was applied in the form of extrinsic rewards (stickers on passport) every time the patient “journeyed” well during a therapy session and completed the daily assignments of the home program. Recommended Family Activities n Discover sounds around the house

that have the characteristic of vibration (blender, toothbrush, toy, hair dryer, cell phone). n Watch a specific and short segment of the movie “Fantasia” that has the introduction of the orchestra instruments and their different sounds.

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n Guess “what sound is this?” using a

CD provided with sound effects. n Watch a cartoon and describe how the characters used their voices to express their feelings. n Listen to different voices and guess “who is talking” and “how they are feeling.” n Stretch the body first. The patient’s mother plays the piano while children walk or dance following the rhythm of the music. n Using background noise (music), family members use alternative ways to communicate without a loud voice: facial expressions, sign language, gestures, clapping the hands, and stomping the feet. School-based voice therapy can be challenging. In the following case, Rebecca Hancock describes a team approach with a voice clinic SLP and a public school SLP in the successful treatment of a 13-year-old with MTD secondary to vocal nodules.

Case Study 12 Rebecca Hancock Pediatric Vocal Fold Nodules and Secondary MTD Treated in Conjunction With a School-Based SLP

History CV, a 13-year-old female, was referred by her school speech therapist for concerns regarding hoarseness identified during cheerleading tryouts. She had a history of hoarseness per her mother

over approximately the past 12 months. She lived in a small apartment including 2 other children under the age of 5, her mother, grandmother, and aunt, and was reported to be vocally dominant in the home. The patient herself had limited self-awareness of hoarseness but did endorse frustration that she was difficult to understand by peers and had to repeat, particularly when reading aloud in class. The medical history was negative for any major illness, intubations, or irritation at onset of hoarseness. Social history reflected poor hydration (almost no water), mainly caffeinated sodas, fried foods, and ketchup as major risk factors identified for irritation. No “mini-throw ups” (terminology used for episodic regurgitation when working with pediatric patients in clinic) or symptoms of reflux were reported; however, the patient was observed to clear her throat frequently during assessment. Her maternal grandmother accompanied her to the initial visit and stated the patient communicated primarily by yelling and screaming across the house.

Voice Evaluation CV underwent acoustic, aerodynamic, and laryngovideostroboscopic assessment of voice. Salient acoustic and aerodynamic data are embedded in Table 3–2. Findings of this assessment yielded elevated jitter, shimmer, reduced fundamental frequency, and significant breaks in her pitch range. Aerodynamic assessment demonstrated reduced airflow with increased pressure during voice production. Rigid videostroboscopy reflected bilateral paired vocal fold nodules, and mild interarytenoid pachydermia.


Table 3–2. Acoustic and Aerodynamic Data Jitter

3.5% increased (expected is <1%)

Phonation Threshold Pressure

8.6 cm H2O, increased (expected 4–6 cm H2O)

Shimmer

2.0 dB increased (expected is <1 dB)

Mean Peak Air Pressure

10.5 cm H2O, increased (delayed onset noted on repetitions, expected 6–8 cm H2O)

Fundamental Frequency

180 Hz (WNL is ~>200 Hz)

Mean Airflow During Voicing

0.02 L/s, reduced (expected at or around 0.2 L/s)

Pitch Range 170–900 Hz (inappropriate pitch break from 440–600 Hz) CSID on sustained /a/: 24.4 (mildly elevated) Expected values reported used in this case are for clinical purposes and are adapted from normal ranges reported for untrained females in this case. These are not intended to be reported norms for the pediatric population.

Medio lateral supraglottic hyperfunction characterized by compression of the ventricular folds was noted during modal pitch. The ENT physician did not feel it was sufficient to implement any medications; however, strong recommendations for dietary improvements were made. Perceptually this patient was noted to be moderately hoarse with primary features of roughness, intermittent breathiness, and voice breaks. The patient, again, did not report any recognition of hoarseness despite improvements demonstrated during clinical treatment probes. The use of negative practice did indicate some stimulability for vocal modification.

Treatment Planning One confounding factor to this patient’s plan of care was inability to travel to clinic for therapy. This was due in part

to work schedules of her family, distance to clinic, and financial limitations for rehab services of the patient’s insurance. The decision was made to implement therapy in the school system. The school SLP, who was integral in identification and obtaining a referral for voice assessment was then involved in the plan of care. The thrust of this case report will discuss the navigation of a treatment protocol within justification for treatment in the school system. In Kentucky (where this patient was seen), the Academic Resource Committee (ARC) is the representative body responsible for obtaining and tracking service progression in the school system. In other states, this may be referred to as an IEP (Individualized Education Plan) committee. The common complaint among school therapists is the difficulty demonstrating that voice has an impact on academic performance. The following section discusses the appropriate

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course of treatment planning, competencies trained for the school SLP, and the role of the voice center in progress monitoring.

Identification and Assessment The area of identification in the school system can be complex. Unlike language, articulation, and social impairments, voice disorders are not appropriate for the “response to intervention” (RTI) paradigm. For those unfamiliar, RTI is a trial phase wherein the classroom teacher collaborates using recommendations from an SLP to collect data about the disorder and give structured cues as appropriate. This will justify both academic impact as well as whether progress may be made outside a structured therapy framework. As hoarseness can be indicative of more serious underlying medical issues, this is considered inappropriate, and medical assessment precludes any voice-related intervention. Typically this can be arranged after discussing the hoarseness with the child’s parents, however if a recommendation is made for “medical assessment,” a fiscal liability is generated within the school and becomes a conflict for school SLPs in determining whether or not to make the recommendation. Involving school administration as well as members of the special education department has been proven to be helpful in this process. Based on personal experience, parents being made aware of the impairment triggers the conversation “what next,” which can then trigger the conversation that ENT physicians and voice centers typically are a required first step prior to treatment. If any individual recommends trial voice therapy prior to assessment, this should be avoided. It is essential to

consider that both benign and malignant lesions present with the similar trait of “hoarseness” and require imaging.

Justification of Impairment on Academic Progress The process of qualifying for services is largely dependent on grade level. It is important to investigate the state department of education curriculum standards, as these will be key to establishing the impact hoarseness will have on student performance. For the purposes of this case, we will use the Kentucky state standards as an example. In Kentucky, the working definition for a voice disorder is “the abnormal production and/or absence of vocal quality, pitch, loudness, resonance and/or duration, which is inappropriate for an individual’s age, sex and/or culture.” When considering eligibility, often it is good to know the limitations when it becomes time to establish a service plan. For instance, understanding the limitations of what would not qualify for services would include when perceptual severity ratings fall within the normal range. Notably, if the clinician does not perceive hoarseness but the child reports excess vocal effort, this may be diagnostic and helpful information to provide to evaluation medical professionals during assessment. From an eligibility standpoint, one may demonstrate effort is detracting from academic focus and affecting attention in class the student requires for learning. Along the lines of “normal perception,” exclusionary factors include when vocal characteristics: n are the result of temporary physi-

cal factors, such as allergies, colds,


abnormal tonsils or adenoids, or transient vocal abuse/misuse n manifest as the result of prepubertal laryngeal changes in male students (unless a pathologic puberphonia is diagnosed or the child becomes a victim of bullying or social exclusion, as is often seen in teens with highpitched voices) n are the result of regional or dialectical difference n do not interfere with educational performance. Inclusion factors for services in Kentucky include adverse effects as listed below: n Decreased participation in classroom

activities and discussions

n Refusal to communicate about cur-

riculum in an oral framework in the classroom n Reluctance/inability to participate in public speaking, school plays, debate, sports, cheerleading n Oral reading in class n Class/peer discussions n Fear of interpersonal interactions, expressing basic needs (ie, bathroom, water) n Impact on physical education if laryngeal structure is impaired n Reluctance to participate in mock interviews may result in inability to obtain internships, college enrollment, or employment n Burden of the listener in severe dysphonia affecting other learners (ie, classmates asking for a repeated instance of information because of dysphonia in the speaker) n Students may become verbally aggressive to force a voice, often it is easier to be loud than soft (this could be measured perceptually, reported as

increased effort, or possibly be measured with a sound-level meter). Once eligibility is established that the voice disorder is creating a disturbance, and medical evaluation is underway, data collection for the depth and frequency of impact is required. Table 3–3 lists ideas for tracking adverse effect and the impact of dysphonia by a teacher, an aide, or an SLP.

Training the Trainer It is not surprising that most pediatric voice intervention workshops have good attendance: this is an area where only a small sampling of practitioners feel comfortable providing intervention. For referrals out of clinic back into the schools, 2 to 3 sessions with the school SLP, the voice specialist, and the patient help to facilitate transition. The treatment plan for CV included modifying social behaviors such as soda intake, food choices, awareness to vocal intensity and surrounding noise (some ecological/conservation goals), as well as rebalancing the respiratory and phonatory subsystems to promote lesion healing. In this case, this involved a coupling of vocal function exercises and resonant voice therapy (for more information on vocal function exercises, see Case Study 13 by Joseph Stemple, Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD, later in this chapter) with an initial focus on the use of negative practice. Prior to training vocal function exercise, the patient and school SLP worked with flow mode phonation for the least tension during voice onset as possible. The use of visual cues such as the phonatory

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Table 3–3. Kentucky Eligibility and Guidelines (2009) Primary (K–3)

Fourth–Fifth Grade

High School

Number of times student is asked to repeat by teacher

Number of repetitions in class

Number of times asked to repeat

Number of times student must repeat in small group environment

Change in level of participation in specials, extracurricular activities

Change in level of participation in specials, extracurricular activities

Episodes where student “shuts down”

Reluctance to speak publicly or withdrawing from group presentations

Reluctance to speak publicly, read aloud, or withdrawing from group presentations

Activities where student is unable to fully participate (specials)

Denials to read aloud, answer questions in class, or withdraw from group discussions

Feedback from job interviews, professional coaching interactions, ie, job fairs with school counselor

Source: Kentucky Eligibility Guidelines Revised — for students with speech or language impairment. Retrieved March 23, 2013, http://education.ky.gov/specialed/excep/Documents/Kentucky%20Eligibi lity%20Guidelines%20for%20students%20with%20speech%20or%20language%20Impairment.pdf.

aerodynamic system to visualize the transition from airflow into phonation as well as a pinwheel were beneficial. Establishing self-awareness, monitoring for nascent self-correction and building a team rapport to keep the patient engaged were the focus of the first session, and half of the second. As the school SLP began to initiate exercise in a team approach, by the third session all parties felt confident this treatment plan could translate into a 2 times per week, 30-minute session. Fortunately, this student was seen alone as no other students on the caseload were available at that time due to course conflicts. If this was in a larger group environment, the focus on resonant voice and conversation was discussed as a potential treatment goal. Ultimately, for maintenance, the student worked in a group environment in conversation with students with mild pragmatic impairment,

but the primary 8 weeks of treatment were solo.

Therapy Outcomes Three months after initial assessment, CV returned to the voice clinic for post-treatment assessment. Stroboscopy yielded complete resolution of the paired midline lesions, however the mild interarytenoid pachydermia persisted. The patient’s family was unable to reduce CV’s intake of fried foods,. She was moved to caffeine-free soda, and a lower volume of ketchup. In terms of vocal domination, she was able to reduce yelling by lowering the volume of the television, establishing a 3-foot to 5-foot distance in lieu of yelling across the house, and communication with her mother and grandmother without yelling over her cousins. These were


notable improvements per the family. Resonant voice was approximately 75% consistent in conversation, and the patient accurately described the traits of “appropriate resonance.” Acoustic and aerodynamic measures are presented in Table 3–4. Perceptually, the patient’s voice was noted to be within normal limits. In conversation, fundamental speaking pitch was appropriate for age/gender, where previously it was excessively low.

Transitioning From Care As the patient was interested in cheerleading, and we could not dissuade her, she was left with a “maintenance” plan of once-weekly group treatment as noted above, to ensure maintenance of technique and adequate voice quality. We determined that given her level of vocal effort, and persistent “risky behaviors,” the prevention of recurrence was necessary. As of publication, she has not reported recurrence. Understanding dismissal criteria is vital, particularly if the student is plateaued.

Below are the typical criteria to dismiss from SLP services taken from Kentucky Eligibility and Guidelines (2009) retrieved online March 23, 2013, from http://www.education.ky.gov/NR/ rdonlyres/5D691CC1-D69C-4CCD-89 CC-EE2A3A60DBA5/0/KYEligibility Guidelines.pdf: n Student has met all objectives from

the IEP related to voice without additional concerns n At parent request n No further measureable benefits despite multiple intervention approaches n Student develops functional compensation skills n Classroom accommodations can manage deficit n No longer required in order to access the general curriculum One consideration is the “no further benefits” concept. Not all therapy is created equal, and not all therapists will achieve the same level with a given patient. One helpful technique in a given patient often falls flat when

Table 3–4. Post-therapy Acoustic and Aerodynamic Results Jitter

0.9% (expected <1%)

Phonation Threshold Pressure

5.0 cm H2O (4–6 cm H2O expected)

Shimmer

1 dB (expected <1 dB)

Mean Peak Air Pressure

7 cm H2O (without onset delay) (expected 608 cm H2O)

Fundamental Frequency

260 Hz (WNL is ~200 Hz)

Mean Airflow During Voicing

0.18 L/s (WNL is at or near 0.2 L/s)

Pitch Range 193–1200 Hz (one break observed at 880 Hz) CSID on sustained /a/: 7

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given to another patient. We carefully established a “treatment toolbox” for the school SLP, so once flow mode proved to plateau, she was comfortable integrating some elements of resonant voice, as well as phonatory linking. By having a treatment arsenal, we achieved a higher level of function without stale intervention. Although vocal hygiene was used in this patient’s case, it is rarely the only method we implement to promote healing. A happy side effect of this experience was the relationship between the school SLP and the clinician in the voice clinic. The school therapist has become a resource for her district for treatment of hoarseness in the class environment and works in conjunction with the voice therapist in assessment and service delivery. The disconnect between school and medical speech pathology is one that requires correction for the benefits of the patients seen in both venues. The importance of a team approach to voice care is further emphasized in the following case of a teacher with secondary MTD. In this case, Joe Stemple describes the use of traditional voice therapy methods such as vocal hygiene counseling and Vocal Function Exercises, in conjunction with surgical intervention to resolve a case of persistent dysphonia.

Case Study 13 Joseph C. Stemple Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD

History Patient F, a 26-year-old second-grade teacher, was referred by a laryngologist to the voice center for a complete diagnostic voice evaluation, with the diagnosis of large bilateral vocal fold nodules and a left vocal process ulcer. Patient F first became symptomatic in the fall of her first year of teaching. In October of that year, she became dysphonic. When the hoarseness persisted, she sought the opinion of the referring physician, whose examination revealed mild bilateral vocal fold edema. The physician instructed her to reduce caffeine intake and to increase intake of water and briefly counseled her regarding voice misuse. The patient followed these instructions, and her voice quality improved. Between fall and late winter, the patient experienced intermittent hoarseness. She thought the mild hoarseness was fairly normal considering her level of voice use in the school setting. In late February, however, she became moderately hoarse during an upper respiratory infection. Like most teachers, she continued to work a normal schedule during her illness. She began to notice not only hoarseness but also voice fatigue and a burning sensation on the left side of her “throat.” When the upper respiratory infection resolved and her voice symptoms persisted, she sought the opinion of the laryngologist. On seeing the vocal nodules and the ulcerated tissue located on the vocal process of the left arytenoid cartilage, the laryngologist prescribed reflux medication [proton pump inhibitor (PPI)] and referred the patient for a voice evaluation and therapy. The PPI was prescribed as a precaution because of the implications of acid reflux on

the development of contact ulcers and granulomas. The information gathered during the voice evaluation confirmed the nature of the voice trauma that had significantly increased the patient’s symptoms in February. Patient F had indeed experienced a mild hoarseness since school began that fall. She reported that her voice quality typically was better on Monday and much worse by Friday but that she always had some level of hoarseness. On a daily basis, she was more symptomatic during the early morning. The hoarseness would clear somewhat by midmorning and worsen again by afternoon. With the onset of the respiratory infection, patient F began coughing and throat clearing. By the time of the voice evaluation, the coughing had decreased, but chronic throat clearing was noted. Her voice use was typical for a second-grade teacher. Students of this age require much instruction, and nonspeech times in the classroom were reported to be minimal. In addition, the patient was assigned playground and school-bus duty, which required occasional shouting and raising the voice above noise to be heard. There was no evidence that the patient misused her voice away from her work environment. She was married and had a 2-year-old daughter. She denied any direct vocal trauma or environmental contributions, such as inhaled dust, fumes, chemicals, or paints. She reported that her voice improved on weekends and always returned to normal during the summer months. The remaining social history was unremarkable as related to this problem. The patient’s medical history also was unremarkable. She was free of any chronic illnesses or disorders; took only


the PPI, although she was not symptomatic with “heartburn”; and was a nonsmoker, living and working in a nonsmoking environment. Her liquid intake was not adequate. She drank 2 cans of caffeinated soda and 2 glasses of iced tea per day. Patient F reported that she “loved” teaching and felt “great” on a daily basis.

Voice Evaluation During the voice evaluation, patient F presented with a moderate dysphonia characterized by dry, breathy hoarseness. The laryngeal videostroboscopic examination revealed large bilateral vocal fold nodules, worse on the right than on the left; bilateral edema and erythema, and an apparent resolving left contact ulcer. The nodules caused glottic closure to demonstrate an hourglass configuration with a slight ventricular fold compression. Both the amplitude of vibration and the mucosal waves were severely decreased bilaterally. The open phase of the vibratory cycle was dominant, whereas the symmetry of vibration generally was irregular. In other words, she presented with significant tissue changes that would present a challenge to functional voice therapy. Acoustic measures demonstrated a limited frequency range of 147 to 562 Hz. Her fundamental frequency remained appropriate at 211 Hz. Although her jitter measures for sustained vowels were normal at 0.87%, her shimmer measures were high at 0.46 dB. Aerodynamic measures yielded significantly high airflow rates for high pitches averaging 305 mL/H2O. Comfort and low pitches were borderline high at 180 and 189 mL/H2O, respectively. The patient was required

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to push more air through her vocal system to support the vibration because of increased vocal fold mass and the hourglass glottal chink. Her subsequent phonation times at all pitch levels were only 11 seconds or less. Patient F also completed the VoiceRelated Quality of Life (V-RQOL), a self-assessment scale to demonstrate the effect the voice disorder was having on her life.102 Results demonstrated a moderate life impact. Following the voice evaluation and testing, a treatment plan was proposed. The plan included: n temporary reassignment from play-

ground and school-bus duties

n site visit to determine environment

and teaching style n elimination of the abusive behavior of throat clearing n oral hydration program n symptom modification n Vocal Function Exercises designed to rebalance respiration, phonation, and resonance.

Temporary Reassignment It was decided to immediately eliminate the potential for the most obvious vocal traumas. The patient therefore requested to be assigned to other duties away from the playground and school buses where voice would not be a factor and she would not be required to raise her voice. If therapy proved to be successful, reassignment would be temporary. Otherwise, it would continue until the end of the school year.

Site Visit Site visits are time consuming and not always practical, but the value of seeing

the patient in the implicated environment cannot be overemphasized. Other useful options to site visits are video or audio recordings of the patient in the speaking environment. Recordings can be viewed or listened to during therapy. Patient F’s school was convenient to the voice center, so a 1-hour site visit was arranged. Observations made during the visit included: n large room n unusually high (16–18 feet) acoustical

tile ceilings n sound was lost in space n only 24 students spread throughout the large room at different “stations” n all sounds (scooting chairs, dropped books, and so forth) were magnified by glass and plastic n speech was hard to discriminate. It was obvious that patient F “loved” her work. She was enthusiastic and had complete control of the classroom. Observations made regarding her teaching style included: n vocally enthusiastic, but does not

shout n room requires that she speak loudly and precisely, not to be heard but to be understood n spends a good deal of time “directing” children when not actually teaching n uses high pitch, limited inflection, and back focus; constantly strains voice. An audio recording was made during the visit that was reviewed later in therapy. The opportunity to visit the patient’s classroom led to several suggestions. These included n Decrease the physical space by rear-

ranging seating and using approxi-

mately two-thirds of the classroom. With a class size of only 24 students, this was easy to accomplish. The patient herself suggested an additional change. She physically decreased the room size by using large, freestanding display boards (which were normally in school storage) as temporary walls. n Soften the acoustics of the room by using the window blinds, pulled halfway down. Use fabric in a work display area by hanging a sheet on the wall to display student papers, pictures, tests, and similar exhibits. The large display boards also functioned well as an acoustic barrier. n Build into the schedule a vocal “timeout” for both the teacher and the students. Learn to respect and appreciate the silent time as a chance to rest the voice and as a reminder to talk only as loudly as necessary in the newly configured classroom. n Develop a sign system for common instructions and requests. It was noted during the site visit that the patient was constantly correcting and directing students’ actions while instructing. When this was brought to her attention, she decided to implement an interesting sign-symbol system that would preclude voice commands. She listed the names of the students on a large magnetic board in the corner of the classroom. Signs were then made with picture symbols depicting the most common corrections and directions that she made. They included symbols representing such directions as the following: be quiet, don’t tilt your chair, slow down, stop talking, talk softer, and pay attention. These symbol pictures were attached to magnets. When the need arose, the patient would place the symbol next to the name of the


offending child, all the while continuing her teaching. A list of consequences for receiving more than one symbol correction was established by the teacher and well understood by the children.

Elimination of Throat Clearing The previous suggestions proved successful in immediately decreasing the daily laryngeal fatigue and voice struggle. The patient, of course, remained dysphonic. The therapy plan then introduced a behavior modification approach for eliminating the phonotraumatic behavior of throat clearing. Until brought to her attention by the therapist, the patient was not aware of the frequency of her throat clearing. Throat clearing may be extremely abusive to the tissue lining of the vocal folds and arytenoid cartilages. Once brought to her attention, the patient was surprised by the number of times she cleared her throat during the session. To modify this behavior, she was told the following. Throat clearing is one of the most abusive things you can do to your vocal folds. When you clear your throat like this (demonstrate), you create an extreme amount of movement of your vocal folds, causing them to slam and rub together (demonstrate using your hands). You should understand that it is not unusual to have developed this habit. The vast majority of patients we see with your type of voice problem also have this habit. Sometimes people do not even know that they are doing it, but often they say that they feel something in their throat, such as a lump or mucus. The majority of the time, however, when you clear your throat, there is nothing there. Often, patients only feel a sensation of thickness from chronic strain. The only thing

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you have accomplished is to create more vocal fold abuse. We have demonstrated to you with the audio recording from your class that, most of the time, you clear your throat right before you begin to speak. We call that a preparatory throat clear. Also, you are clearing many more times than you realized. This is a sign that throat clearing is a habit. As with all habits, it is difficult to break. We are, therefore, going to try to make it easier by giving you a substitute habit that will (1) take the place of throat clearing, (2) accomplish the same thing as throat clearing, and (3) is not abusive. This substitute, nonabusive habit is a hard, forceful swallow. If you do, in fact, occasionally have increased amount of mucus on your vocal folds, a forceful swallow will accomplish the same thing as throat clearing, minus the abuse. The only difference is that throat clearing feels good. It psychologically gives you more relief than the forceful swallow, even though it physically accomplishes no more. It is your goal to overcome the psychological dependence. Understand that this habit is harmful and that it must be broken. To break this habit, you need to tell everyone in your family and any friends who are often around you (and whom you feel comfortable telling) that you are not permitted to clear your throat anymore. When these “helpers” hear you clear your throat, and they will, they are to immediately point it out. You may even consider using your students as helpers. Your task, then, is to swallow forcefully. Obviously, it will not be necessary to swallow because you just cleared your throat, but this is your first step in substituting the hard swallow for the throat clearing. After your family, friends, or students have pointed out your throat clearing to you several times, you will

begin to “catch” yourself. You will clear your throat and almost immediately think, “Oops! I am not supposed to do that.” Your response again should be to swallow forcefully. When you have caught yourself clearing your throat several times, you begin to halt yourself just prior to clearing. Once again, you will substitute the hard swallow, but this time the throat clearing was stopped. By the time you have reached this point, you will be close to breaking the habit totally. The final goal will be met when you realize that you are swallowing many fewer times than the number of times you previously were clearing your throat. I want you to work hard on this problem. I think you will be surprised just how quickly you are able to break this habit. As a matter of fact, the majority of our patients have significantly reduced the habit within 1 to 2 weeks. Most patients, however, cannot do it alone. So please, find other people to help you by having them point out when you are doing it. Any questions?” (Reprinted from Stemple, Glaze, and Klaben103).

Following this explanation, the patient typically will clear his or her throat more times than usual. The voice pathologist immediately points this out, and the patient initiates a forceful swallow substitution. Often, patients make great gains in habit modification during this initial session. Patient F received help from her husband, mother, and a friend and was able to totally eliminate the habit of throat clearing within 2 weeks.

Oral Hydration Program The vocal folds must be well lubricated to decrease the heat and friction of vibration. Thin, slippery mucus secreted onto the vocal folds serves the same purpose

as oil serves to the engine of car. It was explained to patient F that what she swallows does not touch her vocal folds but is diverted around them. Therefore, the amount and type of liquid intake will either permit or inhibit the normal mucus flow to the vocal folds. Caffeine, alcohol, and many medications are drying agents. Many times, when patients feel as if they have too much mucus on the vocal folds, they actually have increased mucous viscosity, which is thicker and stickier than is desirable. This patient’s liquid intake was minimal and caffeinated. She therefore was placed on a hydration program that required a minimum intake of six, 240-mL (8 fl oz) glasses of water or fruit juice per day. In addition, she was asked to decrease her caffeine intake but was not required to totally eliminate caffeine from her diet.

Symptom Modification Direct symptom modification also was introduced. These tasks included the following: n The patient enhanced her awareness

of appropriate pitch and loudness used during teaching. The initial audio recording was used to demonstrate problems with pitch, loudness, and focus. n The patient was instructed to talk only as loudly as was absolutely necessary in the classroom. A combination of these approaches returned her teaching style to a more conversational mode. n Reconfiguring the classroom and improving the acoustics was also a factor in making positive changes in voice production.


Vocal Function Exercises An important part of this patient’s voice therapy program was the use of Vocal Function Exercises. These exercises, first described by Barnes104 and modified by Stemple,92 strive to balance the subsystems of voice production. The exercise program has proven successful in improving and enhancing the vocal function of speakers with normal voices and disordered voices.92,105 In addition, Sabol, Lee, and Stemple106 demonstrated the effectiveness of Vocal Function Exercises in the exercise regimens of singers. The program is rather simple to teach and, when presented appropriately, seems reasonable to patients. Many patients are enthusiastic to have a concrete program, similar in concept to physical therapy, during which they may plot the progress of their return to vocal efficiency. The program is as follows. Describe the problem to the patient, using illustrations as needed or the patient’s own stroboscopic evaluation video. The patient is then taught a series of 4 exercises to be done at home, twice each, 2 times per day, preferably morning and evening. These exercises include: 1. Sustain the /i/ vowel for as long as possible on a musical note F above middle C for all female patients and boys and F below middle C for mature male patients. (Notes may be modified up or down to fit the needs of the patient. Seldom are they modified by more than 2 notes in either direction.) Goal: based on airflow volume. (In our clinic the goal is based on reaching 80 to 100 mL/s of airflow. So, if the flow volume is equal to 4000 mL, then the goal is 40 to 50 seconds. When airflow measures

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are not available, the goal is equal to the longest /s/ that the patient is able to sustain. Placement of the tone should be in an extreme forward focus that is almost, but not quite, nasal. All exercises are produced as softly as possible, but are not breathy. The voice must be “engaged.” This is considered a warm-up exercise.) 2. Glide from your lowest note to your highest note on the word “knoll.” Goal: no voice breaks. (The glide requires the use of all laryngeal muscles. It stretches the vocal folds and encourages a systematic, slow engagement of the cricothyroid muscles.) The word “knoll” encourages a forward placement of the tone as well as an expanded open pharynx. The patient’s lips are to be rounded and a sympathetic vibration should be felt on the lips. (May also use a lip trill, tongue trill, or the word “whoop.”) Voice breaks typically will occur in the transitions between low and high registers. When breaks occur, the patient is encouraged to continue the glide without hesitation. When the voice breaks at the top of the current range and the patient typically has more range, the glide may be continued without voice as the folds will continue to stretch. Glides improve muscular control and flexibility. This is considered a stretching exercise.) 3. Glide from a comfortable note to your lowest note on the word “knoll.” Goal: no voice breaks. (The patient is instructed to feel a half-yawn in the throat throughout this exercise.)

By keeping the pharynx open and focusing the sympathetic vibration at the lips, the downward glide encourages a slow, systematic engagement of the thyroarytenoid muscles without the presence of a back-focused growl. In fact, no growl is permitted. (May also use a lip trill, tongue trill, or the word “boom.”) This is considered a contracting exercise. 4. Sustain the musical notes C, D, E, F, and G for as long as possible on the word “knoll” minus the “kn.” (Middle C for all female patients and boys, an octave below middle C for mature male patients.) Goal: remains the same as for exercise 1. (The “oll” is once again produced with an open pharynx and constricted, sympathetically vibrating lips. The shape of the pharynx to the lips is likened to an inverted megaphone. The fourth exercise may be tailored to the patient’s present vocal ability. Although the basic range starting at middle C, an octave lower for mature male patients, is appropriate for most voices, the exercises may be customized up or down to fit the current vocal condition or a particular voice type. Seldom, however, are the exercises shifted more than 2 notes in either direction. This is considered a lowimpact adductory power exercise.) Quality of the tone is also monitored for voice breaks, wavering, and breathiness. Quality improves as times increase and pathologies begin to resolve. All exercises are done as softly, but engaged. It is much more difficult to produce soft tones; therefore, the vocal

subsystems will receive a better “workout” than if louder tones were produced. Extreme care is taken to teach the production of a forward tone that lacks tension. In addition, attention is paid to the glottal onset of the tone. The patient is asked to breathe in deeply with attention paid to training abdominal breathing, posturing the vowel momentarily, and then initiating the exercise gesture without a forceful glottal attack or an aspirate breathy attack. It is explained to the patient that maximum phonation times increase as the efficiency of the vocal fold vibration improves. Times do not increase because of improved “lung capacity.” Even aerobic exercise does not improve lung capacity but rather the efficiency of oxygen exchange with the circulatory system, thus giving the sense of more air. The patient is provided with an audio CD of live voice doing the exercises which is used to guide the home exercise sessions. We have found that patients who complain of “tone deafness” often can be taught to approximate the correct notes with practice and guidance from the voice pathologist. Finally, patients are given a chart on which to mark their sustained times, which is a means of plotting progress (Table 3–5). Progress is monitored over time, and because of normal daily variability, patients are encouraged not to compare one day with the next. Rather, weekly comparisons are encouraged. Estimated time of completion for the program is 8 to 10 weeks. When the patient has reached the predetermined therapy goal and the voice quality and other vocal symptoms are improved, a tapering maintenance program is recommended. Although some professional voice users choose to


remain in peak vocal condition using the exercises, many of our patients desire to taper the program. The following systematic taper is recommended: n Full program 2 times each, 2 times

per day

n Full program 2 times each, 1 time per

day (morning)

n Full program 1 time each, 1 time per

day (morning)

n Exercise 4, 2 times each, 1 time per

day (morning)

n Exercise 4, 1 time each, 1 time per day

(morning)

n Exercise 4, 1 time each, 3 times per

week (morning)

n Exercise 4, 1 time each, 1 time per

week (morning)

Each taper should last 1 week. Patients should maintain 85% of their peak time, otherwise they should move up 1 step in the taper until the 85% criterion is met. In short, Vocal Function Exercises provide a holistic voice-treatment program that attends to the 3 major subsystems of voice production. The program appears to benefit patients with a wide range of voice disorders both hyperfunctional and hypofunctional. The daily exercises require a reasonable amount of time and effort. In addition, it is similar to other recognizable exercise programs; the concept of “physical therapy” to improve muscle function is understandable; progress may be easily plotted, which is inherently motivating; and it appears to balance airflow, laryngeal activity, and supraglottic placement (reprinted from Stemple, Glaze, and Klaben103). Vocal Function Exercises were helpful in improving the overall condition of patient F’s vocal folds and helped to

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Table 3–5. Vocal Function Daily Record MON

TUE

WED

THU

FRI

SAT

SUN

E/F

/

/

/

/

/

/

/

C

/

/

/

/

/

/

/

D

/

/

/

/

/

/

/

E

/

/

/

/

/

/

/

F

/

/

/

/

/

/

/

G

/

/

/

/

/

/

/

E/F

/

/

/

/

/

/

/

C

/

/

/

/

/

/

/

D

/

/

/

/

/

/

/

E

/

/

/

/

/

/

/

F

/

/

/

/

/

/

/

G

/

/

/

/

/

/

/

MON

TUE

WED

THU

FRI

SAT

SUN

E/F

/

/

/

/

/

/

/

C

/

/

/

/

/

/

/

D

/

/

/

/

/

/

/

E

/

/

/

/

/

/

/

F

/

/

/

/

/

/

/

G

/

/

/

/

/

/

/

E/F

/

/

/

/

/

/

/

C

/

/

/

/

/

/

/

D

/

/

/

/

/

/

/

E

/

/

/

/

/

/

/

F

/

/

/

/

/

/

/

G

/

/

/

/

/

/

/

Date

AM

PM

Date

AM

PM

114

retrain frontal focus. The patient’s baseline mean phonation time for sustaining the appropriate notes was 8.5 seconds. This measure improved to a mean of 18 seconds during 6 weeks of therapy. Significant improvement was noted during 6 weeks of therapy for both subjective observations of voice quality and objective measures of vocal function. The patient was experiencing much less vocal fatigue and laryngeal discomfort. Audio recordings made while teaching demonstrated stabilization of new voicing habits and only very occasional throat clearing. She did, however, remain mildly dysphonic, characterized by a slight breathy hoarseness. Objective measures demonstrated a fundamental frequency of 196 Hz and an expanded frequency range of 165 to 720 Hz. Jitter and shimmer measures were within normal limits. Airflow rates for comfort and low-pitched voices were decreased to 136 and 150 mL/s, respectively. Airflow rate for high-pitched voice was also decreased to 240 mL/s but was still above the normal limit of 200 mL/s. Videostroboscopy also demonstrated improvement. The edema and erythema were resolved, and there was no evidence of the contact ulcer. A slight thickness was noted where the left nodule had been. The right nodule was still present but appeared much more cystlike. Glottic closure retained an hourglass shape; however, the glottal chinks were much smaller. The amplitude of vibration was only slightly decreased left and moderately decreased right. The mucosal wave was normal on the left and moderately decreased around the right lesion. The open phase of the vibratory cycle was slightly dominant, whereas the symmetry of vibration remained irregular.


The results of the therapy program were discussed with patient F’s physician. Considering the cystlike nature and stiffness of the right vocal fold lesion, it appeared unlikely that the lesion would resolve with therapy. It was decided to extend therapy for an additional month to be certain that this was the case. When the remaining lesion did not resolve, surgery was scheduled for the second week in June. The pathologist’s report confirmed the lesion to be a cyst. Following surgery, the patient continued Vocal Function Exercises for 1 month and began a maintenance exercise program for the remainder of the summer. Maximum phonation times improved and stabilized at an average of 32 seconds. The voice quality improved to normal. Changes in objective measures included a higher frequency range (+900 Hz) and a normal airflow rate at high pitch (160 mL H2O/s). Videostroboscopic examination performed just prior to the fall opening of school revealed all observations to be within normal limits except for the symmetry of vibration, which remained irregular at higher pitches. Patient F was followed monthly to confirm her symptom-free status. Her voice remained normal. The combination of medical and surgical treatment and a holistic voice therapy program proved successful in remediating a longterm voice disturbance in this patient. Another voice therapy program, which is popular in Great Britain, Scandinavia, Europe, and the Middle East, is the Accent Method. In this study of a young singer, Sara Harris describes in detail the rationale and the management plan for this approach.

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Case Study 14 Sara Harris Accent Method in the Treatment of Secondary MTD This case study discusses the Accent Method of Voice Therapy and describes its benefits in restoring efficient vocal function to a young singer with mid third vocal fold thickening and a muscular tension pattern of dysphonia.16 The Accent Method is a holistic therapy regime designed to coordinate the muscles of respiration, phonation, and articulation to produce efficient voice production and clear, resonant, wellmodulated speech. Svend Smith, a Danish phonetician, designed the Accent Method in the 1930s. It is used widely in Europe including the Scandinavian countries. Smith was keen to develop a dynamic technique for voice and speech skills that emphasized the whole communication process, including nonverbal aspects such as eye contact and gesture. He was influenced greatly by the rhythmic patterns produced by the bongo drummer Joe Bogdana who accompanied the entertainer Josephine Baker. He saw a potential use of these rhythms to reinforce intonation and prosody, as well as to provide a framework in which to practice voice and articulatory skills. Smith and Bogdana worked together to devise the three tempos — largo, andante, and allegro — that are still used in the technique today. The theoretical underpinning of the Accent Method is based on the following: n the myoelastic-aerodynamic model

of vocal fold vibration

n conditioning (the unconscious pro-

cess of learning) n focus on normal vocal function rather than the pathology.107,108

The myoelastic-aerodynamic theory of vocal fold vibration was described in the 1950s by van den Berg109 and relies on the concept of the Bernoulli effect. Although recent research has dem onstrated that this effect cannot explain all the factors involved in sustaining vocal fold vibration, the need to establish and maintain a satisfactory subglottic pressure and transglottal airflow remains essential to efficient voice production.110 The conditioning of the desired phonation pattern takes place during long periods of repetition of the Accent Method exercises. The exercises include all the vowels and consonants used in spontaneous speech from which the patient produces sequences of sustained sounds and syllables to sentence level. These meaningless babbled sentences incorporate prosodic features such as rhythmic stresses, intonation, and loud-soft vocal dynamics. The practice sessions may range from anywhere between 10 and 30 minutes. Although concentration is needed in the early stages as patients establish the desired patterns, the unconscious processes of learning and overlearning take over as they practice. Carryover of the newly learned skills into spontaneous, continuous speech then occurs easily and reliably, decreasing the likelihood of relapse. This is in stark contrast to other methods in which patients are asked to produce a sustained sound or short utterance but then discuss the effects of it using their habitual pattern of voice production. The Accent Method exercises concentrate on establishing efficient vocal

fold closures for speech in modal voice using simultaneous vocal onset coordinated with a stable, well-controlled expiratory airflow. Initially, the exercises deliberately encourage breathy phonation with gradual increase of vocal fold adduction until comfortable, clear voice is achieved. Research suggests that this phonation pattern made with the vocal folds barely touching produces efficient and particularly resonant voicing.72,111 It allows the therapist to work equally effectively with patients who are hyperadducted or hypoadducted and explains why the Accent Method exercises have been reported as being successful with a wide range of vocal disorders.

Specific Features Establishing abdominal breathing is a specific feature of the Accent Method. Inspiration relies on contraction of the diaphragm, which has been described as the major muscle of inspiration,112 allowing the speed and amount of inspired air to be controlled easily and effectively. Expiration is controlled in part by elastic recoil and in part by contraction of the abdominal musculature. Contractions of the latter may be smooth for sustained vocalization and unstressed utterances or punctuated by smaller, faster contractions that alter the subglottic air pressure to produce changes in vocal intensity associated with stressed words or utterances of increased vocal loudness. Although research has shown that there are a number of different patterns of breathing and breath control,113 it may be argued that diaphragmatic-abdominal control is most economical of muscular effort. Diaphragmatic-abdominal breathing displaces soft tissue and the abdominal


contents, rather than pulling against the semirigid structure of the rib cage. The development of modal voice is also a specific feature of the Accent Method. Modal voice is produced by short, thick vocal folds with relaxed cricothyroid muscles. Good vocal fold closure can be achieved easily and, provided there is sufficient subglottic pressure, satisfactory mucosal waves are generated. The larynx lies neutrally in the neck, and the pharyngeal and supraglottic musculature is less likely to constrict. By contrast, production of a technical falsetto or head voice requires thinned vocal folds and contracted cricothyroid muscles. When the vocal ligaments are stretched, mucosal waves are smaller, and the vocal fold closure may be harder to maintain over long periods. The larynx is raised to shorten the vocal tract and adjust the resonators appropriately for higher pitches, which may lead to constriction in the supraglottic and pharyngeal musculature. In every way, head voice requires more muscular effort on the part of the laryngopharynx. Many of our English patients adopt this type of phonation pattern for speech, and it is especially common in singers who are used to producing head voice for singing. Some singing teachers even encourage a higher speaking voice by suggesting it is more appropriate for sopranos. Unfortunately, clinical evidence suggests that long periods of this pattern of vocal use may result in bowing of the vocal folds as they become unable to maintain closure against the stretching produced by powerful cricothyroid muscle contraction.114 The initial focus on fricatives and close vowels during the Accent Method exercises is also an important feature of the method. These sounds all produce narrowing of the vocal tract within the

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oral cavity and are believed to create back pressure,115 which assists fast closure of the vocal folds and may influence the length of the closed phase. They also encourage a high, forward tongue position, opening space between the back of the tongue and the pharynx, which may be associated with the “forward resonance” described by singers. The high tongue position has also been associated with enhancement of the 250kHz region in the vocal spectrum, providing extra brightness and penetration to the vocal tone and allowing it to be heard through background noise.116

Case History Patient I presented in the ENT clinic at the request of her general practitioner and her singing teacher. She was 22 years old and studying singing at a well-known music college in London. She planned to be a professional mezzo-soprano, specializing in classical and early romantic styles of singing. At the time she was seen, she was in her final year at college with only 3 months remaining before her final examinations and recital. Patient I had been noticing a problem with her voice for approximately 6 months. She reported that it sounded breathy and immature in her singing and that there were “dead patches” in her upper pitch range where the voicing broke into audible air escape. Her singing teacher was particularly concerned because patient I was no longer responding to the usual singing techniques designed to resolve these problems. She reported that her speaking voice was “mostly OK” but became breathy and hoarse both when she was tired and following prolonged voice use.

Patient I’s case history revealed that she was fit and well with no previous or family history of voice problems. In particular, she had no symptoms of gastroesophageal reflux and no asthma, allergies, or other ENT problems. As with many students, patient I needed to work to support herself at college. She worked in a noisy restaurant that was air conditioned and often smoky. She was aware of how much she had to shout in her job, and she also had to do shift work that often involved late nights. In addition to her work and her singing, she ran a youth group at a local church that also involved protracted voice use and shouting. Patient I was the youngest of 3 sisters and described herself as “small but noisy” as a child. She was aware of stress induced by her college work.

Assessment Initially patient I was seen by an otolaryngologist specializing in voice disorders, who carried out videostrobolaryngoscopy. Examination revealed that she had an average to large larynx with significant midthird polypoid thickening of both vocal folds. The right fold thickening was more prominent than the left. There was a wide interarytenoid chink, and the anterior third of the vocal folds failed to close during phonation. Mucosal waves were present but poorly developed, largely because of inefficient voice production. The laryngologist diagnosed patient I’s vocal pathology as a type-2 muscular tension dysphonia, later named laryngeal isometric disorder.2,16 The laryngologist referred patient I for voice therapy with a speech-language therapist who specialized in voice.

Perceptual analysis was carried out informally in clinic and from the patient’s initial audio recording of a standard reading passage. Pitch Patient I’s speaking pitch and intonation range appeared to be well within the norm for her age and gender. Sirening through her full pitch range for singing showed a characteristic break in the upper register where she could no longer sustain phonation. Efforts to overcome this problem area resulted in a breathy “squeak” and visible effort in the extrinsic laryngeal muscles. Intensity and Volume Patient I’s speaking voice was normal in intensity for quiet conversation with no obvious signs of increased laryngeal effort. She was able to shout, but this produced extrinsic laryngeal muscle effort and led to early vocal fatigue. She reported that the intensity of her singing voice had decreased and that she no longer had control over her dynamic range. High-intensity singing tired her voice more quickly and felt effortful. Quality The patient’s speaking voice was rated as mildly-moderately hoarse. She used a thin fold phonation type with audible air escape. Comfort Patient I reported no discomfort when speaking or singing but described a sense of increased effort or tiredness with high-intensity voice use, whether singing or speaking.


Stamina The patient reported that her speaking voice felt “tired” and became increasingly breathy and weak by the evening. Fatigue developed after an hour of singing or speaking loudly. Her voice responded to rest and had usually recovered by morning, although after a heavy week of voice use in the restaurant, the recovery period increased to several days of normal voice use and voice rest. Patient I had no malocclusion, dental problems, or articulatory disorders. She produced a good range of articulatory movement in speech with normal oral-nasal resonance balance. Her tongue position appeared to be reasonably neutral, and her lip set in speech was rated as neutral and slight rounding. Assessment of Breathing Patterns Airflow measures are not available to this clinician for routine use. The assessment therefore was carried out on informal observation in the clinic. The breathing pattern at rest was produced in the upper chest. There was little observable movement of the abdomen during quiet breathing. During speech, this pattern of breath control continued. Expiration was controlled by the upper chest, which was observed pushing inward, particularly when words were stressed. “Top-up” breaths were also upper chest or clavicular. Observation of breath control for singing revealed that patient I was able to produce a more central pattern and was attempting to recruit the abdominal muscles to help control expiration for sustained notes. The pattern was erratic and hampered by poor fold closure and air escape, however. As a result, she frequently used residual air

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and produced signs of increased effort, both in the upper chest and extrinsic laryngeal muscles. She reported that her singing training had provided relatively little guidance on breathing, and she was uncertain about the meaning of the term breath support. Palpation of the Extrinsic Laryngeal Musculature Assessment of the external laryngeal musculature is standard practice in the author’s clinic, and a shortened form of the Lieberman protocol is used.23,114 As yet, there are no international norms for palpatory findings; however, Jacob Lieberman, a qualified osteopath specializing in laryngeal manipulation, has trained this clinician, and practitioner agreement has been reached for the following tasks117: n Jaw: There was some asymmetry of

jaw opening to the right, and the left temporomandibular joint appeared to be more active than the right. This was apparent during the jaw opening assessment tasks and during spontaneous speech. The patient had no awareness of the asymmetry and did not suffer from temporomandibular joint discomfort. Her singing teacher had commented that she felt patient I’s jaw tended to be “tight” during singing. n Suprahyoid and base of tongue musculature: The suprahyoid and base of tongue musculature was assessed as tighter than average on palpation. Patient I did not report any tenderness in these muscles, but there was strong contraction of the geniohyoid muscles during speech and singing. The anterior aspect of the hyoid bone

was aligned with the anterior aspect of the thyroid cartilage. n Thyrohyoid musculature: Palpation of the thyrohyoid musculature revealed that these muscles were judged to be “held” tightly with a reduced thyrohyoid space area. They contracted briskly when speech was initiated and remained contracted throughout the utterance. The normal contractions usually observed during speech were reduced. Patient I was able to release this musculature using the yawn-sigh technique to lower the larynx and was able to maintain a greater thyrohyoid space successfully when the laryngeal position returned to its rest position. She did not report tenderness when these muscles were palpated. n Cricothyroid musculature: The cricothyroid muscles were judged to be held more tightly on the right than on the left, and the patient reported some tenderness when these muscles were palpated. The cricothyroid visor (the anterior space between the lower border of the thyroid cartilage and the upper border of the cricoid cartilage) appeared to open and close as expected with changing vocal pitch (yawn-sigh contrasted with a highpitched “squeak”), but it was habitually held at rest in a closed neutral position. The alignment between the lower border of the thyroid cartilage and the upper border of the cricoid cartilage showed that the cricoid was held in a more anterior position relative to the thyroid. This suggested the possibility of some anterior sliding at the cricothyroid joint.114,118 n Strap musculature: These muscles were judged to be tight, particularly on the right on palpation and laryngeal shift. The larynx moved easily

to the right but was anchored by the tight right strap muscles, restricting laryngeal shift to the left. n Laryngeal position in speech: The patient’s larynx maintained a neutral position in the neck for breathing and raised normally for swallowing. It returned easily to a neutral position in the neck following swallowing, but as patient I anticipated speech, the larynx rose in the neck and maintained the raised position reliably throughout the utterance. It returned to neutral as soon as phonation ceased.

Treatment Plan The assessment findings were explained and discussed with patient I in the clinic. Vocal rest was not an option because of her need to earn money and the fact that her final recital was only 3 months away. Therefore, we agreed that she would continue with her normal vocal commitments but try to schedule her restaurant work during the day or on weekday evenings to avoid the greatest levels of background noise at the weekends. She also agreed to try to reduce some of the talking at her youth club. Her singing lessons would continue as a priority. Six, 1-hour sessions of voice therapy, once weekly, were agreed on, using audio-recorded exercises made during the sessions for home practice. Patient I stated her voice therapy aims as: n restoring her full vocal range without

her voice breaking or hitting a “dead patch” n restoring her clear vocal quality in singing and speaking


n restoring vocal stamina and comfort

for singing and speech.

The therapist’s treatment aims were to: n facilitate full and uniform vocal fold

closure n establish modal (thick fold) phonation during speech n establish a higher subglottic air pressure and better breath control supported by the abdominal musculature n reduce supraglottic muscular effort during speech. The therapist decided to use the Accent Method as the main treatment technique for patient I to establish the above aims. In addition, it would be supported by: n discussion on vocal hygiene and the

use of a “voice diary” to highlight vocal trauma in daily life n techniques such as sirening91 to facilitate better control of the cricothyroid mechanism, improving vocal range and register changes n introduction of some work on “twang” voice quality91 for specific use in the restaurant where shouting was inevitable n specific laryngeal massage to reduce excess tension in the extrinsic laryngeal muscles.

Early Accent Method Exercises: Establishing Abdominal Breathing The patient was seated in a comfortable, upright chair for back support and her posture checked and aligned. She was encouraged to drop her shoulders down

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and to allow her abdominal muscles to relax. She then observed and monitored the movement of her abdominal wall, placing her hand on her abdomen, low down, below the level of her waist. The therapist sat beside her and placed the back of her own hand over patient I’s hand to monitor the movement. The patient, likewise, placed the back of her hand over the therapist’s abdomen to feel the therapist model the desired breathing pattern. As the therapist breathed in, patient I observed her lower abdomen expand and then contract, moving inward on expiration. Gradually, the patient began to produce the same pattern, and the therapist synchronized her own breathing rate to patient I’s, having reminded her not to breathe too quickly or too deeply. As a singer, patient I had little difficulty establishing abdominal breathing. When patients have difficulty, the early Accent Method exercises may be carried out with the patient lying supine so that the abdominal musculature can relax because these muscles are no longer required for postural support. This has the advantage of allowing patients to lie on their sides, which facilitates contraction of the abdominal musculature on expiration, once abdominal breathing has been established. Patient I was asked to repeat sounds modeled by the therapist. The initial sounds recommended are the voiceless fricatives /k/ (bilabial) /s/, /sh/, and /f/, repeated to form a rhythmic sequence designed to increase transglottic airflow. Gradually, the voiced counterparts /g/, /z/, /zs/, /v/, and close vowels such as /i/ and /u/ were introduced into the repeated sequences with emphasis on deliberately gentle, breathy phonation. At this stage, patients are encouraged not to breathe

in more deeply than they would for the previously established rest breathing, and the fricatives are made on elastic recoil rather than recruiting the abdominal musculature for controlling either the length or intensity of the sound. Traditionally, little explanation is given to patients treated with the Accent Method; if errors occur, the therapist simply returns the patient to tasks he or she manages easily before gently increasing the complexity again. This therapist, however, does provide more guidance to patients, depending on their level of knowledge, experience, and skill, because it is vital to maintain the patient’s cooperation for a conditioning activity that can appear eccentric and mindless. At this early stage, if a patient continues to produce a low flow for fricatives, an overly long and controlled expiration, or both, this could be drawn to their attention. It also can be helpful for patients to notice that expiration stops naturally as lung pressure equalizes with the air pressure outside and that expiration pushed past this point requires muscular effort. This observation allows patients to locate any increased effort in the upper chest and strap muscles when they push past the rest position, which they can then correct. The therapist monitors the vocal quality to ensure that the patient uses modal phonation. Voice onset may need to begin with breath before tone (ssszzzss) but should gradually become simultaneous with exhalation and phonation coordinated together. The vocal quality should become clearer but remain somewhat breathy. Phonation should be reliable and consistent as vocal fold closure becomes uniform, with the midthird swelling displaced upward and away from the vibrating edge of the fold by


increased subglottic air pressure and airflow. If these changes are not achieved, the therapist may need to return to an earlier stage, drawing the patient’s attention to any problems that have developed. Other techniques can be incorporated if necessary to provide a bridge from one stage to another, depending on the problem. For example, staying with “breath before tone” onset for longer periods ensures that the patient does not return to his or her previous hyperadduction patterns, and introducing nasal consonants /m/, /n/, /ng/ usually resolves closure problems and the wide glottic chink. Problems of continued supraglottic tension often may be overcome using palpatory monitoring of the thyrohyoid space or the general laryngeal movement. Rarely is it necessary to resort to gentle glottal onsets to ensure modal voice, because this can usually be achieved using palpatory monitoring of the cricothyroid visor. Gradually, patient I was encouraged to produce gentle contractions of her abdominal musculature on expiration. The largo tempo (Figure 3–5) was introduced, in which expiration is punctuated by shorter, sharper rhythmic contractions of the abdominal muscles to produce stressed or “accented” beats. The largo tempo is slow, allowing

Figure 3–5. Largo.

the patient time to coordinate expiration and the activity of the abdominal muscles. It also allows time for a relatively slow inspiration. The therapist and patient I continued to monitor the excursions of the abdominal wall while sitting and standing. Gentle rocking of the entire body may facilitate general relaxation and reinforce the rhythmic structure of the technique. The therapist then works the patient through the andante (Figure 3–6) and allegro (Figure 3–7) tempos, gradually introducing other vowels and consonants until the patient can maintain the desired phonation pattern for babbling long, prosodic utterances of 20 minutes or more. Work designed to alter tongue position or oral-nasal resonance balance can be incorporated into the sound sequences at this stage. Other prosodic features, such as intonation (pitch contrasts) and dynamic (loud-soft) contrasts, can also be practiced. As the patient gains confidence, meaningful words are introduced. Initially, repetition of therapist-modeled utterances or rote-learned materials (such as rhymes or poems) are practiced before the patient graduates to spontaneously generated utterances, such as responding to questions from the therapist or describing events.

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Figure 3–6. Andante.

Figure 3–7. Allegro.

Results Patient I completed seven, 1-hour sessions of Accent Method voice therapy, which took place over 3 months between late February and May, with a 2-week break over the Easter holiday. The sessions were audio recorded, and patient I continued to practice the work at home on a daily basis. Reassessment in early June showed patient I to have improved significantly in her vocal health and voice production. Perceptually, the patient’s voice continued to be slightly breathy, but the audible turbulent air escape present on her original recording had resolved. There were no pitch or voice breaks, and the slow vocal onset initially observed

was no longer present. The “dead patch” in her vocal range had disappeared, and she was able to siren through her range smoothly and reliably. She still had to be careful to balance the air pressure and transglottal flow correctly while producing high and soft notes in her singing, but otherwise her singing voice no longer gave her trouble. Her teacher reported that she was able to continue developing her singing skills. Palpation of the extrinsic laryngeal muscles showed that the tightness noted at her first assessment had largely resolved. All her scores had returned to neutral except those for the thyrohyoid muscles. Although these were judged as having reduced in score by half a scalar degree and were not reported as tender,


they remained slightly elevated at 3.5 (neutral score 3). Patient I continued a slight tendency to raise her larynx during speech. Videostroboscopy showed that patient I was now able to produce full vocal fold closure on phonation and that the midthird swelling had almost resolved. A little minimal thickening remained in the midthird that no longer appeared to be affecting phonation. Patient I completed her final examination at music college, achieving a good grade. She reported that her final recital had been well received and that she had experienced no difficulty with her voice despite a vocally demanding program. In her treatment of a 44-year-old male, Rita Patel uses a specific approach of intensive voice therapy, first conceived by Diane Bless, PhD, at the University of Wisconsin Voice and Swallowing Center, to create a voice rehabilitation plan that includes components of intensive training and dynamic setup to facilitate carryover.

Case Study 15 Rita Patel Voice Therapy Boot Camp in the Treatment of Secondary MTD in an Adult Intensive short-term voice therapy is a new treatment approach that is being developed in the field of therapeutic management of voice to maximize behavior change for long-term recalcitrant dysphonia that has poor response to traditional direct voice therapy. Ther-

apy dropout, the ultimate nonadherence, is a common clinical problem in voice therapy.119 Given the limited availability of resources like clinical voice centers, the limited number of voice clinicians available to provide intensive voice therapy, and the limited number of graduate programs in which voice therapy is a focus of study, this new approach of intensive treatment has benefits, where target behavior change can be accomplished through concentrated practice. Principles of intensive voice treatment are derived from known literature in the fields of exercise physiology, intensive psychotherapy, and motor learning, which states that short-term intensive practice results in desirable physiologic changes120,121 and long-term retention of newly acquired skills.122,123 It is well known in exercise physiology literature that desirable physiologic changes from training occur primarily from intensity overload.124 Similar findings have been noted with regard to intensive psychotherapy. The findings from literature in psychotherapy support the notion of positive behavior change due to high levels of personal awareness and intensive practice, which leads to retention of newly learned skills. In the field of voice therapy, Lee Silverman Voice Therapy provides evidence for intensive voice therapy to improve laryngeal function in patients with idiopathic Parkinson disease. 125 Behavior modification of long-term refractory dysphonia other than of idiopathic Parkinson disease etiology continues to be challenging for voice therapists. Like voice therapy, the goal of intensive short-term voice treatment regimen is to maximize vocal effectiveness and behavior modification. However, unique to this approach of intensive

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treatment is to bring these changes through techniques of concentrated practice, in the short term, in a dynamic setup that involves a maximum degree of experiences/challenges to achieve the desired target vocal behaviors. An intensive short-term voice treatment program involves a highly structured regime of multiple sessions with a variety of clinicians, incorporating multiple simultaneous voice therapeutic approaches necessary for the client. Part of these therapy sessions can also include additional voice/medical evaluations to clarify the nature of the client’s voice disorder. This form of intensive voice therapy provides rigorous practice, involving not only overload, but also opportunities for specificity and individuality, thereby facilitating better transfer of learned skills. An intensive short-term voice treatment program involves voice therapy that is conducted in successive 1-day to 4-day sessions, for an average of 5 hours (range 4–6 hours) of voice therapy, with an average of 5 clinicians (range: 3–7 clinicians) per day. An intensive treatment program is not limited to a particular diagnosis/therapeutic approach. Intensive short-term treatment is particularly beneficial for long-term recalcitrant dysphonia, where voice therapy continues to be indicated; when the patient has plateaued with a traditional form of individual voice therapy; when a patient has upcoming vocal performances within a short duration of initial assessment; and for clients traveling from longer distances to seek treatment at the voice center. Advantages of intensive short-term treatment are that it provides rigorous practice (overload), it provides opportunities for specificity and individuality, simultaneous interventions can be conducted of multiple

components involved in voice production, opportunities facilitate transfer of learned skills, and these opportunities may influence patient compliance. A highly structured voice therapy regimen, an effective team leader, and communication between the clinicians providing treatment are important for successfully conducting intensive shortterm voice treatment. The team leader is responsible for setting up intensive treatment, coordinating team meetings before and after treatments, and creating a plan for transfer of information from one session to the next. The team leader is also responsible for follow-up with the patient after discharge from intensive treatment.

Patient History Patient L, a 44-year-old male, a native of Iceland, was self-referred to the voice center for assessment and treatment of long-standing voice difficulty of 10 years. Patient L was accompanied by his wife for the session. The initial assessment was performed both by a voice pathologist and laryngologist. The patient was first examined by the voice pathologist, who obtained a detailed history of the nature and onset of the voice problem and a detailed medical history, and performed stroboscopy, high-speed digital imaging, acoustic analysis, aerodynamic assessment, and auditory perceptual analysis of voice quality. Subsequently, patient L was examined by the laryngologist, who reviewed the case history, stroboscopy, and high-speed examinations with the voice pathologist, performed indirect laryngoscopy, and performed a detailed head and neck examination.

Patient L reported a gradual worsening of dysphonia since its onset. Voice quality was reported to have reached a plateau in the past 5 years. The patient’s chief complaints were weak, strained voice quality and vocal fatigue. Voice quality was reported to deteriorate at the end of the day. Being an industrialist, patient L had heavy voice use at work and outside of work. Individual meetings and presentations at board meetings constituted voice use at work. Social gatherings at restaurants with increased background noise comprised additional voice use. Frequent throat clearing was also reported. Throat clearing was reported to be productive during the morning hours. Patient L denied dysphagia or dyspnea. Over the past 10 years, the patient was examined and treated by different voice centers across the country and internationally. Patient L was examined by 1 otolaryngologist and 1 speech pathologist in Iceland, 1 otolaryngologist in Germany, and 2 otolaryngologists in the United States. Impressions from these assessments were of laryngopharyngeal reflux, vocal fold scarring, glottal insufficiency, and vocal fold paresis. Patient L was treated with Omeprazole, 40 mg, twice a day, with no improvement of voice quality. At the time of the assessment, the patient was still taking Omeprazole, 40 mg twice a day for reflux management. Patient L underwent unilateral right-sided injection laryngoplasty with Cymetra for glottal insufficiency and vocal fold scarring, in Germany. Due to no improvement of voice quality, patient L underwent left-sided injection laryngoplasty with Cymetra in the United States. Secondary injection laryngoplasty also did not result in improvement of patient symp-


toms of vocal fatigue and hoarseness. Patient L did not undergo preoperative and postoperative voice therapy during the course of the dysphonia. Patient L was a nonsmoker and consumed three 240-mL (8 fl oz) cups of water daily. Intake of 2 cups of coffee per day was reported. Patient L’s medical history did not reveal serious health conditions. He had no history of allergies, postnasal drip, and sinus infections. No evidence of hearing loss or injury to throat or neck region was reported. The patient’s medical history was significant for laryngopharyngeal reflux, which was confirmed with laryngeal endoscopy, bariumesophagram, gastrointestinal (GI) endoscopy, and dual pH probe monitoring. Apart from the above-mentioned laryngeal surgeries of unilateral injections for medialization, patient L had not undergone other surgeries. Depression and anxiety were not reported.

Evaluation Procedures Patient L received a standard battery of vocal function testing in the voice clinic. These assessments included assessment of structure and vibratory function of the vocal folds with the use of stroboscopy using phonatory tasks of normal phonation, high-pitch phonation, loud phonation, soft phonation, glissando, and laryngeal diadochokinesis; detailed assessment of actual vibratory features like mucosal waves, tissue pliability, glottal closure, and cycle-to-cycle periodicity with the use of high-speed digital imaging; acoustic analysis of sustained vowels and sentence production to assess fundamental frequency, loudness, perturbation measurements, and

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harmonic-to-noise ratio; aerodynamic measurement of respiratory function during speech to assess airflow rate, expiratory volume, phonatory threshold pressure; and perceptual assessment of voice quality on the GRBAS scale.96 Following is a summary of the relevant pretreatment baseline observations and measures:

and mucosal wave of the right vocal fold. Mild phase asymmetry was consistently observed. An irregular glottal closure was observed, which was characterized by a moderate gap along the anterior and midmembranous portions of the vocal folds and a small posterior phonatory gap. 2. Acoustic analysis: The patient’s acous 1. Vocal fold structure and function: tic measurements of voice quality Patient L’s endoscopic and strobowere obtained using the Multiscopic assessments were performed Dimensional Voice Profile Module using a flexible and rigid 70-degree of the KayPENTAX Computerized endoscope without need for topiSpeech Lab. The patient’s mean funcal anesthesia. The examination damental frequency was 147 Hz, revealed normal movements of the mean jitter of 0.90% (norm = 0.59%), arytenoids cartilages bilaterally. mean shimmer of 4.23% (norm = Mass lesions were not observed 2.53%), and harmonic-to-noise ratio along the vocal fold margins. Smooth of 27 (normal = 30). These measurebut irregular vocal fold edges were ments represented subnormal perforobserved. During phonation, mild mance based on the expected acousreduction in vibratory amplitude tic measures for the patient’s age and and mucosal wave of both the vocal gender. All intensity measurements folds was observed, suggestive of the patient’s minimum (60 dB of reduced vocal fold pliability. A SPL), habitual (71 dB SPL), and maxismall anterior and posterior glotmum (89 dB SPL) loudness productal gap was noted, suggestive of tions were within the expected range incomplete glottal closure. Phase for his age and gender. asymmetry between the vocal folds 3. Aerodynamic measurements: Airflow was not present. Mild lateral commeasures were taken during suspression of the supraglottic structained vowel productions; intraoral tures was observed, suggestive of pressure measurements were estivocal hyperfunction. mated from repeated productions High-speed analysis of vocal of /pi/ using the Glottal Enterprise fold vibrations was performed at Analysis System. Mean intraoral 2000 frames per second using a pressure was measured at 7.1 cm rigid 70-degree endoscope without H2O, which was greater than the expected norm of 5 cm H2O. The application of topical anesthetic to mean airflow rate was 280 cc/s, the oral mucosa, to further assess which is excessive, suggestive of the extent of patient L’s vibratory an incomplete laryngeal valving disturbances. High-speed examinamechanism. tion revealed moderate reduction in pliability of the left vocal fold 4. Auditory perceptual analysis: Patient L’s voice quality was judged peralong the anterior margins and mild ceptually by the voice pathologist reduction of vibratory amplitude


on a 4-point rating scale, known as the GRBAS scale (normal, mild, moderate, severe) for overall grade of hoarseness (G), roughness (R), breathiness (B), asthenia (A), and strain (S). Patient L exhibited a moderate amount of hoarseness and strain, and a mild amount of breathiness. No evidence of asthenia was noted.

Impression and Rationale for Therapy Approach Overall the patient’s history and examinations revealed reduced pliability of both the vocal folds, left greater than the right; incomplete glottal closure; and vocal hyperfunction. Based on the results of the assessment and nature of the patient’s complaints of vocal fatigue and reduced endurance, the decision was made that patient L should undergo intensive voice therapy for 3 days to reduce hyperfunctional behaviors and improve glottal closure. Successful completion of voice therapy treatment was expected to in turn reduce the degree of hoarseness and enhance vocal stamina. Because the patient was traveling internationally for voice treatments, during the weekly voice clinic team meetings, the decision was made that he would benefit most from concentrated intensive voice therapy. The voice pathologist who performed the initial assessment of patient L was appointed as a team leader to coordinate the patient’s intensive voice therapy program during the weekly voice clinic team meeting. The team leader’s responsibilities included: n scheduling the patient for intensive

treatment

n checking the availability of other

voice pathologists for conducting intensive treatment with the patient n conducting a pretreatment meeting with all voice pathologists to formulate a treatment plan n conducting daily meetings with the patient’s intensive care team either before the initiation or termination of therapy each day to establish goals for the next day n summarizing the patient’s status/ progress each day n formulating a plan for transfer of information between the voice pathologists from one session to the next n creating a home program for practice of the voice exercises n coordinating the patient’s care with the speech pathologist in the patient’s home country/state n scheduling a follow-up appointment.

Therapy Goals and Structure Patient L received 5 hours of voice therapy, conducted by 4 voice pathologists per day for 3 consecutive days. Pretherapy and post-therapy measurements were performed at the beginning and end of each therapy day with stroboscopy, high-speed digital imaging, acoustic, aerodynamic, and auditory perceptual analysis of voice quality. The therapy regimen consisted of 4 different goals focusing on reducing hyperfunctional behaviors, improving glottal closure, building vocal endurance, and increasing hydration. During the 3 days of intensive treatment, patient L was not provided with additional home practice of the voice exercises. The above voice therapy goals were achieved using a combination of voice therapy techniques. Patient L’s

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first therapy session each day consisted of performing the vocal function exercises, abdominal breathing, and neck relaxation exercises. During the subsequent sessions, each day the goal was to systematically progress toward use of resonant voice at conversation level. For this, techniques of resonant voice and flow mode phonation were used at syllable, word, sentence, marked paragraph reading level, paragraph reading level, structured conversation, and conversation. Patient L attended all scheduled voice therapy sessions. Team meetings were conducted prior to the initiation of voice therapy each day to discuss the patient’s response to the targeted voice therapy activities and highlight the therapy plan for each day. During the team meetings, the team leader also summarized the results of the pretherapy and post-therapy voice measurements for the voice pathologists participating in the patient’s care. Patient L had a breakthrough session with one of the voice pathologists during the early afternoon of the second day, in which the patient was able to maintain resonant voice during structured tasks at sentence and paragraph reading levels. Goals for day 3 were changed to accommodate the progress made during day 2 of the intensive voice treatment. During day 3, patient L was provided with increased opportunities to practice carryover of the newly learned skills in the voice therapy session to unique situations like ordering at the cafeteria and conversation at the hospital cafeteria with high levels of background noise. The last session during day 3 was geared toward providing a written home practice plan for the patient.

Results of Therapy Pretherapy and post-therapy measurements performed each day consistently revealed significant improvement of voice quality at the end of an intensive voice therapy day. The results from the last therapy session of a 3-day intensive voice treatment regimen are summarized below: n Laryngeal imaging: Both stroboscopic

and high-speed digital imaging revealed improved glottal closure compared to an irregular incomplete glottal closure that was observed during pretreatment recordings. Glottal closure during complete adduction was now characterized by a small posterior phonatory gap. Healthy vibratory amplitudes and mucosal wave were appreciated along the right vocal fold and minimal reduction in mucosal wave was observed along the left vocal fold. Lateral and anterior posterior compression of the glottis was not observed. High-speed analysis inconsistently revealed phase asymmetry between the vocal folds. n Acoustic analysis: The patient reduced jitter and shimmer measurements and increased the signal-to-noise ratio. Post-test acoustic measurements were grossly within expected norms for the patient’s age and gender. n Aerodynamic analysis: Mean airflow rate was 180 cc/s and mean phonatory threshold pressure was 5.2 cm/ H2O, which are within the expected limits. n Auditory perceptual analysis: Conversational speech was rated to have an overall normal grade (G), mild roughness (R), with no evidence of breathiness and asthenia. The patient’s voice


quality improved markedly as judged by the patient. Even at the end of a 3-day intensive voice therapy regimen, patient L did not complain of vocal fatigue and hoarseness. Subsequent follow-up was conducted once every 2 weeks by means of e-mail and by video-voice interface through the World Wide Web. The team leader discussed the maintenance plan with the patient’s voice therapist in Iceland by e-mail. Subsequent follow-up at 6 months revealed that patient L had continued to maintain the improvement achieved during the initial course of intensive voice treatment. At this time, a follow-up in 1 year was recommended. The positive outcome of this treatment is attributed to the rigorous concentrated practice of structured therapeutic tasks to bring about a change in target vocal behavior. Intensive short-term therapy with a number of voice clinicians inherently created opportunities for differential practice, which facilitated transfer of learned skills. Because the patient had a long-standing voice problem, the intensive nature of voice treatment also aided in reducing the patient’s frustration with the therapeutic tasks and enhanced compliance with the voice exercises, by demonstrating success within a short duration. Though controversy continues to surround the actual prevalence of voice disorders associated with laryngopharyngeal reflux (LPR), patients continue to be referred with this diagnosis. In the following case, Sandy Schwartz discusses both medical and behavioral management of a case of MTD secondary to LPR.

Case Study 16 Sandra A. Schwartz Medical and Therapeutic Management of Laryngopharyngeal Reflux With Resulting Secondary MTD

Previous Patient History Patient SL is a 65-year-old male who presented to the ENT clinic with complaints of vocal quality change and voice deterioration for the past >1.5 years. He had been seen at that time (19 months ago) by another otolaryngologist and speechlanguage pathologist. At that time, he reportedly presented with complaints of “hoarseness” without precipitating event or illness/upper respiratory illness (URI). He also reported excessive “mucous in his throat” and frequent throat clearing. The patient attributed it to postnasal drip (PND) and “allergies,” although he had no other allergy symptoms and denied rhinitis. The previous ENT performed a fiber-optic flexible endoscopy and placed him on a proton pump inhibitor (PPI, such as Omeprezole or Lansoprazole) for reported arytenoid edema and erythema suggestive of laryngopharyngeal reflux (LPR). He was referred for a videostroboscopy. The report of that examination noted mild-moderate posterior laryngeal edema and interarytenoid thickening consistent with LPR. Medial glottal closure was mildly compromised resulting in bilateral false vocal fold hyperfunction and AP supraglottic compression. The patient was reportedly counseled on GERD, dietary

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precautions, and management, and voice therapy was recommended which the patient declined. In the interim between that time and his presentation to our office, he was seen by GI and underwent both an upper endoscopy and Ba swallow. SL presented these reports to our clinic during his initial visit. An upper endoscopy reported normal mucosa of the hypopharynx, upper, middle, and lower esophagus, normal gastroesophageal junction with diffuse erythema. No mass lesions or evidence of Barrett’s esophagus (biopsies were normal). Barium swallow/esophogram noted an approximate 1-cm (or less) Zenker’s diverticulum as well as a small sliding hiatal hernia with free flowing reflux. He was changed to PPI 4 times a day (30 mg in the AM) and histamine blocker (H2) (such as ranitidine, 150 mg) at night by the consulting gastroenterologist. At presentation to our clinic, he reports that he had continued these medications until his primary care physician placed him on ranitidine and he discontinued the medication approximately 6 months ago.

Current Presentation/ Medical and Vocal History The patient’s complaints continue to be of “voice loss” and a “raw” sensation in his throat. Upon questioning, he states that he is “straining to talk” and that his voice deteriorates with extended use. He is a retired teacher (retired 5 years ago) and notes that his “voice used to be strong and effortless.” He denies laryngeal pain, dysphagia, odynophagia, globus, shortness of breath, or cough. He is a nonsmoker. He reports 3 to 4 cups of caffeine/day and approximately 4

glasses of water. Prior medical history of hypertension, small (<1 cm) Zenker’s diverticulum, and anemia. Medications include beta blocker, Lansoprazole, ranitidine, and iron supplements. Review of barium swallow/esophagram films was performed by an otolaryngologist in our clinic to assess size and location of Zenker’s. The diverticulum, as seen at the time of radiographic study (approximately 18 months ago), was felt to be too small for repair and did not show significant retention. The otolaryngologist proceeded with general head and neck examination that was within normal limits followed by behavioral, voice, and videostroboscopic examination by the speech pathologist. The Reflux Symptom Index56 completed by the patient to assess the perception of symptoms related to LPR resulted in a score of 23 (score >13 considered to be suggestive of LPR). The VHI-1053 completed by the patient to subjectively quantify the perception of vocal handicap resulted in a score of 14 (score >11 considered abnormal54). Subjective perceptual impressions of vocal quality were mild harshness and pitch breaks. There was evidence of vocal strain and increased cervical tension during conversational speaking. The patient was observed to use a breathholding pattern during extending speaking. Oral mechanical examination was within normal limits.

Objective Voice Assessment Acoustic Measures Acoustic measures were obtained using the Multi-Dimensional Voice Profile (MDVP) (KayPENTAX), maintaining a microphone-to-mouth distance of 3 cm

at a 45-degree angle. Using a sampling rate of 44 100 analyzing a 3.89-second sample of sustained phonation /a/, the fundamental frequency was 132.20 Hz; pitch perturbation (jitter) = 0.744%; amplitude perturbation (shimmer) = 5.50%; noise-to-harmonic ratio = 0.161; and voice turbulence index = 0.075. Using the real-time pitch (RTP) application during running speech (counting), the mean speaking F0 = 136.46 Hz with a range of 119.34 Hz (min = 109.16/max = 228.50) and intensity is 71 dB (WNL for conversation in quiet room). The maximum phonation time average of 2 trials = 18 seconds. Videostroboscopic Imaging Both flexible and rigid (70-degree) endoscopic visualization were performed using both constant halogen and xenon stroboscopic light without the use of topical anesthetic. The structure of the nasopharynx and hypopharynx were all within normal limits. The velopharyngeal functional examination was normal. True vocal fold superior and medial margins were smooth and regular in appearance. There is significant erythema noted of the vocal processes bilaterally. The medial glottal closure is complete during phonation with the use of both lateral/false vocal fold compression (mild-moderate) and mild anterior posterior hyperfunction. (Initial contact is made at the anterior one-third with a posterior gap, subsequently closed with the assistance of false vocal fold compression). There was mildly reduced amplitude and normal mucosal wave propagation. The vibratory cycle was in-phase with frequent aperiodicity (likely secondary to tension). Adduction and abduction of the vocal folds showed normal mobility during pho-


nation and breathing. There was mildmoderate interarytenoid hypertrophy and postcricoid edema. There was one occasion of upper esophageal sphincter opening/aerophagia seen during the examination. The examination was consistent with his reported and documented gastroesophageal reflux with LPR. Secondarily, there is a mild-moderate degree of laryngeal and supraglottic hyperfunction termed in our report as type 2-3 muscle tension dysphonia.126

Medical Treatment It was recommended that the patient change to an extended-release medication for the LPR which was prescribed by the otolaryngologist. Voice therapy was again recommended. The otolaryngologist had also requested the barium swallow/esophagram to reassess the presence of a Zenker’s diverticulum (previous exam was >18 months).

Voice Therapy Goals and Rationale Gastroesophageal reflux is a known contributing factor to the presence of laryngeal inflammation and voice disorders. It has been reported that approximately half of patients with voice disorders or laryngeal pathology demonstrate gastroesophageal reflux as a causative factor.127 The present patient was believed to exhibit a multifactorial voice disorder resulting from laryngeal inflammation as a result of the LPR with secondary extrinsic and intrinsic muscle tension associated with phonation.128,129

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Voice therapy was initiated 1 time per week with the following goals: n improve the patient’s ability to man-

age LPR using dietary and behavioral strategies (in addition to medical management) n reduce musculoskeletal tension associated with phonation n improve vocal efficiency and projection utilizing airflow while maintaining an open tract/relaxed laryngeal posture. SL was seen for an initial therapy session (session 1) that focused on a review of LPR recommendations and dietary management. Written guidelines were provided. SL was instructed to reduce his caffeine intake and keep a log of his intake (both meals and snacks) for 2 weeks to help him identify potential trigger foods that were listed on the written handout. SL was then taken through a series of cervical stretching exercises to increase his awareness of extrinsic laryngeal muscle tension in his shoulders, neck, and chest. He was instructed in the use of lower abdominal/diaphragmatic breathing to improve his self-awareness of clavicular and chest tension and to promote a relaxed breath support pattern for voicing. These exercises were provided in pictures and writing for home practice. Digital laryngeal manipulation /laryngeal massage19,45 was performed by the speech pathologist to target muscular tension and restore laryngeal balance (the patient was observed to have a high laryngeal carriage). This also served to further increase awareness of laryngeal tension. During manipulation using circumlaryngeal massage to the area between the hyoid and thyroid cartilage, the patient

was instructed to sustain vowel sounds that notably changed in quality with a reduction in laryngeal height. Despite some discomfort reported by the patient, he felt an immediate improvement in strain/tension and was encouraged by the qualitative change heard during vowel production. The following 2 sessions (sessions 2 and 3) were initiated with a brief period of laryngeal massage followed by production of vocal function exercises80 using sustained /i/, pitch glides on the word “knoll,” and sustained notes on “oll.” As designed, these exercises were used to target improved muscle flexibility and encourage airflow with an open pharyngeal posture. Semioccluded vocal tract/straw phonation93 was also used during these sessions on production of a hum (steady pitch and pitch glides) in an effort to target vocal efficiency. All exercises were then prescribed 2 times a day at home. Voice therapy sessions 4 and 5 focused on the patient’s ability to maintain supraglottic relaxation while targeting the use of increased airflow36 during speaking tasks of increasing length. Therapy tasks used phrases and sentences of increasing length loaded with voiceless plosives and fricatives (ie, hockey skate, happy puppy, Sue ate soup; cut fish with a knife, 52 kitty cats ate pasta). Voiceless productions were used as stimuli in order to promote airflow release. He was cued to use a lower abdominal support and slightly increased volume (his “teaching” voice) targeting vocal projection using airflow versus laryngeal “push.” We also used counting on voiceless onsets (counting 40 to 50; 50 to 60), contrasting use of a soft versus loud voice for self-identification of vocal strain. SL was given written lists of home practice stimuli. He


was to continue to use vocal function and straw phonation at the onset of his home practice. Session 6 contrasted voiceless and voiced productions at the word, phrase, and sentence levels for identification of any subjective or observable phonatory tension/strain on utterances of increasing length with voiced loaded consonants. SL was given minimal cues for abdominal support, airflow release, and projection. He was observed to use a lower laryngeal posture throughout the productions and no longer exhibited clavicular tension. No observable pitch breaks during sentence-level productions were documented. During a 10-minute conversational task with the clinician, he was observed to use improved breath support without clavicular tension and without audible vocal strain. SL reported using vocal function and straw phonation exercise at the onset of his home practice as instructed and reported that he feels that this “helps him relax his throat.”

Therapy Outcomes SL was followed by the physician 10 weeks after his initial voice therapy evaluation. He was taking the extendedrelease PPI and reported having reduced his caffeine intake to 1 cup/day and following dietary management guidelines for LPR. He was seen for 6 total voice therapy sessions over 8 weeks with the following changes in his status: Reflux Symptom Index score = 11/45 (pretreatment = 23/45) VTI-10 score = 5/40 (pretreatment = 14/40)

Acoustic Measures MDVP analysis on sustained /a/ (sampling rate = 44 100; sample 3.97 seconds) reported the average fundamental frequency was 133.16 Hz; pitch perturbation (jitter) = 0.626%; amplitude perturbation (shimmer) = 3.92%; noiseto-harmonic ratio = 0.154; and voice turbulence index = 0.045. This acoustic data demonstrated an improvement in the production of sustained vowel when compared with pretreatment results (using a comparable sample length and average F0 which is WNL for adult male). Videostroboscopic Findings Using a rigid (70-degree) endoscope for post-treatment laryngeal visualization and side-by-side comparison of laryngeal images, there was notably reduced erythema noted of the vocal processes bilaterally. Medial glottal closure was complete during phonation without false vocal fold or anterior posterior compression of the supraglottic musculature as previously noted. Both amplitude and mucosal wave were judged to be within normal limits. The vibratory cycle was in-phase without aperiodicity. Mobility was normal during phonation and breathing. There was continued mild interarytenoid hypertrophy and postcricoid edema, though reduced from previous examination. Overall Results SL had improvement of reflux symptoms and laryngeal inflammation using a medical and behavioral management approach. He no longer complained of laryngeal discomfort and stated that his voice did not “give out” during extended conversations. He felt

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that his voice was stronger with more volume and less strain. Visible tension previously noted on videostroboscopy involving overactivation of the false vocal folds with supraglottic anterior posterior compression was not seen on follow-up examination. Repeat barium swallow results were obtained and demonstrated no change in size of the Zenker’s diverticulum when compared to previous examination (<1 cm) and continued to demonstrate minimal retention. The diverticulum was small and asymptomatic at the time of the radiographic assessment and therefore no surgical intervention was recommended. SL was instructed regarding possible symptoms associated with Zenker’s diverticulum including undigested food material regurgitation, sensation of solids stuck in throat, and coughing/choking after eating. SL was instructed to follow up with the otolaryngologist in 6 months. Secondary MTD may result from a variety of causes. In the following case, Heather Starmer describes treatment of MTD secondary to vocal process granulomas caused by prolonged intubation.

Case Study 17 Heather Starmer Management of Secondary MTD Associated With Vocal Process Granulomas

Patient History Patient RC was a 36-year-old male referred for an outpatient voice evalu-

ation due to persistent dysphonia, chronic throat clearing, and neck/ throat pain following prolonged hospitalization. He sustained a closed head injury after falling from a ladder. A craniotomy was performed for decompressive purposes. He required prolonged orotracheal intubation for ventilation. Because of difficulty weaning from the ventilator, he underwent a tracheotomy 16 days following intubation and was successfully decannulated 2 months following trach placement. Speaking valve intervention was implemented during his hospital stay, and the patient reportedly had a rough, coarse vocal quality from initiation of voicing. Voice worsened over the month following extubation, and the patient was able to discern a greater deal of vocal strain/effort. Disinhibition, impulsivity, and tangential speech were observed following the injury, and the patient had undergone intensive cognitive rehabilitation in both inpatient and outpatient settings prior to reporting to the voice clinic. Oropharyngeal dysphagia was present during hospitalization requiring tube feedings with gradual advancement to a normal, unrestricted diet following intensive dysphagia therapy. Pertinent medical history for this patient included a history of significant alcohol abuse, severe seasonal allergies, and GERD. At the time of evaluation he was not taking any medications for his allergies or GERD. He did not have a smoking history. Alcohol intake had been minimal since the injury despite history of heavy use prior. He consumed 3 to 4 cups of coffee per day and 2 to 3 caffeinated sodas. Water intake was estimated to be 240 to 480 mL (8 to 16 fl oz) per day. He denied any history of vocal difficulties prior to his injury. He was married with a 4-year-old son. He pre-

viously worked in construction; however, he had been on disability following his injury. He spent most of his time at home with his family, frequently sitting quietly watching television. He did not sing or use his voice occupationally. Quantity of voice use was described as average to below average.

Initial Evaluation The patient presented to the outpatient voice clinic for evaluation 3 months following his closed head injury. Initial evaluation included clinical assessment, laryngoscopy with videostroboscopy, acoustic analysis of voice using the KayPENTAX Computerized Speech Lab (CSL), and aerodynamic assessment using the Phonatory Aerodynamic System (PAS, KayPENTAX). Patient perception of voice difficulties was ascertained using the Voice Handicap Index (VHI). The Reflux Symptom Index (RSI) was administered as well. The patient presented with a mildmoderate dysphonia characterized by a pressed, strained quality with a rough component. GRBAS scale revealed overall grade =1.5, roughness = 1, breathiness = 0, asthenia = 0, and strain = 1. While pitch levels and variability were appropriate for conversation, he habitually spoke louder than appropriate for a clinical setting. He cleared his throat habitually throughout the session and did not appear to have awareness of this occurring. Impulsivity and tangential speech were noted throughout the evaluation. Articulation, resonance, and fluency were intact. Videostroboscopic evaluation revealed normal mobility of the true vocal folds bilaterally. Large, bilateral lesions were observed on the vocal processes,


left greater than right. The membranous portion of the vocal folds was smooth and straight bilaterally. There was mild erythema of the striking edges of the vocal folds bilaterally. Full glottic closure was accomplished despite the presence of vocal process granulomas. Slight edema of the vocal folds was observed, greater on the left than right, leading to mild reduction of amplitude and mucosal wave. Closed-phase vibration predominated. He had moderate anterior-posterior and lateral supraglottic compression. Acoustic analysis of voice revealed a mean fundamental frequency of 137 Hz for sustained /a/. Mean jitter was elevated at 1.6%. Shimmer was within normal limits at 0.08 dB. The noise-to-harmonics ratio was mildly elevated at 0.32%. Vocal range was somewhat diminished with a low pitch of 111 Hz and a high pitch of 431 Hz (Table 3–6). Aerodynamic assessment revealed maximum sustained phonation of 15 seconds which is on the low end of normal. Estimated vital capacity was appropriate at 3.65 L. Mean airflow during sustained phonation was normal at 120 mL/second. Mean peak air pressure was elevated at 9.76 cmH2O. Airway resistance was mildly elevated at 88.76 cm H2O/L per second (Table 3–7). On the VHI the patient scored 20/40 points on the functional subscale, 10/40 points on the physical subscale, and 6/40 points on the emotional subscale yielding a total score of 36/120 which indicated mild, self-perceived voice handicap. On the RSI he scored a total of 22 points indicating some concern for potential reflux contributions. The threshold for concerning signs/ symptoms of reflux is a score >13 on this scale.56

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Table 3–6. Acoustic Analysis Pretreatment

Post-treatment

Mean F0 in Hz

137

141

Jitter (%) at modal pitch

1.6

1.1

Shimmer (dB) at modal pitch

0.08

0.076

Noise:harmonics ratio (%)

0.32

0.16

111–431

88–440

Pretreatment

Post-treatment

15

19

Vital capacity (L)

3.65

3.68

Mean airflow during sustained /a/ (mL/s)

120

110

Mean peak air pressure (cm H2O)

9.76

8.11

Aerodynamic resistance

88.76

40.23

Pitch range

Table 3–7. Aerodynamic Analysis

Maximum sustained phonation (seconds)

Selection of Management Strategies

established.133–135 The primary goals identified for this patient included:

Medical management was provided by the collaborating otolaryngologist to manage the patient’s vocal process granulomas and reflux. Twice-daily proton pump inhibitors and inhaled budesonide were recommended by the otolaryngologist based upon evidence of their benefit in the management of vocal process granulomas.130–132 Voice therapy was recommended due to evaluation findings of poor vocal hygiene, phonotrauma, and vocal strain/muscular tension. The role of voice therapy in the management of patients with vocal process granulomas has been previously

n improved hydration n behavioral reflux management n elimination of throat-clearing

behaviors

n reduction in vocal strain

Improved hydration: The patient was educated regarding the importance of hydration for laryngeal function and voicing. The concept of phonation threshold pressure was described as the amount of air pressure required to initiate vocal fold vibration. We discussed that poorly hydrated vocal folds require more pressure to initiate vibra-

tion, and therefore may lead to greater vocal strain and fatigue.58 Further, we discussed the evidence that poorly hydrated vocal folds are more prone to mucosal injury.136 We discussed that both systemic and direct hydration may have an impact on vocal fold vibration. In respect to systemic hydration, RC had a significant imbalance between hydrating and dehydrating agents. We discussed how caffeine and alcohol are drying agents and that he needed to balance their intake with improved water intake. We discussed that obtaining a better balance would be beneficial for reducing the amount of effort required to produce voice as well as to reduce the sensation of the need to clear his throat. He was advised to increase his water intake to at least 6 to 8, 240-mL (8 fl oz) servings of water per day. We discussed strategies to help him achieve this goal such as filling a premeasured container in the morning and setting subgoals for water intake throughout the day. Together, we determined that he would drink at least 840 mL (16 fl oz) in the morning before lunchtime, 240 mL (8 fl oz) with lunch, 840 mL in the afternoon before dinner, and 240 mL with dinner. Furthermore, he was asked to reduce his caffeine intake to 2 to 3 servings per day. Behavioral reflux management: Reflux has been implicated both as a causative agent and a contributing agent to the persistence of vocal process granulomas. Although medical management can effectively eliminate acid production in many patients, supplementary behavioral strategies can provide additional benefit. Diet modification was discussed with RC, and a number of items were identified for elimination/ moderation. Caffeine, carbonated beverages, spicy foods, and tomato-based foods were identified as the primary


items to target. RC was educated about moderating these problematic items by reducing the frequency and quantity of consumption. We discussed that he should not lie in a supine position and should avoid activities that result in abdominal compression within 2 hours of meals. Elevation of the head of the bed using phone books or bricks was recommended. Elimination of throat-clearing behaviors: RC had poor awareness of his habitual throat-clearing behavior. We discussed how throat clearing can be traumatic to the tissues of the larynx and discussed the relationship between throat clearing, the vocal process lesions, vocal fold edema, and erythema which he was able to view from his videostroboscopic evaluation. He was educated regarding the cyclical nature of throat clearing. He was told that each time he cleared his throat he caused irritation of the laryngeal mucosa, which would lead to inflammation and a sense of fullness resulting in the perceived need to clear his throat again. Once he was able to demonstrate understanding of this relationship, our efforts shifted to increasing his awareness of the throatclearing behavior. This was accomplished through clinician feedback of raising the hand whenever a throat clear occurred and then by the patient listening to a sample of a 5-minute conversation between he and the clinician and raising his hand whenever the throatclearing behavior occurred. Once the patient demonstrated greater awareness of throat clearing in our session, we discussed alternative behaviors to be used in times where he felt the urge to clear his throat. The primary alternative behaviors we discussed were an effortful swallow and a silent cough. We discussed that both strategies are

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gentler on the vocal folds and will have the same impact of mucous clearance that a throat clear might have. We also discussed that the improved hydration we already discussed would also help with thinning of mucous and reducing the perceived need to clear the throat. We asked the patient’s wife and children to help with improving his awareness of throat clearing in the home setting. They were asked to simply raise their hand whenever they observed RC clearing his throat as a reminder to use his alternate behaviors. During our clinical visits, both RC and the clinician completed throat-clearing logs, and we compared the frequency of throat clearing at the end of each visit. Whenever the patient caught himself clearing his throat during our session, he was asked to implement one of the alternative behaviors. Reduction in vocal strain: Voice therapy was initially recommended on a weekly basis for 1-hour sessions. Initially 4 to 6 sessions were recommended, and we discussed that we would adjust our therapy duration based upon his response to treatment. RC was initially engaged in an activity to help him differentiate physical strain from mental strain as a precursor to our vocal work. He was asked to put his index finger and thumb together like making the “okay” sign with his hand. He was then asked to push the fingers together at different strengths from 1 to 10. We discussed how it was much easier to push harder but that greater mental effort was needed to reduce the pushing. We discussed that in order to change his physical behavior of increased strain, he would need a good deal of mental focus and effort during his vocal exercises. We discussed the importance of self-awareness and kinesthetic feedback, particularly for home practice. He

was informed that he needed to be able to judge for himself whether he was using too much effort/strain since the clinician would not be with him when he used his voice outside of the clinic. Throughout our sessions he was asked to comment on the physical effort/ strain level as well as his mental effort during tasks. We discussed the anatomy and physiology of voice production and used his videostroboscopy to demonstrate the increased strain evidenced by closed phase vibration and false vocal fold compression. We also discussed how the aerodynamic findings of elevated peak air pressure and aerodynamic resistance related to our endoscopic findings. He was educated that his primary goal in vocal exercises was to reduce the effort and strain during voice use and to adopt a gentler voicing pattern. A number of therapeutic strategies were implemented to assess their ability to offload his strain and tension. A resonant voice approach appeared to be of greatest benefit for this patient and was the primary target for our treatment. RC was asked to relax his jaw, lips, and throat to create a “cavern-like” feeling in the oral cavity (like holding a hardboiled egg in the mouth). He was then asked to yawn and feel the retraction and openness of the throat. Once he was able to consistently assume this relaxed posture, he was asked to sigh out a relaxed and resonant hum. He was cued to focus the sound of the voice forward and upward toward the nasal cavity to minimize strain and tension in the throat. Often he produced hard onsets at the initiation of the hum and was therefore instructed to allow a small escape of air prior to voice onset. This resulted in more gentle voice onsets.

Once the patient was able to consistently replicate resonant voice and easy onset, he was taken through a hierarchy. He first advanced to gentle pitch glides up and down the scale using the relaxed jaw posture resonant hum. Once he was able to maintain an open resonant voice for humming and pitch glides, we introduced consonant-vowel (CV) syllables (eg, “me, me, me,” “my, my, my,” “ma, ma, ma,” “mow, mow, mow,” “moo, moo, moo”). Again he was asked to comment on any strain or tension he noted, particularly as he varied vowel sounds. The /m/ onset single words were introduced with gradual increase in syllable count. He was asked initially to extend the nasal /m/ sound and then to gradually blend the sounds together for more natural speech. During the second session, he was asked to complete a negative practice task where he alternated between resonant voice and the old, pressed voice. He was able to perform this task and identified the difference in sensation between the two. He reported that the resonant voice was more comfortable and noted that when he was using relaxed, resonant voice he did not feel the need to clear his voice as frequently. By the third therapy session we began to focus on generalization of the vocal technique into more functional contexts. He was presented with a list of phrases and sentences heavily weighted with nasal consonants (eg, “more and more,” “maybe Monday,” “Mary’s mom made muffins,” “The night man’s name was Nick”). Initially he was asked to chant these stimuli but then gradually increased the naturalness while maintaining forward focus. Once he was able to perform his sentences with consistent accuracy, he was provided with unconstrained reading passages and


asked to maintain his relaxed throat, resonant voice. This task proved to be slightly more difficult for RC, and he was prompted to use a gentle hum as a “reset button” when tension/strain was observed. He demonstrated surprisingly good self-awareness despite his persisting cognitive issues and was able to self-correct performance with good accuracy after 2 sessions working on unconstrained passages. At the same time, we began work on short conversational tasks to assist with generalization. At home he was asked to participate in 5-minute conversations, 3 times per day while focusing on his vocal technique. His wife was asked to help with monitoring his techniques and providing him with supportive feedback. We also completed conversational tasks during our clinic visits. Once he was able to consistently demonstrate resonant voice in all contexts with his wife and the clinician, he was asked to focus on techniques in a variety of settings and with varied interlocutors. He realized that he was often using his techniques with minimal mental effort and was able to repair the times he noted strain easily after his sixth therapy session. At that point he was weaned to home practice and returned 1 month later for reevaluation.

Therapy Outcome RC responded very well to voice therapy despite his preexisting head injury. He adjusted his hydration and caffeine intake according to recommendations by our second session together. He was less enthusiastic, however, about dietary changes for reflux, and though he became more moderate in his food intake, he continued eating spicy foods frequently. Elimination of

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throat-clearing behaviors was the most difficult aspect of treatment for RC. He needed a significant amount of clinician and spousal feedback, but approximately 1 month following initiation of treatment had eliminated throat clearing the majority of the time. He was able to adopt the target resonant voice and extend it to functional contexts by his fifth to sixth therapy session. Formal reevaluation revealed improvement across domains. At the 1-month post-treatment visit, his voice was clear and resonant with only mild, intermittent roughness appreciated. The strained/pressed aspect of voice had fully resolved. The GRBAS scale revealed overall grade = 0.5, roughness = 0.5, breathiness = 0, asthenia = 0, and strain = 0. Videostroboscopic evaluation revealed normal mobility of the true vocal folds bilaterally. Near full resolution of the vocal process lesions was observed with the post-treatment lesions being ~20% of the size of the original lesions. Vocal fold edema and erythema was resolved, and he had full glottic closure and normal amplitude and mucosal waves. He had balanced and periodic vibration with no significant supraglottic hyperfunction. Acoustic and aerodynamic analysis revealed improvement across multiple measures. On the post-treatment VHI, the patient scored 10/40 points on the functional subscale, 5/40 points on the physical subscale, and 2/40 points on the emotional subscale yielding a total score of 17/120 which indicated minimal selfperceived voice handicap and a clinically significant improvement.

Conclusion Multidimensional intervention for vocal process granuloma optimally includes

identification of precipitating factors associated with development and persistence of the lesions. In RC’s case, endotracheal intubation was likely the primary factor associated with development of granulomas; however, untreated reflux disease, poor hydration, and phonotraumatic throat clearing contributed to their persistence. As a result, he developed a secondary muscle tension disorder. Medical management of inflammation and reflux combined with lifestyle modifications and voice therapy significantly improved his laryngeal exam, voice quality, acoustic/aerodynamic measures, and patient-perceived voicerelated quality of life. In the following, Diana Orbelo, Nicole Li, and Katherine Verdolini Abbott present a case to illustrate the use and principles of Lessac-Madsen Resonant Voice Therapy (LMRVT).

Case Study 18 Diana M. Orbelo, Nicole Yee-Key Li, and Katherine Verdolini Abbott Lessac-Madsen Resonant Voice Therapy in the Treatment of Secondary MTD

Introduction LMRVT has origins in a convergence of performing arts traditions and basic science in biomechanics, biology, and perceptual-motor learning. The program also incorporates principles known to affect patients’ adherence to health care recommendations. LMRVT is an integrated program that differs from traditional models of voice ther-

apy that emphasize voice conservation. A foundational notion in LMRVT is that many people with voice problems are required to speak often and even loudly due to occupational or other life circumstances, and sometimes people are led to so do by personality. A basic premise in LMRVT is that our job, as clinicians, is not so much to encourage people with voice problems to adopt a quiescent lifestyle in the interest of vocal health, as it is to figure out how people can accomplish the vocal tasks before them effectively and safely, without incurring injury. We are helped by emerging biomechanical and biological data suggesting that voice produced with barely adducted/abducted vocal folds, often corresponding to the perceptual phenomenon called resonant voice, can help many people with voice problems achieve this goal regardless of the origin of their pathology. In fact, data suggest that resonant voice may not only be useful in the prevention of aggravating pathology that may be cumulative in an individual with voice problems, but may also have actual reparative value in cases of acute phonotrauma.137 This case describes essential concepts in LMRVT in the context of “Patient K,” including symptoms, clinical history, initial observations, treatment goals, treatment course, and pretreatment/posttreatment outcome measures.

History and Complaints Patient K was a 21-year-old female college student and avid singer. She presented to an active Midwestern voice center at the suggestion of her director in a regional musical production. She was seen in the Department of Otolaryngology and was diagnosed with bilateral vocal fold nodules.


Patient K complained of daily hoarseness and throat pain after talking and singing. She had struggled with voice breaks in her high notes and roughness in her speaking voice intermittently for approximately 9 months. Initial evaluation included flexible videostrobolaryngoscopy, perceptual voice evaluation using the CAPE-V,90,138 and patient self-assessment including the Voice Symptoms Scale (VoiSS),139 the Singing Voice Handicap Index (S-VHI),140 and an unpublished clinical questionnaire about voice, which queries patients about their level of concern about voice and speaking effort (scale of 1 to 7), the amount of time they can talk without vocal difficulties, and their perception about their voice in relation to “normal voice,” expressed as a percent.

Baseline Observations The overall impression was a recurring voice problem that ranged from mildmoderate (eg, on the day of the initial evaluation) to moderately severe following extended voice use. For K, the most functionally distressing aspects of her condition were the debilitating effects it had on her singing performance and an inability to speak without fatigue and pain in everyday activities. As noted, the initial otolaryngological diagnosis was bilateral vocal fold nodules. Following treatment, a post hoc review of both baseline and post-treatment stroboscopic exams was obtained from a second board-certified laryngologist, who was otherwise uninvolved in K’s care and was unaware of the purpose of the ratings or even that the images were from the same patient. For the baseline exam, the confederate described bilateral vocal fold edge irregularities, mildly reduced amplitude of

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vibration and moderately reduced mucosal waves bilaterally, and the classic hourglass-shaped glottis characteristic of nodules. A still image captured from the pretherapy exam is shown in Figure 3–8. Perceptual evaluation of the patient’s voice at baseline was completed by the

Figure 3–8. Pretherapy still image of vocal folds.

treating speech-language pathologist using the CAPE-V protocol. Findings indicated mild-moderate overall grade of dysphonia, mild-moderate roughness, mild-moderate breathiness, mildmoderate strain, mild-moderate high pitch in speech, and normal loudness. Similar to the procedure for stroboscopic ratings, after therapy termination, post hoc auditory-perceptual evaluations of K’s pretherapy and post-therapy voice recordings were obtained, using the CAPE-V, from 2 additional speech-language pathologists with extensive experience in perceptual ratings of voice. Also these clinicians were otherwise uninvolved in the patient’s care, the prepost status of the recordings, or the purpose of the evaluations. Results averaged across all 3 clinicians are shown in Figure 3–9, together with the range of

Figure 3–9. Average pretreatment ratings of voice quality across 3 clinicians using the CAPE-V (for each dimension 100 is the worst possible score). Ranges across 3 raters were as follows: overall grade: 10 to 30; roughness 6 to 25; breathi ness: 1 to 20; strain: 1 to 13; pitch 0 to 24 (too high); loudness: 0 to 1.


ratings across clinicians for each voice quality parameter in the CAPE-V. These ratings show that the clinicians were in agreement that K’s voice was patently impaired. Additionally, not shown in Figure 3–9, both the treating clinician and one of the blinded clinicians noted tremulousness during sustained /a/, and the treating clinician also noted intermittent vocal fry in connected speech. Results for the baseline VoiSS and S-VHI are displayed in Figures 3–10 and 3–11, which reveal clear abnormalities. On the third, as yet unvalidated, questionnaire tool, K rated her concern about her voice at 5/7 and vocal effort during speech at 4/7. She rated her voice as 32% of normal voice on a visual analog scale (data not shown). History and observations suggested that the most obvious contribu-

tor to K’s physical pathology and voice problems was voice use patterns, which by clinical observation included both adducted and nonadducted hyperfunction. Adducted hyperfunction was noted especially in singing. The biomechanical result would be large intercordal impact stresses, which increase susceptibility to nodules and attendant voice changes.141–146 In contrast, what appeared to be reactive nonadducted hyperfunction, which can also constitute vocal dysfunction and even episodic voice loss,1 was held to characterize K’s speaking voice, along with a chronic “throaty resonance” and vocal fry. A second factor thought to be contributory to K’s voice problems was relative dehydration. This possibility was based on the patient’s frequent throat clearing apparently to remove

Figure 3–10. Pretreatment results for Voice Symptom Scale (VoiSS).139 Worst possible scores are total score = 120; impairment domain = 60; emotional domain = 32; physical domain = 28.

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146


Figure 3–11. Pretreatment results for Singing Voice Handicap Index (S-VHI).140 Worst possible scores are total score = 144; func tional domain = 40; physical domain = 40; emotional domain = 64. thick mucus from the larynx, and her acknowledgement that she drank very little water. The literature indicates that dehydration may predispose laryngeal tissue to injury or slow recovery from injury, while also increasing the subglottic pressure required for phonation, especially for high pitches.146–148

Treatment Goals and Treatment Specific information about patient K’s treatment goals and treatment is provided in Tables 3–8 and 3–9. Treatment was based on a standard LMRVT program, which is intended as a general platform for treatment that should be varied flexibly depending on the situation.

Treatment Goals As typical for LMRVT, 3 levels of goals were established: functional, medical, and behavioral. For benign conditions affecting voice, such as nodules, functional goals are considered the ultimate target of treatment and are determined by the patient. K identified her functional goals as wanting to have a fully functional speaking and singing voice without dysphonia, hoarseness, or voice breaks, and to reestablish pain-free and effort-free phonation without constant vigilance. The medical goal, implicit in the referral to voice therapy, was to reduce or resolve vocal fold nodules. Biomechanical goals, established by the speech-language pathologist, were divided into 2 subtypes: (1) goals per-


Table 3–8. Goals for Patient K’s Treatment Functional

Medical

Biomechanical

Normal voice, without dysphonia, hoarseness, voice cracks, or effort when speaking or singing, without constant vigilance

Reduction or resolution of nodules

Hygiene • Increase systemic and surface hydration (details in Table 3–2)

tinent to the viscoelastic properties of vocal fold tissue targeted using “indirect methods” (“vocal hygiene”), and (2) goals that address phonation modality (“direct methods”). Biomechanical goals are the only ones specifically addressed in voice therapy in LMRVT under the assumption that if these goals are appropriately established and achieved, functional and medical goals will be attained as a by-product, “for free.” For K, biomechanical goals were to increase both systemic and surface hydration (indirect treatment; see details in Table 3–8), and to establish a voice production pattern involving barely adducted/abducted vocal folds for most phonation in speech and singing. With respect to the voice production goal, data have indicated that the barely adducted/abducted vocal fold configuration tends to optimize the ratio of voice output intensity (strong) to vocal fold impact intensity (relatively small).141 Stated differently, this biomechanical set-up should allow people such as K to use their voices fairly strongly while minimizing collateral damage to the tissue. Perceptually, this voice production modality has been found to be associated with what has been called “reso-

Voice training • Use slightly abducted vocal fold configuration for most speech, especially loud speech, to replace hyperadducted and hypoadducted hyperfunction

nant voice,” perceptually defined as “easy” voice involving awareness of anterior oral vibrations during phonation.111,149,150 In sum, for this patient who presented with apparent phonotrauma and, simultaneously, a need to use her voice frequently and loudly, this biomechanical target was rationally favorable. Moreover, recent reports indicate resonant voice may actually have biological reparative value at least in cases of acute phonotrauma137 which in patients like K may be added to chronic trauma, thus aggravating it. Treatment Details regarding patient K’s treatment are shown in Table 3–9. After her initial evaluation, K received a total of 7 voice therapy sessions over a 3-month period. LMRVT is typically delivered in 6 to 8 sessions over a period of 4 to 8 weeks. However, after the first treatment sessions, there was overlap with K’s rehearsal and performance schedule as a primary character in a regional musical performance. For those sessions, standard LMRVT techniques were expanded to focus on singing and specific needs for her performances.

147

148

Intermittent hoarseness, throat pain and pitch instability

Voice unchanged

Voice unchanged

Therapy #1

Therapy #2

Status at Start of Session

Initial evaluation

Session

Table 3–9. Therapy for Patient K Patient’s Performance Within Session • Hygiene instructions understood • Produced RV well at 85% for nasal consonants

• Produced RV relatively well to sentence level without models; hyperfunction decreased particularly when models stimulated increased airflow • Produced RV well to sentence level with models; patient was focused on singing issues

Therapy Provided During Session

• Hygiene: hydration instructions provided • Voice training: stretches; RV BTG exercises; words

• Voice training: stretches; RV BTG exercises; words-sentences with multiple phonemic contexts

• Voice training: stretches; RV BTG-wordssentences; worked on singing techniques for upcoming performance

• Continue hygiene • Stretches; RV BTGwords-sentences including loudness variations, 10 min bid, frequent mini practice

• Continue hygiene • Stretches; RV BTGwords-sentences 10 min bid, frequent mini practices

• 2–3 qt water daily; steam inhalations 5 min bid; • Stretches; RV foundation “BTG” exercises and RV chants 10 min bid, frequent mini practices

Home Tasks and Exercises

9 days

(patient was extremely busy with upcoming show)

18 days

4 days

Time to Next Session

149

Singing voice feeling better, less pain with singing

Voice less frequently hoarse, still experiencing some pain with long periods of speaking

Voice generally feeling “good” and noticing speaking patterns on phone, loud environments, and when physically tired

Therapy #4

Therapy #5


Therapy #3

Session

Patient’s Performance Within Session • Produced relatively good RV without hyperfunction to phrase level; singing was consistently on pitch without breaks • Produced RV with intermittent mild hyperfunction to 85% with prompts and models (session materials recorded on smartphone for patient use)

• Produced completely hyperfunction-free voice on 50–60% of conversational trials and good approximations on remainder of trials, with some models


• Voice training: stretches; RV BTG-wordssentences; worked on singing techniques for upcoming performance

• Voice training: reviewed hygiene, stretches, RV Core, Chant, Vocal Communicators, minipractice with practice to carry over into conversation; use of real-time visual of pitch and roughness focusing on ends of phrases; introduced loudness work

• Voice training: stretches; RV BTG adding phonemic complexity, variable loudness work, conversation

• Continue hygiene • Same as last session, but adding loudness work and mindfulness about speaking pattern during everyday conversation

• Continue hygiene • Stretches; RV BTGwords-sentences, including loudness variations on vowels, 10 min bid, frequent mini practice, use of vocal communicator

• Continue hygiene • Stretches; RV BTGwords-sentences including loudness variations, 10 min bid, frequent mini practice


4 days

3 days

continues

2 months (left for summer vacation, reported doing exercises 1 time per day, “most days”


150

Voice “feeling very good,” patient confident that she can continue with techniques as she returns to school

Therapy #7

• Throughout session patient was able to produce RV and hyperfunction — approximately 90% of the time in challenging environments with minimal modeling and cues

• By end of session patient produced hyperfunction-free voice on about 75% of trials during structured conversation, with minimal cues

• Voice training: stretches; review and warmup using RV-BTG, core, and chants; work on phrase and conversational-level work in quiet environment with model challenges

• Voice training: stretches; review and warmup using RV-BTG, core, and chants; work on phraselevel and conversationallevel work in challenging environments outside the therapy room, including places where loud and soft voice were required

Patient’s Performance Within Session


• Continue hygiene • Continue exercises as previously, added • Start work with a local singing teacher

• Continue hygiene • Continue exercises, continue mini and mindful practices throughout the day


7 months to reevaluation

2 days


BTG refers to resonant voice (RV) “Basic Training Gesture” exercises in LMRVT. BTG exercises involve explorations in resonant voice during all-voiced consonant productions, words, and phrases. Modeled after Lessac’s “Consonant Orchestra” exercises.161,162 (It is assumed that clinicians are familiar with other acronyms used in the table.)

Voice “very good most of the time” still falling into hyperfunctional habits during long social conversation; no pain with speaking


Therapy #6

Session

Table 3–9. continued


Following completion of her show, K and her family departed for a summer vacation. K resumed therapy shortly after her return. At that time she still experienced symptoms similar to those at baseline, but her voice had not worsened. She reported daily to every-otherday performance of basic resonant voice exercises during her vacation. She continued to sing in preparation for her fall semester at school but was singing less than she had during the show. K resumed therapy and the entire LMRVT course was completed at that point in four, 1-hour sessions during a 2-week period. Beyond voice therapy, K received no other treatments or training during the active therapy period, either medical or vocal (such as singing training). A synopsis of the overarching therapeutic framework — for patient K and for LMRVT in general — is shown in Table 3–10. This basic framework identifies 3 critical factors — in the extreme both “necessary” and “sufficient” to address in physical training of any type.149 Those factors are: (1) the “what,” (2) the “how,” and (3) the “if” of training. The “what” refers to behaviors and biomechanical targets addressed in training. “What” do we want our patients to do differently behaviorally (eg, drink more water) and biomechanically (eg, use a barely abducted vocal fold configuration during phonation) by the end of therapy? The “how” of voice therapy refers to the approach to training, independent of the biomechanical target. That is, “how” will patients acquire the

behaviors and biomechanical targets we identify for them? The “if” of voice therapy refers to patient compliance and adherence, for lack of a better term: “if” the patient will do what we suggest, especially outside the clinic.149 Summary information about these parameters is as follows. The “What” of Training. As noted, in LMRVT as for most voice therapy approaches, the “what” of therapy is subdivided into 2 parts: voice care education (“hygiene”) and voice training. Regarding voice hygiene, a critical concept in LMRVT is that voice care education should limit the number of parameters we ask patients to address as opposed to asking them to adhere to a large list of dos and don’ts, which can be overwhelming and moreover generally lack specificity for a given patient. We consider the “short list” of key domains to evaluate in a hygiene program are: (1) systemic and surface hydration, (2) exogenous inflammation control (from LPR, environmental pollutants, illness allergens, medications, smoke, etc), and (3) patent phonotraumatic behaviors such as all-out uncontrolled, unskilled screaming. Key in patient K’s program and in LMRVT in general was the identification of only those hygiene parameters relevant to the patient in question, based on case history and observations. Recent data indicate patient compliance with targeted hygiene programs can be excellent151 in contrast to poorer compliance with hygiene programs associated

Table 3–10. A Synopsis of the Overarching Therapeutic Framework “What”

“How”

“If”

Biomechanics

Learning

Compliance/Adherence

151

152


with more elaborate, “one-size-fits-all” programs (eg, 152,153). Moreover, new evidence suggests pared down, targeted hygiene interventions may be sufficient to help prevent the onset of new voice problems in at-risk populations (eg, teachers; 151), although such interventions may be insufficient as a single treatment modality in cases of existing pathology.151–153 Regarding direct voice training, in LMRVT for this patient and others, most sessions start with exercises to stretch extrinsic and intrinsic structures involved in phonation. This approach is based on the notion that skilled perceptual-motor behavior in most domains fundamentally involves inhibition of musculature irrelevant to a task, with concomitant activation of relevant musculature. Support for this approach is found in the developmental motor learning literature pointing to selective activation as a hallmark of skilled performance.154 Accordingly, all therapy sessions for patient K initiated with a series of stretches targeting the thorax, cervical region, face, oral structures, oropharynx, and vocal folds, in an attempt to minimize activation of many muscles used in phonation.155 Selective activation exercises followed. Conceptually, the selective activation piece of therapy may proceed according to any one of a number of specific therapy interventions, including Vocal Function Exercises and flow phonation described elsewhere in this text and in the literature.153,156,157 Patient K underwent LMVRT as it is currently taught by Verdolini Abbott and associates.155,158 Table 3–9 describes the specific contents of K’s therapy, which arose from the general framework described. Detailed information about the contents

of LMRVT can be obtained through Plural Publishing,155,158 coupled with handson training in seminar format. Here, discussion is limited to general “philosophical” comments about LMRVT and to newer findings and speculations pertinent to this program for this patient and others. As already implied, in LMRVT the target voice production modality is defined both productively and perceptually. Productively, the target involves voicing with barely adducted or slightly abducted vocal folds.111,150 This configuration, and specifically a configuration involving an approximately 0 to 1.0-mm separation between the vocal processes at phonation onset, appears to generate an optimized ratio of voice output intensity to vocal fold impact intensity under constant subglottic pressure (Ps) and fundamental frequency (F0) conditions.141 Not incidentally, this same general vocal fold configuration requires relatively small subglottal pressure to initiate and maintain vocal fold oscillation47 and thus should be physiologically “easy.” Perceptually, one correlate of this laryngeal setup — in particular when trained using a semi-occluded vocal tract as occurs with LMRVT — is resonant voice (RV), which involves vibratory sensations in the anterior oral cavity in the context of “easy” phonation.111,149,150 Thus far, reliable noninvasive tools have not been identified to detect instrumentally what is recognized perceptually as “resonant voice” (eg, Verdolini, Kobler, Conversano, Walsh, Xiu, Milstein, Hillman, unpublished data, 2000), although one instrumented approach, involving a laryngeal resistance measure (estimated phonatory subglottic pressure divided by glottal airflow 159) may have potential to identify the target laryngeal configu-

ration, at least within a given subject on a given day.160 Interestingly, in that latter data set, laryngeal resistance quantitatively distinguished pressed, normal/ resonant, and breathy voice types across and within vocally healthy subjects, but failed to distinguish normal and resonant voice, which were reliably distinguished perceptually. The implication is that differences between resonant and “normal” voice, at least in healthy vocalists, reside in production parameters not assessed by laryngeal resistance, and that is vocal tract parameters. In fact, the Lessac work as well as LMRVT involve vocal tract manipulations to optimize anterior facial vibratory sensations and also voice output intensity.141,161,162 Stated differently, resonant voice is one voicing modality that likely signals the target laryngeal configuration, adding also vocal tract manipulations in the form of a semi-occluded vocal tract that should increase oral vibratory sensations and output intensity.163 Also a voicing pattern that judges would consider “normal” (for healthy individuals) appears to be associated with the target laryngeal posture, although intensity may be lower as compared to “resonant voice.” In sum, various data sets have indicated the perception of anterior oral vibrations during “easy” voicing are general indicators of the target biomechanical configuration, for both healthy subjects and subjects with nodules.111,150 Recent observations have suggested that the advantages of resonant voice in voice therapy may not only be linked to its connection to a biomechanical setup that favors strong voice production while at the same time protecting from laryngeal injury. 141 Preliminary data from biological studies indicate this voicing approach may have actual “medicinal” therapeutic


properties. Specifically, some data indicate resonant voice exercises may help to attenuate acute vocal fold inflammation even more than voice rest in some cases.137 Speculatively, the reason is related to findings reported for other tissue domains, that tissue stretching — in this case associated with relatively large-amplitude vocal fold oscillations in resonant voice, coupled with highpitch manipulations in LMRVT exercises — deforms cells within the tissue, thereby altering their mechanical signaling in a way that is favorable for the wound healing process.164–167 Thus far, a favorable result from resonant voice and its experimental correlates has been seen in human subjects, in vitro data, and computer modeling of vocal fold inflammation.137,168–171 Further verification is needed. However, clinical anecdotal as well as formal biological observations point to some optimism that resonant voice may have actual biological healing properties, in some cases. LMRVT is similar in emphasis to traditional “forward focus” approaches used by many clinicians. Further, the laryngeal goal is essentially identical to the goal implicitly targeted in Vocal Function Exercises.156,157 The “How” of Voice Therapy. One of the features of LMRVT that distinguishes it from “resonant voice” or “forward focus” training approaches in general lies with its systematic incorporation of well-vetted principles of perceptual motor learning documented in peer-reviewed literature. Adequate discussion is beyond the scope of the present chapter; details are provided elsewhere.163 In brief, although the biomechanical target in LMRVT is clearly specified, based on robust data in the literature, clinicians are to avoid

153

154


instructions about how a person should attempt to achieve that target biomechanically. Instead, training focuses on biomechanical outcomes such as sound and feel of the voice. Perception and an experiential approach rather than biomechanical instructions are emphasized. Further, key “laws of practice” are used to structure exercises, including “laws” indicating augmented feedback should be minimized and provided terminally during training (eg, after a vocalization) rather than concurrent with production. Random practice is emphasized, as are “whole” as opposed to “part” practice and variable practice of the target resonant voice in numerous phonetic, acoustic, and emotional contexts (for details, see also 172). The “If” of Training. Again, full discussion of factors thought to influence patient adherence or compliance is beyond the scope of the present venue (for review, see 163). Briefly, key factors include the concept of self-efficacy for voice (does a patient believe he or she is able to perform exercises?),173–176 and readiness for voice change (is a patient ready to make changes, as discussed in Motivational Interviewing techniques?),177,178 and of course clinician “presence.” These principles are folded into standard LMRVT.

Treatment Outcome and Recommendations Patient K underwent reevaluation of baseline measures 7 months following therapy termination, which corresponded to 10 months post baseline. Results are shown in Figures 3–12 to 3–15. Figure 3–12 displays a post-therapy

Figure 3–12. Post-treatment still image of vocal folds.

image from her post-treatment stroboscopic exam and can be compared with Figure 3–8. The blinded laryngologist, who rated her pretherapy exam, also rated her post-therapy strobe exam at the same time, again blinded to the purpose of his ratings. For post-treatment images, the laryngologist noted a change in glottal shape from hourglass to having a posterior glottal gap, considered normal. Vocal fold edges, amplitude of vibration, and mucosal waves all normalized. The treating speech-language pathologist and 2 blinded cohorts who also rated K’s pretreatment audio recordings provided post-treatment evaluations of voice using the CAPE-V procedures. Average and range of post-treatment results for the 3 raters are shown in Figure 3–13 along with pretherapy ratings for comparison. Post-therapy, raters agreed that all voice quality parameters were well within normal limits. In addition, post-treatment patient K completed the VoiSS, the S-VHI, and the nonvalidated clinical questionnaire. Results for the VoiSS and S-VHI are displayed in Figures 3–14 and 3–15, both


Figure 3–13. Comparison of pretreatment and post-treatment CAPE-V scores, averaged across 3 raters (for each parameter 100 is worst pos sible score). For pretreatment score ranges, see Figure 3–9. Post-treatment ranges were overall grade: 2 to 5; roughness: 0 to 2; breathiness: 0 to 1; strain: 0 to 0; pitch: 0 to 0; loudness: 0 to 0.

showing marked improvements from baseline. Using the unpublished clinical questionnaire, post-therapy K rated her voice at 94% of normal voice on a visual analog scale (compared to 32% pretherapy), she rated her concern about voice as a 2/7 and vocal effort in speech as a 1/7 (compared to 5/7 and 4/7, respectively, pretreatment). Most important were patient K’s results relative to specific therapy goals. Functionally, K felt that she had obtained her goals of speaking normally, without discomfort during most speech. She no longer experienced fatigue during social or occupational conversation,

and she was able to sing more consistently and without discomfort. At the 7-month post-therapy follow-up, both the treating clinician and the blinded raters judged K’s voice to be normal 100% of the time in connected speech, and the treating clinician considered her voice normal 95% of the time in conversational speech. As noted, K herself felt she was doing well with her voice and rated her post-therapy voice at 94% of normal compared to 32% of normal at baseline. She did feel that she still had to be mindful of her voice use in social situations and would occasionally have mild vocal fatigue.

155

Figure 3–14. Comparison of pretreatment and post-treatment scores for Voice Symptom Scale (VoiSS).139 Worst possible scores are total score = 120; impairment domain = 60; emotional domain = 32; physical domain = 28.

Figure 3–15. Comparison of pretreatment and post-treatment scores for Singing Voice Handicap Index (S-VHI).140 Worst pos sible scores are total score = 144; functional domain = 40; physical domain = 40; emotional domain = 64. 156

Medical goals for K were also achieved. Post-therapy, her vocal folds appeared white with straight edges except at the highest pitches for which subtle marginal irregularities were noted. Based on medical and biomechanical findings at treatment termination, the treating clinician recommended that K continue using stretches and resonant voice exercises at least 3 to 4 times weekly, prophylactically, and that she work with a local singing voice teacher. Following discharge from active therapy until her 7-month follow-up, K had about 2 singing lessons with a local teacher but was dissatisfied with them. She then followed up with 4 to 5 lessons with a singing voice specialist prior to her clinical follow-up.

Conclusion Lessac-Madsen Resonant Voice Therapy (LMRVT) was used to address the functional concerns of a female singer who presented with chronic vocal fold nodules and functional consequences thereof. All measures, including blinded measures by clinicians otherwise uninvolved in her care, indicated striking functional and medical improvements as a result of this treatment, achieving normal status. The patient’s functional and medical goals were met. Principles described for this patient may be applicable to other patients with voice disorders involving hyperadduction or hypoadduction of the vocal folds. Acknowledgments. The writing of this section was partly supported by Grant No. R01 DC008567 (Verdolini Abbott, Principal Investigator) and R03DC012112-01 (Li, Principal Investigator) from the National Institute on


Deafness and Other Communication Disorders. In the following case, Tara StadelmanCohen, Jarrad Van Stan, and Robert Hillman demonstrate the potential future role that ambulatory biofeedback may play in voice therapy. The Ambulatory Phonation Monitor (APM, KayPENTAX, Inc.) provides patients with unobtrusive real-time vibratory feedback regarding pitch and loudness as they go about their normal daily activities. When used to reinforce therapeutic goals in natural environments, ambulatory biofeedback has potential to facilitate the carryover phase of voice therapy.

Case Study 19 Tara Stadelman-Cohen, Jarrad Van Stan, and Robert E. Hillman Use of Ambulatory Biofeedback to Supplement Traditional Voice Therapy for Treating Primary MTD in an Adult Female

Case History History of the Problem This 41-year-old female presented with a 4-year history of vocal strain and fatigue, increased dysphonia, and neck muscle pain/discomfort associated with voice use (particularly at the end of a workday), all of which corresponded with the onset of a new job. She had been previously diagnosed with primary muscle tension dysphonia (MTD) at another

157

158


institution where she also received a full course of voice therapy along with bilateral Botox injections. The previous treatments failed to resolve her voice problems that the patient attributed to an inability to feel and hear differences in voice production. She reported that she could “mimic” voice therapists well during therapy sessions, giving the false impression that she was fully integrating the desired therapy goals, but there was little, if any, carryover. Medical History Past medical history included multiple head and neck surgeries (tonsillectomy, partial thyroidectomy, and oral surgery), thyroid disease, GERD/LPR, and environmental allergies. Current medications were loratadine for seasonal allergies, levothyroxine for thyroid disease, and budesonide nasal spray.

Voice Evaluation A complete voice evaluation was performed which included physical examination, auditory-perceptual assessment, acoustic and aerodynamic assessments, endoscopic laryngeal imaging with stroboscopy, and patient self-assessment of vocal function. Physical Examination Upon palpation, the larynx was severely elevated with minimal thyrohyoid space. Reduced lateral and anterior range-of-motion of the hyoid and thyroid lamina was also evident. Evidence of musculoskeletal misalignment was reflected in heel weighting, locked knees, mildly forward pelvis, posterior shoulders, and forward head position.

Audio-Perceptual Assessment Auditory-perceptual evaluation was performed by the examining clinician using the standard CAPE-V,90 and those results are shown in Table 3–11. The patient’s voice was judged to be consistently mildly-moderately dysphonic with associated features of inconsistent mild roughness and breathiness, inconsistent moderate strain, and inconsistent mild-moderate increased pitch and loudness. Acoustic and Aerodynamic Assessment Acoustic and aerodynamic testing were performed in a sound-isolated room as the patient performed a set of standard voice and speech tasks. Results are shown in Table 3–12. The patient displayed abnormally high levels of acoustic perturbation (jitter and shimmer), average fundamental frequency, and average sound pressure level. Her maximum pitch and loudness ranges were abnormally restricted. Aerodynamic measures were all within normal limits. Laryngeal Endoscopy With Stroboscopy Both transnasal flexible and transoral rigid endoscopic examinations were performed to evaluate vocal structures and function. The patient had excellent abduction and adduction of her true vocal folds and arytenoid cartilages. There was an inconsistent temporal asymmetry of motion with the left vocal fold appearing more restricted and sluggish in its motion than the right vocal fold. This was observed to resolve after several minutes of visual monitoring with flexible endoscopy, thus ruling out


Table 3–11. Pretreatment and Post-treatment Measures for the CAPE-V CAPE-V Results for Voice Quality Voice Quality Dimension

Pretreatment Evaluation

Post-Treatment Evaluation

Overall severity

35 (C, mild-mod)

14 (C, mild)

Roughness

17 (I, mild)

8 (I, mild)

Breathiness

16 (I, mild)

4 (I, mild)

Strain

49 (I, mod)

33 (I, mild-mod)

Pitch

35 (I, mild-mod increase)

11 (I, mild increase)

Loudness

24 (I, mild-mod increase)

0 (C, normal)

Resonance

I, decreased oral resonance

I, low tone focus

Additional features

None

I, glottal fry

The scale is 0 = normal to 100 = severely deviant. C represents “consistent,” and I represents “inconsistent.”

Table 3–12. Pretreatment and Post-Treatment Measures for the V-RQOL Voice-Related Quality of Life (V-RQOL) Results Pretherapy Evaluation

Post-Therapy Evaluation

Total V-RQOL

43

78

Social-emotional

31

75

Physical functioning

50

79

Scores

The scale is 0 = lower quality/functioning and 100 = higher qual ity/functioning. Significant post-treatment improvements can be seen when compared to pretreatment.

paresis of the left true vocal fold, and was instead attributed to vocal hyperfunction. During modal phonation, the patient attained good glottal closure with phase symmetric mucosal waves indicating good pliability of the underlying superficial lamina propria layer. As she approached higher frequencies, she displayed symmetric elongation of the true vocal folds, signifying intact

function of the external branches of the superior laryngeal nerve bilaterally. The patient’s voice appeared to be clearer and less effortful as she produced pitches above the normal female range (>230 Hz). When asked to phonate at normal female frequencies between 200 and 230 Hz, the patient had evidence of significant supraglottic muscle hyperfunction and a less clear tone.

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160


Patient Self-Assessment The patient completed the Voice-Related Quality of Life (V-RQOL)102 inventory to assess the impact of her vocal difficulties on her daily function. The V-RQOL generates a total score and two subscores related to physical and social-emotional functioning; scores on all scales range from 0 (lower quality/functioning) to 100 (higher quality/functioning). Results are shown in Table 3–13. The patient displayed scores in the midrange (physical functioning) or below (total score and social-emotional functioning) indicating that the patient’s voice problem was having a significantly negative impact on her daily function/quality of life.

Voice Therapy The primary focus of therapy was reduction of muscle tension in extrinsic neck and intrinsic orolaryngopharyngeal musculature during both voiced and nonvoiced activities. Treatment modalities included paralaryngeal massage and manipulation,19,44 laryngeal manual therapy,23,83 tongue range-of-motion tasks (eg, extension), and suboccipital release.179 Musculoskeletal realignment was also addressed by achieving a balanced plumb line from the ears to the shoulders, pelvis, knees, and ankles with attention to freedom of movement in seated and standing activity.180 Additional treatment goals were reduction of breath holding, shallow breathing, and speaking too long on one breath. Education regarding the anatomy and physiology of voice and speech subsystems was also provided to improve the patient’s ability to prevent difficulty through a greater understanding of how the voice works.

During phonatory tasks, particular emphasis was placed on maintaining an average vocal pitch (fundamental frequency) that was slightly higher than what is considered normal for an adult female (>230 Hz). This was based on the observation during the evaluation that the patient displayed clear signs of hyperfunction when her pitch dropped into the normal range (ie, lowered pitch served as an indirect indication/sign of hyperfunction but was not considered to be the cause of the voice problem). Real-Time Pitch (KayPENTAX) was used intermittently during voice therapy sessions to provide visual biofeedback based on fundamental frequency to reinforce the goal of maintaining a higher pitch while at the same time cueing into the associated reduction in hyperfunction. The biofeedback function of the APM was used with this patient because she failed in previous courses of voice therapy to carry over techniques outside of the therapy session and the drop in pitch associated with her hyperfunctional voice pattern could be targeted by the APM. Biofeedback is meant to provide a patient with information the patient is otherwise unable to acquire (eg, fundamental frequency),181 and it is hoped that when applied on an ambulatory basis, biofeedback can concretely extend therapy techniques into contextual, real-life situations. The APM uses an accelerometer (ACC) placed on the neck just above the sternal notch to sense phonation. The ACC signal is processed by a small digital device (worn in a belt pack) to extract estimates of vocal fundamental frequency, sound pressure level, and phonation duration. The device provides biofeedback to the patient wearing it via a pager vibrator worn on a belt based on thresholds for fundamen-


Table 3–13. Pretreatment and Post-Treatment Aerodynamic and Acoustic Measures Vocal Function Measures Acoustic and Aerodynamic Analysis Results Tasks and Measures (Abnormal Values)

Normal Values

Pretherapy Evaluation

Post-Therapy Evaluation

Jitter (%)

≤1.04

1.9%

1.86%

Shimmer (%)

≤3.81

5.6%

1.94%

Noise (NHR)

≤0.19

0.12

0.104

180–230

253.37 Hz

261 Hz

67–73

81.2 dB

69 dB

Lowest pitch (Hz)

—

175.44 Hz

175.4 Hz

Highest pitch (Hz)

—

462.96 Hz

830. 61 Hz

Maximum pitch range (octaves)

≥2

1.4

2.24

Softest phonation (dB)

—

63.6 dB

45.9 dB

Shout phonation (dB)

—

90.6 dB

95.15 dB

Maximum loudness range (dB)

≥40

27 dB

49.25 dB

Phonation Duration (sec)

≥14

26.6 seconds

42.02 seconds

0.07–0.23

0.10 L/s

0.153 L/s

Air pressure (cm H2O)

≤7.76

7.15 cm H2O

6.13 cm H2O

dB/cm H2O

≥8.6

9.5

11.56

0.05–0.25

0.18 L/s

0.161 L/s

≤11.92

11.9 cm H2O

10.73 cm H2O

≥6.1

6.6

6.60

Steady Vowels

Reading Average F0 (Hz) Average SPL (dB) Maximum Performance

Typical Speaking Voice Airflow (L/s)

Loud Voice Airflow (L/s) Air pressure (cm H2O) dB/cm H2O

Measurements highlighted and italicized in bold represent abnormal values.

tal frequency and sound pressure level which are set by the clinician. In this case the APM was set to provide 250 ms of vibrotactile feedback when the fun-

damental frequency fell below 250 Hz for 500 ms or longer. The APM was introduced after the initial evaluation, and the patient was

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educated thoroughly regarding its use and her biofeedback target of fundamental frequency. During the first 2 days of monitoring, the APM was not providing biofeedback so a baseline could be acquired (days 1 and 2 in Figure 3–16). Biofeedback was provided only after the patient had reliably learned strategies during therapy that decreased vocal hyperfunction and increased pitch. This is because pitch modification indirectly targeted vocal hyperfunction; therefore, the obvious concern was that the patient could use hyperfunctional behaviors to increase pitch and maintain adequate compliance with the biofeedback and defeat the purpose of an ambulatory intervention. To assess the impact of the ambulatory feedback on the patient’s performance, the feedback was turned on and off for several days at a time while the APM continuously monitored vocal function to provide estimates of modal fundamental frequency.

Therapy Outcomes Sixteen therapy sessions were completed. At the end of treatment, the patient expressed increased awareness of inefficient muscle patterns, the ability to alter tension progression, and improved capacity to speak without pain. Laryngeal endoscopy with stroboscopy continued to show good glottal closure and symmetric entrainment of vocal fold vibration and mucosal wave generation. There was also reduced supraglottal compression and an absence of asymmetric arytenoid abduction-adduction. Post-treatment results for auditoryperceptual assessment, acoustic and aerodynamic assessment, and patient selfassessment are shown in Tables 3–11 through 3–13. Compared to pretreatment, there were post-treatment improvements in the CAPE-V–based judgments of overall severity of dysphonia, breathiness, strain, pitch, and loudness, but

Figure 3–16. Modal fundamental frequency values during 17 days of monitoring. Boxes indicate when ambulatory biofeedback was active. Mea sures for days 1 and 2 were obtained prior to the start of voice therapy to establish the patient’s baseline modal fundamental frequency.

only loudness was judged to be within normal limits (see Table 3–11). The improvements in auditoryperceptual judgments of voice quality were reflected by post-treatment reductions in acoustic perturbation (jitter and shimmer) and average sound pressure level with amplitude perturbation (shimmer) and average sound pressure level attaining normal values. Pitch and loudness ranges showed post-treatment increases to within normal limits. Modal pitch continued to be abnormally high following treatment which was expected based on the therapy goal to elevate the patient’s average speaking pitch to a level above the normal range. Post-treatment aerodynamic measures continued to be maintained within normal limits (see Table 3–13). All three scores (total score, physical functioning score, and social-emotional score) from the patient’s self-assessment of her vocal function (V-RQOL) showed significant post-treatment improvements indicating a positive impact of the voice therapy treatment on the patient’s daily function and quality of life (see Table 3–12). Figure 3–16 shows the modal fundamental values for each of the 17 days that the patient wore the APM. These results indicate that the patient maintained a higher modal fundamental frequency when the feedback was turned on (red boxes) as opposed to when the feedback was turned off. This difference was statistically significant (t-test) at the p ≤ 0.03 level (Figure 3–17).

Summary and Concluding Remarks As stated at the beginning of this case report, the intent here was to dem-


Figure 3–17. Overall averages of modal fundamental frequency at baseline, during biofeedback, and without biofeedback. The patient used a significantly higher modal fundamental frequency with biofeedback than without biofeedback (p < 0.03). onstrate the potential future role that ambulatory biofeedback may play in voice therapy. The main objective of using ambulatory biofeedback was to increase the patient’s ability to carry over therapy-induced vocal modifications outside of the therapy session. Even though this patient showed clear post-treatment improvements in vocal function, it is not possible to assign the positive outcome to a particular part or parts of the therapy program, including ambulatory biofeedback, because several approaches were applied simultaneously. In addition, there was no attempt to structure the application of the feedback to facilitate or demonstrate true leaning/retention of the targeted increase in modal speaking fundamental frequency. Better elucidation of the role of ambulatory biofeedback in voice therapy will require the formal application

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of principals based on motor learning theory (eg, varying feedback schedules, formal assessment of retention, etc).182

Use of Glottal Attack in the Treatment of Primary MTD in an Adult Female Presenting With Persistent Falsetto

The open phase of the vibratory cycle was dominant; however, the symmetry of vibrations was regular. Perceptually, patient CC’s voice quality was mildly dysphonic, characterized by a high-pitched, weak phonation. Objectively, she presented with a fundamental frequency of 220 Hz. Her pitch range was 205 to 860 Hz. Most interesting was the fact that she could not shout without overdriving the vocal folds into a high-pitched explosion of sound. Even with young men, one diagnostic sign of this disorder is the inability to shout. The positioning of the vocal folds and disengagement of the thyroarytenoid muscle for falsetto will not permit an appropriate buildup of subglottic air pressure to support a shouting behavior. The tenseness of the folds caused by the contraction of the cricothyroids will not permit the greater amplitude of vibration required for the louder phonation.

History

Treatment

Functional falsetto is associated most often with the postpubescent male. This author, however, has treated several adult women with this disorder. In the most recent case, patient CC was a 52-year-old, third-grade teacher who was referred by a friend with the complaint of having a “weak voice.” The weakness was something that she had noticed all her life, but she never thought that it could be modified. Stroboscopic examination of her vocal folds revealed normal-appearing folds that approximated in a near-parallel relationship. Glottic closure was complete, but the amplitude of vibration was severely decreased with just the medial edge of the folds vibrating.

How does one tell a 52-year-old woman who has always used this voice that it is not her real voice? First, you explore her knowledge of other voices. Patient CC was asked if she could produce voice in any other manner. Her only response was a puzzling look that, without words, questioned the sanity of the therapist. The next attempt to describe the problem was the intellectual approach. Through the use of the stroboscopic videotape and line diagrams, functional falsetto was explained in some detail to the patient. Patient CC showed an intellectual understanding of the disorder but was still somewhat skeptical of the diagnosis as related to her weak voice.

Falsetto voice, sometimes called puberphonia, has been described as a high-pitched voice quality consistent with adolescent males with biologically normal postadolescent vocal mechanisms. In the following case, Joe Stemple discusses the treatment of MTD secondary to persistent use of falsetto voice in a 52-year-old female.

Case Study 20 Joseph C. Stemple


The clincher turned out to be the direct approach. Patient CC was instructed in how to produce a hard glottal attack on the vowel /ae/. Her first attempt resulted in the deepest, loudest tone that she had ever heard emanate from her mouth. The sound also shocked and puzzled her. The therapist explained, “That was normal vibration of the vocal folds.” Once the shock diminished, patient CC was most interested in pursuing this form of voice production. Because of the deep sound, she was not yet interested in permitting anyone else — office staff, family, or friends — to hear her speak in this manner. Desensitization is an important step in dealing with functional falsetto. This patient had a lifetime of using her “old” voice. Her auditory feedback system kept repeating, “That’s not me, that’s not me.” Systematic practice from words (at first using the hard glottal attack), through phrases, paragraph readings, and directed conversations, was necessary to stabilize the “new” voice. Audio recordings were used liberally to demonstrate the normalcy of the “new” voice. Once stabilized in therapy, patient CC had to begin using the new voice with others. She started with a most sympathetic ear, my secretary, who had learned long ago when to positively reinforce. We then developed a hierarchy of situations to be tackled with the new voice, including n ordering food at a drive-through

restaurant

n ordering food in a restaurant n calling for information about a store

product

n talking directly to her daughter n talking to her husband

n talking to her class (who she was sure

would laugh and giggle).

Results At the following session, which was 2 weeks later, patient CC returned to report on her progress. Her new voice was stable and demonstrated remarkably improved inflection and flexibility. Now it was my turn to be puzzled. Patient CC reported that the day after our last session, she developed a bad cold. In the past, she reported becoming aphonic during the initial stages of a cold, and so it was this time. Using her falsetto voice, she “lost” her voice. “So, I decided, what have I got to lose? I tried to talk the new way and my voice came out fine. So, I’ve been using it everywhere ever since. I just tell people my cold changed my voice.” So much for brilliant hierarchies and desensitization plans. Final stroboscopic observation yielded normal wide amplitude of vibration and phase closure. The patient’s fundamental frequency stabilized at 196 Hz. Her pitch range expanded to 159 to 880 Hz. Most important, her voice was strong, easily produced without effort or fatigue, and was heard in all situations. The above case of persistent falsetto in an adult female is not unique. In fact, one might suggest that persistent use of falsetto in this population as a contributor to MTD may be underdiagnosed. In the following case, Mara Behlau and Glaucya Madazio describe multiple therapy approaches used to resolve MTD secondary to persistent falsetto in a female professional voice speaker.

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Case Study 21 Mara Behlau and Glaucya Madazio The Use of a Multi-Approach Therapy in a Female Professional Voice Speaker Presenting With a Primary MTD Marked With Habitual Falsetto Phonation

Case History Vocal complaint: “My voice has been very high and childish. This really does not bother me. However, I was invited to present a TV program and my voice didn’t seem credible for the screen.” (sic) The patient is a female journalist, 29 years old, married with no children. She has been working as a TV program producer on a show about traveling abroad. She is 1.75 m, tall for Brazilian parameters, with an athletic body profile. She referred to herself as a mature woman, very responsible, persistent, highly active and energetic, with a good career. She remembered herself as having this same voice, since she was a teenager. She also stated that the voice is still more infantile when talking to her father, a radio announcer professional. She has an older brother. No other woman in the family has a childish voice. Even if she does not have any recollection of having been bullied at school, some colleagues used to tease her by imitating a highpitched voice. Her family and particularly her husband and her father have perceived the voice as high pitched, but they had not identified any restriction or made a negative remark about it. She has never smoked, has had no reflux symptoms, and has not indicated any phonotraumatic habits.

She has been investing in selfdevelopment, and the opportunity of presenting the TV show she originally produces was received as a good personal challenge. She likes to sing but has no particular interest in developing the singing voice. She has not had any vocal symptoms besides the high-pitched voice and has had no complaint of vocal fatigue or vocal tract discomfort.

Voice Evaluation Audio-Perceptual The patient presented a moderate dysphonia characterized by a high-pitched voice, with reduced loudness without any other deviation on connected speech. Sustained vowels revealed moderate breathiness. No perceived effort was noticed. Frequencies swings were not present. Vocal quality was perceived as a childish voice. CAPE-V assessment indicated G (overall dysphonia) of 60, absence of roughness and tense voice, breathiness of 45; pitch (high) of 60; and loudness (low) of 30. All parameters were consistently present, with the exception of breathiness on connected speech. Anterior tongue carriage was observed (ie, the tongue was high and anteriorly displaced, reducing oral resonance, limiting laryngeal vertical positioning, and contributing to a thin vocal quality). The oral cavity was mostly occupied by an elevated tongue positioning, which blocked full resonance. Moreover, there was a slight anterior tongue interpositioning during “t, d, s, z” Brazilian sounds, which added to the perception of a childish voice. Fundamental frequency in the speech range was reduced at the upper and lower ends of her range. Vocal qual-


ity was constantly soft and breathy; loud voice was occasionally used with a compensatory effort and absence of breathiness. There was a clear influence of both restricted vocal range and resonance. This combination of factors particularly for postpubescent females is well described in the Classification Manual for Voice Disorders.4 Instrumental: Visual Imaging and Acoustics ENT Evaluation. Laryngeal evaluation was performed through videolaryngos troboscopy. The larynx was described as being a normal mobile larynx of adult dimensions, positioned high in the neck with normal appearing vocal folds (ie, long, white, and with a well-defined vocal ligament and mucosal wave). A mild posterior glottic chink was also identified. The ENT conclusion was primary MTD as a result of persistent use of falsetto register in the context of normal appearing vocal folds. Acoustic Analysis. Acoustic analysis of vocal quality was performed by Fonoview and VoxMetria (CTS Infor-

matica Inc, Brazil). The mean fundamental frequency for a sustained open vowel was of 211 Hz; for connected speech the mean value was 206 Hz (counting numbers from 1 to 10). It is interesting to notice that even if fundamental frequency was at the female adult range, close to the mean Brazilian female adult speakers,183 the pitch was high and inadequate for her age and physical appearance, mostly due to the vocal tract postural adjustments (high larynx, reduced oral space, and anterior tongue displacement). Acoustic parameters were essentially normal (jitter, shimmer, and noise parameters, Table 3–14), except for a minor deviation on the irregularity measurement. Spectrographic analysis (Fonoview) revealed a reduced series of harmonics, noise at the high frequencies, and trace instability. Hoarseness diagram [phonatory deviation diagram (PDD)]184 showed a discrete displacement from the normal area (Figures 3–18 and 3–19). Patient Self-Assessment Patient self-assessment of the impact of dysphonia was explored via V-RQOL, a

Table 3–14. Pretherapy Acoustic Parameters From the Sustained Open Vowel /ae/ (VoxMetria, CTS Informatica Inc) From the 29-Year-Old Female Journalist, High-Pitched Voice Acoustic Parameters

Values

Mean fundamental frequency

211 Hz

Software Normal Data

Jitter

0.33

0–0.6

Shimmer

5.36

0–6.5

GNE (noise)

0.79

0.5–1

Irregularity

4.84

0–4.75

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Figure 3–18. Pretherapy phonatory deviation diagram from a 29-yearold female journalist, high-pitched voice (VoxMetria, CTS Informatica Inc, Brazil).

Figure 3–19. Pretherapy spectrogram from a 29-year-old female jour nalist, high-pitched voice (Fonoview, CTS Informatica Inc, Brazil).

general protocol to analyze the effect of a voice problem on the quality of life. This instrument has 10 questions, 6 of them exploring the physical domain of a voice problem and 4 the socioemotional one. Even if this instrument is not spe-

cifically designed for use with persistent falsetto phonation, the total score was 85% (socioemotional = 81% and physical domain = 87%), which indicates a discrete impact on quality of life, with psychosocial negative repercussions.

V-RQOL normal value for the Brazilian adult population total score is 98% (99.4% for socioemotional and 97.1% for physical domain), and for the dysphonic group the total score is 65.9% (70.6% for socioemotional and 62.7% for physical domain).185,186 It is interesting to observe that due to her limited complaints, the score is placed between normal and dysphonic. The patient had also answered the Vocal Tract Discomfort Scale (VTDS),83 which contains 8 symptoms (burning, tight, dry, aching, tickling, sore, irritable, and lump in the throat) to be evaluated according to frequency and intensity. The patient`s answer indicated no discomfort due to the voice problem. This result showed that the vocal tract adjustments were stable and probably due to the restricted usage of the voice. The final conclusion of the case was female puberphonia due to maladaptive muscle adjustment.

Voice Therapy Specific Types of Therapy The persistence of an adolescent voice during adulthood is usually called puberphonia, however, many other terms are also used, such as mutational voice disorder, pubescent falsetto, incomplete maturation, persistent falsetto, or mutational falsetto. Puberphonia is the preferred term especially when organic causes (vocal fold paralysis, sulcus vocalis, endocrine dysfunction, or deafness) are not found. At puberty, the growth of the larynx and vocal folds displaces the male fundamental frequency at approximately 1 octave. The etiology of a persistent prepubescent voice is mainly functional, with probably a psychogenic influence; however, its dynamics has not been properly investigated.19


The real incidence of puberphonia in the general population is not known4 with a single estimation of 1 in 900 000.187 Excluding the hormoneinduced voice disorders (excessive or precocious mutation), the literature recognizes cases of prolonged mutation188 (voice change is observed for more than 6 months189), also called stormy voice mutation19; mutational falsetto, when the high-pitched-voice child is used as habitual phonation; and cases of incomplete mutation, when the voice has not achieved the total range displacement, which is usually seen in performers or boys’ choirs members.190,191 Puberphonia is usually a male disorder and causes are frequently related to psychological difficulties in facing the responsibilities of the adult life.19,39,190,192 The high-pitched voice can be chest register or falsetto, and the sound can be judged as a childish or female quality. Vocal instability and sudden frequency displacements (vocal swings or frequency shifts) can be observed in some cases. Female patients are seldom reported, probably due to the fact that society expects a high-pitched voice for women and men are expected to have a low-pitched voice to reassure masculinity, authority, and assertiveness. The distance between the female adult and girl’s voice is smaller than the male adult and boy’s voice (ie, vocal mutation is more evident in males). Even considering cultural expectations, a female infantile voice can be socially and professional detrimental to the individual. The established management of these cases is vocal rehabilitation, which usually includes changes in muscle adjustment, modification of vocal habits, and vocal image recalibration. Voice therapy is traditionally used with good results.2,19,39,79,187,192–195 Techniques include several vocal exercises, laryngeal

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manipulation,19,45,83 or the use of vegetative sounds to trigger the modal register.187 These patients usually respond to a short duration voice therapy alone, with vocal exercises, critical listening, and conscious displacement of fundamental frequency. Sometimes psychological counseling can be added2,79 and even a surgical procedure was proposed for a resistant case of a 24-year-old male.196 A more invasive approach was used in 26 males by producing laryngeal stretching with an intubation laryngoscope with an immediate improvement of the patient voice. The long pipe of laryngoscope is introduced in the valleculae of the patient while speaking a long “eeee.”197 These authors recognized that treatment of puberphonia is voice therapy; however, when not available, as happens in many cities of India, this direct technique can be employed. The objective of the vocal rehabilitation for this female case was to balance body, voice, and communication attitude to meet the social and professional demands of her life. The expected outcome was to establish a normalized female adult voice in terms of pitch, loudness, and quality. The philosophical orientation was to use one type of program, approach, or method to control therapy outcomes. However, for this functional falsetto dysphonia, with a long history of maladaptive adjustment, we were conscious that a mix of strategies would need to be considered to enhance the opportunities to produce changes via several perspectives. Considering the range of possibilities, we decided first to address vocal image through a communicative competence approach, then to proceed to the muscle adjustment modifications via indirect and direct strategies, and to continue with resonance reinforcement

and stabilization. The rationale used for treating this case was as follows: 1. Communicative competence approach: Use of general comprehension of the impact of vocal psychodynamics and keeping an infantile vocal quality in the adulthood. The FonoTools (CTS Informatica Inc) was used to monitor the changes in speaking fundamental frequency necessary for biofeedback. The patient was informally counseled about a new vocal and body attitude necessary to face the camera and was referred to a psychologist for formal counseling. 2. Muscle adjustment techniques: circumlaryngeal massage and laryngeal vertical displacement. The technique used for circumlaryngeal massage was the Manual Circumlaryngeal Therapy21,44,45 which consisted of unimanual circular pressure over the hyoid bone, within the thyrohyoid space to open it, using the thumb and index fingers. After this maneuver, depression of the larynx is obtained by active vertical displacement of the whole structure in the neck, starting from the upper border of the thyroid cartilage. Vocalization is requested during and after manipulation to monitor vocal changes (see Roy Case Study 5 in this chapter for more details on manual therapies). 3. Active vocal techniques for laryngeal vertical displacement: the strategy used for the patient to produce voice with a lower larynx position was the Finish bilabial fricative sound.115,198 This technique is efficient for lowering the larynx and reducing glottic chink. The patient is asked to attempt prolongating the oral occlusion of the fricative “B,”

followed by a schwa, as if produced on a slow rate, without the plosive pressure characteristic of the bilabial “b.” The large initial phase of the fricative sound, plus the mandible lowering, teeth opening, and enlargement of oral cavity favor the laryngeal lower repositioning. Nasal sounds, particularly the anterior occlusive “m,” was introduced as a facilitating adjustment to keep the lower larynx and vocal tract inner expansion. Low-frequency closed vowels (“o,” “e,” “u”) followed by words and sentences were used to generalize the low larynx position. 4. Resonance tubes: LaxVox technique was administered to maintaining a low vertical larynx positioning and vocal tract expansion, without extra effort. The LaxVox Method is also a Finish technique.199 To start this exercise, the patient is asked to get a 500-mL PET bottle half-filled water, room temperature, to insert a 35-cm-length by 9-mm-diameter silicone tube into the bottle, 2 to 3 cm bellow the upper level and to keep the straw gently with pursed lips and teeth. The patient is encouraged to produce bubbles while blowing air and sound into the flexible straw, for at least 1 minute, at the maximum phonation time. During the exercise, kinesthetic sensations are enhanced inside the vocal tract, including a “bubbling impression” inside the larynx. Modeling during the exercise is essential to control posture, breathing coordination, and upper resonance focus. After finishing the exercise, the patient should try some modulated open vowels or yawning to monitor phonation. Then, try some words and small sentences, particularly loaded


with nasal or fricative consonants, and keep the easy sensation during these productions. Finally, reading poems and short paragraphs was used to generalize the new voice adjustment. The sensation of gentle voice production and openness of the vocal tract were kept after finishing the exercise. 5. Reduced version of VFE to improve vocal resistance at the new adjustment: VFE is a well-established method to achieve coordination between breathing-phonation-resonance.92,103,105 This method consists of 4 exercises to strengthen and balance the laryngeal musculature and to balance airflow to the muscular effort: (1) warm-up exercise: sustained /i/ as long as possible, on a musical note F above middle C for female and children and F below middle C for male adult patients; (2) stretching exercise: glide from the lowest to the highest note in the frequency range on the word “knoll”; (3) contracting exercise: glide from the highest to the lowest note in the frequency range on the word “knoll”; and (4) low-impact adductory power exercise: sustain the musical notes middle C and D, E, F, and G as long as possible, for females and octave below middle C for male adults, using the vowel /o/. For the present patient only the first 3 exercises were used to retain the new phonatory and resonance adjustments. Exercise 4 was not used due to difficulties in carrying the notes. (See the Stemple Case Study 13 for more information on vocal function exercises.) Steps 3, 4, and 5 were combined with visual and auditory monitoring

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via spectrographic trace and audio playback. Critical listening of different voice samples produced at several frequency and intensity levels helped the patient to understand vocal flexibility and to monitor her own voice. Lombard effect and delay auditory feedback, via FonoTools software (CTS Informatica Inc), were used to confirm the inner monitoring of voice. Treatment dosage was conducted for 12 sessions, 8 the first month (twice a week) and 4 at the following month (once a week). Home practice was suggested 8 times a day, one single exercise, for the 2 first weeks and 3 times a day after this period.

Therapy Outcomes Audio-Perceptual The patient obtained a normal adult female voice. CAPE-V assessment indicates overall severity of 20, roughness of 0, breathiness of 15, tense 0; pitch (high) of 15; and loudness (low) of 10. All parameters were consistently present. Anterior tongue carriage was corrected, with use of resonance tasks. The

slight anterior tongue interpositioning was completed and adjusted. Vocal quality was not perceived as childish any longer. However, the patient notes that particularly when talking to her father and some close friends, the old voice tends to appear. The patient fully comprehends the emotional relationship of her voice problem. Instrumental: Visual Imaging and Acoustics ENT Evaluation. Normal examination showed a normal mobile larynx and lower vertical positioning. Glottic chink was reduced to the physiological female pattern. The ENT conclusion was that this was a normal examination. Acoustic Analysis. Acoustic analysis of voice showed a slight reduced mean fundamental frequency for the sustained open vowel /ae/, of 197 Hz; for connecting speech the mean value was of 202 Hz (counting numbers from 1 to 10). Acoustic parameters were essentially normal (Table 3–15), including graphic distribution of the hoarseness diagram (Figures 3–20 and 3–21).

Table 3–15. Posttherapy Acoustic Parameters From the Sustained Open Vowel /ae/ (VoxMetria, CTS Informatica Inc) From the 29-Year-Old Female Journalist, High-Pitched Voice Acoustic Parameters

Values

Mean fundamental frequency

197 Hz

Software Normal Data

Jitter

0.50

0–0.6

Shimmer

4.01

0–6.5

GNE (noise)

0.90

0.5–1

Irregularity

4.61

0–4.75


Figure 3–20. Post-therapy Phonatory Deviation Diagram from a 29-year-old female journalist, high-pitched voice (VoxMetria, CTS Infor matica Inc, Brazil).

Figure 3–21. Post-therapy spectrogram from a 29-year-old female jour nalist, high-pitched voice (Fonoview, CTS Informatica Inc, Brazil).

Patient Self-Assessment V-RQOL total score reduced to 97.5% (socioemotional = 100% and physical

domain = 95.8%), which indicates less impact of the voice problem on quality of life. The data were close to the normal Brazilian population.185,186

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Summary and Concluding Remarks Puberphonia is usually a male disorder. However, the maintenance of a childish voice in adulthood for a professional female can impair her opportunities for career development. Therapy used a mosaic of approaches due to the particular nature of the case: a long-term maladaptive vocal adjustment with a stable vocal psychodynamic. This patient did not have extensive vocal complaints, but the opportunity of facing a new challenge that would include professional voice use on a TV program was the motive to search for voice rehabilitation. The interesting fact is that the show was not scheduled for the season; however the patient was fully satisfied with the new voice, even if the old pattern could emerge in certain situation, with selected speakers. Lisa Fry presents the more traditional case of a young male with functional falsetto. In this case, hard glottal attack is used to facilitate an appropriate modal pitch.

Case Study 22 Lisa Fry Use of Hard Glottal Attack as Laryngeal Manipulation to Modify Mutational Voice in a 16-Year-Old Male

History of the Problem Patient AA was a 16-year-old male referred to the university voice center

by a local otolaryngologist for evaluation and treatment of mutational voice. In a telephone conversation with the patient’s mother prior to the evaluation, she expressed deep concern over her son’s abnormal voice and its impact on his interaction with peers and teachers at school. The patient was brought to the evaluation session by his mother. The mother was present during the interview portion of the evaluation session and left the room after historical information had been obtained. The patient provided the majority of the background and historical information related to his voice condition. AA was reserved throughout the evaluation session, speaking only briefly when asked direct questions by the clinician and offering only limited detail in his comments. The client presented with the primary complaints of a “high voice” and intermittent vocal fatigue at the close of the day. He could not recall the exact time of onset or any circumstances surrounding the onset but believed that the problem had been in existence for about 2 years. AA reported that his voice did not really bother him and that he did not pay much attention to it. He stated that his mother was much more concerned about the problem than he was and that she was the primary instigator of the otolaryngology and voice therapy appointments. During the history-taking portion of the evaluation, AA was asked about his voice behaviors and if/when he had ever heard himself produce “another” voice. (Some young men with this condition experience brief periods where the new, lower pitched voice is heard; however, they find themselves unable to sustain this mode of phonation for functional use.) AA indicated that he

had heard this “other” voice from time to time. He recalled that this generally happened first thing in the morning, just upon waking. He stated that he generally makes only a few statements in this other voice before the high-pitched voice returns and remains for the course of the day.

Medical History AA’s medical history was significant for mild nasal allergies and acne. Current medications included an oral antibiotic for treatment of acne and an over-thecounter pain medication as needed for sports-related orthopedic pain/soreness.

Social History AA was a sophomore at the local high school where he participated in the school’s junior varsity basketball team. As part of the team requirements, he attended practice 4 to 5 times per week and engaged in weightlifting 2 to 3 times per week. He reported great enthusiasm for the sport and indicated that most of his close friends at school were fellow members of the basketball team. When questioned about his behavior and general performance at school, AA indicated that he was “an OK student.” He reported that he rarely spoke up in class and rarely talked with teachers apart from his basketball coaches. AA did converse with close friends in the hallway before and after school and during breaks, but he suggested that these hallway conversations were, at times, difficult, as he could not project his voice over the surrounding noise. AA stated that his friends did not comment on his voice but indicated that


when people met him for the first time they often asked if he had a cold. AA lived at home with his father, mother, and younger sister. He described the home as typically “quiet” and uneventful. There were no smokers living in the home. The family had one small, indoor dog. AA reportedly filled his spare time with basketball, hanging out with friends, and attending churchrelated youth activities.

Voice Evaluation Audio-Perceptual AA spoke in a falsetto voice throughout the evaluation session. His voice quality was moderately harsh, and loudness was reduced. He displayed intermittent pitch breaks into the modal register during conversation. A mild degree of strain was present during voicing. Specific parameters of AA’s voice were rated using the CAPE-V. In brief, AA presented with moderate to severe dysphonia, characterized by a severe deviation of pitch, moderate breathiness, moderate roughness, and a mild to moderate reduction in loudness. Intermittent pitch breaks were noted. Instrumental Visual Imaging. AA’s vocal folds were easily visualized with a 70-degree rigid scope. Vocal fold edges were smooth and straight bilaterally, and vocal fold coloration was normal. Arytenoid movement was normal bilaterally. The glottic closure pattern was incomplete, characterized by a slight gap running the length of the vocal folds. Amplitude of vibration and mucosal wave were mildly reduced bilaterally. The open phase of vibration

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was moderately longer than the closed phase. The vocal folds were elongated and tense during phonation. Acoustics. Key acoustic measures were taken with the Computerized Speech Lab (KayPENTAX). In brief, fundamental frequencies of sustained phonation and conversational speech were increased at 236.37 and 229.97 Hz, respectively. Conversational dB was mildly decreased. Harmonics-to-noise ratio as well as jitter and shimmer calculations indicated an increased degree of noise and aperiodicity in the voice signal.

Voice Therapy Type of Therapy Intensive therapy using education and hard glottal attack productions to establish and then stabilize the targeted lower pitch. Rationale for Treatment Method and Frequency Patients with mutational voice possess deficits in laryngeal function only — that is, they present with abnormal laryngeal muscle use amid normal laryngeal structure. Consequently, most cases of functional falsetto in the pubescent male can be successfully managed in only 1 to 2 treatment sessions. In many cases, the initial treatment session can, in fact, be conducted at the time of the diagnostic voice evaluation, saving the client precious time and offering tremendous support and encouragement to the client and family. In some cases in which the functional use of the falsetto register has been maintained over the course of many years, a few additional treatment sessions may be necessary.

Because the mutational voice is generally amenable to modification and can be managed efficiently, a few guidelines regarding scheduling are generally followed. First, when clinic scheduling permits, it is helpful to arrange an extended block of time for the initial evaluation/ treatment session. I generally schedule a 2-hour to 3-hour session for these cases. When more than 1 session is required, every attempt should be made to avoid long periods between sessions, as this may permit the client to revert back to previous vocal behaviors; arranging sessions on consecutive days is quite helpful.

Therapy Goals and Expected Outcomes n AA will consistently achieve the tar-

geted lower pitched voice after facilitating techniques. n AA will extend use of the new pitch to increasingly complex linguistic contexts (syllables through conversation). n AA will develop a plan for generalizing the new voice to new listeners and situations. n AA will use the lower pitched voice in all speaking contexts. n AA will express satisfaction and comfort with his new speaking voice. It was expected that the patient would achieve the above goals in an extended treatment session conducted at the close of the evaluation session.

Therapy Description Education Treatment began with a thorough description of the anatomy and physiology


of voice production and a discussion of how these features change at puberty. Line drawings by the clinician and a laryngeal model supported the explanation. The clinician reminded the client that his laryngeal structures were normal on exam and that his voice concerns were related to muscle use issues. The physiology of the mutational voice (ie, disengaged thyroarytenoid muscle amid tense suprahyoid and cricothyroid muscles) was presented. The client was reassured that changes in laryngeal anatomy at puberty create challenges for the system and that he was not alone in his experience. Finally, methods of facilitating proper muscle activity were reviewed; the rationale for each method and its ability to restore normal physiology were explained. Facilitating and Stabilizing the Lower Pitch After the above discussion, the clinician spoke with AA about the “other voice” that he reported hearing upon waking some mornings. The clinician asked if AA could produce that voice on command. AA made several attempts to produce the lower pitch without success. (Note that in some instances, this simple technique is sufficient to prompt the lower pitched phonation, which can then be shaped into conversational speech.) As AA was unable to produce the lower pitch on command, a simple facilitating technique, the hard glottal attack, was used. Production of the hard glottal attack requires engagement of the thyroarytenoid muscle and moves the larynx away from the falsetto posture into an appropriate posture for the lower pitch. In keeping with this line of thought, AA was asked to produce a hard, abrupt

“ah.” His initial attempts yielded only breathy, high-pitched “ahs.” The clinician continued to request a harder, louder tone, eventually asking the client to press hard against her hands while attempting the abrupt “ah.” With this maneuver, the glottal attack was produced, immediately triggering a lowerpitched, frylike phonation. The client was instructed to repeatedly produce the glottal attack until the lower pitched tone was stable. Once consistent hard glottal attacks were heard and the client was able to hear/identify the targeted pitch, the abrupt “ah” was sustained for longer periods of time. Eventually, the hard onset was faded, and AA was able to sustain the “ah” for several seconds on command. After the target tone had been stabilized, the tone was slowly extended into other speech contexts. First, the client was asked to generalize the tone to other sustained vowels. Once that step was mastered, the clinician trained the client in chanting, all-voiced nonsense syllables (eg, mamama, momomo, minimini). Chanting syllables such as these permitted AA to extend the lowpitched voice to a variety of articulatory contexts without altering the newly acquired laryngeal posture for inflection or for production of a voiceless consonant. Consequently, the new voice became more stable, and the client was less likely to return to the high pitch as a result of laryngeal maneuvering that would have been required of voicedvoiceless syllables. AA continued chanting all-voiced productions through word, phrase, and sentence levels. Once mastered, AA progressed to producing voiced-voiceless syllables, words, phrases, and sentences in the context of a chanting style. Eventually, the chanting style was faded, and

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the client was able to gradually produce the new pitch with longer utterances with normal prosody. The client was advanced through various readings and conversational topics. Generalizing the Lower Pitch Because of the dramatic nature of voice changes during treatment for mutational voice, transition of the voice outside of the therapy context can be challenging. Consequently, it is recommended that the clinician and client openly discuss this challenge and develop a structured plan for generalizing the new voice. In the case of AA, the clinician posed the question “What do you think others will say about your new voice?” to which AA replied, “They will be shocked. I don’t know if they will like it.” The clinician reassured the client that, although the new voice was notably different, it was also quite pleasing and appropriate. To confirm this for the patient, digital recordings of the new voice were made and played back for the client. After hearing only a few brief statements, the client expressed his pleasure with the new voice, stating that it made him sound stronger and more confident. At this point, the speech pathologist suggested that the client develop a hierarchy of persons and situations where the voice could be gradually introduced. The client agreed to use the new voice with his immediate family and 2 close friends on the day of the session; he would be free to use his higherpitched voice if he so desired with other individuals on that day. On the first day following therapy, AA would expand use of his new voice to include the coaches and members of his basketball

team and members of his extended family. By the second day post-therapy, AA would use the voice with all teachers and with friends and acquaintances in the school hallway. Finally, by the third day following therapy, AA expected to use his lower pitched voice in all situations. With the above plan in place, the session drew to a close. The speech pathologist asked that the client remain in the treatment area while she went to get his mother. Prior to taking the mother into the treatment area, the clinician took a few moments to prepare the mother for AA’s new voice. The results of the session were discussed, and the speech pathologist asked that the mother not respond too dramatically or emotionally to the new voice but that she simply make a few brief comments about the appeal of the new voice. It was believed that preparing the mother for the new voice and practicing her response would reduce the likelihood that she would overreact to the new voice and, thereby, cause the client to be fearful of future interactions where he used the new voice with friends and family. Refining the Lower Pitched Voice At the close of the initial session, AA’s lower pitched voice possessed an element of glottal fry, suggesting that AA had lowered the pitch a bit beyond the target and that a degree of muscle imbalance was still present. To deal with this situation, an additional therapy session was recommended to refine the lowerpitched tone and to promote a proper tone focus (frontal tone focus). AA followed up for the second session 1 week following the initial visit.


Therapy Outcomes

References

Auditory Perceptual At the time of the patient’s 1-week follow up visit, he had been using the lower pitched voice in all contexts for several days. Consistent use of the voice and an increasing comfort with the voice had resulted in a lessening of the fry and a more appealing voice quality. Nonetheless, an abbreviated program of resonant therapy was introduced, and AA was given a program of daily resonance exercises to complete over the next 2 weeks. Patient Self-Assessment A follow-up call was placed to the client 2 weeks following the last session. AA indicated that he was doing well with the lower pitched voice and that the gravelly quality had dissipated. He expressed pleasure with the new voice and an increasing social confidence as well.

Summary and Conclusion Cases of mutational voice in pubescent males are rewarding to both client and clinician. Clients are generally encouraged as they experience normal voice production and improved social confidence after only a very brief therapy experience. Likewise, clinicians are rewarded by the joy of seeing the fruit of their labor in a short period of time. Even though the time spent with patients in this category is generally brief, the positive results of therapy often give patients and clinicians a lasting interest in and respect for one another.

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168. Li NYK, Verdolini K, Clermont G, et al. A patient-specific in silico model of inflammation and healing tested in acute vocal fold injury. PLoS One. 2008; 3(7):e2789. 169. Li NYK, Vodovotz Y, Kim KH, Mi Q, Hebda PA, Verdolini Abbott K. Biosimulation of acute phonotrauma: an extended model. Laryngoscope. Nov 2011;121(11):2418–2428. 170. Li NYK, Abbott KV, Rosen C, An G, Hebda PA, Vodovotz Y. Translational systems biology and voice pathophysiology. Laryngoscope. Mar 2010;120(3): 511–515. 171. Branski RC, Perera P, Verdolini K, Rosen CA, Hebda PA, Agarwal S. Dynamic biomechanical strain inhibits IL-1betainduced inflammation in vocal fold fibroblasts. J Voice. Nov 2007;21(6): 651–660. 172. Schmidt R, Lee T, eds. Motor Control and Learning: A Behavioral Emphasis. Champaign, IL: Human Kinetics Publishers; 2005. 173. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol. Rev. Mar 1977;84(2):191–215. 174. McAuley E, Talbot HM, Martinez S. Manipulating self-efficacy in the exercise environment in women: influences on affective responses. Health Psychol. May 1999;18(3):288–294. 175. Norman P, Bennett P. Health locus of control and health behaviour. J Health Psychol. 1998;3(2):171–180. 176. Schwarzer R, Fuchs R. Self-efficacy and health behaviours. In: Connor M, Norman P, eds. Predicting Health Behavior: Research and Practice with Social Cognition Models. Buckingham, UK: Open University Press; 1996:163–196. 177. Behrman A. Facilitating behavioral change in voice therapy: the relevance of motivational interviewing. Am J Speech Lang Pathol. Aug 2006;15(3): 215–225. 178. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care:

Helping Patients Change Behavior. New York NY: Guilford Publications; 2008. 179. Upledger JE. Craniosacral therapy. Phys Ther. Apr 1995;75(4):328–330. 180. Conable B. How to Learn the Alexander Technique, A Manual for Students. Columbus, OH: Andover Road Press; 1991. 181. Maryn Y, De Bodt M, Van Cauwenberge P. Effects of biofeedback in phonatory disorders and phonatory performance: a systematic literature review. Appl Psychophysiol Biofeedback. Mar 2006;31(1): 65–83. 182. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. 5th ed. Champaign, IL: Human Kinetics; 2011. 183. Behlau M TO, Pontes P. Determinação da frequência fundamental e suas variações em altura (jitter) e intensidade (shimmer), para falantes do português brasileiro. Acta AWHO. 1985;4:5–9. 184. Madazio GLS, Behlau M. The phonatory deviation diagram: a novel objective measurement of vocal function. Folia Phoniatrica Logopaedica. 2011;63: 305–311. 185. Behlau M, Hogikyan ND, Gasparini G. Quality of life and voice: study of a Brazilian population using the voicerelated quality of life measure. Folia Phoniatr Logop. 2007;59(6):286–296. 186. Gasparini G, Behlau M. Quality of life: validation of the Brazilian version of the voice-related quality of life (V-RQOL) measure. J Voice. Jan 2009;23(1):76–81. 187. Banerjee AB, Eajlen D, Meohurst R, Murty GE. Puberphonia—A Treatable Entity. 1st World Voice Congress; 1995; Oporto, Portugal. 188. Rubin JS KG, Gould WJ, Sataloft RT. Diagnosis and Treatment of Voice Disorders. Tokyo: Igaku-Shoin; 1985. 189. Brown WS VB, Crary MA. Organic Voice Disorders — Assessment and Treatment. San Diego, CA: Singular Publishing; 1987. 190. Greene M, Mathieson L. The Voice and Its Disorders. 6th ed. London, UK: Whurr; 2001.

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191. Seth G GD. Speech in Childhood. Oxford, UK: Oxford University; 1935. 192. Behlau M, Azevedo R, Pontes P, Brasil O. Disfonias funcionais. In: Behlau M, ed. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2001:247–281. 193. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice. Mar 1999;13(1):72–104. 194. Pommez J. [Functional disorders of voice changing]. Revue de laryngologieotologie-rhinologie. Mar–Apr 1971;92(3): 137–156.

195. Sapienza C, Ruddy BH. Voice Disorders. San Diego, CA: Plural Publishing; 2009. 196. Pau H, Murty GE. First case of surgically corrected puberphonia. J Laryngol Otol. Jan 2001;115(1):60–61. 197. Vaidya S, Vyas G. Puberphonia: a novel approach to treatment. Indian J Otolaryngol Head Neck Surg. 2006;58(1): 20–21. 198. Elliot N, Sundberg J, Gramming P. Physiological aspects of a vocal exercise. J Voice. Jun 1997;11(2):171–177. 199. Sihvo M, Denizoglu I. Lax Vox®: Voice Therapy Technique. Turkey: AD Iznir; 2007.

4 Management of Glottal Incompetence

Introduction Normal voicing is dependent on neartotal closure of the vocal folds. (The larynges of many women and some men will demonstrate a normal posterior glottal gap of the vocal folds upon adduction.1) Subglottic air pressure from the lungs builds and eventually overcomes the resistance of the adducted folds, and a puff of air escapes. This release of air creates a sudden drop of air pressure between the vocal folds that, along with a reflected downward pressure from the supraglottic structures and the static positioning of the adducted folds, draws the vocal folds back together, completing a vibratory cycle.2 When the vocal folds do not totally approximate, as in the case of glottal incompetence, a greater amount of air pressure and airflow are required

to create and maintain phonation. The speaker, therefore, must work harder to produce voice. The perceptual quality of voice and effort required to produce voice will be reflected directly by the size of the glottal gap. The larger the glottal gap, the breathier the voice will be. As the size of the gap may vary from large to small, the voices of individuals with glottal incompetence may range from a mild breathiness to complete whispered aphonia. Interestingly, some patients with glottal incompetence attempt to compensate for the lack of glottic closure by compressing the supraglottic structures. Therefore, this segment of the population may not present with the expected breathy quality, but with a strained, strangled quality. Glottal incompetence may result from either muscular or anatomical causes. Functional hypoadduction of the vocal folds may be caused by an

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imbalance of respiration, phonation, and resonance caused by voice misuse, use-induced vocal fatigue, or emotional concerns. Inefficient voice use may lead to voice fatigue in an otherwise medically and emotionally healthy individual, such as patients who report that their voice quality is normal in the morning but becomes weak, rough, and breathy as the day progresses. The result of this vocal fatigue may be the development of glottal gaps between the vocal folds,3 usually with increased supraglottic tension. These patients complain that the harder they try to produce voice, the worse the quality becomes. One might correctly argue that the original cause of laryngeal fatigue was hyperfunctional vocal behavior. Nonetheless, stroboscopic observations of many of these patients made during the fatigued state demonstrate unusual anterior glottal chinks, large posterior glottal chinks, and occasional spindle-shaped chinks.4 Lack of glottal closure also may be the result of vocal fold pathology. A number of neurogenic etiologies, both central and peripheral, have been associated with insufficient glottal closure. Vocal fold paralysis is, perhaps, the most common neurogenic cause of glottal incompetence. Although paralysis may be caused by central neurologic disease, more often it is the result of nerve damage or peripheral disease. Vocal fold paralysis may be unilateral or bilateral. It may be caused by damage to or disease of the vagus nerve anywhere along its course from the brainstem to the target muscle and may, therefore, involve the superior laryngeal nerve (to the cricothyroid muscle), the recurrent laryngeal branch (all remaining intrinsic laryngeal muscles), or both. Location of the lesion along the nerve pathway

will determine the type of paralysis, the degree of glottal incompetence, and the resulting voice quality. Glottal incompetence also may be secondary to nonneurologic causes. For instance, aging may bring about a characteristic bowing of the vocal fold edge and a resultant lack of glottal closure. Although such changes have been observed across genders, these changes are most commonly observed in males. Thus, a variety of concerns may lead to glottal incompetence. This chapter highlights management of age-related and neurogenic cases. Unilateral vocal fold paralysis presents a complex diagnostic and therapeutic challenge to the voice care team. In this first case, Stephen McFarlane and Shelley Von Berg discuss multiple facilitating techniques for improving voice production in a 35-year-old woman with a complex medical history.

Case Study 1 Stephen C. McFarlane and Shelley Von Berg Treatment Strategies Used for Unilateral Vocal Fold Paralysis in a Case With a Complex Medical History

Introduction Injuries to the vagus nerve anywhere along its path from the medulla to insertion into the larynx inevitably result in paresis or paralysis of those muscles receiving innervation at or below the level of injury. The most frequently

observed laryngeal paralysis experienced at this clinic and reported in the literature5–7 is unilateral vocal fold paralysis (UVFP), with the involved fold fixed in the paramedian position — that is, halfway between the midline and lateral positions. Unilateral paralyses usually are the result of severing or bruising of the recurrent laryngeal branch of the vagus, the branch responsible for efferent and afferent nerve supply to all of the intrinsic muscles of the larynx except for the cricothyroid muscle, which is innervated by the superior laryngeal branch. At times, the nature of the paralysis is unknown (ie, idiopathic paralysis). Viruses affecting the vagus nerve may be responsible for at least a portion of these idiopathic cases. McFarlane, Holt-Romeo, Lavorato, and Warner8 found that behavioral voice intervention produced superior voice quality in patients with unilateral vocal fold paralysis when compared with one group of patients who had received injections and another group who had undergone muscle-nerve reinnervation surgery. Another study 9 found that voice therapy was instrumental in reducing by half the excessive mean airflow rates in 16 individuals with UVFP. Thus, in the interim period between diagnosis of vocal fold paralysis and final resolution of the problem, voice therapy has been demonstrated to be an effective intervention for helping many patients achieve normal or near-normal voice quality and reducing air wastage.

Patient History Patient O was a 35-year-old woman, referred to our office by her otolaryngologist, with complaints of dysphagia


and poor vocal quality. The patient presented with a complicated and lengthy medical history. Eleven years earlier, she noticed a slight bulge in the neck at the area of the thyroid gland. She underwent total thyroidectomy and partial neck dissection for Hashimoto’s thyroiditis, combined with papillary carcinoma of the thyroid with metastasis to 3 regional lymph nodes. She underwent postoperative iodine 131-treatment. (Iodine is an essential micronutrient; 80% of the iodine present in the body is in the thyroid gland.) Over the years, patient O underwent 12 additional surgeries to the neck area. Some surgeries involved recurrent tumor removal, but others involved laminectomies and Z-plasty. A number of surgeries involved placement of an electrical implant to reduce chronic pain. Patient O had never smoked and reported no alcohol use. She drank 1 cup of caffeinated coffee each day and 6 glasses of water. A videofluoroscopic swallow examination administered 2 weeks earlier had shown a focal narrowing on the right side of the esophagus at about the level of C5 to C6; however, the course, caliber, and motility of the esophagus were reported to be normal. There was no diverticular formation, hiatal hernia, or mucosal abnormality. When questioned about her vocal quality, patient O said that it had deteriorated progressively with successive operations but worsened abruptly after a laminectomy 4 months earlier. She took a fatalistic approach to her dysphonia, stating that she had simply “gotten used to no voice.” Speaking behaviors were characterized by a moderate-tosevere degree of neck tension. Routine questioning revealed that the patient was divorced and that her ex-husband had threatened to kidnap their young

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child. With a wry smile she admitted to having “an element of stress” in her life.

Voice Assessment Upon examination, the voice was high in pitch, rough, strained, and breathy with phonation breaks and reduced intensity. Patient O said that she now considered this to be her typical voice. Sustained vowel production measured on the Visi-Pitch II (KayPENTAX, Inc) revealed a fundamental frequency of 274 Hz with jitter of 2.8% and shimmer of 2.8%. Jitter was considered abnormally elevated, indicating irregular frequency perturbations across vibratory cycles.5 Fundamental frequency was at the high end of normal for females aged 30 to 40 years.10 A rigid endoscope was introduced transorally, and we studied the vocal fold activity by videostroboscopy. Anatomically, the larynx and surrounding structures, including the cricopharyngeal inlet and piriform sinuses bilaterally, appeared normal. During phonation, the left vocal fold was fixed in the paramedian position. The left vocal fold moved slightly toward the midline during adduction, and a limited mucosal wave was observed for this fold. The reduced mucosal wave was partly responsible for the elevated jitter value and the harsh and breathy quality of the voice. During vocal fold vibration, glottal closure was adequate for voice production. A glottal gap did exist from the flava to the posterior commissure, but the gap was judged to be less than 3 mm across, and vocal fold medialization was adequate for either contact at the midline or to take advantage of airflow dynamics to set the vocal folds into vibration. The right false vocal fold

tended to creep toward the midline during phonation and impinge on the true vocal fold, further contributing to increased vibrational aperiodicity, jitter, and harsh, breathy vocal quality (Figure 4–1). The Phonatory Function Analyzer (Kelleher Medical, Richmond, Virginia) revealed airflow rate of 138 mL/s at 220 Hz. These measures are within normal limits, but they were achieved with abnormally brief phonation times of 4 seconds. In summary, patient O presented with a unilateral adductor paralysis of the left vocal fold, most likely associated with numerous surgical interventions for cancer of the thyroid gland. Vocal pitch was high and squeaky, and volume was low. Vocal quality was harsh, strained, and breathy. Phonation times were abnormally brief. Endoscopy revealed incomplete vocal fold closure and limited mucosal wave on the left vocal fold during phonation. Evidence of supraglottal involvement was also observed, characterized by excessive medialization of the right false fold, which was reported as a reactive hyperfunctional response to excessive trans-

Figure 4–1. VF image pretreatment.

glottal airflow. Phonation times were brief, suggesting poor valving of subglottal air.

Swallow Assessment A barium swallow study confirmed a slight, focal esophageal stricture just below the upper esophageal sphincter. However, sequential views of swallow revealed adequate esophageal motility and emptying of the bolus into the stomach. No hiatal hernia, diverticular formations, or reflux of gastric contents were appreciated. Patient O presented with a robust, volitional cough. Oral-pharyngeal swallow was assessed via fiber-optic endoscopic eval uation of swallow. A 3-mm flexible endoscope was introduced transnasally and positioned at the base of the tongue. The patient was presented with consistencies of puree, mechanical soft, and solids. For all consistencies, she presented with hyperextensive neck and choking behaviors upon swallow. Postswallow, patient O reported a globus sensation. Nonetheless, oral-pharyngeal transit times were within normal limits, and inspection of the hypopharynx postswallow revealed no bolus residue. Moderately thick and stringy mucus was observed at the level of the glottis, and it was suggested that this might be contributing to the globus sensation. Patient O was encouraged to increase water intake to 2 quarts (approximately 2 L) per day to thin the mucus.

Swallow Intervention Although patient O presented with normal oral-pharyngeal function and esophageal motility upon swallow, her


symptoms of dysphagia needed to be addressed. It is suspected that, over the years, repeated surgery and radiation to the pharynx and larynx had taken their toll and that the patient had gradually developed defensive postures during swallow, which in reality compromised a physiologically normal functioning system. Therefore, swallow strategies were employed to alleviate these defensive postures. Gentle digital pressure at the anterior aspect of the cricoid cartilage appeared to reduce the sensation of globus and enhance ease of swallow. It was suspected that this midline pressure ameliorated the effects of the stricture. By experimenting with various head turn techniques, it was discovered that the head turned right with chin tucked produced a swallow devoid of hyperextensive posturing. We experimented with several consistencies employing this technique, all of which were swallowed with no complications. Patient O was encouraged by these results and was relieved to avoid esophageal dilation or further surgery for cricopharyngeal myotomy.

Voice Intervention During the initial diagnostic session, it is our practice to devote as much time and effort to attempts to normalize the voice as to documenting the disorder. Therefore, after recording the nonstimulated acoustic, physiologic, and airflow measures of patient O’s voice productions, we introduced facilitating techniques to attempt to improve the voice and acoustic measures. In the case of this patient, we had a dual, simultaneous task: to remove the hyperfunctional component while stimulating the best vocal quality possible by altering glottal activity and phonatory mode.

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We normally introduce several facilitating approaches in the first session as the patient invariably responds better to some techniques than to others. In this case, we introduced the following as described in Boone and McFarlane11: n head turning n lateral digital manipulation of the

thyroid cartilage n half-swallow boom n facial tone focus with nasal-liquidglide stimuli n pitch shifts n inhalation phonation n tongue protrusion /i/ Techniques for Establishing Improved Vocal Fold Medialization

Initially, we instructed patient O to produce half-swallow boom to appreciate the fact that she could generate a stronger voice. Swallow produces as much closure of the glottis and supralaryngeal structures as is physiologically possible. “Boom” is an all-voiced word that is easily produced because air is released from the constricted larynx. Oral opening is minimal, which produces back pressure on the larynx. We instructed the client to swallow and interrupt the swallow with a “boom.” We explained that the “boom” is produced “on top of the swallow” to take advantage of the already closed nature of the vocal folds during the swallowing act. Once she produced a fully voiced “boom,” she was instructed to transition the “boom” into two-word phrases, such as “boom-one,” “boomme,” and then into longer fully voiced phrases to appreciate the fact that she could easily produce short phrases with good vocal quality.

Next, we encouraged her to turn her head to one side and then to the other as we gently placed pressure to either side of the thyroid cartilage. A change in head position away from the paralyzed vocal fold may improve vocal quality and airflow by stretching the paralyzed vocal fold in an A-P manner, thus improving vocal contact at the midline. Conversely, head turn to the side of the paralyzed vocal fold has been observed to shorten the effected vocal fold, thus enhancing the extent of the mucosal wave and resulting in improved vibration and better glottal valving. As she turned her head, prolonging vowels /i/, /I/, /ε/, /e/, /o/, or /u/, we listened for improved vocal quality, intensity, and airflow. When optimum quality was achieved, we encouraged her to keep her head in the new position while she practiced nonsense syllables employing vowels and nasal glides. To capitalize upon enhanced vocal quality, we also applied gentle lateral digital pressure to each aspect of the thyroid cartilage to assess even greater improvements in vocal fold vibration. Our experience has suggested that gentle digital pressure on the affected side of a UVFP helps to medialize the paralyzed vocal fold and improve vocal fold vibration. Likewise, digital pressure to the nonaffected side helps medialize the nonparalyzed fold across the midline, again improving vocal fold vibration. In the case of patient O, the head turned right with pressure to the left thyroid lamina produced the best vocal quality with the strongest vocal intensity and longest phonation time. At this point, she was encouraged to produce nonsense syllables using voiced phonemes, and then generalize to short phrases and sentences.

Finally, patient O was encouraged to develop a kinesthetic sense of the “sound” and “feel” of vocal fold approximation as she slowly brought her head back to midline in steps. We slowly withdrew digital pressure while she continued to produce optimum vocal quality. She was informed that some patients can be taught to apply digital pressure to their own thyroid cartilage. Pitch shifts up and down using extended nasal-liquid-glide stimuli were also probed. A shift in pitch either higher or lower than the patient’s baseline pitch often will alter the vocal fold configuration sufficiently to trigger better vocal quality. Sliding the pitch up to a slightly higher frequency may help elongate the paralyzed vocal fold, thus enhancing vibration. Likewise, a lower pitch may increase the mucosal wave for the paralyzed vocal fold, again enhancing vibration. An added bonus is a growing awareness on the part of the client that he or she is able to manipulate the vocal fold configuration at will and thus alter the voice. Patient O was instructed to gently hum up and down the scale, listening for any improvement in vocal quality. She produced the strongest intensity with the best vocal quality when phonating between 260 and 300 Hz. At this point, she was instructed to extend humming to nonsense nasal productions, maintaining the desired pitch. Nasal productions were then transitioned to short phrases. We set a range of at least 4 keyboard notes B3 (245 Hz) and C4 (262 Hz), within which she was encouraged to vary the pitch. During all of the stimulation techniques, the patient’s attention was directed to self-monitor airflow, laryngeal configuration, vocal quality, and


duration of phonation, as well as to general vocal effort required for phonation. Reducing Hyperfunctional Behaviors Patients with UVFP often place undue emphasis on the larynx when attempting to phonate. They believe that if they valve more forcefully at the level of the glottis, the voice will emerge stronger. This approach tends to excessively increase glottal and supraglottal resistance during phonation, and thus the voice is produced in a strained and strangled manner. Although the voice may indeed be louder, it is almost always rougher in vocal quality with a higher noise-to-harmonic ratio. Throughout therapy, patient O was gently admonished when she tried to “push” the voice out. We explained that pushing the voice simply tightens the larynx “like a purse-string” and overimpounds subglottal air by bringing the false vocal folds into play. Instead, we introduced the concept of focus, explaining that the goal is to transfer the energy of the voice from the larynx to the nose, cheeks, and lips. This nasal or facial focus helps eliminate overvalving at the glottis and supraglottis, thus opening the aditus for enhanced vocal resonance. Only by relaxing the system and placing the resonating focus in the nasal and lip area does the voice quality improve with the least effort. We began by placing our fingers lightly at the bridge of the nose and gently humming. The patient was instructed to follow the clinician’s model. She was asked to feel the amplitude of the clinician’s facial focus by placing a finger on the clinician’s nose and at the same time compare the “buzz” produced by the clinician with his or her own “buzz.”

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Once patient O’s facial focus was similar to the clinician’s, she was instructed to produce phrases loaded with nasals, liquids, and glides to extend the desired focus (eg, “Miami millionaire,” “man on the moon”).12 After she had some success in placing the voice in the face, we discussed with the patient the imagery of what was happening to produce good voice. We provided extensive auditory feedback so patient O could begin to appreciate and monitor her own focus. In addition to focus and nasals, tongue protrusion /i/ and inhalation phonation were introduced. These two techniques are highly effective in reducing hyperfunctional behaviors. 11 Tongue protrusion /i/ entails protruding the tongue slightly beyond the lips while producing /mimimi/ in a high pitch. The forward movement of the tongue pulls its root out of the pharynx and opens the laryngeal aditus. Once acceptable resonance is achieved, the tongue is gradually retracted back inside the mouth, and bilabial phonemes (“buy baby a bib”) and alveolars (“tea for two,” “taking time to talk”) are targeted while the improved tone is established. Inhalation phonation is usually better demonstrated than explained. It involves production of a high-pitched, gentle phonation on inspiration, simi-

lar to the sound one might make when caught by surprise (a sharp, inhalatory gasp). The high-pitched vocalization produced on inhalation is always produced by true vocal fold vibration, thus eliminating involvement of supraglottal structures. The inhalation is followed by an exhalation equal in vocal intensity and quality but shorter in duration. Duration of the exhalatory phase is gradually extended over the course of therapy until it is lengthier than the inspiratory phase. The pitch of the inhalations is eventually lowered to within normal limits, and productions extend to nonsense syllables and then short phrases. Patient O was initially reticent to perform tongue protrusion /i/ and inhalation phonation; however, she complied once it was explained that these approaches are designed to eliminate maladaptive behaviors of vocal hyperfunction. Once she was able to appreciate and maintain a lowered larynx and open pharynx, these approaches were discontinued. By session 3, patient O’s conversational voice was still slightly reduced in intensity, yet the hyperfunctional behaviors, elevated pitch, and phonation breaks had been eliminated (Table 4–1). Acoustic measures using a sustained /i/ on the Visi-Pitch II revealed 243 Hz with jitter of 0.67% and shimmer of

Table 4–1. Perceptual Measures Pretherapy and Post-Therapy Pretherapy

Post-Therapy

Pitch

High and squeaky

Slightly elevated

Vocal quality

Strained, rough, breathy

Fully voiced, pleasant

Loudness

Reduced, soft

Adequate for conversational speech and telephone


1.35%. All measures were within normal limits. Maximum phonation time had more than doubled to 9 seconds, indicating enhanced control of transglottal airflow without hyperfunctional overlay (Table 4–2). Rigid videoendoscopy revealed improved vocal fold contact at the midline and normal mucosal wave bilaterally. No ventricular fold hypertrophy was evident (Figure 4–2). Patient O said that she was thrilled with her “new voice,” notably because of the improved intensity while retaining quality and the effortless manner in which she was able to speak over the telephone.

barium and FEES studies. Counseling involved positioning strategies that patient O found helpful in the clinic environment. The following case is that of a 72-yearold lawyer with unilateral vocal fold paralysis. In the study, Mara Behlau, Gisele Oliveria, and Osíris do Brasil explore the best voice production: changing of the vocal gesture/posture while reinforcing laryngeal mechanics through an active vocal exercise program.

Home Program A video recording featuring patient O performing the facilitating techniques during the final voice session was made. She was encouraged to view it along with her written home voice program issued by this clinic. The home voice program specified all of the techniques introduced above and their rationales. Swallow issues were again addressed, and it was reemphasized that hypopharyngeal and cricopharyngeal motility were normal, as established by earlier

Figure 4–2. VF image post-treatment.

Table 4–2. Acoustic Measures Pretherapy and Post-Therapy Pretherapy

Post-Therapy

274

243

Jitter

2.8%

0.67%

Shimmer

2.85%

1.35%

4 seconds

9 seconds

F0 (Hz)

Phonation time

Normal values for jitter and shimmer are approximately 0.80% and 3.8%, respectively. Mean F0 for women aged 30 to 40 years is 196 Hz, and mean phonation time for adult women is 21.34 seconds.

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Case Study 2 Mara Behlau, Gisele Oliveria, and Osíris do Brasil Use of Physiologic Therapy Approaches to Treat Unilateral Vocal Fold Paralysis Following Complications From a Total Thyroidectomy

Patient History Patient P was a 72-year-old retired Appeals Court Judge. At the time of presentation to our clinic, he was working as a professional writer. The patient had recently undergone a total thyroidectomy for papillary thyroid carcinoma. On the first postoperative day, the patient had a spontaneous left cervical hematoma that was treated clinically. At that time, his voice was normal, and an examination showed normal vocal fold mobility. At postoperative day 30, the patient presented to our office for a voice consultation, reporting progressive dysphonia for 15 days. He indicated that his voice had become weaker and lower in recent weeks. Patient P’s medical history included a myocardial infarction in the remote past (>20 years previous). He exhibited good respiration and no report of auditory problems. He denied smoking and alcohol consumption and stated that he had healthy dietary habits. He denied sleep disturbances and other psychiatric problems, such as depression. Patient P was an extraverted, talkative man who was engaged in multiple social activities. He was a prized poet, novelist, and composer. He considered communication to be one of his main competencies.

History of the Problem Patient P was referred to the otolaryn gologist after a cardiac checkup had pointed out a thyroid lesion. His voice was normal at that time. Laryngeal examination showed mobile vocal folds with complete glottic closure. A total thyroidectomy was performed on Jan uary 22. At the first postoperative day (12 hours after the procedure), the patient presented with a spontaneous cervical hematoma, a rare complication probably associated with the surgical intervention.13,14 Swelling in the neck area was treated with a bedside hematoma evacuation. No respiratory distress, pain, dysphagia, or dysphonia occurred. A laryngeal exam performed on the third day postsurgery showed normal laryngeal mobility. On day 15 postsurgery, the patient noticed that his voice was somewhat softer than usual, but he did not bring this concern to anyone’s attention. In the days that followed, the symptoms worsened, and the patient noticed increasing shortness of breath. A new consultation revealed a left vocal fold paralysis. The affected fold was bowed and positioned in the paramedian position. Glottic closure was incomplete. Speech-language pathology recommended primary management through voice rehabilitation (conservative treatment). This would be followed by surgical intervention, if needed. Because of the patient’s high vocal demand, however, the otolaryngologist advised the patient to undergo thyroplasty type I.15

Evaluation Procedures Patient P received a standard battery of vocal function testing. These assessments included:

n Auditory perceptual analysis using

the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) protocol, Brazilian Portuguese Version16 n Visual perceptual analysis with videostroboscopy to assess the vibratory pattern of the vocal fold and size of glottal gap n Vocal self-assessment using the VoiceRelated Quality of Life (V-RQOL)17 to understand the patient’s perspective of the vocal problem n Acoustic analysis of sustained vowel and sentence productions to assess frequency, perturbation, and range n Laryngeal electromyography (electrophysiologic examination) to confirm the neurologic lesion. 1. Auditory perceptual. In cases of vocal fold paralysis, the degree of vocal impairment is partially related to the position of the paralyzed fold and the degree of muscle atrophy.18 Patient P’s voice quality was assessed perceptually by the speechlanguage pathologist during the evaluation session using the 3 speech tasks of the adapted Brazilian Portuguese version of the CAPE-V16: sustained vowels, selected sentences, and conversational speech (“Tell me about your voice problem”). Scoring was as follows: moderate overall severity of dysphonia (52/100), mild degree of roughness (26/100), moderate degree of breathiness (47/100), and no noticeable tension (0/100). Modal pitch was judged to be mild low (24/100) for his gender and age, and loudness was judged as moderately reduced (46/100). Asthenia was marked as an additional feature of the voice concern and was rated as a mild to moderate deviation (35/100). Occasional phonatory breaks were also observed.


No diplophonia was noticed. Resonance was normal. All voice attributes were consistently present at the assessment session. 2. Visual perceptual. Patient P had a normal laryngeal evaluation presurgery and immediately postsurgery, as well as at the time of his first follow-up consultation. A month after the surgical intervention, P presented with left vocal fold immobility with bowing. Vocal processes were at the same horizontal plane. A reliable image of vocal fold mucosal vibration was obtained, reinforcing that there was a small phonatory gap.19 Supraglottic constriction was observed, with a moderate displacement of right ventricular fold. Vocal rehabilitation was then started and the patient was warned about the possibility of surgery to compensate the deficit. Patient P stated that he preferred voice therapy over an additional surgical procedure, even though the therapy option might suggest a longer period of rehabilitation. 3. Self-assessment protocol. The selfassessment of the voice problem was performed using the validated version of the V-RQOL.17 The total score was 82; the physical score was 75, and the socioemotional score was 93. Lower ratings in the total score and physical score areas clearly showed the nature of the problem.17,20 Two aspects were particularly deviated per patient report: difficulties in speaking loud and problems at work due to the voice. In the socioemotional domain, the patient identified strongly with only one statement, “I am less extroverted due to my voice problem,” an indication that the patient was changing his natural communication habits due to the dysphonia.

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4. Acoustic analysis. Acoustic measures were obtained from sustained vowel /ae/ using the software VoxMetria 2.5 (CTS). The main features are summarized on Table 4–3. Jitter, irregularity, and noise component were evidently deviated. The phonatory deviation diagram21 showed

a spread distribution with a predominance of the irregularity axis (Figure 4–3). Spectrographic trace (Figure 4–4) showed predominance of the noise component and irregularity of trace (FonoView 1.0, CTS) as well as unstable fundamental frequency. Maximum phonation time

Table 4–3. Acoustic Measures for Patient P at the Assessment Session, After 2 Months and After 6 Months (VoxMetria 2.5, CTS) Assessment Session

After 2 Months

After 6 Months

Normal Values

105 Hz

102.75 Hz

114 Hz

80 to 150 Hz

Jitter (PPQ)

0.84

0.27

0.11

0 to 0.6

Shimmer (EPQ)

5.84

5.01

3.23

0 to 6.5

Irregularity

5.78

4.77

3.63

0 to 4.75

GNE (Glottal to noise excitation ratio)

0.35

0.64

0.95

0.5 to 1.0

Parameters Habitual fundamental frequency

Figure 4–3. Phonatory deviation diagram: upper plotting (assessment), middle plotting (after 2 months of therapy), and bottom plotting (after 6 months of therapy); light gray area in lower left corner represents the range of normal (VoxMetria 2.5, CTS).

Figure 4–4. Acoustic spectography of sustained vowel /ae/ (narrow-band 40 Hz) at assessment (top), after 2 months of therapy (middle), and after 6 months of therapy (bottom) (FonoView 1.0, CTS). 201

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for vowel /ae/ was reduced at 7 seconds. The intensity was estimated from a digital decibel sound pressure level (Realistic, RadioShack) with measurements obtained at 1 m from the mouth: habitual intensity was 56 dB, minimum 50 dB and maximum 64 dB, measures that clearly show limitations regarding the habitual and maximum values. The phonatory range of 7 semitones was notably reduced. 5. Laryngeal EMG. Electromyography is used to assist in the diagnosis of laryngeal nerves paralysis.22 In the case of patient P, the eletromyography exam was performed 5½ months following the total thyroidectomy. Results showed normal electrical activity of both superior laryngeal nerves and the right recurrent nerve. The left recurrent nerve had reduced activity with signs of acute denervation and reinnervation.

Description and Rationale for Therapy Approach Post-Thyroidectomy Vocal Fold Paralysis Vocal fold paralysis is probably the most frequent neurological problem seen in a voice clinic. The incidence of recurrent laryngeal nerve injury after thyroid surgery is reported to be from 2 to 7% despite a macroscopically intact nerve during the procedure.23–26 Immobility secondary to thyroid surgery can be transient or permanent and can be due to stretching, traction, compression, ligature entrapment, hematoma, thermal injury, electrical injury, and severing injury.25 Its presentation can vary significantly, and symptoms can include prob-

lems of voicing, breathing, swallowing, airway protection, and proprioception, some of which are described below. Dysphonia resulting from a unilateral paralysis after thyroid surgery is flaccid in nature and relatively constant. The position of paralyzed fold and edge configuration are important in defining vocal rehabilitation. The closer the vocal fold rests to the midline and the straighter the edge, the better the prognosis for improvement with vocal exercise. Potential compensations that may complicate the rehabilitation process include a shift to falsetto register, vestibular fold interference, tension in the neck, and muscle tension dysphonia. Lack of airway protection is the major concern and should have central attention during assessment. Other consequences of glottic incompetence are a sensation of breathing problems (with compensatory tachypnea), difficulties with body stabilization in physical activities, and phonatory restrictions such as soft voice, lack of voice projection, limitations in loud voice reading, vocal fatigue, singing restrictions, effortful phonation, intermittent laryngospasms, globus sensation, and nonspecific hoarseness.27,28 The otolaryngologist and speech-language pathologist must work as a team in the management of vocal fold paralysis, as voice therapy alone or surgery alone may prove ineffective in improving the voice to the desired level. Treatment Options and Recovery Patterns The decision for surgical or conservative (ie, behavioral) intervention is driven by patient perception of vocal handicap and the expectations of both the physician and speech-language

pathologist regarding potential treatment outcomes.27 Patients should see the speech-language pathologist soon after the otolaryngologist has diagnosed the paralysis to begin voice rehabilitation. If voice production improves, the patient may be dismissed from therapy. On the other hand, if improvement is not observed, the patient may be referred back for further surgical management.29 In many cases, therapy alone can result in reasonable improvement in patients with unilateral vocal fold paralysis and eliminate the need for surgical intervention.30 Our patient did not present with any swallowing difficulties except for occasional difficulty when drinking liquids too quickly. Thus, swallowing was not a primary clinical concern. The client did evidence a degree of respiratory instability and a sensation of not having enough air to speak. The patient was reassured by the speech-language pathologist that he was getting an adequate amount of air during quiet breathing, and his concerns over the status of his breathing were lessened. Usually spontaneous recovery can be obtained in 4 to 6 months after paralysis; however, in some rare cases recovery has been reported up to 3 years postinjury. When there is no aspiration, vocal rehabilitation is the primary target of treatment. Surgery usually is performed only after vocal rehabilitation failure.

Goals of Therapy The general goal of vocal rehabilitation is to reduce aspiration, to improve voice, and to avoid negative compensation (diplophonia, vestibular phonation, paralytic falsetto). The rehabilitation program is an active process, and


it requires a cooperative patient. The use of a variety of exercises, different vocal adjustment attempts, and good self-monitoring are some ingredients of successful therapy. The immediate goal after the assessment session is to explore vocal possibilities and to obtain the best possible voice, usually with a softer voice, frontal resonance, and a higher pitch being preferred. Maximum phonation time assessment can help as a predictor of success; a minimum of 4 seconds is usually required to have chances of positive results with vocal rehabilitation. There are 3 basic steps in the vocal rehabilitation for unilateral vocal fold paralysis: (1) to reduce transglottic airflow, (2) to increase vocal fold flexibility, and (3) to increase glottic resistance. Treatment for each of these goals is presented below. Goal 1: To Reduce Transglottic Airflow Rationale. Reducing transglottic airflow is an appropriate goal when the patient uses large amounts of air during speech. Patients with vocal fold paralysis show glottic incompetence and difficulties in controlling the air during phonation. This automatic attempt to increase vocal effectiveness may actually work only to exacerbate the loss of air and worsen the vocal problem.18 Several strategies can be used to help the patient to learn a new physiologic setting. For instance, facilitating sounds (ie, prolonged nasal bilabial “m . . . ” or labiodental “n . . . ”) or glottal attack training may help to produce a sharp onset of vocalization, thereby reducing airflow. In some cases, postural changes, with the head displaced to the contralateral side of the paralysis,

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can help as well. In the present case, patient P was instructed to turn his head to the right and to train repeated short “m” followed by repeated short syllables with the same vowel (“ma, ma, ma, ma” and “me, me, me, me” and “mi, mi, mi, mi”), first 1 syllable per breath, then increasing the number of units per breath group. If the patient presents a hypertonic compensatory muscle involvement, laryngeal manipulation should be used to reduce negative interference. Goal 2: To Increase Vocal Fold Flexibility Rationale. When the air leakage is not too high and the glottic chink is little, vocal fold flexibility is the main goal. Some patients with the vocal fold paralyzed at median position may not need to address goal 1 as described above and can move directly into this goal. Several strategies can be used such as modulated sounds (with nasal “m” or voiced fricatives “z” and “v”— it is important to highlight that these latter sounds require a better control) or small and large interval glissandi. After some frequency displacement control has been achieved, larger gaps can be introduced, even using register shifts, such as vocal fry versus high-pitch exercises. Several facilitating sounds such as nasal and voiced fricatives are recommended before vowels.

Goal 3: To Increase Glottic Resistance Rationale. Glottic resistance exercises are used when the voice is acceptable, yet an element of vocal fatigue remains. In this situation, there is usually complete glottic closure but with a short clo-

sure quotient. For achieving this goal, mild effort techniques such as interlocking hands and prolonged sound production can be used. Maximum phonation time exercises can be of great help. A short version of Vocal Function Exercises (VFEs)31 can be administered, and it is usually a good conditioning program for concluding the rehabilitation process. Another option is the Lee Silverman Voice Treatment-LSVTR,32 a program that shares some of the basic principles of the VFE. In the present case, interlocking hands and sustained vowel production were very important as fundamental frequency was instable. After mastering this task the patient was submitted to a 2-week VFE program, with positive results.

Summary of Rehabilitation Procedures Dysphonia was the primary concern of patient P and the central focus of the treatment. The role of therapy as the primary resource for treating patients with unilateral vocal fold paralysis or a coadjutant of surgery has not been well established,27 but it is usually seen as beneficial.28,30,33 The rationale for this case was to reduce translaryngeal airflow, to increase vocal fold flexibility, and to enhance glottic resistance. Patient P was highly collaborative and adherent to all requested procedures. For the first 2 weeks this therapy regimen was twice a week with 5 short sessions of exercises at home. For the following 2 months the patient was seen on a weekly basis and then every 2 weeks. At the close of therapy, all acoustic parameters had shifted to the normal range, and maximum phonation time had clearly increased. During the beginning of rehabilitation

the patient quickly learned to change his voice setting to a low loudness, front focus, and higher pitch production to appear less dysphonic. The use of short sentences helped him to reduce the sensation of having respiratory distress. The positive outcome was enough to avoid any surgical intervention for the present time.

Results of Therapy 1. Auditory perceptual. Patient P’s voice quality after therapy displayed the following CAPE-V scores: consistently negligible overall severity of dysphonia (13/100), with the same amount of roughness (15/100) and just noticeable degree of breathiness (3/100). Modal pitch and loudness were judged as normal (0/100). Asthenia was not present anymore (0/100). Phonatory breaks were not observed on any task. 2. Visual perceptual. A second evaluation was scheduled after 2 months of a series of weekly sessions (8 sessions). On this occasion, the glottal gap was reduced; however, the left vocal fold was still immobile. Voice had a marked improvement, and patient decided to continue with vocal rehabilitation. After 4 months, a new visual evaluation was performed, the gap was minimal, voice production was comfortable, and left vocal fold paralysis remained unaltered. A new control examination after 6 months showed an unaltered image. When reinnervation occurs, it typically is not observed before a 4-month period.34 It is important to highlight that morphofunctional analysis of the larynx cannot be directly related to


treatment results of patients with unilateral vocal fold paralysis. The patient’s voice was adapted after rehabilitation despite the vocal fold immobility.28 3. Self-assessment protocol. The V-RQOL was administered again after therapy, and results showed a remarkable improvement for the total score increased from 82.5 to 100% which clearly showed that there was no impact of the voice on any aspect of the patient’s related-communication quality of life. The patient did not show any perception of vocal handicap. A recent study that investigated the effect of voice rehabilitation on 40 subjects with unilateral vocal fold paralysis found significant improvement only in voice quality and quality of life,30 which reinforces the importance of investigating such aspects. 4. Acoustic analysis. Measures taken after 2 months of a series of weekly vocal rehabilitation sessions showed improvement on jitter, shimmer, irregularity, and noise component (see Table 4–3). The phonatory deviation diagram (the Gottingen Diagram) showed a closer to normal area distribution (see Figure 4–3). Spectrographic trace (see Figure 4–4) showed a higher number of harmonics, but the trace was irregular (FonoView 1.0, CTS), as was fundamental frequency. After 6 months, the harmonic component had markedly improved (even with some instability), and fundamental frequency trace was more straightforward. Maximum phonation time for vowel /ae/ increased up to almost 16 seconds, allowing normal connected speech at conversational level. The new dynamic range was

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expanded (dB meter, Realistic, RadioShack) and values were closer to normal; the habitual intensity was 62 dB, minimum 50 dB and maximum 98 dB. Phonatory range seemed to show the most marked improvement in the acoustical analysis, changing from 7 semitones to 24; interestingly, at the assessment session just these few semitones were produced with voicing, and as soon as the patient reduced the breathy component the range started to widen. Finally, although number of semitones is not a popular acoustic measure, it does appear to be a good outcome measure for vocal fold paralysis cases.28

Conclusions Vocal fold paralysis after cancer surgery can be seen at the voice clinic, and it is not unusual. However, this patient did not present with vocal fold paralysis soon after the procedure. He showed a rare case of cervical hematoma during the first 24 hours following surgery, and the signs and symptoms of laryngeal recurrent paralysis started only after 15 days. Patient P was submitted to vocal rehabilitation, and in spite of only a partial and minimal restoring of laryngeal movement (mainly at the arytenoid cartilage level), vocal function was considered normal, and the patient was fully satisfied with the results. Follow-up was recommended in this case, as the patient was 72 years old and the potential for presbyphonia negatively influencing the rehabilitated voice existed. Moreover, there was a possibility that his laryngeal nerve injury was transient and that the voice would improve further with time.

In this case study Maria Dietrich demonstrates how important it is to provide early solutions for patients with unilateral vocal fold paralysis to prevent the development of maladaptive vocal behaviors while maximizing vocal functionality in daily life.

Case Study 3 Maria Dietrich Treatment of Glottal Incompetence With Secondary Muscle Tension Dysphonia in a Patient With Unilateral Vocal Fold Paralysis

Case History History of the Problem The patient SS is a 39-year-old woman with a complaint of hoarseness post thyroid surgery who has been referred by her surgeon to a voice center for a voice evaluation. Patient SS underwent thyroid surgery for a large, benign mass 4 months ago and has struggled with a hoarse voice since. Her surgeon observed a unilateral vocal fold paralysis of the left vocal fold, which unfortunately persisted through her 3-months follow-up appointment. The voice disorder was deemed iatrogenic in nature and was linked to direct injury of the patient’s left recurrent laryngeal nerve during thyroid surgery. Abnormalities of the cricoarytenoid joint were ruled out. SS declined any voice problems prior to her thyroid surgery. At the time of her visit at the voice center, patient SS felt that her symptoms had gradually

worsened. Now her voice was not only extremely hoarse and weak but also associated with an increasing degree of vocal effort and frequent vocal fatigue. She also experienced periods of aphonia that occurred at the end of a speaking-intensive workday. Furthermore, she constantly felt she could not be heard and ran out of air during speech and also noticed shortness of breath with exertion. In addition, patient SS reported occasional swallowing difficulties with liquids, but she became more careful and was able to manage these difficulties. Medical History The patient’s medical history was unremarkable aside from her thyroid problems and thyroid surgery. She did not suffer from any diseases and did not have any previous surgeries or any sort of trauma to the head or neck. She rarely suffered from upper respiratory infections. She denied issues with allergies or reflux disease. Social History Patient SS did not smoke and used to exercise regularly. She reportedly drank about 960 mL (32 fl oz) of water per day and 2 cups of coffee or caffeinated tea per day. Patient SS was married with no children and worked in human resources for a medium-sized company. Her job was speaking intensive and included speaking one-onone, on the telephone, to small groups, or holding seminars with a few dozen employees. Prior to her thyroid surgery, she recalled occasional vocal fatigue, but she denied having had any longer lasting voice problems. SS relied on her voice for work, and she became increas-


ingly worried that she might lose or need to change her job due to her ongoing voice problems. Recently, there were a couple of occasions when she had to take a day off from work to recover from vocal fatigue. Furthermore, she stopped running and playing tennis because of shortness of breath. Overall, she became increasingly frustrated that her weak voice limited her participation in professional, social, and recreational activities.

Voice Evaluation Auditory-Perceptual The CAPE-V35 protocol was used to rate patient SS’s voice quality. Ratings were based on conversational speech, sustaining the vowels /a/ and /i/ and reading of sentences. SS could sustain vowels only for a maximum of 3 seconds. The following ratings refer to a visual analogue scale of 100 mm. The patient presented with a severe dysphonia (66 mm) consistently characterized by severe breathiness (80 mm), moderate roughness (36 mm), severe vocal asthenia (88 mm), and severe strain (66 mm). Loudness was severely reduced and pitch was rated mildly increased. Instrumental Visual-Perceptual. A videoendoscopic and videostroboscopic examination was performed of patient SS’s vocal folds with a 70-degree rigid endoscope and without the use of a topical anesthetic. The left vocal fold was immobile and fixed in the paramedian position (slightly off midline) causing an incomplete vocal fold closure pattern. The affected vocal fold had a severely reduced mucosal wave and vibrated

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only irregularly resulting in aperiodicity as seen on stroboscopy. A plane difference of the vocal folds was not seen. Furthermore, supraglottic medial compression of the ventricular folds was observed during phonation consistent with secondary muscle tension dysphonia (MTD) in response to the underlying glottal insufficiency. The vocal folds and posterior larynx were free of lesions and irritation, and function of the unaffected vocal fold was unremarkable. In agreement with the speech-language pathol ogist, the laryngologist suggested a vocal fold injection for the left vocal fold to provide short-term vocal improvement (eg, injection with Cymetra, acellular dermis). The procedure would improve vocal fold closure immediately by increasing the bulk of the paralyzed fold. Acoustic Analysis. Voice fundamental frequency (F0) during reading of the sentence “we were away a year ago” was 285 Hz and increased as compared to normative values matched for age and sex. The patient’s voice intensity was reduced with 50 dB SPL. Reliable values for jitter and shimmer could not be determined due to the stark presence of aperiodicity and noise in the signal (type 3 signal).36 The patient’s pitch and vocal intensity ranges were reduced at the top of the range. A pitch glide on /i/ was recorded (frequency range 87 Hz), and the patient was asked to produce /a/ as quietly and as loudly as possible (intensity range 23 dB SPL). Aerodynamic Assessment. Phonatory airflow and subglottic pressure was derived from intraoral pressure were assessed. The patient was asked to repeat /pi/ 5 times. Average phonatory airflow was 437.2 mL/s and subglottic

pressure was 11.4 cm H2O. Both values were increased in comparison to normative values matched for age and sex and indicative of glottal incompetence and secondary laryngeal hyperfunction. Patient Self-Assessment Patient SS’s total score on the Voice Handicap Index (VHI) was 88/120 indicating a severe voice disorder. Patient SS rated her vocal effort as 600 during conversational speech using direct magnitude estimation (100 equals comfortable amount of effort in voice, 300 equals 3 times as much effort, and so forth).

Voice Therapy The voice care team linked the vocal fold injection procedure with the request that patient SS undergo a course of voice therapy immediately postinjection. A vocal fold injection with Cymetra into the left membranous vocal fold was performed successfully with a direct laryngoscope under general anesthesia. The rationale for subsequent voice therapy was twofold. First, elements of voice production such as respiration, phonation, and resonance should be fine-tuned to optimize vocal function despite the underlying vocal fold paralysis. Second, carryover of vocal hyperfunction (secondary MTD) that developed as a compensatory response to glottal insufficiency should be eliminated considering adequate vocal fold closure by means of vocal fold augmentation. The patient’s work and private communication patterns were also modified to establish a functional voice for challenging situations where the patient was at risk for vocal hyperfunction due to residually compromised vocal endur-

ance and vocal power. The following treatment goals were addressed. To tailor a vocal hygiene program (goal 1): The patient will increase hydration to 1920 mL (64 fl oz) of water per day and modify speaking routines at work and at home to alternate vocal use and vocal recovery. Patient SS’s voice quality immediately improved as the result of the left vocal fold injection as did her vocal endurance. However, vocal endurance remained limited, which put her at risk for vocal fatigue. Moreover, SS was a professional voice user and as such was already at a higher risk for developing a voice disorder. SS was asked to create a weekly chart of all vocal times starting with the moment she would wake up to the time she went to bed. The schedule was discussed in detail and peak times of heavy voicing were identified with regard to both amount and type. The patient was advised to avoid any backto-back scheduling of vocally intensive meetings, to space out vocal demands across the week, to schedule quiet work times several times a day (eg, 30-minute to 1-hour blocks), to avoid large group sessions at the end of the day, and to allow for rest and recovery before, during (10 minutes), and after presentations of a duration of 1 hour or longer. Also, weekly charts would be reviewed where SS would mark times that were vocally difficult and times that were vocally successful. Eventually, SS found a work routine that was functional in daily life. In addition, her husband was involved early on to create a mutual understanding of the medical situation and the functional needs that have evolved. He attended the second therapy session during which the clinician asked SS to review her weekly chart and discuss positive and negative vocal


events to her husband and the clinician. When meeting with friends, the patient was advised to choose a location that did not tax her vocal system, such as a quiet restaurant. If she found herself in a noisy environment, she was advised to sit close to her communication partners and to limit the time she would speak over background noise. Finally, the patient was able to increase water intake to 1920 mL (64 fl oz) per day and to limit caffeine on speaking-intensive days. In addition, voice amplification was recommended for larger group presentations or whenever she anticipated vocal fatigue. To increase awareness and selfcorrection of excessive laryngeal muscle activity (goal 2): Through increased awareness of laryngeal function, patient SS will learn to default to easy and effortless flow phonation. She will practice progressive muscle relaxation for the face and neck to increase awareness of muscle activity in the laryngeal framework. The patient’s compensations for vocal fold paralysis included intralaryngeal and extralaryngeal excessive muscular activity that was directly linked to her experience of vocal effort and vocal fatigue. First, SS had to realize that she engaged in compensatory muscle behaviors and that postsurgery, such compensations would not be necessary and instead would be counterproductive. In other words, she was specifically asked to change her psychological mindset and attitude toward voicing. Her new visualization was supposed to be an easy and effortless voice. She liked the idea of this mindset so much that she decided to put up Post-It notes at work and at home reminding her of it. Progressive muscle relaxation was also practiced to make the patient aware of muscle tension in her face, neck, and

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upper body by increasing and releasing tension.37 Progressive muscle relaxation was performed at the beginning of each therapy session, and SS was asked to use them periodically throughout the day, particularly before any speaking engagements. Also, she was asked to mark on her chart how often she found herself “tensed up” and what the various triggers were. SS became efficient at monitoring her muscular behaviors. She noticed that she would automatically increase muscular tension when in “presentation mode” or when she was excited or annoyed about something. Last, but not least, SS was directed to focus on the interplay between airflow and voicing. Excessive tension at the level of the vocal folds was demonstrated by negative practice involving breath holding and voicing. The patient was a quick study and found a comfortable point of airflow and subglottic pressure in her voice that would support phonation. Flow phonation was then practiced using the hierarchical steps as described by Stone and Casteel38 progressing from sound through words to dialogue. To strengthen and balance vocal function using Vocal Function Exercises (goal 3): Patient SS will practice Vocal Function Exercises (VFEs) twice daily to learn an efficient interplay of airflow and phonation for voicing.39 A structured voice exercise program was essential to maximize vocal efficiency and to maintain therapy outcomes for a chronic voice problem. The patient was introduced to a routine of exercises geared toward exercising the entire vocal range and training an extreme forwardfocused voice production. The exercises used included lip trills and pitch glides and sustaining of vowels at different

pitches for as long as possible (VFEs are described in detail elsewhere). Over time, the patient could track her progress and noticed improvements in vocal power. The exercises were given to the patient on a CD for home practice, which helped the patient to follow the therapy program outside the therapy room. To use resonant voice as an efficient mode of voice production in spontaneous speech (goal 4): VFEs train an extreme vocal forward posture, but transfer to conversational speech sometimes remains a hurdle for patients. Making resonant voice a specific target in voice therapy will increase attention to resonant voice in daily life and will facilitate generalization of resonant voice to conversational speech. In other words, the patient should have an active role in using resonant voice in daily life. Resonant voice therapy is a well-known and well-researched voice therapy approach to produce a voicing pattern that is easy and efficient (ie, minimum phonatory effort to achieve a louder sound). Resonant voice was trained hierarchically starting with the experience of vibrations in the face and negative practice, stabilization of a basic humming gesture,39,40 and the progressive extension to syllables, all voiced phrases, sentences, and conversational speech. The patient did not find it difficult to produce resonant voice in isolation, but caught herself falling out of resonant voice during sentence production. With time, she became increasingly adept at switching back and forth between her regular conversational voice and resonant voice. Brief video and audio recordings of the patient during therapy with time for feedback helped to hone the patient’s vocal and auditory skills. A CD with resonant

voice exercises was created as well as video clips that demonstrated the exercises. In particular, the patient appreciated the video examples to model her own vocal performance at home. SS noticed that resonant voice remarkably improved her vocal endurance and voice quality and she was very pleased with the outcome.

Therapy Outcomes In total, patient SS participated in a total of six 45-minute therapy sessions over an 8-week period. The follow-up visit was scheduled 1 week after the last therapy session, which was 7 months after the thyroid surgery and 10 weeks after the vocal fold augmentation procedure.


Acoustic Analysis. Voice fundamental frequency (F0) was 220 Hz and found to be at the higher end of the normal range. The patient’s speaking intensity was within normal limits at 68 dB SPL. Values for jitter (1.2%), shimmer (0.3%), and noise-to-harmonic ratio (0.112) were overall within normal limits matched for age and sex. Furthermore, the patient’s frequency (160 Hz) and vocal intensity ranges (28 db SPL) improved. Aerodynamic Assessment. Phonatory airflow and subglottic pressure improved post-treatment. Average phonatory airflow rate was 275.4 mL/s and subglottic pressure was 8.0 cm H2O, which are still slightly high but improved from baseline.

Auditory-Perceptual


The CAPE-V protocol was used to rate patient SS’s voice quality. SS was now able to sustain vowels for a maximum of 16 seconds. The patient presented overall with a mild dysphonia (6 mm) and consistent impressions of mild breathiness (4 mm), roughness (7 mm), asthenia (2 mm), and strain (3 mm). Loudness and pitch appeared adequate.

Her total score on the VHI was 30/120 and indicative of a mild voice disorder. Patient SS rated her vocal effort as 150 during conversational speech using direct magnitude estimation. Overall, her voice quality and vocal comfort during speaking had improved significantly, and the patient was extremely pleased.

Instrumental Visual-Perceptual. The videoendoscopic and videostroboscopic examination confirmed the continued presence of a left vocal fold paralysis. However, the vocal folds achieved closure during modal phonation. The mucosal wave of the affected vocal fold was reduced, and vocal fold periodicity was still irregular. Significant secondary MTD characterized by supraglottic hyperfunction was not observed.

Summary and Concluding Remarks The outcome of voice therapy was excellent, and the patient was very pleased with the sound and feel of her voice. The vocal fold augmentation procedure prior to voice therapy improved vocal fold closure immediately, but ultimately the patient’s commitment to the treatment program helped her to better understand her vocal condition, to balance vocal function in therapy, and

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to monitor an easy and efficient voice in daily life. Approximately 6 months after the vocal fold injection, which was about 1 year after onset of vocal fold paralysis, a follow-up visit was scheduled that included laryngeal needle electromyography (EMG). The rationale was to evaluate the current status of innervation in the left vocal fold and to discuss long-term treatment options as the effect of the short-term vocal fold injection would have largely subsided. The instrumental evaluations showed that the left vocal fold paralysis persisted and that vocal fold closure was mildly incomplete. Therefore, the laryngologist suggested a permanent laryngeal framework surgery instead of a repeat vocal fold injection. The patient agreed, and a Gore-Tex medialization thyroplasty was performed. The intent of the surgery was to optimize the position and contour of the affected vocal fold by pushing the affected vocal fold medially. The surgery was performed with local anesthesia under sedation. The patient’s voice was monitored during surgery to find the optimal position for the implantation material through a window in the thyroid cartilage. One refresher voice therapy session was completed to monitor the patient’s adaptation to the medialization thyroplasty. Patient SS was able to maintain a forward-focused voice and was discharged from voice therapy. As the first 3 case studies of this chapter have demonstrated, there are multiple approaches for improving glottal insufficiency secondary to unilateral vocal fold paralysis. In the next case, Julie Barkmeier-Kraemer uses semi-occluded vocal tract methods with a 79-year-old patient presenting with this condition.

Case Study 4 Julie Barkmeier-Kraemer Use of Semi-Occluded Vocal Tract Methods and Resonant Voice Therapy to Treat Unilateral Vocal Fold Paralysis

History of the Problem Patient Q is a 79-year-old female with onset of voice loss 12 months prior to her voice evaluation. Patient Q reported her voice quality to be consistent throughout the day. However, she complained of a sensation of strain in her throat and fatigue after prolonged periods of talking beyond 20 minutes. On a scale from 1 (worst voice could be) to 10 (best voice), she rated her voice as a “5.”

Medical History The patient reported sudden onset of hoarseness associated with an upper respiratory infection 1 year prior to her voice evaluation. A local otolaryngologist evaluated her 11 months after onset and diagnosed her with left-sided vocal fold paralysis. Subsequent CT scan and MRI examination of the head, neck, and chest areas were completed to rule out the presence of a tumor. Normal findings were reported for both exams. No other medical or surgical history was reported. Patient Q confirmed a history of smoking one-half pack of cigarettes per day off and on in the past, completely quitting 8 years ago. Patient Q did not report problems with swallowing but did experience increased levels of reflux over the prior year for which Tums

appeared adequate for managing her symptoms. Patient Q was referred by her otolaryngologist for a voice evaluation and consideration of voice therapy to treat symptoms of excessive laryngeal tension and high-pitched voice production prior to a vocal fold medialization procedure.

Social History Patient Q lives with her husband and has 3 grown children who live in various locations in the northeast United States. She is typically a socially active person but reported that friends have difficulty hearing her during meals, at social events, or in places where there is background noise such that they appear to avoid talking to her at these times. Consequently, the voice problem makes it difficult for patient Q to converse or interact normally. It is also difficult for her to talk on the telephone due to difficulty projecting her voice and because she is embarrassed by her voice quality that she described as sounding like a hoarse “Mickey Mouse.”

Voice Evaluation Auditory-Perceptual Examination The CAPE-V35 is a perceptual rating scale of an individual’s voice completed by the clinician across various speaking tasks. These include sustained phonation of /a/ and /i/ for 3 to 5 seconds, sentence repetition, and spontaneous conversation in response to the request, “Tell me about your voice problem” or “Tell me how your voice is functioning.” The clinician judges the individual’s voice in terms of overall severity, roughness, breathiness, strain, pitch,


and loudness using a 100-mm visual analog scale generally categorized as ranging from mild to moderate to severe ratings. Specific ratings of patient Q’s voice quality are shown in Table 4–4. She was judged to exhibit abnormal amounts of breathiness, strain, reduced loudness, and an excessively high pitch throughout the speech tasks. These qualities, in addition to the intermittent occurrence of downward pitch breaks and diplophonia at lower pitches, gave the perception of a moderate to severely abnormal voice quality. Rigid Videostroboscopy Evaluation A 70-degree rigid videostroboscopic examination was completed to evaluate laryngeal function41 during sustained phonation at comfortable, low, and high pitches and at comfortable, soft, and loud levels of production. Throughout this examination, the left vocal fold remained immobile. During phonation at high pitches, vocal fold approximation and vibratory character istics appeared within normal limits. However, at comfortable and lower pitches, vocal fold approximation was incomplete. Diplophonia was perceived during phonation at low pitch and was associated with intermittent reducedamplitude aperiodic vibration of the left vocal fold. The immobile left vocal fold appeared flaccid and varied between aperiodic and periodic patterns of vibration at comfortable and low pitches. The right vocal fold exhibited normal amplitude of vibration and mucosal wave during phonation at all pitches. During loud voice production at comfortable pitch, the right vocal fold crossed midline and made brief contact with the immobile left vocal fold during the closed portion of glottal cycles.

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Table 4–4. Pretreatment and Post-Treatment Measures for Patient Q Measure

Pretreatment

Post-Treatment

Normal Values

50 mm (moderate-severe)

35 mm (moderate)

0

Roughness

0

0

0

Breathiness

10 mm (mild) all tasks

35 mm (mild-moderate) all tasks

0

Strain

35 mm (moderate) all tasks

0

0

Pitch


0

0



0

Downward pitch breaks

6 mm (mild) intermittently during sentences and conversation

0

0

Diplophonia (low pitches)


40 mm (moderate) all tasks

0

Normal

Normal

Normal

MPT

8s

11 s

15–25 s

s/z ratio

1.4

1.2

0.8–1.3

Laryngeal diadochokinetic rate

2.5

3

4–7 syllables/s

Average F0 during /a/

340 Hz

180 Hz

189 Hz (169–209 Hz)

HNR during /a/

10.2 dB

16 dB

20 dB

Spontaneous conversation F0

360 Hz

190 Hz

155–334 Hz

Conversational intensity

58 dB SPL

63 dB SPL

50–70 dB SPL

Maximum F0 range

400 Hz (100–500 Hz)

600 Hz (100-700 Hz)

978 [131 (±16 – 1109 (±189)]

Maximum intensity range

5 dB SPL (55–60 dB SPL)

15 dB SPL (55-70 dB SPL)

37 dB SPL (+3.67)

Consensus AuditoryPerceptual Evaluation of Voice (CAPE-V) Overall severity

Loudness

Resonance Acoustic

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Table 4–4. continued Measure

Pretreatment

Post-Treatment

Normal Values

Average airflow

0.35 LPS

0.22 LPS

0.1–0.2 LPS

Average intraoral pressure

8 cm H2O

7 cm H2O

6.4 (±1.9) cm H2O

23 cm H2O/LPS

32 cm H2O/LPS

29–47 cm H2O/LPS <18

Aerodynamic

Laryngeal resistance

Voice Handicap Index (VHI) Total score (out of 120)

62

14

Functional subscore (out of 40)

23

7

Physical subscore

30

7

Emotional subscore

9

0

The ventricular folds approximated at phonation initiation and then remained adducted, occluding three-quarters of the left vocal fold and one-half of the right vocal fold. A mild-moderate degree of anterior-posterior supraglottal squeeze occurred at comfortable and lower pitches. Thickened, white mucus was observed on the superior surface of both vocal folds at rest and migrated toward the vocal fold edges during phonation. Acoustic and Aerodynamic Measures As shown in Table 4–4, patient Q exhibited reduced maximum phonation time (MPT)42 and an elevated s/z ratio43 suggestive of impaired phonatoryrespiratory coordination and phonatory efficiency. Also of interest was a gradual decline in the maximum phonation time across 3 trials from 8 to 4 seconds suggesting that she experiences fatigue during repetition of a maximum voice performance task. Laryngeal diado-

chokinetic testing44,45 (repetition of a glottal stop paired with /a/ as quickly and completely as possible for 7 seconds) appeared labored and slow in a high-pitched voice. She was unable to perform this task in the lower pitch range. Patient Q also indicated that this task was difficult to perform due to the sensation of strain in the throat. These results support that the larynx did not valve adequately during phonation. Consistent with the perceptual evaluation, patient Q’s fundamental frequency was higher than expected and her intensity was lower than expected for an adult female46 (see acoustic results in Table 4–4). Furthermore, patient Q exhibited increased noise levels47,48 in her voice quality during sustained phonation as well as reduced maximum F0 and intensity ranges.49 Aerodynamic Examination Airflow and intraoral pressures were obtained during the vowel portion and

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consonant portion, respectively, during repetition of /pi/.50 Several practice trials were necessary before the patient could repeat this syllable in her lower pitch. Only four repetitions were produced at this pitch level for measurement due to excessive air escape during phonation. As shown in Table 4–4, patient Q showed elevated average airflow values and reduced laryngeal resistance51 consistent with observations of incomplete vocal fold approximation during phonation at comfortable and lower pitches during videostroboscopy. Finally, patient Q was observed to inhale, exhale, and then initiate speaking throughout the evaluation. Speech rate and phrasing were judged as normal. However, air replenishment occurred after phrase breaks rather than after completion of a sentence. Patient Self-Assessment The Vocal Handicap Index (VHI)52 was administered to determine the degree of impact patient Q’s voice problem had on her daily life. The VHI examines 3 areas of interest identified as functional, physical, and emotional. The individual must rate each statement on a 4-point scale (0 = “never” and 4 = “always”) indicating the degree to which each statement applies to him or her. A total score of 120 is the worst possible score, whereas a score of 0 is the best possible. Patient Q’s scores on the VHI indicated little emotional impact from her voice problem (see Table 4–4). However, the physical and functional subscores suggest a moderate to severe impairment due to her voice problem. Thus, patient Q’s score on the VHI indicated an overall moderate vocal handicap due to her voice disorder.

Voice Therapy Specific Type of Therapy Semi-occluded vocal tract technique53 and Resonant Voice Therapy.54 Rationale for Using This Approach Patient Q was diagnosed with unilateral vocal fold paralysis with aberrant vocal behaviors consistent with muscle tension dysphonia resulting in increased sensation of strain in her throat region with prolonged talking. The sense of strain likely resulted from 2 behaviors requiring excessive laryngeal muscle activation: high-pitched phonation and supraglottal squeeze. In addition to excessive laryngeal muscle activation, aerodynamic measures indicated that the larynx was excessively leaky. Voice treatment was designed to reduce muscle tension associated with high-pitched phonation and to improve phonatoryrespiratory coordination. The use of semioccluded vocal tract methods partnered with resonant voice therapy is hypothesized to facilitate reduced laryngeal tension, improved voicing efficiency, and transfer of these skills to conversation. Therapy Goals and Expected Outcomes Goal 1: Patient Q will reduce laryngeal tension and improve efficiency in voice production as evidenced by her selfreport of reduced effort and strain at a more typical pitch level during phonatory tasks. Goal 2: Patient Q will utilize her vocal tract to amplify her voice with reduced effort levels maintaining a more typical speaking pitch level during conversation.

Voice Therapy Methods Patient Q was instructed first on stretches to help elongate muscles that may be involved in tongue retraction and pharyngeal constriction. These included tongue stretches and yawn-sigh relaxation (Table 4–5). Next, she was instructed on a variety of semi-occluded vocal tract methods to determine which she could perform most successfully at the onset of therapy. Patient Q was most able to produce lip trills and phonation of /u/ into a drinking straw (largediameter, low-resistance tube). During the first 2 sessions, patient Q was instructed on sustaining phonation of lip trills at a comfortable pitch for as long as comfortable and then during upward and downward pitch glides to facilitate improved respiratory-phonatory coordination and flexibility in pitch use. Patient Q immediately produced her more typical pitch during these tasks and conveyed a sensation of reduced throat strain. During session 3, patient Q continued to progress semi-occluded vocal tract methods toward increasingly more difficult tasks by sustaining phonation using /v/ and continued with phonation of /u/ through the drinking straw. However, initiation of resonant voice therapy began through progressive constriction and then relaxation of lip, tongue, face, jaw, and throat muscles until patient Q achieved maximum sensation of a buzz around the lip region using the least sensation of effort during phonation of /m/. She was also instructed on sustained phonation of /n/ and /ŋ/ during comfortable phonation and then during pitch glides. During sessions 4 and 5, patient Q was progressed to practice sustained phonation of /v/ using more natural intonation patterns (see Table 4–5) and to produce


resonant voicing during sustained phonation of the nasal sounds upon request with self-correction. Resonant phonation was then progressed to production during chanting of the nasal sounds paired with vowels and then during production of single words, phrases, sentences, reading paragraphs, and then conversation during the remaining sessions (see Table 4–5). In addition, she was progressed to a low-diameter, highresistance straw (ie, coffee stirring straw) starting in session 6. Tongue and throat stretches were continued throughout all treatment sessions. Finally, patient Q was recorded during her accurate production of all voiced tasks at the end of each session so that she could take an audio CD recording of the therapy exercises home to use during daily practice. An exercise log providing a summary of the exercises with a weekly chart to log her daily practice was also provided to patient Q. Frequency and Duration of Treatment Patient Q completed 8 weekly therapy sessions over the course of 2 months. She also returned for a follow-up session 3 months after completion of voice therapy. Post-therapy measures reported here were completed during the eighth therapy session.

Therapy Outcomes Auditory-Perceptual Examination The CAPE-V was readministered. As shown in Table 4–4, patient Q showed a reduction in overall severity due to her shift to a more normal pitch level resulting in increased breathiness and diplophonia, but absent pitch breaks, the “Mickey Mouse” voice level, and strain.

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Table 4–5. Patient Q’s Activities Across 8 Voice Therapy Sessions Treatment Task

Method

Sessions 1–2 Tongue stretches

Stretch your tongue by trying to touch your tongue tip to your chin. Hold for a count of 10. Next, stretch your tongue by trying to touch your tongue tip to the roof of your mouth while holding your jaw open. Hold for a count of 10.

Yawn-sign relaxation

Take a deep breath and yawn and sigh at the same time. Repeat 5 times.

Semi-occluded vocal tract task: Lip trills

Comfortable pitch, upward and downward pitch glides (repeat 5–10 each trial)

Semi-occluded vocal tract task: Sustain /u/ into drinking straw


An exercise log sheet and audio CD recording were provided to patient Q to take home and use during her home practice.

Instructed to practice these exercises twice daily at home

Session 3 Tongue stretches

Stretch your tongue by trying to touch your tongue tip to your chin. Hold for a count of 10. Next, stretch your tongue by trying to touch your tongue tip to the roof of your mouth while holding your jaw open. Hold for a count of 10.

Yawn-sigh relaxation

Take a deep breath and yawn and sigh at the same time. Repeat 5 times.

Semi-occluded vocal tract task: Sustain phonation of /v/




Resonant phonation of /m/, /n/, and /ŋ/ using sustained phonation during progressive tension and relaxation of the lips, tongue, face, jaw, and throat muscles to achieve maximum resonant buzzing at the lips with minimal effort




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Table 4–5. continued Treatment Task

Method

Sessions 4–5 Continue tongue and throat stretches Semi-occluded vocal tract task: Sustain phonation of /v/

Practice this phonation technique while producing intonation patterns for such phrases as, “Hi! How are you?” “Where were you yesterday?” “What would you like for dinner?”



Resonant phonation of /m/, /n/, and /ŋ/ upon instruction


Resonant phonation chanting of /m/, /n/, and /ŋ/ paired with vowels and repeated at comfortable pitch

Chant /mu-mu . . . /, /ma-ma . . . /, /mo-mo . . . / while maintaining the resonant voice production. Repeat chanting these syllables substituting /n/ and /ŋ/ for the /m/. Chanting should aim for more than 2 to 3 repetitions approximately 1 syllable per second.

Resonant phonation of single words

Resonant voicing during production of “mom,” “moon,” “mine,” “noon,” “ming,” and “man”



Sessions 6–7 Continue tongue and throat stretches Semi-occluded vocal tract task: Sustain /u/ into coffee stirring straw (low diameter, high resistance)


Resonant phonation of single words

Resonant voicing during production of “mom,” “moon,” “mine,” noon,” “ming,” and “man”

Resonant phonation of phrases

Practice achieving resonant phonation during production of phrases loaded with nasal sounds: “Many more may know,” “Morning moon,” “Kneeling nanny,” “Mountains of money,” etc. Next, expand to phrases with fewer nasal sounds to generalize resonance to more typical speech (eg, “Helpful hammers,” “Making cupcakes,” “Animals walking.”

Resonant phonation of sentences

Expand length of utterances into sentences loaded with nasal sounds and then to more typical sentences. continues 219

220



Method



Sessions 7–8 Continue tongue and throat stretches Semi-occluded vocal tract task: Sustain /u/ into coffee stirring straw (low diameter, high resistance)


Resonant phonation during paragraph reading

Practice resonant voicing during reading of a paragraph. This can either be a standard passage, or a paragraph patient Q selects from a book she is reading, or the newspaper. During initial practice, it may be important to mark phrases where she should stop to replenish her air supply. She should gradually become more independent in sensing the need for more air and her own success in maintaining the sensation of forward voice focus resulting in the buzz at the lips with least effort.

Resonant phonation during conversation

Patient Q should practice maintaining resonant voice production during conversation starting with 1–2 minutes of conversation during the therapy session. Increasing duration of focus on daily conversations can also be assigned for outside of the therapy session until she feels confident and comfortable maintaining this method independently.



Thus, although breathiness and diplophonia remained as significant features of patient Q’s voice problem, the overall score on the CAPE-V indicated improvement.

Rigid Videostroboscopy Evaluation The videostroboscopic evaluation demonstrated that the left vocal fold remained immobile as during the first

recording. The patient was able to produce pitches at low, comfortable, and high levels as well as soft, comfortable, and loud levels on instruction. The primary change in observations from the first evaluation was the reduction in supraglottal activation and the degree of contact between the mobile and immobile vocal fold during comfortable and loud phonations. During comfortable pitch and loudness, the mobile vocal fold crossed midline and approximated with the immobile vocal fold, although contact time appeared brief. During loud phonation, contact time between the vocal folds approached normal limits (almost half of the glottal cycle duration). The left ventricular fold appeared moderately hypertrophied. However, ventricular fold adduction did not occur at onset of phonation, and anteriorposterior supraglottal squeeze was not observed. These findings demonstrate improved laryngeal efficiency. Acoustic Measures As shown in Table 4–4, improved phonatory-respiratory efficiency was evidenced through improved MPT and s/z ratio measures. Laryngeal valving remained impaired as evidenced by air leakage during production of laryngeal diadochokinetic testing. In addition, improvements were demonstrated in fundamental frequency and intensity averages and ranges (see Table 4–4). The degree of noise present in patient Q’s voice was also significantly reduced. Aerodynamic Measures The patient was able to produce all 7 repetitions of /pi/ required for standard measurement. As shown in


Table 4–4, average airflow remained slightly elevated; however, laryngeal resistance was measured to be within normal limits for adult females. VHI Patient Q’s scores on the VHI changed significantly. As shown in Table 4–4, her scores show that there are still some functional and physical issues associated with her voice disorder, and no emotional issues. Her total score on the VHI changed from 62 to 14 points. A therapeutic effect requires a change in score of 18 points or greater. Thus, a total score change of 48 points indicates a significant improvement.

Summary and Concluding Remarks Patient Q was diagnosed with left-sided unilateral vocal fold paralysis and initially adapted to the impaired ability for her larynx to generate symmetrical resistance during phonation by speaking at a higher pitch and using increased squeezing of laryngeal supraglottal muscles. Her breathing pattern was also affected as patient Q quickly ran out of air due to excessive leakage of air during phonation due to impaired vocal fold approximation. She expressed difficulty being heard and experienced significant throat strain associated with an elevated pitch patient Q described as sounding like “Mickey Mouse” with frequent downward pitch breaks. Through the use of semi-occluded vocal tract methods and resonant voice therapy, patient Q was able to achieve more efficient phonation at a lower pitch that was closer to her normal voice, although

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it was more breathy. At the end of voice treatment, the patient achieved more normal levels of laryngeal resistance and significantly reduced self-report of voice handicap. Her speaking voice was more functional overall and remained that way during her 3-month follow-up session. Inspiratory and expiratory muscle strength training has been used for a variety of respiratory compromising conditions. In the following case, Bari Hoffman Ruddy, Christine Sapienza, Erin Silverman, and Henry Ho describe the use of expiratory muscle strength training in a patient with unilateral vocal fold paralysis secondary to chemotherapy/radiation.

Case Study 5 Bari Hoffman Ruddy, Christine M. Sapienza, Erin Silverman, and Henry Ho Use of Expiratory Muscle Strength Training in a Case of Unilateral Vocal Fold Paralysis 4 Years Post Chemotherapy/Radiation The 77-year-old female described in this case history presented with a complex medical history including unilateral vocal fold paralysis with onset 4 years following radiation therapy for a nasopharyngeal squamous cell carcinoma (SCCA). Specifically, the left true vocal fold was paralyzed in the paramedian position. Presenting symptoms included significant glottic insufficiency, dysphonia, and dysphagia.

Case History Remote History This patient has a history of T4N1MO SCCA arising from the left nasopharynx but initially presented to the otolaryngology office with complaints of rightsided left ear pressure and left nasal congestion with intermittent left-sided epistaxis. The patient denied any significant past medical history and reported that she was a lifelong nonsmoker. Initial examination using a flexible endoscope revealed an exophytic mass on the left side of the nasopharynx, completely engulfing the eustachian tube orifice and extending into the nasal cavity. The mass did not appear to cross midline and did not extend into the oropharynx. No abnormalities of the base of tongue or epiglottis were observed. The true vocal folds were mobile bilaterally as determined during laryngostroboscopy. The patient underwent biopsy of the nasopharyngeal mass which revealed undifferentiated SCCA of the left nasopharynx. Chemoradiotherapy was immediately ordered, and subsequently completed, by the patient. History Post Radiation Therapy (4 Years Later) Upon presentation to the otolaryngology office, the patient noted a marked change in vocal quality, beginning 4 years post radiation therapy. Specific complaints included weak voice quality, difficulty producing a loud/audible voice, severe breathiness, vocal strain due to compensatory behavior required for any phonatory task, swallowing difficulty, unproductive cough, and choking on thin liquids. The results of rigid


laryngostroboscopy revealed a complete paralysis of the left true vocal fold in the paramedian position. The right true vocal fold appeared to move normally. During attempts at phonation a spindle-shaped pattern of vocal fold closure was observed. Substantial, bilateral pooling of secretions in the pyriform sinus was also noted with penetration of these secretions into the posterior glottis during inspiration. During attempts at phonation, severe compression of the ventricular folds was observed, at times obscuring the full view of the vocal folds. Medialization thyroplasty was completed in order to address the observed glottal incompetence. The procedure required local monitored anesthesia care and hospitalization for heparinization with discontinuation of Coumadin preoperatively. Postoperatively, the patient

experienced only slight improvement in clinical symptoms relating to glottal insufficiency. A repeat rigid laryngostroboscopy revealed continued glottal incompetence, minimal improvement in glottal closure, a moderate midmembranous opening, and persistent excess secretions within the pyriform sinuses bilaterally. Furthermore, the patient reported worsening dysphagia symptoms including hospitalization for aspiration pneumonia. Due to the patient’s cardiac history and declining health status, she was a poor candidate for procedures requiring general anesthesia. She was also not considered a candidate for repeat medialization thyroplasty. Consequently, injection of Radiesse was recommended and completed by the patient’s otolaryngologist (Figure 4–5). She was also referred to a voice pathologist for evaluation and treatment.

Figure 4–5. Injection of Radiesse.

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Voice Evaluation (Post RadiesseTM Injection)

Laryngeal Examination Post Radiesse Injection

Patient Self-Assessment As a standard part of a case history, the Voice Related Quality of Life (VRQOL) index was used.17 The VRQOL assesses an individual’s perception of vocal function relative to activities of daily living and quality of life variables. Patients rate vocal symptoms none (not a problem) to as bad as it can be. This patient scored a 30 out of 50 indicating voice-related communications were self-perceived as moderately impaired. The Swallowing Quality of Life Questionnaire (SWALQOL) was also administered. The SWAL-QOL was used to evaluate the patient’s quality of life as it relates to swallow function.55,56 This tool includes questions regarding both the oral and pharyngeal phases of swallow as well as appetite, eating duration, and other factors affecting swallow function. The patient’s responses to the SWAL-QOL were suggestive of major impact in the domains of fear, mental health, social function, and overriding quality of life.

Repeat rigid laryngostroboscopy revealed continued left true vocal fold paralysis post injection. The right true vocal fold appeared to be moving normally. An incomplete closure pattern was observed during phonation with persistent, opening in anterior commissure area. Just as prior to injection, substantial pooling of secretions in the pyriform sinus was observed bilaterally. Laryngeal hyperfunction was once again observed, however compression of the false vocal folds was improved relative to pre-injection. These findings were consistent across vocal tasks including comfortable effort and attempts to increase vocal loudness. Aerodynamic Evaluation (Pre and Post Radiesse Injection) Measures of voluntary cough airflow were obtained approximately 30 minutes before and after the Radiesse injections (Table 4–6). Airflow produced during the voluntary cough production

Table 4–6. Change in Voluntary Cough Airflow Measures Pre to Post Radiesse Injection and EMST Intervention CPD (Msec)

EPRT (Msec)

EPPF (L/s)

CVA (L/s/s)

Pre-injection

0.91 (0.17)

0.16 (0.01)

2.7 (0.13)

17.0 (2.8)

Post-injection

1.3 (0.16)

0.18 (0.01)

3.4 (0.52)

24.3 (3.5)

Percentage change

42%

13%

25%

43%

Post EMST

0.17 (0.17)

0.25 (0.03)

3.7 (0.46)

30.1 (4.1)

Percentage change

31%

38%

9%

24%

was sampled using an oral pneumotachograph (MLT 1000, ADInstruments, Inc) connected to a spirometer (ML141, ADInstruments, Inc.). A nose clip was placed to occlude nasal airflow during the cough maneuver. The airflow signal was measured and digitized at 1 KHz and displayed using Chart, version 5 for Windows. Each airflow sample was low-pass filtered at 150 Hz within the Chart software program. The signal was calibrated using a known volume (2 L) and imported into the software program. The instructions given to patients during the voluntary cough maneuver included: (1) relax and breathe into the pneumotachograph tube (held by the researcher); (2) following 3 tidal volume breaths, “take a deep breath and cough hard.” The patient completed at least 3 trials of voluntary cough into the pneumotachograph measurement system. The following measures were derived from the cough flow waveform (Figure 4–6): 1. Compression phase duration (CPD): the time from the end of the inspiratory phase to the beginning of the expiratory phase 2. Expiratory rise time (EPRT): the time from the beginning of the expiratory phase to the peak expiratory flow

Figure 4–6. Cough flow waveform.


3. Expiratory phase peak airflow (EPPF): the peak airflow during the expiratory phase of the cough 4. Cough volume acceleration (CVA): EPPF/EPRT. Four weeks postinjection, expiratory muscle strength training (EMST) was implemented as part of the overall behavioral intervention protocol. In addition to EMST, strategies to enhance vocal fold adduction and assist swallowing function were introduced to the patient and explicitly trained over the ensuing weeks. The rationale for the use of EMST is its known effects on increasing expiratory force pressure generation, vocal fold adduction, and for increased expiratory flow rates during voluntary cough production as well as cough volume acceleration rates.57 The current literature document the known shared brainstem control of cough and swallow as airway protection mechanisms.58 For this patient a focus on both cough and swallow function was considered essential for achieving the desired physiological outcomes of enhanced airway protection. Two main physiologic principles underlie the concept of strength training. First, the exercise stimulus must elicit a change in muscle function. This is referred to as “stimulus intensity” and usually is defined in terms of the amount of load (or weight of load) and duration of the exercise task. Second is the “frequency” of the exercise stimulus, which usually is defined in terms of how many times the exercise is performed (minutes per day/days per week/total weeks). For this patient, EMST was applied 5 days per week for 4 weeks at a pressure threshold setting of 75% of maximum expiratory pressure

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(MEP). MEP was measured through use of a Micromedical digital manometer. Based on a standardized protocol for obtaining MEP, the patient was instructed to stand and occlude her nose with the nose clips. MEP measurements were completed using the pressure manometer coupled to a mouthpiece via 50 cm, and 2-mm inner diameter tubing, with an air leak created by a 14-guage needle. The device was placed between her lips and behind her teeth. She was then instructed to inhale as deeply as possible and blow into the manometer mouthpiece quickly and forcefully. Three values within 5% of each other were required to achieve an average for her individualized MEP score.59 After clinician instruction on how to use the EMST device, patient compliance was manually logged, by the patient, on a form provided by the clinician.

Summary This case illustrates the complexities inherent to treatment of older patients with complex medical comorbidities including cardiovascular disease which stood as a contraindication to the preferred (surgical) gold standard remediation for glottal incompetence. Following a thyroplasty, injection of Radiesse was used to improve vocal fold adduction. The injection was then followed by a multifocal behavioral intervention with simultaneous targeting of voice, cough, and swallow function. EMST was selected to increase expiratory force generation while enhancing the ballistic characteristics of voluntary cough. For this challenging patient, this protocol was successful as judged by perceptual outcomes and laryngoscopic and aerodynamic measures illustrative of vocal fold physiology and airway dynamics.

Evidence-based treatments for symptoms of unilateral superior laryngeal nerve paralysis are lacking. Bruce Poburka discusses the current medical, surgical, and behavioral interventions for this condition as well as the case of a 20-year-old music major who presented with this condition.

Case Study 6 Bruce J. Poburka Brief Discussion and Case Presentation of Treatment for Superior Laryngeal Nerve Paralysis Using Medical, Surgical, and Behavioral Interventions Compared to recurrent laryngeal nerve (RLN) paralysis, considerably less attention has been paid to cases involving the superior laryngeal nerve (SLN). This is likely due to the fact that clinical manifestations of SLN paralysis are more subtle than RLN paralysis; often causing it to be overlooked.60 The SLN is a branch of the vagus (Xth) nerve, and its external branch innervates the cricothyroid (CT) muscle. When contracted, the CT exerts tension on the vocal folds and increases the fundamental frequency.61 The SLN may incur damage from trauma, viruses, high vagus nerve lesions, and iatrogenic causes.62 The following discussion summarizes diagnostic findings and treatment strategies for SLN paralysis.

Diagnostic Findings Auditory perceptual signs and patient complaints associated with SLN paral-

ysis have been reported to be mild to moderate in severity. They include mild breathiness, mild dysphonia, volume disturbance, fatigue, reduction of fundamental frequency range, and loss of upper register. Some studies reported that patients exhibited signs of strain and muscle tension, which were thought to be compensatory in nature.63 Studies using acoustic assessment to evaluate the effects of SLN paralysis yielded mixed results. Robinson et al64 reported increases in jitter, shimmer, and noise-to-harmonic ratio (NHR). Roy et al65 found modest increases in jitter only, but no significant changes in NHR or shimmer. Both studies reported reductions in fundamental frequency range. Interestingly, Roy65 found fundamental frequency “compression,” meaning that range was reduced on both the high and low ends of the range. A variety of endoscopic findings have been reported for SLN paralysis, but history reveals a long-standing lack of agreement over which laryngeal signs are most useful for identifying SLN paralysis.66 Among the reported findings are amplitude and phase asymmetry, a shift or rotation of the posterior glottis toward the paralyzed side, vertical level differences, mild vocal fold bowing, hypomobility or lack of brisk adduction/abduction, and rotation of the larynx.62,63,67 These observations were reported from a variety of clinical settings involving patients who varied with regard to time postonset and use of compensatory behaviors. In a study designed to identify specific voice tasks and laryngeal signs that may reveal CT dysfunction in its acute phase, Roy et al66 induced SLN paralysis in 10 otherwise vocally healthy subjects using lidocaine block. Their findings showed no consistent


evidence of hypomobility or axial rotation of the larynx. The most robust finding was for deviation of the petiole of the epiglottis toward the weak side. Not surprisingly, high-pitched vocal tasks were found to be most helpful in revealing laryngeal dysfunction associated with CT denervation.

Treatment Treatment options for SLN paralysis include pharmacological, surgical, and behavioral methods. Corticosteroids and antiviral medications have been used in the first 2 to 3 weeks postonset.63 Beyond that time, observation and behavioral intervention are most commonly used. However, Nasseri and Maragos62 reported a surgical solution in which Isshiki type IV thyroplasty (cricothyroid approximation) is combined with type I (medialization) thyroplasty. After using this approach on 9 patients, the authors concluded that the cricothyroid approximation surgery corrects differences in vocal fold height and cover tension, whereas the medialization procedure improves acoustic power which was reduced when the type IV procedure was used alone. Behavioral intervention strategies offer an important element in the management of SLN paralysis. A review of the literature revealed that most therapeutic approaches involved patient education, improvement of vocal function, elimination, or prevention of vocally abusive compensatory behaviors, and exercises to increase the fundamental frequency range. These exercises included gentle upward and downward glissandos.63,67 It was stressed that in performing these exercises, care should be taken to avoid strain or other hyperfunctional behaviors. Finally, in cases where the

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patient is a singer, collaboration with a singing teacher was recommended.68 In the following case, a singer diagnosed with superior laryngeal nerve paresis is discussed. This case involves many factors that were discussed above in relation to diagnosis and treatment of SLN paralysis.

otolaryngology and speech-language pathology services. Evaluation procedures included laryngeal videostroboscopy, auditory-perceptual assessment, an abbreviated oral mechanism exam, hearing screening, and selected maximum phonatory performance tasks. Videostroboscopy

Patient History Patient U, a 20-year-old female college student majoring in vocal music education, was referred to the clinic following a visit to an otolaryngologist who made a diagnosis of left superior laryngeal nerve (SLN) paresis. She began experiencing vocal difficulties several months earlier after a virus caused an extended period of laryngitis. After a slow return of her voice, her residual complaints included mild to moderate hoarseness, a reduction in her fundamental frequency range, a tense throat on extended speaking or singing, and pain in the laryngeal area; especially when attempting to sing high notes. Her vocal music education major required a considerable amount of singing, which amounted to approximately 2 to 3 hours per day on average. Patient U was working with a vocal instructor who also noted changes in vocal quality and a reduction in vocal range. With the exception of the severe viral infection, patient U’s medical history was otherwise unremarkable. She was careful to maintain hydration by drinking 1 to 2 L of noncaffeinated beverages per day. She exercised regularly and did not talk during exercise activities.

Evaluation Procedures Patient U’s evaluation involved 2 separate clinics, and she was seen by

The videostroboscopic examination revealed mild asymmetry of vibration with the right vocal fold slightly leading the left. Furthermore, muscle imbalance was observed that indicated SLN paresis. Specifically, the larynx was noted to rotate toward the left side. Vocal fold mobility and mucosal wave were excellent, and there was no evidence of vocal fold lesions, infections, edema, or erythema. Auditory Perceptual Patient U’s vocal quality was judged to be somewhat breathy with mild hoarseness. Vocal fry was observed frequently and appeared related to reduced breath support. Other observations included reduced jaw opening and a lack of oral resonance. This diminished her ability to project the voice across larger spaces. There was no evidence of nasal resonance problems. Vocal Performance Tasks Maximum phonation time averaged 13.5 seconds across 2 trials. She was able to sing notes across 1.5 octaves, which was reduced compared to her normal vocal range. Patient U was asked to sing a choral piece as part of the voice evaluation. During singing, she demonstrated improvements in breath support, vocal quality, loudness, and projection. This revealed a discrepancy when compared

to the vocal technique she used during her conversational speech. Oral Mechanism/Hearing Screens An abbreviated oral mechanism examination revealed normal structure and function. Range of motion, strength, speed, and coordination were normal. Glottal adduction on voluntary cough was excellent. Connected speech was normal with regard to articulation and prosody. Speech intelligibility was judged to be 100%. A pure-tone hearing screening was passed in both ears at 500, 1000, 2000, and 4000 Hz.

Impressions The clinician’s impression was that patient U developed several compensatory behaviors in the wake of her long bout with laryngitis and the vocal changes that resulted from SLN paresis. These behaviors may have developed as a result of trying to “make the voice work” despite its impaired condition. Additionally, after observing her vocal behaviors, it was thought that patient U assumed that her voice needed “protection” and that she was “scaling back” her normal approach to voice production. This impression was compatible with the observations of reduced breath support, fry, and restricted oral cavity opening. Furthermore, the compensatory use of muscles may explain the sensation of tension and pain in the laryngeal area during extended speaking and singing situations. Although SLN paresis certainly could account for some of her complaints, the clinician felt that maladaptive compensatory behaviors could explain several of her symptoms and complaints. Finally, it appeared that


patient U was more likely to use these undesirable compensatory behaviors during conversational speech compared to singing.

Description and Rationale for Therapy Approach It was felt that the compensatory behaviors that patient U used were compounding any residual dysfunction associated with her SLN paresis and possibly creating new problems such as vocal fry, reduced projection, and the sensations of tension and pain. Accordingly, a treatment plan was developed to: (1) provide patient education about SLN paresis and laryngeal function in general, (2) restore more normal use of breath support, (3) increase oral cavity opening and anterior oral focus, and (4) promote relaxation in the laryngeal area. It was felt that these changes would promote more stable vocal fold vibration, enhance resonance and projection, and reduce uncomfortable sensations. The therapeutic approach was somewhat eclectic and included work on speech breathing as well as elements of Resonant Voice Therapy.40,69 Goal 1 Patient U will demonstrate a basic understanding of normal laryngeal function as well as how SLN paresis may impact voice production. This will be measured informally in conversations with patient U. Rationale. Basic education about laryngeal function and SLN paresis was provided for 2 main reasons. First, because U was a vocal music major, it was thought that she could benefit from

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having this information as part of her academic preparation for a career in singing. Second, because U seemed to be compensating and “protecting” her voice, it was thought that she might better understand the nature of SLN paralysis, and that protecting the voice was not necessarily needed for continued recovery and that the compensations may even be counterproductive. Procedure(s). Patient education was accomplished by discussing the main laryngeal structures and how they interact with the airstream to produce the voice. The conversation emphasized that in order to accomplish efficient and optimal voice production, there must be a proper balance among laryngeal muscle forces, respiratory support, and use of the oral cavity as a resonator. This ideal configuration was compared to the voice use patterns that patient U exhibited during the evaluation. As a result of this discussion, patient U gained valuable insight into what was causing her voice problems, and she began to understand the rationale for the specific therapeutic goals that were developed for her. The patient education discussion also included specific information about the superior laryngeal nerve and its role in voice production. Simple terminology was used to convey that this nerve supplies a key muscle (cricothyroid) that plays a significant role in fundamental frequency range as well as plays a role in normal voice production. This information was linked to patient U’s diagnosis of superior laryngeal nerve paresis and to her complaints of reduced fundamental frequency range and mild dysphonia.

Goal 2 Patient U will use optimal breath support during spontaneous conversations

outside the clinical setting with 90% success as judged by the clinician and/ or client report. Optimal breath support was defined as a moderate-sized breath, abdominally focused, and sustained through the end of the utterance. Rationale. This goal was established to eliminate vocal fry, improve loudness control, and help eliminate muscle strain associated with talking beyond a normal breath supply. Procedure(s). Instruction for optimal breathing included focusing on the abdominal area, sensing the ideal lung volume for initiating an utterance, using relaxation pressure, supporting the voice later in the utterance, and sensing when to pause for another breath. The clinicians used the term abdominal area breathing instead of diaphragmatic because it is easier for clients to identify and monitor that part of body. Patient U was instructed to keep the upper chest relaxed and focus on the abdominal area expanding outward during inhalation. To facilitate use of proper lung volume, patient U was encouraged to make a mental note of the physical sensation of taking in a breath that was slightly deeper than she would use for a quiet/ resting breath. This sensation was called just full. This helped her to consistently inhale a proper amount of breath before each utterance. Patient U was made aware of the concept of relaxation pressure and its value in helping to support the voice early in the utterance. By allowing relaxation pressure to do some of the work of driving the vocal folds, she could focus on relaxing the laryngeal area. Next, instruction focused on managing breath support later in the utterance and identifying when to pause for a new breath. To accomplish this, patient U was instructed to sustain


a vowel by first simply “releasing” her air (and use relaxation pressure to support the voice). As relaxation pressure diminished, the voice was supported with gentle abdominal compression until she neared the end of her breath supply. The sensation she felt as her air supply was diminishing was called just empty. To summarize, optimal breathing involved starting the utterance when just full, using relaxation pressure early, supporting with gentle abdominal compression later, and finally pausing for a new breath when she felt just empty.

finally coordinated onset was modeled so that the onset of both airflow and voicing coincided. Patient U was given ample opportunities to learn coordinated voice onset using vowel-initial words. The procedure to habituate use of a relaxed laryngeal area and relaxed phonation relied in part on use of imagery and modeling of relaxed voicing, but it relied most heavily on use of stimuli and tasks to promote a focus on using anterior oral resonance (see procedures for goal 4 below).

Goal 3

Patient U will use optimal oral resonance during spontaneous conversation outside the clinical setting with 90% success as judged by the clinician and/ or client report. Optimal oral resonance was defined as using moderate mandibular movement and anterior oral focus of resonance during speech.

Patient U will use optimal phonation technique during spontaneous conversation outside the clinical setting with 90% success as judged by the clinician and/or client report. Optimal phonation technique was defined as using a coordinated onset, relaxed phonation, and a relaxed laryngeal area during speech production. Rationale. This goal was intended to eliminate muscle fatigue and/or strain associated with patient U’s use of compensatory techniques to protect her voice, such as “holding back” her voice while speaking. It is important to note that in this case, muscle strain was not associated with pressed voice or hyperadduction, but rather with holding the larynx in a “posture” or inhibiting normal function. Procedure(s). In order to teach the concept of coordinated onset, different voice onset patterns were demonstrated. These included a breathy onset, in which airflow preceded voice onset; hard glottal attack, where glottal closure preceded the onset of airflow; and

Goal 4

Rationale. This goal was developed to increase oral cavity opening and to promote optimal tuning of the oral cavity as a resonator. Secondarily, it was felt that this goal might promote laryngeal relaxation by directing the patient’s mental focus away from the larynx. Procedure(s). To encourage use of a more open oral cavity during speaking, patient U was asked to make a mental note of what it felt like to hold the jaw in 3 different positions: clenched, released, and pulled down. She was instructed to think about her jaw varying in openness from somewhere around the “released” position and to avoid the extremes of “clenched” and “pulled down.” She was encouraged to think of the jaw as being “released and free to move.” To habituate the use of anterior oral resonance, a hierarchy of tasks was

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developed using CV syllables, words, phrases, sentences, and paragraphs that were loaded with the /m/ phoneme. Initially, U was asked to send the voice to the lips while producing a sustained /m/ and to note the physical sensation of the voice vibrating or buzzing the lips and oral cavity in general. Once this sensation was familiar to U, she was instructed to continue to focus mentally on sending the voice to the anterior oral cavity and note the buzzing sensations for all productions as she progressed through the hierarchy. Eventually, the /m/ phoneme facilitator was withdrawn, and U was encouraged to continue using her technique in nonloaded materials including conversation in various settings. Upon completion of goal 1 (patient education), the remaining goals were addressed simultaneously. Thus, patient U was taught “optimal vocal technique” using the optimal speech breathing, phonation, and resonance strategies outlined in goals 2 through 4. Therapy focused exclusively on speaking and did not address singing technique. This was due to the fact that patient U did not exhibit many undesirable behaviors during singing compared to speaking, and because she was already seeing a vocal singing instructor.

Results of Therapy Patient U was seen for 6 voice therapy sessions over a 4-week period. She returned to her otolaryngologist for a follow-up evaluation several months after finishing therapy. Patient U was an excellent client who demonstrated a high level of motivation and quick learning ability. At the conclusion of therapy, she had achieved all of the

therapeutic goals with excellent overall results, which are detailed below. Auditory Perceptual At the time of discharge from therapy, patient U used appropriate breath support in conversational speech. This had a positive effect on phonation, which was clear with no evidence of vocal fry. Resonance and projection were improved, and patient U reported far less fatigue during extended speaking and singing. Additionally, her complaint of pain diminished considerably, and she only experienced this when she sang without warming up. Videostroboscopy Follow-up videostroboscopy was completed on her return to otolaryngology several months after discharge from voice therapy. The examination revealed normal symmetry of vibration and none of the laryngeal rotation that was observed at the time of initial diagnosis. All other aspects of phonation remained normal. By the year 2030, one-fifth of the US population will be over the age of 65 years. In addition, the average life span is increasing, and individuals are concerned with maintaining health and active lifestyles. As with all body functions, the vocal mechanism undergoes age-related changes sometimes leading to diminished vocal function. In the following case, Aaron Ziegler and Edie Hapner describe a treatment approach, Phonation Resistance Training Exercises (PhoRTE) used with a 75-year-old woman who presented with presbyphonia.


Case Study 7 Aaron Ziegler and Edie R. Hapner Use of Phonation Resistance Training Exercises (PhoRTE) in a Part-Time Cooking Instructor With Presbyphonia Vocal aging has received considerable attention recently due to the rapid increase in those individuals age 65 years and older.70 However, research investigating efficacious treatment options to rehabilitate individuals who experience age-related voice changes, also known as presbyphonia, is limited. Putatively, age-related voice changes occur, in part as a result of reduced vocal activity,71,72 which may lead to atrophy of the respiratory and phonatory muscles and a deterioration of muscular strength and endurance as happens with skeletal muscle with disuse.73,74 It stands to reason that if some age-related voice changes occur from vocal inactivity, then voice exercises that overload the musculature should lead to increases in muscular strength and endurance,75–77 as well as improvements in vocal function. The following case study demonstrates the use and principles of Phonation Resistance Training Exercises (PhoRTE) with a woman with presbyphonia. A conceptual framework for PhoRTE as well as specific information about this patient’s treatment are also provided.

Case History History of the Problem The patient was a 75-year-old Caucasian female who lived with her husband in

an English-speaking home. She presented to a multidisciplinary voice clinic with complaints of difficulty generating a loud voice, as well as a persistent, rough vocal quality. The patient also described voice production as effortful and strained, which led to increased vocal fatigue with prolonged voice use. Additionally, she reported having an unpredictable vocal quality and aphonic breaks. The onset of her voice problem was 4 months prior to being seen in the clinic, and her symptoms were gradually worsening. The patient noted that her voice had gradually deepened over the years. Her voice problem had negatively affected her part-time work as a culinary arts instructor, forcing her to reduce the number and duration of classes she taught. She stated that people had trouble hearing her and frequently asked her to repeat herself. She denied any signs or symptoms of an upper respiratory infection at the time of onset of voice difficulties. She denied any prior history of voice problems and had not received the services of a speech-language pathologist for her voice problem in the past. Medical History The patient’s past medical history was significant for hypertension and hyperlipidemia, for which she was being treated with Lipitor and Lisinopril, respectively. There were no relevant surgeries. Review of systems was otherwise unremarkable, and cranial nerves II–XII were grossly intact. She denied shortness of breath, cough, or dysphagia. The patient did not have any hearing complaints and passed a hearing screening at 0.5, 1, and 2 kHz at 40 dB conducted in sound field. The patient reported refluxrelated symptoms at her initial medical

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evaluation, including a significant amount of throat clearing and postnasal drip. The physician treated the patient’s postnasal drip symptoms with nasal steroids and nasal irrigation. Social History The patient worked as an author and part-time instructor at a culinary school, which required her to project her voice to large groups over extended periods of time on a regular basis. The patient reported intermittent use of amplification at work when equipment was working properly. In addition to those vocational activities, she was enjoying her retirement by spending time with family and friends. On a self-rating scale of 1 to 7 for innate talkativeness and loudness (where 1 is quiet and introspective and 7 is loud and talkative), the patient rated her degree of talkativeness as 6 and her degree of loudness as 4.5. Phone use was minimal. Voice Hygiene The patient was a nonsmoker, nondrinker, and did not participate in any illicit drug use. Water intake was minimal [ie, about 240 mL (8 fl oz) of water per day] in addition to 2 cups of coffee per day. The patient denied exposure to dust or chemicals known to affect the voice.

Voice Evaluation The initial voice evaluation was conducted to determine the current function of the patient’s vocal mechanism and the functional impact of her voice changes. Results are shown in Figure 4–7.

Auditory-Perceptual Evaluation A voice-specialized speech-language pathologist completed an auditoryperceptual evaluation of the patient’s voice using the CAPE-V.35 The patient exhibited an overall severity score of 28/100, indicating a dysphonia of a mild-to-moderate nature. Aberrant perceptual features identified in the voice were typical for an individual with agerelated voice changes, and included roughness, strain, and decreased loudness.78 Resonance was noted to be laryngeal-pharyngeal in quality. Respiration appeared to be primarily thoracic, and there was no evidence of breath holding. Speech breathing was noted to be mildly abnormal and, in keeping with research findings on speech breathing in the elderly, characterized by increased number of inhalations and placement of pauses/breaths at linguistically inappropriate boundaries.79,80 Laryngeal Imaging A videolaryngostroboscopic evaluation with a rigid endoscope was completed by a fellowship-trained laryngologist. The examination revealed full abduction/adduction of the true vocal folds and the arytenoid processes with no evidence of paresis or paralysis. The laryngeal mucosa was healthy in appearance, and there were no mass lesions on either of the true vocal folds. On phonation, the patient was able to achieve near full closure at modal pitch with a spindleshaped glottal gap at an upper pitch. There was near phase symmetric mucosal wave and equal and symmetric true vocal fold pliability. The true vocal folds exhibited thinning of the lamina propria with prominence of the vocal processes and resulted in a slight concave shape

235

Phase symmetry Mucosal wave motion

d. e.

Healthy laryngeal mucosa, no mass lesions, slight lamina propria thinning with prominence of vocal processes Full abduction/adduction of vocal folds Near full closure at modal pitch with a spindle-shaped glottal gap at upper pitch Near phase symmetry Equal and symmetric mucosal wave and vocal fold pliability Slightly decreased Significant medial compression

a.

177.65 Hz 428.3 Hz (28 ST) 58.85 dB SPL 25 dB 0.287 8.29 cmH2O 0.11 L/sec 82.5 79.17 87.50 200

a. b. c. d. e. a. b. 1. a. b. 2.

f. g.

d. e.

b. c.

28/100 Increased Normal Increased Age- and sex-appropriate Decreased

1. 2. 3. 4. 5. 6.

PRE-THERAPY

Figure 4–7. Pretreatment and post-treatment results.

f. Amplitude of lateral excursion g. Supraglottic compression 2. Acoustic a. Speaking fundamental frequency (Hz) b. Physiological pitch range in Hz (in ST) c. Speaking vocal intensity (dB SPL) d. Dynamic range (dB) e. Noise-to-harmonic ratio 3. Aerodynamic a. Estimated subglottal pressure (cmH2O) b. Air flow during sustained vowel (L/sec) Patient Self-Assessment 1. Voice-Related Quality Of Life (V-RQOL) a. Physical b. Social -emotional 2. Vocal effort

Motion symmetry Glottal closure

b. c.

Consensus Auditory-Perceptual Evaluation of Voice 1. Overall Severity (mm) 2. Roughness 3. Breathiness 4. Strain 5. Pitch 6. Loudness Instrumental 1. Visual Imaging a. Appearance

PARAMETER

Normal excursion Minimal medial compression 181.32 Hz 431.1 Hz (28 ST) 65.76 dB SPL 35 dB 0.114 13.13 cmH2O 0146. L/sec 97.5 95.83 100.00 100

f. g. a. b. c. d. e. a. b. 1. a. b. 2.

d. e.

Unchanged On phonation, full closure at modal pitch with a slight anterior glottal gap at upper pitch Always symmetrical Unchanged

Unchanged

a. b. c.

9/100 Minimal Normal Normal Age- and sex-appropriate Normal

1. 2. 3. 4. 5. 6.

POST-THERAPY

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to each of the vocal folds. The patient demonstrated lateral supraglottic compression. All vibratory characteristics were suggestive of age-related changes of the larynx.81 With use of a loud voice, the patient achieved improved phonatory closure. Instrumented Voice Measures An acoustic and aerodynamic assessment was completed as part of the patient’s multidisciplinary voice evaluation. Reliability of acoustic analysis was based on the following voice typing36: type 1 indicated nearly periodic, with perturbation measures reliable. Average speaking fundamental frequency and vocal intensity were 177.65 Hz and 58.85 dB SPL, respectively. Physiological pitch range was assessed during ascending and descending pitch glides. She exhibited restricted physiological pitch range in the high and low frequencies with a range of 202.59 to 530.62 Hz. She demonstrated a slightly elevated noise-to-harmonic ratio as assessed on sustained /a/. Dynamic range was assessed through /a/ at her softest and loudest levels, and the patient exhibited a restricted dynamic range. Aerodynamic assessment revealed a mean airflow rate on sustained vowel at modal pitch of 0.11 L/s and mean peak air pressure of 8.29 cm of water. Acoustic and aerodynamic results were consistent with research findings.78 Patient-Perceptual Measures The Voice-Related Quality of Life (V-RQOL)17 was self-administered to assess the patient’s perception of the impact of the voice disorder on quality of life. Her raw V-RQOL score was

17 out of 50, which converts to 82.5 out of 100 (higher V-RQOL scores correlate with higher quality of life). Her V-RQOL scores in the physical and social-emotional domains were 79.17 and 87.5 out of 100, respectively. The patient’s overall V-RQOL score indicated the patient’s perception of her voice disorder had a mild impact on her quality of life, and the physical domain of her voice disorder impacted her QOL more than the social-emotional domain. The patient rated her level of perceived phonatory effort at 200, indicating the patient required twice as much vocal effort as comfortable. Treatment Recommendations Trial therapy was conducted and the patient was stimulable for improvement utilizing increased inward abdominal excursion during forced expiratory maneuvers and increased loudness. When asked to rate (on a scale of 1 to 10) her feelings toward voice therapy, the patient provided a rating of 9, indicating an extremely positive attitude. The patient appeared to be an excellent candidate for voice therapy. Positive prognostic indicators included high motivation/level of commitment, recent onset, positive response to trial therapy, and disorder is known to respond to voice therapy. Negative prognostic indicators included low awareness of voice use patterns. The patient indicated that her long-term goal was to improve loudness and decrease vocal fatigue so she could remain effective in the classroom and enjoy socializing with family and friends. The patient was referred for voice therapy with a diagnosis of agerelated voice changes (presbyphonia) by a multidisciplinary voice care team.

Voice Therapy Rationale for Therapy To achieve the patient’s long-term goal, the patient completed exercises that were part of a voice therapy program known as Phonation Resistance Training Exercises (PhoRTE).82 PhoRTE, which is a homophone to the Italian word forte meaning loud and strong, has its origins in research of Lee Silverman Voice Treatment83,84 and voice science,85 exercise physiology75,76 and progressive resistance training for limb skeletal muscle atrophy,86,87 as well as motor control and learning.88 The PhoRTE exercises were selected because of their high-intensity nature that has the potential to reverse the degenerative sarcopenia process77 that causes skeletal muscle atrophy. The program uses progressive resistance training, which, in the exercise science literature, demonstrates positive changes in muscular force production and endurance so people can better live out activities of daily living.89,90 Accordingly, voice exercises that consist of a workload large enough to overload respiratory and laryngeal muscles should result in an increase in respiratory and laryngeal muscle strength and endurance.77 Such an outcome is desirable in voice production given that conversation requires a rather constant and sustained air pressure.91 As a consequence of increased muscle activity, subglottal pressure and transglottal airflow should increase, vocal fold vibratory characteristics should improve, and the patient should optimize conversion of air into sound. Such physiologic changes should result in improvements in vocal function (ie, richer source spectrum),


and address patient complaints, including decreased loudness, increased vocal effort, increased roughness, and phonatory instability. Ultimately, improvement in vocal function should translate into a reduction in the impact of the vocal impairment on quality of life. The PhoRTE therapy program addresses specific patient complaints, including decreased loudness and increased vocal effort. Three mechanisms incorporated into the PhoRTE therapy program promote those outcomes. First, increased subglottal pressure through increased expiratory muscle activity and generation of higher alveolar pressures would lead to changes in loudness. In addition, increased subglottal pressure from increased laryngeal resistance as a result of increased thyroarytenoid and lateral cricoarytenoid (TA/ LCA) muscle activity would also lead to changes in loudness. Furthermore, increased laryngeal resistance would require increased subglottal pressure to overcome the added laryngeal resistance from increased vocal fold adduction and intrinsic vocal fold tension, thereby further increasing loudness. The additional laryngeal resistance should also provide another layer of resistance training for the respiratory musculature to work against, and result in further improvements in expiratory muscle strength and endurance. Finally, the use of a megaphone mouth shape during production of the vowel /a/ maximizes phonatory efficiency and helps to recalibrate phonatory effort. All of these changes allow a speaker to shout safely and without vocal effort.2,85 Phonotrauma was not a concern in this patient because laryngeal configuration during completion of PhoRTE exercises should not go beyond barely touching

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vocal folds, and therefore, impact stress should be maintained at a low level.92 Finally, the PhoRTE program includes functional phrases to help with generalization of voice techniques to conversation,93 which is congruent with a task-dependent model of motor control. Furthermore, feedback is limited to comments that direct the patient to increase his or her vocal intensity during completion of exercises and, as a result, provides an external locus of attention rather than focusing the patient on the biomechanics of voice production. This approach promotes motor learning.94 Execution of Therapy The patient received 4 individual voice therapy sessions, approximately 1 time per week for 60 minutes. The initial session consisted of determining the individualized SPL target for the PhoRTE voice exercises, also known as the phonation resistance training exercise workload. First, the clinician established the patient’s habitual loudness by having the patient read, at a minimum, an allvoiced sentence such as the one from the CAPE-V, “We were away a year ago,” and analyzing it to get the patient’s average vocal intensity. Then, the clinician set the patient’s exercise workload in the PhoRTE therapy program at 50 to 60% of the patient’s measured vocal intensity (dynamic) range. Next, the clinician taught the patient to use low abdominal breathing gestures by relaxing the abdominal musculature to allow natural expansion on inhalation and engaging the abdomen for depression with exhalation. The final part of the initial session consisted of teaching the patient the 4 exercises in the program, which were completed at modal pitch: (1) loud and energized maximum

sustained phonation on /a/; (2) loud and energized ascending and descending pitch glides over the entire pitch range on /a/; (3) production of patientspecific functional phrases using a loud and high voice; and (4) production of phrases from exercise #3 in a loud and low voice. During production of the PhoRTE exercises, the patient was expected to maintain her individualized SPL target as measured by a sound-level meter positioned at a microphone-tomouth distance of 30 cm. At the end of the first session, the patient was asked to contact the clinician should she experience any prolonged discomfort or decline in voice quality from performing the PhoRTE therapy exercises. The patient did not complain of such problems for the duration of her therapy. In addition, the patient received written instructions on how to complete a daily home practice program and a compact disc with audio demonstrations of the exercises. The clinician asked the patient to perform the PhoRTE therapy program twice daily. In addition, the patient maintained a record indicating completed home practice, which included the duration of the maximum sustained phonation exercise. The practice log served as documentation of adherence to treatment recommendations and patient motivation to continue practicing from improvements in maximum sustained phonation values. Each session, the patient brought in the home practice log and shared the previous week’s practice with the clinician. The patient downloaded a decibel (dB) meter app for monitoring her home practice. The second voice therapy session started with a review of the home practice. The patient demonstrated the PhoRTE exercises for the clinician, and the clinician reviewed the patient’s prac-

tice log. Regarding the specific voice therapy exercises, the patient completed repetitions of the PhoRTE exercises using a loud, energized voice production (about 8 to 10 repetitions) to the point of muscular fatigue. However, the clinician modified the minimum workload of the exercises by increasing the vocal intensity target by 5 dB. This change was made because the patient demonstrated improved muscular force and endurance with the PhoRTE voice exercises. (For patients unable to achieve the weekly 5-dB increase in vocal intensity, the patient’s target should only be increased by 3 dB.) During PhoRTE execution, the clinician continually motivated the patient to achieve her target SPL. In addition, the clinician provided feedback on the execution of the PhoRTE voice exercises to optimize patient production and maximize patient benefit. The patient observed a 1-minute rest interval between each set of the PhoRTE therapy exercises. The third and fourth voice therapy sessions consisted of a review of the home practice program and performance of the PhoRTE therapy program. As in the previous sessions, the clinician adjusted the minimum exercise workload by increasing the vocal intensity target by another 5 dB. The formal program ended once the patient consistently produced the exercises at the final target of 20 dB SPL above habitual loudness (ideally, 80 to 90 dB SPL) in addition to patient report of satisfaction with treatment. At that point, the patient was discharged from the clinician’s caseload and provided a home maintenance program. The patient was encouraged to perform PhoRTE steps 3 and 4, 3 times per week, but no more than once per day, at the target loudness level.


Follow-Up Upon completion of therapy, the patient reported satisfaction with her treatment. She stated that her voice improved since completing the PhoRTE therapy program, and she believed the program caused positive changes in her voice. Consequently, the negative impact of her voice problem on quality of life was significantly reduced and her VRQOL value increased to 97.5/100. In addition, she experienced a substantial reduction in perceived phonatory effort to the extent that voice production was now comfortable (ie, rating of 100). Her voice quality also improved as evidenced by an improvement of overall severity on the CAPE-V to 9 mm; the clinician perceived little to no roughness or strain in the patient’s voice and increased loudness during conversational speech. Acoustic and aerodynamic assessment revealed clinically meaningful changes. Average vocal intensity increased to 65.76 dB. The patient’s dynamic range expanded due to increase in the upper limit. The noise-to-harmonic ratio value decreased suggesting an improved vocal quality. Transglottal airflow during sustained vowel production increased as did estimated subglottal pressure. Functionally, the patient reported few requests to repeat herself, and she resumed teaching at her regularly scheduled times. By the end of therapy, the patient stated that she could complete a full day of teaching without experiencing vocal fatigue.

In the following case, Steve Gorman demonstrates the use of Vocal Function Exercise for improving the voice quality and quality of life in a 71-year-old man with presbyphonia.

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Case Study 8 Stephen Gorman Use of Vocal Function Exercises in an Elderly Man With Presbyphonia

History of the Problem Patient M, a 71-year-old self-employed male (engineering consultant), was referred by an otolaryngologist with complaints of throat irritation, hoarseness, and, in his own words, “distorted speech.” According to the patient, he first noticed the degradation of his vocal quality a month prior to his evaluation in the voice laboratory, although his wife noticed it 4 to 5 months prior to that. Medical History His medical history was significant for macular degeneration and kidney stones. He was not taking any medications at the time of the evaluation. He reported drinking 5 glasses of decaffeinated tea, 2 cups of decaffeinated coffee, and very little water in the course of an average day. Social History He was a pipe smoker for 55 years and seldom inhaled but noticed increased hoarseness after he quit smoking the pipe. At the age of 71, he still worked 40 to 50 hours a week. He spent much of his time either on the phone or meeting with clients in person. He always prided himself on a pleasant, yet authoritative, speaking voice. His voice quality was worse in the morning, improved through midday, then deteriorated through the end of the day.

Voice Evaluation Auditory-Perceptual Voice quality was described as being mildly to moderately dysphonic, characterized by a raspy, husky hoarseness. The patient described a feeling of excessive mucus in his throat and admitted to clearing his throat to excess. His voice quality varied throughout the day, with more hoarseness and a feeling of vocal fatigue the more he talked. He demonstrated mildly excessive jaw tension. Instrumental Visual Imaging. Examination of the vibratory characteristics was conducted using videostroboscopy and is listed in Table 4–7. Most notable was the moderate bowing of the membranous vocal folds during all tasks. A mild-to-moderate decrease in the amplitude of vibration and mucosal wave bilaterally was observed. Symmetry of the phase of vibration was 50% asymmetric. Moderate compression of supraglottic structures in both the lateral-medial and anterior-posterior planes was observed. Furthermore, the patient demonstrated thick mucus in the hypopharynx, giving the appearance of inadequate hydration. Acoustics. Speaking fundamental frequency was essentially normal, whereas the range of frequency was reduced. Perturbation measures revealed that mean percent jitter and shimmer (dB) were excessive at high and low pitches, and noise-to-harmonic ratio was excessive at low pitches. Acoustic measurements are summarized in Table 4–8. Aerodynamics. Airflow rate and maximum phonation time were both below

Table 4–7. Stroboscopic Ratings for Patient M Parameter

Pretherapy

Post-Therapy

Glottic closure

Spindle shape

Slight posterior gap

Supraglottic activity

Moderate L-M and A-P compression

Mild A-P compression

Vertical level

Equal

Equal

Vocal fold mobility

Normal

Normal

Amplitude of vibration

Mild-moderate decrease

Mild decrease

Mucosal wave

Mild-moderate decrease

Mild decrease

Phase closure

Close phase mildly dominant

Normal

Phase symmetry

50% asymmetrical

Asymmetrical, high pitch

Overall laryngeal function

Hyperfunctional

Normal

Table 4–8. Acoustic Measures for Patient M Measure

Pretherapy

Post-Therapy

Comfort pitch, Hz

110

122

High pitch

214

250

Low pitch

97

90

Comfort pitch

0.87

0.61

High pitch

1.03

0.73

Low pitch

1.68

0.86

Comfort pitch

0.35

0.21

High pitch

0.45

0.27

Low pitch

0.56

0.31

Comfort pitch

0.14

0.09

High pitch

0.13

0.11

Low pitch

0.16

0.10

Speaking F0 (Hz)

116

121

83–381

80–611

Mean F0, /a/

Jitter (%)

Shimmer (dB)

N/H (dB)

Frequency range (Hz)

241

242


normal limits (Table 4–9). Phonation flow volume was appropriate for his age, physical build, and gender. Patient Self-Assessment The patient was dissatisfied with his voice because it sounded weak and “distorted.” He did not think he could conduct business in an effective, credible manner based on his voice and the more he talked, the worse it was.

Voice Therapy Bowing of the vocal folds is often present in the larynges of the elderly complaining of voice problems. Voice therapy appropriate for this physiologic condition is physiologic voice therapy, supplemented by a formal hydration program and vocal hygiene counseling.

Hydration Program The patient was instructed to drink at least 1920 mL (64 fl oz) of water per day and to eliminate all caffeinated beverages from his diet. These steps would increase systemic hydration and, thereby, decrease the viscosity of the patient’s mucous secretions and improve the lubrication of the vocal folds. Vocal Hygiene With complaints of a sensation of increased mucus in his throat, the patient had developed the habit of frequent and harsh throat clearing. A simple behavior modification program was devised in which the patient simply tallied on a piece of paper each time he cleared his throat. By increasing his awareness of the habit, he was able to significantly reduce the instances of throat clearing.

Table 4–9. Aerodynamic Measurements for Patient M Measure

Pretherapy

Post-Therapy

Comfort pitch

2190

2450

High pitch

2143

2240

Low pitch

2670

2530

Comfort pitch

216

112

High pitch

255

124

Low pitch

193

145

Comfort pitch

10.1

21.9

High pitch

8.4

18.1

Low pitch

13.8

17.4

Phonation flow volume (mL)

Mean airflow rate (mL/s)

Maximum phonation time (s)

Additionally, with the increase in systemic hydration, and thus the decrease in viscosity of mucus, the urge to clear his throat subsided. Vocal Function Exercises This patient was trying to compensate for the lack of glottic closure by hypercompression of the supraglottic structures. It was determined that a low-impact adductory exercise would be most beneficial to improve glottic closure while reducing the hypercompression. The physiologic voice therapy chosen was the Vocal Function Exercise program, which was described to the patient as “a 4-part exercise program similar to physical therapy for the vocal fold muscles.” As an engineer, quantitative exercises appealed to this patient because he could objectively measure his own performance by timing how long he could sustain the musical notes for the warm-up and adductory power exercises. He was instructed to do these exercises 2 times each, 2 times a day. To aid patient M in accomplishing his daily exercises, he was given a prerecorded CD of the exercises to use as a guide. The 4 individual exercises that comprise the Vocal Function Exercise Program were instructed as follows: 1. (WARM-UP) Sustain the vowel E for as long as possible on the musical note D3 after taking as deep a breath as you can. Make the sound as nasal as possible and use all your breath. 2. (STRETCHING) Glide from your lowest note to your highest note on the word “knoll” after taking as deep a breath as you can. 3. (CONTRACTING) Glide from a comfortable high note to your low-


est note on the word “knoll” after taking as deep a breath as you can. Make sure you use all your breath. 4. (ADDUCTORY POWER) Sustain each of the musical notes A2, B2, C3, D3, and E3 for as long as possible on the sound “ol” after taking as deep a breath as you can. Make sure you use all your breath. (See Chapter 3 for a complete description of the Vocal Function Exercise program.) During the initial therapy session, Patient M averaged 26 seconds on each of the 6 timed exercises (warm-up and power). This was described to the patient as his “vocal muscle strength index.” His goal was to achieve an average of at least 43 seconds. This goal is based on the formula whereby the patient’s lung capacity is divided by the target airflow rate of 80 mL/s. Furthermore, it was explained to him that as his vocal muscles increased in strength, he would then be able to sustain the notes for increasingly longer periods of time. The patient questioned whether he simply would be improving his lung capacity, whereupon it was explained that the phonation flow volume is basically a static measure. What improves is the ability of the vocal folds to valve the subglottic airstream more efficiently and effectively because of improved glottic closure. Table 4–10 demonstrates the progression of the patient’s improvement in glottic closure over the course of time that he was receiving voice therapy. He reached his goal by the third session but continued improving after that. He achieved a maximum phonation time of 44.8 seconds and during his final therapy session achieved 42 seconds. This final average was achieved after

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not having performed the exercises in the previous 10 days as he had been on a vacation trip without access to a CD player with which to play his Vocal Function Exercise CD.

Summary Patient M was enrolled in voice therapy once weekly for 2 weeks, once every other week for 6 weeks, once every 3 weeks for 9 weeks, and one more time 6 weeks later. Therapy began with physiologic voice therapy and was supplemented with a systematic increase in systemic hydration, as well as vocal hygiene. The patient maintained a disciplined schedule of performing the exercises twice daily, as well as increasing his hydration and reducing phonotraumatic behaviors. In addition to improving his maximum phonation times from 26 seconds to 44.8 seconds, his vocal quality and vocal stamina improved to a degree such that the patient (or this

Table 4–10. Progression of Vocal Function Exercise Maximum Phonation Times for Patient M Date

Time(s)

voice pathologist) did not consider either to be a problem anymore. The auditory, acoustic, and stroboscopic measures taken during the evaluation were repeated at the conclusion of therapy and are listed in Tables 4–7 to 4–9. Acoustic measures of perturbation improved, as did his frequency range. Airflow measurements were also improved. Stroboscopic ratings improved as the spindle-shaped glottic gap changed to a slight posterior gap with significant decrease in supraglottic compression. The patient continued performing his Vocal Function Exercise at the conclusion of formal voice therapy. He followed a maintenance program outlined in Table 4–11. Two months after the conclusion of therapy, the patient was still maintaining phonation times of 43 seconds and performing Vocal Function Exercises 3 times a week. He remained satisfied with his vocal quality and stamina and reported no further vocal complaints. Table 4–11. Vocal Function Exercise Maintenance Program for Patient M 1. Full exercise program, 2 times each, 2 times a day 2. Two times in the morning, 1 time in the evening, or vice versa

4/1/08

26.0

4/8/08

29.8

4/22/08

36.2

5/6/08

38.2

5. One time a day, 7 days a week

5/20/08

37.2


6/12/08

38.8


7/1/08

41.7


7/29/08

44.8


9/9/08

42.0

3. One time in the morning, 1 time in the evening 4. Two times, morning or evening

10. No vocal function exercises


Once again, highlighting the benefits of a team approach in voice care, Amanda Gillespie and Clark Rosen describe the case of a 36-year-old woman who presented with bilateral sulcus vocalis. Behavioral therapy (resonant voice) was used successfully to reduce the secondary MTD caused by the patient’s compensatory voicing behaviors prior to surgical intervention to improve glottal incompetence.

Case Study 9 Amanda I. Gillespie and Clark A. Rosen Treatment of Glottal Incompetence Caused by Sulcus Vocalis: Evidence of a Team Approach for Vocal Rehabilitation

Sulcus Vocalis Sulcus vocalis is a sulcus or groove in one or both true vocal folds. Stroboscopically, sulcus vocalis causes vocal fold stiffness and reduced mucosal wave. Often one can see vocal fold bowing of the affected side and glottal incompetence.95,96 Sulcus vocalis is often a severely vocally limiting pathology, and despite aggressive treatment, full recovery of normal vocal function is rare.96 Sulcus vocalis is most commonly and successfully treated with surgery.97 Voice therapy is rarely successful as a sole treatment for sulcus. However, in many situations, patients may have developed maladaptive voicing behaviors as compensation for the phonatory defects caused by sulcus. In those cases, voice therapy can play a complemen-

tary role in improving overall voice technique and assisting in restoration of vocal function in individuals with sulcus.95,98,99 It is imperative that a team approach, combining the expertise of a laryngologist and a speech-language pathologist, be utilized in the management of patients with sulcus vocalis. It is also critical that the treating speechlanguage pathologist know the limits of voice therapy for a patient with sulcus, and when discharge from therapy is appropriate. The following case details the behavioral treatment of a patient with sulcus vocalis and its multidisciplinary management.

History of Present Illness Sarah, a 36-year-old female, presented with complaints of severe dysphonia that worsened with prolonged or loud voice use. Sarah reported her voice problems began 12 years ago and had been gradually worsening since onset. While her voice quality was never “normal,” she described more severe dysphonia with voice use and with seasonal changes. For the last 5 years, she had used her voice professionally as an elementary schoolteacher. Prior to that, she worked in the restaurant industry with substantial voice demands. Her past medical history included laryngopharyngeal reflux and migraines. Her past surgical history was significant for microsuspension laryngoscopy at an outside hospital to remove bilateral vocal fold lesions 11 years ago. She reported that although her voice improved temporarily after that surgery, it never completely returned to normal, and within a few months began again deteriorating. She had never participated in voice therapy, and she did not receive consultation by

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a speech-language pathologist. She continued to work after her voice surgery but was currently on medical leave due to severe dysphonia impacting her ability to teach a full day of classes. Voice Hygiene Sarah reported drinking approximately 4 bottles of water and 2 cups of coffee per day. She had a remote history of social tobacco use. Her job as an elementary schoolteacher caused frequent phonotrauma. She did not use amplification.

Voice Evaluation Sarah underwent a comprehensive, multidisciplinary voice evaluation that consisted of an auditory-perceptual and objective voice laboratory evaluation, patient-perceptual evaluation of voice handicap, and laryngeal examination with stroboscopy. The results of these assessments are reviewed next. Auditory-Perceptual Evaluation Sarah’s voice was perceptually evaluated by a speech-language pathologist with the CAPE-V. This evaluation occurred on the same day as her laryngeal examination by a laryngologist in the voice clinic. Her overall voice severity was rated at 72/100 on a visual analog scale, and described as rough, strained, and with a lower than normal pitch for her age and gender. Patient-Perceptual Measures Sarah reported that her voice problem had a moderate-to-severe effect on her daily life and that she experi-

enced severe vocal fatigue. She scored a 36/40 on the Voice Handicap Index10,100 indicating a high degree of selfperceived vocal handicap (mean for nondisordered speakers = 7, standard deviation = 2).101 She reported a direct magnitude estimation of effort rating of 800, which revealed that voice production for Sarah required 8 times as much effort as comfortable. Objective Voice Laboratory Evaluation Sarah underwent an acoustic and aerodynamic voice assessment as part of her initial clinic evaluation. Acoustic analyses revealed a type 2 signal102 and increased noise-to-harmonic ratio (NHR = 0.29), indicating an acoustic voice signal outside the normal range. Aerodynamic evaluation revealed greater than normal mean translaryngeal airflow (237 L/s) and estimated subglottal pressure (psub) (9.01 cm H2O) values. Her hearing was also screened using pure tone audiometry and determined to be within normal limits at 25dB at 250, 500, 1000, 2000, and 4000 Hz. These voice laboratory values, including the patient-perceptual measurements, are consistent with those found in individuals with sulcus vocalis.95,96,103 Laryngeal Evaluation Sarah’s laryngeal function was also evaluated with rigid laryngeal stroboscopy. Mucosal wave of both true vocal folds was decreased. Vocal fold closure was incomplete with an elliptical, and aperiodic. Sarah was diagnosed with right true vocal fold sulcus vocalis causing glottal incompetence, and secondary compensatory muscle tension dysphonia.

Treatment Recommendations A team approach including initial trial voice therapy, followed by reevaluation to determine need for surgical intervention was recommended. The goal of the voice therapy trial was improvement of her speaking voice technique to optimize Sarah’s voice production given her laryngeal disorder. The team felt that most likely Sarah would eventually require surgical treatment given the severity of her pathology, her voice demands, and her expectations. Voice therapy prior to surgery would also improve laryngeal biomechanics to prevent postoperative phonotrauma.

Voice Therapy Sarah began voice therapy 1 week after her initial clinic evaluation. The first session was dedicated to stimulability testing [ie, discovering techniques that improved both the sound and feel (effort, pain, fatigue, etc) of Sarah’s voice]. During that first session, the speech-language pathologist noted that Sarah’s respiratory rate was faster than typical (12–15 breaths per minute is considered normal) and that she demonstrated excessive clavicular movement with respirations. She was frequently out of breath by the middle of phrases but attempted to continue phonating, breathing when linguistically, but not physiologically, appropriate. Sarah was instructed on slowing her respiratory rate, reducing clavicular movements and the use of accessory muscles when breathing, and allowing relaxation of abdominal musculature for free, uncontrolled abdominal movement during breathing.104,105 Resonant voice techniques such as production of prolonged nasal con-


sonants after inhalation successfully decreased her vocal fatigue and discomfort as well as made modest improvements in voice quality. Sarah was also trained in semi-occluded vocal tract (SOVT) exercises, including phonating through straws of varying sizes.53 These exercises further helped eliminate the tension and reduce the effort she experienced during phonation. The results of stimulability exploration in the first therapy session revealed improved vocal quality and reduced vocal effort with resonant voice and SOVT techniques, coupled with a slowed respiratory rate and a focus on abdominal muscle relaxation and natural movements with breathing. These techniques were trained in a series of vocal warm-ups and cool-downs. Sarah was instructed to warm up her voice after any period of prolonged vocal inactivity, and to cool-down her voice after any voice use lasting longer than 10 minutes. Specifically, she was to focus on small nasal inhalations, and prolonged exhalations with vocal output alternating between lip trills, nasal (/m, n, ng/) and /z/ phonemes. These vocalizations were encouraged on single pitches and with small ascending and descending pitch glides. The purpose of the exercises was to bring awareness to anterior vibrations felt during resonant voice production, and to relieve vocal effort and strain.106,107 All of the exercises were recorded on a CD as well as provided in a paper handout for Sarah to practice at home. It was recommended that she practice in short sessions 3 to 4 times daily. Sarah returned weekly for additional 45-minute voice therapy sessions. In the second session, the warm-up and cool-down exercises were reviewed. The speech-language pathologist then

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guided Sarah to carry the anterior vibrations and ease of voicing experienced with resonant voice phonemes in the warm-up to short phrases containing frequent nasal sounds (eg, “My mom married Marvin,” “No one knows Norman”). Sarah had difficulty maintaining forward resonance as her rate of speech increased, so a slower rate was recommended, allowing her more time for conscious awareness of proprioceptive feedback from the resonant voice exercises. At the start of the third voice therapy session, Sarah reported she was able to produce a “good voice” when she was fully focused on phonation, but was unable to generalize to conversational speech outside of the therapy room. This third session focused on elimination of hard glottal attacks in vowelinitial words and phrases, and blending phonemes between words to encourage flow of phonation. These techniques, coupled with resonant voice therapy, were practiced in conversation by Sarah and the speech-language pathologist. The speech-language pathologist produced the target techniques in conversation to provide a model to help guide Sarah’s productions. In addition, Sarah practiced “negative feedback,” a technique that encouraged the patient to alternate between the target technique and the “unbalanced” (or “bad”) former voice technique. This exercise helped Sarah gain more control over her productions, and increased her selfefficacy in her ability to self-correct in conversation. At the start of the fourth voice therapy session, Sarah reported less vocal effort when focused on therapy techniques. She was able to practice in conversation with her family and was even able to read 3 books to her chil-

dren before bed without vocal fatigue or worsening dysphonia. She reported she felt encouraged about her vocal progress and was looking forward to returning to work, and had ordered amplification to assist her classroom voice use.108,109 The fourth therapy session was spent working with the trained techniques in conversational speech, as well as with simulated occupational voice use (ie, classroom teaching), which Sarah was able to independently produce the target voice techniques in conversation as well as with simulated teaching. However, she reported that even with conscious implementation of the techniques in the classroom, she was experiencing severe dysphonia and debilitating vocal fatigue. At that time, it was recommended she discontinue her behavioral treatment and return to the laryngologist for surgical evaluation. Follow-Up On the recommendation of the speechlanguage pathologist, Sarah returned to the voice clinic. Her VHI-10 score was reduced from 36 to 25/40, a clinically meaningful decrease110; however, all other acoustic and aerodynamic analyses were still outside the normal range (ie, psub = 8.79 cm H2O; airflow = 230 L/s, NHR = 0.24; CAPE-V = 68; DME = 500; and a continued Type 2 acoustic signal), findings not uncommon in individuals with sulcus vocalis and glottal incompetence.96 Even though it is not unusual for some voice evaluation components to improve and others to even worsen following treatment,111 based on Sarah’s subjective complaints and inability to continue in her profession because of her voice problem, the voice care team determined now was the appropriate time to proceed with surgi-

cal treatment of her sulcus vocalis and glottal incompetence with thyroplasty medicalization.95,96,112,113

Conclusions Sulcus vocalis is a sulcus or groove in one or both true vocal folds. It may be contained in the mucosa or extend into the vocal ligament.95 Sulcus vocalis can be congenital and may also occur as a result of surgical resection of vocal fold lesions.95 However, vocal fold lesions can develop as a result of glottal incompetence caused by sulcus.114 In addition, vocal fold lesions can mask a sulcus.115 Sulcus vocalis is a challenging disorder for both the patient and voice care team. This case represents a classic presentation of the disorder and highlights the importance of a team approach in successful treatment of a patient with sulcus vocalis. The voice therapy techniques presented in this case were chosen not for the specific diagnosis but because of their appropriateness in ameliorating the specific patient’s unique voice physiology and voice complaints, including vocal effort and fatigue. In concordance with current voice therapy literature, more therapeutic time was spent in direct (voice production) than indirect (voice hygiene) instruction.99 Due to the patient’s severe dysphonia and laryngeal disorder (sulcus vocalis with glottal incompetence), substantial therapy time was dedicated to voice exercise more so than to spontaneous conversation. Transfer to conversational speech is often the most difficult component of voice therapy for patients.116 Therefore, it is imperative that the speech-language pathologist devote significant therapy time to this ecologically valid task. However, some


individual’s voice problems are severe enough that considerable time must be spent finding and practicing a voice technique that improves the sound quality and feel of the patient’s voice. These patients and their disorders, in the end, are likely not amenable to voice therapy alone. This point was well illustrated by the case presented here and has been stated elsewhere in the literature.95,99 The current case represents one in which voice therapy served as a firstline, conservative approach to vocal rehabilitation, as well as an adjuvant to surgical treatment in a patient with glottal incompetence caused by sulcus vocalis. Voice therapy as initial treatment allowed the voice care team to evaluate Sarah’s adherence to voice therapy recommendations, as well as her ability to modify her vocal techniques and behaviors. This information helped the team make decisions about her ability to manage her voice with future surgeries. Sarah’s vocal effort was relieved and her sound quality moderately improved with the use of relaxed abdominal breathing and resonant voice techniques. As was demonstrated by this case, not all diagnoses and physiologic presentations are appropriate for voice therapy alone. It is imperative that the laryngologist and speech-language pathologist establish a respectful working relationship in order to provide optimum, complementary care of these difficult patients. Glottal incompetence also may be seen as a consequence of functional, or muscular, concerns. In the following case, Joe Stemple describes the management of a middle-aged male with an anterior glottal gap and vocal fatigue.

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Case Study 10 Joseph C. Stemple Improvement of Vocal Fold Closure in a Patient With Voice Fatigue

History Patient V was a 36-year-old systems analyst for a large computer networking company with no previous history of voice difficulty. Eight months prior to the voice evaluation, he had experienced bronchitis with associated harsh coughing and hoarseness. Within 2 weeks, all symptoms had resolved. Since that time, however, the patient had noticed that his voice was not quite as “strong” and that it seemed to get “tired” easily. At first, the voice fatigue occurred only occasionally and was usually associated with a busy workday or a normal social gathering. In the previous 2 to 3 months, however, the “tired” voice had become a daily occurrence and, according to the patient, was getting worse. On a daily basis, the patient’s voice quality was slightly hoarse when he awakened at 6 am, cleared to nearly normal by 8 am, but then began fatiguing, often by 11 am. The fatigue was accelerated if he was required to talk on the telephone or make a presentation to a small group. The patient described his voice quality, when the voice was fatigued, as being “breathy and muffled . . . almost like talking out of a barrel.” He described an increased effort to talk and complained that the harder he tried to talk, the worse the quality became. Except for persistent throat clearing, patient V was not a voice abuser. By his own admission he was a “couch

potato.” When not working at his computer at work, he was working on his home computer, watching television, or reading. Social activities were limited to family gatherings, movies, and quiet dinners with friends. He had been married for 10 years and had no children. His wife was an accountant. The patient’s medical history was unremarkable; no surgeries, hospitalizations, or chronic disorders were reported. The patient took no medications; had never smoked, although he grew up in a smoking environment; and drank alcohol only occasionally. His liquid intake was not adequate, consisting mostly of morning coffee and evening iced tea; both were caffeinated. The bronchitis, experienced 8 months ago, was an unusual occurrence for this normally healthy man.

Voice Evaluation Visual Examination Laryngeal videostroboscopic examination revealed grossly normal-appearing vocal folds bilaterally. Glottic closure demonstrated a moderate-sized anterior glottal gap with a slight ventricular fold compression. The bilateral amplitude of vibration and mucosal wave were moderately decreased and slightly decreased, respectively. The open phase of the vibratory cycle was slightly dominant, whereas the symmetry of vibration was irregular during extremes of pitch and loudness. No mass lesions, paresis, or paralysis were evident. Perceptual Description This vocal fold condition left patient V with a mild dysphonia characterized by a dry, breathy hoarseness, high pitch,


and intermittent pitch and phonation breaks. The patient was visibly pushing to produce voice in conversation and was using a forced-back focus, often speaking at the end of expiration as a result. Acoustic and Aerodynamic Measures This subjective judgment of voice quality was confirmed by objective measures including the following: n High fundamental frequency (142 Hz) n Limited frequency range (115 to 380

Management Approach The management approach developed for patient V included the following: n education n relaxation of laryngeal area muscula-

ture during phonation

n direct training in respiratory support

and frontal focus n Vocal Function Exercises n evaluation-modification of telephone voice n elimination of throat clearing n hydration program

Hz)

Education

vowels

The video recording of the stroboscopic examination was used to demonstrate the relationship between the glottal gap, high airflow rate, and increased effort to produce voice. Patient V was made to understand that even with the increased effort, the voice remained weak and breathy; therefore, the effort was useless and harmful to the laryngeal mechanism. The patient’s understanding of why his voice was failing was key to his becoming a willing participant in the therapeutic process. The patient had seen two laryngologists who had reported that his vocal folds were normal. He was frustrated because he knew he had a problem, but no one could “find” it. The relationship between his symptoms and his physiology “made sense,” and he was ready to proceed to eliminate the bothersome problem.

n High jitter measure for sustained n High airflow rates (comfort, 205

mL/s H2O; high pitch, 216 mL/s H2O; low pitch, 320 mL/s H2O) n Low phonation times at all voice conditions Patient V was evaluated in the late afternoon, when he was most symptomatic, of a typical workday. Because he had never experienced vocal difficulties prior to suffering bronchitis, it was speculated that the persistent harsh coughing had strained the laryngeal musculature. Presence of the anterior glottal gap, the unusually high pitch, and his inability to produce a more normal lower pitch range suggested the possibility of a laryngeal muscle imbalance. Patient V’s attempts to sustain lower tones during the stroboscopic examination yielded a larger anterior glottal gap. The presence of this gap during lowpitch production was confirmed by the unusually high airflow rate of 320 mL/ H2O/s. Continued effort to produce voice by force was causing the symptoms not only to persist, but to worsen.

Relaxation As patient V’s voice began to fatigue, his response was to tense his neck and shoulders in an effort to help force a more normal sounding voice. This

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effort, of course, had the opposite effect causing more laryngeal tension and fatigue. The education process was a major step in modifying this tensing behavior. The patient needed a cue for when he was too tense, however. Once cued, he needed a simple technique for reducing unwanted tension. The cue established for the patient was to set the alarm on his watch to sound every hour. When the alarm sounded, his task physically was to relax his neck and shoulders by rolling his head and by stretching his arms back and forth, up and down. This task took less than 1 minute but was quite effective for this patient in reducing physical tension. The patient had found that neck and shoulder tensing often occurred while he sat at his computer, even when he was not talking. He noticed that on occasion, he would not speak for 2 to 3 hours while working at the computer. Then, when he did speak, his voice was weak. The relaxation exercise was helpful in eliminating this problem. Respiratory Support and Frontal Focus Because of the increased airflow necessary to drive the vocal folds, patient V often felt breathless while talking. One reason for this breathless feeling was his inability to complete a phrase on a normal expiration without pushing and using his maximal air reserve. Using his air reserve added to laryngeal tension, which contributed to a backward tone focus. In his attempt to compensate for lack of glottic closure, the patient began elevating his larynx and contracting his tongue to improve laryngeal constriction. A symptomatic therapy was therefore utilized to modify these behaviors.

The following is a description of the 4-step Frontal Focus Exercise used by patient V: 1. Patient education. We began by teaching the patient about the concept of resonance by demonstrating how one sentence may be said with various resonance characteristics. Patients are made aware of how celebrity impersonators change the resonance of the voice to sound like other people. The concepts of frontal, back, and mid focus are introduced by first demonstrating a tight, constricted, backfocused phrase that the patient is asked to imitate. Because this type of tone placement is most often implicated as the problem, most patients, although somewhat embarrassed, are able to produce this voice. Second, a breathy, poorly focused tone is imitated followed by an exaggerated, almost nasal forward-focus. It is explained to the patient that, although the ultimate goal was not to talk in a nasal quality, practicing this placement would help to approximate the desired focus. Practice of this exaggerated forward placement would be one step toward learning the desired placement. 2. Nasalized phrase production. The patient was instructed to slowly and softly chant the following phrases on a comfortable pitch level slightly above his fundamental frequency: OH MY OH MY OH MY OH MY . . . OH ME OH ME OH ME OH ME . . . OH NO OH NO OH NO OH NO . . .


OH MY NO OH MY NO OH MY NO . . . OH ME OH MY OH ME OH MY . . . The forward resonance of each phrase is exaggerated to the extreme, and the patient is instructed to feel and sense the energy of the tone in the nose, on the lips, in the front of the face, and so on. Audio recordings of the phrases are made for both the clinician and the patient, and ear training is accomplished as needed. Once the phrases are produced to the satisfaction of the voice pathologist, negative practice is used. The patient is asked to alternate between forward and back focuses to demonstrate the mastery of the focus technique on these simple phrases. 3. Introduce intensity and rate variations. Using the same phrases, patient V was asked to repeat each phrase multiple times using the following routine: n

Very slow and very soft Faster and louder n Fast and loud n Slower and softer n Very slow and very soft n

All steps of the routine are accomplished in one breath. Changing the rate and loudness of the chanted phrases adds a new dimension to the exercise that forces the patient to concentrate on maintaining the forward placement even as the intensity and rate are increased. The pitch remains the same.

4. Introduce inflected phrase and normal speech. When patient V succeeded in mastering the first 3 steps, the same practice phrases were modified from the single pitch chant to a more “sing-song” or overinflected vocal presentation and then directly into a normally spoken phrase: n

Soft and slow Louder and faster n Exaggerated inflection n Normal speech n

Again, all steps of this routine are accomplished in one breath. The proper focus of the tone is closely monitored during each one of the steps utilizing the phrases. Negative practice is used throughout each session. Some patients move quickly through each of these steps and master a forward focus with ease. Others require many therapy sessions to master the appropriate focus. The final step is to expand the ability to produce a forward focus from these phrases into expanded phrases and sentences, paragraph reading, and conversational speech. Patient V was gradually able to expand into longer phrases. Negative practice was used judiciously throughout the therapy process to confirm the patient’s understanding and control of the concepts of frontal and back focus. Vocal Function Exercises Concurrent with the other therapeutic tasks, patient V was instructed in Vocal Function Exercises (VFEs; see Chapter 3). In our clinical practice, these exercises have proved extremely effective in dealing with obvious hypofunctional voice disorders. This patient had an airflow

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volume of approximately 4000 mL H2O. He should have been able to sustain a tone for at least 35 to 40 seconds. His baseline VFE measures were: Note

Seconds

E/F

22

C

15

D

16

E

24

F

26

G

30

The patient was instructed to do the Vocal Function Exercises 2 times each, twice daily, in the morning and evening. Evaluation and Modification of Telephone Voice During the evaluation, patient V indicated that his voice fatigued more quickly when he was required to talk on the telephone at work. To determine why this occurred, a telephone scenario was utilized. The patient was instructed to call the therapist during the morning, before the onset of typical voice fatigue. The phone call revealed that the patient artificially lowered his pitch, spoke in a back focus, and talked louder than normal on the telephone. Many of us have “telephone voices” that differ from our normal speaking voices. Patient V created more tension and strain, and thus fatigue, by talking with his “telephone voice.” To modify this behavior, the patient was instructed to imagine that the person with whom he was talking was sitting directly in front of him. In addition, he was instructed to hold the receiver to his ear only when listening and to

move it 7 to 10 cm (3 to 4 in) away when he was talking. By holding the receiver away from his ear, he would be monitoring his voice in the same manner as if the listener were present. The telephone receiver would not distort his auditory feedback system. Eliminate Throat Clearing Throat clearing became more and more evident as the patient’s voice fatigued. Behavior modification and the forceful swallow (see Chapter 3) were utilized to eliminate this behavior. Hydration Program Patient V’s liquid intake was inadequate for promotion of laryngeal lubrication. He was instructed to drink six to eight, 240 mL (8 fl oz) glasses of noncaffeinated, nonalcoholic liquids per day. Water and fruit juices were the preferred liquids.

Results of Therapy Three months of therapy were required to complete this program successfully. During this time, the combined therapy approaches were practiced, monitored, and modified as needed. Patient V first began to notice that his voice fatigue began later and later in the day. He then began to develop more of a downward extent of pitch in his VFE and more timbre in his speaking voice. By the middle of the month, he proclaimed his voice to be normal. Post-therapy stroboscopy demonstrated a tiny anterior glottal chink only at low pitches. All other observations were within normal limits. Perceptually, his voice quality was judged to be


normal. Objective measures were as follows: n Fundamental frequency (128 Hz) n Frequency range (98 to 560 Hz) n Jitter measures (normal) n Airflow rates (all less than 200 mL

H2O/s)

n Phonation times for Vocal Function

Exercises (averaged 36.5 s)

The original complaints of voice that lacked strength and tired easily were resolved. Patient V was placed on a maintenance program of modified VFE and discharged from therapy. A 3-month recheck revealed that the patient had successfully discontinued the maintenance program and maintained normal voicing. Combining direct symptom modification with laryngeal exercises and vocal hygiene training proved successful in resolving voice fatigue. The symptom of vocal fatigue is common among singers. In the following case, Chaya Nanjundeswaran describes the use of a Vocal Fatigue Index for identifying the symptom, and then an eclectic management approach to improve it.

Case Study 11

in a high school for the past 4 years. She self-referred herself to the ETSU voice clinic for her presenting voice problems. Her main concern at the evaluation was that she had developed some poor vocal habits and was having difficulty keeping her voice forward resulting in her symptoms of severe vocal fatigue and an increased effort to produce her speaking voice. Patient KS also experienced an increased tension in her neck with voice use. In addition, she noticed a drop in her speaking pitch and experienced glottal fry in her speaking voice. Patient KS mentioned an occasional tickling sensation in her throat when speaking. She experienced some difficulty with her singing voice, including an increased effort and tension during singing. She had formal training as a music major in college but was having a difficult time complying with the formal singing techniques. Patient KS does not smoke or drink alcohol, drinks about 3 glasses of water per day, and drinks about 4 caffeinated drinks per week. Patient KS constantly experiences a feeling of a lump or a sensation of something stuck in her throat. She was enrolled in voice therapy about 3 years ago for similar complaints, received benefits with voice therapy, but reports of having fallen through the cracks with her voice.

Chaya Nanjundeswaran

Medical History

An Eclectic Approach in the Management of an Individual With Vocal Fatigue

Patient KS has an existing problem of laryngopharyngeal reflux and is on Omeprazole (20 mg) for the same condition. In addition, patient KS experiences frequent nasal congestion and takes Zyrtec as needed. She was diagnosed with hypoglycemia but is not on any medication for it.

History of the Problem Patient KS is a 25-year-old female, a trained singer, and the choral director

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Social History Patient KS is an active church choir member. She leads choir sessions every Wednesday night and on Sunday mornings. She is using her voice constantly at work (about 90 minutes to 5 hours per day), as well as outside of work, and rates herself as being very talkative (9 on a scale of 1 to 10, with 1 being least to 10 being most talkative).

Voice Evaluation Audio-Perceptual The CAPE-V35 was used to document the auditory-perceptual judgment about patient KS’s voice. Overall severity was rated at 20, roughness at 40, strain at 30, and pitch was rated as low at 25. The ratings on strain and pitch were consistent, and roughness was rated as intermittent (specifically at the end of a speaking task). Instrumental Visual Imaging. A rigid videostroboscope was used to evaluate the laryngeal anatomy and physiology. No obvious organic pathology was observed; however, an overall redness was noted in the larynx. Bilateral vocal fold motion was normal with complete glottal closure. Excessive and thick mucus was observed on the free edges of the true vocal folds resulting in increased closure time. Furthermore, mild supraglottic compression was observed with the adduction of the false vocal folds. Acoustics. The KayPENTAX Computerized Speech Lab (Model 4500) was

used to obtain various acoustic measures. Mean F0 was 181 Hz and mean intensity was 61.5 dB SPL while reading the CAPE-V sentences, which are both low. Her pitch range when gliding from a low pitch to a high pitch on /a/ was at 143 Hz on low to a 269 Hz at the high end, which indicates a limited range. Patient KS’s intensity range was 31.38 dB SPL as obtained from phonating a soft /a/ and a loud /a/, with minimum intensity 52 dB SPL and maximum intensity 83.38 dB SPL. Spectrogram analysis on the midportion of the sustained /a/ revealed a type I36 pattern indicating good harmonics and less noise. Aerodynamics. The KayPENTAX Phonatory Aerodynamic System (PAS-Model 6600) was used to obtain physiologic measures. Mean intraoral pressure during the production of the syllable train / pi/ was 7.53 cm H2O, and mean airflow for the center 3 /pi/ tokens of a 5-token repetition was 240 mL/s. Pressure and airflow data were at the upper range of norms.

Patient Self-Assessment Patient KS completed the Vocal Handicap Index-10100 (VHI-10) and Vocal Fatigue Index117 (VFI) (Figure 4–8). Patient KS’s score was a 19/40 on the VHI-10. VFI was developed to provide a conceptual definition of vocal fatigue, to identify individuals with vocal fatigue, and to provide a common index across clinics to identify individuals with vocal fatigue. There are 19 questions in the VFI and it has 3 factors (see Appendix A). Factor 1 indicates an avoidance of voice use, factor 2 indicates physical discomfort, and factor 3 indicates improvement or lack of improvement thereof


Vocal Fatigue Index These are some symptoms usually associated with voice problems. Circle the response that indicates how frequently you experience the same symptoms (0- never, 1- almost never, 2- sometimes, 3- almost always, 4- always). Part 1 1) 2) 3) 4) 5) 6)

I don’t feel like talking after a period of voice use My voice feels tired when I talk more I experience increased sense of effort with talking My voice gets hoarse with voice use It feels like work to use my voice I tend to generally limit my talking after a period of voice use 7) I avoid social situations when I know I have to talk more 8) I feel I cannot talk to my family after a work day 9) It is effortful to produce my voice after a period of voice use 10) I find it difficult to project my voice with voice use 11) My voice feels weak after a period of voice use

0 0 0 0 0 0

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

Part 2 12) I experience pain in the neck at the end of the day with voice use 13) I experience throat pain at the end of the day with voice use 14) My voice feels sore when I talk more 15) My throat aches with voice use 16) I experience discomfort in my neck with voice use

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

Part 3 17) My voice feels better after I have rested 18) The effort to produce my voice decreases with rest 19) The hoarseness of my voice gets better with rest

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

Figure 4–8. Vocal Fatigue Index (VFI).

with rest. Patient KS’s scores on the VFI were as follows: factor 1: 42/44; factor 2: 12/20; and factor 3: 12/12. The scores on the VFI indicate that patient KS scored high on factor 1 suggesting avoidance of voice use, and high in factor 2 indicating physical discomfort with voice use. However, the scores on factor 3 indicate that patient KS’s VF improved with voice rest.

Voice Therapy Specific Types of Therapy An eclectic approach including voice care education, stretches, circumlaryngeal massage, and resonant voice was used with patient KS due to her presenting complaints. During the course of therapy, in order to increase awareness

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of patient KS’s vocal habits, an Ambulatory Phonation Monitor (APM; KayPENTAX Model 3200) was used. Rationale for Using the Therapy The review of the client’s history and results from the evaluations, including physiologic and videostroboscopic analysis, indicated that the source of the voice problem was primarily due to the increased impact stress between vocal folds and an adducted hyperfunction pattern of voice use. So, with respect to voice production, the primary goal was to decrease impact stress between vocal folds and to alleviate the adducted hyperfunction, thereby producing a well-balanced voice with decreased effort and vocal fatigue with speaking voice. To decrease impact stress and alleviate hyperfunction, different approaches and goals were chosen. The goals include: (1) to increase knowledge and awareness on voice care, specifically, knowledge on vocal hygiene; (2) to decrease the extralaryngeal muscle tension using stretches and circumlaryngeal massage; and finally, (3) to produce resonant voice as an efficient and alternative mode of voice production to decrease impact stress. A secondary goal was targeted toward modifying her vocal behaviors in her work environment to decrease vocal fatigue and effort. This goal was incorporated as part of hygiene education. Therapy Goals and Expected Outcomes Patient KS’s functional goals were established during the first session of therapy. 1. To be able to produce her voice with less effort at the end of the day

2. To experience less vocal fatigue with speaking voice 3. To consistently use forward voice, to avoid a glottal fry at the end of the sentence, and to practice healthy voice use. After the initial evaluation, patient KS received a total of 13, 50-minute sessions over a period of 2 public school semesters (fall and spring). Typically, patients are seen at the ETSU clinic over a period of 8 to 10 sessions, once a week. However, due to the patient’s work and choir schedule, treatment sessions were more widespread than typical. Treatment focus was divided into voice care education and direct voice therapy. Goal 1: To Increase Awareness and Knowledge of Voice Care. In the first session of voice therapy, the anatomy and physiology of voice production was reviewed with KS. The basic physiology of voice production, including the importance of adequate subglottic pressure and airflow, was discussed. In terms of vocal hygiene, 3 important concepts were addressed (following the hygiene protocol as outlined in Lessac Madsen Resonant Voice TherapyLMRVT.40 These included: (1) increase hydration, (2) manage LPR, and (3) decrease phonotraumatic behaviors. Hydration: The correlation between poor hydration, increased mucus on the vocal folds (as observed on visual stroboscopy), and increased effort to produce voice was explained to patient KS. Based on these discussions, it was recommended that she increase her water intake to about 1920 mL (64 fl oz) per day. Manage LPR: Patient KS was already on prescribed Omeprazole. However, during the evaluation, patient KS

indicated taking the pill after dinner. She was educated on the importance of taking the pill at the appropriate time (30 to 45 minutes before food). In addition, she was provided with tips to decrease acid reflux, including: (1) not eating at least 3 hours prior to bedtime, (2) keeping her head elevated at night, and (3) monitoring a food diary to see if certain foods triggered more reflux symptoms than others. Decrease phonotraumatic behaviors and make changes in her work environment: Patient KS uses her voice frequently at an increased volume in her work environment. The use of a vocal amplifier was recommended to control for vocal amplitude, but she did not feel comfortable using an amplifier at work. Patient KS did not typically practice the use of vocal warm-ups or cool-downs prior to or after her singing lessons at school. Vocal warm-ups and cool-downs aid in the ease of transitioning the mobility and flexibility of the vocal folds from speaking voice to singing voice and from speaking to singing voice, respectively. Patient KS was advised to incorporate some vocal warm-ups and cool-downs as part of her singing lessons with her students. She was also educated on the importance of vocal naps and was asked to incorporate them periodically during her 7-hour working day. Indirect voice therapy is as important as direct voice therapy, due to the influence of factors such as poor hydration and acid reflux on voice. Because patient KS showed signs of dehydration and acid reflux, it was important to manage these factors as they may be potentially influencing increased impact stress on her vocal folds. There is great demand on patient KS’s voice in her work environment. It is important


to modify certain vocal behaviors in her work environment prior to the implementation of efficient voice strategies. Goal 2: To Decrease Extralaryngeal Muscle Tension Using Stretches, Circumlaryngeal Massage, and Flow Phonation. Patient KS demonstrated significant extralaryngeal tension in her neck that was directly related to the significant vocal effort to produce her voice. Upper-body, specifically, face and neck, and whole-body stretches used in LMRVT were part of every session routine. Furthermore, due to the presence of a knot and tightness in the thyrohyoid space, circumlaryngeal massage as outlined by Aronson118 was used to release the thyrohyoid space. To increase awareness of tension in the laryngeal area, patient KS was asked to perform a series of tasks, alternating between voiceless and voiced sounds using flow phonation (see GartnerSchmidt case in Chapter 3).119 A facial tissue was used as a visual feedback mechanism to indicate increased airflow and ease of phonation. Negative practice was used as part of this process as well. Patient KS was asked to voluntarily constrict her neck while producing the voiceless sound and preventing airflow; she then let air flow consistently with the production of a voiceless sound and observed the difference in tension in the throat. Once she achieved the target sensation in the voiceless sound, a voiced sound was introduced. Each time patient KS felt a constriction or tightness in her neck, she would pick up a facial tissue and practice achieving increased airflow and the target sensation. Because extralaryngeal tension seemed to a be a primary cause of patient KS’s vocal issues, it was important for her to discriminate between

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constricted versus a relaxed throat and its effects on voice production. Goal 3: To Produce Resonant Voice as an Efficient and Alternative Mode of Voice Production to Decrease Impact Stress. Impact stress seemed to be a primary reason for her presenting voice complaints. In order to decrease impact stress, the goal was to train patient KS to produce an efficient and easy voice: resonant voice. Resonant voice (RV)107,120 has been well researched and documented for the slightly abducted vocal fold configuration for most speech, thus alleviating vocal hyperfunction. The LMRVT programmatic approach was used with patient KS to reduce impact stress (see Orbelo and Verdolini case in Chapter 3). The sequence included exploring the basic training gesture (BTG) on voiced phonemes to producing resonant voice in the phoneme, word, phrase level, chanting, and in conversational speech. During the exploration at the BTG and word level, negative practice was used to alternate between forward-focused voice production and voice from the throat. Patient KS was asked to perceive the sensation between a forward-focused voice versus a voice from the throat. Initially during the sessions, she had a difficult time perceiving her resonant sound. Patient KS was directed to focus more on the feel and ease of production of voice (in BTG and at the word level) and less on the sound of the voice. Following the ability to discriminate between the different voice production types, resonant voice was altered between voiced and voiceless production. She could produce resonant voice in the BTG and at word level. She could produce RV with ease in chanting at the phrase level. However,

when speaking in a phrase or during conversation, it was difficult for patient KS to stay forward. The emphasis during such tasks and conversation was placed on the ability to identify when she dropped her voice to the throat and to bring it forward. Due to increased need to project her voice in school to her students, messa di voce (increasing loudness using resonant voice) was also explored. Initially, all tasks were performed in a quiet clinic room. Toward the end of therapy, all exercises were performed in a classroom environment, with a specific emphasis on maintaining a loud conversation and staying forward. Patient KS’s major complaint through her sessions was maintaining her voice forward and complying with therapeutic strategies in her work environment. Her major complaint was, “I can feel it in my throat, but I continue to talk and sing.” Increasing awareness of voicing patterns with use of Ambulatory Phonation Monitor (APM): During her therapy sessions, patient KS had a difficult time complying with the voice therapy techniques, given her increased vocal demands. Specifically, she had difficulty sustaining her forward-focus voice during everyday voice use. She would have a few productive voice sessions but would go right back to feeling the tension in her neck and experiencing vocal fatigue. To increase patient KS’s awareness about her vocal habits and how her voice use was exacerbating her vocal symptoms, an Ambulatory Phonation Monitor (KayPENTAX-Model 3200) was used. She was asked to wear the APM for a typical working day (about 7 am to 3 pm). The total duration that the APM was turned on was 7 hours and

57 minutes. The total phonation time in that duration of APM use was 2 hours and 5 minutes and was about 26.33% time of APM use. The mode fundamental frequency, defined as the value at which most phonation occurred, was 176 Hz. The average intensity during that period was 79.26 dB SPL. Her vocal dose was determined by total cycles of vibration (total number of glottal cycles detected) and total distance dose (estimates how far the vocal folds traveled). The total cycles of vibration were 1 794 382 and the distance dose was 5344.37 m. The vocal dose data indicated increased impact stress and can potentially explain her increased vocal fatigue and increased effort to produce voice. The obtained data were discussed with patient KS. The APM was valuable in emphasizing the increased vocal demands in her work environment. She was astonished at her phonatory patterns; “she even stated that although she could hear her voice dropping down, she would continue to talk in the same manner.” Following APM monitoring, patient KS tried to adhere to maintaining a forward-focused voice during her speaking voice use. Her compliance in practicing voice therapy strategies outside the clinic environment, specifically in her work environment, increased. She was able to maintain resonant voice about 75% of the time during conversational speech at the end of therapy. However, she still had difficulty projecting her voice and keeping it forward.

Therapy Outcomes Audio-Perceptual Based on CAPE-V, patient KS’s voice was rated at 10 for overall severity,


roughness at 20, and strain at 10. Pitch was judged to be normal and gender appropriate. Instrumental Acoustics. Post-therapy mean F0 was 200 Hz, and average intensity was at 69 dB SPL while reading CAPE-V sentences. Patient Self-Assessment. Patient KS’s post-therapy score on the VHI-10 was 11/40. On the VFI, patient KS scored 22/44 for factor 1, 6/20 for factor 2, and 12/12 for factor 3. There was a decrease in her overall fatigue symptoms.

Summary and Concluding Remarks An eclectic approach was used with patient KS to alleviate her voice symptoms. There was no underlying organic pathology resulting in her vocal symptoms. However, her increased vocal demands, increased impact stress, and hyperadduction resulted in an increased vocal effort to produce voice and significant vocal fatigue. Increasing her hydration and controlling for acid reflux symptoms decreased her tickle in her throat while speaking. In addition, RV helped reduce her impact stress and decreased effort and vocal fatigue with voice use. Although patient KS had difficulty achieving and maintaining resonant voice initially, data from APM heightened her awareness of the need to change her vocal patterns. APM served as a useful tool to increase awareness of patient KS’s vocal patterns, which in turn increased her compliance to use voice therapy strategies outside of the clinic setting.

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Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. Jul 2011;43(7):1334–1359. 76. American College of Sports Medicine, Chodzko–Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. Jul 2009;41(7):1510–1530. 77. Ramig LO, Gray S, Baker K, et al. The aging voice: a review, treatment data and familial and genetic perspectives. Folia Phoniatr Logop. Sep–Oct 2001; 53(5):252–265. 78. Linville SE. Vocal Aging. San Diego, CA: Singular Thomson Learning; 2001. 79. Hoit JD, Hixon TJ. Age and speech breathing. J Speech Hear Res. Sep 1987; 30(3):351–366. 80. Hoit JD, Hixon TJ, Altman ME, Morgan WJ. Speech breathing in women. J Speech Hear Res. 1989;32(2):353–365. 81. Berg EE, Hapner E, Klein A, Johns MM, 3rd. Voice therapy improves quality of life in age-related dysphonia: a case-control study. J Voice. Jan 2008; 22(1):70–74. 82. Ziegler A, Verdolini Abbott K, Johns M, Klein A, Hapner E. Preliminary data on two voice therapy interventions in the treatment of presbyphonia. In Submission. 83. Ramig LO, Bonitati CM, Lemke JH, Horii Y. Voice treatment for patients with Parkinson disease: development of an approach and preliminary efficacy data. J Med Speech-Lang Path. 1994; 2(3):191–209. 84. Ramig LO, Countryman S, Thompson LL, Horii Y. Comparison of two forms of intensive speech treatment for Parkinson disease. J Speech Hear Res. December 1, 1995;38(6):1232–1251. 85. Titze IR, Verdolini K. Vocology — The Science and Practice of Voice Habilitation.

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Salt Lake City, UT: National Center for Voice and Speech; 2012. 86. Melov S, Tarnopolsky MA, Beckman K, Felkey K, Hubbard A. Resistance exercise reverses aging in human skeletal muscle. PLoS One. 2007;2(5):e465. 87. Ratamess NA, Alvar BA, Evetoch TK, et al. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. Mar 2009;41(3):687–708. 88. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. Champaign, IL: Human Kinetics; 2011. 89. Hunter GR, McCarthy JP, Bamman MM. Effects of resistance training on older adults. Sports Med. 2004;34(5): 329–348. 90. Peterson MD, Rhea MR, Sen A, Gordon PM. Resistance exercise for muscular strength in older adults: a meta-analysis. Ageing Res Rev. 2010;9(3):226–237. 91. Hixon TJ, Hoit JD. Evaluation and Management of Speech Breathing Disorders: Principles and Methods. Tucson, AZ: Redington Brown; 2006. 92. Berry DA, Verdolini K, Montequin DW, Hess MM, Chan RW, Titze IR. A quantitative output-cost ratio in voice production. J Speech Lang Hear Res. Feb 2001;44(1):29–37. 93. Ziegler W. Review. Aphasiology. 2003/ 01/01 2003;17(1):3–36. 94. Schmidt RA, Lee TD. Motor Control and Learning. 4th ed. Champaign, IL: e-Book: HumanKinetics.com; 2005. 95. Giovanni A, Chanteret C, Lagier A. Sulcus vocalis: a review. Eur Arch Otorhino-laryngo. Apr 2007;264(4):337–344. 96. Welham NV, Choi SH, Dailey SH, Ford CN, Jiang JJ, Bless DM. Prospective multi-arm evaluation of surgical treatments for vocal fold scar and pathologic sulcus vocalis. Laryngoscope. Jun 2011;121(6):1252–1260. 97. Ford CN, Inagi K, Khidr A, Bless DM, Gilchrist KW. Sulcus vocalis: a rational analytical approach to diagnosis and

management. Ann Otol Rhinol Laryngol. Mar 1996;105(3):189–200. 98. Xu JH, Ikeda Y, Komiyama S. Biofeedback and the yawning breath pattern in voice therapy: a clinical trial. Auris, nasus, larynx. 1991;18(1):67–77. 99. Gartner-Schmidt JL, Roth DF, Zullo TG, Rosen CA. Quantifying Component Parts of Indirect and Direct Voice Therapy Related to Different Voice Disorders. J Voice. 2013;27(2):210–216. 100. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope. Sep 2004;114(9):1549–1556. 101. Arffa RE, Krishna P, Gartner-Schmidt J, Rosen CA. Normative values for the Voice Handicap Index-10. J Voice. Jul 2012;26(4):462–465. 102. Titze IR. Workshop on acoustic voice analysis: Summary statement. Iowa City, IA: National Center for Voice and Speech; 1995. 103. Welham NV, Dailey SH, Ford CN, Bless DM. Voice handicap evaluation of patients with pathologic sulcus vocalis. Ann Otol Rhinol Laryngol. Jun 2007; 116(6):411–417. 104. Hixon TJ, Putnam A. Voice disorders in relation to respiratory kinematics. Semin Speech Lang. 1983;4:217–231. 105. Hixon TJ, Hoit JD. Evaluation and Management of Speech Breathing Disorders: Principles and Methods. Tucson, AZ: Reddington Brown; 2005. 106. Stemple JC, Lee L, D’Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice. 1994;8(3):271–278. 107. Verdolini K, Druker DG, Palmer PM, Samawi H. Laryngeal adduction in resonant voice. J Voice. Sep 1998;12(3): 315–327. 108. Roy N, Weinrich B, Gray SD, et al. Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study. J Speech Lang Hear Res. Aug 2002;45(4): 625–638.


109. Ziegler A, Gillespie AI, Abbott KV. an overlooked etiology? Laryngoscope. Behavioral treatment of voice disorJan 2010;120(1):114–120. ders in teachers. Folia Phoniatr Logop. 115. Bielamowicz S, Villagomez V. Sulcus 2010;62(1–2):9–23. vocalis concealed by a hemorrhagic 110. Gartner-Schmidt J, Rosen C. Treatpolyp. Ear, Nose Throat J. Oct 2001; ment success for age-related vocal fold 80(10):696. atrophy. Laryngoscope. Mar 2011;121(3): 116. Gartner-Schmidt J, Ziegler AS. What 585–589. does your patient really think about voice 111. Dejonckere PH. Clinical implementatherapy? Conference presentation, 8th tion of a multidimensional basic proAnnual Advanced Practices in Voice and tocol for assessing functional results Dysphagia; Feb 24, 2013; Las Vegas, NV. of voice therapy. A preliminary study. 117. Nanjundeswaran C, Verdolini-Abbott Revue de laryngologie - otologie - rhinoloK, Jacobson B, Gartner-Schmidt J, gie. 2000;121(5):311–313. Rosen CA. Vocal Fatigue Index: Develop112. Zeitels SM, Mauri M, Dailey SH. Mediment and validation. In preparation. alization laryngoplasty with Gore-Tex 118. Aronson A. Clinical Voice Disorders: An for voice restoration secondary to Interdisciplinary Approach. 3rd ed. New glottal incompetence: indications and York, NY: Thieme Medical Publishers; observations. Ann Otol Rhinolo Laryn1990. gol. Feb 2003;112(2):180–184. 119. Gartner-Schmidt J. Flow phonation. In: 113. Welham NV, Rousseau B, Ford CN, Behrman A & Haskell J, eds. Exercises Bless DM. Tracking outcomes after for Voice Therapy. San Diego, CA: Plural phonosurgery for sulcus vocalis: a Publishing; 2008, 42–45. case report. J Voice. Dec 2003;17(4): 120. Verdolini-Marston K, Burke MK, Les571–578. sac A, Glaze L, Caldwell E. Preliminary 114. Carroll TL, Gartner-Schmidt J, Stastudy of two methods of treatment for tham MM, Rosen CA. Vocal process laryngeal nodules. J Voice. Mar 1995; granuloma and glottal insufficiency: 9(1):74–85.

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5 Dystonia, Essential Tremor, and Other Neurogenic Disorders

Neurogenic voice pathologies cause vocal dysfunction by interrupting innervation to the larynx, including both central and peripheral insults. Some of these disorders are confined to voice and laryngeal manifestations, such as vocal fold paralysis (discussed in Chapter 4). Some may represent a focal form of a neurological impairment that often manifests in other parts of the body (spasmodic dysphonia), while others are thought to originate in the brain and result from fluctuating messages from the brain to the muscles

Spasmodic Dysphonia Imagine developing a condition so insidious that it may cause loss of selfrespect and confidence; a disorder so negative as to cause depression, reclu-

of the vocal tract (benign essential voice tremor). Still others may reflect a larger deterioration of many motor control systems, including broader impairment of respiration, resonance, swallowing, and other functions beyond the head and neck where a voice disturbance is only one of many impairments (eg, progressive neurogenic disease). This chapter offers a discussion of treatments for 3 such disorders: spasmodic dysphonia, benign essential voice tremor, and Parkinson disease.

siveness, and thoughts of suicide; a condition that can threaten careers, marriages, and friendships. This disorder is spasmodic dysphonia. Spasmodic dysphonia is a term that describes a family of strained, strangled voices. Perceptually, the voice symptoms

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are classified in two primary groups: adductor and abductor spasmodic dysphonia. Adductor spasmodic dysphonia (ADSD), which is the most common, is characterized by strained, strangled phonation with occasional intermittent stoppages of voice. The severity may range from mild, intermittent symptoms to a severe, persistent struggle to produce phonation. The abductor type is characterized by abductor vocal fold spasms causing sudden, intermittent explosions or escapes of air. Abductor spasms appear to occur most frequently during the transition from voiceless consonants to vowels. Although the incidence of this disorder is thought to be relatively low, the extreme negative effects that it brings to many individuals suffering with the disorder highlight the importance of appropriate professional care. Most researchers agree that the onset of spasmodic dysphonia generally occurs during middle age (although clinical reports include children and older adults).1,2 The exact ratio of female to male cases is unknown, but most agree that the majority of cases seen are women. Some patients experience a rapid onset of symptoms, whereas others experience a gradual onset over many years. Researchers and clinicians have debated the cause of spasmodic dysphonia for many years. Early descriptions linked the disorder to psychoneurosis.3–6 Aronson3 commented that one type of strained, strangled voice has a psychological cause and can be treated as a functional aphonia or a disorder of musculoskeletal tension. An argument could be made that classifying these disorders as spasmodic dysphonia may not be appropriate. Others have advocated a neurologic origin.1,7,8 Blitzer et al9 offered the first evidence that spas-

modic dysphonia is a focal dystonia specific to the larynx and similar to other dystonias, such as blepharospasm and torticollis. Symptom relief as a result of voice therapy has been minimal at best. Until recently, most patients treated in our clinic have had the disorder for many years prior to diagnosis. They have sought treatments from many laryngologists, speech-language pathologists, psychologists, and psychiatrists. They have been prescribed various drugs and have gone through relaxation therapy, biofeedback, hypnosis, and acupuncture. Some patients have sought the services of a faith healer. All patients have been consistent in their frustrations over the lack of relief. Until 1976, most patients with spasmodic dysphonia remained untreated — that is, until Herbert Dedo10 suggested a fairly radical prophylactic treatment for symptom relief. This treatment was to create a unilateral vocal fold paralysis. Dedo and Izdebski11 reported that creation of the unilateral paralysis proved successful in relieving the adductor spasmodic dysphonia symptoms 4 years postoperatively in 90% of 306 patients. Dedo and Shipp12 reported that spasmodic dysphonia returned in 10 to 15% of their patients within 1 month to 2 years following recurrent laryngeal nerve (RLN) resection. Aronson and De Santo13 followed 38 patients and reported that 64% had worse voice quality after 3 years postoperatively. The current treatment for spasmodic dysphonia is prophylactic as well. It involves creating a paretic or weakened vocal fold condition. This is accomplished by injecting botulinum toxin (Botox) into the thyroarytenoid muscle (for adductor spasmodic dysphonia) and the posterior cricoarytenoid


muscle (for abductor spasmodic dysphonia), creating a temporary paresis of the muscles.14 The weakened muscles do not permit the spasms to occur, and thus the vocal symptoms are relieved. The following cases studies are illustrative of the speech-language pathologist’s interaction with individuals presenting with spasmodic dysphonia. Some patients who present with spasmodic dysphonia benefit from a direct symptom modification approach of voice therapy. As a result of the physical struggle inherent in attempting to push the voice through the spasmodic occurrences, many patients develop secondary behaviors that make the voice quality worse than the baseline spasmodic condition. For example, patients develop extreme neck, shoulder, and thoracic tension; lowered pitch and glottal fry phonation; and monotonous phonatory patterns. The first case study in this chapter involves an individual who developed these secondary behaviors. The study describes functional voice therapy that subsequently improved the symptoms significantly, albeit without eliminating the spasms.

Case Study 1 Joseph C. Stemple Functional Voice Therapy for Spasmodic Dysphonia

History Patient VV, a 57-year-old high school English and drama teacher, was referred

to the voice center by the speech-language pathologist serving her school. Her history was typical of many individuals with this disorder. Although she had been symptomatic for 3 years and had consulted 3 laryngologists and 1 speech-language pathologist, the diagnosis of spasmodic dysphonia had never been made. Patient VV had never married and was extremely independent and outgoing. She had taught for 34 years and stated that she “lived to teach.” By the time of the initial evaluation, she was extremely upset, confused, and full of self-doubt. She had independently sought the counsel of a psychologist who, unfortunately, was not familiar with spasmodic dysphonia and who supported the notion that the problem was “all in my head.” She had developed lesson plans and techniques that minimized her own speaking, but she suffered with these teaching modifications. Previously, she had been honored as an outstanding educator, and she was convinced that she had become less than effective in the classroom. Away from school, this normally outgoing individual had withdrawn and, for at least 18 months, lived a reclusive existence. She refused to see friends and totally avoided the telephone. Several weeks into our treatment, she admitted to having had thoughts of suicide. The 2 things most dear to her, teaching and friendship, had been taken from her as a result of her voice disorder. The voice pathologist performed 3 roles during the initial session: evaluator to confirm the presence of spasmodic dysphonia; educator to teach the patient what was known about the disorder; and treatment planner to attempt to remediate the disorder. Patient VV presented with adductor spasmodic

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dysphonia of moderate severity. Phonation was characterized by intermittent glottal stops and glottal fry phonation as well as a flat, monotonous inflection pattern. It was evident from the physical appearance of neck and shoulder tension and facial expression that she was very tense, nervous, upset, and depressed. The voice problem began in the fall 3 years prior to the examination. It manifested as hoarseness that persisted following an upper respiratory infection. Much probing regarding other possible psychosocial issues yielded nothing related to the onset. When the hoarseness persisted for several weeks, she sought the opinion of an otolaryngologist who prescribed antibiotics 3 times over a 4-month period. As the symptoms worsened, hesitations began “shutting off” her voice, requiring her to force to speak. She reported that teaching was actually causing her to be physically fatigued because of the effort it took to speak. She was exhausted at the end of a school day. Some days, her abdominal muscles would become sore from straining to produce voice. During the 2 subsequent years, she sought the opinion of 2 more physicians, one of whom prescribed more medication, with the other recommending psychological counseling. A speech-language pathologist, new to patient VV’s school, heard her speak and thought the patient presented with the symptoms of spasmodic dysphonia. She then suggested that the patient come to our center for evaluation. Desperate for help, she complied.

Voice Evaluation It was determined through examining voice quality characteristics, abilities, and lack of abilities, that she had

adductor spasmodic dysphonia. The diagnosis of spasmodic dysphonia is a diagnosis of perception. She demonstrated normal phonation when humming or singing, or when speaking in lilting accents. She loved to read aloud from the writings of the American dramatist Tennessee Williams because the higher-pitched rhythm of the US southern dialect reduced her effort to talk and improved the voice quality. She could laugh normally and felt that her voice was “near-normal” when she talked to her cat. The patient also thought that her voice quality was improved following ingestion of wine. This led her to try tranquilizers, which did not improve her voice quality. Following identification of the problem, patient VV was given much information regarding spasmodic dysphonia. This included information provided by the National Spasmodic Dysphonia Association (NSDA) website (http://www.dysphonia.org). She was greatly relieved that she suffered from a “recognized” disorder and that the problem was not necessarily psychologically induced. (In retrospect, patient VV also had a very mild head tremor, which is not an unusual co-occurrence with spasmodic dysphonia.) The possibility of a nonspecific central nervous system disorder was discussed. The differences between vocal symptoms of organic tremor and spasmodic dysphonia were discussed because of the patient’s observation of her vocal likeness to a popular actor.

Treatment Treatment options were then discussed. As with many patients, patient VV was distressed to learn that treatments would produce only symptom relief and


not cure the disorder. Botox injections and functional voice therapy designed to eliminate secondary tension, inappropriate pitch, and inflection were discussed. The decision was made to initiate treatment with functional voice therapy. It was interesting to note the change in patient VV’s entire persona from the initial session to the second session. From a tense, depressed, and beaten individual emerged an encouraged, determined, and resolute person. During the first session, we identified the vocal tasks that she could perform well with fair consistency. These included: n humming and singing n speaking at a higher pitch n speaking with a slight Southern

dialect

It was discovered that she could speak well to her cat because she was speaking in a higher-pitched, “baby” voice. She had developed the habit of producing voice with muscle tenseness, back focus, and at low pitch in an effort to overcome the intermittent spasms. Because the patient had no idea when the spasms would occur, she postured her phonatory and respiratory systems in a manner that produced constant tension and pressure. The first step of therapy was to introduce relaxation techniques to demonstrate the degree of tension. Progressive relaxation as well as electromyographic (EMG) biofeedback was successfully utilized for this purpose. Phonatory tasks then were added to this newly relaxed state, utilizing a slightly higher pitch and phrases controlled by length. Although the spasms persisted, the therapist and the patient noted that frequency and severity decreased. Phrases were lengthened, and the patient was trained to breathe more

normally. A midtone focus permitting a slightly breathy phonation was deemed acceptable by the patient. In addition, she felt comfortable in slightly overinflecting her phonation patterns of pitch and loudness, which also seemed to decrease the severity of the spasms. Longer phrases utilizing these techniques were then expanded into paragraph readings with and without phrase or breath markers and finally into practiced conversational speech. Because of patient VV’s background in drama, the entire therapy program was completed within 6 weeks. The spasms persisted, of course, but were heard only as occasional hesitations during speech production. The patient learned to permit her voice to flow through and past the hesitations without redeveloping the previous strained postures. Eliminating the secondary behaviors proved adequate for this patient. She did not then choose to pursue Botox injections. Prior to discharge, the patient was advised that her voice may continue to decline in the months and years to come and that she should seek follow-up care and reconsider the possibility of Botox injections should concerns arise. In the next case study, Edie Hapner and Michael Johns discuss an interdisciplinary comprehensive medical and behavioral management approach for a patient presenting with adductor spasmodic dysphonia.

Case Study 2 Edie R. Hapner and Michael M. Johns Medical and Behavioral Management of Adductor Spasmodic Dysphonia

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Patient History A 56-year-old female teacher presented with a 5-year history of dysphonia. Recently, she had noticed that people asked her if she was upset when she talked. She noted that her voice was better when she was singing. It also improved slightly with a glass of wine. Using the phone made her voice worse, and she had stopped ordering in restaurants because of her voice. She had seen multiple otolaryngologists and had been diagnosed with hoarseness and reflux. She had been treated with several full courses of antibiotics, steroids, proton pump inhibitors for laryngopharyngeal reflux (LPR), and a 14-week course of voice therapy. In voice therapy, she was able to achieve a clearer tone but frustrated both herself and the speech-language pathologist when she was unable to carryover the clear voice outside of therapy. Both the speech-language pathologist and otolaryngologist had suggested that perhaps there was some unconscious stressor in her life that she was not dealing with, and they had recommended that she see a psychiatrist. During her own Internet search, she came across information about a multidisciplinary voice center in her area and made an appointment to be seen.

overlap, the otolaryngologist largely obtained the medical history described above, and the speech-language pathologist obtained the voice history. The otolaryngologist performed the general and otolaryngology examination, and the speech-language pathologist performed the endoscopic laryngeal imaging. A perceptual voice screening was completed in the presence of both the otolaryngologist and speechlanguage pathologist asking the patient to complete the following tasks while observing for phonation breaks, voicevoiceless transitions, and the presence of vocal tremor: (1) prolong the vowels /i/ and /a/; (2) produce vowel-loaded sentences; and (3) count from 60 to 65 and 80 to 85. General Examination

Evaluation

On physical examination, the patient appeared healthy and was breathing comfortably in no acute distress. Vital signs showed that the patient was afebrile. The pulse was 82, respirations were 14, and blood pressure was 146/91. The patient had normal gait. Upper and lower extremity examination demonstrated full muscular strength and normal sensation. No hand tremor or joint cogwheel rigidity was noted. Reflexes were 2+. Respiratory examination showed clear breath sounds with full inspiration and normal forceful expiration.

Overview

Head and Neck Examination

The patient was seen and evaluated in a multidisciplinary voice clinic. Both a speech-language pathologist and an otolaryngologist evaluated the patient on the same day, separately and together. Recognizing that there was significant

The patient’s voice had a severe strained and strangled quality, making her difficult to be understood. The neck was supple without skin lesions, thyromegaly, lymphadenopathy, or masses. There was moderate tenderness to palpation


in the thyrohyoid region that was symmetrical. Cranial nerves II through XII were grossly intact, eye movements were full, and head and neck muscle strength was normal. Otoscopy demonstrated clear external auditory canals, and intact tympanic membranes with aerated middle ear spaces. Hearing was grossly normal. Anterior rhinoscopy showed healthy mucous membranes without masses or obstruction of the nasal cavities. Oral cavity and oropharyngeal examination demonstrated moist mucous membranes without lesions. Palatal rise and gag reflex were normal. Indirect laryngoscopy was somewhat limited by the gag reflex, but there were no gross masses, and vocal fold mobility appeared normal.

try of the vocal mechanism. A mixture of topical ponticaine and oxymetolazine was applied to the nasal mucosa by the clinic nurse for the flexible examination. During the flexible examination, the patient’s voice improved significantly, which considerably increased the overall intelligibility of her communication. Palatal closure was complete and without fatigue. Pharyngeal squeeze was normal. No pharyngeal or laryngeal masses were noted. The laryngeal mucosa appeared healthy with mild interarytenoid pachydermia and postcricoid edema observed. Arytenoid motion showed full adduction and abduction that were symmetrical and brisk bilaterally.

Laryngeal Imaging

Following the office evaluation, the patient was seen by the speech-language pathologist for a comprehensive voice evaluation including: (1) perceptual voice assessment, (2) acoustic assessment, (3) aerodynamic assessment, and (4) assessment of the impact of the voice disorder on quality of life.

Detailed laryngeal imaging was performed using both rigid transoral examination with a 70-degree telescope for detailed mucosal examination and transnasal flexible imaging using a distal-chip videolaryngoscopy for dynamic assessment of the larynx and pharynx. These endoscopic examinations were performed by the speech-language pathologist using both plain and stroboscopic light. The rigid 70-degree stroboscopic assessment was the first laryngeal imaging examination to be completed. The stroboscopic examination yielded symmetrical vocal process approximation in the midline, complete glottal closure, symmetrical entrained vibration of the membranous vocal folds without asymmetry, normal mucosal waves bilaterally (propagating to 50% of the superior surface of the vocal folds), and intermittent vibratory aperiodicity. Flexible transnasal imaging was performed to assess motion and symme-

Behavioral Voice Assessment

Perceptual Assessment The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was administered. The patient had an overall score of 84/100, indicating a dysphonia of a severe nature. Aberrant perceptual features identified in the voice included roughness, pitch breaks, phonation breaks, and strain. There was laryngeal/pharyngeal focused resonance with base of tongue tension that dampened the intensity of voice output. Respiration appeared to be primarily abdominal/thoracic. There was evidence of breath holding during conversational speech indicating poor

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coordination of respiration and phonation for efficient phrasing in running speech and increased tension in the neck and chest. A motor speech evaluation indicated a normal oral mechanism with normal articulatory precision. On vowel prolongation, there were audible voice stoppages with a strain-strangled harshness to the tone though no tremor was noted. Laryngeal diadochokinesis indicated phonation breaks. Aerodynamic Measures Aerodynamic measures of syllable repetition have been suggested for use in differential diagnosis. To complete this task, the patient was fitted with a standard face mask connected to a commercially available pneumotachograph and pressure transducer. She was asked to produce repetitions of the syllable /pa/. Results indicated a lower than normal phonatory flow rate of 130 mL/s (norms = 177 to 187 mL/s), and phonatory airflow was interrupted with 7 instances of airflow perturbations in the task (norms = 1 to 2 instances). Acoustic Assessment A headset microphone was placed at a 45-degree angle at 2 cm from mouth for acquisition of acoustic information per standards recommended by Titze and Winholtz15 in their 1993 article about standards for acoustic assessment of voice. The patient was placed in a soundproof booth for testing. The results of the assessment were abnormal, including: (1) decreased maximum phonation time of 5 seconds; (2) speaking fundamental frequency (sF0) was abnormally low at 165 Hz; (3) standard deviation of sF0 was abnormally high (= 29 Hz);

(4) restricted physiologic pitch range across the entire physiologic frequency range of phonation; (5) abnormally high pitch perturbation (jitter) = 1.05%; (6) abnormally high-intensity perturbation (shimmer = 3.85%; (7) elevated noise to harmonic ratio > 0.12; and (8) elevated degree of voice breaks = 1.01. Results of the testing indicated a voice type 3, with chaotic or random signal acquisition and relative average perturbation high. This indicates that the acoustic data are not a reliable source of information and that perceptual ratings of voice should be used. Trial Therapy During trial therapy, the patient was stimulable for improvement in voice quality using chant talk, high-pitched productions, vegetative vocal tasks, and whispering. Voice Quality of Life Voice-Related Quality of Life (VRQOL)16 was administered to assess the patient’s perception of the impact the voice disorder has on quality of life. The VRQOL raw score was 34/50, which converts to 35/100. (Higher QOL scores correlate with higher quality of life.) These scores indicate that the patient perceives her voice disorder as having a significant impact on her quality of life.

Diagnosis After the evaluation above, the otolaryngologist and the speech-language pathologist conferred and reviewed the patient’s presentation. A diagnosis of spasmodic dysphonia — adductory type was rendered. Together, the clinicians


shared the diagnosis with the patient. They explained that the problem was a focal dystonia, a benign neurologic condition that results in uncontrolled spasm of the laryngeal muscles responsible for vocal fold adduction (primarily the thyroarytenoid and lateral cricoarytenoid muscles). The patient asked what caused the condition and was told that the exact cause is unclear, but that it is felt to result from an abnormality in the basal ganglia (a center of movement control in the brain). The patient was then told of the alternate diagnoses that can present similarly to or simultaneously with spasmodic dysphonia, such as muscle tension dysphonia and benign essential vocal tremor. The patient was given written and online (http://www. dysphonia.org) information about spasmodic dysphonia and watched a video produced by the National Spasmodic Dysphonia Association. The otolaryngologist and speech-language pathologist answered all the questions that the patient had regarding the diagnosis and then a detailed discussion regarding treatment ensued.

Treatment Medication The patient asked about medications that could be used for treatment. She was told that there are no medications that have been demonstrated to provide any long-term benefit. Benzodiazepines, such as diazepam, help some patients for short periods, but the risk of dependency from chronic use was discussed as well as the goal of avoiding the routine use of such medications. Some medications have limited utility for vocal tremor, such as beta blockers

(eg, propranolol) and anti-epileptics (eg, primidone), but these have not been shown to be effective for isolated spasmodic dysphonia. Surgical Options The history of surgical procedures for spasmodic dysphonia was reviewed with the patient including recurrent laryngeal nerve section, recurrent laryngeal nerve avulsion, and the newer selective laryngeal adductory denervation and reinnervation (SLAD-R). The former are limited by frequent recurrences of voice breaks, typically do not have long-term benefits, and may be complicated by permanent breathiness to the voice. The latter is a newer procedure that may be effective in patients who respond well to botulinum toxin injections, but it has not become widely utilized for spasmodic dysphonia, largely due to lack of long-term data regarding its effectiveness. The patient was encouraged to take an initial therapeutic approach with botulinum toxin injections. Voice Therapy The patient asked about returning to voice therapy as a treatment for ADSD. She was counseled that, as she had experienced with her previous attempts at voice therapy, research supports that voice therapy is not the most effective treatment for patients with ADSD. She was told that there are speech-language pathologists who believe that they are able to cure ADSD through the use of inhalation phonation targeting the abductor muscles or a method using a traditional symptomatic voice therapy approach requiring the patient to attend 5 hours of voice therapy 5 days a week

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for 4 to 5 weeks. However, there is limited evidence for either treatment technique’s effectiveness in permanently curing ADSD. Botulinum Toxin Injections The patient was told that the most widely utilized treatment for spasmodic dysphonia is botulinum toxin type-A injection into the laryngeal adductory muscles. Botulinum toxin is neurotoxin that blocks the ability of nerves to make muscles contract. When injected into a target muscle, it impairs the release of neurotransmitter from nerve endings at the neuromuscular junction. This effectively paralyzes or significantly weakens the muscle and prevents muscle contraction. Botulinum toxin acts temporarily, with effects from 3 to 6 months. Because of this, repeated injections are necessary for long-term treatment. She was counseled that botulinum toxin injections for spasmodic dysphonia have been shown to be effective in reducing voice breaks and improving quality of life for patients both in the short term and long term. The injections usually are given to an awake patient in the outpatient setting, utilizing laryngeal electromyography for accurate guidance into the laryngeal adductory muscles. Less commonly, injections are guided by flexible transnasal laryngoscopy, and, rarely, by injection under anesthesia using direct laryngoscopy. Usually a starting dose of 1.25 to 2.5U is used, either unilaterally or bilaterally, in the thyroarytenoid muscles. The expected results of treatment were reviewed, and she was given the following summary: The effects of injection appear after 24 to 48 hours. There is a fairly typical clinical course following injection that is important for her to

understand. Once the botulinum toxin takes effect, patients typically notice a very weak and breathy voice. This is occasionally accompanied by mild dysphagia for liquids. This period usually lasts for 1 to 2 weeks, based on the amount of toxin injected. Patients usually can manage the dysphagia with conservative techniques such as slower rate of drinking, especially thin liquids, using a nectar thick consistency for liquids, slight chin tuck on drinking liquids, and an effortful swallow. After 1 to 2 weeks, the patient’s voice begins to return and gradually gains strength with dramatic improvement in the voice breaks, fluency, effort, and understandability. This therapeutic period typically lasts 2 to 3 months. Following this, the patient will begin to notice voice breaks returning, and a repeat injection is scheduled. The physician went on to explain to the patient that dosing for spasmodic dysphonia is an art and is based on an individual patient’s needs and results from treatment. The breathy period following injection can be very bothersome to patients. This can be minimized by using lower dose (0.625 to 1.25U) bilateral injections, or by performing unilateral injections. Although the weak and breathy voice period is minimized, patients should be counseled that the therapeutic effect might be lower. Alternatively, patients may travel long distances to receive their injections, and they may want to maximize the duration of the effect. In these situations, higher doses can be used (5.0U bilaterally or more). Repeated dosing can be performed for long periods of time. He told her that many patients have had successful treatment with botulinum toxin for nearly 2 decades. He reviewed the possible complications from treatment. He also told her that, aside from


the side effects of breathy voice and mild dysphagia, the possibility of breathing problems existed following any procedure on the vocal folds. She was told to seek immediate medical attention if this occurs. This patient received a starting dose of 2.5U into each thyroarytenoid muscle. She experienced a weak and breathy voice with very mild dysphagia for liquids that was most noticeable in the first week following treatment and waned during the second week. She returned to clinic 1 month following injection with a significantly improved voice. She did notice some vocal strain and occasional voice breaks that were still causing some voice fatigue. She was pleased with the result but asked whether any adjunctive treatment was possible. Adjunctive Voice Therapy Voice therapy was initiated adjunctive to the botulinum toxin injection. It was explained to the patient that a brief course of voice therapy after injection has been found to increase the time between injections by teaching the patient to utilize an open pharyngeal tract and reduce compensatory muscle tension, especially when the toxin begins to wear off in 3 to 4 months. Therefore, the following goals for therapy were established. Goal 1 and Rationale The patient will increase kinesthetic awareness of compensatory muscle tension in the chest, shoulders, jaw/face, and laryngeal/pharyngeal areas of the vocal mechanism. The rationale for this goal lies in the frequency of extralaryngeal muscle tension utilized by those with ADSD in an attempt to overcome

the excessive strain of sound production. Despite the use of botulinum toxin, the patient continued to utilize preinjection compensatory muscle tension. Treatment techniques used were specific to the area of the body targeted. To increase awareness of compensatory tension in the chest and shoulders, the patient was taken through lower abdominal focused breathing exercises and stretching exercises, and was encouraged to meet with the Feldenkrais practitioner in the multidisciplinary center. To target tension in the jaw/face, the patient was instructed in stretching exercises used in the Lessac-Madsen Resonant Voice Therapy (LMRVT). (The LMRVT method is described in full for readers in a case study by Katherine Verdolini Abbott in Chapter 3.) To increase awareness of tension in the pharyngeal/laryngeal area, the patient was taken through a series of exercises comparing voiceless and voiced productions of fricatives. The use of voiceless productions of fricatives allows the patient to experience an easy sound production. Once the target sensation of easy sound production in voiceless fricatives was achieved, the patient was moved on to voiced fricatives and was instructed to maintain the open kinesthetic sensations in the throat felt during voiceless sound productions. Goal 2 and Rationale The patient will reduce effortful production of speech. Despite the use of botulinum toxin injection and the reduced glottal closure, the patient continued to use preinjection effortful voicing behaviors. The rationale for this exercise was to teach the patient to use less subglottal pressure and more of a continuous flow phonation during sound production.

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Treatment began with use of semioccluded vocal tract exercises to balance the resonators in the pharynx and amplify the sound intensity of phonation. Once the patient realized that she could produce phonation of a normal loudness by using an open pharyngeal/laryngeal tract, she was able to implement a speaking style with less phonatory effort, thus decreasing vocal fatigue and encouraging a smoother phonatory style. Goal 3 and Rationale The patient will improve coordination of respiration and phonation. Preinjection, the patient had a tendency to breath-hold in an attempt to overcome the vocal spasm. After injection, the patient continued to utilize breath holding, often producing words on expiratory reserve volume of breath support. Additionally, with the increase in glottal gap due to the effects of botulinum toxin, the patient actually had less glottal valving, impacting coordination of respiration and phonation. Therefore, another goal was to encourage the patient to use shorter breath groups. The rationale for this goal was to increase awareness of coordinated respiratory phonatory support for speech. Treatment began with low abdominal breathing, stressing awareness of the onset of abdominal muscles contraction during exhalation. The next step was to add phonation to the low abdominal breathing, encouraging the patient to use voiceless fricative prolongation to avoid the laryngeal valve effort. Next, she was instructed to do pulsed productions of voiceless fricatives. She was then instructed to repeat the tasks with voiced fricatives. The task progression continued with use of sentences of increasing length and instructing the patient to use shorter breath

groups with brief replenishing breaths in conversation. Quality of Life Impact of the use of botulinum toxin injections on quality of life is personal and usually is dependent on the effectiveness of the injections, the vocal demands of the patient, and the environmental support of the patient. As a teacher, the patient often was plagued with balancing the breathy, whispered immediate postinjection voice and the vocal demands of teaching. She tried to coordinate injections a few days before the winter semester break, right before spring break, during the quieter months of summer when she did not teach, and a few weeks before the school year begins. But, even with all the planning, she often felt her life was ruled by her injections. The speech-language pathologist encouraged her to attend a local National Spasmodic Dysphonia Association support group. In the group, the patient found camaraderie, support, and a wealth of resources from people who had lived with ADSD, undergone botulinum toxin injections, and tried a plethora of adjunctive treatments. This case highlights the need for comprehensive care of patients with adductory-type spasmodic dysphonia. Proper diagnosis, effective treatment, and close monitoring to ensure that the treatment meets the needs of the patient are hallmarks in the care of these patients. In the next case, Eileen Finnegan describes behavioral voice therapy designed to maximize the effects of a first-time botulinum toxin injection in a patient with adductor spasmodic dysphonia.


Case Study 3 Eileen M. Finnegan Combined Laryngeal Injection of Botulinum Toxin and Voice Therapy for Treatment of Adductor Spasmodic Dysphonia

History Patient ## was seen at the Laryngeal Movement Disorders Clinic in the department of Otolaryngology at the University of Iowa Hospital and Clinics. Patient ## was a 38-year-old secondgrade teacher and mother of 2 girls (ages 11 and 14 years), with complaint of dysphonia. The voice problem began 1 year prior to coming to our clinic. Onset was gradual. She reported that she has difficulty getting her words out. She reported her voice disorder occurred following an incident at school where her purse was stolen. She reported additional stress occurred due to legal action she took against her banker who embezzled funds from her accounts. The voice problem has persisted despite interventions including voice therapy (9 sessions over 6 weeks) and a neurology evaluation that found no abnormalities. She reported that her voice was worse in stressful conditions, but that it was never normal. Her voice was better when she was teaching and worse during one-on-one conversation, in background noise, and on the phone (eg, “People tell me that my cell phone is cutting out and I have to explain no, that is the way my voice sounds”). Parentteacher conferences are hard. Her voice feels and sounds “choked up.” Trying to control her voice makes it worse. New

settings are hard, but improve over time. She thought it was easier to speak at school, in part, because she was talking to kids, not adults, and the kids did not care about her voice, and so she did not feel the need to try to control it as much. She also thought it might be better when she was teaching because she was talking louder. She stated that even when she was teaching, it took a little while to warm up (ie, not have as many breaks) in the morning, but that it was usually better by the middle of the day. The patient was otherwise healthy and her only medication was for birth control. She had not experienced any other changes in motor function (no difficulty swallowing, walking/running, hand strength, or strength or coordination of other muscles, etc). She had not noticed any abnormal movement or tremor in other parts of her body. There was no history of tremor or movement disorder in her family. When asked about signs of muscle tension, the patient reported that her neck hurt after a day of parent-teacher conferences. She thought that she tended to carry tension in her neck and shoulders. She had no history of headaches, backaches, gastroesophageal reflux disease (GERD), or ulcers. She had no depression or anxiety. She described herself as a generally happy and outgoing person, but her voice made her feel self-conscious and uncomfortable at times. She had no history of tobacco. The patient had obtained voice therapy for her voice disorder. About 1 year prior to this evaluation, she received treatment from a speech pathologist in her hometown. She reported that although she was able to intermittently produce improved voicing during the therapy session (primarily during sustained phonation and production of

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short responses), she had been unable to successfully generalize these improvements to her everyday speech despite her best efforts. The therapist suggested that she might have spasmodic dysphonia. The patient had not received laryngeal injection of botulinum toxin (Botox) or any other medical or surgical treatment for her voice disorder. The patient rated voice quality today as a 5 (where 0 = completely normal and 6 = severely abnormal) and estimated current voicing effort as 200 (where 100 = normal effort, 200 = twice normal effort, etc). She rated the effect of the voicing disorder as a 5 on the impact scale (0 = no negative impact, 6 = profound impact).

Evaluation Endoscopy Because this patient presented with a movement disorder, flexible nasendoscopy was used to evaluate vocal fold function. The nasendoscope allows the patient to produce the speech tasks needed to assess a movement disorder. The patient was asked to perform a variety of tasks including multiple sustained /i/ phonations (useful for identification of tremor), alternating /i/ and inhale, production of VCV syllables containing voiced and voiceless consonants paired with the vowel /i/ (/isi, isi, isi/, /izi, izi, izi/, etc), and sentences loaded with all voiced consonants (eg, We were away a year ago) or all voiceless consonants (eg, Pop took his socks off). Velar function was normal (no tremor noted during sustained phonation). Vocal folds were normal in structure and had normal range of movement. Moderately prolonged vocal fold closure was noted at initiation of sus-

tained /i/, with auditory perception of hard voice onset. Similarly, prolonged vocal fold closure was noted at the start of production of some of the voiced consonants and vowels during production of the VCV syllables and the sentences. There was mild to moderate medialization of the false folds noted during these hard voicing onsets. Stroboscopic evaluation of the vocal folds indicated normal vocal fold vibration. Clinical Evaluation An audio recording of the patient’s voice was obtained using a digital recorder. A CAPE-V was completed to document perceptual judgments of voice quality. Persons with ADSD generally present with strained voicing, exhibiting one or more of the following: constant strain, episodic strain, waxing and waning strain, sound-specific strain, and strained aphonia. During the sustained /i/, this patient exhibited a hard onset followed by rapidly decreasing strain and then normal voicing. No tremor was heard during the sustained phonation (when it is usually easiest to detect). During sentence production she exhibited sound-specific strain. She demonstrated greater difficulty with words starting with voiced sounds (vowels and voiced consonants) than for words starting with voiceless consonants. In addition to the strain, the patient’s voice became low pitched and moderately rough intermittently during conversation. No abnormal movements were noted during observation of the patient. There was no evidence of midfacial dystonia (Meige’s syndrome), spasmodic torticollis (tilting of the head due to dystonia of neck muscles), or blephrospasm (twitching around the eyes) or writer’s cramp or other dystonias that sometimes occur with laryngeal dysto-


nias. Laryngeal manipulation was used to assess laryngeal pain, stiffness, and elevation. A mild to moderate degree of extralaryngeal stiffness was noted, but no pain or laryngeal elevation was noted. The patient was diagnosed with moderate adductor spasmodic dysphonia (ADSD), with no tremor, with secondary muscle tension dysphonia (MTD). The recommended treatment for this patient was laryngeal injection of botulinum toxin (eg, Botox) into the thyroarytenoid muscles, followed by 6 weeks of voice therapy.

Treatment Laryngeal Injection of Botulinum Toxin The patient was counseled regarding the benefits and side effects associated with Botox injection. The patient is told that “the vocal folds are in the voice box at the top of the windpipe. There are muscles in your voice box that work to open your vocal folds when you breathe and other muscles that bring the vocal folds together when you swallow (to stop food or liquid from going down your windpipe) and when you talk. We plan to inject Botox into the muscles in your vocal folds. These muscles help to bring your vocal folds all the way together when you talk and swallow. The Botox will cause a temporary weakening of the muscles and will prevent them from closing as tightly as they normally would. We expect that this will help to reduce or eliminate the intermittent strain you have when you talk and help to smooth out your speaking voice. However, there are two side effects that you may experience. One is a breathy voice quality and the other is trouble with liquids going down the wrong

pipe. If you have trouble swallowing liquids, it helps to drink sip by sip and to tuck your chin to your chest. Some people find it easier to sip from a straw. If you take vitamins or pills, it might be easier to take them with applesauce or pudding rather than with water. Most people will experience these side effects to a greater or lesser degree. On average the side effects last 10 days to 2 weeks. After that, we expect your voice to grow stronger but to remain smooth. In most cases, this improved voicing lasts for about 3 months.” This patient was being seen for first botulinum toxin injection and so she was offered a choice of either 1.25 units of Botox or 2.5 units of Botox injected into each TA muscle. She was told that with the lower dose, she would be less likely to have side effects, but also less likely to have a change in her voice, and with the larger dose, she would be more likely to have a change in her voice but also more likely to have some side effects. This patient chose to go with the higher dose. It was further explained that it may be necessary to adjust the dose depending on her response and that she should not be discouraged if this first attempt is not entirely successful. It is sometimes necessary to adjust the dose several times before finding the one that provides maximum benefit with minimal side effects. The patient had been given an opportunity to view an online video of the procedure so she had a fairly good idea of what to expect. The injection was done by the otolaryngologist in the clinic exam room. The patient was seated in the clinic exam chair. The skin overlying the cricothyroid space was injected with a local anesthesia to numb the skin, where the greatest density of pain receptors is located. There are not many pain endings in the TA muscle. The patient was

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told that patients typically feel pressure, but not pain, during the injection. The Botox was injected percutaneously (through the skin). The physician placed the needle through the cricothyroid space a few millimeters off midline and oriented the needle superior-laterally to inject the TA muscle. Electromyography (EMG) was used to confirm placement of the needle. If the needle is appropriately placed, the needle tip (which functions as an EMG electrode as well as for injection) will detect electrical activity in the TA muscle when the muscle is activated in response to a request of the patient to perform a Valsalva maneuver (bear down) or to phonate. Once placement was confirmed, the botulinum toxin was injected. Then the needle was withdrawn and reinserted to inject the contralateral TA muscle for the bilateral injections. The injection took only a few moments. The patient was told that the effects of the Botox would not be immediate, but that her voice would start to change in the next 24 to 48 hours. She was provided with a personal amplification system that she could use during the first few weeks if she experienced the expected side effect of breathiness, with the understanding that she would return it once the breathiness had passed. She could purchase her own at a later date, if she found the amplification system helpful. Voice Therapy Some patients obtain sufficient relief from their symptoms from injection alone. Many are able to extend the benefits of the injection by combining it with voice therapy. Because this patient showed signs of muscle tension in addition to SD, we thought she would benefit from voice therapy. The patient

participated in 6 weeks of voice therapy following her botulinum toxin injection. The purpose of the therapy was to maximize the effectiveness of the injection by: (1) reducing any unnecessary muscle tension, (2) connecting exhalation with phonation, and (3) replacing glottal stops and hard onset with softer onsets. Voice therapy is designed to target the underlying pathophysiology that remains after botulinum toxin injection. Reducing Unnecessary Tension To address our first goal, we went through a series of exercises to reduce any excess muscle tension. Multiple goals were addressed during the exercises: (1) reducing excessive tension in the neck, shoulders, back, and articulatory muscles; (2) increasing the client’s sensory awareness of overactive muscles and of breathing; (3) providing an opportunity to attend to breathing, which assists in relaxation and in helping the client to remain within an optimal range of lung volumes during speech; and (4) assisting the client in attaining good posture. We started each exercise in rest position. [Stand easily with your feet about 15 to 20 cm (6 to 8 in) apart. Knees unlocked. Be aware of the weight of your body balanced on both feet.] Then we went through the series of exercises (back stretch, chest stretch, neck stretch, shoulder, jaw, lips, and tongue stretches). I talked her through each exercise. Here is an example of how I talked through the first exercise. Shoulders and Back Stretch, Fingertips Float Up to the Ceiling “As we are doing these exercises take nice, deep, slow breaths, breathing in through your nose and out through


your mouth. Let’s try that a few times. You should not feel any constriction in your throat. Breathe in through your nose and now out through your mouth with a wide open throat. Just let the air flow in through your nose filling your lungs and then feel the air flow out through your mouth. Now I want you to turn palms outward and on your next exhalation gradually let your fingertips float up to the ceiling [try to make sure you are breathing in synchrony with the client and do the slow arm lift together]. You should be looking forward with your head resting on your spine (as if there were a string coming up the spine and through the top of the head lifting the head toward the ceiling). Now maintain this position for 3 nice, slow, deep breaths. Feel the air enter your nose and slowly fill your lungs. On this last exhalation turn your palms out and slowly bring your arms back down to your sides (the hands should touch the sides slowly and gently [not hit against the sides of the body]).” After the exercise, I asked the patient if she noticed any difference in her breathing. We did the exercise again to see how her breathing changed when she had her arms above her head. We did each exercise slowly, maintaining each posture for 3 breaths before slowly returning to rest position. The stretches were performed gently, and the patient was encouraged to relax into the stretch on exhalation. There should not be any discomfort. However, as we went through the series of exercises, the patient identified muscles that were holding tension, particularly in the neck and shoulders. Over the course of the series of exercise, I worked to gradually (and for the most part indirectly) move the patient into a good standing posture (expanded chest, shoulders relaxed

down and slightly forward, head resting lightly on spine). I commented on the improvement in her posture and asked her to maintain it as she sat down and we continued to work on the next set of exercises. Connecting Breath and Voice For the second goal, we wanted to help the patient connect her exhalation with phonation. We started with lip trill and tongue trills. High airflow is required to set the tongue and lips into vibration. The patient was encouraged to attend to the feeling of contraction of the abdominal muscles needed to drive the airflow for the trills. First, we did the trills without phonation, then with phonation, and then playing with gliding pitch up and down. Next, we practiced some tube phonation (ie, having the patient phonate into a straw, using a normal drinking straw). We began with humming with a straw and then alternated between humming with and without the straw, encouraging the patient to “be generous with your air,” and continuing to pay attention to the way the thoracic and abdominal muscles engage to drive the airflow during these exercises. The straw introduces a leak into the system and forces the patient to use greater airflow during phonation. We then moved to producing short sentences with and without the straw, concentrating on prolonging the vowels (so that the sentences were produced in a bit of a singsong manner). Elements of the accent method which uses chanting techniques (see Harris, Chapter 3 for details) were used to encourage connection of exhalation with production of consonants. The patient practiced using the breath to drive rhythmic productions of vowels and fricatives. For example, the patient

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was asked to produce repetitions of “sh,” varying the number of repetitions, the speed (duration) of the repetitions, and the pattern of stress/emphasis. The patient was encouraged to keep articulatory contact light during these exercises and to maintain airflow during the entire phrase. She was asked to pay conscious attention to airflow at initiation of the sound and to articulatory contact as she alternated between production of voiced and voiceless cognates. She then practiced maintaining the feeling of connection between the breath and phonation during production of phrases, sentences, paragraph reading, and conversation. Avoiding Glottal Stops and Using Soft Onsets A third goal of therapy was to reduce glottal stops and voice onsets by: (1) continuing to work on reducing effort associated with onset by using the /h/ phoneme to achieve soft onsets and (2) maintaining continuous voicing during speech to the extent possible by prolonging vowels, linking words, avoiding glottal stops, and speaking in a more legato, rather than staccato, speaking style. This final step builds upon the improved posture and the connection between exhalation and phonation established during the exercises used to achieve the first 2 goals. Now the emphasis of therapy shifts from reducing or eliminating nonfunction compensatory habits that the patient developed, perhaps from “fighting” the ADSD, to developing strategies to work around the symptoms of ADSD. The main problem for this patient is the voicing onsets. We can avoid some voice onsets by using linking strategies, such as /w/ linking [what time do you go (/w/) out]; /j/ linking [Let’s go see (/j/) Ann];

consonant vowel linking (Give it to me). We can try to soften the onsets using a breathy /h/ in front of the voiced sounds. The patient was asked to compile a list of phrases or sentences that she frequently uses at home or at school that are usually difficult for her to say, and we practiced the sentences using the different strategies. It was explained to the patient that intensive therapy was needed to alter habituated patterns regarding posture, breath support, phonatory onsets, and articulation. Therefore, distributed daily practice would be needed in order to replace the old habit with the new one. At the end of each voice therapy session, the patient was provided with a series of exercises to practice at home. She was encouraged to practice for short periods of time several times over the course of the day. We discussed and agreed upon a plan for multiple short practices each day. She was provided with written instructions regarding the purpose of the exercises and how to do them correctly, concentrating on how it feels to do the exercise, more than on how the voice sounds. At the start of each therapy session, the patient was asked to “show me how you have been practicing at home” as the clinician observed without comment in order to get a good idea of what had been learned in the previous session, what aspects of the exercises the patient understood, and which needed additional practice and instruction to ensure she was deriving maximal benefit from her home practice.

Concluding Remarks The patient benefitted from the botulinum injection, with minimal side effects.


After an initial period of breathiness, her voice quality improved to near normal for 4 months followed by gradual return of ADSD symptoms. The postinjection voice therapy helped the patient: (1) to reduce excess muscle tension that remained in her neck and shoulders, and to a lesser extent back and jaw, after the injection and (2) to provide her with strategies that would prove useful as the botulinum toxin became ineffective (possibly due to sprouting of new unaffected axon terminals). The patient preferred to wait as long as possible between injections and found the strategies helped her to manage the symptoms that returned between injections. Although she became adept at the exercises over the course of the 6-week intervention, she continued practicing the exercises daily for another 6 to 8 weeks after that in order to habituate some of the new motor programs. She purchased her own personal amplification system and continues to use it for the week following each injection. She also reports that she finds it helpful to sip water during the day and to return to daily practice of her exercises when the symptoms start to re-occur. Julie Barkmeier-Kraemer discusses a case of moderate vocal tremor. Her ground-breaking research has demonstrated that voice tremor may arise from multiple anatomical structures. The patient presented in the following case study demonstrated involvement in the soft palate, posterior pharyngeal wall, base of tongue, and vocal folds. The therapy approach applied to this patient used the technique of reduced voicing duration, which improved the perception of tremor in connected speech.

Case Study 4 Julie Barkmeier-Kraemer Use of Reduced Voicing Duration to Treat Vocal Tremor

History of the Problem Ms. X is a 73-year-old female with a gradual onset of her voice problem beginning 10 years ago. She noticed that her voice was increasingly shaky and interfered with her ability to be understood by friends. Ms. X was also a member of her church choir and reported increasing difficulty controlling her upper pitch ranges.

Medical History Ms. X has a medical history of essential tremor diagnosed at the age of 52 years when she first experienced onset of tremor in her hands. Ms. X uses propranolol to control her hand tremor, but her shaky voice continues to progressively worsen while taking this medication. Additional medical diagnoses include hypertension and seasonal allergies controlled by taking allergy medication as needed. Ms. X reported that she consumes 1440 to 1920 mL (48 to 64 fl oz) of water daily in addition to 3 additional cups of decaffeinated coffee or a can of decaffeinated soda. She also reported consuming a nightly cocktail and notices that her voice improves after consuming alcohol. Ms. X reported smoking 1 pack per day of cigarettes for 15 years, but she quit when she turned 30 years old. She sleeps an average of 5 hours nightly and

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uses Ambien to help her sleep approximately twice weekly.

Social History Ms. X was widowed 10 years ago and retired from teaching 8 years ago. She has 4 children all living nearby with whom she interacts frequently. Ms. X is also active in her church as well as volunteers to serve meals to elderly in their homes through the local “Meals on Wheels” program.

Voice Evaluation Auditory-Perceptual Examination The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) is a perceptual rating scale of an individual’s voice completed by the clinician across various speaking tasks. These include sustained phonation of /a/ and /i/ for 3 to 5 seconds, sentence repetition, and spontaneous conversation in response to the request, “Tell me about your voice problem.” or “Tell me how your voice is functioning.” The clinician judges the individual’s voice in terms of overall severity, roughness, breathiness, strain, pitch, and loudness using a 100-mm visual analog scale generally categorized as ranging from mild to moderate to severe ratings. Specific ratings of Ms. M’s voice quality are shown in Table 5–1. She was judged to exhibit a moderately severe amount of strain and vocal tremor during sustained phonation of /a/ and /i/. The vocal tremor was perceived as mild to moderate during sentence reading and conversation in addition to a mild degree of breathiness. The overall severity of Ms. X’s voice across all tasks was judged as moderately abnormal.

Nasendoscopic Evaluation A distal-chip nasendoscopic examination was completed to evaluate sensorimotor function of the speech mechanism.17 Due to the possibility of dystonia, no topical anesthesia was used to minimize the impact of sensory distractions other than the presence of the scope. Assessment of velopharyngeal function demonstrated normal valve function during speech and swallowing tasks. A low amplitude and fast frequency soft palate oscillation occurred during sustained phonation of /s/ and /f/. However, during sustained phonation of /a/, the soft palate exhibited a slower and larger amplitude vertical oscillation consistent with the rate of vocal tremor perceived in the voice. Views of the pharynx showed a small amplitude oscillation in the base of the tongue in the anterior-posterior direction. The larynx exhibited mild adductory oscillation during inspiratory respiratory cycles. Bilateral mobility of the vocal folds occurred during sniffing and phonation tasks. During sustained phonation of /i/ at all pitches and loudness levels, mild to moderate rhythmic constriction and relaxation of the lateral pharyngeal wall occurred associated with mild to moderate degrees of rhythmic adductory oscillation of the vocal and ventricular folds. In addition, a mild vertical oscillation of the larynx was observed during sustained phonation. These oscillations were associated with a perceptible vocal tremor. At sustained phonation at high pitch, the vocal folds exhibited incomplete approximation along their length (considered normal) with increased approximation of the arytenoid cartilages that occluded views of the cartilaginous folds. Oscillation of the laryngeal structures lessened at high pitches.

Table 5–1. Pretreatment and Post-treatment Measures for Ms. X Measure

Pretreatment

Post-treatment

Normal Values

55 mm (moderate)

23 mm (mild)

0

Roughness

25 mm (mild) vowels only


0

Breathiness

24 mm (mild) sentences and conversation

24 mm (mild) sentences and conversation

0

Strain

55 mm (moderate) vowels only


0

Pitch

0

0

0

Loudness

0

0

0

Vocal tremor

52 mm (moderate) for vowels and 35 mm (mild to moderate) for sentences and conversation

35 mm (mild to moderate) for vowels and 15 mm (mild) for sentences and conversation

0

Resonance

Normal

Normal

Normal

Laryngeal diadochokinetic rate

4

4

4 to 7 syllables/s

Average F0 during /a/

247 Hz

200 Hz

189 Hz (169 to 209 Hz)

70 dB SPL

68 dB SPL

50 to 70 dB SPL

HNR during /a/

18 dB

20 dB

20 dB

Spontaneous conversation F0

194 Hz

204 Hz

155 to 334 Hz

Conversational intensity

66 dB

69 dB

50 to 70 dB SPL

Maximum F0 range

555 Hz (104 to 659 Hz)

690 Hz (105 to 795 Hz)

978 [131 (±16) – 1109 (±189)]

Maximum intensity range

38 dB SPL (61 to 99 dB SPL)

40 dB SPL (59 to 99 dB SPL)

37 dB SPL (±3.67)

8 Hz

8 Hz

Consensus AuditoryPerceptual Evaluation of Voice (CAPE-V) Overall severity

Acoustic

Average intensity during /a/

Fundamental frequency modulation rate

continues 289

290


Table 5–1. continued Measure

Pretreatment

Post-treatment

3%

2%

Intensity modulation rate

6 Hz

6 Hz

Intensity modulation magnitude

24%

20%

2.9

4.5

5

0.34 LPS

0.18 LPS

0.1 to 0.2 LPS

13 cm H2O

11 cm H2O

6.4 (±1.9) cm H2O

38 cm H2O/LPS

61 cm H2O/LPS

29–47 cm H2O/LPS

<18

Fundamental frequency modulation magnitude

Articulation rate (syllable/second)

Normal Values

Aerodynamic Average airflow Average intraoral pressure Laryngeal resistance

Voice Handicap Index (VHI) Total score (out of 120)

107

42

Functional subscore (out of 40)

36

18

Physical subscore (out of 40)

31

11

Emotional subscore (out of 40)

40

13

During sustained phonation at comfortable and low pitches, the vocal folds exhibited a mild amount of rhythmic oscillation in the elongation/shortening direction and a moderate amount of rhythmic oscillation in the adductory direction. This worsened during loud phonation at comfortable pitch intermittently, resulting in voice stoppages associated with rhythmic overclosure of the vocal folds and increased squeezing of the supraglottal structures. Tracking of the fundamental frequency was slightly off during use of the stroboscopic lighting making it difficult

to judge mucosal wave motion, particularly with oscillations of the laryngeal structures occurring during sustained phonation. Full approximation of the membranous vocal folds was observed to occur at comfortable pitch and loudness with a posterior gap between the cartilaginous folds at comfortable and low pitches. During quiet breathing, the medial edge of the vocal folds exhibited a slightly concave shape with prominent vocal processes suggestive of typical age-related vocal fold tissue changes. A moderate to severe amount of anterior-posterior squeezing was ob-


served throughout the examination. During connected speech tasks, the patient exhibited a reduced rate of speech during sentences loaded with voiced speech sounds with increased occurrence of vocal tremor compared to production of sentences loaded with voiceless speech sounds where vocal tremor was intermittently detectable.18

consonant portion, respectively, during repetition of /pi/.26 As shown in Table 5–1, Ms. X showed elevated average airflow and intraoral pressure values resulting in normal laryngeal resistance.27 Thus, the elevated intraoral pressure likely offset the elevated average airflow to provide a normal measure of laryngeal resistance.

Acoustic Measures


As shown in Table 5–1, Ms. X exhibited normal diadochokinetic testing19,20 (repetition of a glottal stop paired with /a/ as quickly and completely as possible for 7 seconds) indicating adequate valve function of the larynx. During sustained phonation of /a/ (see Table 5–1), Ms. X exhibited a slightly elevated fundamental frequency for her age with slightly increased noise levels,21,22 although the latter could have been related to the low-frequency modulation of the voice. Ms. X exhibited a reduced maximum fundamental frequency range, although maximum intensity range was within normal limits.23 Measures of the nearly rhythmic modulation of fundamental frequency and intensity were completed on a representative 1-second duration segment of sustained phonation of /a/. As shown in Table 5–1, the larger magnitude of voice modulation appeared related to intensity modulation compared to fundamental frequency modulation. In addition, articulation rate was measured24,25 from the CAPE-V sentences and shown to be significantly slower than normal. In addition, prolongation of voiced speech sounds occurred associated with slower articulation rate.

The Vocal Handicap Index (VHI)28 was administered to determine the degree of impact Ms. X’s voice problem had on her daily life. The VHI examines 3 areas of interest identified as functional, physical, and emotional. The individual must rate each statement on a 4-point scale (0 = “never” and 4 = “always”) indicating the degree to which each statement applies to him or her. A total score of 120 is the worst possible score, whereas a score of 0 is the best possible. Ms. X’s scores on the VHI indicated severe impact of her voice problem across functional, physical, and emotional areas of her life (see Table 5–1).

Aerodynamic Examination Airflow and intraoral pressures were obtained during the vowel portion and

Voice Therapy Specific Type of Therapy Reduced voicing duration to “hide” vocal tremor25,29 and easy voice onset. Rationale for Using This Approach Ms. X exhibits signs and symptoms consistent with vocal tremor. Ms. X demonstrated lessening of the perception of vocal tremor during connected speech, in general, and during production of sentences loaded with voiceless speech sounds compared to voice-loaded speech sounds.18 Furthermore, Ms. X exhibits

291

292


a slowed articulation rate associated with prolongation of voiced speech sounds giving opportunity to hear her vocal tremor.30 Thus, training Ms. X to speak with shortened voicing duration and possibly increased articulation rates may facilitate reduced opportunity for listeners to perceive her vocal tremor. In addition, Ms. X exhibited laryngeal squeezing indicative of increased laryngeal muscle activation during speaking, perhaps as a means of attempting to control the tremor perturbation during speaking. Thus, easy voice onset may facilitate reduced supraglottal activation. Therapy Goals and Expected Outcomes Goal 1. Ms. X will use easy voice onset during speaking to reduce excessive levels of supraglottal laryngeal muscle activation and improve coordination of respiration with phonation. Goal 2. Ms. X will speak with shorter voicing duration using a “staccato-like” voicing pattern in addition to inserting pauses intermittently rather than prolonging voicing to reduce the opportunity for listeners to perceive vocal tremor during conversation.

Voice Therapy Methods During sessions 1 and 2, Ms. X was first instructed on tasks that facilitated improved use of the respiratory system to drive voice production. This was achieved by instructing Ms. X to take a deep breath and then shush the clinician loudly (Table 5–2, sessions 1 to 2). After repeating this activity accurately 3 times, Ms. X was instructed to try to

sustain the /ʃ/ sound while alternatively making it loud twice during continued exhalation. Next, a voiced fricative was selected (either /v/ or /z/) to repeat the same pattern. Next, a series of easy voice onset tasks were used to facilitate airflow at speech initiation while practicing shortened production of voiced sounds (see Table 5–2). At the end of these first 2 sessions, Ms. X was instructed to use this technique to say, “Hi!” on a daily basis. Sessions 3 and 4 involved progression in air control by using one of the tasks from the CasperStone Flow Phonation approach to encourage Ms. X to lose all of her air with low effort speaking each time she says a number as she counts from 1 to 10. This can then be performed with 2 numbers spoken at a time (see Table 5–2, sessions 3 to 4). In addition, easy voice onset and shortened vowel duration were practiced during single and 2-syllable words and then h-loaded phrases. For these sessions, Ms. X needs to offer up to 3 daily phrases on which she can practice shortened voicing duration and pause-insertion every day. During sessions 4 and 5, Ms. X continued to expand the duration of speech stimuli using h-loaded words, phrases, and sentences. As Ms. X masters h-loaded sentences, she can begin practicing transfer of shortened voicing duration and easy voice onset while speaking all-voiced single-syllable and 2-syllable words. She also began to monitor her use of the strategies she learned during one 2-minute conversation daily to encourage transfer to conversation. Sessions 6 and 7 focused on practicing the same skills on progressively more difficult all-voiced words, phrases, and sentences and then to sentences with mixed types of speech sounds.

Table 5–2. Voice Therapy Methods for Ms. X Across 8 Sessions Treatment Task

Method

Sessions 1 to 2 Facilitation of respiratory drive during speech — VOICE LESS

Take a deep breath and say, /ʃ/, loudly as though shushing someone. Repeat this 3 times. Next, take a breath and sustain /ʃ/. As you sustain this sound, alternate making it loud then soft by pushing harder with your breath 2 times during the exhale. (Caution: correct production is characterized by continuous exhalation that is pulsed rather than stopping the airstream in between pulses.)

Facilitation of respiratory drive during speech — VOICED

Take a deep breath and say, /v/ or /z/ (pick the one that is easiest to say) loudly. Repeat this 3 times. Next take a breath and sustain /v/, or /z/. As you sustain this sound, alternate making it loud and then soft by pushing harder with your breath 2 times during the exhale so that it sounds like a motor revving.

Easy voice onset during single syllables

Take a breath before you say each of the following sounds. As you say each sound, begin with an audible “h” sound followed by the vowel sound produced with the shortest possible duration [“Huh,” “Ha,” “Hoe,” “Who,” “He,” and “Hey”].

Easy voice onset during single-syllable words

Take a breath then say each of the following words using the same audible “h” sound as before, but use a staccato style of speaking to produce a shortened vowel and then the final speech sound [“Heck,” “Hook,” “Hoop,” “Hiss,” “Hack,” “Hope,” “Hut,” “Heat,” “Hate”].

Daily phrase activity

Each day practice greeting others by saying “Hi!” using an audible “h” sound and a shortened voice portion as practiced in the exercises.

An exercise log sheet and audio CD recording were provided to Ms. X to take home and use during her home practice

Instructed to practice these exercises 2 to 3 times daily at home

Sessions 3 to 4 Casper-Stone flow phonation

Take a deep breath and say the number, “one.” As you say this number, let all your air out so that you run out of air speaking this number. Take a breath and continue counting to 10 this way. Do not rush, or you may get dizzy. If this happens, stop and rest until you recover. After each number, ask yourself if you ran out of air and if saying the number felt easy. Repeat this task counting 2 numbers on each breath using the same technique. continues

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Method

Easy voice onset during single-syllable words

Take a breath and say each of the following words using the same audible “h” sound as before, but use a staccato style of speaking to produce a shortened vowel and then the final speech sound [“Heck,” “Hook,” “Hoop,” “Hiss,” “Hack,” “Hope,” “Hut,” “Heat,” “Hate”].

Progression of shortened voicing duration during multisyllabic words

As you say these words, try to keep the voiced part short and say the words as quickly as is comfortable [“Hippy,” “Henhouse,” “Hamstring,” “Heater,” “Hockey,” “Hoosier,” “Halftime,” “Hopper,” “Haughty,” “Hometown,” “Happy,” “Hokey”].

Progress to “h-loaded” phrases

Use the same shortened voicing pattern with these phrases. Insertion of pauses may also help impose shortened voicing on these [“Heat the home,” “He hissed at her,” “Hope he heals,” “Happy hens,” “Help his hiccups,” “He’s a hero,” “Hit with her hammer,” “Hess was hateful”].


Each day, Ms. X will practice saying her self-selected daily phrases using shortened voicing duration every time she says: “Hi! How are you?” “Come in the house, Daisy!”



Sessions 4 to 5 Easy onset during single-syllable words

Take a breath and say each of the following words using the same audible “h” sound as before, but use a staccato style of speaking to produce a shortened vowel and then the final speech sound [“Heck,” “Hook,” “Hoop,” “Hiss,” “Hack,” “Hope,” “Hut,” “Heat,” “Hate”].

Progression of shortened voicing duration during 2-syllable words

As you say these words, try to keep the voiced part short and say the words as quickly as is comfortable [“Hippy,” “Henhouse,” “Hamstring,” “Heater,” “Hockey,” “Hoosier,” “Halftime,” “Hopper,” “Haughty,” “Hometown,” “Happy,” “Hokey”].

Progress to “h-loaded” phrases

Use the same shortened voicing pattern with these phrases. Insertion of pauses may also help impose shortened voicing on these [“Heat the home,” “He hissed at her,” “Hope he heals,” “Happy hens,” “Help his hiccups,” “He’s a hero,” “Hit with her hammer,” “Hess was hateful”].

Progress to sentences loaded with voiceless speech sounds

Continue practicing speaking with shortened voicing duration and pause insertion using these sentences: [“He took the pepper.” “She cooked fish.” “Ted sipped turtle stew.” “Can she speak today?” “Take this cake for Sue.” “Teach puppies to sit.” “Feed corn and seeds to chickens.” “Throw 10 touchdowns.”]. 294


Method

Shortened voicing duration with voiced words

Practice using easy onset and shortened voicing duration on single-syllable words with all-voiced speech sounds [“And,” “Man,” “Arm,” “Egg,” “Made,” “Noon,” “Mole,” “Lean,” “Gone”].

Expand to 2-syllable all-voiced words

Practice using easy voice onset and shortened voicing duration on 2-syllable all-voiced words [“Many,” “Narrow,” “Melon,” “Ladle,” “Gallon,” “Arrow,” “Needle,” “Borrow,” “Believe,” “Wonder,” “Redeem”].


Practice using shortened voicing duration on 3 selfselected daily phrases. Ms. X chose: “May I try the coffee?” “Can I water the flowers?”

Self-monitor during one conversation

During one conversation during the day, purposefully use the voicing strategies for 2 minutes and monitor your success.



Sessions 6 to 7 Easy onset practice with 2-syllable words

As you say these words, try to keep the voiced part short and say the word as quickly as is comfortable [“Hippy,” “Henhouse,” “Hamstring,” “Heater,” “Hockey” “Hoosier,” “Halftime,” “Hopper,” “Haughty,” “Hometown,” “Happy,” “Hokey”].

Practice shortened voicing duration 2-syllable all-voice words

Practice using easy voice onset and shortened voicing duration on 2-syllable all-voiced words [“Many,” “Narrow,” “Melon,” “Ladle,” “Gallon,” “Arrow,” “Needle,” “Borrow,” “Believe,” “Wonder,” “Redeem”].

Shortened voicing duration during all-voiced phrases and sentences

Practice using easy voice onset and shortened voicing on these phrases and sentences. Insertion of pauses may also help shorten voicing [“My Mom knew Mary,” “were you really there?” “Randy made millions.” “Danny whines all day.” “Larry arose early.” “Lenny drained the oil.” “Running many more.” “Leading the way.” “Mining the moon.”].

Practice skills in sentences with mixed speech sounds

Practice using easy voice onset and shortened voicing on these sentences: [“What is the date today?” “When should I bring this?” “What assignment should be presented to the class?” “Susie makes gourmet ice cream and frosting.” “Can I bring a dessert to the party?” “The boat hit the iceberg and sank.” “The dog paced to and fro panting.” “I would love some chocolate chip cookies.” “My voice is strong and clear.”]. continues 295


Method

Self-monitor during 2 conversations

During 2 conversations during the day, purposefully use the voicing strategies for 2 to 5 minutes and monitor your success.



Sessions 7 to 8 Review speaking using voiceless-loaded sentences

Continue practicing speaking with shortened voicing duration and pause insertion using these sentences: [“He took the pepper.” “She cooked the fish.” “Ted sipped turtle stew.” “Can she speak today?” “Take this cake for Sue.” “Teach puppies to sit.” “Feed corn and seeds to chickens.” “Throw 10 touchdowns.”].

Practice skills in sentences with mixed speech sounds

Practice using easy voice onset and shortened voicing on these sentences: [“What is the date today?” “When should I bring this?” “What assignment should be presented to the class?” “Susie makes gourmet ice cream and frosting.” “Can I bring a dessert to the party?” “The boat hit the iceberg and sank.” “The dog paced to and fro panting.” “I would love some chocolate chip cookies.” “My voice is strong and clear.”].

Paragraph reading

Practice reading aloud using reduced voicing duration and pause insertion. Use a standard passage or a paragraph. Ms. X selects from a book she is reading, or the newspaper. During initial practice, it may be important to mark phrases where she should stop to replenish her air supply. She should gradually become more independent in self-evaluating her accuracy.

Self-monitor during two 5-minute conversations

During 2 conversations during the day, purposefully use the voicing strategies for 5 minutes and monitor your success. These can include telephone conversations as well. The clinician may surprise Ms. X with a phone call during the week to determine how well she is doing outside the therapy room.



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Expansion to self-monitoring of accuracy in using the shortened voicing duration and pause-insertion during two 2 to 5 minute conversations was added. Sessions 7 and 8 add practice of strategies during paragraph reading and increasingly longer durations of self-monitoring during daily conversations to encourage transfer to daily communication situations. Finally, Ms. X was recorded during her accurate production of all voiced tasks at the end of each session so that she could take an audio CD recording of the therapy exercises home to use during daily practice. An exercise log providing a summary of the exercises with a weekly chart to log her daily practice was also provided to Ms. X. Frequency and Duration of Treatment Ms. X completed 8 weekly therapy sessions over the course of 2 months. She also returned for a follow-up session 3 months after completion of voice therapy. Post-therapy measures reported here were completed during the eighth therapy session.

Therapy Outcomes Auditory-Perceptual Examination The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was readministered. As shown in Table 5–1, Ms. X showed a reduction in overall severity associated with reduced perception of vocal tremor during sentences and conversation contexts. In addition, Ms. X exhibited reduction of strain and roughness during sustained phonation of vowels.

Nasendoscopic Evaluation The findings of the nasendoscopic evaluation were similar to pretreatment in the form of identifying the location and patterns of the structures exhibiting oscillation associated with production of vocal tremor. However, Ms. X did not exhibit the same degree of supraglottic squeeze associated with phonation as observed pretreatment. Furthermore, during sustained phonation at comfortable and low pitches and during loud phonation, Ms. X successfully used a breathier phonation that resulted in an absence of enhanced adductory oscillation of the vocal folds as seen pretreatment. In addition, Ms. X was perceived to speak at a more typical rate of articulation with less vocal tremor evident during connected speech tasks. Acoustic Measures As shown in Table 5–1, Ms. X was measured with a more typical fundamental frequency during sustained phonation of /a/ with less noise in her voice. Interestingly, Ms. X showed an increased pitch range even though this was not a focus of treatment. Most importantly, articulation rate increased to 4.5 syllables per second which nears the typical rate of 5 syllables per second. Aerodynamic Measures As shown in Table 5–1, average airflow fell to more typical levels, and intraoral pressure also dropped slightly. This resulted in an elevated laryngeal resistance. Self-Perception Ms. X’s scores on the VHI reduced significantly, although they remained

297

298


elevated suggestive of a mild to moderate voice impairment. As shown in Table 5–1, Ms. X’s scores continue to be spread across all domains with a slightly higher functional subscore compared to physical and emotional. A therapeutic effect requires a change in score of 18 points or greater. Thus, a total score change of 65 points indicates a significant improvement.

Summary and Concluding Remarks Ms. X exhibited signs and symptoms consistent with a moderate vocal tremor. Nasendoscopy showed involvement of the soft palate, posterior pharyngeal wall, base of tongue, and larynx. Given the most severe impairment at the larynx, and reduction of perceived vocal tremor during connected speech and particularly during sentences loaded with voiceless speech sounds, Ms. X was considered a good candidate for modification of voicing duration as a speaking strategy. Furthermore, she was shown to speak at a slower articulatory rate characterized by prolongation of voiced speech sounds. Voice therapy focused on training Ms. X to improve utilization of her respiratory system to drive speaking rather than squeezing at the larynx. In addition, she was encouraged to speak using a staccato-like method to learn the sensation of reduced voicing duration. Insertion of pauses was also helpful. Progression from easy onset speech stimuli to gradually more complex speaking contexts enabled Ms. X to transfer the strategies for reducing the perception of vocal tremor to conversation level. Post-treatment scores demonstrate significant clinical gains associated with reduced strain and improved

respiratory drive during speaking as well as more typical articulatory rate and reduced perception of vocal tremor during connected speech. In this case study, Lorraine Ramig and Cynthia Fox describe how one component of voice production, healthy vocal loudness, positively affects all subsystems of speech production including respiration, phonation, resonance, and articulation. This single cognitive focus makes improving speech feasible in individuals with neurologic conditions who often have limitations in cognition and learning.

Case Study 5 Lorraine Ramig and Cynthia Fox Use of LSVT® LOUD (Lee Silverman Voice Treatment) in the Care of a Patient With Parkinson Disease

Background on LSVT LOUD Nearly 90% of the 8 million individuals with Parkinson disease (PD) worldwide have a speech or voice disorder that significantly diminishes quality of life.31 Over the past 20 years, LSVT LOUD has been developed and advanced as the first efficacious speech treatment for PD.32,33 LSVT LOUD is organized around a simple but powerful therapeutic principal: to increase vocal loudness (targeting amplitude of respiratorylaryngeal movement) in individuals with PD while retraining the sensory motor processes involved in disordered speech communication.34 The training mode of LSVT LOUD requires high


effort (self-perceived effort) and intensive training (16 individual 60-minute treatment sessions in 1 month), consistent with principles of motor learning, skill acquisition, and neural plasticity.35,36 Furthermore, LSVT LOUD results in long-lasting improvements (out to 2 years32) that are correlated with brain reorganization as revealed by recent neural imaging studies.37,38 Improvements following LSVT LOUD extend beyond the respiratorylaryngeal focus to include enhanced articulation, facial expression, swallowing, and communicative gestures.37–42 The positive treatment effects of LSVT LOUD also have been observed in individuals with stroke, multiple sclerosis, ataxic dysarthria, and children with Down syndrome and cerebral palsy.34,43,44

Patient History Patient AAA was a 49-year-old man employed as a family physician. He had been diagnosed with idiopathic Parkinson disease (PD) for 2 years and was in stage 2 (out of stages 1 to 5, with stage 5 being the most severe) on the Hoehn and Yahr Scale.45 His medications for PD included Sinemet and Eldepryl. Neuropsychologic testing revealed some mild attention difficulties. Initial clinical speech examination revealed an oral peripheral mechanism that was normal in both structure and function, with no characteristics atypical of PD; hearing was within normal limits. History of the Problem Patient AAA reported that during the past year his voice had become soft and raspy. He had associated the raspy voice with frequent upper respiratory

infections. He reported that he felt people “could understand” him most of the time. In contrast, his spouse and coworkers reported that it was “often difficult to understand” him. It is not unusual for individuals with PD to have reduced awareness of their speech problem. In fact, the soft-spoken individual with PD often is heard to report “My spouse complains that I am too soft, but she/he really needs a hearing aid!”

Pretreatment Evaluation Patient AAA participated in assessment procedures spanning a range of tasks and measures designed to provide insight about the physiologic bases of the disorder, as well as its impact on speech production. The goal was to sample treatment-related changes across the speech mechanism (respiratory, laryngeal, and oral articulation) to evaluate system-wide effects of treatment accompanying an impact on functional communication. Select pretreatment data are summarized in Table 5–3. Perceptual Measures Patient AAA’s speech was judged to be reduced in loudness and to be monotone, hoarse, and breathy. He was described as having some reduction in articulatory valving. Stimulability testing for increased loudness revealed that he easily was able to increase loudness (to within normal limits) and improve voice quality. This was viewed as a positive sign for potential treatment success. Stroboscopic Measures Pretreatment videostroboscopic images were rated as bowed (lack of medial glottal closure).

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Table 5–3. Selecta Pretreatment Data for Patient AAA Pre 1 X

Pre 1 SD

Pre 2 X

Pre 2 SD

Duration /a/s

24.3

2.5

23.3

2.9

(n = 6)

SPL /a/

61.1

0.6

63.0

0.4

(n = 6)

Jitter /a/

0.45

0.15

0.48

0.20

(n = 6)

SPL “Rainbow”

60.5

2.8

60.7

2.7

SPL Monologue

59.1

3.3

58.5

1.9

SPL /pae/

62.3

0.8

63.4

0.4

(n = 3)

Psub (cm H2O)

4.8

0.8

5.0

0.4

(n = 3)

Rlaw (cm H2O/cc/s)

0.02

0.003

0.02

0.002

(n = 3)

a

Complete data set summarized in reference 46. All SPL data are dB at 50 cm.

Acoustic and Aerodynamic Measures Vocal sound pressure level (SPL), duration, fundamental frequency, and variability of the fundamental were measured from maximum duration sustained vowel phonation, reading, conversational monologue, and dual tasking. Measures of phonatory stability (jitter, shimmer, harmonics-to-noise ratio) were obtained from sustained vowel phonation. Select articulatory acoustic measures (frication duration, rise time, and vowel duration to whole-word duration ratio together with second formant trajectory extent and duration and rate) were measured to assess laryngeal-oral interarticulatory coordination and vocal tract movement. Estimated subglottal air pressure and laryngeal resistance were measured to assess respiratory laryngeal interaction.

Course of Treatment Patient AAA participated in sixteen 1-hour individual sessions of the LSVT

LOUD within 1 month (4 days/week for 4 weeks). LSVT LOUD differs from traditional voice/speech therapy in 3 major areas: target of treatment, mode of delivery, and calibration. There is a single target of improved vocal loudness. The treatment improves vocal loudness by increasing respiratory drive, vocal fold adduction, and vocal tract opening. It is never the goal of the LSVT LOUD to teach a pressed, hyperfunctional voice, but rather a voice with maximally efficient vocal fold closure. Individuals with PD frequently have reduced vocal fold closure and thus need to increase adduction to achieve optimum voice production.46,47 The treatment is delivered in an intensive, high effort mode. This intensity involves more than dosage (4 days/ week for 4 weeks) as it is the intensity and effort required within each treatment session (multiple repetitions of tasks, increasing complexity) that are also required for lasting changes. Finally, calibration addresses the sensory, internal cuing and neuropsychological impairments in people with PD that may limit


generalization of treatment effects outside of the treatment room. Treatment sessions are divided into halves. The first half of the session is spent on 3 “Daily Tasks.” The purpose of these tasks is to rescale the amplitude of vocal output required for within normal limits loudness. These tasks include multiple repetitions of: (1) sustaining “AH” with increased loudness as long as you can; (2) sustaining “AH” while going high/low in pitch; and (3) repeating a list of 10 self-selected functional phrases. The second half of the session (25 to 30 minutes) is spent on a speech hierarchy. The purpose of the speech hierarchy is to train the voice that was achieved during the daily tasks into functional communication. As the weeks of therapy progress, the clients are required to maintain loudness for longer periods of speaking and in more complex speaking situations (eg, progressing from words to conversational speech). The speech hierarchy material is tailored to be salient to each individual consistent with principles that drive experience-dependent neural plasticity.35 In addition to the above treatment tasks, clients are required to complete daily homework practice (all 30 days of the month of therapy) and daily carryover exercises (daily assignment to use LOUD voice with another person outside of the therapy room). Throughout all tasks, calibration was addressed. The patient was encouraged to “Feel that effort, feel that loudness. That is what it needs to feel like when you talk so that people understand you.” The treatment was administered in a mode consistent with principles of motor learning and muscle training (eg, frequent repetitions, intensive, higheffort exercise, simple focus, and progressive resistance).

In addition, the treatment tasks and target behaviors were trained with simplicity and redundancy to facilitate learning in a population with potential neuropsychological problems. Although patient AAA generated increased loudness in sustained phonation and speech with relative ease, he was resistant to use this louder voice outside of the treatment room. As is the case with many individuals with PD, he would “perform” increased loudness tasks in the therapy room but would complain that, “I can’t speak like this outside. I feel like I am shouting.” LSVT LOUD sensory retraining activities (calibration), which include carryover, homework, and education, were administered daily. By the end of the 16 sessions of treatment, patient AAA was convinced and comfortable with the concept that “when he feels like he is ‘talking loud,’ he is speaking at a normal volume and people will understand him.” He was encouraged to continue to keep practicing his homework every day and return in 6 months for a follow-up assessment.

Post-Treatment Evaluation Perceptual Measures The speech of patient AAA was judged to be louder and stronger post-treatment (Table 5–4). His voice quality was clear and the magnitude and precision of his articulatory gestures increased. His wife reported that he now had regained the resonant voice he had when they first met in college, in fact she told him, “that’s the voice I fell in love with!” His coworkers reported that they now could understand him most of the time. Patient AAA reported that he initiated conversations more and was asked to repeat much less often than before

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Table 5–4. Selecta Post-treatment Data for Patient AAA X

SD

X

SD

Duration /a/s

38.6

2.2

41.8

2.2

(n = 6)

SPL /a/

82.8

1.7

83.7

1.3

(n = 6)

Jitter /a/

0.26

0.16

0.30

0.11

SPL “Rainbow”

73.1

3.79

72.8

3.67

SPL Monologue

65.2

4.00

63.7

4.24

SPL /pae/

70.9

0.5

71.2

0.6

(n = 3)

Psub (cm H2O)

7.7

0.2

6.6

0.9

(n = 3)

0.037

0.005

0.037

0.005

(n = 3)

Rlaw a

Complete data set summarized in reference 46. All SPL data are dB at 50 cm.

treatment. He reported with confidence that he knew what to do to make people understand him. Stroboscopic Measures The videostroboscopic examination revealed no vocal fold bowing. Acoustic and Aerodynamic Measures Significant increases were measured across tasks in sound pressure level, maximum duration of phonation, and fundamental frequency variation. Measures of phonatory stability were consistent with improved voice quality and vocal fold closure. Articulatory acoustic measures supported improved valving and precision, consistent with increases in effort and coordination across the speech mechanism accompanying increased loudness. Estimated subglottal air pressure and laryngeal resistance support increased respiratory drive and vocal fold valving post-treatment.

Follow-Up Recommendations A key element in long-term treatment success with any disorder and particularly progressive neurologic conditions, is continued practice. All patients who receive LSVT LOUD are encouraged to continue practicing their LSVT exercises after treatment is over. During the month of treatment, homework practice routines are well established so that the patient is easily able to maintain these routines independently. In addition, various new materials (eg, LSVT practice videos/DVDs) and delivery systems [eg, software supported LSVT delivery (LSVT-Companion,81) and telehealth delivery of LSVT (eg, LSVT®eLOUD)] as well as patient support groups (eg, LOUD Crowds) enhance feasibility of ongoing practice. Application of the LSVT LOUD to this individual with PD was successful immediately post-treatment; positive treatment effects were maintained up to 12 months follow-up. These observations are consistent with previous out-


comes on larger numbers of individuals with PD. Patient AAA demonstrates the importance of early intervention in an individual who was employed and was dependent on his oral communication for his livelihood. The greatest challenge to a successful outcome for patient AAA, and for many individuals with PD, is the need for sensory retraining (LSVT LOUD: concept of calibration). Research data support a breakdown in sensory proprioception in individuals with PD that must be addressed to have successful voice treatment outcomes. As was the case with patient AAA, it is critical to differentiate “performance” in the treatment room from evidence of generalized “learning” outside of the treatment room. The mode of treatment administration (4 times a week for a month of high effort in individual treatment) also appears to be a key element in retraining both the sensory and motor speech systems in PD. Patient AAA also demonstrates the positive system-wide effects of increased loudness. One simple goal, “be loud,” resulted in multiple improvements across the speech mechanism, generating significant improvement in intelligibility. This global effect of “loud” can be particularly beneficial in individuals whose learning may be facilitated by reduced cognitive load. The simplicity and redundancy of the LSVT LOUD also may be particularly valuable in such individuals. It can be a challenge to make lasting improvements in speech and voice in individuals with progressive, neurologic disorders who may also have cognitive impairment. Nonetheless, improved functional oral communication can make a significant impact on the quality of life of these individuals, as it did in the case of patient AAA.

Disclosure Statement Dr. Ramig receives a lecturer honorarium and has ownership interest in LSVT Global, LLC. Dr. Fox receives a lecturer honorarium and has ownership interest in LSVT Global, LLC. Because of the prescriptive nature of LSVT LOUD, this therapy program presented remotely has proven to be successful. In the following case, Lyn Tindall Covert describes the use of telehealth technology for the delivery of therapy.

Case Study 6 Lyn Tindall Covert Use of Telehealth Technology to Provide Voice Therapy Individuals with Parkinson disease (PD) usually develop a speech disorder characterized by reduced loudness, hoarse and breathy voice, monotony of pitch, short rushes of speech, and imprecise consonants. The inability to effectively communicate negatively impacts their ability to function in society and maintain quality of life. A successful program developed to improve speech in these individuals is the Lee Silverman Voice Treatment (LSVT)®.48 A critical component of this treatment is intense daily therapy for 4 weeks, a regimen that is difficult for many elderly clients to accomplish. Videophones placed in the homes of individuals with PD may offer a way to provide treatment that might otherwise be inaccessible.

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Patient Medical History Patient BBB was a 78-year-old male who was referred to speech pathology for low vocal intensity by the neurologist who had diagnosed him with idiopathic Parkinson disease 5 years prior to the referral. His medications included Pramipexole 0.5 mg 3 times daily plus Carbidopa 25/Levodopa 100 1/2 tablet 3 times daily. He had occasional mild hallucinations in the evening, upper extremity resting tremor that was worse in the morning, and stiffness and tightness in muscles that cause difficulty walking. Patient BBB managed his activities of daily living (ADLs) and remained active by assisting his sons on their cattle farm. However, he stated that many of his friends and family members could not understand his speech anymore and that it was getting progressively worse. His voice problem restricted his personal and social life and made him feel handicapped.

Evaluation Procedures Patient BBB received a battery of vocal function tests in the voice laboratory that included: 1. Videostroboscopic examination of the larynx. This examination was completed using the KayPENTAX 70-degree rigid endoscope. Observations revealed incomplete glottal closure, no supraglottic hyperfunction, and normal mucosal wave, bilaterally. 2. Acoustic analysis of sustained vowels and conversation. Patient BBB’s mean fundamental frequency was 133.30 Hz with low and high range of 101.83 to 255.10 Hz. His mean

intensity for vowel prolongation was 59.95 dB, and for conversation it was 58.90 dB with his maximum intensity of 63.60 dB. 3. Mini-Mental State Examination. 49 This tool was used to systematically assess mental status. The maximum score is 30, and a score of 23 or lower is indicative of cognitive impairment. Patient BBB scored 25, indicating that he had the ability to process information and follow directions in order to participate in voice therapy. 4. Voice Handicap Index-10 (VHI-10).50 The VHI-10 was developed as an abbreviated voice handicap assessment compared to the Voice Handicap Index (VHI).51 The VHI-10 is designed to give an indication of a client’s perception of voice handicap before and after treatment. This patient scored 35 on the VHI-10, indicating his voice disorder was almost always a handicap to him. 5. Pretreatment probes of sound pressure level (SPL) measures of vocal tasks including vowel prolongation, reading passage, picture description, and monologue. Recordings of SPL were obtained in a sound-treated room 3 times prior to initiation of therapy. The following tasks were used for analysis: (1) sustaining vowel /a/ phonation, (2) reading the “Rainbow passage,”52 (3) speaking freely on a selfchosen topic, and (4) describing the “Cookie Theft Picture.”53 Instruction to the patient for the first task was “take a deep breath and say ‘ah’ for as long as you can.” Then, he was asked to read the “Rainbow passage.” For the third task, he produced a 1-minute monologue on a topic of his choice. Finally, he was given the “Cookie Theft Picture”


and told to “describe everything that is happening in the picture.” During each probe task, SPL was recorded from the digital handheld sound-level meter. An integrated average sound pressure level (SPL) was calculated for these tasks using digital output of the soundlevel meter placed 30 cm from the patient’s mouth. The digital soundlevel meter was set to average the total duration of the speech signal. The sound-level meter averages the speech signal; pauses during connected speech are not calculated from the sample. Pretreatment averages for these tasks were as follows: Vowel prolongation: 62.9 dB and 8:53 seconds duration Reading: 67.3 dB Monologue: 64.6 dB Picture description: 62.6 dB Results of this evaluation were consistent with moderate hypokinetic dysarthria associated with PD. Treatment goals were targeted to increase vocal loudness and endurance using LSVT,® including: (1) maximum duration of a sustained vowel by the participant to improve glottal competence and respiratory/ laryngeal coordination; (2) practice of pitch range to improve range of motion of the cricothyroid muscle; and (3) practice of maximum functional speech loudness drill to increase phonatory effort.54 Administration of LSVT® requires therapy 4 times a week for 4 weeks; such massed practice is consistent with principles of motor learning, skill acquisition, and muscle training. Nonetheless, the high intensity that makes this program successful also is associated with a tendency to decline initiating therapy or to miss therapy appointments. For

patient BBB, travel to this facility to receive treatment involved driving 160 miles round trip and 4 hours of time, including travel, to provide a 1-hour treatment session. Additionally, patient BBB’s wife, who is his primary caregiver, had to take 6 hours off from her job to transport him and wait for the treatment session to conclude. It should be noted that these typically are nonreimbursable expenses. Therefore, in order to provide this treatment in the manner prescribed, a videophone was issued to patient BBB to enable him to receive therapy at home. The Televyou TV 500SP® from Wind Currents Technology was installed in his home to receive therapy. The TV 500SP® is a stand-alone plug-and-use videophone with duplex speakerphones that use plain old telephone service (POTS) lines. It has a 5-inch active matrix display with adjustable color and brightness and transmits and receives voice and simultaneous video.

Goals for Therapy The LSVT® prescribes 3 treatment tasks for each therapy session to improve vocal intensity, as discussed below. Goal 1: Maximum Duration of a Sustained Vowel The rationale for this goal was to improve glottal competence and respiratory/laryngeal coordination. The goal for patient BBB was to increase vowel prolongation from 8.53 to 15 seconds and intensity from 69.2 to 75 dB. For this task, patient BBB was instructed to “take a deep breath and say /a/ for as long and loud as you can.” This task was performed 15 times daily during each treatment session.

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Goal 2: Improve Range of Motion of the Cricothyroid Muscle To achieve this goal, patient BBB produced /a/ at his highest and lowest pitches 15 times each for a total of 30 trials. For this task, he started at his approximate midfrequency range and sang up to his highest pitch 15 times, and then, starting again at his midfrequency range sang down to his lowest pitch for 15 trials. The highest and lowest pitches were sustained for 2 to 3 seconds each. Goal 3: Practice of Maximum Functional Speech Loudness Drill to Increase Phonatory Effort This goal was accomplished by having patient BBB produce 15 functional phrases/sentences during each session. These phrases and sentences were identified by him prior to therapy for use in his individual daily conversation. He read each phrase/sentence 5 times each for a total of 75 productions per session. In addition to 15 functional phrases, the protocol for LSVT® instructs clinicians to provide additional words the first week, sentences the second week, paragraph reading the third week, and conversation the fourth week in a task that encourages loud speech when producing these stimulus items. These stimulus items were provided by the patient with examples from the LSVT® handbook. Patient BBB was encouraged to complete homework assignments each day during the course of treatment. Homework included performing the same tasks used during treatment but with fewer repetitions. For example, he produced /a/ as loud and long as he could for 6 trials on the days he had

treatment and 12 trials on the days no treatment was scheduled. Using the same procedure utilized during a treatment session, patient BBB produced his highest pitch and then lowest pitch 6 times each on the days of treatment and 12 times each on days with no treatment. Additionally, he read his 15 functional phrases 5 times each on the days of treatment and once each on no treatment days. Patient BBB completed 1 homework page each day while in treatment. After sixteen 1-hour speech therapy treatments over 4 weeks were completed, patient BBB returned to the speech clinic within 1 week and underwent post-treatment data collections previously described. After the post-treatment assessment, he again completed the VHI-10, a Telemedicine Satisfaction Questionnaire (TSQ),55 and cost analysis comparing videophonedelivered therapy to traditional delivery of speech therapy.

Results of Treatment Patient BBB’s performance on voice tasks following therapy were as follows: Vowel prolongation: 79.1 dB and 11.56 seconds Reading: 76.5 dB Monologue: 72.0 dB Picture description: 72.0 dB Results of treatment indicated that posttreatment improvements were achieved in vocal intensity leading to functional speech for patient BBB. His score on the VHI-10 reduced from 35 to 26 post-treatment indicating


that he no longer perceived his voice disorder “almost always” a handicap, but that it was “sometimes” a handicap. Patient satisfaction reflects values and expectations regarding aspects of health care. Therefore, a match between care expected and care received results in user satisfaction. The TSQ was developed to measure user satisfaction with telemedicine. Patient BBB’s responses to the TSQ indicated that he was highly satisfied with the quality of service provided via videophones. In terms of cost comparison of videophone-delivered voice therapy to traditional delivery for patient BBB, round-trip mileage was 160 miles for a traditional visit compared to none for the videophone visit, 4 hours time compared to 1 hour, and $96.80 compared to no cost per visit (Table 5–5). The significant change in pretreatment to post-treatment measures of vocal loudness, cost savings, and client satisfaction with the technology combine to make videophone-delivered voice therapy an efficacious method of service delivery of speech services. Speech pathology services appear to be well-suited for telehealth technology; hence, speech-language pathologists looking for alternative ways to provide

effective, less expensive care should consider telehealth technology as an option for individuals who would otherwise receive limited or no speech therapy services.

References 1. Aronson AE, Brown JR, Litin EM, Pearson JS. Spastic dysphonia. I. Voice, neurologic, and psychiatric aspects. J Speech Hear Disord. Aug 1968;33(3):203–218. 2. Brodnitz FS. Spastic dysphonia. Ann Otol Rhinol Laryngol. Mar–Apr 1976;85(2 pt 1):210–214. 3. Aronson A. Clinical Voice Disorders: An Interdisciplinary Approach. 3rd ed. New York, NY: Thieme Medical Publishers; 1990. 4. Boone D, McFarlane S. The Voice and Voice Therapy. 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1988. 5. Case J. Clinical Management of Voice Disorders. 3rd ed. Austin, TX: Pro-Ed; 1996. 6. Colton R, Casper J. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996. 7. Aminoff MJ, Dedo HH, Izdebski K. Clinical aspects of spasmodic dysphonia. J Neurol Neurosurg Psychiatry. Apr 1978;41(4):361–365.

Table 5–5. Cost Comparison for Outpatient Versus Videophone-Delivered Therapy for Patient BBB Per Visit Costs

Outpatient Visit

Videophone Visit

Round-trip mileage

160 miles

0 miles

Amount of time involved including travel time

4 hours

1 hour

Monetary costs (gas + meal)

$96.80

0

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8. Blitzer A, Lovelace RE, Brin MF, Fahn S, Fink ME. Electromyographic findings in focal laryngeal dystonia (spastic dysphonia). Ann Otol Rhinol Laryngol. Nov– Dec 1985;94(6 pt 1):591–594. 9. Blitzer A. Letter to the editor. Laryngoscope. 1986;96:1300–1301. 10. Dedo HH. Recurrent laryngeal nerve section for spastic dysphonia. Ann Otol Rhinol Laryngol. Jul–Aug 1976;85(4 pt 1): 451–459. 11. Dedo HH, Izdebski K. Intermediate results of 306 recurrent laryngeal nerve sections for spastic dysphonia. Laryngoscope. Jan 1983;93(1):9–16. 12. Dedo HS, T. Spastic Dysphonia: A Surgical and Voice Therapy Treatment Program. Boston, MA: College-Hill Press; 1980. 13. Aronson AE, De Santo LW. Adductor spastic dysphonia: three years after recurrent laryngeal nerve resection. Laryngoscope. Jan 1983;93(1):1–8. 14. Blitzer A, Brin MF, Stewart CF. Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients. Laryngoscope. Oct 1998;108(10):1435–1441. 15. Titze IR, Winholtz WS. Effect of microphone type and placement on voice perturbation measurements. J Speech Hear Res. Dec 1993;36(6):1177–1190. 16. Hogikyan ND, Sethuraman G. Validation of an instrument to measure voicerelated quality of life (V-RQOL). J Voice. Dec 1999;13(4):557–569. 17. Ludlow CL, Adler CH, Berke GS, et al. Research priorities in spasmodic dysphonia. Otolaryng Head Neck. Oct 2008; 139(4):495–505. 18. Lederle A, Barkmeier-Kraemer J, Finnegan E. Perception of vocal tremor during sustained phonation compared with sentence context. J Voice. Sep 2012; 26(5):1–9. 19. Leeper HA, Jones E. Frequency and intensity effects upon temporal and aerodynamic aspects of vocal fold diadochokinesis. Percept Motor Skill. Dec 1991;73(3):880–882.

20. Louzada T, Beraldinelle R, Berretin-Felix G, Brasolotto AG. Oral and vocal fold diadochokinesis in dysphonic women. J Appl Oral Sci. Nov–Dec 2011;19(6): 567–572. 21. Qi YY, Hillman RE. Temporal and spectral estimations of harmonics-to-noise ratio in human voice signals. J Acoust Soc Am. Jul 1997;102(1):537–543. 22. Qi YY, Hillman RE, Milstein C. The estimation of signal-to-noise ratio in continuous speech for disordered voices. J Acoust Soc Am. Apr 1999;105(4):2532–2535. 23. Hwa Chen S. Sex differences in frequency and intensity in reading and voice range profiles for Taiwanese adult speakers. Folia Phoniatr Logop. 2007;59(1):1–9. 24. Lundy DS, Roy S, Xue JW, Casiano RR, Jassir D. Spastic/spasmodic vs. tremulous vocal quality: motor speech profile analysis. J Voice. Mar 2004;18(1):146–152. 25. Barkmeier-Kraemer J, Lato A, Wiley K. Development of a speech treatment program for a client with essential vocal tremor. Semin Speech Lang. Feb 2011; 32(1):43–57. 26. Smitheran JR, Hixon TJ. A clinical method for estimating laryngeal airway resistance during vowel production. J Speech Hear Disord. May 1981;46(2): 138–146. 27. Leeper HA, Graves DK. Consistency of laryngeal airway-resistance in adult women. J Commun Disord. 1984;17(3): 153–163. 28. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS. The Voice Handicap Index (VHI). Am J Speech-Lang Pathol. 1997;6:66–70. 29. Barkmeier-Kraemer J. Hiding vocal tremor. In: Haskell ABaJ, ed. Exercises for Voice Therapy. 2nd ed. San Diego, CA: Plural Publishing; 2013:196–199. 30. Twohig A, Finnegan E. The Effect of Vowel Duration on Tremor Severity for Patients With Vocal Tremor [undergraduate honor’s thesis]. Iowa City, IA: Department of Speech Pathology and Audiology, University of Iowa; 2008.


31. Sapir S, Countryman S, Ramig L, Fox C. Voice, speech, and swallowing dis orders. In: Factor S, Weiner F, eds. Parkinson Disease: Diagnosis and Clinical Management. 2nd ed. New York, NY: Demos Publishing; 2008:77–98. 32. Ramig LO, Sapir S, Countryman S, et al. Intensive voice treatment (LSVT) for patients with Parkinson’s disease: a 2 year follow up. J Neurol Neurosurg Psychiatry. Oct 2001;71(4):493–498. 33. Ramig LO, Sapir S, Fox C, Countryman S. Changes in vocal loudness following intensive voice treatment (LSVT) in individuals with Parkinson’s disease: a comparison with untreated patients and normal age-matched controls. Mov Disord. Jan 2001;16(1):79–83. 34. Fox C, Morrison C, Ramig LO, Sapir S. Current perspectives on the Lee Silverman Voice Treatment (LSVT). Am J Speech Lang Pathol. 2002;11:111–123. 35. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. Feb 2008;51(1):S225–239. 36. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. Champaign, IL: Human Kinetic Publishers; 1999. 37. Liotti M, Ramig LO, Vogel D, et al. Hypophonia in Parkinson’s disease: neural correlates of voice treatment revealed by PET. Neurology. Feb 11 2003;60(3):432–440. 38. Narayana S, Zhang W, Franklin C, Vogel D, Lancaster JL, Fox PT. Changes in speech motor network following speech therapy in Parkinson’s hypophonia: evidence from TMS-PET. Paper presentation Organization of Human Brain Mapping; 2006; Florence, Italy. 39. El Sharkawi A, Ramig L, Logemann JA, et al. Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study. J Neurol Neurosurg Psychiatry. Jan 2002;72(1):31–36. 40. Sapir S, Spielman J, Countryman S, et al. Phonatory and articulatory changes in

ataxic dysarthria following intensive voice therapy with the LSVT: a single subject study. Am J Speech Lang Pathol. 2003;12:387–399. 41. Sapir S, Spielman JL, Ramig LO, Story BH, Fox C. Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson disease: acoustic and perceptual findings. J Speech Lang Hear Res. Aug 2007;50(4):899–912. 42. Spielman JL, Borod JC, Ramig LO. The effects of intensive voice treatment on facial expressiveness in Parkinson disease: preliminary data. Cogn Behav Neurol. Sep 2003;16(3):177–188. 43. Mahler LA. Intensive behavioral voice treatment of dysarthria secondary to stroke. J Clin Linguist Phon. 2012;26: 681–694. 44. Sapir S, Pawlas A, Ramig L, Seeley E, Fox C, Corboy J. Effects of intensive phonatory-respiratory treatment (LSVT) on voice in two individuals with multiple sclerosis. J Speech Lang Pathol. 2001;9(2):35–45. 45. Hoehn M, Yahr M. Parkinsonism: onset progression and mortality. Neurology. 1967;19:427–442. 46. Perez KS, Ramig LO, Smith ME, Dromey C. The Parkinson larynx: tremor and videostroboscopic findings. J Voice. Dec 1996;10(4):354–361. 47. Smith ME, Ramig LO, Dromey C, Perez KS, Samandari R. Intensive voice treatment in Parkinson disease: laryngostroboscopic findings. J Voice. Dec 1995; 9(4):453–459. 48. Ramig L, Bonitati C, Lemke J, Horii Y. Voice treatment for patients with Parkinson disease: development of an approach and preliminary efficacy data. J Med Speech Lang Pathol. 1994;2(3):191–209. 49. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. Nov 1975;12(3):189–198.

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50. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the Voice Handicap Index-10. Laryngoscope. Sep 2004;114(9):1549–1556. 51. Jacobson B, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benniger M. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6(3):66–70. 52. Fairbanks G. Voice and Articulation Handbook. New York, NY: Harper & Row; 1960. 53. Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Boston

Diagnostic Aphasia Examination. 2nd ed. Philadelphia, PA: Lea and Febiger; 1983. 54. Ramig LO, Countryman S, Thompson LL, Horii Y. Comparison of two forms of intensive speech treatment for Parkinson disease. J Speech Hear Res. 1995; 38(6):1232–1251. 55. Yip MP, Chang AM, Chan J, MacKenzie AE. Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary study. J Telemed Telecare. 2003;9(1):46–50.

6 Irritable Larynx Syndrome, Paradoxical Vocal Fold Dysfunction, and Chronic Cough

Chronic cough, paradoxical vocal fold dysfunction, and irritable larynx syndrome are often debilitating problems for patients and are difficult management cases for clinicians. The authors in this chapter demystify these disorders by explaining plausible causes and offering useful therapeutic solutions for therapists who may have little to no insight into the respiratory demands of athletes who

Introduction to Irritable Larynx Syndrome Linda Rammage The term irritable larynx syndrome (ILS) was proposed to represent a compilation of commonly observed chronic symptoms thought to result from hyper-

come to them for treatment or in the case of chronic sensory neuropathic cough, the medical therapies now offered for treatment. The speech-language pathologist often feels like the “last hope” for many of these patients, and the following physiologically based therapeutic suggestions offer clinicians an opportunity to guide the patient out of the chronic problem in many cases.

kinetic laryngeal dysfunction when triggered by specific internal or external stimuli. Primary ILS symptoms may include chronic cough, adductory laryngospasm (AL, also called paradoxical vocal fold motion or vocal cord dysfunction), muscle tension dysphonia, and/or globus pharyngeus. The most commonly reported triggering stimuli are odors; airborne particulates (often first identified

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by accompanying odors); reflux/other esophageal activity (eating certain foods or drinking certain liquids, sometimes with temperature as a contributor); postural changes (typically positions that might increase reflux episodes); voice use; exercise; and emotional stressors.1 More recently, similarities have been identified between the proposed ILS pathophysiology and that of other chronic conditions associated with central (nervous system) sensitivity syndromes (CSS) along with a high coincidence of ILS and other CSS symptoms.2 Diagnostic criteria for ILS diagnosis include symptom(s) attributed to hypertonicity/hyperkinetic activity in the laryngeal and related muscle systems; visual and palpable evidence of laryngeal and paralaryngeal muscle misuse;3 and evidence of specific triggering stimuli.1 ILS exclusion criteria include anatomical laryngeal/pharyngeal/esophageal pathologies that could account for peripheral hypersensitivity and/or laryngeal symptoms; definitive neurologic diseases known to cause any of the ILS symptoms; and preexisting psychiatric diagnosis.1 The latter does not preclude consideration of psychological symptoms such as anxiety and/ or depression that may arise as a result of ILS symptoms, or stressors such as unexpressed negative emotions that may act as symptom triggers, often in conjunction with a sensory trigger, such as an odor associated with an olfactorybased memory, or globus pharyngeus that triggers fear about malignancy.4

Theoretical Foundation — Proposed Physiological Mechanisms ILS theory describes how neural-plastic changes affect the laryngeal CNS con-

trol network to produce a hyperirritable “spasm-ready” state in the peripheral laryngopharyngeal muscles, which represents the status of the resting state. The transition from the “spasm-ready” resting state to ILS symptom manifestation requires a trigger, sometimes heightened by muscle tone modulators, such as psychological stressors or postural factors that make the laryngopharynx more susceptible to spasm in the presence of specific triggers.1 The theoretical mechanisms of ILS symptom development have been inferred from research and theory in chronic pain and central sensitivity disorders.5–14 In ILS, brainstem control of laryngeal sensory-motor processes has been altered so that abnormal muscle tension and spasm occur in response to normal levels of sensory stimuli. In the larynx, a number of central nervous system (CNS) pathologic processes may lead to chronic laryngeal motor stimulation and heightened sensory irritability.1 Neural plasticity may affect the way that laryngeal motor and related systems react to sensations or thoughts through one of several mechanisms: development of new afferent inputs to the central neurons after previous inputs are withdrawn in response to peripheral nerve or tissue injury, resulting in potential change in responses to sensory input15–18; altered central sensory-motor control and heightened reactivity in the larynx as a result of genome changes in the periaqueductal gray (PAG) nuclei of the brainstem caused by a viral illness;1 hypersensitivity due to chronically hypertonic laryngeal muscles associated with unexpressed negative emotions mediated by the sensory-motivation controlling structures in the PAG and periambigual reticular formation19–21; or parasympathetic hyperreactivity reactions in the upper airway to chronic sen-


sory stimuli, such as olfactory stimuli or refluxate from the stomach.1,22 Yunus has proposed a neurohormonal pathophysiological mechanism to explain development of fibromyalgia (FM), myofascial pain syndrome, irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), tension-type headaches (HD), and restless legs syndrome11 and has demonstrated how the related central sensitivity can be verified by testing certain neurotransmitters/ neuromodulators and the nociceptive spinal flexion reflex, or by functional magnetic resonance imaging and cerebral evoked potential.12,13 Yunus challenges the concept that CSS represent a collection of somatic or hysteric symptoms by demonstrating that those symptoms do not meet criteria for somatization disorders presented in the Diagnostic and Statistical Manual of Mental Disorders, and proposes a model where biophysiological and psychosocial factors may interact to trigger symptoms.14 In a retrospective study, the central sensitivity syndrome model was presented as a paradigm from which to explore ILS, and a high prevalence of CSS comorbidities was identified in a clinical population with ILS symptoms.2 ILS appears to fall into a broad syndrome group that includes other central sensitivity syndromes. As with other CSS, ILS treatment should focus on a comprehensive approach to attain goals of minimizing disability, reducing distress, improving general health, and reducing the use of medical resources. These goals are addressed at three primary levels of treatment objectives: Level 1: Minimize sensory stimuli acting as triggers: internal (eg, reflux) and external (eg, odors); identify triggers; maximize reflux management/compliance.

Level 2: Reprogram the habituated (laryngeal) motor response: desensitize; use principles of motor relearning. Level 3: Capitalize on neural plasticity to reprogram the central nervous system: motor relearning; centrally active medications. In this comprehensive evaluation and treatment model, Linda Rammage takes us through steps to grade the location and severity of extralaryngeal muscle use that may contribute to the sense of tension in the throat and her therapeutic concept of the z-swell.

Case Study 1 Linda Rammage A Case of ILS Managed by a Comprehensive Approach to Multiple Central Sensitivity Syndrome Triggers

History of the Problem Over the previous 18 months, DD had experienced progressive difficulty with voice quality, breathing, and swallowing. She became aware of the first symptom — progressively “squeaky,” effortful voice during the day, when she started working in a department store, adjacent to the perfume department. Several weeks later, DD noticed her breathing also was affected when she was in the store. She described a wheezing sensation in her throat and effort in her chest when she was trying to breathe in, which worsened the longer she spoke, as did her dysphonia. A few months later, DD

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began to experience difficulty swallowing. She described increasing effort to swallow solid food, and a feeling of panic when preparing to go on her lunch breaks. She typically took her break with a long-time friend, who regularly expressed great concern about DD’s symptoms and proposed that she might have throat cancer from her husband’s secondhand smoke or from the chemicals coming from the perfume department that seemed to aggravate DD’s symptoms. Based on these comments, DD asked her manager for a transfer to another department, and he complied. She was transferred to a clothing section and initially felt relieved until she noticed a peculiar scent as she opened some new garment packages. These odors triggered the same throat symptoms: increased dysphonia followed by difficulty breathing in. Her doctor recommended that she stop working and referred her to a number of specialists, which culminated in proposed diagnoses of psychological stress, borderline asthma, allergies, FM, IBS, CFS, and HD. As her symptoms persisted, her concern about cancer increased, despite a clear chest x-ray and an otolaryngologist’s exam of “negative findings.” She was sleeping poorly, and waking frequently gasping for breath.

Medical History DD had undergone multiple abdominal surgeries, and sustained back injuries during a motor vehicle accident. Her mother died of colon cancer. On her voice clinic intake form, she checked affirmatively that she currently suffered from, or had in the past experienced the following problems: anxiety, asthma, arthritis, breathing problem,

CFS, chronic coughing and choking, depressed mood, FM, HD, heartburn, hoarseness, irritable bladder (IBL), IBS, lump in throat sensation, multiple chemical sensitivity (MCS), neck or back injury, postnasal drip (PND), severe snoring, swallowing problem, and chronic throat-clearing. She stated she had been moderately overweight all her life, but on sick leave she had gained an additional 25 pounds, which frustrated her. She did not eat regular meals during the day but enjoyed a large meal in the evening. She drank 8 cups of water daily. She was a lifelong abstainer of alcohol and tobacco, and drank no caffeine. Food allergies but no airborne allergies had been identified, and consultation with a respiratory specialist lead to a diagnosis of “borderline asthma,” exacerbated by exercise and allergies. Her family doctor had prescribed antianxiety and steroid inhalers to reduce her “asthma” attacks. DD described her asthma symptoms as difficulty breathing in and coughing, particularly in the presence of certain odors and cold temperatures.

Social History When we first met DD, she was 54, married, with 3 adult children, one of whom still lived with her and her husband in a metro suburb. Her daughter who was living at home accompanied DD to the first voice clinic appointment. Her husband was a heavy smoker, but had limited smoking to outdoors for the past 10 years. She stated she was happily married but worried about her husband’s health, because of his smoking. DD had enjoyed her job in sales. Quitting her job had negative economic


and emotional impacts. In addition to missing the social contact, DD explained that her husband’s business was experiencing some slowdown, which increased the financial burden on the family.

Patient Self-Assessment In addition to responses on the detailed patient-intake form, DD completed the Voice-Related Quality of Life (V-RQOL). Scores were as follows: social-emotional domain: 15/16; physical functioning domain: 22/24; total raw score: 37; and a converted score of 35 indicating that DD’s quality of life is moderately impacted by her disorder.

Evaluation Procedures DD underwent evaluation of her problem with a multidisciplinary team comprised of a laryngologist, speech-language pathologist (SLP), and psychiatrist. Interdisciplinary History The voice clinic team identified physiological and emotional factors that likely contributed to the development of ILS and/or acted as symptom triggers. Asked how her problems have impacted her life, DD stated: “My throat problems took my life away, and I just want to get my life back!” Among the potential predisposing factors were the following: n Abdominal tension: DD’s history of

multiple abdominal surgeries and lower back injury may have contributed to the tendency to hold her abdominal muscles in a “splinting” behavior to inhibit painful abdomi-

nal muscle stretching on inspiration. She was aware of tension in her abdomen and back when she recalled her mother ’s fight with colon cancer. These reactions could act as “tone modulators,” making her more susceptible to reacting to ILS triggers. n Gastroesophageal reflux: DD’s chronic heartburn, globus pharyngeus, sensation of postnasal drip, chronic throatclearing, and choking when supine are common symptoms of reflux. These symptoms had increased as she became more sedentary, went to bed immediately after meals, and gained weight. n Psychological factors: DD’s preoccupation with the possibility she had cancer caused growing anxiety and was fueled by the unabated throat and breathing symptoms. It was evident that DD was burdened by unexpressed fear that she would inherit her mother’s colon cancer, or alternatively that her long-term exposure to her husband’s secondhand smoke might have induced cancer, as was inadvertently reinforced by her work friend. Furthermore, it was clear that DD had developed anticipatory anxiety about her throat, specifically her difficulty breathing in certain environments. Her anxiety may have been borne of previous inconclusive or inadequately explained diagnoses of “borderline asthma” and “multiple chemical sensitivities,” particularly as she was cautioned against exposing herself to environmental agents that seemed to cause these symptoms and had already been exposed to triggering irritants for prolonged periods. A symbolic olfactory association also may have existed during the onset of symptoms. On reflection and discussion with the psychiatrist, DD

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stated that she had never appreciated perfumes since she was a child and a relative whom she disliked and distrusted always wore perfume when she visited. n Central sensitivity syndrome (CSS): DD had been suffering a number of symptoms that had led to diagnoses of multiple CSS. If ILS represents a CSS, DD may have been predisposed to neuroplastic changes that affect the sensory-motor system, with other physiological and psychological factors contributing the laryngopharyngeal focus for symptom formation.1,2,23 Body Alignment and Use Visual observation and manual techniques revealed spinal lordosis, head retraction, and jaw jutting posture in sitting position. DD’s scapulae were moderately adducted and tender. Her head was held rigidly on her neck and suboccipital muscles were extremely tender to palpation. The general postural muscle tension and tenderness noted are consistent with symptoms of FM and HD. Circumferential palpation of DD’s abdomen and lumbar spine regions revealed minimal palpable displacement on inhalation during speech and at rest in upright positions. Facial Muscles Visual observation and palpation were used to evaluate facial muscle use. DD’s eyebrows were held in adducted position for the duration of our interview. Her jaw was clenched, and when asked to release her jaw, she pushed it forward rather than relaxing it down. Her face was tender on palpation between the maxilla and mandible, due to hypertonic jaw muscles. DD’s tongue periph-

ery was scalloped, imprinted from her bottom teeth against which she chronically pressed her tongue. Paralaryngeal Muscle Evaluation Using the grading criteria set out previously, 4 paralaryngeal muscle groups were evaluated at rest and during vocal activities.3 Suprahyoid muscles are evaluated by palpating the submental space at rest and during phonation tasks, such as sustained vowels, counting aloud, and pitch glides. This results in a 0 to 3 scalar score were as follows: 0 = muscles soft (relaxed) at rest and during phonation 1 = muscles soft at rest, moderate contraction during phonation tasks 2 = muscles mildly-moderately hard (hypertonic) at rest and during phonation, jaw jut may be noted to accommodate suprahyoid tension 3 = muscles maximally hypertonic at rest and during phonation Thyrohyoid muscles are evaluated by palpating the thyrohyoid space bilaterally with thumb and middle finger at rest and during phonation tasks. This results in a 0 to 3 scalar score: 0 = palpable thyrohyoid space at rest and minimal contraction (narrowing) during phonation 1 = palpable thyrohyoid space at rest, narrowing on phonation 2 = narrow thyrohyoid space at rest and during phonation 3 = no palpable space between thyroid and hyoid structures consistently


Cricothyroid muscles are evaluated by palpating the cricothyroid space in the midline with the tip of index finger at rest and during pitch glides. This results in a 0 to 3 scalar score: 0 = normal cricothyroid space at low F0 and normal closing of space during pitch ascension 1 = narrowed cricothyroid space at rest with closing during pitch ascension 2 = anterior displacement of cricoid cartilage relative to thyroid cartilage, narrowed cricothyroid space with closing during pitch ascension 3 = no palpable cricothyroid space at rest or during phonation Pharyngolaryngeal muscles can be palpated by rotating the larynx, hooking the posterior edge of the thyroid cartilage with index and middle fingers, and drawing the larynx forward to feel the posterior edge of the cricoid cartilage with the middle and ring finger. This maneuver should only be performed by trained clinicians with experience in palpation. This results in a 0 to 3 scalar score: 0 = larynx easily rotated 90° and posterior cricoarytenoid muscles and arytenoid cartilage movements palpated on sniffing 1 = larynx slightly stiff, cannot palpate posterior cricoarytenoid muscle activity 2 = larynx difficult to rotate but can palpate posterior edge of thyroid cartilage 3 = larynx immobile Alternatively, the larynx can be grasped firmly on either side of the thyroid car-

tilage with the thumb and middle finger on opposite sides and lateral movement of the larynx determined by alternately pushing with the thumb and middle finger. Suprahyoid, thyrohyoid, and cricothyroid muscles all were maximally tense, and her cricoid cartilage was displaced anteriorly. The cricopharyngeus muscle was moderately hypertonic. Acoustic and PerceptualAcoustic Evaluation DD’s mean F0 during speech was 278 Hz, with a low and high range from 270 to 314 Hz. She demonstrated a physiologic F0 range from 125 to 857 Hz, produced during glissando productions on “oo-siren” and phonation with simultaneous lip bubbling. DD’s average vocal intensity during speech matched her low value of 50 dB, but she was able to demonstrate a dynamic range of 42 dB, by imagining she was yelling at someone who had annoyed her, to a maximum intensity level of 92 dB. Inversefiltered acoustic waveform analysis demonstrated abnormal values for pitch perturbation (jitter), amplitude perturbation (shimmer), and harmonics-tonoise ratio. Perceptually, DD’s voice during* speech was characterized by moderately strained and breathy quality during speech, and normal voice quality during laughter. Her breath groups tended to be short and phrasing periodically inappropriate as she frequently ran out of air during speech. Laryngeal Examination Laryngeal examination using transnasal fiber-optic laryngoscopy initially elicited an AL response to the sensory stimulus of the transnasal scope; the

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adductory laryngospasm and voiced inspiratory stridor were viewed and recorded to provide visual and auditory feedback. In addition to the AL, muscle misuse patterns observed in the laryngopharynx included larynx elevation for speech and pitch ascension (due to suprahyoid and thyrohyoid muscle misuse), elongated vocal fold posture during speech, and absence of vocal fold shortening during pitch descent (due to maximal contraction of the cricothyroid muscles). DD also was observed to clear her throat multiple times during the evaluation, and the impact of this behavior was explained to her as she viewed it on the monitor. During evaluation of vocal fold vibratory patterns with stroboscopic light, notable features included reduced amplitude of vibration bilaterally for all vocal tasks, incomplete closure during high-pitched phonation and speech, and reduced mucosal wave bilaterally. Evaluation with continuous light revealed several signs of reflux: moderate erythema in the posterior glottis; edematous arytenoid bodies and interarytenoid region; and pseudosulci inferior to the vocal fold margins.

Trial of Therapy Techniques The therapy trials were initiated during the laryngeal examination, using the transnasal fiber-optic technology for visual feedback as facilitation exercises were introduced. Using a sniffing technique, DD was able to reverse her AL symptoms while watching the video monitor. Vibratory amplitude, mucosal wave, and closure patterns were normalized when techniques were introduced to improve coordination between speech breathing and phonation in

modal register. Spontaneous utterances, “M Hm” and “Hm!” allowed her to initiated phonation in her natural modal register area, around 180 Hz, and a pulsing voiced fricative production on /z/ allowed her to sustain normal phonation. DD responded positively to immediate auditory, sensory, and visual feedback. A multidisciplinary approach to treatment was required to address the various physiological, lifestyle, and emotional factors contributing to DD’s ILS symptoms, with application of the principles of managing ILS as a CSS: Level 1 Minimize sensory stimuli acting as triggers: internal (eg, reflux) and external (eg, odors); identify triggers; maximize reflux management/compliance. n Goal 1. DD will demonstrate an

understanding and acceptance of the multifactorial nature of her breathing and voice problems.

Rationale: DD needed to “buy into” the concept of ILS as a CNS hypersensitivity syndrome with multiple interacting causes, so she could commit to lifestyle changes and comply with recommended treatments. Following detailed description of the problem and review of video recordings with DD and her daughter, the voice care team provided reassurance that DD did not have laryngeal cancer and that the symptoms she suffered can be explained by ILS. n Goal 2. Sensory reflux stimuli that

trigger AL, dysphonia, and globus will be minimized.

A proton pump inhibitor (PPI) was prescribed BID. The voice care team and


a consulting dietician reinforced and monitored DD’s efforts at changing her diet and eating schedule, with special focus on eating frequent small meals, increasing her protein intake, remaining upright for 3 hours after eating, and raising the head of her bed. DD and her daughter viewed a client education tool on laryngopharyngeal reflux (LPR).24 n Goal 3. Exposure to known airborne

irritants will be minimized.

Her husband was invited to participate in discussions about symptom triggers and elimination of airborne irritants. Rationale: DD’s medical history, as well as her ILS history, suggested that reflux played a major role in predisposing her to laryngeal muscle spasm. Her reflux symptoms increased since she gained weight, became more sedentary, and spent more time in supine position. Further, her concern for her husband’s health likely heightened her sensitivity to airborne irritants and odors, particularly cigarette smoke. Level 2 Reprogram the habituated (laryngeal) motor response: desensitize; use principles of motor relearning n Goal 4. DD will learn about mal-

adaptive motor responses causing ILS symptoms.

Psychotherapy was offered to help bring to DD’s conscious awareness the role that unexpressed negative emotions play in hyperkinetic muscle activity, and how olfactory stimuli can serve as ILS symptom triggers. The psychiatrist helped DD recognize how her fears

about her health and olfactory memories, and sensory stimuli from reflux or airborne irritants became inappropriately associated to cause abnormal muscle responses to normal sensory stimuli. In conjunction with a physical therapist and the SLP, the psychiatrist introduced physical activity and relaxation to assist DD in recognizing sensations associated with muscle tension and relaxation, and emotional effects of physical activity. Rationale: DD tended to respond to emotions at a physical level with muscle tension throughout her body causing a variety of CSS symptoms — the consequent pain and fatigue are hallmark symptoms of FM, HD, and CFS. The pain sensation was reinforced through fear of what it might represent. By addressing responses initially at the physical level, using general to specific muscle relaxation, and helping DD recognize associations with inappropriate thought processes, DD’s ILS symptoms gradually subsided. Because endorphins are among the most powerful chemical treatments for negative affect, a regular physical fitness regime was expected to minimize dose/number of pharmacotherapies.

Voice Therapy Weekly sessions were offered for 2 months to help DD learn to extinguish maladaptive motor responses and learn more appropriate functional patterns for breathing and speech. DD’s husband and daughter were asked to participate in therapy activities as appropriate to learn about ILS, provide support, and help with carryover. n Goal 5. DD will change her breath-

ing pattern focus.

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“Back breathing” was introduced: with head dropped forward and spine flexed, DD was instructed to notice which parts of her back moved during breathing. Once able to identify movements in her back, she was asked to continue attending to the sensation of back breathing in upright positions. Rationale: This ergonomic position minimized tension in the upper torso and distracted DD from attending to the typical negative feedback of chest tension and effort that she associated with breathing in. n Goal 6. DD will learn to prevent and

abort AL reactions.

Having already demonstrated appropriate inspiratory vocal fold posture during sniffing, DD was instructed to sniff slowly feeling those areas of her back that were drawing the air in. She would use the sniffing activity throughout her day to visualize the open airway and feel natural back movements. She would use sniffing to enjoy pleasant odors, and imagine smelling a favorite food to pair positive olfactory activity with appropriate breathing patterns during sniffing activities. Rationale: The sniffing exercise works on the same principle as “pursed lips breathing”25 by introducing a restriction in the upper airway that forces a compensatory reaction to abduct the vocal folds maximally, is easy to learn, and can be used in most social situations to prevent and manage AL symptoms. By imagining she was smelling something pleasurable, she was able to pair olfactory sensations with appropriate breathing sensations. n Goal 7. DD will improve body pos-

ture, and reduce specific muscle mis-

uses in the abdomen, head, face, and neck. Appropriate alignment and training in awareness of “tense” versus “neutral” muscles were paired with selective manual therapy to optimize function in neck, face, and laryngeal and pharyngeal muscles that had been chronically hypertonic (see Chapter 3, Roy, and Chapter 7, Leborgne, for discussion of manual therapy).26,27 Rationale: Normalizing posturealignment is essential to restoring natural breathing patterns and neutralizing laryngeal suspension systems. Isometric muscle activity contrasted with “release of muscle contraction” provides a concrete sensory reference when hypertonicity has become the “normal” state and sensory feedback from muscle spindles has been reduced or altered. n Goal 8. DD will learn how to con-

sistently initiate and sustain voice in modal register with minimal muscle misuse in laryngeal suspension muscles.

Voice onset techniques that were successful during diagnostic therapy were applied: coordinated voice onset (CVO) on “spontaneous” utterances: “um hum” and “Hm!” while manually releasing masseter and suprahyoid muscles27; and “z-swell” pulses that use the principle of semi-occluded vocal tract to optimize vocal fold closure, provide feedback on the voiced fricative about continuous airflow, and simulate speech inflections in a continuous phonation segment.28,29 The z-swell (Figures 6–1 through 6–4) helps you make a vocal tone that is supported by abdominal muscles and free-flowing air. Your throat stays


Figure 6–1. Single z-swell. Step 1: Start with a single swell. Feel your mouth buzz as your airflow energy pulses.

Figure 6–2. Double z-swell. Step 2: Now make two “swells” in one breath. (Hint: make the 2 swells faster than the single swell so you do not run out of air before you finish.)

Figure 6–3. Triple z-swell. Step 3: Make 3 “swells” in one breath if you can do so without running out of air and without pushing from your throat. After that, you can try up to 4 “swells “ on your breath out, but do not strain your throat to do it.

Figure 6–4. Z-Swell transition to speech. Step 4: Start the z-swell, then switch to speech without stopping the flow of sound and airflow energy. Use a memorized series of words: counting, days of the week, or months of the year. The flow of the speech phrase should feel just like the flow of the z-swell. relaxed and your voice buzzes in your mouth. Alternatively, you can use a “v” sound.

Preparation: Make sure you are sitting, standing, or lying down in a comfortable, aligned position. Drop your

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jaw and keep it slack, with your lips relaxed and parted. DD’s response to these techniques was evaluated to determine which she could apply most immediately and effectively to speech. She chose CVO (“Hm!”) to cue her modal register, because she had noticed normal voice during this type of utterance in the past, and was immediately able to apply it to short responses, such as, “Sure,” “Hi,” “OK.” Using feedback about abdominal (and back) compression during CVO, she learned to extend the tone. A hierarchical approach was used to transfer the CVO sensations to speech: serial speech (“HmMonday; HmTuesday . . . ”); memorized passages; carrier phrases (“HmI’m going to the market to buy some ______”); and conversational speech. Rationale: Hypertonicity in laryngeal suspension muscles, most notably suprahyoid muscles, was noted during DD’s attempts to initiate speech. Spontaneous voice-onset activities such as CVO tend to elicit natural modal register phonation with appropriate vocal fold adduction associated with low phonation threshold pressures, and CVO allowed DD to feel participation of abdominal muscles and extinguish extraneous muscle activity. n Goal 9. DD will learn to incorpo-

rate her therapy strategies to prevent inappropriate laryngeal motor reactions in the presence of triggers.

A desensitization program was introduced in later stages of the therapy to allow DD to incorporate her management strategies when exposed to odors that previously served as ILS symptom triggers. She applied the open-throat,

back-breathing sniffing that she had used for smelling or imagining pleasant odors to situations she had previously found challenging, setting her own schedule and hierarchy, starting with scheduled exposures in the clinic and in her home. Rationale: The desensitization program allowed DD to learn to extinguish the maladaptive responses to normal sensory stimuli and gave her the control and confidence to return to previously problematic environments, including her workplace. Level 3 Capitalize on neural plasticity to reprogram the central nervous system: motor relearning; centrally active medications. n Goal 10. DD will work with the medi-

cal team to explore use of neuropsychotropic medication.

In consultation with DD, her general practitioner, and the laryngologist, the psychiatrist took responsibility for determining which, if any, prescription medications, such as selective serotonin reuptake inhibitors, combined serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, or a centrally active antispasmolytic drug might assist DD in reducing ILS symptoms. The psychiatrist also helped DD evaluate and monitor psychological effects of her physical exercise program. As progress was demonstrated early in the physical and speech therapy program, she and DD decided to hold off on medications. Rationale: Some patients with ILS and other CSS symptoms benefit from centrally active prescription medications. The neurons involved in the


sensory-motor disorder of ILS and other CSSs use chemicals to communicate with each other, and modifying brain chemistry might make it possible for them to communicate more effectively. A regular aerobic exercise program is known to improve mental health due to production of endorphins, and the long-term benefit to DD probably exceeded effects of neuropsychotropic medication.

Treatment Outcomes: ThreeMonth Post-Treatment Initiation Symptom Abatement DD reported swallowing was easier, she was coughing less, and she was breathing and sleeping better within 3 weeks of PPI therapy. She had lost 5 pounds on the new antireflux lifestyle regime. The recognition of her symptom reduction encouraged DD, and she demonstrated a dogged determination to continue with her success. Within 6 weeks of commencing physical therapy, she was walking 60 minutes daily with friends. She recognized a significant reduction in her general body pain and fatigue. She also stated that she was “getting her life back.” Her V-RQOL scores at 3 months were as follows: socialemotional domain: 9/16; physical functioning domain: 11/24; and total raw score: 20/40. General Posture and Laryngeal and Paralaryngeal Muscle Use The SLP observed progressive improvement in body alignment and reduced sensitivity to palpation of specific muscle areas. DD stated she was “taller”

since she started therapy. She monitored tension in her neck, face, jaw, tongue, and suprahyoid muscles several times daily and was able to accurately report improvement as she observed it visually, proprioceptively, or by palpation. Only mild residual hypertonicity was palpated in target paralaryngeal muscle groups. Laryngeal Examination Examination with the transnasal scope confirmed lowered larynx during phonation, appropriate modal register phonatory posture and normal vocal fold closure pattern, vocal fold vibratory amplitude, and mucosal wave bilaterally. DD initially demonstrated adductory spasm when the flexible scope was inserted but was able to control the symptoms by sniffing and performing what she called her “body meditation” (her term for tuning into positive sensations in her body). The laryngeal exam revealed reduced erythema and edema in the larynx, but a mild pseudosulcus was still evident. Acoustic and PerceptualAcoustic Evaluation Measures of vocal perturbation and harmonics-to-noise ratios were within normal limits. DD’s speaking voice was predominantly clear and produced in modal register, with a mean f0 of 185 Hz. However, when she spoke of issues that caused anxiety, such as being returning to work and financial pressures, she tended to revert to her “squeaky voice.” She recognized the voice change, and, with the assistance of the SLP, was able to recover clear modal register phonation.

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Summary and Concluding Remarks ILS is presented as a central sensitivity syndrome, as hyperkinetic/hypertonic responses in the laryngopharynx to normal stimuli. Because neural plasticity can cause long-term changes in muscle use patterns through a variety of mechanisms at the peripheral and central nervous system levels, treatment typically needs to be directed toward reprogramming subconscious movement patterns. A multidisciplinary approach is often helpful in determining the complex interactions between symptom formation and sensory triggers, and planning the most effective treatment. The rapid abatement of DD’s ILS symptoms can be attributed largely to her motivation to improve her health and return to a normal lifestyle. An intelligent and insightful woman, she was able to recognize and evaluate her physical and emotional responses to various situations and employ appropriate techniques to reduce or extinguish inappropriate muscle responses to symptom triggers. The multiprofessional team provided consistent messages about the causes and appropriate treatments for her symptoms. Although it was almost a year after her first visit to the voice clinic that she claimed to be “symptom-free,” DD accepted the gradual improvement as a predictable response and gave herself due credit for the amount of time and effort she contributed to the changes she made. In this next case, Marc Haxer explains methods to recalibrate laryngeal postures in a difficult case of chronic cough in a 77-year-old woman with long-standing problems.

Case Study 2 Marc Haxer Multimodality Behavioral Treatment of Long-Standing Chronic Cough in an Adult Patient N was a 77-year-old female who presented to otolaryngology for an evaluation and opinion regarding a dry, nonproductive cough along with a secondary complaint of vocal tremor. Onset of the cough was approximately 5 years prior to presentation. She related a previous history of cough since childhood. However, per her report, past episodes were not as severe or as long-lasting as the current cough. Patient N also described a history of recurrent episodes of bronchitis and sinusitis. Further, she noted workups for allergy and extraesophageal reflux; documented reflux signs were noted on upper endoscopy. For this, she had been variously treated with once-daily or twice-daily dosing with a PPI. At the time of her otolaryngology consultation, patient N was taking Nexium one time daily. However, she related no reduction/cessation of cough on this regimen. Onset of cough was often but not always associated with triggers such as eating, exposure to strong smells, or changes in temperature/humidity. Patient N denied any episodes of emesis, incontinence, or loss of consciousness associated with episodes of cough. She reported limited attendance at social events given the number and severity of cough. The vocal tremor had been present for 5 years and was diagnosed as a benign essential tremor. Patient N reported a parent with tremor as well. She was not overly bothered by her voice.


Otolaryngologic and Voice Evaluation Results Results of patient N’s otolaryngology examination revealed her voice to be characterized by quality and intensity appropriate for her age and gender. Subjectively, her vocal tremor was felt to be moderate in presentation. During mirror examination, palatal and pharyngeal tremors were noted during sustained phonation. Results of laryngoscopic and stroboscopic evaluations revealed gross vocal fold mobility to be normal bilaterally. Tremor was noted with exhalation and sustained phonation. Results of her voice evaluation revealed hearing acuity to be adequate in the conversational setting. Completion of an oral-motor examination yielded results consistent with those noted by otolaryngology. Speech perceptual evaluation revealed 100% of her speech to be intelligible in conversation. Although voice quality and intensity were felt to be consistent with her age and gender, a consistent vocal tremor was present. Language and cognitive skills were adequate based on functional assessment. No problems were identified with deglutition. Given that patient N was not overly concerned with her voice, acoustic and aerodynamic testing was not undertaken. An elevated score of 28 on the Reflux Symptom Index30 indicated the presence of ongoing symptoms consistent with extra-esophageal reflux. On the date of her initial evaluation, patient N subjectively rated the severity of her cough as a “7” on a linear 1 to 7 scale where a score of “1” indicated minimal to no daily episodes of cough and “7” indicated daily occurrences of cough. Several goals of therapy were developed. These included improvement

in the overall environment of the larynx (increased hydration, nasal respiration); increasing awareness of situations/ sensations that precipitate episodes of cough; implementing strategies designed to increase control of laryngeal function (proactive versus reactive management); and assisting in maximizing compliance with medical/pharmacologic therapy.31,32 Specific therapy tasks were designed to recalibrate laryngeal function during episodes of cough. This was to be threefold in nature: (1) manipulation of the vocal folds into an abducted position; (2) controlling air pressure between the vocal folds during cough, thus increasing resistance at the level of the glottis; and (3) substituting a gentler pattern of vocal fold adduction prior to or during episodes of cough by initiating use of swallows. During patient N’s first therapy session, a review of chronic cough associated with a disordered loop of laryngeal behavior and potential irritation of the laryngeal complex by refluxed stomach contents was undertaken.31–39 Management strategies for cough secondary to sensory neuropathy were briefly reviewed.40–47 However, in-depth discussion of the same was deferred given patient N’s desire to defer pharmacologic management as an initial treatment modality. Given her diagnosis of reflux disease, a discussion of supportive behavioral management was undertaken to maximize her compliance with reflux treatment.36,37 Multiple vocal hygiene measures were also reviewed.32,48 During patient N’s second visit, improving awareness of situations and/ or sensations that precipitated cough was addressed. This, in turn, led to a discussion of proactive versus reactive management of episodes of cough.49

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Attention was then turned to initiation of modified breathing strategies.31,32,50–54 These strategies were employed to manipulate vocal fold configuration and control air pressure between the vocal folds, thus increasing resistance at the level of the glottis. Initial training focused on therapy tasks advocated by Murry and Sapienza.52 These tasks included: (1) quiet rhythmic breathing where patient N was guided through exhalation with her shoulders relaxed and her focus maintained on abdominal movement in/out consistent with continuous exhalation/inhalation; (2) breathing with vocal resistance where she completed tasks designed to focus on exhaling while sustaining /sh/, /f/, or /z/ for increasing lengths of time; (3) pulsed exhalation where patient N produced pulses of air using /ha/ or /sha/ followed by sniffing in through the nose with a closed mouth; and (4) development of abdominal focus at rest where she was instructed to lie flat with a small book on her stomach, focus on elevation of the book with inhalation, and lowering of the book with exhalation. When this was accomplished, straw breathing was initiated to increase resistance while focusing on abdominal movement; this exercise was then expanded to include sitting/standing positions. Patient N was guided through tasks designed to facilitate increased awareness of rhythmic breathing with a diaphragmatic focus. Once this was accomplished, she completed exhalation tasks against resistance (exhaling while sustaining sibilant phonemes for successively longer periods of time). Pulsed exhalation tasks on /ha/ or /sha/ were coupled with sniffing in through the nose with a closed mouth. Finally, quiet respiration tasks with a focus on diaphragmatic expansion/retraction while

supine were employed. Once this focus was established, the same was combined with straw breathing to increase resistance. When coordination between all of these tasks was accomplished while supine, practice of the same was broadened to include alterations in body positions (sitting and standing). Throughout all tasks, patient N was encouraged to focus on the sensation of a relaxed throat achieved during task completion. A home program, stressing completion of 10 repetitions of each task for 1 set with 3 to 4 sets completed daily was provided. During her third therapy session, variations of modified respiration were introduced.32,50,51 These included: (1) breathing in/out through the nose; (2) breathing in through the nose and out through pursed lips; (3) breathing in and out through pursed lips; (4) breathing in through the nose and out through a straw; (5) breathing in and out through a straw; and (6) sniffing in twice then breathing out through pursed lips or a straw (for breathing out through a straw, varying lengths and bores were used to increase/decrease resistance as needed by the patient). Patient N satisfactorily completed correct repetition of all tasks presented. Given the risk of hyperventilation associated with the last pattern of modified respiration (sniff/blow), an extended amount of time was spent training this maneuver. At the end of the session, patient N was instructed to practice strategies 1 through 5 in 1-minute increments twice daily (10 minutes total) and strategy number 6 in 1-minute increments 10 times daily for a total of 20 minutes of practice for a day. The rationale for employment of 1-minute practice increments was developed to


reduce patient boredom during exercise completion and to allow for patient control of laryngeal function multiple times during the day. Initial practice of all modified respiration exercises was undertaken in isolation. This was recommended to allow for maximum focus on appropriate task completion. After 1 week of practice, exercises were transitioned into practice during activities of daily living for weeks 2 and 3. Movement of exercises into daily routines was undertaken given that patient N’s episodes of cough occurred randomly throughout the day and especially when exposed to certain triggers. After 3 weeks of daily practice, patient N returned to therapy. A review of all exercises was completed. After review, it was clear that she was completing all exercises appropriately with no recalibration needed. A discussion of use of exercises for cough management then occurred. No structured pattern of use of interventions for cessation of cough was recommended. Rather, patient N was encouraged to experiment with use of all exercises to determine which of the same resulted in effective cough management over time. Maintenance of a diary relative to her body’s responses to use of cough suppressant strategies were requested which was to be reviewed at her next therapy session scheduled 2 weeks later. Review of her diary during her next session revealed that episodes of cough were reduced in intensity and duration with use of straw breathing. To a lesser extent, use of 2 sniffs followed by exhalation through a straw was also efficacious. Repeat subjective scoring of cough severity revealed her cough to be reduced from a “7” to a “5.” Repeat administration of the RSI resulted in

a reduced score of 20. Patient N also reported a corresponding reduction in reflux symptomatology. Given these results, she was encouraged to continue her adherence to recommended reflux management strategies along with primary use of straw breathing and secondary use of sniff/blow for cough cessation. A return visit in 1 month was recommended. At her next visit, ongoing review of progress revealed continued reduction in episodes of cough and reflux symptoms. Cough management continued to be most responsive to use of straw breathing. Patient N took to carrying straws with her for use as needed outside the house. With greater control over cough demonstrated, she reported increased attendance at church and other social events. Continued reduction in subjective severity of cough was noted with cough severity reduced to “2 to 3.” Repeat self-scoring on the RSI revealed a score of 9 indicating no symptom correlation with extra-esophageal reflux. Given these results, follow-up was recommended in 3 months. If similar results were reported, it was mutually decided that dismissal from formal therapy would be recommended. After 3 months, patient N returned to therapy as scheduled. She subjectively reported her cough severity was reduced to a “1” over each month she was absent from therapy. No symptoms consistent with extra-esophageal reflux were reported. She felt comfortable with use of her cough management strategies and reported a marked improvement in overall quality of life. Given these findings as well as progress to date, dismissal from formal therapy was recommended. Patient N was in agreement with this recommendation.

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Sometimes therapy just does not work without concomitant medical intervention. In this next case, Madeleine Pethan and Laryngologist Laureano Giraldez-Rodriguez demonstrate the cooperative use of medical and behavioral intervention in chronic cough.

Case Study 3 Madeleine Pethan and Laureano Giraldez-Rodriguez Failed Voice Therapy With Successful Use of Central Nervous System Inhibitors in Chronic Cough

Introduction Cough is a multifactorial disease entity. Postnasal drip in patients with allergic rhinitis or sinus disease, cough-variant asthma, gastroesophageal reflux disease, and medication are the most common causes of chronic cough.55 They all contribute to laryngeal irritability by different mechanisms. Evaluation of the patient with chronic cough must include detailed pulmonary, infectious diseases, allergy/sinus disease, gastrointestinal disease history, and medication history. Angiotensin-converting enzyme (ACE) inhibitors are the most common medications that cause chronic cough. Patients may have 2 or more of these previously stated causes of chronic cough coexisting with each other. Cough related to lung disease, gastroesophageal reflux, allergic rhinitis, and paranasal sinus disease is treated with medications geared toward addressing the underlying pathology. Cough with no known underlying pathology

may be associated to laryngeal irritability as a result of postviral vagal neuropathy (PVNN).55 The majority of patients describe a globus sensation, a tickle, or a feeling of dryness in the throat preceding a bout of dry cough. PVNN, while a relatively new clinical diagnosis, has been observed and well described within the literature in recent years. As additional studies are reported, a growing body of anecdotal and empirical evidence suggests PVVN may be a distinct and treatable cause of idiopathic chronic cough. PVVN varies in presentation but is most commonly seen in adult women with symptoms persisting long after resolution of an acute viral illness. Symptoms are classified according to the vagal branch most affected, either motor, sensory, or both. LPR has also been reported in association with suspected onset of viral neuropathy. At present, there is no standard of care for treating PVVN. This chapter highlights the efficacy, side effect profiles, and supporting evidence of the currently recommended pharmacological interventions. Future studies are needed to provide greater objective evidence as well as the potential pathophysiologic mechanism behind this elusive disease process. There are numerous drugs that are being used for the treatment of chronic cough due to postviral vagal neuropathy. These drugs are primarily used when there are no other organic underlying etiologies to chronic cough. We must remember that cough due to laryngeal irritability is a multifactorial problem, and that in the majority of patients the treatment should include a combination of treating the underlying disease etiology, if present; behavioral respiratory training by a trained speech therapist; and if necessary, medication


treatment with centrally acting neuromodulatory drugs. Gabapentin is a drug of unknown mechanism of action. Gabapentin prevents pain-related behavior in response to a normally innocuous stimulus and exaggerated response to painful stimuli in animal models. It is FDA approved for postherpetic neuralgia and seizure, but not for chronic cough. Ryan et al56 published a randomized, double-blind, placebo control trial of 62 patients that compared cough-specific QOL scores of patients treated with gabapentin versus placebo. Patients treated with gabapentin had improved cough-specific QOL scores, cough severity, and cough frequency as compared to those with placebo. Amitriptyline is a tricyclic antidepressant. It also has sedative qualities. Its mechanism of action is blocking the absorption of neurotransmitters serotonin and norepinephrine. It is FDA approved for depression but has been used for many off-label purposes. Jeyakumar et al57 published a randomized, controlled trial comparing cough patients treated with amitriptyline versus codeine/guaifenesin. Thirteen out of the 15 patients in the amitriptyline group reported improvement versus 1 out of 13 patients in the codeine/guaifenesin group. QOL scores were associated with improvement in the amitriptyline group. Tramadol is a centrally active systemic analgesic that is used to treat moderate to severe pain. It is a weak opioid agonist that induces serotonin release and reuptake of norepinephrine. No studies in patients with chronic cough have been performed in order to demonstrate its efficacy, but it has been documented in 2 studies in the literature. Although we know of its antitussive properties, it is not clear what its

role in chronic cough is or its mechanism of action.

Case History History of the Problem KK is a 40-year-old female who reports a 6-month history of chronic cough. The cough originated as a serious episode of pneumonia/pertussis that kept her home from work for 2 weeks. The cough was originally productive, and KK reports that she would cough up thick, yellowish mucous throughout the day. She went to see her primary care physician and was treated with a full course of antibiotics. This did clear up the infection and thick mucus, but the cough symptom persisted and may even have worsened. Initially, she could suppress the cough when working quietly at her desk or during quiet conversation. She would only notice the cough during particularly stressful conversations or when she was nervous about a meeting. As time progressed, she was unable to speak to clients without coughing and would often have to excuse herself from meetings. KK has been seen by numerous physicians for this problem, including an allergist, pulmonologist, otolaryngologist, psychiatrist, and her primary care physician. KK notices that her cough is worse during stressful or emotionally driven situations, particularly ones that involve a lot of talking. Her job in fundraising involves speaking for long periods of time to important clients, something she finds nearly impossible now. She cannot even “introduce herself” without breaking into a severe coughing episode. With prompting, less obvious triggers were identified as strong odors, cigarette

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smoke, and any level of physical activity (ie, climbing one flight of stairs). Medical History KK was initially treated with antibiotics by her primary care physician. This did improve her upper respiratory infection but did not alleviate her cough. When antibiotics did not alleviate the cough, KK was advised by her primary care physician to seek further psychiatric treatment. KK has a family history of depression and has taken multiple different antidepressant drugs for a longstanding history of depression herself. Her psychiatrist advised her that some mood-altering drugs may cause a temporary cough, but that the cough should reduce as her body becomes accustomed to the medication. Adjustment to these medications failed to reduce coughing episodes. Today, her cough is severe and constant. KK was observed with extreme difficulty reporting her own medical history, as voice use is the most significant trigger for her cough. She denies ever coughing up blood, however she sometimes coughs to the point of incontinence. KK also reports a history of acid reflux disease, asthma, depression, anxiety, and eating disorders. Her asthma and reflux are well controlled through medications provided by her primary care physician and behavioral modifications. Frustrated by her primary care physician’s recommendation to seek further psychiatric treatment, KK made an appointment at a local ENT office. This ENT ordered pulmonary function tests and 24-hour esophageal manometry. All of these tests came back negative. The local ENT then referred KK to the specialized cough clinic within the multidisciplinary voice center in the area.

Social History KK is a fundraising assistant for a nonprofit organization. She has always enjoyed her job. Her work makes her feel valued, and she is well respected across her organization. Unfortunately, her cough has now become so severe that she is unable to work and applied and received disability. She is very stressed and embarrassed by her inability to return to work. She is fearful she may never return to work in fundraising. KK does not smoke cigarettes. She does drink alcohol socially. She is not married and has no children. She lives alone. She is very close with her parents. Her father lives in town and will sometimes accompany her to doctor’s visits. Her mother lives in Florida and KK makes every effort to visit her as much as possible. She has cancelled all of her upcoming trips to see her mother as the cough has become so severe she is uncomfortable driving for long periods of time.

Voice Evaluation KK was seen in the laryngologist’s multidisciplinary clinic. She was seen by a laryngologist and speech-language pathologist in the same day and diagnosed with chronic cough. Audio-Perceptual The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) a 100mm visual analog scale, was used to assess overall severity of voice.58 KK received an overall severity rating of 20, indicating a mild vocal quality deficit. Aberrant perceptual features noted were strain and roughness, particularly


at the end of breath groups or while trying to prevent a coughing episode. Overall, vocal pitch and intensity were noted to be normal. Respiration appears to be primarily thoracic, with abdominal breathing added to the list of cough triggers. There was evidence of breath holding during speech. Instrumental Assessment Videostroboscopy. Laryngeal videostroboscopic examination revealed bilateral vocal fold edema and post cricoid mucosal edema. Mucosal wave, amplitude of vibration, and periodicity were intact bilaterally. There were no mucosal lesions noted. Acoustic and Aerodynamic Assessment. KK was unable to complete the phonatory tasks required for this portion of the evaluation due to coughing. Therefore, acoustic and aerodynamic assessment measures were not obtained given the severity of cough and voice use as the primary trigger. Pulmonary Function Testing. Pulmonary function testing was completed by her pulmonologist prior to KK’s referral to the voice center. These revealed normal vital capacity, forced vital capacity, and maximal aspiratory and expiratory flows indicating no concern that restrictive or obstructive lung diseases are the impetus of the cough.

Patient Self-Assessment The patient completed the Voice-Related Quality of Life (VRQOL) scale, a 50-point validated quality of life scale.59 The patient reported a raw score of 46 and converted score of 10, indicating a severe impact on her quality of life.

Evaluating Results and Developing the Treatment Plan Following the multidisciplinary evaluation, treatment options were discussed with the patient. Treatment options included voice therapy and respiratory retraining therapy,31 or ACE inhibitors which are the most common medications that cause chronic cough.56 KK decided that she would prefer to first try the more conservative treatment method and enroll in behavioral voice therapy and respiratory retraining therapy. She was already on a considerable number of medications and was concerned for the effects of drug interaction, specifically with her psychiatric medications. With counseling from the speech-language pathologist, and the laryngologist, KK enrolled in voice therapy. Therapy was recommended for a total duration of 12 weeks, with 45-minute sessions occurring once every 2 weeks (6 sessions total). Goals 1. The patient will keep a diary of the times of day or specific situations during which the cough is more or less severe to better identify coughing triggers. 2. The patient will implement breathing techniques to maximize vocal fold abduction during all periods of rest or physical exertion. 3. The patient will anticipate the cough response during conversational speech and replace with breathing techniques to minimize perceived laryngeal irritation.

Voice Therapy Treatment goals are addressed at the 3 primary levels that were discussed in

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Morrison and Rammage’s introduction to this chapter. n Level 1: The goal of level 1 of treat-

ment is to minimize sensory stimuli acting as triggers.

The first step to minimizing sensory stimuli that act as triggers is to identify triggers. A thorough discussion of common triggers of chronic cough took place between KK and the treating SLP. KK reported that the cough rarely wakes her up at night. Coughing at night can often be a symptom of laryngopharyngeal reflux (LPR).60 Because KK did not report significant nighttime coughing episodes, or any other somatic complaints of reflux, the focus was not on reflux management as part of the treatment plan. However, she was counseled on the benefits of continuing with reflux medication while participating in behavioral voice therapy and respiratory retraining therapy to minimize all potential triggers. KK reported that the cough occurred at all times of the day. It was sometimes associated with eating but almost always associated with talking. Vocal behavior during the session supported this history as KK was barely able to say 2 or 3 words before she would begin to cough severely. She was observed whispering her responses to questions rather than voicing to avoid triggering the coughing reflex, and this technique was moderately successful. While this was effective at improving her communication in this setting, it was not recommended that she continue to whisper rather than voice her speech as this could lead to maladaptive laryngeal posturing that is also difficult to correct. The voice use has been identified as KK’s most significant cough trig-

gered. KK also identified that emotionally charged conversations (ie, meeting new clients or arguing with family members) are the most likely to trigger a cough. Therapy will therefore focus on increasing KK’s threshold for laryngeal irritation through tasks that facilitate optimal glottal configuration. Tasks will include a gentle hum on sustained /m/, Ingo Titze’s semi-occluded vocal tract exercise with straw phonation,28 or sustained /u/ through pursed lips. n Level 2: The goal of level 2 is to re-

program or desensitize the habituated motor response (ie, the cough) using principles of motor relearning.

The patient entered the first therapy session speaking with reduced loudness and moderate breathiness. However, she did have intermittent clear voice with minimal breathiness both during speech and during the actual cough. For this reason, the breathy voice quality was presumed to be functional in nature and related to insufficient respiratory drive and laryngeal posturing rather than glottal incompetence. This was supported by KK’s videostroboscopic examination. Our first goal of therapy was to desensitize the laryngeal mechanism through quiet breathing exercises. These exercises are designed to minimize laryngeal activation by maintaining cadaveric posture of the vocal folds, therefore reducing perceived irritation. KK was first trained on slow inhalation through the nose and easy exhalation on the voiceless phoneme /s/ with no pauses. Inhalation through the nose causes maximal activation of the posterior cricoarytenoid muscle, the only laryngeal abductor. This prevents vocal fold adduction and therefore perceived


irritation. During this exercise, KK was observed taking very shallow breaths, suggestive of breath holding. Following approximately 3 cycles of this exercise, she would gasp for air, providing further evidence of inadequate gas exchange. KK was cued to shorten or lengthen the inhalation or exhalation appropriately to maintain a comfortable level of gas exchange. During the voice evaluation and interview, it was noted that deep abdominal breathing could also trigger a cough. With cues from the clinician and multiple repetitions (ie, 20 minutes of consistent attention to techniques), KK was able to complete the breathing technique and prevent the cough response. Once the first strategy was mastered and KK was able to eliminate the urge to cough by engaging in breathing exercises, the next step was to introduce simple phonatory tasks with optimal laryngeal muscle activation and breath support as to not elicit the cough response. To complete these tasks, KK was instructed to inhale through either the nose or pursed lips at a comfortable rate, and then exhale while phonating at a comfortable pitch and loudness on any task that does not elicit a cough response from the patient. As mentioned, these could include a gentle hum on sustained /m/, Ingo Titze’s semi-occluded vocal tract exercise with straw phonation,28 or sustained /u/ through pursed lips. KK had the most success while exhaling on straw phonation. It is important that the clinician recognize and teach the importance of not rushing through this technique. The patient must take his or her time to achieve comfortable respiratory and phonatory coordination. This can often take a high number of repetitions (ie, many days or multiple therapy sessions) for patients to become relaxed

and comfortable enough that straw phonation no longer triggers a cough response. It may also be valuable to review the principles of motor learning with the patient and explain the importance of distributed practice.61,62 In KK’s case, she was instructed to practice this technique at least 5 times daily for no more than 10 minutes. Once KK mastered this technique, she was observed altering the shape of her vocal tract to produce various sustained vowels through the straw. As she varied the vowels produced through the straw, her lips remain gently sealed around the edges of the straw. The various vowels produced did not sound significantly different; however, these small changes in vocal tract shape can be difficult for the patient to master and may at first cause perceived laryngeal irritation and trigger a cough response. Varying the vowels produced through the straw is the first step in a hierarchy of tasks that will scaffold KK from sustained straw phonation all the way to voice use in conversational speech that no longer triggers a cough response. KK practiced the hierarchy listed below, practiced first through straw phonation and then immediately following as a spoken production without the straw. The hierarchy was as follows: n various sustained vowels voiced

through the straw

n various sustained vowels said with-

out the straw n single-syllable words (ie, one, two, three, four, five) voiced through the straw n single-syllable words said without the straw n short phrases (ie, good morning, how are you) said through the straw n short phrases said without the straw

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n conversational speech — this level of

the hierarchy does not include straw phonation, as speech is not meant to be intelligible when produced through the straw

Throughout the progression of the hierarchy, KK implemented quiet breathing techniques to eliminate the urge to cough as intensity of voice production was increased. KK successfully moved through this described hierarchy over the course four 45-minute therapy sessions and with regular home practice. Conversational speech was practiced with the clinician by engaging in “small talk” with maximal clinician cues to stop for a breath, or pause conversational speech to implement the quiet breathing strategy. During this therapy task, KK would often have to implement the breathing technique for up to 5 minutes in order to suppress a cough response. The next 2 sessions were spent practicing conversational speech with intermittent emotionally loaded topics (ie, mock job interview questions). It is important to keep in mind that the measure by which the clinician and KK were judging the success of therapy was by KK’s ability to return to work. This meant that emotionally charged conversational speech had to be eliminated as a cough trigger. KK was consistently unable to suppress the cough response when speaking about emotionally loaded topics for even 1 or 2 sentences. After completing the prescribed course of therapy, it was obvious to both KK and the clinician that behavioral therapy alone was not going to be adequate to break the cycle of a perceived laryngeal irritation during emotionally charged conversation. The clinical decision was made for KK to return to her refer-

ring laryngologist to pursue medical management of her cough symptoms. The next section of this case study will describe various ACE inhibitor medications that are commonly used to treat neurogenic chronic cough. n Level 3: This level capitalizes on neu-

ral plasticity to reprogram the central nervous system using centrally active medications.

In the introduction of this chapter, we discussed the different types of medications that operate in the central nervous system and modulate different pathways, usually through a mechanism of sensory inhibition, to dampen the symptoms of chronic cough. KK was referred back to her laryngologist for evaluation of chronic cough. They agreed that the cause of her cough was laryngeal sensory related. It was decided that she would start on amitriptyline 10 mg a day for 7 days and then taper up by an additional 10 mg per week (20 mg the second week, 30 mg the third week, and so on) until a dose of 100 mg a week was reached. KK reached 30 mg of amitriptyline by the third week and her cough improved by 80%. We kept her on that dose for 4 more weeks and began to taper it by reducing the dose by 10 mg per week until she was off the medication. After this significant improvement she was able to implement the breathing strategies learned in therapy to eliminate the cough in emotionally charged situations.

Summary Often in the case of patients with chronic cough, it takes a multidisciplinary approach to treatment. KK required inter-


vention by both the laryngologist and speech pathologist and was only able to eliminate her cough when both treatment plans were implemented in concert. Therapeutic Outcomes Behavioral voice therapy and respiratory retraining therapy were not successful at adequately reducing KK’s neurogenic cough. After 6 sessions of therapy, she was referred back to her treating ENT to discuss medical treatment. She was placed on an ACE-inhibiting medication that, in conjunction with the techniques learned in behavioral therapy, allowed her to reduce her cough response significantly enough to return to work.

Paradoxical Vocal Fold Motion: An Introduction Mary J. Sandage Paradoxical vocal fold motion (PVFM) is a disorder of the upper airway that involves episodes of partial to complete adduction of the vocal folds primarily during inhalation. These breathing “attacks” can occur while awake or asleep and can also be triggered during exercise. The primary clinical presentation is difficulty inhaling, with or without accompanying stridor, and throat tightness. It can start suddenly or gradually, and it does not typically respond to rescue asthma medications. It is often misdiagnosed as asthma, and most individuals will have many years pass from their first breathing attack to proper diagnosis. PVFM/VCD is a disorder of laryngeal airway protection that can be amenable to behavioral intervention by speech-language pathologists. It is not

a disorder of vocal quality; therefore, unless the breathing difficulty is accompanied by a voice disorder, voice assessment procedures such as acoustic and aerodynamic analysis would not be needed to develop the plan of care or for reporting evidence-based outcomes. Physician specialists, such as pulmonologists and allergists, who describe this disorder prefer the label vocal cord dysfunction; therefore, the combined term paradoxical vocal fold motion/vocal cord dysfunction (PVFM/VCD) may be useful to avoid confusion. Several diagnoses have been used to describe this clinical presentation which include but are not limited to episodic paroxysmal laryngospasm, factitious asthma, Munchausen’s stridor, psychogenic stridor, episodic laryngeal dyskinesia, and adductor laryngeal breathing dystonia. A closer look at these diagnostic terms indicates that they are not interchangeable. Many offer a more specific diagnosis that links the presentation to the underlying etiology as described below. The underlying etiology for this upper airway disorder can vary and generally falls into 1 of 3 groups: exposure to environmental irritants, psychogenic, or neurologic causes.63 PVFM/ VCD can occur in males and females and has been identified in ages ranging from infancy to the eighth decade of life. The prevalence of this disorder in the general population is not known; however, a 5% prevalence is described for elite athletes,64 a population that requires special consideration when implementing behavioral intervention. The clinical presentation can range from occasional, brief experiences of throat narrowing and difficulty inhaling to loss of consciousness requiring hospitalization. The differential diagnoses for proper determination of PVFM/

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VCD include asthma, laryngeal pathology, laryngospasm, panic attack, and laryngeal edema secondary to allergic reaction. Prior to referral for speechlanguage pathology services, it is vital for patients to have a thorough pulmonary assessment for asthma, a chest x-ray, and evaluation for extrathoracic obstruction (eg, bilateral vocal fold paralysis, obstructive vocal process granuloma, recurrent respiratory papillomatosis, or unresolved laryngomalacia), all of which may compromise the airway without affecting voice quality. Many individuals with PVFM/VCD have concurrent medical conditions such as panic attack or asthma, the latter of which can co-occur in 40 to 60% of patients with PVFM/VCD. Success of behavioral intervention can only be ensured when a complete medical assessment is obtained. After having evaluated and treated several hundred clients with this disorder, my clinical experience indicates that most individuals with PVFM/VCD develop the disorder after repeated exposure or a single bout of overwhelming exposure to environmental agents that trigger a protective response in the upper airway. These irritants may be intrinsic, such as extra-esophageal reflux disease (EERD), or extrinsic, such as fumes, fragrances, or smoke in the ambient environment. The primary role of the larynx is to protect the lower airway, and PVFM/VCD can be viewed as a protective posture of the larynx that can develop after a threshold of tolerance to the irritant is surpassed.65 For these individuals, it is important to discern the triggers and then take rapid steps to limit exposure to those agents until the breathing recovery training resolves the problem.

Many of these individuals have seen several different medical specialists who have treated a single etiology without resolution of the breathing attacks. More success can be achieved with a broad-spectrum approach that treats all possible triggers at once in company with behavioral intervention by the speech-language pathologist. Limiting exposure to environmental agents often includes medical management of EERD and allergies in company with limited exposure to fragrances, smoke, fumes, and dust in the environment that may trigger a breathing attack. Additional counseling to change eating behaviors and activities that exacerbate reflux is also routine with these individuals. Improvement of the laryngeal environment through medical and behavioral methods is a vital companion to the breathing recovery exercise training provided by the speech-language pathologist. Medical management of EERD early in the intervention process is superior to reliance solely on dietary and behavioral changes for these individuals who are often experiencing anxiety regarding their breathing. A less common and often more challenging clinical presentation is the individual with an overwhelming single chemical exposure that triggered the initial event, for example, a laboratory explosion. For these patients, professional counseling is often recommended in addition to medical and behavioral management. Psychogenic causes for this disorder are less common, and use of the diagnostic labels Munchausen’s stridor and psychogenic stridor would indicate this as an etiology. Much like another complex laryngeal disorder, spasmodic dysphonia, initial accounts of PVFM/ VCD attributed the origin to psycho-


genic pathology. Consideration of psychogenic etiology should be done with care. Overemphasis on psychiatric or psychological issues may undermine effective medical and behavioral interventions required for rapid recovery of symptoms. In rare cases, neurologic conditions can cause inspiratory stridor characterized by persistent difficulty inhaling while awake, with resolution of symptoms while sleeping. This clinical presentation has been observed in children and adults and is distinct from PVFM/ VCD which is characterized by discreet breathing “attacks.” The causes of the neurologic variant may include brainstem compression, cortical or upper motor neuron injury, nuclear or lower motor neuron injury, or movement disorder. Inspiratory stridor secondary to neurologic causes may be called episodic laryngeal dyskinesia or adductor laryngeal breathing dystonia.66 This presentation is distinct in that it will require medical intervention for treatment with little role for behavioral intervention from speech-language pathology. Medical interventions may include tracheotomy, pharmacotherapy, or surgery. It is in the best interest of these patients with this particular presentation to be referred for additional medical assessment before initiating therapy, which may have little to no benefit. The client interview portion of the initial assessment requires skill and care not to lead the client toward a particular conclusion. Careful interviewing will help discern the potential etiology and triggers of the breathing attacks if they were not clearly identified prior to referral. Have the client explain in detail the exact nature of the breathing events without asking leading questions. The

point of the following list of questions should be to discern the exact nature of the individual’s breathing difficulty to inform the behavioral plan: n Do you have trouble inhaling, exhal-

ing, or both?

n Do you make a noise when it

happens”

n Can you imitate the noise? n Do you feel tightness anywhere when

these attacks happen? n In your chest, throat, both? n What typically triggers an event? n How often do these attacks happen? n How long do they last? n Do you do anything for them? What works? What doesn’t? n Do you use an inhaler? Does the inhaler work? How long does it take to work? n Have you ever passed out? n Have you ever been to the emergency room or been hospitalized for these breathing events?

Regardless of etiology, the primary goal of medical and behavioral intervention is complete resolution of the paradoxical vocal fold movement. The overarching breathing recovery method trained may be similar between individuals63,67; however, the details and timing of the intervention will be client-specific. In general, the breathing recovery exercises have 3 basic components: (1) body awareness training via a progressive tightening-relaxing activity, (2) training lower abdominal/rib cage expansion during inhalation, and (3) rapid, deep nasal sniff or oral straw-sip inhalation followed by complete exhalation using a front sibilant or fricative sound (eg, /s/ or /f/). All 3 steps should be practiced while asymptomatic so that

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the client can easily implement step 3 when a breathing attack is imminent. The breathing recovery method should be started before the throat narrows or closes so that the breathing attack can be avoided completely. Success of this method hinges on careful client interview to discern the first physiological signals that a breathing attack may be imminent with rapid employment of step 3 before any air hunger is experienced. Athletes represent a special subpopulation because, in general, PVFM/ VCD events occur at a rather predictable time and the unique features of each sport will require specific adaptations. The timing for medications and meals may need to be adapted. For example, instead of taking reflux medications before breakfast and before bed as is commonly prescribed, the athlete may need to take the first dose of medication an hour before the first training session of the day. Preworkout meals may need to be altered to reduce additional reflux symptoms during training. Finally, the athlete will benefit more from training the breathing recovery exercises regime in a sport-specific manner rather than while sedentary. This sport-specific training done in conjunction with the coach and athletic trainer can forge a path to complete recovery from the PVFM/VCD events. Treating athletes can be a conundrum for many clinicians who are not familiar with the athlete’s sport and have limited resources to assess the athlete. In this next case, Mary Sandage demonstrates the importance of gaining insight into the athlete’s sport demands and assessing during participation in that sport to truly develop an effective treatment plan.

Case Study 4 Mary J. Sandage Treatment of PVCD in a Collegiate Swimmer

Patient History Patient II, an 18-year-old college freshman on a swim scholarship, was referred to the speech-language pathologist by her pulmonologist and sports medicine physician for an assessment to rule out paradoxical vocal fold motion (PVFM). The pulmonologist’s assessment had resulted in a negative methacholine challenge, negative chest x-ray, and spirometry that indicated a flat inspiratory flow volume loop consistent with extrathoracic obstruction during inhalation. The swim team physician had referred patient II to the pulmonologist for a thorough pulmonary assessment to better manage asthma, diagnosed 2 years earlier by the patient’s pediatrician. When it was determined that patient II did not have asthma, the treating physicians determined that the patient might have PVFM. Patient II attended the initial speechlanguage pathology evaluation by herself and served as the sole reporter for her behavioral and medical history. She described some confusion about the referral to a speech-language pathologist (SLP), as she did not believe that she had any difficulty with her speech or language. It was explained that the evaluating SLP specialized in breathing disorders in athletes and worked closely with pulmonologists and sports medicine physicians. Patient II described a successful high school swimming career with


subsequent recruitment to an excellent collegiate swimming program. During high school, she typically competed in the 200- and 400-m freestyle. During her first season of collegiate swimming, her new coach targeted her training and competition for the 200-m freestyle. Patient II reported intermittent breathing problems during swimming for about 3 years with a diagnosis of asthma 2 years prior to her referral to the voice clinic. The patient described her first year on a collegiate swim team as challenging and stressful and described anxiety about losing her scholarship if her breathing problem was not resolved quickly. Patient II indicated that she set high personal goals for herself, both academically and athletically, and her ultimate goal was to make the US Olympic Swim Team. The patient’s medical history was remarkable for diagnosed allergies to pollen, mold, and dust mites, the primary symptoms of which included nasal congestion and sneezing. The patient had no other diagnosed medical conditions. She denied any surgical history and indicated that she did not smoke or drink alcohol. When asked about symptoms of laryngopharyngeal reflux (LPR), patient II indicated that she experienced a persistent globus sensation and often cleared her throat secondary to a perception of phlegm in her throat. She attributed the throat irritation to her history of allergies. Patient II described some nausea and acidy burps before and during swim meets, for which she took over-the-counter antacids. The patient reported that she took birth control pills and over-the-counter allergy medication when her allergies were bothering her. Albuterol, a rescue inhaler, had been prescribed for her to take when she experienced asthma attacks.

When asked about her eating habits, patient II indicated that she frequently ate a high-protein snack before practice (eg, peanut butter sandwich), and she also snacked before bed. She described drinking about 4 to 5 carbonated, caffeinated beverages per day as well as sports drinks during and after practice. Socially, patient II described an atypical college experience secondary to swim team practices both before and after classes. She reported that she did not have much of a social life; however, she indicated that she had close friends on the swim team. She also described missing her family, who lived about 11 hours away.

History of the Problem The client was first asked to describe the nature of the breathing difficulty with as much detail as possible. To avoid leading the patient in a particular direction, open-ended questions were asked with the goal of discerning the exact nature of her unique breathing difficulties. Examples of the questions asked with a summary of each response are as follows: Tell me about your breathing attacks in as much detail as possible. The breathing difficulty generally occurred during timed trials in practice and in competition when she was swimming the 200-m freestyle. She reported that the first 100 m of the race went well; however, she noticed more difficulty breathing during the last 100 m. She described that she was not able to get enough air, and as a result, her times were slower than those that she had achieved in practice.

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How often do these attacks happen? At first, they happened occasionally; however, by the time of the evaluation, they were occurring every time she was being timed in practice and in competition. Are your breathing attacks during swimming like asthma attacks? The patient thought that the breathing difficulties were asthma attacks that were not getting better with medicine. When you are having a breathing attack, do you have trouble breathing in, breathing out, or both? Patient II reported that she always had trouble inhaling and no trouble exhaling. Do you make a noise when you are having trouble breathing? The patient indicated that she did not think she made any noise, but she was not sure. Do you notice any tightness in your body when you are having trouble breathing? Patient II described that she noticed some tightness in her upper torso, but mainly in her throat. When the race is over, what happens with your breathing? She indicated that she took her rescue inhaler as soon as she got out of the pool and her breathing seemed better within a couple of minutes. Does anything help your breathing get better? Patient II indicated that the only thing that really made the breathing problem better was to stop swimming and take her inhaler.

Is your breathing difficulty getting worse, getting better, or staying the same? The patient reported that it slowly worsened over the course of the season and that, at the time of the evaluation, she had trouble every time she was being timed or in competition. Do you ever get short of breath with other forms of physical exertion, such as climbing a flight of stairs? The patient indicated that her breathing difficulties were confined to the contexts already described. She also denied any difficulty breathing at night. Can you describe how you generally breathe during the 200-m freestyle when you are not having any trouble? She reported that she took a breath about 2 strokes before a turn and then again when she resurfaced after a turn. She also indicated that her coach did not care how many strokes she put between each breath as long as she continued to improve her times. Her coach encouraged her to try to avoid taking a breath during the last 50 m of the race. This latter direction was new, per client report, and she described feeling a lot of pressure to achieve this benchmark. When you are swimming as fast as you can in the 200-m freestyle, do you hold your breath until you need another breath or do you let the air out while swimming? The patient reported that she generally held her breath and then let it out as fast as she could before turning her head to take another breath.


Evaluation Procedures Patient II received a standard assessment for suspected PVFM. The assessments included the following. Auditory-Perceptual Assessment The patient’s voice quality was judged as clear by the evaluating clinician using both informal and formal methods. During conversation, the evaluating SLP did not discern any voice disturbances. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)58 was used as a formal voice quality assessment, the findings of which were consistent with the informal assessment of no discernible dysphonia or a score of 0/100. Visual-Perceptual Assessment The structure and function of the patient’s upper airway were assessed using a flexible nasal endoscope, which was carefully advanced through the patient’s nostril after application of topical nasal anesthetic. The flexible endoscope was advanced through the nasopharynx, and the tip of the endoscope was positioned with complete view of the laryngeal structure during resting breathing and breathing maneuvers. Initially, the patient’s larynx was observed during several cycles of rest breathing to allow the patient to get used to the endoscope and to allow the evaluating SLP to observe the behavior of the upper airway during unstressed rest breathing. Frequent “twitching” of the arytenoids cartilages during resting breathing was observed with a patent airway during both inspiration and expiration. The tissue of the membranous vocal folds appeared smooth but somewhat edema-

tous bilaterally, characterized by infraglottic edema bilaterally, which was observed during maximum abduction. Additionally, posterior laryngeal edema and interarytenoid tissue changes were observed, consistent with clinical signs for laryngopharyngeal reflux. The patient then was asked to quickly take a maximum inhalation then exhale quickly and completely through the mouth, during which time the patient was observed to narrow the vocal folds about 50 to 60% of the width of the glottis during inhalation. Given that the referring pulmonologist had ruled out asthma (asthma is a contraindication for panting, which can trigger an asthma attack), the patient was asked to pant, during which the arytenoids cartilages were also observed to “twitch.” At this point in the endoscopic assessment, the patient was asked to view the screen and the patient was oriented to the anatomical structures of her larynx. While watching the screen, the patient was asked if she could imitate what a breathing attack felt like. Her reproduction of the feeling of throat tightness during inhalation resulted in near complete vocal fold adduction, with no production of stridor but obvious glottal narrowing. The patient was able to match the perception of throat tightness with the image of glottal narrowing. The patient was then asked to sniff in deeply through her nose and then exhale out of her mouth. Patient II was able to observe her larynx rapidly lower and widely abduct during the sniff and then remain open during exhalation. Again, the patient was able to match the physical sensation of the open throat with the visual image of the open glottis. Finally, the patient was asked to sip air in through a narrow

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mouth opening, as if sipping through a straw, with subsequent wide abduction of the glottis during inspiration. For purposes of visual feedback and to strengthen the subsequent training of the breathing recovery exercises, the patient was asked to imitate what a breathing attack felt like and then perform the sip inhale on the following breath to simulate application of the breathing recovery method. The dynamic endoscopic laryngeal assessment was reviewed with an otolaryngologist who concurred with the observation of clinical signs of laryngopharyngeal reflux disease and ruled out other laryngeal obstruction or disease.

Description and Rationale for Therapy Approach The patient’s pulmonary and otolaryngology assessments ruled out medical diagnoses that are part of the differential diagnosis for PVFM (eg, pulmonary disease [including asthma], subglottic stenosis, bilateral vocal fold paralysis, laryngeal mass lesion, unresolved laryngomalacia, etc). Key medical assessment information supporting the diagnosis of PVFM included the negative methacholine challenge and the flow volume loop showing a truncated inspiratory loop only with no expiratory obstruction. Additionally, the account that her breathing difficulties resolved only a couple of minutes after taking her rescue inhaler signaled that her difficulty was not asthma — the rescue inhaler would not have worked that quickly per the pulmonologist report. The medical information in combination with the patient’s description and imitation of the breathing “attacks” as well as the information gleaned from the dynamic endo-

scopic assessment assured the evaluating clinician that the patient likely had PVFM and it would be safe to proceed with counseling and behavioral intervention. The treatment program designed for patient II consisted of the following: counseling the patient about the differences between asthma and PVFM and offering a theoretic framework to understand why these breathing attacks may have occurred; counseling regarding dietary and behavioral changes that may improve symptoms of LPR; training of breathing recovery exercises adapted for swimming; and implementation of a step-by-step application of the recovery exercises to swimming with the ultimate goal of total elimination of the breathing attacks. n Goal 1. Counsel the patient about the

differential diagnosis of PFVM and describe a theoretical framework to understand the physiologic triggers for the events.

Rationale: Many patients who carry the diagnosis of asthma and then are suddenly told that they never had asthma in the first place are reluctant to drop the asthma mantle. Detailed descriptions of the physiological differences between the two diagnoses, differences between triggers, and, finally, differences in treatment approaches are important components to include. Counseling also can help patients understand that the breathing attack is not their fault and they have control over the difficulty. For this patient, stress may have played a role, but it was clear that there was a probable physiologic trigger from untreated LPR. Understanding the role of LPR as a trigger helped focus the patient on a systemic approach to recovery.


Counseling for patient II started with the visual feedback provided during the endoscopic assessment, empowering her to see that she had at least 2 strategies for getting her throat open during inhalation, either via a deep, quick nasal sniff or during a sip inhale through her lips. The visual feedback also assisted the patient in pairing the physical perception of throat tightness with narrowed vocal folds, demonstrating how the breathing recovery exercises would reverse the glottal narrowing that characterized her PFVM events. Finally, the whole process of describing PVFM, the typical triggers for it, and treatment approaches, helped the patient overcome her initial confusion about the role of the SLP. n Goal 2. The patient will make dietary

and behavioral changes to reduce the symptoms of laryngopharyngeal reflux (LPR).

Rationale: Given that the patient described symptoms of LPR and the endoscopic assessment indicated clinical signs of the same, counseling patient II about behavioral and dietary changes to reduce LPR was appropriate. Given that she was an elite athlete with a rigorous training regime to follow, the guidelines established to reduce LPR needed to extend beyond the type of counseling that the average voice patient received. A list of foods that can exacerbate reflux was reviewed, and the patient was asked to avoid the following foods until her breathing attacks were well controlled: chocolate, nuts/peanut butter, carbonated and caffeinated drinks, fried food, onions, spicy foods, and high-fat foods. Because the patient required a lot of calories to sustain her physical activity, the patient was asked to refrain from

high-fat foods only prior to practice and bedtime. The patient’s medical team prescribed medication for LPR, and the evaluating SLP worked with the physicians to make sure that patient II timed her medication delivery to get maximum coverage while swimming. n Goal 3. Train a breathing recovery

program with special adaptations for the elite swimmer.

Rationale: With all other obstructive conditions ruled out, counseling regarding the condition completed, and medical/behavioral management of LPR initiated, it was safe to train a breathing recovery program with a measure of confidence that the breathing strategies would be successful in remediating patient II’s breathing difficulties in the pool. The breathing recovery program typically used by the evaluating clinician included three basic steps: body awareness, establishment of lower torso/ belly breathing, and training of a quick, deep nasal sniff followed by complete exhalation through the mouth. The first of these 3 steps, training body awareness, was appropriate for this patient without much adaptation. The progressive awareness tasks, a combination of progressive relaxation and mindfulness, were trained, and the patient was directed to complete the exercise at least twice daily when not at swim practice. The second step of the program, establishment of lower torso/belly breathing, was not appropriate for the patient to use in the pool. Most swimmers are coached to maintain a “streamlined” position in the pool, which translates to a perfectly straight spine with limited chest excursion during inhalation and tight abdominal muscles. The goal of

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the streamlined position is to create a body silhouette whereby the shoulders cut through the water first with little or no drag created by chest or abdominal excursion. To train belly breathing with a swimmer might actually slow her down instead of speeding her up in the pool. Additionally, counseling the patient to pursue a physical profile that was in direct disagreement with her coach’s training may have undermined the SLP’s ability to successfully engage the coach in the generalization process. The third goal of the breathing recovery program (the quick, deep nasal sniff in, followed by the slow, complete exhale) required significant adaptation for this patient. Although many swimmers are able to learn to do the deep nasal sniff while swimming competitively, the ability to learn and apply this depends on the distance and stroke performed. It also requires patent nasal passages while swimming. Patient II competes at the middle distance 200-m freestyle, a stroke that requires her face to be in the water most of the time while taking as few breaths as possible for the fastest time. Given that she described nasal congestion as a symptom of her intermittent allergies, it was more appropriate to train the quick “straw” sip method of inhalation. The patient was trained to purse her lips, as if sipping through a straw, draw air in quickly and completely, and then follow the inhalation with a complete exhalation out of her mouth. Complete exhalation during practice breathing while out of the pool was critical to avoid hyperventilation and the sensation of light-headedness. During swimming, the patient described that after taking a breath, she held it and then rapidly exhaled just before taking another breath. The tension in her throat from this breathholding habit may have contributed to

extraneous neck tension; therefore, she was asked to stop holding her breath and exhale over a period of time leading up to her next breath to allow for greater inhalation. This last direction was discussed with the patient’s coach, and he concurred that this change should translate into improved swim performance. Patient II was asked to perform an appropriate repeat demonstration of the 2 exercises trained during the initial evaluation. She was asked to practice both steps 2 to 3 times per day, when not at swim practice, so that she could focus on the recovery exercise and make it automatic. Patient II was asked to focus on the sensation in her throat to discern when it felt tight and when it felt open. She also was asked to avoid breath holding between the inhalation and the exhalation. The exercises were assigned and the patient was scheduled to return in 1 week, at which time a plan would be established to generalize the new behaviors to the pool. n Goal 4. The patient will apply the

recovery exercises in the pool, gradually working up to race speed, timed trials, and, finally, competition.

Rationale: The application of the recovery exercise to elite sport required a structured step-by-step approach to support the athlete in generalizing to the pool what was relatively easy to do while sitting in a chair in the therapy room or at home. The cardiopulmonary requirements of swimming the 200-m freestyle far exceeded those required for the therapy room. Finally, the specificity requirement for training a new physical skill required that the exercises be generalized to a pool environment while employing the freestyle stroke. For patient II, the generalization program started on land, using a tread-


mill to increase the cardiopulmonary load and require patient II to coordinate the breathing recovery exercise at increasingly higher oxygen requirements. After the patient experienced success applying the recovery exercise in a greater oxygen demand context, the generalization process quickly moved to the pool environment in the third therapy session. Using a lane away from the swim team, patient II was instructed to swim slowly, incorporating the recovery exercise with her stroke. Some time was spent at this stage while patient II learned to coordinate the extended exhale before the head turn and “straw” sip for inhalation. Patient II quickly adapted the inhalation pattern but had more difficulty stopping the breath holding, a practice that she had started when she was a young swimmer. Given that the straw-sip inhalation would not provide enough oxygen for a middledistance elite swimmer, patient II was directed to reserve the straw-sip inhalation for the point in the race when she typically would experience throat tightness. Because patient II knew the distance in the race at which the breathing attack typically occurred, she could start the recovery exercise before this and completely avoid the attack. After 2 therapy sessions at poolside, a baseline of success was established with the new breathing strategies, and the patient’s coach and trainer completed the remainder of the generalization.

Results of Therapy Patient II received 4 sessions of therapy over the course of 1 month and attended one follow-up session 1 month following discharge from treatment. At the final clinic visit, approximately 8 weeks after her initial diagnosis, patient II

reported that she no longer experienced any breathing difficulty when competing at the 200-m freestyle. She also described that she was gradually able to avoid the throat tightness completely and had recently started swimming successfully without the straw-sip inhalation. She was most excited to report she had steadily improved her race time. Her disposition during the clinic visit was optimistic, and she no longer reported anxiety about keeping her athletic scholarship. The outcome of therapy was attributed to the patient’s high level of motivation and compliance with the combination of medical management for LPR, the presumed physiologic trigger for the events, as well as the breathing training. The support of the patient’s family and the coaching staff were also key contributors to her rapid recovery. In this next case, Michael Trudeau, Jennifer Thompson, and Christin Ray demonstrate the use of an inspiratory muscle strength trainer in an athlete with failed respiratory retraining techniques.

Case Study 5 Michael D. Trudeau, Jennifer Thompson, and Christin Ray Management of PVCD: An Adolescent Athlete With Exercise-Induced Dyspnea

History MM is a 16-year-old male rower with a 3-month history of dyspnea on exertion.

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His shortness of breath is triggered during rowing practices, workouts, and during competition. He reports that he tries to continue practicing despite the shortness of breath, but that his coach and teammates worry and do not allow him to continue participating when he starts “wheezing.” He states that the stridor is present on both inhalation and exhalation. On a modified Borg Rating Scale of Perceived Dyspnea68 with 0 representing no shortness of breath and 10 representing severe shortness of breath requiring cessation of activity, MM reports that his shortness of breath varies from an 8 to 10 during practice and competitions. He is asymptomatic at rest. Onset of dyspnea occurred at the beginning of his rowing season when he joined his high school’s varsity rowing club as a sophomore. MM is a straightA student and is also involved in many other extracurricular activities including student council, church group, National Honor Society, and Habitat for Humanity. When asked about the pace of his life, he does report feeling overwhelmed at times and feels that his dyspnea is causing him stress and the inability to participate in rowing practice and regattas with his team. He hopes to continue rowing in college but is afraid his shortness of breath will prohibit this. MM was referred to the otolaryngology clinic by a pulmonologist after pulmonary function testing (PFT) ruled out asthma and exercise-induced asthma. PFT did reveal a flattened inspiratory loop, which is typical of upper airway obstruction. MM did trial use of an albuterol inhaler to no avail. He denied signs and symptoms of acid reflux, stating that he does not experience heartburn. He denied a history of allergies. Voice quality was normal with no perceptual characteristics of hyperfunction or hypofunction during the interview.

While obtaining the patient’s history, MM was not experiencing symptoms of dyspnea (at rest).

Evaluation The diagnostic procedure included flexible laryngoscopy and was explained to MM and his mother by the otolaryngologist and speech pathologist, both present and actively involved in the evaluation. After consent was obtained, MM worked out on a treadmill until symptomatic. The incline was set at 5.0 and speed at 6.0 mph. Shallow breathing with increasing shoulder tension was noted as dyspnea progressed to the point of stridor during the exertion task. Oxygen saturation was monitored and remained at 100% throughout the task. MM was then seated in the exam chair and the flexible laryngoscope was passed through the right nares to the level of the hypopharynx without difficulty. The vocal folds were easily visible and demonstrated paradoxical adduction during both inspiration and expiration. In addition, several episodes of spontaneous breath holding were observed. After viewing his breathing for about 25 seconds, MM was asked to sustain an “ah” for as long as he could. He was also asked to count as high as he could on one breath. During these voicing and speaking tasks, MM displayed constriction of the ventricular folds and anterior-posterior constriction of the glottis, additionally the vocal folds did not fully abduct for inhalation following these tasks. Posterior cricoid edema and pachyderma were also noted. While visualizing the paradoxical vocal fold adduction during breathing, the speech-language pathologist asked the patient to perform various breathing methods to assess for potential tech-


niques that promote vocal fold abduction that could be used during therapy. Techniques included single sniff inhale, multiple (3) quick nasal sniffs, single blowing exhale, and multiple (3) quick pulsed blowing exhalation. All techniques resulted in improved vocal fold abduction during breathing. Continuous nasal inhalation paired with continuous blowing exhalation yielded the greatest vocal fold abduction when applied.

Treatment After the endoscope was removed, the otolaryngologist reviewed the video and discussed treatment options with the patient. Laryngopharyngeal reflux management was recommended by the otolaryngologist who prescribed a oncedaily proton-pump inhibitor (omeprazole) to be taken 30 minutes prior to the patient’s largest meal. The speech pathologist also discussed behavioral and dietary recommendations to reduce potential irritation in the larynx that may have contributed to the paradoxical vocal fold adduction during breathing. Recommendations included avoiding acidic, spicy, and fatty foods and drinks, avoiding caffeine and alcohol, and avoiding lying flat or exercising within 2 hours of eating. As MM denied any overt gastroesophageal reflux symptoms, education regarding laryngopharyngeal reflux (“silent reflux,” which does not typically include heartburn) was provided to him. This education was provided to MM in order for him to understand the importance of treating contributing conditions, as it will also indirectly treat PVCD. Laryngeal control therapy was recommended and initiated. Initially, the patient was given the “rescue” techniques that were noted to improve

abduction during the exam (continuous sniff in, continuous blow out). Noise at the nose (inhalation) and mouth (exhalation) were emphasized to increase feedback of the act of respiration and limit cessation or restriction of airflow associated with glottal closure and stridor associated with glottal narrowing. A follow-up therapy appointment was made for the following week, and MM was cautioned that returning to practice before breathing skills improved was not advisable. When MM returned for his followup session, he and his mother reported that he had attempted to work out with his team and was able to briefly improve his breathing while on the ergometer, but ultimately had to stop secondary to breathlessness and stridor. He reported that while using the breathing strategies, his dyspnea was reduced to a “5 to 6” during practice, but ultimately reached a “9 or 10.” MM reported that he was unable to “keep up” with the learned breathing techniques and the stridor ultimately prevailed. The speech pathologist acknowledged that this was common and introduced low abdominal breathing exercises to reduce laryngeal/ neck/chest/shoulder tension and establish new and improved breathing habits. MM demonstrated low abdominal breathing, or diaphragmatic breathing, in the clinic while lying flat and was able to carry this over to sitting, standing, walking, running, and while climbing stairs across 2 therapy sessions. He reported that he was able to generalize the breathing to practice and while on the ergometer and that the low abdominal breathing in conjunction with the audible sniffs in and blowing out allowed him to resume practice as normal. He was unable, however, to use low abdominal breathing or strategies during his next regatta and again

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complained of shortness of breath and stridor in that high-pressure setting. As a result of continued stridor during rigorous competition despite mastery of breathing techniques and strategies, the SLP introduced inspiratory muscle strength training to overcome any obstruction or laryngeal tension that could not be resolved during competition. The inspiratory muscle strength training consisted of inhaling against a spring-loaded pressure threshold trainer set at 80% of MM’s maximum inspiratory pressure (MIP). He was asked to complete 5 repetitions, 5 times a day, 5 days a week at home with the inspiratory muscle strength trainer in addition to continued low abdominal breathing practice.

Treatment Results After 3 weeks, MM reported noticeable improvement of symptoms at high levels of exercise during practice and during competition. Dyspnea rating was a 1 at this point. He was instructed to continue the training and breathing exercises once a day to maintain function. The SLP scheduled a follow-up session after 4 weeks to monitor progress. After consulting with the otolaryngologist, she also advised MM that he could discontinue use of the omeprazole. In Case Study 6, Maia Braden reminds us that children grow and change and that we may want to follow young children with paradoxical vocal fold dysfunction for longer periods of time to help them adapt to growth and changing respiratory dynamics. Maia also discusses methods to induce high levels of dyspnea when a pool, football field, or track are not available for us in the therapy process with an athlete.

Case Study 6 Maia Braden Treatment of Paradoxical Vocal Fold Motion Disorder in a 9-Year-Old Athlete

History of the Problem HA was a 9-year-old girl referred by her pediatrician for evaluation of breathing difficulties. She reported approximately 1 year of shortness of breath with exercise, specifically with soccer and, most frequently, with swimming. HA described the episodes as tightness in her throat and chest, and more difficulty breathing in than out. She denied stridor. These episodes began almost immediately during competition but took longer to occur during practices. She also had a dry cough with some of these episodes, which typically resolved in several minutes. Resting and sipping water helped to alleviate her symptoms, but the symptoms returned when she resumed exercise. She and her mother also reported a history of hoarseness but were unsure of the duration.

Medical History The patient had no surgical history, no major illnesses, and was on no medications. She had not yet had a pulmonary evaluation at the time of her voice evaluation. She had no allergy symptoms and no history of seasonal allergies or nasal congestion. Her Reflux Symptom Index (RSI) completed by parent proxy was 18 (scores of 12 or higher are suggestive of acid reflux).30 Reflux symptoms included globus sensation and


cough. She consumed frequent tomato products, chocolate, and carbonated caffeinated beverages (diet cola).

Social History The patient lived with her parents and younger brother and was in fourth grade. She was a swimmer and soccer player and had recently moved up in age class in swimming, which required longer-distance swimming and a higher level of competitiveness. Her favorite event was the 200-m individual medley, and her favorite stroke was the butterfly. This was also the most problematic stroke for her breathing. She was described as a good student and a competitive athlete.

Evaluation Audio-Perceptual CAPE-V ratings: overall score: 42/100, roughness: 8/100, breathiness: 45/100, strain: 36/100, pitch: 15/100 (too low), and loudness: 0/100. She was noted to use a shallow, clavicular breathing pattern with minimal abdominal movement at rest and with speech. Visualization Laryngeal visualization was completed with a pediatric flexible fiber-optic endoscope. Exam revealed patent nasal passages without excessive mucus or congestion. She had no adenoid tissue. The patient had normal arytenoid mobility in terms of speed, symmetry, and range of motion. There was moderate arytenoid edema and erythema, moderate posterior pharyngeal cobblestoning,

and infraglottic edema, all suggestive of irritation, possibly due to laryngopharyngeal reflux. There was bilateral swelling at the juncture of the anterior one-third and posterior two-thirds of the membranous vocal folds, diagnosed by the physician as prenodular edema. An episode of dyspnea was not elicited during the evaluation. She was not symptomatic at rest and generally required a high level of exertion to become symptomatic. There was some extraneous “twitching” or adduction of the arytenoid cartilages during rest breathing, which is sometimes seen in cases of paradoxical vocal fold motion.69 Nasal sniff was trained, and maximal arytenoid abduction was seen during sniffing. The patient was able to watch this on the screen during the evaluation, and pair the sniff with the image of widely open vocal folds and a sensation of an open throat. This biofeedback is often used during the evaluation so that the patient can associate the rescue exercise with a visualization of an open glottis. Recommendations for Further Evaluation As she had not yet had a pulmonary evaluation, the patient was referred to pediatric pulmonary as well. The report from the pulmonologist indicated that pulmonary function testing was negative for asthma. Acoustic data using KayPENTAX CSL were as follows: MDVP analysis of jitter, shimmer, and noise-to-harmonic ratio could not be completed due to Type III (aperiodic) signal; maximum phonation time 8.0 s; maximum pitch range 185 to 466 Hz. Aerodynamic data using KayPENTAX Phonatory Aerodynamic System are reported in Table 6–1.

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Table 6–1. Aerodynamic Data Using KayPENTAX Phonatory Aerodynamic System Norms (Female age 6;0 to 9;11)

Scores

Mean peak air pressure

5.59 to 13.31 cm H2O

13.6 cm H2O

Mean airflow during voicing

0.07 to 0.22 L/s

0.16 L/s

Aerodynamic efficiency

17.78 to 609.67 ppm

50.48 ppm

Norms from Weinrich et al (2005).108

Treatment Recommendations Medical Treatment History, self-report, and exam findings suggested laryngopharyngeal reflux. Positive reflux findings have been correlated with PVFM in the literature, and the physician placed the patient on a proton pump inhibitor.69,70 Voice Therapy Behavioral voice therapy to treat PVFM has been described in the literature71–75 and has been shown to be effective.72,76,77 Voice Therapy. Therapy for PVFM typically focuses on the following:

1. Understanding of the disorder and the ability of the patient to regain control of breathing 2. Awareness and reduction of muscle tension patterns 3. Training of rescue breathing exercises to reestablish and maintain an open airway 4. Adaptation of the exercises to the individual’s activity needs 5. Recognition of triggers and early signs of breathing difficulty

6. Use of breathing strategies to prevent episodes before they occur or stop them before they worsen The long-term goal of therapy was to return to her previous level of activity without restrictions. Patients may need to adapt their activity while they are in therapy, but they should be able to return to their sport with no limitations once they regain control of their breathing. HA received therapy focused on both her breathing and on her voice, with 13 sessions completed over a period of 15 months. This consisted of one initial therapy course of 7 sessions every week to 2 weeks and 2 later “refresher” courses due to changes in voice or breathing status. This is a longer course of therapy than is typical in our practice for PVFM due to the combined focus on voice and breathing. For the purposes of this book, we will focus on the therapy for breathing, although she did participate in therapy aimed at modifying her vocal behaviors as well. Voice therapy to treat HA’s dysphonia secondary to vocal fold nodules consisted of a combination of therapy approaches tailored to her learning style and needs. These included semi-occluded vocal tract exercises (lip trills, humming, and phonation through a straw on single


pitches and pitch glides), vocal function exercises (see Chapter 3, Stemple), and resonant voice therapy (see Chapter 3, Leborgne) Session 1: Education and Introduction of Strategies Exam video and explanation of PVFM were reviewed. HA reported that she had not had any breathing difficulties in the week since her evaluation, but she had also not had swim practice. Progressive relaxation. A progressive relaxation exercise was introduced. HA was asked to lie down on the floor on a mat, while the clinician guided her through the exercise. This is done to gain awareness of control of muscle tightness and relaxation, and also to begin therapy in a state of more muscular relaxation. Rescue Exercise. The basic rescue exercise was trained in 3 parts:

1. Establish low breathing: Awareness: HA was asked to sit comfortably or lie down while placing one hand on her chest and one on her belly, observing her breathing for a few cycles. Then the clinician asked — which hand moves when you breathe in and breathe out? The patient was using almost exclusively chest movement, with locked abdominal muscles limiting abdominal movement during breathing. This resulted in shallow breathing without maximal inhale and was contributing to neck tension. Behavior change: Focusing on the exhale first, the patient was asked to let out all her air, by moving her belly-button in toward her spine. A clinician’s

hand on top of the patient’s hand assisted with this. Then she was asked to relax her belly, allowing air to flow into the lungs with little effort. A small stuffed animal was placed on her belly to help provide a visual cue. Positional changes: In some cases, patients have very locked abdominal muscles and are unable to establish low breathing either seated or lying down. In these cases, squatting and leaning forward can relax the abdominal muscles and allow expansion during breathing. This positioning, called the “gorilla walk” with HA, facilitated her best abdominal breathing initially. 2. Sniff in: An audible sniff was trained as the initial rescue exercise. This can be a longer sniff, or several short sniffs. The sniff causes activation of the posterior cricoarytenoid (PCA), automatically abducting the arytenoids and opening the glottis. This should be paired with low rib or abdominal breathing. 3. Exhale out on “sh.” (Patients can use /s/ or /f/ if they prefer.) This creates backpressure in the vocal tract, keeping the glottis open for exhalation. The sniff in and exhale should be repeated for several cycles before taking a break. HA was given a simplified handout with pictures and single sentence instructions for the breathing exercises, to keep with her at all times. 1. Let all your air out like you’re saying “shhhh.” 2. Sniff in like you smell something really good. 3. Make sure the air goes to your belly, and not your shoulders.

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4. Sniff in again, like you smell something good. She was asked to practice for 2 to 3 minutes, 7 to 10 times a day so that this became automatic when she was not having difficulty. Reflux Management. Dietary modifications to manage acid reflux were discussed. HA drank large amounts of diet cola, and it was recommended that she significantly reduce this. It was also recommended that she not eat immediately before bed. This was a difficult recommendation to follow, as HA had a very busy schedule and sometimes did not get home from practice until an hour before bedtime. They did make efforts to eat as early as possible, and make dinner a lighter meal.

Sessions 2 to 7: Adaptation to Individual Needs, Generalization to More Activities HA was on a seasonal break from swimming for the first several weeks of therapy. This allowed her to become adept at the exercises at rest but delayed her ability to practice them while swimming. In addition to voice therapy work for her dysphonia, the second through fourth sessions were spent training the breathing exercises at rest and during activity, and the fifth through seventh were spent adapting to HA’s specific needs in swimming. Practice with Physical Activity. A swimming pool was not available to us for therapy sessions, so other activities were substituted. Breathing exercises were practiced while doing jumping jacks and

running up and down stairs in order to allow for practice with increased cardiovascular effort. Breathing was also practiced during simulated swimming, both standing and lying prone on a mat, to coordinate the breathing with her individual strokes, as this can be one of the more challenging aspects for swimmers. HA frequently held her breath during exercise and had to be reminded not to do so. As with many athletes, the sniff in with “sh” exhale was not comfortable during a high level of exercise, as she is usually a mouth breather with running. HA was given two alternative options: a sniff in with pursed lip exhale, and a pursed lip inhale and exhale. This was practiced on the treadmill, and she found that the sniff in with pursed lip exhale intermittently through the run was the most comfortable. She did not have an attack while running but was able to identify early throat tightness and use the exercises to restore the feeling of an open airway. Low Rib Breathing. In order to have proper form for swimming, swimmers really cannot use full abdominal breathing while swimming — they need to maintain a “streamlined” posture with the abdomen tucked. Once HA learned to lower and relax her shoulders while breathing, attention to low rib expansion was introduced. A Thera-band around her rib cage while practicing, both in and out of the water, facilitated her attention to rib cage movements. Identifying Sensations Early. Early identification of problems is very important, as this allows the child to prevent the attack from worsening. While doing jumping jacks and running, HA was asked to attend to early signs of tight-


ness in her throat, allowing her to begin the rescue exercises sooner than she might have done in the past. She could then identify the sensations earlier while swimming, rather than waiting until she was in severe distress. Specific Adaptations to Swimming. Swim season began between the fourth and fifth sessions. When trying the 3 rescue strategies in the water, she noted that she could not do the nasal inhale while swimming, as it led (not surprisingly) to water up her nose. Thus, incorporation of pursed lip breathing was practiced while simulating her swimming strokes. As her swim season progressed, HA noted increased difficulties on butterfly and freestyle. In between sessions, she was observed in the pool, and based on these observations, the following recommendations were made and trained during the next therapy session: n Avoid breath holding. HA was holding

her breath on the exhale on all strokes. Practice of a seamless inhale/exhale without breath-holding was needed, and this was done during simulated swimming. n Practice at a slower pace. She also needed to work on the pattern of breathing at a slower pace than her race pace. She was somewhat unwilling to do this, as her competitive nature made her want to do her very best every time. n Pulse the exhale. Gently pulsing a continuous exhale helped HA coordinate her breath with her stroke and improved awareness of her timing. n Pay attention to form. She had a tendency to hyperextend her neck and shrug her shoulders on breaststroke and butterfly. Work on improving her

form and breathing at a slower pace was helpful. This is especially important in such a young athlete, who is just developing her form Parental and Other Adult Support. It was vital to enlist the help of HA’s parents and swim coach in her recovery. One of her parents attended every therapy session, and they were also present at most of her swim practices and all of her meets. They helped to remind her to practice her breathing at home and during swim practice, as well as helping her through the exercises when she had breathing difficulty. Her coach was very helpful in identifying aspects of her form that were likely contributing to breathing problems, encouraging her during practice, and ensuring that she was working at an appropriate pace. Counseling. HA was very discouraged by having to swim slower temporarily during practice, as she was competitive and always wanted to do her best. It was helpful to talk about her PVFM as an injury from which she needed time to recover — just as if she had hurt her shoulder or knee, and needed to swim in the “recovery lane.” Her coach and several teammates were instrumental in this, but it was always frustrating for her. Prevention. Once HA was able to consistently use pursed lip breathing as a rescue strategy, she found she was having difficulty mostly at swim meets, often after she had already competed in several events. She began to use pursed lip breathing or sniff inhale with pursed lip exhale in between events, and immediately before each event. She also began using her progressive relaxation

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exercise before beginning a meet. All of these were helpful in reducing the frequency of PVFM episodes. General deep breathing and anxiety management strategies were also addressed, as her breathing difficulties got worse with increased stress and pressure. Her parents also reminded her to use her breathing strategies in between events.

Six-Month Reevaluation This was completed 2 months after discharge from therapy. HA reported that she was able to participate in soccer and swimming without breathing difficulty most of the time but had experienced one episode of breathing difficulty 1 week before, during the 100-m butterfly, and admitted she had forgotten to use her breathing strategies. She was inconsistently taking her antireflux medication. She also had increased dysphonia, and stated that she was not doing her voice exercises or consistently using her “smooth” voice. Increased adherence to antireflux precautions was recommended, as was a return to therapy focusing mostly on voice, but with some breathing emphasis as well.

Reevaluation (8 Months After Initial Evaluation) HA returned and reported infrequent breathing difficulties, almost always when doing a fast butterfly stroke. Reflux medication was being taken inconsistently. She reported that she was usually doing her breathing exercises prior to practice and competition, and usually remembering to do so while swimming. Additional therapy focusing on adapting breathing to specific strokes was recommended. Sessions 12 to 13 Stroke-specific strategies were reviewed. These sessions focused on simulating all of HA’s swimming strokes, practicing breathing in coordination with them, as well as reviewing prevention strategies.

Reevaluation (16 Months)

A “refresher” therapy session was done to review the breathing strategies previously taught, and to remind HA how to coordinate these with specific strokes, especially the butterfly, where she was having the most trouble.

HA reported one episode of breathing difficulty in the past 3 months. It occurred during swimming, and she recovered immediately using her breathing strategies. She was competing at a high level and doing well. She continued to have some vocal complaints, and a refresher course of voice therapy was recommended at that time. Audioperceptual (CAPE-V) measures (all out of 100) were as follows: overall severity: 22; roughness: 8; breathiness: 40; strain: 21; loudness 0: 0; and pitch: 18 (too low). The reflux symptom index = 10.

Sessions 9 through 11

Visual Imaging

These sessions were primarily focused on voice.

Endoscopy with stroboscopy showed that midmembranous lesions were

Session 8


still present but smaller than in previous exams. Mucosal wave was mildly reduced. There was still some posterior glottis edema and erythema suggestive of laryngopharyngeal reflux.

Summary and Concluding Remarks Cases of PVFM are more typical in teens than in school-aged children. Due to age, ability to self-monitor, and co-occurring issues such as reflux, anxiety, allergies, etc, the therapy course for a younger child may be longer than for a teen or adult. It is also particularly important to enlist the support of parents, coaches, teachers, or other adults in the child’s life to aid the therapy process. Refresher sessions are not uncommon, as children advance in their sport to a higher level, switch to a different sport, or simply grow and develop cognitively, emotionally, and physically. It is also important to take into account ways in which the lifestyle of a young athlete may contribute to the difficulty, such as late eating, a very busy schedule, and stress. With any athlete, regardless of age, therapy may need to be adjusted to meet the demands of their sport. In this final case, Mary Andrianopoulos reminds us that psychosocial issues can manifest in a variety of ways and that the clinician, while not a psychotherapist, must cue into discussions that may give a glimpse into why the laryngospasms began and why they persist. Referral to a trained psychotherapist, family counselor, or psychiatrist may be warranted in cases of PVFD and cough in addition to therapy.

Case Study 7 Mary V. Andrianopoulos Paradoxical Vocal Fold Movement (PVFM): A Case of the Young Athlete With Associated Psychosocial Contributions

History of the Problem Patient HH was a 16-year-old young woman referred by her primary care physician for evaluation and treatment of chronic, progressive “respiratory attacks” and possible “laryngeal dysfunction” of indeterminate origin. The mother of the patient requested that her daughter be seen by a SLP with expertise in voice and the condition of paradoxical vocal fold movement (PVFM) as soon as possible, given the urgency of the matter. Apparently, the patient and family were in a state of despair because of the disabling effects of her condition on her general function and quality of life. Because of the chronicity of the respiratory “attacks,” which the family presumed to be asthma related, the patient had been absent from school for a 6-week period and had yet to return to school. Moreover, medical interventions administered to date included multiple asthma pharmacotherapies that were reported to be unsuccessful in managing her condition. Accompanied by her mother to the voice pathology clinic on the day of the evaluation, the 16-year-old patient arrived carrying a shopping bag full of numerous pharmacological products, such as bronchodilators, oral inhalers, nasal drops, antihistamines, muscle relaxants, steroids, anti-allergens, cough medications, and acid reflux protocols.

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In addition, she came prepared with 45 pages of medical reports, several emergency room and hospital records, lab results, and chest and neck radiographs from several medical specialists whom she consulted in an attempt to establish a differential diagnosis regarding her condition. According to the patient, the “asthma-related laryngeal dysfunction” began approximately 2 years prior, marked by infrequent, transient, isolated episodic periods of acute wheezing or inspiratory stridor, respiratory distress, and aphonia only during the acute attack. The acute respiratory distress and associated aphonic episodes were reported to subsequently resolve on their own in a matter of seconds without any direct intervention or administration of prescription medications. The patient indicated that her condition was diagnosed as asthma by the attending physicians on call during one of her visits to the emergency room at a local hospital. She was emotionally labile during the diagnostic interview and intermittently stopped to administer a dose of an oral inhaler as a prophylactic measure given that she was trying to avoid the onset of an “attack.” She expressed frustration and concern because the respiratory-laryngeal attacks or asthma symptoms were occurring more frequently over the past month, and the beneficial effects of the asthma medications prescribed were limited. Although she experienced some relief from some of the asthma protocols, recently it had taken much larger doses to achieve the same effects.

Medical History Allergy and skin testing were negative to foods and inhalants. Hemograms

and electrolyte levels were normal. The patient’s history was negative for smoking, alcohol consumption, and use of recreational drugs. She consumed approximately 3 to 5 caffeine beverages per day. The patient reported that she first experienced an isolated, acute episode of the asthma-related laryngeal dysfunction problem during field hockey practice at age 14 years. She was running vigorously and noticed the sudden onset of wheezing and stridor during inspiration, accompanied by upper airway obstruction at the level of the larynx that subsided after a few seconds. At the request of the field hockey coach, she pursued a general medical evaluation through her primary care physician, who reported normal findings and prescribed an oral inhaler as needed. The transient stridor and respiratory-laryngeal obstruction did not recur until approximately 2 years following the isolated episode. During March of that year, she recalled sitting on the floor reading a book one evening and suddenly developing an episode of chest and neck pain, coughing, wheezing, difficulty breathing on inhalation, and aphonia during the “attack.” This precipitated a trip to the emergency room via ambulance where she was diagnosed with asthma by the attending physician on call and placed on a battery of asthma medications. In May, she experienced a similar isolated episode of acute chest and neck pain, coughing, stridor, and aphonia as she was doing homework in the evening at home. Again, the mother transported her to the emergency room by ambulance because she was emotional, in a panicked state, and her breathing difficulties alarmed the family. The attending physician placed her on a different


combination of asthma medications, and she was subsequently released. The constellation of symptoms and respiratory attacks did not recur until the following month when one day she was at her friend’s house socializing during the morning hours. This incident precipitated another visit to the emergency room, and once again, a series of asthma protocols were prescribed, as well as a Pulmo-Aide machine for home use given that the attending physician suspected her symptoms were consistent with an exacerbation of asthma. Pulmonary function tests (PFTs) were performed the following week, which revealed better-than-normal forced vital capacity (FVC) and forced expiratory volume at 1-second (FEV1) values and “borderline obstruction” findings; however, the results of flow volume loops were not reported. She indicated that an allergy screening revealed negative findings to various allergens. She was free of any symptoms and respiratory “attacks” during the following 2 summer months of July and August, as well as during the month of September upon returning to school. In early October, however, she experienced another acute attack during field hockey practice just prior to the first “big” game of the season. She did not attend the game because she was taken to the emergency room for medical attention by one of her friends. She reported the same constellation of symptoms marked by acute, transient inspiratory stridor, coughing, respiratory distress, and aphonia. In the emergency room, she was administered oxygen with a mask and prednisone intravenously; an unknown type of pill medication was placed under her tongue. As she calmed down, she was released from the emer-

gency room under her mother’s care, and a different host of asthma medications were prescribed. Following the most recent episode in early October, the patient’s general condition and quality of life began to decline rapidly in that she was transported out of school at the request of the mother because the acute “asthma attacks” increased in frequency to approximately 6 to 8 isolated episodes per day. The patient felt that her medical problem disrupted the classroom, and she could not function in school under these circumstances. Moreover, she began vomiting following the consumption of food and liquids for unknown reasons that contributed to a rapid 13-pound weight loss. As of October, the onset of the following coexisting symptoms were also reported by the patient: n tightness in the neck and some chest

tightness

n throat and ear pain n tickling sensations in the throat n throat irritation n chronic cough and throat clearing n frequent bifrontal migraine

headaches n mouth and throat dryness n jaw pain and tension n skin dryness and irritation mainly on the palms of the hands that she attributed to possible side effects of the prescribed medications n difficulty swallowing n dizziness that she attributed to her recent weight loss and poor nutrition The exacerbation of asthma-related symptoms and coexisting problems perpetuated a comprehensive multidisciplinary medical work-up because her respiratory distress was not accompanied by much of any objective symptoms of

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respiratory difficulty. Her primary care physician requested consultations from the following specialties to establish a definitive diagnosis: (1) pulmonologyrespiratory medicine; (2) otolaryngology; (3) gastroenterology; (4) allergy; and (5) speech, language, and voice pathology.

Social History The patient’s history was positive for emotional and stress-related triggers that were noted to precipitate or perpetuate her breathing difficulties, a comprehensive psychosocial history was obtained. The patient responded candidly to questions presented. She was enrolled as a junior in high school, but she had not returned to school for at least 6 weeks because of her respiratory problems. Although she was in jeopardy of repeating her junior year as a result of the high absentee rate, she did not express concern about this possibility. She did express considerable disappointment; however, that her field hockey team had not contacted her to date regarding her health and abrupt departure to the local hospital emergency room preceding the “big game” 6 weeks prior. In terms of varsity sports, she participated in track and field in the past and decided to quit 2 years prior for no apparent reason. Field hockey was the only sport in which she annually participated during the autumn season. She stated that she “likes getting good grades” and her grade point average was a solid “A.” With respect to peer relationships, she reported 2 close friendships. She also indicated having a close and rewarding relationship with her mother. She suggested that her peers perceived her as belonging to a social group composed of “cool kids.”

The family dynamics were noted to be tumultuous for most of her life with the exception of a 1-year period when she and her mother resided alone following her parent’s divorce 2 years prior. The patient is the product of a union between her biological parents who did not marry but cohabitated until she was 11 years old at which time her parents were married. The marriage lasted 3 years and her parents divorced at the patient’s request. There were no other siblings in the family. The patient also stated that her current living situation was intolerable because she and her mother were forced to move in with her maternal grandfather following the death of the maternal grandmother 1 year prior. The grandfather was unable to care for himself because of his poor health and frequent hospitalizations secondary to chronic seizures, multiple strokes, and emphysema attributed to a chronic smoking history. She expressed much emotional distress and sadness residing in the grandparent’s home since her grandmother’s death. A maternal aunt, whom she referred to as the “general,” resided next door. The current living situation was described as not conducive for studying because of noise and other factors. She reported that her mother had missed a significant amount of work transporting both the patient and the grandfather to medical appointments. There was no history of voice remediation, family counseling, or formal psychotherapy to date.

Voice Evaluation Oral Peripheral-Neuromotor Speech Examination The Mayo Clinic Neuromotor Speech Examination78,79 was administered to


assess the structural and functional integrity of the speech mechanism at rest, during movement, during sustained movement, and during spontaneous speech. The face (Cr. 7), lips (Cr. 7), and tongue (Cr. 12) were symmetric at rest, when smiling, during sustained movement, and during spontaneous speech. The patient was able to inflate her cheeks with a strong nasal (Cr. 10, pharyngeal branch) and oral seal (Cr. 7). No air escape or wastage was noted. Lateral jaw (Cr. 5) and tongue (Cr. 12) movements to the right and left were symmetric and rhythmic. On protrusion, the tongue (Cr. 12) was symmetric and extended beyond the incisal surfaces of the teeth. The velum (Cr. 10, pharyngeal branch) was symmetric at rest and during phonation. A gag reflex (Cr. 9; Cr. 10) was elicited. Speech alternate motion rates (AMRs) and sequential motor rates (SMRs) were within normal limits. Multisyllabic words were repeated with good precision. There was no evidence to support a dysarthria, apraxia of speech, or nonverbal oral apraxia. Using Aronson’s digital manipulation technique,80 palpation of the superior and inferior neck regions revealed marked tightness, subjectively. Tightness in the temporomandibular and shoulder regions was also noted subjectively. The patient complained of pain during palpation of the neck, jaw, mandible, and shoulder-clavicular regions. Chronic coughing and throat clearing were noted. On one occasion, the patient stopped responding to the examiner’s questions, and she exhibited an acute onset of inhalatory stridor and respiratory distress. At this moment, the patient began to gasp for air and an audible wheezing sound accompanied the inspiratory phase. The patient exhibited what resembled a single spasm of the laryngeal area lasting approximately

10 to 15 seconds. Elevation of the hyoid bone and a significant degree of muscle tension were observed visually in the neck, shoulder-clavicular, and jaw regions during the stridous, laryngospastic, respiratory attack. The patient was temporarily aphonic only during this isolated moment. On exam, the examiner instructed the patient to breathe in through her nose and then inhale through the oral passages with a pursed lip posturing. Following several seconds of verbal and visual feedback provided by the examiner, the patient’s breathing returned to normal. She indicated that this transient “attack” exemplified the nature of her problem and associated constellation of symptoms. She denied the presence of any sensory, mechanical, or physiological triggers that precipitate or perpetuate the nature of her problem with the exception of emotional and stress-related factors. Audio-Perceptual Evaluation The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)58 was administered to assess the patient’s vocal attributes with respect to roughness, breathiness, strain, pitch, and loudness. Each attribute was graded on a scale of 0 to 100 to describe the vocal attribute deviancy, with 100 being the most severely deviant score attainable. The scores obtained on the CAPE-V were as follows: n Roughness: 10/100 (mildly deviant) n Breathiness: 0/100 (no perceived

deviancy)

n Strain: 10/100 (mildly deviant) n Pitch: 0/100 (deemed to be appropri-

ate for age and gender)

n Loudness: 0/100 (no perceived de-

viancy) n Severity: 10/100 (mildly deviant)

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In summary, the patient’s voice was perceived by the examiner to be mildly hoarse. Pitch range was not perceived to be restrictive or deviant. Conversational pitch was deemed to be appropriate for age and gender. Using a 5-point rating scale for severity of the voice disorder (0 = normal and 4 = severe), the examiner subjectively judged the patient’s voice quality to be a score of 1, mild in severity. Visual Imaging Transnasal fiber-optic laryngoscopy (TFL) performed by the otolaryngologist revealed the classic pathognomonic pattern paradoxical vocal fold movement (PVFM) marked by inspiratory adduction of the anterior two-thirds of the vocal folds with a posterior diamond-shaped gap during symptomatic episodes. Moreover, a normal laryngoscopic exam was immediately achieved with simple vocal reassurance by the otolaryngologist without use of any medication. Possible anterior-posterior or ventricular fold muscle tension patterns were not noted during TFL. Mucous stranding was noted along the junction of the posterior middle third of the vocal folds bilaterally. Mucosal waves were symmetric. Acoustics The Multi-Dimensional Voice Program (MDVP-4305, KayPENTAX, Lincoln Park, NJ) were used for acoustic analysis of the patient’s voice. Following guidelines outlined by the National Center for Voice and Speech,81 voice samples were recorded in a sound-proof booth using a digital audiotape (DAT) recorder (Tascam, DA-P1) and a head-mounted

condenser microphone (AKG, C410) placed in a 45° off-axis position to the mouth. Voice samples were fed into the MDVP programs via DAT recorder for computer analysis. The acoustic tasks consisted of: n vowel /a/ prolongation (3- to 6-second

tokens)

n a 1-minute monologue n a 1-minute reading aloud of a stan-

dard passage.

The patient was instructed to perform each task at a comfortable pitch and loudness level. Approximately 30 seconds or 2000 pitch periods of the monologue and reading samples were analyzed to determine average speaking fundamental frequency (SFF), jitter and shimmer, and a host of other parameters provided by the MDVP software. Results obtained and normative thresholds used for comparisons are noted in Table 6–2. Compared with normative thresholds, the patient’s jitter and shimmer values exceeded normal thresholds for conversation and reading tasks. The patient’s average fundamental frequency (average pitch level) fell within the normal range for age and gender compared with norms. Nonetheless, the patient’s average fundamental frequency of /a/ vowel prolongation was assessed at her natural and comfortable pitch level and fell in the high-average range compared with normative data for age and gender. Conversational speech was assessed to be at an average fundamental frequency level in the low-average range. Average fundamental frequency for reading fell just above the mean level for age and gender compared with norms. Noise-toharmonic ratio for /a/ vowel prolonga-


Table 6–2. Results of Quantitative Voice Analysis Pretreatment for Client KK Average F0 (Hz)

SD of F0 (Hz)

F0 Semitone

Jitter (%)

Shimmer (%)

/a/ vowel

249.0

5.5

7

2.3

3.52

Conversation

196.1

29.3

19

2.9

8.63

Rainbow

210.4

44.1

24

5.1

9.61

Voice Task

tion was within normal limits or below normal threshold. Aerodynamics Pulmonary function tests (PFTs) revealed a normal flow volume loop during asymptomatic periods and attenuation of the inspiratory component of the flow volume loop suggestive of partial upper airway obstruction during an attack. The lungs were noted to be clear bilaterally with no signs of asthma or bronchitis. Lateral soft tissue radiographs of the neck depicted normal glottic, supraglottic, and cervical airways. In addition, sinus, posterior-anterior (PA), and lateral chest films were normal. The following tasks were performed to calculate estimates for maximum phonation time (MPT) or maximum phonation duration (MPD): /a/ vowel prolongation and s/z ratio. Three tokens per task were obtained, and an average score was calculated. Results were as noted: /a/ vowel prolongation, MPT = 22 seconds, and s/z ratio = 0.80. Compared with normative data, MPT for /a/ vowel prolongation was within normal limits.82,83 The s/z ratio of 0.80, however, was below 1.0 and normative data for children of comparable age. This finding was suggestive of hoarseness in the presence of normal vocal folds.84

Audiologic Screening The patient passed an audiologic screening conducted bilaterally in a soundproof booth at 20 dB for all frequencies between 250 and 8000 Hz. Patient Self-Assessment The patient was asked to complete the Voice-Related Quality of Life 59 (V-RQOL) prior to her examination to assess the patient’s self-perception regarding the impact her condition is having on her life. Although the V-RQOL is intended to assess the impact of one’s voice problem on quality of life, the patient was specifically advised to assess not her voice, but her condition, aphonia/dysphonia and acute upper airway obstruction, for which she was being assessed on that day. The V-RQOL scores are based on a 100-point system, whereby a score of 100 suggests little to no impact of one’s [voice] problem on one’s life. The patient’s results on the V-RQOL revealed a standard score of 50 in the social-emotional domain and a 33.34 for the physical-functioning domain. The total V-RQOL score was 40, suggestive of a marked self-perception of a [problem] that interferes with the patient’s daily activities. A total V-RQOL score of 40 is deemed to be a clinically relevant deterioration of health.

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Clinical Impressions Based on subjective and objective exam findings, a differential diagnosis includes the following: n PVFM believed to be secondary to

multiple etiological factors marked by probable emotional, stress-related, functional, or psychogenic phenomena and probable musculoskeletal laryngeal tension factors n Hyperfunctional voice disorder marked by mild hoarseness secondary to phonotraumatic vocal behaviors, including chronic throat clearing and coughing, and palpable musculoskeletal tension of the larynx and perilaryngeal regions n Possible medically related etiological factors, such as laryngeal pharyngeal reflux (LPR) The patient was referred to her physician and otolaryngologist for medical management and follow-up.

Voice Therapy Specific Type of Therapy and the Rationale for Using the Therapy Diagnostic therapy was recommended using a multifactorial treatment program85,86 composed of an eclectic approach: symptomatic-behavioral, psychogenic, etiologic, and physiologic voice therapy.48 The management program developed by this author utilizes a 3-phase program. The aims and the rationale of the 3-phase treatment program follows. Phase 1: Differential diagnosis and inventory of baseline data are established to address etiologic and

precipitating factors underlying syndromes associated with PVFM. Medical management should also be addressed by the medical team in phase 1. Phase 2: In phase 2, behavioral management of this symptom complex is emphasized utilizing principles of motor learning to ensure acquisition and carryover of target behaviors. The need for formal psychotherapy should be justified based on the presence of precipitating or perpetuating emotional, stress-related, or psychogenic phenomena, and a referral to a psychologist with expertise in treating voice disorders should be made accordingly. Phase 3: Self-awareness and independence in controlling aberrant respiratory and phonatory behaviors are encouraged to facilitate sensorimotor changes in the patient by adapting behaviors that restore optimal function. The literature describes several management approaches that are applicable to managing this case. Aspects of a 3-phase management program by Andrianopoulos, Gallivan, and Gallivan87 have been described by Pinho, Tsuji, Sennes, and Menezes.88 These aspects include self-awareness, diaphragmatic breathing, and muscle tension reduction. Ryan, Vertigan, and Gibson89 discuss speech therapy and chronic cough treatment, while Nacci et al90 describe respiratory retraining therapy. Rameau et al91 combine diagnostic and multidisciplinary behavioral intervention for long-term management of PVFM. The efficacy of PVFM intervention in athletes has been investigated primarily in small case-controlled


trials without randomization and control groups92–98 and observational studies.99,100 The efficacy of treatment for PVFM has not been empirically investigated in well-designed, formal, clinical randomized controlled trials, or doubleblind studies or meta-analysis studies. The 3-phase management program implemented for this patient also included relaxation techniques consistent with manual circumlaryngeal therapy (MCT). The efficacy of MCT has been reported mostly in singlesubject or case study designs. Mathieson et al101 and Mathieson102 reported that laryngeal massage therapy (LMT) led to decreases in perturbation and vocal tract discomfort. Van Lierde et al103 found that 4 subjects with muscle tension dysphonia showed improvement following LMT. Dromey and colleagues104 also provided acoustic evidence for articulatory changes following MCT with respect to the F2 slope for 2 different dipthongs, including fewer pauses produced during the speech sample. Roy et al105 provided more acoustic evidence for articulatory changes following MCT with respect to vowel space expansion; Van Lierde et al106 demonstrated improvement in vocal quality following treatment using MCT but not following treatment using vocalization with abdominal breath support. Manual treatment of muscle tension dysphonia and muscle tension factors is also underresearched.

Therapy Goals and Expected Outcomes Phase 1: Differential Diagnosis — Baseline Data Critical information and data obtained from the voice pathology evaluation

session were utilized to establish specific baseline data regarding the constellation of symptoms, the presence of precipitating and triggering stimuli along with the frequency, duration, and estimated severity of each presenting variable. For example, an inventory of the following variables was determined: n psychological-emotional issues n phonotraumatic behaviors n medical factors n muscle tension patterns n triggers and exacerbating stimuli n degree of respiratory and phonatory

system involvement

The relative importance and magnitude that each etiologic variable contributed to the presenting problem were enumerated. The use of a daily journal was implemented to help identify emotional factors, situations, and triggering stimuli that elicit aberrant respiratory and phonatory behaviors. Baseline data should be substantiated with subjective and objective evidence obtained by the patient’s history, diagnostic interview, medical history and reports, and laboratory reports. Examples of psychological, emotional, and stress-related factors include conversion reaction phenomena; functional disorders resulting from learned, maladaptive physiological compensatory behaviors and resulting psychoemotional sequelae; and natural fears, anxiety, and stress resulting from acute respiratory distress. Medical etiological variables, such as gastrointestinal problems, GERD/LPR, sinusitis, rhinitis, organic laryngeal problems, asthma, and bronchitis, should be ruled out and managed by the medical team. Examples of phonotraumatic behaviors include chronic throat clearing and chronic coughing, and voice misuse or

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overuse. In this patient, the following 5 variables were present: 1. PVFM or laryngospasm: 6 to 8 episodes per day, marked to severe 2. Emotional, stress-related, or psychogenic factors precipitating or perpetuating the problem n high rate of school absences because of the problem n chronic bifrontal migraine headaches n possible dysfunctional home environment n possible issues surrounding the grandmother’s death n probable emotional, stressrelated issues surrounding the above factors and PVFM etiology n referral for formal psychotherapy warranted 3. Laryngeal and perilaryngeal muscle tension n neck and perilaryngeal tightness n pain upon palpation of above regions n radiating pain per patient report 4. Phonotraumatic behaviors present n chronic cough and throat clearing n mucous stranding noted during laryngoscopy n dysphonia, mild hoarseness n increased jitter and shimmer perturbation parameters n s/z ratio of 0.80 n possible effects of chronic vomiting on laryngeal health 5. Medically related issues n consumption of multiple pharmacotherapies for asthma n caffeine consumption and possible GERD/LPR etiology n etiology of throat tickle, indeterminate

n rule

out of sinusitis and rhinitis etiologies n chronic vomiting and possible nutritional issues n referral to primary care physician and diagnostic team for medical treatment and follow-up n possible referral to dysphagia specialist for differential diagnosis of chronic vomiting Based on the above symptoms, the following treatment goals were addressed with the patient: 1. To manage PVFM or laryngospasm symptoms n Patient education and counseling regarding the nature of the problem n Implementation of daily home journal to note food habits, situational and psychosocial phenomena, medical factors, sleep habits, and other variables that precipitate, perpetuate, maintain, or alleviate the PVFM problem n Early intervention of voice pathology remediation, frequency of sessions, home practice of tasks, estimated duration of treatment n Patient responsibility regarding success of treatment, carryover of intervention target behaviors, increased self-awareness, and independence in managing PVFM 2. To manage emotional, stress-related, or psychogenic factors precipitating or perpetuating the problem n The need for formal psychotherapy in conjunction with voice therapy regarding management of PVFM and possible coexisting psychological manifestations

Irritable Larynx Syndrome, Paradoxical Vocal Fold Dysfunction, and Chronic Cough n

Increased self-awareness of emotional, psychosocial, and stress reduction coping repertoire to restore optimal function

3. To manage laryngeal and perilaryngeal muscle tension n Suggestions for general or wholebody relaxation techniques n Manual laryngeal musculoskeletal tension reduction techniques to treat functional laryngeal muscle tension21,29 to be provided via speech pathology department 4. To manage phonotraumatic behaviors n Hydration therapy to alleviate cough and throat clearing n Elimination of laryngeal, perilaryngeal, and whole-body stress patterns 5. To manage medically related issues n Referral to primary care physician for medical management, follow-up, and additional medical referrals as needed Phase 2: Modification In phase 2, modification of inappropriate residual respiratory and phonatory behaviors that have not resolved in phase 1 were addressed, and an individualized treatment program for this patient was developed. Treatment goals and objectives were organized to restore lost function and promote optimal function by utilizing purposeful activity; performance was improved with instruction, and various forms of feedback were successful for this patient. Optimal achievement and carryover of desired behaviors were restored by using motor learning principles that address cognitive, associative, and autonomous or automatic stages.107

To restore sensorimotor function of respiratory and phonatory systems, the cognitive phase of treatment emphasized patient education and achievement of specific target behaviors to achieve the desired effect. For example, to alleviate the laryngospasm or PVFM behaviors the following nonspeech tasks were utilized: n blowing n sniffing n panting n pursed-lip inhalation n nasal inhalation

The pursed-lip inhalation and nasal inhalation techniques were most successful in restoring a wide-open airway in this patient. The associative stage consisted of transitioning the patient from conscious, repetitive drills and practices to more automatic control of her breathing and laryngeal dysfunction through trial-and-error paradigms. The use of visual, auditory, and proprioceptive feedback was essential in this stage. The examiner instructed the patient to visualize or “feel” the difference between a wide-open airway sensation from a PVFM state. During the autonomous stage, the patient was able to anticipate and control or alleviate the onset and duration of each attack on a more automatic level with minimal auditory feedback from the examiner. Laryngeal muscle tension coping repertoires were also incorporated into practice sessions, such as digital, manual laryngeal massage; head, neck, and shoulder range-of-motion exercises; and body-posturing techniques. Initially, the examiner physically provided the laryngeal massage to the patient, and auditory and proprioceptive feedback was provided. The patient then developed

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this skill and provided manual laryngeal massage to herself as she sensed the laryngeal musculature tense up. In the automatic stage, the patient utilized this technique as a prophylactic measure or muscle tension coping repertoire to restore optimal function and a relaxed wide-open airway. The patient also chose to incorporate relaxation and breathing techniques she had learned in yoga classes into her daily paradigm to alleviate focal and generalized muscle tension factors. Respiratory Retraining Tasks. Respiratory retraining was also part of phase 2. This retraining was employed through abdominal breathing focus by encouraging the patient to distend the abdominal region during inhalation and maximizing use of the abdominal muscles during exhalation. The patient monitored her performance proprioceptively by placing her hand on the abdominal region as the examiner provided auditory feedback in the cognitive stage. She was able to perform this task automatically for nonspeech and speech tasks in a relatively short period of time. The following respiratory-phonatory synchronization tasks were employed to promote optimal function utilizing purposeful activity: n sibilant prolongation with and with-

out crescendo-diminuendo tasks

n upward and downward glides of sib-

ilant sounds n lip trills n humming n nasal sound prolongations with nasal-vowel syllabic combinations n counting aloud n reading aloud

n singing n spontaneous speech

Because the patient was an athlete engaged in field hockey, variable practices using respiratory retraining tasks were incorporated into physical activities, such as walking, slow jogging, and laps up and down stairs, with success. Aberrant respiratory and laryngeal behaviors were best modified when symptomatic-behavioral intervention was administered early following an accurate diagnosis of PVFM. Drills or brief periods of practice were distributed over time in lieu of lengthy practices. Consistent or repeated practice on a single task was combined with variable practice involving a range of related tasks once the target behavior is achieved with at least some consistency in the associative stage. Moreover, treatment sessions were organized strategically in that the patient was seen more frequently for shorter periods in early stages of therapy to manage the existing PVFM and coexisting clinical manifestations. Stimulus Control. Another aspect of phase 2 involved stimulus control. Phonotraumatic behaviors, such as chronic coughing and throat clearing, were eliminated with the use of hydration therapy techniques. The patient was instructed to take a sip of water when the need to cough or clear her throat arose. She also was instructed to drink at least eight 240 mL (8 fl oz) glasses of water daily as a prophylactic measure. Her primary care physician referred her to a nutritionist to address optimal nutritional intake because she had lost a considerable amount of weight due to chronic vomiting. The patient was instructed


to eliminate caffeinated beverages as a prophylactic measure to eliminate possible GERD/LPR side effects. Formal Psychotherapy. Psychotherapy was the final component of phase 2. The patient sought the help of a psychologist with expertise in treating functional and psychogenic voice disorders. Formal psychotherapy consisted of use of the neurolinguistic programming (NLP) model,31 which incorporated use of hypnosis and psycho-educational techniques, such as pacing, mirroring, modeling, self-awareness, guided visualization, systematic desensitization, and stress-coping repertoires, in achieving optimal laryngeal and respiratory function.

Phase 3: Generalization and Carryover Phase 3 of treatment addressed carry over of target behaviors utilizing behavioral paradigms noted to facilitate optimal function. Although carryover strategies began in phase 1 and phase 2, the focus of this phase emphasized selfawareness, patient independence, and patient control in alleviating and eliminating aberrant respiratory, laryngeal, and phonatory behaviors. The use of “preparatory sets” were organized to achieve optimal function. For example, target behaviors, techniques, and established protocols to restore lost function were emphasized including: n stimulus control (GERD/LPR, sinus-

itis, and rhinitis protocols, hydration therapy to control chronic cough and throat clearing, diet control, etc) n control of musculoskeletal laryngeal and whole-body tension factors using physical methods (manual laryngeal

massage) and other established tension-reducing paradigms n emotional and psychological coping repertoires to eliminate the onset or exacerbation of the aberrant respiratory-laryngeal problem Use of the daily home journal assisted the examiner and patient in determining the efficacy of treatment and the beneficial effects of each treatment paradigm.

Therapy Outcomes Audio-Perceptual The CAPE-V was completed to assess the patient’s vocal attributes with respect to post-treatment. The scores obtained on the CAPE-V post-treatment are as follows: n Roughness: 8/100 (mildly deviant) n Breathiness: 0/100 (no perceived

deviancy)

n Strain: 7/100 (mildly deviant) n Pitch: 0/100 (deemed to be appropri-

ate for age and gender) n Loudness: 0/100 (no perceived deviancy) n Severity: 8/100 (mildly deviant) Visual Imaging

On a follow-up evaluation by otolaryngology, there was no evidence of PVFM during transnasal flexible laryngoscopy. Patient Self-Assessment The patient’s results on the V-RQOL post-treatment revealed a standard score of 80 in the social-emotional domain and a 55 for the physical-functioning domain. The total V-RQOL score was 66.

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4. Rammage L. Emotional expression and voice dysfunction. ASHA Perspect Voice The patient attended 12 treatment sesVoice Disord. 2011;21(1):8–16. sions and 2 follow-up voice therapy 5. Clauw DJ, Taylor-Moon D. Information About Fibromyalgia. 2005. Retrieved treatment sessions before she was disMay 2006, from http://www.rheum charged from therapy. atology.org/public/factsheets/fibr omya_new.asp. 6. Coderre TJ, Katz J, Vaccarino AL, MelSummary and zack R. Contribution of central neuroConcluding Remarks plasticity to pathological pain: review of clinical and experimental evidence. The patient gained control of the Pain. Mar 1993;52(3):259–285. PVFM problem and the frequency of 7. Fuller NS, Morrison RE. Chronic an “attack” decreased to approximately fatigue syndrome. Postgrad Med. 1998; 1 episode over a 3-month period. Hyper103(1):175–176. functional vocal behaviors were elimi- 8. Mihrshahi R BeirmanR. Aetiology and pathogenesis of chronic fatigue nated, and her vocal quality returned to syndrome: a review. NZ Med J. 2005; normal baseline levels. Upon discharge, 118(1227):U1780. objective MDVP findings revealed that 9. Vandvik PO, Lydersen S, Farup PG. jitter and shimmer perturbation meaPrevalence, comorbidity and impact of sures were below thresholds. With irritable bowel syndrome in Norway. the help of formal psychotherapy, the Scand J Gastroenterol. Jun 2006;41(6): patient was transitioned back to school 650–656. as coping repertoires were implemented 10. Mulak A, Paradowski L. [Migraine and to address psychogenic and emotional irritable bowel syndrome]. Neurologia i manifestations underlying her probneurochirurgia polska. 2005;39(4 suppl 1): lem. The patient was followed by her S55–S60. primary care physician for adjust- 11. Yunus MB. Central sensitivity syndromes: a unified concept for fibroment and elimination of oral medicamyalgia, and other similar maladies. J tions prescribed to treat her respiratory Indian Rheumatol Assoc. 2000;8:27–33. distress. 12. Yunus MB. The concept of central sensitivity syndromes. In: Wallace DJ, Clauw DJ, eds. Fibromyalgia and Other Central Syndromes. Philadelphia, PA: References Lippincott Williams & Wilkins 2005. 13. Yunus MB. Fibromyalgia and overlap 1. Morrison M, Rammage L, Emami AJ. ping disorders: the unifying concept of The irritable larynx syndrome. J Voice. central sensitivity syndromes. Semin Sep 1999;13(3):447–455. Arthritis Rheum. Jun 2007;36(6):339–356. 2. Morrison M, Rammage L. The irritable 14. Yunus MB. Central sensitivity synlarynx syndrome as a central sensitivdromes: a new paradigm and group ity syndrome. CJASLPA. 2010;34(4): nosology for fibromyalgia and overlap282–289. ping conditions, and the related issue 3. Angsuwarangsee T, Morrison M. of disease versus illness. Semin ArthriExtrinsic laryngeal muscular tension in tis Rheum. Jun 2008;37(6):339–352. patients with voice disorders. J Voice. 15. Ambalavanar R, Tanaka Y, Damirjian Sep 2002;16(3):333–343. M, Ludlow CL. Laryngeal afferent


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tion: a pilot study. J Voice. Dec 2004; laryngeal therapy. J Commun Disord. 18(4):467–474. Mar–Apr 2009;42(2):124–135. 104. Dromey C, Nissen SL, Roy N, Merrill 106. Van Lierde KM, De Bodt M, Dhaeseleer RM. Articulatory changes following E, Wuyts F, Claeys S. The treatment of treatment of muscle tension dysphonia: muscle tension dysphonia: a comparipreliminary acoustic evidence. J Speech son of two treatment techniques by Lang Hear Res. Feb 2008;51(1):196–208. means of an objective multiparam105. Roy N, Nissen SL, Dromey C, Sapir S. eter approach. J Voice. May 2010;24(3): Articulatory changes in muscle tension 294–301. dysphonia: evidence of vowel space 107. Rosenbaum D. Human Motor Control. expansion following manual circumSan Diego, CA: Academic Press; 1991.

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7 Management of the Professional, Avocational, and Occupational Voice

Interest in defining the professional voice user and who is the “most qualified” to treat this person is not new and has been the focus of articles, books, and conferences for over 20 years. Although this chapter will not answer the question of who should treat, it is the opinion of the editors that speech-language pathologists with additional training in vocal pedagogy for the singer or the actor are the most qualified professionals to treat the disordered voice of a professional voice user. The authors in this chapter introduce the reader to the demands of various professional voice users from the childhood musical theater rising star

to the minister of music in a religious institution. Suggestions for treating not only the voice but the professional voice user’s environment and mind-set toward their vocal demands are also addressed. The reader is guided to be mindful that all the authors of this chapter are well versed not only in the care of voice disorders but also in the musical or theatrical training of the professionals they treat. Care of the professional voice does pose risks and often multidisciplinary care and referral to a speech-language pathologist with expertise in the particular skill and genre of the professional voice user is the best treatment.

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Introduction Marina Gilman The caseloads of speech pathologists treating patients with voice disorders include patients with a wide variety of vocal needs. Vocal demands span from the basic ability to communicate, to interact with family and colleagues, to be heard over noise or just to be heard, to needing a finely tuned instrument that responds easily and freely with a consistent and highly varied sound palate. This chapter focuses on the latter — the patients who must maintain a highly refined flexible vocal instrument to function professionally, and at the same time use that same instrument, their voice, for daily communication and all that implies. The human voice is capable of producing an amazing variety of sounds. Some are pleasing to the ear and others are less so, depending on individual tastes and auditory sensibilities. Common to all the ways the voice can be used and all the sounds it can produce is the need for well-coordinated respiration, phonation, and resonance to maintain the optimal laryngeal function. The role of the voice clinician is to facilitate the rehabilitation or restoration of function of the voice based on the specific vocal needs of the patient. In order to be effective, it is important to understand not only the anatomy and physiology of the vocal tract and its relation to respiration and resonance, but also how the presenting symptoms relate to the diagnosis and the functional demands of the patient. In other words, where or how does the voice break down impairing vocal production so the vocal needs of the patient are

no longer met? Therapy goals, specific plans of treatment, and therapeutic exercises are equally based on diagnosis and presenting symptoms, vocal capabilities, as well as the vocal needs of the patient. Thus, many voice clinicians are hesitant to treat patients who are singers at any level, especially high-level professional singers. Some clinicians and singing teachers argue that the very act of singing in a therapy session is out of the scope of the speech-language pathol ogist. According to ASHA,1 a speechlanguage pathologists’ scope of practice is to “address typical and atypical communication” in voice in order to address “phonation quality, pitch, loudness, respiration.” These clinicians are more comfortable treating a patient who may be a high-level actor because they feel they understand the “speaking voice.” In fact they may not understand the specific vocal demands and professionspecific “instrument tuning” needed by someone in the broadcast industry or a stage actor any more than they do a high-level rap singer. Does this imply that a clinician who is not a high-level, elite voice professional cannot provide successful therapy to this population? Not at all. There is one voice — not a singing voice and a speaking voice. There are many ways in which the one voice can be used. The commonality of speech function — the coordination of respiration, phonation, and resonance to produce the target sound — does not change for singing or speaking. How the systems are used and the demands of the systems do change depending on the task, whether yelling at a football game, singing opera over a large Wagnerian orchestra, or filling a theater with a stage whisper. The treating clinician needs to understand how the presenting pathology disrupts the normal vibratory


characteristics of the vocal folds and vocal mechanism in general. They also need to appreciate that the disruption in function might be more apparent in certain functions than in others. For example, a phonotraumatic pathology will alter the vibratory pattern of the vocal folds, potentially resulting in increased effort, reduced endurance, increased vocal fatigue, reduced range especially the upper range, or phonation breaks or vocal instabilities. All vocal functions are affected from vegetative cough to talking and singing. Once the patient has learned to optimize laryngeal function, vocal quality and ease of phonation improve. The pathology may have resolved together with maladaptive compensatory behaviors, in which case all vocal tasks return to normal. In this instance the full vocal capabilities of the singer should also return. Voice therapy may not have specifically addressed the singing function, but singing is improved because the overall system has improved. In another instance, an accomplished singer or actor with such a pathology might be able to sound reasonably normal speaking even singing in part of his or her range, but the pathology would still impact on their professional activities. In this case it would be more appropriate for the patient to be treated by a clinician with additional knowledge. The maladaptive patterns resulting from the pathology would present in a more subtle way requiring someone with advanced training in voice. Even though the basic therapeutic tools, exercises, and tasks are similar to those used with patients with similar pathologies and symptoms, more experienced eyes and ears are needed. In other words, just because the patient is a singer does not mean the

voice clinician should not begin treatment. It does mean the therapist must understand the limits of his or her knowledge, when it is appropriate to terminate therapy and when it is necessary to refer to someone who can continue the rehabilitative process, either another clinician with the additional qualifications or a singing teacher or an acting coach. The high-level voice professionals’ needs and vocal requirements are not only different as a group but also with each class, whether singer, actor (stage, large or small screen), broadcaster, or preacher. Further subclasses exist within each of these areas. The sports broadcaster has different vocal demands and vocal aesthetics than the newscaster. Likewise, within the realm of singers there are huge differences in aesthetics, vocal style, range (pitch and intensity), and technique. It is the rare clinician who has knowledge of them all. In addition to the expected ability to translate pathology to function, the clinician with supplemental voice training must understand the nuances of vocal production, have extensive knowledge of vocal pedagogy (not limited to classical singing pedagogy), and possess the clinical tools to fine-tune the respiratory/phonatory/resonance interaction. The clinician must be able to discern where the limitations of the physiology end and vocal technique begins. Knowledge of lifestyle, rehearsal, and studio demands is important, but knowing what questions to ask regarding lifestyle, training, and not just how much but what was taught, distinguishes the specialty voice clinician. Clinicians are often at a loss as to when they should refer the patient to a specialty clinician. A referral should be made when the patient does not feel as

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though the presenting issues have been resolved, the treating laryngologist concurs that continuing therapy is appropriate, and the clinician has reached the limits of his or her knowledge. For example, a patient’s voice production is back to baseline for daily use, but demands of singing or acting are still not met and higher function is still impaired. In this case it is important to determine whether the limitations experienced during high vocal function (singing or acting) are due to the continued presence of the pathology, are maladaptive compensatory strategies, or are limitations due to difficulty in generalizing therapeutic techniques for the specific vocal demands of the patient. Followup consultation with the laryngologist is recommended to determine whether or not the presenting pathology has resolved. If it is determined by the voice team that rehabilitative therapy should continue, it is essential that the treating clinician have sufficient training in the art and practice of singing or acting to continue the process. If these skills are lacking, the patient should be referred to a clinician with the necessary skill or to a singing teacher or coach who has knowledge of voice disorders. Therapeutic strategies then would be based on additional knowledge of the art and techniques of singing and/or acting combined with the armamentarium available to the voice therapist. Patients should be referred initially to a clinician with supplemental voice training if the patient presents with symptoms that only limit the high-level vocal function and are not bothered when using the voice for speaking. Likewise, they should be referred to the clinician with supplemental voice training for postoperative care.

Discussion of the training needed to treat elite professionals, especially singers, began in the mid-1980s.2 Discussion centered on developing training programs for singing teachers and speech-language pathologists with the intention of building a better voice care team.2–4 Recently several programs have been established to cross-train speechlanguage pathologists, singing teachers, and voice coaches. The first Summer Vocology Institute, jointly sponsored by the Denver Center for the Performing Arts, the University of Iowa, and the National Center for Voice and Speech was held in 2000. This ongoing 8-week summer program teaches courses including principles of voice production, instrumentation for voice analysis, voice habilitation, and voice for performers.5 The Ohio State University School of Music recently began offering a Singing Health Specialization program. In 1992 ASHA and NATS (National Association of Teachers of Singing) published a joint statement on scope of practice in the treatment of the dysphonic singer.1 This statement was revised in 2005 to include VASTA (Voice and Speech Trainers Association).6 As the field of voice has grown, an increasing number of speech pathologists working with voice disordered patients have singing backgrounds. To date these is no consensus as to the level or extent of additional training needed. The term singing voice specialist is commonly used to designate someone qualified to provide therapy to this elite population. Both speech-language pathologists and singing teachers/voice coaches are using this term. Yet the qualifications and training are different. It is only the speech-language pathologist who is certified and licensed medi-


cally to treat patients with voice disorders. The singing teacher and coach can work with the patient but should do so only in consultation with a medical professional. The line between therapy and a voice lesson needs to be clear. As was eluded to earlier in this introduction, it is important for the clinician to determine the line between limitations of pathology and poor technique. Often it is difficult to determine whether the patient’s function has returned to the premorbid state. The line is drawn when interpretation and vocal technique become the focus of therapy. As long as the exercises are used with a specific functional rehabilitative goal in mind, it is therapy. As soon as the goal is aesthetic enhancement taking the patient beyond his or her premorbid status, the line is crossed. When exercises relate to flexibility rather than reduced tension, range rather than optimizing laryngeal function, repertoire interpretation rather than use of a song as therapy exercise, in other words enhancement of function, then it is time to discharge the patient and send the patient back to his or her coach or voice teacher.

In this first case Patricia Doyle and Starr Cookman discuss the vocally loaded life of a young performer and the need to become a vocal health advocate for the child to manage the endless barrage of “ mandatory” vocally intense situations. They also remind us that the therapeutic process in the young does not differ in goals from that of the adult, and engaging the family, voice or acting teacher, and schoolteachers is of the utmost importance.

Case Study 1 Patricia Doyle and Starr Cookman Management of Vocal Fold Nodules in a Female Prepubescent Singer

Introduction With the onslaught of popular televised singing competitions such as American Idol, X-Factor, and The Voice, combined with glee club TV shows, singing voice video games, karaoke, and social media such as YouTube, singing is enjoying a crescendo in American culture. Young singers can be quite driven, aspiring to everything from a starring role in the school play to a professional career on Broadway. Even though the opportunities to sing seem to abound for children in our society, when to begin vocal instruction for them remains a controversial topic. This puts them at risk for becoming one of the 6 to 23% of schoolaged children in the United States diagnosed with a voice disorder.7 This case will highlight several issues germane to the rehabilitation of a pediatric singer with a voice disorder.

History of the Problem Patient DH is a 9-year-old female fourth grader who presented to the clinic with a complaint of ongoing hoarseness. She began acting and singing at about age 4 or 5, and has been semiprofessional since that time. At age 7, she performed in a musical theater show while attending an overnight performing arts camp. When her mother visited the camp, she

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noted that her daughter’s voice was severely hoarse. DH performed despite her hoarseness. The day after, she was nearly aphonic. Although her voice improved somewhat with rest, it did not fully recover. In response, DH’s mother found her a vocal coach, with whom she worked for 6 months. Her voice worsened during this period. At age 8, the patient’s mother switched DH from a vocal coach to a voice teacher. This teacher focused on technique and gave her vocal hygiene recommendations. After 1 year of instruction, DH’s voice continued to become moderately hoarse after singing. At this point, her pediatrician referred her to otolaryngology.

Social/Medical History At home, DH lived with an older brother and her parents, where she talked frequently and yelled at her brother an average of 2 or 3 times per day. She also sang to herself and along with CDs. DH’s mother reported, “She is singing all the time.” At school, DH participated in class and then talked socially with her peers during lunch and recess. She also played soccer 5 times per week, yelling frequently during practice and games. She had a singing lesson once a week for 1 hour. She auditioned for voiceovers and commercials 2 to 3 times monthly (cast 3 times in the past year) and sang in several local theater productions annually. In terms of singing, DH described herself as an alto who preferred singing in a contemporary musical theater style, and, in particular, belting. Overall, she estimated singing for 2 to 4 hours on a typical day and for a maximum of 6 hours on her busiest vocal day.

As one would expect, DH was a nonsmoker and was not exposed to secondary smoke. She drank approximately 1 caffeinated soda weekly, and 1.5 to 2 L (50 to 70 fl oz) of water daily. The Reflux Symptom Index (RSI) score at the time of her assessment was 9, with 13 or greater being suggestive of reflux.8 DH was born 2½ weeks premature and spent 1 day in the neonatal intensive care unit (NICU). All developmental milestones were reached on time. At age 8, she had whooping cough lasting 2 to 3 months. At the time of the assessment, she was not taking any medications and reported no known allergies. The mother also experienced hoarseness since childhood but had never sought a diagnosis.

Videostroboscopic Assessment Videostroboscopy was completed at the time of the otolaryngological evaluation. The larynx was adequately viewed during sustained phonation at approximately 350 Hz. Laryngeal observations made at the time of the initial examination included bilateral, nontransparent vocal fold nodules at the midpoint of the vibrating portion of the true vocal folds. The right nodule was broader based than the left. An hourglass-shaped glottis prevailed during vibratory cycles. Also observed during vibration were anterior-to-posterior phase asymmetry, moderate decrease of the amplitude of vibration bilaterally, and slight decrease in mucosal wave propagation bilaterally. The nodules appeared stiff and did not freely participate in vocal fold vibration. Normal attributes of the laryngeal evaluation included vertical level of


vocal fold approximation, periodicity of vocal fold vibration, normal arytenoid movement, and vocal fold elongation with elevated pitch. No supraglottic compression was noted during phonation. There was no evidence of velopharyngeal insufficiency, allergic rhinitis, or laryngopharyngeal reflux. Management recommendations from the otolaryngologist included a speechlanguage pathology assessment and treatment, temporary singing restriction, and a 4-month follow-up videostroboscopic evaluation.

Speech-Language Pathology Assessment During conversational speech, DH presented with moderate dysphonia characterized by moderate roughness, mild breathiness, no asthenia, and moderate strain (G2R2B1A0S2).9 Glottal fry was heard on approximately 15% of words, usually, but not always, at the end of a thought. Persistent sharp throat-clearing was observed 7 times in 1 hour. DH used harsh glottal attacks 41% of the time when reading the Towne-Heuer Reading Passage, which exceeds the expected average of 15%.10,11 Resonance was mildly hypernasal. She used a clavicular breathing pattern, appeared to have limited inhalation in preparation for speech, and averaged 18 words per breath, which is greater than the average of 12.12 Additionally, her breath replenishment pattern was agrammatical. Pressed voice quality suggested insufficient breath support. Excessive laryngeal movement was visible during speech. Palpation of the perilaryngeal area by the clinician revealed laryngeal resistance to manual lateral displace-

ment. Other findings included mild constriction of the thyrohyoid space as well as tightness in the submandibular sling. She denied discomfort or tenderness during light palpation of the laryngeal complex. A singing assessment was completed. The patient sang 5 note-ascending and note-descending major scales throughout her range during which time overall vocal technique and singing range were assessed through observation. Ability to control vocal dynamic variation was assessed using a messa di voce task. DH was asked to sing from soft to loud and back to soft on a single pitch. Several representative pitches are chosen based on reported problem areas and perceived register transitions (passaggi). Additional vocal tasks included glissandos (sirens), short staccato high-pitch repetitions, and a sample song. DH’s singing range was from F#3 to B#5, or 185 to 932 Hz. She exhibited overt clavicular movement during preparatory inhalation. Delayed onset of phonation was observed upward from F5 at moderate volume and from C5 at soft volume. Pressed vocal quality prevailed. Pitch was intermittently and randomly flat with no vibrato. She exhibited tongue retraction and limited jaw excursion for higher pitches. Resonance was hypernasal throughout her range. This aspect of her resonance was more pronounced when singing as opposed to scales. Aphonic breaks were noted intermittently, particularly above C5. When singing a selection from her repertoire, vocal register use included modal register from F#3 to A4 and head voice from A#4 to B#5. The shift from modal to head was obvious and marked by an abrupt change from loud/pressed to light/breathy.

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Quality of Life Index The Voice Handicap Index-1013 was administered to determine negative impact on quality of life secondary to DH’s vocal issues in functional, physical, and emotional domains. The patient scored 17 out of a possible 40 points corresponding with moderate negative impact. Laryngeal Function Studies Aerodynamic data were collected using the 6600 KayPENTAX Phonatory Aerodynamics System (PAS) software. At the patient’s medium volume, average subglottal air pressures were 10.18 cm H2O (norms = 4 to 8 cm H2O), airflow rates were 130 mL/s (norms = mL/s), and mean glottal resistance was estimated at 78 cm H2O/L/s (norms = cm H2O/ L/s). Maximum phonation time was decreased at 9 seconds compared with a normative value for girls between the ages of 5 and 12 of 14.97 seconds.14 Maximum prolongation on /s/ was 21 seconds and on /z/ was 13 seconds with an s/z ratio of 1.6 which is considered increased.15 Average fundamental frequency during connected speech was decreased at 233 Hz compared to the expected range for 8-year-old girls of 250 to 340 Hz.16 Frequency range during speech was 141 to 376 Hz. Maximum frequency range was less than 2½ octaves (A3 to B5 or 223 to 932 Hz).

Therapy Goals The patient’s goals included increasing vocal clarity, improving vocal stamina, and decreasing nasality in both speaking and singing. The clinician’s goals for voice therapy were as follows:

1. Provide patient and caregiver education regarding key factors suspected in the pathogenesis and maintenance of vocal fold nodules, optimum vocal hygiene, environmental modifications to promote healthy voice use, and normal laryngeal development through puberty. 2. Improve voice efficiency and reduce vocal fold impact force through reduction of laryngeal hyperfunction, improved breath flow during speech, increased forward resonance, decreased use of harsh glottal attacks, and improved dynamic vocal flexibility. 3. Achieve physiologic changes, including reduction in lesion size, improved mucosal wave vibration, and improved glottal closure pattern (decrease the posterior musculomembranous glottal chink and achieve the desired barely abducted glottal closure pattern described by Verdolini and colleagues).17

Therapy Techniques The authors expound on several techniques particularly relevant to this case. Other essential techniques that were used effectively as part of this eclectic therapeutic approach are included in list form as they are described in more detail elsewhere in this book. Vocal Journal The vocal journal can encourage patient success by increasing patient awareness of things that are affecting the voice positively or negatively. It also becomes a chronicle of changes over time. The vocal journal can serve to remind patients of their vocal successes and not just their


vocal difficulties. When interviewing the patient, the clinician is less likely to get vague responses such as, “It was okay,” or “I didn’t notice any changes.” DH was asked to keep a daily vocal journal. In it, she was asked to document compliance with home practice, vocal accomplishments or setbacks, and any connections she could make as to why the voice was more or less hoarse. She could also write questions for the clinician or comment on how her exercises were going. DH loved keeping the journal, because it gave her the opportunity to “brag” about her vocal improvements. For example, she reported at session 6 that she had a fight with her brother, which involved some yelling and crying. She noted that in the past, that would have led to hoarseness the next day, but this time, she had no vocal deterioration afterward. DH particularly delighted in reporting situations in which she did not lose her voice and her mother did. Then, clinician and patient could talk about why DH thought she and her mother had different outcomes from the same social situation, and DH spoke about vocal conservation strategies or therapy techniques she used. Relaxation Exercises Relaxation exercises were chosen to target specific muscles identified during the speech pathology assessment as interfering with efficient voice production. The rationale is that the muscles in these areas, when tight, can inhibit laryngeal freedom and/or constrict vocal tract space needed for maximizing resonance. n Neck/shoulder stretches: These in-

cluded head drop forward, tilting ear

to shoulder, turning head to look over the shoulder, and shoulder rolls (forward and back). n Lateral laryngeal massage: The patient places one hand on either side of the thyroid cartilage, and then gently rocks the larynx from side to side in the neck. When the motion is mastered, the patient can elect to switch to performing the exercise with one hand using thumb on one side and fingers on the other. n Submandibular massage: With index finger resting laterally on the chin to support the weight of the hand, the patient is instructed to place her thumb into the submandibular area just behind the chin and massage gently. If the area is pliable in response to touch at rest, then the patient can progress to adding a neutral vocalization such as “uh,” “mm,” or “ah.” n Tongue extension word list: The patient reads through a list of 12 words 3 times (“till,” “town,” “teal,” “tot,” “test,” “tips,” “lash,” “style,” “still,” “tall,” “team,” and “hall”). the first time through, the patient protrudes the tongue and keeps it as still as possible hanging over the lower lip while reading the list. The patient is encouraged to move the jaw and lips as normally as possible, recognizing that correct articulation will be compromised. With the second reading, the patient brings the tongue back into the mouth into the neutral position (cradled by the lower teeth), but is still asked to read without using the tongue, with the reminder to move the jaw and lips as normally as possible. On the third reading, the patient reads normally, making note of any change in the sound or feel of the production. The tongue is important for articulation, but is not

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supposed to engage as part of the start of phonation. When the tongue tightens with voicing, it can cause laryngeal elevation and also retract, narrowing the pharyngeal cavity space, and preventing adequate oral cavity space as well. This exercise separates the tongue from the voicing process, and by degrees, adds it back so that the patient learns to keep the tongue free for the appropriate positioning for articulation without interfering with the voicing. This exercise also facilitates tongue/jaw disassociation. These exercises, when combined with the other exercises working on resonance and improved glottal efficiency, helped the patient increase her oral resonance, decrease tongue tension in speech, and decrease harsh vocal quality successfully during the course of treatment. She continued to have some submandibular engagement in singing above about D5. Respiratory Retraining The switch to abdominal/diaphragmatic breathing for DH was intended to decrease muscle tension perilaryngeally, to connect the breath to the voice, and to provide her a basis for sound singing technique moving forward. When asked to take a breath, DH would inhale by pulling in her stomach and raising her shoulders, increasing the likelihood of perilaryngeal tension and underuse of diaphragmatic contraction. To correct this pattern, the clinician first targeted exhalation mechanics. By having her start with exhalation, the abdominals engaged almost immediately and the stomach pulled in. At the end of the breath, the release of the

abdominal musculature gave DH the opportunity to feel the stomach move out with inhalation. A voiceless tongue trill was added to begin the connection of the breath to a valve that the patient can monitor. DH was presented with the rule, “Trill must not die,” meaning that the trill should sound even to the end of the breath, without thinning or cutting out. The voiceless trill helped the patient to understand that, just like the tongue tightening or the trill cutting out completely when she was not supporting to the end of the breath, the vocal folds would be tightening in a similar fashion if voicing were added. DH mastered abdominal/diaphragmatic breathing at the exercise level after only 2 sessions. The correct pattern was incorporated into her speech work by session 3 and into her singing beginning at session 5. Semi-Occluded Vocal Tract Exercises DH’s treatment involved more than one form of semi-occluded vocal tract exercise, with some overlap of purpose, but with different specific subgoals. This patient learned tongue trills, the use of a toy that required the use of a continuous air stream, and vocal function exercises (see Stemple Chapter 3 for a thorough explanation of vocal function exercises). n Tongue trills: After learning the

voiceless tongue trills described in the breathing section and supporting well to the end of the phrase, the patient was asked to add sustained voicing. She performed trills on a comfortable pitch and while sliding her pitch up and down within her speaking range. Finally, she completed an onset/offset exercise in which she had to transition back and


forth between voiceless and voiced trills on 1 breath without any break in the trill or significant airflow change. Unlike with the vocal folds, the vibration at the tongue can easily be felt and monitored by the patient. Lip and tongue trills, like other semi-occluded vocal tract exercises, help to promote a more balanced relationship between the breath and the voice throughout the patient’s range and to encourage a more open vocal tract configuration.18 Particularly when working with a child, having a task that is easily monitored (is the tongue vibrating or not?) is beneficial. The sustained trills are used to teach the patient to evenly distribute the breath to the end of the phrase. The gliding trills introduce the changing breath demand required for higher and lower pitches. The onset/offset trills train the vocal folds how little they have to engage in order to initiate sound. If the patient overengages at onset, the trill stops or there is a noticeable change in the airflow. Finally, sung trill scales are a well-established warm-up exercise for singers and were therefore implemented during treatment and recommended as part of DH’s long-term vocal maintenance protocol. DH mastered the tongue trill exercises very quickly. Then, later in her therapy, the trill work was expanded to warming up with tongue trill scales, with the patient using the trill to determine if she was providing adequate breath support as she explored different parts of her vocal range. n Toy: The toy that was used is called an “Eye Pop,” which was originally developed as an educational toy to teach about aerodynamics. The patient blows into the tube, causing two foam balls to float. The patient

is then asked to keep the balls afloat steadily with and without voicing. In general, the toy or any toy like it is beneficial for patients who are having difficulty connecting to the breath with other semi-occluded vocal tract exercises. For children (and, frankly, adults as well), the toy aspect can make performing vocal exercises more fun, and therefore, increase home practice compliance. The visual feedback provided by the balls can be both motivating and enlightening. If the ball drops with the addition of voicing, the patient can easily understand that they have hyperadducted at the level of the vocal folds. When they learn to maintain ball height with addition of voicing, they can surmise that they have increased transglottal airflow, likely decreasing vocal fold hyperadduction. The clinician monitors for unwanted breathiness. When DH first added voicing to the ball-blower, the balls did not move, even though she had been able to get them to float for the voiceless task. This suggested that she was hyperadducting her vocal folds. With practice, she was able to figure out how to get the balls in the air while phonating. In the case of DH, the clinician was having difficulty getting her to establish the kazoo buzz sound for the Vocal Function Exercises. DH was asked to alternate from the ballblower to the formation of the kazoo buzz for vocal function exercises, and she was then successful. n Vocal Function Exercises19: (See Stemple Chapter 3 for a full explanation of vocal function exercise.) VFEs were introduced to work on balancing the respiratory, phonatory, and resonatory subsystems. The prolongations increase breath control with healthy

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technique to be applied to both speech and singing. With the pitch glides of the exercises, the patient initially would lose breath connection in the passaggio (vocal register transition) from middle to head voice (at about E5, or 622 Hz for her). This was evidenced by a loss of the vibratory buzz on her lip and by the loss of the feeling of breath on her hand. Again, having the external monitor of these sensations provided more obvious and immediate feedback as to when she was starting to strain. By therapy session 4, she could glide correctly to A5 (880 Hz), and by session 8, the range increased to D6 (1175 Hz). Her prolongation times increased from a starting average of 13 seconds to an average of 22 seconds at the time of discharge. Nose-Pinching This task provides an easy and clear way for the patient to monitor and correct hypernasality, remembering that this is a patient who was shown to have normal velopharyngeal function, and was just habitually speaking and singing with hypernasality. The patient practiced reading nonnasal words while repeatedly pinching and unpinching the nares. If she was not getting adequate velopharyngeal closure, then there was an audible change in the sound and sensation between the pinched and unpinched conditions. If the palate is adequately elevated, then there is no change in the sound with the nosepinching task. This was incorporated into singing tasks beginning at session 5. The healthy speaking voice techniques need to be in place prior to advancing to the more difficult vocal context of singing. The clinician extracted nonnasal

phrases from DH’s repertoire and had her practice while monitoring via nosepinching. Sample sung phrases for this patient included “Bibbidi-bobbidy-boo” from Disney’s “Cinderella” and “I’ve got whosits and whatsits galore” from Disney’s “The Little Mermaid.” These were sung having the patient move up and down through her singing range. At the time of discharge, the patient spoke and sang without hypernasality without reminders from the clinician 90% of the time. Twang Programs such as the Estill Voice Model program describe twang as the narrowing of the aryepiglottic sphincter while maintaining retracted false vocal folds and higher tongue position in order to create a formant in the area of 2000 to 4000 Hz. Twang is one of the components of producing a healthy belt according to this training method.20 The clinician, having completed levels I and II of Estill Voice Model training, uses some aspects of the Estill model in her work. With DH, the intent was to increase her vocal clarity and to begin to teach her a healthy belting technique. The patient is asked to produce a brassy spoken “Yeah,” with references to Bugs Bunny or a bratty child as well as clinician models to help guide the sound formation. Once that is established in speech, the patient practices “yeah” sliding up into her upper range and then back down. Other sounds that encourage twang and were used with this patient include “Meow” (tough alley cat sound) and then transitioning to “Yow.” With DH, the clinician moved away from the /m/ quickly so that she could continue to monitor for hypernasality with the nose-pinching. By the end of treatment,


the patient was singing with less strain as she ascended to C and D5 in repertoire, and her vocal quality was less breathy. Additional therapy techniques were incorporated into the patient’s treatment. These included Lessac-Madsen Resonant Voice Therapy (see Orbelo and Verdolini, Chapter 3, for a thorough explanation of the exercises),17 easy onset and blending, throat-clearing reduction, patient and family education, and establishing an age-appropriate vocal warm-up.

Outcome DH received a total of 12 sessions of voice therapy. At the time of discharge, she no longer experienced vocal deterioration and was happy with her vocal quality, range, and stamina. By session 8, the director of the children’s theater troupe to which the patient belonged called DH’s mother to say how much clearer the patient’s voice was. The clinician continued to note a mildly breathy vocal quality to DH’s voice. Videoendoscopic examination post-treatment revealed the resolution of vocal fold edema, and

her nodules were smaller with improved mucosal wave bilaterally. Her posterior glottal chink had reduced to within normal limits. Three years status postdischarge from therapy, the patient returned to the clinic for management of a cough related to allergies. She had no vocal complaints. Laryngeal examination revealed almost complete resolution of her nodules with no signs of any recent exacerbation (Table 7–1).

Discussion Although one might expect to have to significantly change the therapeutic approach when working with someone as young as this patient, performing children are often very outgoing and precocious, and do not need to have most aspects of therapy simplified. The main factor differentiating intervention with a pediatric singer versus an adult is the need to identify key decision-makers in the child’s life and to enable them to effectively support her vocal health. Ideally, the patient’s parent helps by monitoring vocal behaviors. He or

Table 7–1. Pretreatment and Post-treatment Measures for Patient DH Objective Measure

Pretreatment

Post-Treatment

10.18

6.57

Airflow rate (mL/s)

130

130

Glottal resistance (cm H2O/L/s)

78

50

Maximum phonation time (MPT)

9

11

21:13 (1.6)

15:13 (1.15)

233

218

A3 to B5, or 223 to 932 Hz

F3 to E6, or 178 to 1244.5 Hz

Subglottal air pressure (cm H2O)

s/z ratio Average fundamental frequency (Hz) Maximum frequency range

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she may set boundaries for vocal use, such as postponing auditions and/or suspending the patient’s involvement in performance and loud activities such as cheerleading. It was clear to the clinician from the time of the assessment that DH’s mother was acting as the agent for her child’s voice in trying to get her into the professional world, and yet, this mother had no experience as a performer herself and had no background in singing. Therefore, the clinician provided the mother with information about vocal health, about the ways in which the professional performing environment can threaten that health, and how she could be a better advocate for her child’s voice. This was framed as protecting the asset of the child’s voice. Education also focused on vocal conservation strategies in various contexts (ways she could fight with her brother with reduced or no yelling, nonverbal ways for DH to cheer on her teammates at soccer games, reducing loudness required to speak in class by sitting near the teacher). DH’s mother was encouraged to provide visual and verbal reminders to the patient encouraging vocal naps throughout the day. Education was provided regarding possible pubescent vocal changes, including a gradual lowering of vocal pitch, possible increase in breathiness, possible difficulty in register management, and possible difficulty projecting in her upper range.21 Although DH’s mother expressed interest in helping her daughter’s voice, and was pleased with her progress, she often balked at recommended vocal conservation measures and other restrictions. To convince her, the clinician delved deeper into the science and pathophysiology behind the connection between voice use and nodule development.

Even though it is sometimes necessary to have the patient discontinue unmonitored vocal activities such as choirs and theater productions, it is usually advisable for them to continue their private singing lessons. Most voice teachers are extremely motivated to help their students, and with guidance, can incorporate voice therapy exercises into the voice lesson. Typically, the teacher is asked to limit lessons to no more than 30 minutes at a time, with focus on technique, not repertoire, during the treatment process. This case history delineates several points in time where DH needed a vocal health advocate. At the performing arts camp, it is concerning that the camp counselors apparently did not identify this child’s hoarseness as an issue and allowed her to perform with such hoarseness. The patient’s mother did not pull her child from the show when she heard how hoarse she was on parent visitor’s day. She also did not take her to the doctor or otolaryngologist as soon as the child got back from camp. Her decision was to get her vocal coaching. In this case, the vocal coach not only did not recommend that the patient be seen for assessment of her hoarseness, but he also induced more hoarseness after his coaching sessions with DH. Concerned, the mother switched DH to a vocal teacher, who did, in fact, work on technique. However, unlike most voice teachers who would refuse to teach a hoarse student until the cause of that hoarseness had been determined and medical clearance for voice lessons had been issued, this teacher did not refer the patient to a voice clinic. By the time DH received her diagnosis, her nodules were large and stiff. Better education of professionals working with young singers regarding appropriate referrals


for hoarseness could have resulted in the patient’s nodules responding more rapidly to therapy, and would have allowed less time for DH’s compensatory muscle tension to root itself in her muscle memory. In Case 2, Barbara Jacobson describes a comprehensive workup of a singer who is just entering the performance world and continues to need to work as a waitress for financial support. She discusses the collaborative work of multiple physicians, the speech-language pathologist, and the voice teacher to assist this young lady in achieving her performance goals.

Case Study 2 Barbara Jacobson The Developing Performer

History Patient JS, a 21-year-old female aspiring singer/songwriter, was referred to the voice center for complaints of hoarseness in her speaking voice, diminished control of her singing voice, decreased vocal range for singing, and loss of “head register” (ability to produce singing voice for high notes). She experienced vocal fatigue in both her speaking and singing voice. She was seen in the multidisciplinary clinic by a speech-language pathologist, laryngologist, and singing voice specialist, all on the same day. She had scheduled songwriting appointments and singer showcases, and this was the impetus for seeking help.

Voice History Patient JS gave the following voice history. She had been singing since she was very young. She was a cheerleader in high school. She sang in school choirs as an alto/tenor and began singing contemporary country repertoire with a band during her late teens. She attended college for 2 years. After she left school, she typically sang 4 nights per week, with multiple sets (at least three, for 40 minutes each time) per night. She often sang in smoky environments. At age 20, she developed significant problems with her voice, particularly after an episode in which she had a bad bout of bronchitis. At that time, she was diagnosed with vocal nodules. The otolaryngologist she was seeing at that time suspected gastroesophageal reflux. He prescribed a period of total voice rest (including singing), treatment with steroids, and a course of a proton pump inhibitor, and told JS that the nodules appeared to go away with that treatment. She did not receive voice therapy at that time. Her voice became somewhat clearer immediately after starting the treatment, but over the past year, she began to have problems with both her singing and speaking voice. Patient JS had formal voice training during her college years. She acknowledged that she had difficulty applying knowledge from these lessons to her singing technique. Her voice teacher categorized her as a soprano, though patient JS struggled to produce her voice in the higher voice range. She believed her singing style was most consistent with a “belting” technique. Her current singing range was approximately oneand-a-half octaves, which was significantly below her potential range. Any attempts to reach high notes resulted in a breathy, “weak” sound.

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Medical History The patient’s medical history was remarkable for temporomandibular joint dysfunction with bruxism and suspected allergies (which were not documented). The patient described bulimic and anorexic behavior that had occurred approximately 6 years previously and lasted for 1 year. She did not seek medical or psychiatric assistance. The patient currently was talking no medications. She did not use antihistamines or aspirin. Hydration was adequate. She drank 2 to 3 beers per week. She occasionally drank a caffeinated beverage. She had a 2-year history of 1 pack per day cigarette smoking but had quit 3 years ago. She complained of occasional feelings of heartburn. Her sleeping pattern was erratic. Social History Patient JS was employed as a waitress. She described her daily voice use as heavy. She frequently had to raise her voice to be heard at work. She would often go out with friends to bars or music venues after her shift on the nights she was not performing. Her informal songwriting appointments often lasted several hours at a time, and she did the demo work for the songs written during these sessions.

Medical Evaluation Otolaryngologic evaluation revealed slightly dry nasal mucosa. Oral cavity, oropharynx, and nasopharynx were normal. Indirect laryngoscopic examination was remarkable for bilateral vocal fold focal edema. Vocal folds were vascular in appearance. There was increased pain on palpation of the thyrohyoid space with some discomfort on

palpating her strap muscles. There was marked popping in her temporomandibular joints on jaw opening.

Voice Evaluation Voice analysis included videostroboscopy which demonstrated an hourglass closure configuration. There was compression of the ventricular folds on phonation onset. This increased supraglottic activity, which included anterior to posterior compression, which increased as the patient approached her register break, at the transition from her middle to head voice. During stroboscopy, it was noticed that her mucosal wave was moderately decreased bilaterally, especially over the area of midfold swelling. The open phase of vibration predominated. These videostroboscopic results indicated that the patient had a significant amount of air wastage due to decreased glottic efficiency during phonation. She also exhibited increasing extralaryngeal tension as she attempted to sing higher in her range. There was a characteristic “hyperfunction/underclosure” glottic configuration evident at higher pitch productions. The patient’s acoustic analysis is shown in Table 7–2. Acoustic measures indicated a decreased habitual pitch and reflected her rough voice quality. The results of her aerodynamic analysis are shown in Table 7–3. Normally, we might expect that airflow values would be low at all pitches and even across all pitches for singers. Phonation time should be significantly longer than the average 18 to 20 seconds we expect for nonsingers. Results for this patient reflected inefficient laryngeal valving during phonation at her habitual and high pitches. Perceptual analysis of the patient’s voice revealed a mild dysphonia char-


Table 7–2. Pretreatment Acoustic Analysis for Patient JS Mean F0 (Hz)

Jitter (ms)

Shimmer (%)

SNR (dB)

Habitual pitch

173.5

0.114

4.02

25.50

High pitch

624.5

0.020

2.86

20.34

Low pitch

148.3

0.080

3.02

27.22

Oral reading

178.7

26.09

Table 7–3. Pretreatment Aerodynamic Analysis for Patient JS

Mean Flow Volume (mL)

Maximum Phonation Time (second)

Peak Flow Rate (mL/s)

Airflow Rate (mL/s)

Habitual pitch

3630

12.26

390

244.35

High pitch

3360

14.05

240

220.80

Low pitch

3245

13.67

225

130.25

acterized by roughness and breathiness. There was a slight strained voice quality. Habitual (speaking) pitch was perceived as being low. Habitual loudness in conversation was increased. Abusive voice production behaviors included throat clearing. The patient was able to sustain /i/ for only 11 seconds. An oral peripheral examination revealed normal oral structures for voice production. There was significant neck musculoskeletal tension with withdrawal on palpation and manipulation. Muscle tension was also apparent in the shoulders and upper back. The patient sat with a chin/ neck forward posture. Voice Handicap Index (VHI) score was 54 (range = 0 to 120; moderate self-perceived handicap). Singing Voice Handicap Index (SVHI) was 95 (range = 1 to 144; severe self-perceived handicap). The patient rated her voice problem as “moderate to severe.” Her ASHA NOMS score was

level 4 (“Voice is functional for communication, but sometimes distracting. Individual’s ability to participate in vocational, avocation, and social activities requiring voice is occasionally affected in low-vocal demand activities, but consistently affected in high-vocal demand activities”). Singing Voice Assessment Assessment by the voice teacher was significant for reduced vocal range. There were some excessively tense jaw and tongue postures observed during singing. In addition, the patient had difficulty dissociating jaw and tongue movements while singing. Breath support appeared to be normal. Tension was apparent during all aspects of singing. Consensus by the voice team was that the cause of the patient’s voice disorders was multidimensional. There

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appeared to be influences from both her speaking and her singing technique and speaking voice use. Her medical history (bruxism and bulimia) also contributed. She was referred to a gastroenterologist for assessment with pH probe and manometry. This was determined to be normal. Responsibility for day-to-day management was assigned to the voice pathologist and voice teacher.

Voice Therapy Patient JS immediately began voice therapy and voice lessons. Coordination between the voice pathologist and voice teacher was close, and treatment goals were developed to be parallel. We were struck by the patient’s motivation and commitment to achieving improvement in her voice and felt that this reflected favorably on her prognosis and eventual outcomes. In speaking voice therapy, treatment goals were established to educate the patient regarding vocal hygiene (in particular, to reduce loud voice use, throat clearing, and the amount of time spent in aversive, loud environments), to decrease laryngeal area muscle tension, and to increase the use of oral resonance and efficient airflow during voice production. In addition, to optimize vocal fold closure, a low-impact adductory exercise, Vocal Function Exercises (see Stemple, Chapter 3, for thorough discussion of Vocal Function Exercises), was implemented to produce improved vocal fold closure. She simultaneously underwent treatment with a singing voice clinician. Our overarching goals for modifying her voice production were to decrease the phonotrauma due to excessive muscle effort and increase coordinated appropriate airflow and

resonance for better efficiency in overall use. Weekly visits were scheduled, and the patient demonstrated compliance with vocal hygiene recommendations. Areas of treatment emphasis were coordinated with the voice teacher. For example, structured tasks specifically focused on reducing musculoskeletal tension were timed to correspond with work in relaxing jaw and tongue and increasing supraglottic “space” during voice lessons. We determined that myofascial release treatment would be beneficial, and the patient was referred to the Integrative Health Center for physical therapy with the referral diagnosis of cervicalgia. After 4 sessions, the patient’s laryngeal status was monitored with videostroboscopy. At that time, there was a reduction in the size of the bilateral vocal fold swellings. Also evident at that time was an increase in mucosal wave. Subjectively, the patient was beginning to notice an increase in her vocal range. She remarked that she did not feel as though she had to “push” as much to produce voice for either speaking or singing. She noted less roughness in her voice quality. Perceptually, we noticed an increase in her habitual speaking pitch. Over the course of treatment, patient JS was able to increase times for sustaining notes C through G on Vocal Function Exercises. Gradually, she lost the breathy quality on a sustained tone, inferring increased vocal efficiency. In particular, the patient found these exercises to be most helpful for monitoring the status of her voice. If she had used her voice too strenuously on the previous night, then on the following morning she noticed a decrease in the amount of time she was able to produce an engaged, sustained tone. This served


to reinforce her ability to self-monitor vocally abusive behaviors. In addition to Vocal Function Exercises, cup bubble and gargle exercises (see Muckala and Ruel in this chapter, Case Study 9 for a thorough discussion of cup bubble technique) were used to help the patient overtly maintain continuous airflow during sustained phonation and increase oral resonance. She was able to use the change in sensation and awareness of extraneous effort at the laryngeal level as a monitoring device to know when she was “pushing” her voice. She gradually transitioned into nasally loaded syllables, words, phrases, and sentences using these facilitators. Progress in both her speaking and singing voice production was rapid. The patient reported that the coordinated focus of treatment goals in both voice therapy and voice lesions helped her to understand concepts more quickly, even though the vocabulary might be somewhat different. In voice therapy,

the patient was asked to associate consciously techniques and principles for speaking with those for singing. Her voice clinician reported that as she worked during voice lessons, a soprano vocal range was emerging.

Results Voice therapy continued for 8 sessions. At the end of that time, post-treatment objective measures were made, as was a reanalysis of perceptual features. Significant changes were evident in airflow rate at habitual pitch, in fundamental frequency at habitual pitch, and while reading, in vocal quality, and in perceived habitual pitch and loudness. Comparison of pretreatment and post-treatment measures is shown in Tables 7–4 and 7–5. Perceptually, the patient’s speaking voice was more resonant. Loudness in conversation was at a suitable level. There was a reduction in laryngeal area

Table 7–4. Post-treatment Aerodynamic Analysis by Vowel for Patient JS Condition

Flow Volume (mL)

MPT (second)

Airflow Rate (mL/s)

/a/

3480

28.4

122.53

/i/

3740

29..7

125.93

/u/

3610

29.1

124.23

Table 7–5. Post-Treatment Airflow Rates (mL/s) for Patient JS Condition

Pretreatment

PostTreatment

Percent (%) Change

/a/

235.4

122.5

52

/i/

253.3

125.9

49

/u/

244.3

124.2

51

393

394


muscle tension. Overall, the patient reported that producing a voice for speaking was easier. The effort to produce voice with clearer voice quality was more automatic and less conscious. The most telling result of treatment was demonstrated in comparison of recordings of her singing voice at 3 difference stages: 1 year previously, just prior to treatment, and at the end of treatment. In the last recording, the patient reported an overall increase in ease, clarity, and efficiency in use which translated to a maximum phonation time that was within expected limits, a “brighter,” more resonant tone, decreased effort in managing dynamics (moving from a quiet tone production to a louder one), notes produced on pitch, and stronger, clearer notes at the high end of her singing range, creating more of a “one voice” sound throughout her range. Voice therapy was ended with follow-up to be maintained by telephone contact. The patient continues to receive voice lessons. In Case Study 3, Marina Gilman describes a noninstrumental voice assessment including Robert Bastian’s Swelling Test that provides a comprehensive assessment of vocal fold pliability. She goes on to describe in detail a program of encouraging airflow during multiple phonatory tasks that assisted this young man to return to accessing his full range of phonation.

Case Study 3 Marina Gilman 19-Year-Old Talented Male Singer, Presenting With Soft Bilateral Vocal Fold Lesions

History MB, a healthy 19-year-old male, presented at the clinic with a 6-month history of progressive hoarseness. He first noticed problems when attending a 6-week summer musical theater workshop. As a soon-to-be college freshman, he was one of the youngest singers in attendance. Excited to be around other students who shared his musical passions, his naturally outgoing personality bubbled over, resulting in constantly talking when not singing or sleeping. Cast in the lead in the final workshop production of an original one-act rock musical in addition to major parts in 2 scenes from contemporary shows, MB was singing several hours a day in individual coaching, rehearsals, and individual practice time. He did receive private coaching, but this was primarily devoted to learning the music and musical style rather than acquiring vocal technique. During the course of the summer workshop he began to notice increased effort singing in addition to mild hoarseness following rehearsals. Initially the hoarseness resolved by the next day, but by the third week the hoarseness seemed to persist. He was able to sing all the performances, but his vocal quality was rough and he noticed increased effort in the upper range. By the end of the program his voice was moderately hoarse and rough all the time. Once home he had only 6 weeks before beginning his freshman year at a well-known music school. MB could not remember when he was not singing. His family was musical and often gathered together to sing and make music. During high school he had sung with the praise team at church, performed in the school choirs, and was a lead in most of the musical and dramatic productions. A natural


singer with a mature vocal sound, he had been encouraged to sing solos and take on roles better suited to a more mature singer. Hungry to perform, he was singing pop contemporary at church, musical theater, and classical styles at school. During high school he took private voice lessons from the high school music teacher, who was primarily a conductor and pianist. The lessons focused primarily on learning songs with limited attention to breath control.

Voice Evaluation Fortunately he was able to get an appointment with a laryngologist shortly after his return home. A videostroboscopic evaluation of the larynx was performed to assess laryngeal function. Vocal fold mobility, symmetry of motion, and phase symmetry were all normal. Vocal fold closure was in an hourglass configuration due to bilateral midmembranous pliable lesions. Mucosal wave was mildly impaired on the right true vocal fold at the site of the lesions. Increased muscle tension and laryngeal squeeze were also noted on examination in the upper range. Because he was leaving for college at the end of the summer, it was decided that weekly voice therapy sessions with a clinician with additional training in singing would begin at once. He was scheduled for a follow-up with the laryngologist prior to leaving for college. Initial assessment was completed with limited instrumentation as the voice center was in the middle of major renovations. The Consensus AuditoryPerceptual Evaluation of Voice (CAPEV) was completed. An overall severity score of 41 indicated mild-moderate overall perception of the severity of vocal quality. Salient features include moder-

ate roughness and mild breathiness. A keyboard was used to assess speaking and reading fundamental frequency (F0) and physiological pitch range. The F0 during reading sentences 2 to 3 of the Rainbow passage was centered on A2 (110 Hz), speaking F2 (87 Hz), and physiological pitch range was determined to be F2 to C4 (87 to 293 Hz). Phonation breaks, increased strain, and breathiness were noted in the passaggio or register transitions as he glided from low to high. Maximum sustained phonation on comfortable pitch and loudness on /s/, /z/, and /a/ was assessed. Maximum sustained phonation of /s/ was 25 seconds, /z/ was slightly reduced at 20 seconds, but /a/ was only 10 seconds. The discrepancy between the voiced /z/ and /a/ suggests poor respiratory/ phonatory coordination when the vocal tract is open. Because /s/ and /z/ are both semi-occluded sounds, the laryngeal function might be improved due to the occlusion diminishing the effect of shift from voiced to voiceless. However when the vocal tract is open, the airflow is harder to control. (There are times when the relationship shifts with long /s/ and shorter /z/ and /a/ suggesting that the limitation is more related to laryngeal competence during voicing.) In this instance, the fact that the phonation time on /a/ was shorter is less suggestive of laryngeal incompetence (although present) but more suggestive of inefficiency of the airflow and possible overdriving of the system. MB was also asked to sing material from his standard repertoire. As expected based on history and pathology, he had difficulty in his upper range as evidenced by phonation breaks, increased strain, and breathiness. More significant was a tendency to drive his voice, even in the lower range and midrange. On the classical pieces he would darken resonance

395

396


as though trying to make his voice darker and richer; when singing more popular songs he would again overdrive resulting in a pressed yet bright quality. Often young talented singers will overproduce in an attempt to sound more mature. The swelling tests suggested a mucosal ceiling of B3 that is consistent with medical findings because lesions or tension of the vocal folds impede the ability of the vocal folds to vibrate high and softly. The swelling tests, developed by Robert Bastian, MD, are simple vocal tasks that reliably detect acute or chronic vocal fold mucosal injury and/ or the presence of muscle tension.22 They consist of singing the first phrase of “Happy Birthday” (“happy birthday to you”) as softly as possible and a descending 5-note scale on /hu/ sung very soft on a light staccato. The highest note (the “to” in happy birthday to you) that can be sung easily and likewise the highest softest beginning pitch in the descending scale are the mucosal ceiling. Higher notes can be sung, but not quietly.

Voice Therapy Trial therapy began with a brief exploration of what we do when we breathe to sing or speak. Because MB had never had formal lessons, he had picked up tidbits from other singers, teachers, and so forth. His concept of breathing was confused at best. After a brief discussion of the anatomy, what he was doing as opposed to what he imagined he was doing was explored. He was asked to speak, shout, and sing while paying attention to movement of the abdomen. He found making a simple sound on a lip trill much easier once he got the feel of allowing the belly to release on

the inhalation rather than “taking a big breath and holding it back, squeezing a little out at a time.” Because lip/tongue trills demand efficient airflow, he was trained in sustained phonation and glides using the lip and/or tongue trill with attention to how he was engaging breath. Voice use was discussed as well. He was encouraged to be on modified voice rest, talking and singing only when necessary. He was trained in the self-assessment swelling tests. He was asked to monitor progress by keeping a daily log of his “mucosal ceiling.” Home practice was assigned consisting of glides and sustained phonation on lip or tongue trill for 2 to 3 minutes at least 3 times a day. In addition, he was to keep a daily log of the swelling test results and monitor overall voice use. Issues identified during the assessment and trial therapy were low speaking F0, intermittent use of glottal fry especially at the ends of utterances, and increased breath holding, all suggestive of poor respiratory/phonatory coordination. With regard to singing poor respiratory/phonatory coordina tion manifested itself as respiratory overdrive (pushing his voice — louder, harder = better) and a poor sense of how to optimize resonance for different vocal styles. Goals of therapy included strategies to optimize respiratory phonatory coordination, reduce maladaptive compensatory behaviors that impair optimal laryngeal function, educate the patient in strategies to manage voice use in a high-demand setting and provide some strategies to generalize therapy activities into speaking and singing. In other words, work on breath support, work on resonance, and educate MB in basic daily vocal warm-up and strategies to manage the upcoming vocal demands. The beginning of the first full therapy session reviewed what had been


trained during trial therapy. MB seemed to understand. There was a brief discussion about the difference between singing and talking — same larynx, same muscles, same brain, just different application in terms of respiratory/ phonatory coordination and especially resonance. When he returned for the second therapy session, he reported reduced strain and vocal fatigue. He had not been doing much singing beyond the daily warm-ups. Over the next 3 sessions, physiologically based resonant voice therapy techniques were used to help him discover easier phonation with improved resonance. Each session began with a “check in,” in which challenges, questions, and concerns were discussed. Home practice exercises were reviewed. He was asked to do them as he did them at home. They were then modified and expanded. The specific tasks were expanded to include functional daily phrases and lines from songs. Exercises that reduce glottal impact used semioccluded sounds including lip trills, tongue trills, and /v/ and /w/ sounds.18 He found that the /w/ was easiest. The basic tasks included glides through his entire range and sustained phonation at various pitch levels. When sustaining or gliding through his range, he was asked to focus on the sensation of the flow of air through the lips and the sensation of buzz at his mouth. He was asked to notice if there were changes in the shape of his mouth as he went through his range. With attention to airflow at the lips, excess strain and tension began to resolve. Transition to vowels was trained beginning with the /w/ or the lip trill. Because the tongue is free when producing these sounds, it is possible to shape vowels and eventually words while maintaining the semi-occluded shape and airflow. MB was asked to sus-

tain /i/ then /a/, maintaining the /w/ sound. Next he was asked to begin with the /i/ inside the /w/ but relax the lips so the /i/ could emerge. As he began to transition from the semi-occluded sound to an open vowel, his transition was too fast and the vowel reverted to his habituated pattern. Gradually he was able to transition slowly enough between the semi-occluded sound and open vocal tract to maintain the flow of the air. Using the /w/ as the anchor or reference sound, MB was soon able to produce glides and sustained phonation on vowels. Text was introduced in the same manner. Speaking a short phrase such as “good morning” and keeping the air moving through the /w/ with lips rounded and cheeks slightly puffed, MB would attack each syllable, chopping the line. However, attending to maintaining flow, he was able to keep it smooth. After several repetitions he was amazed to hear and feel improved clarity and resonance when he let his lips part to speak normally. The exercise was expanded to include functional sentences. These exercises were trained at a variety of pitch levels within his modal range. When gliding down near the bottom of his range on the lip trill, he had noticed it became harder to maintain the buzz. He then discovered increased effort when transitioning to speaking at the lower frequencies. Exploring the lip trill with text at different pitch levels allowed him to find an easier speaking range. The same exercises were applied to singing isolated phrases from his repertoire. He sang a phrase on the /w/ keeping his cheeks puffed and increasing the intraoral pressure which promoted relaxation of the tissue in the supraglottic area. When he opened his mouth he would immediately begin to overdrive and push, as was his habit. Phonating through a small-diameter

397

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stir straw23 was introduced to further increase intraoral pressure. Initially his pitch became very unstable until intraoral pressure stabilized to the task. By singing through the straw he began to discover that singing was easier without being driven. When he sang without the straw he would “drive the sound.” Alternating between the straw and just singing, he became more proficient at identifying the sensation of push and then being able to stop and readjust. His voice was rough and raspy when he returned for his fourth voice therapy session on a Tuesday. He had spent the weekend with friends singing and talking and not taking care of his voice. He was very discouraged as he felt he was back to square 1 with college looming. Swelling tests, which had gone up from A3 to C4 were back down to B3. Because of the perceived time pressure, therapy had moved forward quickly. MB was a good student, able to mimic well. Even when the home practice exercises were reviewed at the beginning of each session, he seemed to understand what was required. Listening to him talk, vocal quality was rougher than it had been the previous week, speaking F0 was mildly reduced around B2, as he became excited he would take shallow quick breaths if any at all. When demonstrating the glides, his chest would rise and fall with the pitch, suggesting a release of the breath on the descending pattern. He acknowledged that although he was “doing the exercises,” he was not doing them with any level of attention. The rationale of the exercises was reviewed. Although he sensed positive change with the singing exercises, he still felt as though he had to power through to get the sound he thought was required. Negative practice was used to help him clarify and somatically understand

breath support. Alternating between belly in on phonation and belly out on phonation, he began to notice increased effort with the belly out posture. During the session he would find himself reverting to the belly out after singing or speaking for several minutes. He realized he was not renewing the breath at the end of each phrase. Loudness control was then trained. He always felt one had to squeeze the vocal folds to get louder. The loudness control exercises began contrasting short soft /s/ and loud /s/ paying attention to how he managed the breath and whether or not neck muscles were engaged. Next he was asked to softly and gradually increase loudness (<) then reverse beginning loud and decreasing loudness (>). Once he was able to control the crescendo/decrescendo on /s/, he was asked to do the same on lip trill. (If the patient cannot do the lip trill, try tongue trill, /v/ or /w/). At first as he got louder the lip trill would stop as airflow was impeded. Refocusing on the breath stream, he was able to move from the soft/loud to the crescendo/decrescendo. Vowels and short phrases getting louder and softer were introduced. When he began to strain, he was asked to go back to the /s/ or the lip trill to reestablish the sensation. Near the end of the session he was asked to sing. He was amazed how easy singing had become. In the course of the session his vocal quality had also improved with improved respiratory drive. At the beginning of the fifth session he was feeling better about his voice. Limitations were still present, but he was experiencing less fatigue. He was still very nervous about singing. He had to prepare a song for placement auditions during orientation week. He was concerned about range but mostly he was nervous that the “easier” sound


discovered during therapy was not stylistically acceptable. [At this point in the therapy the fact that the clinician had extensive experience teaching all styles of singing was key. If the clinician does not feel he or she has the expertise, then referral to an SLP with that experience or referral to a singing teacher/coach who understands the resonance requirements of the genre is strongly recommended.] The loudness control exercises were carefully reviewed to make sure he was doing what he thought he was doing. Using his favorite /w/ sound, he was asked to produce a dark sound, then a bright forward sound on an /i/, and then on the same pitch sing a bright /i/. Changing to a higher pitch, he was asked to do the same thing, always contrasting first dark then bright on the same pitch. Next he was asked to sing it with increased nasality and no nasality. (This is often easier if the nostrils are occluded for both nasal and nonnasal sounds at first.) After a few trials he was able to demonstrate bright and dark on the /w/. Dynamic variations were introduced: sing /i/ soft and bright, soft and dark, loud and bright, loud and dark, do the same on the /w/ maintaining airflow throughout. Now he was ready to sing a few phrases of his song dark, bright, nasal, like a country and western singer, rock star, etc. Not all these renditions were wonderful, but he discovered that resonance and vocal color could easily be manipulated as long as the vocal folds were able to vibrate freely with good respiratory support.

Results His last session was immediately following the repeat videostroboscopic evaluation of the larynx with the physician. The videostroboscopy showed signifi-

cant reduction of the lesions, although mucosal wave on the right true vocal fold was still mildly impaired. There was no indication of muscle tension or hyperfunction in the upper range. The laryngologist and MB were pleased with the results. A copy of the report and examination was given to MB for his records. (Many elite music conservatory and musical theater programs do laryngeal screening examinations of incoming students to identify potential problems. It was important for MB to have a record of his previous injury.) As this would be his final therapy session, home practice exercises as well as daily warm-up routine were reviewed to make sure he really understood not only what to do, but how to do them. The vocal challenges ahead were discussed in terms of vocal pacing, how to make time for daily warm-ups while living in a dorm with roommates, and vocal self-preservation. He was encouraged to be open with his new teacher regarding voice therapy, if appropriate. Because he felt as though he had made sufficient progress, he did not feel that referral to a speech-language pathologist at his school was necessary. The clinician shared her e-mail with him in the event that he or his teacher had any questions. He was encouraged to return for a follow-up when he was back in town on school breaks.

Discussion Many clinicians feel they need expensive acoustic equipment in order to adequately assess laryngeal function. It is hoped that this case study shows that with a good ear, close observation of the behavior of the patient, a time piece with a second hand, a keyboard (or keyboard app), and understanding of the effect of

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lesions on vibratory characteristics as well as the limitation on function, a clinician is able to do a good examination and determine therapy goals relevant to the patient. In Case Study 4, Wendy LeBorgne describes a combined use of Vocal Function Exercises and a modified resonant voice therapy to improve vocal function in 2 weeks in a traveling performer who has limited time for face-to-face therapy and need for rapid return to performance mode.

Case Study 4 Wendy D. LeBorgne Therapeutic Modalities for the Touring Musical Theater Vocal Athlete

History Patient OO, a 31-year-old woman, was a self-referred performer in town during a national Broadway tour after experiencing several weeks of vocal fatigue following performances. She found particular difficulty in maintaining “clarity” in her upper range and reported her singing voice was quite fatigued after a show. Additionally, she reported difficulty traversing her passagio, but she did not believe that it was audible to her audience. A general tiredness in her voice after shows and that she lacked desire to sing or speak were reported. No perceived change was noted in the quality of her speaking voice. On the day of examination, a complete voice

evaluation was conducted, including laryngeal videostroboscopy and laryngeal function testing, including aerodynamic and acoustic measures. Because patient OO traveled to a new city every 3 to 4 weeks, she was unable to see her regular otolaryngologist for this particular problem. Therefore, a thorough history was taken, and the videostroboscopic examination was reviewed by an otolaryngologist. A case history revealed that 3 weeks prior to her arrival in Cincinnati, she had developed a mild upper respiratory infection, which was treated with 10 days of antibiotics. She reported that she continued to sing during the infection, although she was coughing significantly at the time. She reported that her cough subsided within 4 days of being placed on the antibiotics but that her voice had not felt “quite right” since that time. Currently, patient OO had a supporting role in the show and performed that role 8 times per week. Her typical day included arising around 11 am, going to rehearsal from noon until 2 pm, relaxing or napping in the afternoon, and reporting back to the theater by 6 pm. Following the show, she typically went out to dinner with friends and returned to her hotel by 2 am. The typical length of the show was approximately 2.5 hours. She had been performing professionally for 13 years and had rarely missed a performance due to illness or vocal problems. This was her sixth national tour of a Broadway show. Patient OO was in excellent physical shape and had approximately 17 years of formal voice training and coaching. Early in her career, she reported having vocal fold nodules, which resolved with rest, therapy, and continued vocal training. She was concerned that the nodules may have recurred with all of the recent


harsh coughing. She was a nonsmoker but was often exposed to passive smoke in restaurants and bars, and she also had to perform several scenes with fog on the stage. This patient had no complaints of gastroesophageal reflux or dysphagia. Current medications included Zoloft for treatment of mild depression, and Claritin for seasonal allergies. Patient OO was well versed in vocal hygiene issues and was extremely compliant. She consistently drank 8 to 10 glasses of water per day and only 1 cup of coffee. She reported being a “vocally enthusiastic” person but attempted to use her voice conservatively on days of shows and when in noisy environments. This singer was single, and most of her close friends were scattered across the country. During the intake, the voice pathologist noted a slight “edge” to patient OO’s speaking voice, with some back focus and glottal fry phonation. She did not demonstrate any observed tongue or jaw tension. Breathing and rate of speech also were within normal limits for conversational speech.

Voice Evaluation Videolaryngostroboscopic Examination Under direct light, this patient presented with grossly normal-appearing true vocal folds bilaterally. Some mild vascularity was noted on the superior surface of the vocal folds, but the medial edges appeared smooth and straight bilaterally. While sustaining the vowel /i/, stroboscopic lighting was employed, and it was observed that this patient presented with a small anterior glottal gap, which was present at all pitches tested.

The amplitude of vibration and mucosal wave appeared mildly decreased bilaterally, but the overall system was quite flexible. The open phase of the vibratory cycle was slightly dominant, whereas the symmetry of vibration was irregular at low pitches only. No mass lesions, paralysis, or paresis were noted. Mild pachyderma was noted in the interarytenoid area suggestive of possible laryngopharyngeal reflux. Acoustic Findings This patient was asked to read the “Rainbow Passage” in a normal conversational voice. Her attempt at this task revealed a mean fundamental speaking frequency of 185.3 Hz with a standard deviation of 13.6. Second, this patient was asked to describe a picture. Her attempt at this task revealed a mean fundamental frequency of 186.9 Hz and a standard deviation of 16.4. Both reading and conversational samples of speech were considered to be within normal limits. Next, the patient was asked to glide to her highest and lowest pitches in 2 separate attempts to attain her physiologic frequency range. She peaked at a frequency of 1244 Hz, and her lowest tone was measured at 164 Hz. No audible pitch breaks were noted in her voice. She maintained an adequate range for her age and voice type. A final acoustic measure taken was a modified voice range profile. Tables 7–6 and 7–7 show the Hz, semitones, and decibel levels across 11 pitches encompassing her vocal range. Patient OO had excellent dynamic control of her voice, with the exception of the extremes of her range, and the passaggio into her head voice (at about 698.5 Hz). At that point, she was only able to achieve a dynamic difference of 18 dB. Unfortunately, the

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402


Table 7–6. Pretreatment Voice Range Profile for Patient OO Semitone

Hertz

Minimum dB

Maximum dB

40

164.8

59

76

43.5

207.6

60

86

47

246.9

57

91

50.5

311.1

58

91

54

370

58

93

57.5

466.2

65

98

61

554.4

67

102

64.5

698.5

82

100

68

830.6

74

111

71.5

1046.5

77

113

75

1244.5

81

105

Table 7–7. Post-treatment Voice Range Profile for Patient OO Semitone

Hertz

Minimum dB

Maximum dB

40

164.8

58

76

43.5

207.6

57

85

47

246.9

58

93

50.5

311.1

58

92

54

370

58

95

57.5

466.2

62

98

61

554.4

67

101

64.5

698.5

69

104

68

830.6

71

113

71.5

1046.5

77

112

75

1244.5

79

105

solos that she sang in the show were in that general area of her voice difficulty. Aerodynamic Results Following acoustic testing, this patient completed laryngeal function testing.

Tables 7–8 and 7–9 show the resultant flow volumes, maximum phonation times, and airflow rates. All aerodynamic measurements were within normal limits, with the exception of low sustained pitches that demonstrated an increased airflow rate and decreased


Table 7–8. Pretreatment Aerodynamic Analysis for Patient OO Frequency (Hz)

Flow Volume

Flow Rate

MPT

185

3220

102

33.3

165

3430

160

21.5

500

3370

102

33.1

Table 7–9. Post-treatment Aerodynamic Analysis for Patient OO Frequency (Hz)

Flow Volume

Flow Rate

MPT

185

3360

10

33.7

165

3410

103

33.3

500

3380

101

33.4

maximum phonation time. This was consistent with the anterior glottal gap observed on stroboscopy, particularly at low pitches, indicating a possible intrinsic laryngeal muscle weakness.

Diagnosis and Treatment Based on the above information, it was determined that this patient was experiencing a mild laryngeal myasthenia, which most likely resulted from singing during an upper respiratory infection and severe coughing. At the time of the evaluation, the upper respiratory infection and the coughing had resolved completely, and it was advised that this patient enroll in a formal voice therapy program. The voice therapy program included Vocal Function Exercises (VFE), designed to condition and balance the laryngeal musculature, and modified Resonant Voice Therapy (RVT), designed to promote a frontal, oral, open focus during conversational

speech. Both approaches have the goal of rebalancing the 3 subsystems of voice production: respiration, phonation, and resonance. Voice therapy began immediately. Initially, therapy focused on proper technique of both the VFE and RVT. Patient OO was also counseled regarding vocal hygiene and the importance of recognizing when she needed to take a day off from singing during times of infections. Because of her skill as a singer, she easily assimilated proper technique for both exercise programs. The VFE program that was used for this singer included the musical notes C through G. In the first portion of the exercise program (warm-up), she was asked to sustain the vowel /i/ on the musical note F for as long as possible. Special attention was drawn to the fact that the /i/ sound was to be produced in a nasal, overly forward-placed tone. Patient OO expressed concern that this was not the way in which she would sing an /i/ vowel. It was explained to

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her that these were not “singing exercises” and that she would hopefully never sing with the amount of nasality required for this particular exercise. The second part of the exercise program, designed to stretch the vocal folds to maximal length, was to have patient OO glide from her lowest pitch to her highest pitch on the word knoll using an extremely forward focus. Her first attempt at this exercise resulted in a beautiful glide to her highest note, and then she started to glide back down again. This is a common mistake seen in many singers because it is similar to a vocalization often called the siren, in which one glides from the lowest note to the highest note and back down again in one breath. The importance of stretching only to her highest note and then stopping was impressed on patient OO. She was also reminded to use proper abdominal breathing through all exercises. Step 3 of the exercise program was to glide from her highest note to her lowest note, again on knoll. She was extremely proficient at this but needed a word of caution not to initiate the tone with a hard glottal attack or go into glottal fry phonation at her lowest notes. Finally, the exercises designed to build adductory efficiency and stamina of the intrinsic laryngeal musculature were taught. These consisted of the patient sustaining the musical notes C, D, E, F, and G, on the word old without the /d/, for as long as possible and as softly as possible, but with an engaged tone. Special care was taken to ensure patient OO began with a coup de glotte phonation, meaning that she initiated the phonation at the precise moment the vocal folds adducted and the resonators were perfectly tuned to the vowel. It is important to be extremely precise with singers’ onset of phonation and not allow

them to cheat themselves on a less than optimal onset. Several attempts were made with this patient to ensure precise onset of the tone and breath. She was an extremely astute patient and performed the exercises with accuracy after minimal instruction. Vocal Function Exercises were to be completed 2 times per day, no less, no more. She was provided a log sheet with which to keep track of her phonation times on the exercises and was asked to bring it back during each return visit. A modified regimen of RVT was employed with this patient as she progressed through the steps quickly. As with most singers, this patient had an excellent sense of vocal tract resonance. The first step of RVT was to have her hum on a comfortable pitch in her speech range using /molm-molm-molm/. She was asked to note where she sensed vibrations while phonating. She reported a general sense of “buzzing” in her cheeks and nose. This was repeated several times. Next, the patient was asked to maintain this “buzz” while chanting, then doing a messa di voce (slow-soft, gradually increasing to loud-fast, and then gradually decreasing back to slow-soft), then overinflecting voiced syllables. She was extremely proficient at this, and therapy continued into chanted sentences. Sentences used included frontal consonant, all voiced phrases (eg, “No one knew nanny,” “My mom made money,” “Now nan knew nelly,” “One Monday morning”). The sentences were used to promote a frontal, oral, open focus during connected speech. The patient was asked to first chant the sentences with a nasal, forward tone, then she was to overinflect them with the same tone, and then to speak them in a normal voice while maintaining the forward (not nasal) resonance. Minimal


cues were required when performing this stage of RVT. She reported that her voice “felt good” when doing RVT. She was advised to do these exercises at least twice a day. During the next session, she was able to progress with the next stage of RVT, which entailed warming up with stage 1 and then moving to a list of voiced-voiceless syllables and then sentences. They were performed in the same fashion as the voiced exercises. The only difficulty that patient OO had was during the speaking portion of the sentence level. She had the tendency to drop her voice at the last syllable into a glottal fry phonation pattern. When she was cued, she was able to immediately correct it. Patient OO found RVT easy to do on her afternoon break and was able to do the exercises 3 times daily. Finally, during the third session, the patient was proficient enough in the RVT exercises that paragraph reading was added. The same principles of maintaining a frontal, oral, open focus were applied at this level. By this time, however, patient OO was well aware of any glottal fry phonation and essentially was able to eliminate it from all reading and conversational speech. These strategies were applied to her lines and song text for daily practice. Because of the limited amount of time she was in town, the patient was seen 2 times per week, for the 2 weeks that remained of her stay. She was extremely compliant with all recommendations, and rapid progression was noted with therapy. Her Vocal Function Exercise times (MPT) improved from an average of 22.4 seconds at the initiation of therapy to an average of 35.2 seconds by the fourth therapy session. She particularly enjoyed doing the resonant voice therapy and found that her voice

was “lighter and easier” after only a few days of doing them.

Results At the end of the 2-week period of therapy, patient OO felt her voice was markedly improved but opted to continue doing both Vocal Function Exercises and Resonant Voice Therapy. Post-therapy voice range profile and aerodynamic results may be seen in Tables 7–7 and 7–9. Note the marked improvement in her airflow rates at low pitches, as well as an increase in dynamic range at the 698.5-Hz frequency. A follow-up stroboscopic evaluation also was done, and it revealed only a small posterior glottic gap. No anterior glottic chink was present at any pitch on stroboscopic evaluation. Patient OO received word that following the closing of this Broadway tour, she would begin rehearsing for the New York premiere of a new Broadway musical in a supporting role. Although we were not permitted to spend the ideal amount of time in therapy with her, she had such a strong underlying vocal mechanism that it took only minimal guidance to see dramatic improvement. In this case study, Shirley Gherson reports on a recently injured singer preparing for the rigors of a national tour of a Broadway show.

Case Study 5 Shirley Gherson Voice Intervention for a Touring Broadway Singer

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Patient History Patient XX, a 23-year-old female professional singer and actor, was self-referred to the voice clinic for persistent hoarseness following a reportedly normal laryngeal examination by a local ear, nose, and throat (ENT) physician. She was placed on a trial of reflux treatment and periods of complete voice rest, however was increasingly frustrated by her lack of improvement. Along with a diminished overall voice quality, the patient complained of a raspy voice quality with belting and shouting, difficulty with her upper register and volume control while singing, and an overall lowered speaking pitch. Although she did notice problems in her speaking voice, most of her difficulties occurred in her singing voice. The patient was preparing for her first national tour of a Broadway show. She was cast in a principal role that required a considerable amount of belting. Given her recent problems, and the rapidly approaching start date of her rehearsals, the patient felt extreme pressure to improve and was increasingly anxious about her situation. The patient was initially examined by the otolaryngologist, who performed the laryngeal examination, and then she was seen by the speech-language pathologist. The patient noted that her voice problems began gradually over a 4-month period prior to her visit to the voice center. At the time, she reports having to perform a difficult role in which she was singing outside of her range, projecting without adequate amplification, and socializing both before and after the show. In addition, she was experiencing excessive allergies at the time. Although she had never experienced considerable voice problems in the past, she did report bouts of

hoarseness with allergies or when she had upper respiratory infections. Patient XX began singing at a young age in her church choir. She was known for a strong belt voice and would sing for 2 to 3 hours at a time during a service. Even as a child, she would experience mild throat irritation after singing. She started formal voice training at a performing arts high school. Her voice teacher coached her mainly in a “classical” voice quality with an emphasis on building breath control, vocal agility, and vocal range. The patient notes that when she was studying on a regular basis, she felt “on top of her game.” She admitted to “falling off the bandwagon” with private lessons and foregoing vocal warm-ups, even with more difficult performances. She described herself as a “belter” with a soprano range, but noted that the ease of singing through her passaggio and into her upper register had become significantly more effortful. This was beginning to affect her “belt” voice as well, demonstrated mainly in the stability and quality of her midrange.

Medical History The patient’s medical history was remarkable for significant allergies (environmental and pet dander), suspected laryngopharyngeal reflux (signs and symptoms noted on laryngeal examination although no further gastrointestinal testing was undertaken), and premenstrual syndrome with voice changes. The patient was not taking any medications although she had used over-thecounter decongestants in the past. In general, she tried avoiding allergens, although had been living at home with a cat, which she felt may have been caus-


ing an uptick in her allergy symptoms. The patient noted that she had made recent changes to her diet, with suspicion that the heavy, fried foods she had been eating were not only sapping her energy but also causing the increased mucus she was experiencing in the morning. Prior to this, she admitted to a diet high in fat and sugar, which she felt may have been related to increased fatigue and inadequate rest with difficulty initiating sleep. Water intake was insufficient at 3 to 4 servings per day with the added diuretic effects of 1 to 2 caffeinated beverages daily. She rarely drank alcohol, never smoked, and exercised and danced on a regular basis.

Social History The patient described herself as a “talker,” often speaking emphatically and energetically during social engagements and over the phone with friends or her boyfriend. She often found herself giving advice to friends and offering support to family. Although she had a close relationship with her boyfriend and family, she did admit to occasional arguments when she would scream in anger.

Voice Evaluation Videostroboscopic Examination The laryngeal examination was completed using the KayPENTAX highdefinition videonasolaryngoscope. Under direct light, the nasal cavity, nasopharynx, and oropharynx were normal. The vocal folds were bilaterally mobile with no movement abnormalities noted on diadochokinetic tasks. There was a marked degree of supraglottic compres-

sion with voiced onset and during sustained high-pitched phonation. There was a broad-based, slightly translucent lesion along the vibratory edge of the right vocal fold consistent with a vocal fold polyp. Mild contralateral swelling was noted on the left vocal fold, likely due to impact trauma from the primary right vocal fold lesion. The cephalic aspect of the vocal folds was diffusely hypervascular, with mild edema and erythema of the peri-arytenoid region. With stroboscopic lighting, the vocal folds had a predominantly hourglass configuration with a consistent anterior and posterior glottic gap. Mucosal waveforms appeared slightly asymmetric, mildly reduced in amplitude on the left and mild to moderately reduced on the right. Acoustic and Aerodynamic Analysis Pretreatment acoustic and aerodynamic measures are reported in Table 7–10. Acoustic measures were, on the whole, within normal limits, although habitual speaking pitch and noise-toharmonic ratio were both slightly elevated. Aerodynamic measures using the KayPENTAX Phonatory Aerodynamic System (PAS) revealed elevated measures of both airflow and subglottal pressure during /pa pa pa/ syllable repetition. Perceptual Analysis Perceptual analysis of the patient’s voice revealed a mild dysphonia characterized by mildly increased roughness and breathiness with intermittent, mild to moderate strain (at the ends of her phrases and with high-pitch/highvolume singing), diminished breath support, and mildly reduced oral resonance.

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Additional signs of vocal hyperfunction included visible tension of the jaw and neck, increased conversational volume, and a fast speaking rate. Laryngeal palpation of the extrinsic laryngeal musculature revealed moderately tense base of tongue with speaking, mild to moderate suprahyoid tension with phonation, moderate to significant thyrohyoid muscle tension with laryngeal elevation during phonation, and mildly reduced range of motion (ROM)

of the larynx with lateral movement of the larynx. The patient corroborated the therapist’s sense of muscle tension with reports of tenderness and at times pain during the examination. Quality-of-Life Measures The patient’s pretreatment selfassessment using quality-of-life measures revealed impairment levels as presented in Table 7–11.

Table 7–10. Pretreatment Acoustic and Aerodynamic Measures Task

Measure

Interpretation

Physiological Measures Maximum phonation time (MCPL)* Frequency range

23 seconds

Normal (decreased for a professional singer)

36 ST

Normal

40 dB (45 to 85 dB)

Normal

Relative average perturbation (RAP)

0.6%

Normal

Shimmer

2.9%

Normal

Noise/harmonic ratio

0.14

Slightly increased

Intensity range Acoustic Measures

Aerodynamic Measures Mean speaking F0

209 Hz

Flow @ MCLP

200 mL/s

Psub @ MCLP /pa pa pa/ dB SPL

11.15 cm H2O 79.6 dB

Normal Slightly increased Increased Slightly increased

*MCPL = Most comfortable pitch and loudness; ST = semitones.

Table 7–11. Patient Self-Assessment Scores Reflux Symptom Index

Voice Handicap Index

Singing Vocal Handicap Index

16 (mild)

15 (mild)

26 (moderate)


Voice Therapy Plan and Behavioral Treatment Given the fact that the patient was leaving for her tour in less than a month, it was not feasible to consider surgery so close to her performance date. Even with the very best vocal care and recovery, the sheer intensity and frequency required of her performance would put this patient at high risk for re-injury. Therefore, the plan was to enroll the patient in intensive, focused voice therapy with both the speech therapist and singing voice specialist prior to her departure. She would then call, e-mail, or visit during breaks to maintain therapeutic gains and maintain a watchful eye on her vocal fold lesion. This would also serve as assurance for the patient that she was not getting worse. Voice therapy consisted of counseling for optimal vocal hygiene, laryngeal massage, vocal impedance exercises, and a combination of flow phonation and resonant voice therapy. In vocal hygiene counseling, areas of concern included the patient’s lack of hydration. Coupled with her antihistamine use and caffeine intake, it was likely causing a very dry laryngeal environment. Studies by Verdolini et al24 reported an inverse relationship between phonation threshold pressure and levels of hydration. The patient was counseled on methods of optimal hydration, including increased water intake with a goal of 1.5 to 2.0 L (48 to 64 fl oz) per day, steaming 3 to 5 minutes, 1 to 2 times per day, and using a humidifier when at home. In preparation for the tour, the patient also invested in a portable steam inhaler and humidifier to use in hotels. Laryngeal massage was performed with instruction given for self-massage. Techniques were a combination of

laryngeal manipulation described by Rubin and colleagues25 and circumlaryngeal massage.26 Following the palpatory findings of the initial evaluation, a series of focused massages targeting the release of the tight muscles in the tongue base, thyrohyoid space, and strap muscles were given and presented as a home practice program. Given the amount of time the patient was spending in her belt with visible activity of the strap muscles and high laryngeal posture, the massage focused mainly on returning the larynx to a lower, more neutral posture. This has been shown to not only improve overall patient comfort but to positively influence the vowel space and overall vocal tract function.27 The patient was asked to perform circumlaryngeal massage techniques following rehearsals, performances, and when experiencing overall vocal fatigue. The massage techniques were videotaped using her smartphone to facilitate home practice. Semi-occluded vocal tract postures were demonstrated as a foundation for reducing vocal fold impact stress while establishing an optimal vocal tract shape for improved resonance. The underlying physical principles of these exercises, as described by Titze,18 are to relax supraglottic muscle strain, separate the vocal folds to reduce impact stress, and enhance vocal fold vibration. Verdolini et al28 suggested that enhancing oscillation of the vocal folds while decreasing medial compression may reduce inflammation faster than voice rest alone. Given the patient’s relatively recent vocal injury and the responsibilities of her upcoming role, it was imperative that she engage in soothing, therapeutic exercises prior to and following vigorous vocal use. These also work well as a precursor to holistic treatment programs such as

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flow phonation and resonant voice therapy. These programs use principles of semi-occluded vocal postures to accommodate optimal vocal function in carryover to speech. Exercises are listed below. Semi-Occluded Vocal Tract Exercises 1. Perform lip/tongue trills on sustained voicing and freeform glides 2. Make cup bubbles, using a straw placed 2.5 to 5 cm (1 to 2 in) into a cup/bottle of water. The patient was instructed to vocalize into the straw on freeform glides for 3 to 5 minutes at a time. 3. Perform kazoo buzz (see Stemple’s Vocal Function Exercises in Chapter 3) on sustained tones and in ascending and descending glides 4. Hum (see Verdolini’s Lessac-Madsen Resonant Voice in Chapter 3) on descending glides in midregister for 3 to 5 minutes. Semi-occluded exercises were prescribed in any combination for 5 to 10 minutes, 2 times per day or sporadically throughout the day and following vocally aggressive activities (eg, singing, projecting, prolonged speaking). As a singer, she adopted the use of these exercises easily and found them to be extremely effective in reducing her sensation of constriction and irritation in the throat. By the third week, she noted improved recovery times after rehearsals and performances, and noticed improved transition of the voice from her mid to upper register, where she often felt a “hole” or a voice break. Flow Phonation Flow phonation29 (see Gartner-Schmidt, Chapter 3), was trained both in speech

and in singing to improve respiratoryphonatory coordination and reduce vocal strain. The patient easily moved through the hierarchy of sustained /u/ (with visual feedback using a tissue) into CVCVCV syllable repetition, words with extended /u/, and finally phrases with negative practice. Although there was an immediate recognition, by the patient, of her habit of diminished breath flow, carryover to conversational speech and singing required constant, focused effort. Slowed speech patterns with attention to continuous breath support, reduced laryngeal strain (eg, “go with the flow” and “keep it easy”), and negative practice allowed for improved performance. The patient was asked to perform this series once per day, in the morning. Carryover into singing with flow phonation moved directly from lip and/or tongue trills in scales and glides into trill-initial scales. This was followed by scales and glides initiated by unvoiced fricatives (eg, /sh/ or /th/). Exercises were integrated into her daily vocal warm-up, to be performed once a day. Resonant Voice Therapy A modified program of resonant voice therapy incorporating alternative means of resonance exploration was started in addition to hums and “sound carrier” consonants (eg, /z/, /v/, /n/, /w/). This included the Lessac “Y” buzz and nasal pinch with allowance for a hypernasal and “buzzy” sensation within the nasal passage during sustained /i/, moving forward into words and phrases. Both the “Y” buzz and nasal pinch exercises use the sensation of nasal resonance as an additional vocal tract formant in improving clarity and strength of tone. In addition, like semi-occluded vocal


tract exercises, the closed posture of the /i/ vowel with or without a pinched nostril further provides a narrowing of the vocal tract. This provides increased acoustic impedance, which boosts the overall acoustic viability of the vocal tract.18 The Lessac Y-buzz exercise stems from a holistic series of techniques called the Lessac System. Training focuses on developing a heightened awareness of sensations attributed to specific speech sounds in order to reestablish a “harmonic” balance of body and sound. The Y-buzz uses the production of y (as in “yes”) to enhance the patient’s kinesthetic awareness of speaking and/or singing in the front of the face, particularly in the front of the mouth along the hard palate (directly behind the teeth). The following exercises focus on building a strong “anchor” for resonant voice production (the “buzz” of “Y-buzz”): 1. The patient was asked to produce a sustained /i/ (Y) with the sensation of a yawn in the back of the throat and a forward tongue posture. Through vocal “play” of pitch and volume, the patient tuned in to the physical experiences associated with “frontal focus.” This exploration was also used to adjust for any strain patterns. 2. The exploration of /i/ was noticeably stronger for the patient in her upper range, and therefore descending pitch glides were used as a starting point for initiating tone. 3. Carryover to singing included scales and glides starting with a resonant /i/ then moving into alternate vowels: “you-wee” and “yummyyummy-yummy . . . ” 4. Carryover to speech included repetitive production of the words “yippy,”

“yellow,” “yummy,” or “you” with a prolonged initial /i/. 5. This was then taken into phrases: “The evening breeze,” “She feeds the geese,” and “We need to leave.” The patient found the nasal pinch to be most helpful, as this quickly focused her awareness of the acoustic signal (by sensing vibrations in her nose) and allowed the resonance to “work” for her instead of falling back on supraglottic pressure patterns. Exercises were to be performed both in the beginning of the day and following performances as a cool-down.

Results (Tables 7–12 and 7–13) Following 6 weeks of continuous therapy once per week with additional singing therapy (with the singing specialist) once a week, the patient gained confidence in her singing technique and believed she would be able to complete her tour. Posttreatment measures reflected improved function of the larynx with increased maximum phonation time and evidence of decreased flow and subglottal pressure in aerodynamic measures. She was instructed to call and/or e-mail at least once per week to check in. While on tour, the patient continued to maintain a consistent warm-up and cool-down schedule while dramatically decreasing off-stage voice use. She returned 4 weeks into her tour for a follow-up stroboscopic examination, which revealed a stable (if not slightly smaller) lesion, stable mucosal waveforms, and slightly improved vocal fold hypervascularity. Although she continued to experience some subtle breathiness and intermittent instability in her upper range, on the whole she was managing well.

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Table 7–12. Post-Treatment Physiologic and Aerodynamic Measures Task

Measure

Interpretation

Physiological Measures Max phonation time (MCPL)

29 seconds

Normal

36 ST

Normal

Frequency range Aerodynamic Measures Mean speaking F0

177 Hz

Normal

120 mL/s

Normal

6.12 cm H2O

Normal

74 dB

Normal

Flow @ MCLP Psub @ MCLP /pa pa pa/ dB SPL

Table 7–13. Post-Treatment Self-Assessment Scores Reflux Symptom Index

Voice Handicap Index

Singing Vocal Handicap Index

10 (mild)

14 (mild)

16 (mild)

Discussion Given the initial presentation of hoarseness, restricted voice use, and the stroboscopic findings of a lesion, it may be easy to assume that surgical management is necessary. However, in our increasingly sophisticated understanding of the source-filter interaction of the vibrating vocal folds and vocal tract, even a well-defined lesion may be minimized with diligent and consistent use of vocal exercises that enhance efficiency of the phonatory system as a whole. In Case Study 6, Bari Hoffman Ruddy, Jeffrey Lehman, and Christine Sapienza describe the case of a musical theater performer at a large outdoor theme park who required presurgical and postsurgical voice therapy to return to work. They also describe in detail the use of the expiratory muscle strength trainer (EMST) in the postoperative therapy course.

Case Study 6 Bari Hoffman Ruddy, Jeffrey Lehman, and Christine M. Sapienza The High-Risk Vocal Performer High-risk performers produce their singing or theater voice at their maximum vocal effort level. Typically working in such venues as major theme parks, dinner theaters, and summer repertory, the high-risk performer does not find it uncommon to complete a minimum of 5 shows per day in a 5-day workweek. The environments in which they work are not optimum for producing healthy voice. Factors contributing to their voice problem(s) include the performance demand, physical interference with costumes, and inferior placement of their microphone for amplification. The consequences to the laryngeal anatomy include vocal fold edema and


increased vascularity. Permanent disruption to the vocal fold edge can be observed as vocal fold nodules, polyps, or polypoid changes. Among some of the more prevalent functional consequences experienced by high-risk performers are dehydration, chronic laryngitis, and chronic laryngeal muscle tension. More generally, Sataloff has described common causes of dysphonia in professional voice users.30 Typically, performers present with a combination of these factors. They include: n overcompensation of the speech pro-

duction mechanism as a result of infection and irritation to the larynx n compensatory strategies stemming from inadequate respiratory dynamics and excessive muscle tension n engaging in vocally abusive behavior, such as yelling, screaming, or talking too loudly n improper vocal training n environmental constraints and physical compensation n emotional reaction stemming from the stresses of one’s daily lifestyle. This case study focuses on a performer engaged in street theater within a major theme park. Street theater is a unique setting. The performance site is outside with no covering or barrier walls. The performers are required to project their voices with no amplification. They perform 5 to 9 shows daily. Hoffman et al31 showed that street theater performers present with environmental conditions that have a great negative impact on facilitating healthy voice production. Analysis of environmental variables found external noise levels to be 82 dB with vocal output levels ranging from 107 to 114 dB SPL at 7 cm (3 in).

Patient History Patient MM’s referral course to our clinic was by report from the stage manager to the theme park’s in-house health service center. The medical personnel at the health center, as routinely done, placed the performer on vocal rest for 1 week. Following persistence of the vocal disturbance, the performer then was referred to our clinic for an evaluation by an otolaryngologist. Following completion of an indirect examination of the vocal folds via laryngeal mirror, the patient was referred to a team of speech-language pathologists for videolaryngostroboscopy and vocal function studies. The patient was a 31-year-old female. She reported a successful 10-year history performing in street theater and musical theater in a theme park setting. She had formal coaching in musical theater and majored in theater during her undergraduate education over 12 years prior. Past medical history was unremarkable. Her schooling included studies in music theory, music performance, and theater. During the clinical interview, she reported an awareness of voice and respiratory strategies used in performance for projecting and maintaining a “good” voice. She stated “I have learned about diaphragmatic support for belting and placement of the head voice.” Our interpretation of the patient’s knowledge of voice production was that it was adequate but not focused on the physiologic mechanisms necessary for developing the pressure for her specific performance style. Time Line Patient MM reported a normal voice until September 2007. She experienced

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one incident of vocal disturbance occurring in September when she screamed for about 10 minutes and strained her voice. Although she experienced some acute voice difficulties following this incident, she did not perceive any longstanding voice problems. She continued with her daily activities and performance following this event without modifications. Early the next year, in January 2008, the patient recalled a particular performance during which she was not warmed up, had “no real support” during loud vocalization, and “pushed through her throat” to perform. She stated that during one of 9 performances that day, it “felt like a muscle was pulled in my neck.” Although she struggled, she stated that she was able to complete all 9 shows but experienced intermittent aphonia and vocal strain. She also reported concurrent emotional stress from caring for a family member who was extremely ill. She stated that she had extensive periods of crying and “high amounts of tension in her throat.”

Voice Evaluation Voice evaluation included the patient interview as described above, assessment of performance site and demand, videolaryngostroboscopy, perceptual assessment of vocal characteristics, and acoustic recording and analysis of the voice signal prior to intervention. Perceptual Impressions At the initial office visit, patient MM’s speaking voice was perceived as moderately breathy and slightly strained with frequent glottal fry occurring throughout conversation. There were repeated

episodes of hard glottal attacks at voice onset. Vocal pitch was perceived to be within normal limits, and vocal loudness was perceived as too loud. Occasional voice breaks were perceived during conversation, which appeared to be related to the degree of vocal strain. Laryngeal muscle tension was determined to be moderate based on external laryngeal palpation. The patient reported mild soreness with palpation of the hyoid and midthyroid area. A maximum phonation time of 12 seconds was measured during sustained vowel production of /a/. Evaluation of the singing voice revealed the highest pitch easily sung was E above middle C and the lowest was C below middle C with a 17 semitone (limited) range; pitch control during this task was fair. Acoustic Evaluation and Results The KayPENTAX Computerized Speech Lab (CSL), Model 4300 and Multidimensional Voice Program (MDVP; KayPENTAX, Lincoln Park, New Jersey) were used to document vocal features both prior to and following intervention. This analysis was used to document and objectively define the frequency, intensity, and temporal characteristics of the patient’s voice. Recordings were obtained using an omnidirectional headset microphone and digital audio recorder. The voice signal was digitized and analyzed for the selected parameters of fundamental frequency (average, high, and low), standard deviation of fundamental frequency, and noise-toharmonics ratio. These parameters were selected because they provide information about the voice source and its variability during phonation. Fundamental frequency indicates the number of


cycles of vocal fold vibration, and noiseto-harmonic ratio compares the spectral energy with the energy of noise existent in the voice signal. Phonatory tasks included a sustained vowel phonation at both comfortable and loud phonation, pitch glides, and oral reading of the Rainbow Passage.32 The same tasks were evaluated post-treatment. (Table 7–14 presents the results of the acoustic analysis for only the sustained vowel /a/ and reading passage prior to intervention.) Videolaryngostroboscopy Results Prior to Intervention The KayPENTAX RLS 9100 70-degree Endo-Stroboscope with Computerintegrated System Model 9195, CCD camera Toshiba (Model 9110) was used for imaging the larynx. Following topical anesthesia with pontocaine spray, a complete view of patient MM’s vocal folds was obtained. The patient was compliant and tolerated the procedure well. Using the Hirano and Bless33 rating form as a general guide, rating of the stroboscopic image was completed. Results were as follows: n Vocal fold edge: A wide-based polyp

on the left true vocal fold was identified at the junction of the anterior one-third and the posterior twothirds of the membranous vocal fold

with moderate vascularity noted. On the contralateral vocal fold, a moderate degree of edema with a small reactive nodular change was identified, presumably secondary to irritation from the left vocal fold pathology. n Glottic closure: Hourglass n Phase closure: Open-phase predominated n Vertical level: Equal n Amplitude: Moderately decreased in both vocal folds, slightly more on the left vocal fold n Mucosal wave: Moderately decreased in both vocal folds, more on the left n Vibratory behavior: Partial absence always, more on the left n Phase symmetry: Mostly irregular n Hyperfunction: Present

Behavioral Intervention Treatment for this patient involved a behavioral approach that focused on modifying behaviors and factors that appeared related to the vocal pathology. The general strategies at the onset of the behavioral program included identifying and eliminating any form of phonotraumatic behavior, initiating a modified voice rest program (no more than 2 hours of talking per day for approximately 1 week), and modified work duty, which meant performance duties were stopped. This patient maintained some income by working in a job

Table 7–14. Acoustic Characteristics of Patient MM’s Voice During Sustained Vowel and Oral Reading Pretreatment and Post-treatment F0 (Hz)

STD (Hz)

Jitter (%)

Shimmer (%)

NHR

Flo (Hz)

Fhi (Hz)

Pretreat

201

4.3

3.23

5.18

0.18

145

239

Post-Treat

223

1.4

.35

2.38

0.11

142

269

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that did not require any voicing (filing, etc). Most individuals are taken out of their performance role when vocal dysfunction arises, but complete voice rest was not recommended because of the nature of this performer’s personality, and performance demands. The likelihood of a performer going back to the same performance schedule and producing the same phonotraumatic behaviors is high without strategies in place to reduce strained, back-focused voicing. Consequently, in the first therapy session with this patient, the concept of the therapeutic voice was introduced. Soft voice (low-impact), relaxed voice production (without strain), and use of a breathy voice characterized the therapeutic voice. Clinicians may recall that these techniques share similarities to the Confidential Voice program.14 With these recommendations, we attempted to reduce overadduction of the vocal folds, reduce the collision force during vocal fold closure, and prolong the open phase of vocal fold vibration. The main goal was to preserve the normal tissue properties, prevent more damage to the vocal fold mucosa, and restore the vibratory characteristics of the damaged area. For this high-risk performer, complete restoration of fluid balance after vocal exercise was also an important consideration to the recovery process. She performed in an outside environment that ranged on average from 70 to more than 90ºF with high humidity. Within the recovery process, we required the performer not only to hydrate with water, but also to replace electrolytes. Exercise performance becomes impaired when complete rehydration is not achieved.34 It has been estimated that approximately 88.7 mL (3 oz) of

water should be replaced per 20 minutes of moderate exercise.35 With this patient, water intake was recommended at between eight and ten 237 mL (8-oz) glasses of water per day with electrolyte replacement from over-the-counter juices. This patient drank 2 to 3 cups of juice per day. A general overview of the patient’s nutrition also was reviewed to identify any potential contributions to vocal fold irritation or diminished drive. We discussed overall general body health and its relationship to the health of her larynx. Additionally, external sources of stress and tension were discussed. For patient MM, this included performance demand, financial reliance on her job, strategies in coping with her ill family member, sleep difficulties, and her motivation for participating in the voice therapy program. None of the difficulties mentioned above necessitated referral to other medical professionals. The patient’s awareness of these factors was noted to be elevated based on her compliance with recommendations for change as well as her ability to learn how to monitor her vocal behaviors that were not conducive to vocal health. To relax the laryngeal musculature and reduce laryngeal height and stiffness, circumlaryngeal massage was employed.36 To further facilitate a lower laryngeal position, an open-mouth posture was used during voice production when articulatorily feasible. Although lung volume levels were not measured, the patient was instructed to take an adequate breath prior to initiating voicing. Breathing to higher lung volumes assists in lowering laryngeal position.37 Also, approaches similar to the yawn-sigh technique38 were implemented. These techniques concentrated on the inspiratory and expiratory phases


of the breathing cycle and slow and controlled expiration for correspondence with the onset of voicing. Performers spend many hours in rehearsal perfecting the show voice and placing it properly. Nonetheless, we have found that when the rehearsal or performance is over, the forward focus falls to the back of the throat, the breathing techniques become more lax, and little attention is paid to the amount of vocal use. Forward placement of the voice focuses on relaxing the tongue musculature, using nasal resonance to “move” the tone to the upper vocal tract rather than the lower vocal tract, and paying close attention to the relationship between what is produced and what is heard. A forward placement is achieved by implementing strategies that incorporate humming (/m/, /n/, and /ng/), short resonant words and phrases, conversational voicing, chanting, and singing. Forward voice placement refers to the location where an individual can feel sensations in their resonating cavity (sometimes referred to as the mask). Because the actual source of voice is caused by vibration of the vocal folds within the laryngeal cavity, the sensations one might feel with a forward placement are associated with air passing through the supraglottal track and acoustic energy. The typical places where individuals may feel vibrations are around the nose, above the lip, and on the tongue. In the clinical setting, producing the nasal sounds /m/, /n/, or /ng/ as well as humming can help an individual feel these forward placed vibrations. The goal of forward placement is to increase the power and clarity of voice while decreasing any muscular pressure in the laryngeal cavity that may result in an overpressure of the vocal folds and ultimately lead

to vocal trauma. Forward placement is accomplished not just by creating vibrations in the resonating cavity but also by creating a balance of air pressure from the respiratory system and a relaxed laryngeal configuration. This patient was encouraged to explore both the sensory and the physiologic components of these exercises.39 Self-auditory perception was developed by contrasting the forward resonant production to the back focus production (negative practice). Back focus production is where the tongue is elevated high in the back of the mouth. It was described as if the voice were deep in the throat and focused on the anatomic site of the problem.

Results of Behavioral Voice Therapy Program After 7 weeks of voice therapy, patient MM’s vocal folds were reexamined using oral endoscopy and videostroboscopy. The patient was compliant with the voice therapy, and review of the videostroboscopic examination revealed improvement in the movement of the right vocal fold, increased mucosal wave on the left side, and a decrease in the overall generalized edema and vascularity of both vocal folds. Unfortunately, polypoid changes and dysphonia persisted. Surgery was recommended.

Surgical Procedure and Result The patient was brought to the operating room and placed under general anesthesia via oroendotracheal intubation with a small-diameter tube. A Dedo laryngoscope was inserted and suspended, and

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the endolarynx was visualized with a binocular operating microscope under high magnification. Bilateral vocal fold polyps were noted at the junction of the anterior and middle thirds of the vocal folds, the left being larger than the right. Both polyps were removed by retraction with Bouchayer forceps and precise excision with curved microscissors. Excised tissue was sent for pathology evaluation, confirming the clinical impression of benign, traumatic vocal polyps. The patient tolerated the surgical procedure well and recovered uneventfully. Perceptual Impressions and Acoustic Analysis of Voice Following Surgery Recall that the initial perceptual impressions of the patient’s speaking voice were characterized as moderately breathy, slightly strained, with glottal fry and frequent episodes of hard glottal attacks, occasional voice breaks, and a vocal loudness that was perceived as too loud. Post-treatment perceptual impressions of the patient’s voice were characterized as appropriate vocal pitch and loudness without any perceived strain, breathiness, glottal attacks, or phonatory breaks. A maximum phonation time of 23 seconds was measured during sustained vowel production of /a/. Evaluation of the singing voice revealed the highest sung tone without strain to be A, one octave above middle C; the lowest was G, one octave below middle C with a 27 semitone range. Table 7–14 shows the results of the acoustic analysis for the sustained vowel /a/ and reading passage following behavioral and surgical intervention. All acoustic parameters were within the normal range post-treatment.

Videolaryngostroboscopic Results Following Surgery n Vocal fold edge: Smooth bilaterally;

free of laryngeal lesion and no edema

n Glottic closure: Complete n Phase closure: Normal n Vertical level: Equal n Amplitude: Normal n Mucosal wave: Normal n Vibratory behavior: Fully present n Phase symmetry: Regular n Hyperfunction: Not present

Behavioral Voice Therapy Postsurgery After the lesions were surgically removed and the vocal fold structure and function were observed to be returning to normal, voice therapy was reinitiated. The program focused on retraining, strengthening, and balancing the 3 systems responsible for voice production and quality: respiration, phonation, and resonance. Principles of vocal exercise physiology, as well as breathing physiology, were used to help the patient maintain an optimum vocal performance. The patient was taught that the muscles in the respiratory and laryngeal system can be trained much as athletes train the muscles that govern movement during a particular type of athletic task. An analogy that we often use is, “A runner would not enter in a track meet without proper training in endurance, strength, flexibility, and muscle toning,” and a singer should not return to a high-performance work demand without considering the same training principles. We consider singers and actors (or any professional voice user) as “vocal athletes” such that work-


ing with respiratory and vocal exercise physiology addresses the issues of strength, flexibility, and endurance as they apply to the voice. Due to her work demand and style of voicing, expiratory muscle strength training (EMST) was recommended. Several of our studies have examined the use of respiratory muscle strength training as an alternative treatment technique for those patients who have respiratory muscle weakness or high upper airway resistance or performers who encounter high physical demand, excessive laryngeal workloads, and environmental constraints that were not responsive to traditional therapies.40–43 The EMST paradigm was implemented because it is known that the expiratory muscles are critical for the generation of sounds. Specifically, strengthening the muscles will enhance the performance of the expiratory musculature by providing an increased ability to develop the pressure for sound production with less physiologic effort. This type of training is applicable to those who are required to develop high pressures and for sustaining a given pressure for a long duration (ie, a vocal performer). Patient MM was issued an EMST device and participated in a 4-week training program. She was seen for a baseline evaluation 2 times before the training began, and her maximum expiratory pressure (MEP) was averaged at 72 cm H2O. She was seen in our office weekly to reestablish her training threshold pressure based on her new MEP measurement. After 4 weeks of EMST training, her MEP averaged at 156 cm H2O. Subjective assessment revealed that her perception of her voice quality and “support” for singing had substantially improved.

Protocol for Using the EMST in Voice Therapy Determining Where to Start Your Training The first step is to measure your maximum expiratory strength, and you can do that simply by using the device. To do the training, follow these steps: 1. Place the nose clip provided with your package on your nose. 2. Turn the knob for the EMST 150 until the small metal screw on the bottom lines up with the number 30. 3. Take a deep breath in; insert the EMST mouthpiece in your mouth, behind your teeth, making a tight lip seal around the mouthpiece. Don’t breathe any air out until the mouthpiece is securely in place. You can use the hand that is not holding the device to help secure your lips around the mouthpiece, if needed. 4. Next, blow hard and fast through the device until air rushes through, then stop. 5. If you were able to accomplish steps 1 through 4 easily, turn the knob clockwise one-quarter turn and repeat.* 6. If you were unable to move air through the device, turn the knob one-quarter turn counterclockwise and continue to do until you are able to move air through the device. When you have found your training pressure from step 5, use this setting for your week of training. * Continue turning the knob clockwise until you are unable to move air through the device easily. This stopping point will be the maximum pressure you are able to create.

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First Week of Training First, turn the knob one-quarter turn counterclockwise from where maximum expiratory strength was determined. The reason to do this is because training muscles should be at 75% of your maximum strength. Note: Pick a time of day where you have time to train and are not tired. It will take you between 20 and 30 minutes per day. Picking the same time each day is recommended. You can either sit or stand although we recommend sitting down when you are doing the exercises. And, remember, during week 1 you will train 5 days per week at this initial setting and then the levels will be adjusted. Week 1 — Steps to Training

1. Place the noseclips on your nose. 2. Take a deep breath in, do not breathe out. 3. Place the mouthpiece in your mouth, behind your teeth, securing your lips tightly around it, holding/pressing the sides of your cheeks if needed. 4. Breathe out hard and fast using your chest and stomach muscles to push air through the device. This breathing effort should only last a couple seconds for the air to move through. 5. Rest for a minimum of 15 to 30 seconds. Do not skip resting in between breaths. Your muscles need time to prepare for the next set. 6. Repeat this exercise 5 times (steps 1 through 5). Then you need a minute break. This is called a 5-breath trial. 7. After the 1-minute break, do another 5-breath trial (steps 1 through 5). Take another 1-minute break. 8. You need to do five 5-breath trials for a total of 25 training breaths. 9. If you feel lightheaded at any time during the exercise, stop and discontinue.

10. Record the date and time the exercises were completed. At the end of training week 1, move the knob on the device one-quarter turn clockwise and begin training for week 2. If you feel you can turn the knob to a higher level, then do so, but remember air must move freely through the device without extreme effort. Weeks 2, 3, 4, and 5 Continue training as described. Maintenance Program After the 5 weeks of training have been completed, continue to train at the final setting you achieved in week 5. During the maintenance program you will train 3 days per week, 25 breaths into the device. Over the course of the maintenance program, if you feel the knob can be turned to a higher level, then do so. But again, always remember training with the device should never cause extreme breathing effort or fatigue. The application of EMST with this patient involved training the laryngeal and expiratory musculature as well as avoiding improper use of the mechanism. A secondary effect of these methods was to train the proper mechanics of breathing to utilize the natural recoil forces of the respiratory system to facilitate voice production. This provided the patient with a mechanism of producing her voice in an efficient, low-risk manner for meeting her performance and lifestyle demand. The schedule for patient MM included a return to work on a gradual basis. It is important to note that although her vocal pathology was eliminated and her vocal function restored, the train-


ing strategies needed to be maintained prior to returning to the performance environment. The patient successfully engaged in practicing these strategies. She understood that vocal warm-ups and cool-downs were mandatory prior to and following a performance and that the vocal exercises were tailored to fit her individual needs.

next week to perform 4 shows per day. Intervention continued throughout this time period 2 times per week. As she moved into her regular work schedule, therapy focused on maintaining the training strategies outlined above with her actual script.

Returning to Work

We find that high-risk performers are unique compared with general vocal performers. At a minimum, this conclusion can be based on the supported evidence of a high environmental demand. Consequently, clinicians must understand the relationship between the environmental demand and the structural and functional deviations presented to them. As with many types of rehabilitation, there is no single therapeutic technique that fits all individual needs, although the underlying pathology, structure, and function may share common traits. Most typically, the treatment program for the high-risk performer is based on occupational, social, and behavioral needs. We have found ourselves advocating for management issues related to performance scheduling and believe it is critical for speech-language pathologists who are involved in the care of the professional voice to advocate for improved training and management.

The patient’s gradual return to work 5 weeks postsurgery progressed as follows. She completed one show per day in a 5-day workweek, incorporating modification strategies and carrying out various laryngeal strengthening exercises to increase vocal endurance throughout this week. In addition, the patient implemented laryngeal relaxation strategies on a regular basis and particularly right after vocal performance. The patient returned to our clinic weekly for reevaluation and voice therapy. The results of the videostroboscopic evaluation after her first day back to work revealed straight vocal fold edges, slight edema bilaterally, and slight limitations in vibratory amplitude. It was recommended that she continue increasing the time involved working. The second week she completed 2 shows per day for 3 days and 3 shows for the remaining 7 days. In week 4, the patient began feeling comfortable with her performance and was able to incorporate modification strategies to meet the demand of her performance schedule. On reevaluation, the vocal fold structure and function were deemed to be within normal limits. The vocal fold edges continued to be straight with an absence of the generalized edema. It was recommended that she return the

Final Thoughts

In the next case, Sarah Schneider and laryngologist Mark Courey provide a comprehensive description of the perioperative course of voice use and voice therapy including a look at the lack of supporting literature for the role of reflux in lesion formation and persistence.

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Semi-Occluded Vocal Tract Exercises and Resonant Voice Therapy in the Perioperative Management of a Professional Actor and Singer With a Vocal Fold Cyst

alto range. She characterizes herself as a belter. Other than a few private singing lessons, her vocal training has concentrated mostly on speaking voice production. She characterizes herself as having a low-pitched voice since high school and has had intermittent voice complaints. At age 22 she underwent excision of a right vocal fold “lesion.”

History of the Problem

Medical History

Patient DF is a 39-year-old female actor/ singer who has been performing in local and regional theater since the age of 22. She has been able to sustain her career through performing mostly character roles. Over the last 9 months she notes that her singing voice range has contracted. She has difficulty accessing her head voice with cracking in the middle of her range. Over the same time period, her speaking voice has become rougher. She complains of intermittent voice breaks, increased vocal effort, and vocal fatigue with use. She experiences a sense of anterior neck pain associated with voice use that has not happened before. Even though her coaches and production managers have not said anything to her, she notices the changes and is concerned. She denies any associated illnesses or events at the onset other than performing in a modestly demanding role. She is breathing and swallowing without difficulty, and she does not have a cough or other symptoms of reflux disease, sinusitis, nasal congestion, or nasal drainage.

Except for surgical excision of a right vocal fold lesion, her history is unremarkable. She is not on any medications.

Vocal History

Laryngeal Palpation

She obtained an undergraduate degree in theater performance and sings in the

Due to the patient’s complaints of vocal effort, increased anterior neck discom-

Case Study 7 Sarah L. Schneider and Mark S. Courey

Social History The patient is married and makes her primary living through theater performance with supplemental income as an acting teacher. She was raised by supportive parents and describes her home environment as loud. At presentation she smoked marijuana weekly along with social alcohol.

Voice Evaluation Audio-Perceptual Evaluation Initial audio-perceptual evaluation revealed a mild to moderate breathy quality with mild, intermittent roughness, mildly reduced pitch, and mild strain. She spoke with pressed phonation and had posterior (or throaty) resonance and variable airflow. No voice breaks or diplophonia were observed.


fort, and vocal fatigue with use, laryngeal palpation was performed at rest and during phonation to determine the potential role of muscle tension in voice production patterns. These findings are significant. At rest, the thyrohyoid space was present and malleable. It was nearly absent during phonation. Suprahyoid/base of tongue (BOT) tension was present at rest and increased with phonation. Also during palpation DF reported moderate tenderness in the thyrohyoid area and mild tenderness in the BOT. Relaxation of the laryngeal and extralaryngeal musculature at rest and excessive engagement of those muscles during voice production indicate that voice use patterns are contributing to her vocal complaints. In addition, tenderness in these areas indicates chronic versus more transient muscle tension. Laryngeal Imaging Direct Light. To inspect the pharyngeal and laryngeal mucosa for integrity, gross lesions, joint/muscle function or motion, and general relative color, the patient’s larynx was imaged first with continuous light. The findings showed that the patient had normal pharyngeal mucosa and muscular activity without excessive pooling of secretions. Continuous light laryngeal examination identified relatively symmetric vocal fold adduction and abduction. However, the right vocal fold showed a fusiform expansion at the junction of the anterior and middle third or at the midmembranous vocal fold. The left vocal fold was relatively normal. In our office, video endoscopy is used. Therefore, color can be distorted by camera settings and judgments of erythema must be made relative to other structures. Next continuous light examination is useful for assessing pha-

ryngeal and laryngeal mucous as well as patterns of pooling or stasis of secretions in the pharynx and larynx. Healthy patients in this age group should normally have thin secretions minimally coating the surface of the mucosa. There should not be excessive stasis or pooling secretions in any region of the pharynx or larynx, as this is a sign of malfunction from either muscular weakness or neurogenic dysfunction. Both the pharynx and larynx are inspected for muscular activity. With regard to the larynx, the patient is asked to phonate /i/ repetitively and then to breath in through his or her mouth. This should create rapid and relatively symmetric vocal fold adduction and abduction, respectively. The activity should be sustainable for several syllables without significant fatigue. The patient is then asked to glide up in pitch to a relatively high region for his or her voice type. The patient can also be asked to squeal on a /i/. Both of these activities normally result in contraction of the lateral pharyngeal walls. In this age range, coordinated activity of the pharynx and larynx in the upper range should result in pharyngeal contraction with near complete obliteration of the pyriform sinus. This indicates intact pharyngeal muscular strength.44 Finally, the mucosal surfaces of the pharynx and larynx are inspected for lesions. The vocal folds should be relatively straight without bowing, mass lesions, or excessive vascularity. The region of the vocal process or cartilaginous glottis is inspected for masses or ulcerations. Vocal process granuloma or ulceration is associated with reflux disease and hyperfunctional voice disorders. This association has been recognized since the mid-20th century.45 However, in spite of 30 years of exhaustive research on the role of reflux in the creation of vocal process lesions,

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relatively little more is known now that was postulated nearly half a century ago. The posterior commissure is inspected for hypertrophic or hyperemic mucosa, which along with edema of the ventricles or infraglottic region can be associated with “reflux disease.”46 However, these findings are nonspecific and can just as likely be associated with voice overuse, infection, or chronic muscular tension induced coughing.47 In a similar manner, the pharyngeal mucosa is inspected for irregularity. Irregularities of pharyngeal mucosa are more likely secondary to neoplastic disease than behaviorally induced trauma, as these regions are not subject to shear during voicing or swallowing.] Although somewhat controversial, this portion of the examination can be performed with either flexible indirect endoscopic techniques or rigid indirect endoscopic techniques. Proponents for both techniques exist. Those who favor flexible techniques do so because the flexible endoscope allows the patient to phonate in a more natural position. They believe that this is critical to assessing vocal fold abduction and adduction. However, there is no empirical evidence to support this contention. In addition, patients often gag on the flexible endoscope and/or report a sense of nasal or pharyngeal discomfort during insertion. This technique is usually performed with topical anesthesia that may also distort pharyngeal and laryngeal function as sensation is altered. Examiners who favor the indirect rigid technique of examination often do so because the exam can generally be accomplished without topical anesthesia and produces minimal discomfort. During the exam the patient is required to protrude his or her tongue which is usually stabilized by the examiner’s hand. This

places the patient in an unnatural position and may elicit a strong gag reflux. In addition, it has been hypothesized that the tongue-out position alters arytenoid adduction and does not allow the posterior portion of the glottis to close fully. But, to be successful, the indirect rigid technique of examination requires that the patient be able to relax his or her tongue and separate tongue function from laryngeal and pharyngeal function. This forces the patient to “unload the larynx.” The patient’s ability to perform this task provides valuable information to the examiner; however, there remains no empirical evidence to support this. Stroboscopic Light. Due to the rapid nature of vocal fold vibration, the application of stroboscopic light is required to perform a detailed inspection of vocal fold mucosal integrity and behavior during passive vibration that occurs during voice production. These vibratory patterns must be evaluated at multiple vocal pitches and intensities as laryngeal vibratory behaviors are altered by the choice of intensity and pitch. Because our patient, an alto, complained of difficulty in her mixed and head voice, her examination was most critical at these frequencies. Evaluation of the mucosal vibratory parameters demonstrated dampening of vibration on the right vocal fold throughout the patient’s range. However, this dampening and actual absence was most pronounced in the patient’s upper register. At the highest frequency obtainable, vibration over the lesion in the midmembranous right vocal fold completely stopped, and vibration continued in the segments anterior and posterior to the lesion giving the appearance of a teeter-totter. This indicated that the


fusiform-like swelling was actually not allowing the cover to separate from the body during phonation and was suggestive of a deeper intramucosal lesion such as a vocal fold cyst.48

Voice Therapy Given the patient’s diagnosis of a right vocal fold cyst, her current ability to maintain some vocal function, and the high vocal demand related to her work in theater and as an acting teacher, voice therapy was recommended as the first line of treatment by the multidisciplinary team. In all voice users, especially those who rely on their voice for their livelihood, we consider the cost/ benefit of conservative versus more aggressive behavioral or medical/surgical intervention. The patient’s level of motivation and willingness to accept primary responsibility for contributing voice use patterns is a key factor in working with this population. If a professional voice user is resistant to making vocal modifications in the presence of increased vocal complaints and vocal fold tissue changes, it raises questions regarding their ability to follow potential postoperative guidelines to promote healing and avoid reoccurrence of voice problems. A trial of voice therapy is critical to learn more about the patient and his or her willingness and ability to make vocal modifications. In this case, DF was stimulable for voice change during the initial evaluation session with the laryngologist and speech pathologist. Prior to exposing her to the risks of vocal fold surgery, the voice care team needed to assess her response to behavioral intervention given that the lesion may reduce in size, vocal fold pliability may improve, and

the patient may be able to learn how to use her voice adequately in the presence of the vocal fold lesion. The patient was very open to behavioral voice management and vocal rehabilitation, hoping to avoid further surgical intervention. Primary goals of voice therapy were to reduce phonotrauma and to improve the patient’s vocal efficiency. This was attempted through indirect and direct voice therapy. The desired outcome was to improve vocal quality, ameliorate her vocal complaints, and allow her to sufficiently meet her vocal demands. The goals of direct voice therapy are multifactorial. They are to improve overall vocal efficiency, promote motor learning, and develop new muscle patterns for voice production to be applied and habituated in all vocal contexts — daily speaking, acting, singing, teaching, and so on. We worked through the stages of skills acquisition as described by Bonnie Raphael in 2003.49 In turn, practicing and working to habituate the targeted voice use patterns should decrease phonotrauma which was a likely etiology in lesion development. Through successful direct voice therapy, impact during vocal fold vibration is reduced. This will promote healing, potentially reduce the size of the lesion, and improve vocal fold pliability enhancing symmetry and periodicity of vocal fold vibration. Specific Types of Therapy Indirect therapy was completed in 20 minutes of the first therapy session. This included counseling on vocal hygiene, the anatomy and physiology of voice production, how vocal fold lesions produced voice changes, and how this related to what the patient was experiencing. Specifically, DF was counseled

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on factors including possible causes and contributing factors to vocal fold cyst development; how the vocal fold cyst added mass to the vocal fold resulting in a lower speaking pitch; the effect the cyst had on her singing range and ability to move through her range due to reduced ability to achieve vocal fold stretch, consistent vocal fold vibration, and glottic closure; and that the cyst resulted in delayed voice onset due to the increased stiffness and weight of the vocal fold requiring increased subglottic pressure to initiate vibration. Under vocal hygiene counseling, recommendations were made in relation to hydration, avoiding drying agents, and minimizing exposure to laryngeal irritants. These were reinforced throughout the course of therapy as needed. Phonotraumatic voice use patterns were identified, and the patient was counseled on how to eliminate unnecessary loud voice use, throat clearing, and other concerns. In the case of DF, projection was a necessity. Voice amplification was not always available in the smaller houses to which she performed, and providing her own amplification was not acceptable. Voice management and vocal choices became very important. She had to begin assessing, with some vocal guidance, the cost/benefit of specific situations. We began to discuss her involvement in certain projects and the level of importance with regard to career growth (and financial livelihood). She began to decide what was a necessity and what could be eliminated in the short term and resumed as her voice began to improve. Vocal demand was addressed with regard to daily scheduling. Together we worked to evaluate her routines to implement voice breaks/periods for

vocal recovery. In addition, we identified specific times to practice vocal exercises to promote muscle memory and as a way to reset her voice throughout the day (resetting the voice will be discussed later in this text). With this in mind, she was advised to avoid speaking and singing to the point of vocal fatigue or quality deterioration. She was instructed to rest her voice briefly or reset her voice when she noted vocal change. The benefits of vocal warm-up and cool-down are not fully understood, but use is common among vocal professionals. Therefore, a warm-up routine of 10 to 15 minutes and a cool-down routine of 5 minutes were established. They were composed of physical body movements (which she had a previously established routine) and vocal exercises to minimize tension, balance coordination of breathing and phonation, and maximize forward resonance as follows. Direct voice therapy was completed using tension reduction techniques including laryngeal massage, tongue stretches, and body movement along with various semi-occluded vocal tract techniques and resonant voice therapy techniques. Laryngeal massage techniques and tactile cueing (provided first by the clinician and then by the patient herself) were used to reduce engagement in the thyrohyoid area and base of tongue during breathing and phonation. Circumlaryngeal massage and laryngeal reposturing are useful for achieving more consistent voicing when used with certain populations.36 In this case, the techniques were used to achieve neutral laryngeal positioning and release compensatory hyperfunction that lead to fatigue or anterior neck discomfort. (See Roy, Chapter 3, for a


complete explanation of circumlaryngeal massage techniques.) Three distinct tongue stretches were introduced. They were to be performed 3 times each and held for about 2 breaths (or longer if tolerated). The patient was taken through the stretches as follows: 1. Keeping the tongue fat, extend it toward the chin and hold the tongue in this position. The goal was to feel a stretch at the back of the tongue, along the sides, and potentially in the submandibular region. 2. Extend the tongue up toward the nose, keep the jaw released, and hold this position. The goal was to feel a stretch underneath the tongue. 3. Place the tongue tip behind the bottom teeth and arch the tongue up and out (a “backbend” for the tongue). The goal was to feel a stretch in the back of the tongue, along the sides, and/or in the submandibular region. For all stretches the patient was cautioned not to overextend the jaw, rather to let it release in a neutral position and to provide counterpressure at the temporal mandibular joint as needed. Various semi-occluded vocal tract exercises were used to promote interaction between the vocal source and resonating cavities (filter) to increase vocal efficiency and economy.18 The therapeutic focus was to achieve balanced airflow and to improve oral/ nasal resonance during phonation. This began with tongue-0out trills (tongue raspberry) to promote consistent airflow with simultaneous tongue release during breathing alone and then coordinated with phonation.

Breath work was completed throughout the therapy process with a focus on expansion of the rib cage and abdomen during inhalation and gradual deflation during exhalation. Breath training was kept relatively simple in this case as the patient could already demonstrate abdominal breathing — the target was primarily coordination of breathing with phonation and decreasing inefficient laryngeal valving to control airflow. Once breath and the initial tongueout trill were established, attention was brought to the sensations of oral resonance and the ease of voice production throughout her range while continuing the trill (scales gliding up and down on a fifth, eg, C-G-C, and 5-note scales, CDEFGFEDC — or sustained sounds, ascending glides, descending glides, sirens, and various scales). This sensation was used as a point of reference throughout therapy focusing on balanced airflow and oral/nasal resonance without effort. Resonant voice therapy using /m/ was then introduced; first with the tongue protruded and then gradually bringing the tongue to a neutral position inside the mouth. Attention to tongue release and consistent airflow remained while maintaining and maximizing the sensations associated with resonant voice production (buzz/vibration/energy at the lips, teeth, tongue, alveolar ridge, in between the nose and mouth in the face, etc). The patient was also instructed in /f/ and /s/ exhalation, targeting easy exhalation of airflow with resistance at the teeth and lip and teeth, respectively. This was then coordinated with phonation on /v/ and /z/, continuing to target consistent breath flow coordinated with voice production feeling buzz/vibration at the point

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of resistance. The same goals were targeted as in the resonant voice therapy. Therapeutic Hierarchy — this could be used with /m/, /v/, /z/, etc: 1. /m/ tongue out (in) — sustained sounds, ascending glide, descending glide, siren; 10 times each n exhale to make voice (feel air coming through your nose) n feel buzzing on your lips 2. /m/ into vowels n feel buzz on lips every time they come together Ma-ma-mam, Me-me-mem, My-my-mym, Mo-mo-mom, Moo-moo-moom Note: Start each of the following steps with an easy /m/ as above. Maintain consistent airflow and buzz. As you add words you will feel more energy in the mouth and less distinct buzz. 3. /m/ into words — chanting/inflection mine mane man mean mall maybe moan moon mail meet 4. /m/ into phrases — chanting/with inflection Me and you Monday morning Maybe tomorrow My best friend 5. /m/ into sentences — chanting/ inflection Marvin made me make more money. Momma made me mince my M&M’s Many men went to mow a meadow.

6. /m/ into your own phrases — chanting/inflection 7. Choose 5 “reset” words — practicing starting with /m/ and then without/m/ n

maintain the same ease and quality with and without the /m/

The goal of resonant voice therapy exercises is to achieve easy phonation while experiencing energy or vibration of sound in the oral cavity.50 Verdolini, Druker, Palmer, and Samawi17 demonstrated that the vocal folds are nearly adducted at that onset of phonation during resonant voice production, therefore reducing vocal fold impact at the onset of vibration. In addition to the kinesthetic sensations of resonant voice production, as speech pathologists we want to keep in mind the potential tissue benefits that may result from lowerimpact vocal fold vibration. It is our role to help the patient understand this to promote therapeutic buy in. As above, in each technique, the patient was taken through a hierarchy of exercises of increasing complexity from sustained sounds, glides, and sirens. When consistency was achieved, messa di voce was introduced to aid in building vocal ease and consistency during volume variation. This sound (/m/, /v/, or /z/) was then shaped into words, phrase, reading, conversation, and performance level voice use with varying vocal intensity, pitch range, and emotion. As the complexity of the vocal tasks increased, the patient was asked to bring in scripts from shows that she was rehearsing, performing, or teaching. Early in the therapy process, the concept of “resetting” voice use patterns was introduced. The goal of this tool is


to promote carryover of the new voice use patterns as soon as possible, maybe even from the first session. The patient practiced 5 specific reset words (frequently used words, ie, yes, no, okay) several times per day using the therapeutic techniques from the session. She was encouraged to feel the same ease and quality of voice production during the reset words as she did while practicing in structured tasks. This practice helped to develop muscle memory and awareness of the sensation of the targeted voice production. Then, throughout the day she could begin to “catch” herself producing the target voice or producing her habitual voice. In both instances the catch is positively reinforcing. Vocal awareness is increasing and there are increasing opportunities/ awareness to reset the voice. Bodywork was also used to varying degrees throughout therapy sessions to continually target tension reduction in the muscles of voice production and target activation or a refocusing of energy in the whole body. For example, bending over at the waist was used to increase awareness of the sensations of breath in the abdomen and back while also targeting more intense vibration in the face during resonant voice production. A head turn was used to employ the neck muscles in turning the head rather than assisting in voice pro duction. DF had excellent kinesthetic awareness and could easily identify the changes associated with various body positioning or activities and then work to apply the sensations in a more typical body position. As she began to apply techniques in her speaking voice at a modal intensity, vocal projection was targeted more specifically. This work began in an emotionally neutral context beginning

with sustained trills, /v/, /z/, and /m/, while completing a messa di voce (softloud-soft). Completing this vocal task keeps the primary focus on volume change rather than pitch and volume. Although the following description is not completely consistent with our knowledge of the physiologic underpinnings of loud voice production, cueing the patient to release more air faster and feel more intense vibration in the oral cavity aids in achieving increased vocal intensity with less effort. The patient was educated that subglottic pressure increases during loud voice production51; however, she was cautioned that her primary focus should be on maintaining breath and the energy of sound in the mouth rather than the throat when getting louder. When consistency was established on the messa di voce on various pitches and vowels, the target voice was reestablished and shaped into words and phrases with varying intensity through the techniques outlined above. The same phrase or sentence was completed 3 times at a soft, medium, and then louder volume. The complexity of the louder task was gradually increased in utterance length and duration of loud voice use to increase stamina. Introducing emotional context to projected voice use adds a layer of complexity that takes practice, a high level of kinesthetic awareness, and confidence in allowing the established vocal techniques to work. With behavioral guidance during therapy sessions, DF was able to call upon her knowledge of expressing emotion within the context of a specific character. Rather than expressing emotion only by increasing vocal intensity, choices were discussed and practiced. Variations in vocal intensity are often more effective than escalating

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loudness alone. Altering breathing patterns, varying pitch inflection patterns, and body language are used to express emotion. With practice, DF learned to increase vocal intensity in an efficient manner, and she also had developed alternate methods of expressing emotion that could help preserve her voice. An additional concern when working on vocal intensity with a patient with a stiff vocal fold, in this case a cyst, is that softer intensity may be more difficult than louder. It is important to target volume variation and be sure that airflow and oral resonance remain while decreasing intensity. As the speaking voice became more consistent using the above techniques, more therapy time was dedicated to the singing voice. It became apparent relatively quickly that the patient’s vocal range remained limited despite speaking voice improvement. Her voice became breathy, thin, and unstable around A4, and she was unable to work around this. She did not have any singing demands in the near future and she decided to forego an upcoming singing audition because of vocal limitations. Given our knowledge of the size and location of the vocal fold cyst, we decided together, the patient and SLP, to accept the limitations of the singing voice at that time and focus on the gains she was making in her speaking voice. As mentioned, therapeutic expectations were to promote healing, reduce the size of the vocal fold lesion, and reduce lesion exacerbation while modifying voice production patterns to maximize efficiency and promote carryover of techniques into all voice use contexts. There was little expectation that the vocal fold cyst would resolve; however,

it was hoped that she may be able to learn to work with the cyst. The patient was seen for 45 to 60 minute sessions of voice therapy 1 time weekly for the first 4 weeks, every other week for 8 weeks, and then monthly or as needed based on vocal demand and exacerbation of vocal complaints. She was able to work professionally, primarily performing in character roles, for about 2 years. Throughout the course of therapy the patient was followed by the multidisciplinary voice team to monitor vocal fold appearance and complaints. Therapeutic goals were adjusted as needed based on patient response and vocal needs at the time.

Reassessment Vocal Function Reassessment of our patient’s response to therapy intervention involved obtaining impressions from the patient regarding her satisfaction with her post-therapy vocal abilities, the SLP regarding the patient’s ability to create and comply with the requested changes, and the surgeon’s opinion on the appropriateness of the lesion for surgical removal. Even though the patient had been working with the SLP on behavioral changes as outlined to improve laryngeal efficiency, these concepts are complicated and not every patient has the coordinated ability to make the changes requested. The SLP must provide an accurate assessment of the patient’s ability to make the changes and comply with the recommendations. The physician must then decide what portion of the lesion may be responsive to surgical changes and with the SLP what remaining portion of


the lesion and/or voice complaints are due to continued vocal misuse. These opinions are presented to the patient, and from them a surgical risk/ benefit discussion is created. In our patient, she appeared to be relatively compliant with vocal hygiene measures and she was attempting to reduce vocal inefficiency by improving airflow; however, this was somewhat elusive to her. She continued to exhibit “posterior focus voice” with a “heavy laryngeal mechanism.” The preoperative risk/benefit discussion centered on the possibility that perhaps due to the right vocal fold stiffness, the patient could not fully unload her larynx, because pushing to initiate vibration for phonation was required secondary to the presence of the lesion. However, the patient was cautioned that if she continued to “push” postoperatively that her healing would be delayed, she would risk increasing postoperative stiffness that could result in permanent vocal deterioration, and that with continued pushing, she was at greater risk for developing a second or recurrent lesion. Reassessment Goals With regard to the patient goals, through behavioral intervention strategies, she was able to produce stable voice. She noted significantly less vocal fatigue, less anterior cervical pain, and less voice use-related vocal deterioration. She also noted that her upper vocal register improved. However, she was still unable to sing in a meaningful way on stage, and this limited her career options. Due to this overall vocal limitation, she elected to attempt excision of the cyst to see if this would provide

additional range and allow her to compete more successfully for more and different roles. Surgical Decision Making: Indications The indication for surgery in this patient was her successful completion and adherence to a behavior modification program that allowed her to improve and stabilize her voice. The patient demonstrated improvement over a 3-month period of active retraining and was able to maintain these changes in the face of liberalizing her vocal activities. Serial stroboscopic examination of her vocal folds revealed stabilization in the appearance of the lesion on the right vocal fold and reduction in the thickening of the left vocal fold. The left vocal fold became supple and vibrated through all frequencies obtained. The right vocal fold had a persistent intramucosal mass that stopped vibration at the sight of the mass when the patient attempted to phonate greater than 440 cycles per second. This mass resulted in vocal range limitation, specifically with an inability to access her upper singing (head) voice as well as an unacceptably rough quality, which was professionally unsatisfying. The patient was therefore counseled on the risks and benefits of surgery. The risks of surgery in this case included exacerbation of scarring or stiffening of the right vocal fold which could result in further vocal decline with increased roughness and strain and loss of ability to speak or sing in a meaningful manner. Furthermore, the patient was informed that postoperative resonant and flow phonation was imperative to improve healing and ulti-

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mate vocal fold suppleness as the vocal fold vibratory parameters have been shown to affect the mRNA expression of the vocal fold fibroblasts, thus influencing the healing and ultimate condition of the postoperative vocal fold mucosa. In plain terms, the patient was told that surgery and noncompliance with voice recommendations could result in vocal fold scarring with loss of the ability to speak or sing. In addition, she was told that operation on the airway could result in airway swelling with death or a need for tracheotomy. Finally, she was informed that because the exact etiology of the vocal fold lesion was not known, she could have a recurrence of the lesion postoperatively. Surgical Techniques For our patient, stroboscopic examination revealed an intramucosal lesion that inhibited vocal fold vibration. At surgery a microlaryngoscope was placed to distend the patient’s mouth, oropharynx, hypopharynx, and larynx in such a way that allowed direct access to the larynx through the mouth with straight instruments. After visualization was obtained, rod-lens telescope was used to visually inspect the vocal folds. Next an operating microscope was brought in to view the vocal folds at high magnification. The vocal fold mucosa and lesion were palpated. The lesion was adherent to the deeper layers of the vocal fold. Therefore, a surgical approach was planned to allow the surgeon to access the microarchitecture of the vocal fold mucosa first through an area of relatively normal mucosa. Once the normal structures were identified, sharp dissection was undertaken to identify and separate

the lesion from the surrounding normal tissues. Some surgeons prefer to use hot or laser instrumentation for this procedure. However, these potentially result in excess heat that could damage normal surrounding structures. Cold knife or steel instruments are less likely to create this injury. Careful dissection allowed removal of the lesion, in this case a mucous retention cyst, from the vocal fold. The remaining normal mucosal structures were draped over the deeper layers of the vocal fold to promote primary healing.

Postoperative Recovery and Voice Therapy Weeks 1 Through 4 The patient was asked to observe 6 days of voice rest postoperatively. This was primarily to allow resolution of surgicalinduced trauma and edema that could negatively impact on the vocal fold mucosa vibration as well as reduce the likelihood of patient-induced trauma from inefficient voice use patterns. There is a growing body of evidence to suggest that surgically induced inflammation is resolving by postoperative day 3 or 5 and that early mobilization of the vocal folds with efficient vibratory patterns may result in improved healing characteristics. Due to clinical scheduling, our practice pattern remains that patients stay on voice rest for 6 days. The team examines the patient together with audio-perceptual evaluation and stroboscopy. Audio-perceptual evaluation revealed a moderate breathy quality with moderate asthenia. Vocal fold stiffness is common following cyst


excision, and this often manifests in the described vocal quality, especially after the week of voice rest. Stroboscopy confirmed erythema and stiffness of the right vocal fold. At low frequency, there was evidence of beginning vibration. Therefore, during the second postoperative week, she was advised to speak about 5 minutes per hour. She was advised to listen to her body. If she experienced increased vocal strain, fatigue, or a negative change in quality, she should rest her voice. She was advised to maintain hydration and avoid all loud voice use, and she was reminded of alternatives to throat clearing. At this point, the patient was encouraged to use her voice to promote vocal fold vibration and healing rather than be tempted to continue voice rest. The patient asked if continued voice rest would be better for her voice to “maximize healing.” Although it is important to balance voice use and rest in the initial healing stages, if we consider the work of Steve Gray and those who continue work with vocal fold wound healing, it appears that regular, low-impact vocal fold vibration can promote healing.52 Initial postoperative exercises included resuming laryngeal massage and tongue stretches and the use of airflow and resonant voice therapy techniques. We called upon previously successful therapeutic exercises. Vocal practice was completed with a focus on maintaining consistent airflow without strain and attempting to feel increased oral resonance on sustained sounds, glides, and sirens for 2 minutes about 5 times per day. The patient was advised of the same guidelines as above; she should listen to her body. The exercises should not cause strain, fatigue, or a negative change in quality. If there were sev-

eral hours of quiet during the day, she should complete the exercises in lieu of complete voice rest. As mentioned, the healing vocal fold is stiff postoperatively. As a result, vocal fold closure is incomplete. To experience the intense sensations of oral resonance requires relatively complete vocal fold closure and a robust acoustic signal. With incomplete vocal fold closure, the signal is weaker and the harmonics cannot be amplified by the shape of the vocal tract in the same way. With this in mind, the patient was educated and reassured that she would not feel the same amount of energy or vibration in the sound that she felt preoperatively. As vocal fold pliability improved, vocal fold closure improved, and she began to have increased sensations associated with resonant voice production. Each week for the first month postoperatively, the patient’s voice use time was gradually increased. By postoperative week 4 she had nearly resumed daily voice use patterns with continued regard to vocal awareness. Weeks 4 Through 8 By 4 weeks postoperatively, on stroboscopy the operated vocal fold showed the development of an upper and lower mass at modal and low-pitched phonation. The speaking voice was near normal, and the voice use time is increased. DF continued to avoid loud social situations as she felt it was difficult for her to self-monitor and maintain selfcontrol with regard to vocal intensity. As speaking voice time increased, vocal exercises were increased. The same exercises established preoperatively were used postoperatively with specific considerations given to the healing vocal

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folds. Vocalizations were introduced in a comfortable and gradually increasing pitch range. Initially, a tongue-out trill was used on a 12321 pattern to begin. She could vocalize from B3 to C5. Weeks 8 Through 12 Stroboscopy continued to show improvement in vibratory characteristics. Therapy on speaking voice production was complete, and singing voice continued. As DF moved from semi-occluded vocal tract exercises to open vowels, she had difficulty vocalizing above A4 without a voice break. Continued work was completed working to balance the transition from semi-occluded vocal tract exercises to open vowels and various consonants. This was completed on note patterns with increasing complexity working to stretch her range. As she could maintain consistency with less resistance in the anterior portion of the mouth, we began to implement techniques into the repertoire. Her vocal range remained limited up E5 (from G/A4 preoperatively), and for the purposes of the singing roles that she played this was adequate. Weeks 12 and Beyond The patient returned to performing approximately 4 months postoperatively in a speaking role. Daily voice use patterns were fairly consistent at this point. The patient generally did not experience vocal fatigue, and vocal quality was normal and consistent with improved airflow and resonance. She had resumed teaching. With the expectation of performing for up to 2 to 3 hours per night several nights per week, we began to increase training to promote vocal stamina. Within the therapy session, we began working monologue and text

for increasing lengths of time, practicing volume variation and emotion. This was initially targeted in a very structured way using the /m/, /v/, or /z/ as a facilitator into dialogue. The facilitator was faded and then only used to reset as needed. Eventually the patient was able to “think” about the therapy technique with regard to physical sensation and achieve the desired vocal outcome. Independently, the patient was encouraged to work through her script in a similar way to the therapy session. In addition, she was advised to begin to work for increasing lengths of time that are not possible within a session. She was typically able to teach a 60 to 90 minute acting class at this time without fatigue. However, the physical and vocal demand of teaching was not the same — she was advised to begin with 30-minute intervals of dialogue work, take a 5 to 10 minute break, and resume work. This could be completed for up to 2 to 3 hours of work (if needed). She was provided with guidelines to monitor her voice, similar to the postoperative guidelines mentioned previously, and to listen to her body with regard to implementing breaks. As she began formal rehearsals with the cast, she was able to continue stamina building with a new regard to how she was managing her voice. Audio-Perceptual Evaluation At her most recent visit 2 years status post cyst excision, DF’s audio-perceptual evaluation revealed borderline raspy, breathy quality with variable airflow and resonance with minimal strain. Laryngeal Palpation Laryngeal palpation revealed a soft and present thyrohyoid space at rest with


mild engagement during phonation. Suprahyoid/base of tongue tension was mild with phonation. No tenderness was reported by the patient. Visual Imaging Continuous light evaluation showed subtle bilateral vocal fold fullness. On stroboscopy, the vibratory parameters were present and intact at low and modal pitch. On higher pitches the right vocal fold was less vibratory than the left. At all frequencies the closure pattern was in the form of an enlarged posterior chink. Patient Self-Assessment The patient was pleased with her voice and able to work consistently. She has maintained a regular warm-up and cool-down routine and independent bodywork to manage personal tension/ stressors. She still had some inconsistency with singing and had been working with a voice teacher on and off per our recommendation and is satisfied with her progress and is able to meet vocal demands. She generally does not feel limited by her voice. If we had not asked her to follow-up for her last visit, she would not have independently been compelled to come.

Summary There are many factors to be taken into consideration when evaluating and treating a professional voice user with vocal complaints. Cases such as this are multifactorial and require a multidisciplinary approach to be most successful. In addition to the typical medical and behavioral considerations, it is para-

mount that we understand the patient’s lifestyle, vocal demand, vocal expectations, and schedule. Preoperative voice therapy can often be the best postoperative therapy. In some cases, preoperative therapy can help avoid surgical intervention. But in the cases it does not, we want to provide the patient with the knowledge and tools to achieve the best vocal outcome and avoid future vocal problems. In Case Study 8, Wendy LeBorgne describes the use of myofascial release in the overall treatment plan of a long-time performer in a vocally, physically, and emotionally demanding role.

Case Study 8 Wendy D. LeBorgne Treating Vocal Injury in a Physically and Vocally Demanding Performer

History Patient XX, a 38-year-old woman, was referred by her company manager during her tech week, just prior to a 7-week run (8 shows per week) of a very small ensemble show (3 people), which was physically, emotionally, and vocally demanding. She began to experience vocal fatigue, throat pain, neck and jaw discomfort, upper back tightness, and “tightness in her breathing patterns” throughout the 5-week rehearsal process. As a New York–based actress, she was only in Cincinnati for a period of 12 weeks for rehearsals and performances. As this patient made a point

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to keep her voice healthy, she routinely saw her New York otolaryngologist once a year for a wellness visit and to manage her seasonal allergies. Consent to release records were signed by the patient and her otolaryngologist in New York was contacted for her most recent videostroboscopic examination report as comparative data. A complete case history was taken regarding voice, medical, social, and performance concerns. Videostroboscopic imaging was completed and reviewed with an otolaryngologist, and recommendations were made. Aerodynamic and acoustic measures were completed as well as a technical voice assessment during performance. Due to her physical complaints related to jaw tension, chest tightness, and neck pain, she was evaluated by both a pulmonologist and orthopedist before her ENT/ voice center consult. She was cleared medically from any cervical, thoracic, or pulmonary anomalies. Both physicians reported increased musculoskeletal tension/pain. She was prescribed a muscle relaxant and an anti-inflammatory. This patient had been a professional stage actress for approximately 20 years, held an MFA in drama, and had an extensive professional performing resume off-Broadway and at major regional houses. With the exception of when she took 2 years off in her late 20s to have a child, she worked consistently as an actress and did not report history of vocal problems other than associated with an acute illness. Patient XX reported that if she did have an illness that affected her voice, she did not hesitate to “call out” of a given show for adequate recovery. Patient XX’s current role was the leading role in a 3-person show. The nature of her role required extensive

physical demands including stage combat, highly emotional scene work with screaming/crying, and costume restrictions due to period costuming utilizing a corset that she felt restricted her breathing. Her daily routine including going to the gym at 8 am for either a cardiovascular/weight training 90-minute workout or a 90-minute hot yoga class. Due to the class schedule limitations, she had been unable to get to many yoga classes that she reported to help with the stress of being away from home and focusing her mind/body. An arrival at the theater to begin rehearsal around noon, followed by a 4 to 6 hour rehearsal process, costume fittings, promotional work for the show, with a 1 to 2 hour dinner break was typical. Upon completion of her daily rehearsals, she would often go out with the other 2 cast members for dinner, drinks, and social activities. Modern technology allowed her to “see” her daughter most nights via Skype, so she would attempt to talk to her daughter around 9 pm and then be in bed around 10 pm during the rehearsal process. Due to the technical demands of the show, her schedule has changed going into tech and performances and she reported that she had less time to exercise and did not get to see her daughter as often.

Medical History Patient XX was a vocally enthusiastic person but denied overt vocal abuse. She was a lifelong nonsmoker and consumed 3 to 5 alcoholic beverages per week. Medical history was significant for seasonal allergies (Zytrtec), cosmetic septoplasty (age 22), C-section (age 29), and reflux (Dexilant in conjunction with diet and lifestyle management).


Voice Evaluation Perceptually, the patient rated her own speaking voice as mildly dysphonic with increased physical effort. She reported that she did not feel like she could take an unrestricted breath and that her neck was tight. The voice pathologist noted a mild dysphonia characterized by a tight hoarseness with increased vocal strain. Physically, she had an asymmetrical stance and right shoulder elevation with a forward head position. Her respiratory patterns were inconsistent ranging from appropriate diaphragmatic breathing to shallow and clavicular. Upon palpation of the larynx, this patient had significant tenderness (with light touch) to the thyrohyoid space, the larynx was elevated, and base of tongue tension was noted. Jaw tension was also noted. In addition to an assessment in the clinic, an on-site assessment of character demands was performed at the theater. The following concerns contributing to the patient’s current complaints were observed: postural alignment was consistently altered due to character demands (crawling/ reaching/pleading, fetal position crying, on knees screaming), physical fight scenes (including face slap and being thrown to floor), emotional context requiring vocal gymnastics, restriction of breath due to tight corset, varying levels of stage platforms requiring physical agility, patient did not leave the stage during 90-minute performance, and the microphones were just being introduced during tech week. Videolaryngostroboscopic Examination Rigid and flexible endoscopy were completed on this patient. Rigid tasks under stroboscopic lighting included

sustained /i/ at comfort, low and high frequencies, repeated /hi-hi-hi/, and frequency glides low to high and high to low on /i/. Mild bilateral diffuse vocal fold edema and erythema were noted. As a result, small anterior and posterior glottis gaps were noted with mild ventricular fold compression noted at increased vocal intensity. The amplitude of vibration and mucosal wave were mildly decreased bilaterally. Mild pachyderma was noted in the interarytenoid area suggestive of possible laryngopharyngeal reflux. In addition to the above tasks, this patient was asked to perform one of her monologues with the flexible endoscope in place. Flexible endoscopy tasks additionally assessed posterior and lateral pharyngeal wall compression with increased vocal intensity. Also, this patient was noted to significantly elevate her laryngeal position with heightened speech. Acoustic Findings Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) Sentences and Rainbow Passage (RP) were recorded as well as her monologue used in the previous endoscopy task. Her mean fundamental speaking frequencies were CAPE-V 181.3 Hz [standard deviation (SD) 21.3]; RP 185.3 Hz (SD 19.1); and monologue 192.4 (SD 47.8). Both reading and conversational samples of speech were considered to be within normal limits. However, her monologue resulted in significant vocal flexibility/ variability reflected in the standard deviation. Next, the patient was asked to glide to her highest and lowest pitches in 2 separate attempts to attain her physiologic frequency range. Maximum frequency of 1088 Hz and lowest at 151 Hz were

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recorded. There was a noted registration break at E5. She maintained an adequate range for her age and voice type. Aerodynamic Results Following acoustic assessment, this patient completed aerodynamic tasks of vital capacity, mean airflow rates at maximum and comfortable sustained phonation, as well as voicing efficiency using the Phonotory Aerodynamic System (PAS). Results and normative data range are included in Figure 7–1.

Diagnosis and Treatment Based on the above information, it was determined that this patient was experiencing a compromise in the laryngeal mechanism due to mild vocal fold edema, resulting in compromised glottis closure and flexibility. Due to the physical, emotional, and vocal demands of this role, this patient likely has begun to develop compensatory physical strategies resulting in jaw pain, laryngeal tightness, and breath tightness. Voice therapy for this patient included: (1) myofascial release (MFR) to alleviate fascial restrictions and reduce pain; (2) circumlaryngeal massage; (3) Vocal Function Exercises (VFEs); (4) integrated resonant voice therapy (RVT); (5) technical/physical reintegration of heightened vocal performance; (6) counseling and compliance with all vocal health, hygiene, hydration, and reflux precautions; and (7) coordination with stage management on amplification, costume design, and considerations for staging modifications where artistically appropriate.

Myofascial Release (MFR) and Circumlaryngeal Massage (CLM) Due to the significant hyperfunctional voice patterns this patient was required to embrace with her character demands and the resultant physical discomfort associated with her muscular patterning, she felt that she was unable to access her proper vocal technique and training. Therefore, as a level I MFR trained person, the initial 1-hour therapy session focused on 30 minutes of MFR and CLM followed by 30 minutes of introduction to VFE and RVT. This patient was placed in a supine position and therapy began with an assessment of fascial restrictions. The most significant fascial restrictions were noted in the sternal/rib cage area, between her scapula, bilateral shoulders (R>L), bilateral jaw, and extrinsic laryngeal muscles. Full discussion of MFR techniques is beyond the scope of this chapter, however, references are provided for further understanding. Therefore, MFR began with an occipital-condyle release. The clinician’s hands were placed lightly under the patient’s head with the fingers lightly touching the base of the occipital bone (Figure 7–2). This position was held for 60 to 90 seconds to allow for release. This patient was noted to have fascial restriction and contraction with each inspiration for the first several minutes indicating patterning of pulling the base of skull down and “setting” her body with each breath. It is not uncommon during MFR work to note changes in respiratory patterns. Within the first session, this patient’s respiratory patterns changed from high, shallow, clavicular breathing, to broad-based, low, full, diaphragmatic breathing.

Aerodynamic & Acoustic Analysis

Patient Name:

Date:______________________

Patient XX

Vital Capacity: 3.72 Liters (Expiratory Volume)* VFE Goal based on VC: 46 seconds Maximum Sustained Phonation: dB Mean SPL: 85.2 Hz Mean Pitch: 183.4 Phonation Time: 41 seconds Liters/sec* (Norm <.20) Mean Expiratory Airflow: .18 Comfortable Sustained Phonation: dB Mean SPL: 83.7 Hz Mean Pitch: 185.9 Phonation Time: 7.3 seconds Mean Expiratory Airflow: .20

Liters/sec* (Norm <.20)

Voicing Efficiency: dB Mean SPL: 84.1 Mean Pitch: 182.3 Hz cmH2O* (Norm 4-8) Mean Peak Air Pressure: 4.2 Aerodynamic Resistance (Laryngeal Airway Resistance): 48

cmH2O* (Norm 31-45)

The Blaine Block Institute for Voice Analysis and Rehabilitation 369 West First Street – Suite 408 – Dayton, OH – 45402 (937) 496-2622 (phone) – (937) 496-2614 (fax)

Figure 7–1. Aerodynamic and acoustic analysis.

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Figure 7–2. Myofascial release (MFR), occipital-condyle release.

Following the occipital-condyle release, a bilateral jaw release was accomplished. There were MFR techniques employed to facilitate release of fascial restrictions in the jaw and facial region (Figure 7–3). Specifically, external light touch was applied bilaterally to areas of restriction. Once fascial restriction release was achieved, light masseter massage was utilized. MFR continued to further address restrictions in the extrinsic laryngeal musculature and thoracic regions (Figure 7–4). Following 30 minutes of MFR, this patient reported significant decrease in physical tension, improvement physical mobility, the perception that her breathing patterns had returned to normal/typical, and immediate improvement in quality of her speaking voice with decreased effort. This patient was strongly encouraged to return to her

yoga regimen as it provided her the ability to maintain physical alignment, respiratory patterns, and mental health. Patient XX was then introduced to VFEs. A CD of the VFE was provided to this patient for 2-times-daily home practice. Time was taken to ensure that proper exercise technique was independently executed with minimal modeling. RVT was modified from its traditional approach to use her text from the script. As this patient had extensive training in actor-training resonant voice work, she had an excellent grasp of being able to execute resonant voice. Therefore, the traditional RVT of chanted syllables, phrases, and sentences was modified to carry over into her script. She was instructed to begin each of her lines with a resonant /molm/, extending the hum for several seconds and then chanting a line of her text. The second step was to inflect the given line and then speak it


Figure 7–3. Myofascial release (MFR), bilateral jaw release.

Figure 7–4. Myofascial release (MFR), thoracic region.

with typical characterization. All resonant voice work was done initially in a standing position.

Daily home exercises included physical stretching and alignment exercises (either yoga or her own personal

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routine), VFE 2 times per day, and RVT as a 10 to 15 vocal warm-up prior to her rehearsals as well as the end of her vocal breaks. This patient was compliant with all exercises and recommendations. She was scheduled for the following week for a return 30-minute therapy session. Review and refinement of the VFE and RVT techniques were completed on her follow-up visit. She reported marked improvement in vocal and physical ability during her rehearsal week. Specifically, she had decreased physical pain, she reported that her breathing felt free and easy, and that she was able to use her vocal range and emotional content without significant compromise by the end of her rehearsal. MFR was utilized for 15 minutes of the second therapy session. This patient was noted to have less fascial restriction in the neck, jaw, and thoracic regions. The release of the fascial restrictions occurred in a shorter amount of time (30 seconds as opposed to 90 seconds). Finally, the session concluded with RVT carryover into her characterizations. This patient chose a monologue with heightened emotion. Within the therapy confines, she was asked to get into her physical position (kneeling, laying, etc) for the given monologue, and we worked through each of the lines working toward maximum vocal and character output with minimal vocal and physical detriment. As each line and monologue has unique demands, balancing physical alignment, adequate respiratory support, healthy phonation patterns, maximal resonance enhancement, and artistic character integrity becomes a dynamic and creative process between the patient and therapist in these situations. This patient was aware that not every choice she made was “vocally healthy.”

However, to maintain the integrity of the character and her long-term vocal health, she learned to minimize her vocal abuses, maximize her resonance strategies, release her unnecessary physical tensions/use her functional alignment to her advantage and not detriment, and to recalibrate her voice and body to “neutral” after each performance. Suggested readings are as follows: n Manheim C. The Myofascial Release

Manual. 3rd ed. Thorofare, NJ: SLACK, Inc.; 2008. n Barnes JF. Myofascial Release: The Search for Excellence — A Comprehensive Evaluatory and Treatment Approach (A Comprehensive Evaluatory and Treatment Approach) [Ring-bound]. Malvern, PA: Rehabilitation Services Inc.; 1990. n Myers T, Earls J. Fascial Release for Structural Balance. Chichester, UK: Lotis Publishing; 2010. In Case Study 9, Jenny Muckala and Brienne Ruel discuss a difficult case of a country singer who who had suffered a traumatic brain injury such that he could still perform but required attention to the type of instructions and whose injury impacted his compliance to therapy. They provide excellent suggestions to address mild cognitive deficits within voice therapy.

Case Study 9 Jennifer C. Muckala and Brienne Ruel Voice Recalibration With the Cup Bubble Technique for a Country Singer


Case History The patient was a 43-year-old professional male country singer and also a respiratory therapist. He presented to the Vanderbilt Voice Center 3 years prior complaining of 1 year of chronic hoarseness, increased throat clearing, loss of portions of his high range, and fluctuations in his speaking voice quality. The onset of these symptoms was 3 years ago, without any precipitating event.

yelling or loud voice use. He reported singing 4 times per week for 45-minute sets and occasional 15-minute second sets. In total, he had sung 200 shows in that year. He had not sought any formal voice training and did not have a regular voice warm-up regimen. When he was not performing weekends with his trio, he was working full time as a hospital-based respiratory therapist, which required consistent speaking voice use throughout the workweek.

Medical History

Perceptual Evaluation

He denied any shortness of breath, pain, dysphagia, otalgia, or cough. He had a history of gastrointestinal reflux disease symptoms and had been using Prevacid for 3 years with benefit. At the time of his most recent visit, the patient had been taking Prednisone for 3 weeks for his current dysphonia as prescribed by another physician without any improvement in voice quality or range. Past medical history was significant for gastroesophageal reflux disease (GERD), obstructive sleep apnea, and high cholesterol. He had a recent weight increase secondary to steroid use. Palpation of the larynx revealed reduced thyrohyoid space with patient report of tenderness and intermittent pain. He drank 4 glasses of water per day and 2 caffeinated sodas. He did not use tobacco, alcohol, or illicit drugs.

Perceptually, voice production was characterized by moderate dysphonia with roughness, reduced habitual speaking pitch, and occasional glottal fry.

Voice Use The patient was the male lead in a country trio, and although he was categorized as a baritone, he frequently sang in the tenor range for the majority of his performances. At the time of his evaluation, he reported a high level of voice use, with extensive talking, but denied

Laryngeal Imaging Laryngovideoendoscopy, oral view, demonstrated: n Bilateral true vocal fold mobility

within normal limits (WNL)

n Bilateral true vocal fold varices with

erythema and irregular medial edges

n Interarytenoid pachydermia

Stroboscopy parameters included: n Vertical phase difference = present n Periodic vibration n Amplitude grossly WNL n Mucosal wave reduced bilaterally n Complete closure pattern with a

small posterior gap

Diagnosis and Recommended Treatment The patient was diagnosed with dysphonia, chronic laryngitis, bilateral true vocal fold ectasias, and GERD. The laryngology and speech pathology team

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recommended speaking and singing voice intervention, continuation of PPI use, elimination of Levaquin and prednisone, and increased water intake to 2.5 to 3.0 L (80 to 100 oz) per day. The patient did not complete voice intervention or follow-up at the standard 3-month interval. Three years later, the patient returned to the clinic with persistent symptoms of hoarseness and difficulty singing, particularly in his mid-range. He denied pain. He was performing 3 or more days per week for a total of more than 250 shows this year. Medical history change included a motor vehicle accident where he sustained a facial fracture and shortterm memory impairment. There were no new changes in social history. Laryngovideoendoscopy revealed: n Bilateral true vocal fold (TVF) mobil-

ity WNL

n Right TVF lesion n Left TVF reactive tissue changes, ir-

regular medial edge n Bilateral TVF erythema n Pooling viscous mucous n Bilateral TVF ectasias

The laryngologist diagnosed the patient with dysphonia, a right TVF polyp with left TVF reactive changes, persistent bilateral TVF ectasias, and GERD. As during his original visit, speaking and singing voice intervention were strongly recommended, along with a review of vocal hygiene guidelines, which included increasing water intake and consistent Prevacid use based on his GERD complaints.

Voice Evaluation During a follow-up visit 1 month later, the patient had a voice evaluation with

one of the voice center’s speech pathologists with a specialty in singing voice rehabilitation. He reiterated the following concerns: hoarseness, vocal fatigue, a reduced voice range, deterioration of voice quality, intensity and stamina with use, a chronic “tightness” in his throat, and strain to speak and sing. He often began the week with what he described as a functional “passable” voice in quality and range, but there was an increased effort during singing voice use that had never been such a significant problem previously. After his first performance each weekend, he had difficulty speaking at the “meet and greet” afterwards, which led to voice loss and further strain by the second night. He had tried addressing these issues with a vocal coach without success. He had tried a myriad of vocal warm-ups including lip trills, tongue trills, and “tongue forward” exercises (patient’s words) without noticeable improvement. Perceptual Evaluation Perceptually, his voice quality was moderately dysphonic, characterized by roughness, strain, and breathiness at the conversational level. Habitual respiratory pattern was primarily chest/clavicular involvement with breath holding. Treatment goals were most affected by assessment of voice quality, observations of body stance and movement, and his stimulability for voice change.53 Other important data points included: n Maximum phonation time (MPT):

6 seconds (norms: 25 to 32 seconds for males); reduced MPT indicates glottal inefficiency n Voice range: limited from 92 to 220 Hz (norms: approximately 2 to 2.5 octaves; males: 96 to 500 Hz)


n Habitual speaking pitch/fundamen-

tal frequency: 92 Hz (norms: males average 125, range 107 to 146 Hz spanning ages 20 to 89 years) n Upon palpation, his thyroid hyoid space was reduced, with patient reporting pain level of 6 (1 = no pain, 10 = severe pain) n Visible muscle recruitment during phonation including consistently elevated shoulder posture with chin extension and tightness in the strap muscles of the neck during all voice production n ASHA NOMS: 4 n VHI Total = 49 (P = 19; F = 12; E = 16)54; outcome indicated a moderate degree of self-perceived voice handicap; patient self-rated his voice handicap as severe

Treatment Rationale Based on patient history, vocal hygiene and voice conservation combined with a flow phonation approach were judged to be the most appropriate combination of intervention strategies. Therapy attendance and compliance with physician and speech pathologist recommendations were a challenge with this individual from the onset. He toured heavily 3 to 5 days each week, and this involved a heavy amount of speaking voice use, often in competing noise and on a regular basis. He reported considerable fatigue from speaking before a concert has begun. The patient’s phonotrauma was multivariant, and therefore the intervention would need to have a tiered approach to have broad-spectrum effect and change in the patient’s status. Clinician-related factors, which could have impacted patient compliance, were addressed preliminarily. The patient was treated by a speech

pathologist specializing in voice disorders with particular familiarity in commercial voice issues. Adequate patient education, gauging the patient’s readiness for change, heavy follow-up, and consistent communication between the speech pathologist and physician were all high-level priorities.55 Of equal relevance were the patient-related factors that could have affected the success of intervention such as patient readiness for change, patient compliance with therapeutic recommendations, stimulability for target behaviors and voice change, and the patient’s emotional and physical condition.56 In his initial physician visits, lengthy conversations about the rehabilitation value of speech pathology services were noted in his chart. Although he was a trained respiratory therapist, he was not currently employed as such, and his family was entirely reliant on income from his touring. Therefore, the speech pathologist and the physician worked closely to coordinate care for the patient that coincided with his heavy touring schedule. At the time of treatment planning, he got less than 6 hours of sleep nightly, and he had a reported low tolerance for this fatigue physicially, but there were also negative effects on cognition and psychomotor tasks consistent with research on fatigue.57,58 He also reported significant anxiety associated with his inability to meet the speaking and singing demands of his touring trio. A complicating factor in treatment planning was his recent traumatic brain injury, which negatively impacted his short-term memory and processing of abstract concepts with multistep directions. As a result of this disclosure and chronic fatigue level as well as his lack of compliance with previous physician recommendations, therapy was framed with multiple modalities of support

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to improve his concept retention and active follow-through with recommendations. The current standard of care in voice therapy, written and verbal instructions, was amplified using mp4 recordings of each treatment session using the patient’s iPhone to assist in home replication of treatment targets and better generalization of gains.59

Therapy Goals and Expected Outcomes Vocal hygiene, voice conservation, and efficiency of voice production were all necessary components in this patient’s treatment program but would have been valueless without patient compliance with the treatment regimen. He had poor self-care habits that contributed to poor vocal hygiene, poor voice conservation, and low self-awareness of his body and movement. The Voice Handicap Index proved to be a helpful tool in monitoring patient perception of change from session to session.54 He was easily overwhelmed with information, difficult to physically get into therapy, and continually reiterated his high stress, fatigue, and anxiety associated with his voice disorder. Therefore, the focus of his initial treatment session was vocal hygiene and voice conservation, with an introduction to efficiency in phonation using a flow phonation facilitator. This was intended to establish contrast between the dysphonia and strain of his habitual voice use, with the ease of a balanced phonation using the cup bubble facilitator. Vocal Hygiene Program Historically, acute vocal fold injury has first been addressed through varied

levels of voice rest ranging from moderated use throughout the day to strict observance of silence, depending on the injury.28 In this patient’s case, reduction in and ideally elimination of abuse was proposed to allow for tissue healing and recovery, and to avoid further aggravation of his unilateral true vocal fold lesion. This reduction in use was combined with clearly defined parameters for establishing vocal hygiene, but vocal hygiene alone would not have yielded as dramatic of a result.60 The specific hygiene program included: n Hydrate adequately with approxi-

mately 2 L of water daily, or until his urine was pale in color, because hydration and phonatory effort are inversely related.24 n Steam his voice twice daily. n Use a cool mist humidifier over his side of the bed at night. n Manage reflux through consistent and appropriate use of his proton pump inhibitor. n Initiate behavioral changes to his eating habits to reduce his predisposition toward GERD such as eating smaller meals, not eating late at night, avoiding spicy foods and high-fat foods, elevating his head at night, and so forth. n Decrease caffeine intake daily to less than 237 mL (8 oz) per day. Voice Conservation Program Patient was instructed to: n Avoid speaking in competing noise n In a 60-minute period, be silent for

10 consecutive minutes to increase awareness of frequency of voice use, and to insert a structured voice rest; called the 60/10 rule


n Stay within touching distance of his

listeners while at home and on the road to control vocal intensity and conversational loudness n Limit unnecessary phone use n Redirect throat-clearing behaviors into a hard swallow or using multiple small sips of water.

ration. His instructions were to touch his upper lip to the water, but not to submerge it, inhale through his nose, and to start a bubble that was as steady as a motorboat, not inconsistent rhythmically like “Morse code” might sound. The clinician modeled the target to provide the patient with a standard. Targets were:

Flow Phonation Facilitator

n Continuous bubbles in the water dur-

This patient’s low self-awareness, lack of voice training, and high level of stress necessitated a concrete, simple treatment approach to create a higher likeli hood of success. Subglottal air pressure and adductory forces are much greater in nonclassical, untrained singing typical of the country singing that this patient engaged in,61 and therefore the potential for voice abuse and strain during rigorous voice use was much greater. Trained classical singers create a louder sound with less subglottal air pressure than untrained singers.61 The cup bubble facilitator provided the patient with a visual and auditory confirmation of the continuity of airflow during phonation with low impedance from the water. This approach to voice rehabilitation was designed to assist this singer with calibration of subglottal air pressure and true vocal fold engagement while increasing his awareness of a lower level of effort during production. The cup bubble allowed him to maintain spinal alignment with a neutral head position, most similar to the position people assume in conversational speech and in singing. Because country singing has been demonstrated to be most similar in respiratory support to speaking voice use,62 little treatment focus was on breath intake to vital capacity. Instead he was encouraged to breathe as he normally would on inspi-

n Clarity of tone also described to the

ing phonation

patient as a “smooth” tone

n No sensation of effort, tightness,

or strain during phonation in the extrinsic or intrinsic muscles of the larynx and neck (Refer to Jennifer C. Muckala and Brienne Ruel, in this chapter, Case Study 9 for cup bubble technique.)

Length of phonation was not as critical at the beginning as continuity of the subglottic airflow. Initially, an inconsistent bubble brought the patient’s awareness to his breath-holding habit as well as hyperfunction in the extrinsic and intrinsic musculature of the larynx. A voiceless bubble at a consistent rate was used to establish airflow rate and low effort level prior to the infusion of sound. At that point, effort level remained low, and the patient immediately reported ease of phonation without strain. The task at this level also remained simple enough to allow the clinician to draw attention to the patient’s slumped posture, anterior chin and neck posturing, and forward shoulder posture, which reduced his access to his vital capacity and a more efficient sound production. Each repetition of the cup bubble exercise provided him with success in clarity of tone and ease of phonation with postural correction to improve

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access to vital capacity. There was no report of patient fatigue or deterioration in tone quality after 10 repetitions of this facilitator, contrary to his report of rapid onset of vocal fatigue with limited conversational voice use. This stimulability and immediate change in voice quality surprised the patient. Application of this recalibrated tone to more functional speech was the anticipated progression of therapy, but initial session goals remained: (1) increased patient awareness of his habits as well as (2) establishing of motor memory for a lower level of effort in sound production with clarity and consistency. The clinician and the patient thoroughly discussed the need for motor memory, which could only be achieved through daily practice and consistency, for vocalization at greater vocal intensity with optimal efficiency and ease. This would be best achieved in his case through calibration exercises (such as the cup bubble) that were airflow based and facilitate a reduction in excessive glottic tension and effort during continuous airflow use. This was utilized effectively at a vocal intensity appropriate for one-on-one conversational use but not applied at greater subglottal airflow pressure levels necessary for louder voice production. At that point in time, muscle memory was greater for excessive glottic effort to facilitate louder vocal intensities, which were abusive and inefficient. Recommendations for singing voice use were for limited use for a 4-week period during voice rehabilitation, because it put the patient at risk for the exacerbation of his dysphonia through abuse and overuse. Unfortunately, the patient was unwilling to modify or cancel his performance schedule. Daily application of this technique as well as observation recommendations

for eliminating voice abuse and minimizing misuse and overuse were paramount to producing the best outcome of treatment. The patient was provided with a detailed explanation of therapy technique as well as an audio and video recording of the session to aid in carry over of gains and vocal awareness activities in home practice. The patient reported that it was as helpful to have reiteration of vocal hygiene guidelines and voice conservation parameters, as it was to have video recordings of the clinician modeling and the patient selfmodeling of therapy tasks. His next treatment session was 23 days later. He was not compliant with voice recommendations made for voice conservation and vocal hygiene, and his voice quality was worse as he had continued the intensity of his performance and touring schedule. He had been unable to finish performances without his voice “cutting out,” and he was unable to speak by the end of a 3-performance weekend. His VHI score was 89 that day and correlated well with his deterioration in status. He reported vocal fatigue and strain with all levels of voice use, and significant fatigue and soreness in the strap muscle of his neck. He was visibly exhausted with flat facial affect and was very verbal about how “he wasn’t sure what he could do” to improve his voice. Based on the deterioration in his vocal quality, the patient’s vocal folds were visualized using videostroboscopy. There was bilateral true vocal fold erythema and edema with severely reduced mucosal wave and reduced vertical phase difference bilaterally. The right true vocal fold polyp had become hemorrhagic. His laryngologist was consulted along with the speech pathologist, and the patient was counseled to observe strict voice rest for


1 week based on stroboscopic findings. At that point, the physician, speech pathologist, and patient had a lengthy conversation about his long-term career goals and his readiness for change to achieve these goals. Prognosis was only fair for a successful therapeutic outcome because of a long history of poor patient compliance with treatment recommendations; the complexity of his voice disorder; a high-pressure, voice-dependent occupation; a high VHI score; and other complicating medical factors that have been demonstrated to be related to negative treatment outcomes.55 Based on this data, he was at high risk for voice therapy dropout. His reasons for failure to comply with voice therapy recommendations were of critical importance to his ultimate success or failure in treatment. The patient indicated, at this point, he was committed to “do whatever it took to get [his] voice back.” He returned for his third treatment session 8 days later to assess his voice quality and compliance status and to discuss how to proceed with voice rehabilitation. The patient had been compliant with voice rest and followed voice hygiene guidelines. Voice quality was perceptually better. Stroboscopic evaluation of his vocal folds revealed a decrease in erythema and a stable right true vocal fold lesion. A small set of concrete treatment goals was deemed most appropriate to assess patient readiness for treatment. The patient committed to keeping data on a daily basis on the following: n Observing the 60/10 rule 9 times

each day

n Drinking 8 glasses of water each day n Staying within touching distance of

his listeners

n Bringing all data back to the voice cen-

ter in 9 days for his next appointment n Cancelling all singing engagements until his next appointment n Not using a loud voice for any period of time until his next appointment. He returned for his fourth treatment session 9 days later to assess his voice status and ascertain how best to continue with voice rehabilitation. Perceptually, his voice quality was characterized by a moderately severe roughness, mild breathiness, and strain at a lower pitch (92 Hz) with consistent glottal fry at the ends of phrases. His habitual respiratory pattern was chest elevation with clavicular involvement during inspiration with visible recruitment of the shoulders and strap muscles of his neck during phonation. He reported at that time that he had cancelled all performances until further notice, and reiterated that he was ready to “do whatever it took” to rehabilitate his voice. At that time, 4 more treatment sessions, spaced 1 week apart, were scheduled to establish and maintain a high level of accountability between the clinician and the patient. At this time the patient was reintroduced to the cup bubble hierarchy (Table 7–15) with singular focus on the external confirmation of continuity of airflow during tone production within his speaking voice range. Ongoing complaints of fatigue, soreness in the strap muscles of his neck, and rapid deterioration in voice quality were used as the most salient references of inefficient production during this recalibration exercise. After 10 moderated productions of the continuous phonation using the cup bubble, his voice was mildly breathy and mildly rough, but he had no complaints of strain during voice

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Table 7–15. Cup and Bubble Hierarchy Cup Bubble Hierarchy Level Cup bubble alone

Target

Accuracy

10 times

90%

10 times

90%

10 times

90%

3 times

90%

• Stretch out that BUBBLE to sound clearer and more consistent due to the energy the airflow gives to the sound • Make sure your upper lip is partially under the water, not completely submerged • Bubbles in the water should be consistent and clear; it is an “air-filled vowel” that you do not have to work any harder to produce than blowing bubbles in the water Cup bubble + “ooo” • Bubble for 2 to 3 seconds to establish a clear and consistent tone with EASE before removing the cup to hear the “ooo” • Still should feel EASE during the “ooo” Cup bubble + “ooo” + count • Stretch out the vowel • Eg, Bbbbbb + “oooooooo-one” à no break, all one sound • Bubble for 2 to 3 seconds again to get that smooth tone without effort • Remove the cup as you start to get a really consistent bubbling going Cup bubble + “ooo” + phrase

Phrase Level

For example:

Hierarchy of production

• How are you? • What’s for dinner? • Where’s the bathroom? • What did you want? • What time is it? • What’s the rush? • Where did you go? • What’s your name? • Why is it cold? • How are things? • Why did he go? • When do you close? • Where is the car?

First time through Long “Ooooo” + phrase on monotone pitch Second time through Long “Ooooo” + phrase with intonation Third time through Short “Ooooo” + phrase with intonation

production. As a test for vocal fatigue, the patient produced 30 sustained cup bubbles at 110 Hz for 5 to 6 seconds each

time. The patient reported no fatigue, deterioration in voice quality, or sensation of effort during these 5 minutes of


continuous use. Spontaneous speech was still characterized by a moderately severe roughness, mild breathiness, and strain during production with glottal fry at the ends of phrases. However, this was a helpful contrast for differences in voice function and assisted in increasing the patient’s awareness of salient acoustic and sensory differences between the target production and his habitual, dysphonic production. Although his fundamental frequency for speech was not directly discussed, his speaking pitch elevated from 92 to 110 Hz during the cup bubble, and he commented that this tone was “more pleasant” to listen to. High-frequency use of a low-impact voice facilitator with discrete therapy tasks yielded a voice with proportionately more clarity, consistency, and comfort during production. Targets were simple enough for the patient to replicate accurately with minimal clinician assistance. Transfer of this calibrated tone to sustained phonation at each of the subsequent levels (sustained vowel, single word, and phrase length) yielded consistent tone clarity, ease of production, and no complaints of fatigue. Goals for increased patient awareness, independence, and transfer were facilitated through mp4 recordings of each session and high-frequency use by the patient at home. Patient compliance with every recommendation for the next 3 sessions was exemplary. He refrained from all singing voice use, followed voice conservation and hygiene recommendations, and utilized the flow phonation hierarchy using the cup bubble through functional speech level on a daily basis. His countenance improved significantly, and he reported that despite the financial strain, this break from constant touring and performance had allowed

him time to recuperate and reconnect with his family which had all improved his overall quality of life. On his eighth session in this series, perceptually, his voice was characterized by a mild but inconsistent breathiness through the phrase level with efficiency and ease. His voice production was “the best it has been in ages,” and his VHI total score was 32 that day which supported this. His vocal folds were visualized and the right TVF lesion was gone. Normal mucosal wave, vertical phase difference, and amplitude were noted during stroboscopy. Based on this surprising development, the laryngologist was consulted. The patient wanted to return immediately to a full touring schedule. Since he had not been using his voice at any greater degree of rigor than moderate intensities for speaking voice use for 1 month, it was recommended he follow a course of 2 to 3 more therapy sessions. The use of resonant focus at higher levels of rigor throughout his voice range were planned to assist in transfer of his efficiency established with the flow phonation approach. The patient agreed to this plan but never showed for any of the subsequent sessions.

Treatment Outcome It was disappointing, although not surprising given his prior history, that the patient did not return for further voice rehabilitation once he became aware that his right TVF lesion had resolved. Voice range increased and overall voice quality improved. His compliance with voice care parameters had significantly limited his heavy voice use and abuse. Direct therapy had improved his vocal efficiency. This combination approach provided the patient with a framework

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for better balance of sound production between the respiration, phonation, and resonant systems, but risk for relapse is high given his history of noncompliance with voice care recommendations. This unrelenting voice use is common among commercial voice users. A simple staged approach for voice care and use combined with his successful treatment outcome provided the patient with confidence in his medical support team, the laryngologist, and his speech pathologist, as well as his own active role in voice care and maintenance if future voice issues arise for him. In Case Study 10, Marina Gilman teaches us about the life and vocal demands of the praise and worship leader and the barriers often encountered in working to eliminate the vocal load in this population prone to voice problems due to vocal overuse.

Case Study 10 Marina Gilman Praise and Worship Leader Preremoval and Postremoval of Bilateral Vocal Fold Lesions Praise and worship teams have sprung up all over the country. Larger as well as smaller church congregations use them as part of regular worship. Praise teams are generally small bands including vocalists (anywhere from lead alone to lead with backup singers), keyboard, drums, bass, and guitar. Some are smaller, some bigger, and all use electric instruments with varying qualities of sound systems. The musical style ranges

from soft rock to Christian contemporary. Generally the vocalists are members of the congregation with nonmusical day jobs; few of them have formal musical or vocal training. Frequently they are playing either keyboard or guitar in addition to singing. They are often intuitive singers with little vocal technique to help them meet their vocal demands. Members of the praise team are also frequently called upon to read scripture or lead worship in nonmusical ways. Praise team members can be talented teens or adult congregants. They frequently rehearse 1 to 2 times during the week for 1 to 2 hours plus rehearsals on Sunday mornings before services. They may participate in multiple services on Sunday or during the week. The instrumentalists they work with are also talented amateurs, but they often lack the flexibility to change keys to suit the needs of the singer. Like most congregational singing, what is good for the congregation may not be good for the singer. Sound tracks or enhancement tracks are sometimes used as well, limiting the option for the singer to find a favorable key. More often than not these singers do not know where to turn when vocal problems arise. It may take months or longer before they find a qualified laryngologist and voice care team. The following case study is that of a 45-year-old praise and worship team leader and occasional worship leader in her small church.

History RR is a 45-year-old Christian Contemporary singer. She began experiencing vocal problems about 3 or more years prior to coming to our specialty voice clinic. Initially her symptoms of hoarse-


ness and difficulty singing in her upper range occurred mainly when leading worship (reading scripture or leading prayers) or speaking for extended periods of time. She attributed her voice problems to stress, allergies, and reflux. Her primary care physician put her on reflux medications and although she noted some improvement, it was not significant. Over the past year the roughness in her voice never diminished. Speaking and singing were affected to the point that she is often unable to lead worship or sing due to extreme hoarseness. Her symptoms include rough, often strained, vocal quality, vocal instability, reduced endurance, increased effort, and decreased range. Her medical history is unremarkable. RR worked successfully in the corporate world for 15 years. The highpressure environment combined with family issues led her to leave the corporate world and focus more on her music. In her current day job the work environment was more relaxed, but no less vocally demanding. RR began singing when she was 5 years old but never had formal training. Over the past several years since joining the praise and worship team, her vocal demands increased. On a talkativeness scale (1 = quiet and reserved, 7 = verbal and outgoing), she rates herself as a 7+. Recently she was asked to function as volunteer music director and lay reader. She reads scripture 2 Sundays per month but directs, sings, and plays keyboard with the praise and worship band (guitar, bass, keyboard, percussion, and often 2 to 4 backup singers) every Sunday for 2 services. The band rehearses 1 to 2 times a week and Sunday morning before the first service. Currently she has 2 children at home and is the go-to person within her extended family. RR reports no reg-

ular vocal warm-up routine, although she would sing a bit before rehearsals and on some Sundays. Recently in an attempt to “save her voice,” she eliminated vocal warm-ups, especially on Sunday morning.

Laryngeal and Voice Assessment A laryngeal stroboscopic examination of the vocal folds was completed by the referring physician. Movement of the vocal folds, phase symmetry, amplitude of excursion, and periodicity were within normal range. Bilateral midmembranous swellings with edema resulting in an hourglass-closing pattern with resultant air escape through anterior and posterior gaps was observed. Mucosal wave was reduced at the site of the lesions greater on the right than the left resulting in differential vibratory patterns within and between each vocal fold. Lateral compression indicative of compensatory muscle tension was also reported. She was referred for voice therapy. The treating speech-language pathologist has more than 10 years of experience as part of a multidisciplinary voice team. The CAPE-V (Consensus AuditoryPerceptual Evaluation of Voice) was completed. The score was 46/100 indicating a dysphonia of a moderate nature. Aberrant features identified in the voice included breathiness, roughness, and mild strain. Patient Self-Assessment: VRQOL (Voice Related Quality of Life) self-assessment of the impact of her voice disorder on her quality of life raw score of 19/50 converting to 77.5/100 suggests that her perception of her voice disorder has a moderate impact on her quality of life. The KayPENTAX CSL (computerized speech lab with multidimensional

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voice program and real-time pitch) was used for voice analysis. The acoustic analysis was deemed to be reliable based on voice typing suggested by Titze.63 Maximum phonation time on /a/ and /z/ was significantly reduced at only 7 seconds. Maximum phonation time on /s/ was 15 seconds. The s/z ratio was 2.1, suggestive of laryngeal hyperfunction. Speaking fundamental frequency (F0) was reduced at 194 Hz, yet F0 on sustained /a/ was within the normal range at 209 Hz. Physiological pitch range was reduced in the upper range (134 to 619 Hz) with phonation breaks at the transition to the upper range or upper passaggio. Pitch perturbation was increased at 3.5% (norms >1.05%). Intensity perturbation was also elevated at 8.6% (norms ≥ 3.85%). Aerodynamic Assessment Aerodynamic measures were completed using the KayPENTAX PAS (Phonatory Aerodynamic System). Mean expiratory airflow rate on the sustained vowel /a/ was significantly increased [0.58 L/s (norms 0.14 L/s, standard deviation, SD, 0.08)]; mean peak expiratory pressure on voicing efficiency “papapa” task to suggest level of subglottal pressure was increased [7.8 cm H2O norm 5.76, SD 1.51)]; and mean airflow during voicing on same task (“papapa”) was also significantly increased [0.50 L/s (norms 0.13, SD 0.06)].

Treatment Recommendations Six sessions of voice therapy were recommended. Due to her busy schedule and the unpredictable nature of her job, she was not always able to come in

regularly for her therapy appointments. She was, however, compliant with home practice. The overall functional goal of therapy was to improve vocal function to the level at which she was able to use her voice effectively speaking and/or singing. During the initial evaluation and trial therapy, it quickly became apparent that she held her breath when thinking and often began speaking on residual air. This was evident in her frequent use of hard glottal onsets and speaking for long periods of time with occasional pauses without breathing. Teaching her appropriate respiratory/ phonatory coordination and strategies to reduce breath holding became a priority. Although RR had sung since she was a child, she had no formal training. Until recently her native talent served her well. Her increased vocal demands combined with poor vocal problemsolving ability due to lack of technical knowledge of voice production left her vulnerable to voice disorders. An additional goal for therapy was to give her enough understanding of the dynamics of voice production to build awareness of her current maladaptive patterns and provide alternatives that would promote optimal laryngeal function and healing. An essential ingredient was to teach her a basic daily warm-up routine that she could easily incorporate into her busy schedule. Strategies for vocal pacing and maintenance of general vocal health were developed during therapy breaks and during the check-in at the beginning of each session.

Voice Therapy During the first session it was important to find out what she knew about vocal


production, breath support, resonance, and the difference between speaking and singing. Overall she had a good sense of the anatomy and understood the relationship of the 3 systems (respiration, phonation, and resonance). However, although she understood the theory, she was confused as to how to make it work in her body. The goals for this session were: (1) to begin developing a vocal warm-up that served as daily vocal check-in, promoted coordination of the systems, and began the process of awareness building and optimizing laryngeal function; and (2) to bring somatic clarity to breath support. Semi-occluded sounds such as lip trill, tongue trill (raspberry), /z/, /v/, or /w/ on glides (sirens) are excellent for coordinating the 3 systems.18 They optimize airflow (one cannot sustain the lip/tongue trill while breath holding), promote resonance, and allow the vocal folds to vibrate freely. The semioccluded sounds are especially useful for a singer as they are noises and do not activate the singer self-criticism such as “The voice needs to be placed right,” “The voice must be in tune,” and so forth. In preparation for the lip trill, she would lift her chest high on inhalation and then stiffen her abdominal muscles on the exhalation. Allowing the abdominal muscles to release, letting the diaphragm contract, followed by a gentle pull of the abdominal muscles in and up (thinking of the navel moving toward the base of the neck) provided her with a very different and easier breath with a clearer sound. Once she had a feeling of the easier breathing pattern on the lip trill, she was trained in gliding and sustaining phonation on either the lip trill or tongue trill. Bringing her attention to releasing the belly at the end of each

utterance, she gradually began to sense how much she was breath holding. When she came in for her second voice therapy session, she reported improvement. Her voice was not as hoarse at the end of the day. The glides and sustained phonation on lip/tongue trills with attention to a full release of the breath were reviewed. These were expanded to include phonation on /v/ and /w/ sounds, also semi-occluded but allowing easier transition to open vocal tract vowels. First she was trained to speak the vowels while maintaining the /v/, /w/, or tip trill. At first she found it difficult to shift the tongue to speak the vowels while maintaining the lip trill. Once she was able to easily speak the target vowel keeping the buzz, she was asked to slowly part her lips making the transition to the already present vowel. At first the vowel would “pop out” when she opened her mouth, reverting to her habituated laryngeal resonance. By the end of the session it was possible to speak 2- to 3-syllable words or phrases maintaining the buzz before dropping into a near fry quality. By the third session RR reported continued progress. She was able to pace her overall voice use and resume her daily vocal routine including some singing without increased hoarseness. Overall stamina was still a concern. Overall vocal quality improved but continued to be rough. Range was still limited. Breath holding resulting in increased use of glottal fry at the ends of utterances, and hard onset of vowel initial words was still an issue. She was trained in a simple exercise called “the /s/ pulse” designed to bring awareness of breath holding and help her identify when and how she was holding her breath. The exercise consists of short /s/ release /s/ release. Attention to the full release of the belly

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muscles at the end of each short /s/ is essential. The /s/ pause /s/ is repeated over 15 to 20 seconds. It is important that it be done in a meditative, calming way. The inhalation happens spontaneously, and without auditory inhalation, hyperventilation will occur. Often the first 5 to 10 repetitions are fine, and then there will be a sudden inhale or exhalation of stacked air. If done correctly the breath is replenished during the pause in which the diaphragm descends and the air automatically fills the lungs. Once the patient is able to do this on the voiceless /s/ the sound is changed to a lip or tongue trill. Again if the airflow is stopped, the lips/tongue will not vibrate. If the sound with vibration does not speak right away, this indicates poor respiratory/phonatory coordination. The voiced sound is also short at the beginning, but once the patient is able to maintain the “lip trill-pauserepeat-lip trill,” the length of the voicing is expanded and pitch or variations of intonation are introduced, beginning to mimic speech. RR was encouraged to do this exercise several times throughout her day. Sitting in traffic at a red light is an ideal time, as the light will change after 10 to 20 seconds. She gradually was able to feel when she began holding her breath during conversation. Between her third and fourth therapy sessions, she had traveled to Los Angeles to visit a sister congregation. She had lead services worked with their praise team and sung 4 services over a long weekend. It was more voice use than she had had in a long time. She was pleased that her voice held up. Although she was getting better, her frustration level remained high. Her voice was still rough, range still reduced although better, and although her voice was more predicable it was still not nor-

mal and it took a lot of effort to maintain the voice she had. The option of surgery was discussed in therapy and then in consultation with the laryngologist. On repeat laryngeal examination her vocal folds were no longer edematous, and the bilateral midmembranous lesions were reduced but still present. Initially resistant to the idea of surgery, she realized she had maximized her capabilities given the pathology. Therapy resumed 2 weeks following surgery. When RR arrived for her first postoperative therapy session, she was speaking softly and holding back or protecting her voice. Many patients, particularly singers, will begin to protect their voice following surgery. She had been encouraged to begin speaking a little every day at a comfortable conversational level. However, she was so unsure of her “new voice” that she was almost whispering. Breath support was reviewed. She began with lip trills on sustained phonation at a comfortable pitch, and gentle glides (not full range). Tongue trills and /v/ with text were also reviewed so she could reconnect with airflow on phonation. She was very surprised at how effortless it was to speak. She was encouraged to let her range expand on the glides both on the semi-occluded sounds as well as vowels. Sustained phonation exercises were modified. As she warmed up she was to sustain on the vowels at comfortable pitch and loudness in the middle, lower, and higher ranges. As she found that her glides would easily extend beyond the upper passaggio, she was asked to listen for the place in the upper range that was easy and free and then glide down to that level and sustain the pitch for a few additional seconds. In this way she began to be able to sustain easily in the


upper (previously inaccessible) range. She was encouraged to sing (away from the piano) several times a day. Being away from the piano allows for greater spontaneity. Using the keyboard will often put the singer back into a state of vocal self-criticism or heightened selfawareness which will often put the person back in control mode rather than just letting the voice find its own way. At her second postoperative visit, she returned somewhat frustrated. Singing was much easier. Speaking also was easier because there was less effort — but where was her voice? She had been struggling for so long with a voice that did not work, with low speaking F0 and increased effort, that she had no idea what her real voice was or how to find it. Following the warm-ups on glides and sustained phonation, her speaking F0 would spontaneously rise, but within 3 syllables drop back down near glottal fry phonation. She found it difficult to sense what her real voice should sound like. Postoperatively, she was pleased that singing was so much easier. Because she understood singing, breath support, and maintaining the airflow and vocal energy through a musical line, therapy shifted from focus primarily on speaking to bringing singing into her speaking. She was asked to sing a phrase (Good morning, how are you), chant it, and then let it become more spoken. Alternately she was asked to speak a line from a song she was working on, speak it in the contour of the pitches, and then sing it. Linking speaking and singing allowed her to first reconnect with breath support in a context she understood, and second, learn to maintain the support and resulting resonance while speaking. By the third postoperative therapy session she was beginning to feel comfortable

with her voice. Good, clear vocal quality was maintained throughout a conversation with only brief moments of glottal fry, which she quickly corrected. Her endurance was back to normal with no vocal fatigue. With regard to her singing, with healthy vocal folds, a better understanding of how her voice worked, attention to respiratory/phonatory coordination, and reduced breath holding, she was able to return to singing. Her vocal technique was fundamentally sound. It was the vocal folds lesions together with increased compensatory behaviors and poor breath management because of the increased effort in bringing the vocal folds into vibration that resulted in her not being able to sing. Once the lesions were gone, she basically knew what to do. She was encouraged to find a singing teacher who understood the vocal demands and style necessary for singing contemporary Christian music.

Discussion This case is presented in part because so many colleagues are hesitant to treat singers. Even though the patient was a singer, the pathology, phonotraumatic lesions, secondary to too much vocal use was not specifically related to or caused by singing. The pathology prevented the ability of the vocal folds to vibrate appropriately. Her voice was equally impaired for speaking as it was for singing. The treating voice clinician needed expertise in the treatment of voice disorders to provide successful therapy, specifically the skills common to qualified speech-language pathologists: understanding of the limitation of vocal function secondary to the lesions, understanding of the nature of her vocal

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demands, the ability to notice how she was producing voice, and where the systems were breaking down. During the postoperative rehabilitation, it was helpful that the treating clinician had extensive vocal pedagogy and singing experience so the therapy could continue 1 to 2 additional sessions to connect speaking and singing in her “new voice.” Had the clinician not had the additional training, referral to a dualtrained clinician or to a qualified singing teacher would have been the best course for the patient. In this next case, Brian Petty and Miriam van Mersbergen describe the difficult case of an elite singer who presented with bilateral sulci/scar. The case involves multiple descriptors of therapeutic interventions including both presurgical and postsurgical attempts to release the scarred vocal folds.

Case Study 11 Brian E. Petty and Miriam van Mersbergen Use of Voice Therapy in Conjunction With Minimal Injection Medialization in the Longitudinal Treatment of Dysphonia in an Elite Operatic Singer

History of the Problem Patient QQ, a 45-year-old lyric tenor, self-referred to the voice and swallowing clinic with a 1- to 2-year history of vocal quality and stamina changes. He described instability in the passaggio (the transition range between modal

and high pitch ranges), as well as significant difficulty maintaining controlled vocal production in the top 2 notes of his range, around B5 and C5. He reported that he was able to phonate in these pitches, but “it requires so much mental concentration and physical effort to stay on this very narrow path . . . I’ve never had a super strong extreme high range, but it’s always been easier than this.” The patient self-referred to the voice and swallowing clinic after approximately 6 months of noticing the aforementioned symptoms.

Medical History Patient QQ’s medical history was significant only for a remote history of chronic bronchitis, which in recent years had been well controlled. There was no history of head or neck injury. Patient had no history of vocally phonotraumatic activities. Hearing acuity was within normal limits. No chronic medical problems were appreciated other than seasonal allergies, which were well controlled using fexofenadine prn. Water consumption was within normal limits, 5 to 7 glasses daily.

Social History Patient managed a full university teaching load consisting of studio instruction of undergraduate and graduate-level singers, as well as classroom and seminar instruction. He also maintained a busy performance schedule, particularly in the spring and summer months. His professional specialization was in baroque cantatas, which he performed extensively every year during international concert tours. The vocal ease and


agility required in this type of literature were becoming progressively more problematic for this patient, prompting his presentation to the clinic. He exercised frequently, through high-level tennis and golf activities. He was happily married and had 3 children.

Voice Evaluation Audio-Perceptual Patient QQ’s voice quality was judged perceptually by the speech-language pathologist during informal conversation as well as singing tasks, using the 4-point GRBAS scale measuring overall (general) voice performance (G), roughness (R), breathiness (B), weakness or asthenia (A), and strain (S).9 Patient QQ showed mild breathiness and strain in the passaggio. Some mild pitch instability was noted in the passaggio and the upper range, with a perceptually delayed voice onset time. In conversation, the patient was perceptually normal compared to age- and gender-matched nonsinging peers; however, he presented with a mildly pressed vocal quality with a slightly higher modal pitch. Instrumental The speech-language pathologist visualized the larynx using 70-degree rigid oral endoscopy without anesthetic, revealing bilaterally mobile vocal folds. Adduction of the vocal folds during modal and high pitches was characterized by a minimal gap extending along the length of the glottis. The left vocal fold showed decreased mucosal wave propagation at modal and high pitches associated with a groove-like lesion along the vibratory margin extending

from the anterior commissure to the vocal process, although propagation resumed on the superior surface. Mild phase asymmetry was noted through the modal and high-pitch ranges. Supraglottic hyperfunction was noted with variable severity throughout the examination. Subsequent evaluation and interpretation of stroboscopic data with the laryngologist revealed bilateral sulcus vocalis (types II and III), mucosal bridge, as well as evidence of diffuse vocal fold scarring. Acoustic and Aerodynamic Measures As is often customary in highly trained professional singers, acoustic and aerodynamic measures all were within functional limits. Therefore, the evaluation of the patient’s reported vocal change was necessarily completed using careful perceptual and patient self-report processes.

Voice Therapy Specific types of therapy include: n Vocal Function Exercises n Resonant voice therapy n Estill “twang”

Rationale for Therapy Approach Treatment for high-level vocal performers can be a daunting task, particularly when the degree of change that is sought consists of subtle improvement that would be considered within the range of normal variability. After collaborative discussion regarding possible treatment options, the team decided together to offer a behaviorally aggressive and

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surgically conservative approach, focusing on a combination of Vocal Function Exercises, which have been shown to be effective in treating a variety of voice disorders19 and have been shown to be a useful tool in the practice regimen of trained singers64; resonant voice therapy, which has been shown to affect laryngeal configuration during phonatory tasks17; and Estill twang strategy, which has been shown to enhance the “singer’s formant.”65 With the patient’s extensive history of classical Italianate vocal training, maximizing behavioral change before considering structural alteration was thought to be preferable. The patient was in agreement with this approach. The patient was seen for behavioral voice treatment by 2 speech-language pathologists over a 2-year period. Both speech-language pathologists had extensive experience as classically trained singers and singing teachers and were members of the National Association of Teachers of Singing. Therapy Goals Goal 1. Patient QQ will complete Vocal Function Exercises with 95 to 100% accuracy independently. Therapy description: The patient was instructed to sustain /i/ as long as possible on F above middle C. He was then instructed to glide from the lowest to the highest note in his comfortable frequency range, using /o/. Following this, he glided from the highest to the lowest note in his comfortable frequency range, using /o/. He then sustained the musical notes middle C and D, E, F, and G above middle C for as long as possible, using /o/. He repeated these notes 2 times. He was encouraged to produce all tones as quietly and as long as was

comfortably possible, with frontal tone focus. He kept a written log of daily maximum phonation times for all tasks other than glides. Frequency and duration of treatment: The patient was trained in this protocol over four 1-hour sessions of behavioral voice treatment over 8 weeks. The patient adhered to home practice recommendations with remarkable consistency. After 8 weeks, the patient reported improvement of vocal stamina and range access to within his normal baseline.

Therapy Outcomes Repeat videostroboscopy of the larynx revealed improved vocal fold adduction during modal and high-pitch phonation, as well as decreased supraglottic hyperfunction. Patient QQ continued to use Vocal Function Exercises at home as a daily warm-up, and returned to his teaching and performance work without difficulty. Approximately 1 year after his initial visit, patient QQ returned to the voice and swallowing clinic for followup. He reported initial success using Vocal Function Exercises, but had noted a slight return of the previous symptoms of decreased access to and control of the high range as well as pitch instability and increased vocal effort. A repeat videostroboscopy of the larynx revealed findings that were consistent with the previous images, with slightly increased supraglottic hyperfunction compared to baseline.

Follow-Up Therapy Goal 1. The goal of follow-up therapy was to reacquaint patient QQ with pho-


nation in the absence of vocal “pressing,” a quality consistently observed in the patient’s speech and singing, albeit mild compared to nonsinging peers. The focus on a highly sensorybased technique was used to facilitate self-awareness in habitual vocal techniques. The patient demonstrated excellent acquisition of resonant hum and excellent awareness of the difference between pressed and relaxed voicing. To address the patient’s continued concerns regarding the unpredictability of certain notes throughout and above his passaggio, particularly at the top of his functional singing range, Estill “twang” techniques were used primarily as a distraction technique to eliminate anticipatory accessory behaviors characterized by chin-jutting and shoulder-raising before these notes. This served to reacquaint him with successful technique used in the past.

tory gestures was observed. Kinesthetic awareness was emphasized. The nasendoscope was removed and the patient successfully utilized kinesthetic cues to sustain resonant production in range extension tasks.

Goal 2. Patient QQ will perform resonant hum in the absence of extralaryngeal resistance and strain to facilitate optimal laryngeal configuration during a simple phonatory task, with 100% accuracy independently. Therapy description: The patient was seated in the examination chair. A flexible nasendoscope was placed in the left nostril without the use of topical anesthetic, under stroboscopic light source. Patient was instructed to drop his jaw, adopt a comfortable “open throat” posture, and produce a hum in a descending glide in comfortable modal range during which he noticed a sensation of vibration on his lips or face. Visual stroboscopic biofeedback was utilized to illustrate absence of anterior-posterior compression, false vocal fold compression, or pharyngeal squeeze. Vocal fold configuration before and during phona-

Audio-Perceptual

Goal 3. Patient will produce Estill twang during singing tasks throughout and above the passaggio to facilitate singer’s formant in the absence of vocal pressing, with 90% accuracy independently. The patient was instructed to produce short spoken twang tasks such as a child’s “nya nya nya” taunt and other sounds featuring an /ae/ phoneme. The kinesthetic sensation of constriction of the aryepiglottic sphincter was contrasted with the sensation of resonant voice production.

Follow-Up Therapy Outcomes

The patient did well and achieved goals 2 and 3, reporting that during performances these techniques worked well for him. Audio-perceptual assessment during focused practice of behavioral strategies revealed perceptually normal vocal quality in spoken and sung tasks. Patient Self-Assessment Despite his progress, the patient began to experience heightened levels of anxiety during practice and prior to performance, which inhibited his ability to focus on behavioral strategies and musicianship. After an intensive counseling session with one of the treating speechlanguage pathologists, patient QQ met with the voice team to discuss further options. Until this time, the patient

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had been understandably resistant to exploring more invasive medical and surgical options. Behavioral treatment had been effective in alleviating initial complaints (unpredictability in voicing and poor vocal power), but it also exposed deeper underlying difficulties (the increased cognitive effort to vocally excel after the reduction of previously employed, habitual compensatory strategies). The treatment team included the treating speech-language pathologists, a specialist in high-speed imaging, and the otolaryngologist. The patient underwent additional evaluation using high-speed imaging with an integration of past medical and behavioral training. High-speed imaging elucidated the impairment of vocal fold stiffness, which resulted in a confirmed diagnosis of sulcus vocalis. During this process, patient QQ appreciated his anatomic deficit, which resulted in a concrete realization of his vocal limitations. As a result of this meeting, patient QQ decided to undergo the recommended exploratory direct microlaryngoscopy, which resulted in confirmation of left vocal fold type II sulcus, left vocal fold scar, and left vocal fold type III sulcus in the infraglottic space. The otolaryngologist decided to employ subepithelial infusion of saline and injection medialization of the left vocal fold using a conservative 0.3 mL of Restylane.66 The patient was scheduled for postoperative voice therapy. One-Week Postoperative Treatment The patient employed total voice rest for 3 days, with very gradual onset of voicing using resonant hum after that. After positive and negative practice and awareness building, patient QQ demonstrated excellent awareness of how

his behaviors contributed to postoperative vocal instability. Subsequently, he obtained conversational resonant voice quickly after establishing selfmonitoring strategies.

Results of Therapy By the 1-month postoperative date, the patient reported that he had experienced a significant improvement in his vocal quality and stamina, describing his ability to control his high range as “better than ever.” He had returned to his teaching and performance activities with much improved ease. Videostroboscopy and high-speed imaging of the larynx showed improvement in glottic closure pattern, vibratory symmetry, and tissue pliability. Follow-up at 1-year post-op revealed continued functional success. Patient QQ had managed a busy performance schedule that summer and reported that he had been able to continue his easy and effective vocal production without significant difficulty. This report at 1-year post-op revealed that the patient’s success was due not only to his enthusiastic compliance with home programming but also to the careful and collaborative planning of behavioral and surgical intervention and management of the understandable emotional factors that potentially could have interfered with an otherwise solid plan. By allowing this patient to pursue perioperative behavioral management before surgical intervention, he was able to improve his initial vocal quality and function, identify underlying technical issues that might not have been identified otherwise, and facilitate quicker recovery of superior vocal function. A collaborative team approach to


voice care was therefore optimal for this patient, particularly given the special nature of his vocal needs. In Case Study 12, Kate DeVore discusses the generalization of learned vocal behaviors into the actual speaking situations of a vocally active actress/ choreographer/theater director.

Case Study 12 Kate DeVore Voice Therapy in a 28-Year-Old Theater Actor

History The patient was a 28-year-old actor working in legitimate (straight) theater as well as musical theater. She worked consistently in professional theaters as an actor, singer, choreographer, assistant director, and dance captain. She had a long history of reflux, and was diagnosed with vocal nodules just prior to seeking treatment. She believed that her voice problems were caused by her speaking voice onstage and off, rather than her singing voice. While she had trained her singing voice, her speaking voice was untrained because she trained primarily as a dancer rather than an actor. She therefore believed that the loud, authoritative talking required as a choreographer and assistant director coupled with the demands on her speaking voice as an actor were most likely at the root of the development of nodules. The patient’s speaking voice was mildly hoarse and breathy, with glot-

tal fry prevalent at the ends of phrases. She reported the evaluation day as “a good day” because of a weekend of rest. Her singing voice was mild-moderately pushed and breathy, with excessive jaw tension and misalignment of the head. She reported drinking 4 to 5 glasses of water per day, about 2 alcoholic drinks per week, and she just cut out caffeine. She exercised extensively. Aciphex was her only medication. Her s/z ratio of 1.3 was indicative of possible poor membranous vocal fold closure during phonation. Her L-DDK was normal for rate, strength, and consistency of diadochokinetic adductions, indicating normal arytenoid movement. The patient attended seven 1-hour therapy sessions over 9 weeks subsequent to the evaluation. She then returned for a “check-up” 4 months after discharge. At this time (6 months post evaluation) she reported that the referring otolaryngologist told her the nodules were resolved.

Treatment Approaches We began with counseling regarding reflux precautions and hydration. Therapy then included exercises to decrease physical tension in the neck, shoulders, and jaw, and to increase awareness of habitual physical tension in muscles associated with phonation. We did exercises to promote easy, natural abdominal breathing in speech, and connecting to the abdominal wall to create adequate airflow for healthy phonation. We moved on to exercises for vocal placement that promote phonation with the optimal laryngeal configuration, allowing the greatest acoustic output for the least impact force between the vocal folds. After spending some time

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integrating these new behaviors into conversation at different loudness levels, we looked at applying the techniques to spoken text and singing. We also addressed the energy and psychology of her voice use. Finally, we created a short warm-up that she could do before rehearsals and performances, as well as clarifying the exercises she was to continue to do to maintain her vocal health. After the case history was obtained, the patient was educated (in simple terms) about the anatomy and physiology of healthy voice production, and the cause of vocal nodules. We discussed the likely causes of her nodules as being a combination of tissue irritation from reflux coupled with the impact force of vocal fold vibration; the quality and/ or quantity of impact force was simply more than her tissue could tolerate without nodule formation. We discussed the fact that voice therapy would help her retrain the muscles she uses in speech and singing so she could use them in a way that would heal the nodules rather than exacerbate them. The therapy process was explained as having 3 main sections: (1) physical relaxation and adjustments in order to keep the channel for sound open; (2) breathing for speech and singing; and (3) placement, or resonance, to promote therapeutic phonatory behaviors. Each element had a skill acquisition and integration component; after the skill was learned, we would also spend time applying the new behaviors to speech and singing. Vocal Hygiene The hygiene counseling portion of therapy was brief. The significance of hydration was discussed, and increased water intake and direct steam inhalation were recommended. In order to promote the

best possible mucosal wave, thoroughly hydrated vocal folds are advised. Given how much she exercised (and therefore sweated), it was likely that she would benefit from drinking more water. Even though 8 glasses a day is a reasonable starting point, the classic “pee pale” counsel remains the best yardstick. To further enhance the likelihood of a pliable mucosa, direct steam inhalation twice a day for 5 to 10 minutes was recommended to topically hydrate the vocal folds. Because the effects of steam inhalation are short-lived, twice a day for 5 minutes is more useful than once a day for 10. It is possible to inhale steam from a pot of water boiled over the stove, but this method is cumbersome enough that people often do not bother with it; for that reason, a personal steam inhaler was recommended. The only other aspect of vocal hygiene that warranted discussion with this patient was reflux precautions. She was already on medication, and had been counseled by her otolaryngologist, so we simply reviewed the foods and behaviors that are known to cause reflux in many people. Specifically, caffeine, coffee (even decaffeinated), carbonation, fatty foods, acidic foods (like citrus and tomatoes), and spicy foods can cause reflux. Anything that puts pressure on the abdomen, especially when the stomach is full, is also a possible cause of reflux. Therefore, the potentially detrimental effects of tight waistbands, large meals all at once, athletic speaking or singing after meals, exercising after eating, and lying down within 2 hours of eating were all discussed. Behavioral Therapy The behavioral therapy then began with physical relaxation and alignment.


The principle is that most people carry habitual tension, of which they are largely unaware, in many of the muscles associated with voice production. The neck, shoulders, and jaw are common places for people to somaticize stress, which manifests as physical tension in muscles of the larynx itself, as well as muscles that connect to it. And many aspects of modern lifestyles (like driving and sitting at a computer, for example) encourage a rounding of the shoulders that creates distortion in the channel for voice. Furthermore, once a vocal injury begins to form, people typically habituate by recruiting additional muscles into the act of phonation. This behavior becomes habituated, which is why we need therapy to retrain it. We began with a series of stretches intended to increase awareness of muscle tension and aid in its reduction. We stretched the front, sides, and back of the neck as well as the muscles that run diagonally across the front and back. We introduced awareness of breathing at this time, using breath to time the stretches. So many voice patients want to speed through the stretches and cross them off the list; the whole point is to take the time to get centered, present, and attentive to the body. It is not uncommon for people to hold their breath when they stretch, so holding each stretch for 3 slow, deep breaths addresses several issues at once. It encourages patients to relax into the process and genuinely relax the tense muscles, and it trains awareness of breath and the body. The second aspect of physical adjustments involved training awareness of habitual tension in the neck, jaw, and tongue, followed by the ability to release this tension. The patient was guided into a natural head alignment,

so as to release muscles of the neck and skull base, and create a vocal tract shape that acoustically amplifies voice rather than diminishes it. She was then guided to release any habitual tension of the masseter, allowing her jaw to hang freely. Releasing jaw tension also helps create a pathway whereby the sound can reach resonating surfaces. Finally, she was guided to allow the tongue to lay flat instead of lifting or moving the tongue forward. Many people carry substantial tension in the tongue base, which attaches to the larynx. This tension not only creates an obstructed channel, it can cause the sound waves to be absorbed by soft tissue before they can reach a resonating surface. This loss of acoustic energy leads to additional strain in an attempt to get sound out, and the cycle of tension reinforces itself. The patient was advised to do the stretches once or twice a day, and to incorporate some of the more relevant ones throughout her day. The second exercises were not something to hold for prolonged periods, but rather something to remember multiple times throughout the day. The idea is that the muscles will learn to stop holding tension if we repeatedly release them; that is a key way to train out habitual tension. Over the course of therapy, her alignment remained a pervasive issue and one we returned to frequently. She noticed a significant improvement in freedom, strain, fatigue, vocal quality, and loudness when her head was aligned instead of in front of her torso. The second element of training was breath support. Because the patient had previous breathing training, little time had to be spent explaining the principles of abdominal breathing. We went through a series of exercises using the

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elastic recoil principles of respiration to facilitate a passive inhale. The exercises involved engaging the muscles of the abdominal wall to create a controlled and steady force of exhalatory pressure. She discovered that when she engaged her abdominal wall more deliberately during speech, her voice quality automatically improved. At this point, we spent time integrating into conversation the breath work and the increased range of motion of the articulators that came from the stretches and physical work. With focus on allowing her jaw to open and move more during speech as well as using abdominal breath support, she was able to produce a voice without hoarseness and clear up the glottal fry. She continued to sink into fry in the last word or two of sentences, and we continued to focus on this for the remainder the therapy process. She was initially able to hear it only after she had done it, but eventually she was able to keep the energy of breath and movement going to the end of the phrase to stay clear. The third element, and the final piece in the general voice work, was placement, or resonance. This is referred to using various terms, including maxillary resonance, forward focus, forward placement, and resonant voice. The idea is that when voice is produced with a kinesthetic sensation of vibration on the alveolar ridge, coupled with a sense of ease in the throat, the vocal folds close in the “optimal laryngeal configuration.” In this vocal fold closure pattern, the vocal processes of the arytenoids are barely abducted, and the folds close completely and gently with each vibratory cycle. Because of the vocal tract shaping/formant tuning that is required for this voicing pattern, this closure pattern creates the greatest acoustic output for the least wear and tear on the folds.

It promotes healing as well as vocal health maintenance. Beginning with the relaxed jaw and tongue position and aligned head trained in the first segment of therapy, we used nasals (/m/, /n/) to facilitate the sensation of vibration on the alveolar ridge. The building blocks had already been laid for success with this task, as we had worked with opening the channel for sound as well as producing solid breath support required to sense this vibration without strain in the throat. Keeping the tongue base down and relaxed was essential to her success, as the sound waves were otherwise absorbed by the tongue before they could reach the bones of the face that create resonance. A challenge she faced was the tendency to listen rather than feel. It is essential that the criteria for success are based on the physical sensation and not the sound, because it is easy to produce a similar sound using a different (and nontherapeutic) physiology. Focusing on nasal consonants (whose turbulence facilitates the kinesthetic sensation of vibration), we moved through a hierarchy, fading models at each level to allow for self-assessment. The hierarchy began with consonants in isolation, then consonant + vowel syllables, to single-syllable words, to multisyllabic words, to phrases, then to sentences. The goal at that juncture was not to sound “natural,” but rather to exaggerate the nasal sounds to truly learn to feel them. She needed to be reminded that the goal was the combination of the sensation of vibration and the sense of ease in the throat. After the read words and sentences, we transitioned to using the word “hum” as a carrier to promote forward resonance on self-generated sentences.


Using “hum” as an “arc” to the sentence and focusing primarily on the vibration of the “m” in that word places the sensation in the target location, and the subsequent sentence stays in the same place. The final phase was the fading of the carrier word. In this step, she produced the self-generated sentence preceded by the carrier “hum” (which creates the optimal laryngeal configuration), then took a breath whether or not it was needed (to abduct the folds and lose the closure pattern), then imitated the sentence without the carrier, sensing it in the same place. This part was most relevant to carryover, as it trained her to find the desired vocal fold closure pattern without using the carrier. From here we moved on to questions and answers followed by spontaneous conversation, with prompts and adjustments, with the focus on her attention to maintaining the forward placement of the voice. Throughout the process, the spontaneous utterance of “mm-hmm,” produced as though agreeing with something or encouraging someone to continue talking, was used to find the target sensation of easy alveolar vibration. Troubleshooting for her included releasing the tongue to the bottom of the mouth, relaxing the jaw, permitting adequate breath support, and holding a pitch that allowed for this vibratory sensation. Once we had laid the groundwork of supported, healthy phonation, we moved to application of this technique in various contexts. In addition to conversation, we worked on singing as well as projected speech. In terms of her singing voice, the most salient aspect of the work turned out to be head position, or alignment. She had a deeply habituated tendency to jut her head forward

and lift her chin, which constricted the channel for sound such that she needed to push harder from the throat muscles to “get the sound out.” We worked with her singing while keeping the back of her head against a wall to encourage her neck to remain long and free. She found this technique very helpful, and used it at home with regularity. We used some Estill voice techniques for singing as well, specifically false vocal fold retraction and working with different thicknesses of vocal folds during phonation to train safe belting. The reader is referred directly to the Estill trainers to learn more about those techniques.67 Working on projected, or perhaps shouted, speech was necessary because of her work as an actor and also choreographer. The major changes required for her to be able to maintain a loud style of speech for an extended period were keeping her head aligned and muscles of the neck and jaw free, and using adequate breath support. We practiced spontaneous conversation as well as functional conversation related to her choreography work and text from a current show at various loudness levels. The last topic we addressed was the more holistic issue of the emotional and energetic components of her particular forms of physical holding. She found that in both speech and singing, there was a tendency to brace her muscles and hold back her voice, breath, and energy. This holding led to a need to push, using extraneous muscle effort, in order to get the sound out. This combination of behaviors created the circular pattern of tensing and pushing, almost as though antagonistic muscle pairs were being simultaneously contracted and therefore at redundant war. We discussed her feelings around this pattern, and did some energy work

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to help her release the pattern. While not something trained in most speech pathology graduate programs, it was part of the training of this clinician and the specifics are beyond the scope of this case study. We also did some counseling around the issue of trusting her voice. Because it had not been reliable for so long, she was naturally leery of its ability to “be there for her” in performance. Seeing herself as in control of her voice helped her to be able to trust it more, which allowed her to gradually let go of the bracing and pushing behaviors that were part of the causation of the nodules.

Results of Therapy As part of her discharge plan, we enumerated a daily warm-up for her to continue to work on by herself. The focus of the warm-up was to incorporate a little bit of every important element trained. She was counseled to do some, if not all, of the stretches, the breathing exercises that focused on connecting to the abdominal wall at various phrase lengths, and an abridged version of the vocal placement hierarchy. After the evaluation and 7 therapy sessions, her ENT told her the nodules were resolved and she was able to finish integrating the material on her own. Four months later, she returned for a checkup. She had seen the ENT for a followup the day before, and he reported that her folds were healthy. She was working on several demanding shows at the same time, and simply wanted to make sure that she was using all of her newly acquired behaviors optimally. We went through her warm-up with only minor coaching adjustments, as she was gen-

erally integrating and carrying over her new behaviors well. The primary areas in which she still needed prompts were related to using abdominal breath support, and dropping to a pitch that was too low to allow maxillary resonance. Additional suggested readings are as follows: n Cookman S, Verdolini K. Interrelation

of mandibular and laryngeal functions. J Voice. Mar 1999;13(1):11–24. n DeVore K, Cookman S. The Voice Book: Caring For, Protecting, and Improving Your Voice. Chicago, IL: Chicago Review Press; 2009. n DeVore K. Voice care tips for clinicians. Adv Speech-Lang Pathol. Jan 19 2004;14(3):9. n DeVore K, Verdolini K. Professional speaking voice training and applications to speech-language pathology. Curr Opin Otolaryngol Head Neck Surg. 1998;6:145–150. n DeVore K, Harvey PL. Behavioral management of the performing voice. In: Fried M, Ferlito A. ed. The Larynx. 2nd ed. San Diego, CA: Plural Publishing; 2007:743–769. n Estill J. Primer of Compulsory Figures. Santa Rosa, CA: Estill Voice Training Systems; 2003. n Jiang JJ, Diaz CE, Hanson DG. Finite element modeling of vocal fold vibration in normal phonation and hyperfunctional dysphonia: implications for the pathogenesis of vocal nodules. Ann Otol Rhinol Laryngol. Jul 1998;107(7):603–610. n Jiang JJ, Shah AG, Hess M, et.al. Vocal fold impact stress analysis. J Voice. Mar 2001;15(1):4–14. n Raphael BN, Sataloff RT. Increasing vocal effectiveness. In: Sataloff RT, ed. Professional Voice: The Science and


Art of Clinical Care. 2nd ed. San Diego, CA: Plural Publishing; 1997:721–729. n Titze IR, Verdolini Abbott K. Vocology. Salt Lake City, UT: National Center for Voice and Speech; 2012. n Titze IR. Acoustic interpretation of resonant voice. J Voice. Dec 2001;15(4): 519–528. n Titze I. Principles of Voice Production. Englewood Cliffs, NJ: Prentice Hall; 1994. n Verdolini Abbott K, Li NY, Branski RC, et al. Vocal exercise may attenuate acute vocal fold inflammation. J Voice. 2012; 26(6):814. n Verdolini K, Li NY. Resonant voice therapy. In: Stemple JC, Thomas LB. eds. Voice Therapy: Clinical Studies. 3rd ed. San Diego, CA: Plural Publishing; 2009. n Verdolini K, Druker DG, Palmer PM, et.al. Laryngeal adduction in resonant voice. J Voice. Sep 1998;12(3):315–327. n Verdolini K, Titze IR, Fennell A. Dependence of phonatory effort on hydration level. J Speech Hear Res. Oct 1994;37(5):1001–1007. n Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E. A preliminary study on two methods of treatment for laryngeal nodules. J Voice. 1995;9:74–85. n Verdolini-Marston K, Balota DA. The role of elaborative and perceptualintegrative processes in perceptualmotor performance. J Exp Psychol 1994;20:739–749. In this case, Alison Behrman describes a therapy approach to be used with public speakers and those occupational speakers who use their voice in meetings and presentations. The approach capitalizes on rate and pauses.

Case Study 13 Alison Behrman Conversational Voice Therapy: A Case Describing Application of Public Speaking Techniques to Voice Disorders

Case History Miguel was a 53-year-old bilingual (Spanish-English) regional sales manager for a manufacturing company. (His name is changed and the company’s products are not described to protect his identity. He did request, however, that a Spanish pseudonym be used because he is proud of his Hispanic identity.) He had been with the company for 19 years, working his way up from sales to district manager and then finally 4 years before I met him, to regional sales manager for the northeastern area of the United States. He was responsible for the productivity of 26 salespeople. He was on the road 3 weeks of every month, meeting with teams of 1 to 3 of his salespeople throughout each week. In these meetings, typically an hour long, he would present information on new product, corporate policies, and sales data, and role-play situations that his salespeople might encounter with their customers. His job was to be a motivator and problem solver, and interface between corporate headquarters and the salespeople. He also met regularly with one or more salespeople together with their customers, particularly when training junior salespeople. His social voice use was unremarkable. His children were grown, and he said

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that he was generally soft spoken when at home, and only yelled sometimes at the TV when his soccer team was underperforming. Miguel’s chief vocal complaint was vocal fatigue, sensation of effort and effortful breathing when speaking, and impaired voice quality (“sounds like I have a frog in my throat”), particularly after extended voice use. He reported that he had been experiencing these vocal problems for years and the symptoms had not progressed. He had longstanding laryngopharyngeal reflux (LPR) and managed it with medication and diet, as best as he was able. He had intermittent laryngeal stroboscopic examinations over the past 2 years, all of which had revealed mild vocal fold irritation consistent with LPR and intermittent irregular mucosal wave vibration, but not distinct focal adhesions or lesions. He had been referred for voice therapy approximately a year before I met him and reported that the focus was vocal hygiene and (what I surmised from his description) resonant voice therapy. He said that the vocal hygiene guidelines had helped him a lot, but he found himself unable to carry over any of the voice techniques into his daily speaking, and gave up the therapy after 2 months. He was referred to me from the vice president of marketing at his company, whom I had coached in public speaking skills for their annual corporate sales meeting.

Voice Evaluation Miguel presented as a soft-spoken man, but with great energy and passion. His voice quality was characterized by frequent use of glottal fry, particularly at phrase group endings, and a nonreso-

nant (almost nasal) vocal quality. He appeared to use limited pitch variability. He spoke rapidly and used many filler words (uhm, so). Mean speaking fundamental frequency was 97 Hz, measured from the third sentence of the rainbow passage, extracted from his reading of the entire first paragraph. His voice handicap index score was 45. His vocal complaints, together with my observations and the relatively benign findings of the laryngeal exams, suggested muscle tension dysphonia. He appeared to be using excessive muscular effort with insufficient breath support. My impression was that his vocal style had to be altered to meet the needs of his occupational vocal demands.

Voice Therapy My primary concern in devising a therapy plan for Miguel was his inability to use resonant voice as his daily work voice. I was acquainted with the therapist who had worked with him previously, and I knew her to be a skilled clinician. Honestly, I did not think that I could bring anything novel to the table with a resonant approach that would suddenly make it successful for him. Given his small group presentations, his individual high consequence meetings with customers and salespeople, and his passionate (yet not loud) vocal style, I elected to use an approach that I have come to identify as conversational voice therapy. I have spent a number of years coaching executives in public speaking skills and conducting therapy for patients with voice disorders. In my mixed practice, I could not help but notice the voice quality improvements of many of my public speaking clients;


in particular, decreased harshness and nasality, and increased oral resonance. Many of these same clients noted a similar improvement in their voices when they compared recordings of their presentations before and after coaching. I considered the possible reasons for the perceived vocal improvement. The coaching techniques, directly or indirectly, facilitated slower speech, greater movement of the articulators, greater breath support, and wider intonation contour. I hypothesized that these changes might well increase oral resonance and yield a more pleasing vocal quality for Miguel, and relieve his sensation of excessive effort and running out of breath when he spoke. The version of conversational voice therapy I used with Miguel is composed of 3 exercises — pausing, clear vowels, and vocal variety, all accompanied by frequent video analyses. It is recommended that pausing be addressed first. It is the most basic skill and a prerequisite for all additional skills. It is deceptively simple to describe, but quite challenging for most clients to integrate into conversation, particularly those clients who naturally use lots of filler words. Pausing Start by having the client pause at every period, using an exaggerated pause of 2 full beats. All pauses are completely silent, with no fillers such as “um” or “and.” Next, have the client pause for 2 beats at all commas and periods. Initially the pause will feel extraordinarily long. After the client has achieved success using the exaggerated pause at all periods and commas, reduce the duration to 1 beat. Ultimately, the length of the pause will vary, and will be determined by the needs of the speaker and

the listener. Have the client return to the exaggerated length pause, and briefly inhale during each pause, making sure not to inhale deeply, which is unnecessary and counterproductive. Do make sure the client inhales by expanding the lower thorax/abdomen. Finally, have the client identify a monologue or discussion topic in which he or she commonly engages at work, and use it to practice pausing. It should be noted that clients who are not familiar with diaphragmatic breathing, or who confuse speed of the inhalation with the volume of air, will likely benefit from attention to breathing exercises before attempting to connect the inhale with the pause. Use the term inhale rather than breathe during instruction. Otherwise, you risk having the client complete a full breathe cycle (inhale and exhale) during the pause, and then the client is left with insufficient air for the next utterance. Clear Vowels Select a series of 1- or 2-syllable words that, all together, promote a variety of exaggerated oral movements, such as “you, lie, vowel.” Direct the client to overenunciate the vowels. Have him or her select a mental image of the vowels (perhaps a large red balloon) and use that visualization to help the client focus on the vowels. Provide some text to the client (the content is not critical) and direct him or her to read aloud but read only the vowels. Caution your client that he or she will not be intelligible and it will sound odd. For example, for the utterance “read this aloud,” it would sound like “ee ih uh ow.” Have the client try to use the rhythm and syllable stress of the sentence that would be used if reading the sentence normally.

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Immediately after completing this step, then have the client re-read the text including all of the sounds (reading “normally”) but trying to continue to visualize the vowels and emphasize them. Next, use each of the following vowels in turn: ah (as in hot), oh (as in hoe), ee (as in heat), oo (as in hoot). Starting with the first vowel, ask the client to insert it into the following nonsense words, overenunciating the vowels. Then repeat the nonsense words, this time inserting the second vowel. Continue through all 4 vowels. (In the following list, the capital V represents the vowel to be inserted.) cVdV pVtV sVlA fVrV Repeat the exercise, but now place each nonsense word in the phrase: “I see a [nonsense word] by the house.” Direct the client to focus on overenunciating the vowels, not only in the nonsense word, but also in the other words in the phrase. One the client has achieved success on this exercise, repeat it, but decrease the exaggeration of the vowels a little. The goal is to maintain the vowel overenunciation while restoring natural-sounding speech. Now, starting with reading, ask the client to pronounce the vowels clearly, as if speaking to someone from a different language background or who otherwise has difficulty understanding the words easily. Once this speaking style becomes comfortable while reading, engage the client in practicing clear vowels in simple conversation and then more complex discussion, and finally, with a topic in which the client commonly engages at work. Vocal Variety Instruct the client to read aloud a passage with a “sing-song” style (exagger-

ated vocal variety). It may be helpful to ask the client to pretend that he or she is telling a story to young children. Alternatively, consider the analogy to move the vocal pitch up and down “like a boat riding over big waves” or “like riding on a roller coaster.” Make sure that the client is using brief silent pauses at all punctuation. Next, repeat the exercise, but decrease the sing-song style by 20%. Continue to monitor the client’s pausing during the exercise. With repeated readings, alter (upward or downward) the degree of vocal variety by specific percentages until you feel that the client has obtained a natural-sounding but expressive voice. Then, prepare a list of questions, from simple (“Is it supposed to rain today?”) to more complex (“Why do you think most people get annoyed when someone is talking loudly on their cell phone in a public place?”) Direct the client to use exaggerated vocal variety while alternating roles as the questioner or responder with you as the conversational partner. Repeat this exercise again but decrease the sing-song style by 20%, and then continue to adjust the percentages until an optimal amount of vocal variety is demonstrated. Another exercise that can facilitate vocal variety is to make statements that elicit a contradictory or corrective response from your client. For example, in the following exchange, the italics shows the target words for greater pitch changes. SLP: “Joe is my friend.” Client: “No, he’s not. Joe is my friend. Warren is your friend.” And finally, ask your client to identify a monologue or discussion topic in which he or she commonly engages at work. Direct your client to think about


the words and ideas that he or she wants to emphasize. Then, have your client give the monologue to you, or engage in discussion with you, using exaggerated vocal variety to emphasize the words and ideas that have been previously identified. (It may be helpful to let the client write out some of the text beforehand in order to identify the desired emphasis. However, it is important that the client then puts away the notes, and speaks spontaneously, recognizing that the specific words may change.) Video Analysis Video analysis is particularly helpful in facilitating discussion on the effect of the target behavior changes on the overall impression the client is projecting to the listeners. At the first therapy session, obtain a baseline video. Record 1½ to 2 minutes of a client monologue. Ideally, the client should select a topic commonly addressed at work, one on which the client is comfortable and knowledgeable speaking. View the video with the client silently. Then, ask questions to generate introspection on the part of the client, such as, “What surprises you about how you look and/or sound?”; “If you were a stranger watching the video, what impressions would you have about the speaker?”; and “What do you like and dislike about the impression you are portraying?” Then, provide your assessment. It is important that your assessment focuses upon the interpersonal connection the client is achieving. Link the assessment to: (1) the client’s self-impressions generated above; (2) the 3 dimensions of pausing, vowel clarity, and vocal variety; and (3) the connection to vocal improvement. At most subsequent therapy sessions, video record short speaking

segments (1 minute or less) to provide feedback to demonstrate improvement, error in the client’s perception, and introduction of a new behavior. Engage your client in introspective dialogue with questions including: What does this behavior (the newly demonstrated target behavior) do for your listener and your connection with the listener? What does it do for your voice? On a regular basis, require the client video himself or herself in select conversational/presentational encounters. Review and analyze these videos during subsequent therapy sessions.

Therapy Outcomes Miguel had 9 therapy sessions over the course of 12 weeks, 4 of which were conducted via Skype due to his travel schedule. Afterward, his VHI score dropped to 21 (from an initial 45), and his mean speaking fundamental frequency was 126 Hz (up from 97 Hz). His voice sounded livelier with less nasal resonance, and I heard minimal glottal fry at the end of utterances. Most importantly, Miguel said that he no longer felt out of breath when he talked, and he said that only rarely did he experience vocal fatigue, and at those times, it was still “much less than before.” He also said that he felt more confident, in control, and relaxed when he met with his salespeople, and that he found it easy to use his new vocal behaviors at work.

Summary and Concluding Remarks These exercises are intended primarily for clients who engage frequently in group discussions, presentations, and

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one-on-one high-consequence conversations. Conversation is the exchange of ideas. One premise of these exercises is that effective conversation is achieved through connection with individuals, even when speaking to a group (such as teaching a class or presenting an idea to a team). Consequently, the behavioral changes that are targeted in these exercises are motivated by improving the client’s voice through more effective interpersonal connections. Important for Miguel, the focus was upon enhancing the effectiveness of his communicative connection with his listener. The distinction is important, because, I believe, it helps the speaker to naturally integrate these techniques into important and stressful communicative acts — the situations in which maintaining healthy voice use can be most difficult. Hence, the therapist is urged to engage the client frequently in discussion and provide feedback on the effect of the target behaviors on their communicative connection with their listeners.

management of benign voice disorders. In: Rubin JS, Korovin GS, Gould WJ, Sataloff RT, ed. Diagnosis and Treatment of Voice Disorders. New York, NY: Igakushoin; 1995:405–423. 5. Titze IR. Inaugural year of the summer vocology institute. VASTA News. 2001; 15(1):6. 6. American Speech Language-Hearing Association Ad Hoc Joint Committee with National Association of Teachers of Singing, The Voice and Speech Trainers Association. The Role of the SpeechLanguage Pathologist, the Teacher of Singing, and the Speaking Voice Trainer in Voice Habilitation [Technical report]. Rockville, MD: ASHA; 2005. 7. Faust RA. Childhood voice disorders: ambulatory evaluation and operative diagnosis. Clin Pediatr (Phila). Jan–Feb 2003;42(1):1–9. 8. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. Jun 2002; 16(2):274–277. 9. Hirano M. Clinical Examination of Voice. New York: Springer-Verlag/Wien; 1981. 10. Andrade DF, Heuer R, Hockstein NE, Castro E, Spiegel JR, Sataloff RT. The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign References masses. J Voice. Jun 2000;14(2):240–246. 11. Heuer R, Towne C, Hockstein NE, 1. American Speech-Language-Hearing Andrade DF, Sataloff RT. The TowneAssociation, National Association of Heuer reading passage — a reliable aid Teachers of Singing. The Role of the to the evaluation of voice. J Voice. Jun Speech-Language Pathologist and Teacher 2000;14(2):236–239. of Singing in Remediation of Singers With 12. Pindzola RH, Cain BH. Duration and Voice Disorders [Joint technical report]. frequency characteristics of tracheoBethesda, MD: ASHA; 1993. esophageal speech. Ann Otol Rhinol Lar 2. Radionoff SL. Preparing the singing yngol. Dec 1989;98:960–964. voice specialist revisited. J Voice. Dec 13. Rosen CA, Lee AS, Osborne J, Zullo T, 2004;18(4):513–521. Murry T. Development and validation 3. Sataloff R, Heman-Ackah YD. Who of the Voice Handicap Index-10. Laryntakes care of voice problems? A guide to goscope. Sep 2004;114(9):1549–1556. the voice care provider. J Singing. 2002; 14. Colton R, Casper J. Understanding Voice 59(2):139–146. Problems: A Physiological Perspective for 4. Riley W, Carroll L. The role of the singDiagnosis and Treatment. 2nd ed. Baltiing voice specialist in the non-medical more, MD: Williams & Wilkins; 1996.


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51. Plant RL, Younger RM. The interrelationship of subglottic air pressure, fundamental frequency, and vocal intensity during speech. J Voice. Jun 2000;14(2):170–177. 52. Titze IR, Hitchcock RW, Broadhead K, et al. Design and validation of a bioreactor for engineering vocal fold tissues under combined tensile and vibrational stresses. J Biomechanics. Oct 2004;37(10): 1521–1529. 53. Behrman A. Common practices of voice therapists in the evaluation of patients. J Voice. Sep 2005;19(3):454–469. 54. Jacobson B, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benniger M. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6(3):66–70. 55. Smith BE, Kempster GB, Sims HS. Patient factors related to voice therapy attendance and outcomes. J Voice. Nov 2010;24(6):694–701. 56. van Leer E, Hapner ER, Connor NP. Transtheoretical model of health behavior change applied to voice therapy. J Voice. Nov 2008;22(6):688–698. 57. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. Jul 17 1997;388(6639):235. 58. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. Oct 2000;57(10):649–655. 59. van Leer E, Connor NP. Use of portable digital media players increases patient motivation and practice in voice therapy. J Voice. Jul 2012;26(4):447–453. 60. Behrman A, Rutledge J, Hembree A, Sheridan S. Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma. J Speech Lang Hear Res. Apr 2008; 51(2):350–366. 61. Cleveland TF, Stone RE, Jr., Sundberg J, Iwarsson J. Estimated subglottal pressure in six professional country singers. J Voice. Dec 1997;11(4):403–409.


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8 Successful Voice Therapy

The chapters of this text have focused on the successful management of a wide range of voice disorders by clinical, medical, and surgical methods. Each contributor demonstrated techniques and approaches that proved successful in improving voice quality of patients with various laryngeal disorders. These successful cases, however, may set an unrealistically high standard for the beginning voice clinician and may not adequately reflect the many management

Introduction Joseph C. Stemple

Clinical Preparation To manage voice disorders successfully, voice pathologists must be well grounded in anatomy, physiology, etio-

pitfalls that are encountered even by experienced voice clinicians. Such pitfalls may lead to delayed success in treatment, less than totally successful results, or failure to resolve the voice problem. In many of the preceding case studies, it was shown that the clinician and the patient share equally in the success or failure of voice therapy. In this chapter, we examine in detail some determinants of successful voice therapy.

logic correlates, laryngeal pathology, and the psychodynamics of voice production. They also must possess outstanding skills in human interaction and be well grounded in evidence-based approaches of voice therapy. Without a complete grasp of these areas of clinical knowledge, their efforts to provide successful voice therapy may be sabotaged by some or all of the factors discussed in this chapter.

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Interview and Counseling Skills The ability to talk to people — to skillfully and systematically divine the important aspects of the voice disorder and then to counsel appropriately — is a skill that must be mastered. For some, it is natural and easily applied in clinical use. For others, it is developed only with practice and experience. Most clinicians continue to hone this skill throughout their careers. The initial patient interview and subsequent counseling are the most important components of a voice evaluation. When these are conducted poorly, successful resolution of the patient’s voice problem is in doubt. The following is but one example.

Case Study: Patient CCC During her second year of graduate training, a student was assigned to intern at the voice center. Following appropriate observation, she was given her first case in which she was to conduct the patient interview portion of the voice evaluation. Patient CCC was a 38-yearold man who had been experiencing 6 weeks of persistent hoarseness. Laryngeal examination revealed only mild erythema of the bilateral folds. Voice quality was only mildly dysphonic, with a dry, strained hoarseness. The patient also complained of a “thickness” feeling in his throat that he tried to eliminate with throat clearing. Other than throat clearing, the patient denied all aspects of voice overuse or trauma, and his medical history was unremarkable as related to this problem. The interview broke down when the intern began questioning the patient regarding his

social history. It was obvious throughout the interview that the intern was nervous, which is certainly understandable in a new clinician. Unfortunately, she became even more uncomfortable when asking questions regarding the patient’s personal life. Every interview provides the clinician with either several little “ahas” or one big “aha” as the diagnosis becomes clearer; however, this intern was more attentive to her scripted questions than to the answers she received. The exchange between the student (S) and patient (P) went something like this: S: “Are you married, single, or divorced?” P: (Heavy sigh) “I was married until 2 months ago.” (Tear in eye; face turned red.) S: (Assuming divorce, with face down in her prepared questions) “How many children do you have?” She missed it! She missed the most important moment during the interview and moved right along to the next question. To that point, only one etiologic factor had been identified: throat clearing. Because of the intern’s lack of experience, she failed to “tune in” to the patient. She listened to what the patient said but not to how he said it. This breakdown was later pointed out to her as part of her internship training. In a follow-up discussion with the patient, it was discovered that his wife had been fatally injured in an automobile accident just prior to the onset of his voice disorder. The patient was suffering from an emotional dysphonia. Learning this, the intern was then able to adequately explain the relationship of emotions to voice quality. In this patient,

Successful Voice Therapy

the voice problem was not resolved until he received psychological support along with voice therapy. It is not adequate to simply ask the right questions. Successful voice evaluation, and thus voice therapy, is determined by the clinician’s ability to apply the questions appropriately during the interview, together with the ability to listen to what is said and how it is said and to respond appropriately.

Clinical Understanding of the Problem The clinician who does not fully understand all aspects of voice disorders may not grasp the less obvious nuances of various pathologic conditions. Certainly, if the clinician does not understand the problem, then successful resolution will either be by luck, or it will be doomed. I have received many secondary referrals from speech pathologists who obviously did not have a complete understanding of the clinical problem. These cases have included lack of recognition of functional dysphonia, functional falsetto, and functional ventricular phonation, among others. In all cases, the clinicians were attempting direct symptom modification without recognition of the true diagnosis. Clinicians also may have unrealistic expectations of therapy results if they do not grasp the effects of neurologic or surgical changes of the vocal folds. Patients with vocal fold paralysis may become frustrated when effort closure therapy is continued for a lengthy period of time. Our experience has demonstrated that if this management approach is at all helpful, positive results are seen within 2 to 3 weeks of daily exercise. Contin-

ued exercise appears to yield little, if any, benefit. Large glottic gaps often do not improve significantly, although we have secondarily seen patients in our clinic who have had months of voice therapy for “vocal fold compensation.” I recall also a postsurgical case in which, because of the clinician’s lack of understanding regarding surgical treatment, both the patient’s and clinician’s expectations for improvement were unrealistically high. The patient was identified through indirect laryngoscopy as having bilateral edema and erythema with a suspicious lesion located on the superior surface of the middle third of the left true vocal fold. The patient underwent a microlaryngoscopy and biopsy of both vocal folds. The biopsy was positive for the suspicious lesion, but biopsies taken in a wide area around the lesion and on the right fold were negative. The decision was made to treat the lesion aggressively through surgical excision. In 9 months of postsurgical voice therapy during which the patient stopped smoking, she improved from a severe to a moderate dysphonia. The patient was very frustrated, however, because her presurgical voice, although low pitched, was not nearly as dysphonic and “hard to push out.” The clinician fed this frustration by indirectly accusing the patient of “doing something” to maintain the hoarseness. The clinician should have understood that aggressive surgery of a cancerous lesion might permanently damage the mucous membrane of the vocal fold. The tradeoff for this conservative treatment of cancer most likely would be some level of permanent hoarseness. Stroboscopic examination of this patient’s vocal folds revealed severe stiffness of the mucosal wave and amplitude of vibration of the left vocal fold. The clinician simply

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did not understand the consequences of surgery. Countless examples could be given regarding clinicians’ lack of understanding about some aspect of the voice disorder affecting treatment. Even the most experienced voice clinicians always are learning new information to add to their bank of clinical knowledge, and the most successful possess the largest “bank accounts” of knowledge.

Misapplied Management Techniques One of the problems in preparing a text of this nature is the fear that it will be used as a voice management “cookbook”: Look up the recipe, stir in this and that ingredient, use this and that technique, practice for 8 weeks, and create a lovely normal voice. No! Voice therapy cannot be successful with a cookbook approach. Every patient is an individual with different problems requiring individual interventions. People with similar voice disorders will not necessarily respond to the same management approaches. For example, some patients with vocal nodules may require and respond well to a progressive relaxation therapy, whereas this approach may be totally inappropriate for others. Some patients with unilateral vocal fold paralysis may benefit from effort closure exercises, whereas others already are spontaneously using too much effort closure. The voice clinician cannot and should not arbitrarily apply certain management techniques to certain voice disorders. Successful voice clinicians are aware of and ready to use any and all manage-

ment techniques as deemed appropriate, but, again, the appropriateness of the chosen technique is dependent on the clinician’s knowledge and expertise of all aspects of the voice disorder. Knowledge of the voice disorder will dictate the use of the various therapy approaches. The management technique does not dictate its own use.

Lack of Patient Education or Understanding of the Problem Most patients have little concept of why they sound dysphonic. Voice production, like speech production, is just one of those bodily functions that we all take for granted, that is, until a problem arises. Education is one key to successful management. The more information patients have regarding their voice disorders, the more likely it is that they can successfully remediate the problem. For patients to “buy” the concept of voice therapy, they must understand why they were referred to a speech pathologist. Once this is adequately explained, the nuances of their particular disorder must be described in detail. With this information, the patient should be able to understand the purpose behind the management techniques (some of which seem silly unless fully understood). Without a full understanding of the problem, the total management burden remains with the clinician. The clinician must use education to shift the burden to the patient. The patient must become an equal, if not greater than equal, partner in the process of voice improvement. For patients to be motivated to change vocal behaviors, they must


understand why the change is required. The successful voice clinician will take great care in educating the patient in all aspects of the voice disorder.

Recognition of One Philosophical Orientation or One Etiologic Factor Successful voice therapy is eclectic. We need not say more regarding the folly of subscribing to one management philosophy. Another potential cause for a poor management result is failure to identify and treat all of the etiologic correlates. For example, much of the emphasis of management for children with vocal abuse problems is placed on eliminating or modifying shouting, screaming, and loud talking. The more subtle causes, such as throat clearing and noises of vocal play (mimicking cars, guns, and so on), may not be identified. I have had the experience of meeting with frustrated speech-language pathologists who are consulting about children who they “know” are no longer shouting. “But he’s not getting any better!” Without modifying or eliminating all contributing factors, the voice disorder is likely to continue. The following is an example from my case files.

Case Study: Patient DDD Patient DDD, a 36-year-old woman, presented with small bilateral vocal fold nodules, as well as mild bilateral vocal fold edema. The abusive behaviors of shouting at her 3 adolescent children, shouting at sporting events, straining her voice while singing in a gospel choir,

and chronic throat clearing were identified. All of these problems were either modified or eliminated through therapy, and her voice quality improved. During each Monday appointment, however, patient DDD was more dysphonic than when seen for a Thursday appointment. As a result of this quality fluctuation, the problem was not totally resolving. What was going on? What had I missed? Although patient DDD was not singing in the church choir at that time, she attended a church that apparently was verbally and vocally enthusiastic to the pastor’s message. Patient DDD admitted to many loud vocal outbursts over a period of 2 hours every Sunday. As it turned out, the patient chose not to control her vocal enthusiasm in church, and she remained mildly dysphonic. The successful voice clinician realizes that voice problems do not just happen. There is always a reason for the dysphonia. Seeking and modifying all of the etiologic factors are essential for the successful remediation of the problem.

Premature Discontinuation of Therapy One of the most difficult stages of therapy for any communication disorder is the carryover phase. Voice therapy is no exception. Many aspects of the communication process are modified during voice therapy. These aspects include the patient’s own perception of vocal image, voicing habits, and behaviors, as well as the direct anatomic and physiologic modifications that often must occur in the laryngeal, respiratory, and resonance systems. In addition, new skills acquired in the therapy setting will not

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automatically be applied outside of this setting. The carryover phase of therapy must not be isolated from the changes demonstrated in the office. The new behaviors must occur in all situations. I recall the difficulty I had with one young man who presented with the classic pseudoauthoritative voice.

Case Study: Patient EEE The patient was a recent college graduate in business who, in his new job, had been made supervisor of a small auditing department. Being young, and even younger in appearance, he had affected a low-pitched voice with intermittent glottal fry phonation. This behavior had led to irritation (not yet ulcerated) of the vocal processes of the arytenoid cartilages. He was noticeably hoarse, with the chief complaint of voice fatigue. Interestingly, the patient was readily able to modify the inappropriate vocal properties during the initial session. I assumed carryover would be rather easy to accomplish. At one point (at about 4 weeks), he was discharged from therapy only to return 1 month later with recurring symptoms. This young man was so involved in his perceived need for a different vocal image at work that he continued his abusive vocal behaviors. As his clinician, I had not ensured carryover of his improved vocal habits to the offending environment and had discharged him from therapy prematurely. We then worked more diligently on his vocal image with the appropriate counseling, and the problem was successfully remediated. The successful voice clinician will ensure carryover of the improved vocal condition to all environments before

discharging the patient. Follow-up rechecks also are advisable to guarantee habituation of the vocal improvement.

The Clinical Ear Sometimes a clinician’s clinical training cannot account for all the skills necessary to conduct successful voice therapy. In some instances, natural talent plays a role. One of these skills is the musical “ear.” In a clinical study, we gave 30 speech-pathology graduate students pretreatment and posttreatment phonatory function tests, including acoustic and aerodynamic analyses. During the posttest, subjects were required to match pretest frequency levels. I was amazed at the number of students who could not readily match pitch. Empirically, the number exceeded 50%. Possession of a clinical-musical ear is necessary in voice therapy to recognize quality deviations and changes, to model inappropriate and appropriate voice productions, to recognize pitch deviations, and to work on pitch-matching exercises. The successful voice clinician must possess a clinical-musical ear.

Patient Realities Assuming adequate preparation of the voice clinician, failure to achieve success in voice therapy may be related to the patient. The patient must bring to the therapy process a level of cooperation necessary to permit change. Voice change and developing habits of good vocal hygiene are not always easy, and the process often is frustrating for the

patient. Several situations, described in the following sections, may occur that could lead to therapeutic failure.

Lack of Patient Motivation for Voice Therapy Any therapeutic change requires the individual to perceive that a problem exists and that the problem needs to be changed (decisional balance). The voice pathologist will determine the patient’s readiness to change. The next task is, through education and counseling, to induce the patient to have the incentive to follow through and adhere with the management suggestions. Many patients are motivated and require little encouragement to improve their voices. Some patients, however, are simply not interested in committing to voice therapy to achieve a change in their voice. Case Study: Patient FFF Patient FFF was a 56-year-old male insurance agent who had become dysphonic 4 months prior to the laryngeal examination. He sought the opinion of a physician only after much encouragement from his wife. Because of the publicity regarding hoarseness as a sign of cancer, this patient, a smoker, was frightened and delayed going to the doctor. Examination by the laryngologist revealed the presence of diffuse polypoid degeneration. When informed that he did not have cancer, patient FFF was obviously relieved. Patient FFF was referred to the voice center for laryngeal videostroboscopy, a phonatory function test, and a voice evaluation. During the interview, it became evident that the man no longer


was concerned about the hoarseness. Although he submitted to the voice evaluation, he did not perceive the need to improve his voice quality. He was satisfied that he did not have cancer and was not concerned that his current vocal condition was a sign of negative tissue change. Patient FFF did not seek further treatment. The voice clinician should always try to work with the patient to seek improvement of the voice, but, as illustrated, will not always be successful. Successful voice therapy depends on a patient who is ready to work toward positive vocal change through changing vocal behaviors.1

Resistance to Share Information Information gathered during the patient interview is valuable only if it is complete and accurate. The patient must be willing to share all pertinent information. Even the most skilled clinician has experienced situations in which, several sessions into therapy, a patient finally releases information critical to management decisions. Some patients are reticent to talk about personal or family problems that may be directly related to the voice disorder (such as tension, shouting, or crying). Certain behaviors such as drug use, smoking, and alcohol consumption are inaccurately reported. An eating disorder (such as bulimia) or an emotional problem requiring medication may not be mentioned. Successful voice therapy is dependent on an open and honest relationship between patient and clinician. The clinician must establish credibility and a positive, relaxed therapeutic atmosphere. The patient must be made aware of the

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importance of answering all questions honestly and accurately. Ultimately, the patient has final control over the information he or she is willing to share.

Perceived Need for Negative Vocal Behavior The young man previously described in this chapter as having a pseudoauthoritative voice perceived a need to produce a low-pitched voice with glottal fry phonation. He was resistant to vocal change, even though he was dysphonic and uncomfortable, and he maintained the inappropriate vocal symptoms in his work environment. He wanted to project a more mature image and chose voice modification as a means of accomplishing this task. The gospel-singing, vocally enthusiastic parishioner decided that her abusive vocal response to the pastor’s message was more important than her vocal health. Her Sunday response was a deeply religious experience that she chose not to modify, and as a result, she remained dysphonic. Over the years, I have had several patients who had another motive for maintaining negative vocal behaviors. I recall the case of a woman who, during the evaluation, exhibited body language signaling that she did not want to participate in the process. She refused to remove her coat, gave monosyllabic responses, and gave little effort to produce her “best” voice during testing. We learned later that she was seeking disability for a work-related injury (inhaling toxic fumes), and therefore it was in her best interest not to improve her negative vocal behavior. Voice therapy is composed of a series of choices by both the clinician

and the patient. One choice is to follow the management suggestions of the clinician. Successful voice therapy is dependent on the patient recognizing negative vocal behaviors and choosing the need to modify those behaviors. Need to Identify With the Problem Vocal image has a strong psychological influence on many people. Patients often find it difficult to modify even moderate to severe vocal disturbances because of the effect this change may have on their image. Individuals close to or related to the patient also may object to vocal change. For example: “Matthew has always sounded a little husky. We think it’s cute.” In this case, the parent so strongly identifies the voice problem with the child that cooperation for modification may prove difficult. Occasionally, patients may say something such as, “My husband likes my voice; he thinks it’s sexy,” or “I don’t want to change very much. I won’t sound like me,” or “But to me I’d sound like I’m shouting if I talk like that.” All of these comments are legitimate concerns to the owners of these voices. Our auditory feedback systems dictate to us what we are supposed to sound like. The feedback system may become accustomed to even the most dysphonic voice. Some patients become resistant to vocal change either because they like or approve of the dysphonic voice or because they dislike the new feedback they are receiving. Occasionally, this resistance is powerful enough to make the therapy program unsuccessful. Many voice disorders may be a symptom of emotional or psychological disorientation. In this circumstance, the need to maintain a voice problem may far outweigh the benefits of vocal

improvement. An obvious sign of emotional well-being is voice quality. Case Study: Patient GGG Patient GGG, a 38-year-old woman, was identified as having an “emotional dysphonia” (MTD) caused by a recent divorce and other serious family problems. As efforts were made to modify the problem, the patient continually sabotaged the proceedings. The sabotage came in the form of new ailments (“My chest hurts when I do these exercises”) or lists of rather bizarre questions (“Do you think this all started when the horse bit my ear?”) that monopolized much management time. At that moment in her life, this patient needed to sound ill. Family counseling was suggested, and voice therapy was postponed. Subsequent voice therapy was not needed because patient GGG’s vocal problem spontaneously cleared as her life’s problems resolved. Patients may feel the need to project poor voice quality as a means of subconsciously demonstrating emotional upheaval in their lives. Successful voice therapy is dependent on the patient’s willingness and ability to identify with a different, and, it is hoped, an improved voice quality. To accomplish this, the patient often must override the auditory feedback system and yield to a new vocal image.

Finances Unfortunately, a patient’s finances may play a role in the successful remediation of a voice disorder. As with all medically related services, the costs of providing vocal rehabilitation are rising. When prioritizing the use of funds,


some patients will find other areas for spending that they deem more important than voice therapy. When finances prove to be a factor in the patient’s decision to participate in therapy, the clinician must be willing to provide the patient with a reasonable estimation of the number of sessions, time frame, and cost of services. Third-party payors often support the cost of voice therapy services. Voice pathologists should learn as much as possible about funding services to assist patients in their decision to seek treatment. Successful voice therapy may be dependent on the patient’s willingness to assume financial responsibility for the services provided.

Personality Issues “He never met a person he didn’t like.” In a Pollyanna world, maybe this statement could be made, but I must admit, the statement does not apply to me. I have worked with a few patients with whom I had a difficult time appreciating their personalities. (To be blunt, I did not like them.) This being the case, I am sure some of these patients, and others, did not necessarily appreciate my personality and skills. Being a professional, however, I usually have been able to recognize the problem and to work through it, and the patients have successfully remediated their voice disturbances. Occasionally, when it becomes evident that a clinician and patient cannot work well together, modifications must be made. With some patients, I always felt that we were on different pages of the same book. We could not communicate well, and progress was not made. Successful voice therapy is dependent on excellent communication between

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clinician and patient. This may require constant adjustment in the mindset of the clinician from patient to patient. When personality conflicts arise and communication breaks down, they must be handled with frank discussion of the problem and with referral to another clinician reserved as an option.

Can All Voices Be Improved? Most voice disorders can be improved. Through the many management approaches now available, most vocal systems, and the personalities that own them, can be manipulated, modified, medicated, undergo surgical intervention, or a combination of these, to yield voice quality improvement. The level of improvement will range from dramatic to subtle, but improvement most often is possible. The patient must be given a realistic expectation of the level of improvement. With this information, informed decisions can be made regarding the advantages of various treatment approaches or whether to be treated at all. Some patients require dramatic change for the treatment to be considered worthwhile. Others relish subtle improvements that increase the effectiveness of their communication skills. The remainder of this chapter introduces the concepts of patient adherence and self-efficacy written by individuals who have studied successful voice therapy from theoretical and practical clinical perspectives. These cases will aid the clinician in understanding patient motivations for successfully completing treatment — or not.

In this next case, Amanda Gillespie introduces the reader to Bandura’s concept of self-efficacy, a well-understood principle that drives behavior change. Belief that one can change vocal behavior is paramount to successful voice therapy.

Case Study 1 Amanda I. Gillespie The Role of Self-Efficacy on Voice Therapy Adherence Self-efficacy is an individual’s personal belief in his or her ability to successfully execute a behavior.2 Self-efficacy is rooted in the social cognitive theory that people are capable of influencing their own actions by manipulating how they think about those actions. Self-efficacy is not self-esteem. Rather, self-efficacy is situation-specific and highly variable across tasks and behaviors. Self-efficacy can be altered in the following 4 ways. First, successful performance of a behavior predicts greater self-efficacy for that behavior (ie, mastery experience). Second, vicarious experiences — observing another individual with similar qualities successfully execute the desired behavior — can increase self-efficacy in the observer. Third, emotional states surrounding a behavior can change self-efficacy for that behavior. Finally, language used about an individual’s abilities to perform a behavior can influence self-efficacy for that behavior.2 Of significance for the health care provider is the role self-efficacy plays in adherence to health care directives.

Many factors influence adherence with health directives. These include patient perception of disease severity, patient education about the disease process, length of illness, socioeconomic circumstances, complexity of treatments, and clinician warmth.3 Self-efficacy is also a strong predictor of health-related behaviors. The 4 sources of self-efficacy described above can interact to play an influential role over the many internal and external patient factors that impact adherence. For example, a positive patient attitude and positive strong social support both improve adherence and can be influenced by mastery experience and the language used by care providers. Unfortunately, health care providers are unable to change many of these factors that combine to influence adherence. The health care provider cannot, for instance, change a patient’s socioeconomic status or social support. However, health care providers can affect some sources of self-efficacy. Specifically, the health care provider can manipulate self-efficacy by using positive language, which can, in turn, improve patient adherence with health care recommendations. Of particular importance, negative language weakens self-efficacy more easily than positive encouragement strengthens self-efficacy.2,4 This observation is especially critical for the voice care professional. When diagnosing voice problems, provider language has an influential role on the patient’s selfefficacy and can, in turn, affect adherence. Specifically, the terms vocal abuse and vocal misuse, often used to describe the origins of behavioral voice problems are emotionally charged terms with negative, judgmental associations.5 These words do not support a patient’s


beliefs in his or her ability to use his or her voice in a healthy way. When used to counsel patients about the cause of their dysphonia, these terms can actually reduce the increase in self-efficacy expected to occur with patient education.6 When compared to the more physiologically appropriate term phonotrauma, the words vocal abuse/misuse, negatively impact self-efficacy.5,6 The following case represents one in which clinician behavior influenced a patient’s self-efficacy and, in turn, adherence with voice therapy recommendations.

History of Present Illness Erin was a 21-year-old musical theater student at a prestigious university. She presented to the voice center with complaints of progressive dysphonia for 3 years, coinciding with the start of her university training. She self-referred from an outside facility where she had received 12 sessions of voice therapy and 6 stroboscopic examinations, all requiring large amounts of out-of-pocket payments as the provider’s office did not accept insurance. Social History Erin was an active college student pursuing a double major in theater and psychology. She performed in 3 to 4 theatrical productions per year, each requiring heavy voice use. She sang most weekends as part of a wedding band. She also worked part time as an event planner and promoter. This job required long hours on the phone and significant voice use in loud environments such as conferences, nightclubs, and sporting

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events. Erin was a self-described social butterfly. When she was not using her voice professionally, she was speaking with friends socially in restaurants and bars. She reported going out to eat 4 to 5 nights/week. Voice History Erin reported that singing had always been very easy for her. She began singing for weddings, family gatherings, and the national anthem at sporting events as a young child. She felt very blessed by her singing gift and was supported and encouraged to pursue a music career by her family and friends. She sang in soprano voice and had studied musical theater singing with 2 private teachers, as well as in many choirs. Erin had never experienced any dysphonia, even when singing sick, until 3 years ago. She reported she was told she was abusing her voice with her lifestyle, but that she did not understand why or how she could suddenly develop a problem if she had never experienced dysphonia in the past. Examination Erin underwent a videolaryngostrobo scopic evaluation by a laryngologist, and voice laboratory testing that included voice change stimulability assessment (ie, trial voice therapy) for appropriateness for voice therapy by a speechlanguage pathologist (SLP). Results of the laryngoscopic examination revealed that Erin had bilateral vocal fold lesions with reduced mucosal wave, more so on the left vocal fold than right; vocal fold gross motion, vibratory periodicity, and symmetry were normal; closure was hourglass. After voice laboratory testing, the SLP determined Erin’s current

speaking voice technique was stimulable for behavioral therapeutic intervention. Erin was hesitant about undergoing additional therapy; however, she admitted to not practicing her exercises prescribed by her last SLP, and she had not generalized any of the techniques to her everyday conversational speech. Erin reluctantly enrolled in voice therapy for an initial 4 sessions.

Voice Therapy Erin canceled her first voice therapy session 5 minutes before the session was to begin, citing a school commitment. Because a strong clinician-patient relationship can improve adherence,3,7 the following week, the treating SLP called Erin the day before her scheduled appointment to verify that she would be in attendance. Erin was surprised to hear from the SLP and confirmed she would come to therapy the next day, which she did. Sensing Erin’s reluctance to commit to voice therapy, the SLP used the first session as a way to probe Erin’s voice history and experience with voice therapy. Strong, positive clinician attention and engagement in the first session can improve adherence with future therapy. The SLP also wanted to improve Erin’s emotional state toward voice and voice therapy, a factor that influences self-efficacy. Erin reported that she was skeptical about the benefits of voice therapy. She said her past SLP had accused her of being vocally abusive, that her voice technique and chosen profession were to blame, and threatened that she would never recover vocal function if she did not change her personality. Erin stated that she was a loquacious, energetic person and wanted to be able to con-

tinue living as such, while maintaining a healthy voice. She said she felt embarrassed that she was the only one of her theater classmates with a voice problem, and she felt ashamed that her longpracticed technique and personality were apparently to blame. She described feelings of isolation, hopelessness, and intimated that she was crying a lot because of the loss of her voice. She also said she thought she needed to hide her ongoing vocal problems from her professors, who had threatened she would not be allowed to stay in the university’s program if she reduced her vocal load in her courses. She was experiencing guilt in asking her parents for money to pay for her voice care expenses, especially because her voice was not improving. The conversation then turned toward Erin’s adherence with her former SLP’s recommendations. Erin reported she was taking medicine for laryngopharyngeal reflux and had increased her water intake. However, she stated that she did not practice her voice exercises and did not have faith that therapy techniques could help her in daily life because the recommendations were incongruous with her vocal demands. Her past SLP had blamed her voice problem on her talkativeness and recommended she stop going out socially, perform less, and limit phone use. Erin thought the SLP did not seem to take her lifestyle into account in her treatment planning. In order to improve Erin’s sense of vicarious experience (one source of self-efficacy), the SLP told Erin about a patient she had successfully treated who had similarly high vocal demands. She reaffirmed that making voice change is difficult, but that it was possible to make small changes to Erin’s phonatory biomechanics without changing her personality. The SLP then explained the


cause of Erin’s voice problem using the term phonotrauma in place of the vocal abuse that Erin had heard previously, in attempt to use positive language to improve self- efficacy. The SLP talked at length with Erin about her vocal goals and expectations from treatment. She gave Erin written information about voice problems, as well as specific voice hygiene instructions tailored to Erin’s hygiene needs, instead of a one-sizefits-all hygiene approach.8 Erin left the session with a more optimistic outlook and promised to return for her second session the following week. The second session focused on improving Erin’s sense of mastery experience. First, the SLP congratulated Erin on her ability to adhere to voice hygiene recommendations. Then she began voice production exercises. To coordinate phonation with respiration, Erin was trained in slow, relaxed breathing with exhalations on voiced fricatives (/z, v/). These fricatives evolved to other resonant voice exercises. Resonant voice trains a focus on anterior vibrations sensed initially during production of nasal consonants to achieve easy voice production with optimum vocal fold vibratory behavior to improve voicing efficiency and reduce phonotrauma.9 Once Erin mastered resonant voice in simple words and phrases, the SLP transitioned the technique to conversation. While modeling the desired production, the SLP encouraged Erin to vocalize common phrases, generated by Erin, which she used on the phone at her event-planning job, using the healthy voice production techniques. After mastery of these phrases, Erin was instructed to use her job’s phone requirements as a specific daily occurrence for voice practice. Erin left the session with a CD recording of her voice therapy, as well as written

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instructions of all exercises and specific stimuli to help in home voice practice. Erin attended each of her additional 3 sessions of voice therapy as scheduled. The SLP frequently used negative practice — encouraging Erin to switch between her “old” phonotraumatic/ inefficient vocal behaviors, and “new” healthy voice techniques to improve Erin’s ability to self-correct if necessary during conversational speech in her daily life. The stimulus for each session was simulated occupational voice use. The SLP and Erin worked on loud vocalizations, appropriate phone voice techniques, as well as casual speech Erin would use with friends. After 5 sessions, Erin reported an improvement in not only her voice quality, but in her sense of control over her vocal abilities. It was recommended that Erin undergo singing voice therapy and a follow-up with her laryngologist.

Conclusion In the health care domain, self-efficacy and adherence are inextricably linked. Self-efficacy influences adherence, as the results of adherence (or nonadherence) influence self-efficacy. Due to the high drop-out rates with voice therapy as a whole, it is imperative that the voice care team investigate all potential sources of nonadherence.10 Self-efficacy, an individual’s belief that he or she can change a behavior, has a major impact on adherence. The 4 sources of selfefficacy — mastery experience, vicarious experience, emotional state, and language — can all be manipulated in the context of the voice therapy session, to improve self-efficacy and with it, adherence.

Erin’s poor adherence with past therapeutic advice was likely influenced by many factors. One factor was her sense of isolation among her vocal peers.11 Despite being in a high-risk occupation for voice problems,12 professional vocalists are less likely to seek voice care than help for other medical issues.11 The shame experienced by professional voice users may also prevent information sharing about what types of treatments and providers are available.11 In addition, the first SLP Erin visited may have harmed Erin’s self-efficacy for voice change through her use of negative terminology (vocal abuse). This language may have undermined Erin’s sense of vocal mastery by accusing her vocal behaviors and lifestyle as being the cause of her problems and insinuating they must be changed if Erin was to experience any vocal rehabilitation. This information was given without providing Erin vocal alternatives to her current phonotraumatic behaviors that would have allowed her to remain in her chosen career and supported her personality. These behaviors also influenced Erin’s sense of control, or loss of control, another factor that impacts adherence.13 Next, Erin had been struggling with dysphonia for years when she presented at the voice clinic. The longer an individual has an illness, the worse that individual’s locus of control, and the greater the chance for learned helplessness, both of which negatively impact self-efficacy and adherence.13 The voice center’s SLP improved Erin’s self-efficacy through the use of positive reinforcing language, sharing vicarious experiences, providing education about voice anatomy, physiology, and Erin’s specific disorder, including


Erin in the treatment goal-setting and decision-making processes, introducing transfer to conversational speech exercises early in the therapeutic sessions to improve mastery experience, and utilizing negative practice for spontaneous correction of vocal behaviors and assist in transfer.2,3,14,15 Because of these techniques, Erin’s self-efficacy improved, she was adherent with her SLP’s recommendations, and as a result, she experienced an improvement in voice quality. No matter the age of the patient, the use of smartphones and tablets has revolutionized the clinician’s ability to guide the patient in home practice, essentially “being there” with them during homework time. Eva van Leer is a pioneer in the use of apps to improve therapy adherence. In this next case, Eva demonstrates her research-based approach to improving therapy outcomes with the use of apps for patient support.

Case Study 2 Eva van Leer Using iPod Apps to Improve Voice Therapy Adherence Between Sessions: A SocialCognitive Approach As a voice clinician and clinical researcher in treatment adherence, I know 1 or 2 things, perhaps even 3, about patient adherence to voice therapy. First, voice therapy is a challenging behavioral intervention, and second, patient motivation is important. Third, strate-

gies can be devised to increase patients’ ability to overcome the trials of voice therapy. When these support strategies are successful, voice therapy is easier to adhere to and requires less patient motivation. Behavioral interventions are typically challenging, else the readers and contributors of this book would all be well rested, physically active, caught up with their research projects, and resistant to excess caffeine intake. But changing one’s speaking-voice mechanics or “technique” is a uniquely difficult behavioral task. First, moving from a poor habitual voice technique to an optimal target requires awareness. A patient must be able to identify the difference between the habitual and the target technique in order to independently monitor, implement, evaluate, and selfcorrect voice production. According to patients, this is not so easy.16 Patients in the clinic will often say “I can get the good voice here, but not by myself! Will you just come with me everywhere to keep me in my good voice?” Some patients speculate the trouble lies in the abstract nature of voice production. Targets such as “resonant” and “effortless” appear to be on a continuum with their suboptimal counterparts. One of my patients shared the analogy that learning to ride a bicycle is easier than learning to produce resonant voice: “You know when you’ve fallen off the bicycle, but not sure when you’re back in the wrong voice.” Even when patients are skilled in finding and maintaining the target voice technique independently, habitual voice production presents a maddening default attractor state.17 Substantial patient motivation is needed to reach automaticity of such goals as “80% accuracy producing resonant,

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non-hyperfunctional voice in connected speech across communication settings.” In order to conceptualize vocal behavior change and the strategies to support it, Bandura’s classic SocialCognitive Theory model of “triadic asymmetrical reciprocal causation” can be applied.18 In this model, a behavior such as voice production is influenced by a triad of factors: external influences such as vocal job demands and social life, social support for voice change, and clinician influence; internal beliefs such as confidence in the ability to change voice technique (ie, self-efficacy), trust in the therapist and treatment, and vocal self-concept; and behavioral factors such as habituation to shouting or using vocal fry. These factors reciprocally influence each other, in particular with each adherence attempt. When the patient succeeds in using the target voice technique between sessions, selfefficacy may increase, motivating future attempts to produce the target voice. Conversely, failures between sessions have a demoralizing effect. Mobile devices offer one way to externally support the patient between sessions. Although clinicians cannot follow patients around or consult with them remotely throughout the day, software applications on mobile devices can provide helpful feedback regarding voice production. We can conceptualize this feedback according to social-cognitive theory as an “external” factor that may improve voice production accuracy (ie, behavior) and boost self-efficacy (ie, internal belief) to independently find and use the target voice. Moreover, as posited by theories of self-regulation and motor learning, feedback is essential to self-regulated learning and behavior.17,19 Thus, the strategy of using mobile devices for patient feedback anytime,

anywhere, is theory driven in addition to being intuitive and practical. The following case provides an example.

History A 59-year-old retired female teacher presented with a 6-month history of vocal fatigue and laryngeal effort, unpredictable voice quality, reduced top range in singing, and difficulty being heard in loud environments. She had some hallmark complaints of laryngopharyngeal reflux (LPR) that included a globus sensation and frequent throat clearing. On initial voice evaluation, she had already completed a 2-month trial of proton pump inhibitors and reflux precautions recommended by our laryngologist that resulted in some reduction in globus and throat clearing but no appreciable vocal improvement. Voice production was reduced in loudness, laryngeal in tone-focus, mild to moderately rough in quality, and nearly consistently in fry. Her posture was characterized by neck extension combined with a furrowed brow that worsened when answering questions. As an actress in community theater, the patient was planning to audition for an avant-garde show of women’s monologues. However, she was having difficulty in conversational voice use, and her voice would likely not hold up on stage. Stroboscopic examination revealed mild bilateral vocal fold edema, a substantial posterior glottal gap, but no other overt abnormalities or lesions. Taken together, the signs and symptoms suggested a possible LPR-related change in voice use. The plan was to change voice production mechanics (including posture) in order to improve voice quality, loudness, and resilience while continuing treatment for LPR.

During the first 3 sessions the patient attained resonant, forward-focused voice through a variety of voice therapy approaches. It was easy to elicit resonant voice in this patient. For example, by initiating speech at a higher than habitual lung volume, she produced resonant h-initial sentences (eg, “Hey! How are you!”) that did not feel laryngeally effortful to the patient. Likewise, accent method strategies such as pulsed “v” sirens followed by v-initial words and phrases also resulted in normal, resonant voice. Loud humming followed by m-initial phrases (“My oh my oh my! Maybe Monday morning!”) worked as well. However, no matter how successful the strategy, the patient was unsure of her ability to differen tiate her habitual from her resonant target voice production, and of her ability to replicate resonant voice outside of the clinic. She typically commented, “Was that better?” and responded to the answer, “Really?” After discussing this during the third session, she realized that her default mindset across life situations was to doubt her own judgment, minimize her achievements, and “over think.” Interestingly, when it came to voice production, the less she furrowed her brow and tried, the better was her voice. After auditioning the patient got a part in the avant-garde play. When I asked her to demonstrate her “stage voice,” the result was surprisingly good. With some minor feedback, she produced a very loud, projected, effortless stage voice. Yet when told that this was spot on, she extended her head, furrowed her brow, and questioned, “really?” We decided together that the primary goal of therapy was to boost her independent analysis of her voice production technique and to switch to the


resonant, nonhyperfunctional voice reliably. To wean her off my judgment and support her between sessions, we found 2 feedback forms to use: one was an interactive real-time frequency spectrum software application, “Analyzer pro” (Dexus), and the other was a piano keyboard application “Pianist” (MooCowMusic Ltd). During her treatment sessions, the patient was impressed to see the visible increase in energy between approximately 2900 and 4300 Hz on the spectral display of the Analyzer Pro application when she moved from her habitual to her target voice production technique in sustained phonation, syllable repetition, and phrases. This made the change more concrete to her. The greatest energy increase was noted when she “tuned” her voice to around middle C as mean fundamental frequency. Although I am not a proponent of optimum pitch approaches, the strategy of chanting phrases on middle C worked for the patient as a starting point for her to find her resonant voice. Both the visual frequency spectrum display and the piano application became the concrete feedback and support mechanisms to find, maintain, and self-correct the target voice production technique between sessions. The patient borrowed an iPod Touch from the clinic for 1 week with the apps, because she did not own a smartphone. After this session, therapy took a new and positive turn. One week later the patient returned able to replicate her target voice with minimal instruction from me. She reported practicing with the interactive spectral display and intermittently playing the middle C throughout the day to check her pitch when she felt particularly resonant, consistently finding this center frequency to be her vocal sweet spot in speaking.

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After another week she no longer needed the interactive app and returned the iPod. Our remaining sessions were spent creating ways to produce resonant voice for a variety of communication tasks, strategizing ways to maintain resonant voice in emotionally challenging situations, and practicing “linking” (ie, avoiding hard onsets) in the monologues for her play. Her furrowed-browneck-extension behavior was replaced with an increasingly confident smile. Recently, the patient texted me that her singing voice is returning. Follow-up with stroboscopy is planned this week. I expect reduced posterior glottal gap on the transnasal exam and reduced vocal fold edema on the rigid exam. However, the behavioral outcomes — resonant voice, resolution of vocal fatigue, and return to social, theatrical, and singing activities — are the primary outcomes in this case.

Epilogue As noted by Dr. Bandura, an intricate and inaccurate relationship exists between individuals’ potential to learn a skill and their self-perceived ability to do so.18,20,21 When we do not believe we are capable of achieving a learning goal, we will either not pursue it, or fail to do so effectively. When we believe we can achieve the goal, we continue to pursue it even in the face of failure, in turn increasing our chances to actually achieve it. Although an occasional patient cannot learn to alter his or her voice production mechanics no matter the approach, almost all of my patients can. However, they have highly variable skills and beliefs in their ability to do so, to do so independently, and to do so

consistently across a variety of challenging situations. Fortunately, as clinicians, we do not entirely depend on patients’ early beliefs about their ability to produce a target voice. Rather, we can help patients modify these limiting beliefs through various strategies, so that they will encounter fewer failures between sessions, persevere in the face of remaining obstacles, and ultimately succeed in achieving their voice therapy goals. In this clinical case, the patient’s ability to produce resonant voice was much greater than she realized, but her self-doubt and limited self-evaluation skills were a barrier to progress. By adding concrete mobile voice feedback and checking strategies to therapy between sessions, she received consistent and unequivocal evidence of her own skill, and, when encountering failure, straightforward feedback to right her voice production. This resulted in voice use successes outside of the clinic, where it matters. I did not quantitatively track her self-efficacy for resonant voice use formally as can be done easily with a Readiness Ruler.1,22,23 However, her confidence to produce resonant voice independently, clearly inadequate at the onset of therapy, grew after developing an effective support strategy. Using a mobile device to provide feedback was particularly useful to this patient because it was always available across communication settings. Furthermore, this affordable mobile strategy supplemented traditional voice therapy without alteration in the treatment approach. Given the mobile and “mHealth” revolution of today, more mobile tools will become available for our patients that can be applied in creative, effective, theory-driven ways, for optimal vocal outcomes.


No matter the access, it is clear that the “wired” revolution has improved patient adherence to therapy. It may feel that the entire world is attached to an iPod or iPhone, but there are those who are Android friendly or need to use the Internet in a wired home computer to access applications to assist in home practice. In this next case, Bryn Olson and Carissa Portone-Maira continue the use of apps in therapy to improve patient adherence by using Androidbased applications and ones that can be used on a home desktop computer.

Case Study 3 Bryn Olson and Carissa Portone-Maira There’s an App for That: Use of Portable Electronic Software Applications to Facilitate Home Practice of Voice Exercises in a Lawyer With Vocal Fold Nodules

Case History A 37-year-old attorney presented with a 10-month history of gradually worsening dysphonia characterized by rough, strained vocal quality, difficulty projecting her voice, and vocal fatigue. Symptoms progressively worsened during the course of the day. Additional complaints included frequent coughing and throat clearing, intermittent sore throat, and intermittent globus. The patient reported onset of symptoms following an upper respiratory infection that corresponded with a 2-day deposition in which she stated that she “had to talk a

lot and push through the hoarseness.” She stated that she was prescribed a course of steroids by her primary care physician shortly after onset of dysphonia and that she subsequently noted mild improvement in vocal quality. The patient denied a history of acid reflux; however, she did report an increase in throat clearing and globus associated with consumption of spicy or fatty foods. She reported minimal water intake, stating that her primary hydration consisted of 4 to 6 coffees and 1 to 2 caffeinated colas per day. She reported an 18-pack/year smoking history but stated that she quit smoking 2 years prior to the date of her initial evaluation. She denied dysphagia or shortness of breath. Past medical history was otherwise unremarkable as it pertained to the patient’s complaints. The patient reported significant daily voice use both at work and in her personal life. She stated that her position as an attorney involved heavy vocal demands, including frequent telephone use. She also reported significant telephone use in her personal life. She reported frequent meetings and social gatherings in loud, busy restaurants. She described herself, her husband, and her 2 elementary-aged children as “very loud, social, fast-talking people.”

Voice Evaluation Audio-Perceptual The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), a validated tool for auditory-perceptual assessment,24,25 was performed by an experienced voice clinician. The CAPE-V is a visual analog scale used to assess

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overall severity of voice quality and to quantify aberrant perceptual features identified in the voice. The anchors for the scale are 0 = normal voice and 100 = most impaired. The patient’s vocal quality was noted to be moderately aberrant overall (31/100) with moderate roughness (29/100), mild breathiness (13/100), moderate strain (31/100), and mild-moderate instability (23/100). Overall vocal intensity was noted to be mildly increased. Overall vocal pitch was noted to be reduced. Resonance was noted to be laryngeal/pharyngeal in quality. Respiration appeared to be primarily thoracic. There was evidence of breath holding (released breath at the end of utterances, and particularly after sustained vowels).

Figure 8–1. Pretreatment still image demonstrating bilateral vocal fold nodules.

Visual Imaging Multidisciplinary assessment included performance of transoral videolaryngostroboscopy using a rigid, 70-degree endoscope. The true vocal folds were noted to be diffusely erythematous. Additionally, smooth, pliable lesions were observed at the anterior two-thirds commissure, resulting in hourglass glottal closure at modal pitch. There was no evidence of paralysis or paresis. Vibratory amplitude and mucosal wave were grossly within normal limits. Vibration was predominantly periodic; however, intermittent aperiodicity was noted at phonation onset. Phase symmetry was normal. Thickened secretions, postcricoid edema, and interarytenoid pachydermia were consistent with possible laryngopharyngeal reflux (LPR). The referring otolaryngologist diagnosed bilateral true vocal fold nodules and possible underlying LPR (Figures 8–1 and 8–2). The patient was subsequently prescribed a proton-pump inhibitor and

Figure 8–2. Pretreatment still image demonstrating bilateral vocal fold nodules.

was referred to the speech-language pathologist for voice therapy. Acoustics Analysis Laryngeal function studies were completed utilizing the Kay Elemetrics Computerized Speech Lab with Multi dimensional Voice Profile (MDVP) program and Real-Time Pitch analysis. A headset microphone was placed at a 45-degree angle at 2 cm from the mouth for data acquisition. Acoustic analysis

revealed the patient’s speaking fundamental frequency to be slightly low at 191 Hz (norm: 200 to 250 Hz). Maximum phonation time on sustained /a/ was 9.6 seconds. The patient’s physiological pitch range was 122 to 569 Hz, restricted in high pitch. Loudness instability was evidenced by a peak-to-peak amplitude variation (vAm) of 17.067% and intensity perturbation (shimmer) of 4.5% (norm: less than 3.810%). Pitch instability was evidenced by a fundamental frequency variation of 1.27% (vF0) and pitch perturbation (jitter) of 2.8% (norm: less than 1.040%). These findings were grossly consistent with perceptual ratings of vocal roughness, breathiness, and instability.


of life (QOL). The patient rated 30 statements involving functional, physical, and emotional aspects of her dysphonia. The total score on this measure was 64/120, which suggested a significant level of impairment in voice-related QOL (physical: 33/40; emotional: 15/40; functional: 16/40). These results suggested that issues within the physical domain had the greatest impact on voice-related quality of life. The Reflux Symptom Index (RSI)27 was administered to assess perception of 10 statements related to LPR. The patient’s total score was 24/45, above the threshold of 13. This was consistent with the physician’s diagnosis of possible LPR and suggestive of a possible contribution of LPR to the patient’s throat symptoms.

Aerodynamic Assessment Aerodynamic assessment was conducted using the KayPENTAX Phonatory Aerodynamic System (PAS). Vital capacity was normal at 3.28 L [3.01 L, standard deviation (SD): 0.7]. Mean flow rate on sustained vowel /a/ was high, at 0.21 L/s (norms: 0.1 L/s, SD: 0.07), indicative of glottic incompetence. Phonation threshold pressure (PTP) measurements were also recorded at modal pitch. PTP is the minimum subglottal pressure required to initiate voicing and is an indication of ease of voice onset. PTP averaged 9.76 cm H2O, indicating high subglottal pressure, or increased effort, required to produce voice. Patient Self-Report Measures The patient rated herself a 9 out of 10 for talkativeness and 8 out of 10 for loudness. Two short, validated questionnaires were completed by the patient. The Voice Handicap Index (VHI)26 assessed perception of voice-related quality

Voice Therapy Following comprehensive, interdisciplinary evaluation and gathering of a thorough case history, the clinician designed a therapy program consisting of vocal hygiene education and direct facilitation through use of Vocal Function Exercises28 and techniques intended to facilitate resonant voice production. Though research suggests that direct voice treatment is more effective than vocal hygiene education alone,29 the use of vocal hygiene education as an adjunct to direct therapy may reduce behaviors underlying the development of the voice disorder and help to ensure maintenance of healthy vocal fold tissue in the future.30 The patient underwent a total of 6 voice therapy sessions over the course of 2 months. Therapeutic goals included reducing patient-perceived vocal roughness, strain, and fatigue in vocal tasks at home and in the workplace, reducing

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coughing and throat-clearing behaviors, and improving vocal hygiene. In the initial therapy session, principles of voice hygiene were discussed with the patient. Dietary and behavioral modifications for acid reflux were encouraged, including eating small meals more frequently throughout the day, avoiding lying down for 3 hours after eating, avoiding wearing tight-fitting clothing, elevating the head of the bed, and limiting consumption of foods that promote reflux. Spicy foods and caffeine consumption were identified as the primary refluxogenic components of the patient’s diet; thus, the patient was encouraged to target reduction of these foods. Behavioral strategies to reduce coughing and throat clearing, including taking a sip of water, performing a hard swallow, and performing a “silent cough”31 were introduced. The patient was encouraged to involve her husband and her children in her endeavor to reduce coughing and throat clearing so as to facilitate increased awareness of these behaviors in the initial stages of therapy. Numerous studies suggest that adequate hydration can reduce phonatory effort and increase vocal endurance.32,33 As such, vocal hygiene education emphasized the importance of improving systemic hydration by reducing intake of caffeinated beverages and increasing water intake. During the discussion about adequate hydration, the patient stated that she “likes water” but that she “has trouble remembering to drink it during the day.” To facilitate an increase in water intake, use of a drinking water application for the patient’s smartphone was initiated. The patient downloaded a free drinking water application (Water Your Body for Android), which allowed her to set and track her target number of glasses of drinking water per day. The

application also issued periodic reminders to drink water throughout the day. By the final therapy session, the patient reported that she was “consistently drinking the target number of glasses almost every day.” As phonotrauma is widely considered a contributing factor in the development of vocal fold nodules,34 reduction of potentially phonotraumatic voice behaviors including yelling and screaming was included in the discussion of vocal hygiene. The patient expressed concern about her ability to reduce these voice behaviors because of her need to project over the noise of her “hectic office, loud social-environments, and boisterous family.” The patient and clinician outlined a number of strategies to reduce vocal demands in these situations, including increasing proximity to the communication partner to reduce the need to project over background noise, increasing use of alternative modes of communication such as e-mail and text messaging, consistent use of the available amplification system in the office boardroom during large meetings, and use of nonverbal communication such as gesturing, whistling, or clapping. Additionally, the patient downloaded a free “air horn” application (Air Horn! for Android) on her smartphone to use as an alternative to vocal cheering at sporting events. At subsequent sessions, the patient reported implementing use of the air horn to alert her children that it was time to leave for school and to beckon them to the table for dinner in the evening. She stated that the family “turned it (the air horn) into a game” and that the app served as an “entertaining and effective alternative to screaming at the kids.” At the initial voice therapy session, Vocal Function Exercises (VFEs) were

introduced. VFEs consist of a warm-up on a maximally sustained /i/ (F above middle C for women, F below middle C for men), ascending pitch glide on the word “knoll,” descending pitch glide on the word “knoll,” and maximally sustained musical notes C-D-E-F-G on the word knoll minus the “kn.” VFEs are intended to be performed twice daily with 2 repetitions of each exercise. The exercises should be performed as softly as possible with forward-focused tone. VFEs are intended to rebalance the voice-production subsystems, namely respiration, phonation, and resonance.29 This is thought to “improve the strength, endurance, and flexibility” of the aforementioned subsystems and protect against the “negative vocal effects of extended voice use”).29 To facilitate home practice of VFEs, the patient downloaded a pitch application (GStrings for Android). The application provided real-time pitch assessment with feedback in musical notes and hertz (Hz), which helped the patient to maintain her target pitch during maximally sustained vowel tasks. Additionally, the application enabled the patient to monitor her maximum and minimum pitch on the pitch glide tasks. When pitch glides were initially introduced, the patient demonstrated difficulty accessing her low pitch range on a descending glide. With the visual feedback provided by the pitch-tracking application, she was able to successfully and consistently access her full pitch range on both the ascending and descending pitch glide tasks. She also reported a “sense of accomplishment” as her pitch range improved over time and stated that this feedback provided “motivation to keep practicing.” Direct therapy included facilitation of resonant voice production using tech-


niques based on the Lessac-Madsen Resonant Voice Therapy program (LMRVT). Therapy was conducted by a clinician who underwent a 2-day LMRVT training course. The goal of resonant voice therapy is to elicit and maintain easy phonation that creates anterior oral vibrations. Biomechanically, this achieves a glottal closure pattern that is barely adducted/abducted, optimizes output intensity, and minimizes vocal fold impact.35 A variety of semi-occluded vocal tract exercises were introduced in the initial voice therapy session to establish resonant phonation. The patient was most successful with a lip trill and humming. Initially, she performed multiple repetitions of the semi-occluded vocal tract exercises in isolation, focusing on maintaining a sensation of relaxation in her throat and consistent anterior vibrations. As she gained confidence and consistency with resonant voice production, practice progressed to the single word level, phrase level, and conversational speech level. At subsequent therapy sessions, variable practice was performed at each of the aforementioned speech hierarchy levels. To facilitate home practice of the resonant voice therapy exercises, the patient downloaded a free video application (Vimeo for Android) and a free audio-recording application (Easy Voice Recorder for Android). She used these applications in a variety of ways — to supplement written instructions and to help monitor her progress. At the end of each session, the patient and clinician reviewed the important exercises and cues used during the course of the session, and the patient used the Vimeo application to video record herself successfully modeling each exercise. The video application allowed the patient to log in and access her videos from any

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device with Internet access, enabling her to practice in a variety of locations. She used the Easy Voice Recorder to take note of observations she made and questions or concerns she encountered during home practice. She also made periodic video and audio recordings of herself practicing her voice exercises at home. Before each therapy session, the patient and the clinician reviewed and discussed the recorded notes and videos the patient had compiled over the preceding week. The patient reported that the video and audio recordings helped her to feel confident when practicing her voice exercises independently and allowed her to “easily keep track of things that worked and didn’t work” during her at-home practice and voice use in her everyday life. She stated that it was “motivating to go back and listen to early voice recordings to hear how (her voice) improved over time.”

Patient Self-Assessment The Voice Handicap Index (VHI) was administered at the end of the final therapy session. The total score was reduced 42 points to 20/120, which suggested a minimal level of impairment in voice-related QOL (physical: 12/40; emotional: 3/40; functional: 5/40). An 18-point change in total score is considered significant26; thus, the patient’s 22-point reduction in total score demonstrates a significant improvement in psychosocial function as it pertains to voice. Anecdotally, the patient reported significant improvement in her vocal quality, citing reduced vocal roughness, strain, and fatigue. She noted a significant reduction in coughing and throatclearing behaviors and a resolution of globus. She expressed significantly increased awareness of patterns of voice use in all domains of her life and stated that she was “no longer negatively affected” by the quality of her voice at work or in her personal life.

Therapy Outcomes Audio-Perceptual The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was performed at the final therapy session. The patient’s vocal quality was noted to be mildly aberrant overall (12/100) with mild roughness (16/100), no breathiness (0/100), and mild strain (7/100). Pitch appeared grossly within normal limits (0/100), as did vocal loudness (0/100). Resonance was judged to be within normal limits, and breath support was adequate during conversational speech. This demonstrated an obvious perceptual improvement compared to pretreatment values.

Summary and Concluding Remarks As portable technologies such as smartphones, tablets, and MP3 players become a larger presence in daily life, voice therapy patients have access to an ever-expanding pool of engaging, innovative, and inexpensive therapeutic tools. There are myriad uses for smartphone and tablet applications (apps) in the therapy room: apps can provide audio or visual biofeedback, monitor success in home practice, improve therapy adherence, and simply make therapy more fun and engaging. An addendum of apps the authors have


found useful in their clinical practice is attached for the reader’s reference (Appendix 8–A). Speech-language pathologists often feel it is their responsibility to “make” the patient adherent to therapy, but the literature teaches us that people must take responsibility for their own behavior change. In this next case, Carissa Portone-Maira shows us that transferring the responsibility for behavior change to the patient is important, and that often the threat of “firing” the patient from therapy because of nonadherence may be a good solution to encouraging the patient to take responsibility for his or her own behavior change.

Case Study 4 Carissa Portone-Maira Threat of Being Fired From Therapy Improved a Vocal Overdoer’s Adherence

Case History Patient X was a healthy 39-year-old male with a past medical history of environmental allergies. He took 2 different antihistamines for allergy relief. He did not smoke or consume alcohol. Patient X had longstanding vocal complaints. He stated that 10 years ago, he woke one morning suddenly unable to sing in his high range. He reported that he was evaluated by a local otolaryngologist, diagnosed with vocal fold nodules, and underwent surgical excision, which he stated did not change his voice for the

better or the worse. The patient reported the next treatment for his voice was several years later, when another otolaryngologist treated him with “a shot in [his] hip,” which reportedly improved his voice for 1 week. Patient X did not know what was in the shot. He went on to state that 4 years ago, a third otolaryngologist diagnosed him with reflux and prescribed Nexium, which he did not take due to the expensive co-pays. Patient X’s voice use requirements at work consisted of minimal demands. He ran a machine at a soft drink bottling plant and only rarely had to speak at work. However, when comparing his vocal quality singing in the car before work to after work, he noticed a significant worsening. Outside of work, patient X was a gospel and smooth R&B singer. He preached most Sundays in addition to singing. He never warmed up or cooled down his voice. There was no history of formal singing training. He considered hoarseness after singing or preaching to be a normal consequence of the activity. He was frustrated by his inability to sing the high falsetto notes he used to reach easily. Although his speaking voice was rough, that was not bothersome to him.

Voice Evaluation Patient X was evaluated in a multidisciplinary voice clinic. Instrumental assessment included rigid videostroboscopy to closely evaluate the patient’s laryngeal biomechanics and vocal fold oscillation. He was noted to have a hemorrhage overlying a possible right vocal fold lesion. Mucosal wave on the right was impaired overall due to the extensive hemorrhage. The left vocal fold

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was significantly scarred at the anterior one-third, leading to a focal disruption of mucosal wave. There was also erythema and edema of the arytenoids and postcricoid mucosa. In an attempt to decrease the overlying edema and better diagnose the underlying mucosal abnormality, patient X was started on a Medrol Dosepak and complete voice rest for 1 week. When he returned for reevaluation by the physician 1 week later, the hemorrhage had improved, and a large varix on the superior surface of the right true vocal fold was revealed. The varix led to an area of pooled blood (ectasia) in the midmuscular membranous true vocal fold. During phonation, the right vocal fold lesion prematurely contacted the opposite side, resulting in incomplete glottic closure with an hourglass configuration. The patient was scheduled for suspension microlaryngoscopy in order to examine the vocal folds under anesthesia; treatment of the varices with potassium-titanyl-phosphate (KTP) laser was also planned to take place during the procedure. Saline infusions as well as possible steroid infusions would be considered, depending on the findings during direct laryngoscopy.

well as additional postoperative guidelines (avoidance of throat clearing, coughing, drying agents, and intense physical exertion; maintenance of excellent topical and systemic hydration). He was scheduled for a 1-week follow-up in a multidisciplinary clinic.

Surgery

Laryngeal Imaging

During surgery, a very deep sulcus was identified. The laryngologist attempted to release the tethered epithelium from the vocal ligament with a saline infusion, which was not successful. At this point, the scar was excised. A KTP laser was used as planned to ablate the right true vocal fold varix that was causing hemorrhage and scarring. The patient was provided paperwork instructing him in 1 week of complete voice rest as

Laryngeal imaging showed resolution of the right true vocal fold hemorrhage. During phonation there was good glottic approximation at lower frequencies. As he approached mid and high frequencies, the protuberance on the right true vocal fold (previously identified as an ectasia) continued to contact the opposite side prematurely, resulting in an hourglass configuration. However, the area was softer and more pliable

Voice Evaluation — Postoperative The patient returned to clinic 3 weeks after surgery without having followed up to be returned to voice use in a gradual manner. He stated that he had communicated by whispering while on voice rest. He had not read the paperwork provided regarding postoperative guidelines. Since taking himself off voice rest, he noticed some improvement in his hoarseness and started to sing again. He felt that his upper register had improved, and he had regained approximately 50% of his preoperatively lost notes. He continued to complain of increased effort to sing in his high range, reduced endurance, hoarseness, and effortful phonation. He was instructed by the physician to hold off on singing until undergoing several sessions of rehabilitative voice therapy.

than preoperatively, because it was no longer filled with blood. This allowed for better oscillation and vibration and accounted for the patient’s report of moderate vocal improvement. Audio-Perceptual Assessment The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), a 100mm visual analog scale, was utilized to assess overall severity of voice quality and to quantify aberrant perceptual features identified in the voice.24 The anchors for the scale are 0 = normal voice and 100 = most impaired. The overall score was 29/100, indicating mild-to-moderate vocal quality deficits. Aberrant perceptual features identified in the voice included breathiness, roughness, and strain. Overall vocal intensity was noted to be reduced. Overall vocal pitch was noted to be normal. Resonance was noted to be laryngeal/pharyngeal in quality. Respiration appeared to be primarily thoracic, with breath holding noted. Acoustics Phonatory stability and range were assessed with the KayPENTAX Multidimensional Voice Profile (MDVP), RealTime Pitch, and Analysis of Dysphonia in Speech and Voice (ADSV) programs. A headset microphone was placed at a 45-degree angle at 2 cm from the mouth for data acquisition. Cycle-to-cycle pitch instability (jitter) on sustained vowel was elevated at 2.51% (norm: less than 1.040%), as was cycle-to-cycle loudness instability (shimmer), at 8.79% (norm: less than 3.810%). Pitch range of 88 to 350 Hz was limited on the high end (norm: 90 to 550 Hz), and there was a


prominent phonation break around 200 Hz with significant muscular tension engaged to reach pitches above this level. Cepstral analysis with the ADSV program was completed on sustained vowel /a/ due to the aperiodic signal and therefore unreliable perturbation measures. Mean cepstral peak prominence (CPP) was 5.200 dB (norm: 13.03 dB, SD 1.68). The SD of CPP was 16.694 dB (norm: 0.63 dB, SD 0.24). These values indicate significantly disturbed periodicity and reduced steadiness/ consistency during sustained voicing.36 The cepstral/spectral index of dysphonia (CSID), an estimate of dysphonia severity, was 69.661 (higher values reflect increased severity; norm: 3.58, SD 10.37). Aerodynamics Maximum phonation time (MPT) on /a/ was decreased at 12.4 seconds. The patient’s self-rating of effort on this task was 5.5/10. With a trial of abdominal respiratory support, MPT on /a/ was 17.3 seconds with effort rating of 3/10. Instrumental aerodynamic assessment was conducted with the KayPENTAX Phonatory Aerodynamic System (PAS). Vital capacity was within the normal range at 4.6 L (norm: 3.53 L, SD 1.36). Mean flow rate on sustained vowel was on the low end of normal at 0.06 L/s (norm: 0.14 L/s, SD 0.08). Mean peak air pressure was high at 9.47 cm H2O (norm: 6.08 cm H2O, SD 1.65), indicative of increased phonatory effort at modal pitch/normal loudness. Estimated phonation threshold pressure, the minimal lung volume required to produce phonation, was high at 8.73 cm H2O (norm 4.79 cm H2O), indicating increased subglottic effort required to initiate phonation at minimal loudness.37

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Patient Self-Assessment Patient self-perception: The patient rated the quality of his voice as a 5/7. At best he would rate it 6/7. At worst, it would be rated 4/7. Worst quality occurred after extended singing. The Voice-Related Quality of Life Measure (V-RQOL)38 was administered to assess the impact of the patient’s voice disorder on quality of life (QOL). His raw score of 15/50 indicated a mild impact on QOL but did not reflect the impact of his singing voice disturbance on QOL. Therefore, the Singing Voice Handicap Index-10 (SVHI-10), a 10-question singing-specific QOL questionnaire, was administered. Patient X scored 37/40, indicating a severe impact of singing voice difficulties on QOL.39

Voice Therapy Specific type(s) of therapy and rationale: 1. Evidenced by repeated vocal fold surgeries, patient X clearly required vocal hygiene education regarding vocal dose and vocal efficiency as well as vocal exercises to reduce risk of recurrent vocal fold hemorrhage and need for repeated surgeries. Improved vocal hygiene practices were introduced in the evaluation session, specifically elimination of throat clearing and improved systemic and topical hydration. Due to voice degrading during the workday despite minimal voice use, further investigation was warranted. Patient X reported lifting heavy containers at work. He was trained in using abdominal breath support and continuous exhalation to prevent Valsalva (ie, glottic pressure)

during lifting. The laryngologist wrote a script for an abdominal/ back support device to use at work to help patient X focus on using core muscles to lift the boxes and break the habit of breath holding and grunting. 2. Postoperative vocal fold pliability exercises were initiated in the evaluation session on sustained tones as well as ascending and descending pitch glides over gradually increasing pitch range. At the evaluation session, voiceless and voiced lip trills were utilized. In later sessions, other semi-occluded sounds were introduced. Initially there was strain at 200 Hz and above, but after multiple sessions of voice therapy, he was able to produce a glide through a range of motion up to 600 Hz without strain. Particularly helpful cues were increasing oropharyngeal space by lifting the velum (“yawn” while phonating) and visualizing the voice filling the space behind the eyes. Over the course of therapy, messa di voce exercises (sustained tones held while gradually increasing then decreasing loudness) were ultimately introduced in order to train patient X in increasing loudness without increasing vocal fold trauma. 3. Abdominal breath support was trained in order to improve efficiency of voice use during speech and singing. This training was initiated during vocal fold exercises using semi-occluded vocal tract sounds: lip trills, phonation into a straw, /v/, kazoo buzz, humming, and /ng/,40 and ultimately the skills were advanced into speech and singing. 4. Resonant voicing techniques were shown to maintain a minimally


adducted/partially abducted vocal fold posture during phonation. 9 This technique was also initially trained in the context of vocal pliability exercises and was later advanced into gradually more challenging tasks (words, phrases, conversation, songs, and preaching/ loud voice use). Therapy Goals and Expected Outcomes n Long-term goal was to return to

preaching and participation in singing at church without subsequent hoarseness n Short-term goals were to decrease effort in phonation, improve vocal endurance, and increase pitch range n Frequency and duration of treatment: therapy was planned for 4 sessions, over 60 days. Actual Course of Therapy Between the evaluation and the first therapy visit, patient X practiced his vocal exercises only once daily (3 to 5 times per day had been recommended). Without being cleared to sing, he sang at church and performed 5 songs. Per his report, his vocal quality was good during the service. That afternoon, however, he drank only 2 cups of water, slept only 2 hours, and ate just before going to sleep. He woke with a significant change in his voice. Due to his history of recurrent bleeds, videostroboscopy was performed in lieu of therapeutic exercises that visit. The laryngologist reviewed the examination and diagnosed a new small left vocal fold hemorrhage and acute edema. The patient was placed on strict voice rest and was to follow up with the physician in 1 week.

Due to the findings and voice rest restrictions, the remainder of the therapy session that day was devoted to voiceless tasks. Previously provided vocal hygiene instruction was again reinforced. The previously trained breathing techniques for vocally safe lifting practices were practiced by lifting and stacking chairs in the therapy room while monitoring steady breath flow out during exertion and in during rest. Abdominal breathing was practiced during voiceless sounds (/s/, /S/, and voiceless lip trills). Patient X was encouraged to continue these voiceless exercises 3 times daily while on voice rest and to resume vocal exercises when cleared to return to voice use. Given his immediate postoperative communication patterns, the fact that whispering is not permitted while on voice rest was underscored, and nonverbal communication methods were discussed in detail. Patient X was provided with a clip-on button to wear on his clothing that informed the viewer that he was on voice rest and could not speak. He was encouraged to carry pen and paper at all times for written communication. A free text-to-speech app (iSpeech) for his iPhone was downloaded, and its use was demonstrated. The patient did not return for his first full therapy visit until 1 month later. He had been cleared for voice use by the physician 2 weeks prior but had trouble getting an appointment to fit into his schedule. He apologized for being 20 minutes late for the appointment and blamed traffic. Because the clinician had a cancellation just after his appointment, he was seen for a full hour despite being late. Patient X reported that since he was last seen, he had implemented vocal hygiene recommendations and had returned to

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the once-daily practice of postoperative vocal exercises. His endurance was improving, so he decided to try singing. He sang 4 to 5 songs at church before having to stop due to vocal strain, but he did not attempt to preach. His voice no longer degraded during the workday, attributable to exhaling while lifting crates, as we had practiced. However, he continued to complain of loss of high range and reduced endurance for his personal (likely unrealistic) goal to be able to preach loudly and perform 10 songs (solo and background) within the same service. After practicing techniques again, he was cleared to return to singing with the understanding that he should stop when his vocal effort increased and prior to developing hoarseness. A “voice nap” strategy was developed where he would sing 1 to 2 songs and then sit out the next song to slowly build his endurance. This strategy was later reported to be effective in enabling him to sing 7 or 8 songs during a service. The next few visits were sporadic (1 to 2 per month) due to patient cancellations. When he did come for sessions, patient X arrived 30 to 45 minutes late for his appointments. He was always apologetic for his lateness, always had an excuse, and always made progress in his therapy, despite the brief visits and long duration between sessions. After the second late arrival, only the remaining visit time was used in hopes of curbing his growing tendency to arrive late. He consistently demonstrated incorrect home practice patterns (focusing on counterproductive techniques not trained in therapy, such as “speaking low,” “barely moving the lips while singing,” and forcefully pushing and holding the abdomen outward while singing). The clinician felt pressure to correct his inaccurate practice

and attempt to advance exercises and performance of therapy techniques in the short visits; extended discussion of the tardiness problem was consistently deferred in favor of direct therapy. Due to the short visits, inaccurate practice between visits, and long duration between visits, goals were not met after 4 sessions as originally anticipated. However, there was demonstrated progress (albeit slow) since the evaluation, and it was determined that therapy would continue. After several brief visits and another 1-month lapse between sessions, patient X arrived 40 minutes late for his sixth appointment. His lack of adherence and incorrect practice outside the therapy room was evidenced by a moderate vocal change. The patient declined to see the laryngologist that day, and the vocal change was not dramatic. However, he was instructed to follow up with the physician if the hoarseness did not resolve within a week. In lieu of direct therapy, the remaining time that visit was spent having “The Talk” about his attendance. The clinician expressed that he could not expect to see improvement in 15-minute visits each month. Patient X was told that his lateness was unfair to himself, to the clinician, and to the patients scheduled immediately after him who were deprived of some of their therapy time due to his tardiness. He expressed remorse for his tardiness and stated that along his 80.5 k (50-mile) drive to our clinic, something unpredictable always seemed to come up due to morning traffic. We determined that if morning traffic was the issue, he could schedule an afternoon appointment. Patient X arrived for his afternoon appointment 30 minutes late. The clinician told him this could not continue, and he was “fired” from therapy. However, the previously observed hoarse-

ness from the last visit did not resolve, and patient X did not follow up with the laryngologist as recommended. Instead, he increased his vocal demand by preaching for the first time, and he became severely hoarse. Due to acute significant voice change, videostroboscopy was completed and was reviewed by the laryngologist. There was new bleeding in both vocal folds. Voice rest, 2-week MD follow-up, and continued voice therapy were recommended. The clinician and physician discussed privately that patient X had just been discharged from therapy due to his poor adherence. The physician felt strongly that the patient should continue therapy. Therefore, the compromise was to continue therapy with the understanding that a single additional arrival 20 minutes late or more, or a cancellation with less than 24 hours notice would result in therapy termination. The clinician returned to the patient and explained that his doctor had bought him one last chance. The above guidelines were outlined, and the clinician explained that the “rules” would be dictated into the medical record. An infraction of the contract would not be tolerated, and no therapist in our group would work with him The next visit was the eighth voice therapy session. Patient X arrived 10 minutes early for his appointment. After 2 weeks of voice rest, he had significant vocal improvement and had been cleared for voice use. He was able to return to singing without vocal detriment. He had not attempted to preach again. Over the course of 3 consecutive full-length visits over a 5-week time frame, therapy techniques were advanced as discussed above, including safe loud voice use for preaching and falsetto-range singing without strain. At that point, his rehabilitative goals were met, and follow-up with a nonmedical


vocal coach was recommended to continue his progress toward his habilitative goals.

Therapy Outcomes Audio-Perceptual Assessment The CAPE-V score improved to 15. Instrumental CSID improved to 4.586. Pitch range improved to 83 to 625 Hz without strain. Patient Self-Assessment SVHI improved to 20/40, indicating a significant improvement in singingrelated QOL.

Summary and Concluding Remarks Voice therapy adherence can be viewed from several perspectives: attendance, participation in therapy sessions, and practice between visits. In the case pre sented, there were limitations in all categories. Patient X’s increasingly late arrivals seemed to reflect a low motivation to participate in therapy; however, his continuing efforts to make the 2-hour round-trip drive to attend sessions seemed to indicate a high motivation to attend sessions. His pleasant demeanor, apologies for lateness, and resistance to the idea that “this may not be the right time for voice therapy” led the clinician to accept his apologies and continue brief therapy sessions. Only after he was “fired” from therapy and rescued by his laryngologist did patient X truly commit to the therapy process. Perhaps this strategy would

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have been helpful if employed earlier in the process. It could also be the case that the fear of the sudden withdrawal of the clinician’s established support was the factor that ultimately influenced the change in patient X’s behavior. Interestingly, once he made the commitment to arrive on time and to keep his appointments every 1 to 2 weeks, he also began focusing more keenly during sessions and practicing more accurately at home. Due to his poor adherence in the middle of the therapy process, his course of treatment lasted 10 sessions instead of the anticipated 4, but he ultimately met his goals. This case also underscores the importance of presurgical voice therapy. In this situation, the patient’s hemorrhagic lesion was considered operative, so presurgical therapy was not scheduled. The patient’s health literacy was limited, and his understanding of the vocal mechanism and its limitations was poor. Many months of consistent education were required in order for him to understand the importance of vocal pacing and limitations of vocal load. In that time frame, he had at least 2 additional hemorrhages from blood vessels outside the surgical site due to his poor adherence. Preoperative voice therapy could have been helpful to begin the education process, and the physician would have been made aware of a risk of poor postoperative adherence, which could have changed the surgical plan.

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2. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. Mar 1977;84(2):191–215. 3. Titze IR, Verdolini K. Vocology — The Science and Practice of Voice Habilitation. Salt Lake City, UT: National Center for Voice and Speech; 2012. 4. McAuley E, Talbot HM, Martinez S. Manipulating self-efficacy in the exercise environment in women: influences on affective responses. Health Psychol. May 1999;18(3):288–294. 5. Verdolini K. Critical analysis of common terminology in voice therapy: a position paper. Phonoscope. 1999;2(1):1–8. 6. Gillespie AI, Abbott KV. The influence of clinical terminology on self-efficacy for voice. Logoped Phoniatr Vocol. 2011; 36(3):91–99. 7. Portone C, Johns MM, 3rd, Hapner ER. A review of patient adherence to the recommendation for voice therapy. J Voice. Mar 2008;22(2):192–196. 8. Ziegler A, Gillespie AI, Abbott KV. Behavioral treatment of voice disorders in teachers. Folia phoniatrica et logopaedica. 2010;62(1–2):9–23. 9. Verdolini K, Druker DG, Palmer PM, Samawi H. Laryngeal adduction in resonant voice. J Voice. Sep 1998;12(3): 315–327. 10. Hapner E, Portone-Maira C, Johns MM, 3rd. A study of voice therapy dropout. J Voice. May 2009;23(3):337–340. 11. Gilman M, Merati AL, Klein AM, Hapner ER, Johns MM. Performer’s attitudes toward seeking health care for voice issues: understanding the barriers. J Voice. Mar 2009;23(2):225–228. 12. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. Sep 1997;11(3): 254–259. 13. Haselden K, Powell T, Drinnan M, Carding P. Comparing health locus of control in patients with spasmodic dysphonia, functional dysphonia and nonlaryngeal dystonia. J Voice. Nov 2009;23(6):699–706.

14. Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emerg Med Clin North Am. May 2005;23(2):529–549. 15. Wahbeh H, Elsas SM, Oken BS. Mindbody interventions: applications in neurology. Neurology. Jun 10 2008;70(24): 2321–2328. 16. van Leer E, Connor NP. Patient perceptions of voice therapy adherence. J Voice. Jul 2010;24(4):458–469. 17. Verdolini K, Lee TD. Optimizing motor learning in speech intervention: theory and practice. In: Sapienza JC, ed. For Clinicians by Clinicians: Vocal Rehabilitation in Medical Speech-Lanaguage Pathology. Austin, TX: Pro-Ed; 2001:403–446. 18. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986. 19. Schneider-Stickler B, Knell C, Aichstill B, Jocher W. Biofeedback on voice use in call center agents in order to prevent occupational voice disorders. J Voice. Jan 2012;26(1):51–62. 20. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: WH Freeman; 1997. 21. Bandura A. Social cognitive theory: an agentic perspective. Ann Rev Psychol. 2001;52(1):1–26. 22. DiIorio C, Resnicow K, McDonnell M, Soet J, McCarty F, Yeager K. Using motivational interviewing to promote adherence to antiretroviral medications: a pilot study. J Assoc Nurses AIDS Care. Mar–Apr 2003;14(2):52–62. 23. van Leer E, Hapner ER, Connor NP. Transtheoretical model of health behavior change applied to voice therapy. J Voice. Nov 2008;22(6):688–698. 24. Kempster GB, Gerratt BR, Verdolini Abbott K, Barkmeier-Kraemer J, Hillman RE. Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol. Am J Speech Lang Pathol. May 2009;18(2): 124–132. 25. Zraick RI, Kempster GB, Connor NP, et al. Establishing validity of the Con-


sensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Am J Speech Lang Pathol. Feb 2011;20(1):14–22. 26. Jacobson B, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benniger M. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6(3):66–70. 27. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. Jun 2002; 16(2):274–277. 28. Stemple JC, Lee L, D’Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice. Sep 1994;8(3):271–278. 29. Roy N, Gray SD, Simon M, Dove H, Corbin-Lewis K, Stemple JC. An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. J Speech Lang Hear Res. Apr 2001; 44(2):286–296. 30. Thomas LB, Stemple JC. Voice therapy: does science support the art? Comm Disord Rev. 2007;1(1):51–97. 31. Zwitman DH, Calcaterra TC. The “silent cough” method for vocal hyper function. J Speech Hear Disord. 1973;38(1): 119–125. 32. Verdolini K, Sandage M, Titze IR. Effect of hydration treatments on laryngeal nodules and polyps and related voice measures. J Voice. 1994;8(1):30–47. 33. Yiu EM, Chan RM. Effect of hydration and vocal rest on the vocal fatigue in amateur karaoke singers. J Voice. Jun 2003;17(2):216–227. 34. Behrman A, Rutledge J, Hembree A, Sheridan S. Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma. J Speech Lang Hear Res. Apr 2008; 51(2):350–366. 35. Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E. Preliminary study of two methods of treatment for laryngeal nodules. J Voice. Mar 1995;9(1):74–85.

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Appendix 8–A. Selected Applications Useful in Voice Therapy App Name

Icon

Platform

Cost

Comments

Pitch extraction/tuners We use these to provide starting pitches for and check pitch during vocal exercises [eg, Lee Silverman Voice Treatment (LSVT), Vocal Function Exercises] and vocal warm-ups. They are also helpful in developing pitch awareness in the “tone deaf” individual. Da Tuner

Android

Free or $2.34

*Best in class for iOS* Tuner and pitch pipe in one. Free version, pay $2.34 for increased functions, or download the “experimental” version. Color changes to green when in tune. Small loudness meter on the side as well. More functions than g-strings, particularly for instrumental musicians. Recommended by participant — not tested by authors.

G-Strings

Android

Free

Tuner + pitch pipe in one. Realtime pitch assessment in hertz and notes — analog guide with numbers ideal for biofeedback. Also will play a pitch from the home screen of the app, allowing for immediate biofeedback. Slightly slow to pick up on the pitch.

Gibson Tuner

iOS and Android

Free

*Best in class for iOS* Chromatic tuner and metronome in one. Tuner mode provides analog guide for precise note tuning, ideal numerical hertz value for the target pitch, and actual produced hertz value. Will play notes, but only for the 6 guitar strings and requires switching modes then switching back to check pitch.

Pano Tuner Free

iOS

Free

Functional real-time pitch assessment in hertz and notes. Can sound a tone if you know the hertz only, and not through the home screen. Interface is not as nice as some. continues

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Appendix 8–A. continued App Name

Icon

Platform

Cost

Comments

n-Track Tuner

iOS and Android

Free

Functional real-time pitch assessment in hertz and notes. Can sound a tone, but that requires switching between modes and then switching back to check pitch. Interface is not as nice as some.

Tuner by Cateater

iOS

$0.99

Freezes frequently and does not play the tone selected most of the time. Not reliable for use in voice therapy.

Cleartune Chromatic Tuner

iOS and Android

$3.99

$3.99 is excessive when there are free apps with the same functionality. Note that the wheel interface is pleasant.

Spectral Analyzer Pro

Android

$5.49

Creates colorful real-time spectrograms. Suggested by workshop participant but untested by authors.

Pitch pipes, pianos, and warm-ups (There are no free pitch pipes for iOS — recommend using a free piano app instead.) Chromatic pitch pipe

Android

Free

Decent pitch pipe — we generally use the built-in pitch production within another app instead.

XPiano

iOS and Android

Free

*Best in class for iOS* Range from C1–B7. Up to 7 octaves on screen at one time. Supports chords (must have very small fingers for iPhone, but functional on iPad). Allows for recording and playback of multiple files, which can be renamed. C’s are labeled but cannot turn labels on other keys.

Android

iOS

514


Icon

Platform

Cost

Comments

Piano DX

iOS

Free

Notes range from A0–C8. Can have 1–2 octaves on screen at one time with slider to quickly change keys available. Supports chords (must have very small fingers for iPhone, but functional on iPad). Can turn on key labeling for patients/clients to find starting notes. Note: turn on the second row of keys option to have just over 2 octaves on screen.

Pocket Piano

iOS

$0.99

Not useful for singers — only has from C3 to C5. Does allow recording and playback of only 1 recording. Minimally useful for Vocal Function Exercises for a nonsinger. Better off making an audio recording. Waste of $0.99.

Singer’s Friend Lite

iOS

Free

Warm-up app: User selects from preestablished vocal range and type of scale (including major, minor, blues/hexatonic, arpeggios), and speed is adjustable. Scales are played for warm-up. Ranges are not changeable and are extreme. The $3.99 upgrade adds more scale options, but you still cannot change the ranges.

Vocal Scaler

Android

Free

Warm-up app: User selects lowest and highest note and type of scale, and scales are played for warm-up

Mobile warm-ups

iOS

Free

Warm-up app: The free version has only one pattern. The paid version ($4.99) has multiple patterns and is customizable. (Paid version was not tested by authors.) continues

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Icon

Platform

Cost

Comments

Loudness-related and voice-rest helpers We use sound-level meters to self-monitor loudness during voice-building therapy and LSVT home practice. The vocal overuser can use these apps to develop loudness awareness and to cue in to potential vocally “dangerous” environments (eg, test the loudness in the car, in a restaurant, with the water running while washing dishes, etc). See descriptions of other apps for potential uses. Decibel Meter

Android

Free

Sound-level meter. Analog and digital feedback. Has a calibration function. Has a color-coded wheel and provides a pleasant interface.

Sound Meter

Android

Free

Sound-level meter. Analog and digital feedback.

DeciBel

Android

Free

Sound-level meter. Digital and waveform readout. Provides minimum, maximum, and average loudness. Cannot calibrate.

Digital Sound Meter Free

iOS

Free

Sound-level meter. Analog and digital feedback. Vertical bars with digital readout below. Provides a pleasant interface. Cannot calibrate.

VUMeter by Cateater

iOS

$0.99

Digital and analog sound-level meter. Biofeedback options include graph and green, yellow, red lights. Red light triggers at 75 dB and cannot change that. However, can adjust calibration settings.

iSpeech — text to speech

iOS and Web

Free

Free text-to-speech app for use while on voice rest. Can save canned/frequently used phrases for future use. Free for US or UK female voice. All others are $0.99 each. The speech is very good, and there is different intonation for questions versus statements versus exclamations. Test here: http://www.ispeech.org/text.to .speech

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Icon

Platform

Cost

Comments

Speak It

iOS

Free

Free text-to-speech app for use while on voice rest. Can save canned/frequently used phrases for future use. Multiple male and female voice options, though the intonation is not as normal sounding as iSpeech.

Text to Speech Toy

Android

Free

Free text-to-speech app for use while on voice rest. Can save canned/frequently used phrases for future use. Untested.

Air Horn

iOS and Android

Free

Noisemaker to avoid yelling through the house. Not loud enough for large distances. Note: shake to increase loudness.

VoicePlus

iOS

Free

Changes the voice in a variety of ways. Has a megaphone function where the voice is played back louder — helpful in a noisy environment rather than repeating the statement louder. Also has a Helicopter playback, useful for practicing speaking over background noise. Fun voice task for children.

Voice recording/file sharing/drawing Drawing apps are very open ended. Think tic-tac-toe as a reward for kids; illustrated views of respiration, phonation, resonance; white-board substitute for people on voice rest, etc. iTalk by Griffin labs

iOS

Free

Voice recording program. Better quality than the voice memos app that comes preinstalled on the iPhone. Use on the patient/client’s device to record audio of the session. continues

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Icon

Platform

Cost

Comments

Vimeo app

iOS and Android

Free

Allows viewing, minimal editing, and supposedly uploading of videos to Vimeo website. Editing is limited, and we were unable to upload videos from the iPhone. Helpful for the individual to download if he or she creates a Vimeo account, uploads video from his or her session, and wants to view recordings when away from the computer.

YouTube

iOS and Android

Free

Preinstalled on most devices. Search for “Titze straw” (disable autocorrect) on your device for a how-to in semi-occluded vocal tract exercises. If video from session is uploaded to YouTube, allows viewing of recordings when away from the recording.

Draw for iPad

No icon avail able

iPad only

Free

Drawing app with 9 colored pencils; can save and e-mail files. Includes a tic-tac-toe and a word game template. No “undo” function.

Drawing notepad

No icon avail able

iOS

Free

Simple app where user draws with finger (or stylus on iPad). No “undo” function.

Draw!

Android

Free

Simple drawing app.

Easy Voice Recorder

Android

Free

Voice recording program with sharing feature and unlimited recording time.

iOS and Android

Free

Repeats in a high-pitched voice. Can be motivating to draw voicing out of children and to increase awareness of roughness or glottal fry. See also VoicePlus above for more voice-changing fun.

Pediatrics Talking Tom (Cat)

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Appendix 8–A. continued App Name Many games

Icon

Platform

Cost

iOS and Android

Comments Can be adapted for pediatric voice therapy. Examples: Angry Birds [say w-w-w-w while pulling back the bird, then “wheee!” as it flies (Jan Potter Reed)], Memory (must use target voice when announcing the matched pair), Guess Who (say “hmmmmm” while thinking of a question to ask, answer with “m-hm or m-m/no”)

Dysarthria/diction/accent reduction Speech Rates

iOS

Free

Tap to count the number of syllable repetitions in a set time frame to assess speech rate, or time how long it takes to reach a certain number of repetitions.

e-nunciation

iOS

Free

Shows drawing of correct mouth position for producing sounds. Can record a target and patient’s production for comparison.

Pronounce it Right

Android

Free

A pronunciation engine. Type a word or sentence and let this app pronounce it, use it to listen, and try to mimic. Supports the following languages: Italian (Italy), German (Deutsch), French (France), Spanish (Spain), English (Great Britain), and English (US). (Not tested by presenters.)

DrawMD ENT

iOS

Free

Provides colorful pictures of the larynx, onto which you can draw/ label.

ICD9 Codes

iOS

Free

Searchable and browsable database of ICD-9 (diagnosis) codes. Can make a list of favorites for fast future searching.

ICD9 Consult

iOS and Android

Free

Searchable and browsable database of ICD-9 (diagnosis) codes. Note: search for “vocal” and get a comprehensive list of codes.

Medical

continues 519


Icon

Platform

Cost

Comments

Android

Free

Easy customization of daily water intake goal. Provides periodic reminders to facilitate an increase in water intake. Allows for tracking of water intake trends over time.

Other Water Your Body

Developed for the workshop “There’s an App for That,” Voice Foundation Symposium, June 1, 2012. Carissa Maira, MS, CCC-SLP; Edie Hapner, PhD, CCC-SLP; and Bryn Olson, MS, CCC-SLP. Note: SVOX for Android offers different software and voices for other speaking applications (eg, turn-by-turn directions). It is not a self-contained text-to-speech app usable for people on voice rest. Disclaimer: The following is the opinion of the authors with regard to the utility of these apps as it applies to the speaking and singing voice only. Some apps are untested by the authors (indicated as such). The authors of this document assume no responsibility for any problems with a listed app. Always use caution when downloading software. Take care when downloading apps, particularly for Android. Malware can hide in a seemingly harm less app, especially games. Lookout Mobile Security is an excellent free software scanner and backup program for Android devices. iOS apps undergo a more rigorous testing process and are more likely to be free of malware but are not guaranteed safe. Signs of malware include the device running much slower or the battery draining much more quickly than it previously did. Looking for more apps? https://play.google.com/store has a list of all Android apps. http://iphoneappli cationlist.com/apps/ is a searchable list of apps for the iPhone.

520

Index

Note: Page numbers in bold reference non-text material.

A Abdominal breathing, in Accent Method, 117, 121–123 Abdominal breath support, 506 Accent Method abdominal breathing in, 117, 121–123 close vowels in, 117–118 description of, 6 exercises used in, 116–117, 121–123 fricatives in, 117–118 history of, 116 modal voice, 117 results of, 124–125 secondary muscle tension dysphonia treated with, 116–125 theory of, 116 Acoustic analysis, before manual circumlaryngeal therapy for primary muscle tension dysphonia, 59 Adductor laryngeal breathing dystonia, 337 Adolescent(s) flow phonation in, with primary muscle tension dysphonia, 45–53 glottal attack as laryngeal manipulation for mutational voice in, 174–179 primary muscle tension dysphonia in, 41–45 secondary muscle tension dysphonia in, 90

Adventures in Voice, for secondary muscle tension dysphonia caused by vocal nodules, 91–100 Ambulatory biofeedback and voice therapy, for primary muscle tension dysphonia, 157–164 Ambulatory phonation monitor (APM), 260–261 Amitriptyline, 329 Angiotensin-converting enzyme inhibitors, 328 Articulatory precision, 51

B Back breathing, 320 Behavioral modification, for secondary muscle tension dysphonia, 66–72 Behavioral shaping in primary muscle tension dysphonia masquerading as elective mutism, 29–37 Behavioral therapy, 464–468 Belting, 389 Biofeedback, ambulatory, 157–164 Boone, Daniel, 4 Botulinum toxin injections, for spasmodic dysphonia, 270, 278–279, 281–287 Breathing recovery program, 343–344 Breath support, 465–466 Brodnitz, Friedrich, 5

522


C CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice), 21, 42, 46, 72, 143–145, 166, 207, 213, 214, 217, 246, 275, 282, 288, 289, 297, 330, 341, 359, 395, 437, 453, 497, 502, 505 Casper-Stone flow phonation, 293 Central sensitivity syndrome, 313–324 Chronic cough central nervous system inhibitors for, 328–335 multimodality behavioral treatment of, 324–327 Circumlaryngeal massage. See also Laryngeal massage description of, 43 in high-risk vocal performers, 416 in primary muscle tension dysphonia assessment and treatment, 53–60, 170 in professional singer with vocal fold cysts, 426 technique for, 55–57, 170 for vocal injury in physically and demanding vocal performer, 438, 440–442 Clinical-musical ear, 484 Clinical problem clinician’s understanding of, 481–482 etiologic factors, 483 misapplied management techniques for, 482 patient’s lack of understanding of, 482–483 Communicative competence approach, to falsetto voice, 170 Conversational voice therapy, 469–474 Coordinated voice onset, 320, 322 Counseling skills, 480–481 Cricothyroid musculature, 120, 317 Cup bubble technique for voice recalibration in country singer, 442–452

D Diaphragmatic-abdominal breathing, 117 Dysphonia

muscle tension. See Muscle tension dysphonia in operatic singer, minimal injection medialization and voice therapy for, 458–463 spasmodic. See Spasmodic dysphonia Dyspnea, exercise-induced, 345–348 Dysregulated laryngeal muscle tension, 29

E Eclectic approach, for vocal fatigue, 255–261 Eclectic voice therapy, for secondary muscle tension dysphonia caused by vocal fold cyst, 72–78 Elective mutism, behavioral shaping in primary muscle tension dysphonia masquerading as, 29–37 Electromyography, 202 Episodic laryngeal dyskinesia, 337 Estill Voice Model program, 386 Exercise-induced dyspnea, 345–348 Expiratory muscle strength training (EMST) in high-risk vocal performers, 419–421 steps involved in, 420–421 for unilateral vocal fold paralysis, 222–226 Extra-esophageal reflux disease (EERD), 336 Extralaryngeal muscle tension, 259 “Eye Pop,” 385

F Falsetto voice definition of, 164 glottal attack for primary muscle tension dysphonia treatment in patient with, 164–165 incidence of, 169 multi-approach therapy for primary muscle tension dysphonia in patient with, 166–174 for phonation modification in primary muscle tension dysphonia, 38–41 Family education, for secondary muscle tension dysphonia, 66–72

Index 523

Flow phonation airflow release skill of, 47–50, 48 breathy phonation skill of, 50–52 in Broadway singer, 410 Casper-Stone, 293 definition of, 45 primary muscle tension aphonia in teenager treated with, 45–53 skill levels of, 47–52, 48 steps of, 48 Flow phonation facilitator, 447–451 Focal laryngeal palpation, 54–55 Forward focus, 153, 466 Forward placement, 417, 466 Fricatives in Accent Method, 117–118 voiceless to voiced, 50–51 Frontal Focus exercise, 252–253

G Gabapentin, 329 Gargling technique, 47 Gastroesophageal reflux, 315 Glottal attack as laryngeal manipulation, for mutational voice in adolescent, 174–179 for primary muscle tension dysphonia treatment in falsetto voice, 164–165 Glottal incompetence nonneurologic causes of, 190 overview of, 189–190 presbyphonia, Phonation Resistance Training Exercises for, 233–239 secondary muscle tension dysphonia and, in unilateral vocal fold paralysis, 206–212 sulcus vocalis as cause of, team-based vocal rehabilitation approach to, 245–249 superior laryngeal nerve paralysis, 226–232 unilateral vocal fold paralysis after total thyroidectomy, 198–206 complex medical history, 190–197 expiratory muscle strength training for, 222–226 physiologic therapy approaches for, 198–206 postchemotherapy/radiation therapy, 222–226

resonant voice therapy for, 212–222 secondary muscle tension dysphonia and, 206–212 semi-occluded vocal tract technique, 212–222 treatment strategies for, 190–197 vocal fatigue eclectic management approach for, 255–261 vocal fold closure improvement in patient with, 250–255 GRBAS (grade, roughness, breathiness, asthenia, strain) scale, 42, 46, 459

H History of therapy Daniel Boone, 4 eclectic voice therapy, 6 facilitating techniques, 4 Friedrich Brodnitz, 5 hygienic voice therapy, 3–4 physiologic voice therapy, 5–6 resonant voice therapy, 6 symptomatic voice therapy, 4–5 vocal function exercises, 6 Hyperfunctional voice disorders definition of, 27 muscle tension dysphonia. See Muscle tension dysphonia

I Inhalation phonation, 196 Inspiratory stridor, 337 Interview, 480–481 Irritable larynx syndrome (ILS) as central sensitivity syndrome, 313–324 chronic cough central nervous system inhibitors for, 328–335 multimodality behavioral treatment of, 324–327 comprehensive approach to, 313–324 diagnostic criteria for, 312 overview of, 311–312 paradoxical vocal fold motion/vocal fold dysfunction. See Paradoxical vocal fold motion/vocal fold dysfunction (PVFM/VFD)

524


Irritable larynx syndrome (ILS) (continued) pathophysiological mechanisms of, 312–313 symptoms of, 311 triggers of, 311–312

Jaw, 120

Lee Silverman Voice Therapy, 125, 237, 298–303, 305–306 Lessac-Madsen resonant voice therapy, 142–157, 258, 279, 410–411, 501 Lieberman, Jacob, 120 Lip bubbles, 49–50 Loudness-related helpers, 516–517 Lower pitch, 177–178 Low rib breathing, 352

K

M

KayPENTAX, 46, 67, 73, 128, 132, 137, 160, 176, 192, 256, 260, 304, 349, 360, 382, 407, 414–415, 453–454, 499, 505 Kazoo sound, 51

Manual circumlaryngeal techniques in paradoxical vocal fold motion, 363 in primary muscle tension dysphonia assessment and treatment, 53–60 Maxillary resonance, 466 Mayo Clinic Neuromotor Speech Examination, 358 Meige’s syndrome, 282 Midmembranous lesions, muscle tension dysphonia caused by, 78–85 Minimal injection medialization and voice therapy, for dysphonia in operatic singer, 458–463 Modal voice, 117 Motivation, 485 Multi-Dimensional Voice Program (MDVP), 46, 132, 360, 414, 498, 505 Munchausen’s stridor, 336 Muscle tension dysphonia description of, 27 laryngoscopic patterns for classifying, 29 primary ambulatory biofeedback with voice therapy for, 157–164 behavioral shaping in, masquerading as elective mutism, 29–37 definition of, 27 etiology of, 27–28 falsetto voice used to modify phonation in, 38–41 flow phonation in adolescent with, 45–53 glottal attack for, 164–165 laryngeal massage for, 41–45 manual circumlaryngeal technique in assessment and treatment of, 53–60

J

L Laryngeal control therapy, 347 Laryngeal diadochokinetic testing, 215 Laryngeal massage. See also Circumlaryngeal massage in Broadway singer, 409 for primary muscle tension dysphonia in adolescent, 41–45 in professional singer with vocal fold cysts, 426 technique for, 383 Laryngeal musculature excessive, self-correction of, 209–210 extrinsic, 120–121 tension on, 259, 365 Laryngeal vertical displacement, 170–171 Laryngeal videoendoscopy, 38–39, 57, 57–58 Laryngopharyngeal reflux in athlete, 343 muscle tension dysphonia caused by, 131–136 treatment of, 131–136 Laryngospasm, 364 Larynx electromyography of, 202 hard glottal attack as manipulation of, for mutational voice in adolescent, 174–179 imaging of, 130, 423–425, 504 LaxVox Method, 171

Index 525

multi-approach therapy for, in patient with habitual falsetto phonation, 166–174 as paralytic dysphonia, 60–65 secondary Accent Method for, 116–125 Adventures in Voice for, 91–100 bilateral lesions as cause of, 85–91 definition of, 27 eclectic voice therapy for, 72–78 glottal incompetence with, in unilateral vocal fold paralysis patient, 206–212 laryngopharyngeal reflux as cause of, 131–136 Lessac-Madsen resonant voice therapy for, 142–157 midmembranous lesions as cause of, 78–85 patient-family education and behavioral modification for, 66–72 psychosocial management approach for treatment of, 78–85 school-based speech and language pathologist’s involvement in treatment of, 100–106 telehealth approach to, 85–91 vocal function exercises for, 106–115 vocal nodules as cause of, 66–72, 91–100, 91–106 vocal process granulomas as cause of, 136–142 voice therapy boot camp for, 125–131 Muscle tension voice disorders, 28 Musical ear, 484 Mutational voice, hard glottal attack as laryngeal manipulation for modification of, 174–179 Myoelastic-aerodynamic theory of vocal fold vibration, 116 Myofascial release, 438, 440–441

N National Association of Teachers of Singing, 378 National Spasmodic Dysphonia Association, 272, 277

Negative vocal behaviors, 486 Nose-pinching, 386

O Occupational voice case study, 469–474 Oral hydration for laryngeal function, 138 for vocal folds, 110–111, 139

P Paradoxical vocal fold motion/vocal cord dysfunction (PVFM/VCD) in adolescent athlete, 345–348 assessment of, 337 breathing recovery exercises for, 337 collegiate swimmer case study of, 338–345 definition of, 335 description of, 311 differential diagnosis of, 335–336 environmental irritants associated with, 336 etiology of, 335 in exercise-induced dyspnea, 345–348 inspiratory stridor associated with, 337 neurologic conditions, 337 psychogenic causes of, 335–336 psychosocial issues and, 355–368 in young athletes, 348–368 Paralytic dysphonia, management of primary muscle tension dysphonia masquerading as, 60–65 Parkinson disease, Lee Silverman Voice Treatment LOUD in care of patient with, 298–303 Patient(s) education of lack of, voice therapy affected by, 482–483 secondary muscle tension dysphonia treated with, 66–72 lack of motivation by, 485 perceived need for negative vocal behavior by, 486–487 resistance to information sharing by, 485–486 self-efficacy of, in voice therapy adherence, 488–493

526


Pediatric Voice Handicapped Index, 92 Periaqueductal gray nuclei, 312 Perilaryngeal tension laryngoscopy of, 29 management of, 365 symptoms of, 28 Pharyngolaryngeal muscles, 317 Phonation falsetto voice for modification of, in primary muscle tension dysphonia, 38–41 flow. See Flow phonation PhoRTE: Phonation Resistance Training Exercises, for presbyphonia, 233–239 Phonatory Aerodynamic System (PAS), 46 Phonatory Function Analyzer, 192 Phonotrauma, 259, 425–426, 500 Pneumotachograph, 225 Postviral vagal neuropathy (PVNN), 328 Presbyphonia Phonation Resistance Training Exercises for, 233–239 vocal function exercises in elderly man with, 240–244 Primary muscle tension dysphonia. See Muscle tension dysphonia, primary Professional voice cases bilateral vocal fold lesions in male singer, 394–400 Broadway singer, voice intervention for, 405–412 cup bubble technique for voice recalibration in country singer, 442–452 developing performer, 389–394 high-risk vocal performers, 412–421 myofascial release, 438, 440–441 overview of, 376–377 semi-occluded vocal tract exercises and resonant voice therapy for vocal fold cysts in professional actor and singer, 422–435 therapeutic modalities for touring musical theater vocal athlete, 400–405 vocal fold lesions in praise and worship leader, 452–458 vocal fold nodules in female prepubescent singer, 379–389

vocal injury in physically and demanding vocal performer, 435–442 voice therapy in actor, 463–469 Pseudoauthoritative voice, 484, 486 Psychosocial management approach, for secondary muscle tension dysphonia, 78–85 Puberphonia, 169. See also Falsetto voice Public speaking techniques, for voice disorders, 469–474 Pursed-lip breathing, 320, 365

R Recurrent laryngeal nerve paralysis, 226 Reduced voicing duration, for vocal tremor, 287–298 Referrals, 377–378 Reflux Symptom Index (RSI), 132, 380 Relaxation exercises, 383–384 Resonance tubes, 171 Resonant voice, 143, 210, 260, 466 Resonant voice therapy (RVT) in Broadway singer, 410–411 description of, 6 goal of, 428 Lessac-Madsen, 142–157, 258, 279, 410– 411, 501 primary muscle tension dysphonia in adolescent treated with, 41–45 secondary muscle tension dysphonia in adolescent treated with, 90 semi-occluded vocal tract exercises and, for vocal fold cysts in professional actor and singer, 422–435 touring musical theater vocal athlete treated with, 403–405 unilateral vocal fold paralysis treated with, 212–222 Respiratory retraining, 384

S Secondary muscle tension dysphonia. See Muscle tension dysphonia, secondary Selective laryngeal adductory denervation and reinnervation (SLAD-R), 277

Index 527

Self-auditory perception, 417 Self-efficacy, in voice therapy adherence, 488–493 Semi-occluded vocal tract exercises and technique in Broadway singer, 409–410 in child with vocal fold nodules, 384–385 for glottal incompetence caused by sulcus vocalis, 247 in praise and worship singer, 455 resonant voice therapy and, for vocal fold cysts in professional actor and singer, 422–435 unilateral vocal fold paralysis treated with, 212–222 Short-term voice therapy, for secondary muscle tension dysphonia, 125–131 Singers bilateral vocal fold lesions in male singer, 394–400 Broadway singer, voice intervention for, 405–412 cup bubble technique for voice recalibration in country singer, 442–452 developing performer case study, 389–394 dysphonia in operatic singer, 458–463 high-risk vocal performers, 412–421 operatic, voice therapy and minimal injection medialization for dysphonia in, 458–463 semi-occluded vocal tract exercises and resonant voice therapy for vocal fold cysts in professional actor and singer, 422–435 vocal fold lesions in praise and worship leader, 452–458 vocal fold nodules in female prepubescent singer, 379–389 vocal injury in physically and demanding vocal performer, 435–442 Singing Voice Handicap Index (S-VHI), 143 Singing voice specialist, 378 Sniffing exercise, 320 Social-cognitive approach, for voice therapy adherence, 493–496

Spasmodic dysphonia abductor, 270 adductor behavioral management of, 273–280 botulinum toxin and voice therapy for, 281–287 description of, 270 medical management of, 273–280 age of onset, 270 botulinum toxin injections for, 270, 278–279, 281–287 causes of, 270 description of, 29, 269–270 functional voice therapy for, 271–273 prophylactic therapies for, 270–271 unilateral voice fold paralysis for, 270 Speech, laryngeal position in, 121 Speech-language pathologists cross-training of, 378 scope of practice for, 376 in secondary muscle tension dysphonia treatment, 100–106 Sports broadcasters, 377 Strap musculature, 120–121 Submandibular massage, 383 Sulcus vocalis, glottal incompetence caused by, 245–249 Superior laryngeal nerve injury to, 62, 65 paralysis of, 226–232 Suprahyoid muscle, 120, 317 Swallowing Quality of Life Questionnaire, 224

T Telehealth secondary muscle tension dysphonia and, 85–91 voice therapy provided using, 303–307 Throat clearing, 109–110, 139–140, 254 Thyrohyoid musculature, 120, 317 Tongue extension word list, 383–384 Tongue muscles, 120 Tongue stretches, 427 Tongue trills, 384–385, 456 Tramadol, 329 Twang, 386–387

528


U Unilateral vocal fold paralysis after total thyroidectomy, 198–206 complex medical history, 190–197 description of, 190 expiratory muscle strength training for, 222–226 physiologic therapy approaches for, 198–206 postchemotherapy/radiation therapy, 222–226 resonant voice therapy for, 212–222 secondary muscle tension dysphonia and, 206–212 semi-occluded vocal tract technique, 212–222 spasmodic dysphonia treated with, 270 treatment strategies for, 190–197 /u/ prolongation, 49–51

V Videolaryngostroboscopy, 98, 133, 401 Videostroboscopy, 213, 220–221, 228, 232, 331 Visi-Pitch (KayPENTAX), 192, 256, 414 Vocal cord dysfunction. See Paradoxical vocal fold motion/vocal cord dysfunction (PVFM/VCD) Vocal fatigue perilaryngeal tension as cause of, 28 vocal fold closure improvement in patient with, 250–255 Vocal Fatigue Index (VFI), 256–257, 257 Vocal fold(s) bilateral lesions of, in male singer, 394–400 closure of, in voice fatigue patient, 250–255 medialization of, 194–195 Vocal fold cysts muscle tension dysphonia caused by, eclectic voice therapy for, 72–78 semi-occluded vocal tract exercises and resonant voice therapy for, 422–435 Vocal fold lesions bilateral, in male singer, 394–400 preremoval and postremoval of, in praise and worship leader, 452–458

Vocal fold nodules in female prepubescent singer, 379–389 portable electronic software applications to facilitate home vocal exercises for, 497–503 Vocal fold paralysis bilateral, 190 glottal incompetence caused by, 190 unilateral after total thyroidectomy, 198–206 complex medical history, 190–197 description of, 190 expiratory muscle strength training for, 222–226 physiologic therapy approaches for, 198–206 postchemotherapy/radiation therapy, 222–226 resonant voice therapy for, 212–222 secondary muscle tension dysphonia and, 206–212 semi-occluded vocal tract technique, 212–222 treatment strategies for, 190–197 Vocal function exercises description of, 171 glottal incompetence treated with, 210 home practice of, portable electronic software applications to facilitate, 497–503 for presbyphonia in elderly man, 240–244 secondary muscle tension dysphonia in adult treated with, 106–115 touring musical theater vocal athlete treated with, 403–404 for vocal fold nodules in child, 384–385 for vocal injury in physically and demanding vocal performer, 440–442 Vocal Handicap Index-10 (VHI-10), 256, 291 Vocal hygiene program, 209, 446, 464 Vocal image, 486 Vocal journal, 382–383 Vocal nodules, muscle tension dysphonia secondary to, 66–72, 91–106 Vocal pedagogy, 377 Vocal process granulomas, muscle tension dysphonia secondary to, 136–142

Index 529

Vocal rehabilitation, for glottal incompetence caused by sulcus vocalis, 245–249 Vocal strain, 140 Vocal tremor, reduced voicing duration for treatment of, 287–298 Vocal warm-up, 426, 514–515 Voice clinicians, 376 Voice conservation program, 446–447 Voice disorders clinical understanding of, 481–482 factors that affect, 488 muscle tension, 28 public speaking techniques for, 469–474 Voice evaluation CAPE-V (Consensus AuditoryPerceptual Evaluation of Voice), 21 counseling skills, 480–481 impressions, 23–24 interview, 480–481 introduction, 13–14 loudness, 22–23 management team, 14–15 medical evaluation, 15 medical history, 19 oral-peripheral examination, 20–21 phonation, 21 pitch, 22 problem history, 18–19 prognosis, 24 rate, 23 resonance, 21–22 respiration, 21 social history, 20 voice pathology evaluation referral rationale determination, 16–18 referral source determination, 16 Voice Handicap Index (VHI), 42, 46, 208, 304, 382, 391, 499, 502 Voiceless phonemes, 49–50 Voiceless phrases/conversation, 50 Voiceless to voiced fricatives, 50–51 Voice-Related Quality of Life (V-RQOL), 108, 160, 199, 205, 224, 236, 276, 315, 331, 453, 499 Voice rest, 516–517 Voice stimulability testing, 55 Voice Symptoms Scale (VoiSS), 143 Voice therapy in actor, 463–469

adherence to, 503–510 iPod apps used to improve, 493–496 self-efficacy’s role in, 488–493 social-cognitive approach for, 493–496 ambulatory biofeedback and, for primary muscle tension dysphonia, 157–164 applications useful in, 513–520 for bilateral vocal fold lesions in male singer, 396–399 botulinum toxin injections and, for spasmodic dysphonia, 281–287 clinical preparation for, 479 conversational, 469–474 factors that affect clinical-musical ear, 484 clinical understanding of problem, 481–482 clinician’s expectations for, 481 etiologic factors, 483 finances, 487 lack of understanding or patient education about problem, 482–483 misapplication of techniques, 482 patient motivation, 485 patient-related, 484–488 perceived need for negative vocal behavior, 486–487 personality issues, 487–488 premature discontinuation of therapy, 483–484 resistance by patient to information sharing, 485–486 goals of, 425 minimal injection medialization and, for dysphonia in operatic singer, 458–463 in occupational voice patients, 470–473 overview of history, 2–6 hygienic voice therapy overview, 3–4 impressions report study example, 7–8 medical history example, 6–7 overview, 1–2 problem history example, 6 recommendations report study example, 8–10 social history example, 7 study example, 6–10 voice care professionals, 10 voice evaluation study example, 7

530


Voice therapy (continued) premature discontinuation of, 483–484 primary muscle tension dysphonia in patient with habitual falsetto phonation treated with, 169–172 in professional singer with vocal fold cysts, 425–430 short-term, for secondary muscle tension dysphonia, 125–131

spasmodic dysphonia treated with, 271–273, 281–287 telehealth technology used to provide, 303–307 VoxMetria 2.5 software, 200

Z Z-swell, 320, 321

Therapy

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