Voice Therapy - Plural Publishing, Inc. · viii Voice Therapy: Clinical Case Studies Case Study 3.13. Lessac-Madsen Resonant Voice Therapy in a 132 Young Woman with Vocal Nodules

Voice TherapyClinical Case Studies

Fifth Edition

Voice TherapyClinical Case Studies

Fifth Edition

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

5521 Ruffin RoadSan Diego, CA 92123

e-mail: [email protected]: http://www.pluralpublishing.com

Copyright © 2019 by Plural Publishing, Inc.

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 byTelephone: (866) 758-7251Fax: (888) 758-7255e-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

Names: Stemple, Joseph C. | Hapner, Edie R.Title: Voice therapy : clinical case studies / [edited by] Joseph C. Stemple, Edie R. Hapner.Description: Fifth edition. | San Diego, CA : Plural Publishing, [2019] | Includes bibliographical references and index.Identifiers: LCCN 2018028949| ISBN 9781635500356 (alk. paper) | ISBN 1635500354 (alk. paper)Subjects: | MESH: Voice Disorders — therapy | Case ReportsClassification: LCC RF510 | NLM WV 500 | DDC 616.85/56 — dc23LC record available at https://lccn.loc.gov/2018028949

v

Contents

Preface xiiiContributors xvii

1 Principles of Successful Voice Therapy 1 Joseph C. StempleIntroduction 1

Scientific Nature of Voice Care 2Artistic Nature of Voice Care 2

How to Use This Text 3Historical Perspective 3

Hygienic Voice Therapy 4Symptomatic Voice Therapy 5Psychogenic Voice Therapy 5Physiologic Voice Therapy 6Eclectic Voice Therapy 6Case Study 1.1 7Joseph C. Stemple

Voice Care Team 10Issues Related to Successful Voice Therapy 10

Clinician Realities Associated with Voice Therapy Success 11Interview and Counseling Skills 11

Case Vignette 1.1. A Missed Opportunity 11 Joseph C. Stemple

Clinical Understanding of the Problem 12Misapplied Management Techniques 13Lack of Patient Education or Understanding of the Problem 14Recognition of One Philosophical Orientation or One 14 Etiologic Factor

Case Vignette 1.2. The Obvious Is Not Always the Cause 14 Joseph C. Stemple

Premature Discontinuation of Therapy 15Case Vignette 1.3. The Pseudoauthoritative Voice 15 Joseph C. Stemple

The Clinical Ear 15Patient Realities Associated with Voice Therapy Success 16

Lack of Patient Motivation for Voice Therapy 16

vi Voice Therapy: Clinical Case Studies

Case Vignette 1.4. “As Long as I Don’t Have Cancer . . .” 16 Joseph C. StempleCase Vignette 1.5. The Role of Self-Efficacy and Adherence 17 Amanda Gillespie

Resistance to Share Information 19Perceived Need for Negative Vocal Behavior 19Need to Identify with the Problem 20

Case Vignette 1.6. “My Chest Hurts When I Do These Exercises” 20 Jospeh C. Stemple

Finances 21Personality Issues 21Can All Voices Be Improved? 22

Case Vignette 1.7. He Was “Fired” from Voice Therapy 22 Carissa Maira

Beyond Successful Voice Therapy Techniques and Tasks: 28 The Concept of Meta-TherapyLeah Helou

Chapter Summary 31References 31

2 Comments on the Voice Evaluation 35 Joseph C. StempleIntroduction 35Management Team 37Medical Evaluation 37Voice Pathology Evaluation 38

Referral 38Reason for the Referral 38History of the Problem 41Medical History 42Social History 42Oral-Peripheral Examination 43Voice Evaluation 43Instrumental Voice Assessment 45Hearing Screening 46Impressions 46Prognosis 46Recommendations 46

Chapter Summary 46References 47

3 Primary and Secondary Muscle Tension Dysphonia 49Introduction: Muscle Tension Dysphonia: An Overview 49 Nelson Roy

Contents vii

Primary MTD 51Case Study 3.1. Management of Primary MTD in a 13-Year-Old 51 Using Falsetto Voice to Modify Functional AphoniaJoseph C. StempleCase Study 3.2. Flow Phonation in a Teenager with Primary 55 Muscle Tension Dysphonia (Aphonia)Jackie Gartner-SchmidtCase Study 3.3. Manual Circumlaryngeal Techniques in the 63 Assessment and Treatment of Primary Muscle Tension Dysphonia in a 55-Year-Old WomanNelson RoyCase Study 3.4. Management of a Functional Dysphonia 70 Mimicking a Superior Laryngeal Nerve (SLN) ParesisClaudio MilsteinCase Study 3.5. The Use of Hard Glottal Attacks to Facilitate 76 Age-Appropriate Pitch in a 16-Year-Old Male with Mutational FalsettoLisa FryCase Study 3.6. The Use of Glottal Attack in the Treatment of 82 Primary MTD in an Adult Female Presenting with Persistent FalsettoJoseph C. Stemple

Secondary MTD 84Case Study 3.7. Using Patient-Family Education and Behavior 84 Modification to Treat MTD Secondary to Vocal Nodules in a School-Aged ChildLeslie GlazeCase Study 3.8. Pediatric Vocal Nodules and Secondary Muscle 90 Tension Dysphonia Treated in Connection with a School-Based SLPRebecca HancockCase Study 3.9. Treating a Child with Muscle Tension Dysphonia 98 Secondary to Vocal Nodules Using Concepts from “Adventures in Voice”Rita HersanCase Study 3.10. The Use of Vocal Function Exercises in the 106 Treatment of an Adult with Secondary Muscle Tension DysphoniaJoseph C. StempleCase Study 3.11. The Accent Method (AM) of Voice Therapy in 116 Clinical PracticeSara HarrisCase Study 3.12. The Use of Intensive Short-Term Voice Therapy 126 (aka Voice Therapy Boot Camp) in a Professional Voice User with Vocal HyperfunctionRita Patel

viii Voice Therapy: Clinical Case Studies

Case Study 3.13. Lessac-Madsen Resonant Voice Therapy in a 132 Young Woman with Vocal NodulesDiana Marie Orbelo, Nicole Yee-Key Li, and Katherine Verdolini-AbbottCase Study 3.14. Multimodal and Multidisciplinary Treatment of 141 Vocal Process Granulomas and Secondary Muscle Tension DysphoniaHeather StarmerCase Study 3.15. An Eclectic Approach in the Management of an 148 Individual with Vocal FatigueChaya NanjundeswaranCase Study 3.16. Conversation Training Therapy (CTT) Applied 154 to a Patient with Benign Mid-Membranous LesionsJackie L. Gartner-Schmidt and Amanda I. Gillespie

References 160

4 Management of Glottal Incompetence 171Introduction: Bridging “Gaps” with Voice Therapy in Patients 171 with Glottal Dysfunction Aaron Ziegler

Case Study 4.1. The Use of PhoRTE for Presbyphonia 175Aaron Ziegler and Edie HapnerCase Study 4.2. The Use of Vocal Function Exercises in an 183 Elderly Man with PresbyphoniaSteve GormanCase Study 4.3. Eclectic Voice Therapy to Treat Glottal 188 Incompetence with Secondary MTD in a Patient with Unilateral Vocal Fold ParalysisMaria DietrichCase Study 4.4. A Case of Superior Laryngeal Nerve Paralysis in a 195 Patient After Subtotal ThyroidectomyDaniel CroakeCase Study 4.5. LaxVox Therapy Used in a Case of Muscle Tension 201 Dysphonia Hiding an Underlying Glottal IncompetenceIlter DenizogluCase Study 4.6. Treatment of Glottal Incompetence Caused by 212 Sulcus Vocalis: Evidence of a Team Approach for Vocal RehabilitationAmanda I. Gillespie and Clark RosenCase Study 4.7. Improvement of Vocal Fold Closure in a Patient 217 with Voice FatigueJoseph C. StempleCase Study 4.8. The Use of Expiratory Muscle Strength Training 222 in a Case of Unilateral Vocal Fold Paralysis with Weak Cough and Aspiration PneumoniaBari Hoffman Ruddy, Christine M. Sapienza, Erin Pearson, and Henry Ho

Contents ix

Case Study 4.9. The Use of Semi-Occluded Vocal Tract Methods and 225 Resonant Voice Therapy to Habilitate Unilateral Vocal Fold ParalysisJulie M. Barkmeier-Kraemer

References 235

5 Dystonia, Essential Tremor, and Parkinson’s Disease 243Introduction: Neurogenic Voice Disorders 243 Richard AndreattaSpasmodic Dysphonia 245 Joseph C. Stemple

Case Study 5.1. Functional Voice Therapy for Spasmodic Dysphonia 247Joseph C. StempleCase Study 5.2. Medical and Behavioral Management of Adductor 250 Spasmodic DysphoniaEdie R. Hapner and Michael M. Johns IIICase Study 5.3. Combined Laryngeal Injection of Botulinum Toxin 256 and Voice Therapy for Treatment of Adductor Spasmodic DysphoniaEileen FinneganCase Study 5.4. The Use of Reduced Voicing Duration to Treat 263 Vocal TremorJulie M. Barkmeier-KraemerCase Study 5.5. Treatment for Vocal Tremor in a Classical Singer 274Kristen BondCase Study 5.6. Use of LSVT LOUD® (Lee Silverman Voice 281 Treatment) in the Care of a Patient with Parkinson DiseaseLorraine Ramig and Cynthia Fox

References 287

6 Disorders of the Upper Airway: Irritable Larynx Syndrome, 293 Chronic Cough, Paradoxical Vocal Fold Dysfunction, and Upper Airway ChallengesIntroduction to Irritable Larynx Syndrome 293 Linda Rammage

Case Study 6.1. A Case of ILS Managed by a Comprehensive 295 Approach to Multiple Central Sensitivity Syndrome TriggersLinda RammageCase Study 6.2. Combined Voice Therapy with the use of 304 Central Nervous System Inhibitors in the Successful Treatment of Chronic CoughMadeleine Pethan and Laureano Giraldez-RodriguezCase Study 6.3. Therapy for Chronic Refractory Cough 311Thomas Murry

x Voice Therapy: Clinical Case Studies

Introduction to Paradoxical Vocal Fold Motion 324 Mary J. Sandage

Case Study 6.4. Treatment of PVFM/VCD in a Collegiate Swimmer 327Mary J. SandageCase Study 6.5. Treatment of Paradoxical Vocal Fold Motion 335 Disorder in a 9-Year-Old AthleteMaia BradenCase Study 6.6. Long-Term Management of Odor-Induced 341 PVFM After Environmental Fume ExposureCarissa MairaCase Study 6.7. Inspiratory Muscle Strength Training in a Patient 347 with Upper Airway LimitationSusan Baker Brehm and Barbara Weinrich

References 354

7 Management of the Professional, Avocational, and 359 Occupational VoiceIntroduction 360 Marina Gilman

Case Study 7.1. Semi-Occluded Vocal Tract and Resonant Voice 364 Therapy in the Perioperative Management of a Professional Actor and Singer with a Vocal Fold CystSarah L. Schneider and Mark S. CoureyCase Study 7.2. Management of Vocal Fold Nodules in a Female 376 Pre-Pubescent SingerPatricia Doyle and Starr CookmanCase Study 7.3. Therapeutic Intervention for the Touring Musical 386 Theatre Vocal Athlete with High Physical and Vocal DemandsWendy LeBorgneCase Study 7.4. Voice Intervention for a Touring Broadway Singer 394Shirley GhersonCase Study 7.5. Combined Modality Management of the 400 High-Risk Vocal PerformerBari Hoffman Ruddy, Jeffrey Lehman, and Christine SapienzaCase Study 7.6. Voice Recalibration with the Cup Bubble Technique 408 for a Country SingerJennifer C. Muckala and Brienne RuelCase Study 7.7. Praise and Worship Leader Pre-Post Removal of 416 Bilateral Vocal Fold LesionsMarina GilmanCase Study 7.8. The Use of Voice Therapy in Conjunction with 423 Minimal Injection Medialization in the Longitudinal Treatment of Dysphonia in an Elite Operatic SingerBrian E. Petty and Miriam van Mersbergen

Contents xi

Case Study 7.9. Voice Therapy in a 28-Year-Old Theater Actor 427Kate DeVoreCase Study 7.10. Conversational Voice Therapy: A Case Describing 433 Application of Public Speaking Techniques to Voice DisordersAlison Behrman

References 438

8 Nontraditional Therapy Delivery Models and 443 Therapeutic ChallengesIntroduction 443 Vrushali Angadi

Case Study 8.1. Voice Therapy Telepractice: “Live on Stage!” 446Michael ToweyCase Study 8.2. Treatment of Vocal Hyperfunction and Bilateral 451 Lesions in a Child: A Traditional Therapeutic Approach Delivered via TelepracticeLisa KelchnerCase Study 8.3. Use of Telepractice to Provide Voice Therapy for a 457 Patient with Parkinson DiseaseLyn CovertCase Study 8.4. Communication Modification in a 462 Transgender WomanSandy HirschCase Study 8.5. The Use of Physiologic Voice Therapy Exercises 467 in a Transgender Male ClientJoAnna SloggyCase Study 8.6. Treatment of Muscle Tension Dysphagia 476Christina H. KangCase Study 8.7. The Use of Conversation Training Therapy for an 483 Individual with Voice Fatigue and Pervasive Vocal FryLauren Timmons and Edie Hapner

References 491

Index 497

xiii

Preface

This fifth edition of Voice Therapy: Clini-cal Case Studies marks the twenty-fifth anniversary of this text. Since the first edition, 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, laryngolo-gists, 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 produc-tion continues to expand, so, too, have the publications dedicated to describ-ing this knowledge. There are currently excellent texts and journals that report and explore the scientific understanding of voice. Other publications are avail-able to help prepare students to evalu-ate and manage clinical voice disorders. By necessity, these texts must include great quantities of didactic information so that the student learns not only the “how” but the “why” of voice evalua-tion and treatment. To utilize a manage-ment 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. Voice Therapy: Clinical Case Studies is meant to fill that gap.

The fifth edition of this text includes 54 case studies and 7 case vignettes sam-

pling a wide variety of voice disorders with various pathologies, etiologies, and therapy techniques. Through a system-atic case study format, 64 voice experts and master clinicians have provided detailed descriptions of voice assess-ment and management approaches and techniques. It is our hope that the expertise offered in these pages will serve the reader well in guiding clinical voice practice.

Utilizing the format of actual case studies, complete descriptions of diag-nostic and therapeutic methods and results are provided for a full array of voice disorders. Chapter 1 is an expanded discussion devoted to the principles of successful voice therapy. What makes therapy successful or unsuccessful? This chapter examines both the qualities and preparation of the voice therapist and the responsibilities and challenges of the patient, and describes the pitfalls that may influence the ultimate goal of our interventions, improved vocal function.

Chapter 2 comments on vari-ous voice evaluation protocols. These include the formal questionnaire, the patient interview, perceptual voice anal-ysis, patient self-assessment, and instru-mental assessment of voice production. The role of the evaluation process as a part of the overall management plan is also discussed.

Chapter 3 presents treatment approaches for the most common type of voice disorder, muscle tension dysphonia (MTD). Following an overview of MTD by Nelson Roy, management approaches

xiv Voice Therapy: Clinical Case Studies

for both children and adults includ-ing hygiene programs, symptomatic modifications, attention to psychosocial issues, and direct physiologic manipula-tion and exercises are presented in illus-trative case studies of both primary and secondary MTD.

Aaron Ziegler introduces Chapter 4, a discussion of treatments for vari-ous etiologies of glottal incompetence. Management for presbyphonia, vocal fold paralysis, sulcus vocalis, and voice fatigue are described, including direct voice therapies, surgical intervention, and a combination of these approaches. Many techniques including voice facili-tating techniques, semi-occluded vocal tract, expiratory muscle strength train-ing, and phonation resistance training are discussed.

Chapter 5 presents management strategies for laryngeal dystonia, essen-tial tremor, and Parkinson’s disease. Fol-lowing an introduction of neurogenic voice disorders by Richard Andreatta, a series of cases will describe strategies for behavioral and medical management of spasmodic dysphonia, voice therapy for essential tremor, and treatment of voice and speech symptoms related to Parkin-son’s disease.

Because of the speech language pathologist’s unique blend of knowl-edge regarding upper airway anatomy and physiology and behavioral ther-apy, 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 irri-table larynx syndrome and paradoxi-cal vocal fold motion (PVFM). These cases include treatments for laryngo-pharyngeal reflux, laryngeal sensitiv-

ity triggers, and PVFM in the young child, young athlete, and elite athlete. The background for these cases are first introduced in excellent discussions by Linda Rammage (Irritable Larynx Syn-drome) and Mary Sandage (Paradoxical Vocal Fold Motion).

The consequences of a voice dis-order not only may impact the quality of life but may also threaten the liveli-hood of individuals dependent upon a healthy voice. Marina Gilman intro-duces Chapter 7, which presents case studies for those dependent upon their voices, 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 new to this text. Vrushali Angadi intro-duces the reader to a chapter dedicated to discussing nontraditional therapy delivery models and therapeutic chal-lenges. Case studies describe the use of telemedicine in the delivery of voice therapy in a traveling performer, a child who lives in a rural area, and an individ-ual with Parkinson’s disease. Speech-language pathologists also treat indi-viduals desiring to make their voices representative of their gender identity. Cases describing communication and voice modification in the transgender population are included. Because of the shared anatomy, voice and swallowing issues may co-occur in an individual. This chapter also includes an interest-ing case of “muscle tension dyspha-gia.” Finally, glottal fry phonation has become somewhat of a social norm. In some cases, however, this recognized vocal register may create vocal diffi-culties as described by a case in which chronic and pervasive use of vocal fry appeared to be a primary component of a voice complaint.

Contributors xv

As with the first four editions of Voice Therapy: Clinical Case Studies, the most exciting element in the preparation of this text was the support received by the voice experts and master clinicians who graciously and generously submit-ted case studies. The list of contributors is literally a “Who’s Who” in the field of voice disorders. 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 a 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 prepar-ing references, organizing tables, fig-ures, 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 preparation of this text to have the invaluable edito-rial assistance of the Plural Publishing professionals. We are indebted to Angie Singh, Valerie Johns, and Kalie Koscielak for encouraging and supporting this fifth edition and to Linda Shapiro and Jessica Bristow on the production side of the text preparation. 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

xvii

Contributors

Richard D. Andreatta, PhDAssociate ProfessorDepartment of Rehabilitation SciencesDivision of Communication Sciences

and DisordersUniversity of KentuckyLexington, KY

Vrushali Angadi, PhDAssistant ProfessorDepartment of Rehabilitation SciencesDivision of Communication Sciences


Susan Baker-Brehm, PhDProfessor & ChairDepartment of Speech Pathology and

AudiologyMiami UniversityOxford, OH

Julie M. Barkmeier-Kraemer, PhD, ASHA-FProfessorDepartment of SurgeryDivision of OtolaryngologyUniversity of UtahSalt Lake City, UT

Alison Behrman, PhDAssistant ProfessorSchool of Health Sciences, Human

Services, and NursingDepartment of Speech-Language-

Hearing SciencesLehman College

City University of New YorkNew York, NY

Kristen Bond, MM, MSSpeech Language PathologistSan Francisco Voice and Swallowing

CenterSan Francisco, CA

Maia Braden, MSSpeech-Language PathologistUniversity of Wisconsin–MadisonVoice and Swallow ClinicsAmerican Family Children’s HospitalMadison, WI

Starr Cookman, MAAssistant Professor, Clinical FacultyVoice and Speech ClinicUniversity of Connecticut Health

CenterFarmington, CT

Mark S. Courey, MDProfessor, Otolaryngology–Head and

Neck SurgeryDivision Chief, LaryngologyDirector, Grabscheid Voice and

Swallowing CenterMount Sinai Health SystemNew York, NY

Lyn Tindall Covert, PhD, ASHA-FSpeech-Language PathologistDepartment of Veterans Affairs

Medical Center, RetiredLexington, KY

xviii Voice Therapy: Clinical Case Studies

Daniel Croake, PhDAssistant ProfessorDepartment of Rehabilitation

SciencesDivision of Communication Sciences


Ilter Denizoglu, MDPhonosurgeon and Voice PathologistClinical Vocology UnitMedical Park Izmir HospitalIzmir, Turkey

Kate DeVore, MASpeech-Language PathologistTotal Voice, Inc.Chicago, IL

Maria Dietrich, PhDAssistant ProfessorDepartment of Communication

DisordersUniversity of MissouriColumbia, MO

Patricia B. Doyle, MAInstructorVoice and Speech ClinicUniversity of Connecticut Health

CenterFarmington, CT

Eileen M. Finnegan, PhDAssociate ProfessorDepartment of Communication

Sciences and DisordersUniversity of IowaIowa City, IA

Cynthia M. Fox, PhD, ASHA-FResearch AssociateNational Center for Voice and SpeechUniversity of Colorado–BoulderDenver, CO

Lisa Fry, PhDAdjunct Faculty, Department of

Communication DisordersMarshall UniversityHuntington, WV

Jackie Gartner-Schmidt, PhD, ASHA-FProfessor of OtolaryngologyCo-Director of the UPMC Voice CenterDirector of Speech Pathology-Voice

DivisionUniversity of Pittsburgh Medical

CenterPittsburgh, PA

Shirley Gherson, MAClinical Specialist–Voice DisordersNYU Langone Medical CenterRusk RehabilitationNew York, NY

Amanda I. Gillespie, PhDAssistant ProfessorCo-DirectorEmory Voice CenterOtolaryngology Head and Neck SurgeryEmory UniversityAtlanta, GA

Marina Gilman, MM, MASpeech-Language PathologistEmory Voice CenterOtolaryngology Head & Neck SurgeryEmory UniversityAtlanta, GA

Laureano A. Giraldez-Rodriguez, MDDirector, The Voice and Swallowing

Center of Puerto RicoAssistant ProfessorSection of Otolaryngology–Head and

Neck SurgeryUniversity of Puerto Rico School of

MedicineSan Juan, Puerto Rico

Contributors xix

Leslie E. Glaze, PhD, ASHA-FSpeech-Language PathologistMinneapolis, MN/Tucson, AZ

Stephen Gorman, PhDVoice PathologistBlaine Block Institute for Voice

Analysis and RehabilitationDayton, OH,Professional Voice Center of GreaterCincinnati, OH

Rebecca Lynne Hancock, MEdSpeech-Language PathologistChildren’s Healthcare of AtlantaAtlanta, GA

Edie R. Hapner, PhD, ASHA-FProfessor, Caruso Department of

Otolaryngology Head and Neck Surgery

Director of Speech-Language PathologyUSC Voice CenterKeck School of MedicineLos Angeles, CA

Sara Harris, FRCSLTSpeech-Language PathologistLewisham Hospital Voice Disorders

UnitLondon, United Kingdom

Leah Helou, PhDAssistant ProfessorDepartment of Communication

Sciences and DisordersUniversity of PittsburghPittsburgh, PA

Rita Hersan, MSSpeech-Language Pathologist/Voice

ClinicianUniversity of Pittsburgh Voice CenterPittsburgh, PA

Sandy Hirsch, MSSpeech-Language Pathologist

Give VoiceSeattle, WA

Henry N. Ho, MD, FACSDirector, Head and Neck ProgramThe Florida Hospital Cancer InstituteOrlando, FL

Bari Hoffman Ruddy, PhD, ASHA-FProfessorDepartment of Communication

Sciences and DisordersUniversity of Central FloridaOrlando, FL

Michael M. Johns, MD, FRCSProfessorCaruso Department of Otolaryngology

Head and Neck SurgeryDirector of LaryngologyUSC Voice CenterUniversity of Southern CaliforniaLos Angeles, CA

Christina H. Kang, MM, MSSpeech-Language PathologistDepartment of Otolaryngology–Head

and Neck CancerMayo ClinicScottsdale, AZ

Lisa N. Kelchner, PhD, BCS-S, ASHA-FProfessorDepartment of Communication

Sciences and DisordersUniversity of CincinnatiCincinnati, OH

Wendy DeLeo LeBorgne, PhDVoice Pathologist/Singing Voice

Specialist/Clinical DirectorThe Blaine Block Institute of Voice

Analysis and RehabilitationProvoice Center of Cincinnati College–

Conservatory of MusicDayton, OH/Cincinnati, OH

xx Voice Therapy: Clinical Case Studies

Jeffrey J. Lehman, MD, FACSClinical ProfessorCollege of Health and Public AffairsUniversity of Central FloridaMedical DirectorThe Voice Care CenterWinter Park, FL

Claudio F. Milstein, PhDDirector, The Voice CenterCleveland ClinicAssociate Professor of OtolaryngologyCleveland Clinic Lerner College of

MedicineCleveland, OH

Jennifer Muckala, MASpeech-Language PathologistVanderbilt Bill Wilkerson CenterUniversity of VanderbiltNashville, TN

Thomas Murry, PhD, ASHA-FProfessor, Department of

OtolaryngologyLoma Linda University Medical

CenterLoma Linda, CA

Chayadevie Nanjundeswaran, PhDAssistant ProfessorDept. of Audiology and Speech-

Language PathologyEast Tennessee State UniversityJohnson City, TN

Diana Orbelo, PhDSpeech-Language PathologistDepartment of OtorhinolaryngologyMayo Clinic College of MedicineRochester, MN

Rita R. Patel, PhDAssistant ProfessorDepartment of Hearing and Speech

Sciences

Indiana UniversityBloomington, IN

Madeleine Pethan, MASpeech-Language PathologistLevine Children’s HospitalCharlotte, NC

Brian E. Petty, MA, MASpeech-Language Pathologist

Emory Voice CenterDepartment of Otolaryngology Head

and Neck SurgeryEmory University

Atlanta, GA

Carissa Portone-Maira, MSSpeech-Language PathologistEmory Voice CenterDepartment of Otolaryngology Head

and Neck SurgeryEmory UniversityAtlanta, GA

Lorraine A. Ramig, PhD, ASHA-FProfessor, University of

Colorado–BoulderSenior Scientist, National Center for

Voice and Speech–DenverAdjunct Professor, Columbia

UniversityNew York, NY

Linda Rammage, PhD, RSLPDirectorProvincial Voice Care Resource

Program, UBCVancouver, BC, Canada

Clark A. Rosen, MD, FACSProfessor, Otolaryngology–Head and

Neck SurgeryChief, Division of LaryngologyUCSF Voice and Swallowing CenterUniversity of California, San FranciscoSan Francisco, CA

Contributors xxi

Nelson Roy, PhD, ASHA-FProfessorDepartment of Communication

Sciences and DisordersDivision of Otolaryngology Head and

Neck SurgeryDepartment of Surgery, School of

MedicineUniversity of UtahSalt Lake City, UT

Brienne Ruel, MASpeech-Language PathologistUW Voice and Swallow Clinics,

Department of SurgeryMadison, WI

Mary J. Sandage, PhDAssociate ProfessorDepartment of Communication

DisordersAuburn UniversityAuburn, AL

Christine Sapienza, PhD, ASHA-FDean, Brooks Rehabilitation College of

Health SciencesProfessor, Communication Sciences

and DisordersJacksonville UniversityJacksonville, FL

Sarah L. Schneider, MSSpeech-Language Pathology DirectorUCSF Voice and Swallowing CenterUniversity of California

San FranciscoSan Francisco, CA

Erin Pearson Silverman, PhDResearch Assistant ProfessorUniversity of FloridaGainesville, FL

JoAnna Sloggy, MASpeech-Language Pathologist

University of Kentucky Voice and Swallow Clinic

Lexington, KY

Heather Starmer, MAAssistant ProfessorDirector of the Head and Neck

Cancer Speech and Swallowing Rehabilitation Center

Department of Otolaryngology Head and Neck Surgery

Stanford UniversityStanford, CA

Joseph C. Stemple, PhD, ASHA-FProfessor, Communication Sciences

and DisordersCollege of Health SciencesUniversity of KentuckyLexington, KY

Lauren Timmons, MSSpeech-Language PathologistUSC Voice CenterCaruso Department of Otolaryngology

Head and Neck SurgeryLos Angeles, CA

Michael Towey, MA, ASHA-FManager, Department of Speech-

Language PathologyVoice and Swallowing Center of MaineWaldo County General HospitalBelfast, ME

Miriam van Mersbergen, PhDAssistant ProfessorSchool of Communication Sciences and

DisordersUniversity of MemphisMemphis, TN

Kittie Verdolini Abbott, PhD, ASHA-FProfessor, Communication Science and

DisordersUniversity of DelawareNewark, DE

xxii Voice Therapy: Clinical Case Studies

Barbara Weinrich, PhD, ASHA-FProfessor EmeritaDepartment of Speech Pathology and

AudiologyMiami UniversityOxford, OH

Nicole Yee-Key, PhDAssistant ProfessorSchool of Communication Sciences

and Disorders

McGill UniversityMontreal, QC, Canada

Aaron Ziegler, PhDAssistant ProfessorOregon Health and Science UniversityNorthwest Clinic for Voice and

SwallowingPortland, OR

1

1

Principles of Successful Voice Therapy

Joseph C. Stemple

Introduction

The profession of speech-language pathology began in 1925, with the birth of the American Academy of Speech Correction, the predecessor of the American Speech-Language-Hearing Association (ASHA). The first practi-tioners of speech correction were most interested in correcting articulation and treating fluency disorders. In the middle to late 1930s, two first-edition textbooks, The Rehabilitation of Speech by West, Kennedy, and Carr1 and Speech Correction Principles and Methods by Van Riper,2 began to discuss improving the quality of disordered voice. As many of

the early speech correctionists had back-grounds in training the theater voice, elocution, and public speaking, many of the voice therapy techniques arose from these disciplines with a heavy empha-sis on keeping the vocal instrument healthy, or vocal hygiene. The number of traditional therapy approaches that continue to be used in voice therapy today is a strong statement of apprecia-tion and admiration for the voice peda-gogues, clinicians, and speech 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

2 Voice Therapy: Clinical Case Studies

research.3 Proof of the usefulness of many of these techniques, however, has been well established by the clini-cal results of skilled speech-language pathologists (SLPs).

The major difference in voice ther-apy today compared with even 20 to 30 years ago is the ability to diagnose vocal function quickly and accurately and to confirm the efficacy of our man-agement approaches through a multi-modal assessment approach. As you will read in the case studies in this text, voice evaluation and treatment are interdisciplinary with speech-language pathologists and laryngologists often practicing side-by-side in patient care. The recommended evaluation pro-cess comprises five domains of voice assessment, patient self-report, audio-perceptual evaluation, acoustic analy-sis, aerodynamic measures, and visual imaging of vocal fold function.4 These objective measures may also be used as patient feedback during the thera-peutic process. Although our manage-ment approaches have evolved over the years, voice therapy remains a blend of science and art.

Scientific Nature of Voice Care

The scientific nature of voice therapy involves the clinician’s knowledge of several important areas of study. These areas include the anatomy and physi-ology of normal and disordered voice production; the nuances of laryngeal pathologic conditions; the acoustics and aerodynamics of voice production; and the etiologic correlates of voice disor-ders, including patient behaviors, medi-cal causes, and psychological contribu-tions. Regarding the scientific nature of voice care we may state:

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, functional com-ponents, and the interactions of the voice subsystems, respiration, pho-nation, and resonance.

n To fully evaluate the voice, we must possess a broad knowledge of the common causes of voice disorders and the nuances of laryngeal patho-logic conditions.

n To document the voice, we must have the skills to measure these com-ponents objectively and to relate these measures to our management choices.

Artistic Nature of Voice Care

The artistic nature of voice therapy is dependent on the human interaction skills of the clinician as related to the desires and needs of the patient. Com-passion, understanding, empathy, and projection of credibility, together with listening, counseling, and motivational skills are essential attributes of the suc-cessful 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.

1. Principles of Successful Voice Therapy 3

The successful voice clinician will combine attributes of the artistic approaches of voice therapy with the objective scientific bases to identify the problem and then plan and carry out appropriate management strategies. Possession of a solid base of didactic information related to evaluation and treatment augments practical experi-ence. However, experience continues to teach even the master clinician. It is hoped that the experiences of others provided in this text will prove helpful in the development of superior voice clinicians.

How to Use This Text

In this fifth edition of Voice Therapy: Clin-ical Case Studies, over 60 master voice cli-nicians and voice experts share 54 com-plete case studies and 7 case vignettes that involve detailed background, his-tory, and evaluation and management approaches for a wide variety of voice and upper airway disorders. These management approaches include a vari-ety of voice therapy techniques from all orientations of voice therapy, including vocal hygiene therapy, symptomatic approach to voice therapy, psychogenic voice therapy, and physiologic orien-tation to voice therapy. The disorders include those classified as muscle ten-sion dysphonia, disorders caused by glottal incompetence, neurogenic voice problems, voice disorders caused by an irritable larynx and other upper air-way problems, and disorders specific to professional voice users. New to this edition is a final chapter that discusses treatment for nontraditional voice chal-lenges as well as nontraditional service delivery models.

This text is meant for the novice clinician who seeks an understanding of the types of patients seen in a voice clinic and the decisions made by mas-ter clinicians in their care. The text is also meant for the seasoned clinician searching for additional treatment sug-gestions. Readers may search the text-book by type of disorder and/or type of treatment chosen to modify that disor-der. We have stressed that cases should include the thought processes of the clinicians as they plan evidence-based treatments supported by evaluation data as well as detailed explanations of the specific management plans. A word of caution . . . This text is not meant to be a voice therapy cookbook. The authors stress that we do not treat disorders, rather we address the voice needs of our patients through systematic evalu-ation and treatment planning that will address those needs. Each patient is an individual with a unique problem asso-ciated with voice production. Success-ful voice therapy requires that we honor the individual and seek to understand that uniqueness.

Historical Perspective

In examining the evolution of the treat-ment of voice disorders, we find it was not until around 1930 that a few lar-yngologists, singing teachers, instruc-tors 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 nor-mal voice in an attempt to modify disor-dered voice production. Many of these rehabilitation techniques were and


remain creative and effective, but they were not necessarily based on scientific principles as realized today. Indeed, the “artistic” portion of voice treatment was the strong point of the 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 retrain-ing, and (6) special drills for cleft pal-ate and velopharyngeal insufficiency.1,2 These treatment suggestions became the foundation of vocal rehabilitation.

Several general management phi-losophies have arisen from the early foundations of voice rehabilitation. These philosophical orientations are based primarily on the clinician’s mind-set and previous training regarding voice disorders that directs the manage-ment focus. For the sake of discussion, we classify these management philoso-phies as:

n hygienic voice therapyn symptomatic voice therapyn psychogenic voice therapyn physiologic voice therapyn 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. Symptom-atic voice therapy focuses on modification of the deviant vocal symptoms identi-fied by the SLP, such as breathiness, low pitch, glottal attacks, and so on. The focus of psychogenic voice therapy is on the emotional and psychosocial sta-tus of the patient that led to and main-tains 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 cor-rect 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.5

Indeed, none of these philosophi-cal orientations is pure. Much overlap is present, most often leading to the use of an eclectic approach. With this intro-duction, 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, screaming, vocal noises, chronic coughing, chronic throat clearing, smoking, and poor hydration. When the inappropriate vocal behaviors are identified, then appropri-ate treatments can be devised for modify-ing 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 such as glottal attacks, or inappropriate reso-nance. Functional inappropriate use of these voice components may contribute to the development and maintenance of a voice disorder. Hygienic voice therapy presumes that many voice dis-orders have a direct behavioral cause. This therapy strives to instill healthy vocal behaviors in the patient’s habit-ual speech/voice patterns. Good vocal hygiene also focuses on maintaining the


health of the vocal fold cover through adequate internal and surface hydra-tion 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.6 This voice management approach is based on the premise that modifying the symptoms of voice production includ-ing pitch, loudness, breathing, laryn-geal tension, and so on will improve the voice disorder. Once identified, the mis-uses 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 exist-ing 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 particu-lar patient, enables him easily to produce a good voice. Once discovered, the facili-tating technique and resulting phonation become the symptomatic focus of voice therapy. . . . This use of a facilitating tech-nique to produce a good phonation is the core of what we do in symptomatic voice therapy for the reduction of hyperfunc-tional voice disorders.6(p11)

Boone’s original facilitating techniques included:

1. altering 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. establishing new pitch 9. explanation of the problem10. feedback11. hierarchy analysis12. negative practice13. open mouth exercises14. pitch inflections15. pushing approach16. relaxation17. respiration training18. target voice models19. voice rest20. 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 glottal attack, and respiration training. The SLP 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.7,8 West, Kennedy, and Carr1 and Van Riper2 dis-cussed the need for emotional retraining in voice therapy. Murphy9 presented an excellent discussion of the psychody-namics of voice. Friedrich Brodnitz,10 as an otolaryngologist, was one of the early physicians who 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,11 Case,12 Stemple,13 and Colton and Casper.14 These authors discussed the need for determining the emotional dynamics of the voice dis-turbance. Psychogenic voice therapy focuses on identification and modifica-tion of the emotional and psychosocial factors associated with the onset and maintenance of the voice problem. Psy-chogenic voice therapy is based on the assumption of persistent underlying emotional causes for the voice disorder. 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 voice producing mechanisms. Normal voice produc-tion is dependent on a relative balance among airflow, supplied by the respi-

ratory system; phonation, dependent upon laryngeal muscle balance, coordi-nation, and stamina; and coordination among these and the supraglottic reso-nators (pharynx, oral cavity, nasal cav-ity). Any disturbance in the physiologic balance of these vocal subsystems may lead to a voice disturbance.5

These disturbances may be in respi-ratory support, volume, power, pressure, and flow. Disturbances also may mani-fest in vocal fold tone, mass, stiffness, flexibility, and approximation. Finally, the coupling of the supraglottic resona-tors and the placement of the laryngeal tone may cause or may be perceived as a voice disorder. The overall causes may be mechanical, neurogenic, or psycho-logical. Whatever the cause, the man-agement approach is direct modification of the inappropriate physiologic activity through exercise and manipulation of the voice subsystems.

Inherent in physiologic voice ther-apy is a holistic approach to the treat-ment of voice disorders. They are ther-apies 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 loud-ness. Examples of physiologic voice ther-apy approaches include Vocal Function Exercises,15 Resonant Voice Therapy,16,17 the Accent Method of Voice Therapy,18 Manual Techniques,19,20 and Lax Vox Therapy,21 all of which are presented in this text.

Eclectic Voice Therapy

Adherence to one philosophical ori-entation of voice therapy would not be advisable. Indeed, successful voice therapy depends on utilization of an approach that happens to work for the


therapist and the individual patient. The more management approaches under-stood and mastered by the clinician, the greater the likelihood for success. Since we are treating the individual and not the disorder, management techniques that prove successful for one patient may not be successful for a similar patient. The successful voice clinician, therefore, must possess the knowledge and skills to adjust the management approach to fit the needs of the patient.

On the other hand, some tech-niques that work well for one clinician may prove to be difficult or challenging for another. In whatever management approach you choose, you must have supreme confidence in your under-standing of the technique and your ability to make that approach work suc-cessfully. 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 difficul-ties of this composite patient.

Case Study 1.1

Joseph C. Stemple

Case History

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 (severe Reinke’s edema) were first identified by an anesthesiologist while intubating the patient for a lami-nectomy 6 months prior to her voice evaluation. Because of the large polyps, intubation had been difficult. The prob-lem was reported to her family physi-cian, 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. Audi-ble inspiratory stridor was noted by the physician, and the patient reported shortness of breath during even lim-ited physical exertion. Therefore, two KTP (potassium-titanyl-phosphate) laser surgeries were conducted 2 weeks apart followed by 7 days voice rest for each surgery. 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, bother-some dysphonia 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 laminectomy performed earlier this year. Even with the difficult intubation and the risk of vocal fold paralysis inherent in laminectomy, her presurgical voice quality was main-tained. 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 pres-sure, 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 one-and-a-half to two packs of cigarettes per day. Her liquid intake consisted mostly of six cups of caffeinated coffee per day. Chronic throat clearing and a persistent cough were noted throughout the evaluation.

Social History. Patient A had been mar-ried 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-in-law lived with her and her husband, a situation that often caused friction and conflict with her husband. Indeed, she was not shy in reporting her unhappiness with her marital relation-ship. 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 environ-ment 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 shop-ping with her daughter, talking on the telephone, caring for her home, watch-ing daytime television “talk” shows, and bowling two nights per week in two different leagues (back permitting).

Voice Evaluation

Audio-Perceptual Examination. Per-ceptually, the patient’s voice quality as scored on the CAPE-V22 was moderately dysphonic, characterized by low pitch,

inappropriate loudness, roughness, and intermittent glottal fry phonation.

Acoustic Analysis and Aerodynamic Measures. These instrumental assess-ments revealed a low fundamental frequency (150 Hz), limited frequency range (118–290 Hz), increased habitual intensity (76 dB0), normal airflow vol-ume (2300 mL H2O), reduced airflow rate (<80 mL H2O/sec), and reduced maximum phonation time (<12 sec).

Laryngeal Imaging. Laryngeal video-stroboscopic observation revealed mild-to-moderate bilateral true vocal fold edema and erythema. Glottic closure demonstrated an irregular glottal chink with a moderate ventricular fold com-pression. 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 bilat-erally. 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 disor-der that derived from the following pos-sible causal factors:

n cigarette smokingn harsh employment environmentn talking over noise at workn large caffeine intaken frequent upper respiratory infectionsn prescription medicationsn coughing and throat clearingn emotional instability


n talking too loudly (suggesting pos-sible hearing loss, which later proved not to be present)

n using a low pitchn laryngeal muscle tensionn postsurgical vocal fold mucosal

changes

Recommendations per Voice Therapy Orientation

The following are recommendations for voice therapy if one were to adhere to a single orientation of voice therapy. The folly of this approach is readily evident.

Hygienic Voice Therapy. The general focus would be to identify the pri-mary and secondary vocal misuses and then to modify or eliminate these non-hygienic behaviors. The primary etio-logic correlates include:

n smokingn laryngeal dehydration from caffeine

and prescription medicationsn voice abuse, such as coughing, throat

clearing, and talking loudly over noise at work

Therapy would focus on modifi-cation or elimination of the perceived primary causes. The patient would be aided in her attempt to stop smoking, encouraged to begin a hydration pro-gram, and given vocal hygiene counsel-ing to aid in elimination or reduction of the vocally traumatic behaviors.

Symptomatic Voice Therapy. General focus would use facilitating techniques to:

n raise pitchn reduce loudnessn reduce laryngeal area tension and

effort

Psychogenic Voice Therapy. General focus would explore the psychodynam-ics 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 the patient regarding the effects of emotions on voice production

n reduction of the musculoskeletal ten-sion with the use of laryngeal manip-ulation/laryngeal massage

n referral for marital counseling as deemed appropriate

Physiologic Voice Therapy. The general focus would be to evaluate the present physiologic condition of the patient’s voice production and develop direct therapeutic exercises to improve that condition. We know that the patient presented with extreme laryngeal ten-sion. Irregular vocal fold edges caused a glottal chink. In addition, her vocal folds were extremely stiff, as demon-strated by the amplitude of vibration 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, permit-ting the release of one puff of air. As the air rushes between the vocal folds, subglottal, supraglottal, and intra-glottal pressures, along with the static position of the vocal folds, draw them back together to complete one vibra-tory cycle.23 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 com-pensations 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 therapeutic exercises designed to rebalance the three subsys-tems 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, among oth-ers. (All methods are described in sub-sequent chapters.)

Eclectic Voice Therapy. In this review of philosophical orientations of voice therapy, you have seen the various strengths of each management orien-tation, as well as the difficulty in sub-scribing to any one philosophy. All patients will be treated best by a speech language pathologist with knowledge and understanding of all possible man-agement 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 bet-ter understanding the reasons for the selected approach. The successful SLP is both an artist and a scientist with an eclectic point of view. Consequently, therapy for Patient A should focus on:

n vocal hygiene counselingn symptom modification as required

n attention to the psychodynamics of the problem

n direct physiologic vocal exercise

Voice Care Team

Thus far we have discussed the treat-ment of voice disorders in terms of voice therapy. Voice care, however, is a shared province, with contributions from the primary care physician, laryngologist, SLP, neurologist, allergist, gastroenter-ologist, pulmonologist, psychologist, vocal coach, singing instructor, and oth-ers. In addition to these professionals, the patient also carries great responsibil-ity in the improvement of her/his voice. In fact, we would suggest that both cli-nician and patient share equally in the success or failure of voice therapy as described below.

Issues Related to Successful Voice Therapy

The chapters of this text focus on the successful management of a wide range of voice disorders by clinical, medi-cal, and surgical methods. Each con-tributor demonstrates techniques and approaches that prove 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 manage-ment pitfalls that are encountered even by experienced voice clinicians. Such pitfalls may lead to delayed success in treatment, less than totally successful

Documents

Voice Therapy - Plural Publishing, Inc. · viii Voice Therapy: Clinical Case Studies Case Study 3.13. Lessac-Madsen Resonant Voice Therapy in a 132 Young Woman with Vocal Nodules