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 (chil- dren 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 drink- ing enough water; talking loudly with
Primary and Secondary Muscle Tension Dysphonia 95
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 Jour- ney 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 cli- nician, 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 evalu- ation. 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 imme- diately 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 eat- ing 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 direc- tions well. The patient was encouraged to invite other people to go on the jour- ney with him. His father and a special friend were suggested as special “jour- ney partners” for his therapy program. He would need to show his journey map, and to participate in some activi- ties with them.
Taking into account the patient’s interest in music and singing, the jour- ney 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 some- thing 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
96 Voice Therapy: Clinical Case Studies
facilitate vocal fold vibration). The jour- ney 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 pro- ducing /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 . . . (musi- cian), 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 “hum- ming” 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-
Primary and Secondary Muscle Tension Dysphonia 97
ating a “scene” for animated repetitions of /l/ and /r/ in different emotional situations.
The patient was asked to find pic- tures 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 associ- ated with body movement and embed- ded on different emotional situations associated with the story. Examples of emotional situations included the fol- lowing: 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 “Per- cussion Town.” Initially, patient M and the journey guide used gestures and body movement associated with a vari- ety of rhythmic patterns and loudness on syllable trains, such as: bambam- bambambam; bombombom BOMBOM bombombom; dindindindindindin;
gaingaingaingain; dundun dun dun dun dun [dn]. To engage the patient in the functional use of loudness varia- tions, 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 Sam- muel! 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 particu- larly important to engage the patient in activities that were more representa- tive of his habitual behavior. The jour- ney 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 sound- level meter to monitor the loudness of their voices while playing a video game.
Afterward, an activity was sug- gested 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
98 Voice Therapy: Clinical Case Studies
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 ther- apy, his mother had been always pres- ent 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 caus- ing 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 consid- erable reduction of bilateral subepithe- lial lesions, normal mucosal wave and amplitude of vibration, and a small pos- terior glottic gap.
Acoustic measures revealed a speak-
ing fundamental frequency of 250 Hz in connected speech and 246 Hz on sus- tained “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
Primary and Secondary Muscle Tension Dysphonia 99
airflow of 160 mL/s and estimated sub- glottal 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 re- ported that his voice was not bothering him anymore, and he had no problems with the way it sounded or effort to pro- duce the voice.
Summary and
Concluding Remarks
Children require frequent and tangible evidence of progress across time. Visual charts assume great importance in ana- lyzing the child’s progress. The notion of getting better is translated by going higher on numbers using a chart repre- senting steps. This idea is very benefi- cial for motivation, helping the patient to quantify his progress, and to under- stand 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 fin- ished 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 prog- ress noted in each therapy session, only 2 or 3 voice activities were selected each week for the home program, besides “vocal care” (voice hygiene) recom- mendations. The use of CDs recorded during the therapy sessions, the jour- ney 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 activi- ties). These activities were only sugges- tions, and not considered essential for the therapy outcome.
Informational feedback was pres- ent throughout the therapy process to reflect how well the patient was doing (emphasis on positive aspects). In addi- tion, motivational feedback was applied in the form of extrinsic rewards (stick- ers on passport) every time the patient “journeyed” well during a therapy ses- sion and completed the daily assign- ments of the home program.
Recommended Family Activities
n Discover sounds around the house
that have the characteristic of vibra- tion (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 instru- ments and their different sounds.
100 Voice Therapy: Clinical Case Studies
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 chil- dren 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 lan- guage, gestures, clapping the hands, and stomping the feet.
School-based voice therapy can be chal- lenging. 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 con- cerns 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 includ- ing 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 lim- ited self-awareness of hoarseness but did endorse frustration that she was dif- ficult to understand by peers and had to repeat, particularly when reading aloud in class. The medical history was nega- tive 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 work- ing 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 pri- marily by yelling and screaming across the house.
Voice Evaluation
CV underwent acoustic, aerodynamic, and laryngovideostroboscopic assess- ment of voice. Salient acoustic and aero- dynamic data are embedded in Table 3–2. Findings of this assessment yielded elevated jitter, shimmer, reduced funda- mental frequency, and significant breaks in her pitch range. Aerodynamic assess- ment demonstrated reduced airflow with increased pressure during voice production.
Rigid videostroboscopy reflected bilateral paired vocal fold nodules, and mild interarytenoid pachydermia.
Primary and Secondary Muscle Tension Dysphonia 101
Medio lateral supraglottic hyperfunc- tion characterized by compression of the ventricular folds was noted during modal pitch. The ENT physician did not