GG was encouraged to continue once- daily practice of Vocal Function Exer- cises and additional semi-occluded vocal tract exercises with straw phona- tion as a warm-up prior to auditions and rehearsals. He expressed understanding that he would need to maintain atten- tion to speaking with forward focus consistently for several weeks to estab- lish his new voice as a habit. His mother
78 Voice Therapy: Clinical Case Studies
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 ini- tial conservative approach with the understanding that he would likely need surgery to fully resolve his com- plaints. GG was able to improve his vocal efficiency using resonant voicing techniques and Vocal Function Exer- cises 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 func- tional 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 consis- tently. 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, some- times leading to vocal pathology. In the following case study, Moya Andrews explores the psychosocial aspects of a child’s behavior related to the develop- ment 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 mid- membranous 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
Primary and Secondary Muscle Tension Dysphonia 79
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 young- est 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 hus- band had been in the US military ser- vice. 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 mild- moderate 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 res- onance; limited vocal variety; and fre- quent throat clearing. She could prolong a vowel for only 3 seconds and exhibited hearing sensitivity within normal limits bilaterally. The results of an examina- tion of her peripheral speech mechanism were unremarkable. The school psychol- ogist’s report noted above-average intel- ligence, frequent temper tantrums and episodes of crying, and use of manipu- lative 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 daugh- ter’s behavior in the following way: “She is quite a handful at times, but she’s intelligent and has had more opportuni- ties 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 inter- personal and vocal strategies to estab- lish satisfying relationships with her peers and teachers. Therefore, the ther- apy program was designed to include work on relevant psychosocial issues, as well as modification of abusive vocal behaviors.