Narrow­band 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 post­treatment 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 post­treatment narrowband spectrogram (B) and power spectrum (C). The presence and amplitude of the dominant harmonic in the post­treatment cepstrum (D) substantiates these improvements.

60 Voice Therapy: Clinical Case Studies

reported infrequent, partial, and self- limiting recurrences early in the follow- up phase (ie, less than 2 months post- treatment). It appears, then, that the case presented here is not exceptional from a treatment-and-relapse perspec- tive. Roy et al44 _{advised that, for some}

patients, superior long-term results might be found when manual laryngeal techniques are combined with support- ive counseling, more frequent clinical support, or both. Certainly, patient XX’s eventual sustained voice improvement following manual circumlaryngeal ther- apy and short-term psychological coun- seling seems to support this contention. During the second treatment, pa- tient XX progressed through stages of decreasing dysphonia and laryngeal dis- comfort until voice symptoms gradually remitted. These findings are also consis- tent 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 repre- sents 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 environ- mental triggers and stressors combined with individual differences in coping style.10,86 _{Understanding the contribu-}

tion of laryngeal and extralaryngeal muscle dysregulation to these disorders, therefore, is critical to proper diagnosis and selection of appropriate treatments. Manual techniques, including focal pal- pation, laryngeal reposturing maneu- vers, 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 elemen- tary school music teacher (kindergarten through grade 6) for the last 10 years. She had a 4-year history of formal clas- sical voice training in college, and over the years continued to take individual voice lessons for short periods to “tune-

Primary and Secondary Muscle Tension Dysphonia 61

up” her voice. Her teaching technique consisted of demonstrating the songs to her students, and then singing with them throughout the entire class. There- fore, over the course of an 8-hour work- ing 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 sig- nificant 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 pro- tective 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 thy- roidectomy, her surgeon explained the potential risks of damage to laryngeal nerves, and stated that she would prob- ably experience some hoarseness after the procedure. She had a nonevent- ful 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 immedi- ately 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 physi- cian, who confirmed that both vocal folds were mobile. He found general- ized laryngeal edema and erythema and prescribed antireflux medication. The patient discontinued this medication after 3 weeks due to lack of improve- ment. 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 physi- cian 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 sig- nificant difficulties performing her job. She was unable to sing and was experi- encing extreme vocal fatigue at end of the day. She had started using a micro- phone 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 cata- strophic 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” local-

ized to the lateral aspect of the lar- ynx, hyoid, and submandibular area

62 Voice Therapy: Clinical Case Studies

bilaterally, particularly when attempt- ing 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 hor- mone levels were balanced, as per her endocrinologist. On the weekends, when she rested and maintained a self- imposed complete voice rest, her energy levels were good. She attributed the fatigue during the week days to the con- stant 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 neuropa- thy, and more rarely in bilateral involve- ment.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 dys- phagia. Superior laryngeal nerve (SLN) transient or permanent injuries are rela- tively frequent and are often underesti- mated.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 symptomatol- ogy, 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 per- form 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 parala- ryngeal 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 re- vealed essentially a normal larynx. There were no lesions, tumor, masses, ulcer- ations, 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 comfort- able pitch level, the pattern of glottal clo- sure was complete. Phase symmetry of vocal fold vibration was regular. Ampli- tude 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 signifi- cant 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

Primary and Secondary Muscle Tension Dysphonia 63

reached. This was confirmed with multi- ple pitch glide repetitions, in which con- striction 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 percep- tion of a legitimate attempt to do so.

After the initial evaluation, sev- eral 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 evalua- tion, 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 subglot- tic pressures, and laryngeal mechanism and valving appeared to be intact.

Treatment recommendations in- cluded an electromyographic (EMG) study to evaluate the status of laryngeal nerves and the initiation of an individ- ual 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 thera- peutic approach would be beneficial to decrease the hyperfunctional component. Therefore, the goals of therapy were estab- lished as follows: (1) decrease muscular tension during voicing, (2) increase pitch range and loudness levels while main- taining a relaxed voicing mechanism, and (3) achieve effortless and relaxed sound. Prognosis for voice improvement was deemed good based on the initial posi- tive response to therapeutic intervention during her evaluation.

The patient initially presented for 2 therapy sessions where several ther- apeutic 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 digi- tal laryngeal manipulation during the initial evaluation, further improve- ment 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 ten- sion was elicited.

64 Voice Therapy: Clinical Case Studies

Based on the clinician’s belief that there was no physiologic impediment for producing louder voice, by mutual agreement, a third session was sched- uled to focus exclusively on vocal loud- ness. The intent was to encourage and motivate the patient to overcome the loudness threshold and achieve louder phonation. An overview of the thera- peutic 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. Eventu- ally, she was able to produce a very loud voice. Encouraged, she tried a couple more times, actually yelling, and this elic- ited 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 evalu- ation of her pitch range revealed com- plete 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 dis- comfort. She also reported a significant improvement in her singing voice. Post- therapy videostroboscopic examination was deemed unnecessary.

Primary and Secondary Muscle Tension Dysphonia 65

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 fur- ther damage.

Even though some of the symptoms appeared consistent with postoperative SLN injury, this was a unique manifesta- tion of what turned out to be a case of functional dysphonia, or musculoskel- etal tension. Muscle tension disrupted two parameters of vocal function, cre- ating 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 con- trol, 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 particu- larly varied. It was a relentless, contin- ued 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 limita- tion. 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 resis- tance, 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, some- times 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 thera- peutic 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 tired- ness (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-fam-