Establishing abdominal breathing is a specific feature of the Accent Method. Inspiration relies on contraction of the diaphragm, which has been described as the major muscle of inspiration,112
allowing the speed and amount of inspired air to be controlled easily and effectively. Expiration is controlled in part by elastic recoil and in part by contraction of the abdominal muscu- lature. Contractions of the latter may be smooth for sustained vocalization and unstressed utterances or punctu- ated by smaller, faster contractions that alter the subglottic air pressure to pro- duce changes in vocal intensity associ- ated with stressed words or utterances of increased vocal loudness. Although research has shown that there are a num- ber of different patterns of breathing and breath control,113 it may be argued
that diaphragmatic-abdominal control is most economical of muscular effort. Diaphragmatic-abdominal breathing displaces soft tissue and the abdominal
contents, rather than pulling against the semirigid structure of the rib cage.
The development of modal voice is also a specific feature of the Accent Method. Modal voice is produced by short, thick vocal folds with relaxed cricothyroid muscles. Good vocal fold closure can be achieved easily and, provided there is sufficient subglottic pressure, satisfactory mucosal waves are generated. The larynx lies neutrally in the neck, and the pharyngeal and supraglottic musculature is less likely to constrict. By contrast, production of a technical falsetto or head voice requires thinned vocal folds and contracted cri- cothyroid muscles. When the vocal liga- ments are stretched, mucosal waves are smaller, and the vocal fold closure may be harder to maintain over long periods. The larynx is raised to shorten the vocal tract and adjust the resonators appro- priately for higher pitches, which may lead to constriction in the supraglottic and pharyngeal musculature. In every way, head voice requires more muscular effort on the part of the laryngopharynx. Many of our English patients adopt this type of phonation pattern for speech, and it is especially common in singers who are used to producing head voice for singing. Some singing teachers even encourage a higher speaking voice by suggesting it is more appropriate for sopranos. Unfortunately, clinical evi- dence suggests that long periods of this pattern of vocal use may result in bow- ing of the vocal folds as they become unable to maintain closure against the stretching produced by powerful crico- thyroid muscle contraction.114
The initial focus on fricatives and close vowels during the Accent Method exercises is also an important feature of the method. These sounds all produce narrowing of the vocal tract within the
118 Voice Therapy: Clinical Case Studies
oral cavity and are believed to create back pressure,115 which assists fast clo-
sure of the vocal folds and may influ- ence the length of the closed phase. They also encourage a high, forward tongue position, opening space between the back of the tongue and the pharynx, which may be associated with the “for- ward resonance” described by singers. The high tongue position has also been associated with enhancement of the 250- kHz region in the vocal spectrum, pro- viding extra brightness and penetration to the vocal tone and allowing it to be heard through background noise.116
Case History
Patient I presented in the ENT clinic at the request of her general practitio- ner and her singing teacher. She was 22 years old and studying singing at a well-known music college in Lon- don. She planned to be a professional mezzo-soprano, specializing in classical and early romantic styles of singing. At the time she was seen, she was in her final year at college with only 3 months remaining before her final examinations and recital.
Patient I had been noticing a prob- lem with her voice for approximately 6 months. She reported that it sounded breathy and immature in her singing and that there were “dead patches” in her upper pitch range where the voic- ing broke into audible air escape. Her singing teacher was particularly con- cerned because patient I was no lon- ger responding to the usual singing techniques designed to resolve these problems. She reported that her speak- ing voice was “mostly OK” but became breathy and hoarse both when she was tired and following prolonged voice use.
Patient I’s case history revealed that she was fit and well with no previ- ous or family history of voice problems. In particular, she had no symptoms of gastroesophageal reflux and no asthma, allergies, or other ENT problems.
As with many students, patient I needed to work to support herself at college. She worked in a noisy restau- rant that was air conditioned and often smoky. She was aware of how much she had to shout in her job, and she also had to do shift work that often involved late nights. In addition to her work and her singing, she ran a youth group at a local church that also involved protracted voice use and shouting. Patient I was the youngest of 3 sisters and described herself as “small but noisy” as a child. She was aware of stress induced by her college work.
Assessment
Initially patient I was seen by an oto- laryngologist specializing in voice dis- orders, who carried out videostrobolar- yngoscopy. Examination revealed that she had an average to large larynx with significant midthird polypoid thicken- ing of both vocal folds. The right fold thickening was more prominent than the left. There was a wide interaryte- noid chink, and the anterior third of the vocal folds failed to close during pho- nation. Mucosal waves were present but poorly developed, largely because of inefficient voice production. The lar- yngologist diagnosed patient I’s vocal pathology as a type-2 muscular ten- sion dysphonia, later named laryngeal isometric disorder.2,16 The laryngologist
referred patient I for voice therapy with a speech-language therapist who spe- cialized in voice.
Primary and Secondary Muscle Tension Dysphonia 119
Perceptual analysis was carried out
informally in clinic and from the patient’s initial audio recording of a standard reading passage.
Pitch
Patient I’s speaking pitch and intona- tion range appeared to be well within the norm for her age and gender. Sire- ning through her full pitch range for singing showed a characteristic break in the upper register where she could no longer sustain phonation. Efforts to overcome this problem area resulted in a breathy “squeak” and visible effort in the extrinsic laryngeal muscles. Intensity and Volume
Patient I’s speaking voice was normal in intensity for quiet conversation with no obvious signs of increased laryngeal effort. She was able to shout, but this produced extrinsic laryngeal muscle effort and led to early vocal fatigue. She reported that the intensity of her sing- ing voice had decreased and that she no longer had control over her dynamic range. High-intensity singing tired her voice more quickly and felt effortful. Quality
The patient’s speaking voice was rated as mildly-moderately hoarse. She used a thin fold phonation type with audible air escape.
Comfort
Patient I reported no discomfort when speaking or singing but described a sense of increased effort or tiredness with high-intensity voice use, whether singing or speaking.
Stamina
The patient reported that her speaking voice felt “tired” and became increas- ingly breathy and weak by the eve- ning. Fatigue developed after an hour of singing or speaking loudly. Her voice responded to rest and had usually recovered by morning, although after a heavy week of voice use in the restau- rant, the recovery period increased to several days of normal voice use and voice rest.
Patient I had no malocclusion, den- tal problems, or articulatory disorders. She produced a good range of articula- tory movement in speech with normal oral-nasal resonance balance. Her tongue position appeared to be reasonably neu- tral, and her lip set in speech was rated as neutral and slight rounding.
Assessment of Breathing Patterns Airflow measures are not available to this clinician for routine use. The assess- ment therefore was carried out on infor- mal observation in the clinic. The breath- ing pattern at rest was produced in the upper chest. There was little observable movement of the abdomen during quiet breathing. During speech, this pattern of breath control continued. Expira- tion was controlled by the upper chest, which was observed pushing inward, particularly when words were stressed. “Top-up” breaths were also upper chest or clavicular. Observation of breath control for singing revealed that patient I was able to produce a more central pattern and was attempting to recruit the abdominal muscles to help control expiration for sustained notes. The pat- tern was erratic and hampered by poor fold closure and air escape, however. As a result, she frequently used residual air
120 Voice Therapy: Clinical Case Studies
and produced signs of increased effort, both in the upper chest and extrinsic laryngeal muscles. She reported that her singing training had provided rela- tively little guidance on breathing, and she was uncertain about the meaning of the term breath support.
Palpation of the Extrinsic Laryngeal Musculature
Assessment of the external laryngeal musculature is standard practice in the author’s clinic, and a shortened form of the Lieberman protocol is used.23,114
As yet, there are no international norms for palpatory findings; however, Jacob Lieberman, a qualified osteopath spe- cializing in laryngeal manipulation, has trained this clinician, and practitioner agreement has been reached for the fol- lowing tasks117:
n Jaw: There was some asymmetry of
jaw opening to the right, and the left temporomandibular joint appeared to be more active than the right. This was apparent during the jaw opening assessment tasks and during spon- taneous speech. The patient had no awareness of the asymmetry and did not suffer from temporomandibular joint discomfort. Her singing teacher had commented that she felt patient I’s jaw tended to be “tight” during singing.
n Suprahyoid and base of tongue muscu-
lature: The suprahyoid and base of
tongue musculature was assessed as tighter than average on palpation. Patient I did not report any tender- ness in these muscles, but there was strong contraction of the geniohyoid muscles during speech and singing. The anterior aspect of the hyoid bone
was aligned with the anterior aspect of the thyroid cartilage.
n Thyrohyoid musculature: Palpation of
the thyrohyoid musculature revealed that these muscles were judged to be “held” tightly with a reduced thyro- hyoid space area. They contracted briskly when speech was initiated and remained contracted throughout the utterance. The normal contractions usually observed during speech were reduced. Patient I was able to release this musculature using the yawn-sigh technique to lower the larynx and was able to maintain a greater thyrohyoid space successfully when the laryngeal position returned to its rest position. She did not report tenderness when these muscles were palpated.
n Cricothyroid musculature: The crico-
thyroid muscles were judged to be held more tightly on the right than on the left, and the patient reported some tenderness when these muscles were palpated. The cricothyroid visor (the anterior space between the lower border of the thyroid cartilage and the upper border of the cricoid car- tilage) appeared to open and close as expected with changing vocal pitch (yawn-sigh contrasted with a high- pitched “squeak”), but it was habitu- ally held at rest in a closed neutral position. The alignment between the lower border of the thyroid cartilage and the upper border of the cricoid cartilage showed that the cricoid was held in a more anterior position rela- tive to the thyroid. This suggested the possibility of some anterior sliding at the cricothyroid joint.114,118
n Strap musculature: These muscles
were judged to be tight, particularly on the right on palpation and laryn- geal shift. The larynx moved easily
Primary and Secondary Muscle Tension Dysphonia 121
to the right but was anchored by the tight right strap muscles, restricting laryngeal shift to the left.
n Laryngeal position in speech: The pa-
tient’s larynx maintained a neutral position in the neck for breathing and raised normally for swallow- ing. It returned easily to a neutral position in the neck following swal- lowing, but as patient I anticipated speech, the larynx rose in the neck and maintained the raised position reliably throughout the utterance. It returned to neutral as soon as phona- tion ceased.