The patient was dispensed a desktop for dedicated TH use. Software require- ments and operating systems permitted uploading and downloading of acoustic and video images; speakers; and head- phone microphones (with increased acoustic sensitivity, high definition, and low interference). In addition, compat- ibility specifications were cross-refer- enced on all components to include the patient web-portal, video client, and standard antivirus requirements. Cisco Telepresence Movi 4.2 was the teleconferencing software. To provide ample in-home Internet connectivity, the household was required to have the following minimum high-speed broad- band requirements: high-speed cable or DSL with download and upload speeds of 1.5 Mbps or greater.
At the start of therapy, Sam and his parents were provided an orientation and instructional session to learn how
to use the Web-based home program portal and instructions for providing us Web-based feedback.
The structure of the Telehealth Ses- sion: Therapy via the telehealth model used included weekly half-hour syn- chronous hospital to home sessions. The sessions were scheduled to flex with the family and therapist’s availability. The family attempted to secure a relatively quiet space and time for the sessions, although this did not always happen. Use of a departmental computer was the model of TH used at the time of this therapy due to security, privacy, and configuration reasons. A relatively small desktop rather than a laptop was used for durability reasons.
Each session was started by affirm- ing that the audio and video connections were clear and stable. Camera and audio adjustments were made as needed. “Eye contact” between Sam and the clinician was encouraged by having both look at the “camera art”— a visual cue to look up at the camera versus at the screen (although Sam frequently liked to look at himself on the small insert). Each screen had both the clinician and Sam on it. The clinician also viewed the room or asked Sam and his parent to inform her of any guests in the treatment ses- sion. Pop-in visits by curious siblings were more common in the first few ses- sions. Sam kept his headset mic and headphones on most of the time.
Each session started with a review of the previous week’s home program results that Sam and his parents entered on the interactive website. Successes and challenges with vocal hygiene and vocal behaviors and any important events from the previous week were discussed.
The remainder of the time was spent on the direct therapy approaches.
Primary and Secondary Muscle Tension Dysphonia 89
Any technical issues with either the syn- chronous or Web home program ses- sions were discussed with parents and Sam at the end of the session.
Voice Therapy
Sam’s voice therapy program was initi- ated with the standard long-term goals of improving vocal hygiene and reduc- ing laryngeal irritability, and improv- ing voice quality and connected speech intelligibility.
Indirect strategies for accomplish- ing LT Goal 1 included the following: Provide patient and parent education regarding vocal function and voice care in order to identify ways to avoid vocally harsh behaviors and situations that pro- voke laryngeal hyperfunction; identify substitute behaviors for harsh vocal behaviors (eg, sip water and long, hard swallow, turning down background noise/volumes; walk to listener); drink more water and reduce carbonated, caf- feinated drinks; model and teach easy onset shout; use ear plugs to lower vol- ume; and take voice naps during other activity (homework, game playing). Specific strategies to manage reflux included providing a basic description of what reflux is and how it can impact laryngeal health. They were also pro- vided a list of foods and behaviors that are known to aggravate reflux. The dose and timing of the prescribed PPIs were also reviewed. The family was under the impression Sam should take the medi- cation only if he was symptomatic. Tak- ing the medication 30 minutes prior to the selected meals was emphasized. Of note, we did not ask Sam to eliminate all potential reflux triggers but rather pace and proportion such foods (eg, pizza) and to avoid late-night snacks.
Instead of charting all specific behaviors, Sam was asked to answer questions related to his vocal health and behavior on his daily Web home- work session. That website had high- interest graphics and a series of yes/ no questions that reinforced an under- standing of why the behaviors should be used (or avoided). Positive feedback was provided at the end of the website question session. Information regarding voice care guidelines was also conveyed to Sam’s elementary school personnel including his classroom teacher, school nurse, school SLP, music teacher, and PE teacher.
Direct Therapy: Modification of Vocal Function Exercises and Resonant Voice were used to accomplish the second LT goal. Initially Sam had dif- ficulty producing the desired semi- occluded vocal tract gestures to achieve easy vibration and frontal focus during vocal tasks. This issue was addressed by having Sam do lip and tongue trills, sustained labiodental “vv” sounds, and “whistle with voice.” This whistle tech- nique makes use of a long, plastic whis- tle that can act like a kazoo (which also could have been used). After 2 weeks of (2 live and daily Web) sessions (mean- ing Sam uploaded an audio/video sample during Web practice), Sam was able to achieve the appropriate gesture. It is important to note that we did dem- onstrate this with some hands-on cues during the initial voice evaluation. We also worked on him finding the tense spot in his belly while he sustained the sound, rather than “pushing” from the neck area. Maintaining the gesture while switching back and forth from high and tense to low and relaxed vowel sounds was also a practice task.
With the semi-occluded “focused” gesture in place, work on modified Vocal
90 Voice Therapy: Clinical Case Studies
Function Exercises (VFEs) and Reso- nant Voice Therapy (RVT) started (for more information, see Case Study 13, by Joseph Stemple, Use of Vocal Func- tion Exercises in the Treatment of an Adult With Secondary MTD, later in this chapter). Sam started by using the warm-up exercises and 3 within-range, comfortable pitch levels (low, medium, and high). His initial times averaged 9 seconds for lower and midpitch (CDE) notes and increased to 17 by the end of therapy. Averages for high notes (FG) started at 7 seconds. Glides up were especially hard for him, and we needed to use a lip trill to avoid significant voice breaks. Sam was able to progress to the fully differentiated scale of 5 notes by the end of the 10 weeks and remained working on them in the form of a home program. We tended to use the vowel sound “oo” as in hoot (owl) for the power exercises. Average times for the highest notes improved to 15 seconds but never exceeded the low and mid note times.
Modified Resonant Voice Therapy (RVT) was used in conjunction with the VFEs to reinforce easy vocal fold vibra- tion and distribution of physical energy for voicing in connected speech. Admit- tedly, Sam was rather shy at joining in with some of the chanting and voiced/ voiceless syllable, phrase, and sentence practice. Initially more time was mak- ing him comfortable with the series of exercises and a lot of time was spent on natural melodic contour humming and easy chanting coordinated with ease of respiratory support. During this task, it was useful for the treating clinician to have Sam’s parents pay attention to the degree of tension throughout his chest, neck, and face area. To reinforce the use and practice of the modified RVT, we uploaded videos (with permission) of other children who had excellent tech-
nique. We also were able to record and upload Sam’s practice and point out some subtle differences. Both Sam’s and the sample videos were available to him on the website.
Therapy Outcomes
At the end of the 10 weeks, Sam and his parents returned for an interval voice evaluation. At that time we were able to document a number of positive changes related to Sam’s vocal health. Audio-Perceptual CAPE-V expert rat- ings revealed the following: overall severity: 48 (mild-moderate dysphonia; and moderate improvement in intelli- gibility); roughness: 36; breathiness: 32; strain: 13; pitch: 12 (low); and loudness: 5 (stable). The acoustic values revealed a more stable type I signal, elevated F0 (210 Hz), and greater range (155 to
330 Hz). Improvement in aerodynamic function was evident in changes in aver- age airflow (145 cc/s) and estimated subglottal pressure (5 cm/H2O ).
Repeat laryngeal digital strobos- copy revealed mild improvement in the size of the bilateral lesions with the adjacent edema and erythema resolved; improved glottic closure characterized by a reduction in the posterior gap and apparent size of the bilateral lesions. The posterior commissure hypertrophy remained but erythema was resolved. Simulated slow-motion images revealed that mucosal wave and amplitude of vibration were greater, phase closure was more equal, and the symmetry of vibration was normal.
Parent proxy ratings on the PVI revealed perceived improvements in both the functional (7) and physical domains (8), dropping by 8 and 7 points, respectively. Recall that the emotional
Primary and Secondary Muscle Tension Dysphonia 91
domain was not particularly elevated at the start of treatment (4). When dis- cussing the results directly with Sam, he agreed that he was aware he did not have to force his voice like he did at the start of treatment. Both Sam and his par- ents agreed that his voice was clearer and “less hoarse.” Intermittent raspi- ness persisted.
Importantly, Sam’s laryngeal irri- tability quieted. He was doing much less throat clearing and definitely was able to self-cue to talk at a lower volume in key school and home situations. He remained on his Ritalin with no vocal side effects.
Summary and
Concluding Remarks
Sam, his family, and the treating clini- cian experienced success. Use of the interactive website for homework proved quite successful with a demon- strated 85% participation rate. The hos- pital bioinformatics department had to reset and refresh a small number of practice sessions where Sam had let the sessions time out as opposed to log out. Everyone was pleased with the ability to check practice of gestures through the uploading and downloading of samples in the file share format. Manipulating the rather simple technology aspects of the therapy appealed to Sam.
In general the family and clinician reported that using teleconferencing helped maintain Sam’s attention, that he enjoyed the website graphics, and liked the uploaded images that helped remind them of specific therapeutic ges- tures. He especially enjoyed recording his own voice and uploading the record- ings on the website message board so the clinician could monitor progress
between synchronous sessions. Like- wise, the clinician felt she was more an active participant in the home program and only had to make minor adjust- ments to her usual instructions. There was some burden on the family to appear organized to have the clinician “come to their home” via telehealth, but after the first couple of synchronous ses- sions the family and siblings relaxed. One advantage to the synchronous ses- sions was that the clinician was able to gauge the family’s natural communica- tive style, and she often spontaneously invited siblings into the therapy session, in part to satisfy their curiosity.
Children often need to be able to use their voices strongly, while avoiding damage, and to promote healing of exist- ing vocal injury. In the following case, Rita Hersan describes a therapeutic
approach called Adventures in Voice
to treat a child with MTD Secondary to Vocal Nodules.
Case Study 11
Rita Hersan
Treating a Child With MTD
Secondary to Vocal Nodules Using Concepts From Adventures in Voice
Case History
History of the Problem
Patient M, an 8-year-old boy, came to the voice center accompanied by his parents who described a gradual but noticeable change in the patient’s voice quality
92 Voice Therapy: Clinical Case Studies
over the preceding 9 months approxi- mately. Initially, the voice problem was considered transient and did not seem to bother M or impact his communica- tion or activities at school. M’s parents reported frequent periods of hoarseness that they considered “normal” during this period, until hoarseness worsened and persisted after M attended a sum- mer camp. His parents decided to have M’s voice evaluated, once he expressed frustration saying his voice “was not working right.” M’s teacher had also noticed M’s worsening of voice, but she reassured the parents that no negative comments had been made about it by M’s classmates.
Medical History
Parents described M as a healthy boy with normal developmental history. M had tympanostomy tubes placed when he was 3 years old. His mother reported that M had been “aggressively” clearing his throat, unrelated to eating or drink- ing, and she was concerned about this “habit.” His medical history revealed no evidence of allergy or acid reflux symptoms.
Social History
Patient M was the oldest of 3 children; his younger brothers were 6 and 3 years old. The parents considered M a socially and academically well-adjusted, second- grade student who had special interest in music, singing, and soccer. Both par- ents were professional classical musi- cians. The home environment was char- acterized as moderately noisy because M’s mother taught piano lessons at home. The patient and his brothers had the assistance of a babysitter for after- school activities, but M liked to assume leadership in keeping his brothers enter-
tained while his mother taught piano lessons. The parents described M as not aggressive but a “natural captain,” espe- cially with his soccer team and brothers. He strained his voice while playing and occasionally imitated monsters’ voices. The parents reported that M had always showed mature behaviors compared to his peers.
Voice Evaluation
The patient was evaluated by a voice team that consisted of a speech-language pathologist, audiologist, and otolaryngol- ogist. Hearing was within normal limits. Audio-Perceptual
The audio-perceptual evaluation used a modified ordinal GRBAS96 scale, evalu-
ating overall grade, roughness, breathi- ness, asthenia, strain, adding pitch, and loudness variables. Overall grade (G) was scored based on the CAPE-V90 pro-
cedures. For that parameter, on a visual analog scale of 100 mm, the overall “G” score for M was 52/100. For remaining voice quality parameters, using an ordi- nal scale on which 0 = normal, 1 = mild, 2 = moderate, and 3 = severe, the follow- ing results were obtained: roughness: 1; breathiness: 2; asthenia: 0; strain: 1; pitch: 1 (low); and loudness: 0. An addi- tional note was that intermittent phona- tion breaks were perceived during all the assessment tasks.
Patient Self-Assessment
The parental proxy Pediatric Voice Hand- icapped Index (pVHI)43 was adminis-
tered to quantify the effects of the voice problem. The score was 45/92. Addition- ally, M answered verbally the following
Primary and Secondary Muscle Tension Dysphonia 93
3 questions to self-assess the impact of the voice problem:
n “How much does your voice problem
bother you?” “It bothers you a little bit (mildly), quite a bit (moderately), or a lot (severely)?” He answered “a lot!”
n “Do you think the problem is just
the way the voice sounds, just the way the voice feels, or both?” He answered, “both!”
n “How is your voice today?” Using a
chart representing 10 steps (1 = the worst voice to 10 = the best voice), the patient pointed to step 4.
Instrumental
Videolaryngostroboscopy revealed a bilat-
eral symmetric midsubepithelial lesion of true vocal folds with normal mucosal wave and slightly reduced amplitude of vibration bilaterally. Glottic closure revealed an hourglass configuration.
Acoustic measures revealed a speak-
ing fundamental frequency of 238 Hz in connected speech, based on the all- voiced sentence, “We were away a year ago,” and 226 Hz taken on sustained “ah” at comfortable loudness. A fundamental frequency of 250 Hz was expected for his age on sustained “ah” at comfortable loudness.97,98 Frequency range varied
from 178 to 295 Hz on sustained “ah.” Mean intensity was 68 dB SPL mea- sured during connected speech, and the dynamic intensity range was 65 to 86 dB SPL on sustained “ah.” Patient M’s loudness measures were within normal range.
Aerodynamic measures based on
repeated syllable trains of /pa/ showed a high mean airflow of 250 mL/s at comfortable pitch and loudness, and estimated subglottal pressure at 8.5 cm H2O, which was expected for his age.97