It is not surprising that most pediat- ric voice intervention workshops have good attendance: this is an area where only a small sampling of practitioners feel comfortable providing intervention. For referrals out of clinic back into the schools, 2 to 3 sessions with the school SLP, the voice specialist, and the patient help to facilitate transition. The treat- ment plan for CV included modifying social behaviors such as soda intake, food choices, awareness to vocal inten- sity and surrounding noise (some eco- logical/conservation goals), as well as rebalancing the respiratory and pho- natory subsystems to promote lesion healing.
In this case, this involved a cou- pling of vocal function exercises and resonant voice therapy (for more infor- mation on vocal function exercises, see Case Study 13 by Joseph Stemple, Use of Vocal Function Exercises in the Treat- ment of an Adult With Secondary MTD, later in this chapter) with an initial focus on the use of negative practice. Prior to training vocal function exercise, the patient and school SLP worked with flow mode phonation for the least ten- sion during voice onset as possible. The use of visual cues such as the phonatory
104 Voice Therapy: Clinical Case Studies
aerodynamic system to visualize the transition from airflow into phonation as well as a pinwheel were beneficial.
Establishing self-awareness, moni- toring for nascent self-correction and building a team rapport to keep the patient engaged were the focus of the first session, and half of the second. As the school SLP began to initiate exercise in a team approach, by the third session all parties felt confident this treatment plan could translate into a 2 times per week, 30-minute session. Fortunately, this student was seen alone as no other students on the caseload were available at that time due to course conflicts. If this was in a larger group environment, the focus on resonant voice and con- versation was discussed as a potential treatment goal. Ultimately, for mainte- nance, the student worked in a group environment in conversation with stu- dents with mild pragmatic impairment,
but the primary 8 weeks of treatment were solo.
Therapy Outcomes
Three months after initial assessment, CV returned to the voice clinic for post-treatment assessment. Strobos- copy yielded complete resolution of the paired midline lesions, however the mild interarytenoid pachydermia persisted. The patient’s family was unable to reduce CV’s intake of fried foods,. She was moved to caffeine-free soda, and a lower volume of ketchup. In terms of vocal domination, she was able to reduce yelling by lowering the volume of the television, establishing a 3-foot to 5-foot distance in lieu of yelling across the house, and communication with her mother and grandmother with- out yelling over her cousins. These were
Table 3–3. Kentucky Eligibility and Guidelines (2009)
Primary (K–3) Fourth–Fifth Grade High School
Number of times student is
asked to repeat by teacher Number of repetitions in class Number of times asked to repeat Number of times student
must repeat in small group environment Change in level of participation in specials, extracurricular activities Change in level of participation in specials, extracurricular activities Episodes where student
“shuts down” Reluctance to speak publicly or withdrawing from group presentations
Reluctance to speak publicly, read aloud, or withdrawing from group presentations
Activities where student is unable to fully participate (specials)
Denials to read aloud, answer questions in class, or withdraw from group discussions
Feedback from job interviews, professional coaching interactions, ie, job fairs with school counselor
Source: Kentucky Eligibility Guidelines Revised — for students with speech or language impairment.
Retrieved March 23, 2013, http://education.ky.gov/specialed/excep/Documents/Kentucky%20Eligibi lity%20Guidelines%20for%20students%20with%20speech%20or%20language%20Impairment.pdf.
Primary and Secondary Muscle Tension Dysphonia 105
notable improvements per the fam- ily. Resonant voice was approximately 75% consistent in conversation, and the patient accurately described the traits of “appropriate resonance.” Acoustic and aerodynamic measures are presented in Table 3–4.
Perceptually, the patient’s voice was noted to be within normal limits. In conversation, fundamental speaking pitch was appropriate for age/gender, where previously it was excessively low.
Transitioning From Care
As the patient was interested in cheer- leading, and we could not dissuade her, she was left with a “maintenance” plan of once-weekly group treatment as noted above, to ensure maintenance of technique and adequate voice qual- ity. We determined that given her level of vocal effort, and persistent “risky behaviors,” the prevention of recur- rence was necessary. As of publication, she has not reported recurrence. Under- standing dismissal criteria is vital, par- ticularly if the student is plateaued.
Below are the typical criteria to dismiss from SLP services taken from Ken- tucky Eligibility and Guidelines (2009) retrieved online March 23, 2013, from http://www.education.ky.gov/NR/ rdonlyres/5D691CC1-D69C-4CCD- 89 CC-EE2A3A60DBA5/0/KYEligibility Guidelines.pdf:
n Student has met all objectives from
the IEP related to voice without addi- tional concerns
n At parent request
n No further measureable bene-
fits despite multiple intervention approaches
n Student develops functional compen-
sation skills
n Classroom accommodations can
manage deficit
n No longer required in order to access
the general curriculum
One consideration is the “no fur- ther benefits” concept. Not all therapy is created equal, and not all therapists will achieve the same level with a given patient. One helpful technique in a given patient often falls flat when
Table 3–4. Posttherapy Acoustic and Aerodynamic Results Jitter 0.9% (expected <1%) Phonation
Threshold Pressure
5.0 cm H2O (4–6 cm
H2O expected)
Shimmer 1 dB (expected <1 dB) Mean Peak Air
Pressure 7 cm Honset delay) (expected 2O (without
608 cm H2O)
Fundamental
Frequency 260 Hz (WNL is ~200 Hz) Mean Airflow During Voicing 0.18 L/s (WNL is at or near 0.2 L/s)
Pitch Range
193–1200 Hz (one break observed at 880 Hz)
106 Voice Therapy: Clinical Case Studies
given to another patient. We carefully established a “treatment toolbox” for the school SLP, so once flow mode proved to plateau, she was comfortable integrating some elements of resonant voice, as well as phonatory linking. By having a treatment arsenal, we achieved a higher level of function without stale intervention. Although vocal hygiene was used in this patient’s case, it is rarely the only method we implement to promote healing.
A happy side effect of this experi- ence was the relationship between the school SLP and the clinician in the voice clinic. The school therapist has become a resource for her district for treatment of hoarseness in the class environment and works in conjunction with the voice therapist in assessment and ser- vice delivery. The disconnect between school and medical speech pathology is one that requires correction for the ben- efits of the patients seen in both venues.
The importance of a team approach to voice care is further emphasized in the following case of a teacher with secondary MTD. In this case, Joe Stemple describes the use of traditional voice therapy methods such as vocal hygiene counseling and Vocal Function Exercises, in conjunction with surgical intervention to resolve a case of persis- tent dysphonia.
Case Study 13
Joseph C. Stemple
Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD
History
Patient F, a 26-year-old second-grade teacher, was referred by a laryngolo- gist to the voice center for a complete diagnostic voice evaluation, with the diagnosis of large bilateral vocal fold nodules and a left vocal process ulcer. Patient F first became symptomatic in the fall of her first year of teaching. In October of that year, she became dys- phonic. When the hoarseness persisted, she sought the opinion of the referring physician, whose examination revealed mild bilateral vocal fold edema. The physician instructed her to reduce caf- feine intake and to increase intake of water and briefly counseled her regard- ing voice misuse. The patient followed these instructions, and her voice quality improved.
Between fall and late winter, the patient experienced intermittent hoarse- ness. She thought the mild hoarseness was fairly normal considering her level of voice use in the school setting. In late February, however, she became moder- ately hoarse during an upper respira- tory infection. Like most teachers, she continued to work a normal schedule during her illness. She began to notice not only hoarseness but also voice fatigue and a burning sensation on the left side of her “throat.” When the upper respiratory infection resolved and her voice symptoms persisted, she sought the opinion of the laryngologist.
On seeing the vocal nodules and the ulcerated tissue located on the vocal process of the left arytenoid car- tilage, the laryngologist prescribed reflux medication [proton pump inhibi- tor (PPI)] and referred the patient for a voice evaluation and therapy. The PPI was prescribed as a precaution because of the implications of acid reflux on
Primary and Secondary Muscle Tension Dysphonia 107
the development of contact ulcers and granulomas.
The information gathered dur- ing the voice evaluation confirmed the nature of the voice trauma that had sig- nificantly increased the patient’s symp- toms in February. Patient F had indeed experienced a mild hoarseness since school began that fall. She reported that her voice quality typically was better on Monday and much worse by Friday but that she always had some level of hoarseness. On a daily basis, she was more symptomatic during the early morning. The hoarseness would clear somewhat by midmorning and worsen again by afternoon.
With the onset of the respiratory infection, patient F began coughing and throat clearing. By the time of the voice evaluation, the coughing had decreased, but chronic throat clearing was noted. Her voice use was typical for a second-grade teacher. Students of this age require much instruction, and nonspeech times in the classroom were reported to be minimal. In addition, the patient was assigned playground and school-bus duty, which required occa- sional shouting and raising the voice above noise to be heard.
There was no evidence that the patient misused her voice away from her work environment. She was mar- ried and had a 2-year-old daughter. She denied any direct vocal trauma or envi- ronmental contributions, such as inhaled dust, fumes, chemicals, or paints. She reported that her voice improved on weekends and always returned to nor- mal during the summer months. The remaining social history was unremark- able as related to this problem.
The patient’s medical history also was unremarkable. She was free of any chronic illnesses or disorders; took only
the PPI, although she was not symptom- atic with “heartburn”; and was a non- smoker, living and working in a non- smoking environment. Her liquid intake was not adequate. She drank 2 cans of caffeinated soda and 2 glasses of iced tea per day. Patient F reported that she “loved” teaching and felt “great” on a daily basis.
Voice Evaluation
During the voice evaluation, patient F presented with a moderate dysphonia characterized by dry, breathy hoarse- ness. The laryngeal videostroboscopic examination revealed large bilateral vocal fold nodules, worse on the right than on the left; bilateral edema and ery- thema, and an apparent resolving left contact ulcer. The nodules caused glot- tic closure to demonstrate an hourglass configuration with a slight ventricular fold compression. Both the amplitude of vibration and the mucosal waves were severely decreased bilaterally. The open phase of the vibratory cycle was dominant, whereas the symmetry of vibration generally was irregular. In other words, she presented with signifi- cant tissue changes that would present a challenge to functional voice therapy.
Acoustic measures demonstrated a limited frequency range of 147 to 562 Hz. Her fundamental frequency remained appropriate at 211 Hz. Although her jit- ter measures for sustained vowels were normal at 0.87%, her shimmer measures were high at 0.46 dB.
Aerodynamic measures yielded significantly high airflow rates for high pitches averaging 305 mL/H2O.
Comfort and low pitches were bor- derline high at 180 and 189 mL/H2O,
108 Voice Therapy: Clinical Case Studies
to push more air through her vocal sys- tem to support the vibration because of increased vocal fold mass and the hour- glass glottal chink. Her subsequent pho- nation times at all pitch levels were only 11 seconds or less.
Patient F also completed the Voice- Related Quality of Life (V-RQOL), a self-assessment scale to demonstrate the effect the voice disorder was having on her life.102 Results demonstrated a mod-
erate life impact.
Following the voice evaluation and testing, a treatment plan was proposed. The plan included:
n temporary reassignment from play-
ground and school-bus duties
n site visit to determine environment
and teaching style
n elimination of the abusive behavior
of throat clearing
n oral hydration program n symptom modification
n Vocal Function Exercises designed to
rebalance respiration, phonation, and resonance.