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www.pluralpublishing.comVoice Therapy
Clinical Case Studies
Voice Therapy
Clinical Case Studies
Fourth Edition
Joseph C. Stemple, PhD, CCC-SLP, ASHAF
Edie R. Hapner, PhD, CCC-SLP
5521 Ruffin Road San Diego, CA 92123
e-mail: [email protected]
Website: http://www.pluralpublishing.com
Copyright © by Plural Publishing, Inc. 2014
Typeset in 11/13 Palatino by Flanagan’s Publishing Services, Inc. Printed in the United States of America by McNaughton & Gunn, Inc.
All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher.
For permission to use material from this text, contact us by Telephone: (866) 758-7251
Fax: (888) 758-7255
e-mail: [email protected]
Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity.
Library of Congress Cataloging-in-Publication Data
Voice therapy : clinical case studies / [edited by] Joseph C. Stemple, Edie R. Hapner. -- Fourth edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-59756-558-5 (alk. paper) — ISBN 1-59756-558-X (alk. paper) I. Stemple, Joseph C., editor of compilation. II. Hapner, Edie R., editor of compilation.
[DNLM: 1. Voice Disorders — therapy — Case Reports. WV 500] RF510
616.85'5606 — dc23
2014000154 Proudly sourced and uploaded by [StormRG] Kickass Torrents | TPB | ET | h33t
Contents
Preface xiii Contributors xvii
1
Principles of Voice Therapy
1
Joseph C. Stemple
Introduction 1
Historical Perspective 2
Hygienic Voice Therapy 3
Symptomatic Voice Therapy 4
Psychogenic Voice Therapy 5
Physiologic Voice Therapy 5
Eclectic Voice Therapy 6
Case Study: Patient A 6
Voice Care Professionals 10
References 10
2
Comments on Voice Evaluation
13
Joseph C. Stemple
Introduction 13
Management Team 14
Medical Examination 15
Voice Pathology Evaluation 15
Instrumental Voice Assessment 23
Hearing Screening 23 Impressions 23 Prognosis 24 Recommendations 24 Summary 24 References 24
3
Primary and Secondary Muscle Tension Dysphonia
27
Introduction: Muscle Tension Dysphonia: An Overview 27
Nelson Roy
Case Study 1. Behavioral Shaping in Primary MTD Masquerading 29 as Elective Mutism in a 10-Year-Old Boy
vi Voice Therapy: Clinical Case Studies
Case Study 2. Management of Primary MTD in a 13-Year-Old Using 38 Falsetto Voice to Modify Phonation
Joseph C. Stemple
Case Study 3. Use of Laryngeal Massage and Resonant Therapy in 41 Primary MTD in an Adolescent
Susan Baker Brehm
Case Study 4. Flow Phonation in a Teenager with Primary Muscle 45 Tension Aphonia
Jackie Gartner-Schmidt
Case Study 5. Manual Circumlaryngeal Techniques in the Assessment 53 and Treatment of Primary MTD in a 55-Year-Old Woman
Nelson Roy
Case Study 6. Management of Primary MTD Initially Masquerading 60 as a Paralytic Dysphonia in a 39-Year-Old Woman Using an Enabling
Approach Claudio Milstein
Case Study 7. Use of Patient-Family Education and Behavior 66 Modification to Treat MTD Secondary to Vocal Nodules
Leslie Glaze
Case Study 8. Eclectic Voice Therapy for Secondary MTD in a 72 10-Year-Old With a Vocal Fold Cyst
Carissa Portone-Maira
Case Study 9. Using a Psychosocial Management Approach in the 78 Therapy of a Child With Midmembranous Lesions and Secondary MTD Moya Andrews
Case Study 10. Treatment of Secondary MTD in a Child With Early 85 Bilateral Lesions: A Telehealth Approach
Lisa N. Kelchner
Case Study 11. Treating a Child With MTD Secondary to Vocal Nodules 91 Using Concepts From Adventures in Voice
Rita Hersan
Case Study 12. Pediatric Vocal Fold Nodules and Secondary MTD 100 Treated in Conjunction With a School-Based SLP
Rebecca Hancock
Case Study 13. Use of Vocal Function Exercises in the Treatment of an 106 Adult With Secondary MTD
Joseph C. Stemple
Case Study 14. Accent Method in the Treatment of Secondary MTD 116 Sara Harris
Case Study 15. Voice Therapy Boot Camp in the Treatment of 125 Secondary MTD in an Adult
Contents vii
Case Study 16. Medical and Therapeutic Management of 131
Laryngopharyngeal Reflux With Resulting Secondary MTD Sandra A. Schwartz
Case Study 17. Management of Secondary MTD Associated With 136 Vocal Process Granulomas
Heather Starmer
Case Study 18. Lessac-Madsen Resonant Voice Therapy in the 142 Treatment of Secondary MTD
Diana M. Orbelo, Nicole Yee-Key Li, and Katherine Verdolini Abbott
Case Study 19. Use of Ambulatory Biofeedback to Supplement 157 Traditional Voice Therapy for Treating Primary MTD in an
Adult Female
Tara Stadelman-Cohen, Jarrad Van Stan, and Robert E. Hillman
Case Study 20. Use of Glottal Attack in the Treatment of Primary MTD 164 in an Adult Female Presenting With Persistent Falsetto
Joseph C. Stemple
Case Study 21. The Use of a Multi-Approach Therapy in a Female 166 Professional Voice Speaker Presenting With a Primary MTD Marked
With Habitual Falsetto Phonation Mara Behlau and Glaucya Madazio
Case Study 22. Use of Hard Glottal Attack as Laryngeal Manipulation 174 to Modify Mutational Voice in a 16-Year-Old Male
Lisa Fry
References 179
4
Management of Glottal Incompetence
189
Introduction 189 Case Study 1. Treatment Strategies Used for Unilateral Vocal Fold 190 Paralysis in a Case With a Complex Medical History
Stephen C. McFarlane and Shelley Von Berg
Case Study 2. Use of Physiologic Therapy Approaches to Treat 198 Unilateral Vocal Fold Paralysis Following Complications From a
Total Thyroidectomy
Mara Behlau, Gisele Oliveria, and Osíris do Brasil
Case Study 3. Treatment of Glottal Incompetence With Secondary 206 Muscle Tension Dysphonia in a Patient With Unilateral Vocal Fold
Paralysis Maria Dietrich
Case Study 4. Use of Semi-Occluded Vocal Tract Methods and 212 Resonant Voice Therapy to Treat Unilateral Vocal Fold Paralysis
viii Voice Therapy: Clinical Case Studies
Case Study 5. Use of Expiratory Muscle Strength Training in a Case of 222 Unilateral Vocal Fold Paralysis 4 Years Post Chemotherapy/Radiation
Bari Hoffman Ruddy, Christine M. Sapienza, Erin Silverman, and Henry Ho
Case Study 6. Brief Discussion and Case Presentation of Treatment for 226 Superior Laryngeal Nerve Paralysis Using Medical, Surgical, and
Behavioral Interventions Bruce J. Poburka
Case Study 7. Use of Phonation Resistance Training Exercises (PhoRTE) 233 in a Part-Time Cooking Instructor With Presbyphonia
Aaron Ziegler and Edie R. Hapner
Case Study 8. Use of Vocal Function Exercises in an Elderly Man With 240 Presbyphonia
Stephen Gorman
Case Study 9. Treatment of Glottal Incompetence Caused by Sulcus 245 Vocalis: Evidence of a Team Approach for Vocal Rehabilitation
Amanda I. Gillespie and Clark A. Rosen
Case Study 10. Improvement of Vocal Fold Closure in a Patient With 250 Voice Fatigue
Joseph C. Stemple
Case Study 11. An Eclectic Approach in the Management of an 255 Individual With Vocal Fatigue
Chaya Nanjundeswaran
References 262
5
Dystonia, Essential Tremor, and Other Neurogenic Disorders
269
Spasmodic Dysphonia 269
Case Study 1. Functional Voice Therapy for Spasmodic Dysphonia 271 Joseph C. Stemple
Case Study 2. Medical and Behavioral Management of Adductor 273 Spasmodic Dysphonia
Edie R. Hapner and Michael M. Johns
Case Study 3. Combined Laryngeal Injection of Botulinum Toxin and 281 Voice Therapy for Treatment of Adductor Spasmodic Dysphonia
Eileen M. Finnegan
Case Study 4. Use of Reduced Voicing Duration to Treat Vocal Tremor 287 Julie Barkmeier-Kraemer
Case Study 5. Use of LSVT® LOUD (Lee Silverman Voice Treatment) 298
in the Care of a Patient With Parkinson Disease Lorraine Ramig and Cynthia Fox
Case Study 6. Use of Telehealth Technology to Provide Voice Therapy 303 Lyn Tindall Covert
Contents ix
6
Irritable Larynx Syndrome, Paradoxical Vocal Fold
311
Dysfunction, and Chronic Cough
Introduction to Irritable Larynx Syndrome 311
Linda Rammage
Case Study 1. A Case of ILS Managed by a Comprehensive Approach 313 to Multiple Central Sensitivity Syndrome Triggers
Linda Rammage
Case Study 2. Multimodality Behavioral Treatment of Long-Standing 324 Chronic Cough in an Adult
Marc Haxer
Case Study 3. Failed Voice Therapy With Successful Use of Central 328 Nervous System Inhibitors in Chronic Cough
Madeleine Pethan and Laureano Giraldez-Rodriguez
Paradoxical Vocal Fold Motion: An Introduction 335
Mary J. Sandage
Case Study 4. Treatment of PVCD in a Collegiate Swimmer 338
Mary J. Sandage
Case Study 5. Management of PVCD: An Adolescent Athlete With 345 Exercise-Induced Dyspnea
Michael D. Trudeau, Jennifer Thompson, and Christin Ray
Case Study 6. Treatment of Paradoxical Vocal Fold Motion Disorder 348 in a 9-Year-Old Athlete
Maia Braden
Case Study 7. Paradoxical Vocal Fold Movement (PVFM): A Case of 355 the Young Athlete With Associated Psychosocial Contributions
Mary V. Andrianopoulos
References 368
7
Management of the Professional, Avocational, and
375
Occupational Voice
Introduction 376 Marina Gilman
Case Study 1. Management of Vocal Fold Nodules in a Female 379 Prepubescent Singer
Patricia Doyle and Starr Cookman
Case Study 2. The Developing Performer 389
Barbara Jacobson
Case Study 3. 19-Year-Old Talented Male Singer, Presenting With 394 Soft Bilateral Vocal Fold Lesions
x Voice Therapy: Clinical Case Studies
Case Study 4. Therapeutic Modalities for the Touring Musical Theater 400 Vocal Athlete
Wendy D. LeBorgne
Case Study 5. Voice Intervention for a Touring Broadway Singer 405 Shirley Gherson
Case Study 6. The High-Risk Vocal Performer 412
Bari Hoffman Ruddy, Jeffrey Lehman, and Christine M. Sapienza
Case Study 7. Semi-Occluded Vocal Tract Exercises and Resonant 422 Voice Therapy in the Perioperative Management of a Professional
Actor and Singer With a Vocal Fold Cyst Sarah L. Schneider and Mark S. Courey
Case Study 8. Treating Vocal Injury in a Physically and Vocally 435 Demanding Performer
Wendy D. LeBorgne
Case Study 9. Voice Recalibration With the Cup Bubble Technique for 442 a Country Singer
Jennifer C. Muckala and Brienne Ruel
Case Study 10. Praise and Worship Leader Preremoval and 452 Postremoval of Bilateral Vocal Fold Lesions
Marina Gilman
Case Study 11. Use of Voice Therapy in Conjunction With Minimal 458 Injection Medialization in the Longitudinal Treatment of Dysphonia
in an Elite Operatic Singer
Brian E. Petty and Miriam van Mersbergen
Case Study 12. Voice Therapy in a 28-Year-Old Theater Actor 463 Kate DeVore
Case Study 13. Conversational Voice Therapy: A Case Describing 469 Application of Public Speaking Techniques to Voice Disorders
Alison Behrman
References 474
8
Successful Voice Therapy
479
Introduction 479 Joseph C. Stemple
Interview and Counseling Skills 480
Clinical Understanding of the Problem 481
Misapplied Management Techniques 482
Lack of Patient Education or Understanding of the Problem 482 Recognition of One Philosophical Orientation or One Etiologic Factor 483
Premature Discontinuation of Therapy 483
Contents xi
Patient Realities 484
Can All Voices Be Improved? 488
Case Study 1. The Role of Self-Efficacy on Voice Therapy Adherence 488 Amanda I. Gillespie
Case Study 2. Using iPod Apps to Improve Voice Therapy Adherence 493 Between Sessions: A Social-Cognitive Approach
Eva van Leer
Case Study 3. There’s an App for That: Use of Portable Electronic 497 Software Applications to Facilitate Home Practice of Voice Exercises in a Lawyer With Vocal Fold Nodules
Bryn Olson and Carissa Portone-Maira
Case Study 4. Threat of Being Fired From Therapy Improved a Vocal 503 Overdoer’s Adherence
Carissa Portone-Maira
References 510 Appendix 8–A. Selected Applications Useful in Voice Therapy 513 Index 521
Preface
The fourth edition of Voice Therapy:Clinical Case Studies marks the 20-year
anniversary of this text. We are excited to introduce Edie Hapner as co-editor of this fourth edition. Hapner’s clinical and research contributions to the field of voice pathology are recognized nation-ally and internationnation-ally. She is a master clinician and a teacher and mentor to a generation of voice clinicians. We are pleased to have Edie on board and know that her contributions will enhance the quality of the learning experience for voice students and professionals alike.
Since its initiation, the purpose of this text has remained the same:
. . . to provide both the student and the
working clinician with a broad sampling of management strategies as presented by master voice clinicians, laryngologists, and other voice care professionals. The text is meant to serve as a practical adjunct to the more didactic publications.
As the knowledge of voice produc-tion continues to expand, so, too, have the publications dedicated to describ-ing this knowledge. There are currently excellent texts and journals dedicated to the scientific understanding of voice. Other publications are available to help prepare students to evaluate and man-age clinical voice disorders. By necessity, these texts must include great quantities of didactic information so that the stu-dent learns not only “how” but “why.” To utilize a management approach without understanding the underlying basis of the approach is inappropriate.
Nonetheless, because of the breadth of material necessary in these texts, thera-peutic methods for voice disorders are often given only a cursory and gener-alized discussion. This text is meant to bridge that gap. In over 60 case studies involving a wide variety of voice disor-ders with various pathologies and eti-ologies, master clinicians have provided detailed descriptions of management approaches and techniques. It is our hope that the expertise offered in these pages will serve the reader well in guid-ing clinical practice.
Utilizing the format of actual case studies, complete descriptions of diag-nostic and therapeutic methods are pro-vided for a full array of voice disorders. Chapter 1 includes information on the various philosophies of treatment. With the maturation of the voice care spe-cialty, different schools of thought have evolved regarding treatment designs. These philosophical orientations include hygienic, symptomatic, psychogenic, physiologic, and eclectic orientations. Each orientation is discussed and illus-trated with a representative case study. Chapter 2 comments on various voice evaluation techniques. These tech-niques include the formal questionnaire, the patient interview, perceptual voice analysis, patient self-assessment, and instrumental assessment of voice duction. The role of the evaluation pro-cess as a part of the overall management plan is also discussed.
Chapter 3 discusses treatment ap- proaches for the most common type
xiv Voice Therapy: Clinical Case Studies
of voice disorder, muscle tension dys-phonia (MTD). Following an over-view of MTD by Nelson Roy, manage-ment approaches for both children and adults including hygiene programs, symptomatic modifications, attention to psychosocial issues, and direct phys-iologic manipulation and exercises are presented in illustrative case studies of both primary and secondary MTD.
Treatments for various etiologies of glottal incompetence are described in Chapter 4. Management for voice fatigue, bowed vocal folds, senile lar-yngis, and vocal fold paralysis are described, including direct voice thera-pies, surgical intervention, and a com-bination of these approaches. Many techniques including voice facilitating techniques, semi-occluded vocal tract, expiratory muscle strength training, and phonation resistance training are discussed.
Chapter 5 presents management strategies for laryngeal dystonia, essen-tial tremor, and other neurologic voice disorders. These strategies include be- havioral and medical management of spasmodic dysphonia, voice therapy for essential tremor, and face-to-face and remote treatment of voice and speech symptoms related to Parkinson disease.
Because of the speech-language pathologist’s unique blend of knowl-edge regarding upper respiratory anat-omy and physiology and behavioral therapy, we have become the caregivers for complex respiratory and laryngeal disorders. Chapter 6 provides several detailed case studies regarding the various etiologies, patient profiles, and evaluation and treatment approaches used with those diagnosed with irri-table larynx syndrome. Included in this category are chronic cough and vocal cord dysfunction (VCD). These cases
include treatments for laryngopharyn-geal reflux and VCD in the young child, young athlete, and elite athlete.
The consequences of a voice disor-der may impact the quality of life and threaten the livelihood of individuals dependent upon a healthy voice. Chap-ter 7 presents case studies for those dependent upon their voice such as the elite vocal performer, the occupational voice user, and those whose avocational voice use is related to their quality of life.
The final chapter, Chapter 8, is devoted to a discussion of success-ful voice therapy and patient adher-ence. What makes therapy successful or unsuccessful? This chapter looks at both the therapist and the patient and describes the pitfalls that may influence the ultimate goal of therapy: improved vocal function.
As with the first three editions of
Voice Therapy: Clinical Case Studies, the
most exciting element in the preparation of this text was the support received by the master clinicians who graciously and generously submitted the case studies. What a wonderful opportunity it is to learn from those who are in the trenches, those experts who embody not only superior clinical skills, but won-derful insight as to why they do what they do. We are deeply indebted to all of them and proudly offer their collec-tive expertise. We are certain that the reader will benefit from their vast clini-cal experiences.
Text preparations are extremely time-consuming and require many hours of tedious work. Checking and preparing references, organizing tables, figures, and their legends, reading and re-read-ing in an attempt to make the intent clear to those we are trying to reach are only a few of the tasks involved. We were so very fortunate in the
Preface xv
tion of this text to have the invaluable editorial assistance of the Plural Pub-lishing professionals. We are indebted to Angie Singh, Megan Carter, Milgem Rabanera, and Mckenna Bailey for en- couraging and supporting this fourth
edition. In addition, we wish to thank our students and colleagues who have suggested ways to improve the text with each new writing. Finally, as usual, we are most appreciative for the support of our families.
— Joseph C. Stemple Edie R. Hapner
Contributors
Moya L. Andrews, EdD
Professor Emerita
Department of Speech and Hearing Sciences Indiana University Bloomington, Indiana Chapter 3 Mary V. Andrianopoulos, PhD Associate Professor Clinical Consultant Department of Communication Disorders
Center for Language, Speech, and Hearing
University of Massachusetts-Amherst Amherst, Massachusetts
Chapter 6
Susan Baker Brehm, PhD
Associate Professor and Chair
Department of Speech Pathology and Audiology Miami University Oxford, Ohio Chapter 3 Julie Barkmeier-Kraemer, PhD Professor Department of Otolaryngology University of California, Davis Sacramento, California
Chapters 4 and 5
Mara Behlau, PhD
Permanent Professor
Graduate Program in Human Communication Disorders Director
Specialization Course in Voice
Universidade Federal de São Paulo UNIFESP and Centro de Estudos da
Voz-CEV
São Paulo, SP, Brazil Chapters 3 and 4
Alison Behrman, PhD, CCC-SLP
Associate Professor
Department of Speech-Language-Hearing Sciences
Lehman College/City University of New York
Bronx, New York Chapter 7
Maia Braden, MS
Speech-Language Pathologist University of Wisconsin-Madison Voice and Swallow Clinics
American Family Children’s Hospital Madison, Wisconsin
Chapter 6
Kimberly Coker, MS
Speech-Language Pathologist North Texas Voice Center Dallas, Texas
Chapter 3
Starr Cookman, MA
Assistant Professor Clinical Faculty
University of Connecticut Health Center
Farmington, Connecticut Chapter 7
Mark S. Courey, MD
Professor
xviii Voice Therapy: Clinical Case Studies
Director
Division of Laryngology
University of California, San Francisco San Francisco, California
Chapter 7
Kate DeVore, MA
Speech-Language Pathologist Total Voice, Inc.
Chicago, Illinois Chapter 7 Maria Dietrich, PhD Assistant Professor Department of Communication Disorders University of Missouri Columbia, Missouri Chapter 4 Osíris do Brasil, MD
Centro de Estudos da Voz CEV, São Paulo, SP Associate Professor São Paulo, Brazil Chapter 4
Patricia B. Doyle, MA
Instructor
University of Connecticut Health Center Farmington, Connecticut Chapter 7 Eileen M. Finnegan, PhD Associate Professor University of Iowa Iowa City, Iowa Chapter 5
Cynthia Fox, PhD
Research Associate
National Center for Voice and Speech University of Colorado-Boulder Denver, Colorado Chapter 5 Lisa Fry, PhD Adjunct Faculty Department of Communication Disorders Marshall University Huntington, West Virginia Chapter 3
Jackie Gartner-Schmidt, PhD
Associate Professor Otolaryngology Associate Director UPMC Voice Center
Director of Speech Pathology-Voice Division
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Chapter 3
Shirley Gherson, MA
Clinical Specialist-Voice Disorders NYU Langone Medical Center Rusk Rehabilitation
New York, New York Chapter 7
Amanda I. Gillespie, PhD
Assistant Professor University of Pittsburgh UPMC Voice Center Pittsburgh, PA Chapters 4 and 8
Marina Gilman, MM, MA, CCC-SLP
Speech-Language Pathologist Emory Voice Center
Otolaryngology-Head & Neck Surgery Emory University
Atlanta, Georgia Chapter 7
Laureano A. Giraldez-Rodriguez, MD
Fellow
Head and Neck Cancer Surgery– Microvascular Reconstruction
Contributors xix
Department of Otolaryngology-Head & Neck Surgery
Mount Sinai School of Medicine New York, New York
2013 Fellow
Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery
Emory University Atlanta, Georgia Chapter 6 Leslie E. Glaze, PhD Speech-Language Pathologist Minneapolis, Minnesota Tucson, Arizona Chapter 3 Stephen Gorman, PhD Voice Pathologist
Blaine Block Institute for Voice Analysis and Rehabilitation Dayton, Ohio
Professional Voice Center of Greater Cincinnati
Cincinnati, Ohio Chapter 4
Rebecca L. Hancock, MEd
Senior Speech Pathologist
University of Kentucky Voice and Swallow Clinic Lexington, Kentucky Chapter 3 Edie R. Hapner, PhD, CCC-SLP Associate Professor Department of Otolaryngology-Head & Neck Surgery
Emory University School of Medicine Director
Speech-Language Pathology Emory Voice Center
Atlanta, Georgia Chapters 4 and 5
Sara Harris, FRCSLT
Speech-Language Pathologist Lewisham Hospital Voice Disorders
Unit
London, United Kingdom Chapter 3
Marc Haxer, MA
Clinical Senior Speech Pathologist Departments of
Otolaryngology-Head & Neck Surgery and Speech-Language Pathology
University of Michigan Health System Ann Arbor, Michigan
Chapter 6
Rita Hersan, MS
Speech-Language Pathologist Voice Clinician
University of Pittsburgh Voice Center Pittsburgh, Pennsylvania
Chapter 3
Robert E. Hillman, PhD
Co-Director Research Director
Center for Laryngeal Surgery and Voice Rehabilitation
Massachusetts General Hospital Director
Research Programs
MGH Institute of Health Professions Professor of Surgery
Harvard Medical School Boston, Massachusetts Chapter 3
Henry Ho, MD, FACS
Director
Head and Neck Program
The Florida Hospital Cancer Institute Orlando, Florida
Chapter 4
Bari Hoffman Ruddy, PhD
xx Voice Therapy: Clinical Case Studies Department of Communication
Sciences and Disorders University of Central Florida Orlando, Florida
Chapters 4 and 7
Barbara Jacobson, PhD
Assistant Professor Associate Director
Medical Speech-Language Pathology Department of Hearing & Speech
Sciences Vanderbilt University Nashville, Tennessee Chapter 7 Michael M. Johns, MD, FRCS Associate Professor Otolaryngology Director
Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery
Emory University Atlanta, Georgia Chapter 5
Lisa N. Kelchner, PhD, BCS-S
Associate Professor
Director of Graduate Studies Department of Communication
Sciences and Disorders University of Cincinnati Cincinnati, Ohio
Chapter 3
Wendy D. LeBorgne, PhD, CCC-SLP
Voice Pathologist Singing Voice Specialist Clinical Director
The Blaine Block Institute of Voice Analysis and Rehabilitation
Provoice Center of Cincinnati College-Conservatory of Music
Dayton and Cincinnati, Ohio Chapter 7
Jeffrey Lehman, MD, FACS
Clinical Professor
College of Health and Public Affairs University of Central Florida
Medical Director The Voice Care Center Winter Park, Florida Chapter 7
Glaucya Madazio, PhD
Fonoaudiologa Especialista em Voz Consultora em Comunicacao Humana Sao Paulo, SP, Brazil
Chapter 3
Stephen C. McFarlane, PhD
Foundation Professor/Professor Emeritus
Speech Pathology Department University of Nevada, School of
Medicine Reno, Nevada Chapter 4
Claudio F. Milstein, PhD
Director
The Voice Center Cleveland Clinic Associate Professor Otolaryngology
Cleveland Clinic Lerner College of Medicine
Cleveland, Ohio Chapter 3
Jennifer C. Muckala, MA, CCC-SLP
Senior Speech Pathologist Singing Voice Specialist Vanderbilt Voice Center Nashville, Tennessee Chapter 7
Chayadevie Nanjundeswaran, PhD
Assistant Professor
Department of Audiology and Speech-Language Pathology
Contributors xxi
East Tennessee State University Johnson City, Tennessee
Chapter 4
Gisele Oliveria, PhD
Associate Professor
CEV–Centro de Estudos da Voz Sao Paulo, SP, Brazil
Assistant Professor Touro College Brooklyn, New York Chapter 4
Bryn Olson, MS
Speech-Language Pathologist The Communication Development
Center
Madison, Wisconsin Chapter 8
Diana M. Orbelo, PhD
Assistant Professor
Mayo Clinic College of Medicine Rochester, Minnesota
Chapter 3
Rita R. Patel, PhD
Assistant Professor
Department of Hearing and Speech Sciences Indiana University Bloomington, Indiana Chapter 3 Madeleine Pethan, MA Speech-Language Pathologist Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery
Atlanta, Georgia Chapter 6
Brian E. Petty, MA, MA
Speech-Language Pathologist Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery
Atlanta, Georgia Chapter 7
Bruce J. Poburka, PhD
Professor
Communication Disorders
Minnesota State University, Mankato Mankato, Minnesota
Chapter 4
Carissa Portone-Maira, MS
Lead Speech-Language Pathologist Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery
Atlanta, Georgia Chapters 3 and 8 Lorraine Ramig, PhD Professor University of Colorado-Boulder Senior Scientist
National Center for Voice and Speech-Denver
Adjunct Professor Columbia University New York, New York Chapter 5
Linda Rammage, PhD, RSLP
Director
Provincial Voice Care Resource Program, UBC
Vancouver, BC, Canada Chapter 6
Christin Ray, MA (ABD)
Doctoral Candidate
Department of Speech and Hearing Science
The Ohio State University Columbus, Ohio
xxii Voice Therapy: Clinical Case Studies
Clark A. Rosen, MD, FACS
Professor
Department of Otolaryngology University of Pittsburgh School of
Medicine Director
University of Pittsburgh Voice Center Pittsburgh, Pennsylvania
Chapter 4
Nelson Roy, PhD, CCC-SLP, ASHAF
Professor
Department of Communication Sciences and Disorders
Division of Otolaryngology-Head & Neck Surgery
Department of Surgery, School of Medicine
University of Utah Salt Lake City, Utah Chapter 3
Brienne Ruel, MA
Speech-Language Pathologist UW Voice and Swallow Clinics,
Department of Surgery Madison, Wisconsin Chapter 7 Mary J. Sandage, PhD Assistant Professor Auburn University Auburn, Alabama Chapter 6 Christine M. Sapienza, PhD Program Director Speech Pathology Associate Dean
College of Health Sciences Jacksonville University Jacksonville, Florida
Research Career Scientist BRRC Malcolm Randall VA Gainesville, Florida Chapters 4 and 7 Sarah L. Schneider, MS Director Speech-Language Pathology
UCSF Voice and Swallowing Center University of California, San Francisco San Francisco, California
Chapter 7 Sandra A. Schwartz, MS Clinical Faculty/Instructor Duquesne University Pittsburgh, Pennsylvania Chapter 3 Erin Silverman, PhD
Research Assistant Professor University of Florida
Gainesville, Florida Chapter 4
Tara Stadelman-Cohen, BM, MS
Senior Voice Pathologist
Center for Laryngeal Surgery and Voice Rehabilitation
Massachusetts General Hospital Adjunct Clinical Instructor
School of Health and Rehabilitation Sciences
MGH Institute of Health Professions Part-time Faculty Boston Conservatory Boston, Massachusetts Chapter 3 Heather Starmer, MA Assistant Professor Department of Otolaryngology-Head & Neck Surgery
Johns Hopkins University Baltimore, Maryland Chapter 3
Joseph C. Stemple, PhD, CCC-SLP, ASHAF
Professor
Contributors xxiii
College of Health Sciences University of Kentucky Lexington, Kentucky Chapters 1, 2, 3, 4, 5, and 8 R.E. Stone Jr, PhD Retired Director of Speech-Language Pathology
Vanderbilt Voice Center
Vanderbilt Bill Wilkerson Department of Communication Sciences and Disorders
Nashville, Tennessee Chapter 3
Jennifer Thompson, MA
Clinical Voice Pathologist Clinical Instructor
James Care Voice and Swallowing Disorders Clinic
The Ohio State University Columbus, Ohio
Chapter 6
Lyn Tindall Covert, PhD
Speech-Language Pathologist Department of Veterans Affairs
Medical Center Lexington, Kentucky Chapter 5
Michael D. Trudeau, PhD
Emeritus Associate Professor The Ohio State University Columbus, Ohio
Chapter 6
Eva van Leer, PhD, MFA Assistant Professor
Department of Education
Psychology, Special Education, and Communication Disorders
College of Education Georgia State University Atlanta, Georgia
Chapter 8
Miriam van Mersbergen, PhD
Assistant Professor
Speech-Language Pathology Northern Illinois University DeKalb, Illinois
Chapter 7
Jarrad Van Stan, MA, BRS-S
Senior Clinical Research Coordinator Speech-Language Pathologist
MGH Center for Laryngeal Surgery and Voice Rehabilitation
PhD Student
MGH Institute of Health Professions Boston, Massachusetts
Chapter 3
Katherine Verdolini Abbott, PhD
Professor
Department of Communication Science and Disorders, Otolaryngology McGowan Institute for Regenerative
Medicine
University of Pittsburgh Center for the Neural Basis of
Cognition
Carnegie-Mellon University and University of Pittsburgh Pittsburgh, Pennsylvania Chapter 3
Shelley Von Berg, PhD
Associate Professor
Communication Sciences and Disorders
California State University, Chico Chico, California
Chapter 4
Nicole Yee-Key Li, PhD, M.Phil.
Assistant Professor
University of Maryland-College Park
College Park, Maryland Chapter 3
xxiv Voice Therapy: Clinical Case Studies
Aaron Ziegler, MA (ABD)
Doctoral Candidate University of Pittsburgh Pittsburgh, Pennsylvania Chapter 4
1
Principles of Voice Therapy
Introduction
In preparing the fourth edition of this text, it was necessary to review almost 80 years of history related to voice ther-apy techniques and approaches. It is a rich and interesting history that gives an excellent understanding of how the treatment of voice disorders has grown and evolved to our present practice. Some of the therapy approaches devel-oped by early speech pathologists con-tinue to be used successfully in the remediation of voice disorders to this day. Because of the growth in our knowl-edge and understanding of voice pro-duction, other therapy approaches once commonly used were proven to be inef-fective. The past 30 years have yielded tremendous growth in our knowledge and understanding of vocal function. Computer models of phonation,1–6
his-tologic studies of the vocal folds,7–10
analysis of the vocal fold cover and tis-sue engineering,11–19 and genetic issues
associated with voice disorders20–23 are
but a few of the many advances in voice science. Furthermore, consider the rap-idly evolving ability to measure and describe normal and pathologic voice function objectively through sophisti-cated acoustic and aerodynamic instru-mentation, as well as the ability to observe vocal fold vibration. All of these scientific advancements have provided voice clinicians with the tools to confirm the efficacy of their approaches.
The number of traditional therapy approaches that continue to be used in voice therapy today is a strong state-ment of appreciation and admiration for the voice pedagogues, clinicians, and scientists of earlier days. The accuracy of their practical observations regard-ing voice function has proved to be uncanny. The efficacy of many of these traditional voice therapy techniques is now being tested through systematic outcomes research.24 Proof of the
use-fulness of many of these techniques, however, has been well established by
2 Voice Therapy: Clinical Case Studies
the clinical results of skilled speech-language pathologists.
The major difference in voice ther-apy today compared with even 20 to 25 years ago is the ability to diagnose a problem quickly and accurately and to confirm the efficacy of our management approaches through objective measures. These objective measures may also be used as patient feedback during the therapeutic process. Although our man-agement approaches have changed over the years, voice therapy remains a blend of science and art.
The scientific nature of voice ther-apy involves the clinician’s knowledge of several important areas of study. These areas include the anatomy and physiology of normal and pathologic voice production; the nuances of laryn-geal pathologic conditions; the acoustics and aerodynamics of voice production; and the etiologic correlates of voice disorders, including patient behav-iors, medical causes, and psychological contributions:
n When considering the voice, we are
considering the most widely used instrument on earth.
n To understand the voice disorder, we
must understand the instrument’s physical structure and functional components.
n We must have the skills to measure
these components objectively and to relate these measures to our manage-ment choices.
n In addition, we must possess a broad
knowledge of the common causes of voice disorders and the nuances of laryngeal pathologic conditions.
The artistic nature of voice therapy is dependent on the human interac-tion skills of the clinician. Compassion,
understanding, empathy, and projec-tion of credibility, together with listen-ing, counsellisten-ing, and motivational skills are essential attributes of the success-ful voice clinician. Philosophically, we might make these statements about the artistic nature of voice:
n When considering the voice, we must
consider the whole person.
n To examine a voice disorder is to
examine a unique individual.
n The feelings of that individual, both
physical and emotional, may be directly reflected in the voice.
n To remediate a voice disorder, we
must have the skills to counsel and motivate the patient and empower readiness for change.
The successful voice clinician will combine attributes of the artistic ap- proaches toward voice therapy with the objective scientific bases to identify the problem and then plan and carry out appropriate management strategies. Nonetheless, possession of a solid base of didactic information augments expe-rience. Experience continues to teach even the masters. It is hoped that the experiences of others provided in this text will prove helpful in the develop-ment of superior voice clinicians.
Historical Perspective
In examining the evolution of the treat-ment of voice disorders, we find it was not until around 1930 that a few lar-yngologists, singing teachers, instruc-tors in the speech arts, and a fledgling group of speech correctionists became interested in retraining individuals with voice disorders. This group used drillsPrinciples of Voice Therapy 3
and exercises borrowed from voice and diction manuals designed for the normal voice in an attempt to modify disordered voice production. Many of these rehabilitation techniques were and remain creative and effective, but they were not necessarily based on sci-entific principles. The “artistic” portion of voice treatment was the strong point of early clinicians.
Out of this artistic approach came the general treatment suggestions of: (1) ear training, (2) breathing exercises, (3) relaxation training, (4) articulatory compensations, (5) emotional retrain-ing, and (6) special drills for cleft palate and velopharyngeal insufficiency.25,26
These treatment suggestions became the foundation of vocal rehabilitation.
Several general management phi-losophies have arisen from the early foundations of voice rehabilitation. These philosophical orientations are based primarily on the clinician’s mind-set and previous training regarding voice disorders that directs the manage-ment focus. For the sake of discussion, we classify these management philoso-phies as:
n hygienic voice therapy n symptomatic voice therapy n psychogenic voice therapy n physiologic voice therapy n eclectic voice therapy
In short, hygienic voice therapy focuses on identifying inappropriate vocal hygiene behaviors, which then are modified or eliminated. Once modified, voice production has the opportunity to improve or return to normal.
Symptom-atic voice therapy focuses on modification
of the deviant vocal symptoms identi-fied by the speech-language pathologist, such as breathiness, low pitch, glottal
attacks, and so on. The focus of
psycho-genic voice therapy is on the emotional
and psychosocial status of the patient that led to and maintains the voice dis-order. The physiologic orientation of voice therapy focuses on directly modifying and improving the balance of laryngeal muscle effort to the supportive airflow, as well as the correct focus of the laryn-geal tone. Finally, the eclectic approach of voice therapy is the combination of any and all of the previous voice therapy orientations.27
None of these philosophical orienta-tions are pure. Much overlap is present, often leading to the use of an eclectic approach. With this introduction, let us examine the orientations of voice ther-apy in greater detail.
Hygienic Voice Therapy
Hygienic voice therapy often is the first step in many voice therapy programs. Many etiological factors contribute to the development of voice disorders. Poor vocal hygiene may be a major develop-mental factor. Some examples of behav-iors that constitute poor vocal hygiene include shouting, talking loudly over noise, screaming, vocal noises, cough-ing, throat clearcough-ing, and poor hydration. When the inappropriate vocal behaviors are identified, then appropriate treat-ments can be devised for modifying or eliminating them. Once modified, voice production has the opportunity to improve or return to normal.Poor vocal hygiene may also in- clude the habitual use of inappropriate pitch or loudness, reduced respiratory support, poor phonatory habits (glot-tal attacks, fry), or inappropriate reso-nance. Functional inappropriate use of
4 Voice Therapy: Clinical Case Studies
these voice components may contribute to the development and maintenance of a voice disorder. Hygienic voice therapy presumes that many voice dis-orders have a direct behavioral cause. This therapy strives to instill healthy vocal behaviors in the patient’s habitual speech patterns. Good vocal hygiene also focuses on maintaining the health of the vocal fold cover through ade-quate internal hydration and diet. Once identified, poor vocal hygiene habits can be modified or eliminated leading to improved voice production.
Symptomatic Voice Therapy
Symptomatic voice therapy was a term first introduced by Daniel Boone.28 Thisvoice management approach is based on the premise that modifying the symp-toms of voice production including pitch, loudness, respiration, and so on, will improve the voice disorder. Once identi-fied, the misuses of these various voice components are modified or reduced using voice therapy facilitating techniques.
In the voice clinician’s attempt to aid the patient in finding and using his best voice production, it is neces-sary to probe continually within the patient’s existing repertoire to find the best one voice which sounds “good” and which he is able to produce with relatively little effort. A voice therapy facilitating technique is that technique which, when used by a particular patient, enables him easily to produce a good voice. Once discovered, the facilitating technique and resulting phonation become the symptomatic focus of voice therapy . . . This use of a facilitating technique to produce a
good phonation is the core of what we do in symptomatic voice therapy for the reduction of hyperfunctional voice disorders.28(p11)
Boone’s original facilitating ap- proaches included:
1. altering of tongue position 2. change of loudness
3. chewing exercises 4. digital manipulation 5. ear training
6. elimination of abuses
7. elimination of hard glottal attack 8. establishment of a new pitch 9. explanation of the problem 10. feedback
11. hierarchy analysis 12. negative practice 13. open mouth exercises 14. pitch inflections 15. pushing approach 16. relaxation
17. respiration training 18. target voice models 19. voice rest
20. yawn-sigh approach
Many if not all of these facilitators remain useful and popular in the treatment of voice disorders and are described in greater detail in cases throughout this text.
The main focus of symptomatic voice therapy is direct modification of vocal symptoms. For example, if the patient presents with a voice quality characterized by low pitch, breathiness, and hard glottal attacks, then the main focus of therapy is to directly modify the symptoms. The facilitating approaches used to modify these symptoms might include explanation of the problem, ear training, elimination of hard
glot-Principles of Voice Therapy 5
tal attack, and respiration training. The speech-language pathologist constantly probes for the “best” voice and attempts to stabilize that voice with the various, appropriate facilitating techniques. Symptomatic voice therapy assumes voice improvement through direct symptom modification.
Psychogenic Voice Therapy
Early in the study of voice disorders, the relationship of emotions to voice pro-duction was well recognized. As early as the mid-1800s, journal articles dis-cussed hysteric aphonia.29,30 West,Ken-nedy, and Carr26 and Van Riper25
dis-cussed the need for emotional retraining in voice therapy. Murphy31 presented
an excellent discussion of the psycho-dynamics of voice. Friedrich Brodnitz,32
as an otolaryngologist, was uniquely sensitive to the relationship of emotions to voice. These early readings are most interesting and remain informative to those treating voice disorders.
Our understanding of psychogenic voice therapy was further expanded by Aronson,33 Case,34 Stemple,35 and
Colton and Casper.36 These authors
discussed the need for determining the emotional dynamics of the voice dis-turbance. Psychogenic voice therapy focuses on identification and modifica-tion of the emomodifica-tional and psychosocial disturbances associated with the onset and maintenance of the voice problem. Pure psychogenic voice therapy is based on the assumption of underlying emo-tional causes. Voice clinicians, therefore, must develop and possess superior interview skills, counseling skills, and the skill to know when the treatment
for the emotional or psychosocial prob-lem is beyond the realm of their skills. A referral system of support profession-als must be readily available.
Physiologic Voice Therapy
Physiologic voice therapy includes voice therapy programs that have been devised to directly alter or modify the physiology of the vocal mechanism. Normal voice production is dependent on a balance among airflow, supplied by the respiratory system; laryngeal muscle balance, coordination, and stam-ina; and coordination among these and the supraglottic resonatory structures (pharynx, oral cavity, and nasal cav-ity). Any disturbance in the physiologic balance of these vocal subsystems may lead to a voice disturbance.37These disturbances may be in respi-ratory volume, power, pressure, and flow. Disturbances also may manifest in vocal fold tone, mass, stiffness, flexibil-ity, and approximation. Finally, the cou-pling of the supraglottic resonators and the placement of the laryngeal tone may cause or may be perceived as a voice disorder. The overall causes may be mechanical, neurologic, or psychologi-cal. Whatever the cause, the manage-ment approach is direct modification of the inappropriate physiologic activity through exercise and manipulation.
Inherent in physiologic voice ther-apy is a holistic approach to the treat-ment of voice disorders. They are thera-pies that strive to at once balance the three subsystems of voice production as opposed to working directly on sin-gle voice components, such as pitch or loudness. Examples of physiologic voice
6 Voice Therapy: Clinical Case Studies
therapy include Vocal Function Exer-cises,38 Resonant Voice Therapy,39 and
the Accent Method of Voice Therapy,40
all of which are presented in this text.
Eclectic Voice Therapy
Adherence to one philosophical ori-entation of voice therapy would not be advisable. Successful voice therapy depends on utilization of an approach that happens to work for the therapist and the individual patient. The more management approaches are under-stood and mastered by the clinician, the greater the likelihood for success. Man-agement techniques that prove success-ful for one patient may not be successsuccess-ful for a similar patient. The clinician, there-fore, must possess the knowledge to adjust the management approach.Some techniques that work well for one therapist may prove to be difficult for another. In whatever management approach you choose, you must have supreme confidence in your under-standing of the technique and your ability to make that approach work suc-cessfully. Your confidence is one factor that will determine the success or failure of therapy. Using a typical case, let us examine how each therapy orientation might be used to treat the vocal difficul-ties of this composite patient.
Case Study: Patient A
Patient A, a 52-year-old woman, was referred by her laryngologist to the voice center for postsurgical evaluation and treatment. Large, bilateral, draping polyps were first identified by ananes-thesiologist while intubating the patient for a laminectomy 6 months prior to her voice evaluation. Because of the large polyps, intubation had been difficult. The problem was reported to her fam-ily physician, who in turn referred the patient to an otolaryngologist for a laryngeal examination.
Indirect mirror examination revealed bilateral polypoid degeneration, worse on the left than the right. Audible inspi-ratory stridor was noted by the physi-cian, and the patient reported shortness of breath during even limited physical exertion. Therefore, two surgeries (one for each vocal fold) were scheduled 6 weeks apart for aspiration of fluid and laser vaporization of redundant tissue. The surgeries were performed without complication, and the patient was seen for voice evaluation following appropri-ate healing.
History of the Problem
The patient reported that she had always had a “deep” voice, which had lowered even more over the past several years. Her presurgical voice quality had not been a concern to her, however. Instead, it was the shortness of breath that led her to agree to surgery. She reported that voice quality following the first sur-gery (left fold) was a little “hazy” but returned to “normal” within 1 week. The second surgery left her with signifi-cant, bothersome hoarseness that made her “wish I had never had surgery.”
Medical History
The patient reported undergoing two previous surgeries: removal of her gall bladder 10 years earlier and the
lami-Principles of Voice Therapy 7
nectomy performed earlier this year. Even with the difficult intubation and the risk of vocal fold paralysis inherent in laminectomy, her presurgical voice quality was maintained. In addition to surgeries, she had been hospitalized 3 years before for 3 weeks and treated for chronic depression.
Chronic medical disorders included frequent upper respiratory infections including bronchitis, high blood pres-sure, circulatory problems in her legs, elevated blood sugar, and chronic neck and back pain. Daily medications were taken for blood pressure, chronic pain, depression, and sleep. She continued a 30-year history of smoking 1½ to 2 packs of cigarettes per day. Her liquid intake consisted mostly of 6 cups of caffeinated coffee per day. Chronic throat clear-ing and a persistent cough were noted throughout the evaluation.
Social History
Patient A had been married for 12 years to her second husband, following a first marriage of 18 years and divorce. She had two adult children from her previ-ous marriage. Her elderly mother-in-law lived with her and her husband, a situation that often caused friction and conflict with her husband. She was not shy in reporting her unhappiness with her marital relationship. This unhappi-ness was said to be a major factor in her history of depression.
Both the patient and her husband were employed by the local automobile assembly plant. She had worked as an assembler for 14 years in an environ-ment described as “noisy, dusty, and full of fumes” and was on a temporary medical disability because her back problems precluded her working in the
plant. Present activities included shop-ping with her daughter, talking on the telephone, caring for her home (back permitting), watching daytime televi-sion “talk” shows, and bowling two nights per week in two different leagues.
Voice Evaluation
Perceptually, the patient’s voice quality was described as moderately dysphonic, characterized by low pitch, inappropriate loudness, strained raspiness, and inter-mittent glottal fry phonation. Acoustic and aerodynamic analyses revealed a low fundamental frequency (150 Hz), limited frequency range (118–290 Hz), increased habitual intensity (76 dB), normal airflow volume (2300 mL H2O), reduced airflow
rate (<80 mL H2O/s), and reduced
maxi-mum phonation time (<12 s).
Laryngeal videostroboscopic ob- servation revealed mild-to-moderate bilateral true vocal fold edema and ery-thema. Glottic closure demonstrated an irregular glottal chink with a moder-ate ventricular fold compression. The edges of the vocal folds were rough and irregular, worse on the left than on the right. The amplitude of vibration was severely decreased bilaterally. The mucosal waves were barely percep-tible. The closed phase of the vibratory cycle was strongly dominant, whereas the symmetry of vibration was gener-ally irregular. No mass lesions, paresis, or paralysis was evident. In short, the patient had an edematous, stiff, hyper-functioning vocal fold system.
Impressions
Patient A presented with a voice disor-der that disor-derived from the following pos-sible causal factors:
8 Voice Therapy: Clinical Case Studies
n cigarette smoking
n harsh employment environment n talking over noise at work n large caffeine intake
n frequent upper respiratory infections n prescription medications
n coughing and throat clearing n emotional instability
n talking too loudly (suggesting
pos-sible hearing loss, which later proved not to be present)
n using a low pitch
n laryngeal muscle tension
n postsurgical vocal fold mucosal
changes
Recommendations
Hygienic Voice Therapy
The general focus would be to identify the primary and secondary vocal mis-uses and then to modify or eliminate these nonhygienic behaviors. The pri-mary etiologic correlates include:
n Smoking
n Laryngeal dehydration from caffeine
and drugs
n Voice abuse, such as coughing, throat
clearing, and talking loudly over noise at work
Secondary precipitating factors that result from the pathologic condition include:
n Laryngeal area muscle tension and
hyperfunction caused by vocal fold stiffness
n Low pitch caused by increased mass n Increased loudness caused by the
effort used to force stiff vocal folds to vibrate
Therapy would focus on modifi-cation or elimination of the primary
causes. The patient would be aided in her attempt to stop smoking, encour-aged to begin a hydration program, and given vocal hygiene counseling to aid in elimination or reduction of the vocally abusive behaviors. The second-ary causes most likely would improve spontaneously as the primary causes were modified and the vocal fold con-dition improved.
Symptomatic Voice Therapy
The general focus would include use of facilitating techniques to:
n raise pitch n reduce loudness
n reduce laryngeal area tension and
effort
This direct symptom modification would follow an explanation of the problem and would run concurrently with mod-ification of vocally abusive behaviors, including:
n smoking n caffeine intake
n coughing and throat clearing
Psychogenic Voice Therapy
The general focus would be to explore the psychodynamics of the voice disor-der. Techniques would include:
n Detailed interview with the patient
to determine the cause and effects of depression
n Determination of the relationship
of emotional problems and voice problem
n Counseling of the patient
regard-ing the effects of emotions on voice production
Principles of Voice Therapy 9
n Reduction of the musculoskeletal
tension with the use of laryngeal manipulation/laryngeal massage
n Referral for marital counseling as
deemed appropriate.
The secondary focus would deal with modification or elimination of the abu-sive behaviors, including:
n smoking
n caffeine and medications n coughing and throat clearing
Inappropriate use of pitch and loud-ness would most likely be viewed as obvious symptoms of the problem. These symptoms would likely improve as the psychodynamics were improved.
Physiologic Voice Therapy
The general focus would be on evalu-ating the present physiologic condition of the patient’s voice production and developing direct physical exercises to improve that condition. We know that the patient presented with extreme laryngeal tension. Irregular vocal fold edges caused a glottal chink. In addi-tion, her vocal folds were extremely stiff, both in amplitude and mucosal wave.
Normal voicing is dependent on near total closure of the vocal folds, permitting air pressure to build below the folds. As the pressure builds, it eventually overcomes the resistance of the approximated folds, permitting the release of one puff of air. As the air rushes between the vocal folds, sub-glottal, suprasub-glottal, and intraglottal pressures, along with the static posi-tion of the vocal folds, draw them back together to complete one vibra-tory cycle. Air gaps, or glottal chinks, change the physical dynamics of vocal
fold vibration, requiring an increased subglottic pressure. Patients such as this woman often make physical com-pensations in an attempt to push out the “best” voice by hyperfunctioning the supraglottic structures. Add vocal fold muscular and mucosal stiffness to this mix, and the patient presents with a significant muscle tension dysphonia with associated respiratory, laryngeal, and resonance dysfunctions.
Direct physiologic voice therapy would focus on exercises designed to rebalance the three subsystems of voice production: respiration, phonation, and resonance. Therapy methods chosen to accomplish this task might include Vocal Function Exercises, Resonant Voice Therapy, or the Accent Method of Voice Therapy. (All methods are described in subsequent chapters.)
Eclectic Voice Therapy
In this review of philosophical orienta-tions of voice therapy, you have seen the various strengths of each management orientation, as well as the difficulty in subscribing to any one philosophy. All patients will be treated best by a speech-language pathologist with knowledge and understanding of all possible man-agement strategies and alternatives. As you read and study the many case presentations of this text, it is benefi-cial to evaluate the philosophy behind the treatment approach as a means of better understanding the reasons for the approach. The successful speech-language pathologist is both an artist and a scientist with an eclectic point of view. Therapy for Patient A should focus on:
n vocal hygiene counseling n symptom modification
10 Voice Therapy: Clinical Case Studies
n attention to the psychodynamics of
the problem
n direct physiologic vocal exercise
Voice Care Professionals
Thus far, we have discussed the treat-ment of voice disorders in terms of direct voice therapy. Voice care, however, is a shared province, with contributions from the primary care physician, laryn-gologist, speech-language pathologist, neurologist, allergist, gastroenterolo-gist, pulmonologastroenterolo-gist, psychologastroenterolo-gist, vocal coach, singing instructor, and others. Case studies presented in all chapters of this text describe the unique interdis-ciplinary and complementary relation-ships of each of these professionals with the others and with their patients.References
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