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Voice Therapy
Clinical Case Studies

Fourth Edition
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


Copyright by Plural Publishing, Inc. 2014

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Library of Congress Cataloging-in-Publication Data

Voice therapy : clinical case studies / [edited by] Joseph C. Stemple, Edie R.
Hapner. -- Fourth edition. Proudly sourced and uploaded by [StormRG]
p. ; cm. Kickass Torrents | TPB | ET | h33t
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
[DNLM: 1. Voice DisorderstherapyCase Reports. WV 500]

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
R. E. Stone Jr and Kimberly Coker
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
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
Rita Patel

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 Osris do Brasil
Case Study 3. Treatment of Glottal Incompetence With Secondary 206
Muscle Tension Dysphonia in a Patient With Unilateral Vocal Fold
Maria Dietrich
Case Study 4. Use of Semi-Occluded Vocal Tract Methods and 212
Resonant Voice Therapy to Treat Unilateral Vocal Fold Paralysis
Julie Barkmeier-Kraemer
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
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
References 307

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
Marina Gilman
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
The Clinical Ear 484

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. Theres 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
Overdoers Adherence
Carissa Portone-Maira
References 510
Appendix 8A. Selected Applications Useful in Voice Therapy 513

Index 521

The fourth edition of Voice Therapy: Nonetheless, because of the breadth of

Clinical Case Studies marks the 20-year material necessary in these texts, thera-
anniversary of this text. We are excited peutic methods for voice disorders are
to introduce Edie Hapner as co-editor often given only a cursory and gener-
of this fourth edition. Hapners clinical alized discussion. This text is meant to
and research contributions to the field of bridge that gap. In over 60 case studies
voice pathology are recognized nation- involving a wide variety of voice disor-
ally and internationally. She is a master ders with various pathologies and eti-
clinician and a teacher and mentor to a ologies, master clinicians have provided
generation of voice clinicians. We are detailed descriptions of management
pleased to have Edie on board and know approaches and techniques. It is our
that her contributions will enhance the hope that the expertise offered in these
quality of the learning experience for pages will serve the reader well in guid-
voice students and professionals alike. ing clinical practice.
Since its initiation, the purpose of Utilizing the format of actual case
this text has remained the same: studies, complete descriptions of diag-
nostic and therapeutic methods are pro-
. . . to provide both the student and the vided for a full array of voice disorders.
working clinician with a broad sampling
Chapter 1 includes information on the
of management strategies as presented by
various philosophies of treatment. With
master voice clinicians, laryngologists,
and other voice care professionals. The text the maturation of the voice care spe-
is meant to serve as a practical adjunct to cialty, different schools of thought have
the more didactic publications. evolved regarding treatment designs.
These philosophical orientations include
As the knowledge of voice produc- hygienic, symptomatic, psychogenic,
tion continues to expand, so, too, have physiologic, and eclectic orientations.
the publications dedicated to describ- Each orientation is discussed and illus-
ing this knowledge. There are currently trated with a representative case study.
excellent texts and journals dedicated Chapter 2 comments on various
to the scientific understanding of voice. voice evaluation techniques. These tech-
Other publications are available to help niques include the formal questionnaire,
prepare students to evaluate and man- the patient interview, perceptual voice
age clinical voice disorders. By necessity, analysis, patient self-assessment, and
these texts must include great quantities instrumental assessment of voice pro-
of didactic information so that the stu- duction. The role of the evaluation pro-
dent learns not only how but why. cess as a part of the overall management
To utilize a management approach plan is also discussed.
without understanding the underlying Chapter 3 discusses treatment ap-
basis of the approach is inappropriate. proaches for the most common type
xiv Voice Therapy: Clinical Case Studies

of voice disorder, muscle tension dys- include treatments for laryngopharyn-

phonia (MTD). Following an over- geal reflux and VCD in the young child,
view of MTD by Nelson Roy, manage- young athlete, and elite athlete.
ment approaches for both children and The consequences of a voice disor-
adults including hygiene programs, der may impact the quality of life and
symptomatic modifications, attention threaten the livelihood of individuals
to psychosocial issues, and direct phys- dependent upon a healthy voice. Chap-
iologic manipulation and exercises are ter 7 presents case studies for those
presented in illustrative case studies of dependent upon their voice such as the
both primary and secondary MTD. elite vocal performer, the occupational
Treatments for various etiologies voice user, and those whose avocational
of glottal incompetence are described voice use is related to their quality of life.
in Chapter 4. Management for voice The final chapter, Chapter 8, is
fatigue, bowed vocal folds, senile lar- devoted to a discussion of success-
yngis, and vocal fold paralysis are ful voice therapy and patient adher-
described, including direct voice thera- ence. What makes therapy successful
pies, surgical intervention, and a com- or unsuccessful? This chapter looks at
bination of these approaches. Many both the therapist and the patient and
techniques including voice facilitating describes the pitfalls that may influence
techniques, semi-occluded vocal tract, the ultimate goal of therapy: improved
expiratory muscle strength training, vocal function.
and phonation resistance training are As with the first three editions of
discussed. Voice Therapy: Clinical Case Studies, the
Chapter 5 presents management most exciting element in the preparation
strategies for laryngeal dystonia, essen- of this text was the support received by
tial tremor, and other neurologic voice the master clinicians who graciously
disorders. These strategies include be- and generously submitted the case
havioral and medical management of studies. What a wonderful opportunity
spasmodic dysphonia, voice therapy for it is to learn from those who are in the
essential tremor, and face-to-face and trenches, those experts who embody not
remote treatment of voice and speech only superior clinical skills, but won-
symptoms related to Parkinson disease. derful insight as to why they do what
Because of the speech-language they do. We are deeply indebted to all
pathologists unique blend of knowl- of them and proudly offer their collec-
edge regarding upper respiratory anat- tive expertise. We are certain that the
omy and physiology and behavioral reader will benefit from their vast clini-
therapy, we have become the caregivers cal experiences.
for complex respiratory and laryngeal Text preparations are extremely
disorders. Chapter 6 provides several time-consuming and require many hours
detailed case studies regarding the of tedious work. Checking and preparing
various etiologies, patient profiles, and references, organizing tables, figures,
evaluation and treatment approaches and their legends, reading and re-read-
used with those diagnosed with irri- ing in an attempt to make the intent
table larynx syndrome. Included in this clear to those we are trying to reach are
category are chronic cough and vocal only a few of the tasks involved. We
cord dysfunction (VCD). These cases were so very fortunate in the prepara-

tion of this text to have the invaluable edition. In addition, we wish to thank
editorial assistance of the Plural Pub- our students and colleagues who have
lishing professionals. We are indebted suggested ways to improve the text with
to Angie Singh, Megan Carter, Milgem each new writing. Finally, as usual, we
Rabanera, and Mckenna Bailey for en- are most appreciative for the support of
couraging and supporting this fourth our families.

Joseph C. Stemple
Edie R. Hapner

Moya L. Andrews, EdD Universidade Federal de So Paulo

Professor Emerita UNIFESP and Centro de Estudos da
Department of Speech and Hearing Voz-CEV
Sciences So Paulo, SP, Brazil
Indiana University Chapters 3 and 4
Bloomington, Indiana
Chapter 3 Alison Behrman, PhD, CCC-SLP
Associate Professor
Mary V. Andrianopoulos, PhD Department of Speech-Language-
Associate Professor Hearing Sciences
Clinical Consultant Lehman College/City University of
Department of Communication New York
Disorders Bronx, New York
Center for Language, Speech, and Chapter 7
University of Massachusetts-Amherst Maia Braden, MS
Amherst, Massachusetts Speech-Language Pathologist
Chapter 6 University of Wisconsin-Madison
Voice and Swallow Clinics
Susan Baker Brehm, PhD American Family Childrens Hospital
Associate Professor and Chair Madison, Wisconsin
Department of Speech Pathology and Chapter 6
Miami University Kimberly Coker, MS
Oxford, Ohio Speech-Language Pathologist
Chapter 3 North Texas Voice Center
Dallas, Texas
Julie Barkmeier-Kraemer, PhD Chapter 3
Department of Otolaryngology Starr Cookman, MA
University of California, Davis Assistant Professor
Sacramento, California Clinical Faculty
Chapters 4 and 5 University of Connecticut Health
Mara Behlau, PhD Farmington, Connecticut
Permanent Professor Chapter 7
Graduate Program in Human
Communication Disorders Mark S. Courey, MD
Director Professor
Specialization Course in Voice Otolaryngology-Head & Neck Surgery
xviii Voice Therapy: Clinical Case Studies

Director Lisa Fry, PhD

Division of Laryngology Adjunct Faculty
University of California, San Francisco Department of Communication
San Francisco, California Disorders
Chapter 7 Marshall University
Huntington, West Virginia
Kate DeVore, MA Chapter 3
Speech-Language Pathologist
Total Voice, Inc. Jackie Gartner-Schmidt, PhD
Chicago, Illinois Associate Professor
Chapter 7 Otolaryngology
Associate Director
Maria Dietrich, PhD UPMC Voice Center
Assistant Professor Director of Speech Pathology-Voice
Department of Communication Division
Disorders University of Pittsburgh Medical
University of Missouri Center
Columbia, Missouri Pittsburgh, Pennsylvania
Chapter 4 Chapter 3

Osris do Brasil, MD Shirley Gherson, MA

Centro de Estudos da Voz Clinical Specialist-Voice Disorders
CEV, So Paulo, SP NYU Langone Medical Center
Associate Professor Rusk Rehabilitation
So Paulo, Brazil New York, New York
Chapter 4 Chapter 7

Patricia B. Doyle, MA Amanda I. Gillespie, PhD

Instructor Assistant Professor
University of Connecticut Health University of Pittsburgh
Center UPMC Voice Center
Farmington, Connecticut Pittsburgh, PA
Chapter 7 Chapters 4 and 8

Eileen M. Finnegan, PhD Marina Gilman, MM, MA, CCC-SLP

Associate Professor Speech-Language Pathologist
University of Iowa Emory Voice Center
Iowa City, Iowa Otolaryngology-Head & Neck Surgery
Chapter 5 Emory University
Atlanta, Georgia
Cynthia Fox, PhD Chapter 7
Research Associate
National Center for Voice and Speech Laureano A. Giraldez-Rodriguez, MD
University of Colorado-Boulder Fellow
Denver, Colorado Head and Neck Cancer Surgery
Chapter 5 Microvascular Reconstruction

Department of Otolaryngology-Head Sara Harris, FRCSLT

& Neck Surgery Speech-Language Pathologist
Mount Sinai School of Medicine Lewisham Hospital Voice Disorders
New York, New York Unit
2013 Fellow London, United Kingdom
Emory Voice Center Chapter 3
Department of Otolaryngology-Head
& Neck Surgery Marc Haxer, MA
Emory University Clinical Senior Speech Pathologist
Atlanta, Georgia Departments of Otolaryngology-
Chapter 6 Head & Neck Surgery and Speech-
Language Pathology
Leslie E. Glaze, PhD University of Michigan Health System
Speech-Language Pathologist Ann Arbor, Michigan
Minneapolis, Minnesota Chapter 6
Tucson, Arizona
Chapter 3 Rita Hersan, MS
Speech-Language Pathologist
Voice Clinician
Stephen Gorman, PhD
University of Pittsburgh Voice Center
Voice Pathologist
Pittsburgh, Pennsylvania
Blaine Block Institute for Voice
Chapter 3
Analysis and Rehabilitation
Dayton, Ohio
Robert E. Hillman, PhD
Professional Voice Center of Greater
Research Director
Cincinnati, Ohio
Center for Laryngeal Surgery and
Chapter 4
Voice Rehabilitation
Massachusetts General Hospital
Rebecca L. Hancock, MEd Director
Senior Speech Pathologist Research Programs
University of Kentucky Voice and MGH Institute of Health Professions
Swallow Clinic Professor of Surgery
Lexington, Kentucky Harvard Medical School
Chapter 3 Boston, Massachusetts
Chapter 3
Edie R. Hapner, PhD, CCC-SLP
Associate Professor Henry Ho, MD, FACS
Department of Otolaryngology-Head Director
& Neck Surgery Head and Neck Program
Emory University School of Medicine The Florida Hospital Cancer Institute
Director Orlando, Florida
Speech-Language Pathology Chapter 4
Emory Voice Center
Atlanta, Georgia Bari Hoffman Ruddy, PhD
Chapters 4 and 5 Associate Professor
xx Voice Therapy: Clinical Case Studies

Department of Communication Jeffrey Lehman, MD, FACS

Sciences and Disorders Clinical Professor
University of Central Florida College of Health and Public Affairs
Orlando, Florida University of Central Florida
Chapters 4 and 7 Medical Director
The Voice Care Center
Barbara Jacobson, PhD Winter Park, Florida
Assistant Professor Chapter 7
Associate Director
Medical Speech-Language Pathology Glaucya Madazio, PhD
Department of Hearing & Speech Fonoaudiologa Especialista em Voz
Sciences Consultora em Comunicacao Humana
Vanderbilt University Sao Paulo, SP, Brazil
Nashville, Tennessee Chapter 3
Chapter 7
Stephen C. McFarlane, PhD
Michael M. Johns, MD, FRCS Foundation Professor/Professor
Associate Professor Emeritus
Otolaryngology Speech Pathology Department
Director University of Nevada, School of
Emory Voice Center Medicine
Department of Otolaryngology-Head Reno, Nevada
& Neck Surgery Chapter 4
Emory University
Atlanta, Georgia Claudio F. Milstein, PhD
Chapter 5 Director
The Voice Center
Lisa N. Kelchner, PhD, BCS-S Cleveland Clinic
Associate Professor Associate Professor
Director of Graduate Studies Otolaryngology
Department of Communication Cleveland Clinic Lerner College of
Sciences and Disorders Medicine
University of Cincinnati Cleveland, Ohio
Cincinnati, Ohio Chapter 3
Chapter 3
Jennifer C. Muckala, MA, CCC-SLP
Wendy D. LeBorgne, PhD, CCC-SLP Senior Speech Pathologist
Voice Pathologist Singing Voice Specialist
Singing Voice Specialist Vanderbilt Voice Center
Clinical Director Nashville, Tennessee
The Blaine Block Institute of Voice Chapter 7
Analysis and Rehabilitation
Provoice Center of Cincinnati College- Chayadevie Nanjundeswaran, PhD
Conservatory of Music Assistant Professor
Dayton and Cincinnati, Ohio Department of Audiology and Speech-
Chapter 7 Language Pathology

East Tennessee State University Department of Otolaryngology-Head

Johnson City, Tennessee & Neck Surgery
Chapter 4 Atlanta, Georgia
Chapter 7
Gisele Oliveria, PhD
Associate Professor Bruce J. Poburka, PhD
CEVCentro de Estudos da Voz Professor
Sao Paulo, SP, Brazil Communication Disorders
Assistant Professor Minnesota State University, Mankato
Touro College Mankato, Minnesota
Brooklyn, New York Chapter 4
Chapter 4
Carissa Portone-Maira, MS
Bryn Olson, MS Lead Speech-Language Pathologist
Speech-Language Pathologist Emory Voice Center
The Communication Development Department of Otolaryngology-Head
Center & Neck Surgery
Madison, Wisconsin Atlanta, Georgia
Chapter 8 Chapters 3 and 8

Diana M. Orbelo, PhD Lorraine Ramig, PhD

Assistant Professor Professor
Mayo Clinic College of Medicine University of Colorado-Boulder
Rochester, Minnesota Senior Scientist
Chapter 3 National Center for Voice and
Rita R. Patel, PhD Adjunct Professor
Assistant Professor Columbia University
Department of Hearing and Speech New York, New York
Sciences Chapter 5
Indiana University
Bloomington, Indiana Linda Rammage, PhD, RSLP
Chapter 3 Director
Provincial Voice Care Resource
Madeleine Pethan, MA Program, UBC
Speech-Language Pathologist Vancouver, BC, Canada
Emory Voice Center Chapter 6
Department of Otolaryngology-Head
& Neck Surgery Christin Ray, MA (ABD)
Atlanta, Georgia Doctoral Candidate
Chapter 6 Department of Speech and Hearing
Brian E. Petty, MA, MA The Ohio State University
Speech-Language Pathologist Columbus, Ohio
Emory Voice Center Chapter 6
xxii Voice Therapy: Clinical Case Studies

Clark A. Rosen, MD, FACS Sarah L. Schneider, MS

Professor Director
Department of Otolaryngology Speech-Language Pathology
University of Pittsburgh School of UCSF Voice and Swallowing Center
Medicine University of California, San Francisco
Director San Francisco, California
University of Pittsburgh Voice Center Chapter 7
Pittsburgh, Pennsylvania
Chapter 4 Sandra A. Schwartz, MS
Clinical Faculty/Instructor
Nelson Roy, PhD, CCC-SLP, ASHAF Duquesne University
Professor Pittsburgh, Pennsylvania
Department of Communication Chapter 3
Sciences and Disorders
Division of Otolaryngology-Head & Erin Silverman, PhD
Neck Surgery Research Assistant Professor
Department of Surgery, School of University of Florida
Medicine Gainesville, Florida
University of Utah Chapter 4
Salt Lake City, Utah
Chapter 3 Tara Stadelman-Cohen, BM, MS
Senior Voice Pathologist
Brienne Ruel, MA Center for Laryngeal Surgery and
Speech-Language Pathologist Voice Rehabilitation
UW Voice and Swallow Clinics, Massachusetts General Hospital
Department of Surgery Adjunct Clinical Instructor
Madison, Wisconsin School of Health and Rehabilitation
Chapter 7 Sciences
MGH Institute of Health Professions
Mary J. Sandage, PhD Part-time Faculty
Assistant Professor Boston Conservatory
Auburn University Boston, Massachusetts
Auburn, Alabama Chapter 3
Chapter 6
Heather Starmer, MA
Christine M. Sapienza, PhD Assistant Professor
Program Director Department of Otolaryngology-Head
Speech Pathology & Neck Surgery
Associate Dean Johns Hopkins University
College of Health Sciences Baltimore, Maryland
Jacksonville University Chapter 3
Jacksonville, Florida
Research Career Scientist BRRC Joseph C. Stemple, PhD, CCC-SLP,
Malcolm Randall VA ASHAF
Gainesville, Florida Professor
Chapters 4 and 7 Communication Sciences and Disorders

College of Health Sciences Miriam van Mersbergen, PhD

University of Kentucky Assistant Professor
Lexington, Kentucky Speech-Language Pathology
Chapters 1, 2, 3, 4, 5, and 8 Northern Illinois University
DeKalb, Illinois
R.E. Stone Jr, PhD Chapter 7
Director of Speech-Language Jarrad Van Stan, MA, BRS-S
Pathology Senior Clinical Research Coordinator
Vanderbilt Voice Center Speech-Language Pathologist
Vanderbilt Bill Wilkerson Department MGH Center for Laryngeal Surgery
of Communication Sciences and and Voice Rehabilitation
Disorders PhD Student
Nashville, Tennessee MGH Institute of Health Professions
Chapter 3 Boston, Massachusetts
Chapter 3
Jennifer Thompson, MA
Clinical Voice Pathologist
Katherine Verdolini Abbott, PhD
Clinical Instructor
James Care Voice and Swallowing
Department of Communication Science
Disorders Clinic
and Disorders, Otolaryngology
The Ohio State University
McGowan Institute for Regenerative
Columbus, Ohio
Chapter 6
University of Pittsburgh
Center for the Neural Basis of
Lyn Tindall Covert, PhD
Speech-Language Pathologist
Carnegie-Mellon University and
Department of Veterans Affairs
University of Pittsburgh
Medical Center
Pittsburgh, Pennsylvania
Lexington, Kentucky
Chapter 3
Chapter 5

Michael D. Trudeau, PhD Shelley Von Berg, PhD

Emeritus Associate Professor Associate Professor
The Ohio State University Communication Sciences and
Columbus, Ohio Disorders
Chapter 6 California State University, Chico
Eva van Leer, PhD, MFA Chico, California
Assistant Professor Chapter 4
Department of Education
Psychology, Special Education, and Nicole Yee-Key Li, PhD, M.Phil.
Communication Disorders Assistant Professor
College of Education University of Maryland-College
Georgia State University Park
Atlanta, Georgia College Park, Maryland
Chapter 8 Chapter 3
xxiv Voice Therapy: Clinical Case Studies

Aaron Ziegler, MA (ABD)

Doctoral Candidate
University of Pittsburgh
Pittsburgh, Pennsylvania
Chapter 4
Principles of Voice Therapy

associated with voice disorders2023 are

Introduction but a few of the many advances in voice
science. Furthermore, consider the rap-
In preparing the fourth edition of this idly evolving ability to measure and
text, it was necessary to review almost describe normal and pathologic voice
80 years of history related to voice ther- function objectively through sophisti-
apy techniques and approaches. It is a cated acoustic and aerodynamic instru-
rich and interesting history that gives mentation, as well as the ability to
an excellent understanding of how the observe vocal fold vibration. All of these
treatment of voice disorders has grown scientific advancements have provided
and evolved to our present practice. voice clinicians with the tools to confirm
Some of the therapy approaches devel- the efficacy of their approaches.
oped by early speech pathologists con- The number of traditional therapy
tinue to be used successfully in the approaches that continue to be used in
remediation of voice disorders to this voice therapy today is a strong state-
day. Because of the growth in our knowl- ment of appreciation and admiration for
edge and understanding of voice pro- the voice pedagogues, clinicians, and
duction, other therapy approaches once scientists of earlier days. The accuracy
commonly used were proven to be inef- of their practical observations regard-
fective. The past 30 years have yielded ing voice function has proved to be
tremendous growth in our knowledge uncanny. The efficacy of many of these
and understanding of vocal function. traditional voice therapy techniques is
Computer models of phonation,16 his- now being tested through systematic
tologic studies of the vocal folds,710 outcomes research.24 Proof of the use-
analysis of the vocal fold cover and tis- fulness of many of these techniques,
sue engineering,1119 and genetic issues however, has been well established by
2 Voice Therapy: Clinical Case Studies

the clinical results of skilled speech- understanding, empathy, and projec-

language pathologists. tion of credibility, together with listen-
The major difference in voice ther- ing, counseling, and motivational skills
apy today compared with even 20 to are essential attributes of the success-
25 years ago is the ability to diagnose a ful voice clinician. Philosophically, we
problem quickly and accurately and to might make these statements about the
confirm the efficacy of our management artistic nature of voice:
approaches through objective measures.
These objective measures may also be n When considering the voice, we must
used as patient feedback during the consider the whole person.
therapeutic process. Although our man- n To examine a voice disorder is to
agement approaches have changed over examine a unique individual.
the years, voice therapy remains a blend n The feelings of that individual, both
of science and art. physical and emotional, may be
The scientific nature of voice ther- directly reflected in the voice.
apy involves the clinicians knowledge n To remediate a voice disorder, we
of several important areas of study. must have the skills to counsel and
These areas include the anatomy and motivate the patient and empower
physiology of normal and pathologic readiness for change.
voice production; the nuances of laryn-
geal pathologic conditions; the acoustics The successful voice clinician will
and aerodynamics of voice production; combine attributes of the artistic ap-
and the etiologic correlates of voice proaches toward voice therapy with the
disorders, including patient behav- objective scientific bases to identify the
iors, medical causes, and psychological problem and then plan and carry out
contributions: appropriate management strategies.
Nonetheless, possession of a solid base
n When considering the voice, we are of didactic information augments expe-
considering the most widely used rience. Experience continues to teach
instrument on earth. even the masters. It is hoped that the
n To understand the voice disorder, we experiences of others provided in this
must understand the instruments text will prove helpful in the develop-
physical structure and functional ment of superior voice clinicians.
n We must have the skills to measure
these components objectively and to
Historical Perspective
relate these measures to our manage-
ment choices.
n In addition, we must possess a broad In examining the evolution of the treat-
knowledge of the common causes of ment of voice disorders, we find it was
voice disorders and the nuances of not until around 1930 that a few lar-
laryngeal pathologic conditions. yngologists, singing teachers, instruc-
tors in the speech arts, and a fledgling
The artistic nature of voice therapy group of speech correctionists became
is dependent on the human interac- interested in retraining individuals with
tion skills of the clinician. Compassion, voice disorders. This group used drills
Principles of Voice Therapy 3

and exercises borrowed from voice attacks, and so on. The focus of psycho-
and diction manuals designed for the genic voice therapy is on the emotional
normal voice in an attempt to modify and psychosocial status of the patient
disordered voice production. Many of that led to and maintains the voice dis-
these rehabilitation techniques were order. The physiologic orientation of voice
and remain creative and effective, but therapy focuses on directly modifying
they were not necessarily based on sci- and improving the balance of laryngeal
entific principles. The artistic portion muscle effort to the supportive airflow,
of voice treatment was the strong point as well as the correct focus of the laryn-
of early clinicians. geal tone. Finally, the eclectic approach of
Out of this artistic approach came voice therapy is the combination of any
the general treatment suggestions of: and all of the previous voice therapy
(1)ear training, (2) breathing exercises, orientations.27
(3) relaxation training, (4) articulatory None of these philosophical orienta-
compensations, (5) emotional retrain- tions are pure. Much overlap is present,
ing, and (6) special drills for cleft palate often leading to the use of an eclectic
and velopharyngeal insufficiency.25,26 approach. With this introduction, let us
These treatment suggestions became the examine the orientations of voice ther-
foundation of vocal rehabilitation. apy in greater detail.
Several general management phi-
losophies have arisen from the early
foundations of voice rehabilitation.
Hygienic Voice Therapy
These philosophical orientations are
based primarily on the clinicians mind-
set and previous training regarding Hygienic voice therapy often is the first
voice disorders that directs the manage- step in many voice therapy programs.
ment focus. For the sake of discussion, Many etiological factors contribute to
we classify these management philoso- the development of voice disorders. Poor
phies as: vocal hygiene may be a major develop-
mental factor. Some examples of behav-
n hygienic voice therapy iors that constitute poor vocal hygiene
n symptomatic voice therapy include shouting, talking loudly over
n psychogenic voice therapy noise, screaming, vocal noises, cough-
n physiologic voice therapy ing, throat clearing, and poor hydration.
n eclectic voice therapy When the inappropriate vocal behaviors
are identified, then appropriate treat-
In short, hygienic voice therapy ments can be devised for modifying
focuses on identifying inappropriate or eliminating them. Once modified,
vocal hygiene behaviors, which then are voice production has the opportunity to
modified or eliminated. Once modified, improve or return to normal.
voice production has the opportunity to Poor vocal hygiene may also in-
improve or return to normal. Symptom- clude the habitual use of inappropriate
atic voice therapy focuses on modification pitch or loudness, reduced respiratory
of the deviant vocal symptoms identi- support, poor phonatory habits (glot-
fied by the speech-language pathologist, tal attacks, fry), or inappropriate reso-
such as breathiness, low pitch, glottal nance. Functional inappropriate use of
4 Voice Therapy: Clinical Case Studies

these voice components may contribute good phonation is the core of what we
to the development and maintenance do in symptomatic voice therapy for
of a voice disorder. Hygienic voice the reduction of hyperfunctional voice
therapy presumes that many voice dis- disorders.28(p11)
orders have a direct behavioral cause.
This therapy strives to instill healthy Boones original facilitating ap-
vocal behaviors in the patients habitual proaches included:
speech patterns. Good vocal hygiene
also focuses on maintaining the health 1. altering of tongue position
of the vocal fold cover through ade- 2. change of loudness
quate internal hydration and diet. Once 3. chewing exercises
identified, poor vocal hygiene habits 4. digital manipulation
can be modified or eliminated leading 5. ear training
to improved voice production. 6. elimination of abuses
7. elimination of hard glottal attack
8. establishment of a new pitch
9. explanation of the problem
Symptomatic Voice Therapy 10. feedback
11. hierarchy analysis
Symptomatic voice therapy was a term 12. negative practice
first introduced by Daniel Boone.28 This 13. open mouth exercises
voice management approach is based on 14. pitch inflections
the premise that modifying the symp- 15. pushing approach
toms of voice production including pitch, 16. relaxation
loudness, respiration, and so on, will 17. respiration training
improve the voice disorder. Once identi- 18. target voice models
fied, the misuses of these various voice 19. voice rest
components are modified or reduced 20. yawn-sigh approach
using voice therapy facilitating techniques.
Many if not all of these facilitators remain
In the voice clinicians attempt to useful and popular in the treatment
aid the patient in finding and using of voice disorders and are described
his best voice production, it is neces- in greater detail in cases throughout
sary to probe continually within the this text.
patients existing repertoire to find the The main focus of symptomatic
best one voice which sounds good voice therapy is direct modification of
and which he is able to produce with vocal symptoms. For example, if the
relatively little effort. A voice therapy
patient presents with a voice quality
facilitating technique is that technique
characterized by low pitch, breathiness,
which, when used by a particular
patient, enables him easily to produce and hard glottal attacks, then the main
a good voice. Once discovered, the focus of therapy is to directly modify the
facilitating technique and resulting symptoms. The facilitating approaches
phonation become the symptomatic used to modify these symptoms might
focus of voice therapy . . . This use of include explanation of the problem,
a facilitating technique to produce a ear training, elimination of hard glot-
Principles of Voice Therapy 5

tal attack, and respiration training. The for the emotional or psychosocial prob-
speech-language pathologist constantly lem is beyond the realm of their skills.
probes for the best voice and attempts Areferral system of support profession-
to stabilize that voice with the various, als must be readily available.
appropriate facilitating techniques.
Symptomatic voice therapy assumes
voice improvement through direct
Physiologic Voice Therapy
symptom modification.

Physiologic voice therapy includes

voice therapy programs that have been
Psychogenic Voice Therapy
devised to directly alter or modify the
physiology of the vocal mechanism.
Early in the study of voice disorders, the Normal voice production is dependent
relationship of emotions to voice pro- on a balance among airflow, supplied
duction was well recognized. As early by the respiratory system; laryngeal
as the mid-1800s, journal articles dis- muscle balance, coordination, and stam-
cussed hysteric aphonia.29,30 West, Ken- ina; and coordination among these and
nedy, and Carr26 and Van Riper25 dis- the supraglottic resonatory structures
cussed the need for emotional retraining (pharynx, oral cavity, and nasal cav-
in voice therapy. Murphy31 presented ity). Any disturbance in the physiologic
an excellent discussion of the psycho- balance of these vocal subsystems may
dynamics of voice. Friedrich Brodnitz,32 lead to a voice disturbance.37
as an otolaryngologist, was uniquely These disturbances may be in respi-
sensitive to the relationship of emotions ratory volume, power, pressure, and
to voice. These early readings are most flow. Disturbances also may manifest in
interesting and remain informative to vocal fold tone, mass, stiffness, flexibil-
those treating voice disorders. ity, and approximation. Finally, the cou-
Our understanding of psychogenic pling of the supraglottic resonators and
voice therapy was further expanded the placement of the laryngeal tone may
by Aronson,33 Case,34 Stemple,35 and cause or may be perceived as a voice
Colton and Casper.36 These authors disorder. The overall causes may be
discussed the need for determining the mechanical, neurologic, or psychologi-
emotional dynamics of the voice dis- cal. Whatever the cause, the manage-
turbance. Psychogenic voice therapy ment approach is direct modification of
focuses on identification and modifica- the inappropriate physiologic activity
tion of the emotional and psychosocial through exercise and manipulation.
disturbances associated with the onset Inherent in physiologic voice ther-
and maintenance of the voice problem. apy is a holistic approach to the treat-
Pure psychogenic voice therapy is based ment of voice disorders. They are thera-
on the assumption of underlying emo- pies that strive to at once balance the
tional causes. Voice clinicians, therefore, three subsystems of voice production
must develop and possess superior as opposed to working directly on sin-
interview skills, counseling skills, and gle voice components, such as pitch or
the skill to know when the treatment loudness. Examples of physiologic voice
6 Voice Therapy: Clinical Case Studies

therapy include Vocal Function Exer- thesiologist while intubating the patient
cises,38 Resonant Voice Therapy,39 and for a laminectomy 6 months prior to her
the Accent Method of Voice Therapy,40 voice evaluation. Because of the large
all of which are presented in this text. 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
Eclectic Voice Therapy
laryngeal examination.
Indirect mirror examination revealed
Adherence to one philosophical ori- bilateral polypoid degeneration, worse
entation of voice therapy would not on the left than the right. Audible inspi-
be advisable. Successful voice therapy ratory stridor was noted by the physi-
depends on utilization of an approach cian, and the patient reported shortness
that happens to work for the therapist of breath during even limited physical
and the individual patient. The more exertion. Therefore, two surgeries (one
management approaches are under- for each vocal fold) were scheduled
stood and mastered by the clinician, the 6weeks apart for aspiration of fluid and
greater the likelihood for success. Man- laser vaporization of redundant tissue.
agement techniques that prove success- The surgeries were performed without
ful for one patient may not be successful complication, and the patient was seen
for a similar patient. The clinician, there- for voice evaluation following appropri-
fore, must possess the knowledge to ate healing.
adjust the management approach.
Some techniques that work well for
one therapist may prove to be difficult History of the Problem
for another. In whatever management
approach you choose, you must have The patient reported that she had always
supreme confidence in your under- had a deep voice, which had lowered
standing of the technique and your even more over the past several years.
ability to make that approach work suc- Her presurgical voice quality had not
cessfully. Your confidence is one factor been a concern to her, however. Instead,
that will determine the success or failure it was the shortness of breath that led
of therapy. Using a typical case, let us her to agree to surgery. She reported
examine how each therapy orientation that voice quality following the first sur-
might be used to treat the vocal difficul- gery (left fold) was a little hazy but
ties of this composite patient. 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.
Case Study: Patient A

Patient A, a 52-year-old woman, was Medical History

referred by her laryngologist to the
voice center for postsurgical evaluation The patient reported undergoing two
and treatment. Large, bilateral, draping previous surgeries: removal of her gall
polyps were first identified by an anes- bladder 10 years earlier and the lami-
Principles of Voice Therapy 7

nectomy performed earlier this year. plant. Present activities included shop-
Even with the difficult intubation and ping with her daughter, talking on the
the risk of vocal fold paralysis inherent telephone, caring for her home (back
in laminectomy, her presurgical voice permitting), watching daytime televi-
quality was maintained. In addition to sion talk shows, and bowling two
surgeries, she had been hospitalized nights per week in two different leagues.
3years before for 3 weeks and treated
for chronic depression.
Chronic medical disorders included Voice Evaluation
frequent upper respiratory infections
Perceptually, the patients voice quality
including bronchitis, high blood pres-
was described as moderately dysphonic,
sure, circulatory problems in her legs,
characterized by low pitch, inappropriate
elevated blood sugar, and chronic neck
loudness, strained raspiness, and inter-
and back pain. Daily medications were
mittent glottal fry phonation. Acoustic
taken for blood pressure, chronic pain,
and aerodynamic analyses revealed a low
depression, and sleep. She continued a
fundamental frequency (150 Hz), limited
30-year history of smoking 1 to 2 packs
frequency range (118290 Hz), increased
of cigarettes per day. Her liquid intake
habitual intensity (76 dB), normal airflow
consisted mostly of 6 cups of caffeinated
volume (2300 mL H2O), reduced airflow
coffee per day. Chronic throat clear-
rate (<80 mL H2O/s), and reduced maxi-
ing and a persistent cough were noted
mum phonation time (<12 s).
throughout the evaluation.
Laryngeal videostroboscopic ob-
servation revealed mild-to-moderate
bilateral true vocal fold edema and ery-
Social History
thema. Glottic closure demonstrated an
irregular glottal chink with a moder-
Patient A had been married for 12 years
ate ventricular fold compression. The
to her second husband, following a first
edges of the vocal folds were rough
marriage of 18 years and divorce. She
and irregular, worse on the left than on
had two adult children from her previ-
the right. The amplitude of vibration
ous marriage. Her elderly mother-in-
was severely decreased bilaterally. The
law lived with her and her husband, a
mucosal waves were barely percep-
situation that often caused friction and
tible. The closed phase of the vibratory
conflict with her husband. She was not
cycle was strongly dominant, whereas
shy in reporting her unhappiness with
the symmetry of vibration was gener-
her marital relationship. This unhappi-
ally irregular. No mass lesions, paresis,
ness was said to be a major factor in her
or paralysis was evident. In short, the
history of depression.
patient had an edematous, stiff, hyper-
Both the patient and her husband
functioning vocal fold system.
were employed by the local automobile
assembly plant. She had worked as an
assembler for 14 years in an environ- Impressions
ment described as noisy, dusty, and
full of fumes and was on a temporary Patient A presented with a voice disor-
medical disability because her back der that derived from the following pos-
problems precluded her working in the sible causal factors:
8 Voice Therapy: Clinical Case Studies

n cigarette smoking causes. The patient would be aided in

n harsh employment environment her attempt to stop smoking, encour-
n talking over noise at work aged to begin a hydration program,
n large caffeine intake and given vocal hygiene counseling to
n frequent upper respiratory infections aid in elimination or reduction of the
n prescription medications vocally abusive behaviors. The second-
n coughing and throat clearing ary causes most likely would improve
n emotional instability spontaneously as the primary causes
n talking too loudly (suggesting pos- were modified and the vocal fold con-
sible hearing loss, which later proved dition improved.
not to be present)
n using a low pitch Symptomatic Voice Therapy
n laryngeal muscle tension
n postsurgical vocal fold mucosal The general focus would include use of
changes facilitating techniques to:

n raise pitch
Recommendations n reduce loudness
n reduce laryngeal area tension and
Hygienic Voice Therapy effort
The general focus would be to identify
the primary and secondary vocal mis- This direct symptom modification would
uses and then to modify or eliminate follow an explanation of the problem
these nonhygienic behaviors. The pri- and would run concurrently with mod-
mary etiologic correlates include: ification of vocally abusive behaviors,
n Smoking
n Laryngeal dehydration from caffeine n smoking
and drugs n caffeine intake
n Voice abuse, such as coughing, throat n coughing and throat clearing
clearing, and talking loudly over
noise at work Psychogenic Voice Therapy

Secondary precipitating factors that result The general focus would be to explore
from the pathologic condition include: the psychodynamics of the voice disor-
der. Techniques would include:
n Laryngeal area muscle tension and
hyperfunction caused by vocal fold n Detailed interview with the patient
stiffness to determine the cause and effects of
n Low pitch caused by increased mass depression
n Increased loudness caused by the n Determination of the relationship
effort used to force stiff vocal folds to of emotional problems and voice
vibrate problem
n Counseling of the patient regard-
Therapy would focus on modifi- ing the effects of emotions on voice
cation or elimination of the primary production
Principles of Voice Therapy 9

n Reduction of the musculoskeletal fold vibration, requiring an increased

tension with the use of laryngeal subglottic pressure. Patients such as
manipulation/laryngeal massage this woman often make physical com-
n Referral for marital counseling as pensations in an attempt to push out
deemed appropriate. the best voice by hyperfunctioning
the supraglottic structures. Add vocal
The secondary focus would deal with fold muscular and mucosal stiffness to
modification or elimination of the abu- this mix, and the patient presents with
sive behaviors, including: a significant muscle tension dysphonia
with associated respiratory, laryngeal,
n smoking and resonance dysfunctions.
n caffeine and medications Direct physiologic voice therapy
n coughing and throat clearing would focus on exercises designed to
rebalance the three subsystems of voice
Inappropriate use of pitch and loud- production: respiration, phonation, and
ness would most likely be viewed as resonance. Therapy methods chosen to
obvious symptoms of the problem. These accomplish this task might include Vocal
symptoms would likely improve as the Function Exercises, Resonant Voice
psychodynamics were improved. Therapy, or the Accent Method of Voice
Therapy. (All methods are described in
Physiologic Voice Therapy subsequent chapters.)

The general focus would be on evalu- Eclectic Voice Therapy

ating the present physiologic condition
of the patients voice production and In this review of philosophical orienta-
developing direct physical exercises to tions of voice therapy, you have seen the
improve that condition. We know that various strengths of each management
the patient presented with extreme orientation, as well as the difficulty in
laryngeal tension. Irregular vocal fold subscribing to any one philosophy. All
edges caused a glottal chink. In addi- patients will be treated best by a speech-
tion, her vocal folds were extremely stiff, language pathologist with knowledge
both in amplitude and mucosal wave. and understanding of all possible man-
Normal voicing is dependent on agement strategies and alternatives.
near total closure of the vocal folds, As you read and study the many case
permitting air pressure to build below presentations of this text, it is benefi-
the folds. As the pressure builds, it cial to evaluate the philosophy behind
eventually overcomes the resistance of the treatment approach as a means of
the approximated folds, permitting better understanding the reasons for
the release of one puff of air. As the air the approach. The successful speech-
rushes between the vocal folds, sub- language pathologist is both an artist
glottal, supraglottal, and intraglottal and a scientist with an eclectic point
pressures, along with the static posi- of view. Therapy for Patient A should
tion of the vocal folds, draw them focus on:
back together to complete one vibra-
tory cycle. Air gaps, or glottal chinks, n vocal hygiene counseling
change the physical dynamics of vocal n symptom modification
10 Voice Therapy: Clinical Case Studies

n attention to the psychodynamics of 7. Kersing W, Jennekens FG. Age-related

the problem changes in human thyroarytenoid mus-
n direct physiologic vocal exercise cles: a histological and histochemical
study. Eur Arch Otorhinolaryngol. 2004;
8. Kahane JC. Histologic structure and
Voice Care Professionals properties of the human vocal folds. Ear
Nose Throat J. 1988;67(5):322, 324325,
Thus far, we have discussed the treat- 9. Hirano M. Morphological structure of the
ment of voice disorders in terms of direct vocal cord as a vibrator and its variations.
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a shared province, with contributions 10. Gray SD, Titze IR, Alipour F, Hammond
from the primary care physician, laryn- TH. Biomechanical and histologic obser-
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Case studies presented in all chapters Prestwich GD. Vocal fold tissue repair
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12. Hansen JK, Thibeault SL. Current
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13. Hansen JK, Thibeault SL, Walsh JF, Shu
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Comments on Voice Evaluation

n Pretreatment and post-treatment

Introduction measures used to describe the effi-
cacy of intervention
Voice clinicians use a variety of tools to n Patient education and feedback.
evaluate and document voice disorders.
Traditional components of the voice Many of the case studies presented
evaluation have included the medical in this text use instrumental measures of
examination to diagnose the disorder, voice production. Although instrumen-
systematic interviewing of the patient tal measures are an important adjunct
to determine causes, and a perceptual to the traditional components of voice
voice evaluation to describe the vocal evaluation, they are not meant to replace
symptoms. Other tools include acous- any other component. The eyes and ears
tic and aerodynamic measures of voice of the physician and the clinician cannot
production, along with observation of be replaced. The most important aspect
vocal fold vibration through laryngeal of the diagnostic voice evaluation is the
videostroboscopy,1 kymography,2,3 and ability to talk to ones patientsthat is,
high-speed digital imaging.47 Informa- to conduct a patient interview that will
tion gathered through these evaluation yield the necessary diagnostic informa-
tools will provide: tion. If only one evaluation component
was available to me, the patient inter-
n An understanding of the perceptual view would be my choice.
symptoms Another important aspect of the
n A means of systematically describing evaluation process is gaining an under-
the vocal condition standing of the functional impact of
14 Voice Therapy: Clinical Case Studies

the voice disorder on the individual voice disorders. In addition, the well-
in daily life. Those in clinical practice informed patient may better under-
know that individual patients will per- stand the therapy process and therefore
ceive similar voice disorders differently. is ready to adhere to the therapy process
For example, a professional voice user and change behavior.
with vocal nodules may be devastated It is essential that the credibility
by the effect that nodules have on the of the SLP be established early during
voice, whereas a computer programmer the evaluation. Many probing ques-
may not consider the mild hoarseness tions regarding the patients personal
to be a problem. One method of gain- life must be asked in seeking etiologic
ing this functional measure is through factors. The patient must trust the voice
the use of validated tools that measure pathologists intent to use this informa-
the patients self-assessment of the voice tion appropriately. The voice pathologist
disorder.8,9 who projects a casual yet professional
The primary objective of the voice demeanor may develop credibility and
evaluation is to uncover etiologic, phys- trust at the initial patient contact. This
iologic, or behavioral factors specific to type of relaxed demeanor will reduce
the development and persistence of the anxieties and establish an atmosphere
voice disorder. Voice pathologists will for easy discussion.
use all of their scientific acumen and Once the primary etiologic factors
artistic skill in a systematic evaluation have been discovered, the vocal symp-
to determine these specific causes. In toms have been subjectively and objec-
addition, a detailed analysis of the vocal tively described, the impact of the dis-
symptoms, both subjective and objec- order has been determined, the patient
tive, will be completed. A systematic has been educated, and the clinician has
management approach will be the result. established credibility, the management
Secondary objectives of the diag- plan can be outlined. When patients
nostic evaluation include education understand the causes of the problem
and motivation of the patient and the and are presented with a systematic
establishing of credibility and trust in management approach, along with a
the voice pathologist. Most patients reasonable estimated time for comple-
have little knowledge or understanding tion, a positive therapeutic attitude usu-
of the normal voice, to say nothing of ally is developed.
their own voice disorders. During the
voice evaluation, the speech-language
pathologist (SLP) may find it useful to
Management Team
explain, in simple terms, normal voicing
and how it relates to the patients cur-
rent problem. Videostroboscopy, when Evaluation and management of patients
available, is invaluable as a patient edu- with voice disorders increasingly have
cator and often encourages patients to been accomplished through the team-
become partners in their own care. The work of several professionals. The two
better understanding patients have of primary professionals are laryngologists
their voice disorders, the more help- and SLPs. SLPs who specialize in the
ful they can be in answering questions treatment of voice disorders are some-
designed to discover the causes of their times called voice pathologists. You will
Comments on Voice Evaluation 15

notice that both terms, SLP and voice viewed on a monitor. A laryngeal stro-
pathologist, are used by case study con- boscope also may be used with the digi-
tributors in this text. Other medical spe- tal video equipment and endoscopes to
cialists who might contribute to the care provide a simulated, slow-motion view
of patients with voice disorders include of vocal fold vibration.
allergists, pulmonologists, gastroenter- The vocal folds also may be viewed
ologists, and neurologists, among others. directly through direct laryngoscopy
In addition, speech/voice trainers and performed in the operating room. Dur-
singing teachers or coaches may be part ing this surgical procedure, the patient
of the team. The laryngologist is trained receives general anesthesia, and a mag-
to examine the laryngeal mechanism nifying laryngoscope is placed into the
and to determine the need for medical, oral cavity and pharynx to yield a direct
surgical, or behavioral intervention. The view of the larynx. Biopsies and surgi-
voice pathologist is trained to identify cal excisions also may be performed
the precipitating and persisting func- through the laryngoscope. This pro-
tional causes of the voice problem, eval- cedure is generally limited to patients
uate the vocal symptoms, and establish requiring surgical intervention or explo-
improved vocal function through vari- ration and is not a routine diagnostic
ous therapeutic methods. The speech/ test of vocal health.
voice trainer or singing teacher judges The medical examination also may
the efficiency and correctness of perfor- include special radiographs of the head
mance technique and suggests modifi- and neck, as well as blood analysis and
cations as deemed necessary. This com- swallow studies. The final result of the
plementary professional relationship medical examination is a diagnosis of
has significantly improved the care of the problem and recommendations for
the voice-disordered population. treatment including medical, surgical,
voice evaluation, and voice therapy, or
any combination thereof.
Medical Examination

Voice Pathology Evaluation

A laryngologic examination involves
examination of the entire head and
neck region, as well as a detailed medi- The evaluation format presented here
cal history. It includes otoscopic exami- may be classified as semistructured.
nation of the ears; observation of the The basic questions remain the same
oral and nasal cavities; palpation of the from patient to patient, but the answers
salivary glands, lymph nodes, and thy- given by individual patients dictate the
roid gland; and a visual examination direction in which the questioning will
of the larynx. The visual examination proceed and the order in which each
of the larynx may be performed in the diagnostic section is reviewed. This for-
office using indirect mirror observa- mat favors the more experienced voice
tion, a fiber-optic nasal endoscope, or a pathologist. The beginning clinician may
rigid oral endoscope. The fiber-optic or feel the need for a more structured for-
rigid scopes may be attached to a digital mat. As experience is gained, the struc-
camera, permitting the vocal folds to be tured formats may prove limiting, and
16 Voice Therapy: Clinical Case Studies

the semistructured method is often the naires useful, however. The following
method of choice. Some voice patholo- interview procedure (reprinted from
gists also feel most comfortable audio Stemple, Glaze, and Klaben10) describes
or video recording the entire diagnostic specific goals for each component of the
session for later review. This may help patient interview, as well as pertinent
in determining the exact vocal compo- areas of investigation.
nents produced during the evaluation
and serves as a record of the baseline
voice quality. Even if the entire diagnos- Referral
tic session is not recorded, recording of
a standard speech sample is necessary The primary referral source will be the
for later comparison. It is not unusual otolaryngologist, but referrals may also
for the voice pathologist and the patient come from other physician specialties
to forget the actual severity of the base- like pulmonology, gastroenterology,
line quality. Audio recordings serve as allergy, and neurology. Speech-language
an objective reminder and should be pathologists, singing teachers, and voice
used liberally. coaches are referral sources as are the
When referral is made for a diag- patients relatives and friends, or the
nostic voice evaluation, the four major patient may be self-referred.
objectives of the voice pathologist are to
do the following:
Reason for the Referral
1. Uncover etiologic, physiologic, or
behavioral factors specific to the The goals are to:
development and persistence of the
voice disorder. n establish the exact reasons for patient
2. Describe the aberrant respiratory, referral
phonatory, resonatory, and articula- n establish patient understanding of
tory components in the voice. the referral
3. Determine prognosis for treatment n develop the patients knowledge of
through trial therapy. his or her voice disorder
4. Develop an individualized treat- n establish the credibility of examiner.
ment plan.
It is important to have adequate
Various methods have been used information regarding the exact reason
to identify the precipitating and per- the patient was referred. When a physi-
sisting behavioral causes of the voice cian refers a patient, the specific medi-
disorder and those that might impact cal diagnosis should be reported along
optimal surgical outcomes. These meth- with the physicians expectations. There
ods include the formal interview with are many reasons for patient referrals.
the patient or a predeveloped case his- These may include preoperative objec-
tory form to be completed either by the tive measures of voice, evaluation with-
patient or by the patient and clinician out management, baseline description
together. This author finds prepared of present voice, preoperative trial ther-
forms to be restrictive and prefers to use apy, postoperative follow-up therapy,
the patient interview format. Beginning or a complete diagnostic voice evalu-
clinicians may find prepared question- ation with appropriate vocal manage-
Comments on Voice Evaluation 17

ment. Understanding the physicians detail the three major goals he or she
expectations will avoid confusion and intends to accomplish during the evalu-
help maintain the necessary working ation. The more patients understand the
relationships. procedures, the more reliable they will
Voice therapy suffers from poor be in communicating pertinent infor-
patient adherence, and several stud- mation to the clinician throughout the
ies have documented a high dropout evaluation.
rate from therapy.11,12 The literature It also is helpful to establish and
documents that there is an improved develop the patients knowledge of
likelihood that the patient may follow the voice disorder before proceeding.
through with the recommendation for This may be accomplished by explain-
voice therapy if these three key elements ing briefly how the normal laryngeal
occur: (1) communication between the mechanism works and how it is affected
physician, speech-language patholo- by the disorder. With this information,
gist, and patient is open and optimized; patients will better understand where
(2) the expected outcome from therapy certain questions are leading and may
is discussed prior to the initiation of be able to give more reliable informa-
therapy; and (3) the patients readiness tion. Some patients even volunteer per-
for change is determined and addressed tinent information following this dis-
early in the therapy process. Chapter 8 cussion and before other questions are
presents detailed descriptions of cases asked. For example:
whereby adherence was a problem, and
solutions suggested result in improved VP: Do you understand what vocal
adherence to the treatment plan. nodules are?
There are differing opinions regard-
PT: Theyre some kind of growths
ing explanation of diagnosis and treat-
on my vocal cords, arent they?
ment processes. Some believe in cog-
nitive simplification of therapy, motor VP: Something like that. Do you
learning, and increased self-awareness know what your vocal cords look
through vocal work with little expla- like?
nation of the actual therapy process
PT: No, not really.
(ERH). This author (JCS) believes it is
also desirable at this time to establish VP: Well, when the doctor looked
the patients understanding of the refer- down your throat at your vocal
ral for speech therapy. A typical dia- folds, she or he was essentially
logue between a patient (PT) and voice looking at two solid shelves of
pathologist (VP) might be as follows: muscle tissue, one on each side.
(Draw a diagram, show pictures,
VP: Do you understand why the or use a video.) Those shelves are
doctor referred you here? the vocal folds, or cords, and were
PT: Not really. The doctor just said looking down on top of them. The
I needed speech therapy, but I really point here where they meet is your
dont understand what it is all about. Adams apple. Can you feel yours?
My speech is OK; Im just hoarse. (Give patient spatial orientation.)
Now, the space between the vocal
This is an excellent opportunity for folds is the airway where air travels
the voice pathologist to explain in some to the lungs as we breathe.
18 Voice Therapy: Clinical Case Studies

Attached to the back of each noticed that when you do a lot of

vocal fold we have two cartilages: talking your voice fatigues, and
one here, and one here. The reason it becomes quite an effort just to
we have these cartilages is so that talk. Sometimes by the end of the
other muscles that work the vocal day, you may be worn out from the
folds may have a place on which to effort, and you simply dont feel like
attach. Some muscles separate the talking anymore.
folds, whereas other muscles draw One final point. Vocal nodules
them together. This is certainly a are not cancer, are not related to
simplified explanation, but I think it cancer, and do not lead to cancer.
will give you the basic idea of how Many people do not understand
the system works. this, and I think its important to
To move the vocal folds mention. So do you now understand
together, we have muscles attached basically what the vocal folds are
to each cartilage pulling in opposite like and what vocal nodules are?
directions. These pull the vocal folds
to the middle where they vibrate, PT: Yes, now I do. Im glad you
giving us our voices. mentioned cancer. I was worried
If these muscles pull too hard, about that. But what do you think
such as when we shout, talk loudly caused the nodules? I dont raise my
for a long time, or clear our throats, voice very much.
this excessive pull will cause the VP: Thats what were here today
vocal folds to rub and bang together. to find out. Im going to ask you
(Demonstrate with clapping hands.) many questions. I need to get to
If this rubbing and banging occur know who you are and how you use
too frequently, they eventually will your voice. From that information,
cause some swelling of the tissues we will try to determine what
that usually causes temporary specifically has caused your nodules.
hoarseness. The hoarseness may Any questions?
go away after a day or so, but if
whatever caused the swelling
persists, the folds will remain It also should be noted that this
swollen and eventually attempt to type of discussion goes far in develop-
protect themselves from further ing your credibility as an expert in this
damage. In your case, theyve done area. You usually will have managed to
this by developing, layer by layer, develop a high level of trust before you
small, callouslike structures, which begin questions regarding the history of
are called vocal nodules. the problem.
As youve experienced, the
nodules cause a change in your
voice. Because of the swelling and History of the Problem
the nodules, your voice is deeper
in pitch; because the nodules are The goals are as follows:
holding your folds apart when
you try to vibrate them, your voice n Establish the chronologic history of
is breathy. Youve also probably the problem.
Comments on Voice Evaluation 19

n Seek etiologic factors associated with n The effort to talk is sometimes a real
the history. problem for people. On a scale of 0 to
n Determine patient motivation. 7 with 0 being no effort and 7 being
extreme effort to talk, how much
This section of the evaluation is effort does it take you to make your
designed to yield a chronological his- voice work throughout the day?
tory of the voice disorder from the onset n How much does this problem actu-
of vocal difficulties, through the devel- ally bother you?
opment of the problem over time, and n Are you interested in doing some-
ending with the patients present vocal thing about it?
experiences. All questions are designed
to yield information regarding the
Medical History
causes of vocal difficulties. Finally, the
patients motivation for seeking vocal
The goals are as follows:
improvement is determined. A list of
appropriate questions may include the n Seek medically related etiologic factors.
following: n Help establish awareness of the pa-
tients basic personality.
n When did you first notice you were
having some difficulties with your Taking the medical history is the
voice? process of seeking out any medically
n Was this the first time you ever expe- related etiologic factors regarding the
rienced vocal difficulties? presenting disorder. Questions are
n How did the problem progress from asked regarding past surgeries and
there? hospitalizations. Chronic disorders are
n What finally made you decide to see probed, along with the use of medica-
your doctor about it? tions. Smoking history and alcohol and
n How did the doctor treat the problem? drug use are explored. The patients
n Did your family doctor refer you to hydration habits also are discussed. The
the otolaryngologist? medical history also helps to establish in
n Has anyone else in your family ever the clinicians mind how patients feel
had voice problems? about their physical and emotional
n Is your voice better in the morning well-being. Asking patients whether, on
than in the evening or vice versa? a day-to-day basis, they feel excellent,
n Have you ever totally lost your voice? good, fair, or poor may accomplish
n Do you have any occasion at all to this task. The response to this ques-
raise your voice, to shout, or to talk tion will provide the voice patholo-
loudly over noise? gist with insight into how patients feel
n Do you talk often to anyone who is about themselves. Some patients report
hard of hearing? lengthy medical histories with many
n Do you have a pet? chronic disorders, but they indicate that
n Not knowing you prior to your vocal they feel good on a day-to-day basis.
difficulties, I dont know what your Other patients with unremarkable med-
normal voice is like. I have a scale of ical histories may report feeling fair
0 to 5. How hoarse are you right now or poor. This information is helpful in
if 0 is normal and 5 is very hoarse? learning patients basic personalities.
20 Voice Therapy: Clinical Case Studies

Social History know who they are and what they do

to find the causes for their vocal diffi-
The goals are as follows: culties. You want patients to excuse
you if some of the questions seem per-
n Know the patients work, home, and sonal. This questioning is necessary to
recreational environments. discover all possible causes. Do not be
n Discover emotional, social, and fam- surprised when patients open up to
ily difficulties. you with many personal, family, social,
n Seek more etiologic factors for the marital, or work problems. If you have
disorder. developed your credibility and gained
their trust, you often will be entrusted
The social history finalizes in the with this important information.
clinicians mind a perception of the
patient. It yields information regard-
ing work, home, recreational, and social
Oral-Peripheral Examination
lifestyles and whether these lifestyles
contributed to the development of
laryngeal disorders. All questions probe The goals are as follows:
for answers to possible etiologic factors.
For example: n Determine the physical condition of
oral mechanisms.
n Are you married, single, divorced, or n Observe areas of the upper body for
widowed? tension during breathing, speaking,
n How long have you been (married, and at rest.
divorced, widowed)? n Check for swallowing difficulties.
n Do you have children? n Check for laryngeal sensations.
n What are their ages?
n How many are still at home? A routine oral-peripheral examina-
n Does anyone else live in your home? tion also should be conducted to deter-
Parents? Others? mine the condition of the oral mecha-
n Do you work? Where? How long? nism in its relation to the patients speech
n Specifically, what do you do in your and voice production. Also included is
work? observation of the patients laryngeal
n How much talking is required? area tension utilizing visual observa-
n What is the work environment? tion of posture and neck muscle ten-
n Does your husband or wife work? sion, as well as digital manipulation of
Where? How long? What shift? the thyroid cartilage. The patient should
n When youre not working, what do be asked whether any swallowing diffi-
you enjoy doing? (Include clubs, culties are present to determine whether
groups, hobbies, organizations, and this function has been affected by or is
so forth.) affecting vocal production. Finally, the
patient should be asked whether any
As you begin the social history laryngeal sensations are present. The
questions, it often is helpful to explain laryngeal sensations most often associ-
to patients that you need to get to ated with voice disorders include ach-
Comments on Voice Evaluation 21

ing, dryness, tickling, burning, and a above, each vocal component may be
feeling of a lump in the throat. examined separately as follows.

Voice Evaluation
This includes a description of:
The goals are as follows:
n conversational breathing patterns, in-
n Describe the present vocal compo- cluding supportive or nonsupportive
nents. n locus of respiration such as clavicu-
n Examine inappropriate use of the lar, thoracic, or abdominal-diaphrag-
vocal components. matic breathing
n breath holding or shallow breathing
Following the patient interview, the n coordination of respiration and
perceptual and instrumental voice eval- phonation.
uations are conducted. Several formal
voice rating scales have been developed Phonation
and utilized for perceptually judging
voice quality.13 In an attempt to improve Subjective observations regarding vocal
the perceptual evaluation of voice, a function are made through critical lis-
committee of the American Speech- tening and are well documented on
Language-Hearing Association Special validated flexible tools like the CAPE-V.
Interest Group 3, Voice and Voice Dis- The presence of hard glottal attacks,
orders, developed the Consensus Audi- glottal fry, diplophonia, tremor, spasm,
tory-Perceptual Evaluation of Voice etc, can be added to the validated form
(CAPE-V).14,15 The CAPE-V uses a 100- and judged on a 100-mm visual ana-
mm visual analog scale to assess voice log scale providing a rating metric.
quality at the vowel, sentence, and con- These vocal characteristics should be
versational speech levels. The param- observed in prolonged vowels, pho-
eters of voice assessed include overall nemically loaded sentences, standard
severity, roughness, breathiness, strain, reading passages, and conversational
pitch, and loudness. Areas for describ- speech. In addition, the voice patholo-
ing additional features such as diplo- gist is guided to listen throughout the
phonia, fry, falsetto, asthenia, aphonia, evaluation for changes in quality when
pitch instability, tremor, wet/gurgly, or the patient is not responding to formal
other relevant terms are provided. testing requests.
The perceptual voice evaluation is
conducted to describe the current con- Resonance
dition of voice production and to deter-
mine whether any vocal components The term resonance refers to the loca-
such as pitch, loudness, breathiness, tion of amplified sound transmission
and so onare inappropriate to the in the upper aerodigestive tract. Terms
degree of contributing to the develop- like hypernasal and assimilative nasality
ment or maintenance of the disorder. are used when describing the quality of
Beyond the formal scales described sound as a result of the extent of sound
22 Voice Therapy: Clinical Case Studies

transmission in the nasal cavity and are while time consuming, is an excellent
most often used in reference to persons method to assess the pitch and loudness
with velopharyngeal incompetence or capabilities of the vocal mechanism is
insufficiency. Cul de sac resonance may the use of a phonetogram (also known
occur when the tongue is held in a pos- as a Voice Range Profile). The phoneto-
terior fashion, and the sound is primar- gram is a graphic picture of the limits of
ily focused in the oral pharyngeal port. the vocal system. The patient is asked to
This type of resonance is most often produce the lowest pitch and the highest
associated with hearing loss, velopha- pitch at softest and loudest phonation
ryngeal incompetence, and has been that are graphed on a chart with pitch on
noted in patients with significant com- the horizontal axis and loudness on the
pensatory posterior tongue carriage vertical axis. Finally, a thorough assess-
in the absence of a pathological cause. ment of pitch should include examining
Hyponasality is the sound associated the use of inflection and pitch variability
with an upper respiratory infection and in a conversational context.
stuffy nose. Often called denasal, the
patient with hyponasality should be Loudness
referred to the otolaryngologist for fol-
low-up of the presence of nasal obstruc- The appropriateness of the patients
tion. Finally, the term resonance in voice speaking loudness level during the eval-
often means the place in the hypophar- uation is described. It is also important
ynx for primary sound transmission, or to test the patients ability to increase
what people refer to as focus of the voice. subglottic air pressure. This may be
There remains no standardized method accomplished by asking the patient to
to identify tone focus/resonance of shout hey. The ability to produce a
voice transmission. The evaluation of more solid phonation during a shout is
resonance is auditory perceptual. Many a good indicator of the severity of the
voice pathologists believe that reso- problem. If the patient is able to over-
nance is sensed as the place where the ride the dysphonia with increased loud-
voice emanates or where the patient ness (which is determined by the ability
senses vibration of sound. of the folds to approximate tightly to
increase subglottic air pressure), the dis-
Pitch order is perhaps not as severe as when a
patient cannot easily increase loudness.
Pitch range is tested by having the If there is a vocal fold tissue pliabil-
patient sing up a scale from the lowest ity issue, the patient may complain that
note to the highest note and from high- there are places in the vocal range that
est to lowest note while matching the require greater loudness/effort to pro-
extremes to a pitch pipe or a keyboard. duce the sound. One simple task is to
Many patients are embarrassed to pro- ask the patient to sing up the scale while
duce pitch range. Another method to maintaining a steady-state loudness. If
assess range of phonation is the use of the patient reverts to a louder sound at
a functional phonatory task one might the higher notes, ask the patient to pro-
do when riding a rollercoaster or a sled, duce the same notes cueing them with
the whee sound from lowest to high- softer, softer, softer. If the patient is
est pitch. One additional method that, unable to produce sound softly, there is
Comments on Voice Evaluation 23

likelihood that an adynamic area is pres- n maximum phonation time

ent on the vocal folds (an area that does n subglottic air pressure
not vibrate) requiring greater subglottal n glottal efficiency
pressures to initiate and maintain vocal n phonation threshold pressure
fold vibration. n laryngeal airway resistance

Rate Laryngeal videostroboscopy demon-

strates a simulated, slow-motion view
The rate of the patients speech may of the vocal fold vibration. This view
contribute to the development of the provides much additional diagnostic
vocal disorders. This is especially true information, including:
for the individual who speaks with
an exceptionally fast rate. During the n configuration of glottic closure
diagnostic work-up, the rate of conver- n degree of supraglottic activity
sational speech is described as normal, n vertical level approximation of the
fast, or slow. vocal folds
n condition of the vocal fold edge
n amplitude of vibration
n integrity of the mucosal wave
Instrumental Voice
n nonvibrating areas of the vocal folds
n phase and symmetry of the vibratory
pattern of the vocal folds
Instrumental measures of vocal func-
tion, sometimes called laryngeal function
studies or phonatory function tests, may be
Hearing Screening
conducted if the appropriate instrumen-
tation is available. Acoustic, aerody-
namic, and laryngeal imaging analyses The American Speech-Language-Hearing
are used to objectively describe vocal Association mandates that patients who
function. Common acoustic measures undergo speech, voice, and language
include: evaluations must have a current hear-
ing screening. Audiometric evaluation
n fundamental frequency is important for the patient with a voice
n frequency range disorder. The inability to monitor ones
n frequency perturbations (jitter) voice may result in the use of inappro-
n habitual intensity priate vocal components. Severe voice
n intensity range (maximum/minimum) disorders are often observed in hard-of-
n intensity perturbations (shimmer) hearing and deaf populations.
n signal-to-noise ratio
n spectral analyses
n cepstral peak
Useful aerodynamic measures include:
The goal is to summarize the etiologic
n airflow volume factors associated with the development
n airflow rate and maintenance of the individuals
24 Voice Therapy: Clinical Case Studies

voice disorder. This section of the diag-

nostic procedure is used as a summary Summary
for the causes of the voice disorder
discovered throughout the evaluation. Successful voice therapy is totally de-
These causes are listed in order of per- pendent on an in-depth and accurate
ceived importance, relating first to the diagnostic evaluation. This author views
initiation of the problem and second the voice evaluation as a primary ther-
to the maintenance of the problem. apy tool. The evaluation determines
Remember that the precipitating factor the causes for the disorder, teaches the
may not be the maintenance factor. patient about the disorder, and describes
the vocal function that must be modi-
fied for voice improvement to occur.
The remainder of this text is devoted
to management techniques for voice dis-
orders. You will realize in studying the
The goal is to analyze the probability many case presentations that selecting
of improvement through voice therapy. the appropriate treatments depends on
The prognosis for improving many the multidisciplinary cooperation and
voice disorders through voice therapy is management by the voice team mem-
generally good. Nonetheless, many fac- bers. The chapters are organized to
tors influence prognosis (see Chapter 8), describe management strategies for dis-
including the motivation, interest, and orders of primary and secondary mus-
time of the patient; ability of the patient cle tension dysphonia (MTD), glottal
to follow instructions; the physical and incompetence, irritable larynx/cough/
emotional conditions of the patient; and paradoxical vocal fold dysfunction,
the general condition of the vocal folds. neurogenic voice disorders, and profes-
The prognosis section permits the voice sional voice. Many crossovers in man-
pathologist to give a subjective opinion agement approaches are evident and
regarding the chances for successful useful for the various disorders. All suc-
remediation based on the diagnostic cessful voice therapy, however, begins
information. A reasonable time frame with accurate diagnosis and planning
for expected completion of the manage- through the medical examination and
ment program also should be stated. voice evaluation.

Recommendations References

The management plan should be out- 1. Hirano M, Bless, D. Videostroboscopic

Examination of the Larynx. San Diego,
lined based on the etiologic, physiologic,
CA: Singular; 1993.
and behavioral factors that precipitated
2. Larsson H, Hertegard S, Lindestad PA,
the voice disorder and that cause it to Hammarberg B. Vocal fold vibrations:
persist which were discovered during high-speed imaging, kymography, and
the evaluation. The plan includes the acoustic analysis: a preliminary report.
therapy approaches to be used, results Laryngoscope. 2000;110(12):21172122.
of trial therapy, prognosis, and addi- 3. Wittenberg T, Tigges M, Mergell P,
tional referrals suggested. Eysholdt U. Functional imaging of vocal
Comments on Voice Evaluation 25

fold vibration: digital multislice high- 9. Jacobson B, Johnson A, Grywalski C, Sil-

speed kymography. J Voice. 2000;14(3): bergleit A, Jacobson G, Benninger MS.
422442. The Voice Handicap Index (VHI): devel-
4. Patel R, Dailey S, Bless D. Comparison opment and validation. Am J Speech Lang
of high-speed digital imaging with stro- Pathol. 1997;6:6670.
boscopy for laryngeal imaging of glot- 10. Stemple JC, Glaze L, Klaben B. Clinical
tal disorders. Ann Otol Rhinol Laryngol. Voice Pathology: Theory and Management.
2008;117(6):413424. 4th ed. San Diego, CA: Plural; 2009.
5. Bonilha HS, Aikman A, Hines K, Deli- 11. Portone C, Johns M, Hapner E. A review
yski DD. Vocal fold mucus aggregation of patient adherence to the recommen-
in vocally normal speakers. Logoped Pho- dation for voice therapy. J Voice. 2008;
niatr Vocol. 2008;33(3):136142. 22(2):192196.
6. Deliyski DD, Petrushev PP, Bonilha 12. Portone C, Johns M, Hapner E. Correla-
HS, Gerlach TT, Martin-Harris B, Hill- tion of the Voice Handicap Index (VHI)
man RE. Clinical implementation of and the Voice-Related Quality of Life
laryngeal high-speed videoendoscopy: Measure (V-RQOL). J Voice. 2007;21(6):
challenges and evolution. Folia Phoniatr 723727.
Logop. 2008;60(1):3344. 13. Hirano M. Clinical Examination of Voice.
7. George NA, de Mul FF, Qiu Q, Rakhorst New York, NY: Springer-Verlag; 1981.
G, Schutte HK. New laryngoscope for 14. American Speech-Language-Hearing As-
quantitative high-speed imaging of sociation. Consensus Auditory-Perceptual
human vocal folds vibration in the hori- Evaluation of Voice (CAPE-V) Purpose
zontal and vertical direction. J Biomed and Applications. Retrieved from http://
Opt. 2008;13(6):064024. www.asha.org.
8. Hogikyan ND, Wodchis WP, Terrell JE, 15. Kempster GB, Gerratt BR, Verdolini
Bradford CR, Esclamado RM. Voice- Abbott K, Barkmeier-Kraemer J, Hillman
related quality of life (V-RQOL) fol- RE. Consensus Auditory-Perceptual
lowing type I thyroplasty for unilateral Evaluation of Voice: development of
vocal fold paralysis. J Voice. 2000;14(3): a standardized clinical protocol. Am J
378386. Speech Lang Pathol. 2009;18(2):124132.
Primary and Secondary
Muscle Tension Dysphonia

activity as the proximal cause of the

Introduction: Muscle Tension dysphonia and distinguishes it from
Dysphonia: An Overview secondary MTD, wherein the hyperfunc-
tional muscle activity is interpreted to
Nelson Roy either coexist with or compensate for
some underlying mucosal disease and/
Poorly regulated activity of the peri- or glottic insufficiency.47
laryngeal muscles affects phonatory In primary MTD, the origin of
function and contributes to a class of abnormal muscle activity is not fully
disorders known as hyperfunctional elucidated, but it has been attributed
or musculoskeletal tension voice dis- to a variety of potentially overlapping
orders.1 Several characterizations of sources, including: (1) psychological
laryngeal hyperfunction exist, but a and/or personality factors that tend
recurrent feature in almost all descrip- to induce elevated perilaryngeal ten-
tions includes excessive laryngeal mus- sion and/or muscular laryngeal inhibi-
culoskeletal activity, force, or tension. tion,812 (2) technical misuses of the vocal
More recently, muscle tension dysphonia mechanism in the context of extraordi-
(MTD) has become the preferred diag- nary voice demands,1316 (3) learned
nostic label for such hyperfunctional adaptations following upper respira-
syndromes,2,3 with some clinicians pre- tory tract infection,17 and (4) increased
ferring the term primary MTD, to refer pharyngolaryngeal tone secondary to
to a voice disturbance that exists in the laryngopharyngeal reflux reflex.18
the absence of structural or neurologi- Despite uncertainty surrounding the
cal pathology.4 Primary emphasizes the source(s) of muscle tension, these ten-
principal role of dysregulated muscle sion-based disorders often represent
28 Voice Therapy: Clinical Case Studies

the most perceptually abnormal voices terns on laryngeal and extralaryngeal

encountered clinically.8 Furthermore, structures. That is, the disordered voice
most clinicians agree that recognizing reflects the cumulative effects of abnor-
the untoward effects of abnormal mus- mal tensions affecting both the source
culoskeletal tension is an important and the filter (ie, the entire vocal tract).
component of the diagnostic process, In cases where excess perilaryngeal
and restoring normal laryngeal muscu- tension has persisted for some time, addi-
lar balance is an essential part of suc- tional features may be present. Patients
cessful voice therapy. commonly report a dull to severe ache
Muscle tension voice disorders often and tightness of the anterior neck, lar-
leave the impression that the speaker is ynx, and shoulder regions that is accom-
expending considerable physical effort panied by increased vocal effort and
to produce voice, and there is a decid- fatigue with all symptoms intensifying
edly laryngeal/perilaryngeal focus to with extended voice use.1821 According
this effort.1821 Perilaryngeal tension to Morrison, the inferior bellies of the
refers to excess tension primarily in the omohyoid muscles where they cross the
extrinsic and intrinsic laryngeal mus- supraclavicular fossae are often tense
cles, but this tension may also extend to and prominent during speech. General
include the pharyngeal constrictor mus- body posture may be rigid with the jaw
cles and the deep muscles of the neck. jutting forward.23 Jaw, tongue, and respi-
The putative effect of such excess ten- ratory movements can be restricted,
sion is foreshortening and stiffening of reflecting the held nature of the voice
muscles which interfere directly or indi- and articulatory system.18,24 Boone and
rectly with normal voice production.20 McFarlane25 observed we see too many
Because excess perilaryngeal tension people with vocal hyperfunction who
tends to restrict vocal flexibility, most appear to speak through clenched teeth,
patients are described as pitch and loud- with very little mandibular or labial
ness locked, often displaying a mark- movement.25(p177) Similarly, Sapir26 rec-
edly reduced dynamic range in both ognized the complex effects of laryngeal
speaking and singing. Vocal fatigue is tension on both voice and articulation.
a frequent concomitant.13,20 Voice qual- He noted articulatory movements
ity symptoms can vary in severity and may induce or exacerbate, via mechani-
type, ranging from severely pressed to cal or neural coupling, the phonatory
extreme breathiness with myriad com- abnormalities.26(p49) Although muscle
binations depending on the muscle tension dysphonia (MTD) is properly
groups involved.18 Many dysphonia regarded as a voice disorder, exces-
types are observed including hoarse- sive tension in the perilaryngeal mus-
ness, pressed voice, glottal fry, breathi- cles could also constrain articulatory
ness, high-pitched falsetto, diplophonia, movements and vocal tract dynamics,
as well as voice and pitch breaks that by virtue of the mechanical linkage of
vary in consistency and severity.19,22 the articulators to the hyolaryngeal
In the absence of mucosal, structural, complex, central nervous system influ-
or neurological pathology, however, ences (eg, heightened muscle tension in
these myriad voice effects can only be the jaw muscles), orolaryngeal senso-
explained on the basis of the deleterious rimotor interactions, or a combination of
effects of abnormal musculoskeletal pat- these.2629 Recent research suggests that
Primary and Secondary Muscle Tension Dysphonia 29

successful treatment of MTD appears to tic and supraglottic contraction patterns

positively affect vocal tract dynamics should raise the suspicion of a tension-
with acoustic evidence of vowel space based voice disorder.
expansion to suggest improved articula- Despite some controversy surround-
tory movements after treatment.27,30 ing causal mechanisms and nosological
Dysregulated laryngeal and peri- imprecision, the clinical voice literature
laryngeal muscle tension can often be is replete with evidence that symp-
observed laryngoscopically. In this re- tomatic voice therapy for hyperfunc-
gard, a variety of glottic and supra- tional voice disorders like MTD can
glottic contraction patterns have been often result in rapid and dramatic voice
associated with primary MTD, and improvement. Because there are few
several classification systems have studies directly comparing the effec-
been offered to describe these laryngo- tiveness of specific therapy techniques,
scopic features.2,17,18 Often-cited laryn- not much is known whether one ther-
geal manifestations of dysregulated apy approach for MTD is superior to
laryngeal muscle tension include tight another. In the following section, case
mediolateral glottic and/or supraglot- examples serve to illustrate the various
tic contraction, anteroposterior glot- approaches used to manage MTD.
tic and/or supraglottic compression,
incomplete glottic closure, posterior
glottic chink, and bowing of the vocal
Case Study 1
folds.2,31 It should be noted, however,
that researchers have recently chal-
lenged the existence of specific laryn- R.E. Stone Jr with comments
goscopic clusters/features believed to by Kimberly Coker
uniquely and reliably distinguish MTD
from nondysphonic speakers, and Behavioral Shaping in Primary
other voice disorder types including MTD Masquerading as Elective
spasmodic dysphonia (SD).3235 Accord- Mutism in a 10-Year-Old Boy
ing to these investigators, many of the
laryngoscopic patterns used to classify
It is truly an honor to contribute to the
MTD such as supraglottic mediolateral
work of my mentor, Dr R.E. Ed Stone.
and/or anterior-posterior compression,
Dr Stone has influenced and mentored so
are frequently observed in individuals
many in our field through his ideas and
with normal voices and spasmodic dys-
demonstrations of superior clinical skill.
phonia, and thus fail to distinguish such
The term master clinician is often used
individuals from patients with MTD.
but not better represented than by this
Given the likely involvement of a vari-
gentleman. This timeless case study gives
ety of intrinsic and extrinsic laryngeal
us a glimpse of him at his best. I have
musclesin diverse states of relaxation
always felt Dr Stones talents were shown
and contractionmyriad laryngeal con-
most brightly when the patients could
figurations may be present in MTD. So,
not complete the first step of traditional
although no single laryngoscopic pat-
therapy approaches. He makes us feel con-
tern should be uniquely and definitively
fident in trusting our skills and meeting
identified with musculoskeletal tension
the patient where he/she is. Enjoy . . .
voice disorders, observing certain glot-
30 Voice Therapy: Clinical Case Studies

Case History through the larynx a little bit

(strained sounding voice-making
History of the Problem that vocal-fry kind of voice)?

Patient Y was only 10 years old but rep- M: I would say it was like a
resented one of the greatest intervention week. He went to a pediatrician the
challenges I have encountered in nearly following day, and he thought it was
30 years of clinical practice. At the moth- laryngitis, so he told him not to try
ers telephone contact for an appoint- to talk. So he made no attempt of
ment, I learned that patient Y came any kind to talk for a week until he
home from school one day with extreme went to a throat specialist who then
dysphonia after attending a soccer got him to make that vocal-fry noise.
game. She thought that he had devel- That was when he started with . . .
oped laryngitis. When supper was over, C: So he kind of learned to produce
he produced no voice and indicated the sound then, huh?
that he couldnt talk. Professional help
from various disciplines over a 7-week M: Yes, I think so, yes.
period was unproductive in restoring
normal voice and communication. Medical History
A history provided to the clinician
(C) by the mother (M) follows: Dr Stone continued his history inquiring
about the patients prior treatment. The
C: Tell us a little bit about when patients medical history was unremarkable.
patient Y started talking with a
really tight voice. C: What other things has he done
in trying to get voice back again?
M: OK. He came home from school You have been to the pediatrician
hoarse. They had a soccer game; and to an ear, nose, and throat
he had some voice, but it sounded specialist.
like he had been screaming a lot.
Within maybe 2 hours, the voice was M: And he was hospitalized for
completely gone. a week and was treated then by a
psychologist, a throat specialist, and
C: All he could do, then, was a physical therapist. All who were
produce this sound? trying to make him relax enough
to be able to make his vocal cords
M: He did not even do that; there
work. They said they were too
was just nothing.
C: Did he mouth his words, or did
C: What kinds of things did they
he stop talking altogether?
do for relaxation?
M: He stopped talking, and when
M: They did hypnotic suggestion,
I would ask him to try, he would
they put him in whirlpool baths, they
just make indications that there was
played games with him, and they
nothing there.
just talked to him about other things,
C: How long after that was it anything that was unrelated to his
before he started pushing air being unable to talk.
Primary and Secondary Muscle Tension Dysphonia 31

C: You spent a great deal of money Instrumental Assessment

pursuing this then, havent you?
Visual Imaging. Previously completed
M: Yes, about $7000. during visits to an ear, nose, and throat
specialist and was found to be within
This would be roughly $16 000.00 today. normal limits.
Unfortunately, this occurrence continues
today with patients subjected to multiple Acoustics and Aerodynamics. Not com-
doctors and tests that in many instances are pleted in this case due to the patients
unnecessary. limited vocalizations.

Social History
Patient Self-Assessment
Patient Y was adopted during infancy
There were no indications that the patient
into a home of two older female siblings.
could reliably provide a self-assessment at
The family life seemed healthy. The par-
the time of the evaluation. Additionally, this
ents were well educated, and the father
case study occurred prior to the common
was a vice president of a large company
use of validated and reliable self-assessment
in a large metropolitan Midwestern city.
tools. Today, we might have had the mother
Both parents were energetic and had
fill out a Pediatric Voice Handicap Index.
outgoing personalities. They did not
give the impression of being overbear-
ing or unreasonably demanding of their
Voice Therapy
Specific Types of Therapy
Voice Evaluation Stretch n flow,36 gargle, general shaping
of voice production, and negative prac-
tice37 were all used to achieve desired
When we met, patient Ys only vocal- target.
izations were utterances of vocal fry
but with no accompanying lip, jaw, or Rationale for Using the Therapy
tongue movements needed for word
formation. These movements were not The clinician is charged with identifying
elicited even when the boy was asked behaviors present, deficits present, and
to whisper. If it werent for the vocal determining the next step/behavior the
fry productions, he might have been patient is capable of. The clinician must
thought to show elective mutism. One trust his/her knowledge of the voice-produc-
got the impression that his talking was ing mechanism and engage in a dynamic
reduced to a series of vocal-fry grunts assessment of the patients abilities. This
that may have showed syllabification, patient was unable to utilize traditional
thought pauses, and interphrase silences. facilitative techniques; thus, Dr Stone
Additionally, the pitch and loudness of began with increasing patient awareness
the grunts varied within restricted lim- and control of the respiratory system pro-
its but seemed to suggest his attempts gressing to articulated airflow in hierar-
at prosody. chical speech tasks while building patient
32 Voice Therapy: Clinical Case Studies

confidence. With neuromuscular reeduca- 3. Getting on with developing the use

tion already begun, Dr Stone then used of the desired skill (or absence of the
gargle to engage the vocal folds followed undesired behavior) in a hierarchy
by successive approximations toward nor- of speaking situations
mal phonation. Once this was completed,
Dr Stone engaged in negative practice to After the patient achieves success
confirm the patient was volitionally able to criterion at one level of the hierarchy,
control the voice-producing subsystems. He the erg is repeated at another level. Each
was able to discuss the patients progress recycling would involve a new bit of
with the patient and his family and found behavior. The bits are designed to shape
them to be pleased with the patients prog- the individuals eventual performance
ress and prepared should the patient have into the use of normal physiology for
difficulty in the future. phonation, finally in normal proposi-
tion communication.38
Therapy Goal and The childs potential for voice pro-
Expected Outcome duction using a variety of facilitative
techniques,39 including inspiratory voice,
Return to within normal limits sound yawn-sigh, humming, throat clearing,
production to meet all vocal needs. coughing, and chewing was unproduc-
tively probed.
Complete Description of Evaluating patient Y, initially,
How to Do the Therapy Isought to recognize those behaviors he
brought to the task of communication
We will now return to Dr Stones account that obviated normal voice production.
of the rationale and description of therapy. Hollien40 has reviewed the character-
istics of vocal fry (pulse register) pro-
My involvement with patient Y was ductions, suggesting there is increased
governed by a model I have called erg. glottal resistance and decreased airflow.
In physics, an erg is a unit for measur- Patient Y consequently needed to reduce
ing work. It involves moving a mass muscle effort and increase airflow to
through a certain distance in a given the task of voice production. Teaching
unit of time. Applied to the therapeu- muscular relaxation41 of the interary-
tic setting, one might consider taking a tenoid, lateral cricoarytenoid, and thy-
patient (mass) from one point of behav- roarytenoid muscles to a 10-year-old
ior to another (distance) within an indi- child within 1 or 2 days (before he and
vidual therapy session (or segment of it) his parents returned home several hun-
divided into three parts: dreds of miles away) seemed an unreal-
istic clinical undertaking.
1. Evaluation of behavior or skill that Recommendation, therefore, deem-
is needed or (needs to be aban- phasized formal relaxation training and
doned) to bring the person closer to focused on increasing airflow. I learned
normal quickly that asking patient Y to change
2. Recommendation of desirable be- behavior during speech-like activities
havior through verbal instruction led to failure. When a patient fails at a
and modeling task that I recommend, I am obligated to
Primary and Secondary Muscle Tension Dysphonia 33

assume the responsibility for the error in forth. (These positions resulted in the
asking something that is too difficult or production of different whispered vow-
in not adequately communicating what els; however, this fact was not pointed
I want of the person. Because failure out to patient Y because of the need to
tends to foster undesirable thoughts in a avoid the chance of failure that might
patient and unproductive consequences have accompanied a request to whis-
of my guidance, I must present requests per /i/, whisper /a/, for example.)
that the individual can understand and After the boy successfully produced
accomplish. multiple events, meeting at least 80%
Teaching increased airflow, at what success in the desired partial behaviors
task could I expect patient Y to succeed? while instruction (discriminative stimu-
Finally, I merely asked him to blow lus) and positive feedback were with-
against his upheld index finger as if he held, it was pointed out that he indeed
were blowing out a match. This was produced many tokens of various vow-
nonpropositional use of airflow and els. He then was asked to practice pro-
was a request of a behavior with which duction of airflow (no voice) on vowels
he had previous experience. It was that he read from flash cards. (This rep-
behavior that easily could be molded resented another level of the hierarchy:
by later instruction and was a task with purposeful vowel production with flow
a simplicity that anyone with normal of air through an untensed mechanism.)
anatomy could do. The component or The use of unvoiced flow of air through
partial behaviors to which patient Ys a relatively relaxed speech mechanism
attention was drawn through verbal was eventually shaped through care-
instruction included unimpeded inspi- fully graded increments of a speaking
ration, no holding of the breath between hierarchy into employment for propo-
inspiration and expiration, and lack of sitional speech. At this point, after
work (muscular action) in the neck area approximately 1 hour of intervention,
(and consequently in the larynx) on patient Y was whispering normally.
exhalation. These partial behaviors were Mouth, lip, and tongue movements had
adopted, then, as the recommended become reestablished communication
behaviors to be employed repetitively behaviors along with unimpeded flow
(that is, practiced, which constitutes of air. Not only had an erg been accom-
getting on with the behavior) in a vari- plished, but the idea of elective mutism
ety of tasks one might consider as con- as a diagnostic label no longer was an
stituting a speaking-situations hierarchy. appropriate consideration.
Lowest on the hierarchical lad- The second session began with an
der was purposeful flow of air through evaluation of what behavior was needed
the untensed speech mechanism. Next, to bring patient Y a step closer to normal
patient Y practiced flow of air while his communication. Even the uninitiated
mouth and lips were placed in various clinician would recognize the patients
static positions. This was done by ask- need for vocal fold activity superim-
ing that he produce a relaxed flow of air posed on the flow of air through a rela-
with his mouth open, then somewhat tively relaxed speech mechanism. But
closed with the corners of the lips pulled how could vocal fold activity be recom-
back, then with lips rounded, and so mended without a statement such as,
34 Voice Therapy: Clinical Case Studies

OK, now produce the airflow like you P: The patient tried. He produced
did last hour, but this time with voice? the bubbling sound louder than
The reader also may ask, Whats before, but still no voice. After he
wrong with asking for voice? Maybe swallowed the mouthful of water,
nothing would be wrong, but I submit he gave a little laugh with one
that it would have risked the patient short period in which the voice was
adopting behaviors similar to those he produced in a high-pitched squeal
demonstrated when he first entered sound.
therapy (which was vocal fry). Guarding
C: Immediately, the clinician
against this possibility, I was compelled
remarked, Hey, did you notice that
not to refer to voicing. Also, Idid not
part of your laugh had some voice to
want to ask the patient to do any of the
it? Here, gargle another sip of water
activities previously requested because he
and make that little squeak sound as
failed at them. What could Ido that might
you gargle.
rely on referents that the child knew, that
were not requests to produce voice P: Patient Y succeeded.
(because he knew he couldnt produce
C: Do that again, but this time
voice), and that would ensure success?
make the sound longer.
I decided to approach voice pro-
duction by recommending gargling. P: Again, patient Y succeeded.
Unvoiced gargling really wasnt much
C: This time, make your gargle
different from the activity patient Y had
sound bigger, like your Dad might
engaged in during the previous hour.
The recommendation proceeded as fol-
lows, where C is the clinician and P is P: Again, patient Y succeeded.
the patient.
C: Okay, this time make that
sound, but without using a sip of
C: I know you can let air flow
out of your mouth. This time Id
like you to do so while gargling a P: Again, the patient succeeded.
small mouthful of water. (Clinician
models, tilting the head backward Voice was produced, and the gur-
and gargling with voice.) Now you gling sound probably resulted from
do it. interruption of the voice airstream by
repetitive action of the uvula against
P: The patient tried. He produced
and away from the base of the tongue.
the bubbling sound, but no voice.
Practice followed until the patient
C: Okay, you kept the air flowing and the clinician both felt assured that
out all the time. Thats a good thing, this behavior could be repeated any time
too! If you hadnt, youd have done the patient wished. The next evaluation
a lot of choking. Keeping the air established the need to alter the boys
going is pretty important. Now, head position to an upright posture.
this time lets have you gargle like Accomplishing this was done in
your Dad might dowith a lot of three trials in which gradual increments
sound. (Clinician models vocalized of head position change minimized the
gargling.) Now, you do it. potential for failure that might have
Primary and Secondary Muscle Tension Dysphonia 35

accompanied moving the head in a sin- speaking backward, lets now say some
gle trial to a position more suitable for words forward, was the recommenda-
communication. tion used to elicit meaningful words.
Next, the evaluation established Use of words to form phrases and
the need to alter the gurgling of sound sentences was based on increasing the
to a continuous voice production by length of utterance, word for word, and
eliminating the tongue-uvula vibration. then finally uttering the entire unit. For
The recommendation to the patient was example
a simple instruction to open the mouth
widely (separating the tongue from the C: Say I.
uvula) accompanied by providing a
P: I.
mode of sustained /a/. Five trials were
done before the patient indicated that C: Say, I want.
he felt able to do this consistently when-
P: I want.
ever he wanted.
The next intervention step needed C: Say, I want some.
to establish patient Ys ability to main-
P: I want some. (etc, etc)
tain continuous voice while moving
parts of the speech mechanism with- P: I want some eggs for breakfast.
out triggering his dysphonic behaviors
conditioned to the act of speaking. The By the end of this session (2 hours),
recommendations involved leading the patient Y was able to engage in dia-
boy, by modeling, through a sequence logue, maintaining voice that was differ-
of behaviors starting with opening and ent from that with which he presented
closing the mouth (vowel productions) initially and was closer to normal. The
with continuous voice. Next, vowel-like voice still had a falsetto-like quality and
utterances were made individually was produced with guarded participa-
rather than the continuous vowel series. tion. I decided to accompany patient Y
Following this, individual vowel pro- and his parents to lunch and observe
ductions each were terminated with an the degree to which the boy maintained
articulatory valving; then, vowels were his present skill outside the clinical set-
initiated and terminated with conso- ting. He did admirably. Not once did he
nants. Even though patient Y was pro- lapse into vocal fry, and during lunch
ducing nonsense and finally meaning- he even seemed to modify voice pro-
ful syllables at this time, the fact that he duction to be more normal. After lunch,
merely was copying the model set by intervention resumed and constituted
the clinician seemed to keep him from a review of the processes the boy had
recognizing that he was using voice used in reacquiring use of voice. With a
in speech-like units. Finally, after the trend during lunch for him to improve
boy had produced several CVC units voice toward normal, formal activities
that would have resulted in meaning- focusing on voice normalization were
ful words if they had been uttered in deferred until the next day.
reverse, it was pointed out that the Patient Y returned the next day, and
patient had been saying words back- his parents vouched for the accuracy of
ward. For example, tube said back- his contention that he had maintained
ward would be boot. You have been use of the improved vocal function
36 Voice Therapy: Clinical Case Studies

established during the previous after- M: Well, we were told that

noon and evening. Although he pre- our sons problem was purely
sented this morning with normal voice, psychological, that until he could
I was uncertain of his awareness of the learn to cope with a lot of the
clinical processes and goals. To test this, fears and things that were going
I asked the boy to demonstrate the way on inside of him he would not
he talked before we started intervention. be able to produce a voice that
He did. Then, he successfully switched his subconscious would not
at will between normal voice and that allow him to speak. So we went
which he used previously. through a whole lot of guilt and
One last evaluation seemed nec- embarrassment. I think that each one
essary. Because patient Y lived nearly of us wondered . . . were we the ones
300 miles away, and he could not con- who caused that kind of trauma
veniently return to the clinic, I needed and what have we done when
satisfaction that he knew what to do to we thought that we had a typical,
reestablish normal voice if he ever began normal family. You know there was
speaking with his pre-intervention be- a lot of self-doubt and wondering if
haviors. Notice the absence of the term he would ever get over this.
remission. Within a behavioral model of
intervention, the use of medical terms C: Pretty spooky!
such as remission, exacerbation, and cure M: Yes, it was very scary, yup.
tend to be used in ways that do not fos-
ter a patients development of the aware- C: Do you have any concerns or
ness that the behavior brought to the questions now that you know he is
task of speaking is the responsibility of producing voice again?
the patient. I was seeking indication that
this patient had become his own clinician M: No, I dont think so; I guess, if
and that he had an appropriate plan of he comes down with laryngitis I will
approach to solving future problems of be very nervous. I think I am really
voice of a similar nature should he exhibit satisfied with the psychological end
them. Patient Y reiterated and success- of it and . . .
fully demonstrated the intervention steps C: Explain what you mean.
he used to reestablish normal voice.
Because his parents participated in M: Well, I guess I worried about
the therapy sessions, it seemed impor- a lot of deep-seated problems
tant to sample the parents understand- and, you know, I dont think I am
ing of how their son implemented a worried about that anymore. In the
change to normal and the implications beginning, I would have said if he
of this change. This was assessed on the had gotten his voice back maybe
second morning through an interview there would be another time when
at the end of the patients hour-long if a traumatic experience occurred,
session. he would lose it again. I see it now
more as a physical thing that he can
C: What thoughts went through deal with and we can help him if
your mind as you and the family he, you know, if it would come to
were experiencing this? a point where there was a problem
Primary and Secondary Muscle Tension Dysphonia 37

with voice, I think we would know Dr Stone demonstrates how to synthesize

how to handle it. knowledge of anatomy and physiology,
combined with keen observational skills,
Frequency and Duration of Treatment knowledge of learning styles, and psychol-
ogy to treat a functional voice disorder. In
Patient Y was seen for approximately real time, he completes task analysis for
5hours across 2 days. Dr Stone addition- voicing and determines the patient cannot
ally accompanied the family to lunch. This coordinate all vocal subsystems and is not
was consistent with how patients were often readily able to produce typical stimulabil-
treated when I was employed with Dr Stone ity tasks. A bridge step is created, reduc-
at the Vanderbilt Voice Center. We often saw ing the complexity of the task and utilizing
patients for multiple, consecutive sessions demonstrated skills. With a specific goal in
over several days due to distances patients mind, he confidently and patiently explores
had traveled or lack of qualified resources coupling airflow and articulation in the
near their homes. We found this type of absence of voicing for over an hour, increas-
treatment to be very effective. Recently, the ing the patients body awareness, creating
University of Wisconsin has written about behavioral change, building rapport, build-
a similar intensive program they refer to as ing confidence, and relaxing the upper body.
boot camp which has initially promising All the while, he assessed for understanding
results. It should be noted that an impor- and checked for a shift from an external to
tant aspect of boot camp, which differs from an internal locus of control, an optimistic
this account, involves use of multiple thera- attitude, and accurate placement of respon-
pists.42 (See Case Study 15 by Rita Patel, sibility required to ensure success. Dr Stone
Voice Therapy Boot Camp, presented later further demonstrates the essential skill of
in this chapter, for more information.) pacing and timing sessions, introducing
voicing via nontraditional methods, and
continuing to shape skills with successive
Therapy Outcomes approximations toward the ultimate goal.
He modifies his plan after observing the
Audio-Perceptual patient with his family and progresses him
Within normal limits voicing. accordingly. The patient tests or evaluates
whether he has brought under voluntary
control the behavior that had previously
Patient Self-Assessment
been involuntary. Finally, the patient dem-
Patient Y demonstrated volitional control, onstrates awareness of behaviors involved
coordination, and responsibility for his voice in speaking, positive attitude regarding per-
returning to baseline voice. He also reported formance, understanding of how to proceed
confidence that he knew what to do if any following therapy, and a within normal
voice difficulty recurred. limits voice.

Summary and Muscle tension dysphonia may occur

across all ages. In the following case,
Concluding Remarks
Joe Stemple describes using a falsetto
voice to disrupt the inappropriate voice
The above case study represents an eclec-
production pattern of a 13-year-old.
tic management approach to remediation.
38 Voice Therapy: Clinical Case Studies

Case Study 2
Laryngeal videostroboscopy was per-
formed at this point of the evaluation
Joseph C. Stemple
as a means of educating the patient
about the anatomy and physiology of
Management of Primary MTD the laryngeal mechanism and vocal
in a 13-Year-Old Using Falsetto folds. Patient X presented with normal-
Voice to Modify Phonation appearing vocal folds. The whisper,
of course, did not permit slow-motion
observation of fold vibration, but the
Patient History folds were shown to adduct toward
the midline, only to stop in an incom-
Patient X, a 13-year-old, eighth-grade plete closure. The lack of approxima-
student, was referred with a 4-week his- tion of the folds was pointed out to the
tory of voice loss. The patient and her patient with an explanation similar to
mother were interviewed together, and the following:
then the interview was continued when
the mother was asked to leave the exam- Your vocal folds look very good and
ination room. As is the case with many healthy. For some reason, the muscles that
functional voice problems, the onset of pull them together are simply not pull-
whispering was associated with a cold. ing the way that they should. Therefore,
the vocal folds are not closing all the way.
The patients mother reported that her
When they do not close all the way, they
daughter had developed laryngitis
do not vibrate, and we hear whispered
4 weeks prior to this examination and speech. Our goal in therapy, therefore, is
then lost her voice totally 2 days to do whatever is necessary to encourage
later. The cold quickly resolved, but the those muscles to pull hard enough to make
patients voice had not yet returned. the vocal folds come together.
The patient was reported to be a
rather shy child who succeeded rea- With this approach, the voice
sonably well in her academic activities. pathologist has given the patient a non-
Socially, she had two best friends and threatening explanation as to why pho-
participated in the school choir, library nation is not occurring. No comment
club, and 4-H activities. Her medical is yet made regarding the patients
history was unremarkable as related to inherent ability to phonate. In fact, the
this problem. Although she had never blame for lack of phonation has been
experienced vocal difficulties before, removed from the patient and placed
her mother reported that the girl had squarely on the faulty mechanism.
experienced a chronic cough 1 year
earlier for which no diagnosis could
be found. Following several weeks of Management
excessive coughing, the behavior sud-
denly stopped. The childs mother was Traditional management approaches
hoping the voice would come back in then might examine the patients ability
the same manner. to phonate during nonspeech phona-
Primary and Secondary Muscle Tension Dysphonia 39

tory behaviors such as coughing, throat vocal folds in a manner that would
clearing, laughing, crying, or sighing. encourage her muscles to pull the folds
When clear phonation is identified dur- together. The therapist then produced a
ing one of these behaviors, it is then high-pitched falsetto tone on the vowel
shaped into vowel sounds, nonsense /ai/. The patient was told, in a matter-
syllables, words, and short phrases. of-fact manner, that, by stretching the
The voice pathologist must demonstrate vocal folds for this high pitch, the folds
patience at this time. Most patients have are more closely approximated. Every-
not phonated for several weeks. The one, even those with vocal problems,
possibility of proceeding too quickly can produce this tone. The falsetto again
and frightening the patient away from was demonstrated, and the patient was
phonation is present. Once good, con- told to produce the same sound.
sistent phonation is established under Following several unsuccessful
practice conditions, the voice patholo- attempts, the patient produced a high-
gist begins to insist gently that it be used pitched squeak. This was promptly rein-
during the therapy conversations. Some forced with praise and repeated several
claim that, when voice is regained in times. As the falsetto voice strengthened
this manner, it is seldom lost again, and and the sound became clearer, other
patients do not substitute other symp- vowel sounds were introduced and sta-
toms. Long-term studies are needed to bilized at this pitch level.
substantiate this claim. It was explained to patient X that
Another technique that we have we were going to use the muscle ten-
found useful is the use of direct visual sion created by producing the falsetto
feedback using laryngeal videoendos- tone to encourage the vocal folds to
copy. While the patient is being scoped, pull together normally. The patient was
with either a rigid or flexible endo- given a list of 150 two-syllable phrases
scope, an explanation is given related and asked to read them in the falsetto
to the positioning of the vocal folds voice. During this exercise, she was con-
and how that positioning relates to the stantly encouraged to read swiftly and
present vocal problem. The patient is loudly. After the voice stabilized in a rel-
able to monitor the video over the voice atively strong falsetto, the patient was
pathologists shoulder. The patient is halted and asked to match the clinician
then instructed in various manipula- when singing down the scale about 3 to
tions of the vocal folds, such as deep 4 notes from the original falsetto tone.
breathing, light throat clearing, laugh- The patient was then asked to continue
ing, and attempts to produce tones of reading the phrases at this new pitch
various loudness levels and pitches. We level. The same procedure was repeated
have had surprising success in the quick 2 to 3 more times until the young wom-
return of normal voicing using these ans pitch closely approximated a nor-
visual biofeedback procedures. mal pitch level. She was continually
A different management strategy encouraged to produce these phrases
was used with patient Xthat is, the use louder and faster until her voice eventu-
of falsetto voice as a facilitator of normal ally broke into normal phonation.
voicing. It was explained to the patient Occasionally, the patient will ap-
that we were going to manipulate her proximate normal phonation but then
40 Voice Therapy: Clinical Case Studies

hesitate as if somewhat reluctant to pro- tionally draining. Can you think of any-
duce normal voice. When this occurs, thing that has been going on lately that
the patient is asked to drop way has been upsetting to you?
down and produce a guttural voice
quality while reading the phrases. This By this time, it is hoped that the
will produce more appropriate muscle patient has developed strong confi-
pull. After a few minutes, the patient dence in the voice pathologist and will
is taken back to the falsetto voice with open up a floodgate of information
the break into normal phonation usually about deaths, family problems, work
occurring soon after. problems, and the like. In discussing
It is extremely important for the these problems, the voice pathologist
voice pathologist to be patient when attempts to accomplish two major objec-
utilizing this technique. The normal tives: (1) Give the patient total and final
time frame from aphonia to normal control over the laryngeal mechanism
voice is approximately 30 to 45 minutes. and (2) determine the patients general
The voice pathologist must not only be emotional state to decide the need for
patient but also must present a very further professional counseling.
matter-of-fact, confident manner. Voice Up to this point, the voice patholo-
pathologists are not cheerleaders. They gist has been manipulating the voice.
are simply presenting a technique that The patient now must understand that
they know will work. despite the ultimate cause of the apho-
Why do these techniques work? nia, he or she is in total control of the
voice and does not need to permit the
n The patient is ready for change. problem to recur. If it does, the patient
n The voice pathologist has given a knows how to regain control of the voice.
reasonable explanation for what the Finally, just because the need for
vocal folds are doing. the functional reaction no longer may
n The voice pathologist has demon- be present, this does not mean that for-
strated confidence in the therapeutic mal family, psychiatric, or psychologi-
techniques. cal counseling would not be helpful. If
the voice pathologist feels the problem
Following return of voice, it is nec- is not resolved and further counseling is
essary to explore the actual cause for the in order, the suggestion should be dis-
voice disorder. It is desirable to do this in cussed with the patient, and appropri-
a direct manner. For example, the voice ate referrals should be made.
pathologist could say the following: In discussing the problem with the
patients mother, it became evident that
Im very pleased that the muscles are all patient X had experienced other epi-
functioning well now and that your voice sodes of possible functional behaviors,
has returned to normal. It sounds really
most notably several long-term cough-
good. The thing that still puzzles me some-
what is why the muscles stopped clos-
ing spells. Patient X was shy and she
ing the folds in the first place. I can tell lacked confidence. Physically, she was
you quite frankly that with a lot of other overweight and had, in the past year,
patients we have seen with the same prob- become sensitive about her appearance.
lem, the cause has been something that has Her mother reported that around the
happened that was very upsetting or emo- onset of this voice problem, her daugh-
Primary and Secondary Muscle Tension Dysphonia 41

ter had come home from school very tory illness that lasted for about 2weeks.
upset about being teased by some class- During this illness, she coughed and
mates about her weight. Like many chil- cleared her throat frequently. About 1
dren in this age group, she was sensitive week into the illness she became apho-
to comment by her peers and was strug- nic. Her pediatrician referred her to a
gling to find her own identity. Sugges- general practice otolaryngologist who
tions were made for further counseling. completed an indirect laryngoscopy.
In a follow-up voice therapy ses- Patient X was told that her vocal folds
sion, patient X had maintained normal did not meet in the middle during
voicing. As a matter of fact, she was phonation. She was then referred to the
looking forward to singing with her specialized hospital-based voice clinic.
school choir in a concert that week. At the beginning of her evaluation,
Her ability to control her voice produc- a case history was obtained through
tion was reinforced. She was told that completion of a medical history form
if she felt the whisper returning, all she by the patients mother and an inter-
needed to do was produce the falsetto view conducted by the evaluating clini-
tone and most likely her voice would cian (speech-language pathologist). Her
return to normal. That was our last con- medical history revealed no current or
tact with this patient. past significant illness or disease. All
aspects of development (motor, speech,
cognition) were normal.
Many therapy techniques have been
The interview with the patient and
used successfully to remediate MTD. In
her mother revealed several sources of
the following case study, Susan Baker
stress and anxiety for patient X over
Brehm describes the use of laryngeal
the past 3 to 4 months. She was a high
massage and resonant voice therapy with
school freshman and her transition to
an adolescent presenting with MTD.
her new school had been challenging.
Her parents separated 1 month prior to
the start of the school year. The patient
was moved to a new school district as
Case Study 3
her mother was required to relocate.
She was having trouble making new
Susan Baker Brehm friends and was struggling academi-
cally in several classes. When she was
Use of Laryngeal Massage and sick 2 months ago with the respiratory
Resonant Therapy in Primary illness, she missed school for several
MTD in an Adolescent days prior to an Algebra test. She took
the test when she returned to school
and performed very poorly. Her mother
Case History revealed that the complete loss of voice
began the night after she took the test.
Patient X, a 14-year-old female, was She had become very hoarse during that
referred for a voice evaluation at a day from crying and was completely
pediatric hospitalbased voice clinic. aphonic by the evening.
Approximately 2 months prior to her The onset and consequences of the
evaluation, she had an upper respira- aphonia appeared to be stressful for all
42 Voice Therapy: Clinical Case Studies

of the family members. Throughout the the rigid examination. No evidence of

interview, the clinician began to under- laryngeal irritation or edema from gas-
stand that patient X was spending a lot troesophageal reflux was observed.
of time with both of her parents through The pediatric otolaryngologist on
many of the doctor appointments. She the team was present for the exami-
was also getting some additional atten- nation as well. The otolaryngologist
tion at school from her peers as she was assured the patient and her mother
not able to participate in her school that the larynx looked healthy and that
choir of which she was a member. she had a condition called muscle ten-
sion dysphonia. The speech-language
pathologist used the recorded examina-
Voice Evaluation tion to show the patient and her mother
the incomplete closure of the vocal
A formal perceptual assessment of voice folds during phonation and discussed
quality such as the Consensus Audi- how the vocal folds are normally con-
tory-Perceptual Evaluation of Voice figured during phonation. The patient
(CAPE-V) or grade, roughness, breathi- and her mother appeared to understand
ness, asthenia, strain (GRBAS) scale why the voice sounded so breathy but
was not completed because the patient then began to question why the onset
was aphonic. In her written evaluation of aphonia occurred with this particular
report, the patients voice was described respiratory illness. The evaluating team
as severely breathy characterized by discussed the excessive tension that can
significant strain observed in the entire occur in the larynx due to illness and
upper body (particularly in the neck excessive use of the voice (eg, excessive
region) during attempts at phonation. coughing). The team also briefly men-
Acoustic and aerodynamic measures tioned how stress and anxiety leading
were also not obtained with this patient to tension in the neck region can lead to
due to her aphonia. excess tension in the larynx.
A rigid videostroboscopic examina- The patients parents were asked to
tion was performed with this patient by complete the Pediatric Voice Handicap
the evaluating clinician. She tolerated Index.43 This assessment tool is a vali-
the examination well and all laryngeal dated modification of the Voice Handi-
structures appeared normal. When cap Index (VHI). The format is similar;
asked to sustain the vowel /i/, she had however, the statements are focused
incomplete closure with mild anterior- more to children and adolescents and
posterior and lateral compression of the it is completed by parent-proxy. Due
supraglottic structures. Abduction of to the age of the patient, the evaluat-
the vocal folds was normal during quiet ing clinician encouraged the patient to
breathing and sniffing tasks. The patient provide input regarding the responses.
was asked to clear her throat to remove The following are the subset scores:
excessive mucus off the vocal folds dur- Functional = 20 (out of 28); Physical =
ing the examination, and she was able 30 (out of 36); Emotional = 20 (out of 28).
to achieve closure of the vocal folds dur- The total score was 70 (out of 92). The
ing this event. She was also observed to scores on this index indicated that the
have a typical sounding laugh during patient was experiencing a high level
Primary and Secondary Muscle Tension Dysphonia 43

of impact on her daily activities related aware (as should the clinician be with
to her voice impairment and a related all patient populations) of the loca-
emotional impact. tion of the carotid arteries in the neck
and not provide any compression in
this area. Resonant therapy techniques
Voice Therapy were chosen as well to provide a means
of reducing tension at the larynx and
Diagnostic Therapy moving the tension to the face and lips
during phonation.
Once the formal evaluation with the
team was completed, the clinician ini- Session 1
tiated a brief (10 minute) diagnostic
therapy session. The patient was exhib- Because of the nature of the disorder,
iting a significant amount of tension the next therapy session was scheduled
in her neck and shoulders and upon as soon as possible. Patient X was able
palpation of the larynx, demonstrated to return the next day for a half-hour
significant tension in the thyrohyoid therapy session. Both of her parents
space. Circumlaryngeal massage was were present at the appointment. The
initiated as described by Roy and col- clinician felt that more progress might
leagues,3 and patient X was able to pro- be made in the session if the parents did
duce a relatively normal voice during not join the session and remained in the
this procedure. [For more information waiting room.
on circumlaryngeal massage, see case The clinician began with having the
study 5 by Nelson Roy, Manual Circum- patient perform unvoiced lip buzzes/
laryngeal Techniques in the Assessment trills with as little effort and tension as
and Treatment of Primary Muscle Ten- possible. The patient completed these
sion Dysphonia (MTD) in a 55-year-old unvoiced lip buzzes 10 times (duration
woman, later in this chapter.] However, was about 2 s each). Next, phonation/
when the clinician removed her hands voicing was added to the lip buzz. The
from the laryngeal area, the patient was exercise was also completed 10 times.
immediately aphonic. For the next exercise, the clinician
Based on this initial therapy ses- had the patient perform the voiced lip
sion, the clinician felt that the patients buzzes at her pitch extremes. She per-
prognosis was good and that she could formed 5 lip buzzes (approximately 3
benefit from circumlaryngeal massage to 4 s) at a high pitch and 5 lip buzzes
techniques paired with exercises that (approximately 3 to 4 s) at a low pitch.
promote the use of easy, front-focused The clinician had the patient perform
phonation utilizing resonant voice these exercises again with added laryn-
activities. The success of circumlaryn- geal massage at the pitch extremes, and
geal massage has been demonstrated she was able to sustain phonation for
in patients with functional voice dis- approximately 4 to 5 s.
orders exhibiting excessive tension of From there, the clinician had the
the extrinsic and intrinsic laryngeal patient use the lip buzz and perform
muscles.44,45 When using this technique glides from her pitch extremes. So, lip
with an adolescent, the clinician must be buzzing with phonation from her highest
44 Voice Therapy: Clinical Case Studies

pitch down to comfort pitch 5 times and nician felt that the less time the patient
then from her lowest pitch up to comfort had to move back into excessive tension
pitch 5 times. This exercise was used to and poor voicing patterns, the more
assist the patient in gaining more ease rapidly she would be able to use a nor-
and flexibility with the front-focused mal voice consistently. Fortunately, the
voicing pattern. Following this exercise patient and her family were motivated
with some additional laryngeal mas- to continue, and session 2 was sched-
sage, the patient was now able to pho- uled 3 days after session 1.
nate for approximately 5 to 6 s. Patient X entered the therapy room
Next the goal was to extend the for this session using a nearly normal
voiced lip buzz into phrases. The cli- voice. The voice was mildly breathy. The
nician modeled the first exercises as a clinician led patient X through voice lip
lip buzz extended into a mmm (eg, buzz into phrase exercises used in the
voiced buzzmmmm). This was per- previous session to reestablish frontal
formed at a comfortable pitch 5 times. focus. The clinician then advanced the
Then the lip buzz was extended into patient to using front-focused chanting
m-vowel combinations (eg, voiced buzz for m-initial sentences (eg, Mary made
ma-ma-ma-ma . . . voiced buzzmi- me mad). After frontal focus was estab-
mi-mi-mi, etc). This exercise was per- lished, the clinician had the patient
formed 5 times. Finally, the lip buzz overinflect the sentences and then speak
was extended into /m/ initial sentences them. After the completion of 10 sen-
(eg, voiced buzzMary made me mad tences using the chanting, overinflection
. . . voiced buzzMy mother made then speaking sequence, the patient was
marmalade, etc). This exercise was com- able to able to self-monitor the appro-
pleted 5 times. priate use of frontal focus about 90%
At the conclusion of the session, of the time. The same pattern of chant-
the patient reported that she felt fatigue, ing, overinflecting, and speaking was then
but she seemed encouraged about the used for voiced and unvoiced sentences
progress that had been made. She dem- (eg, Mom may move Pollys movie to
onstrated her ability to phonate dur- 10). Again, after the completion of the
ing the phrase exercises for her parents 10 voiced/unvoiced sentences, the pa-
when they were invited into the therapy tient was able to self-monitor and cor-
room at the end of the session. The cli- rect errors in frontal focus about 90%
nician provided a written instruction of the time. The clinician then had the
sheet outlining the exercises performed patient say sentences of increasing
in the session and asked the patient to length (voiced and unvoiced) while self-
perform each of the exercises in two monitoring for frontal focus.
separate sessions throughout the day Approximately midway through
for the next several days. this session, when this stable, essen-
tially normal voice was reestablished,
Session 2 the clinician invited the patients par-
ents into the therapy room. The clinician
Again, due to the nature of this disorder, began a more significant discussion of
the treating clinician felt it was impor- how stress and anxiety can create ten-
tant to continue the success obtained in sion during speaking and interfere with
the first session relatively soon. The cli- normal laryngeal function. The parents
Primary and Secondary Muscle Tension Dysphonia 45

were very pleased with the outcome of that you can help the patient obtain his
therapy; however, all parties agreed that or her old voice again is often a key
the onset of the aphonia was a sign that to success.
patient X would benefit from speaking
with a counselor or psychologist to dis-
Flow phonation is another therapy
cuss some of her current life stressors.
approach often used to remediate MTD.
From this session, patient X was
In the next case, Jackie Gartner-Schmidt
discharged. She was encouraged to con-
gives a detailed description of the use of
tinue the exercises at home for another
this technique with a teenager present-
week and to call if she had any problems.
ing with MTD.

Therapy Outcome
Case Study 4
The clinician called patient X 2 weeks
after her final session. The patient dem-
onstrated a normal voice over the Jackie Gartner-Schmidt
phone and reported no further difficul-
ties with the voice. Patient X indicated Flow Phonation in a Teenager with
that she was going to start counseling Primary Muscle Tension Aphonia
sessions the following week.
This case is presented to illustrate the
use and concepts of flow phonation. The
Summary and therapeutic concept was introduced by
Concluding Remarks Stone and Casteel46 and later instrumen-
tally examined by Gauffin and Sund-
Primary muscle tension dysphonia is berg,47 who coined the term flow phonation
not a common diagnosis observed in based on their work with flow glotto-
children and adolescents; however, grams. Flow phonation is a modification
those patients who present with this of stretch and flow phonation.46,4850
disorder can be difficult to treat. Sens-
ing sources of stress, how much to push
the patient forward in the exercises, Case History
and the timing of the push are all com-
plex aspects of treating these patients. Patient J, a 17-year-old female high
Additionally, the clinician must sense school student, reported a sudden
from the patient when it is appropriate onset of total voice loss approximately
to discuss that stress, anxiety, and ten- 3 months prior to her clinical visit. This
sion may have played a large role in the loss was precipitated by heavy voice use
onset of the disorder and that psycho- while playing high school basketball,
therapy may be recommended. There is although nothing out of the ordinary.
not a one-size-fits-all approach with Patient Js chief complaints were total
this patient population; however, gen- voice loss, extreme vocal fatigue, and
erally getting the point across that the severe throat constriction when talking.
laryngeal structures are healthy and She did not have any prior history of
that you as the clinician feel confident voice loss before this episode. Patient J
46 Voice Therapy: Clinical Case Studies

was a product of a split family, although Js assessment of her overall voice prob-
her mother and father were still mar- lem was severe based on an ordinal
ried. She admitted to being afraid of scale (none, mild, mild-moderate, mod-
her father but denied physical abuse. erate, moderate-severe, severe), and her
Her father was very competitive when chief complaint included both the sound
it came to his daughters basketball and feel of her voice. She also described
playing and was at the game the night herself as an extremely talkative per-
she lost her voice. Patient J denied her son. To quantify the effect of patient Js
fathers presence as the trigger, given perception of her voice handicap, the
that he often attended her games. How- VHI-1053 was used. Patient Js score was
ever, she admitted that She did not like 36/40, which is above the normative
him. She divulged that she had been value of 11.54 In addition, because stress
admitted to the hospital for vomiting reactivity may be an etiologic factor in
and dehydration months before her laryngopharyngeal reflux (LPR),55the
current voice problem; she and the phy- Reflux Symptom Index56 was given to
sicians believed that the episode was patient J and her score was 10/45, which
probably due to stress. In fact, patient is within normal limits.
J described herself as always very Patients Js assessment of her over-
stressed. She had never been evaluated all vocal effort as measured via a Direct
by a mental health professional. Other Magnitude Estimation Scale5759 was 1
than this information, the patients 000 000. An example of how we have
medical and speech history were unre- modified the original DME for vocal
markable. She was a healthy teenager effort is as follows:
who drank over 1920 mL (64 fl oz) of
water a day. If I told you that 100 represents an
easy amount of vocal effort and 200 is
twice that amount and 450 is 4.5 times
that amount and 1200 is 12 times . . .
Voice Evaluation there is no ceiling. Pick a number in
the hundreds that best indicates how
The following noninstrumental and much vocal effort it takes you to voice
instrumental measures were taken: when you are having a bad day.
Auditory-perceptual evaluation using
a modified version of the CAPE-V51 Patient J described her feeling of
revealed a Visual Analogue Scale mea- vocal effort as 10 000 times that of an
sure of 95/100 for overall severity of easy amount of vocal effort. Unfortu-
voice quality. The following audio-per- nately, frequency measures were not
ceptual descriptions of voice were rated valid as the patient had a type III Signal
with an ordinal scale as done with the Typing 60,61 defined as no apparent fun-
GRBAS52: roughness (0); breathiness (0); damental frequency as obtained from
strain (3); pitchhigh (2); pitchlow the Multi-Dimensional Voice Program
(0); loudnessloud (0); loudnesssoft (MDVP) (KayPENTAX, 2008).
(2); hoarseness (3); and aphonic. Aerodynamic measures were re-
It is important to note that the pitch corded using the Phonatory Aerody-
rating was probably due to resonating namic System (PAS, KayPENTAX, 2006),
frequencies of the vocal tract (ie, formant and mean airflow for the center 3/pa/
frequencies) as she was aphonic. Patient tokens of a 5-token repetition showed 50
Primary and Secondary Muscle Tension Dysphonia 47

mL/s with subglottal air pressure esti- to-back with a 20-minute rest between
mates of 17.3 H2O at her most comfort- sessions. At the time, insurance compa-
able pitch and loudness (MCPL). These nies were reimbursing 2 voice therapy
measures were interpreted to mean sessions on the same day; unfortunately,
that perhaps she was holding back her currently, they only reimburse 1 a day.
airflow (as demonstrated by low flow Presented in Figure 31 is a summary of
measures) and using increased thyro- the basic skills of flow phonation and a
arytenoid and lateral cricoarytenoid conceptual diagram of the hierarchical
muscle tension to spike high, indirect, steps of flow phonation.
subglottal air pressure measures.62 This Patients are asked to become aware
appeared to corroborate the speech-lan- of frontal energy/airflow while feeling
guage pathologists audio-perceptual no throat tightness. Patients go through
assessment of severe breath holding. the hierarchy, but if problems recur,
Phonatory mean airflow rate for a spo- they go down a step until they reach
ken sentence (Peter picked a pound of functional performance. It is important
pickled peppers) was 40 mL/s. Hence, to note that patients do not have to go
both of the decreased airflow measures through all the steps in order. Also,
could perhaps be indicative of severe patients can go back and forth between
pressed phonation [eg, muscle tension the steps as much as necessary, and
dysphonia (MTD)]. Her intensity range because vocal balance is the ultimate
was 11 dB SPL, which is below the norm, goal, it does not matter if each step is
perhaps due to the limited vocal agility used. Finally, this is not a programmatic
of her mechanism due to muscle tension. approach to voice therapy64; many times
The laryngologist visualized the the reader will see the words et cetera
larynx using a chip-tip flexible endo- because the reader is encouraged to
scope and reported no lesions and nor- invent new stimuli based on the con-
mal bilateral vocal fold motion. Flexible cepts of flow phonation.65 The examples
endoscopy versus rigid endoscopy is given are in no way exhaustive.
routinely used in the clinic for the diag-
nosis of MTD because it allows visual-
ization of speech during the exam. Two Skill Levels of Flow
sentences are used which are phoneti- Phonation (Table 31)
cally different to elicit specific laryngeal
articulatory gestures: We eat eels every Skill 1: Airflow Release
day and She speaks pleasingly.63 No Unarticulated Airflow
evidence of LPR was found on endos-
copy corroborating the RSI result. The Gargling Technique: Patient J was first
patient was diagnosed with severe asked to do the gargle technique. Patient
primary muscle tension dysphonia J was given a glass of water. The SLP
(MTD-1). modeled the gesture, and patient J was
asked to produce plenty of bubbles
with the water. Patient J was able to
Voice Therapy gargle well, which represented the first
step toward flow phonation, as gargling
After her initial evaluation, patient J is merely airflow in a nonspeech task.
received 2 voice therapy sessions back- Having a patient gargle initiates airflow

Articulatory Precision:

No reduction in rate

Airflow PLUS voicing:

(Either breathy / flow phonation) No overenunciation

Gargling Crispness of articulation

Lip bubbles Conversational Speech

Establish Airflow Release: Prolonged fricatives:

Gargling /z, v, j/

/u/ prolongation /u/ prolongation kazoo sound

Lip bubbles Whistling

Prolonged fricatives: Words, phrases

/s, f, sh/ Etc


Other voiceless phonemes

Words, phrases, etc

Figure 31. Hierarchical steps of flow phonation.

Table 31. Skill Levels of Flow Phonation

Skill 1: Airflow Skill 2: Breathy Skill 3: Flow Skill 4: Articulatory

Release Phonation Phonation Precision
1.Unarticulated 1.Unarticulated 1.Unarticulated Conversational
airflow breathy phonation flow phonation speech
2.Articulated 2.Articulated 2.Articulated flow
airflow breathy phonation phonation

Primary and Secondary Muscle Tension Dysphonia 49

release without the maladaptive habits was asked to take a breath and immedi-
of extralaryngeal/intralaryngeal ten- ately exhale a sigh on a /u/. At first, the
sions. The head, chin, and elongated tissue moved only with the initial exha-
neck posture characteristic of a gargling lation, but then the patient appeared to
posture dissuaded patient J from raising hold back her airflow; the tissue did not
her larynx higher than it was. In a gar- move. She did an audible semi-Valsalva
gling posture, a patient cannot make the as she stopped the airflow. The instruc-
hyolaryngeal sling tighter than it often tion was given again, and this time the
already is. The posture also stretches the patient released the exhalation for a lon-
extrinsic laryngeal strap muscle. ger duration but the exhalatory airflow
The next instruction to patient J sounds were jerky and not consistent.
was to add the gargle sound to the Often the SLP will use the following
air bubbles, being careful not to use the verbiage to instruct the patient: I want
word voicing so as not to introduce you to pretend that you have had a long
any anxiety ridden verbiage. Patient day and that you are just letting out a
J again was successful. The final step nice, relaxed sigh but on the letter /u/.
in the gargling technique was to have She performed much better this time.
the patient slowly lower her chin while Lip Bubbles:Wanting to capital-
still gargling with sound. With some ize on her success thus far, I moved on
patients, once phonation is established to another airflow-inducing technique.
with this technique, shaping the sus- I asked her to do an easy voiced lip
tained gargle into speech is all that is bubble. Patient J could lip bubble with
needed. In general, whenever a SLP the aid of placing her 2 index fingers on
feels that a patient can jump right to the corners of her lips. She lip bubbled
conversational speech in the therapeu- for long and short durations, producing
tic process, the sooner the patient tries, high-pitched and low-pitched sirens.
the better.66 Unfortunately, patient J was All the while, patient J was asked if
unable to transfer the voiced gargle to she could feel airflow energy at her
phonemes, words, and phrases. lips and if her throat felt relaxed. Some
/u/ Prolongation: The next instruc- patients find this very difficult to do; if
tion I gave patient J was to produce a so, they are asked to move to the next
/u/ without voicing. A strip of facial exercise.
tissue was held between her index and
third fingers, approximately 5 cm (2 in) Skill 1: Airflow Release
from her nose. The reason a voiceless Articulated Airflow
/u/ is used is because the lip contour
for /u/ directs the airflow in a column Voiceless Phonemes: Now that airflow
from the lips, and it is easy to move the was being released, she was informed
tissue and hear a steady airflow stream. that she could produce approximately
The cycle of inhalation followed by 31% of the sounds of the alphabet; out
exhalation on a voiceless /u/ should be of 26 letters, she produced 7 without a
produced smoothly and without hesita- problem, which were all the voiceless
tion resulting in a consistently uplifted consonants (f, h, k, p, q, s, t). I immedi-
tissue. The goal is to achieve the task ately advanced to prolonging the voice-
with minimal throat effort and a feeling less fricatives /s, f, sh/. Once she could
of airflow energy at the lips. Patient J prolong them, she was asked to do pitch
50 Voice Therapy: Clinical Case Studies

(ie, formant frequencies) glides, sirens, issues if the SLP thinks that the voice
and be loud and soft with the fricatives. problem may be secondary to stress-
All the while, patient J was asked if she reactivity-personality profiles and/or
could feel airflow energy at her lips psychosocial trait or states.12,6770 Fur-
and if her throat felt relaxed. thermore, all patients are asked to adopt
Voiceless Phrases/Conversation: this easy unstrained whispering in
When it was apparent that patient J could between sessions (eg, at home) if voice
easily release unvoiced airflow, she was reinstatement is not achieved within the
asked to articulate around the airflow first few sessions.
done in an easy, breathy unvoiced whis-
per. First, I wanted to model articulated Skill 2: Breathy Phonation
airflow (ie, efficient whisper) and sec- Unarticulated
ond, I did not want patient J to reinforce
the old strained whisper in between all /u/ Prolongation: Patient J was asked
her successful trials to establish airflow to make voice while continuing to use
release done so far. This is a very impor- the tissue as feedback. Patient J was
tant instruction to a patient that should told that the most important part of the
be said as follows: I want you to move exercise was to see and hear the airflow
your tongue and lips around this steady versus produce voice. Patient J was
stream of airflow that you have done so asked to take a breath and exhale on a
far. Having patients concentrate on breathy /u/ in a downward glide like
airflow versus speech articulation may a sigh. The tissue should move with the
disentangle the possible maladaptive airflow. The sound she produced was
habits found in speech. The concept of breathy but unsteady, and at the end,
airflow always must be front and cen- she cut off her airflow. I asked her to do
ter with this therapy. So, keeping the the /u/ on just airflow alone to reestab-
facial tissue in the same position as was lish the easy feel and see/feel the air-
done for the voiceless /u/, patient J was flow on the tissue. Then I asked her to
asked to produce phrases with just air- try again with sound, and this time she
flow. The tissue should move with the was more successful.
airflow. Within each phrase, patient J Voiced Lip Bubbles: Patient J was
was asked to connect each of the sylla- educated about coordination of airflow
bles or words together, so that no sepa- with sound and told that these exercises
ration or pausing occurs. Examples of were merely coordinating her airflow
phrases that direct the airflow to easily with her sound generator. Next she did
uplift the tissue are Poo-loo-poo-loo- voiced lip bubbles and was very stimu-
poo-loo and Who is Lou? Who is Sue? lable, producing a wonderful voice.
Who are you?
At this juncture in the therapy, Skill 2: Breathy Phonation
communications between patient J and Articulated
I were done in an easy, breathy, unvoiced
whisper. During this stage of therapy, Voiceless to Voiced Fricatives: Patient J
often it is a good time to interrupt the was now asked to do a true vocal bal-
structured tasks of therapy and just ancing technique; that is, to prolong an
talk. This can be an opportunity for /s/ and seamlessly add voicing into the
the SLP to discover any psychosocial cognate /z/. Patient J was asked to pay
Primary and Secondary Muscle Tension Dysphonia 51

attention to how little effort was needed back. Then she was asked to produce
to make voice. She was asked to do an /u/ using flow phonation, allowing the
/f/ into a /v/ and back and forth, as tissue to move but without the breathy
well as voiceless [th] to voiced [th] and voice quality. She also was asked to con-
[sh] to [dz]. trast the sensation and degree of effort
Phrases/Conversation: This is the for the different modes of phonation:
very short section of flow phonation, breathy, flow, and pressed.47
which is to ask patients to actually
converse in breathy phonation. This is Flow PhonationArticulated.Voice-
very much like Confidential Voice,71 but less to Voiced Fricatives: Patient J was
because we know that breathy phona- asked to get louder when doing the
tion actually takes more effort than effi-
seamless transition from the voiceless
cient voicing,72 this part of therapy is cognates into the voiced cognates, and
meant only to gradually introduce the to do them on pitch glides. For example,
patient to voicing with lots of airflow. on a siren, patient J produced /s//z/
Patient J was told that she might need /s//z/, and so forth. This was done
more breaths per phrases because of the on the other fricative cognates. This can
breathiness. The same sentences were be a difficult step for some patients as
used as before, but with added voice different pitches, different articulatory
this time. Patient J was again reminded postures, and transitions from voiceless
to feel airflow energy at her lips and to voiced sounds are being introduced.
see that her throat felt relaxed. She wasPatient J, with some practice, did well.
asked to say: Poo-loo-poo-loo-poo- Phrases/Conversation:Patient J
loo and Who are you? Who is Lou? was then asked to say the following
Who is Sue? phrases in flow phonation and contrast
that to pressed phonation (explained as
Flow PhonationUnarticulated./u/ holding back all the airflow): Poo-loo-
Prolongation and the Kazoo Sound: poo-loo-poo-loo and Who are you?
Patient J was asked to prolong an /u/ Who is Lou? Who is Sue?
just like in breathy phonation but to Patient J did very well and discrimi-
make the sound louder and not sound nated not only between the difference in
breathy. In other words, produce a non- the 2 sounds (pitch lower and rougher
breathy sound yet achieve the same for pressed phonation) but between the
movement of the tissue (flow phona- differences in feeling in the throat (con-
tion). Often, the only instruction a stricted for pressed and open for flow
patient needs to go from breathy to phonation).
flow phonation is to get louder. Patient Articulatory Precision:An easy
J was fairly successful in making the technique that seems to link cognition
transition to flow phonation but needed to flow phonation in speech is having
much time simply doing pitch glides patients concentrate on articulatory pre-
and sirens on /u/. She was then asked cision in their speech. The final key to
to contrast pressed and flow phonation using flow phonation in conversational
styles on /u/. First, she was asked to speech is to allow articulation to facili-
produce the /u/ again but not to allow tate the sensation of airflow energy at
any airflow to move the tissue. She was the front of the mouth. Practice using
simply instructed to hold her breath flow phonation while maintaining
52 Voice Therapy: Clinical Case Studies

awareness of articulatory activity first cessful in monitoring lack of flow at the

with sentences that include many pho- ends of linguistic strings.
nemes generated in the front of the At the end of the session, patient Js
mouth. Patient J was asked to pretend mother was invited into the session. As a
that she was speaking clearly73,74 to a rule, the SLP usually dissuades parents
person who was hard of hearing while or caregivers coming to the voice ther-
she said the following sentences that apy sessions. The SLP likes to invite par-
were loaded with voiceless/voiced ents or caregivers after the session and
consonants and, in particular, voiceless have patients explain to them what they
fricatives. Here are examples: did in therapy. It is not important that
patient J understood how she did some-
n Fat Freddy prefers French fries. thing,76 but rather that she was aware
n See Sammy slither in the grass. of the effects of different sensations and
how they related to the sound and feel
Finally, patient J and the voice of voicing. Patient J nicely demonstrated
therapist had a conversation about the difference between breathy, flow
a topic chosen by patient J. The only and pressed phonation. She was skepti-
thing patient J was asked to do was to cally happy that her voice came back.
use articulatory precision monitoring However, when she made that remark, I
airflow energy at the lips without any quickly intervened with voice produc-
throat constriction. Although the area tion came back. It was important for
in the brain that governs speech (speech patient J to think of herself as an active
motor cortex) is different from the area participant in voicing and not just a vic-
of the brain that governs vocalization, tim of her voice. This is a key point in
the periaqueductal gray (PAG),75 the any type of therapy.
patient was asked to feel the energy of
articulation and not be concerned with
feeling any constriction in the throat. Therapy Outcome
If not, patients can be very precise in
articulation but aphonic at the same Patient J was fully speaking after being
time. The patient must produce airflow aphonic for 3 months. As is common
energy at the mouth without throat with many muscle tension aphonic
constriction. Patient J did well at using patients, the patient unfortunately did
articulatory precision at the begin- not return for follow-up. Although this
nings of her phrases, but she often let was the first time the patient had lost
her airflow drop at the end of linguistic her voice production, her history and
strings, once again engaging in pressed conversations led me to believe that per-
phonation. This is a common trait in haps her aphonia may have been related
North American English because of to stress reactivity. The patient certainly
decreased pitch intonation contours at had other known forms of stress-related
the ends of linguistic strings. To counter illnesses, and she described herself as
this, she was asked to end every phrase being always stressed. It is hoped
with a voiceless /p/ to offset phonation that she will not relapse, but as the lit-
with abducted vocal folds versus tightly erature indicates, 60% of patients are
adducted vocal folds. Patient J thought prone to relapse.67 For now, flow phona-
this was very weird but seemed to tion seemed to reestablish vocal balance
understand the rationale and was suc- and give her a conceptual framework
Primary and Secondary Muscle Tension Dysphonia 53

for understanding how she could again chronic mild-to-moderate dysphonia

reinstate her voice if needed. with sporadic acute exacerbations. These
acute episodes, which bordered on
aphonia, persisted for less than a week
Manual manipulation of the larynx has
and resolved gradually. The patient
proven to be a technique that modifies
indicated that she seemed to be gradu-
maladaptive phonatory patterns. In the
ally losing the full force of her voice.
next case, Nelson Roy describes the use
She reported a persistent ache and tight-
of manual circumlaryngeal techniques
ness of the anterior neck, larynx, and
to remediate MTD in an adult woman.
shoulder regions. She had also noticed
episodic neck swellings that she labeled
as swollen glands. According to the
patient, these lumps would worsen
Case Study 5
according to her amount of voice use,
and the degree of perceived laryngeal
Nelson Roy tension, fatigue, and effort. She added
that the swellings coincided with the
Manual Circumlaryngeal acute dysphonic exacerbations and that
Techniques in the Assessment their appearance was not accompanied
and Treatment of Primary MTD or preceded by symptoms of an upper
in a 55-Year-Old Woman respiratory infection (URI). The patient
reported no change in health status and
Without exception, contemporary voice occupational or social voice use pre-
texts cite excessive or poorly regulated ceding the onset of vocal symptoms.
activity of the intrinsic and extrinsic Her recent medical history included
laryngeal muscles as important causal treatment for asthma, allergies, hyper-
considerations in a variety of voice dis- tension, depression, tension head-
orders.2,19,7780 This imbalanced laryn- aches, gastroesophageal reflux disease
geal and paralaryngeal muscle activity (GERD), and temporomandibular joint
seems to be the common denominator dysfunction. Her current medications
behind a class of voice disorders referred included Altace (antihypertensive), Pro-
to as hyperfunctional or musculoskel- zac (antidepressant), Cimetidine (ant-
etal tension voice disorders.1 In this acid), and Premarin (estrogen replace-
regard, manual circumlaryngeal tech- ment). She had received psychological
niques recently have received attention treatment for clinical depression 4 years
in the clinical voice literature as poten- previously, but she was not currently
tially valuable diagnostic and treatment consulting a mental health professional.
tools. This case study illustrates the use
of these manual laryngeal techniques
and highlights important procedural Psychosocial Interview
During the psychosocial interview,
patient XX reported numerous work-
Voice and Medical History related stresses. She indicated that just
prior to the onset of her voice difficulties,
Patient XX, a 55-year-old paralegal, her workload at the firm had become
presented with a 6-month history of horrendous and had doubled following
54 Voice Therapy: Clinical Case Studies

a company takeover. PatientXX displayed reduced pitch range and

explained, I found every single day experienced noticeable phonatory dis-
stressful at work, and thats when some integration early during upward pitch
of this started. . . . Every day I went into glides. She seemed to be functioning
work to put out the fires, rather than toward the bottom of her phonatory
doing something freshit was constant frequency range.
pressure. She admitted feeling over- Rigid videolaryngostroboscopy re-
whelmed and exhausted. Patient XX vealed no evidence of structural or neu-
indicated that 2 months earlier, she had rological pathology. Both vocal folds
missed work for 1 week with chronic moved symmetrically and were free
fatigue accompanied by complete voice of mucosal disease. Mild mediolateral
loss. Although she was frustrated by the supraglottic compression was noted.
increased workload and the limited sup- Vocal fold vibratory characteristics,
port offered by her superiors, she had including mucosal wave and amplitude
not expressed this dissatisfaction to her of vibration, were essentially within
manager and was reluctant to do so. Her normal limits; however, the closed
employer had hired additional office phase dominated the vibratory cycle.
help recently, but she was solely respon-
sible for training that individual. Conse-
quently, she was forced to neglect some Treatment
of her own duties in the process, only
adding to the burden. In addition to the Focal Laryngeal Palpation: At rest, mus-
work-related stresses, the patient admit- culoskeletal tension was appraised man-
ted to a long-standing communication ually by palpation of the laryngeal area
breakdown with her only daughter. She to assess the degree, nature, and location
had not communicated with her daugh- of focal tenderness, muscle tautness,
ter over the past several years. Despite muscle nodularity, or pain. Care was
probing by the clinician, patient XX taken to avoid sustained carotid artery
denied knowing the precise cause of compression during these maneuvers.
the communication breakdown, but she With the occiput gently supported in a
confessed to thinking about the unre- neutral position, pressure was directed:
solved conflict on a daily basis. (1) over the major horns of the hyoid
bone, (2) over the superior cornu of the
thyroid cartilage, (3) within the thyro-
Voice Evaluation hyoid space, (4) within the suprahyoid
region, and (5) along the anterior border
Perceptually, her connected speech was of the sternocleidomastoid muscle. Dur-
characterized by a mildly pressed, tight ing palpation, the degree of compres-
vocal quality, which worsened over sion applied was roughly equal to the
the course of the assessment period. pressure required to cause the thumb-
By the end of the interview, patient XX nail tip to blanch when pressed against
was in glottal fry 80% of the time. a firm surface. When this amount of
Repeated readings of a standard pas- pressure was used, focal sites of ten-
sage produced further deterioration in sion evoked discomfort and pain. The
voice. Sustained vowel production was patient winced, withdrew, and vocal-
somewhat superior in quality when ized her discomfort when tender points
compared with connected speech. She were specifically identified. These sites
Primary and Secondary Muscle Tension Dysphonia 55

of tenderness were over the major horns for normal voice and was suggestive of
of the hyoid and the superior cornu of muscular tension and laryngeal eleva-
the thyroid cartilage. The patient con- tion as possible causal mechanisms.
firmed that these sites were the location (Other manual reposturing techniques,
of her episodic laryngeal swellings. The including pressure in a posterior direc-
discomfort was more pronounced on tion over the inferior aspect of the
the left than on the right and radiated hyoid bone, did not produce noticeable
to both ears. This severe tenderness in improvement in voice quality.) Before
response to pressure in the laryngeal proceeding with manual circumlaryn-
region, along with extreme muscle taut- geal therapy, the diagnosis of muscle
ness, was considered abnormal and tension dysphonia was explained to the
highly suggestive of excess laryngeal patient, and she was educated regard-
musculoskeletal tension. ing the negative effects of excessive
The extent of laryngeal elevation musculoskeletal tension on voice and
was examined by palpating within the the possibility that such tensions may
suprahyoid region and the thyrohy- be responsible, solely or in part, for her
oid space from the posterior border of voice disorder. In addition, the results
the hyoid bone to the thyroid notch.8 of the laryngoscopic examination were
Noticeable muscle tautness was appre- reviewed, emphasizing the absence
ciated in the suprahyoid region. The of vocal fold pathology sufficient to
patient also demonstrated a narrowed account for the severity and fluctuating
thyrohyoid space that caused the lar- nature of her voice symptoms. Once she
ynx and hyoid to be suspended high in appeared to understand the relation-
the neck. This finding was also highly ship between muscle dysregulation,
suggestive of excess muscle tension. stress, and voice, the manual therapy
Attempting to maneuver the larynx procedure was outlined, and the posi-
from side to side along the horizontal tive outlook for recovery was explained.
plane tested its mobility. Ample resis- She was warned that the technique may
tance to lateral movement indicated produce some initial discomfort but that
generalized extralaryngeal tension. with continued kneading of the muscu-
lature, the pain gradually would remit.
Voice Stimulability Testing She was also encouraged to attend care-
Using Manual Techniques fully to any voice improvement and the
laryngeal sensation accompanying such
With the index finger and thumb situ- improvement.
ated within the thyrohyoid space, the
clinician applied gentle downward Circumlaryngeal Massage
traction over the superior border of
the thyroid lamina while the patient Rationale. Once the assessment proce-
vocalized a sustained ah vowel. The dures were completed and the results
voice improvement associated with were explained to the patient, the man-
such laryngeal lowering (reposturing) ual tension reduction technique (ie,
was immediate and audible to both the circumlaryngeal massage) was under-
patient and the clinician. Such a posi- taken according to the description of
tive response to laryngeal reposturing Aronson.19 Skillfully applied, systematic
and stimulability testing was informa- kneading of the extralaryngeal region is
tive regarding the patients potential postulated to stretch muscle tissue and
56 Voice Therapy: Clinical Case Studies

fascia, promote local circulation with ally. Sites of focal tenderness, nodular-
removal of metabolic wastes, relax tense ity, or tautness were deliberately given
muscles, and relieve pain and discom- more attention. Gentle kneading or sus-
fort associated with muscle spasms.81 tained pressure was focused over these
The putative physical effect of such sites and then released. The procedure
massage is reduced laryngeal height began superficially, and the depth of
and stiffness and increased mobility.82 massage was increased according to
Once the larynx is released and the degree of tension encountered and
range of motion is normalized, an the tolerance of the patient. The clini-
improvement in vocal effort, quality, cian extended the technique into the
and dynamic range should follow. Focal medial and lateral suprahyoid muscu-
palpation and massage help patients lature, because excess tension and pain
become more aware of where they are were encountered over those sites. The
holding tension. By being conscious patient was encouraged by the clinician
of these laryngeal trouble spots, the to unhinge her jaw and assume a more
patient can begin to focus on relaxing relaxed jaw position. The immediate
them during self-massage, which can effects of massage were noticeable on
be undertaken on a daily basis. In a the skin. A slight reddening and warm-
series of articles, Roy and others have ing of the skin accompanied friction and
evaluated the clinical utility of manual circular stroking movements.
techniques with a variety of voice dis- During the above procedures,
orders.3,7,27,30,44,45,8385 The results of these patient XX was asked to sustain vow-
investigations suggest that the major- els while both the clinician and the
ity of patients studied derived notice- patient noted changes in vocal quality.
able voice improvement within a single The patient, as an active participant in
treatment session using manual circum- the therapy process, was encouraged
laryngeal therapy. to continually self-monitor the type
and manner of voice produced. Given
Description of the Technique her marked sensitivity to pressure in
the laryngeal region, some discomfort
The hyoid bone was encircled with the during the procedure was unavoid-
thumb and index finger, which were then able. Nonetheless, the clinicians goal
worked posteriorly into the tips of the was to achieve sufficient tension reduc-
major horns of the hyoid bone. Pressure tion without inducing reactive-reflexive
was applied in a circular motion over muscle tensing because of pain. Improve-
the tips of the hyoid bone. The proce- ment in voice was noted almost imme-
dure was repeated within the thyrohy- diately and was combined with reduc-
oid space, beginning from the thyroid tions in pain and laryngeal height. Such
notch and working posteriorly. The changes were suggestive of a relief of
posterior borders of the thyroid carti- tension. The patient commented, Even
lage medial to the sternocleidomastoid though it hurts, it still feels good. Over
muscles were located, and the proce- the course of approximately 20 min-
dure was repeated there. With the fin- utes, the improved voice was extended
gers over the superior border of the thy- from vowels to words (automatic serial
roid cartilage, the larynx was stretched speech, ie, counting, days of the week),
downward and, at times, moved later- to short phrases loaded with nasals (eg,
Primary and Secondary Muscle Tension Dysphonia 57

many men in the Moon, one Monday at self-laryngeal massage were com-
morning), to sentences and paragraph pletely unsuccessful in modifying the
recitations, and then to conversation. voice. She denied any new situational
Once sufficient tension was released conflicts, stresses, or voice-use patterns
and the patient assumed a more nor- that may have contributed to the onset
mal laryngeal posture, progress was but had not pursued counseling.
swift, with complete amelioration of the Rigid and flexible videolaryngo
dysphonia. Following the procedure, stroboscopy revealed an extraordinary
patient XX commented that the voice sequence of laryngeal movements,
felt free of tension and effort. most obvious during laryngeal ddks
On repeated laryngeal palpation, (rapid abduction and adduction of
the sites of most severe tenderness were vocal folds). The laryngeal movement
no longer apparent. Pain no longer radi- pattern was characterized by prepho-
ated to the ears. The patient was warned natory supraglottic compression with
that she could experience some mild complete obliteration of the view of
laryngeal discomfort over the next 24 to true vocal folds by the overadducted
48 hours as a consequence of the intense ventricular folds. Phonatory initia-
massage but that this should resolve. tion was preceded by abduction of the
Patient XX was instructed in self- left arytenoid complex while the right
laryngeal massage techniques and en- arytenoid remained adducted, produc-
couraged to perform them twice daily ing an irregular-shaped posterior glot-
and whenever she experienced any tic and supraglottic chink (Figure 32).
tightness or fatigue in the laryngeal
region. She was scheduled for a follow-
up visit in 1 month to assess progress
and determine future management.
Patient XX was instructed to contact
the clinician should she experience any
acute exacerbations. In the interim, the
patient was encouraged to make modi-
fications to her work schedule to allevi-
ate some of the situational stresses and
to explore psychological counseling to
acquire relaxation skills.

Recurrence and Relapse

Figure 32.Pretreatment rigid video
goscopy obtained during sustained
Patient XX contacted the clinician 2 weeks
phonation illustrates the asymmetric appear
later with a severe strained dysphonia
ance of the arytenoids, combined with
(with frequent aphonic breaks) that had mediolateral and anteroposterior supraglot
suddenly begun a day earlier, which tic constriction that was sufficient to obscure
was Sunday. Until this exacerbation, the the view of the true vocal folds. An irregular-
patient reported symptom-free voice shaped, posterior glottic and supraglottic
for the 2-week post-treatment period. chink was created by the partially abducted
She indicated that her recent attempts left arytenoid complex.
58 Voice Therapy: Clinical Case Studies

This paradoxical movement of the left

arytenoid during phonatory initiation
appeared to represent a decoupling of
conjugate vocal fold movements.
The dysphonia was interpreted by
the clinician to be a more severe mani-
festation of the original muscle ten-
sion disorder. Manual circumlaryngeal
therapy again was undertaken accord-
ing to the previous description. In spite
of paralaryngeal tension and pain that
were judged to be more severe than
the original visit, normal voice quality
was again rapidly reestablished within Figure 33.Videolaryngoscopy com
a single treatment session. This time, pleted immediately following successful
the patient transitioned through several manual circumlaryngeal therapy (same ses
sion) confirmed normal glottic and supra
stages of decreasing vocal severity until
glottic symmetry and function. All vibratory
normal voice was restored. One inter-
parameters, as assessed by stroboscopy,
mediate stage of dysphonia was quite returned to within normal limits.
reminiscent of her original dysphonia.
Post-treatment rigid videolaryngostro-
boscopy (same session) showed no evi- seling. Arrangements were made for her
dence of the atypical and asymmetric to return to her counselor.
arytenoid movement pattern and con-
firmed normal vibratory characteristics
(Figure 33). Short-Term and
The pretreatment and post-treatment Long-Term Follow-Up
sustained vowel acoustic analyses are
shown in Figures 34A and 34B, respec- The patient was reevaluated in the voice
tively. Her severely disturbed voice in clinic at 3 and 6 months post-treatment.
the pretreatment analysis is replaced On each occasion, she reported no fur-
by a normal post-treatment voice. All ther relapse. Initially post-treatment,
results are based on samples obtained patient XX completed self-laryngeal
within the same assessment and treat- massage on a daily basis, then weekly,
ment session. and eventually as needed. She returned
Once the voice was restored, a frank to her psychologist for relaxation train-
discussion ensued regarding the com- ing and short-term cognitive-behavioral
plex interplay of laryngeal muscle ten- therapy. By 6 months post-treatment, she
sion, life stresses, situational conflicts, had discontinued counseling and self-
and her apparently ineffectual coping laryngeal massage, and had made many
strategies. She agreed that she needed positive life and work adjustments. Con-
to develop more pragmatic coping tact by telephone approximately 2 years
skills and that long-term maintenance post-treatment confirmed maintenance
of voice improvement probably would of therapy gains without any evidence
require supportive psychological coun- of partial or complete relapse.
Primary and Secondary Muscle Tension Dysphonia 59

Figure 34. Acoustic analysis before (A) and after (B) manual circumlaryngeal therapy
for the acute exacerbation (ie, recurrence). Each figure illustrates the middle 1-second
segment extracted from the pretreatment and post-treatment sustained vowel /a/ produc
tions, sampled at 25 kHz, and acoustically analyzed using the Computerized Speech Lab
(CSL Model 4300B, Kay Elemetrics Corp., Lincoln Park, NJ). A: Sound pressure waveform.
B: Narrow-band spectrogram of the preemphasized downsampled (12.5 kHz) waveform
generated using a 36 Hz analyzing filter. C: FFT (power spectrum) at the cursor location.
D: Cepstrum power spectrum. The time axis is frequency and shows the dominant energy
corresponding to the harmonic peaks in the spectrum. A prominent peak in the cepstrum is
called the dominant harmonic, and its amplitude reflects the harmonic structure of the voice
signal. Visual inspection of the pretreatment and post-treatment acoustic analyses confirms
substantial improvement in spectral and cepstral characteristics following manual circumlaryn
geal therapy. Improvement in harmonic intensity and structure following treatment is apparent
in the post-treatment narrowband spectrogram (B) and power spectrum (C). The presence
and amplitude of the dominant harmonic in the post-treatment cepstrum (D) substantiates
these improvements.

Comparisons With Roy and colleagues.44 All patients with

Existing Research FD received a single treatment ses-
sion of manual circumlaryngeal mas-
Patient XXs positive response to man- sage. Although the majority of patients
ual circumlaryngeal therapy and her improved across perceptual and acous-
subsequent relapse and exacerbation tic indices of vocal function, interviews
are compatible with the results of an during the follow-up phase revealed
investigation of 25 patients with func- that over two-thirds of the patients
tional dysphonia (FD) conducted by who had initially responded favorably
60 Voice Therapy: Clinical Case Studies

reported infrequent, partial, and self- valuable tools that augment the voice
limiting recurrences early in the follow- practitioners diagnostic and treatment
up phase (ie, less than 2 months post- armamentarium.
treatment). It appears, then, that the
case presented here is not exceptional
Voice disorders often are complex in
from a treatment-and-relapse perspec-
nature and challenging to fully define
tive. Roy et al44 advised that, for some
at the time of the initial evaluation.
patients, superior long-term results
Consequently, clinicians may find
might be found when manual laryngeal
themselves reconsidering their initial
techniques are combined with support-
impressions as they walk with patients
ive counseling, more frequent clinical
through the therapeutic process and
support, or both. Certainly, patient XXs
observe the patients response to various
eventual sustained voice improvement
methods. The following case of primary
following manual circumlaryngeal ther-
muscle tension dysphonia by Claudio
apy and short-term psychological coun-
Milstein highlights the importance of
seling seems to support this contention.
approaching clients with an open mind
During the second treatment, pa-
and a flexible treatment plan.
tient XX progressed through stages of
decreasing dysphonia and laryngeal dis-
comfort until voice symptoms gradually
remitted. These findings are also consis-
Case Study 6
tent with Aronsons 19(p315) accounts and
the reports of Roy, Bless, et al44 Whether
this gradual remission of dysphonia and Claudio Milstein
laryngeal pain during treatment repre-
sents a steady reduction in laryngeal Management of Primary MTD
tension, as Aronson maintained, remains Initially Masquerading as a Paralytic
open for debate. Dysphonia in a 39-Year-Old Woman
Using an Enabling Approach

Case History
It is apparent from this case study that
voice and musculoskeletal symptoms The patient is a 39-year-old woman who
can be consequences of specific environ- was referred by her ear, nose, and throat
mental triggers and stressors combined physician (ENT) for a 3-month history
with individual differences in coping sudden onset of hoarseness following
style.10,86 Understanding the contribu- a total thyroidectomy. She is a trained
tion of laryngeal and extralaryngeal singer and has worked as an elemen-
muscle dysregulation to these disorders, tary school music teacher (kindergarten
therefore, is critical to proper diagnosis through grade 6) for the last 10 years.
and selection of appropriate treatments. She had a 4-year history of formal clas-
Manual techniques, including focal pal- sical voice training in college, and over
pation, laryngeal reposturing maneu- the years continued to take individual
vers, and circumlaryngeal massage, are voice lessons for short periods to tune-
Primary and Secondary Muscle Tension Dysphonia 61

up her voice. Her teaching technique he could tell, there had been no nerve
consisted of demonstrating the songs trauma as a result of the procedure. She
to her students, and then singing with was referred to her local ENT physi-
them throughout the entire class. There- cian, who confirmed that both vocal
fore, over the course of an 8-hour work- folds were mobile. He found general-
ing day, she estimated singing for about ized laryngeal edema and erythema and
4 to 5 hours. Prior to this event, she has prescribed antireflux medication. The
not had a voice problem in the past and patient discontinued this medication
was able to complete her working days after 3 weeks due to lack of improve-
with no vocal fatigue. ment. On her next ENT follow-up visit,
Her past medical history was sig- she was urged to comply with the
nificant for occasional sinus problems. reflux management recommendations.
Otherwise, she was a healthy woman. After 3 months of medical treatment
Her history was negative for smoking. with no improvement, the ENT physi-
She rarely consumed alcohol, drank cian referred the patient to our clinic for
about one serving of caffeine daily, what he described as a frustrating lack
and reportedly drank lots of water. of progress.
Medications included thyroid hormone During her first evaluation, the
replacement therapy and birth control patient reported that she had returned
pills. She stated that she was very pro- to work full time but was having sig-
tective of her voice, has been well aware nificant difficulties performing her job.
of vocal hygiene guidelines, and did She was unable to sing and was experi-
not engage in any vocal behaviors that encing extreme vocal fatigue at end of
would put my voice at risk. the day. She had started using a micro-
Prior to undergoing a total thy- phone at school when teaching, but this
roidectomy, her surgeon explained the was not helping much. She appeared
potential risks of damage to laryngeal quite anxious about the future of her
nerves, and stated that she would prob- voice and indicated that this was cata-
ably experience some hoarseness after strophic for her career both as a music
the procedure. She had a nonevent- teacher and a singer. She described her
ful postoperative period and was sent symptoms as follows:
home the same day. She experienced
minimal pain during the following n Consistent hoarseness
2days. She noticed a change in her voice n Straining to speak
quality with some hoarseness immedi- n Significant drop in her speaking fun-
ately following the surgery but was not damental frequency, resulting in a
concerned about it initially, as she had very deep voice
expected to have some temporary voice n Significant drop in her singing pitch
changes, as explained by her doctor. range with a 1 octave loss in the
However, after a month of hoarseness, upper range
she started worrying about possible n Inability to increase loudness beyond
vocal fold nerve damage. She consulted a quiet voice
with her surgeon, who indicated that n Pain described as cramping local-
the laryngeal nerves were monitored ized to the lateral aspect of the lar-
during the operation, and that, as far as ynx, hyoid, and submandibular area
62 Voice Therapy: Clinical Case Studies

bilaterally, particularly when attempt- a consistently low loudness level. Her

ing to sing at high pitches average speaking F0 was 165 Hz, which
n Voice fatigue that increased with was considered low for her age and
voice use gender. During testing for voice range,
n Increased shoulder/neck tension she had an inability to increase either
with voice use pitch or loudness. When asked to per-
n Globus sensation with difficulty form a pitch glide toward higher pitch
swallowing. levels, the patient reported throat pain
starting consistently at around 250 Hz.
She indicated that her thyroid hor- She was unable to go any higher than
mone levels were balanced, as per her 260 Hz. This, for a classically trained
endocrinologist. On the weekends, soprano, was devastating. Palpation of
when she rested and maintained a self- the neck musculature during upward
imposed complete voice rest, her energy pitch glides revealed sudden and severe
levels were good. She attributed the tightening of the laryngeal and parala-
fatigue during the week days to the con- ryngeal musculature. When prompted
stant effort required for speaking. to increase volume, her voice remained
soft and weak, despite clear efforts from
the patient to do the task correctly.
Voice Evaluation Videostroboscopic evaluation re-
vealed essentially a normal larynx. There
Trauma to the laryngeal branches of the were no lesions, tumor, masses, ulcer-
vagus nerve following thyroid surgery is ations, or areas of leukoplakia identified.
a known potential risk of this procedure. Mobility of the vocal folds was within
The nerves may be stretched, bruised, or normal limits bilaterally. There was no
severed, resulting in unilateral neuropa- edema or erythema. The vocal folds
thy, and more rarely in bilateral involve- appeared with good color and straight
ment.87 In some patients, the damage is edges. During phonation at a comfort-
permanent, whereas others experience able pitch level, the pattern of glottal clo-
spontaneous recovery up to 9 months sure was complete. Phase symmetry of
after the nerve insult. Trauma to the vocal fold vibration was regular. Ampli-
recurrent laryngeal nerve may result in tude of vibration and mucosal waves
unilateral vocal fold paralysis or paresis, were within normal limits bilaterally.
causing hoarseness and sometimes dys- The only significant finding from
phagia. Superior laryngeal nerve (SLN) the videostroboscopic examination was
transient or permanent injuries are rela- an odd laryngeal posturing when the
tively frequent and are often underesti- patient attempted to phonate above
mated.88,89 Deeper voices and a loss of 250Hz. There was noticeable narrowing
the upper part of the register are not of the posterior pharyngeal wall, and
infrequent in these cases. Based on this supraglottic constriction, with signifi-
patients case history and symptomatol- cant tilting forward of the arytenoids.
ogy, trauma to the SLN was considered. In other words, laryngeal posturing
On initial evaluation, her voice was normal below 250 Hz, and a severe
quality was judged to be consistently constriction with an odd posturing was
mildly hoarse and low pitched, with observed as soon as that pitch level was
Primary and Secondary Muscle Tension Dysphonia 63

reached. This was confirmed with multi- Voice Therapy

ple pitch glide repetitions, in which con-
striction was elicited exactly at the same Even if a neuropathy was confirmed at
pitch level every trial. When the patient a later time, it was believed that a thera-
was asked to produce a louder voice, she peutic approach would be beneficial to
simply could not do it, despite percep- decrease the hyperfunctional component.
tion of a legitimate attempt to do so. Therefore, the goals of therapy were estab-
After the initial evaluation, sev- lished as follows: (1) decrease muscular
eral therapeutic probes, which included tension during voicing, (2)increase pitch
digital laryngeal manipulation and range and loudness levels while main-
neck and shoulders stretching exercises, taining a relaxed voicing mechanism, and
were implemented. Following this brief (3) achieve effortless and relaxed sound.
treatment, the patient was able to raise Prognosis for voice improvement was
pitch slightly higher than before, up to deemed good based on the initial posi-
300Hz, but not any higher. She could tive response to therapeutic intervention
not increase loudness level. during her evaluation.
Based on the results of this evalua- The patient initially presented for
tion, nerve trauma was suspected. The 2 therapy sessions where several ther-
deepening of her conversational voice, apeutic techniques were tried. These
together with the inability to produce included:
higher pitches, and the odd laryngeal
posturing seen during endoscopy were n laryngeal repositioning maneuvers
thought to be secondary to insult to the n digital laryngeal manipulation
superior laryngeal nerve. In addition, n head-neck-shoulders relaxation
musculoskeletal tension was observed. n coordination of respiratory and pho-
Although the decrease in pitch range natory behaviors
could be attributed to SLN neuropathy, n breath support for increased loudness
there was no physiological explanation n phonation through semi-occluded
for the inability to go beyond a soft voice. vocal tract configurations
The comprehensive evaluation did not n pitch glides with lip and tongue trills
reveal any physiological impediment for n voice placement with forward focus
increasing loudness, as her respiratory
system, ability to produce large subglot- All of these techniques failed to
tic pressures, and laryngeal mechanism improve pitch or loudness ranges. Even
and valving appeared to be intact. though she had responded well to digi-
Treatment recommendations in- tal laryngeal manipulation during the
cluded an electromyographic (EMG) initial evaluation, further improve-
study to evaluate the status of laryngeal ment was not achieved with therapy. It
nerves and the initiation of an individ- appeared as if there was a threshold for
ual course of voice therapy to address both pitch and loudness above which
musculoskeletal tension. The patient the patient could not operate. Phonation
refused to undergo a diagnostic EMG below that threshold could be achieved
examination for fear of needles and the in a relaxed manner, with no hoarseness
invasive nature of the procedure. She or discomfort, but above it, severe ten-
agreed to initiate voice therapy. sion was elicited.
64 Voice Therapy: Clinical Case Studies

Based on the clinicians belief that C: Keep trying, as loud as you

there was no physiologic impediment can! Yell now! One more time!
for producing louder voice, by mutual
agreement, a third session was sched- After approximately 15 more trials,
uled to focus exclusively on vocal loud- her voice got increasingly louder. Eventu-
ness. The intent was to encourage and ally, she was able to produce a very loud
motivate the patient to overcome the voice. Encouraged, she tried a couple
loudness threshold and achieve louder more times, actually yelling, and this elic-
phonation. An overview of the thera- ited an emotional catharsis. Evaluation
peutic approach follows. The process of her voice quality after this sequence
occurred within a 30-minute time frame: of events revealed a normal voice, with
normal loudness level, and ability to
Clinician: We are going to focus on voluntarily increase volume as desired.
the volume of your voice today, and Voice quality during loud productions
try to get very loud. I want you to was judged to be within normal limits,
look out of the window and try to with no evidence of the prior hoarse and
yell, Hey you! loud enough to get breathy voice she had at the onset of the
that persons attention. voice therapy session. Moreover, and this
was surprising to both the patient and
Patient: I dont think I can do that. the clinician, once loudness range was
reestablished, her average fundamental
C: Just try.
frequency during conversational speech
P: Patient initiates a series of was noticeably higher. Immediate evalu-
Hey You! productions, trying to ation of her pitch range revealed com-
increase loudness after each trial plete recovery of her pitch range without
as prompted by the clinician. Her further intervention. The patient was
willingness to do the required task able to produce pitch glides up to 1050
was evident; however, the more she Hz without effort or discomfort. This
tried to get loud, her voice would appeared to be a simultaneous benefit
become breathier and more strained of the breakthrough with loudness.
but not any louder.
C: As the patient would stop and Therapy Outcomes
think between trials, the clinician
A 1-week over-the-phone follow-up
prompted her to: Just do itdont
revealed that she had maintained a
think about itjust do the task!
normal voice quality, with an increase
The more the patient tries, the
in her overall fundamental frequency
more frustrated she gets by her
for speech, ability to phonate at normal
inability to get louder, and she
and loud voice levels, and recovery of
becomes emotional and tearful. The
her normal pitch range. She was able to
emotional display did not stop the
stop using a microphone at work and
unrelenting prompts by the clinician
was able to teach all day without dis-
to continue to try to yell.
comfort. She also reported a significant
P: Im exhausted, I cant do improvement in her singing voice. Post-
anymore, this is not going to therapy videostroboscopic examination
work. was deemed unnecessary.
Primary and Secondary Muscle Tension Dysphonia 65

Summary and cant emotional catharsis manifested in

Concluding Remarks crying, not only during the process, but
after the breakthrough. The patients
This case demonstrates the use of an reflection was that it was really hard,
enabling voice therapy technique in a and she was convinced she could not
patient who had developed an inability do it. She genuinely believed she was
to phonate above a specific threshold. It physically unable to get louder. She
appeared that the patient had acquired was grateful that the clinician pushed
maladaptive strategies in an attempt to her beyond levels that she did not think
protect her voice after surgery, as if possible. The reader should understand
she was holding back for fear of fur- that sometimes tough love is required
ther damage. in therapy. We cannot use the patients
Even though some of the symptoms words, or emotional reaction of resis-
appeared consistent with postoperative tance, to be the indicators of the end point
SLN injury, this was a unique manifesta- of the therapeutic approach. In order to
tion of what turned out to be a case of allow the patient to push through an
functional dysphonia, or musculoskel- emotional and physiologic limit, some-
etal tension. Muscle tension disrupted times the guidance has to be done in an
two parameters of vocal function, cre- encouraging but strict manner.
ating a ceiling-effect beyond which Voice improvement in this case
the patient could not operate. Below was not a slow, gradual response to
those levels, physiologic parameters of therapy to obtain a normal voice. In the
voice production were intact. Once the treatment of patients with functional
patient regained access to volume con- dysphonia, often there is little or no
trol, it appeared to recalibrate the entire evidence of success during the thera-
system, with immediate restoration of peutic process, until the patient reaches
full pitch range. a breakthrough moment, after which
The clinical relevance of this case recovery is achieved quite rapidly. In
lies in the therapeutic approach. As these cases, the clinicians persistence is
demonstrated, at times, coaching of this paramount to success. It appears as if,
patient required gentle guidance, and once the patients reach a level of tired-
at other times coaching needed to be ness (mental or physical) during the
more assertive and harsh. The approach therapeutic process, their physical or
was met with resistance, in terms of the mental blocks go down, and they are
patient believing she could not perform not able to continue to hold on to the
the required tasks. The actual dialogue maladaptive patterns of vocal function
was neither sophisticated nor particu- that resulted in dysphonic voices.
larly varied. It was a relentless, contin-
ued urging of the patient to get louder,
In the following case study, Leslie Glaze
louder, louder, followed by additional
advocates for supplemental patient-fam-
prompts such as: You can do this,
ily involvement to support traditional
You need to push yourself, It doesnt
treatment strategies, including voice
matter how it feels, just do it, and so
conservation and a vocal exercise
on. This focused on only one goal, to
regimen, in the case of a 7-year-old child
force the patient to overcome her limita-
with MTD secondary to vocal nodules.
tion. Not surprisingly, there was signifi-
66 Voice Therapy: Clinical Case Studies

never been hospitalized and was not on

Case Study 7 any medication. The patient reported
that she drank approximately 3 cans
Leslie Glaze of caffeinated soda per day and drank
milk with meals, but consumed little or
Use of Patient-Family Education no water regularly. Her favorite foods
and Behavior Modification to Treat were spaghetti, pizza, and McDon-
MTD Secondary to Vocal Nodules alds. She denied any symptoms of
burping, hot spit-up, burning throat,
or stomachaches.
Patient History

Patient D, a 7-year-old girl, was referred History of the Problem

for voice evaluation and treatment by
the otolaryngologist, who had diag- Initially, patient Ds first-grade and sec-
nosed bilateral vocal fold nodules. ond-grade teachers noticed that she had
Her mother described her daughter as frequent hoarseness with approximately
active, energetic, and frequently diffi- 4 episodes per year of complete voice
cult, based on temper tantrums and loss. The patient had no evidence of
episodes of yelling and screaming with other speech or language problems, but
her younger brother. Her second-grade they reported this concern to patientDs
schoolwork was average and she did mother, the school speech-language
not pose behavior problems at school. pathologist, and the school nurse. The
Her parents divorced 2 years ago, child did not qualify for school services,
and the patient lived primarily with her but the school nurse asked the family
mother, but spent extended summer to seek a medical evaluation and treat-
vacations at her father s home. Patient D, ment for the voice problem. The otolar-
her mother, and her brother were receiv- yngologist examined her larynx with a
ing family counseling sessions weekly mirror and observed soft-appearing,
to resolve problems with discipline and moderate-sized, bilateral vocal fold
communication at home. The patient nodules. The remainder of the head
reported that her favorite activities were and neck examination was negative,
watching videos, playing outside with including normal appearing ears, nose,
neighbor friends, riding her bicycle, and mouth, pharynx, and neck.
Scouts. She was also active in a summer The patients mother reported that
softball league, spring gymnastics team, she believed her daughters voice had
and a winter hockey league. worsened gradually over about a 3-year
Patient D had a normal, healthy period, beginning during the time when
medical history, with very infrequent she and her ex-husband were separat-
middle ear infections during the first ing. Patient D and her younger brother
4years of life. She had no history of were upset about the transition and
allergies, postnasal drip, chronic colds, the mother reported a general increase
sinus infections, or other upper respi- in vocal arguments, crying, and tan-
ratory infections. She had not had any trum behavior by both children during
injury to the throat, nose, or neck, and that time. However, her mother also
had no evidence of hearing loss. She had noted that in 2 consecutive summers,
Primary and Secondary Muscle Tension Dysphonia 67

her daughters voice had improved fol- 2. Acoustic analysis.Patient Ds re-

lowing vacations with her father. Her corded mean fundamental frequency
mother believed this improvement was was 237 Hz during sustained vowel
attributable to the fact that the patients /i/, following the elicitation cue,
father is a psychologist who manages the start counting and when you get to
childrens behavior differently, such that 3, hold out the ee sound. Follow-
fewer tantrums or vocally abusive epi- ing cues for pitch glide on /i/ from
sodes occur. In fact, the principal goal of lowest to highest sounds, patient D
the ongoing family counseling sessions produced a range from 157 to 314 Hz.
was to learn different behavior man- Perturbation values were also ob-
agement styles, to create a calmer, more tained during sustained vowel /i/
communicative home environment. using the CSL software program
(KayPENTAX), with results for jitter
measuring 1.68% (normal = <1.0%);
Evaluation Procedures shimmer 0.56 dB (normal = <0.35 dB);
and signal-to-noise ratio of 14 dB
Patient D received a standard battery of (normal = 20 dB or greater). All of
vocal function testing in the voice labo- these measures represented sub-
ratory. These assessments included: normal performance based on the
expected acoustic measures for a
1. Visual-perceptual. A stroboscopic ex- 7-year-old girl. Patient D produced
amination was conducted using a a maximum loudness of 87 dB SPL
rigid 70-degree endoscope with- following the cue to yell Hey! as
out need for topical anesthesia. loudly as possible. Her minimum
The recording revealed moderate- loudness was 62 dB SPL on a sus-
sized, bilateral vocal fold nodules tained /a/ produced as quietly
at the anterior two-thirds junction as possible. Her habitual loud-
of the vocal folds with no evidence ness was 70 dB SPL, measured dur-
of edema or hemorrhage. Mucus ing conversational speech. All of
stranding between the vocal nod- patient Ds loudness productions
ules was persistent. The nodules were within typical expectations.
appeared to vibrate with the vocal 3. Aerodynamic measures. Airflow mea-
folds, although mucosal wave and sures were taken during sustained
amplitude were reduced at the vowel productions; intraoral pres-
midline bilaterally, presumably as a sure measures were estimated from
result of stiffness at the lesion sites. repeated productions of /pi/. Mean
Phase symmetry and periodicity airflow rate was 270 cc/s, which
were always irregular. Supraglottic exceeds the normal range of approx-
hyperfunction was evident through- imately 120 to 200 cc/s, suggesting
out sustained vowel productions air leak through the laryngeal valv-
because of a mild, but consistent, ing mechanism. Intraoral pressure
medial compression and bulging was measured at 8.3 cm H2O, which
of the ventricular folds. There was is also greater than the expected
no evidence of tissue irregularity or norm of approximately 5cm H2O.
irritation anywhere else on the vocal 4. Audio-perceptual. Patient Ds voice
folds or in the posterior larynx. quality was judged perceptually by
68 Voice Therapy: Clinical Case Studies

the voice pathologist during infor- ing with excessive tension or loudness.
mal conversation and sentence pro- This shared approach to detecting and
ductions, using the CAPE-V proto- modifying faulty voice patterns was
col and form developed by Special designed to increase mutual aware-
Interest Division 3 of the American ness and responsibility for establishing
Speech-Language-Hearing Associa- healthy vocal communication patterns.
tion. On the day of the evaluation, Because some arguments occurred
patient D exhibited consistently between patient D and her mother, the
moderate vocal roughness (55 mm) family counselor also supported patient
and strain (42 mm) with a mild D and her mother in this aspect of voice
amount of intermittent breathiness therapy. Counseling emphasized the
(23 mm) and intermittent aphonia need to resolve conflicts at home with-
of 1-syllable to 2-syllable duration out screaming, arguing, and yelling,
occurring about once each sentence. thereby avoiding further vocal damage.
Her habitual loudness level was In working together on this challenge,
appropriate, and she did not exhibit patient D and her mother strengthened
any signs of hard glottal attack dur- their mutual support for voice goals.
ing casual conversation. She also The treatment program involved both
sang Happy Birthday to You to voice conservation strategies, to maxi-
assess pitch-changing ability in song mize vocal fold tissue health, and active
and demonstrated 5pitch breaks. therapy exercises, to restore and stabi-
lize improved voice quality. Five spe-
cific treatment goals were established
Description and Rationale for the patient, focusing on patient and
for Therapy Approach family education, eliminating vocal
abuse, increasing hydration, achieving
The patients history, medical diagno- healthy voice through active vocal exer-
sis of bilateral nodules, and evaluative cises, and increasing patient Ds vocal
findings all corroborated the clinical self-awareness and personal responsi-
impression that patient D has developed bility for voice quality.
a hyperfunctional voice disorder due to
her frequent phonotraumatic behaviors, Goal 1
aggravated by chronic, ongoing stress in
the family setting. Patient D, her mother, and her brother
Accordingly, the initial treatment learned about the origin and recovery
need was to eliminate the vocal behav- patterns for vocal nodules, including
iors that contribute to vocal nodules the effects of vocally abusive behaviors
and modify the communicative envi- on vocal fold structure and function
ronment that produced stressful or and the risks of future tissue deteriora-
aggressive communications. To address tion with prolonged vocally aggressive
these concerns comprehensively, both behaviors.
patient D and her mother agreed to work
together to identify, then reduce or Rationale. Teaching children and fami-
eliminate aggressive vocal behaviors in lies about the pathologic impact of
each other that injure vocal fold tissue, problem vocal behaviors is essential
such as crying, screaming, and speak- to ensure compliance with a conserva-
Primary and Secondary Muscle Tension Dysphonia 69

tion component of voice therapy. When agreed to be silent for a 10-minute

children develop a proprietary sense of recovery period, spent in a pleasant,
responsibility for the voice problem, it relaxed, quiet activity, such as reading
can motivate the child to control behav- or taking a walk. Each week, patient D
iors that influence vocal health. Visual and the voice pathologist predetermined
aids and other demonstrations help a target maximum of vocally abusive
convey this information to children. For episodes, for example, no more than
patient D, viewing the videostroboscopy twice per day. If, at the end of the week,
recordings of her larynx was particu- patient D stayed at or below the weekly
larly illustrative. Another example of target, she earned a specific reward, such
vocal fold injury was simulated by hav- as a video rental or a trip to the park.
ing the patient and her brother rub their
hands together for a 3-minute period so Rationale. Home programming allows
that they could feel how tired and hot the greatest potential for treatment suc-
their hands were after clapping hard cess and generalization, especially when
together for that time. Pictures of just the goal is to reduce vocally aggressive
a few other benign structural patholo- behaviors. In my experience, without
gies (eg, hemorrhagic nodules, polyps, home compliance, the prognosis for
and cysts) sparked her further interest improvement with therapy is limited.
in vocal fold tissue health. From session Moreover, home programming is fam-
to session, the voice pathologist asked ily therapy; if other family members
patient D to answer a game-show-style exhibit vocally aggressive behaviors (as
question we called Treatment Knowl- in the case of patient Ds mother), these
edge Check, such as, For 5 stickers, members must also participate in treat-
patient D, please describe how drink- ment, if possible.
ing more water might help your vocal To clarify the incidence and sever-
folds get better! or Why is it helpful to ity of problem behaviors, it is helpful
rest your voice after speaking loudly? to implement a token charting system,
Patient D appeared to enjoy displaying to reinforce self-awareness and moti-
her new knowledge, as the voice pathol- vate patients to change. When vocally
ogist reinforced the cause-and-effect aggressive behaviors occur, patients
relationship between voice behaviors can experience success and control by
and the rehabilitation plan. applying a defined alternative response,
such as a 10-minute silent recovery time,
Goal 2 immediately afterward. This recovery
time is never intended to be punitive;
Patient D and her mother participated rather, it provides a specific reminder
in a home program designed to iden- that tissue damage requires a recovery
tify and reduce their instances of vocal period. For patient D, it was especially
abuse and to provide recovery time important that her mother participate,
for each occurrence. Patient D and her so that both were able to distinguish
mother monitored and recorded every their voice program responsibilities
vocally abusive production on a chart from their other work, school obliga-
at home, including screaming, yelling, tions, household chores, and disciplin-
excessive crying, and tantrum behav- ary events. As patient D developed
ior. Each time, patient D (or her mother) increasing compliance, she successfully
70 Voice Therapy: Clinical Case Studies

reduced vocal abuse incidents in 5 out roaring with a big X over the mouth),
of 7 regular treatment sessions. and wrote large signs to use instead of
yelling (eg, LEAVE ME ALONE). Her
Goal 3 journal contained pictures she drew
or cut from magazines to describe her
Patient D eliminated all colas and caf- feelings whenever she was sad, angry,
feinated beverages from her diet and or upset. Initially, patient D received a
drank a minimum of five 240-mL (8 fl small reward (eg, a quarter or sticker)
oz) glasses of water per day. every time she used these graphic cues
instead of a vocally aggressive response.
Rationale. Evidence of mucus strand- Quickly, these rewards ceased as she
ing and reports of patient Ds typical learned to describe her feelings in con-
caffeine consumption raise questions versational exchanges with her mother.
about sufficient vocal fold hydration. Moreover, patient Ds mother reported
By increasing water intake and avoiding that as the frequency of aggressive vocal
caffeine, she increased the possibility of behavior lessened, the overall level of
adequate hydration, without modifying household calmness, behavioral coop-
her age-appropriate milk consumption. eration, and positive communication
Because caffeine also can be associated increased.
with hyperactive behavior and laryn-
geal reflux, minimizing or eliminating Goal 5
caffeine is a useful adjunct to most voice
care routines for children. Patient D and her mother both attended
voice therapy sessions, where they
Goal 4 learned to perform a series of direct
vocal exercises, including a warm-up
In conjunction with her family therapy, routine and Stemples vocal function
patient D kept a daily journal of pic- exercises. They received a 10-minute
tures, drawings, or written material CD recording of home practice cues to
describing her voice use that day, based allow them to practice therapy tasks
on feelings and events that created twice daily. The warm-up consisted of
opportunities for positive or negative vocal play cues for relaxed breathing,
voice use. gentle sighs and pitch glides, humming
nursery rhymes and other simple tunes,
Rationale. The family counselor began and short conversational phrases. The
this journal project earlier with the vocal function exercise segment con-
patient and her brother to encourage tained pitch cues for sustained resonant
greater self-awareness of their feel- tones, according to that protocol.
ings. With the counselors permission, a
voice use component was added for the Rationale. Besides learning about voice
patient to allow her to relate everyday care and addressing the psychosocial
stress responses to her vocally abusive contributors to the patients voice prob-
behaviors. She made schematic draw- lems, it is essential for patients and their
ings of the nodules in her throat, drew families to learn to produce healthy
pictures for her room to remind her voice independently, outside the treat-
not to yell (such as a drawing of a lion ment room. Audio-recorded exercises
Primary and Secondary Muscle Tension Dysphonia 71

conducted at home are a useful adjunct pitch increased to 547 Hz. All of these
to therapy time, because they create post-test acoustic measures were within
opportunities for consistent and accu- expected norms for her age. Habitual
rate vocal practice. For patient D, the pitch and loudness tasks did not change.
home exercises provided a fun and
relaxing opportunity for her and her Aerodynamic Measures
mother to talk, sing, and play quietly
using audio cues to progress through Mean airflow rate decreased to a final
the warm-up and vocal function exer- mean rate of 150 cc/s, which was within
cise routine. expected normal limits. Mean intraoral
pressure was measured at 5.7 cm H2O,
which is also decreased from initial
Results of Therapy measures and within expected limits.

Patient D received 7 sessions of voice Audio-Perceptual

therapy over the course of 3 months and
attended 2 follow-up sessions at 1 and Patient Ds voice quality improved
3months following treatment. At the markedly as judged perceptually by
final session (approximately 6 months the patient, her mother, and the voice
from initial diagnosis), we collected pathologist. She eliminated pitch breaks
post-treatment data. and intermittent aphonia entirely dur-
ing a repeat perceptual assessment using
Visual-Perceptual the CAPE-V. Both the patient and thera-
pist rated conversational voice produc-
Patient Ds vocal fold nodules resolved tions as normal overall with only mild,
as judged by the patient and her voice intermittent evidence of roughness
pathologist from visual records of her (11 mm), and no evidence of breathiness,
pretreatment and post-treatment strobo- or strain. She sang Happy Birthday to
scopic recordings. The otolaryngologist You again without any pitch breaks.
confirmed this judgment during a fol- The positive outcome of this treat-
low-up indirect mirror examination that ment plan is attributable to the patient
revealed no evidence of any midline and family compliance with the home
vocal fold lesion or supraglottic hyper- programming effort. The concurrent
function. Under stroboscopic light, family counseling process undoubtedly
vibratory movement exhibited normal assisted with creative problem-solving
phase closure, with normal mucosal strategies to mitigate angry or emotional
wave and amplitude. Phase symmetry vocal outbursts. During the course of
and periodicity were still irregular. voice treatment, patient D developed
a sense of self-awareness and responsi-
Acoustic Analysis bility toward her voice problem, as evi-
denced by her willingness to report her
Using the same sustained vowel /i/ pro- weekly progress and to display some
tocol measured at pretesting, patientD of her creative journal entries when she
reduced jitter to 0.89% and shimmer to came to therapy. The behavioral modi-
0.31 dB. She also increased signal-to- fication program of effort and reward
noise ratio to 25 dB SPL. Her maximum did seem to reinforce her control over
72 Voice Therapy: Clinical Case Studies

vocally abusive behaviors. Certainly, loudness, inability to project his voice,

not all children can eliminate vocally and voice loss after attempts to raise the
aggressive behaviors. Fortunately, pa- voice (such as calling across the football
tient D enjoyed the positive attention field). GG reported that he had to repeat
and support she received from her himself frequently to be understood,
mother and brother for her compliance and he agreed that he had problems
with vocal exercises and voice conser- with losing his voice.
vation strategies. Thus, her decisions
about good voice use were motivated
Medical History
by her own sense of self-determination
and satisfaction, and the entire house- GG underwent adenotonsillectomy in
hold benefitted from improved com- 2010. He had asthma and seasonal aller-
munication patterns. Both she and her gies but otherwise was a healthy boy. He
mother were pleased with the outcome. used an Asmanex inhaler and Nasonex
for allergy management. He was a full-
In the following case of a 10-year-old term infant, and there were no reported
with MTD secondary to a vocal fold hospitalizations. He had seen a general-
cyst, Carissa Portone-Maira uses vocal practice otolaryngologist, who diag-
hygiene counseling, vocal function nosed him with vocal fold nodules.
exercises, and resonant voice therapy to
improve vocal function. Social History

GG lived with his mother, father, and

younger sister (age 4). He attended a
Case Study 8 public elementary school and was audi-
tioning for roles in commercials and
local community theatre productions.
Carissa Portone-Maira There was no tobacco exposure in the
home. He had no history of speech
Eclectic Voice Therapy for therapy in early childhood, and he was
Secondary MTD in a 10-Year-Old not receiving speech therapy services
With a Vocal Fold Cyst at school.

Case History
Voice Evaluation
History of the Problem
Audio-Perceptual Assessment
GG presented as a pleasant 10-year-old
boy who was a good fourth-grade stu- The CAPE-V,90 a 100-mm visual ana-
dent and had recently become interested log scale, was utilized to assess overall
in acting. His mother reported that over severity of voice quality and to quantify
the past 3 years, GG had developed pro- aberrant perceptual features identified
gressively worsening vocal difficulties. in the voice. The overall severity score
The specific complaints were a rough was 72/100, indicating a moderate-
and breathy voice, decreased vocal stam- severe dysphonia. The aberrant percep-
ina, decreased pitch flexibility, decreased tual features identified in the voice were
Primary and Secondary Muscle Tension Dysphonia 73

moderate breathiness, moderate rough- Aerodynamic Measures. Maximum

ness, and severe strain. GG frequently phonation times were as follows: /a/ =
spoke with excessive hard glottal 6.8 seconds, /s/ = 12.6 seconds, /z/ =
attacks, but overall vocal intensity was 7.5 seconds. The s/z ratio was 1.68,
reduced. There was a low laryngeal tone indicative of glottal incompetence.
focus. Locus of respiration was primar- Instrumental aerodynamic assessment
ily thoracic. Vocal pitch and prosody was conducted with the KayPENTAX
were normal for age and gender. Articu- Phonatory Aerodynamic System. Mean
lation and language skills were within flow rate on sustained vowels was 0.17
the normal range for age and gender. L/s, on the highest end of the normal
range. Mean peak air pressure on the
Instrumental Assessment voicing efficiency task (an estimate of
subglottic pressure) was 11.45 cm H2O,
Laryngeal Imaging.Multidisciplinary on the high end of the normal range.
voice evaluation was conducted. Laryn- Phonation threshold pressure was ele-
geal videostroboscopy was performed vated at 6.93 cm H2O, consistent with
transorally with a 70-degree endo- the perceptual assessment of hard glot-
scope. Arytenoid motion was brisk and tal attacks.
symmetric. There was a right-sided
subepithelial lesion that led to moder- Acoustic Measures.Laryngeal func-
ate reduction in mucosal wave. There tion studies were completed utilizing
was also a contralateral softer reactive the KayPENTAX Computerized Speech
lesion that did not impact mucosal Lab. A headset microphone was placed
wave. The larger right vocal fold lesion at a 45-degree angle at 2 cm from the
fit into the left lesion with a cup-and- mouth for data acquisition. Speak-
saucer appearance. Glottic closure was ing fundamental frequency (SF0) was
incomplete with an hourglass superior within the normal range at 260.57 Hz
configuration. This was particularly with a standard deviation of 28.41 Hz.
prominent in higher pitches. There was Physiological pitch range was 204 to
normal amplitude of vibration on the 655Hz, with a midrange gap from 350
left, but reduced amplitude on the right to 500 Hz. When asked to produce a
side. This led to consistent phase asym- pitch glide with reduced loudness, high-
metry. Vibration was frequently aperi- est F0 was limited to 400 Hz. Fundamen-
odic, but periodic cycles were observed. tal frequency on sustained vowels was
There were no vascular abnormalities, 249.845 Hz. Vocal instability was evi-
and no other lesions noted in his phar- denced by elevated pitch perturbation
ynx or the remainder of his larynx. The (jitter) of 3.593% and intensity perturba-
laryngologists diagnosis was right- tion (shimmer) of 10.352%. An elevated
sided subepithelial cyst with a reactive noise-to-harmonic ratio (0.321%) was
lesion on the contralateral (left) vocal consistent with the perceptual assess-
fold. The laryngologist referred GG for ment of roughness.
voice therapy but stated that if there
were ongoing limitations after com- Patient Self-Assessment
pleting voice therapy, he would likely
require surgical excision of the right- Pediatric Voice Handicap Index score
sided cyst. was 60/120. When asked to rate his
74 Voice Therapy: Clinical Case Studies

voice on a scale from 1 to 10 (10 = best), tion. During the evaluation, there was
GG rated his voice as a 3/10. At its best, a notable improvement in GGs percep-
he would rate it at 7.5. At worst, he tual voice assessment as well as normal-
would rate it a 1. On a self-rating scale ization of perturbation measures with
of 1 to 7 for talkativeness and loud- cues for forward-focused resonance and
ness (1 = quiet and introspective; 7 = increased transglottal airflow. GGs age
loud and talkative), GG rated his innate and stimulability to improvement with
talkativeness as 5/7 and loudness forward focus would support use of the
as 5/7. Adventures in Voice program94 (for more
information on Adventures in Voice, see
Hersans Treating a Child with Second-
Voice Therapy ary MTD using concepts from Adven-
tures in Voice, Chapter 3). However,
Therapy was planned for 6 weekly GGs high maturity level did not neces-
sessions. The primary goal of therapy sitate full immersion into Adventures
was to improve the efficiency of vocal in Voice, which creates a make-believe
mechanics sufficient to enable GG to adventure for the voice patient, com-
participate fully in his normal activi- plete with passport to travel to lands
ties, including sports and acting, with- where various skills are mastered. Still,
out voice loss. A secondary goal was some specific therapy tasks from the
to avoid the need for surgical remedia- program were used advantageously.
tion. GG agreed at the time of the ini- The first treatment session intro-
tial evaluation to refrain from yelling duced coordination of respiration with
or raising his voice until he was taught phonation specifically targeting reduc-
methods for healthy vocal projection in tion of hard glottal attacks. Forward-
voice therapy. One of his parents was focused resonance was introduced as
present for the entire evaluation and for well. Both concepts were incorporated
all therapy sessions to promote carry- into a semi-occluded vocal tract exer-
over of therapy techniques to the home cise: GG phonated into a drinking straw
environment. placed within a cup of water. Using this
Therapy targeted vocal hygiene exercise, he was able to avoid a hard glot-
education, forward-focused resonance tal attack (sudden splash of water in the
to improve the efficiency of vocal tract face). He increased his awareness of for-
posturing, and coordination of abdom- ward focus versus vocal tract straining
inal respiration with phonation to by attending to sensations. During the
improve vocal quality and efficiency session, he was able to identify effortful
and reduce hard glottal attacks. Reso- versus easy phonation in his mothers
nant voice therapy91 and Vocal Function voice as well as the clinicians voice. He
Exercises92 were the primary treatment was able to demonstrate introductory
paradigms used in order to balance the awareness of the same in his own voice
3 subsystems of voice (respiration, pho- by the end of the session. Vocal hygiene
nation, and resonance). Semi-occluded recommendations from the evaluation
vocal tract exercises93 were incorporated session were reviewed, and he was able
into Vocal Function Exercises to reduce to independently recall recommenda-
phonatory impact during practice and tions for hydration and elimination of
facilitate optimal vocal tract configura- coughing/throat clearing.
Primary and Secondary Muscle Tension Dysphonia 75

At the second voice therapy ses- of Vocal Function Exercises in the Treat-
sion, GG reported daily homework ment of an Adult With Secondary MTD,
practice between visits. He expressed later in this chapter), but the sound used
low confidence in his ability to identify for all tasks was phonation into a straw,
target versus nontarget voice during his as GG was already familiar with straw
practice, but his mother stated that she phonation.
thought his voice already sounded bet- Unfortunately, at this point, GG did
ter. GG described tension in his upper not return for over 1 month. When he
back, a new complaint. Because tension returned for his third therapy session, he
in the upper back could refer and create reported inconsistent homework prac-
tension within the vocal tract, therapy tice. He cited after-school activities and
began with stretches for the back of overload of academic homework as the
the neck/upper back to promote more causes for his lack of practice. Therefore,
relaxed postures of the laryngeal mech- therapy began with identifying a moti-
anism. Attention was then turned to vator to practice, and we agreed that he
coordination of abdominal respiration would receive a prize of chocolate if he
with phonation. Elimination of high practiced every day before his next ses-
chest breathing was easily established sion. Stretches for the back of the neck/
simply by cueing easy inhalation and upper back were reviewed. Awareness
shifting the focus to exhalation rather and production of forward focus with-
than inspiration. Ideal transglottal air out vocal tract straining were targeted at
flow (flow phonation)95 was established the sentence level during a game of 20
on sustained and pulsed /S/ and /m/. Questions. Chanting and negative prac-
The nasal sound /m/ was then gen- tice were incorporated on a limited basis
eralized to m-hm for use as a self- as needed to achieve target voice and
cueing mechanism (carrier phrase) to to ensure a contrast between habitual
achieve forward focus in conversation. voice versus forward focus. GG noted
The use of self-cueing on m-hm was a sensation of reduced laryngeal effort
incorporated into a game of Memory using the techniques. Vocal Function
with m-initial words. Negative prac- Exercises (modified with straw phona-
tice was contrasted with the target to tion) were reviewed, and considerable
increase awareness. GG noted a sensa- time and attention were paid to ensure
tion of reduced laryngeal effort using there was no vocal tract straining dur-
the techniques as compared to negative ing the exercises.
practice, and he expressed increased The fourth treatment session was
confidence in his awareness of target 1week later. GG reported consistent
versus nontarget vocal quality. To pro- daily homework practice and was re-
mote ease of home practice, GG was warded with a chocolate bar as prom-
advanced from phonation into a straw ised. Awareness and production of for-
within a cup of water to phonation into ward focus without vocal tract straining
a straw without water. Modified Vocal were targeted at the paragraph level
Function Exercises (VFEs) were intro- during story reading. Semi-occluded
duced. The VFE tasks were performed vocal tract techniques between para-
as described by Stemple (for more infor- graphs were helpful as a facilitating
mation on Vocal Function Exercises, see technique. Forward focus was also tar-
Case Study 13 by Joseph Stemple, Use geted at an increased loudness level.
76 Voice Therapy: Clinical Case Studies

Phonation into a very narrow straw in modified Vocal Function Exercises,

(coffee stirrer) was helpful to internal- on carrier phrase (m-hm), and in sen-
ize the amount of breath needed to tences. GG was successful in imple-
phonate loudly without strain during a menting target voice independently at
game of Mother, May I? in the clinic these levels but still questioned his own
hallway. When acting as the mother, awareness. Awareness and production
GG would reply to requests with either were targeted in a monologue being
m-hm, Yes you may or m-mm, No prepared for audition, at conversational
you may not. Asking GG to base his and stage/projected loudness levels.
answer of yes or no on whether or not After each sentence, GG was asked for a
the opposing player utilized forward- self-assessment of forward versus laryn-
focused resonance simultaneously tar- geal tone focus, and his confidence in
geted awareness of forward focus. The his awareness improved. Vocal Function
clinician intermittently demonstrated Exercises were advanced to the stan-
laryngeal tone focus as a foil to ensure dard protocol to help generalize therapy
GGs awareness. When acting as a skills to new sounds. Standard nasal /i/
player rather than the mother, GG was used for the warm-up sound and
had the option of producing target voice kazoo buzz for the stretch, contraction,
with increased loudness to make his and power phase. Care was taken to
request or to engage in negative prac- avoid straining with the new sounds.
tice followed by self-correction. Phonat- GG agreed to follow through with prac-
ing into the coffee stirrer intermittently ticing Vocal Function Exercises twice
through the game promoted increased daily. He expressed understanding that
success in performance. Modified Vocal he needed to begin paying attention to
Function Exercises were reviewed and speaking with forward focus, and he
were continued with phonation into a elected to begin by using forward focus
straw as in the previous session. GG when speaking with his parents. Note
was encouraged to produce one produc- that both parents had attended suf-
tion of each VFE exercise into the coffee ficient therapy sessions to be aware of
stirrer and one into a standard straw. forward versus laryngeal tone focus in
We agreed that chocolate reinforcement GGs speech.
would again be provided if homework At the sixth therapy session, 2weeks
was completed each day prior to the later, GG reported consistent twice daily
next session. homework practice; however, he was
GG again did not return for 1 month not sure if he was using target voice
between sessions. When he arrived for when attempting to do so. After ensur-
his fifth therapy session, he reported ing Vocal Function Exercises were being
inconsistent homework practice. Voice performed accurately, the remainder of
recording was compared to the ini- the session was spent targeting aware-
tial pretreatment recording. Hearing ness of forward focus without vocal
the improvement in his voice led to tract straining. GG was consistently able
immediate stated motivation to return to produce target voice, despite his res-
to more consistent practice. Awareness ervations. Given the repeated failure to
and production of forward focus with- maintain awareness between treatment
out vocal tract straining were reviewed sessions, a new approach was needed.
Primary and Secondary Muscle Tension Dysphonia 77

Awareness was targeted via recording closure with an hourglass superior con-
and playing back the voice in a quiz figuration, reduction in mucosal wave
format. Grant would mark each pro- on the right, and intermittent phase
duction as +, , or , while the asymmetry. Vibration was consistently
clinician did the same. We then com- periodic, however.
pared scores, and GG was in agreement
with the clinician over 80% of the time. Acoustic and Aerodynamic Measures.
His confidence improved as he saw the Instrumental aerodynamic measures
answers on his quiz being graded as were not repeated. Maximum phona-
correct consistently. His real-time self- tion time on /a/ was 10.4 seconds, a
assessment was then targeted by first substantial increase from the initial
judging the clinicians voice in real time, assessment. Brief acoustic assessment
then his own voice in a slow counting demonstrated slight increase in mean
task, then a sentence-level reading task, speaking F0 to 275 Hz. Pitch range was
still using the quiz format. Awareness 200 to 650 Hz at a moderate loudness
remained accurate with greater than level, and the midrange gap was elimi-
80% success. The session improved nated. In soft phonation, pitch range
GGs confidence in identification and was 210 to 507 Hz. Perturbation mea-
production of target voice during play- sures (jitter and shimmer) reduced to
back and in real time to such a degree 1.98% and 5.54%, respectively. Noise-
that only one final discharge session to-harmonic ratio improved to 0.134%.
was planned for the next week.
Patient Self-Assessment
Therapy Outcomes GG reported consistent homework prac-
tice and confidence in his awareness and
Audio-Perceptual use of target voice. He no longer had
difficulties with losing his voice in any
At the seventh treatment visit, GG pre- situation. His hoarseness was largely
sented with a mild dysphonia character- resolved. He was able to project his voice
ized by mild breathiness, intermittent loudly without strain.
mild roughness, and occasional laryn-
geal tone focus. His overall score on the
CAPE-V was 12/100. Follow-Up Plan

Instrumental Assessment GG was encouraged to continue once-

daily practice of Vocal Function Exer-
Laryngeal Imaging. Follow-up video- cises and additional semi-occluded
stroboscopy demonstrated resolution vocal tract exercises with straw phona-
of the left vocal fold reaction change tion as a warm-up prior to auditions and
and slight reduction in the right vocal rehearsals. He expressed understanding
fold lesion, attributed to reduction of that he would need to maintain atten-
superimposed vocal fold edema. The tion to speaking with forward focus
subepithelial cyst remained present and consistently for several weeks to estab-
continued to result in incomplete glottic lish his new voice as a habit. His mother
78 Voice Therapy: Clinical Case Studies

telephoned 2 months later as requested

At times, children manipulate their
to report that GG was maintaining his
environments with their voices, some-
new voice and had not had return of his
times leading to vocal pathology. In the
previous difficulties.
following case study, Moya Andrews
explores the psychosocial aspects of a
childs behavior related to the develop-
Summary and
ment of a voice disorder and introduces
Concluding Remarks
voice-facilitating techniques including
storytelling, role-playing, and others.
GG presented with a subepithelial cyst
not likely to be remediated by voice
therapy. However, his laryngologist
recommended voice therapy as an ini- Case Study 9
tial conservative approach with the
understanding that he would likely
need surgery to fully resolve his com- Moya Andrews
plaints. GG was able to improve his
Using a Psychosocial Management
vocal efficiency using resonant voicing
Approach in the Therapy of a
techniques and Vocal Function Exer-
Child With Midmembranous
cises incorporating flow phonation and
Lesions and Secondary MTD
semi-occluded vocal tract postures. The
behavioral modifications, including
changes in vocal technique and vocal Patient History
hygiene, resulted in reduction in the
overall edema overlying his vocal fold Patient C, aged 4 years and 6 months,
cyst and elimination of the contralateral was referred to the otolaryngologist by
reaction change to such a degree that her teacher at a Montessori preschool
surgery was not warranted. The voice because of hoarseness, loud talking, and
remained slightly impaired, but func- frequent attention-getting behaviors in
tional for GGs needs, including sports class. The otolaryngologist imaged
participation and acting voice demands. the child and reported bilateral mid-
On two occasions during his course membranous lesions with secondary
of therapy, GG had a 1-month lapse MTD. She was brought to the speech
between treatment sessions, during and hearing clinic by her mother, who
which time he did not practice consis- had taken the patient from school in
tently. Each lapse resulted in a setback time for their 11 AM appointment. The
from the previous session, but not to mother apologized for the fact that the
baseline status. Motivation to practice child insisted she needed to bring a
was a continuing challenge. Extrinsic large, fast-food milkshake into the
motivation with a prize was effective in diagnostic room with her. She always
the short term but not in the long term. has to have a shake, said the mother
Lasting motivation was achieved with with a shrug, while the little girl smiled
demonstration of treatment effect and complacently and toyed with her straw.
building confidence in the accuracy of When the speech pathologist suggested
self-assessment. that patient C should sit in the waiting
Primary and Secondary Muscle Tension Dysphonia 79

room until she had finished her shake, The mother characterized her daugh-
the mother looked distressed and said, ters behavior in the following way: She
Oh no, she wouldnt like that at all. is quite a handful at times, but shes
The patients smile widened, she tossed intelligent and has had more opportuni-
her head, did a little dance around the ties than other children her age because
room, and spilled some of the shake on we lived abroad. Also, she has had to be
the floor. Oh dear, said the mother assertive or her brothers ignore her. She
helplessly, shes just so full of energy. is a live wire and can be difficult, but she
During the interview, the mother is so cute and talented that we can never
reported that patient C was the young- stay angry with her for long. It appeared
est of 3 children. Her older brothers, that the psychodynamics in the patients
aged 14 and 16 years, attended the local family merited further attention.
high school. The mother, a homemaker, Further questions resulted in the
said that the patient had been born in information that when the patients
Germany during the time that her hus- vocal behavior was loud and forceful,
band had been in the US military ser- she usually got what she wanted at
vice. The father was currently employed home. The patients teacher reported
at a local hospital. My husband always that the childs interpersonal strategies
wanted a daughter, so I suppose we did not help her succeed in her school
spoil her, said her mother. environment, however. Rather, she
Patient C presented with a mild- needed to develop more effective inter-
moderate dysphonia characterized by personal and vocal strategies to estab-
roughness, breathiness, and the use of lish satisfying relationships with her
intermittent glottal fry at the end of breath peers and teachers. Therefore, the ther-
groups. She was noted to demonstrate apy program was designed to include
many of the classic behaviors associated work on relevant psychosocial issues,
with vocal abuse: inefficient respiratory as well as modification of abusive
pattern; tension in the shoulder, neck, vocal behaviors.
and jaw; phonation breaks; hard glottal
attacks; loud conversational level; rough
and breathy vocal quality; laryngeal res- General Awareness Phase
onance; limited vocal variety; and fre-
quent throat clearing. She could prolong Voice therapy programs for children
a vowel for only 3 seconds and exhibited usually begin with a general aware-
hearing sensitivity within normal limits ness phase. During this phase, the
bilaterally. The results of an examina- child is oriented to the general area of
tion of her peripheral speech mechanism voice and taught basic concepts and the
were unremarkable. The school psychol- background information that are nec-
ogists report noted above-average intel- essary before the clinician targets spe-
ligence, frequent temper tantrums and cific symptoms. For example, patient C
episodes of crying, and use of manipu- needed a general awareness of respira-
lative interpersonal strategies. The child tion because it was an area of her behav-
was involved in after-school programs ior that needed to be modified. The cli-
such as ballet, swimming, an art class, nician used a science project format to
and a neighborhood playgroup. teach the girl general information about
80 Voice Therapy: Clinical Case Studies

breathing. Activities were designed to her puzzle and started to watch

achieve 2 sets of goals. Jennifer, who was having trouble
with hers. Mary picked up 2 of the
1. I can talk about breathing. pieces of Jennifers puzzle, shrieked
n I can describe some different ways loudly, and ran across the room.
people and animals breathe. Jennifer ran after Mary and tried to
n I can describe how air is used (to grab the pieces from her, but Mary
sustain life, to make sound, to quickly threw them under a storage
pant, and so forth). cabinet. It took Jennifer a long time
n I can label the body parts used to crawl under the low cabinet and
during breathing (such as lungs find them.
and windpipe).
n I can tell my teacher how to breathe Answer these questions:
in without tensing her shoulders
n How did Mary feel?
and neck.
n How did Jennifer feel?
n I can time the number of seconds
n Why do you think Mary threw
it takes for my teacher to breathe
the pieces away?
out air.
n What would you suggest Mary
2. I can talk about what happened in
should do next?
stories my teacher reads to me.
n Does Mary like Jennifer? Explain

Another general awareness goal why or why not?

for patient C was for her to develop an n What would you do if you were

understanding of psychosocial factors the teacher?

relevant to vocal communication. The
clinician used a story format to teach 2. Ann told Cathy that she was mean
the patient some general principles of and no one wanted to play with
communication. The following activi- her anymore. Cathy felt very bad,
ties were designed to achieve this: but she didnt want Ann to know,
so she knocked over the glue and
n I can guess what might happen when
then screamed loudly that Ann had
storybook characters act in certain knocked the glue over on purpose
ways (utilization of cause and effect). and ruined Cathys work. Cathy
n I can make up different endings to
screamed so much she got red in the
some stories (analysis of choices). face, and the teacher had to tell her to
n I can explain why some things go
have a drink of water to calm down.
wrong for some children in our sto- The teacher also told Ann to go and
ries (identification of unproductive work on the other side of the room.
strategies). Cathy felt she had paid Ann back.
n I can suggest some other ways the
characters may handle situations Answer these questions:
(problem solving).
n What do you think the other chil-
Sample Stories dren in the class were thinking
during the uproar?
1. Jennifer and Mary were both doing n Why do you think Ann said Cathy
puzzles at preschool. Mary finished was mean?
Primary and Secondary Muscle Tension Dysphonia 81

n How do you think Cathy could Specific Awareness Phase

have solved the problem dif-
ferently? During the specific awareness phase
n What would Cathy wish Ann had of therapy, the child is taught to focus
said instead? on specific behaviors, discriminate be-
tween behaviors, and describe pertinent
3. During recess, Emily was playing behavioral characteristics. This creates
by herself. A new girl named Lindy a perceptual and linguistic framework
stood nearby. Emily asked Lindy if that prepares the child to modify criti-
she wanted to play with her in the cal behaviors during the subsequent
sandbox. Lindy was pleased when production phase of therapy. Four goals
Emily quietly asked her about her for patient C included:
family and where she lived. Lindy
thought Emily was a really friendly n Identification of abusive vocal behav-
girl. iors exhibited by others
n Description of the salient characteris-
Answer these questions: tics of vocal behaviors
n Why did Lindy think Emily was n Discrimination of differences be-
friendly to her? tween appropriate and inappropriate
n Why didnt Emily talk more behaviors
about herself? n Explanation of ways inappropriate
n Describe how it feels on the first behaviors can be avoided or changed
day at a new school.
n What advice would you give to Targets
someone who wanted to make
friends? Respiration
n Use lower chest breathing
4. Mrs. Browns class was having a n Use more replenishing breaths
discussion about different ways to n Eliminate unnecessary upper torso
talk. They had 2 boxes. One box was movement.
labeled loud talking, and one
box was labeled soft talking. The Phonation
children had to think of times when
n Use easy onsets
they talked in loud or soft voices.
n Use easy breathy quality (clear qual-
The teacher wrote their ideas on
pieces of paper, and they put them ity is not realistic until the nodules
in the correct box. Here are some are resolved)
n Decrease tension
of their ideas. You decide which
n Decrease loudness level in conversa-
box they go in. In the library; at a
ball game; telling secrets; visiting tional speech
n Employ vocal variety (not only in-
a sick relative; calling the dog; say-
ing goodnight; fighting with my creased loudness).
brother; making friends; calling for
help; calming a frightened animal;
when Im not getting my fair share; n Increase question asking
when my mom has a headache. n Improve listening-to-talking ratio
82 Voice Therapy: Clinical Case Studies

n Use other referenced statements in restful posture and relaxed expres-

addition to self referenced ones. sion. As she began to dance she
hummed to the music and the bones
Resonance of her face vibrated. Hmmmm she
hummed as she glided smoothly
n Improve resonance
across the flower-strewn stage under
n Increase articulatory precision.
the glittering chandelier.
Because patient C needed to mod- Answer these questions:
ify a number of different behaviors sub- n Describe how the ballerina
sumed under 4 different areas, the cli- breathes.
nician decided to present the behaviors n How does she hum?
as a set or a gestalt. Consequently, the n Explain how she keeps her body
appropriate behaviors were associated relaxed.
with one storybook character and the
inappropriate behaviors with another. 2. Tense Tessie tightens her jaw and
The beautiful ballerinas voice was neck and raises her shoulders when
relaxed and airy and her lips danced she breathes in. She pushes hard
when she used them. She made music with her throat and makes a little
by a humming on the front of her face, click or grunt on phrases such as
and the music was carried over into
the voice as she chanted words. The Im always eager.
ballerina voice was characterized by But everywhere I go.
appropriate breathing patterns, easy I jerk instead of glide.
onsets, resonance, and lack of laryngeal I feel all stiff, you know!
tension. The voice was light and musi-
cal and easy to listen to. Listeners felt Answer these questions:
relaxed and pleased when they heard it. n Can you tell Tessie what she must
In contrast, laryngeal effort, hard do to breathe more efficiently?
glottal attacks, excessive loudness, and n How can she relax her neck?
inefficient breathing patterns character- n Can you tell which words Tessie
ized tense Tessies voice. Patient C makes with a hard start?
was given ample opportunity to iden-
tify the 2 patterns and their effects on
listeners during discussion of stories. Sample Activity

When your teacher tells you an action,

Sample Stories do it the way tense Tessie would do it
and then do it the way the beautiful bal-
1. The beautiful ballerina came onto lerina does it. Explain the difference.
the stage wearing a frothy white
tutu. She breathed deeply and her
lower chest swelled with the air. She Production Phase
stood with her lovely head, neck,
and shoulders relaxed and poised. During the production phase of ther-
The audience admired her patient, apy, patient C learned to produce and
Primary and Secondary Muscle Tension Dysphonia 83

monitor target vocal behaviors in struc- 8. Describe the characteristics of ones

tured and controlled situations. Initially, own production in terms of the
cues and monitoring were provided following:
by the clinician. Gradually, however, n preparatory set
the patient learned to assume more n strategies used
and more of this responsibility. For n reactions of self
this patient, the production goals were n reactions of others
sequenced as follows:
9. Monitor ones own production:
1. Produce each target behavior cor- n when cued verbally
rectly (in isolation): n when cued nonverbally
n after practicing aloud
n with instructions, cues, and pre-
n after thinking about it first
sentation of the model
n spontaneously
n with instructions and cues
n with instructions
n spontaneously Sample Materials
2. Prolong and repeat the target be- Facilitating Techniques
3. Stop and start the target behavior at
will. Humming

4. Demonstrate both the appropri- Chanting

ate and inappropriate forms of the
behavior (negative practice). Facilitating Contexts

5. Produce the target behavior, vary- n Minimal pairs to teach breathy onset.
ing length of utterance: Think the [h] in the second word of
the following pairs:
n isolated sounds
n syllables whose ooze
n words hear ear
n phrases
hair air
n sentences
has as
6. Produce the target behavior, vary-
his is
ing the complexity of processing:
how ow
n imitation
n automatic responses ha ah
n limited repertoire of responses hoe oh
n simple self-generated responses heel eel
n complex self-generated responses
high eye
7. Produce the target behavior, vary- hobo oboe
ing the timing of the response:
n predictable response time n Words and phrases containing only vow
n unpredictable response time els and voiced continuant consonants
84 Voice Therapy: Clinical Case Studies

for continuity of tone and maximum 7. topple

vibration of facial structures: 8. toddle
9. pretty
/z/ /l/ /m/
10. dainty
zulus lovely Maisie
zoo lazy Molly
Zoro long mowing 1. Pop goes the weasel.
2. Pitter patter water splatters.
Zelma lions money 3. Fit as a fiddle.
zero lying Moses 4. Tap with your toes.
/v/ /th/ 5. Pearl buttons to button up.
6. Touch Tillys white tulle tutu.
Vivian them 7. Leap up and down.
violin those 8. Tiptoe through the tulips.
Vera there 9. Puppies snap and yip and yap.
vision these 10. You yell at little lizards.
Volvo then
Sample Activities
n Sentences
1. Be the dancing teacher and sing
Mow the lawn. as you count for the ballerinas to
Move the Volvo. practice at the bar: One and two
and three and four.
Vivian is lazy.
2. Play singing Simon says, and
The lions were lying in the zoo. sing the instructions for dance
Molly loves violins. movements.
My mom never loses money. 3. Look at this stack of cards with the
names of foods (ie, eggs, apples,
Noses are nozzles.
onions). Use the carrier phrase
I was living in Germany then. Ieat and make a sentence with
Zionsville is near there. each card in the stack. You get
Nellie is never nosy. 1point for each word you say with
an easy onset. Try lengthening the
n Words, phrases, and sentences loaded vowel sound.
with front sounds to promote artic- 4. Find the sounds that will help you
ulatory movement and forward tone vibrate your voice on the front of
focus: your face. (Ill say some words, and
you tell me which sounds helped
Words: you when you repeated the words.)
1. whirl
2. bounce
3. jump The Carryover Phase
4. wobble
5. tap The clinician arranged with the teacher
6. tumble for patient C to present some of her sci-
Primary and Secondary Muscle Tension Dysphonia 85

ence projects in her school classroom. turn to talk and that loud interruptions
Patient C enjoyed the opportunities for and shouting down other siblings was
attention as she explained and demon- not reinforced. When patient C lapsed
strated some of the information she had into her immature, manipulative pat-
learned about respiration. The teacher terns of interacting, the parents calmly
also implemented a unit on voice pic- said, Lets replay that in a more grown-
tures into her classroom curriculum and up way.
provided opportunities for patient C to Fortunately, patient Cs parents
be the expert on how to make pictures understood the importance of address-
with her voice without talking loudly ing the psychosocial issues underlying
or in a tense manner. The patient dem- their daughters vocal behavior. Their
onstrated high jumps, and broad commitment to change and, not coin-
jumps, and long worms, and soft cidentally, patient Cs progress were
fur using vocal variety, and she served remarkable. From the outset, their inter-
as the judge when the teacher organized a est in their daughters well-being was
voice-picture competition. The patient reinforced, and the clinician served as a
also starred in another classroom activ- facilitator encouraging them to expand
ity where picture cards were used. For their range of parenting skills. PatientC
example, 2 cards, one with a bird (blue attended therapy for 2 years, twice
jay) and one with a letter (blue J), were weekly for 45-minute sessions. After she
held up. The listeners had to identify to was dismissed from therapy, she was
which card patient C was referring. followed for 1 year to ensure that gains
The patients mother routinely were maintained.
observed therapy sessions and observed
the ways in which the clinician insisted
on mature, direct interpersonal interac- When travel distance required to receive
tions. The mother also met for several voice therapy is prohibitive or there
sessions alone with the clinician and the is lack of local professional speech-
school psychologist so that she could language pathology services, remote
talk about ways to help the patient at treatment may be a solution. In the
home. The teacher and the parents following case, Lisa Kelchner describes
agreed to give the patient lots of atten- the use of a telehealth approach in
tion and praise when she used mature, treating a child with MTD secondary to
nonabusive vocal strategies. early bilateral vocal fold lesions.
Patient Cs father agreed to read
stories with his daughter each evening
before bedtime and to reinforce appro-
priate voice use. For example, he used Case Study 10
phrases such as, I really like these
times when we talk quietly together.
You make me see the pictures in my Lisa N. Kelchner
head, and the stories come alive for me,
and you have the prettiest quiet voice Treatment of Secondary MTD
Iknow. The parents set up rules during in a Child With Early Bilateral
mealtimes to ensure that everyone had a Lesions: A Telehealth Approach
86 Voice Therapy: Clinical Case Studies

Case History enjoys math, computers, and gaming.

He is on grade level and his mother
A 10-year-old male Sam was referred reports the Ritalin is helping with over-
to a pediatric voice center after being all behavior management and perfor-
seen by his pediatrician. This was Sams mance in school. He does have a long
second referral to the center in 2 years. history of vocal exuberance with lots of
Sam has a history of intermittent hoarse- yelling and shouting in the home and
ness secondary to vocal exuberance in during play. Without the Ritalin, Sam
the form of loud talking and forceful has frequent episodes of upset and out-
yelling. The previous laryngeal exam bursts. He also has a pattern of excessive
of 2 years ago revealed mild bilateral loud talking. Sam is one of 3 children
vocal fold edema, erythema, and mild (2 boys, 1 girl), all of who are within
evidence of LPR. At that time, vocal 2 years of each other. Mom described
hygiene education was provided, but their household as noisy.
the recommendations for therapy were On the day of his exam, Sam was
not heeded. generally cooperative although he was
During this exam Sams parents more interested in playing games on his
report his hoarseness was getting worse mothers iPhone. He had undergone
as was his throat clearing and coughing. a full evaluation before, so he was not
In the time since his first visit Sam has fearful about the exam. Sam was quite
been placed on Ritalin for management inquisitive about the equipment used
of his recently diagnosed attention- for the evaluation and wanted to know
deficit/hyperactivity disorder (ADHD). about all the controls.
Although he is now on the proper ther-
apeutic dosage, there was a period of
3months when he was demonstrating Voice Evaluation
chronic throat clearing and vocal tics, a
known side effect of Ritalin. The vocal During this visit, Sam underwent a full
tics have mostly subsided after his devel- voice and laryngeal examination. After
opmental pediatrician adjusted (down) the initial interview, Sams mother was
the dose. Sam also suffers periodic asked to fill out a pVHI and answer
upper and lower respiratory infections questions related to voice use and reflux
and has a known allergy to cats. This symptoms. Sam was taken into the
allergy is treated with over-the-counter sound-treated booth where the follow-
medications as needed and environmen- ing data were gathered using the Real
tal controls. Sams hearing and vision Time Pitch Program of the CSL and the
were within normal limits. There were Phonatory Aerodynamic System.
no other major medical concerns.

Social and Educational History Sam was administered the CAPE-V. The
expert rating of the perceptual param-
Sam has a history of hyperactivity and eters generated the following scores:
difficulty concentrating during sus- overall severity: 63/100 (consistent
tained tasks. He experiences some chal- moderate-severe dysphonia), intelligi-
lenges with completing schoolwork but bility of his connected speech (separate
Primary and Secondary Muscle Tension Dysphonia 87

analysis) was informally judged to be There was mild posterior commissure

moderately affected by the presence of hypertrophy and erythema suggestive
dysphonia; roughness: 45/100; breathi- of acid irritation and moderate latero-
ness: 58/100; strain: 45/100 (during con- medial compression of the ventricu-
nected speech samples); pitch: 21/100 lar folds during phonatory segments.
(low); and loudness: 32/100 (inconsis- Sustained views during phonation
tent; loud and soft). adequate for interpretation of discreet
vibratory parameters revealed mild-
Instrumental Assessment moderate decrease in mucosal wave and
amplitude of vibration. Phase symme-
Acoustic. Inspection of the harmonics try was inconsistent, but it did appear
during sustained vowel production via that phase closure was dominated by
a narrow band spectrogram revealed prolongation of the closed phase of the
dominance of a type 2 signal. His aver- vibratory cycle. The overall impression
age fundamental frequency (F0) was was one of laryngeal hyperfunction.
180Hz; His highest F0 was 267 Hz and
his lowest was 155 Hz. Glides up and Patient Self-Assessment
down the scale were marked by pho-
nation breaks. Fundamental frequency Sam reported that he frequently felt
during counting was 78 dB/SPL. Sam he had to push his voice and that his
was able to get louder (90 dB/SPL), but voice became tired by the end of the
he was unable to lower his volume. day. When asked if he gives his voice a
break when it felt tired, he responded
Aerodynamics.Measures of average he didnt know. Scores on the Pediat-
airflow, estimated subglottic pressure ric Voice Handicap (pVHI)43 (as filled
and maximum sustained phonation out by his mother) were physical (15),
were measured. The values are as fol- functional (15), and emotional (5). Sam
lows: average airflow: 120 cc/s; esti- and his parents agreed he was pretty
mated subglottal pressure: 9 cm/H2O); hoarse and that sometimes he cannot
MPT: 10 seconds. be understood when on the playground,
at baseball, and in the classroom.
Imaging.Using both rigid and flex-
ible endoscopy, direct light images of
the larynx and segments of simulated Impressions and
slow-motion stroboscopy during sus- Recommendations
tained phonation and connected speech
were captured. This exam revealed sym- It was the consensus opinion of the voice
metric, bilateral true vocal fold lesions team (SLP and ENT) that Sam demon-
at the juncture of the anterior one-third strated bilateral prenodular-type thick-
and posterior two-thirds vocal fold edge ness and laryngeal hyperfunction due
resulting in a large posterior gap con- to his chronic coughing and periods
figuration during glottic closure. The of voice overuse. Vocal hygiene coun-
anterior segments of the folds did make seling, reflux precautions, and voice
full contact during phonation and the therapy were recommended. At the
lesions appeared soft and compress- time of this evaluation, receiving voice
ible. Both CA joints were fully mobile. therapy via telehealth was an option.
88 Voice Therapy: Clinical Case Studies

Given Sams proclivity for technology, to use the Web-based home program
the familys in-home technology setup portal and instructions for providing us
and access to broadband along with the Web-based feedback.
familys reluctance to travel weekly to The structure of the Telehealth Ses-
the urban medical center for treatment, sion: Therapy via the telehealth model
an 8-session over 10-week program of used included weekly half-hour syn-
voice therapy to be delivered by syn- chronous hospital to home sessions. The
chronous teleconferencing and an inter- sessions were scheduled to flex with the
active website was arranged. The inten- family and therapists availability. The
tion was to make gains using private family attempted to secure a relatively
therapy and to transfer information quiet space and time for the sessions,
and care (as needed) to the school SLP, although this did not always happen.
as possible. Use of telehealth for deliv- Use of a departmental computer was
ery of behavioral-based therapies to the model of TH used at the time of this
children is relatively new but support- therapy due to security, privacy, and
ive data exist in the treatment of adult configuration reasons. A relatively small
voice and other pediatric communica- desktop rather than a laptop was used
tion disorders to warrant its use in this for durability reasons.
application. Each session was started by affirm-
ing that the audio and video connections
were clear and stable. Camera and audio
Telehealth Setup adjustments were made as needed. Eye
contact between Sam and the clinician
The patient was dispensed a desktop was encouraged by having both look at
for dedicated TH use. Software require- the camera arta visual cue to look
ments and operating systems permitted up at the camera versus at the screen
uploading and downloading of acoustic (although Sam frequently liked to look
and video images; speakers; and head- at himself on the small insert). Each
phone microphones (with increased screen had both the clinician and Sam
acoustic sensitivity, high definition, and on it. The clinician also viewed the room
low interference). In addition, compat- or asked Sam and his parent to inform
ibility specifications were cross-refer- her of any guests in the treatment ses-
enced on all components to include sion. Pop-in visits by curious siblings
the patient web-portal, video client, were more common in the first few ses-
and standard antivirus requirements. sions. Sam kept his headset mic and
Cisco Telepresence Movi 4.2 was the headphones on most of the time.
teleconferencing software. To provide Each session started with a review
ample in-home Internet connectivity, of the previous weeks home program
the household was required to have the results that Sam and his parents entered
following minimum high-speed broad- on the interactive website. Successes
band requirements: high-speed cable or and challenges with vocal hygiene and
DSL with download and upload speeds vocal behaviors and any important
of 1.5 Mbps or greater. events from the previous week were
At the start of therapy, Sam and his discussed.
parents were provided an orientation The remainder of the time was
and instructional session to learn how spent on the direct therapy approaches.
Primary and Secondary Muscle Tension Dysphonia 89

Any technical issues with either the syn- Instead of charting all specific
chronous or Web home program ses- behaviors, Sam was asked to answer
sions were discussed with parents and questions related to his vocal health
Sam at the end of the session. and behavior on his daily Web home-
work session. That website had high-
interest graphics and a series of yes/
Voice Therapy no questions that reinforced an under-
standing of why the behaviors should
Sams voice therapy program was initi- be used (or avoided). Positive feedback
ated with the standard long-term goals was provided at the end of the website
of improving vocal hygiene and reduc- question session. Information regarding
ing laryngeal irritability, and improv- voice care guidelines was also conveyed
ing voice quality and connected speech to Sams elementary school personnel
intelligibility. including his classroom teacher, school
Indirect strategies for accomplish- nurse, school SLP, music teacher, and
ing LT Goal 1 included the following: PE teacher.
Provide patient and parent education Direct Therapy: Modification of
regarding vocal function and voice care Vocal Function Exercises and Resonant
in order to identify ways to avoid vocally Voice were used to accomplish the
harsh behaviors and situations that pro- second LT goal. Initially Sam had dif-
voke laryngeal hyperfunction; identify ficulty producing the desired semi-
substitute behaviors for harsh vocal occluded vocal tract gestures to achieve
behaviors (eg, sip water and long, hard easy vibration and frontal focus during
swallow, turning down background vocal tasks. This issue was addressed
noise/volumes; walk to listener); drink by having Sam do lip and tongue trills,
more water and reduce carbonated, caf- sustained labiodental vv sounds, and
feinated drinks; model and teach easy whistle with voice. This whistle tech-
onset shout; use ear plugs to lower vol- nique makes use of a long, plastic whis-
ume; and take voice naps during other tle that can act like a kazoo (which also
activity (homework, game playing). could have been used). After 2 weeks of
Specific strategies to manage reflux (2 live and daily Web) sessions (mean-
included providing a basic description ing Sam uploaded an audio/video
of what reflux is and how it can impact sample during Web practice), Sam was
laryngeal health. They were also pro- able to achieve the appropriate gesture.
vided a list of foods and behaviors that It is important to note that we did dem-
are known to aggravate reflux. The dose onstrate this with some hands-on cues
and timing of the prescribed PPIs were during the initial voice evaluation. We
also reviewed. The family was under the also worked on him finding the tense
impression Sam should take the medi- spot in his belly while he sustained the
cation only if he was symptomatic. Tak- sound, rather than pushing from the
ing the medication 30 minutes prior to neck area. Maintaining the gesture while
the selected meals was emphasized. Of switching back and forth from high and
note, we did not ask Sam to eliminate all tense to low and relaxed vowel sounds
potential reflux triggers but rather pace was also a practice task.
and proportion such foods (eg, pizza) With the semi-occluded focused
and to avoid late-night snacks. gesture in place, work on modified Vocal
90 Voice Therapy: Clinical Case Studies

Function Exercises (VFEs) and Reso- nique. We also were able to record and
nant Voice Therapy (RVT) started (for upload Sams practice and point out
more information, see Case Study13, some subtle differences. Both Sams and
by Joseph Stemple, Use of Vocal Func- the sample videos were available to him
tion Exercises in the Treatment of an on the website.
Adult With Secondary MTD, later in
this chapter). Sam started by using the
warm-up exercises and 3 within-range, Therapy Outcomes
comfortable pitch levels (low, medium,
and high). His initial times averaged At the end of the 10 weeks, Sam and
9seconds for lower and midpitch (CDE) his parents returned for an interval
notes and increased to 17 by the end of voice evaluation. At that time we were
therapy. Averages for high notes (FG) able to document a number of positive
started at 7 seconds. Glides up were changes related to Sams vocal health.
especially hard for him, and we needed Audio-Perceptual CAPE-V expert rat-
to use a lip trill to avoid significant voice ings revealed the following: overall
breaks. Sam was able to progress to the severity: 48 (mild-moderate dysphonia;
fully differentiated scale of 5 notes by and moderate improvement in intelli-
the end of the 10 weeks and remained gibility); roughness: 36; breathiness: 32;
working on them in the form of a home strain: 13; pitch: 12 (low); and loudness:
program. We tended to use the vowel 5 (stable). The acoustic values revealed
sound oo as in hoot (owl) for the power a more stable type I signal, elevated
exercises. Average times for the highest F0 (210 Hz), and greater range (155 to
notes improved to 15 seconds but never 330 Hz). Improvement in aerodynamic
exceeded the low and mid note times. function was evident in changes in aver-
Modified Resonant Voice Therapy age airflow (145 cc/s) and estimated
(RVT) was used in conjunction with the subglottal pressure (5 cm/H2O ).
VFEs to reinforce easy vocal fold vibra- Repeat laryngeal digital strobos-
tion and distribution of physical energy copy revealed mild improvement in
for voicing in connected speech. Admit- the size of the bilateral lesions with the
tedly, Sam was rather shy at joining in adjacent edema and erythema resolved;
with some of the chanting and voiced/ improved glottic closure characterized
voiceless syllable, phrase, and sentence by a reduction in the posterior gap and
practice. Initially more time was mak- apparent size of the bilateral lesions.
ing him comfortable with the series of The posterior commissure hypertrophy
exercises and a lot of time was spent on remained but erythema was resolved.
natural melodic contour humming and Simulated slow-motion images revealed
easy chanting coordinated with ease of that mucosal wave and amplitude of
respiratory support. During this task, it vibration were greater, phase closure
was useful for the treating clinician to was more equal, and the symmetry of
have Sams parents pay attention to the vibration was normal.
degree of tension throughout his chest, Parent proxy ratings on the PVI
neck, and face area. To reinforce the use revealed perceived improvements in
and practice of the modified RVT, we both the functional (7) and physical
uploaded videos (with permission) of domains (8), dropping by 8 and 7 points,
other children who had excellent tech- respectively. Recall that the emotional
Primary and Secondary Muscle Tension Dysphonia 91

domain was not particularly elevated between synchronous sessions. Like-

at the start of treatment (4). When dis- wise, the clinician felt she was more an
cussing the results directly with Sam, active participant in the home program
he agreed that he was aware he did not and only had to make minor adjust-
have to force his voice like he did at the ments to her usual instructions. There
start of treatment. Both Sam and his par- was some burden on the family to
ents agreed that his voice was clearer appear organized to have the clinician
and less hoarse. Intermittent raspi- come to their home via telehealth, but
ness persisted. after the first couple of synchronous ses-
Importantly, Sams laryngeal irri- sions the family and siblings relaxed.
tability quieted. He was doing much One advantage to the synchronous ses-
less throat clearing and definitely was sions was that the clinician was able to
able to self-cue to talk at a lower volume gauge the familys natural communica-
in key school and home situations. He tive style, and she often spontaneously
remained on his Ritalin with no vocal invited siblings into the therapy session,
side effects. in part to satisfy their curiosity.

Children often need to be able to use

Summary and
their voices strongly, while avoiding
Concluding Remarks
damage, and to promote healing of exist-
ing vocal injury. In the following case,
Sam, his family, and the treating clini-
Rita Hersan describes a therapeutic
cian experienced success. Use of the
approach called Adventures in Voice
interactive website for homework
to treat a child with MTD Secondary to
proved quite successful with a demon-
Vocal Nodules.
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
Case Study 11
sessions time out as opposed to log out.
Everyone was pleased with the ability
to check practice of gestures through the Rita Hersan
uploading and downloading of samples
in the file share format. Manipulating Treating a Child With MTD
the rather simple technology aspects of Secondary to Vocal Nodules Using
the therapy appealed to Sam. Concepts From Adventures in Voice
In general the family and clinician
reported that using teleconferencing
helped maintain Sams attention, that Case History
he enjoyed the website graphics, and
liked the uploaded images that helped History of the Problem
remind them of specific therapeutic ges-
tures. He especially enjoyed recording Patient M, an 8-year-old boy, came to the
his own voice and uploading the record- voice center accompanied by his parents
ings on the website message board so who described a gradual but noticeable
the clinician could monitor progress change in the patients voice quality
92 Voice Therapy: Clinical Case Studies

over the preceding 9 months approxi- tained while his mother taught piano
mately. Initially, the voice problem was lessons. The parents described M as not
considered transient and did not seem aggressive but a natural captain, espe-
to bother M or impact his communica- cially with his soccer team and brothers.
tion or activities at school. Ms parents He strained his voice while playing and
reported frequent periods of hoarseness occasionally imitated monsters voices.
that they considered normal during The parents reported that M had always
this period, until hoarseness worsened showed mature behaviors compared to
and persisted after M attended a sum- his peers.
mer camp. His parents decided to have
Ms voice evaluated, once he expressed
frustration saying his voice was not Voice Evaluation
working right. Ms teacher had also
noticed Ms worsening of voice, but she The patient was evaluated by a voice
reassured the parents that no negative team that consisted of a speech-language
comments had been made about it by pathologist, audiologist, and otolaryngol-
Ms classmates. ogist. Hearing was within normal limits.

Medical History
Parents described M as a healthy boy
with normal developmental history. M The audio-perceptual evaluation used a
had tympanostomy tubes placed when modified ordinal GRBAS96 scale, evalu-
he was 3 years old. His mother reported ating overall grade, roughness, breathi-
that M had been aggressively clearing ness, asthenia, strain, adding pitch, and
his throat, unrelated to eating or drink- loudness variables. Overall grade (G)
ing, and she was concerned about this was scored based on the CAPE-V90 pro-
habit. His medical history revealed cedures. For that parameter, on a visual
no evidence of allergy or acid reflux analog scale of 100 mm, the overall G
symptoms. score for M was 52/100. For remaining
voice quality parameters, using an ordi-
nal scale on which 0 = normal, 1 = mild,
Social History 2 = moderate, and 3 = severe, the follow-
Patient M was the oldest of 3 children; ing results were obtained: roughness:
his younger brothers were 6 and 3 years 1; breathiness: 2; asthenia: 0; strain: 1;
old. The parents considered M a socially pitch: 1 (low); and loudness: 0. An addi-
and academically well-adjusted, second- tional note was that intermittent phona-
grade student who had special interest tion breaks were perceived during all
in music, singing, and soccer. Both par- the assessment tasks.
ents were professional classical musi-
cians. The home environment was char- Patient Self-Assessment
acterized as moderately noisy because
Ms mother taught piano lessons at The parental proxy Pediatric Voice Hand-
home. The patient and his brothers had icapped Index (pVHI)43 was adminis-
the assistance of a babysitter for after- tered to quantify the effects of the voice
school activities, but M liked to assume problem. The score was 45/92. Addition-
leadership in keeping his brothers enter- ally, M answered verbally the following
Primary and Secondary Muscle Tension Dysphonia 93

3questions to self-assess the impact of Voice Therapy:Using Concepts

the voice problem: of Adventures in Voice

n How much does your voice problem Adventures in Voice (AIV) was devel-
bother you? It bothers you a little oped by Verdolini, Hersan, Hammer,
bit (mildly), quite a bit (moderately), and Reed to teach children to use their
or a lot (severely)? He answered voices strongly, when needed, while
a lot! avoiding damage and promoting heal-
Do you think the problem is just ing to existent vocal injury.99,100 The
the way the voice sounds, just the program is founded on a framework
way the voice feels, or both? He grounded in basic science on: (1) the
answered, both! biomechanics and biology of voice pro-
n How is your voice today? Using a duction, (2) perceptual-motor learning,
chart representing 10 steps (1 = the and (3) factors affecting patient compli-
worst voice to 10 = the best voice), the ance. Throughout the program, all ther-
patient pointed to step 4. apy exercises are based on 3 principles
of perceptual-motor learning that are
Instrumental particularly relevant for children, sum-
marized in the acronym APT as follows:
Videolaryngostroboscopy revealed a bilat-
eral symmetric midsubepithelial lesion Active
of true vocal folds with normal mucosal
wave and slightly reduced amplitude This refers to the concept of the child as
of vibration bilaterally. Glottic closure an active participant in the learning pro-
revealed an hourglass configuration. cess, in evaluating different modalities
Acoustic measures revealed a speak- of voice use, and in discovering how to
ing fundamental frequency of 238 Hz produce different voice exemplars with-
in connected speech, based on the all- out explicit biomechanical instructions.
voiced sentence, We were away a year Some voice clinicians may argue that
ago, and 226 Hz taken on sustained ah children are not aware of the voice prob-
at comfortable loudness. A fundamental lem, and consequently have no motiva-
frequency of 250 Hz was expected for tion to engage on a therapeutic program
his age on sustained ah at comfortable such as Adventures in Voice. In fact, in
loudness.97,98 Frequency range varied challenge situations, motivation is also
from 178 to 295 Hz on sustained ah. addressed by keeping the child actively
Mean intensity was 68 dB SPL mea- involved as co-creator of the tasks in
sured during connected speech, and all phases of the program. Moreover,
the dynamic intensity range was 65 to the attention required to learn a new
86 dB SPL on sustained ah. Patient motor task is continually encouraged by
Ms loudness measures were within requiring the childs participation.
normal range.
Aerodynamic measures based on Perception and Production
repeated syllable trains of /pa/ showed
a high mean airflow of 250 mL/s at This refers to the constant alternation
comfortable pitch and loudness, and between perceiving and producing the
estimated subglottal pressure at 8.5 cm target vocal pattern. Biomechanically,
H2O, which was expected for his age.97 the target pattern involves vocal folds
94 Voice Therapy: Clinical Case Studies

barely touching or barely separated, Adventures in Voice 101 promotes

which the child will learn to identify as targeting and tailoring individualized
easy vibration voice or simply easy vocal care activities, which may have
voice associated with vibrations in the a greater likelihood of benefiting the
anterior oral cavity.72 The child and the child, as compared to generic programs
voice clinician (also known as the Adven- that may be overwhelming and irrel-
ture Guide) are continually engaged in evant to the patient.
activities that promote perception and The broad goal of the program is
production aimed at voice outcomes, not for the child to acquire a healthy vocal
the biomechanics of voice production. pattern in a variety of contexts, includ-
ing background noise and emotional
Therapeutic situations. Biomechanically, this vocal
pattern involves barely adducted or
This refers to the principle that the activ- abducted vocal folds, perceptually
ities should be structured to be differ- corresponding to resonant voice, or
ent from events likely occurring outside easy voice associated with perceptible
the clinic. Specifically, therapy activities anterior oral vibrations.72
emphasize functionality (having a prac-
tical application, or serving a useful
purpose), salience, repetition, and vari- Therapy Goals and
ability of practice. Expected Outcomes

The long-term therapy goal for the

Rationale for Using patient was to maximize his vocal out-
Adventures in Voice put relative to the existing laryngeal dis-
order. It was expected that the patient
Many children use their voices exten- would be able to produce clear and
sively and vigorously, placing them strong voice with minimal vocal fold
at risk for phonotrauma. Noisy play- impact stress,101 and to integrate target
grounds, sports events, and parties are vocal behaviors in a variety of contexts.
typical environments sought by this
population, and yelling, cheering, and
loud singing represent common vocal Description of How to
behaviors in children. Do the Therapy
The traditional therapy approach
for children, which focuses on voice Are You Ready for This
conservation by encouraging them to Adventure With Your Voice?
reduce or eliminate phonotraumatic
behaviors (historically referred to as The patient heard a simple story about
vocal abuse and misuse), seems how hurt voices and healing voices100
pragmatically hopeless from the outset. may happen to a lot of people (chil-
It usually provides patients with long dren and adults) because we all use our
lists of dos and donts, lacking a cohe- voice frequently and not always in the
sive framework, and ultimately poten- best conditions. He learned about facts
tially promoting fear of talking, cough- that can cause hurt voices: not drink-
ing, singing, and even laughing. ing enough water; talking loudly with
Primary and Secondary Muscle Tension Dysphonia 95

background noise; irritation caused by cient for him to understand the negative
throat clearing, yelling, and screaming impact of throat clearing and screaming.
in different situations; and talking a lot It was explained to the patient that
while feeling sick. When asked about he could face some challenges during
what he thought could have caused his the journey but certainly he would have
hurting voice, the patient responded lots of fun. He could always get a stamp
maybe I yelled a lot at the soccer on his passport for following the direc-
games and didnt drink much water! tions well. The patient was encouraged
His mother added too much throat to invite other people to go on the jour-
clearing! ney with him. His father and a special
The Adventures in Voice for this friend were suggested as special jour-
particular patient was called A Jour- ney partners for his therapy program.
ney to Discover My Easy Voice. Most He would need to show his journey
of the activities were planned using map, and to participate in some activi-
the patients own ideas, supported by ties with them.
his mother throughout the therapy Taking into account the patients
sessions. The map of the journey was interest in music and singing, the jour-
prepared by the patient. The voice cli- ney guide suggested that the first stop
nician, also known as the journey guide, would be at the Wind Town. To
proposed a visit to 8 different towns enter Wind Town, all the visitors were
and asked, We will start our journey, requested to produce special sounds.
how is your voice today? The patient Pictures of some of the wind family
confirmed not good! For each session, instruments of an orchestra were shown,
the patient was asked to self-assess his and the target sounds /v/, /z/, and /Z/
voice using the same representation of were introduced. Initially, the patient felt
steps that was used on the initial evalu- easy vibrations on his lips using a straw
ation. The patient had in mind that his and colored water; he made bubbles
voice could improve as he progressed while producing a kazoo-like sound.
on the journey. To incorporate the activity into some-
The patient received materials that thing meaningful, the patient selected
he needed before going on the journey: cards with written words and pictures
a bottle of water, a backpack, a journey from a small backpack. As he took the
diary, and a passport. The patient imme- cards out, the journey guide produced
diately understood that he would need extremely vibrating sounds on words,
to drink water more frequently. The such as zebra, vase, viola, measure, very,
patient was told that he could help his zero, television, voice, zoo, and treasure.
voice by taking sips of water and eat- Patient M heard the difference when the
ing watery fruits to increase vocal fold journey guide alternated easy vibrating
hydration. Patient M was asked if he voice and voice without easy vibrations
knew why clearing the throat frequently on words beginning with /f/, /s/, and
and yelling at the soccer game were not /S/, such as sea, fifth, shop, fat, ship,
helping the voice. He felt the difference soup, shoe, feet, shelf, soap, face (that is
by way of example in the force and voiceless-initial consonants as opposed
friction while clapping, rubbing, and to voiced-initial consonants, which
gently vibrating one hand against the involve a semi-occluded vocal tract
other. These demonstrations were suffi- during phonation, and consequently
96 Voice Therapy: Clinical Case Studies

facilitate vocal fold vibration). The jour- example: Many men on the . . . (moon),
ney guide asked if the patient would My nanny made . . . (lemonade), String
like to practice very vibrating sounds Land is . . . (fun), My Mom is a . . . (musi-
before playing a game. After consistent cian), I love lemon . . . (muffins), Manny
response (80% accuracy), the patient and Lenny are . . . (twins), Monna made
was invited to play a game: each player me ... (mad), No one found the ...
got 3 points if a word with /v/, /z/, or (money), Noah is mowing the . . . (lawn),
/Z/ was pulled out from the backpack May I know your . . . (name).
and produced with a tickle (that is, easy The patient produced more hum-
oral vibrations), and only 1 point for a ming words while playing bingo; all
word with /f/, /s/, or /S/ and no tickle. the Wind Town and String Town target
Patient M and the journey guide sounds were combined: van, music,
then prepared together a home program dozen, vision, news, visit, museum,
called Tracking my Voice that used a nose, violin, television, navy, eleven,
charting and added personalized vocal venture, and zombie. To transition from
care and vocal activities. humming (chanting) to more natural
voice production, the patient, his mother,
The Journey Continues and the journey guide had to answer
10 questions each using mhmm for
The journey guide pretended to play yes or nnno, gliding the voice and
string instruments while producing focusing on easy vibrations.
easy vibrations on /m/, /n/, and //, The patient heard a story about
and immediately patient M guessed Tony, a telephone that enjoyed very
that he was going to visit String Town much ringing all day and listening to
on the second session. conversations, until the day that nobody
The patient was asked to cover his was at home to answer him. After hours
mouth and nose to feel the vibrations of constant ringing, Tony felt exhausted
on the palm of his hands. Once he was and had no energy to produce a ringing
able to feel them, he was asked to keep sound. The story reinforced the idea
his lips very tight while producing /m/ that Tony recovered his ringing sound
or the tongue very pressed while pro- after some rest and care. Patient M
ducing /n/. Once again, the patient prepared his version of the story using
recognized the difference between easy the Story Kit, an iPad app, and he
vibrations and no vibration. The patient added tongue trills to produce Tonys
was told that in String Town everyone ringing sound.
enjoyed humming; they were called
Humming People because they liked to Where Are We Going Now?
prolong sounds. Humming People were
very smart because they loved to feel a The third session was a visit to Brass
tickle inside the mouth, around the lips, Town, and the target sounds /l/ and
or behind the teeth to make sure they /r/ were introduced, with emphasis on
were using their easy voice. Patient M pitch glides and humming (chanting)
and the journey guide played a game on rhymes. For pitch glides the patient
filling in blanks on sentences using and journey guide prepared a road
words beginning with /m/, /n/, and template using curves, going up and
// while humming (chanting). For down through the mountains, and cre-
Primary and Secondary Muscle Tension Dysphonia 97

ating a scene for animated repetitions gaingaingaingain; dundun dun dun

of /l/ and /r/ in different emotional dun dun [dn]. To engage the patient
situations. in the functional use of loudness varia-
The patient was asked to find pic- tions, he used different sizes of fake
tures of animals, objects, and people that pebbles made of cardboard to build a
he would like to include on the scene, trail on the floor. Patient M was shown
and he created a story using suggested how to vary the voice loudness while
words with target sounds: red, car, rock, stepping on the pebbles: the bigger the
rain, rainbow, parrot, yellow, tire, run, pebble, the louder is the voice. Several
long river, lizard, rolling, Lori, Rosie, target sounds were included in greeting
Larry, Liz, and Ryan. He called it: The expressions and short sentences, and
Road to Brass Town. Patient M learned the patient was asked to add names.
voice release strategies such as sigh, Here are some examples: Bye-bye Ben!
lip trills, stretches, and yawn associ- Hello Dan! Come here, Ross! Hi Sam-
ated with body movement and embed- muel! No, Bryan! Lets go Mom! Stop
ded on different emotional situations Jimmy!
associated with the story. Examples of
emotional situations included the fol- Bring a Partner to the Journey
lowing: The car run out of gas journey
guide felt upset and said arrr (with It was arranged with the patients
tight /r/). Then, to release the voice, mother that on the fifth therapy session
she used ahh (like a sigh). A flat tire M could invite a friend to participate in
patient expressed frustration with a the journey. This strategy was particu-
tight uhh; and then, he released the larly important to engage the patient
voice with lip trills and shoulder shrug. in activities that were more representa-
Feeling exhausted by driving patient tive of his habitual behavior. The jour-
stopped at the gas station, sipped water, ney guide asked the patient to show the
and stretched the body with a big yawn! journey map to his friend, including all
For chanting, the patient enjoyed: the towns he had visited, and the most
Rain, rain, go away/come again another special characteristics of each town.
day/little Johnny wants to play. M felt really excited to share with his
friend what he had done on the journey
We Are Halfway There to discover his easy voice.
To work on loud and safe voice,
Another series of target sounds /b/, the patient and his friend used a sound-
/d/, and /g/ were introduced for the level meter to monitor the loudness of
particular work on loudness variation their voices while playing a video game.
associated with precise articulation. Afterward, an activity was sug-
The fourth session was the visit to Per- gested which prompted the use of soft,
cussion Town. Initially, patient M and normal, and loud voice associated with
the journey guide used gestures and different situations. For example, M
body movement associated with a vari- went to the library, and he needed to ask
ety of rhythmic patterns and loudness for a book (soft voice). The space rocket
on syllable trains, such as: bambam- was about to launch, and Ms friend
bambambam; bombombom BOMBOM had to count 5, 4, 3, 2, 1 (loud voice).
bombombom; dindindindindindin; Dad was taking a nap but M wanted to
98 Voice Therapy: Clinical Case Studies

play (soft voice). The soccer coach was ous conversation and challenging the
teaching the team how to dribble (loud patient to recognize risky situations.
voice). M wanted to invite his friend to
play (normal voice). Mom was asking
her kids to come for dinner (loud voice). Frequency and Duration
of Treatment
When Loud Is Too Loud
The patient attended a total of eight
The sixth therapy session introduced 45-minute voice therapy sessions over
the experience of background noise a 10-week period. The initial 6 sessions
and loud talking. It was reported that were scheduled once a week, and the
the home environment was moderately last 2 sessions every 2 weeks.
noisy. Since patient M had started ther-
apy, his mother had been always pres-
ent in the therapy and very supportive. Therapy Outcomes
She had already made arrangements
for her children to play distant from the Audio-Perceptual
piano room while she taught at home.
Patient M read a story about Zeca, The overall severity of voice quality that
a boy who yelled frequently at soccer was considered moderate (52/100) at
games. Zeca finally realized that it was the initial evaluation indicated a marked
not his loud voice that helped him to improvement (15/100) at 1 month post
score a goal, but rather his strong legs therapy reevaluation. The patient did
and good skills. Yelling was just caus- not have phonation breaks in any of the
ing confusion among the other players tasks. Perceptually, his voice showed no
and affecting Zecas voice to the point, evidence of breathiness, or strain, and
he had almost no voice after the soccer only mild, intermittent roughness. The
games. Loud background noise with pitch of his voice was considered normal.
headphones was played during reading
activity. Patient M.s voice was recorded Instrumental
and played back after his reading. Both
patient and mother were impressed by Videolaryngostroboscopy revealed mild
the effect of background noise on voice edema of true vocal folds with consid-
loudness. erable reduction of bilateral subepithe-
Using the Story Kit, an iPad app, lial lesions, normal mucosal wave and
patient M wrote his version of Zecas amplitude of vibration, and a small pos-
story, adding drawings and voice terior glottic gap.
recordings. Acoustic measures revealed a speak-
ing fundamental frequency of 250 Hz in
Lets Vibrate the Voice connected speech and 246 Hz on sus-
tained ah. The frequency range was
The two last therapy sessions were less 178 to 385 Hz. The mean intensity was
structured and basically a review of all 69 dB SPL in connected speech and the
concepts of healthy voice use through dynamic range was 62 to 98 dB SPL.
stories and games. They focused on Aerodynamic measures based on 5
applying target sounds to spontane- syllable trains of /pa/ showed mean
Primary and Secondary Muscle Tension Dysphonia 99

airflow of 160 mL/s and estimated sub- ible support, the voice clinician was
glottal pressure of 7.5 cm H2O. Both attentive to not overload the parents
measures were considered normal for with too many tasks. Based on the prog-
his age. ress noted in each therapy session, only
2 or 3 voice activities were selected each
Patient Self-Assessment week for the home program, besides
vocal care (voice hygiene) recom-
Using the Pediatric Voice Handicapped mendations. The use of CDs recorded
Index (pVHI), score was 12/92 at the during the therapy sessions, the jour-
1-month post therapy follow-up visit. ney diary containing a summary of
With regard to self-assessment, M re- all the activities worked in therapy, and
ported that his voice was not bothering the chart Tracking my Voice assisted
him anymore, and he had no problems the child and his parents in adhering
with the way it sounded or effort to pro- to the therapy process.
duce the voice. The voice clinician reviewed the
chart at the beginning of each therapy
session. She suggested specific times for
Summary and home practice, accordingly to the family
Concluding Remarks availability. A family activity was also
recommended as Ms parents were very
Children require frequent and tangible interested and asked for other materials
evidence of progress across time. Visual (see list of recommended family activi-
charts assume great importance in ana- ties). These activities were only sugges-
lyzing the childs progress. The notion tions, and not considered essential for
of getting better is translated by going the therapy outcome.
higher on numbers using a chart repre- Informational feedback was pres-
senting steps. This idea is very benefi- ent throughout the therapy process to
cial for motivation, helping the patient reflect how well the patient was doing
to quantify his progress, and to under- (emphasis on positive aspects). In addi-
stand the long-term goals. tion, motivational feedback was applied
Patient M perceived a significant in the form of extrinsic rewards (stick-
improvement after the third and fourth ers on passport) every time the patient
session, jumping to steps 6 and 7 in his journeyed well during a therapy ses-
self-evaluation of voice (on a scale of sion and completed the daily assign-
10), in his self-assessment chart. Then ments of the home program.
he went back 1 point in session 5, most
likely because he had a cold. He reached Recommended Family Activities
a plateau on step 7 and remained there
for 2 consecutive sessions, and he fin- n Discover sounds around the house
ished on step 9 at the last session. He that have the characteristic of vibra-
expressed great satisfaction with his tion (blender, toothbrush, toy, hair
progress. dryer, cell phone).
Home practice should be part of n Watch a specific and short segment
real life, not time out from it. In the case of the movie Fantasia that has the
of patient M, family participation was introduction of the orchestra instru-
remarkable, but even with their incred- ments and their different sounds.
100 Voice Therapy: Clinical Case Studies

n Guess what sound is this? using a over approximately the past 12 months.
CD provided with sound effects. She lived in a small apartment includ-
n Watch a cartoon and describe how ing 2 other children under the age of 5,
the characters used their voices to her mother, grandmother, and aunt, and
express their feelings. was reported to be vocally dominant in
n Listen to different voices and guess the home. The patient herself had lim-
who is talking and how they are ited self-awareness of hoarseness but
feeling. did endorse frustration that she was dif-
n Stretch the body first. The patients ficult to understand by peers and had to
mother plays the piano while chil- repeat, particularly when reading aloud
dren walk or dance following the in class. The medical history was nega-
rhythm of the music. tive for any major illness, intubations,
n Using background noise (music), or irritation at onset of hoarseness.
family members use alternative Social history reflected poor hydration
ways to communicate without a loud (almost no water), mainly caffeinated
voice: facial expressions, sign lan- sodas, fried foods, and ketchup as major
guage, gestures, clapping the hands, risk factors identified for irritation. No
and stomping the feet. mini-throw ups (terminology used
for episodic regurgitation when work-
ing with pediatric patients in clinic)
School-based voice therapy can be chal-
or symptoms of reflux were reported;
lenging. In the following case, Rebecca
however, the patient was observed
Hancock describes a team approach with
to clear her throat frequently during
a voice clinic SLP and a public school
assessment. Her maternal grandmother
SLP in the successful treatment of a
accompanied her to the initial visit and
13-year-old with MTD secondary to
stated the patient communicated pri-
vocal nodules.
marily by yelling and screaming across
the house.

Case Study 12
Voice Evaluation

Rebecca Hancock CV underwent acoustic, aerodynamic,

and laryngovideostroboscopic assess-
Pediatric Vocal Fold Nodules ment of voice. Salient acoustic and aero-
and Secondary MTD Treated in dynamic data are embedded in Table 32.
Conjunction With a School-Based SLP Findings of this assessment yielded
elevated jitter, shimmer, reduced funda-
mental frequency, and significant breaks
History in her pitch range. Aerodynamic assess-
ment demonstrated reduced airflow
CV, a 13-year-old female, was referred with increased pressure during voice
by her school speech therapist for con- production.
cerns regarding hoarseness identified Rigid videostroboscopy reflected
during cheerleading tryouts. She had bilateral paired vocal fold nodules,
a history of hoarseness per her mother and mild interarytenoid pachydermia.
Primary and Secondary Muscle Tension Dysphonia 101

Table 32. Acoustic and Aerodynamic Data

Jitter 3.5% increased Phonation 8.6 cm H2O, increased

(expected is <1%) Threshold (expected 46 cm H2O)
Shimmer 2.0 dB increased Mean Peak Air 10.5 cm H2O, increased
(expected is <1 dB) Pressure (delayed onset
noted on repetitions,
expected 68 cm H2O)
Fundamental 180 Hz (WNL is ~>200 Mean Airflow 0.02 L/s, reduced
Frequency Hz) During Voicing (expected at or around
0.2 L/s)
Pitch Range
170900 Hz (inappropriate pitch break from 440600 Hz)
CSID on sustained /a/: 24.4 (mildly elevated)
Expected values reported used in this case are for clinical purposes and are adapted from normal
ranges reported for untrained females in this case. These are not intended to be reported norms for
the pediatric population.

Medio lateral supraglottic hyperfunc- to work schedules of her family, dis-

tion characterized by compression of tance to clinic, and financial limitations
the ventricular folds was noted during for rehab services of the patients insur-
modal pitch. The ENT physician did not ance. The decision was made to imple-
feel it was sufficient to implement any ment therapy in the school system. The
medications; however, strong recom- school SLP, who was integral in iden-
mendations for dietary improvements tification and obtaining a referral for
were made. voice assessment was then involved in
Perceptually this patient was noted the plan of care. The thrust of this case
to be moderately hoarse with primary fea- report will discuss the navigation of a
tures of roughness, intermittent breathi- treatment protocol within justification
ness, and voice breaks. The patient, again, for treatment in the school system.
did not report any recognition of hoarse- In Kentucky (where this patient
ness despite improvements demonstrated was seen), the Academic Resource Com-
during clinical treatment probes. The use mittee (ARC) is the representative body
of negative practice did indicate some responsible for obtaining and tracking
stimulability for vocal modification. service progression in the school system.
In other states, this may be referred to as
an IEP (Individualized Education Plan)
Treatment Planning committee. The common complaint
among school therapists is the difficulty
One confounding factor to this patients demonstrating that voice has an impact
plan of care was inability to travel to on academic performance. The follow-
clinic for therapy. This was due in part ing section discusses the appropriate
102 Voice Therapy: Clinical Case Studies

course of treatment planning, compe- consider that both benign and malignant
tencies trained for the school SLP, and lesions present with the similar trait of
the role of the voice center in progress hoarseness and require imaging.

Justification of Impairment
Identification and Assessment on Academic Progress

The area of identification in the school sys- The process of qualifying for services
tem can be complex. Unlike language, is largely dependent on grade level.
articulation, and social impairments, It is important to investigate the state
voice disorders are not appropriate for department of education curriculum
the response to intervention (RTI) standards, as these will be key to estab-
paradigm. For those unfamiliar, RTI lishing the impact hoarseness will have
is a trial phase wherein the classroom on student performance. For the pur-
teacher collaborates using recommenda- poses of this case, we will use the Ken-
tions from an SLP to collect data about tucky state standards as an example. In
the disorder and give structured cues as Kentucky, the working definition for
appropriate. This will justify both aca- a voice disorder is the abnormal pro-
demic impact as well as whether prog- duction and/or absence of vocal qual-
ress may be made outside a structured ity, pitch, loudness, resonance and/or
therapy framework. As hoarseness can duration, which is inappropriate for an
be indicative of more serious underlying individuals age, sex and/or culture.
medical issues, this is considered inap- When considering eligibility, often
propriate, and medical assessment pre- it is good to know the limitations when
cludes any voice-related intervention. it becomes time to establish a service
Typically this can be arranged after plan. For instance, understanding the
discussing the hoarseness with the childs limitations of what would not qualify
parents, however if a recommendation is for services would include when per-
made for medical assessment, a fiscal ceptual severity ratings fall within the
liability is generated within the school normal range. Notably, if the clinician
and becomes a conflict for school SLPs does not perceive hoarseness but the
in determining whether or not to make child reports excess vocal effort, this
the recommendation. Involving school may be diagnostic and helpful informa-
administration as well as members of tion to provide to evaluation medical
the special education department has professionals during assessment. From
been proven to be helpful in this process. an eligibility standpoint, one may dem-
Based on personal experience, parents onstrate effort is detracting from aca-
being made aware of the impairment demic focus and affecting attention in
triggers the conversation what next, class the student requires for learning.
which can then trigger the conversation Along the lines of normal per-
that ENT physicians and voice centers ception, exclusionary factors include
typically are a required first step prior to when vocal characteristics:
treatment. If any individual recommends
trial voice therapy prior to assessment, n are the result of temporary physi-
this should be avoided. It is essential to cal factors, such as allergies, colds,
Primary and Secondary Muscle Tension Dysphonia 103

abnormal tonsils or adenoids, or increased effort, or possibly be mea-

transient vocal abuse/misuse sured with a sound-level meter).
n manifest as the result of prepubertal
laryngeal changes in male students Once eligibility is established that
(unless a pathologic puberphonia is the voice disorder is creating a dis-
diagnosed or the child becomes a vic- turbance, and medical evaluation is
tim of bullying or social exclusion, underway, data collection for the depth
as is often seen in teens with high- and frequency of impact is required.
pitched voices) Table33 lists ideas for tracking adverse
n are the result of regional or dialectical effect and the impact of dysphonia by a
difference teacher, an aide, or an SLP.
n do not interfere with educational
Training the Trainer
Inclusion factors for services in
Kentucky include adverse effects as It is not surprising that most pediat-
listed below: ric voice intervention workshops have
good attendance: this is an area where
n Decreased participation in classroom only a small sampling of practitioners
activities and discussions feel comfortable providing intervention.
n Refusal to communicate about cur- For referrals out of clinic back into the
riculum in an oral framework in the schools, 2 to 3 sessions with the school
classroom SLP, the voice specialist, and the patient
n Reluctance/inability to participate in help to facilitate transition. The treat-
public speaking, school plays, debate, ment plan for CV included modifying
sports, cheerleading social behaviors such as soda intake,
n Oral reading in class food choices, awareness to vocal inten-
n Class/peer discussions sity and surrounding noise (some eco-
n Fear of interpersonal interactions, logical/conservation goals), as well as
expressing basic needs (ie, bathroom, rebalancing the respiratory and pho-
water) natory subsystems to promote lesion
n Impact on physical education if healing.
laryngeal structure is impaired In this case, this involved a cou-
n Reluctance to participate in mock pling of vocal function exercises and
interviews may result in inability to resonant voice therapy (for more infor-
obtain internships, college enroll- mation on vocal function exercises, see
ment, or employment Case Study 13 by Joseph Stemple, Use
n Burden of the listener in severe dys- of Vocal Function Exercises in the Treat-
phonia affecting other learners (ie, ment of an Adult With Secondary MTD,
classmates asking for a repeated later in this chapter) with an initial focus
instance of information because of on the use of negative practice. Prior
dysphonia in the speaker) to training vocal function exercise, the
n Students may become verbally aggres- patient and school SLP worked with
sive to force a voice, often it is easier flow mode phonation for the least ten-
to be loud than soft (this could be sion during voice onset as possible. The
measured perceptually, reported as use of visual cues such as the phonatory
104 Voice Therapy: Clinical Case Studies

Table 33. Kentucky Eligibility and Guidelines (2009)

Primary (K3) FourthFifth Grade High School

Number of times student is Number of repetitions in Number of times asked to
asked to repeat by teacher class repeat
Number of times student Change in level of Change in level of
must repeat in small group participation in specials, participation in specials,
environment extracurricular activities extracurricular activities
Episodes where student Reluctance to speak Reluctance to speak
shuts down publicly or withdrawing publicly, read aloud, or
from group presentations withdrawing from group
Activities where student is Denials to read aloud, Feedback from job
unable to fully participate answer questions in class, interviews, professional
(specials) or withdraw from group coaching interactions,
discussions ie, job fairs with school
Source: Kentucky Eligibility Guidelines Revisedfor students with speech or language impairment.
Retrieved March 23, 2013, http://education.ky.gov/specialed/excep/Documents/Kentucky%20Eligibi

aerodynamic system to visualize the but the primary 8 weeks of treatment

transition from airflow into phonation were solo.
as well as a pinwheel were beneficial.
Establishing self-awareness, moni-
toring for nascent self-correction and Therapy Outcomes
building a team rapport to keep the
patient engaged were the focus of the Three months after initial assessment,
first session, and half of the second. As CV returned to the voice clinic for
the school SLP began to initiate exercise post-treatment assessment. Strobos-
in a team approach, by the third session copy yielded complete resolution of
all parties felt confident this treatment the paired midline lesions, however
plan could translate into a 2 times per the mild interarytenoid pachydermia
week, 30-minute session. Fortunately, persisted. The patients family was
this student was seen alone as no other unable to reduce CVs intake of fried
students on the caseload were available foods,. She was moved to caffeine-free
at that time due to course conflicts. If soda, and a lower volume of ketchup.
this was in a larger group environment, In terms of vocal domination, she was
the focus on resonant voice and con- able to reduce yelling by lowering the
versation was discussed as a potential volume of the television, establishing a
treatment goal. Ultimately, for mainte- 3-foot to 5-foot distance in lieu of yelling
nance, the student worked in a group across the house, and communication
environment in conversation with stu- with her mother and grandmother with-
dents with mild pragmatic impairment, out yelling over her cousins. These were
Primary and Secondary Muscle Tension Dysphonia 105

notable improvements per the fam- Below are the typical criteria to dismiss
ily. Resonant voice was approximately from SLP services taken from Ken-
75% consistent in conversation, and the tucky Eligibility and Guidelines (2009)
patient accurately described the traits of retrieved online March 23, 2013, from
appropriate resonance. Acoustic and http://www.education.ky.gov/NR/
aerodynamic measures are presented in rdonlyres/5D691CC1-D69C-4CCD-89
Table 34. CC-EE2A3A60DBA5/0/KYEligibility
Perceptually, the patients voice Guidelines.pdf:
was noted to be within normal limits.
In conversation, fundamental speaking n Student has met all objectives from
pitch was appropriate for age/gender, the IEP related to voice without addi-
where previously it was excessively low. tional concerns
n At parent request
n No further measureable bene-
Transitioning From Care fits despite multiple intervention
As the patient was interested in cheer- n Student develops functional compen-
leading, and we could not dissuade sation skills
her, she was left with a maintenance n Classroom accommodations can
plan of once-weekly group treatment manage deficit
as noted above, to ensure maintenance n No longer required in order to access
of technique and adequate voice qual- the general curriculum
ity. We determined that given her level
of vocal effort, and persistent risky One consideration is the no fur-
behaviors, the prevention of recur- ther benefits concept. Not all therapy
rence was necessary. As of publication, is created equal, and not all therapists
she has not reported recurrence. Under- will achieve the same level with a
standing dismissal criteria is vital, par- given patient. One helpful technique
ticularly if the student is plateaued. in a given patient often falls flat when

Table 34. Post-therapy Acoustic and Aerodynamic Results

Jitter 0.9% (expected <1%) Phonation 5.0 cm H2O (46 cm

Threshold H2O expected)
Shimmer 1 dB (expected <1 dB) Mean Peak Air 7 cm H2O (without
Pressure onset delay) (expected
608 cm H2O)
Fundamental 260 Hz (WNL is ~200 Mean Airflow 0.18 L/s (WNL is at or
Frequency Hz) During Voicing near 0.2 L/s)
Pitch Range
1931200 Hz (one break observed at 880 Hz)
CSID on sustained /a/: 7
106 Voice Therapy: Clinical Case Studies

given to another patient. We carefully History

established a treatment toolbox for
the school SLP, so once flow mode Patient F, a 26-year-old second-grade
proved to plateau, she was comfortable teacher, was referred by a laryngolo-
integrating some elements of resonant gist to the voice center for a complete
voice, as well as phonatory linking. By diagnostic voice evaluation, with the
having a treatment arsenal, we achieved diagnosis of large bilateral vocal fold
a higher level of function without stale nodules and a left vocal process ulcer.
intervention. Although vocal hygiene Patient F first became symptomatic in
was used in this patients case, it is the fall of her first year of teaching. In
rarely the only method we implement to October of that year, she became dys-
promote healing. phonic. When the hoarseness persisted,
A happy side effect of this experi- she sought the opinion of the referring
ence was the relationship between the physician, whose examination revealed
school SLP and the clinician in the voice mild bilateral vocal fold edema. The
clinic. The school therapist has become physician instructed her to reduce caf-
a resource for her district for treatment feine intake and to increase intake of
of hoarseness in the class environment water and briefly counseled her regard-
and works in conjunction with the ing voice misuse. The patient followed
voice therapist in assessment and ser- these instructions, and her voice quality
vice delivery. The disconnect between improved.
school and medical speech pathology is Between fall and late winter, the
one that requires correction for the ben- patient experienced intermittent hoarse-
efits of the patients seen in both venues. ness. She thought the mild hoarseness
was fairly normal considering her level
of voice use in the school setting. In late
The importance of a team approach
February, however, she became moder-
to voice care is further emphasized in
ately hoarse during an upper respira-
the following case of a teacher with
tory infection. Like most teachers, she
secondary MTD. In this case, Joe
continued to work a normal schedule
Stemple describes the use of traditional
during her illness. She began to notice
voice therapy methods such as vocal
not only hoarseness but also voice
hygiene counseling and Vocal Function
fatigue and a burning sensation on the
Exercises, in conjunction with surgical
left side of her throat. When the upper
intervention to resolve a case of persis-
respiratory infection resolved and her
tent dysphonia.
voice symptoms persisted, she sought
the opinion of the laryngologist.
On seeing the vocal nodules and
the ulcerated tissue located on the
Case Study 13
vocal process of the left arytenoid car-
tilage, the laryngologist prescribed
Joseph C. Stemple reflux medication [proton pump inhibi-
tor (PPI)] and referred the patient for a
Use of Vocal Function Exercises voice evaluation and therapy. The PPI
in the Treatment of an Adult was prescribed as a precaution because
With Secondary MTD of the implications of acid reflux on
Primary and Secondary Muscle Tension Dysphonia 107

the development of contact ulcers and the PPI, although she was not symptom-
granulomas. atic with heartburn; and was a non-
The information gathered dur- smoker, living and working in a non-
ing the voice evaluation confirmed the smoking environment. Her liquid intake
nature of the voice trauma that had sig- was not adequate. She drank 2 cans
nificantly increased the patients symp- of caffeinated soda and 2 glasses of iced
toms in February. Patient F had indeed tea per day. Patient F reported that she
experienced a mild hoarseness since loved teaching and felt great on a
school began that fall. She reported that daily basis.
her voice quality typically was better
on Monday and much worse by Friday
but that she always had some level of Voice Evaluation
hoarseness. On a daily basis, she was
more symptomatic during the early During the voice evaluation, patient F
morning. The hoarseness would clear presented with a moderate dysphonia
somewhat by midmorning and worsen characterized by dry, breathy hoarse-
again by afternoon. ness. The laryngeal videostroboscopic
With the onset of the respiratory examination revealed large bilateral
infection, patient F began coughing vocal fold nodules, worse on the right
and throat clearing. By the time of the than on the left; bilateral edema and ery-
voice evaluation, the coughing had thema, and an apparent resolving left
decreased, but chronic throat clearing contact ulcer. The nodules caused glot-
was noted. Her voice use was typical tic closure to demonstrate an hourglass
for a second-grade teacher. Students of configuration with a slight ventricular
this age require much instruction, and fold compression. Both the amplitude
nonspeech times in the classroom were of vibration and the mucosal waves
reported to be minimal. In addition, the were severely decreased bilaterally.
patient was assigned playground and The open phase of the vibratory cycle
school-bus duty, which required occa- was dominant, whereas the symmetry
sional shouting and raising the voice of vibration generally was irregular. In
above noise to be heard. other words, she presented with signifi-
There was no evidence that the cant tissue changes that would present
patient misused her voice away from a challenge to functional voice therapy.
her work environment. She was mar- Acoustic measures demonstrated a
ried and had a 2-year-old daughter. She limited frequency range of 147 to 562 Hz.
denied any direct vocal trauma or envi- Her fundamental frequency remained
ronmental contributions, such as inhaled appropriate at 211 Hz. Although her jit-
dust, fumes, chemicals, or paints. She ter measures for sustained vowels were
reported that her voice improved on normal at 0.87%, her shimmer measures
weekends and always returned to nor- were high at 0.46 dB.
mal during the summer months. The Aerodynamic measures yielded
remaining social history was unremark- significantly high airflow rates for
able as related to this problem. high pitches averaging 305 mL/H2O.
The patients medical history also Comfort and low pitches were bor-
was unremarkable. She was free of any derline high at 180 and 189 mL/H2O,
chronic illnesses or disorders; took only respectively. The patient was required
108 Voice Therapy: Clinical Case Studies

to push more air through her vocal sys- the patient in the implicated environ-
tem to support the vibration because of ment cannot be overemphasized. Other
increased vocal fold mass and the hour- useful options to site visits are video or
glass glottal chink. Her subsequent pho- audio recordings of the patient in the
nation times at all pitch levels were only speaking environment. Recordings can
11 seconds or less. be viewed or listened to during therapy.
Patient F also completed the Voice- Patient Fs school was convenient
Related Quality of Life (V-RQOL), a to the voice center, so a 1-hour site visit
self-assessment scale to demonstrate the was arranged. Observations made dur-
effect the voice disorder was having on ing the visit included:
her life.102 Results demonstrated a mod-
erate life impact. n large room
Following the voice evaluation and n unusually high (1618 feet) acoustical
testing, a treatment plan was proposed. tile ceilings
The plan included: n sound was lost in space
n only 24 students spread throughout
n temporary reassignment from play- the large room at different stations
ground and school-bus duties n all sounds (scooting chairs, dropped
n site visit to determine environment books, and so forth) were magnified
and teaching style by glass and plastic
n elimination of the abusive behavior n speech was hard to discriminate.
of throat clearing
n oral hydration program It was obvious that patient F loved
n symptom modification her work. She was enthusiastic and
n Vocal Function Exercises designed to had complete control of the classroom.
rebalance respiration, phonation, and Observations made regarding her teach-
resonance. ing style included:

n vocally enthusiastic, but does not

Temporary Reassignment
n room requires that she speak loudly
It was decided to immediately elimi-
and precisely, not to be heard but to
nate the potential for the most obvious
be understood
vocal traumas. The patient therefore
n spends a good deal of time direct-
requested to be assigned to other duties
ing children when not actually
away from the playground and school
buses where voice would not be a factor
n uses high pitch, limited inflection, and
and she would not be required to raise
back focus; constantly strains voice.
her voice. If therapy proved to be suc-
cessful, reassignment would be tempo-
An audio recording was made dur-
rary. Otherwise, it would continue until
ing the visit that was reviewed later in
the end of the school year.
therapy. The opportunity to visit the
patients classroom led to several sug-
Site Visit gestions. These included

Site visits are time consuming and not n Decrease the physical space by rear-
always practical, but the value of seeing ranging seating and using approxi-
Primary and Secondary Muscle Tension Dysphonia 109

mately two-thirds of the classroom. offending child, all the while con-
With a class size of only 24 stu- tinuing her teaching. A list of conse-
dents, this was easy to accomplish. quences for receiving more than one
The patient herself suggested an symbol correction was established by
additional change. She physically the teacher and well understood
decreased the room size by using by the children.
large, freestanding display boards
(which were normally in school stor-
age) as temporary walls. Elimination of Throat Clearing
n Soften the acoustics of the room by
using the window blinds, pulled The previous suggestions proved suc-
halfway down. Use fabric in a work cessful in immediately decreasing the
display area by hanging a sheet on daily laryngeal fatigue and voice strug-
the wall to display student papers, gle. The patient, of course, remained
pictures, tests, and similar exhibits. dysphonic. The therapy plan then intro-
The large display boards also func- duced a behavior modification approach
tioned well as an acoustic barrier. for eliminating the phonotraumatic be-
n Build into the schedule a vocal time- havior of throat clearing. Until brought
out for both the teacher and the stu- to her attention by the therapist, the
dents. Learn to respect and appreci- patient was not aware of the frequency
ate the silent time as a chance to rest of her throat clearing. Throat clearing
the voice and as a reminder to talk may be extremely abusive to the tissue
only as loudly as necessary in the lining of the vocal folds and arytenoid
newly configured classroom. cartilages. Once brought to her atten-
n Develop a sign system for common tion, the patient was surprised by the
instructions and requests. It was number of times she cleared her throat
noted during the site visit that the during the session. To modify this
patient was constantly correcting behavior, she was told the following.
and directing students actions while
Throat clearing is one of the most abu-
instructing. When this was brought sive things you can do to your vocal
to her attention, she decided to imple- folds. When you clear your throat
ment an interesting sign-symbol sys- like this (demonstrate), you create an
tem that would preclude voice com- extreme amount of movement of your
mands. She listed the names of the vocal folds, causing them to slam and
students on a large magnetic board rub together (demonstrate using your
in the corner of the classroom. Signs hands). You should understand that it
were then made with picture symbols is not unusual to have developed this
depicting the most common correc- habit. The vast majority of patients
tions and directions that she made. we see with your type of voice prob-
lem also have this habit. Sometimes
They included symbols represent-
people do not even know that they are
ing such directions as the following:
doing it, but often they say that they
be quiet, dont tilt your chair, slow feel something in their throat, such as
down, stop talking, talk softer, and a lump or mucus. The majority of the
pay attention. These symbol pictures time, however, when you clear your
were attached to magnets. When the throat, there is nothing there. Often,
need arose, the patient would place patients only feel a sensation of thick-
the symbol next to the name of the ness from chronic strain. The only thing
110 Voice Therapy: Clinical Case Studies

you have accomplished is to create begin to catch yourself. You will

more vocal fold abuse. clear your throat and almost imme-
We have demonstrated to you diately think, Oops! I am not sup-
with the audio recording from your posed to do that. Your response again
class that, most of the time, you clear should be to swallow forcefully.
your throat right before you begin to When you have caught yourself
speak. We call that a preparatory throat clearing your throat several times, you
clear. Also, you are clearing many more begin to halt yourself just prior to clear-
times than you realized. This is a sign ing. Once again, you will substitute the
that throat clearing is a habit. As with hard swallow, but this time the throat
all habits, it is difficult to break. We are, clearing was stopped. By the time you
therefore, going to try to make it easier have reached this point, you will be
by giving you a substitute habit that close to breaking the habit totally. The
will (1) take the place of throat clear- final goal will be met when you realize
ing, (2) accomplish the same thing as that you are swallowing many fewer
throat clearing, and (3) is not abusive. times than the number of times you
This substitute, nonabusive habit is a previously were clearing your throat.
hard, forceful swallow. I want you to work hard on this
If you do, in fact, occasionally problem. I think you will be surprised
have increased amount of mucus on just how quickly you are able to break
your vocal folds, a forceful swallow this habit. As a matter of fact, the
will accomplish the same thing as majority of our patients have signifi-
throat clearing, minus the abuse. The cantly reduced the habit within 1 to
only difference is that throat clearing 2weeks. Most patients, however, can-
feels good. It psychologically gives not do it alone. So please, find other
you more relief than the forceful swal- people to help you by having them
low, even though it physically accom- point out when you are doing it. Any
plishes no more. It is your goal to over- questions? (Reprinted from Stemple,
come the psychological dependence. Glaze, and Klaben103).
Understand that this habit is harmful
and that it must be broken. Following this explanation, the
To break this habit, you need to patient typically will clear his or her
tell everyone in your family and any throat more times than usual. The voice
friends who are often around you pathologist immediately points this out,
(and whom you feel comfortable tell- and the patient initiates a forceful swal-
ing) that you are not permitted to clear
low substitution. Often, patients make
your throat anymore. When these
great gains in habit modification during
helpers hear you clear your throat,
and they will, they are to immediately this initial session. Patient F received help
point it out. You may even consider from her husband, mother, and a friend
using your students as helpers. Your and was able to totally eliminate the habit
task, then, is to swallow forcefully. of throat clearing within 2 weeks.
Obviously, it will not be necessary to
swallow because you just cleared your
throat, but this is your first step in Oral Hydration Program
substituting the hard swallow for the
throat clearing. The vocal folds must be well lubricated
After your family, friends, or stu- to decrease the heat and friction of vibra-
dents have pointed out your throat tion. Thin, slippery mucus secreted onto
clearing to you several times, you will the vocal folds serves the same purpose
Primary and Secondary Muscle Tension Dysphonia 111

as oil serves to the engine of car. It was Vocal Function Exercises

explained to patient F that what she
swallows does not touch her vocal folds An important part of this patients voice
but is diverted around them. Therefore, therapy program was the use of Vocal
the amount and type of liquid intake Function Exercises. These exercises,
will either permit or inhibit the normal first described by Barnes104 and modi-
mucus flow to the vocal folds. Caffeine, fied by Stemple,92 strive to balance the
alcohol, and many medications are dry- subsystems of voice production. The
ing agents. Many times, when patients exercise program has proven successful
feel as if they have too much mucus in improving and enhancing the vocal
on the vocal folds, they actually have function of speakers with normal voices
increased mucous viscosity, which is and disordered voices.92,105 In addition,
thicker and stickier than is desirable. Sabol, Lee, and Stemple106 demonstrated
This patients liquid intake was the effectiveness of Vocal Function Exer-
minimal and caffeinated. She therefore cises in the exercise regimens of singers.
was placed on a hydration program The program is rather simple to
that required a minimum intake of six, teach and, when presented appropri-
240-mL (8 fl oz) glasses of water or fruit ately, seems reasonable to patients.
juice per day. In addition, she was asked Many patients are enthusiastic to have a
to decrease her caffeine intake but was concrete program, similar in concept to
not required to totally eliminate caffeine physical therapy, during which they may
from her diet. plot the progress of their return to vocal
efficiency. The program is as follows.
Describe the problem to the patient,
Symptom Modification using illustrations as needed or the
patients own stroboscopic evaluation
Direct symptom modification also was video. The patient is then taught a series
introduced. These tasks included the of 4 exercises to be done at home, twice
following: each, 2 times per day, preferably morn-
ing and evening. These exercises include:
n The patient enhanced her awareness
of appropriate pitch and loudness 1. Sustain the /i/ vowel for as long as
used during teaching. The initial possible on a musical note F above
audio recording was used to demon- middle C for all female patients
strate problems with pitch, loudness, and boys and F below middle C for
and focus. mature male patients. (Notes may
n The patient was instructed to talk be modified up or down to fit the
only as loudly as was absolutely nec- needs of the patient. Seldom are
essary in the classroom. A combina- they modified by more than 2 notes
tion of these approaches returned in either direction.)
her teaching style to a more conver- Goal: based on airflow volume.
sational mode. (In our clinic the goal is based on
n Reconfiguring the classroom and reaching 80 to 100 mL/s of airflow.
improving the acoustics was also a So, if the flow volume is equal to
factor in making positive changes in 4000 mL, then the goal is 40 to 50
voice production. seconds. When airflow measures
112 Voice Therapy: Clinical Case Studies

are not available, the goal is equal By keeping the pharynx open and
to the longest /s/ that the patient focusing the sympathetic vibra-
is able to sustain. Placement of the tion at the lips, the downward
tone should be in an extreme for- glide encourages a slow, systematic
ward focus that is almost, but not engagement of the thyroarytenoid
quite, nasal. All exercises are pro- muscles without the presence of
duced as softly as possible, but a back-focused growl. In fact, no
are not breathy. The voice must be growl is permitted. (May also use
engaged. This is considered a a lip trill, tongue trill, or the word
warm-up exercise.) boom.) This is considered a con-
tracting exercise.
2. Glide from your lowest note to your
highest note on the word knoll. 4. Sustain the musical notes C, D, E,
F, and G for as long as possible on
Goal: no voice breaks. (The glide the word knoll minus the kn.
requires the use of all laryngeal (Middle C for all female patients
muscles. It stretches the vocal folds and boys, an octave below middle
and encourages a systematic, slow C for mature male patients.)
engagement of the cricothyroid mus-
cles.) The word knoll encourages Goal: remains the same as for exer-
a forward placement of the tone as cise 1. (The oll is once again pro-
well as an expanded open pharynx. duced with an open pharynx and
The patients lips are to be rounded constricted, sympathetically vibrat-
and a sympathetic vibration should ing lips. The shape of the pharynx
be felt on the lips. (May also use a to the lips is likened to an inverted
lip trill, tongue trill, or the word megaphone. The fourth exercise
whoop.) Voice breaks typically may be tailored to the patients pres-
will occur in the transitions between ent vocal ability. Although the basic
low and high registers. When breaks range starting at middle C, an octave
occur, the patient is encouraged to lower for mature male patients, is
continue the glide without hesita- appropriate for most voices, the
tion. When the voice breaks at the exercises may be customized up or
top of the current range and the down to fit the current vocal con-
patient typically has more range, dition or a particular voice type.
the glide may be continued without Seldom, however, are the exercises
voice as the folds will continue to shifted more than 2 notes in either
stretch. Glides improve muscular direction. This is considered a low-
control and flexibility. This is con- impact adductory power exercise.)
sidered a stretching exercise.)
Quality of the tone is also monitored
for voice breaks, wavering, and breathi-
3. Glide from a comfortable note to your
ness. Quality improves as times increase
lowest note on the word knoll.
and pathologies begin to resolve.
Goal: no voice breaks. (The patient All exercises are done as softly, but
is instructed to feel a half-yawn in engaged. It is much more difficult to
the throat throughout this exercise.) produce soft tones; therefore, the vocal
Primary and Secondary Muscle Tension Dysphonia 113

subsystems will receive a better work- remain in peak vocal condition using the
out than if louder tones were pro- exercises, many of our patients desire to
duced. Extreme care is taken to teach the taper the program. The following sys-
production of a forward tone that lacks tematic taper is recommended:
tension. In addition, attention is paid to
the glottal onset of the tone. The patient n Full program 2 times each, 2 times
is asked to breathe in deeply with atten- per day
tion paid to training abdominal breath- n Full program 2 times each, 1 time per
ing, posturing the vowel momentarily, day (morning)
and then initiating the exercise gesture n Full program 1 time each, 1 time per
without a forceful glottal attack or an day (morning)
aspirate breathy attack. It is explained n Exercise 4, 2 times each, 1 time per
to the patient that maximum phonation day (morning)
times increase as the efficiency of the n Exercise 4, 1 time each, 1 time per day
vocal fold vibration improves. Times do (morning)
not increase because of improved lung n Exercise 4, 1 time each, 3 times per
capacity. Even aerobic exercise does week (morning)
not improve lung capacity but rather n Exercise 4, 1 time each, 1 time per
the efficiency of oxygen exchange with week (morning)
the circulatory system, thus giving the
sense of more air. Each taper should last 1 week. Patients
The patient is provided with an should maintain 85% of their peak time,
audio CD of live voice doing the exer- otherwise they should move up 1 step in
cises which is used to guide the home the taper until the 85% criterion is met.
exercise sessions. We have found that In short, Vocal Function Exercises
patients who complain of tone deaf- provide a holistic voice-treatment pro-
ness often can be taught to approxi- gram that attends to the 3 major sub-
mate the correct notes with practice and systems of voice production. The pro-
guidance from the voice pathologist. gram appears to benefit patients with
Finally, patients are given a chart a wide range of voice disorders both
on which to mark their sustained times, hyperfunctional and hypofunctional.
which is a means of plotting progress The daily exercises require a reasonable
(Table 35). Progress is monitored over amount of time and effort. In addition,
time, and because of normal daily vari- it is similar to other recognizable exer-
ability, patients are encouraged not to cise programs; the concept of physical
compare one day with the next. Rather, therapy to improve muscle function is
weekly comparisons are encouraged. understandable; progress may be easily
Estimated time of completion for the plotted, which is inherently motivating;
program is 8 to 10 weeks. and it appears to balance airflow, laryn-
When the patient has reached the geal activity, and supraglottic place-
predetermined therapy goal and the ment (reprinted from Stemple, Glaze,
voice quality and other vocal symptoms and Klaben103).
are improved, a tapering maintenance Vocal Function Exercises were help-
program is recommended. Although ful in improving the overall condition
some professional voice users choose to of patient Fs vocal folds and helped to
Table 35. Vocal Function Daily Record


E/F / / / / / / /
C / / / / / / /
AM D / / / / / / /
E / / / / / / /
F / / / / / / /
G / / / / / / /

E/F / / / / / / /
C / / / / / / /
PM D / / / / / / /
E / / / / / / /
F / / / / / / /
G / / / / / / /


E/F / / / / / / /
C / / / / / / /
AM D / / / / / / /
E / / / / / / /
F / / / / / / /
G / / / / / / /

E/F / / / / / / /
C / / / / / / /
PM D / / / / / / /
E / / / / / / /
F / / / / / / /
G / / / / / / /

Primary and Secondary Muscle Tension Dysphonia 115

retrain frontal focus. The patients base- The results of the therapy program
line mean phonation time for sustaining were discussed with patient Fs physi-
the appropriate notes was 8.5 seconds. cian. Considering the cystlike nature
This measure improved to a mean of 18 and stiffness of the right vocal fold
seconds during 6 weeks of therapy. lesion, it appeared unlikely that the
Significant improvement was noted lesion would resolve with therapy. It
during 6 weeks of therapy for both sub- was decided to extend therapy for an
jective observations of voice quality and additional month to be certain that this
objective measures of vocal function. was the case. When the remaining lesion
The patient was experiencing much did not resolve, surgery was scheduled
less vocal fatigue and laryngeal dis- for the second week in June.
comfort. Audio recordings made while The pathologists report confirmed
teaching demonstrated stabilization of the lesion to be a cyst. Following sur-
new voicing habits and only very occa- gery, the patient continued Vocal Func-
sional throat clearing. She did, however, tion Exercises for 1 month and began
remain mildly dysphonic, characterized a maintenance exercise program for
by a slight breathy hoarseness. the remainder of the summer. Maxi-
Objective measures demonstrated mum phonation times improved and
a fundamental frequency of 196 Hz and stabilized at an average of 32 seconds.
an expanded frequency range of 165 to The voice quality improved to normal.
720 Hz. Jitter and shimmer measures Changes in objective measures included
were within normal limits. Airflow rates a higher frequency range (+900 Hz)
for comfort and low-pitched voices were and a normal airflow rate at high pitch
decreased to 136 and 150 mL/s, respec- (160mL H2O/s). Videostroboscopic
tively. Airflow rate for high-pitched examination performed just prior to
voice was also decreased to 240 mL/s the fall opening of school revealed all
but was still above the normal limit of observations to be within normal limits
200 mL/s. except for the symmetry of vibration,
Videostroboscopy also demon- which remained irregular at higher
strated improvement. The edema and pitches.
erythema were resolved, and there was Patient F was followed monthly to
no evidence of the contact ulcer. A slight confirm her symptom-free status. Her
thickness was noted where the left nod- voice remained normal. The combina-
ule had been. The right nodule was still tion of medical and surgical treatment
present but appeared much more cyst- and a holistic voice therapy program
like. Glottic closure retained an hour- proved successful in remediating a long-
glass shape; however, the glottal chinks term voice disturbance in this patient.
were much smaller. The amplitude of
vibration was only slightly decreased
Another voice therapy program, which
left and moderately decreased right.
is popular in Great Britain, Scandina-
The mucosal wave was normal on the
via, Europe, and the Middle East, is
left and moderately decreased around
the Accent Method. In this study of a
the right lesion. The open phase of the
young singer, Sara Harris describes in
vibratory cycle was slightly dominant,
detail the rationale and the management
whereas the symmetry of vibration re-
plan for this approach.
mained irregular.
116 Voice Therapy: Clinical Case Studies

n conditioning (the unconscious pro-

Case Study 14 cess of learning)
n focus on normal vocal function rather
Sara Harris than the pathology.107,108

Accent Method in the Treatment The myoelastic-aerodynamic theory of

of Secondary MTD vocal fold vibration was described in
the 1950s by van den Berg109 and relies
This case study discusses the Accent on the concept of the Bernoulli effect.
Method of Voice Therapy and describes Although recent research has dem
its benefits in restoring efficient vocal onstrated that this effect cannot explain
function to a young singer with mid all the factors involved in sustaining
third vocal fold thickening and a mus- vocal fold vibration, the need to estab-
cular tension pattern of dysphonia.16 lish and maintain a satisfactory subglottic
The Accent Method is a holistic ther- pressure and transglottal airflow remains
apy regime designed to coordinate the essential to efficient voice production.110
muscles of respiration, phonation, and The conditioning of the desired
articulation to produce efficient voice phonation pattern takes place during
production and clear, resonant, well- long periods of repetition of the Accent
modulated speech. Method exercises. The exercises include
Svend Smith, a Danish phoneti- all the vowels and consonants used in
cian, designed the Accent Method in spontaneous speech from which the
the 1930s. It is used widely in Europe patient produces sequences of sustained
including the Scandinavian countries. sounds and syllables to sentence level.
Smith was keen to develop a dynamic These meaningless babbled sentences
technique for voice and speech skills incorporate prosodic features such
that emphasized the whole commu- as rhythmic stresses, intonation, and
nication process, including nonverbal loud-soft vocal dynamics. The practice
aspects such as eye contact and gesture. sessions may range from anywhere
He was influenced greatly by the rhyth- between 10 and 30 minutes. Although
mic patterns produced by the bongo concentration is needed in the early
drummer Joe Bogdana who accompa- stages as patients establish the desired
nied the entertainer Josephine Baker. patterns, the unconscious processes of
He saw a potential use of these rhythms learning and overlearning take over as
to reinforce intonation and prosody, as they practice. Carryover of the newly
well as to provide a framework in which learned skills into spontaneous, con-
to practice voice and articulatory skills. tinuous speech then occurs easily and
Smith and Bogdana worked together to reliably, decreasing the likelihood of
devise the three temposlargo, andante, relapse. This is in stark contrast to other
and allegrothat are still used in the methods in which patients are asked
technique today. to produce a sustained sound or short
The theoretical underpinning of the utterance but then discuss the effects of
Accent Method is based on the following: it using their habitual pattern of voice
n the myoelastic-aerodynamic model The Accent Method exercises con-
of vocal fold vibration centrate on establishing efficient vocal
Primary and Secondary Muscle Tension Dysphonia 117

fold closures for speech in modal voice contents, rather than pulling against the
using simultaneous vocal onset coor- semirigid structure of the rib cage.
dinated with a stable, well-controlled The development of modal voice
expiratory airflow. Initially, the exercises is also a specific feature of the Accent
deliberately encourage breathy phona- Method. Modal voice is produced by
tion with gradual increase of vocal fold short, thick vocal folds with relaxed
adduction until comfortable, clear voice cricothyroid muscles. Good vocal fold
is achieved. Research suggests that this closure can be achieved easily and,
phonation pattern made with the vocal provided there is sufficient subglottic
folds barely touching produces efficient pressure, satisfactory mucosal waves
and particularly resonant voicing.72,111 are generated. The larynx lies neutrally
It allows the therapist to work equally in the neck, and the pharyngeal and
effectively with patients who are hyper- supraglottic musculature is less likely
adducted or hypoadducted and explains to constrict. By contrast, production of a
why the Accent Method exercises have technical falsetto or head voice requires
been reported as being successful with a thinned vocal folds and contracted cri-
wide range of vocal disorders. cothyroid muscles. When the vocal liga-
ments are stretched, mucosal waves are
smaller, and the vocal fold closure may
Specific Features be harder to maintain over long periods.
The larynx is raised to shorten the vocal
Establishing abdominal breathing is a tract and adjust the resonators appro-
specific feature of the Accent Method. priately for higher pitches, which may
Inspiration relies on contraction of the lead to constriction in the supraglottic
diaphragm, which has been described and pharyngeal musculature. In every
as the major muscle of inspiration,112 way, head voice requires more muscular
allowing the speed and amount of effort on the part of the laryngopharynx.
inspired air to be controlled easily and Many of our English patients adopt this
effectively. Expiration is controlled type of phonation pattern for speech,
in part by elastic recoil and in part by and it is especially common in singers
contraction of the abdominal muscu- who are used to producing head voice
lature. Contractions of the latter may for singing. Some singing teachers even
be smooth for sustained vocalization encourage a higher speaking voice by
and unstressed utterances or punctu- suggesting it is more appropriate for
ated by smaller, faster contractions that sopranos. Unfortunately, clinical evi-
alter the subglottic air pressure to pro- dence suggests that long periods of this
duce changes in vocal intensity associ- pattern of vocal use may result in bow-
ated with stressed words or utterances ing of the vocal folds as they become
of increased vocal loudness. Although unable to maintain closure against the
research has shown that there are a num- stretching produced by powerful crico-
ber of different patterns of breathing thyroid muscle contraction.114
and breath control,113 it may be argued The initial focus on fricatives and
that diaphragmatic-abdominal control close vowels during the Accent Method
is most economical of muscular effort. exercises is also an important feature of
Diaphragmatic-abdominal breathing the method. These sounds all produce
displaces soft tissue and the abdominal narrowing of the vocal tract within the
118 Voice Therapy: Clinical Case Studies

oral cavity and are believed to create Patient Is case history revealed
back pressure,115 which assists fast clo- that she was fit and well with no previ-
sure of the vocal folds and may influ- ous or family history of voice problems.
ence the length of the closed phase. In particular, she had no symptoms of
They also encourage a high, forward gastroesophageal reflux and no asthma,
tongue position, opening space between allergies, or other ENT problems.
the back of the tongue and the pharynx, As with many students, patient I
which may be associated with the for- needed to work to support herself at
ward resonance described by singers. college. She worked in a noisy restau-
The high tongue position has also been rant that was air conditioned and often
associated with enhancement of the 250- smoky. She was aware of how much she
kHz region in the vocal spectrum, pro- had to shout in her job, and she also had
viding extra brightness and penetration to do shift work that often involved late
to the vocal tone and allowing it to be nights. In addition to her work and her
heard through background noise.116 singing, she ran a youth group at a local
church that also involved protracted
voice use and shouting. Patient I was
Case History the youngest of 3 sisters and described
herself as small but noisy as a child.
Patient I presented in the ENT clinic She was aware of stress induced by her
at the request of her general practitio- college work.
ner and her singing teacher. She was
22 years old and studying singing at
a well-known music college in Lon- Assessment
don. She planned to be a professional
mezzo-soprano, specializing in classical Initially patient I was seen by an oto-
and early romantic styles of singing. At laryngologist specializing in voice dis-
the time she was seen, she was in her orders, who carried out videostrobolar-
final year at college with only 3 months yngoscopy. Examination revealed that
remaining before her final examinations she had an average to large larynx with
and recital. significant midthird polypoid thicken-
Patient I had been noticing a prob- ing of both vocal folds. The right fold
lem with her voice for approximately thickening was more prominent than
6months. She reported that it sounded the left. There was a wide interaryte-
breathy and immature in her singing noid chink, and the anterior third of the
and that there were dead patches in vocal folds failed to close during pho-
her upper pitch range where the voic- nation. Mucosal waves were present
ing broke into audible air escape. Her but poorly developed, largely because
singing teacher was particularly con- of inefficient voice production. The lar-
cerned because patient I was no lon- yngologist diagnosed patient Is vocal
ger responding to the usual singing pathology as a type-2 muscular ten-
techniques designed to resolve these sion dysphonia, later named laryngeal
problems. She reported that her speak- isometric disorder.2,16 The laryngologist
ing voice was mostly OK but became referred patient I for voice therapy with
breathy and hoarse both when she was a speech-language therapist who spe-
tired and following prolonged voice use. cialized in voice.
Primary and Secondary Muscle Tension Dysphonia 119

Perceptual analysis was carried out Stamina

informally in clinic and from the patients
initial audio recording of a standard The patient reported that her speaking
reading passage. voice felt tired and became increas-
ingly breathy and weak by the eve-
ning. Fatigue developed after an hour
Pitch of singing or speaking loudly. Her voice
Patient Is speaking pitch and intona- responded to rest and had usually
tion range appeared to be well within recovered by morning, although after a
the norm for her age and gender. Sire- heavy week of voice use in the restau-
ning through her full pitch range for rant, the recovery period increased to
singing showed a characteristic break several days of normal voice use and
in the upper register where she could voice rest.
no longer sustain phonation. Efforts to Patient I had no malocclusion, den-
overcome this problem area resulted in tal problems, or articulatory disorders.
a breathy squeak and visible effort She produced a good range of articula-
in the extrinsic laryngeal muscles. tory movement in speech with normal
oral-nasal resonance balance. Her tongue
position appeared to be reasonably neu-
Intensity and Volume tral, and her lip set in speech was rated
Patient Is speaking voice was normal as neutral and slight rounding.
in intensity for quiet conversation with
no obvious signs of increased laryngeal Assessment of Breathing Patterns
effort. She was able to shout, but this
produced extrinsic laryngeal muscle Airflow measures are not available to
effort and led to early vocal fatigue. She this clinician for routine use. The assess-
reported that the intensity of her sing- ment therefore was carried out on infor-
ing voice had decreased and that she mal observation in the clinic. The breath-
no longer had control over her dynamic ing pattern at rest was produced in the
range. High-intensity singing tired her upper chest. There was little observable
voice more quickly and felt effortful. movement of the abdomen during quiet
breathing. During speech, this pattern
Quality of breath control continued. Expira-
tion was controlled by the upper chest,
The patients speaking voice was rated which was observed pushing inward,
as mildly-moderately hoarse. She used particularly when words were stressed.
a thin fold phonation type with audible Top-up breaths were also upper chest
air escape. or clavicular. Observation of breath
control for singing revealed that patient
Comfort I was able to produce a more central
pattern and was attempting to recruit
Patient I reported no discomfort when the abdominal muscles to help control
speaking or singing but described a expiration for sustained notes. The pat-
sense of increased effort or tiredness tern was erratic and hampered by poor
with high-intensity voice use, whether fold closure and air escape, however. As
singing or speaking. a result, she frequently used residual air
120 Voice Therapy: Clinical Case Studies

and produced signs of increased effort, was aligned with the anterior aspect
both in the upper chest and extrinsic of the thyroid cartilage.
laryngeal muscles. She reported that n Thyrohyoid musculature: Palpation of
her singing training had provided rela- the thyrohyoid musculature revealed
tively little guidance on breathing, and that these muscles were judged to be
she was uncertain about the meaning of held tightly with a reduced thyro-
the term breath support. hyoid space area. They contracted
briskly when speech was initiated and
Palpation of the Extrinsic remained contracted throughout the
Laryngeal Musculature utterance. The normal contractions
usually observed during speech were
Assessment of the external laryngeal reduced. Patient I was able to release
musculature is standard practice in the this musculature using the yawn-sigh
authors clinic, and a shortened form technique to lower the larynx and was
of the Lieberman protocol is used.23,114 able to maintain a greater thyrohyoid
As yet, there are no international norms space successfully when the laryngeal
for palpatory findings; however, Jacob position returned to its rest position.
Lieberman, a qualified osteopath spe- She did not report tenderness when
cializing in laryngeal manipulation, has these muscles were palpated.
trained this clinician, and practitioner n Cricothyroid musculature:The crico-
agreement has been reached for the fol- thyroid muscles were judged to be
lowing tasks117: held more tightly on the right than
on the left, and the patient reported
n Jaw: There was some asymmetry of some tenderness when these muscles
jaw opening to the right, and the left were palpated. The cricothyroid visor
temporomandibular joint appeared (the anterior space between the lower
to be more active than the right. This border of the thyroid cartilage and
was apparent during the jaw opening the upper border of the cricoid car-
assessment tasks and during spon- tilage) appeared to open and close as
taneous speech. The patient had no expected with changing vocal pitch
awareness of the asymmetry and did (yawn-sigh contrasted with a high-
not suffer from temporomandibular pitched squeak), but it was habitu-
joint discomfort. Her singing teacher ally held at rest in a closed neutral
had commented that she felt patient position. The alignment between the
Is jaw tended to be tight during lower border of the thyroid cartilage
singing. and the upper border of the cricoid
n Suprahyoid and base of tongue muscu- cartilage showed that the cricoid was
lature: The suprahyoid and base of held in a more anterior position rela-
tongue musculature was assessed as tive to the thyroid. This suggested the
tighter than average on palpation. possibility of some anterior sliding at
Patient I did not report any tender- the cricothyroid joint.114,118
ness in these muscles, but there was n Strap musculature:These muscles
strong contraction of the geniohyoid were judged to be tight, particularly
muscles during speech and singing. on the right on palpation and laryn-
The anterior aspect of the hyoid bone geal shift. The larynx moved easily
Primary and Secondary Muscle Tension Dysphonia 121

to the right but was anchored by the n restoring vocal stamina and comfort
tight right strap muscles, restricting for singing and speech.
laryngeal shift to the left.
n Laryngeal position in speech: The pa- The therapists treatment aims were to:
tients larynx maintained a neutral
position in the neck for breathing n facilitate full and uniform vocal fold
and raised normally for swallow- closure
ing. It returned easily to a neutral n establish modal (thick fold) phona-
position in the neck following swal- tion during speech
lowing, but as patient I anticipated n establish a higher subglottic air pres-
speech, the larynx rose in the neck sure and better breath control sup-
and maintained the raised position ported by the abdominal musculature
reliably throughout the utterance. It n reduce supraglottic muscular effort
returned to neutral as soon as phona- during speech.
tion ceased.
The therapist decided to use the
Accent Method as the main treatment
Treatment Plan technique for patient I to establish the
above aims. In addition, it would be
The assessment findings were explained supported by:
and discussed with patient I in the clinic.
Vocal rest was not an option because of n discussion on vocal hygiene and the
her need to earn money and the fact use of a voice diary to highlight
that her final recital was only 3 months vocal trauma in daily life
away. Therefore, we agreed that she n techniques such as sirening91 to facili-
would continue with her normal vocal tate better control of the cricothyroid
commitments but try to schedule her mechanism, improving vocal range
restaurant work during the day or on and register changes
weekday evenings to avoid the greatest n introduction of some work on
levels of background noise at the week- twang voice quality91 for specific
ends. She also agreed to try to reduce use in the restaurant where shouting
some of the talking at her youth club. was inevitable
Her singing lessons would continue as n specific laryngeal massage to reduce
a priority. excess tension in the extrinsic laryn-
Six, 1-hour sessions of voice ther- geal muscles.
apy, once weekly, were agreed on, using
audio-recorded exercises made during
the sessions for home practice. Patient I Early Accent Method
stated her voice therapy aims as: Exercises:Establishing
Abdominal Breathing
n restoring her full vocal range without
her voice breaking or hitting a dead The patient was seated in a comfortable,
patch upright chair for back support and her
n restoring her clear vocal quality in posture checked and aligned. She was
singing and speaking encouraged to drop her shoulders down
122 Voice Therapy: Clinical Case Studies

and to allow her abdominal muscles in more deeply than they would for the
to relax. She then observed and moni- previously established rest breathing,
tored the movement of her abdominal and the fricatives are made on elastic
wall, placing her hand on her abdo- recoil rather than recruiting the abdom-
men, low down, below the level of her inal musculature for controlling either
waist. The therapist sat beside her and the length or intensity of the sound.
placed the back of her own hand over Traditionally, little explanation is
patient Is hand to monitor the move- given to patients treated with the Accent
ment. The patient, likewise, placed the Method; if errors occur, the therapist
back of her hand over the therapists simply returns the patient to tasks he
abdomen to feel the therapist model the or she manages easily before gently
desired breathing pattern. As the thera- increasing the complexity again. This
pist breathed in, patient I observed her therapist, however, does provide more
lower abdomen expand and then con- guidance to patients, depending on
tract, moving inward on expiration. their level of knowledge, experience,
Gradually, the patient began to produce and skill, because it is vital to maintain
the same pattern, and the therapist syn- the patients cooperation for a condi-
chronized her own breathing rate to tioning activity that can appear eccen-
patient Is, having reminded her not to tric and mindless. At this early stage, if a
breathe too quickly or too deeply. patient continues to produce a low flow
As a singer, patient I had little diffi- for fricatives, an overly long and con-
culty establishing abdominal breathing. trolled expiration, or both, this could be
When patients have difficulty, the early drawn to their attention. It also can be
Accent Method exercises may be carried helpful for patients to notice that expi-
out with the patient lying supine so that ration stops naturally as lung pressure
the abdominal musculature can relax equalizes with the air pressure outside
because these muscles are no longer and that expiration pushed past this
required for postural support. This has point requires muscular effort. This
the advantage of allowing patients to lie observation allows patients to locate
on their sides, which facilitates contrac- any increased effort in the upper chest
tion of the abdominal musculature on and strap muscles when they push
expiration, once abdominal breathing past the rest position, which they can
has been established. then correct.
Patient I was asked to repeat sounds The therapist monitors the vocal
modeled by the therapist. The initial quality to ensure that the patient uses
sounds recommended are the voice- modal phonation. Voice onset may
less fricatives /k/ (bilabial) /s/, /sh/, need to begin with breath before tone
and /f/, repeated to form a rhythmic (ssszzzss) but should gradually become
sequence designed to increase trans- simultaneous with exhalation and pho-
glottic airflow. Gradually, the voiced nation coordinated together. The vocal
counterparts /g/, /z/, /zs/, /v/, and quality should become clearer but remain
close vowels such as /i/ and /u/ were somewhat breathy. Phonation should be
introduced into the repeated sequences reliable and consistent as vocal fold clo-
with emphasis on deliberately gen- sure becomes uniform, with the midthird
tle, breathy phonation. At this stage, swelling displaced upward and away
patients are encouraged not to breathe from the vibrating edge of the fold by
Primary and Secondary Muscle Tension Dysphonia 123

increased subglottic air pressure and air- the patient time to coordinate expira-
flow. If these changes are not achieved, tion and the activity of the abdominal
the therapist may need to return to an ear- muscles. It also allows time for a rela-
lier stage, drawing the patients attention tively slow inspiration. The therapist
to any problems that have developed. and patient I continued to monitor the
Other techniques can be incorpo- excursions of the abdominal wall while
rated if necessary to provide a bridge sitting and standing. Gentle rocking of
from one stage to another, depending on the entire body may facilitate general
the problem. For example, staying with relaxation and reinforce the rhythmic
breath before tone onset for longer structure of the technique. The thera-
periods ensures that the patient does pist then works the patient through the
not return to his or her previous hyper- andante (Figure 36) and allegro (Fig-
adduction patterns, and introducing ure37) tempos, gradually introducing
nasal consonants /m/, /n/, /ng/ usu- other vowels and consonants until the
ally resolves closure problems and the patient can maintain the desired pho-
wide glottic chink. Problems of contin- nation pattern for babbling long, pro-
ued supraglottic tension often may be sodic utterances of 20 minutes or more.
overcome using palpatory monitoring Work designed to alter tongue position
of the thyrohyoid space or the general or oral-nasal resonance balance can be
laryngeal movement. Rarely is it neces- incorporated into the sound sequences
sary to resort to gentle glottal onsets to at this stage. Other prosodic features,
ensure modal voice, because this can such as intonation (pitch contrasts) and
usually be achieved using palpatory dynamic (loud-soft) contrasts, can also
monitoring of the cricothyroid visor. be practiced.
Gradually, patient I was encour- As the patient gains confidence,
aged to produce gentle contractions of meaningful words are introduced. Ini-
her abdominal musculature on expi- tially, repetition of therapist-modeled
ration. The largo tempo (Figure 35) utterances or rote-learned materials
was introduced, in which expiration is (such as rhymes or poems) are practiced
punctuated by shorter, sharper rhyth- before the patient graduates to sponta-
mic contractions of the abdominal mus- neously generated utterances, such as
cles to produce stressed or accented responding to questions from the thera-
beats. The largo tempo is slow, allowing pist or describing events.

Figure 35.Largo.
124 Voice Therapy: Clinical Case Studies

Figure 36.Andante.

Figure 37.Allegro.

Results was no longer present. The dead patch

in her vocal range had disappeared, and
Patient I completed seven, 1-hour ses- she was able to siren through her range
sions of Accent Method voice ther- smoothly and reliably. She still had to be
apy, which took place over 3 months careful to balance the air pressure and
between late February and May, with transglottal flow correctly while pro-
a 2-week break over the Easter holiday. ducing high and soft notes in her sing-
The sessions were audio recorded, and ing, but otherwise her singing voice no
patient I continued to practice the work longer gave her trouble. Her teacher
at home on a daily basis. Reassessment reported that she was able to continue
in early June showed patient I to have developing her singing skills.
improved significantly in her vocal Palpation of the extrinsic laryn-
health and voice production. Perceptu- geal muscles showed that the tightness
ally, the patients voice continued to be noted at her first assessment had largely
slightly breathy, but the audible turbu- resolved. All her scores had returned to
lent air escape present on her original neutral except those for the thyrohyoid
recording had resolved. muscles. Although these were judged as
There were no pitch or voice breaks, having reduced in score by half a scalar
and the slow vocal onset initially observed degree and were not reported as tender,
Primary and Secondary Muscle Tension Dysphonia 125

they remained slightly elevated at 3.5 apy dropout, the ultimate nonadher-
(neutral score 3). Patient I continued a ence, is a common clinical problem in
slight tendency to raise her larynx dur- voice therapy.119 Given the limited avail-
ing speech. ability of resources like clinical voice
Videostroboscopy showed that centers, the limited number of voice
patient I was now able to produce full clinicians available to provide intensive
vocal fold closure on phonation and voice therapy, and the limited number
that the midthird swelling had almost of graduate programs in which voice
resolved. A little minimal thickening therapy is a focus of study, this new
remained in the midthird that no longer approach of intensive treatment has
appeared to be affecting phonation. benefits, where target behavior change
Patient I completed her final exami- can be accomplished through concen-
nation at music college, achieving a good trated practice.
grade. She reported that her final recital Principles of intensive voice treat-
had been well received and that she had ment are derived from known literature
experienced no difficulty with her voice in the fields of exercise physiology, inten-
despite a vocally demanding program. sive psychotherapy, and motor learning,
which states that short-term intensive
practice results in desirable physiologic
In her treatment of a 44-year-old male,
changes120,121 and long-term retention
Rita Patel uses a specific approach of
of newly acquired skills.122,123 It is well
intensive voice therapy, first conceived
known in exercise physiology literature
by Diane Bless, PhD, at the University
that desirable physiologic changes from
of Wisconsin Voice and Swallowing
training occur primarily from intensity
Center, to create a voice rehabilitation
overload.124 Similar findings have been
plan that includes components of
noted with regard to intensive psycho-
intensive training and dynamic setup to
therapy. The findings from literature in
facilitate carryover.
psychotherapy support the notion of
positive behavior change due to high
levels of personal awareness and inten-
sive practice, which leads to retention of
Case Study 15
newly learned skills. In the field of voice
therapy, Lee Silverman Voice Therapy
Rita Patel provides evidence for intensive voice
therapy to improve laryngeal function
Voice Therapy Boot Camp in in patients with idiopathic Parkinson
the Treatment of Secondary disease. 125 Behavior modification of
MTD in an Adult long-term refractory dysphonia other
than of idiopathic Parkinson disease
Intensive short-term voice therapy is a etiology continues to be challenging for
new treatment approach that is being voice therapists.
developed in the field of therapeu- Like voice therapy, the goal of inten-
tic management of voice to maximize sive short-term voice treatment regi-
behavior change for long-term recalci- men is to maximize vocal effectiveness
trant dysphonia that has poor response and behavior modification. However,
to traditional direct voice therapy. Ther- unique to this approach of intensive
126 Voice Therapy: Clinical Case Studies

treatment is to bring these changes components involved in voice produc-

through techniques of concentrated tion, opportunities facilitate transfer
practice, in the short term, in a dynamic of learned skills, and these opportu-
setup that involves a maximum degree nities may influence patient compli-
of experiences/challenges to achieve ance. A highly structured voice therapy
the desired target vocal behaviors. regimen, an effective team leader, and
An intensive short-term voice treat- communication between the clinicians
ment program involves a highly struc- providing treatment are important for
tured regime of multiple sessions with successfully conducting intensive short-
a variety of clinicians, incorporating term voice treatment. The team leader
multiple simultaneous voice therapeu- is responsible for setting up intensive
tic approaches necessary for the client. treatment, coordinating team meetings
Part of these therapy sessions can also before and after treatments, and creat-
include additional voice/medical evalu- ing a plan for transfer of information
ations to clarify the nature of the clients from one session to the next. The team
voice disorder. This form of intensive leader is also responsible for follow-up
voice therapy provides rigorous prac- with the patient after discharge from
tice, involving not only overload, but intensive treatment.
also opportunities for specificity and
individuality, thereby facilitating better
transfer of learned skills. An intensive Patient History
short-term voice treatment program
involves voice therapy that is conducted Patient L, a 44-year-old male, a native
in successive 1-day to 4-day sessions, for of Iceland, was self-referred to the
an average of 5 hours (range 46 hours) voice center for assessment and treat-
of voice therapy, with an average of 5 ment of long-standing voice difficulty
clinicians (range: 37 clinicians) per day. of 10 years. Patient L was accompanied
An intensive treatment program is not by his wife for the session. The initial
limited to a particular diagnosis/thera- assessment was performed both by a
peutic approach. Intensive short-term voice pathologist and laryngologist. The
treatment is particularly beneficial for patient was first examined by the voice
long-term recalcitrant dysphonia, where pathologist, who obtained a detailed
voice therapy continues to be indicated; history of the nature and onset of the
when the patient has plateaued with a voice problem and a detailed medical
traditional form of individual voice ther- history, and performed stroboscopy,
apy; when a patient has upcoming vocal high-speed digital imaging, acoustic
performances within a short duration of analysis, aerodynamic assessment, and
initial assessment; and for clients travel- auditory perceptual analysis of voice
ing from longer distances to seek treat- quality. Subsequently, patient L was
ment at the voice center. Advantages of examined by the laryngologist, who
intensive short-term treatment are that it reviewed the case history, stroboscopy,
provides rigorous practice (overload), and high-speed examinations with the
it provides opportunities for specificity voice pathologist, performed indirect
and individuality, simultaneous inter- laryngoscopy, and performed a detailed
ventions can be conducted of multiple head and neck examination.
Primary and Secondary Muscle Tension Dysphonia 127

Patient L reported a gradual wors- toms of vocal fatigue and hoarseness.

ening of dysphonia since its onset. Voice Patient L did not undergo preoperative
quality was reported to have reached a and postoperative voice therapy during
plateau in the past 5 years. The patients the course of the dysphonia.
chief complaints were weak, strained Patient L was a nonsmoker and
voice quality and vocal fatigue. Voice consumed three 240-mL (8 fl oz) cups
quality was reported to deteriorate at of water daily. Intake of 2 cups of cof-
the end of the day. Being an industri- fee per day was reported. Patient Ls
alist, patient L had heavy voice use at medical history did not reveal serious
work and outside of work. Individual health conditions. He had no history
meetings and presentations at board of allergies, postnasal drip, and sinus
meetings constituted voice use at work. infections. No evidence of hearing loss
Social gatherings at restaurants with or injury to throat or neck region was
increased background noise comprised reported. The patients medical history
additional voice use. Frequent throat was significant for laryngopharyngeal
clearing was also reported. Throat clear- reflux, which was confirmed with laryn-
ing was reported to be productive dur- geal endoscopy, bariumesophagram,
ing the morning hours. Patient L denied gastrointestinal (GI) endoscopy, and
dysphagia or dyspnea. dual pH probe monitoring. Apart from
Over the past 10 years, the patient the above-mentioned laryngeal surger-
was examined and treated by different ies of unilateral injections for medializa-
voice centers across the country and tion, patient L had not undergone other
internationally. Patient L was exam- surgeries. Depression and anxiety were
ined by 1 otolaryngologist and 1 speech not reported.
pathologist in Iceland, 1 otolaryngolo-
gist in Germany, and 2 otolaryngologists
in the United States. Impressions from Evaluation Procedures
these assessments were of laryngopha-
ryngeal reflux, vocal fold scarring, glot- Patient L received a standard battery of
tal insufficiency, and vocal fold paresis. vocal function testing in the voice clinic.
Patient L was treated with Omeprazole, These assessments included assessment
40 mg, twice a day, with no improve- of structure and vibratory function of
ment of voice quality. At the time of the the vocal folds with the use of strobos-
assessment, the patient was still tak- copy using phonatory tasks of normal
ing Omeprazole, 40 mg twice a day for phonation, high-pitch phonation, loud
reflux management. Patient L under- phonation, soft phonation, glissando,
went unilateral right-sided injection and laryngeal diadochokinesis; detailed
laryngoplasty with Cymetra for glottal assessment of actual vibratory features
insufficiency and vocal fold scarring, like mucosal waves, tissue pliability,
in Germany. Due to no improvement glottal closure, and cycle-to-cycle peri-
of voice quality, patient L underwent odicity with the use of high-speed digi-
left-sided injection laryngoplasty with tal imaging; acoustic analysis of sus-
Cymetra in the United States. Second- tained vowels and sentence production
ary injection laryngoplasty also did not to assess fundamental frequency, loud-
result in improvement of patient symp- ness, perturbation measurements, and
128 Voice Therapy: Clinical Case Studies

harmonic-to-noise ratio; aerodynamic and mucosal wave of the right vocal

measurement of respiratory function fold. Mild phase asymmetry was
during speech to assess airflow rate, consistently observed. An irregular
expiratory volume, phonatory thresh- glottal closure was observed, which
old pressure; and perceptual assessment was characterized by a moderate
of voice quality on the GRBAS scale.96 gap along the anterior and mid-
Following is a summary of the relevant membranous portions of the vocal
pretreatment baseline observations and folds and a small posterior phona-
measures: tory gap.
2. Acoustic analysis: The patients acous-
1. Vocal fold structure and function: tic measurements of voice quality
Patient Ls endoscopic and strobo- were obtained using the Multi-
scopic assessments were performed Dimensional Voice Profile Module
using a flexible and rigid 70-degree of the KayPENTAX Computerized
endoscope without need for topi- Speech Lab. The patients mean fun-
cal anesthesia. The examination damental frequency was 147 Hz,
revealed normal movements of the mean jitter of 0.90% (norm = 0.59%),
arytenoids cartilages bilaterally. mean shimmer of 4.23% (norm =
Mass lesions were not observed 2.53%), and harmonic-to-noise ratio
along the vocal fold margins. Smooth of 27 (normal = 30). These measure-
but irregular vocal fold edges were ments represented subnormal perfor-
observed. During phonation, mild mance based on the expected acous-
reduction in vibratory amplitude tic measures for the patients age and
and mucosal wave of both the vocal gender. All intensity measurements
folds was observed, suggestive of the patients minimum (60 dB
of reduced vocal fold pliability. A SPL), habitual (71 dB SPL), and maxi-
small anterior and posterior glot- mum (89 dB SPL) loudness produc-
tal gap was noted, suggestive of tions were within the expected range
incomplete glottal closure. Phase for his age and gender.
asymmetry between the vocal folds 3. Aerodynamic measurements: Airflow
was not present. Mild lateral com- measures were taken during sus-
pression of the supraglottic struc- tained vowel productions; intraoral
tures was observed, suggestive of pressure measurements were esti-
vocal hyperfunction. mated from repeated productions
High-speed analysis of vocal of /pi/ using the Glottal Enterprise
fold vibrations was performed at Analysis System. Mean intraoral
2000 frames per second using a pressure was measured at 7.1 cm
rigid 70-degree endoscope without H2O, which was greater than the
application of topical anesthetic to expected norm of 5 cm H2O. The
the oral mucosa, to further assess mean airflow rate was 280 cc/s,
the extent of patient Ls vibratory which is excessive, suggestive of
disturbances. High-speed examina- an incomplete laryngeal valving
tion revealed moderate reduction mechanism.
in pliability of the left vocal fold 4. Auditory perceptual analysis: Patient
along the anterior margins and mild Ls voice quality was judged per-
reduction of vibratory amplitude ceptually by the voice pathologist
Primary and Secondary Muscle Tension Dysphonia 129

on a 4-point rating scale, known n checking the availability of other

as the GRBAS scale (normal, mild, voice pathologists for conducting
moderate, severe) for overall grade intensive treatment with the patient
of hoarseness (G), roughness (R), n conducting a pretreatment meeting
breathiness (B), asthenia (A), and with all voice pathologists to formu-
strain (S). Patient L exhibited a late a treatment plan
moderate amount of hoarseness n conducting daily meetings with the
and strain, and a mild amount of patients intensive care team either
breathiness. No evidence of asthe- before the initiation or termination of
nia was noted. therapy each day to establish goals
for the next day
n summarizing the patients status/
Impression and Rationale progress each day
for Therapy Approach n formulating a plan for transfer of
information between the voice pathol-
Overall the patients history and exami- ogists from one session to the next
nations revealed reduced pliability of n creating a home program for practice
both the vocal folds, left greater than of the voice exercises
the right; incomplete glottal closure; n coordinating the patients care with
and vocal hyperfunction. Based on the the speech pathologist in the patients
results of the assessment and nature of home country/state
the patients complaints of vocal fatigue n scheduling a follow-up appointment.
and reduced endurance, the decision
was made that patient L should undergo
intensive voice therapy for 3 days to Therapy Goals and Structure
reduce hyperfunctional behaviors and
improve glottal closure. Successful com- Patient L received 5 hours of voice
pletion of voice therapy treatment was therapy, conducted by 4 voice patholo-
expected to in turn reduce the degree of gists per day for 3 consecutive days.
hoarseness and enhance vocal stamina. Pretherapy and post-therapy measure-
Because the patient was traveling inter- ments were performed at the beginning
nationally for voice treatments, during and end of each therapy day with stro-
the weekly voice clinic team meetings, boscopy, high-speed digital imaging,
the decision was made that he would acoustic, aerodynamic, and auditory
benefit most from concentrated inten- perceptual analysis of voice quality. The
sive voice therapy. The voice patholo- therapy regimen consisted of 4 differ-
gist who performed the initial assess- ent goals focusing on reducing hyper-
ment of patient L was appointed as a functional behaviors, improving glottal
team leader to coordinate the patients closure, building vocal endurance, and
intensive voice therapy program during increasing hydration. During the 3 days
the weekly voice clinic team meeting. of intensive treatment, patient L was not
The team leaders responsibilities provided with additional home practice
included: of the voice exercises.
The above voice therapy goals
n scheduling the patient for intensive were achieved using a combination of
treatment voice therapy techniques. Patient Ls
130 Voice Therapy: Clinical Case Studies

first therapy session each day consisted Results of Therapy

of performing the vocal function exer-
cises, abdominal breathing, and neck Pretherapy and post-therapy measure-
relaxation exercises. During the subse- ments performed each day consistently
quent sessions, each day the goal was revealed significant improvement of
to systematically progress toward use voice quality at the end of an intensive
of resonant voice at conversation level. voice therapy day. The results from the
For this, techniques of resonant voice last therapy session of a 3-day intensive
and flow mode phonation were used at voice treatment regimen are summa-
syllable, word, sentence, marked para- rized below:
graph reading level, paragraph read-
ing level, structured conversation, and n Laryngeal imaging: Both stroboscopic
conversation. and high-speed digital imaging re-
Patient L attended all scheduled vealed improved glottal closure
voice therapy sessions. Team meetings compared to an irregular incomplete
were conducted prior to the initiation glottal closure that was observed dur-
of voice therapy each day to discuss the ing pretreatment recordings. Glottal
patients response to the targeted voice closure during complete adduction
therapy activities and highlight the ther- was now characterized by a small
apy plan for each day. During the team posterior phonatory gap. Healthy
meetings, the team leader also summa- vibratory amplitudes and mucosal
rized the results of the pretherapy and wave were appreciated along the
post-therapy voice measurements for right vocal fold and minimal reduc-
the voice pathologists participating in tion in mucosal wave was observed
the patients care. along the left vocal fold. Lateral and
Patient L had a breakthrough ses- anterior posterior compression of the
sion with one of the voice pathologists glottis was not observed. High-speed
during the early afternoon of the second analysis inconsistently revealed phase
day, in which the patient was able to asymmetry between the vocal folds.
maintain resonant voice during struc- n Acoustic analysis: The patient reduced
tured tasks at sentence and paragraph jitter and shimmer measurements and
reading levels. Goals for day 3 were increased the signal-to-noise ratio.
changed to accommodate the progress Post-test acoustic measurements were
made during day 2 of the intensive grossly within expected norms for the
voice treatment. During day 3, patient L patients age and gender.
was provided with increased opportu- n Aerodynamic analysis:Mean airflow
nities to practice carryover of the newly rate was 180 cc/s and mean phona-
learned skills in the voice therapy ses- tory threshold pressure was 5.2 cm/
sion to unique situations like order- H2O, which are within the expected
ing at the cafeteria and conversation at limits.
the hospital cafeteria with high levels n Auditory perceptual analysis: Conver-
of background noise. The last session sational speech was rated to have an
during day 3 was geared toward pro- overall normal grade (G), mild rough-
viding a written home practice plan for ness (R), with no evidence of breathi-
the patient. ness and asthenia. The patients voice
Primary and Secondary Muscle Tension Dysphonia 131

quality improved markedly as judged

by the patient. Even at the end of a Case Study 16
3-day intensive voice therapy regi-
men, patient L did not complain of Sandra A. Schwartz
vocal fatigue and hoarseness.
Medical and Therapeutic
Subsequent follow-up was con- Management of Laryngopharyngeal
ducted once every 2 weeks by means Reflux With Resulting
of e-mail and by video-voice interface Secondary MTD
through the World Wide Web. The team
leader discussed the maintenance plan
with the patients voice therapist in Ice- Previous Patient History
land by e-mail. Subsequent follow-up
at 6 months revealed that patient L had Patient SL is a 65-year-old male who pre-
continued to maintain the improvement sented to the ENT clinic with complaints
achieved during the initial course of of vocal quality change and voice dete-
intensive voice treatment. At this time, a rioration for the past >1.5 years. He had
follow-up in 1 year was recommended. been seen at that time (19 months ago)
The positive outcome of this treatment by another otolaryngologist and speech-
is attributed to the rigorous concen- language pathologist. At that time, he
trated practice of structured therapeutic reportedly presented with complaints
tasks to bring about a change in target of hoarseness without precipitating
vocal behavior. Intensive short-term event or illness/upper respiratory ill-
therapy with a number of voice clini- ness (URI). He also reported excessive
cians inherently created opportunities mucous in his throat and frequent
for differential practice, which facili- throat clearing. The patient attributed it
tated transfer of learned skills. Because to postnasal drip (PND) and allergies,
the patient had a long-standing voice although he had no other allergy symp-
problem, the intensive nature of voice toms and denied rhinitis.
treatment also aided in reducing the The previous ENT performed
patients frustration with the therapeu- a fiber-optic flexible endoscopy and
tic tasks and enhanced compliance with placed him on a proton pump inhibitor
the voice exercises, by demonstrating (PPI, such as Omeprezole or Lansopra-
success within a short duration. zole) for reported arytenoid edema and
erythema suggestive of laryngopha-
ryngeal reflux (LPR). He was referred
Though controversy continues to
for a videostroboscopy. The report of
surround the actual prevalence of voice
that examination noted mild-moderate
disorders associated with laryngopha-
posterior laryngeal edema and inter-
ryngeal reflux (LPR), patients continue
arytenoid thickening consistent with
to be referred with this diagnosis. In
LPR. Medial glottal closure was mildly
the following case, Sandy Schwartz
compromised resulting in bilateral false
discusses both medical and behavioral
vocal fold hyperfunction and AP supra-
management of a case of MTD second-
glottic compression. The patient was
ary to LPR.
reportedly counseled on GERD, dietary
132 Voice Therapy: Clinical Case Studies

precautions, and management, and glasses of water. Prior medical history

voice therapy was recommended which of hypertension, small (<1 cm) Zenk-
the patient declined. ers diverticulum, and anemia. Medi-
In the interim between that time cations include beta blocker, Lansopra-
and his presentation to our office, he zole, ranitidine, and iron supplements.
was seen by GI and underwent both Review of barium swallow/esopha-
an upper endoscopy and Ba swal- gram films was performed by an otolar-
low. SL presented these reports to our yngologist in our clinic to assess size and
clinic during his initial visit. An upper location of Zenkers. The diverticulum,
endoscopy reported normal mucosa of as seen at the time of radiographic study
the hypopharynx, upper, middle, and (approximately 18 months ago), was felt
lower esophagus, normal gastroesoph- to be too small for repair and did not
ageal junction with diffuse erythema. show significant retention. The otolar-
No mass lesions or evidence of Barretts yngologist proceeded with general head
esophagus (biopsies were normal). and neck examination that was within
Barium swallow/esophogram noted normal limits followed by behavioral,
an approximate 1-cm (or less) Zenkers voice, and videostroboscopic examina-
diverticulum as well as a small sliding tion by the speech pathologist.
hiatal hernia with free flowing reflux. He The Reflux Symptom Index56 com-
was changed to PPI 4 times a day (30 mg pleted by the patient to assess the per-
in the AM) and histamine blocker (H2) ception of symptoms related to LPR
(such as ranitidine, 150 mg) at night by resulted in a score of 23 (score >13 con-
the consulting gastroenterologist. sidered to be suggestive of LPR). The
At presentation to our clinic, he VHI-1053 completed by the patient to
reports that he had continued these subjectively quantify the perception of
medications until his primary care phy- vocal handicap resulted in a score of 14
sician placed him on ranitidine and he (score >11 considered abnormal54). Sub-
discontinued the medication approxi- jective perceptual impressions of vocal
mately 6 months ago. quality were mild harshness and pitch
breaks. There was evidence of vocal
strain and increased cervical tension
Current Presentation/ during conversational speaking. The
Medical and Vocal History patient was observed to use a breath-
holding pattern during extending speak-
The patients complaints continue to be ing. Oral mechanical examination was
of voice loss and a raw sensation in within normal limits.
his throat. Upon questioning, he states
that he is straining to talk and that his
voice deteriorates with extended use. Objective Voice Assessment
He is a retired teacher (retired 5 years
ago) and notes that his voice used to be Acoustic Measures
strong and effortless. He denies laryn-
geal pain, dysphagia, odynophagia, glo- Acoustic measures were obtained using
bus, shortness of breath, or cough. He the Multi-Dimensional Voice Profile
is a nonsmoker. He reports 3 to 4 cups (MDVP) (KayPENTAX), maintaining a
of caffeine/day and approximately 4 microphone-to-mouth distance of 3 cm
Primary and Secondary Muscle Tension Dysphonia 133

at a 45-degree angle. Using a sampling nation and breathing. There was mild-
rate of 44 100 analyzing a 3.89-second moderate interarytenoid hypertrophy
sample of sustained phonation /a/, the and postcricoid edema. There was one
fundamental frequency was 132.20 Hz; occasion of upper esophageal sphincter
pitch perturbation (jitter) = 0.744%; am- opening/aerophagia seen during the
plitude perturbation (shimmer) = 5.50%; examination.
noise-to-harmonic ratio = 0.161; and The examination was consistent
voice turbulence index = 0.075. Using with his reported and documented gas-
the real-time pitch (RTP) application troesophageal reflux with LPR. Second-
during running speech (counting), the arily, there is a mild-moderate degree of
mean speaking F0 = 136.46 Hz with a laryngeal and supraglottic hyperfunc-
range of 119.34 Hz (min = 109.16/max = tion termed in our report as type 2-3
228.50) and intensity is 71 dB (WNL for muscle tension dysphonia.126
conversation in quiet room). The maxi-
mum phonation time average of 2 trials
= 18 seconds.
Medical Treatment

Videostroboscopic Imaging It was recommended that the patient

change to an extended-release medica-
Both flexible and rigid (70-degree) endo-
tion for the LPR which was prescribed
scopic visualization were performed
by the otolaryngologist. Voice therapy
using both constant halogen and xenon
was again recommended.
stroboscopic light without the use of
The otolaryngologist had also
topical anesthetic. The structure of the
requested the barium swallow/esopha-
nasopharynx and hypopharynx were
gram to reassess the presence of a Zenk-
all within normal limits. The velopha-
ers diverticulum (previous exam was
ryngeal functional examination was
>18 months).
normal. True vocal fold superior and
medial margins were smooth and regu-
lar in appearance. There is significant
erythema noted of the vocal processes Voice Therapy Goals
bilaterally. The medial glottal closure is and Rationale
complete during phonation with the use
of both lateral/false vocal fold compres- Gastroesophageal reflux is a known con-
sion (mild-moderate) and mild anterior tributing factor to the presence of laryn-
posterior hyperfunction. (Initial contact geal inflammation and voice disorders.
is made at the anterior one-third with a It has been reported that approximately
posterior gap, subsequently closed with half of patients with voice disorders or
the assistance of false vocal fold com- laryngeal pathology demonstrate gas-
pression). There was mildly reduced troesophageal reflux as a causative fac-
amplitude and normal mucosal wave tor.127 The present patient was believed
propagation. The vibratory cycle was to exhibit a multifactorial voice disorder
in-phase with frequent aperiodicity resulting from laryngeal inflammation
(likely secondary to tension). Adduc- as a result of the LPR with secondary
tion and abduction of the vocal folds extrinsic and intrinsic muscle tension
showed normal mobility during pho- associated with phonation.128,129
134 Voice Therapy: Clinical Case Studies

Voice therapy was initiated 1 time was instructed to sustain vowel sounds
per week with the following goals: that notably changed in quality with a
reduction in laryngeal height. Despite
n improve the patients ability to man- some discomfort reported by the
age LPR using dietary and behavioral patient, he felt an immediate improve-
strategies (in addition to medical ment in strain/tension and was encour-
management) aged by the qualitative change heard
n reduce musculoskeletal tension asso- during vowel production.
ciated with phonation The following 2 sessions (sessions 2
n improve vocal efficiency and projec- and 3) were initiated with a brief period
tion utilizing airflow while maintain- of laryngeal massage followed by pro-
ing an open tract/relaxed laryngeal duction of vocal function exercises80
posture. using sustained /i/, pitch glides on
the word knoll, and sustained notes
SL was seen for an initial therapy on oll. As designed, these exercises
session (session 1) that focused on a were used to target improved muscle
review of LPR recommendations and flexibility and encourage airflow with
dietary management. Written guide- an open pharyngeal posture. Semi-
lines were provided. SL was instructed occluded vocal tract/straw phonation93
to reduce his caffeine intake and keep a was also used during these sessions on
log of his intake (both meals and snacks) production of a hum (steady pitch and
for 2 weeks to help him identify poten- pitch glides) in an effort to target vocal
tial trigger foods that were listed on the efficiency. All exercises were then pre-
written handout. scribed 2 times a day at home.
SL was then taken through a Voice therapy sessions 4 and 5
series of cervical stretching exercises focused on the patients ability to main-
to increase his awareness of extrinsic tain supraglottic relaxation while tar-
laryngeal muscle tension in his shoul- geting the use of increased airflow36
ders, neck, and chest. He was instructed during speaking tasks of increasing
in the use of lower abdominal/dia- length. Therapy tasks used phrases and
phragmatic breathing to improve his sentences of increasing length loaded
self-awareness of clavicular and chest with voiceless plosives and fricatives
tension and to promote a relaxed breath (ie, hockey skate, happy puppy, Sue ate
support pattern for voicing. These exer- soup; cut fish with a knife, 52 kitty cats
cises were provided in pictures and writ- ate pasta). Voiceless productions were
ing for home practice. Digital laryngeal used as stimuli in order to promote
manipulation /laryngeal massage19,45 airflow release. He was cued to use a
was performed by the speech patholo- lower abdominal support and slightly
gist to target muscular tension and increased volume (his teaching voice)
restore laryngeal balance (the patient targeting vocal projection using airflow
was observed to have a high laryngeal versus laryngeal push. We also used
carriage). This also served to further counting on voiceless onsets (counting
increase awareness of laryngeal tension. 40 to 50; 50 to 60), contrasting use of a
During manipulation using circumla- soft versus loud voice for self-identifica-
ryngeal massage to the area between the tion of vocal strain. SL was given writ-
hyoid and thyroid cartilage, the patient ten lists of home practice stimuli. He
Primary and Secondary Muscle Tension Dysphonia 135

was to continue to use vocal function Acoustic Measures

and straw phonation at the onset of his
home practice. MDVP analysis on sustained /a/ (sam-
Session 6 contrasted voiceless and pling rate = 44 100; sample 3.97 seconds)
voiced productions at the word, phrase, reported the average fundamental
and sentence levels for identification frequency was 133.16 Hz; pitch per-
of any subjective or observable phona- turbation (jitter) = 0.626%; amplitude
tory tension/strain on utterances of perturbation (shimmer) = 3.92%; noise-
increasing length with voiced loaded to-harmonic ratio = 0.154; and voice
consonants. SL was given minimal cues turbulence index = 0.045. This acoustic
for abdominal support, airflow release, data demonstrated an improvement in
and projection. He was observed to use the production of sustained vowel when
a lower laryngeal posture throughout compared with pretreatment results
the productions and no longer exhib- (using a comparable sample length and
ited clavicular tension. No observable average F0 which is WNL for adult male).
pitch breaks during sentence-level
productions were documented. Dur- Videostroboscopic Findings
ing a 10-minute conversational task
with the clinician, he was observed to Using a rigid (70-degree) endoscope for
use improved breath support without post-treatment laryngeal visualization
clavicular tension and without audible and side-by-side comparison of laryn-
vocal strain. geal images, there was notably reduced
SL reported using vocal function erythema noted of the vocal processes
and straw phonation exercise at the bilaterally. Medial glottal closure was
onset of his home practice as instructed complete during phonation without
and reported that he feels that this false vocal fold or anterior posterior
helps him relax his throat. compression of the supraglottic muscu-
lature as previously noted. Both ampli-
tude and mucosal wave were judged to
Therapy Outcomes be within normal limits. The vibratory
cycle was in-phase without aperiodicity.
SL was followed by the physician 10 Mobility was normal during phonation
weeks after his initial voice therapy and breathing. There was continued
evaluation. He was taking the extended- mild interarytenoid hypertrophy and
release PPI and reported having reduced postcricoid edema, though reduced from
his caffeine intake to 1 cup/day and fol- previous examination.
lowing dietary management guidelines
for LPR. He was seen for 6 total voice Overall Results
therapy sessions over 8 weeks with the
following changes in his status: SL had improvement of reflux symp-
toms and laryngeal inflammation using
Reflux Symptom Index score = a medical and behavioral management
11/45 (pretreatment = 23/45) approach. He no longer complained
of laryngeal discomfort and stated
VTI-10 score = 5/40 (pretreatment = that his voice did not give out dur-
14/40) ing extended conversations. He felt
136 Voice Therapy: Clinical Case Studies

that his voice was stronger with more ation due to persistent dysphonia,
volume and less strain. Visible tension chronic throat clearing, and neck/
previously noted on videostroboscopy throat pain following prolonged hospi-
involving overactivation of the false talization. He sustained a closed head
vocal folds with supraglottic anterior injury after falling from a ladder. A cra-
posterior compression was not seen on niotomy was performed for decompres-
follow-up examination. sive purposes. He required prolonged
Repeat barium swallow results orotracheal intubation for ventilation.
were obtained and demonstrated no Because of difficulty weaning from the
change in size of the Zenkers diver- ventilator, he underwent a tracheotomy
ticulum when compared to previous 16 days following intubation and was
examination (<1 cm) and continued to successfully decannulated 2 months fol-
demonstrate minimal retention. The lowing trach placement. Speaking valve
diverticulum was small and asymp- intervention was implemented during
tomatic at the time of the radiographic his hospital stay, and the patient report-
assessment and therefore no surgical edly had a rough, coarse vocal quality
intervention was recommended. SL was from initiation of voicing. Voice wors-
instructed regarding possible symptoms ened over the month following extuba-
associated with Zenkers diverticulum tion, and the patient was able to discern
including undigested food material a greater deal of vocal strain/effort.
regurgitation, sensation of solids stuck Disinhibition, impulsivity, and tangen-
in throat, and coughing/choking after tial speech were observed following the
eating. SL was instructed to follow up injury, and the patient had undergone
with the otolaryngologist in 6 months. intensive cognitive rehabilitation in
both inpatient and outpatient settings
prior to reporting to the voice clinic.
Secondary MTD may result from a
Oropharyngeal dysphagia was present
variety of causes. In the following case,
during hospitalization requiring tube
Heather Starmer describes treatment of
feedings with gradual advancement to
MTD secondary to vocal process granu-
a normal, unrestricted diet following
lomas caused by prolonged intubation.
intensive dysphagia therapy.
Pertinent medical history for this
patient included a history of significant
alcohol abuse, severe seasonal allergies,
Case Study 17
and GERD. At the time of evaluation
he was not taking any medications for
Heather Starmer his allergies or GERD. He did not have
a smoking history. Alcohol intake had
Management of Secondary been minimal since the injury despite
MTD Associated With Vocal history of heavy use prior. He consumed
Process Granulomas 3 to 4 cups of coffee per day and 2 to 3
caffeinated sodas. Water intake was esti-
Patient History mated to be 240 to 480 mL (8 to 16 fl oz)
per day. He denied any history of vocal
Patient RC was a 36-year-old male difficulties prior to his injury. He was
referred for an outpatient voice evalu- married with a 4-year-old son. He pre-
Primary and Secondary Muscle Tension Dysphonia 137

viously worked in construction; how- left greater than right. The membranous
ever, he had been on disability follow- portion of the vocal folds was smooth
ing his injury. He spent most of his time and straight bilaterally. There was mild
at home with his family, frequently sit- erythema of the striking edges of the
ting quietly watching television. He did vocal folds bilaterally. Full glottic clo-
not sing or use his voice occupationally. sure was accomplished despite the pres-
Quantity of voice use was described as ence of vocal process granulomas. Slight
average to below average. edema of the vocal folds was observed,
greater on the left than right, leading
to mild reduction of amplitude and
Initial Evaluation mucosal wave. Closed-phase vibration
predominated. He had moderate ante-
The patient presented to the outpatient rior-posterior and lateral supraglottic
voice clinic for evaluation 3 months fol- compression.
lowing his closed head injury. Initial Acoustic analysis of voice re-
evaluation included clinical assessment, vealed a mean fundamental frequency
laryngoscopy with videostroboscopy, of 137 Hz for sustained /a/. Mean jit-
acoustic analysis of voice using the Kay- ter was elevated at 1.6%. Shimmer was
PENTAX Computerized Speech Lab within normal limits at 0.08 dB. The
(CSL), and aerodynamic assessment noise-to-harmonics ratio was mildly
using the Phonatory Aerodynamic Sys- elevated at 0.32%. Vocal range was
tem (PAS, KayPENTAX). Patient per- somewhat diminished with a low pitch
ception of voice difficulties was ascer- of 111 Hz and a high pitch of 431 Hz
tained using the Voice Handicap Index (Table 36).
(VHI). The Reflux Symptom Index (RSI) Aerodynamic assessment revealed
was administered as well. maximum sustained phonation of 15
The patient presented with a mild- seconds which is on the low end of
moderate dysphonia characterized by a normal. Estimated vital capacity was
pressed, strained quality with a rough appropriate at 3.65 L. Mean airflow dur-
component. GRBAS scale revealed over- ing sustained phonation was normal at
all grade =1.5, roughness = 1, breathi- 120 mL/second. Mean peak air pressure
ness = 0, asthenia = 0, and strain = 1. was elevated at 9.76 cmH2O. Airway
While pitch levels and variability were resistance was mildly elevated at 88.76
appropriate for conversation, he habitu- cm H2O/L per second (Table 37).
ally spoke louder than appropriate for On the VHI the patient scored
a clinical setting. He cleared his throat 20/40 points on the functional subscale,
habitually throughout the session and 10/40 points on the physical subscale,
did not appear to have awareness of and 6/40 points on the emotional sub-
this occurring. Impulsivity and tangen- scale yielding a total score of 36/120
tial speech were noted throughout the which indicated mild, self-perceived
evaluation. Articulation, resonance, and voice handicap. On the RSI he scored a
fluency were intact. total of 22 points indicating some con-
Videostroboscopic evaluation re- cern for potential reflux contributions.
vealed normal mobility of the true vocal The threshold for concerning signs/
folds bilaterally. Large, bilateral lesions symptoms of reflux is a score >13 on
were observed on the vocal processes, this scale.56
138 Voice Therapy: Clinical Case Studies

Table 36. Acoustic Analysis

Pretreatment Post-treatment
Mean F0 in Hz 137 141
Jitter (%) at modal pitch 1.6 1.1
Shimmer (dB) at modal pitch 0.08 0.076
Noise:harmonics ratio (%) 0.32 0.16
Pitch range 111431 88440

Table 37. Aerodynamic Analysis

Pretreatment Post-treatment
Maximum sustained phonation 15 19
Vital capacity (L) 3.65 3.68
Mean airflow during sustained 120 110
/a/ (mL/s)
Mean peak air pressure 9.76 8.11
(cm H2O)
Aerodynamic resistance 88.76 40.23

Selection of Management established.133135 The primary goals

Strategies identified for this patient included:

Medical management was provided n improved hydration

by the collaborating otolaryngologist n behavioral reflux management
to manage the patients vocal process n elimination of throat-clearing
granulomas and reflux. Twice-daily behaviors
proton pump inhibitors and inhaled n reduction in vocal strain
budesonide were recommended by the
otolaryngologist based upon evidence Improved hydration: The patient
of their benefit in the management of was educated regarding the impor-
vocal process granulomas.130132 Voice tance of hydration for laryngeal func-
therapy was recommended due to eval- tion and voicing. The concept of phona-
uation findings of poor vocal hygiene, tion threshold pressure was described
phonotrauma, and vocal strain/muscu- as the amount of air pressure required
lar tension. The role of voice therapy in to initiate vocal fold vibration. We dis-
the management of patients with vocal cussed that poorly hydrated vocal folds
process granulomas has been previously require more pressure to initiate vibra-
Primary and Secondary Muscle Tension Dysphonia 139

tion, and therefore may lead to greater items to target. RC was educated about
vocal strain and fatigue.58 Further, we moderating these problematic items by
discussed the evidence that poorly reducing the frequency and quantity
hydrated vocal folds are more prone of consumption. We discussed that he
to mucosal injury.136 We discussed that should not lie in a supine position and
both systemic and direct hydration may should avoid activities that result in
have an impact on vocal fold vibration. abdominal compression within 2 hours
In respect to systemic hydration, RC of meals. Elevation of the head of the
had a significant imbalance between bed using phone books or bricks was
hydrating and dehydrating agents. We recommended.
discussed how caffeine and alcohol are Elimination of throat-clearing behav-
drying agents and that he needed to bal- iors: RC had poor awareness of his
ance their intake with improved water habitual throat-clearing behavior. We
intake. We discussed that obtaining a discussed how throat clearing can be
better balance would be beneficial for traumatic to the tissues of the larynx
reducing the amount of effort required and discussed the relationship between
to produce voice as well as to reduce the throat clearing, the vocal process lesions,
sensation of the need to clear his throat. vocal fold edema, and erythema which
He was advised to increase his water he was able to view from his videostro-
intake to at least 6 to 8, 240-mL (8 fl oz) boscopic evaluation. He was educated
servings of water per day. We discussed regarding the cyclical nature of throat
strategies to help him achieve this goal clearing. He was told that each time he
such as filling a premeasured container cleared his throat he caused irritation
in the morning and setting subgoals of the laryngeal mucosa, which would
for water intake throughout the day. lead to inflammation and a sense of
Together, we determined that he would fullness resulting in the perceived need
drink at least 840 mL (16 fl oz) in the to clear his throat again. Once he was
morning before lunchtime, 240 mL (8 fl able to demonstrate understanding of
oz) with lunch, 840 mL in the afternoon this relationship, our efforts shifted to
before dinner, and 240 mL with dinner. increasing his awareness of the throat-
Furthermore, he was asked to reduce his clearing behavior. This was accom-
caffeine intake to 2 to 3 servings per day. plished through clinician feedback of
Behavioral reflux management: Re- raising the hand whenever a throat clear
flux has been implicated both as a caus- occurred and then by the patient listen-
ative agent and a contributing agent to ing to a sample of a 5-minute conversa-
the persistence of vocal process granu- tion between he and the clinician and
lomas. Although medical management raising his hand whenever the throat-
can effectively eliminate acid produc- clearing behavior occurred. Once the
tion in many patients, supplementary patient demonstrated greater aware-
behavioral strategies can provide addi- ness of throat clearing in our session,
tional benefit. Diet modification was we discussed alternative behaviors to
discussed with RC, and a number of be used in times where he felt the urge
items were identified for elimination/ to clear his throat. The primary alterna-
moderation. Caffeine, carbonated bev- tive behaviors we discussed were an
erages, spicy foods, and tomato-based effortful swallow and a silent cough.
foods were identified as the primary We discussed that both strategies are
140 Voice Therapy: Clinical Case Studies

gentler on the vocal folds and will have was informed that he needed to be able
the same impact of mucous clearance to judge for himself whether he was
that a throat clear might have. We also using too much effort/strain since the
discussed that the improved hydration clinician would not be with him when
we already discussed would also help he used his voice outside of the clinic.
with thinning of mucous and reducing Throughout our sessions he was asked
the perceived need to clear the throat. to comment on the physical effort/
We asked the patients wife and children strain level as well as his mental effort
to help with improving his awareness of during tasks.
throat clearing in the home setting. They We discussed the anatomy and
were asked to simply raise their hand physiology of voice production and
whenever they observed RC clearing used his videostroboscopy to demon-
his throat as a reminder to use his alter- strate the increased strain evidenced
nate behaviors. During our clinical vis- by closed phase vibration and false
its, both RC and the clinician completed vocal fold compression. We also dis-
throat-clearing logs, and we compared cussed how the aerodynamic findings
the frequency of throat clearing at the of elevated peak air pressure and aero-
end of each visit. Whenever the patient dynamic resistance related to our endo-
caught himself clearing his throat dur- scopic findings. He was educated that
ing our session, he was asked to imple- his primary goal in vocal exercises was
ment one of the alternative behaviors. to reduce the effort and strain during
Reduction in vocal strain: Voice voice use and to adopt a gentler voicing
therapy was initially recommended on pattern.
a weekly basis for 1-hour sessions. Ini- A number of therapeutic strategies
tially 4 to 6 sessions were recommended, were implemented to assess their ability
and we discussed that we would adjust to offload his strain and tension. Areso-
our therapy duration based upon his nant voice approach appeared to be of
response to treatment. RC was initially greatest benefit for this patient and was
engaged in an activity to help him dif- the primary target for our treatment.
ferentiate physical strain from mental RC was asked to relax his jaw, lips, and
strain as a precursor to our vocal work. throat to create a cavern-like feeling
He was asked to put his index finger in the oral cavity (like holding a hard-
and thumb together like making the boiled egg in the mouth). He was then
okay sign with his hand. He was then asked to yawn and feel the retraction
asked to push the fingers together at and openness of the throat. Once he
different strengths from 1 to 10. We dis- was able to consistently assume this
cussed how it was much easier to push relaxed posture, he was asked to sigh
harder but that greater mental effort out a relaxed and resonant hum. He was
was needed to reduce the pushing. We cued to focus the sound of the voice for-
discussed that in order to change his ward and upward toward the nasal cav-
physical behavior of increased strain, ity to minimize strain and tension in the
he would need a good deal of mental throat. Often he produced hard onsets at
focus and effort during his vocal exer- the initiation of the hum and was there-
cises. We discussed the importance of fore instructed to allow a small escape
self-awareness and kinesthetic feed- of air prior to voice onset. This resulted
back, particularly for home practice. He in more gentle voice onsets.
Primary and Secondary Muscle Tension Dysphonia 141

Once the patient was able to consis- asked to maintain his relaxed throat,
tently replicate resonant voice and easy resonant voice. This task proved to be
onset, he was taken through a hierar- slightly more difficult for RC, and he
chy. He first advanced to gentle pitch was prompted to use a gentle hum as
glides up and down the scale using a reset button when tension/strain
the relaxed jaw posture resonant hum. was observed. He demonstrated sur-
Once he was able to maintain an open prisingly good self-awareness despite
resonant voice for humming and pitch his persisting cognitive issues and was
glides, we introduced consonant-vowel able to self-correct performance with
(CV) syllables (eg, me, me, me, my, good accuracy after 2 sessions working
my, my, ma, ma, ma, mow, mow, on unconstrained passages. At the same
mow, moo, moo, moo). Again he time, we began work on short conversa-
was asked to comment on any strain or tional tasks to assist with generalization.
tension he noted, particularly as he var- At home he was asked to participate in
ied vowel sounds. The /m/ onset single 5-minute conversations, 3 times per day
words were introduced with gradual while focusing on his vocal technique.
increase in syllable count. He was asked His wife was asked to help with moni-
initially to extend the nasal /m/ sound toring his techniques and providing
and then to gradually blend the sounds him with supportive feedback. We also
together for more natural speech. Dur- completed conversational tasks during
ing the second session, he was asked to our clinic visits. Once he was able to con-
complete a negative practice task where sistently demonstrate resonant voice in
he alternated between resonant voice all contexts with his wife and the clini-
and the old, pressed voice. He was able cian, he was asked to focus on techniques
to perform this task and identified the in a variety of settings and with varied
difference in sensation between the two. interlocutors. He realized that he was
He reported that the resonant voice was often using his techniques with minimal
more comfortable and noted that when mental effort and was able to repair the
he was using relaxed, resonant voice he times he noted strain easily after his sixth
did not feel the need to clear his voice therapy session. At that point he was
as frequently. weaned to home practice and returned
By the third therapy session we 1 month later for reevaluation.
began to focus on generalization of the
vocal technique into more functional
contexts. He was presented with a list of Therapy Outcome
phrases and sentences heavily weighted
with nasal consonants (eg, more and RC responded very well to voice ther-
more, maybe Monday, Marys mom apy despite his preexisting head injury.
made muffins, The night mans name He adjusted his hydration and caf-
was Nick). Initially he was asked to feine intake according to recommenda-
chant these stimuli but then gradually tions by our second session together.
increased the naturalness while main- He was less enthusiastic, however,
taining forward focus. Once he was about dietary changes for reflux, and
able to perform his sentences with con- though he became more moderate in
sistent accuracy, he was provided with his food intake, he continued eating
unconstrained reading passages and spicy foods frequently. Elimination of
142 Voice Therapy: Clinical Case Studies

throat-clearing behaviors was the most identification of precipitating factors

difficult aspect of treatment for RC. He associated with development and per-
needed a significant amount of clini- sistence of the lesions. In RCs case,
cian and spousal feedback, but approxi- endotracheal intubation was likely the
mately 1 month following initiation of primary factor associated with develop-
treatment had eliminated throat clear- ment of granulomas; however, untreated
ing the majority of the time. He was able reflux disease, poor hydration, and pho-
to adopt the target resonant voice and notraumatic throat clearing contributed
extend it to functional contexts by his to their persistence. As a result, he devel-
fifth to sixth therapy session. oped a secondary muscle tension disor-
Formal reevaluation revealed im- der. Medical management of inflamma-
provement across domains. At the tion and reflux combined with lifestyle
1-month post-treatment visit, his voice modifications and voice therapy signif-
was clear and resonant with only mild, icantly improved his laryngeal exam,
intermittent roughness appreciated. voice quality, acoustic/aerodynamic
The strained/pressed aspect of voice measures, and patient-perceived voice-
had fully resolved. The GRBAS scale related quality of life.
revealed overall grade = 0.5, roughness
= 0.5, breathiness = 0, asthenia = 0, and
In the following, Diana Orbelo, Nicole
strain = 0. Videostroboscopic evalua-
Li, and Katherine Verdolini Abbott
tion revealed normal mobility of the
present a case to illustrate the use and
true vocal folds bilaterally. Near full
principles of Lessac-Madsen Resonant
resolution of the vocal process lesions
Voice Therapy (LMRVT).
was observed with the post-treatment
lesions being ~20% of the size of the
original lesions. Vocal fold edema and
erythema was resolved, and he had full
Case Study 18
glottic closure and normal amplitude
and mucosal waves. He had balanced
and periodic vibration with no signifi- Diana M. Orbelo, Nicole Yee-Key Li, and
cant supraglottic hyperfunction. Acous- Katherine Verdolini Abbott
tic and aerodynamic analysis revealed
improvement across multiple measures. Lessac-Madsen Resonant Voice
On the post-treatment VHI, the patient Therapy in the Treatment
scored 10/40 points on the functional of Secondary MTD
subscale, 5/40 points on the physical
subscale, and 2/40 points on the emo- Introduction
tional subscale yielding a total score of
17/120 which indicated minimal self- LMRVT has origins in a convergence
perceived voice handicap and a clini- of performing arts traditions and basic
cally significant improvement. science in biomechanics, biology, and
perceptual-motor learning. The pro-
gram also incorporates principles
Conclusion known to affect patients adherence to
health care recommendations. LMRVT
Multidimensional intervention for vocal is an integrated program that differs
process granuloma optimally includes from traditional models of voice ther-
Primary and Secondary Muscle Tension Dysphonia 143

apy that emphasize voice conservation. Patient K complained of daily

Afoundational notion in LMRVT is that hoarseness and throat pain after talk-
many people with voice problems are ing and singing. She had struggled
required to speak often and even loudly with voice breaks in her high notes and
due to occupational or other life circum- roughness in her speaking voice inter-
stances, and sometimes people are led mittently for approximately 9 months.
to so do by personality. A basic premise Initial evaluation included flexible
in LMRVT is that our job, as clinicians, videostrobolaryngoscopy, perceptual
is not so much to encourage people with voice evaluation using the CAPE-V,90,138
voice problems to adopt a quiescent and patient self-assessment including
lifestyle in the interest of vocal health, the Voice Symptoms Scale (VoiSS),139
as it is to figure out how people can the Singing Voice Handicap Index
accomplish the vocal tasks before them (S-VHI),140 and an unpublished clinical
effectively and safely, without incur- questionnaire about voice, which que-
ring injury. We are helped by emerg- ries patients about their level of concern
ing biomechanical and biological data about voice and speaking effort (scale of
suggesting that voice produced with 1 to 7), the amount of time they can talk
barely adducted/abducted vocal folds, without vocal difficulties, and their per-
often corresponding to the perceptual ception about their voice in relation to
phenomenon called resonant voice, can normal voice, expressed as a percent.
help many people with voice problems
achieve this goal regardless of the ori-
gin of their pathology. In fact, data sug- Baseline Observations
gest that resonant voice may not only be
useful in the prevention of aggravating The overall impression was a recurring
pathology that may be cumulative in voice problem that ranged from mild-
an individual with voice problems, but moderate (eg, on the day of the initial
may also have actual reparative value in evaluation) to moderately severe follow-
cases of acute phonotrauma.137 This case ing extended voice use. For K, the most
describes essential concepts in LMRVT functionally distressing aspects of her
in the context of Patient K, includ- condition were the debilitating effects it
ing symptoms, clinical history, initial had on her singing performance and an
observations, treatment goals, treat- inability to speak without fatigue and
ment course, and pretreatment/post- pain in everyday activities.
treatment outcome measures. As noted, the initial otolaryngo-
logical diagnosis was bilateral vocal
fold nodules. Following treatment, a
History and Complaints post hoc review of both baseline and
post-treatment stroboscopic exams was
Patient K was a 21-year-old female col- obtained from a second board-certified
lege student and avid singer. She pre- laryngologist, who was otherwise unin-
sented to an active Midwestern voice volved in Ks care and was unaware of
center at the suggestion of her director the purpose of the ratings or even that
in a regional musical production. She the images were from the same patient.
was seen in the Department of Otolar- For the baseline exam, the confederate
yngology and was diagnosed with bilat- described bilateral vocal fold edge irreg-
eral vocal fold nodules. ularities, mildly reduced amplitude of
144 Voice Therapy: Clinical Case Studies

vibration and moderately reduced muco- treating speech-language pathologist

sal waves bilaterally, and the classic using the CAPE-V protocol. Findings
hourglass-shaped glottis characteristic of indicated mild-moderate overall grade
nodules. A still image captured from the of dysphonia, mild-moderate rough-
pretherapy exam is shown in Figure 38. ness, mild-moderate breathiness, mild-
Perceptual evaluation of the patients moderate strain, mild-moderate high
voice at baseline was completed by the pitch in speech, and normal loudness.
Similar to the procedure for stroboscopic
ratings, after therapy termination, post
hoc auditory-perceptual evaluations of
Ks pretherapy and post-therapy voice
recordings were obtained, using the
CAPE-V, from 2 additional speech-lan-
guage pathologists with extensive expe-
rience in perceptual ratings of voice.
Also these clinicians were otherwise
uninvolved in the patients care, the pre-
post status of the recordings, or the pur-
pose of the evaluations. Results aver-
Figure 38.Pretherapy still image of aged across all 3 clinicians are shown in
vocal folds. Figure 39, together with the range of

Figure 39. Average pretreatment ratings of voice quality across 3 clinicians

using the CAPE-V (for each dimension 100 is the worst possible score). Ranges
across 3 raters were as follows: overall grade: 10 to 30; roughness 6 to 25; breathi
ness: 1 to 20; strain: 1 to 13; pitch 0 to 24 (too high); loudness: 0 to 1.
Primary and Secondary Muscle Tension Dysphonia 145

ratings across clinicians for each voice tor to Ks physical pathology and voice
quality parameter in the CAPE-V. These problems was voice use patterns, which
ratings show that the clinicians were in by clinical observation included both
agreement that Ks voice was patently adducted and nonadducted hyper-
impaired. Additionally, not shown in function. Adducted hyperfunction was
Figure 39, both the treating clinician and noted especially in singing. The bio-
one of the blinded clinicians noted trem- mechanical result would be large inter-
ulousness during sustained /a/, and the cordal impact stresses, which increase
treating clinician also noted intermittent susceptibility to nodules and attendant
vocal fry in connected speech. voice changes.141146 In contrast, what
Results for the baseline VoiSS and appeared to be reactive nonadducted
S-VHI are displayed in Figures 310 and hyperfunction, which can also consti-
311, which reveal clear abnormalities. tute vocal dysfunction and even epi-
On the third, as yet unvalidated, ques- sodic voice loss,1 was held to charac-
tionnaire tool, K rated her concern about terize Ks speaking voice, along with a
her voice at 5/7 and vocal effort during chronic throaty resonance and vocal
speech at 4/7. She rated her voice as fry. A second factor thought to be con-
32% of normal voice on a visual analog tributory to Ks voice problems was
scale (data not shown). relative dehydration. This possibility
History and observations sug- was based on the patients frequent
gested that the most obvious contribu- throat clearing apparently to remove

Figure 310.Pretreatment results for Voice Symptom Scale

(VoiSS).139 Worst possible scores are total score = 120; impairment
domain = 60; emotional domain = 32; physical domain = 28.
146 Voice Therapy: Clinical Case Studies

Figure 311. Pretreatment results for Singing Voice Handicap

Index (S-VHI).140 Worst possible scores are total score = 144; func
tional domain = 40; physical domain = 40; emotional domain = 64.

thick mucus from the larynx, and her Treatment Goals

acknowledgement that she drank very
little water. The literature indicates that As typical for LMRVT, 3 levels of goals
dehydration may predispose laryngeal were established: functional, medical,
tissue to injury or slow recovery from and behavioral. For benign conditions
injury, while also increasing the sub- affecting voice, such as nodules, func-
glottic pressure required for phonation, tional goals are considered the ultimate
especially for high pitches.146148 target of treatment and are determined
by the patient. K identified her func-
tional goals as wanting to have a fully
Treatment Goals and Treatment functional speaking and singing voice
without dysphonia, hoarseness, or voice
Specific information about patient Ks breaks, and to reestablish pain-free and
treatment goals and treatment is pro- effort-free phonation without constant
vided in Tables 38 and 39. Treatment vigilance. The medical goal, implicit
was based on a standard LMRVT pro- in the referral to voice therapy, was to
gram, which is intended as a general reduce or resolve vocal fold nodules.
platform for treatment that should Biomechanical goals, established by
be varied flexibly depending on the the speech-language pathologist, were
situation. divided into 2 subtypes: (1) goals per-
Primary and Secondary Muscle Tension Dysphonia 147

Table 38. Goals for Patient Ks Treatment

Functional Medical Biomechanical

Normal voice, without Reduction or Hygiene
dysphonia, hoarseness, resolution of Increase systemic and surface hydration
voice cracks, or nodules (details in Table 32)
effort when speaking
or singing, without Voice training
constant vigilance Use slightly abducted vocal fold
configuration for most speech, especially
loud speech, to replace hyperadducted
and hypoadducted hyperfunction

tinent to the viscoelastic properties of nant voice, perceptually defined as

vocal fold tissue targeted using indi- easy voice involving awareness of
rect methods (vocal hygiene), and anterior oral vibrations during phona-
(2) goals that address phonation modal- tion.111,149,150 In sum, for this patient who
ity (direct methods). Biomechani- presented with apparent phonotrauma
cal goals are the only ones specifically and, simultaneously, a need to use her
addressed in voice therapy in LMRVT voice frequently and loudly, this biome-
under the assumption that if these chanical target was rationally favorable.
goals are appropriately established Moreover, recent reports indicate reso-
and achieved, functional and medical nant voice may actually have biological
goals will be attained as a by-product, reparative value at least in cases of acute
for free. For K, biomechanical goals phonotrauma137 which in patients like K
were to increase both systemic and sur- may be added to chronic trauma, thus
face hydration (indirect treatment; see aggravating it.
details in Table 38), and to establish
a voice production pattern involving Treatment
barely adducted/abducted vocal folds
for most phonation in speech and sing- Details regarding patient Ks treatment
ing. With respect to the voice production are shown in Table 39. After her ini-
goal, data have indicated that the barely tial evaluation, K received a total of 7
adducted/abducted vocal fold configu- voice therapy sessions over a 3-month
ration tends to optimize the ratio of voice period. LMRVT is typically delivered
output intensity (strong) to vocal fold in 6 to 8 sessions over a period of 4 to
impact intensity (relatively small).141 8 weeks. However, after the first treat-
Stated differently, this biomechanical ment sessions, there was overlap with
set-up should allow people such as K Ks rehearsal and performance sched-
to use their voices fairly strongly while ule as a primary character in a regional
minimizing collateral damage to the tis- musical performance. For those ses-
sue. Perceptually, this voice production sions, standard LMRVT techniques
modality has been found to be associ- were expanded to focus on singing and
ated with what has been called reso- specific needs for her performances.
Table 39. Therapy for Patient K

Status at Start Therapy Provided During Patients Performance Home Tasks and Time to Next
Session of Session Session Within Session Exercises Session
Initial Intermittent Hygiene: hydration Hygiene instructions 23 qt water daily; 4 days
evaluation hoarseness, instructions provided understood steam inhalations
throat pain and Voice training: stretches; Produced RV well 5min bid;
pitch instability RV BTG exercises; words at 85% for nasal Stretches; RV
consonants foundation BTG
exercises and RV
chants 10 min bid,
frequent mini practices
Therapy #1 Voice unchanged Voice training: stretches; Produced RV relatively Continue hygiene 18 days

RV BTG exercises; well to sentence Stretches; RV BTG- (patient was
words-sentences with level without models; words-sentences 10 extremely
multiple phonemic hyperfunction min bid, frequent mini busy with
contexts decreased particularly practices upcoming
when models
stimulated increased
Therapy #2 Voice unchanged Voice training: stretches; Produced RV well to Continue hygiene 9 days
RV BTG-words- sentence level with Stretches; RV BTG-
sentences; worked on models; patient was words-sentences
singing techniques for focused on singing including loudness
upcoming performance issues variations, 10 min bid,
frequent mini practice
Status at Start Therapy Provided During Patients Performance Home Tasks and Time to Next
Session of Session Session Within Session Exercises Session

Therapy #3 Singing voice Voice training: stretches; Produced relatively Continue hygiene 2 months (left
feeling better, RV BTG-words- good RV without Stretches; RV BTG- for summer
less pain with sentences; worked on hyperfunction to phrase words-sentences vacation,
singing singing techniques for level; singing was including loudness reported doing
upcoming performance consistently on pitch variations, 10 min bid, exercises
without breaks frequent mini practice 1time per day,
most days
Therapy #4 Voice less Voice training: reviewed Produced RV with Continue hygiene 3 days
frequently hoarse, hygiene, stretches, intermittent mild Stretches; RV BTG-
still experiencing RV Core, Chant, Vocal hyperfunction to words-sentences,
some pain with Communicators, mini- 85% with prompts including loudness
long periods of practice with practice and models (session variations on vowels,
speaking to carry over into materials recorded on

10 min bid, frequent
conversation; use of smartphone for patient mini practice, use of
real-time visual of pitch use) vocal communicator
and roughness focusing
on ends of phrases;
introduced loudness work
Therapy #5 Voice generally Voice training: stretches; Produced completely Continue hygiene 4 days
feeling good RV BTG adding hyperfunction-free Same as last session,
and noticing phonemic complexity, voice on 5060% but adding loudness
speaking patterns variable loudness work, of conversational work and mindfulness
on phone, loud conversation trials and good about speaking pattern
environments, approximations on during everyday
and when remainder of trials, with conversation
physically tired some models

Table 39. continued

Status at Start Therapy Provided During Patients Performance Home Tasks and Time to Next
Session of Session Session Within Session Exercises Session

Therapy #6 Voice very good Voice training: stretches; By end of session Continue hygiene 2 days
most of the time review and warmup patient produced Continue exercises,
still falling into using RV-BTG, core, and hyperfunction-free continue mini and
hyperfunctional chants; work on phrase voice on about 75% of mindful practices
habits during and conversational-level trials during structured throughout the day
long social work in quiet environment conversation, with
conversation; with model challenges minimal cues
no pain with

Therapy #7 Voice feeling Voice training: stretches; Throughout session Continue hygiene 7 months to
very good, review and warmup patient was able Continue exercises as reevaluation
patient confident using RV-BTG, core, and to produce RV and previously, added
that she can chants; work on phrase- hyperfunction Start work with a local
continue with level and conversational- approximately 90% of singing teacher
techniques as level work in challenging the time in challenging
she returns to environments outside the environments with
school therapy room, including minimal modeling and
places where loud and cues
soft voice were required
BTG refers to resonant voice (RV) Basic Training Gesture exercises in LMRVT. BTG exercises involve explorations in resonant voice during all-voiced consonant
productions, words, and phrases. Modeled after Lessacs Consonant Orchestra exercises.161,162 (It is assumed that clinicians are familiar with other acronyms
used in the table.)
Primary and Secondary Muscle Tension Dysphonia 151

Following completion of her show, K behaviors and biomechanical targets

and her family departed for a summer we identify for them? The if of voice
vacation. K resumed therapy shortly therapy refers to patient compliance
after her return. At that time she still and adherence, for lack of a better term:
experienced symptoms similar to those if the patient will do what we suggest,
at baseline, but her voice had not wors- especially outside the clinic.149
ened. She reported daily to every-other- Summary information about these
day performance of basic resonant voice parameters is as follows.
exercises during her vacation. She con-
tinued to sing in preparation for her The What of Training.As noted, in
fall semester at school but was singing LMRVT as for most voice therapy
less than she had during the show. K approaches, the what of therapy is
resumed therapy and the entire LMRVT subdivided into 2 parts: voice care edu-
course was completed at that point in cation (hygiene) and voice training.
four, 1-hour sessions during a 2-week Regarding voice hygiene, a critical con-
period. Beyond voice therapy, K received cept in LMRVT is that voice care educa-
no other treatments or training during tion should limit the number of param-
the active therapy period, either medical eters we ask patients to address as
or vocal (such as singing training). opposed to asking them to adhere to a
A synopsis of the overarching ther- large list of dos and donts, which can be
apeutic frameworkfor patient K and overwhelming and moreover generally
for LMRVT in generalis shown in lack specificity for a given patient. We
Table 310. This basic framework iden- consider the short list of key domains
tifies 3 critical factorsin the extreme to evaluate in a hygiene program are:
both necessary and sufficient to (1) systemic and surface hydration,
address in physical training of any (2) exogenous inflammation control (from
type.149 Those factors are: (1) the what, LPR, environmental pollutants, illness
(2) the how, and (3) the if of training. allergens, medications, smoke, etc), and
The what refers to behaviors and bio- (3) patent phonotraumatic behaviors
mechanical targets addressed in train- such as all-out uncontrolled, unskilled
ing. What do we want our patients screaming. Key in patient Ks program
to do differently behaviorally (eg, drink and in LMRVT in general was the iden-
more water) and biomechanically (eg, tification of only those hygiene param-
use a barely abducted vocal fold con- eters relevant to the patient in question,
figuration during phonation) by the end based on case history and observations.
of therapy? The how of voice therapy Recent data indicate patient compliance
refers to the approach to training, inde- with targeted hygiene programs can be
pendent of the biomechanical target. excellent151 in contrast to poorer compli-
That is, how will patients acquire the ance with hygiene programs associated

Table 310. A Synopsis of the Overarching Therapeutic Framework

What How If
Biomechanics Learning Compliance/Adherence
152 Voice Therapy: Clinical Case Studies

with more elaborate, one-size-fits-all of LMRVT can be obtained through Plu-

programs (eg, 152,153). Moreover, new ral Publishing,155,158 coupled with hands-
evidence suggests pared down, targeted on training in seminar format. Here,
hygiene interventions may be sufficient discussion is limited to general philo-
to help prevent the onset of new voice sophical comments about LMRVT and
problems in at-risk populations (eg, to newer findings and speculations per-
teachers; 151), although such interven- tinent to this program for this patient
tions may be insufficient as a single and others.
treatment modality in cases of existing As already implied, in LMRVT
pathology.151153 the target voice production modality is
Regarding direct voice training, defined both productively and percep-
in LMRVT for this patient and others, tually. Productively, the target involves
most sessions start with exercises to voicing with barely adducted or slightly
stretch extrinsic and intrinsic struc- abducted vocal folds.111,150 This configu-
tures involved in phonation. This ration, and specifically a configuration
approach is based on the notion that involving an approximately 0 to 1.0-mm
skilled perceptual-motor behavior in separation between the vocal processes
most domains fundamentally involves at phonation onset, appears to gener-
inhibition of musculature irrelevant to ate an optimized ratio of voice output
a task, with concomitant activation of intensity to vocal fold impact intensity
relevant musculature. Support for this under constant subglottic pressure (Ps)
approach is found in the developmen- and fundamental frequency (F0) condi-
tal motor learning literature pointing tions.141 Not incidentally, this same gen-
to selective activation as a hallmark of eral vocal fold configuration requires
skilled performance.154 Accordingly, all relatively small subglottal pressure to
therapy sessions for patient K initiated initiate and maintain vocal fold oscil-
with a series of stretches targeting the lation47 and thus should be physiologi-
thorax, cervical region, face, oral struc- cally easy. Perceptually, one correlate
tures, oropharynx, and vocal folds, in an of this laryngeal setupin particular
attempt to minimize activation of many when trained using a semi-occluded
muscles used in phonation.155 Selective vocal tract as occurs with LMRVTis
activation exercises followed. resonant voice (RV), which involves
Conceptually, the selective acti- vibratory sensations in the anterior oral
vation piece of therapy may proceed cavity in the context of easy phona-
according to any one of a number of tion.111,149,150 Thus far, reliable nonin-
specific therapy interventions, includ- vasive tools have not been identified
ing Vocal Function Exercises and flow to detect instrumentally what is recog-
phonation described elsewhere in this nized perceptually as resonant voice
text and in the literature.153,156,157 Patient (eg, Verdolini, Kobler, Conversano,
K underwent LMVRT as it is cur- Walsh, Xiu, Milstein, Hillman, unpub-
rently taught by Verdolini Abbott and lished data, 2000), although one instru-
associates.155,158 mented approach, involving a laryngeal
Table 39 describes the specific resistance measure (estimated phona-
contents of Ks therapy, which arose tory subglottic pressure divided by
from the general framework described. glottal airflow 159) may have potential
Detailed information about the contents to identify the target laryngeal configu-
Primary and Secondary Muscle Tension Dysphonia 153

ration, at least within a given subject on properties. Specifically, some data indi-
a given day.160 Interestingly, in that lat- cate resonant voice exercises may help
ter data set, laryngeal resistance quanti- to attenuate acute vocal fold inflamma-
tatively distinguished pressed, normal/ tion even more than voice rest in some
resonant, and breathy voice types across cases.137 Speculatively, the reason is
and within vocally healthy subjects, but related to findings reported for other tis-
failed to distinguish normal and reso- sue domains, that tissue stretchingin
nant voice, which were reliably distin- this case associated with relatively
guished perceptually. The implication large-amplitude vocal fold oscillations
is that differences between resonant and in resonant voice, coupled with high-
normal voice, at least in healthy vocal- pitch manipulations in LMRVT exer-
ists, reside in production parameters not cisesdeforms cells within the tissue,
assessed by laryngeal resistance, and thereby altering their mechanical sig-
that is vocal tract parameters. In fact, the naling in a way that is favorable for the
Lessac work as well as LMRVT involve wound healing process.164167 Thus far,
vocal tract manipulations to optimize a favorable result from resonant voice
anterior facial vibratory sensations and its experimental correlates has been
and also voice output intensity.141,161,162 seen in human subjects, in vitro data,
Stated differently, resonant voice is one and computer modeling of vocal fold
voicing modality that likely signals the inflammation.137,168171 Further verifica-
target laryngeal configuration, add- tion is needed. However, clinical anec-
ing also vocal tract manipulations in dotal as well as formal biological obser-
the form of a semi-occluded vocal tract vations point to some optimism that
that should increase oral vibratory sen- resonant voice may have actual biologi-
sations and output intensity.163 Also a cal healing properties, in some cases.
voicing pattern that judges would con- LMRVT is similar in emphasis to
sider normal (for healthy individuals) traditional forward focus approaches
appears to be associated with the target used by many clinicians. Further, the
laryngeal posture, although intensity laryngeal goal is essentially identical
may be lower as compared to resonant to the goal implicitly targeted in Vocal
voice. In sum, various data sets have Function Exercises.156,157
indicated the perception of anterior oral
vibrations during easy voicing are The How of Voice Therapy. One of the
general indicators of the target biome- features of LMRVT that distinguishes
chanical configuration, for both healthy it from resonant voice or forward
subjects and subjects with nodules.111,150 focus training approaches in general
Recent observations have sug- lies with its systematic incorporation
gested that the advantages of resonant of well-vetted principles of percep-
voice in voice therapy may not only tual motor learning documented in
be linked to its connection to a biome- peer-reviewed literature. Adequate
chanical setup that favors strong voice discussion is beyond the scope of the
production while at the same time present chapter; details are provided
protecting from laryngeal injury. 141 elsewhere.163 In brief, although the
Preliminary data from biological stud- biomechanical target in LMRVT is
ies indicate this voicing approach may clearly specified, based on robust data
have actual medicinal therapeutic in the literature, clinicians are to avoid
154 Voice Therapy: Clinical Case Studies

instructions about how a person should

attempt to achieve that target biome-
chanically. Instead, training focuses on
biomechanical outcomes such as sound
and feel of the voice. Perception and an
experiential approach rather than biome-
chanical instructions are emphasized.
Further, key laws of practice are used
to structure exercises, including laws
indicating augmented feedback should
be minimized and provided terminally
during training (eg, after a vocalization)
rather than concurrent with production. Figure 312. Post-treatment still image
Random practice is emphasized, as are of vocal folds.
whole as opposed to part practice
and variable practice of the target reso-
nant voice in numerous phonetic, acous- image from her post-treatment strobo-
tic, and emotional contexts (for details, scopic exam and can be compared with
see also 172). Figure 38. The blinded laryngologist,
who rated her pretherapy exam, also
The If of Training.Again, full dis- rated her post-therapy strobe exam at
cussion of factors thought to influence the same time, again blinded to the pur-
patient adherence or compliance is pose of his ratings. For post-treatment
beyond the scope of the present venue images, the laryngologist noted a
(for review, see 163). Briefly, key factors change in glottal shape from hourglass
include the concept of self-efficacy for to having a posterior glottal gap, con-
voice (does a patient believe he or she sidered normal. Vocal fold edges, ampli-
is able to perform exercises?),173176 and tude of vibration, and mucosal waves
readiness for voice change (is a patient all normalized.
ready to make changes, as discussed The treating speech-language pa-
in Motivational Interviewing tech- thologist and 2 blinded cohorts who also
niques?),177,178 and of course clinician rated Ks pretreatment audio recordings
presence. These principles are folded provided post-treatment evaluations of
into standard LMRVT. voice using the CAPE-V procedures.
Average and range of post-treatment
results for the 3 raters are shown in Fig-
Treatment Outcome and ure 313 along with pretherapy ratings
Recommendations for comparison. Post-therapy, raters
agreed that all voice quality parameters
Patient K underwent reevaluation of were well within normal limits.
baseline measures 7 months follow- In addition, post-treatment patient
ing therapy termination, which cor- K completed the VoiSS, the S-VHI, and
responded to 10 months post baseline. the nonvalidated clinical questionnaire.
Results are shown in Figures 312 to Results for the VoiSS and S-VHI are dis-
315. Figure 312 displays a post-therapy played in Figures 314 and 315, both
Primary and Secondary Muscle Tension Dysphonia 155

Figure 313. Comparison of pretreatment and post-treatment CAPE-V

scores, averaged across 3 raters (for each parameter 100 is worst pos
sible score). For pretreatment score ranges, see Figure 39. Post-treatment
ranges were overall grade: 2 to 5; roughness: 0 to 2; breathiness: 0 to 1;
strain: 0 to 0; pitch: 0 to 0; loudness: 0 to 0.

showing marked improvements from and she was able to sing more consis-
baseline. Using the unpublished clinical tently and without discomfort. At the
questionnaire, post-therapy K rated her 7-month post-therapy follow-up, both
voice at 94% of normal voice on a visual the treating clinician and the blinded
analog scale (compared to 32% prether- raters judged Ks voice to be normal
apy), she rated her concern about voice 100% of the time in connected speech,
as a 2/7 and vocal effort in speech as a and the treating clinician considered her
1/7 (compared to 5/7 and 4/7, respec- voice normal 95% of the time in conver-
tively, pretreatment). sational speech. As noted, K herself felt
Most important were patient Ks she was doing well with her voice and
results relative to specific therapy rated her post-therapy voice at 94% of
goals. Functionally, K felt that she had normal compared to 32% of normal at
obtained her goals of speaking normally, baseline. She did feel that she still had
without discomfort during most speech. to be mindful of her voice use in social
She no longer experienced fatigue dur- situations and would occasionally have
ing social or occupational conversation, mild vocal fatigue.
Figure 314. Comparison of pretreatment and post-treatment
scores for Voice Symptom Scale (VoiSS).139 Worst possible scores
are total score = 120; impairment domain = 60; emotional domain
= 32; physical domain = 28.

Figure 315. Comparison of pretreatment and post-treatment

scores for Singing Voice Handicap Index (S-VHI).140 Worst pos
sible scores are total score = 144; functional domain = 40; physical
domain = 40; emotional domain = 64.

Primary and Secondary Muscle Tension Dysphonia 157

Medical goals for K were also Deafness and Other Communication

achieved. Post-therapy, her vocal folds Disorders.
appeared white with straight edges
except at the highest pitches for which
In the following case, Tara Stadelman-
subtle marginal irregularities were noted.
Cohen, Jarrad Van Stan, and Robert
Based on medical and biomechani-
Hillman demonstrate the potential
cal findings at treatment termination,
future role that ambulatory biofeedback
the treating clinician recommended that
may play in voice therapy. The
K continue using stretches and reso-
Ambulatory Phonation Monitor (APM,
nant voice exercises at least 3 to 4 times
KayPENTAX, Inc.) provides patients
weekly, prophylactically, and that she
with unobtrusive real-time vibratory
work with a local singing voice teacher.
feedback regarding pitch and loudness
Following discharge from active ther-
as they go about their normal daily
apy until her 7-month follow-up, K
activities. When used to reinforce thera-
had about 2 singing lessons with a local
peutic goals in natural environments,
teacher but was dissatisfied with them.
ambulatory biofeedback has potential
She then followed up with 4 to 5 lessons
to facilitate the carryover phase of
with a singing voice specialist prior to
voice therapy.
her clinical follow-up.

Case Study 19
Lessac-Madsen Resonant Voice Therapy
(LMRVT) was used to address the Tara Stadelman-Cohen, Jarrad Van
functional concerns of a female singer Stan, and Robert E. Hillman
who presented with chronic vocal fold
nodules and functional consequences Use of Ambulatory Biofeedback
thereof. All measures, including blinded to Supplement Traditional Voice
measures by clinicians otherwise unin- Therapy for Treating Primary
volved in her care, indicated striking MTD in an Adult Female
functional and medical improvements
as a result of this treatment, achieving
normal status. The patients functional Case History
and medical goals were met. Princi-
ples described for this patient may be History of the Problem
applicable to other patients with voice
disorders involving hyperadduction or This 41-year-old female presented with a
hypoadduction of the vocal folds. 4-year history of vocal strain and fatigue,
increased dysphonia, and neck muscle
Acknowledgments. The writing of pain/discomfort associated with voice
this section was partly supported by use (particularly at the end of a work-
Grant No. R01 DC008567 (Verdolini day), all of which corresponded with
Abbott, Principal Investigator) and the onset of a new job. She had been pre-
R03DC012112-01 (Li, Principal Inves- viously diagnosed with primary muscle
tigator) from the National Institute on tension dysphonia (MTD) at another
158 Voice Therapy: Clinical Case Studies

institution where she also received a Audio-Perceptual Assessment

full course of voice therapy along with
bilateral Botox injections. The previous Auditory-perceptual evaluation was
treatments failed to resolve her voice performed by the examining clinician
problems that the patient attributed to using the standard CAPE-V,90 and those
an inability to feel and hear differences results are shown in Table 311. The
in voice production. She reported that patients voice was judged to be con-
she could mimic voice therapists well sistently mildly-moderately dysphonic
during therapy sessions, giving the false with associated features of inconsistent
impression that she was fully integrat- mild roughness and breathiness, incon-
ing the desired therapy goals, but there sistent moderate strain, and inconsis-
was little, if any, carryover. tent mild-moderate increased pitch and
Medical History
Acoustic and Aerodynamic
Past medical history included multiple Assessment
head and neck surgeries (tonsillectomy,
partial thyroidectomy, and oral sur- Acoustic and aerodynamic testing were
gery), thyroid disease, GERD/LPR, and performed in a sound-isolated room
environmental allergies. Current medi- as the patient performed a set of stan-
cations were loratadine for seasonal dard voice and speech tasks. Results are
allergies, levothyroxine for thyroid dis- shown in Table 312. The patient dis-
ease, and budesonide nasal spray. played abnormally high levels of acous-
tic perturbation (jitter and shimmer),
average fundamental frequency, and
Voice Evaluation average sound pressure level. Her max-
imum pitch and loudness ranges were
A complete voice evaluation was per- abnormally restricted. Aerodynamic
formed which included physical exami- measures were all within normal limits.
nation, auditory-perceptual assessment,
acoustic and aerodynamic assessments, Laryngeal Endoscopy
endoscopic laryngeal imaging with stro- With Stroboscopy
boscopy, and patient self-assessment of
vocal function. Both transnasal flexible and transoral
rigid endoscopic examinations were
Physical Examination performed to evaluate vocal structures
and function. The patient had excellent
Upon palpation, the larynx was severely abduction and adduction of her true
elevated with minimal thyrohyoid vocal folds and arytenoid cartilages.
space. Reduced lateral and anterior There was an inconsistent temporal
range-of-motion of the hyoid and thy- asymmetry of motion with the left vocal
roid lamina was also evident. Evidence fold appearing more restricted and slug-
of musculoskeletal misalignment was gish in its motion than the right vocal
reflected in heel weighting, locked fold. This was observed to resolve after
knees, mildly forward pelvis, posterior several minutes of visual monitoring
shoulders, and forward head position. with flexible endoscopy, thus ruling out
Primary and Secondary Muscle Tension Dysphonia 159

Table 311. Pretreatment and Post-treatment Measures for the CAPE-V

CAPE-V Results for Voice Quality

Voice Quality Pretreatment Post-Treatment
Dimension Evaluation Evaluation
Overall severity 35 (C, mild-mod) 14 (C, mild)
Roughness 17 (I, mild) 8 (I, mild)
Breathiness 16 (I, mild) 4 (I, mild)
Strain 49 (I, mod) 33 (I, mild-mod)
Pitch 35 (I, mild-mod increase) 11 (I, mild increase)
Loudness 24 (I, mild-mod increase) 0 (C, normal)
Resonance I, decreased oral I, low tone focus
Additional features None I, glottal fry
The scale is 0 = normal to 100 = severely deviant.
C represents consistent, and I represents inconsistent.

Table 312. Pretreatment and Post-Treatment

Measures for the V-RQOL

Voice-Related Quality of Life (V-RQOL) Results

Pretherapy Post-Therapy
Scores Evaluation Evaluation
Total V-RQOL 43 78
Social-emotional 31 75
Physical functioning 50 79
The scale is 0 = lower quality/functioning and 100 = higher qual
ity/functioning. Significant post-treatment improvements can be
seen when compared to pretreatment.

paresis of the left true vocal fold, and function of the external branches of the
was instead attributed to vocal hyper- superior laryngeal nerve bilaterally. The
function. During modal phonation, the patients voice appeared to be clearer
patient attained good glottal closure and less effortful as she produced
with phase symmetric mucosal waves pitches above the normal female range
indicating good pliability of the under- (>230 Hz). When asked to phonate at
lying superficial lamina propria layer. normal female frequencies between 200
As she approached higher frequencies, and 230 Hz, the patient had evidence of
she displayed symmetric elongation of significant supraglottic muscle hyper-
the true vocal folds, signifying intact function and a less clear tone.
160 Voice Therapy: Clinical Case Studies

Patient Self-Assessment During phonatory tasks, particu-

lar emphasis was placed on maintain-
The patient completed the Voice-Related ing an average vocal pitch (fundamen-
Quality of Life (V-RQOL)102 inventory to tal frequency) that was slightly higher
assess the impact of her vocal difficulties than what is considered normal for an
on her daily function. The V-RQOL gen- adult female (>230 Hz). This was based
erates a total score and two subscores on the observation during the evalu-
related to physical and social-emotional ation that the patient displayed clear
functioning; scores on all scales range signs of hyperfunction when her pitch
from 0 (lower quality/functioning) to dropped into the normal range (ie, low-
100 (higher quality/functioning). Results ered pitch served as an indirect indica-
are shown in Table 313. The patient dis- tion/sign of hyperfunction but was not
played scores in the midrange (physical considered to be the cause of the voice
functioning) or below (total score and problem). Real-Time Pitch (KayPEN-
social-emotional functioning) indicat- TAX) was used intermittently during
ing that the patients voice problem was voice therapy sessions to provide visual
having a significantly negative impact biofeedback based on fundamental fre-
on her daily function/quality of life. quency to reinforce the goal of main-
taining a higher pitch while at the same
time cueing into the associated reduc-
Voice Therapy tion in hyperfunction. The biofeedback
function of the APM was used with this
The primary focus of therapy was reduc- patient because she failed in previous
tion of muscle tension in extrinsic neck courses of voice therapy to carry over
and intrinsic orolaryngopharyngeal techniques outside of the therapy ses-
musculature during both voiced and sion and the drop in pitch associated
nonvoiced activities. Treatment modali- with her hyperfunctional voice pattern
ties included paralaryngeal massage could be targeted by the APM. Biofeed-
and manipulation,19,44 laryngeal man- back is meant to provide a patient with
ual therapy,23,83 tongue range-of-motion information the patient is otherwise
tasks (eg, extension), and suboccipital unable to acquire (eg, fundamental fre-
release.179 Musculoskeletal realignment quency),181 and it is hoped that when
was also addressed by achieving a bal- applied on an ambulatory basis, bio-
anced plumb line from the ears to the feedback can concretely extend therapy
shoulders, pelvis, knees, and ankles techniques into contextual, real-life situ-
with attention to freedom of movement ations. The APM uses an accelerometer
in seated and standing activity.180 Addi- (ACC) placed on the neck just above
tional treatment goals were reduction the sternal notch to sense phonation.
of breath holding, shallow breathing, The ACC signal is processed by a small
and speaking too long on one breath. digital device (worn in a belt pack) to
Education regarding the anatomy and extract estimates of vocal fundamental
physiology of voice and speech sub- frequency, sound pressure level, and
systems was also provided to improve phonation duration. The device pro-
the patients ability to prevent difficulty vides biofeedback to the patient wear-
through a greater understanding of how ing it via a pager vibrator worn on a
the voice works. belt based on thresholds for fundamen-
Primary and Secondary Muscle Tension Dysphonia 161

Table 313. Pretreatment and Post-Treatment Aerodynamic and Acoustic Measures

Vocal Function Measures

Acoustic and Aerodynamic Analysis Results
Tasks and Measures Pretherapy Post-Therapy
(Abnormal Values) Normal Values Evaluation Evaluation
Steady Vowels
Jitter (%) 1.04 1.9% 1.86%
Shimmer (%) 3.81 5.6% 1.94%
Noise (NHR) 0.19 0.12 0.104
Average F0 (Hz) 180230 253.37 Hz 261 Hz
Average SPL (dB) 6773 81.2 dB 69 dB
Maximum Performance
Lowest pitch (Hz) 175.44 Hz 175.4 Hz
Highest pitch (Hz) 462.96 Hz 830. 61 Hz
Maximum pitch range 2 1.4 2.24
Softest phonation (dB) 63.6 dB 45.9 dB
Shout phonation (dB) 90.6 dB 95.15 dB
Maximum loudness 40 27 dB 49.25 dB
range (dB)
Phonation Duration (sec) 14 26.6 seconds 42.02 seconds
Typical Speaking Voice
Airflow (L/s) 0.070.23 0.10 L/s 0.153 L/s
Air pressure (cm H2O) 7.76 7.15 cm H2O 6.13 cm H2O
dB/cm H2O 8.6 9.5 11.56
Loud Voice
Airflow (L/s) 0.050.25 0.18 L/s 0.161 L/s
Air pressure (cm H2O) 11.92 11.9 cm H2O 10.73 cm H2O
dB/cm H2O 6.1 6.6 6.60
Measurements highlighted and italicized in bold represent abnormal values.

tal frequency and sound pressure level damental frequency fell below 250 Hz
which are set by the clinician. In this for 500 ms or longer.
case the APM was set to provide 250 ms The APM was introduced after the
of vibrotactile feedback when the fun- initial evaluation, and the patient was
162 Voice Therapy: Clinical Case Studies

educated thoroughly regarding its use Therapy Outcomes

and her biofeedback target of funda-
mental frequency. During the first 2 days Sixteen therapy sessions were completed.
of monitoring, the APM was not provid- At the end of treatment, the patient
ing biofeedback so a baseline could be expressed increased awareness of inef-
acquired (days 1 and 2 in Figure 316). ficient muscle patterns, the ability to
Biofeedback was provided only after the alter tension progression, and improved
patient had reliably learned strategies capacity to speak without pain. Laryn-
during therapy that decreased vocal geal endoscopy with stroboscopy con-
hyperfunction and increased pitch. This tinued to show good glottal closure and
is because pitch modification indirectly symmetric entrainment of vocal fold
targeted vocal hyperfunction; therefore, vibration and mucosal wave generation.
the obvious concern was that the patient There was also reduced supraglottal
could use hyperfunctional behaviors to compression and an absence of asym-
increase pitch and maintain adequate metric arytenoid abduction-adduction.
compliance with the biofeedback and Post-treatment results for auditory-
defeat the purpose of an ambulatory perceptual assessment, acoustic and aero-
intervention. To assess the impact of the dynamic assessment, and patient self-
ambulatory feedback on the patients assessment are shown in Tables 311
performance, the feedback was turned through 313. Compared to pretreatment,
on and off for several days at a time there were post-treatment improvements
while the APM continuously monitored in the CAPE-Vbased judgments of
vocal function to provide estimates of overall severity of dysphonia, breathi-
modal fundamental frequency. ness, strain, pitch, and loudness, but

Figure 316. Modal fundamental frequency values during 17 days of

monitoring. Boxes indicate when ambulatory biofeedback was active. Mea
sures for days 1 and 2 were obtained prior to the start of voice therapy to
establish the patients baseline modal fundamental frequency.
Primary and Secondary Muscle Tension Dysphonia 163

only loudness was judged to be within

normal limits (see Table 311).
The improvements in auditory-
perceptual judgments of voice quality
were reflected by post-treatment reduc-
tions in acoustic perturbation (jitter
and shimmer) and average sound pres-
sure level with amplitude perturbation
(shimmer) and average sound pressure
level attaining normal values. Pitch and
loudness ranges showed post-treat-
ment increases to within normal limits.
Modal pitch continued to be abnormally
high following treatment which was
expected based on the therapy goal to
elevate the patients average speaking
pitch to a level above the normal range.
Figure 317. Overall averages of modal
Post-treatment aerodynamic measures
fundamental frequency at baseline, during
continued to be maintained within nor- biofeedback, and without biofeedback. The
mal limits (see Table 313). patient used a significantly higher modal
All three scores (total score, physical fundamental frequency with biofeedback
functioning score, and social-emotional than without biofeedback (p < 0.03).
score) from the patients self-assessment
of her vocal function (V-RQOL) showed
significant post-treatment improve- onstrate the potential future role that
ments indicating a positive impact ambulatory biofeedback may play in
of the voice therapy treatment on the voice therapy. The main objective of
patients daily function and quality of using ambulatory biofeedback was to
life (see Table 312). increase the patients ability to carry
Figure 316 shows the modal fun- over therapy-induced vocal modifica-
damental values for each of the 17 days tions outside of the therapy session.
that the patient wore the APM. These Even though this patient showed clear
results indicate that the patient main- post-treatment improvements in vocal
tained a higher modal fundamental fre- function, it is not possible to assign the
quency when the feedback was turned positive outcome to a particular part or
on (red boxes) as opposed to when the parts of the therapy program, includ-
feedback was turned off. This difference ing ambulatory biofeedback, because
was statistically significant (t-test) at the several approaches were applied simul-
p 0.03 level (Figure 317). taneously. In addition, there was no
attempt to structure the application of
the feedback to facilitate or demonstrate
Summary and true leaning/retention of the targeted
Concluding Remarks increase in modal speaking fundamental
frequency. Better elucidation of the role
As stated at the beginning of this case of ambulatory biofeedback in voice ther-
report, the intent here was to dem- apy will require the formal application
164 Voice Therapy: Clinical Case Studies

of principals based on motor learning The open phase of the vibratory cycle
theory (eg, varying feedback schedules, was dominant; however, the symmetry
formal assessment of retention, etc).182 of vibrations was regular.
Perceptually, patient CCs voice
quality was mildly dysphonic, charac-
Falsetto voice, sometimes called
terized by a high-pitched, weak phona-
puberphonia, has been described as a
tion. Objectively, she presented with a
high-pitched voice quality consistent
fundamental frequency of 220 Hz. Her
with adolescent males with biologically
pitch range was 205 to 860 Hz. Most
normal postadolescent vocal mecha-
interesting was the fact that she could
nisms. In the following case, Joe Stemple
not shout without overdriving the
discusses the treatment of MTD second-
vocal folds into a high-pitched explo-
ary to persistent use of falsetto voice in
sion of sound. Even with young men,
a 52-year-old female.
one diagnostic sign of this disorder is
the inability to shout. The positioning
of the vocal folds and disengagement of
the thyroarytenoid muscle for falsetto
Case Study 20
will not permit an appropriate buildup
of subglottic air pressure to support a
Joseph C. Stemple shouting behavior. The tenseness of the
folds caused by the contraction of the
Use of Glottal Attack in the Treatment cricothyroids will not permit the greater
of Primary MTD in an Adult Female amplitude of vibration required for the
Presenting With Persistent Falsetto louder phonation.

History Treatment

Functional falsetto is associated most How does one tell a 52-year-old woman
often with the postpubescent male. who has always used this voice that it
This author, however, has treated sev- is not her real voice? First, you explore
eral adult women with this disorder. her knowledge of other voices. Patient
In the most recent case, patient CC CC was asked if she could produce
was a 52-year-old, third-grade teacher voice in any other manner. Her only
who was referred by a friend with the response was a puzzling look that, with-
complaint of having a weak voice. out words, questioned the sanity of the
The weakness was something that she therapist.
had noticed all her life, but she never The next attempt to describe the
thought that it could be modified. problem was the intellectual approach.
Stroboscopic examination of her Through the use of the stroboscopic vid-
vocal folds revealed normal-appearing eotape and line diagrams, functional
folds that approximated in a near-par- falsetto was explained in some detail to
allel relationship. Glottic closure was the patient. Patient CC showed an intel-
complete, but the amplitude of vibra- lectual understanding of the disorder
tion was severely decreased with just but was still somewhat skeptical of the
the medial edge of the folds vibrating. diagnosis as related to her weak voice.
Primary and Secondary Muscle Tension Dysphonia 165

The clincher turned out to be n talking to her class (who she was sure
the direct approach. Patient CC was would laugh and giggle).
instructed in how to produce a hard
glottal attack on the vowel /ae/. Her
first attempt resulted in the deepest,
loudest tone that she had ever heard
At the following session, which was
emanate from her mouth. The sound
2 weeks later, patient CC returned to
also shocked and puzzled her. The
report on her progress. Her new voice
therapist explained, That was normal
was stable and demonstrated remark-
vibration of the vocal folds.
ably improved inflection and flexibil-
Once the shock diminished, pa-
ity. Now it was my turn to be puzzled.
tientCC was most interested in pur-
Patient CC reported that the day after
suing this form of voice production.
our last session, she developed a bad
Because of the deep sound, she was
cold. In the past, she reported becom-
not yet interested in permitting anyone
ing aphonic during the initial stages of
elseoffice staff, family, or friendsto
a cold, and so it was this time. Using her
hear her speak in this manner. Desen-
falsetto voice, she lost her voice.
sitization is an important step in deal-
ing with functional falsetto. This patient So, I decided, what have I got to lose?
had a lifetime of using her old voice. Itried to talk the new way and my voice
Her auditory feedback system kept came out fine. So, Ive been using it
repeating, Thats not me, thats not everywhere ever since. I just tell people
me. Systematic practice from words my cold changed my voice.
(at first using the hard glottal attack),
through phrases, paragraph readings, So much for brilliant hierarchies
and directed conversations, was nec- and desensitization plans. Final stro-
essary to stabilize the new voice. boscopic observation yielded normal
Audio recordings were used liberally wide amplitude of vibration and phase
to demonstrate the normalcy of the closure. The patients fundamental fre-
new voice. quency stabilized at 196 Hz. Her pitch
Once stabilized in therapy, patient range expanded to 159 to 880 Hz. Most
CC had to begin using the new voice important, her voice was strong, easily
with others. She started with a most produced without effort or fatigue, and
sympathetic ear, my secretary, who had was heard in all situations.
learned long ago when to positively
reinforce. We then developed a hierar-
The above case of persistent falsetto in
chy of situations to be tackled with the
an adult female is not unique. In fact,
new voice, including
one might suggest that persistent use of
falsetto in this population as a contribu-
n ordering food at a drive-through
tor to MTD may be underdiagnosed.
In the following case, Mara Behlau and
n ordering food in a restaurant
Glaucya Madazio describe multiple
n calling for information about a store
therapy approaches used to resolve
MTD secondary to persistent falsetto in
n talking directly to her daughter
a female professional voice speaker.
n talking to her husband
166 Voice Therapy: Clinical Case Studies

She has been investing in self-

Case Study 21 development, and the opportunity of
presenting the TV show she originally
Mara Behlau and Glaucya Madazio produces was received as a good per-
sonal challenge. She likes to sing but has
The Use of a Multi-Approach no particular interest in developing the
Therapy in a Female Professional singing voice. She has not had any vocal
Voice Speaker Presenting With symptoms besides the high-pitched
a Primary MTD Marked With voice and has had no complaint of vocal
Habitual Falsetto Phonation fatigue or vocal tract discomfort.

Voice Evaluation
Case History
Vocal complaint:My voice has been
very high and childish. This really does The patient presented a moderate dys-
not bother me. However, I was invited phonia characterized by a high-pitched
to present a TV program and my voice voice, with reduced loudness with-
didnt seem credible for the screen. (sic) out any other deviation on connected
The patient is a female journalist, speech. Sustained vowels revealed mod-
29years old, married with no children. erate breathiness. No perceived effort
She has been working as a TV program was noticed. Frequencies swings were
producer on a show about traveling not present. Vocal quality was perceived
abroad. She is 1.75 m, tall for Brazilian as a childish voice.
parameters, with an athletic body pro- CAPE-V assessment indicated G
file. She referred to herself as a mature (overall dysphonia) of 60, absence of
woman, very responsible, persistent, roughness and tense voice, breathiness
highly active and energetic, with a good of 45; pitch (high) of 60; and loudness
career. She remembered herself as hav- (low) of 30. All parameters were con-
ing this same voice, since she was a teen- sistently present, with the exception of
ager. She also stated that the voice is still breathiness on connected speech.
more infantile when talking to her father, Anterior tongue carriage was ob-
a radio announcer professional. She has served (ie, the tongue was high and
an older brother. No other woman in the anteriorly displaced, reducing oral reso-
family has a childish voice. Even if she nance, limiting laryngeal vertical posi-
does not have any recollection of having tioning, and contributing to a thin vocal
been bullied at school, some colleagues quality). The oral cavity was mostly
used to tease her by imitating a high- occupied by an elevated tongue posi-
pitched voice. Her family and particu- tioning, which blocked full resonance.
larly her husband and her father have Moreover, there was a slight anterior
perceived the voice as high pitched, but tongue interpositioning during t, d, s,
they had not identified any restriction z Brazilian sounds, which added to the
or made a negative remark about it. She perception of a childish voice.
has never smoked, has had no reflux Fundamental frequency in the
symptoms, and has not indicated any speech range was reduced at the upper
phonotraumatic habits. and lower ends of her range. Vocal qual-
Primary and Secondary Muscle Tension Dysphonia 167

ity was constantly soft and breathy; matica Inc, Brazil). The mean funda-
loud voice was occasionally used with mental frequency for a sustained open
a compensatory effort and absence of vowel was of 211 Hz; for connected
breathiness. There was a clear influ- speech the mean value was 206 Hz
ence of both restricted vocal range and (counting numbers from 1 to 10). It is
resonance. This combination of factors interesting to notice that even if fun-
particularly for postpubescent females damental frequency was at the female
is well described in the Classification adult range, close to the mean Brazilian
Manual for Voice Disorders.4 female adult speakers,183 the pitch was
high and inadequate for her age and
Instrumental:Visual physical appearance, mostly due to the
Imaging and Acoustics vocal tract postural adjustments (high
larynx, reduced oral space, and anterior
ENT Evaluation. Laryngeal evaluation tongue displacement).
was performed through videolaryngos Acoustic parameters were essen-
troboscopy. The larynx was described as tially normal (jitter, shimmer, and noise
being a normal mobile larynx of adult parameters, Table 314), except for a
dimensions, positioned high in the neck minor deviation on the irregularity
with normal appearing vocal folds (ie, measurement. Spectrographic analysis
long, white, and with a well-defined vocal (Fonoview) revealed a reduced series of
ligament and mucosal wave). A mild pos- harmonics, noise at the high frequencies,
terior glottic chink was also identified. and trace instability. Hoarseness diagram
The ENT conclusion was primary [phonatory deviation diagram (PDD)]184
MTD as a result of persistent use of fal- showed a discrete displacement from the
setto register in the context of normal normal area (Figures318 and 319).
appearing vocal folds.
Patient Self-Assessment
Acoustic Analysis.Acoustic analy-
sis of vocal quality was performed by Patient self-assessment of the impact of
Fonoview and VoxMetria (CTS Infor- dysphonia was explored via V-RQOL, a

Table 314. Pretherapy Acoustic Parameters From the

Sustained Open Vowel /ae/ (VoxMetria, CTS Informatica Inc)
From the 29-Year-Old Female Journalist, High-Pitched Voice

Acoustic Parameters Values Normal Data
Mean fundamental 211 Hz
Jitter 0.33 00.6
Shimmer 5.36 06.5
GNE (noise) 0.79 0.51
Irregularity 4.84 04.75
168 Voice Therapy: Clinical Case Studies

Figure 318. Pretherapy phonatory deviation diagram from a 29-year-

old female journalist, high-pitched voice (VoxMetria, CTS Informatica Inc,

Figure 319. Pretherapy spectrogram from a 29-year-old female jour

nalist, high-pitched voice (Fonoview, CTS Informatica Inc, Brazil).

general protocol to analyze the effect of cifically designed for use with persistent
a voice problem on the quality of life. falsetto phonation, the total score was
This instrument has 10 questions, 6 of 85% (socioemotional = 81% and physi-
them exploring the physical domain of a cal domain = 87%), which indicates a
voice problem and 4 the socioemotional discrete impact on quality of life, with
one. Even if this instrument is not spe- psychosocial negative repercussions.
Primary and Secondary Muscle Tension Dysphonia 169

V-RQOL normal value for the Brazil- The real incidence of puberpho-
ian adult population total score is 98% nia in the general population is not
(99.4% for socioemotional and 97.1% known4 with a single estimation of 1
for physical domain), and for the dys- in 900 000.187 Excluding the hormone-
phonic group the total score is 65.9% induced voice disorders (excessive or
(70.6% for socioemotional and 62.7% precocious mutation), the literature rec-
for physical domain).185,186 It is interest- ognizes cases of prolonged mutation188
ing to observe that due to her limited (voice change is observed for more than
complaints, the score is placed between 6 months189), also called stormy voice
normal and dysphonic. mutation19; mutational falsetto, when
The patient had also answered the the high-pitched-voice child is used as
Vocal Tract Discomfort Scale (VTDS),83 habitual phonation; and cases of incom-
which contains 8 symptoms (burning, plete mutation, when the voice has not
tight, dry, aching, tickling, sore, irrita- achieved the total range displacement,
ble, and lump in the throat) to be evalu- which is usually seen in performers or
ated according to frequency and inten- boys choirs members.190,191
sity. The patient`s answer indicated no Puberphonia is usually a male dis-
discomfort due to the voice problem. order and causes are frequently related
This result showed that the vocal tract to psychological difficulties in facing the
adjustments were stable and probably responsibilities of the adult life.19,39,190,192
due to the restricted usage of the voice. The high-pitched voice can be chest reg-
The final conclusion of the case was ister or falsetto, and the sound can be
female puberphonia due to maladaptive judged as a childish or female quality.
muscle adjustment. Vocal instability and sudden frequency
displacements (vocal swings or frequency
shifts) can be observed in some cases.
Voice Therapy
Female patients are seldom re-
Specific Types of Therapy ported, probably due to the fact that
society expects a high-pitched voice for
The persistence of an adolescent voice women and men are expected to have
during adulthood is usually called a low-pitched voice to reassure mas-
puberphonia, however, many other culinity, authority, and assertiveness.
terms are also used, such as mutational The distance between the female adult
voice disorder, pubescent falsetto, and girls voice is smaller than the male
incomplete maturation, persistent fal- adult and boys voice (ie, vocal mutation
setto, or mutational falsetto. Puberpho- is more evident in males). Even consid-
nia is the preferred term especially when ering cultural expectations, a female
organic causes (vocal fold paralysis, sul- infantile voice can be socially and pro-
cus vocalis, endocrine dysfunction, or fessional detrimental to the individual.
deafness) are not found. At puberty, the The established management of
growth of the larynx and vocal folds dis- these cases is vocal rehabilitation, which
places the male fundamental frequency usually includes changes in muscle
at approximately 1 octave. The etiology adjustment, modification of vocal hab-
of a persistent prepubescent voice is its, and vocal image recalibration. Voice
mainly functional, with probably a psy- therapy is traditionally used with good
chogenic influence; however, its dynam- results.2,19,39,79,187,192195 Techniques in-
ics has not been properly investigated.19 clude several vocal exercises, laryngeal
170 Voice Therapy: Clinical Case Studies

manipulation,19,45,83 or the use of vegeta- and stabilization. The rationale used for
tive sounds to trigger the modal regis- treating this case was as follows:
ter.187 These patients usually respond to
a short duration voice therapy alone, 1. Communicative competence approach:
with vocal exercises, critical listening, Use of general comprehension of
and conscious displacement of funda- the impact of vocal psychodynamics
mental frequency. Sometimes psycho- and keeping an infantile vocal qual-
logical counseling can be added2,79 and ity in the adulthood. The FonoTools
even a surgical procedure was proposed (CTS Informatica Inc) was used to
for a resistant case of a 24-year-old male.196 monitor the changes in speaking
A more invasive approach was fundamental frequency necessary
used in 26 males by producing laryngeal for biofeedback. The patient was
stretching with an intubation laryngo- informally counseled about a new
scope with an immediate improvement vocal and body attitude necessary to
of the patient voice. The long pipe of face the camera and was referred to a
laryngoscope is introduced in the val- psychologist for formal counseling.
leculae of the patient while speaking 2. Muscle adjustment techniques:cir-
a long eeee.197 These authors recog- cumlaryngeal massage and laryn-
nized that treatment of puberphonia is geal vertical displacement. The
voice therapy; however, when not avail- technique used for circumlaryngeal
able, as happens in many cities of India, massage was the Manual Circum-
this direct technique can be employed. laryngeal Therapy21,44,45 which con-
The objective of the vocal rehabili- sisted of unimanual circular pres-
tation for this female case was to bal- sure over the hyoid bone, within the
ance body, voice, and communication thyrohyoid space to open it, using
attitude to meet the social and profes- the thumb and index fingers. After
sional demands of her life. The expected this maneuver, depression of the
outcome was to establish a normalized larynx is obtained by active vertical
female adult voice in terms of pitch, displacement of the whole structure
loudness, and quality. in the neck, starting from the upper
The philosophical orientation was border of the thyroid cartilage.
to use one type of program, approach, Vocalization is requested during
or method to control therapy outcomes. and after manipulation to monitor
However, for this functional falsetto vocal changes (see Roy Case Study5
dysphonia, with a long history of mal- in this chapter for more details on
adaptive adjustment, we were conscious manual therapies).
that a mix of strategies would need to 3. Active vocal techniques for laryngeal
be considered to enhance the opportu- vertical displacement:the strategy
nities to produce changes via several used for the patient to produce
perspectives. Considering the range of voice with a lower larynx position
possibilities, we decided first to address was the Finish bilabial fricative
vocal image through a communicative sound.115,198 This technique is effi-
competence approach, then to proceed cient for lowering the larynx and
to the muscle adjustment modifications reducing glottic chink. The patient
via indirect and direct strategies, and to is asked to attempt prolongating the
continue with resonance reinforcement oral occlusion of the fricative B,
Primary and Secondary Muscle Tension Dysphonia 171

followed by a schwa, as if produced with nasal or fricative consonants,

on a slow rate, without the plosive and keep the easy sensation during
pressure characteristic of the bila- these productions. Finally, reading
bial b. The large initial phase of poems and short paragraphs was
the fricative sound, plus the man- used to generalize the new voice
dible lowering, teeth opening, and adjustment. The sensation of gentle
enlargement of oral cavity favor the voice production and openness of
laryngeal lower repositioning. Nasal the vocal tract were kept after fin-
sounds, particularly the anterior ishing the exercise.
occlusive m, was introduced as a 5. Reduced version of VFE to improve
facilitating adjustment to keep the vocal resistance at the new adjust-
lower larynx and vocal tract inner ment:VFE is a well-established
expansion. Low-frequency closed method to achieve coordination
vowels (o, e, u) followed by between breathing-phonation-reso-
words and sentences were used to nance.92,103,105 This method consists
generalize the low larynx position. of 4 exercises to strengthen and bal-
4. Resonance tubes: LaxVox technique ance the laryngeal musculature and
was administered to maintaining to balance airflow to the muscular
a low vertical larynx positioning effort: (1) warm-up exercise: sus-
and vocal tract expansion, without tained /i/ as long as possible, on a
extra effort. The LaxVox Method is musical note F above middle C for
also a Finish technique.199 To start female and children and F below
this exercise, the patient is asked to middle C for male adult patients;
get a 500-mL PET bottle half-filled (2) stretching exercise: glide from
water, room temperature, to insert a the lowest to the highest note in
35-cm-length by 9-mm-diameter sil- the frequency range on the word
icone tube into the bottle, 2 to 3 cm knoll; (3) contracting exercise:
bellow the upper level and to keep glide from the highest to the lowest
the straw gently with pursed lips note in the frequency range on the
and teeth. The patient is encouraged word knoll; and (4) low-impact
to produce bubbles while blow- adductory power exercise: sustain
ing air and sound into the flexible the musical notes middle C and D,
straw, for at least 1 minute, at the E, F, and G as long as possible, for
maximum phonation time. During females and octave below middle
the exercise, kinesthetic sensations C for male adults, using the vowel
are enhanced inside the vocal tract, /o/. For the present patient only the
including a bubbling impression first 3 exercises were used to retain
inside the larynx. Modeling during the new phonatory and resonance
the exercise is essential to control adjustments. Exercise 4 was not
posture, breathing coordination, used due to difficulties in carrying
and upper resonance focus. After the notes. (See the Stemple Case
finishing the exercise, the patient Study 13 for more information on
should try some modulated open vocal function exercises.)
vowels or yawning to monitor pho-
nation. Then, try some words and Steps 3, 4, and 5 were combined
small sentences, particularly loaded with visual and auditory monitoring
172 Voice Therapy: Clinical Case Studies

via spectrographic trace and audio slight anterior tongue interpositioning

playback. Critical listening of different was completed and adjusted.
voice samples produced at several fre- Vocal quality was not perceived
quency and intensity levels helped the as childish any longer. However, the
patient to understand vocal flexibility patient notes that particularly when
and to monitor her own voice. Lombard talking to her father and some close
effect and delay auditory feedback, via friends, the old voice tends to appear.
FonoTools software (CTS Informatica The patient fully comprehends the emo-
Inc), were used to confirm the inner tional relationship of her voice problem.
monitoring of voice.
Treatment dosage was conducted Instrumental:Visual
for 12 sessions, 8 the first month (twice Imaging and Acoustics
a week) and 4 at the following month
(once a week). Home practice was sug- ENT Evaluation. Normal examination
gested 8 times a day, one single exercise, showed a normal mobile larynx and
for the 2 first weeks and 3 times a day lower vertical positioning. Glottic chink
after this period. was reduced to the physiological female
The ENT conclusion was that this
Therapy Outcomes was a normal examination.

Audio-Perceptual Acoustic Analysis.Acoustic analysis

of voice showed a slight reduced mean
The patient obtained a normal adult fundamental frequency for the sustained
female voice. CAPE-V assessment indi- open vowel /ae/, of 197 Hz; for connect-
cates overall severity of 20, roughness of ing speech the mean value was of 202
0, breathiness of 15, tense 0; pitch (high) Hz (counting numbers from 1 to 10).
of 15; and loudness (low) of 10. All Acoustic parameters were essen-
parameters were consistently present. tially normal (Table 315), including
Anterior tongue carriage was cor- graphic distribution of the hoarseness
rected, with use of resonance tasks. The diagram (Figures 320 and 321).

Table 315. Posttherapy Acoustic Parameters From the

Sustained Open Vowel /ae/ (VoxMetria, CTS Informatica Inc)
From the 29-Year-Old Female Journalist, High-Pitched Voice

Acoustic Parameters Values Normal Data
Mean fundamental 197 Hz
Jitter 0.50 00.6
Shimmer 4.01 06.5
GNE (noise) 0.90 0.51
Irregularity 4.61 04.75
Primary and Secondary Muscle Tension Dysphonia 173

Figure 320.Post-therapy Phonatory Deviation Diagram from a

29-year-old female journalist, high-pitched voice (VoxMetria, CTS Infor
matica Inc, Brazil).

Figure 321. Post-therapy spectrogram from a 29-year-old female jour

nalist, high-pitched voice (Fonoview, CTS Informatica Inc, Brazil).

Patient Self-Assessment domain = 95.8%), which indicates less

impact of the voice problem on quality
V-RQOL total score reduced to 97.5% of life. The data were close to the normal
(socioemotional = 100% and physical Brazilian population.185,186
174 Voice Therapy: Clinical Case Studies

Summary and by a local otolaryngologist for evalua-

Concluding Remarks tion and treatment of mutational voice.
In a telephone conversation with the
Puberphonia is usually a male disorder. patients mother prior to the evalua-
However, the maintenance of a childish tion, she expressed deep concern over
voice in adulthood for a professional her sons abnormal voice and its impact
female can impair her opportunities on his interaction with peers and teach-
for career development. Therapy used ers at school.
a mosaic of approaches due to the par- The patient was brought to the eval-
ticular nature of the case: a long-term uation session by his mother. The mother
maladaptive vocal adjustment with was present during the interview por-
a stable vocal psychodynamic. This tion of the evaluation session and left the
patient did not have extensive vocal room after historical information had
complaints, but the opportunity of fac- been obtained. The patient provided the
ing a new challenge that would include majority of the background and histori-
professional voice use on a TV program cal information related to his voice con-
was the motive to search for voice reha- dition. AA was reserved throughout the
bilitation. The interesting fact is that the evaluation session, speaking only briefly
show was not scheduled for the season; when asked direct questions by the clini-
however the patient was fully satisfied cian and offering only limited detail in
with the new voice, even if the old pat- his comments.
tern could emerge in certain situation, The client presented with the pri-
with selected speakers. mary complaints of a high voice and
intermittent vocal fatigue at the close
of the day. He could not recall the exact
Lisa Fry presents the more traditional
time of onset or any circumstances sur-
case of a young male with functional
rounding the onset but believed that the
falsetto. In this case, hard glottal attack
problem had been in existence for about
is used to facilitate an appropriate modal
2 years. AA reported that his voice did
not really bother him and that he did
not pay much attention to it. He stated
that his mother was much more con-
cerned about the problem than he was
Case Study 22
and that she was the primary instigator
of the otolaryngology and voice therapy
Lisa Fry appointments.
During the history-taking portion
Use of Hard Glottal Attack of the evaluation, AA was asked about
as Laryngeal Manipulation his voice behaviors and if/when he had
to Modify Mutational Voice ever heard himself produce another
in a 16-Year-Old Male voice. (Some young men with this con-
dition experience brief periods where
History of the Problem the new, lower pitched voice is heard;
however, they find themselves unable
Patient AA was a 16-year-old male to sustain this mode of phonation for
referred to the university voice center functional use.) AA indicated that he
Primary and Secondary Muscle Tension Dysphonia 175

had heard this other voice from time when people met him for the first time
to time. He recalled that this generally they often asked if he had a cold.
happened first thing in the morning, AA lived at home with his father,
just upon waking. He stated that he gen- mother, and younger sister. He de-
erally makes only a few statements in scribed the home as typically quiet
this other voice before the high-pitched and uneventful. There were no smokers
voice returns and remains for the course living in the home. The family had one
of the day. small, indoor dog. AA reportedly filled
his spare time with basketball, hanging
out with friends, and attending church-
Medical History related youth activities.

AAs medical history was significant for

mild nasal allergies and acne. Current Voice Evaluation
medications included an oral antibiotic
for treatment of acne and an over-the- Audio-Perceptual
counter pain medication as needed for
sports-related orthopedic pain/soreness. AA spoke in a falsetto voice throughout
the evaluation session. His voice qual-
ity was moderately harsh, and loudness
Social History was reduced. He displayed intermit-
tent pitch breaks into the modal regis-
AA was a sophomore at the local high ter during conversation. A mild degree
school where he participated in the of strain was present during voicing.
schools junior varsity basketball team. Specific parameters of AAs voice were
As part of the team requirements, rated using the CAPE-V. In brief, AA
he attended practice 4 to 5 times per presented with moderate to severe
week and engaged in weightlifting 2 dysphonia, characterized by a severe
to 3 times per week. He reported great deviation of pitch, moderate breathi-
enthusiasm for the sport and indicated ness, moderate roughness, and a mild to
that most of his close friends at school moderate reduction in loudness. Inter-
were fellow members of the basket- mittent pitch breaks were noted.
ball team. When questioned about his
behavior and general performance at Instrumental
school, AA indicated that he was an
OK student. He reported that he rarely Visual Imaging. AAs vocal folds were
spoke up in class and rarely talked easily visualized with a 70-degree rigid
with teachers apart from his basketball scope. Vocal fold edges were smooth and
coaches. AA did converse with close straight bilaterally, and vocal fold color-
friends in the hallway before and after ation was normal. Arytenoid movement
school and during breaks, but he sug- was normal bilaterally. The glottic clo-
gested that these hallway conversations sure pattern was incomplete, character-
were, at times, difficult, as he could not ized by a slight gap running the length of
project his voice over the surrounding the vocal folds. Amplitude of vibration
noise. AA stated that his friends did not and mucosal wave were mildly reduced
comment on his voice but indicated that bilaterally. The open phase of vibration
176 Voice Therapy: Clinical Case Studies

was moderately longer than the closed Because the mutational voice is gen-
phase. The vocal folds were elongated erally amenable to modification and can
and tense during phonation. be managed efficiently, a few guidelines
regarding scheduling are generally fol-
Acoustics. Key acoustic measures were lowed. First, when clinic scheduling per-
taken with the Computerized Speech Lab mits, it is helpful to arrange an extended
(KayPENTAX). In brief, fundamental block of time for the initial evaluation/
frequencies of sustained phonation and treatment session. I generally schedule a
conversational speech were increased at 2-hour to 3-hour session for these cases.
236.37 and 229.97 Hz, respectively. Con- When more than 1 session is required,
versational dB was mildly decreased. every attempt should be made to avoid
Harmonics-to-noise ratio as well as jitter long periods between sessions, as this
and shimmer calculations indicated an may permit the client to revert back to
increased degree of noise and aperiodic- previous vocal behaviors; arranging ses-
ity in the voice signal. sions on consecutive days is quite helpful.

Voice Therapy
Therapy Goals and
Type of Therapy Expected Outcomes

Intensive therapy using education n AA will consistently achieve the tar-

and hard glottal attack productions to geted lower pitched voice after facili-
establish and then stabilize the targeted tating techniques.
lower pitch. n AA will extend use of the new pitch to
increasingly complex linguistic con-
Rationale for Treatment texts (syllables through conversation).
Method and Frequency n AA will develop a plan for general-
izing the new voice to new listeners
Patients with mutational voice possess and situations.
deficits in laryngeal function onlythat n AA will use the lower pitched voice
is, they present with abnormal laryn- in all speaking contexts.
geal muscle use amid normal laryngeal n AA will express satisfaction and com-
structure. Consequently, most cases of fort with his new speaking voice.
functional falsetto in the pubescent male
can be successfully managed in only 1 to It was expected that the patient would
2 treatment sessions. In many cases, the achieve the above goals in an extended
initial treatment session can, in fact, be treatment session conducted at the close
conducted at the time of the diagnostic of the evaluation session.
voice evaluation, saving the client pre-
cious time and offering tremendous
support and encouragement to the cli- Therapy Description
ent and family. In some cases in which
the functional use of the falsetto register Education
has been maintained over the course of
many years, a few additional treatment Treatment began with a thorough de-
sessions may be necessary. scription of the anatomy and physiology
Primary and Secondary Muscle Tension Dysphonia 177

of voice production and a discussion of ah. His initial attempts yielded only
how these features change at puberty. breathy, high-pitched ahs. The cli-
Line drawings by the clinician and a nician continued to request a harder,
laryngeal model supported the expla- louder tone, eventually asking the client
nation. The clinician reminded the cli- to press hard against her hands while
ent that his laryngeal structures were attempting the abrupt ah. With this
normal on exam and that his voice con- maneuver, the glottal attack was pro-
cerns were related to muscle use issues. duced, immediately triggering a lower-
The physiology of the mutational voice pitched, frylike phonation. The client
(ie, disengaged thyroarytenoid muscle was instructed to repeatedly produce
amid tense suprahyoid and cricothy- the glottal attack until the lower pitched
roid muscles) was presented. The client tone was stable. Once consistent hard
was reassured that changes in laryngeal glottal attacks were heard and the client
anatomy at puberty create challenges was able to hear/identify the targeted
for the system and that he was not alone pitch, the abrupt ah was sustained for
in his experience. Finally, methods of longer periods of time. Eventually, the
facilitating proper muscle activity were hard onset was faded, and AA was able
reviewed; the rationale for each method to sustain the ah for several seconds
and its ability to restore normal physiol- on command.
ogy were explained. After the target tone had been sta-
bilized, the tone was slowly extended
Facilitating and Stabilizing into other speech contexts. First, the
the Lower Pitch client was asked to generalize the tone
to other sustained vowels. Once that
After the above discussion, the clinician step was mastered, the clinician trained
spoke with AA about the other voice the client in chanting, all-voiced non-
that he reported hearing upon waking sense syllables (eg, mamama, momomo,
some mornings. The clinician asked if minimini). Chanting syllables such as
AA could produce that voice on com- these permitted AA to extend the low-
mand. AA made several attempts to pitched voice to a variety of articula-
produce the lower pitch without suc- tory contexts without altering the newly
cess. (Note that in some instances, this acquired laryngeal posture for inflection
simple technique is sufficient to prompt or for production of a voiceless con-
the lower pitched phonation, which sonant. Consequently, the new voice
can then be shaped into conversational became more stable, and the client was
speech.) less likely to return to the high pitch as
As AA was unable to produce the a result of laryngeal maneuvering that
lower pitch on command, a simple facil- would have been required of voiced-
itating technique, the hard glottal attack, voiceless syllables.
was used. Production of the hard glottal AA continued chanting all-voiced
attack requires engagement of the thyro- productions through word, phrase, and
arytenoid muscle and moves the larynx sentence levels. Once mastered, AA pro-
away from the falsetto posture into an gressed to producing voiced-voiceless
appropriate posture for the lower pitch. syllables, words, phrases, and sentences
In keeping with this line of thought, AA in the context of a chanting style. Even-
was asked to produce a hard, abrupt tually, the chanting style was faded, and
178 Voice Therapy: Clinical Case Studies

the client was able to gradually produce team and members of his extended fam-
the new pitch with longer utterances ily. By the second day post-therapy, AA
with normal prosody. The client was would use the voice with all teachers
advanced through various readings and and with friends and acquaintances in
conversational topics. the school hallway. Finally, by the third
day following therapy, AA expected
Generalizing the Lower Pitch to use his lower pitched voice in all
Because of the dramatic nature of voice With the above plan in place, the
changes during treatment for mutational session drew to a close. The speech
voice, transition of the voice outside of pathologist asked that the client remain
the therapy context can be challenging. in the treatment area while she went
Consequently, it is recommended that to get his mother. Prior to taking the
the clinician and client openly discuss mother into the treatment area, the cli-
this challenge and develop a structured nician took a few moments to prepare
plan for generalizing the new voice. the mother for AAs new voice. The
In the case of AA, the clinician results of the session were discussed,
posed the question What do you think and the speech pathologist asked that
others will say about your new voice? the mother not respond too dramati-
to which AA replied, They will be cally or emotionally to the new voice
shocked. I dont know if they will like but that she simply make a few brief
it. The clinician reassured the client comments about the appeal of the new
that, although the new voice was nota- voice. It was believed that preparing
bly different, it was also quite pleasing the mother for the new voice and prac-
and appropriate. To confirm this for ticing her response would reduce the
the patient, digital recordings of the likelihood that she would overreact to
new voice were made and played back the new voice and, thereby, cause the
for the client. After hearing only a few client to be fearful of future interac-
brief statements, the client expressed tions where he used the new voice with
his pleasure with the new voice, stating friends and family.
that it made him sound stronger and
more confident. Refining the Lower Pitched Voice
At this point, the speech patholo-
gist suggested that the client develop At the close of the initial session, AAs
a hierarchy of persons and situations lower pitched voice possessed an ele-
where the voice could be gradually ment of glottal fry, suggesting that AA
introduced. The client agreed to use the had lowered the pitch a bit beyond the
new voice with his immediate family target and that a degree of muscle imbal-
and 2 close friends on the day of the ses- ance was still present. To deal with this
sion; he would be free to use his higher- situation, an additional therapy session
pitched voice if he so desired with other was recommended to refine the lower-
individuals on that day. On the first day pitched tone and to promote a proper
following therapy, AA would expand tone focus (frontal tone focus). AA fol-
use of his new voice to include the lowed up for the second session 1 week
coaches and members of his basketball following the initial visit.
Primary and Secondary Muscle Tension Dysphonia 179

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Management of
Glottal Incompetence

to create and maintain phonation. The

Introduction speaker, therefore, must work harder to
produce voice. The perceptual quality
Normal voicing is dependent on near- of voice and effort required to produce
total closure of the vocal folds. (The voice will be reflected directly by the size
larynges of many women and some of the glottal gap. The larger the glottal
men will demonstrate a normal poste- gap, the breathier the voice will be. As
rior glottal gap of the vocal folds upon the size of the gap may vary from large
adduction.1) Subglottic air pressure from to small, the voices of individuals with
the lungs builds and eventually over- glottal incompetence may range from a
comes the resistance of the adducted mild breathiness to complete whispered
folds, and a puff of air escapes. This aphonia. Interestingly, some patients
release of air creates a sudden drop of with glottal incompetence attempt to
air pressure between the vocal folds compensate for the lack of glottic clo-
that, along with a reflected downward sure by compressing the supraglottic
pressure from the supraglottic structures structures. Therefore, this segment of
and the static positioning of the adducted the population may not present with
folds, draws the vocal folds back together, the expected breathy quality, but with a
completing a vibratory cycle.2 strained, strangled quality.
When the vocal folds do not totally Glottal incompetence may result
approximate, as in the case of glot- from either muscular or anatomical
tal incompetence, a greater amount of causes. Functional hypoadduction of
air pressure and airflow are required the vocal folds may be caused by an
190 Voice Therapy: Clinical Case Studies

imbalance of respiration, phonation, will determine the type of paralysis, the

and resonance caused by voice misuse, degree of glottal incompetence, and the
use-induced vocal fatigue, or emotional resulting voice quality.
concerns. Glottal incompetence also may be
Inefficient voice use may lead to secondary to nonneurologic causes.
voice fatigue in an otherwise medically For instance, aging may bring about a
and emotionally healthy individual, characteristic bowing of the vocal fold
such as patients who report that their edge and a resultant lack of glottal clo-
voice quality is normal in the morning sure. Although such changes have been
but becomes weak, rough, and breathy observed across genders, these changes
as the day progresses. The result of this are most commonly observed in males.
vocal fatigue may be the development Thus, a variety of concerns may lead to
of glottal gaps between the vocal folds,3 glottal incompetence. This chapter high-
usually with increased supraglottic ten- lights management of age-related and
sion. These patients complain that the neurogenic cases.
harder they try to produce voice, the
worse the quality becomes. One might
Unilateral vocal fold paralysis presents
correctly argue that the original cause of
a complex diagnostic and therapeutic
laryngeal fatigue was hyperfunctional
challenge to the voice care team. In
vocal behavior. Nonetheless, strobo-
this first case, Stephen McFarlane and
scopic observations of many of these
Shelley Von Berg discuss multiple
patients made during the fatigued state
facilitating techniques for improving
demonstrate unusual anterior glottal
voice production in a 35-year-old
chinks, large posterior glottal chinks,
woman with a complex medical history.
and occasional spindle-shaped chinks.4
Lack of glottal closure also may
be the result of vocal fold pathology.
A number of neurogenic etiologies,
Case Study 1
both central and peripheral, have been
associated with insufficient glottal clo-
sure. Vocal fold paralysis is, perhaps, Stephen C. McFarlane and
the most common neurogenic cause of Shelley Von Berg
glottal incompetence. Although paraly-
sis may be caused by central neurologic Treatment Strategies Used for
disease, more often it is the result of Unilateral Vocal Fold Paralysis in a
nerve damage or peripheral disease. Case With a Complex Medical History
Vocal fold paralysis may be unilateral or
bilateral. It may be caused by damage to
or disease of the vagus nerve anywhere Introduction
along its course from the brainstem to
the target muscle and may, therefore, Injuries to the vagus nerve anywhere
involve the superior laryngeal nerve (to along its path from the medulla to inser-
the cricothyroid muscle), the recurrent tion into the larynx inevitably result in
laryngeal branch (all remaining intrin- paresis or paralysis of those muscles
sic laryngeal muscles), or both. Location receiving innervation at or below the
of the lesion along the nerve pathway level of injury. The most frequently
Management of Glottal Incompetence 191

observed laryngeal paralysis expe- and poor vocal quality. The patient pre-
rienced at this clinic and reported in sented with a complicated and lengthy
the literature57 is unilateral vocal fold medical history. Eleven years earlier, she
paralysis (UVFP), with the involved fold noticed a slight bulge in the neck at the
fixed in the paramedian positionthat area of the thyroid gland. She underwent
is, halfway between the midline and lat- total thyroidectomy and partial neck
eral positions. dissection for Hashimotos thyroiditis,
Unilateral paralyses usually are combined with papillary carcinoma of
the result of severing or bruising of the the thyroid with metastasis to 3 regional
recurrent laryngeal branch of the vagus, lymph nodes. She underwent postop-
the branch responsible for efferent and erative iodine 131-treatment. (Iodine is
afferent nerve supply to all of the intrin- an essential micronutrient; 80% of the
sic muscles of the larynx except for the iodine present in the body is in the thy-
cricothyroid muscle, which is inner- roid gland.) Over the years, patient O
vated by the superior laryngeal branch. underwent 12 additional surgeries to
At times, the nature of the paralysis the neck area. Some surgeries involved
is unknown (ie, idiopathic paralysis). recurrent tumor removal, but others
Viruses affecting the vagus nerve may involved laminectomies and Z-plasty.
be responsible for at least a portion of A number of surgeries involved place-
these idiopathic cases. ment of an electrical implant to reduce
McFarlane, Holt-Romeo, Lavorato, chronic pain.
and Warner8 found that behavioral voice Patient O had never smoked and re-
intervention produced superior voice ported no alcohol use. She drank 1cup of
quality in patients with unilateral vocal caffeinated coffee each day and 6 glasses
fold paralysis when compared with one of water. A videofluoroscopic swallow
group of patients who had received examination administered 2 weeks ear-
injections and another group who had lier had shown a focal narrowing on the
undergone muscle-nerve reinnerva- right side of the esophagus at about the
tion surgery. Another study 9 found level of C5 to C6; however, the course,
that voice therapy was instrumental in caliber, and motility of the esophagus
reducing by half the excessive mean air- were reported to be normal. There was
flow rates in 16 individuals with UVFP. no diverticular formation, hiatal hernia,
Thus, in the interim period between or mucosal abnormality.
diagnosis of vocal fold paralysis and When questioned about her vocal
final resolution of the problem, voice quality, patient O said that it had dete-
therapy has been demonstrated to be an riorated progressively with successive
effective intervention for helping many operations but worsened abruptly after
patients achieve normal or near-normal a laminectomy 4 months earlier. She
voice quality and reducing air wastage. took a fatalistic approach to her dyspho-
nia, stating that she had simply gotten
used to no voice. Speaking behaviors
Patient History were characterized by a moderate-to-
severe degree of neck tension. Routine
Patient O was a 35-year-old woman, questioning revealed that the patient
referred to our office by her otolaryn- was divorced and that her ex-husband
gologist, with complaints of dysphagia had threatened to kidnap their young
192 Voice Therapy: Clinical Case Studies

child. With a wry smile she admitted to tended to creep toward the midline
having an element of stress in her life. during phonation and impinge on the
true vocal fold, further contributing to
increased vibrational aperiodicity, jit-
Voice Assessment ter, and harsh, breathy vocal quality
Upon examination, the voice was high The Phonatory Function Analyzer
in pitch, rough, strained, and breathy (Kelleher Medical, Richmond, Virginia)
with phonation breaks and reduced revealed airflow rate of 138 mL/s at
intensity. Patient O said that she now 220Hz. These measures are within nor-
considered this to be her typical voice. mal limits, but they were achieved with
Sustained vowel production measured abnormally brief phonation times of
on the Visi-Pitch II (KayPENTAX, Inc) 4seconds.
revealed a fundamental frequency of In summary, patient O presented
274 Hz with jitter of 2.8% and shimmer with a unilateral adductor paralysis of
of 2.8%. Jitter was considered abnor- the left vocal fold, most likely associated
mally elevated, indicating irregular fre- with numerous surgical interventions
quency perturbations across vibratory for cancer of the thyroid gland. Vocal
cycles.5 Fundamental frequency was at pitch was high and squeaky, and vol-
the high end of normal for females aged ume was low. Vocal quality was harsh,
30 to 40 years.10 strained, and breathy. Phonation times
A rigid endoscope was introduced were abnormally brief. Endoscopy re-
transorally, and we studied the vocal vealed incomplete vocal fold closure
fold activity by videostroboscopy. Ana- and limited mucosal wave on the left
tomically, the larynx and surrounding vocal fold during phonation. Evidence
structures, including the cricopharyn- of supraglottal involvement was also
geal inlet and piriform sinuses bilaterally, observed, characterized by excessive
appeared normal. During phonation, the medialization of the right false fold,
left vocal fold was fixed in the parame- which was reported as a reactive hyper-
dian position. The left vocal fold moved functional response to excessive trans-
slightly toward the midline during
adduction, and a limited mucosal wave
was observed for this fold. The reduced
mucosal wave was partly responsible for
the elevated jitter value and the harsh
and breathy quality of the voice.
During vocal fold vibration, glot-
tal closure was adequate for voice pro-
duction. A glottal gap did exist from
the flava to the posterior commissure,
but the gap was judged to be less than
3 mm across, and vocal fold medializa-
tion was adequate for either contact
at the midline or to take advantage of
airflow dynamics to set the vocal folds
into vibration. The right false vocal fold Figure 41. VF image pretreatment.
Management of Glottal Incompetence 193

glottal airflow. Phonation times were symptoms of dysphagia needed to be

brief, suggesting poor valving of sub- addressed. It is suspected that, over the
glottal air. years, repeated surgery and radiation to
the pharynx and larynx had taken their
toll and that the patient had gradually
Swallow Assessment developed defensive postures during
swallow, which in reality compromised
A barium swallow study confirmed a a physiologically normal functioning
slight, focal esophageal stricture just system. Therefore, swallow strategies
below the upper esophageal sphincter. were employed to alleviate these defen-
However, sequential views of swallow sive postures. Gentle digital pressure at
revealed adequate esophageal motil- the anterior aspect of the cricoid carti-
ity and emptying of the bolus into the lage appeared to reduce the sensation of
stomach. No hiatal hernia, diverticular globus and enhance ease of swallow. It
formations, or reflux of gastric contents was suspected that this midline pressure
were appreciated. Patient O presented ameliorated the effects of the stricture.
with a robust, volitional cough. By experimenting with various head
Oral-pharyngeal swallow was as- turn techniques, it was discovered that
sessed via fiber-optic endoscopic eval the head turned right with chin tucked
uation of swallow. A 3-mm flexible produced a swallow devoid of hyperex-
endoscope was introduced transnasally tensive posturing. We experimented with
and positioned at the base of the tongue. several consistencies employing this tech-
The patient was presented with consis- nique, all of which were swallowed with
tencies of puree, mechanical soft, and no complications. Patient O was encour-
solids. For all consistencies, she pre- aged by these results and was relieved
sented with hyperextensive neck and to avoid esophageal dilation or further
choking behaviors upon swallow. Post- surgery for cricopharyngeal myotomy.
swallow, patient O reported a globus
sensation. Nonetheless, oral-pharyngeal
transit times were within normal lim- Voice Intervention
its, and inspection of the hypopharynx
postswallow revealed no bolus residue. During the initial diagnostic session, it is
Moderately thick and stringy mucus our practice to devote as much time and
was observed at the level of the glottis, effort to attempts to normalize the voice
and it was suggested that this might be as to documenting the disorder. There-
contributing to the globus sensation. fore, after recording the nonstimulated
Patient O was encouraged to increase acoustic, physiologic, and airflow mea-
water intake to 2 quarts (approximately sures of patient Os voice productions,
2 L) per day to thin the mucus. we introduced facilitating techniques to
attempt to improve the voice and acous-
tic measures. In the case of this patient,
Swallow Intervention we had a dual, simultaneous task: to
remove the hyperfunctional component
Although patient O presented with while stimulating the best vocal quality
normal oral-pharyngeal function and possible by altering glottal activity and
esophageal motility upon swallow, her phonatory mode.
194 Voice Therapy: Clinical Case Studies

We normally introduce several facil- Next, we encouraged her to turn her

itating approaches in the first session as head to one side and then to the other as
the patient invariably responds better to we gently placed pressure to either side
some techniques than to others. In this of the thyroid cartilage. A change in head
case, we introduced the following as position away from the paralyzed vocal
described in Boone and McFarlane11: fold may improve vocal quality and air-
flow by stretching the paralyzed vocal
n head turning fold in an A-P manner, thus improving
n lateral digital manipulation of the vocal contact at the midline. Conversely,
thyroid cartilage head turn to the side of the paralyzed
n half-swallow boom vocal fol