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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 e-mail:
[email protected] Website: http://www.pluralpublishing.com
Copyright © by Plural Publishing, Inc. 2014 Typeset in 11/13 Palatino by Flanagan’s Publishing Services, Inc. Printed in the United States of America by McNaughton & Gunn, Inc. All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail:
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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 compilation. [DNLM: 1. Voice Disorders — therapy — Case Reports. WV 500] RF510 616.85'5606 — dc23 2014000154
Contents Preface xiii Contributors xvii
1
Principles of Voice Therapy
1
Joseph C. Stemple Introduction 1 Historical Perspective 2 Hygienic Voice Therapy 3 Symptomatic Voice Therapy 4 Psychogenic Voice Therapy 5 Physiologic Voice Therapy 5 Eclectic Voice Therapy 6 Case Study: Patient A 6 Voice Care Professionals 10 References 10
2
Comments on Voice Evaluation
13
Joseph C. Stemple Introduction 13 Management Team 14 Medical Examination 15 Voice Pathology Evaluation 15 Instrumental Voice Assessment 23 Hearing Screening 23 Impressions 23 Prognosis 24 Recommendations 24 Summary 24 References 24
3
Primary and Secondary Muscle Tension Dysphonia
27
Introduction: Muscle Tension Dysphonia: An Overview Nelson Roy Case Study 1. Behavioral Shaping in Primary MTD Masquerading as Elective Mutism in a 10-Year-Old Boy R. E. Stone Jr and Kimberly Coker
27 29
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Case Study 2. Management of Primary MTD in a 13-Year-Old Using Falsetto Voice to Modify Phonation Joseph C. Stemple Case Study 3. Use of Laryngeal Massage and Resonant Therapy in Primary MTD in an Adolescent Susan Baker Brehm Case Study 4. Flow Phonation in a Teenager with Primary Muscle Tension Aphonia Jackie Gartner-Schmidt Case Study 5. Manual Circumlaryngeal Techniques in the Assessment and Treatment of Primary MTD in a 55-Year-Old Woman Nelson Roy Case Study 6. Management of Primary MTD Initially Masquerading as a Paralytic Dysphonia in a 39-Year-Old Woman Using an Enabling Approach Claudio Milstein Case Study 7. Use of Patient-Family Education and Behavior Modification to Treat MTD Secondary to Vocal Nodules Leslie Glaze Case Study 8. Eclectic Voice Therapy for Secondary MTD in a 10-Year-Old With a Vocal Fold Cyst Carissa Portone-Maira Case Study 9. Using a Psychosocial Management Approach in the Therapy of a Child With Midmembranous Lesions and Secondary MTD Moya Andrews Case Study 10. Treatment of Secondary MTD in a Child With Early Bilateral Lesions: A Telehealth Approach Lisa N. Kelchner Case Study 11. Treating a Child With MTD Secondary to Vocal Nodules Using Concepts From Adventures in Voice Rita Hersan Case Study 12. Pediatric Vocal Fold Nodules and Secondary MTD Treated in Conjunction With a School-Based SLP Rebecca Hancock Case Study 13. Use of Vocal Function Exercises in the Treatment of an Adult With Secondary MTD Joseph C. Stemple Case Study 14. Accent Method in the Treatment of Secondary MTD Sara Harris Case Study 15. Voice Therapy Boot Camp in the Treatment of Secondary MTD in an Adult Rita Patel
38
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116 125
Contents vii
Case Study 16. Medical and Therapeutic Management of Laryngopharyngeal Reflux With Resulting Secondary MTD Sandra A. Schwartz
131
Case Study 17. Management of Secondary MTD Associated With Vocal Process Granulomas Heather Starmer
136
Case Study 18. Lessac-Madsen Resonant Voice Therapy in the Treatment of Secondary MTD Diana M. Orbelo, Nicole Yee-Key Li, and Katherine Verdolini Abbott
142
Case Study 19. Use of Ambulatory Biofeedback to Supplement Traditional Voice Therapy for Treating Primary MTD in an Adult Female Tara Stadelman-Cohen, Jarrad Van Stan, and Robert E. Hillman
157
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 Professional Voice Speaker Presenting With a Primary MTD Marked With Habitual Falsetto Phonation Mara Behlau and Glaucya Madazio
166
Case Study 22. Use of Hard Glottal Attack as Laryngeal Manipulation to Modify Mutational Voice in a 16-Year-Old Male Lisa Fry
174
References 179
4
Management of Glottal Incompetence
189
Introduction 189 Case Study 1. Treatment Strategies Used for Unilateral Vocal Fold Paralysis in a Case With a Complex Medical History Stephen C. McFarlane and Shelley Von Berg
190
Case Study 2. Use of Physiologic Therapy Approaches to Treat Unilateral Vocal Fold Paralysis Following Complications From a Total Thyroidectomy Mara Behlau, Gisele Oliveria, and Osíris do Brasil
198
Case Study 3. Treatment of Glottal Incompetence With Secondary Muscle Tension Dysphonia in a Patient With Unilateral Vocal Fold Paralysis Maria Dietrich
206
Case Study 4. Use of Semi-Occluded Vocal Tract Methods and Resonant Voice Therapy to Treat Unilateral Vocal Fold Paralysis Julie Barkmeier-Kraemer
212
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Case Study 5. Use of Expiratory Muscle Strength Training in a Case of 222 Unilateral Vocal Fold Paralysis 4 Years Post Chemotherapy/Radiation Bari Hoffman Ruddy, Christine M. Sapienza, Erin Silverman, and Henry Ho Case Study 6. Brief Discussion and Case Presentation of Treatment for 226 Superior Laryngeal Nerve Paralysis Using Medical, Surgical, and Behavioral Interventions Bruce J. Poburka Case Study 7. Use of Phonation Resistance Training Exercises (PhoRTE) 233 in a Part-Time Cooking Instructor With Presbyphonia Aaron Ziegler and Edie R. Hapner Case Study 8. Use of Vocal Function Exercises in an Elderly Man With 240 Presbyphonia Stephen Gorman Case Study 9. Treatment of Glottal Incompetence Caused by Sulcus 245 Vocalis: Evidence of a Team Approach for Vocal Rehabilitation Amanda I. Gillespie and Clark A. Rosen Case Study 10. Improvement of Vocal Fold Closure in a Patient With 250 Voice Fatigue Joseph C. Stemple Case Study 11. An Eclectic Approach in the Management of an 255 Individual With Vocal Fatigue Chaya Nanjundeswaran References 262
5
Dystonia, Essential Tremor, and Other Neurogenic Disorders
269
Spasmodic Dysphonia 269 Case Study 1. Functional Voice Therapy for Spasmodic Dysphonia 271 Joseph C. Stemple Case Study 2. Medical and Behavioral Management of Adductor 273 Spasmodic Dysphonia Edie R. Hapner and Michael M. Johns Case Study 3. Combined Laryngeal Injection of Botulinum Toxin and 281 Voice Therapy for Treatment of Adductor Spasmodic Dysphonia Eileen M. Finnegan Case Study 4. Use of Reduced Voicing Duration to Treat Vocal Tremor 287 Julie Barkmeier-Kraemer 298 Case Study 5. Use of LSVT® LOUD (Lee Silverman Voice Treatment) 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
Contents ix
6
Irritable Larynx Syndrome, Paradoxical Vocal Fold Dysfunction, and Chronic Cough
311
Introduction to Irritable Larynx Syndrome Linda Rammage
311
Case Study 1. A Case of ILS Managed by a Comprehensive Approach to Multiple Central Sensitivity Syndrome Triggers Linda Rammage
313
Case Study 2. Multimodality Behavioral Treatment of Long-Standing Chronic Cough in an Adult Marc Haxer
324
Case Study 3. Failed Voice Therapy With Successful Use of Central Nervous System Inhibitors in Chronic Cough Madeleine Pethan and Laureano Giraldez-Rodriguez
328
Paradoxical Vocal Fold Motion: An Introduction Mary J. Sandage
335
Case Study 4. Treatment of PVCD in a Collegiate Swimmer Mary J. Sandage
338
Case Study 5. Management of PVCD: An Adolescent Athlete With Exercise-Induced Dyspnea Michael D. Trudeau, Jennifer Thompson, and Christin Ray
345
Case Study 6. Treatment of Paradoxical Vocal Fold Motion Disorder in a 9-Year-Old Athlete Maia Braden
348
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 Occupational Voice
375
Introduction 376 Marina Gilman Case Study 1. Management of Vocal Fold Nodules in a Female Prepubescent Singer Patricia Doyle and Starr Cookman
379
Case Study 2. The Developing Performer Barbara Jacobson
389
Case Study 3. 19-Year-Old Talented Male Singer, Presenting With Soft Bilateral Vocal Fold Lesions Marina Gilman
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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
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Patient Realities 484 Can All Voices Be Improved? 488 Case Study 1. The Role of Self-Efficacy on Voice Therapy Adherence 488 Amanda I. Gillespie Case Study 2. Using iPod Apps to Improve Voice Therapy Adherence 493 Between Sessions: A Social-Cognitive Approach Eva van Leer Case Study 3. There’s an App for That: Use of Portable Electronic 497 Software Applications to Facilitate Home Practice of Voice Exercises in a Lawyer With Vocal Fold Nodules Bryn Olson and Carissa Portone-Maira Case Study 4. Threat of Being Fired From Therapy Improved a Vocal 503 Overdoer’s Adherence Carissa Portone-Maira References 510 Appendix 8–A. Selected Applications Useful in Voice Therapy 513 Index 521
Preface The fourth edition of Voice Therapy: Clinical Case Studies marks the 20-year anniversary of this text. We are excited to introduce Edie Hapner as co-editor of this fourth edition. Hapner’s clinical and research contributions to the field of voice pathology are recognized nationally and internationally. She is a master clinician and a teacher and mentor to a generation of voice clinicians. We are pleased to have Edie on board and know that her contributions will enhance the quality of the learning experience for voice students and professionals alike. Since its initiation, the purpose of this text has remained the same: . . . to provide both the student and the working clinician with a broad sampling of management strategies as presented by master voice clinicians, laryngologists, and other voice care professionals. The text is meant to serve as a practical adjunct to the more didactic publications.
As the knowledge of voice production continues to expand, so, too, have the publications dedicated to describing this knowledge. There are currently excellent texts and journals dedicated to the scientific understanding of voice. Other publications are available to help prepare students to evaluate and manage clinical voice disorders. By necessity, these texts must include great quantities of didactic information so that the student learns not only “how” but “why.” To utilize a management approach without understanding the underlying basis of the approach is inappropriate.
Nonetheless, because of the breadth of material necessary in these texts, therapeutic methods for voice disorders are often given only a cursory and generalized discussion. This text is meant to bridge that gap. In over 60 case studies involving a wide variety of voice disorders with various pathologies and etiologies, master clinicians have provided detailed descriptions of management approaches and techniques. It is our hope that the expertise offered in these pages will serve the reader well in guiding clinical practice. Utilizing the format of actual case studies, complete descriptions of diagnostic and therapeutic methods are provided for a full array of voice disorders. Chapter 1 includes information on the various philosophies of treatment. With the maturation of the voice care specialty, different schools of thought have evolved regarding treatment designs. These philosophical orientations include hygienic, symptomatic, psychogenic, physiologic, and eclectic orientations. Each orientation is discussed and illustrated with a representative case study. Chapter 2 comments on various voice evaluation techniques. These techniques include the formal questionnaire, the patient interview, perceptual voice analysis, patient self-assessment, and instrumental assessment of voice production. The role of the evaluation process as a part of the overall management plan is also discussed. Chapter 3 discusses treatment approaches for the most common type
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of voice disorder, muscle tension dysphonia (MTD). Following an overview of MTD by Nelson Roy, management approaches for both children and adults including hygiene programs, symptomatic modifications, attention to psychosocial issues, and direct physiologic manipulation and exercises are presented in illustrative case studies of both primary and secondary MTD. Treatments for various etiologies of glottal incompetence are described in Chapter 4. Management for voice fatigue, bowed vocal folds, senile laryngis, and vocal fold paralysis are described, including direct voice therapies, surgical intervention, and a combination of these approaches. Many techniques including voice facilitating techniques, semi-occluded vocal tract, expiratory muscle strength training, and phonation resistance training are discussed. Chapter 5 presents management strategies for laryngeal dystonia, essential tremor, and other neurologic voice disorders. These strategies include behavioral and medical management of spasmodic dysphonia, voice therapy for essential tremor, and face-to-face and remote treatment of voice and speech symptoms related to Parkinson disease. Because of the speech-language pathologist’s unique blend of knowledge regarding upper respiratory anatomy and physiology and behavioral therapy, we have become the caregivers for complex respiratory and laryngeal disorders. Chapter 6 provides several detailed case studies regarding the various etiologies, patient profiles, and evaluation and treatment approaches used with those diagnosed with irritable larynx syndrome. Included in this category are chronic cough and vocal cord dysfunction (VCD). These cases
include treatments for laryngopharyngeal reflux and VCD in the young child, young athlete, and elite athlete. The consequences of a voice disorder may impact the quality of life and threaten the livelihood of individuals dependent upon a healthy voice. Chapter 7 presents case studies for those dependent upon their voice such as the elite vocal performer, the occupational voice user, and those whose avocational voice use is related to their quality of life. The final chapter, Chapter 8, is devoted to a discussion of successful voice therapy and patient adherence. What makes therapy successful or unsuccessful? This chapter looks at both the therapist and the patient and describes the pitfalls that may influence the ultimate goal of therapy: improved vocal function. As with the first three editions of Voice Therapy: Clinical Case Studies, the most exciting element in the preparation of this text was the support received by the master clinicians who graciously and generously submitted the case studies. What a wonderful opportunity it is to learn from those who are in the trenches, those experts who embody not only superior clinical skills, but wonderful insight as to why they do what they do. We are deeply indebted to all of them and proudly offer their collective expertise. We are certain that the reader will benefit from their vast clinical experiences. Text preparations are extremely time-consuming and require many hours of tedious work. Checking and preparing references, organizing tables, figures, and their legends, reading and re-reading in an attempt to make the intent clear to those we are trying to reach are only a few of the tasks involved. We were so very fortunate in the prepara-
Preface xv
tion of this text to have the invaluable editorial assistance of the Plural Publishing professionals. We are indebted to Angie Singh, Megan Carter, Milgem Rabanera, and Mckenna Bailey for encouraging and supporting this fourth
edition. In addition, we wish to thank our students and colleagues who have suggested ways to improve the text with each new writing. Finally, as usual, we are most appreciative for the support of our families. — Joseph C. Stemple Edie R. Hapner
Contributors Moya L. Andrews, EdD Professor Emerita Department of Speech and Hearing Sciences Indiana University Bloomington, Indiana Chapter 3 Mary V. Andrianopoulos, PhD Associate Professor Clinical Consultant Department of Communication Disorders Center for Language, Speech, and Hearing University of Massachusetts-Amherst Amherst, Massachusetts Chapter 6 Susan Baker Brehm, PhD Associate Professor and Chair Department of Speech Pathology and Audiology Miami University Oxford, Ohio Chapter 3 Julie Barkmeier-Kraemer, PhD Professor Department of Otolaryngology University of California, Davis Sacramento, California Chapters 4 and 5 Mara Behlau, PhD Permanent Professor Graduate Program in Human Communication Disorders Director Specialization Course in Voice
Universidade Federal de São Paulo UNIFESP and Centro de Estudos da Voz-CEV São Paulo, SP, Brazil Chapters 3 and 4 Alison Behrman, PhD, CCC-SLP Associate Professor Department of Speech-LanguageHearing Sciences Lehman College/City University of New York Bronx, New York Chapter 7 Maia Braden, MS Speech-Language Pathologist University of Wisconsin-Madison Voice and Swallow Clinics American Family Children’s Hospital Madison, Wisconsin Chapter 6 Kimberly Coker, MS Speech-Language Pathologist North Texas Voice Center Dallas, Texas Chapter 3 Starr Cookman, MA Assistant Professor Clinical Faculty University of Connecticut Health Center Farmington, Connecticut Chapter 7 Mark S. Courey, MD Professor Otolaryngology-Head & Neck Surgery
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Director Division of Laryngology University of California, San Francisco San Francisco, California Chapter 7 Kate DeVore, MA Speech-Language Pathologist Total Voice, Inc. Chicago, Illinois Chapter 7
Lisa Fry, PhD Adjunct Faculty Department of Communication Disorders Marshall University Huntington, West Virginia Chapter 3
Maria Dietrich, PhD Assistant Professor Department of Communication Disorders University of Missouri Columbia, Missouri Chapter 4
Jackie Gartner-Schmidt, PhD Associate Professor Otolaryngology Associate Director UPMC Voice Center Director of Speech Pathology-Voice Division University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Chapter 3
Osíris do Brasil, MD Centro de Estudos da Voz CEV, São Paulo, SP Associate Professor São Paulo, Brazil Chapter 4
Shirley Gherson, MA Clinical Specialist-Voice Disorders NYU Langone Medical Center Rusk Rehabilitation New York, New York Chapter 7
Patricia B. Doyle, MA Instructor University of Connecticut Health Center Farmington, Connecticut Chapter 7
Amanda I. Gillespie, PhD Assistant Professor University of Pittsburgh UPMC Voice Center Pittsburgh, PA Chapters 4 and 8
Eileen M. Finnegan, PhD Associate Professor University of Iowa Iowa City, Iowa Chapter 5
Marina Gilman, MM, MA, CCC-SLP Speech-Language Pathologist Emory Voice Center Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 7
Cynthia Fox, PhD Research Associate National Center for Voice and Speech University of Colorado-Boulder Denver, Colorado Chapter 5
Laureano A. Giraldez-Rodriguez, MD Fellow Head and Neck Cancer Surgery– Microvascular Reconstruction
Contributors xix
Department of Otolaryngology-Head & Neck Surgery Mount Sinai School of Medicine New York, New York 2013 Fellow Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 6 Leslie E. Glaze, PhD Speech-Language Pathologist Minneapolis, Minnesota Tucson, Arizona Chapter 3 Stephen Gorman, PhD Voice Pathologist Blaine Block Institute for Voice Analysis and Rehabilitation Dayton, Ohio Professional Voice Center of Greater Cincinnati Cincinnati, Ohio Chapter 4 Rebecca L. Hancock, MEd Senior Speech Pathologist University of Kentucky Voice and Swallow Clinic Lexington, Kentucky Chapter 3 Edie R. Hapner, PhD, CCC-SLP Associate Professor Department of Otolaryngology-Head & Neck Surgery Emory University School of Medicine Director Speech-Language Pathology Emory Voice Center Atlanta, Georgia Chapters 4 and 5
Sara Harris, FRCSLT Speech-Language Pathologist Lewisham Hospital Voice Disorders Unit London, United Kingdom Chapter 3 Marc Haxer, MA Clinical Senior Speech Pathologist Departments of OtolaryngologyHead & Neck Surgery and SpeechLanguage Pathology University of Michigan Health System Ann Arbor, Michigan Chapter 6 Rita Hersan, MS Speech-Language Pathologist Voice Clinician University of Pittsburgh Voice Center Pittsburgh, Pennsylvania Chapter 3 Robert E. Hillman, PhD Co-Director Research Director Center for Laryngeal Surgery and Voice Rehabilitation Massachusetts General Hospital Director Research Programs MGH Institute of Health Professions Professor of Surgery Harvard Medical School Boston, Massachusetts Chapter 3 Henry Ho, MD, FACS Director Head and Neck Program The Florida Hospital Cancer Institute Orlando, Florida Chapter 4 Bari Hoffman Ruddy, PhD Associate Professor
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Voice Therapy: Clinical Case Studies
Department of Communication Sciences and Disorders University of Central Florida Orlando, Florida Chapters 4 and 7 Barbara Jacobson, PhD Assistant Professor Associate Director Medical Speech-Language Pathology Department of Hearing & Speech Sciences Vanderbilt University Nashville, Tennessee Chapter 7 Michael M. Johns, MD, FRCS Associate Professor Otolaryngology Director Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Emory University Atlanta, Georgia Chapter 5 Lisa N. Kelchner, PhD, BCS-S Associate Professor Director of Graduate Studies Department of Communication Sciences and Disorders University of Cincinnati Cincinnati, Ohio Chapter 3 Wendy D. LeBorgne, PhD, CCC-SLP Voice Pathologist Singing Voice Specialist Clinical Director The Blaine Block Institute of Voice Analysis and Rehabilitation Provoice Center of Cincinnati CollegeConservatory of Music Dayton and Cincinnati, Ohio Chapter 7
Jeffrey Lehman, MD, FACS Clinical Professor College of Health and Public Affairs University of Central Florida Medical Director The Voice Care Center Winter Park, Florida Chapter 7 Glaucya Madazio, PhD Fonoaudiologa Especialista em Voz Consultora em Comunicacao Humana Sao Paulo, SP, Brazil Chapter 3 Stephen C. McFarlane, PhD Foundation Professor/Professor Emeritus Speech Pathology Department University of Nevada, School of Medicine Reno, Nevada Chapter 4 Claudio F. Milstein, PhD Director The Voice Center Cleveland Clinic Associate Professor Otolaryngology Cleveland Clinic Lerner College of Medicine Cleveland, Ohio Chapter 3 Jennifer C. Muckala, MA, CCC-SLP Senior Speech Pathologist Singing Voice Specialist Vanderbilt Voice Center Nashville, Tennessee Chapter 7 Chayadevie Nanjundeswaran, PhD Assistant Professor Department of Audiology and SpeechLanguage Pathology
Contributors xxi
East Tennessee State University Johnson City, Tennessee Chapter 4 Gisele Oliveria, PhD Associate Professor CEV–Centro de Estudos da Voz Sao Paulo, SP, Brazil Assistant Professor Touro College Brooklyn, New York Chapter 4 Bryn Olson, MS Speech-Language Pathologist The Communication Development Center Madison, Wisconsin Chapter 8 Diana M. Orbelo, PhD Assistant Professor Mayo Clinic College of Medicine Rochester, Minnesota Chapter 3 Rita R. Patel, PhD Assistant Professor Department of Hearing and Speech Sciences Indiana University Bloomington, Indiana Chapter 3 Madeleine Pethan, MA Speech-Language Pathologist Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapter 6 Brian E. Petty, MA, MA Speech-Language Pathologist Emory Voice Center
Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapter 7 Bruce J. Poburka, PhD Professor Communication Disorders Minnesota State University, Mankato Mankato, Minnesota Chapter 4 Carissa Portone-Maira, MS Lead Speech-Language Pathologist Emory Voice Center Department of Otolaryngology-Head & Neck Surgery Atlanta, Georgia Chapters 3 and 8 Lorraine Ramig, PhD Professor University of Colorado-Boulder Senior Scientist National Center for Voice and Speech-Denver Adjunct Professor Columbia University New York, New York Chapter 5 Linda Rammage, PhD, RSLP Director Provincial Voice Care Resource Program, UBC Vancouver, BC, Canada Chapter 6 Christin Ray, MA (ABD) Doctoral Candidate Department of Speech and Hearing Science The Ohio State University Columbus, Ohio Chapter 6
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Voice Therapy: Clinical Case Studies
Clark A. Rosen, MD, FACS Professor Department of Otolaryngology University of Pittsburgh School of Medicine Director University of Pittsburgh Voice Center Pittsburgh, Pennsylvania Chapter 4 Nelson Roy, PhD, CCC-SLP, ASHAF Professor Department of Communication Sciences and Disorders Division of Otolaryngology-Head & Neck Surgery Department of Surgery, School of Medicine University of Utah Salt Lake City, Utah Chapter 3 Brienne Ruel, MA Speech-Language Pathologist UW Voice and Swallow Clinics, Department of Surgery Madison, Wisconsin Chapter 7 Mary J. Sandage, PhD Assistant Professor Auburn University Auburn, Alabama Chapter 6 Christine M. Sapienza, PhD Program Director Speech Pathology Associate Dean College of Health Sciences Jacksonville University Jacksonville, Florida Research Career Scientist BRRC Malcolm Randall VA Gainesville, Florida Chapters 4 and 7
Sarah L. Schneider, MS Director Speech-Language Pathology UCSF Voice and Swallowing Center University of California, San Francisco San Francisco, California Chapter 7 Sandra A. Schwartz, MS Clinical Faculty/Instructor Duquesne University Pittsburgh, Pennsylvania Chapter 3 Erin Silverman, PhD Research Assistant Professor University of Florida Gainesville, Florida Chapter 4 Tara Stadelman-Cohen, BM, MS Senior Voice Pathologist Center for Laryngeal Surgery and Voice Rehabilitation Massachusetts General Hospital Adjunct Clinical Instructor School of Health and Rehabilitation Sciences MGH Institute of Health Professions Part-time Faculty Boston Conservatory Boston, Massachusetts Chapter 3 Heather Starmer, MA Assistant Professor Department of Otolaryngology-Head & Neck Surgery Johns Hopkins University Baltimore, Maryland Chapter 3 Joseph C. Stemple, PhD, CCC-SLP, ASHAF Professor Communication Sciences and Disorders
Contributors xxiii
College of Health Sciences University of Kentucky Lexington, Kentucky Chapters 1, 2, 3, 4, 5, and 8 R.E. Stone Jr, PhD Retired Director of Speech-Language Pathology Vanderbilt Voice Center Vanderbilt Bill Wilkerson Department of Communication Sciences and Disorders Nashville, Tennessee Chapter 3 Jennifer Thompson, MA Clinical Voice Pathologist Clinical Instructor James Care Voice and Swallowing Disorders Clinic The Ohio State University Columbus, Ohio Chapter 6 Lyn Tindall Covert, PhD Speech-Language Pathologist Department of Veterans Affairs Medical Center Lexington, Kentucky Chapter 5 Michael D. Trudeau, PhD Emeritus Associate Professor The Ohio State University Columbus, Ohio Chapter 6 Eva van Leer, PhD, MFA Assistant Professor Department of Education Psychology, Special Education, and Communication Disorders College of Education Georgia State University Atlanta, Georgia Chapter 8
Miriam van Mersbergen, PhD Assistant Professor Speech-Language Pathology Northern Illinois University DeKalb, Illinois Chapter 7 Jarrad Van Stan, MA, BRS-S Senior Clinical Research Coordinator Speech-Language Pathologist MGH Center for Laryngeal Surgery and Voice Rehabilitation PhD Student MGH Institute of Health Professions Boston, Massachusetts Chapter 3 Katherine Verdolini Abbott, PhD Professor Department of Communication Science and Disorders, Otolaryngology McGowan Institute for Regenerative Medicine University of Pittsburgh Center for the Neural Basis of Cognition Carnegie-Mellon University and University of Pittsburgh Pittsburgh, Pennsylvania Chapter 3 Shelley Von Berg, PhD Associate Professor Communication Sciences and Disorders California State University, Chico Chico, California Chapter 4 Nicole Yee-Key Li, PhD, M.Phil. Assistant Professor University of Maryland-College Park College Park, Maryland Chapter 3
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Aaron Ziegler, MA (ABD) Doctoral Candidate University of Pittsburgh Pittsburgh, Pennsylvania Chapter 4
1 Principles of Voice Therapy
Introduction In preparing the fourth edition of this text, it was necessary to review almost 80 years of history related to voice therapy techniques and approaches. It is a rich and interesting history that gives an excellent understanding of how the treatment of voice disorders has grown and evolved to our present practice. Some of the therapy approaches developed by early speech pathologists continue to be used successfully in the remediation of voice disorders to this day. Because of the growth in our knowledge and understanding of voice production, other therapy approaches once commonly used were proven to be ineffective. The past 30 years have yielded tremendous growth in our knowledge and understanding of vocal function. Computer models of phonation,1–6 histologic studies of the vocal folds,7–10 analysis of the vocal fold cover and tissue engineering,11–19 and genetic issues
associated with voice disorders20–23 are but a few of the many advances in voice science. Furthermore, consider the rapidly evolving ability to measure and describe normal and pathologic voice function objectively through sophisticated acoustic and aerodynamic instrumentation, as well as the ability to observe vocal fold vibration. All of these scientific advancements have provided voice clinicians with the tools to confirm the efficacy of their approaches. The number of traditional therapy approaches that continue to be used in voice therapy today is a strong statement of appreciation and admiration for the voice pedagogues, clinicians, and scientists of earlier days. The accuracy of their practical observations regarding voice function has proved to be uncanny. The efficacy of many of these traditional voice therapy techniques is now being tested through systematic outcomes research.24 Proof of the usefulness of many of these techniques, however, has been well established by
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Voice Therapy: Clinical Case Studies
the clinical results of skilled speechlanguage pathologists. The major difference in voice therapy today compared with even 20 to 25 years ago is the ability to diagnose a problem quickly and accurately and to confirm the efficacy of our management approaches through objective measures. These objective measures may also be used as patient feedback during the therapeutic process. Although our management approaches have changed over the years, voice therapy remains a blend of science and art. The scientific nature of voice therapy involves the clinician’s knowledge of several important areas of study. These areas include the anatomy and physiology of normal and pathologic voice production; the nuances of laryngeal pathologic conditions; the acoustics and aerodynamics of voice production; and the etiologic correlates of voice disorders, including patient behaviors, medical causes, and psychological contributions: n When considering the voice, we are
considering the most widely used instrument on earth. n To understand the voice disorder, we must understand the instrument’s physical structure and functional components. n We must have the skills to measure these components objectively and to relate these measures to our management choices. n In addition, we must possess a broad knowledge of the common causes of voice disorders and the nuances of laryngeal pathologic conditions. The artistic nature of voice therapy is dependent on the human interaction skills of the clinician. Compassion,
understanding, empathy, and projection of credibility, together with listening, counseling, and motivational skills are essential attributes of the successful voice clinician. Philosophically, we might make these statements about the artistic nature of voice: n When considering the voice, we must
consider the whole person. n To examine a voice disorder is to examine a unique individual. n The feelings of that individual, both physical and emotional, may be directly reflected in the voice. n To remediate a voice disorder, we must have the skills to counsel and motivate the patient and empower readiness for change. The successful voice clinician will combine attributes of the artistic approaches toward voice therapy with the objective scientific bases to identify the problem and then plan and carry out appropriate management strategies. Nonetheless, possession of a solid base of didactic information augments experience. Experience continues to teach even the masters. It is hoped that the experiences of others provided in this text will prove helpful in the development of superior voice clinicians.
Historical Perspective In examining the evolution of the treatment of voice disorders, we find it was not until around 1930 that a few laryngologists, singing teachers, instructors in the speech arts, and a fledgling group of speech correctionists became interested in retraining individuals with voice disorders. This group used drills
and exercises borrowed from voice and diction manuals designed for the normal voice in an attempt to modify disordered voice production. Many of these rehabilitation techniques were and remain creative and effective, but they were not necessarily based on scientific principles. The “artistic” portion of voice treatment was the strong point of early clinicians. Out of this artistic approach came the general treatment suggestions of: (1) ear training, (2) breathing exercises, (3) relaxation training, (4) articulatory compensations, (5) emotional retraining, and (6) special drills for cleft palate and velopharyngeal insufficiency.25,26 These treatment suggestions became the foundation of vocal rehabilitation. Several general management philosophies have arisen from the early foundations of voice rehabilitation. These philosophical orientations are based primarily on the clinician’s mindset and previous training regarding voice disorders that directs the management focus. For the sake of discussion, we classify these management philosophies as: n hygienic voice therapy n symptomatic voice therapy n psychogenic voice therapy n physiologic voice therapy n eclectic voice therapy
In short, hygienic voice therapy focuses on identifying inappropriate vocal hygiene behaviors, which then are modified or eliminated. Once modified, voice production has the opportunity to improve or return to normal. Symptomatic voice therapy focuses on modification of the deviant vocal symptoms identified by the speech-language pathologist, such as breathiness, low pitch, glottal
Principles of Voice Therapy
attacks, and so on. The focus of psychogenic voice therapy is on the emotional and psychosocial status of the patient that led to and maintains the voice disorder. The physiologic orientation of voice therapy focuses on directly modifying and improving the balance of laryngeal muscle effort to the supportive airflow, as well as the correct focus of the laryngeal tone. Finally, the eclectic approach of voice therapy is the combination of any and all of the previous voice therapy orientations.27 None of these philosophical orientations are pure. Much overlap is present, often leading to the use of an eclectic approach. With this introduction, let us examine the orientations of voice therapy in greater detail.
Hygienic Voice Therapy Hygienic voice therapy often is the first step in many voice therapy programs. Many etiological factors contribute to the development of voice disorders. Poor vocal hygiene may be a major developmental factor. Some examples of behaviors that constitute poor vocal hygiene include shouting, talking loudly over noise, screaming, vocal noises, coughing, throat clearing, and poor hydration. When the inappropriate vocal behaviors are identified, then appropriate treatments can be devised for modifying or eliminating them. Once modified, voice production has the opportunity to improve or return to normal. Poor vocal hygiene may also include the habitual use of inappropriate pitch or loudness, reduced respiratory support, poor phonatory habits (glottal attacks, fry), or inappropriate resonance. Functional inappropriate use of
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Voice Therapy: Clinical Case Studies
these voice components may contribute to the development and maintenance of a voice disorder. Hygienic voice therapy presumes that many voice disorders have a direct behavioral cause. This therapy strives to instill healthy vocal behaviors in the patient’s habitual speech patterns. Good vocal hygiene also focuses on maintaining the health of the vocal fold cover through adequate internal hydration and diet. Once identified, poor vocal hygiene habits can be modified or eliminated leading to improved voice production.
Symptomatic Voice Therapy Symptomatic voice therapy was a term first introduced by Daniel Boone.28 This voice management approach is based on the premise that modifying the symptoms of voice production including pitch, loudness, respiration, and so on, will improve the voice disorder. Once identified, the misuses of these various voice components are modified or reduced using voice therapy facilitating techniques. In the voice clinician’s attempt to aid the patient in finding and using his best voice production, it is necessary to probe continually within the patient’s existing repertoire to find the best one voice which sounds “good” and which he is able to produce with relatively little effort. A voice therapy facilitating technique is that technique which, when used by a particular patient, enables him easily to produce a good voice. Once discovered, the facilitating technique and resulting phonation become the symptomatic focus of voice therapy . . . This use of a facilitating technique to produce a
good phonation is the core of what we do in symptomatic voice therapy for the reduction of hyperfunctional voice disorders.28(p11)
Boone’s original facilitating approaches included: 1. altering of tongue position 2. change of loudness 3. chewing exercises 4. digital manipulation 5. ear training 6. elimination of abuses 7. elimination of hard glottal attack 8. establishment of a new pitch 9. explanation of the problem 10. feedback 11. hierarchy analysis 12. negative practice 13. open mouth exercises 14. pitch inflections 15. pushing approach 16. relaxation 17. respiration training 18. target voice models 19. voice rest 20. yawn-sigh approach Many if not all of these facilitators remain useful and popular in the treatment of voice disorders and are described in greater detail in cases throughout this text. The main focus of symptomatic voice therapy is direct modification of vocal symptoms. For example, if the patient presents with a voice quality characterized by low pitch, breathiness, and hard glottal attacks, then the main focus of therapy is to directly modify the symptoms. The facilitating approaches used to modify these symptoms might include explanation of the problem, ear training, elimination of hard glot-
Principles of Voice Therapy
tal attack, and respiration training. The speech-language pathologist constantly probes for the “best” voice and attempts to stabilize that voice with the various, appropriate facilitating techniques. Symptomatic voice therapy assumes voice improvement through direct symptom modification.
Psychogenic Voice Therapy Early in the study of voice disorders, the relationship of emotions to voice production was well recognized. As early as the mid-1800s, journal articles discussed hysteric aphonia.29,30 West, Kennedy, and Carr26 and Van Riper25 discussed the need for emotional retraining in voice therapy. Murphy31 presented an excellent discussion of the psychodynamics of voice. Friedrich Brodnitz,32 as an otolaryngologist, was uniquely sensitive to the relationship of emotions to voice. These early readings are most interesting and remain informative to those treating voice disorders. Our understanding of psychogenic voice therapy was further expanded by Aronson,33 Case,34 Stemple,35 and Colton and Casper.36 These authors discussed the need for determining the emotional dynamics of the voice disturbance. Psychogenic voice therapy focuses on identification and modification of the emotional and psychosocial disturbances associated with the onset and maintenance of the voice problem. Pure psychogenic voice therapy is based on the assumption of underlying emotional causes. Voice clinicians, therefore, must develop and possess superior interview skills, counseling skills, and the skill to know when the treatment
for the emotional or psychosocial problem is beyond the realm of their skills. A referral system of support professionals must be readily available.
Physiologic Voice Therapy Physiologic voice therapy includes voice therapy programs that have been devised to directly alter or modify the physiology of the vocal mechanism. Normal voice production is dependent on a balance among airflow, supplied by the respiratory system; laryngeal muscle balance, coordination, and stamina; and coordination among these and the supraglottic resonatory structures (pharynx, oral cavity, and nasal cavity). Any disturbance in the physiologic balance of these vocal subsystems may lead to a voice disturbance.37 These disturbances may be in respiratory volume, power, pressure, and flow. Disturbances also may manifest in vocal fold tone, mass, stiffness, flexibility, and approximation. Finally, the coupling of the supraglottic resonators and the placement of the laryngeal tone may cause or may be perceived as a voice disorder. The overall causes may be mechanical, neurologic, or psychological. Whatever the cause, the management approach is direct modification of the inappropriate physiologic activity through exercise and manipulation. Inherent in physiologic voice therapy is a holistic approach to the treatment of voice disorders. They are therapies that strive to at once balance the three subsystems of voice production as opposed to working directly on single voice components, such as pitch or loudness. Examples of physiologic voice
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Voice Therapy: Clinical Case Studies
therapy include Vocal Function Exercises,38 Resonant Voice Therapy,39 and the Accent Method of Voice Therapy,40 all of which are presented in this text.
Eclectic Voice Therapy Adherence to one philosophical orientation of voice therapy would not be advisable. Successful voice therapy depends on utilization of an approach that happens to work for the therapist and the individual patient. The more management approaches are understood and mastered by the clinician, the greater the likelihood for success. Management techniques that prove successful for one patient may not be successful for a similar patient. The clinician, therefore, must possess the knowledge to adjust the management approach. Some techniques that work well for one therapist may prove to be difficult for another. In whatever management approach you choose, you must have supreme confidence in your understanding of the technique and your ability to make that approach work successfully. Your confidence is one factor that will determine the success or failure of therapy. Using a typical case, let us examine how each therapy orientation might be used to treat the vocal difficulties of this composite patient.
Case Study: Patient A Patient A, a 52-year-old woman, was referred by her laryngologist to the voice center for postsurgical evaluation and treatment. Large, bilateral, draping polyps were first identified by an anes-
thesiologist while intubating the patient for a laminectomy 6 months prior to her voice evaluation. Because of the large polyps, intubation had been difficult. The problem was reported to her family physician, who in turn referred the patient to an otolaryngologist for a laryngeal examination. Indirect mirror examination revealed bilateral polypoid degeneration, worse on the left than the right. Audible inspiratory stridor was noted by the physician, and the patient reported shortness of breath during even limited physical exertion. Therefore, two surgeries (one for each vocal fold) were scheduled 6 weeks apart for aspiration of fluid and laser vaporization of redundant tissue. The surgeries were performed without complication, and the patient was seen for voice evaluation following appropriate healing.
History of the Problem The patient reported that she had always had a “deep” voice, which had lowered even more over the past several years. Her presurgical voice quality had not been a concern to her, however. Instead, it was the shortness of breath that led her to agree to surgery. She reported that voice quality following the first surgery (left fold) was a little “hazy” but returned to “normal” within 1 week. The second surgery left her with significant, bothersome hoarseness that made her “wish I had never had surgery.”
Medical History The patient reported undergoing two previous surgeries: removal of her gall bladder 10 years earlier and the lami-
nectomy performed earlier this year. Even with the difficult intubation and the risk of vocal fold paralysis inherent in laminectomy, her presurgical voice quality was maintained. In addition to surgeries, she had been hospitalized 3 years before for 3 weeks and treated for chronic depression. Chronic medical disorders included frequent upper respiratory infections including bronchitis, high blood pressure, circulatory problems in her legs, elevated blood sugar, and chronic neck and back pain. Daily medications were taken for blood pressure, chronic pain, depression, and sleep. She continued a 30-year history of smoking 1½ to 2 packs of cigarettes per day. Her liquid intake consisted mostly of 6 cups of caffeinated coffee per day. Chronic throat clearing and a persistent cough were noted throughout the evaluation.
Social History Patient A had been married for 12 years to her second husband, following a first marriage of 18 years and divorce. She had two adult children from her previous marriage. Her elderly mother-inlaw lived with her and her husband, a situation that often caused friction and conflict with her husband. She was not shy in reporting her unhappiness with her marital relationship. This unhappiness was said to be a major factor in her history of depression. Both the patient and her husband were employed by the local automobile assembly plant. She had worked as an assembler for 14 years in an environment described as “noisy, dusty, and full of fumes” and was on a temporary medical disability because her back problems precluded her working in the
Principles of Voice Therapy
plant. Present activities included shopping with her daughter, talking on the telephone, caring for her home (back permitting), watching daytime television “talk” shows, and bowling two nights per week in two different leagues.
Voice Evaluation Perceptually, the patient’s voice quality was described as moderately dysphonic, characterized by low pitch, inappropriate loudness, strained raspiness, and intermittent glottal fry phonation. Acoustic and aerodynamic analyses revealed a low fundamental frequency (150 Hz), limited frequency range (118–290 Hz), increased habitual intensity (76 dB), normal airflow volume (2300 mL H2O), reduced airflow rate (
