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An Introduction to Voice Therapy

NYU October 2012

James Curtis

on 8 March 2013

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Transcript of An Introduction to Voice Therapy

NYU October 2012 Voice Therapy: An Introduction Biomechanics of Voice Production Vocal Pathologies Who Needs Voice Therapy? Professional Voice Users: teachers, telephone workers, receptionists, counselors, dispatchers, trial lawyers, broadcasters, performing artists, ministers, child caretakers, public speakers, auctioneers, aerobic instructors, coaches, stock traders etc.
Persons with structural damage (laryngectomee) and progressive diseases
Accent Modification
Transgender Voice (primarily MtF) James Curtis
M.S. Candidate in Speech-Language Pathology at New York University – Class 2013
Specialized interest in voice therapy and vocology
How did I become interested in speech-language pathology? Who Am I? Voice Disorder: A Definition A voice disorder is a persistent abnormality in quality, pitch, and loudness outside the normal range of an individual
Organic: anatomical changes (e.g., physical injury, cancer, surgery, etc.)
Functional: vocal inefficiency & poor vocal economy (e.g., hyper/hypofunctional phonatory production)
Psychogenic: emotional & stress induced Introduction Speech Mechanism Speech involves the coordination of four subsystems:
resonation Biomechanics of Phonation Vocal folds are open while breathing
Arytenoid cartilages adduct to initiate phonation
Subglottic air pressure increases and forces the folds to open (remaining closed at arytenoids)
Elasticity and the Bernoulli's Principle cause the vocal folds to close
Subglottic pressure builds up and forces VFs to open, etc. Scope of Practice Scope of Practice SLPs are physiologists who treat the functioning mechanics of the speech mechanism
SLPs diagnose voice disorders (e.g. dysphonia) by assessing perceptual, acoustic, observable and measurable signs Perceptual Signs Eliciting phonation and assessing quality
GRBAS Scale (rate each between 0-3)
Strain Acoustic Signs Measuring speech through acoustic analysis software (e.g., Praat)
Intensity Range
Frequency Range
Mean speaking frequency and intensity
Normal acoustics (e.g., s/z ratio, MPT, jitter/shimmer) Measurable Signs Variety of Instrumentation
Mean airflow: airflow passing through glottis during phonation
Air pressure: subglottic pressure (the area below the adducted vocal folds)
Vital Capacity
Glottal Resistance
Closed/Open Phase Time
Nasal air emission
Not a voice disorder, but hyper/hyponasality can affect the efficiency of the respiratory system (i.e. the driving force of phonation)
Resonance directly correlates with efficient vocal economy (i.e. output intensity v. input intensity) – (Verdolini, 2011) Observable Signs Vocal Tract Visualization
Laryngeal examination can be direct or indirect
Mirror examination
Flexible Laryngoscopy (transnasal)
Rigid Laryngoscopy (transoral)
Halogen light source
Stroboscopic light source (used to differentiate physiological behaviors from anatomic lesions ) Observable Signs Cont. Describe the larynx:
vocal folds,
ventricular folds
pyriform sinuses
post-cricoid area, anterior/posterior commisure

Describing lesions
Location/Color/Shape (e.g., mid-membranous,erythemic, broad-based)
Closure Pattern (e.g. hour glass, incomplete, etc.)
Periodicity (e.g. aperiodic)
Phase Symmetry (e.g. RVF vibrates more frequently)
Symmetry of movement (e.g. flush along midline)
Mucosal Wave Excursion (e.g. reduced)
Amplitude (e.g. lateral excursion from midline
Lateral/Medial and Posterior/Anterior Compression

*SLPs do not diagnose structural impairments – Laryngologists do * Observable Signs Cont Laryngeal Videoendoscopic Evaluation:
A YouTube Example Vocal Fold Nodules Benign growths that develop in the mid-membranous portion of the vocal folds due to phonotraumatic injury.

Think rough “calluses.”

Always bilateral (although contralateral lesions may co-occur)

Symptoms include:
effortful voice,
and rapid vocal fatigue Vocal Fold Polyp Benign fluid-filled lesion that develop in the mid-membranous portion of the vocal folds due to phonotraumatic injury or localized bleeding.

Think rough “blisters.”

Unilateral and/or bilateral

Symptoms include:
effortful voice,
and rapid vocal fatigue Cysts Fluid-filled sacs (usually of mucus) surrounded by an epidermal layer.

Found in the mid-membranous portion of the vocal folds.

May form spontaneously or due phonotraumatic injury

Under the second layer of the VF (superficial layer of the lamina propria) and more broad-based than a VF polyp Polypoid Degeneration/Reinke's Edema Irregular swelling and “ballooning” along the entire superficial area of both vocal folds.

Occurs almost exclusively in smokers (and others with chronic exposure to irritants)

deviantly low speaking pitch
rough voice
impaired breathing Vocal Fold Paralysis/Paresis (Uni-/Bi-lateral) One or both vocal folds do not move (stuck in a lateral or medial position)

Vocal folds vibrate (Bernoulli principle), but cartilages do not adduct/abduct

If paralyzed in the lateral position, speech will sound breathy (air escapes due to incomplete adduction) Spasmodic Dysphonia Condition in which movement is abnormal during meaningful tasks (e.g., speech).

Vegetative functions may be normal.

Voice may present as tremors, vocal fold spasm, and breathy. Who needs voice therapy?... Who needs voice therapy?... 28.8% of working population report at least one occurrence of dysphonia during the life span.
57.7 % of teachers report prevalence of dysphonia during their life
Teachers of vocal music, performing arts, drama, physical education, and chemistry are at increased risk (Smith, Kirchner, Taylor, Hoffman, & Lmke, 1998z; Thibeault et. al., 2004) Who needs voice therapy?... Consequences of voice problems to the professional voice user include:
Physical injury to laryngeal tissue
Limitation in job satisfaction
Limitation in job performance
Limitation in job attendance
Limitation in social, psychological, emotional, physical, and communicative functioning Who needs voice therapy?... According to the United States Bureau of Labor Statistics (Titze, Lemke, & Montequin, 1997; The U.S. Department of Labor, 2008), about one-fourth of the working population in the United States (30 million persons) depend on their voice for some critical aspect of their job.
This suggests loss/impairment of the voice constitutes as an occupational limitation Treatment Content of Treatment Indirect therapy (vocal hygiene)
Direct therapy (voice production therapy) Indirect Therapy Vocal Hygiene: teach the patients how to take care of their vocal fold tissue
Education about diet and dietary effects
Keep vocal folds hydrated (e.g. superficially and deep)
Keep vocal folds free from irritants
Gastric Reflux Treatment (when needed) Direct Therapy/Voice Production Resonant Voice Therapy (Dr. Verdolini)
Vocal Function Exercises (Briess, Stemple, Titze)
Confidential Voice Therapy (Casper)
Accent Method
Lee Silverman Voice Treatment
Laryngeal Massage
Transgender Voice Treatment (Adler)
Relaxed Throat Breathing Transgender Voice A new(er) voice therapy practice.

Goal is to improve to client's desired goal of voice feminization

Used for MtF, FtM, or both? Why?

MtF Voice Therapy Focuses on:
Increased fundamental frequency (least feminizing quality. Gender neutral 180Hz)
Articulatory style (light v. hard)
Stress: using frequency v. intensity
Listen to sound clip (125Hz to 165 Hz) Questions? References Bhatnagar, S., (2008). Neuroscience for the study of Communication Disorders, 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins
Colton, R., Casper, J., & Leaonard, R. (2011) Understanding voice problems: A physiological perspective for diagnosis and treatment. Baltimore, MD: Lippincott Williams & Wilkins
Hanschmann, H., Lohmann, A., Berger, R. (2010) Comparison of Subjective Assessment of Voice Disorders and Objective Voice Measurement. Folia Phoniatrac et Logopaedica. 63, 83-87
Maryn. Y. (2010). The Acoustic Voice Quality Index: toward improved treatment outcomes assessment in voice disorders. Journal of Communication Disorders. 43, 161-174.
Sataloff, R. (2005). Treatment of voice disorders. San Diego, CA: Plural Publishing Inc.
Seikkel, J. Anthony, King, W. & Drumright, David G. (2009). Anatomy & Physiology for Speech Language and Hearing Fourth Edition, New York, NY. Delmar Cengage Learning.
Thibeault, S., Roy, N., Merril, R., Gray, S., & Smith, E. (2004). Voice disorders in teacher and the general population: effects on work performance, attendance, and future career choices. Journal of speech language hearing research. 47(3): 542-51.
Titze, I. & Verdolini, K. (2012). Vocology: The science and practice of voice habilitation. Salt Lake City, UT: National Center for Voice and Speech
Verdolini, K., Rosen, C., & Branski, R. (2006). Classification manual for voice disorders-I. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.
Verdolini, K. (1998). Guide to vocology. Salt Lake City, UT: National Center for Voice and Speech
Yiu, E. (2002). Impact and prevention of voice problems in the teaching profession: embracing the consumer's view. Journal of voice. 16(2): 215-28. Thank you!
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