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Flashcards in 72 Voice Disorders & Voice Therapy Deck (20):
1

What pathologies/conditions are appropriate for a referral to a speech-language pathologist?

What pathologies/conditions are appropriate for a referral to a speech-language pathologist?

Voice therapy can be successful for those patients with the following functional etiologies: muscle tension dysphonia, diplophonia, phonation breaks, pitch breaks, falsetto, and functional aphonia.

Voice therapy can be beneficial after medical and/or surgical intervention with the following organic etiologies: vocal nodules or polyps, Reinke’s edema, sulcus vocalis, contact ulcers, granuloma, papilloma, spasmodic dysphonia, and leukoplakia. Voice therapy would focus on elimination of any unhealthy vocal compensation such as hard glottal attacks or hyperfunction, elimination of coughing or throat clearing habits, and promotion of improved vocal hygiene and reflux management.

In neurogenic etiologies such as myasthenia gravis and Guillain-Barre, the speech-language pathologist can provide education for compensatory techniques and caregiver education of optimal voicing. Unilateral vocal fold paralysis may improve with voice therapy intervention and can act as a bridge in the case of a spontaneous recovery.

Those patients with hypokinetic dysarthria as seen in Parkinson’s disease (PD) are appropriate for therapeutic intervention provided by a speech-language pathologist. Surgical intervention such as deep brain stimulation (DBS) may provide the patient with relief from other symptoms related to PD but it typically does not improve vocal quality. Therefore, voice therapy should be recommended prior to DBS surgery.

Hyperkinetic dysarthria seen in essential tremor and ataxic dysarthria may benefit from trials of voice therapy while spasmodic dysphonia (SD) has seen little evidence that voice therapy is the optimal treatment to improve voice quality. While botulinum toxin injections are the primary approach for treating SD, those patients who follow up with voice therapy have significantly better voice outcomes compared to those who just received injections secondary to retraining of poor compensatory behaviors that developed as a result of the SD.

Mixed dysarthrias can be seen in patients with amyotrophic lateral sclerosis, multiple sclerosis, and traumatic brain injury. The dysarthrias may benefit from voice therapy intervention, recommendations for augmentative or alternative communications, oral prostheses, and dysphagia recommendations as the disease progresses.

2

What medical documentation should a speech-language pathologist have to complete an optimal voice assessment?

What medical documentation should a speech-language pathologist have to complete an optimal voice assessment?

Prior to initiation of an evaluation of voice, the patient should complete an otolaryngologic examination. Reports and findings including the following are essential to complete an optimal voice assessment: detailed medical and surgical history, current medication list, past and current laryngeal diagnosis, still images or videos of larynx, results of hearing screening or evaluation, radiologic image interpretation of the head and neck, and results of any swallowing evaluations.

3

What intake information is collected during a speech-language pathologist voice evaluation?

What intake information is collected during a speech-language pathologist voice evaluation?

Speech-language pathologists comprehensively evaluate patients with voice utilizing a combination of methods. The main goals of the speech-language pathologist voice evaluation are to:

  1. Determine etiologic factors relating to voice disorder
  2. Determine severity of voice disorder
  3. Determine the clinical plan of care and the expected prognosis

Case history, instrumental and physical assessment, acoustic analysis, and perceptual ratings are typically collected during a speech-language pathology voice evaluation. Speech-language pathologists aim to discover behaviors, environmental factors, patterns of occupational and social voice use, and relevant medical and surgical history that impact the patient’s voice. The timing and nature of a patient’s voice complaints, for example, are extremely valuable pieces of information that help determine the nature of the patient’s disorder. Was onset gradual or sudden? Is the problem consistent or intermittent in nature? The patient’s vocal hygiene is also evaluated and discussed.

In addition to collecting a case history, a physical examination of the head and neck and cranial nerve examination are usually conducted by the referring physician and provide valuable information to the evaluating speech-language pathologist. Speech-language pathologists may also conduct an oral mechanism exam, such as the Oral Speech Mechanism Screening Examination, or OSMSE-3 (see chart). This standardized protocol is used to assess the appearance and function of the oral mechanism including the lips, tongue, jaw, teeth, palate, pharynx, velopharyngeal mechanism, breathing, and diadochokinetic rates. The larynx may also be palpated for assessment of range of motion.

Singing voice assessment in vocal performers will also be included when indicated. From amateur singers to professional opera stars, the vocal production of a vocal performer requires additional assessment. Special attention is given to reported vocal effort, voice production across pitch range, and vocal demands of the patient’s performing schedule, among other factors.

4

Describe objective measures/evaluation completed during a speech-language pathologist voice evaluation.

Describe objective measures/evaluation completed during a speech-language pathologist voice evaluation.

Rigid Videostroboscopy or Transnasal Flexible Laryngoscopy: Laryngoscopic evaluation allows the structure and function of the vocal folds to be assessed, imaged, and digitally recorded. In most states, speech-language pathologists with expertise in voice can complete either rigid videostroboscopy or transnasal flexible laryngoscopy with stroboscopy with proper training and physician supervision. The AAO-HNS and American Speech Language and Hearing Association have created a joint position statement outlining the roles of physicians and speech-language pathologists completing this procedure. In that statement it is noted that “physicians are the only professionals qualified and licensed to render medical diagnoses related to the identification of laryngeal pathology as it affects voice.” Speech-language pathologists with expertise in voice and specialized training can use laryngoscopy “for the purpose of assessing voice production and vocal function.” Laryngoscopy also can be an important tool in helping determine the presence of compensatory vocal behaviors and can be used as a biofeedback tool. Direct observation of vocal folds and vocal fold vibration is an essential component of evaluation, as the laryngeal mechanism can be observed and described.

Quantification of other vocal parameters can be performed using advanced equipment to measure aerodynamic and acoustic properties of voice. As equipment cost and time can be prohibitive for some speech-language pathologists, acoustic analysis of voice offers speech-language pathologists a noninvasive and low-cost method for obtaining a significant amount of patient data. For example, fundamental frequency, pitch range, and vocal intensity can be evaluated. These parameters are, in most cases, clinically significant in voice therapy and are therefore often measured throughout treatment, helping to measure patient progress.

5

What patient-centered assessments are used during a voice evaluation?

What patient-centered assessments are used during a voice evaluation?

Throughout voice evaluation, the speech-language pathologist listens and forms an impression regarding the patient’s vocal quality, pitch, and vocal intensity (loudness) as a way of describing the patient’s voice and to set a baseline of the patient’s vocal presentation. The use of digital recording equipment to collect patient speech samples is recommended. Because clinician perception can vary, standardized perceptual rating scales are used to help standardize impressions. The CAPE-V, or the Consensus on Auditory Perceptual Evaluation of Voice, is a tool created by voice professionals to do just that.

Patients’ perception of their voice disorder and how it impacts their daily life is another factor that is important to discuss. Quantification of patients’ feelings and impressions of their voice can be achieved using additional rating tools. The Vocal Handicap Index (VHI) is one such tool that measures how a voice problem impacts a patient’s quality of life. Other scales are available for measuring patient perception including the Singing Voice Handicap Index and The Voice-Related Quality of Life Scale (VRQOL) (Table 72-1).

6

What are the parameters of voice that can be affected?

What are the parameters of voice that can be affected?

The three parameters in which patients have vocal complaints are vocal pitch, loudness, and quality.

7

What are the respective therapeutic interventions for vocal pitch, loudness, and quality?

What are the respective therapeutic interventions for vocal pitch, loudness, and quality?

There are many therapeutic techniques that can be applied to improve vocal pitch, loudness, and quality. It may be appropriate to use one or more techniques during a course of voice therapy, based on patient need and therapeutic response. Patient-centered techniques that focus on increasing self-awareness, the practice of good vocal hygiene, counseling, negative vocal practice, redirection of phonation (coughing, throat clearing, laughing, trilling) are used to improve patient understanding of vocal parameters. Additional respiratory training, relaxation, yawn-sigh, laryngeal massage, and digit manipulation are helpful techniques for improvement of all parameters of voice secondary to hyperfunction. Last, changes in loudness, chant talking, chewing, resonance, confidential voice, and head positioning are valuable techniques to elicit optimal voicing.

8

Describe common stretches and massage techniques used to decrease laryngeal musculoskeletal tension.

Describe common stretches and massage techniques used to decrease laryngeal musculoskeletal tension.

If laryngeal tension is a primary or secondary cause of dysphonia, then release of tension provides a means of regaining optimal voicing. Stretches of the neck, shoulders, torso, jaw, and tongue as well as laryngeal massage provide release of extrinsic muscle tension (Table 72-2). Stretches and massage should be completed at least once daily.

9

What are optimal reflux precautions?

What are optimal reflux precautions?

The presence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are commonly present in those patients who present with laryngologic complaints. While treatment via behavioral, pharmacologic, and surgical means can have benefit toward improving vocal quality, a speech-language pathologist (SLP) can incorporate education of behavioral strategies into the session. Behavioral strategies include but are not limited to: elevating the head of the bed, avoiding overeating, remaining upright for at least 60 minutes after eating, not exercising after eating, decreasing consumption of caffeine, alcohol, and carbonated drinks, avoiding foods that can trigger acid, weight reduction, avoiding tight clothing, taking medication appropriately, and avoiding drinking excessive quantities of water right before bed.

10

What is vocal hygiene?

What is vocal hygiene?

Vocal hygiene is a term that refers to the ongoing maintenance of a patient’s vocal health. The vocal health of patients with voice disorders is a high priority for voice therapists and often a continuing focus of voice therapy. The core issues that surround vocal health include adequate hydration, discussion and elimination of excessive caffeine and alcohol intake, optimal nutrition, elimination and behavioral management of laryngeal irritants such as postnasal drainage and allergies, laryngopharyngeal reflux, and identification and elimination of phonotraumatic behaviors including chronic cough and throat clearing. Poor vocal hygiene contributes to vocal pathology and speech-language pathologists aim to educate patients about the benefits of optimal vocal health. Adherence to optimal vocal health behaviors contributes greatly to success of voice therapy.

11

What are common voice therapy goals for a patient with muscle tension dysphonia?

What are common voice therapy goals for a patient with muscle tension dysphonia?

When a patient is referred for behavioral management of muscle tension dysphonia (MTD), goals are created to reduce hyperfunctional or hypofunctional vocal production that contributes to laryngeal muscle tension. As patients with MTD often demonstrate visible signs of increased muscle activity in the head and neck, commons goals for a patient include implementation of passive and active laryngeal, head, and neck stretches. Additionally, management techniques can include biofeedback, improved airflow with speech at the word, phrase, sentence, and conversational levels, achievement of easy vocal onset, use of resonant voice therapy techniques or circumlaryngeal massage. Additionally, behaviors that contribute to phonotrauma such as yelling or chronic throat clearing are discussed and eliminated. The role of stress and its impact on voice is often an important component to examine and discuss for patients with MTD. In some cases, referral for psychosocial management of voice disorder is indicated.

12

What is resonant voice therapy and when is it indicated?

What is resonant voice therapy and when is it indicated?

Resonant voice therapy techniques aim to achieve optimal vocal resonance in speech with balanced respiratory effort and articulatory control. Dr. Verdolini Abbott developed a formal, programmatic approach to resonant voice therapy she termed “Lessac-Madsen Resonant Voice Therapy” or LMRVT, as a nod to the contributions of Dr. Arthur Lessac and Dr. Mark Madsen to the voice community. The basic goals of LMRVT include achieving a target laryngeal configuration involving vocal production that results in the strongest voice with the least amount of respiratory effort and stress impact on the vocal folds. Thirty- to 45-minute sessions occur once to twice weekly and patients work through a hierarchy of resonant voice tasks with an emphasis on sensory processing and variable practice. These include discussion of vocal hygiene and provision of stretches, along with resonant voice exercises that include speech tasks incorporating resonant production in a variety of functional settings such as in background noise, while discussing emotional topics, or over the telephone.

13

What is the best therapeutic option for voices affected by Parkinson’s disease?

What is the best therapeutic option for voices affected by Parkinson’s disease?

Common vocal traits of those diagnosed with Parkinson’s disease (PD) include monopitch, a weak or breathy voice, vocal tremor, and decreased speech intelligibility. The Lee Silverman Voice Therapy (LSVT) Loud has provided Level 1 efficacy data outcomes for the improvement in vocal quality, intensity, and speech intelligibility in patients with idiopathic PD. Intensive therapy is completed 4 days a week over 4 consecutive weeks with daily homework focusing on 5 integral concepts: (1) think loud; (2) high effort across the speech system; (3) intensive treatment; (4) recalibrating sensory deficits; (5) quantifying improvements.

14

Discuss treatment for paradoxical vocal fold motion (PVFM)/vocal cord dysfunction (VCD).

Discuss treatment for paradoxical vocal fold motion (PVFM)/vocal cord dysfunction (VCD).

Initial treatment for PVFM/VCD includes making of speech sounds, “s breathing,” and “f breathing,” which directs emphasis away from the respiratory system therefore relaxing the larynx and dissipating the attack. Additional maneuvers such as panting (rapid shallow breathing) and/or yawning to open up the oropharynx have also been implemented with some success. While these maneuvers may be effective for some patients, others find them ineffective. Pursed lip breathing has also been documented as a successful maneuver to dissipate episodes of PVFM/VCD. The patient is first instructed to relax upper body tension and use diaphragmatic breathing. The patient should take a gentle but short sniff (1 second) via the nose/mouth and then gently exhale via pursed lips (2 to 3 seconds). Using pursed lip breathing allows the building of back pressure to open and relax the airway, reversing the episode of PVFM/VCD. The application of PLB is tailored to the individual and may be used for retraining, pretreating, and the moments of attacks.

15

What is a speech-language pathologist’s role with patients with laryngeal cancer?

What is a speech-language pathologist’s role with patients with laryngeal cancer?

A speech-language pathologist can provide patients who are postsurgical and postradiotherapy with vocal techniques to improve voicing, as well as promotion of vocal hygiene. Therapeutic outcomes are also impacted by the degree to which the mucosal wave has been preserved.

A speech-language pathologist should also be contacted prior to treatment of laryngeal cancers for education and counseling of dysphagia. Patients typically benefit from ongoing therapy during and after surgical and radiologic treatment.

If a patient is to undergo a laryngectomy, a speech-language pathologist is an essential part of the medical team because laryngectomy alters respiration, swallowing, and speech. The SLP can also provide education, recommendations, and training/therapy of postlaryngectomy communication options including esophageal speech, electrolarynx, and tracheoesophageal voice restoration.

16

What are hypernasality, hyponasality, and assimilative nasality?

What are hypernasality, hyponasality, and assimilative nasality?

Hypernasality is an excessive and inappropriate amount of perceived nasal cavity resonance during phonation. Velopharyngeal dysfunction (VPD) or velopharyngeal insufficiency (VPI) are terms used to describe this phenomenon whether due to impaired motion of the VP mechanism, tissue insufficiency or both. Characteristics of this include inappropriate nasal emissions, decreased intraoral pressure, and increased nasal resonance during speaking tasks.

Hyponasality is reduced nasal resonance for /m/, /n/ and “ing” sounds. This is typically as a result of an anatomic obstruction, including but not limited to large adenoids/tonsils, deviated septum, choanal atresia, nasal cavity turbinate swelling, or allergic rhinitis. Articulation substitutions of /b/, /d/, and /g/ are typically seen.
Assimilative nasality appears when the speaker’s vowels or voiced consonants present as nasal when adjacent to nasal consonants. This occurs because the velopharyngeal port opens too soon and remains open inappropriately. This may be due to faulty speech patterns or an exaggerated regional dialect.

17

What should be completed for a clinical evaluation of nasal resonance disorders?

What should be completed for a clinical evaluation of nasal resonance disorders?

Patients with resonance disorders are evaluated in a similar manner to patients with other voice disorders. Clinicians should listen carefully to voice during spontaneous conversation, vowels in isolation, and sentences loaded with only oral phonemes and sentences loaded with nasal phonemes. Speech samples loaded with oral phonemes or nasal phonemes help the listener distinguish between hyponasality, hypernasality, and assimilative nasality. Another informal screening tool involves having the patient say these two sentences while pinching the nares shut: “My name means money” and “Mary made lemon jam.” If the sentence produced sounds “plugged” with both open and occluded nares, the patient has a hyponasal voice quality. If there is a significant difference between the two sentences, hypernasality may be suspected. Stimulability testing, articulation testing, and oral examination are also included in a patient with a resonance disorder.

18

What additional laboratory diagnostics should be completed for a thorough nasal resonance disorders evaluation?

What additional laboratory diagnostics should be completed for a thorough nasal resonance disorders evaluation?

Various aspects of nasal resonance are measured. Aerodynamic instrumentation includes pressure transducers and pneumotachometers that measure relative air pressures and airflows emitted simultaneously from the nasal and oral cavities during speech. Acoustic measures may include use of a Nasometer, a noninvasive microcomputer-based system that measures the relative amount of oral to nasal acoustic energy in an individual’s speech. The ratio of oral intensity to nasal intensity is described as nasalance. Spectrography may also be used as part of acoustic analysis. Radiographic instruments and visual probing via endoscopy are other available instruments that can be used to describe the appearance and function of speech mechanisms, such as the velopharyngeal mechanism during speech.

19

What are treatment options for hypernasality?

What are treatment options for hypernasality?

Treatment approaches for a person with hypernasal voice depends on organic or functional causes of the underlying hypernasality. If functional causes exist, voice therapy will be initiated with focus on altering tongue position during speech, change of loudness, auditory feedback, establishing optimal pitch, counseling, opening of mouth, and respiration training. When a physical inadequacy of the velopharyngeal port is suspected, the patient may be referred to an otolaryngologist for surgical options or a prosthodontist to determine the necessity of a palatal lift, obturator, or prosthesis. The speech-language pathologist shares the results of the patient evaluation and can make recommendations related to optimal surgical approach or to suggest which dental appliances may work best for the patient.

20

What are treatment options for hyponasality?

What are treatment options for hyponasality?

Appropriate medical therapy should precede voice therapy for hyponasality to rule out and manage organic causes such as severe nasopharyngeal obstruction or infection. When indicated, voice therapy for increasing nasal resonance may include auditory feedback, counseling, nasal-glide stimulation, and focus of directing tone into a facial mask with speech.

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