Voice Int 2 Flashcards
Diagnoses and treats medical conditions, such as polys, and nodules
ENT (Otolaryngologist)
Videofluoroscopic imaging of the larynx, assessing laryngeal function
Radiologist
For psychologically rooted voice issues
Psychologist/psychiatrist
Addressing concerns with CV (cardiovascular) endurance and respiration
Physical therapist
Administer formal hearing tests to rule out hearing loss
Audiologist
Trains persons to use the vocal mechanism healthily, and to maximize voice potential
Voice coach
Treatment of pulmonary and respiratory conditions
Pulmonologist
What is the role of an SLP in the management of patients with voice disorders?
Provide voice intervention to enhance activity and participation.
Educate the patient about the nature of the disorder
Teach voice intervention procedures
What are the main approaches to voice treatment?
Medical (this is where ENTs’ come in–phonosurgery, pharmaceutical, radiation)
Environmental (modifying surroundings, adjusting to the vocal demands of environment/occupation)
Behavioral (symptomatic voice therapy–VFT’s, LSVT, etc.,)
What is the role of mucolytics
Thins mucus and relieves congestion, if the problem is respiratory based
What do the antacids do?
Specific for GERD and LPR concerns
On-demand medication (Gaviscon, TUMS, Kremil-S)
Proton Pump inhibitors → Omeprazole (prolonged reduction of acid production)
What are systemic steroids?
Methylprednisolone → inflammatory relief
True or False. Surgical treatment for benign laryngeal lesions only recommended after medical (pharmaceutical) and voice therapy failed
True
True or False. Surgery for the pediatric population should be avoided. Voice therapy is usually initiated at around 10-13 years old, when they exhibit adequate self control for behavior modification.
True
This is the surgical removal of the larynx, to prevent further metastasis of tumorous tissue, usually due to cancer. Patients are incapable of traditional voicing due to the absence of the voice box.
Laryngectomy
This is after the laryngectomy. It is a vibrating device placed on the neck to transmit vibration into the pharyngeal column. Serves as a substitute for the vocal folds in voice production.
Electrolarynx
What is a voice prosthesis valve?
This can be done after the laryngectomy
One way, silicone valve
Occludes the stoma to allow airflow through the pharynx
What is esophageal speech?
This is done after the laryngectomy
Learned technique by swallowing air
Air is injected to the esophagus
(+) Appropriate tension of pharyngeal walls
(+) Expiratory airflow
= Sound
What usually happens when there is an acute onset conditions, caused by virus, bacteria, or single episode vocal abuse
Usually resolves spontaneously
Conserve voice use during recovery period → (1) vocal rest (2) reduced volume
What usually happens when there is a recurrent event of inflammatory changes
Consideration of tonsillectomy
Aggressive therapy of reflux
Pharmaceutical
Medical management for reflux?
Avoid lying down immediately post meal
Elevate head while sleeping
Avoid throat clearing or coughing → clearing of throat and coughing will encourage the upward excursion of the acid from the stomach
Avoid the following foods: citrus juices, chili food (spicy), chocolate, carbonated beverages
What are voice facilitating approaches?
These are therapeutic techniques used by speech-language pathologists (SLPs) to help clients modify their vocal behaviors and improve voice disorders. These approaches are client-centered and aim to facilitate the production of a healthy voice by modifying various aspects of voice production, such as pitch, loudness, resonance, and phonation.
What is auditory feedback?
Patients who displayed a window of voice improvement during the evaluation session (such as when masking was used as a diagnostic probe resulting in an immediate improvement in voice) often benefit from the use of auditory feedback during therapy sessions.Regardless of the causal factor of the disorder (organic, neurogenic, or functional), the patient’s voice may improve with such feedback.
What is a confidential voice?
Using a soft, confidential voice as an alternative to hyperfunctional effortful voice. Similar to level II of “Loudness levels”
Confidential voice is useful for
Reducing overall hyperfunction
Affects breath control
Slows down speaking rate
Opens the airway
What is glottal fry?
Using glottal fry when speaking to shorten thyroarytenoid muscles and vocal ligaments → reduces the rate of vocal fold vibration
Glottal fry is useful for the following
Nodules, polyps
Cord thickening
Spasmodic dysphonia
Ventricular phonation
Hyperfunctional behaviors
What is laryngeal massage?
Circumlaryngeal, manual therapy of the thyroid cartilage
Aims to relieve stress, psychological conflict, and overall systemic tension
Useful for: hyperfunction/excessive laryngeal tension, usually following yawn-sigh, as YS is shown to be more effective for relaxation
What is the gold standard therapy technique for relaxation?
Yawn sigh
What is nasal-glide stimulation?
Usage of sonorants (m, n, l, r vowels) as these are easy to produce (little to no obstruction of voiced energy in oral cavities)
Facilitates better voicing patterns and makes phonation easier
Useful for: functional dysphonia, spasmodic dysphonia, nodules, polyps, and other masses
What is an open mouth approach?
Encouraging more oral openness during speaking
Promotes a more optimum approximation of the vocal folds
Corrects problems of loudness, pitch, and quality
Useful for reducing strain (vocal hyperfunction), often combined with other VFAs
What is relaxation?
Applying systematic relaxation methods to influence the vocal tract
Despite not reducing actual stress, methods may relax components of the vocal tract instead
Relaxation: a realistic responsiveness to the environment, with minimal energy expended (more energy = more tension so we want to promote minimal energy)
Useful for hyperfunctional behaviors/MTD
What is tongue protrusion?
Produce /i/ with the tongue extended outside of the mouth, with a higher pitch, or low falsetto
Offsets the squeezing of the pharynx → directly relaxes muscle strains under the chin
Useful for: ventricular phonation, strained voice, hyperfunctional behaviors,
Often used with glottal fry/yawn sigh
This is the first line of intervention for relaxation before doing other relaxation techniques that may also help for hyperfunction
Yawn-sigh
What is yawn-sigh?
One of the most effective therapy techniques for minimizing vocal hyperfunction, and lessening tension
Larynx drops to a low position, tongue is more forward, and there is a slight opening between the vocal folds
Useful for: any hyperfunction behaviors, polyps and nodules, spasmodic dysphonia, functional aphonia
What is the most effective therapy technique to reduce hyperfunction?
Yawn-sigh
Usually the first initiated treatment for hyperfunction behaviors, then combined with other “relaxers” to maximize effect.
Yawn-sigh
What is auditory/visual feedback?
Immediate auditory or visual feedback from digitized instrumentation (microphone and headphones, visual feedback through monitors)
The auditory/visual feedback is useful for:
Individuals who need and increased awareness of their vocal behaviors
What is masking?
Masking of auditory feedback that the patient receives during speech
Shown to reveal “windows” of improved phonation for patients with functional dysphonia (poor real time of auditory monitoring)
Masking is useful for patients with
Functional aphonia → patients perform a lighter voice (masking helps patients to perform a lighter voice)
Focused on the direct explanation of the voice problem and its cause. Sometimes, this is enough to change the phonation style, or eliminate the misuse-abuse
Counseling
What are the elimination of abuses?
Recognizing and eliminating abusive behaviors to voice such as: yelling, screaming, speaking with a loud background noise, excessive coughing/throat clear, smoking, hard glottal attacks, cheerleading, etc.,
What is hierarchy analysis?
Centered around the anxious contexts that the patient engages in
Listing various situations in a person’s life that produces anxiety
Ordering them in sequential order
Apply also to voice
Makes the patient aware of variations of voice depending on the situation
Hierarchy analysis is useful for
Gender transitioning care
Psychogenic/psychologically rooted concerns
What is respiration training?
Dedicated training of breath support by singing teachers or vocal coaches
Patients with functional voice disorders, who are not vocal performers may also need only some instruction for expiratory control
Emphasizing diaphragmatic-abdominal breathing
Respiration training is useful for
Patients with inadequate breath support
Modifying the actual function of the vocal folds during phonation
Modification of the phonatory and related behaviors
What is digital manipulation?
This is useful for patients who have problems with pitch
Finger pressure on the thyroid cartilage (Adam’s apple)
Light placing of fingers on the thyroid to assess laryngeal vertical position → Patients wil MTD had higher hyolaryngeal resting positions, compared to controls
Useful to lower the larynx along with the yawn-sigh method
What is digital manipulation?
Excessive laryngeal vertical movement
UFVP
What is establishing a new pitch?
Creating and facilitating patient’s awareness and feedback of conversational pitch
Describing where the habitual pitch vs the target pitches are
Establishing a new pitch is useful for
Additional masses that produce lower pitch levels
Personality and psychological etiologies (persistent falsetto)
A good focus is “from the middle of the mouth” . Problems occur when the tongue is too far forward or too backward. This is useful for thin front voice, back voice, low in the throat voice, singers
Focus
What is head positioning?
Placing the head during speaking in different positions in an attempt to find one that facilitates better voice. This is useful for neurogenic diseases (UVFP), and functional aphonia
What is inhalation phonation? It is useful for
Teaching the patient how to phonate while inhaling
Alternating inhalation, and exhalation matched phonation
Useful for: ventricular phonation, hyperfunction, functional aphonia
What are pitch inflections?
Promoting pitch variations to prevent monotony
Useful for: monotonic speaker, functional dysphonia (little to no pitch fluctuations)
Often combined with increasing loudness (loudness + pitch for better prosody)
What is redirected phonation?
Searching for some kind of vegetative phonations (coughing, gargling, laughing, etc.,), intentional voicing (playing kazoo, humming, singing, etc.,) or saying “um-hmmm” sounds
Useful for: functional aphonia → important to find any kind of vocal vibration to be the first step in treatment (if total functional aphonia, it is important to have redirected phonation)
This is total or limited inhibition of laryngeal usage. Restriction of the usage of voice for a specified period of time (4 days to 2 weeks). Avoidance of the following: speaking (except for modified voice rest→ 15 minutes), singing, humming, whispering, coughing, laughing, pushing, lifting
Vocal rest
What are the advantages of vocal rest?
Reduction in lesion size
Avoidance of vocal abuse
What are the disadvantages of vocal rest?
Financially impractical
Emotional and depressing
Specific treatment approach for PD and other neurological conditions. Focusing on calibrating the perceptions of individuals about how soft or loud they sound. This is the “think loud” “think shout”. Usage of voice in a “normal” loudness level
Lee Silverman Voice Treatment (LSVT)
What is the target goal for LSVT?
Target: vocal loudness (amplitude). These strategies are consistent with the most effective, evidenced-based strategies for learning and neuroplasticity (the brain’s ability to change)
What is the mode for LSVT?
Intensive dosage and high effort
What is the calibration for LSVT?
Generalization
What are the environmental modifications to help improve voice?
Humidification
Increasing water consumption → less throat irritation, modify viscosity of mucus secretions (thinner)
Amplification devices (microphones, lapels, etc.,)–establishing a normal level of pitch and loudness while still being participative in occupation
Mr. Chua, 38/M, highschool teacher with 2-year history of hoarseness and throat pain secondary to vocal nodules. History is significant for laryngopharyngeal reflux and vocal abuse.
Butch, 8/M, presented with a low-pitched, breathy voice. ENT findings reveal infectious laryngitis 2 weeks prior to consult. He is extremely active, talks incessantly, likes to imitate voices of TV actors and sound effects in cartoons.
