Overview Steam, Straws & Stroboscopy: An Update on Vocal Health

Elizabeth SavinaSpeech Pathologist, Brisbane Voice Clinic

Chunky Harmonies Choir

Red Hot ChilliParkies(As part of Asia Pacific Sing to Beat Parkinsons’Research Project 2017)

Overview 1. Making sure there is enough

moisture inside and out

2. Balancing Rest and

Rehabilitation

3. Red Flags requiring

Laryngeal Stroboscopy

4. Laryngopharyngeal Reflux

5. Medications and Your Voice

Out there on the interweb…

Is it really so?

1. Making Sure

there is enough

moisture inside

and out

NNasendoscopy/ Laryngoscopy with labelling of the anatomy.

Hi Speed Digital Imaging >8000 frames/ second

Fluid within the Vocal Folds –

•Needs to be just right •Too much – bass guitar string

• Lower pitch • Harder work to set them in

vibration.

•Too little – thinner vocal folds• More work to get them to meet

in the midline

Caffeine & Voice(Hartley et al 2014)

• Caffeine 250mg-480mg – no changes to acoustic, perceptual, PTP (but extremes of range weren’t tested)

Caffeine Doses•Expressso 47-75mg•Instant: 27-175mg•Black tea: 14-70mg•Green tea: 24-45mg

Surface Hydration

• Glands just above VF + surface cells secrete

• Mucous dries out -> cycle of sticking, pushing (imagine talking wi

• If you can feel it, it is possibly: • Too dry• From post-nasal drip that needs treatment• Or your larynx is hypersensitive.

When weswallow:

The voice box is closed off by the epiglottis so food & drink shouldn’t be touching or coating the vocal folds.

Vocal folds

How to get moisture to the surface of the Vocal Folds.

Steam- Heat - Moisture might

never make it to the vocal folds

- Still standard recommendation

Nebulised Isotonic Saline

- Smaller particles/- Matches body fluids- No heat involved - Not a standard

recommendation in Aus

Another thought•Another benefit of “steaming” may be the warmth -> Muscle relaxation

•Alternate sensory input for the hypersensitive larynx

•Increased blood flow -> larynx secretes more?

•Allows someone to rest

Take Home Messages - 1

•Hydration is important for body, brain and larynx

•Steaming might still be useful

•Might use nebulized saline in the future

2. Balancing Rest and Rehabilitation

When I trained (18 years ago)

•Common to hear of 2 weeks - 1 month of Voice Rest

•“Total Voice Rest”

But!!!!!

• Do we put patients in bed for 2 or 4 weeks post hip surgery???

“Good” Vibrations and Movement of Vocal Folds

Heal the Vocal Folds(Verdolini et al 2012, Kaneko 2017) )

Good Vibrations (Verdolini et al 2012)

•3 College Students•Vocal load task = 15 min loud talking, 5 minute rest x3 –> acute inflammation

•Random -> •Spontaneous speech, •Rest •Resonant Voice

Good Vibrations (Verdolini et al 2012)

Pro-Inflammatory Mediator: interleukin (IL)-1β

Post Surgical Research (Kaneko 2017)

•31 Patients Randomised Control•(3 vs 7 day voice rest) + therapy•3 days did better on acoustic and patient self-report at 1 and 3 months

What about STRAWS?

1 type of Semi-Occluded Vocal TractExercises SOVT-E

Just Right Closure

•Overclosure -> damage (e.g. nodules)

•Under closure -> breathy, dry out, ↓volume

•Just Right Closure ~0.6 0.7 mm

SOVT-E (Verdolini 2011)

•↓↑closure of the vocal folds

SOVT-E (Verdolini 2011)

•↑Amplitude of VF vibration•↑loudness without ↑collision forces

•best for healing

Different SOVT (Andrade 2014)

Narrowing/Lengthening

•m, n, ng•v, z, dʃ, w, y•Straw into airTend to be less effortful

2nd Source of Vibration

•Lip Trills•Tongue Trills•Straw into water (- ?massage)

What other changes occur(Guzman et al 2016)

- ↑diameter of the vocal tract - Good for amplification

Narrower Straw -> wider vocal tract (Guzman et al 2016)

No Straw 5mm Straw 2.7mm Straw

Lowering of the larynx (sometimes) (Guzman et al 2016)

Aryepiglottic Narrowing (sometimes)(Guzman et al 2016)

Amplifies the formants/harmonics in 2-4000Hz rangeSounds Bright, a part of Twang, Opera, rural singing

Newer Trends in Voice Therapy•Intensive Treatment (e.g. 6 hours in 1 week)

•Telehealth (treatment by equivalent of skype)

•Massage of the anterior neck •Vocal Unloading•Myofascial Release

Reusable Straws

•2 main diameters •Metal, Silicone (Ihave found Glass can break a bit more easily)

•Ebay/Kmart

Take Home Messages 2

•Rest or reduce use if voicing is feeling effortful/strained or lower pitched.

•Follow ENT advice, but Total Voice Rest > 3 days or a week is rare now

•Often best to have Voice Therapy pre as well post Surgery

3. Red Flags requiring Laryngeal Stroboscopy

Lary

ngos

copy

Stro

bosc

opy

Stroboscopy

•Details of the surface of the vocal folds that can’t be seen with standard laryngoscopy•Scars, sulcus, stiffness – pre nodular swelling

•Much more available now

Hint

•When booking an ENT appointment, it is helpful to say you want stroboscopy done, as ENTs often work out of multiple offices, but only have stroboscopy available at some of them.

What can go wrong with a voice?

Lesions of the Vocal Folds Benign•Nodules•Polyp•Cyst•Granuloma•Leukoplakia Voice Therapy 1st

Cancerous - Most commonly associated with smoking/alcohol

Cancerous, smaller lesion, would expected to have less change to the voice.

• Not cancerous, but very large lesion, so would be expected to cause massive change to the voice.

Degree of voice change does not necessarilyindicate the seriousness of the issue

Other Issues Neurological- Paralysis- Tremor- Dystonia (Spasmodic Dysphonia)

- Progressive –MS, Parkinson’s

Joint or Connective Tissue Disorders - Rheumatoid Arthritis

Autoimmune/Inflammatory

Guidelines for Hoarseness (Dysphonia) 2018•Voice changes lasting > 4 weeks should be investigated•Earlier if specific concerns

•High voice use, No URTI, Sudden Voice Loss •Laryngoscopy (with stroboscopy) before Voice Therapy

Take Home Messages 3•Stroboscopy is essential for complete evaluation

• Seek help if voice changes last > month, or earlier if •High vocal demands•No URTI •Sudden loss of voice

Reflux!!! •Acid & Pepsin of stomach ->

larynx and pharynx = Larngopharyngeal Reflux (LPR) • → ssue damage• → muscles tensing to guard

the area.

Reflux Symptom Index (RSI) for LPR

RSI

•Only 35% also have “heartburn”Franco 2015

Reflux and Singing

Managing Reflux Shaw (2010)

Sports Drinks Cochrane et al(2012)

Managing Reflux Shaw (2010)

and Singing

Take Home Messages 4

•Laryngopharyngeal reflux can have a significant effect on the voice

•Avoid large meals/large amounts of water before lying down OR singing

5. Medications and Your Voice

Several classes of medications are known to affect the voice in different ways

The National Centre for Voice and Speech in America has a great resources to check your medications.

National Centre for Voice and Speech

Take Home Message 5

•Many medications can have a significant effect on the Voice

•Start with GP or pharmacist if concerned

National Voice/Laryngological Organisations

•Australian Voice Association•Laryngology Society of

Australasia

•The Voice Foundation (USA)•British Voice Association

Good Sources of Health Information

•Better Health Channel •Mayo Clinic•Cleveland Clinic•John Hopkins

Overview Thankyou!

Elizabeth SavinaCertified Practising Speech Pathologist