Emma Coulter

Allyssa Farris

Hannah Janes

VOICE DISORDERSThe Role of Speech and Language Pathologists

Agenda:

Purpose of the Voice

General Prevalence Statistics

Incidence of Voice Disorders

Affected Populations

Quick Overview of Anatomy of Phonation

Quick Overview of Respiratory System

Quick Overview of Voice Disorders

The Role of the Speech-Language Pathologist

Purpose of the Voice

Protect our airway

Express our feelings, wants, needs

Facilitate our participation in the world around us

Express meaning through words, our rate of

speech, intonation, inflection, etc.

Prevalence

Prevalence of voice disorders:

3-9% of a normal adult population

29% of older adults

75% of cheerleaders

7% of school aged children

27% of teachers

Incidence

Estimated incidence of voice disorders: 100%

Everyone has had a voice disorder at some time

throughout their lives

Affected Populations Professionals who use their voice throughout the day,

use voice with excessive loudness, or have poor vocal hygiene habits Teachers Salespersons Singers/performers Coaches Receptionists Factory workers Attorneys Nurses Police officers Students Restaurant workers

Anatomy of Phonation

The Larynx

Positioned above the trachea

Allows air to flow in and out of the lungs

Protects the airway from foreign bodies

Hosts the vocal folds which enable phonation

through their adduction (closing) and abduction

(opening)

The Larynx

Anatomy of Phonation Laryngeal Framework Cartilages, ligaments, membranes, and folds make up

the larynx Intrinsic and extrinsic muscles facilitate the movement of

the larynx Intrinsic Laryngeal Muscles: Posterior Cricoarytenoids, Lateral Cricoarytenoids, Oblique

Arytenoids, thyroarytenoids, cricothyroid

Extrinsic Laryngeal Muscles: Divided into elevators and depressors Elevators (move larynx superiorly): diagastrics, geniohyoid,

mylohyoid, stylohyoid, genioglossu, geniohyoid, hypoglossus, thyropharyngeus

Depressors (move larynx inferiorly): omohyoid, sternohyoid, sternothyroid, thyrohyoid

Extrinsic Laryngeal Muscles

Intrinsic Laryngeal Muscles

Overview of Respiratory System Respiratory system used in phonation: lungs,

thorax, muscles and tissues

Proper breath support is essential to speaking with a voice that is both comfortable and least damaging to the larynx.

During respiration there are both active forces (inhalation/exhalation muscles) and passive forces (recoil/relaxation pressures) Muscles of Inhalation: diaphragm, external

intercostals

Muscles of Exhalation: internal intercostals, abdominal muscles

Respiratory System

Overview of Voice Disorders Organic Voice Disorders: Those related to structural variations in the vocal tract or

disease of structures in the vocal tract The vocal tract consists of: lungs, respiration muscles, larynx,

pharynx, oral cavity

Organic Voice disorders include:

Granulomas (contact ulcers), Cysts, Endocrine Changes, Hemagnioma (blood filled sac), Hyperkeratosis, Papilloma, Pubertal changes, Reflux, Sulcus Vocalis, Laryngeal Webbing, etc.

Congenital Abnormalities include:

Laryngomalacia: failure of cartilages to stiffen, slow development of epiglottis

Subglottal Stenosis: narrowing of subglottic space

Tracheoesophageal Fistulas and Esophageal Atresia: openings that occur between trachea and esophagus; abnormal occlusion of esophagus

Many of these organic voice disorders first require medical or surgical intervention before initiating voice therapy

Overview of Voice Disorders Neurogenic Voice Disorders: Related to injury or disease, occurring at any age,

of the peripheral nervous system or the central nervous system that affects muscle control and innervation of muscles of respiration, phonation, resonance, and articulation Neurogenic Voice disorders include: Flaccid Dysarthria due

to vocal fold paralysis, myasthenia gravis, or Guillain-Barre, Unilateral Upper Motor Neuron Dysarthria, Spastic Dysarthria, Hypokinetic Dysarthria seen in Parkinson’s Disease, Hyperkinetic Dysarthria, Spasmodic Dysarthria, Essential Tremor, Huntington’s Disease, Ataxic Dysarthria, and Mixed Dysarthria as seen in ALS, MS, and Traumatic Brain Injuries

Overview of Voice Disorders Functional Voice Disorders: Those with no Organic or Neurogenic origin; the respiration,

phonation, and resonance mechanisms are in some way producing a functional imbalance

Separated by two different causes: psychogenic and excessive muscle tension

Psychogenic Voice Disorders: Occur when an emotional trauma negatively affects the voice Include: Falsetto, Functional Aphonia, Functional Dysphonia,

Somatization Dysphonia

Excessive Muscle Tension Disorders: Include: muscle tension dysphonia (most prevalent voice

disorder, commonly occurring due to phonating with excessive effort), Reinke’s Edema, Vocal Fold Nodules, Vocal Fold Polyps, Traumatic Laryngitis, Ventricular Dysphonia, Diplopohia, Phonation Breaks, and Pitch Breaks

Role of SLP-ASSESS Patient referred for voice evaluation by physician,

ENT, friends, family, etc.

Gather following information from client Reason for referral: the chief concern

History of concern

Medical history

Medical evaluations done: laryngoscopy, oral-endoscopy, stroboscopy, etc.

Social history: home environment, social/emotional difficulties related to voice deficits, etc.

Oral mechanism exam: checking function of mouth, tongue, palates, lips, etc.

Voice Evaluation: acoustic measurements and quality measurement

Role of SLP-VOICE EVALUATION

Acoustic Measurements:

Pitch breaks

Stopping: vocal folds stop moving

Phonation time: sustaining a given sound

Spectral noise

Amplitude

Fundamental frequency

Quality Measurements:

Is the voice hoarse, breathy, quivering, strained, and/or

tense?

Role of SLP-COUNSEL First step to any voice therapy

SLPs work to prepare clients for life changes occurring before surgical/medical intervention and then move to a more therapeutic role post surgery

The client first needs to understand the voice problem, what may have caused the problem, and necessary lifestyle adjustments before tackling the problem itself

In some cases a loss of voice equates to a loss of identity; whether permanent or transient Listening and counseling play major roles in voice therapy

Providing clients and their families with resources and support group information is also important

Role of SLP-COUNSEL Abuse Elimination Initiate conversation regarding abusive voice behaviors

which can include:

Excessive yelling/screaming

Smoking, excessive drinking

Singing incorrectly with poor breath support

Excessive crying or laughing

Hard, excessive coughing

Weight lifting with effortful grunts

Speaking with increased tension, hard glottal attacks, in inappropriate pitches, with a lot of background noise

Establish behaviors which facilitate good vocal health

Over rest, vocal rest, water ingestion, using unstrained voice, speaking at appropriate loudness levels, etc.

Role of SLP-COUNSEL

Vocal Misuse Elimination

Initiate conversations regarding vocal misuse

behaviors which can include:

Speaking with hard glottal attack

Singing excessively at the lower or upper end of one’s

range

Increasing vocal loudness by squeezing out the voice at the

level of the larynx

Speaking at excessive intensity levels

Speaking over time at an inappropriate pitch level

Speaking or singing for excessively long periods of time

Role of SLP-THERAPY

Most voice disorders are treated medically first

Voice therapy is never initiated before the client

has been evaluated by a physician or ENT

Therefore, therapy might involve:

Medical intervention

Therapy intervention

Combined: medical and therapy intervention

Role of SLP-THERAPY

While assessing and counseling client, we work

to build a positive, trusting relationship

From that stepping stone, we target effective

communication through the use of the best

possible voice the client can use that meets the

client’s occupational, educational, and social

needs

Therapy is individualized; each client has very

different needs and therapy is centered around

those specialized needs

Therapy Strategies Here are a few strategies we use in voice therapy. Please

note that not every strategy listed below is appropriate for every client. Therapy is created and implemented on a client by client basis.

Auditory Feedback:

Helpful in having client evaluate their own speech

Amplification is used to ensure the client is hearing the voice they are speaking with

Procedure: Amplification of speech and voice is used to clearly hear oneself.

Amplifier, microphone, and headset are needed

Beats from a metronome may provide a good pacing measurement for those who need to increase or decrease their rate of speech

Loop playback enables the client to immediately hear what was said

Therapy Strategies Change in Loudness:

Facilitates appropriate loudness of voice

Ensure the client has adequate hearing before attempting to reduce or increase vocal loudness

Procedure: For decreased in loudness: focus is placed on making client

aware of problem, client practices using a quiet voice which can be facilitate through using instruments that give feedback on intensity of voice used

For increase in loudness: focus is placed on making client aware of problem, exploration of pitch level and fundamental frequency is done, the best pitch is the one that produces best loudness and quality, respiration therapy may be included, client practices using best pitch which is the once that facilitates appropriate loudness and vocal quality

Therapy Strategies Chant-Talk:

Helps client elevate their pitch

Helpful for those voice problems related to hyperfunction

Chant is characterized by an elevation in pitch, prolongation of vowels, lack of syllable stress, and softening of glottal attack

Procedure: Chant talk is explained to client as a way to reduce the effort used in

speech

The client imitates clinician as the chant voicing pattern is initiated

Client reads aloud while alternating between a regular voice and a chant voice

The client is recorded while reading loud. The differences between the two voices (regular and chant) are discussed

Client begins to tapper off the chant voice while still maintaining the pitch and vocal quality used to produce the chant talk

Therapy Strategies

Confidential Voice:

Helpful in reducing loud voice by encouraging client

to use a soft voice

Procedure:

Client produces breathy, confidential voice after the clinician

models

The breathy, light voice uses more air, which allows greater

air to pass through the larynx

Specific instruction is given as to when the client is to use

the breathy, confidential voice

Therapy Strategies Head Positioning: Practice speaking with different head positions in an

attempt to elicit a better voice

Distinct head positions are tried in therapy: Normal straight ahead

Neck extended forward with head tilted down, face looking up

Neck flexed downward with head titled down, face looking down

Neck flexed unilaterally with head tilted to either the left or right, with titled face looking forward

Head upright and rotated left or right, face looking in that direction

More Therapy Strategies Establishing a New Pitch:

Used to establish a new pitch for speaking that would do less damage to the vocal folds

Laryngeal Massage:

Especially helpful for clients who have excessive laryngeal tension

Massage may help relax vocal system

Relaxation:

Helpful in decreasing pressure and tension in the vocal system

Many different relaxation techniques may be tried before finding one that works for a specific client

Therapy Strategies Respiration Training: Education on proper breath support to aid phonation,

loudness, and quality of voice

Vocal Rest: Many disorders are caused by vocal abuse Resting the voice is one way to improve the overall

function of the vocal system

Vocal Exercises: Exercising the vocal muscles through various

productions of vowels, with different durations, and on scales of loudness

The muscles within the vocal system need exercise to maintain strength and longevity like any other muscle of the body

Takes a Team Establishing vocal hygiene and voice therapy

techniques may need multidisciplinary approach

SLPs may work closely with: Counselors

Psychologists

Physicians/surgeons

Psychiatrists

The client, as well as the client’s support system (family, friends, colleagues) are also included in the intervention process in order to facilitate long lasting vocal health

ReferencesBoone, D. R., McFarlane, S. C., Von Berg, S. L., & Zraick, R. I. (2010). The

voice and voice therapy. (8th ed., pp. 54-243). Boston: Pearson

Education, Inc.

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