Practical Strategies for Treatment of Common Voice Disorders
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Transcript Practical Strategies for Treatment of Common Voice Disorders
Practical Strategies for
Treatment of Common
Voice Disorders
Carol Krusemark, M.A., CCC-SLP
Voice Pathologist/Singing Voice
Specialist
MGH Center for Laryngeal Surgery and
Voice Rehabilitation
Common Voice Disorders
Muscle Tension Dysphonia
• Primary
• Secondary
Vocal pathology associated with
abuse/misuse
• Nodules
• Vocal scarring or loss of vibratory layer
Primary Muscle Tension Dysphonia
a posterior
glottic “chink”
caused by
simultaneous
activation of
vocal fold
“closers” and
“openers”
Can be normal
in females
Primary Muscle Tension Dysphonia
False vocal fold
approximation:
medio-lateral
supraglottic
compression
Primary Muscle Tension Dysphonia
Supraglottic
compression in
the anterior to
posterior axis
Primary Muscle Tension Dysphonia
Compression
from both the AP and mediolateral directions
Vocal Nodules
Reactive
fibrovascular
lesions formed at
the site of
greatest vocal
fold contact
Scar or loss of vibratory layer
Loss of superficial
lamina propria,
resulting in
reduced musocal
wave
Treatment modalities
Facilitating Strategies
Reduction of vocal fold and supraglottic
hyperfunction
Type I: posterior glottic “chink”
• Glottal fry
• Inhalation phonation
Types II-IV: Supraglottic compression
• Semi-occluded vocal tract tasks
Type I
Glottal fry phonation
• Low subglottal “driving” pressure
• Reduced tension of the muscle within
the vocal folds (thyroarytenoid)
• Vocal folds are short and thick
• Increased interarytenoid activity
• Complete vocal fold closure front to
back
Eliminating posterior chink
• Isolation/syllables/words/etc.
MTD: Posterior glottic gap
Inhalation Phonation
• Phonation during inspiratory phase
• Results in improved vocal fold closure
along entire length
• Vocal tract adjustment can assist with
transition from inspiratory to expiratory
phonation
• Hierarchy of tasks
MTD: Compression
Goals:
• Reduce supraglottic compression
• Reduce vocal fold medial compression
Task requirements:
• Complete closure of the vocal folds
along their length (coordination of
“closers)
• Adduction to a “just barely touching”
position
Semi-occluded vocal tract tasks
Lowers phonation
threshold pressure
Decreases medial
compression
Reduces laryngeal
muscular tension
Improves laryngeal
muscular coordination
“squares up” vocal
fold edges for efficient
vibration
Phonation through a
straw (small is better)
Sustained phonation
of voiced fricative
consonants
Lip bubbles/trills
Tongue trills
Rolled /r/
Humming
Fringe benefit:
highlights oral
resonance
Straw phonation
Daily exercises program (2-3 times)
Three Principles:
• Lips around straw
• Sound through straw only
• Vibratory feeling at the lips
Four tasks:
• One long, slow slide from low to high and back
again
• A series of slow slides on a single breath
• A series of accented slides (revving)
• Song phonation
From straw to speech
Assure correct production through straw
Practice phrases before and after straw
Note auditory and ideally kinesthetic
contrast
Maintenance of kinesthetic similarity
“Make it feel like it did after you used
the straw”
Gradually fade straw use
Circumlaryngeal massage
Addresses paralaryngeal resting
muscle tension
Massage and manipulation of the
supporting muscular “sling”
Focuses on muscular attachments to
the thyroid cartilage and hyoid bone
Muscle relaxation encourages inferior
movement of the thyroid cartilage
Circumlaryngeal
Massage/Evidence
Significant changes in patient severity
ratings (Roy, 1993) and acoustic voice
measures (Roy, 1997) after one session
93% able to maintain improvement for a
week without further treatment (Roy,
1993)
Improved voice was maintained for up to
5 months for 72% of patients (Roy 1997)
Circumlaryngeal
Massage/Evidence
Professional voice users with moderate to
severed muscle tension dysphonia
• 25 sessions
• Improvements in acoustic measurements
Strain
Highest frequency
Average fundamental frequency
Jitter and shimmer
• Improvements in Dysphonia Severity Index
Structure identification
Muscles of the anterior neck
Suprahyoid
Digastric
Mylohyoid
Geniohyoid
Stylohyoid
Infrahyoid
Thyrohyoid
Sternohyoid
Omohyoid
Sternthyroid
Circumlaryngeal Massage
Using small
circles,
massage in
the
thyrohyoid
space,
moving
horizontally
through the
space
Circumlaryngeal Massage
Use larger
circles to
massage
from the
thyrohyoid
space to
above the
hyoid bone
and back
Circumlaryngeal Massage
Massage in
the
thyrohyoid
space
moving
from back
to front
Circumlaryngeal Massage
Massage up
and down in a
“C” shape
from the
thyrohyoid
space to the
cricoid
cartilage and
back
Questions??