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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

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Practical Strategies for Treatment of Common Voice Disorders

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  1. 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

  2. Common Voice Disorders • Muscle Tension Dysphonia • Primary • Secondary • Vocal pathology associated with abuse/misuse • Nodules • Vocal scarring or loss of vibratory layer

  3. Primary Muscle Tension Dysphonia • a posterior glottic “chink” caused by simultaneous activation of vocal fold “closers” and “openers” • Can be normal in females

  4. Primary Muscle Tension Dysphonia • False vocal fold approximation: medio-lateral supraglottic compression

  5. Primary Muscle Tension Dysphonia • Supraglottic compression in the anterior to posterior axis

  6. Primary Muscle Tension Dysphonia • Compression from both the A-P and medio- lateral directions

  7. Vocal Nodules • Reactive fibrovascular lesions formed at the site of greatest vocal fold contact

  8. Scar or loss of vibratory layer • Loss of superficial lamina propria, resulting in reduced musocal wave

  9. 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

  10. 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.

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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)

  18. 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

  19. Structure identification

  20. Muscles of the anterior neck Suprahyoid Digastric Mylohyoid Geniohyoid Stylohyoid Infrahyoid Thyrohyoid Sternohyoid Omohyoid Sternthyroid

  21. Circumlaryngeal Massage • Using small circles, massage in the thyrohyoid space, moving horizontally through the space

  22. Circumlaryngeal Massage • Use larger circles to massage from the thyrohyoid space to above the hyoid bone and back

  23. Circumlaryngeal Massage • Massage in the thyrohyoid space moving from back to front

  24. Circumlaryngeal Massage • Massage up and down in a “C” shape from the thyrohyoid space to the cricoid cartilage and back

  25. Questions??

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