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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.
Images retrieved from www.google.com