19/05/2015

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Telehealth The Voice Clinic and Paediatric Voice Disorder

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The Voice Clinic and Paediatric Voice Disorders

Kate Osland & Sarah Inglis Speech Pathologists, Voice Clinic The Children’s Hospital at Westmead

19th May 2015

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Outline of the session

• What is the Voice Clinic? • 3 case studies – Patient journey from assessment to and follow-up • Highlighting some of the issues and considerations when working with the paediatric voice population. • A description – not a prescription!

What is the Voice Clinic?

• Joint ENT and Speech clinic • Fortnightly clinic, 2 patients per clinic • Referral by GP, ENT, paediatrician, or other specialist • Each appointment consists of 45 min-1hr speech pathology assessment, ½ hr for ENT consult & feedback • Student involvement • Purpose of Ax = differential diagnosis and suitability for therapy

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Who do we see?

• Children referred by medical professionals • Children from age 3-16 • Children who present with a primary voice complaint

A typical Voice Clinic assessment 1. Case history

2. Oral-motor assessment 3. Perceptual assessment and acoustic assessment during functional voice tasks 4. Therapy trial 5. ENT consultation 6. Feedback

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Student experience

• Unique clinical experience – Orientation – Practical voice assessment experience

What do students say?

‘Having an experience with child voice is quite rare’

‘We had to think carefully of how we could make the tasks fun and motivating for the client to participate in. This differed from my experiences in assessing an adult voice client’

‘Through this, I learnt a lot about my own abilities and limitations in terms of carrying out techniques’

‘It was great seeing how speech pathologists can work with medical professionals in the area of voice.’

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Case Study 1 – S

Background • Male; 14 years, 11 months • Presenting concern: Breathy voice, difficulty achieving volume and projection. • Voice Hx: Onset approx. 18 months ago, stable. • Med Hx: Eczema, allergic rhinitis, mild asthma. Uses steroidal nasal spray. • Social Hx: Eldest child, attends academically selective high school, in school choir, interest in public speaking.

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Results of Scope

• Incomplete closure of the vocal folds (posterior glottic chink) • Increased vocal fold tension • Rise in laryngeal position with

Assessment results • OMA: Significant elevation of on phonation. No other structural or functional abnormalities detected. • Perceptual assessment: Mildly breathy and strained, elevated pitch for age/gender. A deeper vocal quality was noted when S laughed or cleared his throat. • Acoustic assessment: Measure Norm Result Fundamental frequency Mean 125Hz 223 Hz Harmonics-to-Noise ratio 20 dB+ 28 dB Maximum phonation time 22 s (range 9-35s) 11 s Pitch range 80-724 Hz for post- 146-528+ Hz pubertal male

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Therapy trial

• Responsive to therapy trial to lower voice with cues – Yawn – Initiation of phonation on ‘oh’ with a glottal stroke onset – Short phrases

• S did not readily identify with this deep pitch

Diagnosis?

=

Puberphonia

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Puberphonia • Definition: the persistence of a high-pitched voice beyond the age at which voice change is expected to have occurred (Desai & Mishra, 2012) • Aetiology: Increased laryngeal muscular tension leading to excessive laryngeal elevation, psychosocial factors impacting upon acceptance of new voice (e.g. social immaturity) (Desai & Mishra, 2012). • Prevalence: 1 in 900,000 (Banerjee et al, 1995); more common in adolescent males • Clinical features: – High fundamental frequency for age/gender (> 200Hz) – Pitch breaks – Hoarseness – Breathiness – Difficulty in vocal projection – Visible laryngeal muscle tension

Puberphonia • Desai and Mishra’s prospective study (2012) • Subjects: 30 males aged between 14-18 years of age with a diagnosis of puberphonia based on ENT/SP assessment using videostroboscopy, perceptual and acoustic analysis. • Treatment: – Humming whilst gliding down a scale – Phonation of vowels with glottal attack – Use of vegetative sounds such as cough/throat clear to initiate voicing – Production of glottal fry – Digital manipulation of thyroid cartilage – Counselling – Relaxation exercises • Outcome: – All 30 patients showed improvement on acoustic and perceptual measures. – Majority of patients needed 4 sessions to achieve acceptable outcome.

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Management considerations

• Nature of condition – Potential for rapid improvement • Client factors – Self-awareness – Motivation – Secondary gains/limiting variables

Recommendations

• Direct voice therapy indicated • No scope indicated • ‘Counselling’ as a part of the therapy process

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Therapy • Focus on lowering of larynx and increasing control of voice at lower pitch – Kinaesthetic feedback – Use of low vowel with glottal stroke onset – Giggle to promote release of constriction – Humming, smooth onset • Progress – Initially slipping back into ‘usual voice’ – Generalised well outside of session – Desired outcome achieved in 4 sessions

Follow-up

• 3 months post therapy • Clear, effortless voice quality • More confident speaking in front of class • Improving control of pitch in singing, working with singing teacher

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Case Study 2 – A

Background

• 15 year old boy referred following concerns regarding a prolonged period of aphonia (1.5 years). • Medical history: ASD diagnosed mid Dec 2013. • Previous speech pathology/ENT involvement: – Two ENT investigations prior to Voice Clinic assessment. – Two blocks of voice therapy between February and March 2013. • Social history: Lives with mother and 11-year-old brother in a regional area. Home-schooled. • Other health professionals: Saw psychologist for anxiety management.

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Assessment results

• OMA: Nil abnormalities observed, weak prompted cough noted but spontaneous cough was stronger. • Perceptual characteristics: ‘Whispered’ and breathy vocal quality and aphonic voice. • Acoustic assessment: Acoustic analysis invalid.

Diagnosis?

=

Psychogenic dysphonia

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Psychogenic Dysphonia • Definition: A type of ‘non-organic’ voice disorder where there is loss of voice in the absence of structural or neurological pathology to explain the extent of the patient’s voice loss, and where this volitional loss of voice is linked to psychological imbalance (Baker, 2003.) • Aetiology: Psychogenic voice disorders are the ‘manifestation of psychological disequilibrium’ (Aronson, 1990.) • Prevalence: Difficult to ascertain, though psychogenic aphonia noted more predominantly in women (Martins, Tavares, Ranalli, Branco, Pessin, 2014,) with a ratio of 8:1 (Baker, 2003.) There is a low prevalence of conversion reaction (Baker, 2003.)

Psychogenic Dysphonia • Clinical and perceptual features: - Onset of dysphonia is sudden (Martins, Taveres, Ranalli, Branco & Pessin, 2014.) - Patient histories indicate significant emotional stress (Seifert & Kollbrunner, 2005) and potentially conflict over ‘speaking out’ about something (Baker, 2003.) - May have difficulty describing how they feel about their loss of voice or other traumatic situations/events in their lives. - Non-speech vocalisations are clear (Seifert & Kollbrunner, 2005.) - Dysphonia or aphonia can be intermittent (Martins, Tavares, Ranalli, Branco & Pessin, 2014.) - Absence of laryngeal pathology under instrumental examination.

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Psychogenic Dysphonia • Treatment available: - Aim of therapy: maximise function and reduce negative effects of difficulties on life participation (Seifert & Kollbrunner, 2005.) - Counselling will be important (Seifert & Kollbrunner, 2005.) - Shaping non-speech vocalisations into speech gradually over time (Colton, Casper & Leonard, 2011.) • Outcomes: - Multi-disciplinary approach leads to the best results (Martin, Tavares, Ranalli, Branco & Pessin 2014.) - High rate of relapse without psychological intervention (Seifert & Kollbrunner, 2005.)

Considerations for Rx

• A lives in a regional centre. • A schooling situation. • A’s limited exposure to individuals outside his family. • A’s personal investment in therapy. • A’s ‘special interests.’

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Recommendations

• Intensive 2-week block of voice therapy - 10 sessions (30 minutes daily) • Referral to Psychological

Therapy

• Progress – A unable to be seen by Psychological Medicine team during his stay at the hospital. – A made exponential progress through voicing hierarchy. – Performance in remaining 5 sessions = reversion in volitional voicing.

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Therapy (cont.)

• Outcome – Making little progress overall and ambivalent about his personal investment in therapy. – Clinicians unsure how to treat in future given psychological component. – Mother to contact the department to discuss review assessment and a possible therapy block in less than a month’s time.

Follow-up Review

• Conducted in presence of mother and younger brother. • Reported participating in home practice, with difficulty voicing in that environment. • Demonstrated fairly consistent voicing on all levels trialled apart from scripted interactions. • A reported that he was ready to engage in therapy and wanted to start therapy this week.

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Therapy • Joint SP/Psychological Medicine intervention recommended: Rehab-style, one week outpatient block. • Progress – A able to use clear, consistent in conversation beyond the therapy room. – A more personally invested in therapy.

Therapy (cont.)

• Outcome – A left therapy block consistently and volitionally using his voice in naturalistic settings, with some therapy activities given to increase his volume. • Plan – A to contact the clinicians via telephone later in the year, and arrange a review assessment for early 2015.

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Follow Up Review (3 months)

• A using clear, audible, and louder voice since last seen in department. • Using voice functionally in everyday life. • More outgoing and happier, with career aspirations and plans for the future. • Plan of action: discharge.

Case Study 3 – M

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Background • 7 year-old female • Presenting concern: – Hoarse voice with reduced voice volume • Voice Hx: – Unclear onset of voice problem – Voice stable over time • Medical Hx: – Normal birth history and early development – No major illness or – Family history of thyroid abnormalities and hormonal issues • Social Hx: – Separation anxiety; psychological involvement

Assessment results • OMA: No structural or functional abnormalities detected. • Perceptual assessment: Mildly breathy, rough and strained voice quality. • Acoustic assessment: Measure Norm Result Fundamental frequency 261Hz (range 195- 275 Hz 303Hz) Harmonics-to-Noise 20 dB+ 19 dB ratio Maximum phonation 13.7s (range 8.9-18.5s) 6.6 seconds time Pitch range No norms for children 232 – 285 Hz

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Therapy trial

• +++ encouragement to participate • Strategies trialled: – Giggle technique for release of constriction – Resonant voice with ‘mmm’ to cue smooth onset to voicing – Sob • Limited response to therapy trial

Diagnosis? =

Hyperfunctional voice disorder (+ nodules?)

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Hyperfunctional Voice Disorder • Definition: – A condition in which there is excess tension of the muscles within and around the larynx, a posterior glottic chink, elevation of the larynx with voicing, and frequent mucosal changes on the (Lee & Son, 2005). • Aetiology: – Psychological or personality factors that induce tension; – Suboptimal use of the voice in the context of high vocal demands; – Compensatory strategy for underlying pathology, – Learned (mal)adaptive behaviour following a respiratory illness (Morrison et al, 1983). • Prevalence: – Nodules - 21.6% in males; 11.7% in females (Kilic et al, 2004) • Clinical features: – Hoarseness, strain, breathiness; pitch or phonation breaks; unusually high or low pitch – In children, there is a lack of reporting of laryngeal discomfort with use, although there may be detectable deterioration in quality (Lee & Son, 2005)

Hyperfunctional Voice Disorder • Treatment options: - Voice therapy (direct vs. indirect) - Medical management - No management/observation alone • Adult literature indicates that a combination of direct and indirect therapy is best practice for treating vocal fold nodules (Ruostalainen et al, 2008). No clear conclusion in children. • No clear evidence for which treatment is best or how long to implement it (Pederson & McGlashan, 2012; Ongkasuwan & Friedman, 2013). • Motivation and behaviour change are important factors to success (Lee & Son, 2005; Mori, 1999). • typically has a reduced role in paediatrics (Sulica & Behrman, 2003).

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Hyperfunctional Voice Disorder • Accent method • Chant talk • Confidential voice therapy • Froeschel’s chewing technique • Giggle technique • Resonant voice therapy • Sob quality • Yell Well • Yawn sigh • Vocal hygiene • Open mouth approach • Other (trilling, singing, relaxation, twang, pitch exercises… etc etc)

Hyperfunctional Voice Disorder • The upshot of this: SPs rely on relatively low levels of evidence combined with clinical experience to guide management of this population (Signorelli et al, 2011).

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Management considerations • What is the recommended treatment given our hypothesised diagnosis? • Is scoping strongly indicated? • Likelihood of compliance with scoping? • Will M be a suitable therapy candidate? • Will M’s family engage with therapy process?

Recommendations

• Trial of voice therapy at CHW • Review by ENT pending progress in therapy, with view to scope as indicated.

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Therapy • Progress: – M attended 6 therapy sessions – Resonant voice therapy – Difficult to engage in therapy sessions – Sensitive to feedback – Mother and M reluctant to separate – Intermittent illness disrupting therapy practice – Not making progress • Plan: – ENT review

ENT Findings

Image courtesy of http://www.bbivar.com/vidimg/

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Follow-up

• Joint decision with family to discontinue voice therapy • Monitoring of voice quality and follow-up in one year

Summary

• An ENT diagnosis is not essential before progressing to therapy – but can be helpful. • Use the best available evidence and your clinical experience to guide selection of voice therapy techniques. • Paediatric voice is a challenging and varied caseload. • Many factors can impact on progress – it is not always smooth sailing! • Important to validate your diagnosis if there is no progress.

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How do I refer?

• Encourage your client to see their GP or other relevant specialist to obtain a referral

• Referrals should be addressed to: Dr John Curotta The Voice Clinic The Children’s Hospital at Westmead Fax (02) 9845 2078

References • Aronson, A.E. (1990). Clinical voice disorders: an interdisciplinary approach. New York: Thieme Inc. • Baker, J. (2000). Psychogenic voice disorders – heroes or hysterics? A brief overview with questions and discussion. Logopaedics, phoniatrics, and vocology, 27: 84-91. • Baker, J. (2003). Psychogenic Voice Disorders and Traumatic Stress Experience: A Discussion Paper with Two Case Reports. Journal of Voice, 17 (3): 308-318. • Banerjee, A.B., Eajlen, D., Meohurst, R., & Murty, G.E. (1995). Puberphonia – A treatable entity, 1st World Voice Congress Oporto: Portugal. • Colton, R. H., Casper, J.K., & Leonard, R. (2011.) Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment (3rd edition.) Baltimore, MD: Lippincott Williams & Wilkins. • Desai, V., and Mishra, P. (2012). Voice therapy outcome in puberphonia. Journal of and Voice, 2: 26-29. • Kilic, M.A., Okur, E., Yildirim, I., Guzelsoy, S. (2004). The prevalence of vocal fold nodules in school-age children. International Journal of Pediatric , 68: 409-412. • Lee, E., & Son, Y. (2005). in children: voice characteristics and outcome of therapy. International Journal of Pediatric Otorhinolaryngology, 69: 911-917. • Sulica, L., & Behrmann, A. (2003). Management of benign vocal fold lesions: A survey of current opinion and practice. The Annals of Otology, Rhinology and Laryngology, 112: 827-833.

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References • Martins, R.H.G, Tavares, E.L.M, Ranalli, P.F., Branco, A., & Pessin, A.B.B. (2014). Psychogenic dysphonia: diversity of clinical and vocal manifestations in a case series. Brazilian Journal of Otorhinolaryngology, 80 (6): 497-502. • Mori, K. (1999). Vocal fold nodules in children: preferable therapy. International Journal of Pediatric Otorhinolaryngology, 49 Suppl 1:S303-6. • Morrison, M.D., Rammage, L.A., Belisle, G.M. , Pullan, C.B., & Nichol H. (1983). Muscular tension dysphonia. Journal of Otolaryngology, 12: 302-306. • Ongkasuwan, J., & Friedman, E.M. (2013). Is voice therapy effective in the management of vocal nodules in children. The Laryngoscope, 123: 2930-2931. • Pederson, M., & McGlashan, J. (2012). Surgical versus non-surgical interventions for vocal cord nodules: Review. The Cochrane Library, Issue 6. John Wiley & Sons, Ltd. • Ruostalainen, J., Sellman, J., Lehto, L., & Verbeck, J. (2008). Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngology-Head and Neck Surgery, 138, 557–565. • Seifert, E. & Kollbrunner, J. (2005.) Stress and distress in non-organic voice disorders. Swiss Medicine Weekly, 135: 387-397. • Signorelli, M.E., Madill, C.J., & McCabe, P. (2011). The management of vocal fold nodules in children: A national survey of speech-language pathologists. International Journal of Speech- Language Pathology, 13(3), 227-238.

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