Voice Therapy Clinical Case Studies

Fifth Edition

Voice Therapy Clinical Case Studies

Fifth Edition

Joseph C. Stemple, PhD, CCC-SLP, ASHAF Edie R. Hapner, PhD, CCC-SLP, ASHAF 5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Website: http://www.pluralpublishing.com

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Library of Congress Cataloging-in-Publication Data

Names: Stemple, Joseph C. | Hapner, Edie R. Title: Voice therapy : clinical case studies / [edited by] Joseph C. Stemple, Edie R. Hapner. Description: Fifth edition. | San Diego, CA : Plural Publishing, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018028949| ISBN 9781635500356 (alk. paper) | ISBN 1635500354 (alk. paper) Subjects: | MESH: Voice Disorders — therapy | Case Reports Classification: LCC RF510 | NLM WV 500 | DDC 616.85/56 — dc23 LC record available at https://lccn.loc.gov/2018028949 Contents

Preface xiii Contributors xvii

1 Principles of Successful Voice Therapy 1 Joseph C. Stemple Introduction 1 Scientific Nature of Voice Care 2 Artistic Nature of Voice Care 2 How to Use This Text 3 Historical Perspective 3 Hygienic Voice Therapy 4 Symptomatic Voice Therapy 5 Psychogenic Voice Therapy 5 Physiologic Voice Therapy 6 Eclectic Voice Therapy 6 Case Study 1.1 7 Joseph C. Stemple Voice Care Team 10 Issues Related to Successful Voice Therapy 10 Clinician Realities Associated with Voice Therapy Success 11 Interview and Counseling Skills 11 Case Vignette 1.1. A Missed Opportunity 11 Joseph C. Stemple Clinical Understanding of the Problem 12 Misapplied Management Techniques 13 Lack of Patient Education or Understanding of the Problem 14 Recognition of One Philosophical Orientation or One 14 Etiologic Factor Case Vignette 1.2. The Obvious Is Not Always the Cause 14 Joseph C. Stemple Premature Discontinuation of Therapy 15 Case Vignette 1.3. The Pseudoauthoritative Voice 15 Joseph C. Stemple The Clinical Ear 15 Patient Realities Associated with Voice Therapy Success 16 Lack of Patient Motivation for Voice Therapy 16

v vi Voice Therapy: Clinical Case Studies

Case Vignette 1.4. “As Long as I Don’t Have Cancer . . .” 16 Joseph C. Stemple Case Vignette 1.5. The Role of Self-Efficacy and Adherence 17 Amanda Gillespie Resistance to Share Information 19 Perceived Need for Negative Vocal Behavior 19 Need to Identify with the Problem 20 Case Vignette 1.6. “My Chest Hurts When I Do These Exercises” 20 Jospeh C. Stemple Finances 21 Personality Issues 21 Can All Voices Be Improved? 22 Case Vignette 1.7. He Was “Fired” from Voice Therapy 22 Carissa Maira Beyond Successful Voice Therapy Techniques and Tasks: 28 The Concept of Meta-Therapy Leah Helou Chapter Summary 31 References 31 2 Comments on the Voice Evaluation 35 Joseph C. Stemple Introduction 35 Management Team 37 Medical Evaluation 37 Voice Pathology Evaluation 38 Referral 38 Reason for the Referral 38 History of the Problem 41 Medical History 42 Social History 42 Oral-Peripheral Examination 43 Voice Evaluation 43 Instrumental Voice Assessment 45 Hearing Screening 46 Impressions 46 Prognosis 46 Recommendations 46 Chapter Summary 46 References 47 3 Primary and Secondary Muscle Tension Dysphonia 49 Introduction: Muscle Tension Dysphonia: An Overview 49 Nelson Roy Contents vii

Primary MTD 51 Case Study 3.1. Management of Primary MTD in a 13-Year-Old 51 Using Falsetto Voice to Modify Functional Aphonia Joseph C. Stemple Case Study 3.2. Flow Phonation in a Teenager with Primary 55 Muscle Tension Dysphonia (Aphonia) Jackie Gartner-Schmidt Case Study 3.3. Manual Circumlaryngeal Techniques in the 63 Assessment and Treatment of Primary Muscle Tension Dysphonia in a 55-Year-Old Woman Nelson Roy Case Study 3.4. Management of a Functional Dysphonia 70 Mimicking a Superior Laryngeal Nerve (SLN) Paresis Claudio Milstein Case Study 3.5. The Use of Hard Glottal Attacks to Facilitate 76 Age-Appropriate Pitch in a 16-Year-Old Male with Mutational Falsetto Lisa Fry Case Study 3.6. The Use of Glottal Attack in the Treatment of 82 Primary MTD in an Adult Female Presenting with Persistent Falsetto Joseph C. Stemple Secondary MTD 84 Case Study 3.7. Using Patient-Family Education and Behavior 84 Modification to Treat MTD Secondary to Vocal Nodules in a School-Aged Child Leslie Glaze Case Study 3.8. Pediatric Vocal Nodules and Secondary Muscle 90 Tension Dysphonia Treated in Connection with a School-Based SLP Rebecca Hancock Case Study 3.9. Treating a Child with Muscle Tension Dysphonia 98 Secondary to Vocal Nodules Using Concepts from “Adventures in Voice” Rita Hersan Case Study 3.10. The Use of Vocal Function Exercises in the 106 Treatment of an Adult with Secondary Muscle Tension Dysphonia Joseph C. Stemple Case Study 3.11. The Accent Method (AM) of Voice Therapy in 116 Clinical Practice Sara Harris Case Study 3.12. The Use of Intensive Short-Term Voice Therapy 126 (aka Voice Therapy Boot Camp) in a Professional Voice User with Vocal Hyperfunction Rita Patel viii Voice Therapy: Clinical Case Studies

Case Study 3.13. Lessac-Madsen Resonant Voice Therapy in a 132 Young Woman with Vocal Nodules Diana Marie Orbelo, Nicole Yee-Key Li, and Katherine Verdolini-Abbott Case Study 3.14. Multimodal and Multidisciplinary Treatment of 141 Vocal Process Granulomas and Secondary Muscle Tension Dysphonia Heather Starmer Case Study 3.15. An Eclectic Approach in the Management of an 148 Individual with Vocal Fatigue Chaya Nanjundeswaran Case Study 3.16. Conversation Training Therapy (CTT) Applied 154 to a Patient with Benign Mid-Membranous Lesions Jackie L. Gartner-Schmidt and Amanda I. Gillespie References 160

4 Management of Glottal Incompetence 171 Introduction: Bridging “Gaps” with Voice Therapy in Patients 171 with Glottal Dysfunction Aaron Ziegler Case Study 4.1. The Use of PhoRTE for Presbyphonia 175 Aaron Ziegler and Edie Hapner Case Study 4.2. The Use of Vocal Function Exercises in an 183 Elderly Man with Presbyphonia Steve Gorman Case Study 4.3. Eclectic Voice Therapy to Treat Glottal 188 Incompetence with Secondary MTD in a Patient with Unilateral Vocal Fold Paralysis Maria Dietrich Case Study 4.4. A Case of Superior Laryngeal Nerve Paralysis in a 195 Patient After Subtotal Thyroidectomy Daniel Croake Case Study 4.5. LaxVox Therapy Used in a Case of Muscle Tension 201 Dysphonia Hiding an Underlying Glottal Incompetence Ilter Denizoglu Case Study 4.6. Treatment of Glottal Incompetence Caused by 212 Sulcus Vocalis: Evidence of a Team Approach for Vocal Rehabilitation Amanda I. Gillespie and Clark Rosen Case Study 4.7. Improvement of Vocal Fold Closure in a Patient 217 with Voice Fatigue Joseph C. Stemple Case Study 4.8. The Use of Expiratory Muscle Strength Training 222 in a Case of Unilateral Vocal Fold Paralysis with Weak Cough and Aspiration Pneumonia Bari Hoffman Ruddy, Christine M. Sapienza, Erin Pearson, and Henry Ho Contents ix

Case Study 4.9. The Use of Semi-Occluded Vocal Tract Methods and 225 Resonant Voice Therapy to Habilitate Unilateral Vocal Fold Paralysis Julie M. Barkmeier-Kraemer References 235

5 Dystonia, Essential Tremor, and Parkinson’s Disease 243 Introduction: Neurogenic Voice Disorders 243 Richard Andreatta Spasmodic Dysphonia 245 Joseph C. Stemple Case Study 5.1. Functional Voice Therapy for Spasmodic Dysphonia 247 Joseph C. Stemple Case Study 5.2. Medical and Behavioral Management of Adductor 250 Spasmodic Dysphonia Edie R. Hapner and Michael M. Johns III Case Study 5.3. Combined Laryngeal Injection of Botulinum Toxin 256 and Voice Therapy for Treatment of Adductor Spasmodic Dysphonia Eileen Finnegan Case Study 5.4. The Use of Reduced Voicing Duration to Treat 263 Vocal Tremor Julie M. Barkmeier-Kraemer Case Study 5.5. Treatment for Vocal Tremor in a Classical Singer 274 Kristen Bond Case Study 5.6. Use of LSVT LOUD® (Lee Silverman Voice 281 Treatment) in the Care of a Patient with Parkinson Disease Lorraine Ramig and Cynthia Fox References 287

6 Disorders of the Upper Airway: Irritable Larynx Syndrome, 293 Chronic Cough, Paradoxical Vocal Fold Dysfunction, and Upper Airway Challenges Introduction to Irritable Larynx Syndrome 293 Linda Rammage Case Study 6.1. A Case of ILS Managed by a Comprehensive 295 Approach to Multiple Central Sensitivity Syndrome Triggers Linda Rammage Case Study 6.2. Combined Voice Therapy with the use of 304 Central Nervous System Inhibitors in the Successful Treatment of Chronic Cough Madeleine Pethan and Laureano Giraldez-Rodriguez Case Study 6.3. Therapy for Chronic Refractory Cough 311 Thomas Murry x Voice Therapy: Clinical Case Studies

Introduction to Paradoxical Vocal Fold Motion 324 Mary J. Sandage Case Study 6.4. Treatment of PVFM/VCD in a Collegiate Swimmer 327 Mary J. Sandage Case Study 6.5. Treatment of Paradoxical Vocal Fold Motion 335 Disorder in a 9-Year-Old Athlete Maia Braden Case Study 6.6. Long-Term Management of Odor-Induced 341 PVFM After Environmental Fume Exposure Carissa Maira Case Study 6.7. Inspiratory Muscle Strength Training in a Patient 347 with Upper Airway Limitation Susan Baker Brehm and Barbara Weinrich References 354 7 Management of the Professional, Avocational, and 359 Occupational Voice Introduction 360 Marina Gilman Case Study 7.1. Semi-Occluded Vocal Tract and Resonant Voice 364 Therapy in the Perioperative Management of a Professional Actor and Singer with a Vocal Fold Cyst Sarah L. Schneider and Mark S. Courey Case Study 7.2. Management of Vocal Fold Nodules in a Female 376 Pre-Pubescent Singer Patricia Doyle and Starr Cookman Case Study 7.3. Therapeutic Intervention for the Touring Musical 386 Theatre Vocal Athlete with High Physical and Vocal Demands Wendy LeBorgne Case Study 7.4. Voice Intervention for a Touring Broadway Singer 394 Shirley Gherson Case Study 7.5. Combined Modality Management of the 400 High-Risk Vocal Performer Bari Hoffman Ruddy, Jeffrey Lehman, and Christine Sapienza Case Study 7.6. Voice Recalibration with the Cup Bubble Technique 408 for a Country Singer Jennifer C. Muckala and Brienne Ruel Case Study 7.7. Praise and Worship Leader Pre-Post Removal of 416 Bilateral Vocal Fold Lesions Marina Gilman Case Study 7.8. The Use of Voice Therapy in Conjunction with 423 Minimal Injection Medialization in the Longitudinal Treatment of Dysphonia in an Elite Operatic Singer Brian E. Petty and Miriam van Mersbergen Contents xi

Case Study 7.9. Voice Therapy in a 28-Year-Old Theater Actor 427 Kate DeVore Case Study 7.10. Conversational Voice Therapy: A Case Describing 433 Application of Public Speaking Techniques to Voice Disorders Alison Behrman References 438

8 Nontraditional Therapy Delivery Models and 443 Therapeutic Challenges Introduction 443 Vrushali Angadi Case Study 8.1. Voice Therapy Telepractice: “Live on Stage!” 446 Michael Towey Case Study 8.2. Treatment of Vocal Hyperfunction and Bilateral 451 Lesions in a Child: A Traditional Therapeutic Approach Delivered via Telepractice Lisa Kelchner Case Study 8.3. Use of Telepractice to Provide Voice Therapy for a 457 Patient with Parkinson Disease Lyn Covert Case Study 8.4. Communication Modification in a 462 Transgender Woman Sandy Hirsch Case Study 8.5. The Use of Physiologic Voice Therapy Exercises 467 in a Transgender Male Client JoAnna Sloggy Case Study 8.6. Treatment of Muscle Tension Dysphagia 476 Christina H. Kang Case Study 8.7. The Use of Conversation Training Therapy for an 483 Individual with Voice Fatigue and Pervasive Vocal Fry Lauren Timmons and Edie Hapner References 491

Index 497

Preface

This fifth edition of Voice Therapy: Clini- pling a wide variety of voice disorders cal Case Studies marks the twenty-fifth with various pathologies, etiologies, and anniversary of this text. Since the first therapy techniques. Through a system- edition, the purpose of this text has atic case study format, 64 voice experts remained the same. and master clinicians have provided detailed descriptions of voice assess- . . . to provide both the student and the ment and management approaches working clinician with a broad sampling and techniques. It is our hope that the of management strategies as presented expertise offered in these pages will by master voice clinicians, laryngolo- serve the reader well in guiding clinical gists, and other voice care professionals. voice practice. The text is meant to serve as a practical Utilizing the format of actual case adjunct to the more didactic publications. studies, complete descriptions of diag- nostic and therapeutic methods and As the knowledge of voice produc- results are provided for a full array of tion continues to expand, so, too, have voice disorders. Chapter 1 is an expanded the publications dedicated to describ- discussion devoted to the principles of ing this knowledge. There are currently successful voice therapy. What makes excellent texts and journals that report therapy successful or unsuccessful? This and explore the scientific understanding chapter examines both the qualities and of voice. Other publications are avail- preparation of the voice therapist and able to help prepare students to evalu- the responsibilities and challenges of the ate and manage clinical voice disorders. patient, and describes the pitfalls that By necessity, these texts must include may influence the ultimate goal of our great quantities of didactic information interventions, improved vocal function. so that the student learns not only the Chapter 2 comments on vari- “how” but the “why” of voice evalua- ous voice evaluation protocols. These tion and treatment. To utilize a manage- include the formal questionnaire, the ment approach without understanding patient interview, perceptual voice anal- the underlying basis of the approach ysis, patient self-assessment, and instru- is inappropriate. Nonetheless, because mental assessment of voice production. of the breadth of material necessary The role of the evaluation process as a in these texts, therapeutic methods for part of the overall management plan is voice disorders are often given only a also discussed. cursory and generalized discussion. Voice Chapter 3 presents treatment ap- Therapy: Clinical Case Studies is meant to proaches for the most common type of fill that gap. voice disorder, muscle tension dysphonia The fifth edition of this text includes (MTD). Following an overview of MTD 54 case studies and 7 case vignettes sam- by Nelson Roy, management approaches

xiii xiv Voice Therapy: Clinical Case Studies

for both children and adults includ- ity triggers, and PVFM in the young ing hygiene programs, symptomatic child, young athlete, and elite athlete. modifications, attention to psychosocial The background for these cases are first issues, and direct physiologic manipula- introduced in excellent discussions by tion and exercises are presented in illus- Linda Rammage (Irritable Larynx Syn- trative case studies of both primary and drome) and Mary Sandage (Paradoxical secondary MTD. Vocal Fold Motion). Aaron Ziegler introduces Chapter 4, The consequences of a voice dis- a discussion of treatments for vari- order not only may impact the quality ous etiologies of glottal incompetence. of life but may also threaten the liveli- Management for presbyphonia, vocal hood of individuals dependent upon fold paralysis, sulcus vocalis, and voice a healthy voice. Marina Gilman intro- fatigue are described, including direct duces Chapter 7, which presents case voice therapies, surgical intervention, studies for those dependent upon their and a combination of these approaches. voices, such as the elite vocal performer, Many techniques including voice facili- the occupational voice user, and those tating techniques, semi-occluded vocal whose avocational voice use is related tract, expiratory muscle strength train- to their quality of life. ing, and phonation resistance training The final chapter, Chapter 8, is are discussed. new to this text. Vrushali Angadi intro- Chapter 5 presents management duces the reader to a chapter dedicated strategies for laryngeal dystonia, essen- to discussing nontraditional therapy tial tremor, and Parkinson’s disease. Fol- delivery models and therapeutic chal- lowing an introduction of neurogenic lenges. Case studies describe the use voice disorders by Richard Andreatta, a of telemedicine in the delivery of voice series of cases will describe strategies for therapy in a traveling performer, a child behavioral and medical management of who lives in a rural area, and an individ- spasmodic dysphonia, voice therapy for ual with Parkinson’s disease. Speech- essential tremor, and treatment of voice language pathologists also treat indi- and speech symptoms related to Parkin- viduals desiring to make their voices son’s disease. representative of their gender identity. Because of the speech language Cases describing communication and pathologist’s unique blend of knowl- voice modification in the transgender edge regarding upper airway anatomy population are included. Because of the and physiology and behavioral ther- shared anatomy, voice and swallowing apy, we have become the caregivers issues may co-occur in an individual. for complex respiratory and laryngeal This chapter also includes an interest- disorders. Chapter 6 provides several ing case of “muscle tension dyspha- detailed case studies regarding the gia.” Finally, glottal fry phonation has various etiologies, patient profiles, and become somewhat of a social norm. In evaluation and treatment approaches some cases, however, this recognized used with those diagnosed with irri- vocal register may create vocal diffi- table larynx syndrome and paradoxi- culties as described by a case in which cal vocal fold motion (PVFM). These chronic and pervasive use of vocal fry cases include treatments for laryngo- appeared to be a primary component of pharyngeal reflux, laryngeal sensitiv- a voice complaint. Contributors xv

As with the first four editions of of tedious work. Checking and prepar- Voice Therapy: Clinical Case Studies, the ing references, organizing tables, fig- most exciting element in the preparation ures, and their legends, reading and re- of this text was the support received by reading in an attempt to make the intent the voice experts and master clinicians clear to those we are trying to reach are who graciously and generously submit- only a few of the tasks involved. We ted case studies. The list of contributors were so very fortunate in the preparation is literally a “Who’s Who” in the field of this text to have the invaluable edito- of voice disorders. What a wonderful rial assistance of the Plural Publishing opportunity it is to learn from those professionals. We are indebted to Angie who are in the trenches, those experts Singh, Valerie Johns, and Kalie Koscielak who embody not only superior clinical for encouraging and supporting this fifth skills, but a wonderful insight as to why edition and to Linda Shapiro and Jessica they do what they do. We are deeply Bristow on the production side of the indebted to all of them and proudly text preparation. In addition, we wish to offer their collective expertise. We are thank our students and colleagues who certain that the reader will benefit from have suggested ways to improve the text their vast clinical experiences. with each new writing. Finally, as usual, Text preparations are extremely we are most appreciative for the support time-consuming and require many hours of our families.

— Joseph C. Stemple & Edie R. Hapner

Contributors

Richard D. Andreatta, PhD City University of New York Associate Professor New York, NY Department of Rehabilitation Sciences Division of Communication Sciences Kristen Bond, MM, MS and Disorders Speech Language Pathologist University of Kentucky San Francisco Voice and Swallowing Lexington, KY Center San Francisco, CA Vrushali Angadi, PhD Assistant Professor Maia Braden, MS Department of Rehabilitation Sciences Speech-Language Pathologist Division of Communication Sciences University of Wisconsin–Madison and Disorders Voice and Swallow Clinics University of Kentucky American Family Children’s Hospital Lexington, KY Madison, WI Susan Baker-Brehm, PhD Professor & Chair Starr Cookman, MA Department of Speech Pathology and Assistant Professor, Clinical Faculty Audiology Voice and Speech Clinic Miami University University of Connecticut Health Oxford, OH Center Farmington, CT Julie M. Barkmeier-Kraemer, PhD, ASHA-F Mark S. Courey, MD Professor Professor, Otolaryngology–Head and Department of Surgery Neck Surgery Division of Otolaryngology Division Chief, Laryngology University of Utah Director, Grabscheid Voice and Salt Lake City, UT Swallowing Center Mount Sinai Health System Alison Behrman, PhD New York, NY Assistant Professor School of Health Sciences, Human Lyn Tindall Covert, PhD, ASHA-F Services, and Nursing Speech-Language Pathologist Department of Speech-Language- Department of Veterans Affairs Hearing Sciences Medical Center, Retired Lehman College Lexington, KY

xvii xviii Voice Therapy: Clinical Case Studies

Daniel Croake, PhD Lisa Fry, PhD Assistant Professor Adjunct Faculty, Department of Department of Rehabilitation Communication Disorders Sciences Marshall University Division of Communication Sciences Huntington, WV and Disorders University of Kentucky Jackie Gartner-Schmidt, PhD, Lexington, KY ASHA-F Professor of Otolaryngology Ilter Denizoglu, MD Co-Director of the UPMC Voice Center Phonosurgeon and Voice Pathologist Director of Speech Pathology-Voice Clinical Vocology Unit Division Medical Park Izmir Hospital University of Pittsburgh Medical Izmir, Turkey Center Pittsburgh, PA Kate DeVore, MA Speech-Language Pathologist Shirley Gherson, MA Total Voice, Inc. Clinical Specialist–Voice Disorders Chicago, IL NYU Langone Medical Center Rusk Rehabilitation Maria Dietrich, PhD New York, NY Assistant Professor Department of Communication Amanda I. Gillespie, PhD Disorders Assistant Professor University of Missouri Co-Director Columbia, MO Emory Voice Center Otolaryngology Head and Neck Surgery Patricia B. Doyle, MA Emory University Instructor Atlanta, GA Voice and Speech Clinic University of Connecticut Health Marina Gilman, MM, MA Center Speech-Language Pathologist Farmington, CT Emory Voice Center Otolaryngology Head & Neck Surgery Eileen M. Finnegan, PhD Emory University Associate Professor Atlanta, GA Department of Communication Sciences and Disorders Laureano A. Giraldez-Rodriguez, MD University of Iowa Director, The Voice and Swallowing Iowa City, IA Center of Puerto Rico Assistant Professor Cynthia M. Fox, PhD, ASHA-F Section of Otolaryngology–Head and Research Associate Neck Surgery National Center for Voice and Speech University of Puerto Rico School of University of Colorado–Boulder Medicine Denver, CO San Juan, Puerto Rico Contributors xix

Leslie E. Glaze, PhD, ASHA-F Give Voice Speech-Language Pathologist Seattle, WA Minneapolis, MN/Tucson, AZ Henry N. Ho, MD, FACS Stephen Gorman, PhD Director, Head and Neck Program Voice Pathologist The Florida Hospital Cancer Institute Blaine Block Institute for Voice Orlando, FL Analysis and Rehabilitation Dayton, OH, Bari Hoffman Ruddy, PhD, ASHA-F Professional Voice Center of Greater Professor Cincinnati, OH Department of Communication Sciences and Disorders Rebecca Lynne Hancock, MEd University of Central Florida Speech-Language Pathologist Orlando, FL Children’s Healthcare of Atlanta Atlanta, GA Michael M. Johns, MD, FRCS Professor Edie R. Hapner, PhD, ASHA-F Caruso Department of Otolaryngology Professor, Caruso Department of Head and Neck Surgery Otolaryngology Head and Neck Director of Laryngology Surgery USC Voice Center Director of Speech-Language Pathology University of Southern California USC Voice Center Los Angeles, CA Keck School of Medicine Los Angeles, CA Christina H. Kang, MM, MS Sara Harris, FRCSLT Speech-Language Pathologist Speech-Language Pathologist Department of Otolaryngology–Head Lewisham Hospital Voice Disorders and Neck Cancer Unit Mayo Clinic London, United Kingdom Scottsdale, AZ

Leah Helou, PhD Lisa N. Kelchner, PhD, BCS-S, ASHA-F Assistant Professor Professor Department of Communication Department of Communication Sciences and Disorders Sciences and Disorders University of Pittsburgh University of Cincinnati Pittsburgh, PA Cincinnati, OH

Rita Hersan, MS Wendy DeLeo LeBorgne, PhD Speech-Language Pathologist/Voice Voice Pathologist/Singing Voice Clinician Specialist/Clinical Director University of Pittsburgh Voice Center The Blaine Block Institute of Voice Pittsburgh, PA Analysis and Rehabilitation Provoice Center of Cincinnati College– Sandy Hirsch, MS Conservatory of Music Speech-Language Pathologist Dayton, OH/Cincinnati, OH xx Voice Therapy: Clinical Case Studies

Jeffrey J. Lehman, MD, FACS Indiana University Clinical Professor Bloomington, IN College of Health and Public Affairs University of Central Florida Madeleine Pethan, MA Medical Director Speech-Language Pathologist The Voice Care Center Levine Children’s Hospital Winter Park, FL Charlotte, NC

Claudio F. Milstein, PhD Brian E. Petty, MA, MA Director, The Voice Center Speech-Language Pathologist Cleveland Clinic Emory Voice Center Associate Professor of Otolaryngology Department of Otolaryngology Head Cleveland Clinic Lerner College of and Neck Surgery Medicine Emory University Cleveland, OH Atlanta, GA

Jennifer Muckala, MA Carissa Portone-Maira, MS Speech-Language Pathologist Speech-Language Pathologist Vanderbilt Bill Wilkerson Center Emory Voice Center University of Vanderbilt Department of Otolaryngology Head Nashville, TN and Neck Surgery Emory University Thomas Murry, PhD, ASHA-F Atlanta, GA Professor, Department of Otolaryngology Lorraine A. Ramig, PhD, ASHA-F Loma Linda University Medical Professor, University of Center Colorado–Boulder Loma Linda, CA Senior Scientist, National Center for Voice and Speech–Denver Chayadevie Nanjundeswaran, PhD Adjunct Professor, Columbia Assistant Professor University Dept. of Audiology and Speech- New York, NY Language Pathology East Tennessee State University Linda Rammage, PhD, RSLP Johnson City, TN Director Provincial Voice Care Resource Diana Orbelo, PhD Program, UBC Speech-Language Pathologist Vancouver, BC, Canada Department of Otorhinolaryngology Mayo Clinic College of Medicine Clark A. Rosen, MD, FACS Rochester, MN Professor, Otolaryngology–Head and Neck Surgery Rita R. Patel, PhD Chief, Division of Laryngology Assistant Professor UCSF Voice and Swallowing Center Department of Hearing and Speech University of California, San Francisco Sciences San Francisco, CA Contributors xxi

Nelson Roy, PhD, ASHA-F University of Kentucky Voice and Professor Swallow Clinic Department of Communication Lexington, KY Sciences and Disorders Division of Otolaryngology Head and Heather Starmer, MA Neck Surgery Assistant Professor Department of Surgery, School of Director of the Head and Neck Medicine Cancer Speech and Swallowing University of Utah Rehabilitation Center Salt Lake City, UT Department of Otolaryngology Head and Neck Surgery Brienne Ruel, MA Stanford University Speech-Language Pathologist Stanford, CA UW Voice and Swallow Clinics, Department of Surgery Joseph C. Stemple, PhD, ASHA-F Madison, WI Professor, Communication Sciences and Disorders Mary J. Sandage, PhD College of Health Sciences Associate Professor University of Kentucky Department of Communication Lexington, KY Disorders Lauren Timmons, MS Auburn University Speech-Language Pathologist Auburn, AL USC Voice Center Christine Sapienza, PhD, ASHA-F Caruso Department of Otolaryngology Head and Neck Surgery Dean, Brooks Rehabilitation College of Los Angeles, CA Health Sciences Professor, Communication Sciences Michael Towey, MA, ASHA-F and Disorders Manager, Department of Speech- Jacksonville University Language Pathology Jacksonville, FL Voice and Swallowing Center of Maine Waldo County General Hospital Sarah L. Schneider, MS Belfast, ME Speech-Language Pathology Director UCSF Voice and Swallowing Center Miriam van Mersbergen, PhD University of California Assistant Professor San Francisco School of Communication Sciences and San Francisco, CA Disorders University of Memphis Erin Pearson Silverman, PhD Memphis, TN Research Assistant Professor University of Florida Kittie Verdolini Abbott, PhD, ASHA-F Gainesville, FL Professor, Communication Science and Disorders JoAnna Sloggy, MA University of Delaware Speech-Language Pathologist Newark, DE xxii Voice Therapy: Clinical Case Studies

Barbara Weinrich, PhD, ASHA-F McGill University Professor Emerita Montreal, QC, Canada Department of Speech Pathology and Audiology Aaron Ziegler, PhD Miami University Assistant Professor Oxford, OH Oregon Health and Science University Northwest Clinic for Voice and Nicole Yee-Key, PhD Swallowing Assistant Professor Portland, OR School of Communication Sciences and Disorders 1

Principles of Successful Voice Therapy

Joseph C. Stemple

the early speech correctionists had back- Introduction grounds in training the theater voice, elocution, and public speaking, many of The profession of speech-language the voice therapy techniques arose from pathology began in 1925, with the birth these disciplines with a heavy empha- of the American Academy of Speech sis on keeping the vocal instrument Correction, the predecessor of the healthy, or vocal hygiene. The number American Speech-Language-Hearing of traditional therapy approaches that Association (ASHA). The first practi- continue to be used in voice therapy tioners of speech correction were most today is a strong statement of apprecia- interested in correcting articulation tion and admiration for the voice peda- and treating fluency disorders. In the gogues, clinicians, and speech scientists middle to late 1930s, two first-edition of earlier days. The accuracy of their textbooks, The Rehabilitation of Speech practical observations regarding voice by West, Kennedy, and Carr1 and Speech function has proved to be uncanny. The Correction Principles and Methods by Van efficacy of many of these traditional Riper,2 began to discuss improving the voice therapy techniques is now being quality of disordered voice. As many of tested through systematic outcomes

1 2 Voice Therapy: Clinical Case Studies

research.3 Proof of the usefulness of n When considering the voice, we are many of these techniques, however, considering the most widely used has been well established by the clini- instrument on earth. cal results of skilled speech-language n To understand the voice disorder, we pathologists (SLPs). must understand the instrument’s The major difference in voice ther- physical structure, functional com- apy today compared with even 20 to ponents, and the interactions of the 30 years ago is the ability to diagnose voice subsystems, respiration, pho- vocal function quickly and accurately nation, and resonance. and to confirm the efficacy of our man- n To fully evaluate the voice, we must agement approaches through a multi- possess a broad knowledge of the modal assessment approach. As you common causes of voice disorders will read in the case studies in this text, and the nuances of laryngeal patho- voice evaluation and treatment are logic conditions. interdisciplinary with speech-language n To document the voice, we must pathologists and laryngologists often have the skills to measure these com- practicing side-by-side in patient care. ponents objectively and to relate The recommended evaluation pro- these measures to our management cess comprises five domains of voice choices. assessment, patient self-report, audio- perceptual evaluation, acoustic analy- sis, aerodynamic measures, and visual Artistic Nature of Voice Care imaging of vocal fold function.4 These objective measures may also be used The artistic nature of voice therapy is as patient feedback during the thera- dependent on the human interaction peutic process. Although our manage- skills of the clinician as related to the ment approaches have evolved over the desires and needs of the patient. Com- years, voice therapy remains a blend of passion, understanding, empathy, and science and art. projection of credibility, together with listening, counseling, and motivational skills are essential attributes of the suc- Scientific Nature of Voice Care cessful voice clinician. Philosophically, we might make these statements about The scientific nature of voice therapy the artistic nature of voice: involves the clinician’s knowledge of several important areas of study. These n When considering the voice, we must areas include the anatomy and physi- consider the whole person. ology of normal and disordered voice n To examine a voice disorder is to production; the nuances of laryngeal examine a unique individual. pathologic conditions; the acoustics and n The feelings of that individual, both aerodynamics of voice production; and physical and emotional, may be the etiologic correlates of voice disor- directly reflected in the voice. ders, including patient behaviors, medi- n To remediate a voice disorder, we cal causes, and psychological contribu- must have the skills to counsel and tions. Regarding the scientific nature of motivate the patient and empower voice care we may state: readiness for change. 1. Principles of Successful Voice Therapy 3

The successful voice clinician This text is meant for the novice will combine attributes of the artistic clinician who seeks an understanding approaches of voice therapy with the of the types of patients seen in a voice objective scientific bases to identify the clinic and the decisions made by mas- problem and then plan and carry out ter clinicians in their care. The text is appropriate management strategies. also meant for the seasoned clinician Possession of a solid base of didactic searching for additional treatment sug- information related to evaluation and gestions. Readers may search the text- treatment augments practical experi- book by type of disorder and/or type of ence. However, experience continues treatment chosen to modify that disor- to teach even the master clinician. It is der. We have stressed that cases should hoped that the experiences of others include the thought processes of the provided in this text will prove helpful clinicians as they plan evidence-based in the development of superior voice treatments supported by evaluation clinicians. data as well as detailed explanations of the specific management plans. A word of caution . . . This text is not meant to be How to Use This Text a voice therapy cookbook. The authors stress that we do not treat disorders, rather we address the voice needs of In this fifth edition of Voice Therapy: Clin- our patients through systematic evalu- ical Case Studies, over 60 master voice cli- ation and treatment planning that will nicians and voice experts share 54 com- address those needs. Each patient is an plete case studies and 7 case vignettes individual with a unique problem asso- that involve detailed background, his- ciated with voice production. Success- tory, and evaluation and management ful voice therapy requires that we honor approaches for a wide variety of voice the individual and seek to understand and upper airway disorders. These that uniqueness. management approaches include a vari- ety of voice therapy techniques from all orientations of voice therapy, including Historical Perspective vocal hygiene therapy, symptomatic approach to voice therapy, psychogenic voice therapy, and physiologic orien- In examining the evolution of the treat- tation to voice therapy. The disorders ment of voice disorders, we find it was include those classified as muscle ten- not until around 1930 that a few lar- sion dysphonia, disorders caused by yngologists, singing teachers, instruc- glottal incompetence, neurogenic voice tors in the speech arts, and a fledgling problems, voice disorders caused by group of speech correctionists became an irritable larynx and other upper air- interested in retraining individuals with way problems, and disorders specific voice disorders. This group used drills to professional voice users. New to this and exercises borrowed from voice and edition is a final chapter that discusses diction manuals designed for the nor- treatment for nontraditional voice chal- mal voice in an attempt to modify disor- lenges as well as nontraditional service dered voice production. Many of these delivery models. rehabilitation techniques were and 4 Voice Therapy: Clinical Case Studies

remain creative and effective, but they balance of laryngeal muscle effort to were not necessarily based on scientific the supportive airflow, as well as the cor- principles as realized today. Indeed, the rect focus of the laryngeal tone. Finally, “artistic” portion of voice treatment was the eclectic approach of voice therapy is the strong point of the early clinicians. the combination of any and all of the Out of this artistic approach came previous voice therapy orientations.5 the general treatment suggestions of Indeed, none of these philosophi- (1) ear training, (2) breathing exercises, cal orientations is pure. Much overlap (3) relaxation training, (4) articulatory is present, most often leading to the use compensations, (5) emotional retrain- of an eclectic approach. With this intro- ing, and (6) special drills for cleft pal- duction, let us examine the orientations ate and velopharyngeal insufficiency.1,2 of voice therapy in greater detail. These treatment suggestions became the foundation of vocal rehabilitation. Several general management phi- Hygienic Voice Therapy losophies have arisen from the early foundations of voice rehabilitation. Hygienic voice therapy often is the first These philosophical orientations are step in many voice therapy programs. based primarily on the clinician’s mind- Many etiological factors contribute to set and previous training regarding the development of voice disorders. voice disorders that directs the manage- Poor vocal hygiene may be a major ment focus. For the sake of discussion, developmental factor. Some examples we classify these management philoso- of behaviors that constitute poor vocal phies as: hygiene include shouting, screaming, vocal noises, chronic coughing, chronic n hygienic voice therapy throat clearing, smoking, and poor n symptomatic voice therapy hydration. When the inappropriate vocal n psychogenic voice therapy behaviors are identified, then appropri- n physiologic voice therapy ate treatments can be devised for modify- n eclectic voice therapy ing or eliminating them. Once modified, voice production has the opportunity to In short, hygienic voice therapy improve or return to normal. focuses on identifying inappropriate Poor vocal hygiene may also in- vocal hygiene behaviors, which then are clude the habitual use of inappropriate modified or eliminated. Once modified, pitch or loudness, reduced respiratory voice production has the opportunity to support, poor phonatory habits such as improve or return to normal. Symptom- glottal attacks, or inappropriate reso- atic voice therapy focuses on modification nance. Functional inappropriate use of of the deviant vocal symptoms identi- these voice components may contribute fied by the SLP, such as breathiness, to the development and maintenance low pitch, glottal attacks, and so on. of a voice disorder. Hygienic voice The focus of psychogenic voice therapy is therapy presumes that many voice dis- on the emotional and psychosocial sta- orders have a direct behavioral cause. tus of the patient that led to and main- This therapy strives to instill healthy tains the voice disorder. The physiologic vocal behaviors in the patient’s habit- orientation of voice therapy focuses on ual speech/voice patterns. Good vocal directly modifying and improving the hygiene also focuses on maintaining the 1. Principles of Successful Voice Therapy 5 health of the vocal fold cover through 5. ear training adequate internal and surface hydra- 6. elimination of abuses tion and diet. Once identified, poor 7. elimination of hard glottal attack vocal hygiene habits can be modified or 8. establishing new pitch eliminated leading to improved voice 9. explanation of the problem production. 10. feedback 11. hierarchy analysis 12. negative practice Symptomatic Voice Therapy 13. open mouth exercises 14. pitch inflections Symptomatic voice therapy was a term 15. pushing approach first introduced by Daniel Boone.6 This 16. relaxation voice management approach is based 17. respiration training on the premise that modifying the 18. target voice models symptoms of voice production includ- 19. voice rest ing pitch, loudness, breathing, laryn- 20. yawn-sigh approach geal tension, and so on will improve the voice disorder. Once identified, the mis- Many if not all of these facilitators re- uses of these various voice components main useful and popular in the treatment are modified or reduced using voice of voice disorders and are described therapy facilitating techniques: in greater detail in cases throughout this text. In the voice clinician’s attempt to aid The main focus of symptomatic the patient in finding and using his best voice therapy is direct modification of voice production, it is necessary to probe vocal symptoms. For example, if the continually within the patient’s exist- patient presents with a voice quality ing repertoire to find the best one voice characterized by low pitch, breathiness, which sounds “good” and which he is able and hard glottal attacks, then the main to produce with relatively little effort. A focus of therapy is to directly modify the voice therapy facilitating technique is that symptoms. The facilitating approaches technique which, when used by a particu- used to modify these symptoms might lar patient, enables him easily to produce a good voice. Once discovered, the facili- include explanation of the problem, tating technique and resulting phonation ear training, elimination of hard glottal become the symptomatic focus of voice attack, and respiration training. The SLP therapy. . . . This use of a facilitating tech- constantly probes for the “best” voice nique to produce a good phonation is the and attempts to stabilize that voice with core of what we do in symptomatic voice the various appropriate facilitating therapy for the reduction of hyperfunc- techniques. Symptomatic voice therapy tional voice disorders.6(p11) assumes voice improvement through direct symptom modification. Boone’s original facilitating techniques included: Psychogenic Voice Therapy 1. altering tongue position 2. change of loudness Early in the study of voice disorders, 3. chewing exercises the relationship of emotions to voice 4. digital manipulation production was well recognized. As 6 Voice Therapy: Clinical Case Studies

early as the mid-1800s, journal articles ratory system; phonation, dependent discussed hysteric aphonia.7,8 West, upon laryngeal muscle balance, coordi- Kennedy, and Carr1 and Van Riper2 dis- nation, and stamina; and coordination cussed the need for emotional retraining among these and the supraglottic reso- in voice therapy. Murphy9 presented an nators (pharynx, oral cavity, nasal cav- excellent discussion of the psychody- ity). Any disturbance in the physiologic namics of voice. Friedrich Brodnitz,10 balance of these vocal subsystems may as an otolaryngologist, was one of the lead to a voice disturbance.5 early physicians who was uniquely These disturbances may be in respi- sensitive to the relationship of emotions ratory support, volume, power, pressure, to voice. These early readings are most and flow. Disturbances also may mani- interesting and remain informative to fest in vocal fold tone, mass, stiffness, those treating voice disorders. flexibility, and approximation. Finally, Our understanding of psychogenic the coupling of the supraglottic resona- voice therapy was further expanded tors and the placement of the laryngeal by Aronson,11 Case,12 Stemple,13 and tone may cause or may be perceived as Colton and Casper.14 These authors a voice disorder. The overall causes may discussed the need for determining the be mechanical, neurogenic, or psycho- emotional dynamics of the voice dis- logical. Whatever the cause, the man- turbance. Psychogenic voice therapy agement approach is direct modification focuses on identification and modifica- of the inappropriate physiologic activity tion of the emotional and psychosocial through exercise and manipulation of factors associated with the onset and the voice subsystems. maintenance of the voice problem. Psy- Inherent in physiologic voice ther- chogenic voice therapy is based on the apy is a holistic approach to the treat- assumption of persistent underlying ment of voice disorders. They are ther- emotional causes for the voice disorder. apies that strive to at once balance the Voice clinicians, therefore, must develop three subsystems of voice production as and possess superior interview skills, opposed to working directly on single counseling skills, and the skill to know voice components, such as pitch or loud- when the treatment for the emotional ness. Examples of physiologic voice ther- or psychosocial problem is beyond the apy approaches include Vocal Function realm of their skills. A referral system of Exercises,15 Resonant Voice Therapy,16,17 support professionals must be readily the Accent Method of Voice Therapy,18 available. Manual Techniques,19,20 and Lax Vox Therapy,21 all of which are presented in this text. Physiologic Voice Therapy

Physiologic voice therapy includes Eclectic Voice Therapy voice therapy programs that have been devised to directly alter or modify the Adherence to one philosophical ori- physiology of the voice producing entation of voice therapy would not mechanisms. Normal voice produc- be advisable. Indeed, successful voice tion is dependent on a relative balance therapy depends on utilization of an among airflow, supplied by the respi- approach that happens to work for the 1. Principles of Successful Voice Therapy 7 therapist and the individual patient. The to an otolaryngologist for a laryngeal more management approaches under- examination. stood and mastered by the clinician, the Indirect mirror examination re- greater the likelihood for success. Since vealed bilateral polypoid degeneration, we are treating the individual and not worse on the left than the right. Audi- the disorder, management techniques ble inspiratory stridor was noted by that prove successful for one patient the physician, and the patient reported may not be successful for a similar shortness of breath during even lim- patient. The successful voice clinician, ited physical exertion. Therefore, two therefore, must possess the knowledge KTP (potassium-titanyl-phosphate) and skills to adjust the management laser surgeries were conducted 2 weeks approach to fit the needs of the patient. apart followed by 7 days voice rest for On the other hand, some tech- each surgery. Surgeries were performed niques that work well for one clinician without complication, and the patient may prove to be difficult or challenging was seen for voice evaluation following for another. In whatever management appropriate healing. approach you choose, you must have supreme confidence in your under- History of the Problem. The patient standing of the technique and your reported that she had always had a ability to make that approach work suc- “deep” voice, which had lowered even cessfully. Your confidence is one factor more over the past several years. Her that will determine the success or failure presurgical voice quality had not been a of therapy. Using a typical case, let us concern to her, however. Instead, it was examine how each therapy orientation the shortness of breath that led her to might be used to treat the vocal difficul- agree to surgery. She reported that voice ties of this composite patient. quality following the first surgery (left fold) was a little “hazy” but returned to “normal” within 1 week. The second Case Study 1.1 surgery left her with significant, bother- some dysphonia that made her “wish I Joseph C. Stemple had never had surgery.”

Case History Medical History. The patient reported undergoing two previous surgeries: Patient A, a 52-year-old woman, was removal of her gall bladder 10 years referred by her laryngologist to the earlier and the laminectomy performed voice center for postsurgical evaluation earlier this year. Even with the difficult and treatment. Large bilateral draping intubation and the risk of vocal fold polyps (severe Reinke’s edema) were paralysis inherent in laminectomy, her first identified by an anesthesiologist presurgical voice quality was main- while intubating the patient for a lami- tained. In addition to surgeries, she nectomy 6 months prior to her voice had been hospitalized 3 years before evaluation. Because of the large polyps, for 3 weeks and treated for chronic intubation had been difficult. The prob- depression. lem was reported to her family physi- Chronic medical disorders included cian, who in turn referred the patient frequent upper respiratory infections 8 Voice Therapy: Clinical Case Studies

including bronchitis, high blood pres- inappropriate loudness, roughness, and sure, circulatory problems in her legs, intermittent glottal fry phonation. elevated blood sugar, and chronic neck and back pain. Daily medications were Acoustic Analysis and Aerodynamic taken for blood pressure, chronic pain, Measures. These instrumental assess- depression, and sleep. She continued a ments revealed a low fundamental 30-year history of smoking one-and-a- frequency (150 Hz), limited frequency half to two packs of cigarettes per day. Her range (118–290 Hz), increased habitual liquid intake consisted mostly of six cups intensity (76 dB0), normal airflow vol- of caffeinated coffee per day. Chronic ume (2300 mL H2O), reduced airflow throat clearing and a persistent cough rate (<80 mL H2O/sec), and reduced were noted throughout the evaluation. maximum phonation time (<12 sec).

Social History. Patient A had been mar- Laryngeal Imaging. Laryngeal video- ried for 12 years to her second husband, stroboscopic observation revealed mild- following a first marriage of 18 years to-moderate bilateral true vocal fold and divorce. She had two adult children edema and erythema. Glottic closure from her previous marriage. Her elderly demonstrated an irregular glottal chink mother-in-law lived with her and her with a moderate ventricular fold com- husband, a situation that often caused pression. The edges of the vocal folds friction and conflict with her husband. were rough and irregular, worse on the Indeed, she was not shy in reporting her left than on the right. The amplitude of unhappiness with her marital relation- vibration was severely decreased bilat- ship. This unhappiness was said to be a erally. The mucosal waves were barely major factor in her history of depression. perceptible. The closed phase of the Both the patient and her husband vibratory cycle was strongly dominant, were employed by the local automobile whereas the symmetry of vibration was assembly plant. She had worked as an generally irregular. No mass lesions, assembler for 14 years in an environ- paresis, or paralysis was evident. In ment described as “noisy, dusty, and short, the patient had an edematous, stiff, full of fumes” and was on a temporary hyperfunctioning vocal fold system. medical disability because her back problems precluded her working in the Impressions plant. Present activities included shop- ping with her daughter, talking on the Patient A presented with a voice disor- telephone, caring for her home, watch- der that derived from the following pos- ing daytime television “talk” shows, sible causal factors: and bowling two nights per week in two different leagues (back permitting). n cigarette smoking n harsh employment environment Voice Evaluation n talking over noise at work n large caffeine intake Audio-Perceptual Examination. Per- n frequent upper respiratory infections ceptually, the patient’s voice quality as n prescription medications scored on the CAPE-V22 was moderately n coughing and throat clearing dysphonic, characterized by low pitch, n emotional instability 1. Principles of Successful Voice Therapy 9 n talking too loudly (suggesting pos- Psychogenic Voice Therapy. General sible hearing loss, which later proved focus would explore the psychodynam- not to be present) ics of the voice disorder. Techniques n using a low pitch would include: n laryngeal muscle tension n postsurgical vocal fold mucosal n detailed interview with the patient changes to determine the cause and effects of depression Recommendations per Voice n determination of the relationship Therapy Orientation of emotional problems and voice problem The following are recommendations for n counseling the patient regarding voice therapy if one were to adhere to a the effects of emotions on voice single orientation of voice therapy. The production folly of this approach is readily evident. n reduction of the musculoskeletal ten- sion with the use of laryngeal manip- Hygienic Voice Therapy. The general ulation/laryngeal massage focus would be to identify the pri- n referral for marital counseling as mary and secondary vocal misuses and deemed appropriate then to modify or eliminate these non- hygienic behaviors. The primary etio- Physiologic Voice Therapy. The general logic correlates include: focus would be to evaluate the present physiologic condition of the patient’s n smoking voice production and develop direct n laryngeal dehydration from caffeine therapeutic exercises to improve that and prescription medications condition. We know that the patient n voice abuse, such as coughing, throat presented with extreme laryngeal ten- clearing, and talking loudly over sion. Irregular vocal fold edges caused noise at work a glottal chink. In addition, her vocal folds were extremely stiff, as demon- Therapy would focus on modifi- strated by the amplitude of vibration cation or elimination of the perceived and mucosal wave. primary causes. The patient would be Normal voicing is dependent on aided in her attempt to stop smoking, near total closure of the vocal folds, encouraged to begin a hydration pro- permitting air pressure to build below gram, and given vocal hygiene counsel- the folds. As the pressure builds, it ing to aid in elimination or reduction of eventually overcomes the resistance the vocally traumatic behaviors. of the approximated folds, permit- ting the release of one puff of air. As Symptomatic Voice Therapy. General the air rushes between the vocal folds, focus would use facilitating techniques to: subglottal, supraglottal, and intra- glottal pressures, along with the static n raise pitch position of the vocal folds, draw them n reduce loudness back together to complete one vibra- n reduce laryngeal area tension and tory cycle.23 Air gaps, or glottal chinks, effort change the physical dynamics of vocal 10 Voice Therapy: Clinical Case Studies

fold vibration, requiring an increased n attention to the psychodynamics of subglottic pressure. Patients such as the problem this woman often make physical com- n direct physiologic vocal exercise pensations in an attempt to push out the “best” voice by hyperfunctioning the supraglottic structures. Add vocal Voice Care Team fold muscular and mucosal stiffness to this mix and the patient presents with a significant muscle tension dysphonia Thus far we have discussed the treat- with associated respiratory, laryngeal, ment of voice disorders in terms of voice and resonance dysfunctions. therapy. Voice care, however, is a shared Direct physiologic voice therapy province, with contributions from the would focus on therapeutic exercises primary care physician, laryngologist, designed to rebalance the three subsys- SLP, neurologist, allergist, gastroenter- tems of voice production: respiration, ologist, pulmonologist, psychologist, phonation, and resonance. Therapy vocal coach, singing instructor, and oth- methods chosen to accomplish this task ers. In addition to these professionals, might include Vocal Function Exercises, the patient also carries great responsibil- Resonant Voice Therapy, or the Accent ity in the improvement of her/his voice. Method of Voice Therapy, among oth- In fact, we would suggest that both cli- ers. (All methods are described in sub- nician and patient share equally in the sequent chapters.) success or failure of voice therapy as described below. Eclectic Voice Therapy. In this review of philosophical orientations of voice therapy, you have seen the various Issues Related to strengths of each management orien- Successful Voice Therapy tation, as well as the difficulty in sub- scribing to any one philosophy. All patients will be treated best by a speech The chapters of this text focus on the language pathologist with knowledge successful management of a wide range and understanding of all possible man- of voice disorders by clinical, medi- agement strategies and alternatives. cal, and surgical methods. Each con- As you read and study the many case tributor demonstrates techniques and presentations of this text, it is beneficial approaches that prove successful in to evaluate the philosophy behind the improving voice quality of patients treatment approach as a means of bet- with various laryngeal disorders. These ter understanding the reasons for the successful cases, however, may set an selected approach. The successful SLP unrealistically high standard for the is both an artist and a scientist with an beginning voice clinician and may not eclectic point of view. Consequently, adequately reflect the many manage- therapy for Patient A should focus on: ment pitfalls that are encountered even by experienced voice clinicians. Such n vocal hygiene counseling pitfalls may lead to delayed success in n symptom modification as required treatment, less than totally successful