The Management of Voice Disorders

The Management ofVoice Disorders

Murray Morrison

Head Division of OtolaryngologyThe University of British Columbiaand Vancouver General Hospital

Canada

and

Linda Rammage

Speech Pathology Consuliani and Research DireciorVancouver Voice Clinic

The University of British ColumbiaCanada

with:

Hamish Niehol. Psychiatrist

Bruce Pullan, Singing ieacher

Phillip May, Singing ieacher

Lesley Salkeld, Pediairic otolaryngologist

Members oi the Voice Clinic Team, Vancouver, British Columbia, Canada

Springer-Science+Business Media, B.Y

First edition 1994

© 1994 Murray Morrison, Linda Rammage, Hamish Niehol. Bruce Pullan, Phillip May,Lesley SalkeldOriginally published by Chapman & Hall in 1994.

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ISBN 978-0-412-35090-0 ISBN 978-1-4899-2903-7 (eBook)DOI 10.1007/978-1-4899-2903-7

"t f "I" "" " " 0 our amI Ies """

Contents

Preface xii

Acknowledgements xv

1 Evaluation of the voice disordered patient 1

1.1 Principles of joint assessment 11.2 History Taking 3

1.2.1 Rationale and philosophy 31.2.2 Chronology of the problem as it unfolded 31.2.3 Family history 51.2.4 Psychological fadors and stressors 51.2.5 Patient's perception of the voice disorder 51.2.6 Medical history and reflux 61.2.7 Vocal abuse history 6

1.3 Psychological evaluation 61.4 Acoustic and perceptual-acoustic assessment 9

1.4.1 Rationale, environment and basic recording hardware 91.4.2 Acoustic assessment : instrurnentation , application, protocols

and interpretation 101.5 Aerodynamic evaluation 18

1.5.1 Mean phonatory flow rate 181.5.2 Flow volume 191.5.3 Pressure and resistance 201.5.4 Flow glottograms 21

1.6 Musculoskeletal evaluation 22

1.6.1 Indicators of body misalignment 22

1.6.2 Specific muscle misuses during phonation 241.7 Physical examination of the larynx and vocal tract 28

1.7.1 Basic equipment needs 281.7.2 Regional examination 301.7.3 Instrumental assessment of vocal fold vibratory patterns 33

1.8 Neurological evaluation 451.9 Diagnostic voice therapy 45

viii Conienis

1.9.1 Facilitation techniques for probe and symptomatic therapy 46

References 47

2 Classification of muscle misuse voice disorders 502.1 Definitions and rationale 50

2.2 Problems of classification 52

2.3 History of classification 53

2.4 Musculoskeletal approach to the Classifieation of dysphonias 53

2.4.1 Type I : Laryngeal isometrie disorder 54

2.4.2 Type 2: Lateral eontraction 57

2.4.3 Type 3: Anteroposterior supraglottic eontraction 59

2.4.4 Type 4: Conversion aphonia/dysphonia 60

2.4.5 Type 5: Psyehogenic dysphonia with bowed voeal folds 60

2.4.6 Type 6 : Adoleseent transitional dysphonia 61References 62

3 Medical aspects of voice disorders 643.1 Tumors 64

3.2 Infection 65

3.3 Chronic noninfective laryngitis 67

3.4 Misuse and abuse 69

3.5 Laryngeal trauma 703.6 Other mueosal diseases 72

3.6.1 Contact uIcer and granulona 723.6.2 Cysts, sulci, and mueosal bridges 733.6.3 CongenitaI web 743.6.4 Crico-arytenoid joint problems 75

3.7 Psychogenic muscle misuse dysphonia 75

3.8 Neurogenie voice disorders 75

3.8.1 Voeal fold paralysis 753.8.2 Dystonia and tremor 76

References 78

4 Approaches to voice therapy 80

4.1 Purpose of therapy 80

4.2 Factors influencing selection and success of therapy programs 80

4.3 Symptomatic therapy 814.4 Comprehens ive voice rehabilitation programs 82

4.4.1 Edueation 83

4.4.2 Problem solving 834.4.3 Relaxation training 834.4.4 Alignment-posture training 83

4.4.5 Specific relaxation exercises 84

4.4.6 Co-ordinated voice onset 84

Conienis ix

4.4.7 Resonance enhancement 844.4.8 Vocal flexibility 854.4.9 Generalization 85

4.5 Therapy for special voiee disorder populations 864.5.1 Interdisciplinary management for pat ients with organie

disorders : optimizing fundion 864.5.2 Role of voiee therapy for treatment of spasmodie dysphonias 864.5.3 Voiee therapy for gender dysphoria 884.5.4 Communication rehabilitation following laryngedomy 904.5.5 Voiee therapy for children : special considerations 914.5.6 Principles and voiee techniques for treating pat ients with

conversion dysphonia/aphonia 92References 96Further reading 97

5 Psychological management of the voice disordered patient 98

5.1 Introduction 985.2 Brief review of the literature 995.3 Indications for referral for psychiatric consultation 1005.4 Types of pathogenesis observed in dysphonia of psychologieal origin 1025.5 Fundion of psychogenie dysphonia 1025.6 Preparation of the pat ient for psychiatrie referral 1075.7 Psychiatrie treatment 108

References 108

6 Psychological and neurological interactions in dysphonia 1106.1 Interachorts and diagnostic directions 1106.2 An approach to disentanglernent: shift fadors in dysphonia 112

6.2.1 Vocal technique 1136.2.2 Psychologieal state 1136.2.3 Chronie gastro-esophageal reflux 114

6.3 Clinieal example 1156.4 Case studies of mixed dysphonia 116

7 Pediatric voice disorders: special considerations 120

7.1 Descriptions, definitions, and epidemiology 1207.2 Natural history of voiee and vocal tract development 1227.3 Causes of voiee disorders in children 124

7.3.1 Primary organie disorders 1257.3.2 Secondary organie disorders 126

7.3.3 Disorders of muscle misuse 1277.4 Application of technologieal advances to the management of

pediatric voiee disorders 1277.5 Voiee disorders in specific populations 131

x Conienis

7.5.1 Hearing impairment 1317.5.2 Prematurity 1327.5.3 The tracheotomized child 133

7.6 Disorders of nasal resonance 1337.6.1 Hypemasal speech 1347.6.2 Hyponasal speech 136

7.7 The young performer 1367.8 Clinical cases 137References 139

8 Voice disorders in the elderly 1418.1 Nature of the disorders: an overview 1418.2 Normal effeds of aging on the larynx 1428.3 Disorders due to attempts to compensate for normal aging processes 1448.4 Psychogenic voice disorders in the elderly 1458.5 Voice disorders and neurological disease 1468.6 Miscellaneous causes of dysphonia in the elderly 1468.7 Treatment of voice disorders in the elderly 147

8.7.1 Counselling 1478.7.2 Voice therapy 1478.7.3 Psychological management 1478.7.4 Medical management 1488.7.5 Surgical management 148

References 148

9 The singing teacher in the voice dinic 1509.1 Deteding technical errors in vocal produdion 150

9.1.1 Appearance ISO9.1.2 Sound 152

9.2 Techniques for reducing misuse 1549.2.1 Guidelines for the re-education of muscle behavior 1549.2.2 General suggestions for reducing misuse 1559.2.3 Distracting, disabling and rebuilding 1589.2.4 Speech habits 158

9.3 Interaction with laryngologists and speech pathologists 1589.4 Some final thoughts 159

10 Anatomy and physiology of voice production 16110.1 Fundion of phonation in verbal communication 16110.2 Neuromuscular systems involved in speech and phonation 16310.3 Fundions of the respiratory system : 'speech-breathing' 165

10.3.1 Nature of the mechanism: an overview 165

10.3.2 Respiratory kinematics and dynamics 16910.3.3 What do we know about speech-breathing7 170

Conienis

10.3.4 Glossary for respiration10.4 Phonation: conversion of DC to AC energy

10.4.1 Histology and biomechanics of the vocal folds10.4.2 Dynamic control of pitch, intensity and quality

10.5 Acoustic resonators of speech10.6 Normal variability in strudure and function

10.6.1 Normal development and agingReferencesFurther reading

11 Basics of singing pedagogy11.1 Overview of the vocal Instrument11.2 Posture

11.2.1 Predictable faults in postural organization11.2.2 Posture and singing performance11.2.3 Checklist of good posture for singing

11.3 Breathing11.3.1 Breathing and the singer11.3.2 Techniques for the control of breathing11.3.3 Summary of breathing for singing

11.4 Onset and release of vocal tone11.4.1 Onset11.4.2 Release

11.5 Resonance11.5.1 Tonal concept as a control fador11.5.2 An approach to vocal freedom and tonal modelling

11.6 Imagery in vocal pedagogy11.6.1 Tonal placement11.6.2 Registers and range11.6.3 Breath support11.6.4 Open throat11.6.5 Problems of imagery11.6.6 Images as a teaching tool

11.7 Registers and range11.7.1 Register terminology11.7.2 Current understanding about registers11.7.3 Registers as a mechanical phenomenon11.7.4 Model of vocal registers11.7.5 Useful analogy of register mechanics11.7.6 Vocal registers as a resonance phenomenon11.7.7 Range

References

Appendix A Antireflux instructions

xi

177178178183188194194196200

201202203204

204207207207209212

213213

215215216217218

218218219219220220220221

222222

223

223225228

228

230

xii Contents

Appendix B Vocal rehabilitation exercises 232B.1 Vocal hygiene: how to get the best mileage from your voice 232B.2 Gravity and relaxation 234B.3 Dynamic alignment: optimizing posture for movement 235B.4 SpeciEic relaxation: liberating the speech articulators 239

B.4.1 Face 239B.4.2 [aw 241B.4.3 Tongue 244~.4~ lliB.4.5 Throat 246

B.5 Coordinated voice onset 247B.6 Feeding the resonators and mmmaking the mmmost of resonance 249B.7 Extending your dynamic pitch range 251

B.7.1 Bubbling and trilling 251B.7.2 Vocal siren 252

Index 255

Preface

There has been a tremendous growth of interest in the human voice and its disordersduring the past decade. This has led to the development of a variety of 'voice labs' or'voice clinics' that are able to offer unique interdisciplinary assessment and treatmentfacilities. To cover aJl the bases, the voice care team requires input frorn laryngology,speech-language pathology, psychiatry, neurology, voice science, music pedagogy,biomedical engineering and other peripheral fields. Because of the multidisciplinarynature of voice dinics there have been a number of books written that address oursubject from different professional perspectives. These tend to be multi-authored worksthat draw on expertise from around the world, such as a laryngologist frorn New York,a speech pathologist from Toronto, etc. All are coJleagues that share similar interestsbut never actually share the management problems of the same patients.

This book has been planned and written by the members of a single 'voice clinic'i It isour hope that it will reflect a singleness of direction and purpose in the way it presentsour approach to a complex topic. Because of our regular interactive meetings overproblem patients in which we debate the meaning of our observations, the evolution ofetiological dassification systems, and the rationale for particular therapy approaches,we feel that we have become a team that is greater than the sum of its parts, and thatthere is value in sharing our cumulative thoughts with others .

This is not simply a laryngology text for laryngologists. Neither is it a speechpathology text exdusively for speech pathologists . .. we hope that this text will fill inthe gaps between the professions that must work together for the benefit of the voicedisordered patient. It should expand the understanding of medical and surgicallaryngology for the singing teacher, and should help to demystify the art of vocalpedagogy for both the laryngologist and the speech pathologist. It should help thepsychiatrist appreciate the ways in which musde misuses lead to dysphonia, andprovide some extra tools to the speech pathologist embarking on a therapy programwith a psychologicaJly unbalanced patient.

Our dinic is the product of who we are, where we live, the politics of our health caresystem, where and how we were educated, the expectations of our ellentele. and anassortment of personal biases. No other dinic group can be the same or share just thesame philosophies. Some will function more effectively and some less so. Should you be

xiv Preface

heading in a similar diredion we hope that you too will find that learning from eachother is Fun and rewarding.

Murray MorrisonLinda Rammage

Acknowledgements

The many original and redrawn illustrations in this book have been done by FrankCrymble, Bambi Edlund and [ane Rowlands. Dr Ioseph Tsui provided helpful advice onthe neurological aspects of the manuscript and Susan Kemested provided extensivesecretarial assistance. The authors extend thanks to these individuals.