Voice

 

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    Voice care is provided for adults and children, including professional voice users such as teachers, lawyers, salespersons, clergy and others who require good voice for their occupation.  We also work with singers who experience impaired technique related to their voice disorder.  All patients receive a full voice assessment prior to therapy.  Patients are required to have a laryngeal examination by an Ear, Nose, and Throat doctor (Otolaryngologist) before therapy begins.

    Voice Disorders
    There are many types of voice problems (known as Dysphonia) that can affect the vocal folds (vocal cords) and voice production.  They are often viewed as being primarily disorders of voice use versus those which are neurologically based.  The most commonly seen voice disorders include the following:

    Associated in part with voice abuse/misuse:

    Vocal nodule – a small, benign callous-like growth usually on the edge of each vocal fold at the point where the folds meet with maximum pressure when voicing.  Voice therapy is the primary treatment.

    Polyp – a benign, fluid filled, blister- like growth usually appearing on one vocal fold (but often creating a rough edge on the opposing vocal fold from contact).  It can vary in size and often requires surgical removal.  Voice therapy can facilitate healthful voice production that can improve voice quality and reduce the chance of recurrence even if surgery is required.

    Cyst – a fluid filled sack, thought to result from a blocked mucous gland within the vocal fold.  The resulting mass is benign but often requires surgical removal.  As with a polyp, voice therapy can improve voice technique to relieve excessive voice stress and prevent recurrence even if surgery is required.

    Contact Ulcer (Granuloma) – often associated with high stress voice use and gastric reflux, this involves the formation of an ulcer-like irritation in the cartilage toward the back of the vocal folds where they press together for speech.  Granuloma tissue (rough tissue irritation in the same area) can be associated with intubation from surgery as well.  Treatment can include increased voice rest, therapy, and reflux medication.

    Muscle Tension Dysphonia – characterized by vocal hoarseness, roughness, and sometimes throat discomfort and fatigue which progresses with increased voice use, without an actual vocal fold pathology.  This is due to incorrect use of the throat muscles when speaking.

     

    Neurogically based voice disorders include:

    Vocal fold paralysis and paresis (weakness) – a vocal fold movement disorder in which one vocal fold (infrequently both) does not open or close normally, usually creating a significantly weakened voice or voice loss.  This can result from injury or neurologic insult, as well as for unknown reasons often associated with an upper respiratory illness or unknown cause.  This condition is not usually considered permanent until at least a year has passed.  Voice therapy can improve control over voice production, sometimes improving quality  and projection as long as the vocal folds make adequate contact.

    Spasmodic dysphonia – characterized by a strained-strangled voice quality, this voice disorder most often presents in a patient’s 40’s, possibly a predisposed condition triggered by a stressful time or event.  There is no cure and periodic botulinum toxin injections are considered to be the primary mode of management.   Voice therapy is limited to strategies that may help ease the patient into speech.

    Laryngeal Tremor– characterized by a shaky, tremorous voice.  There is no cure and short term voice treatment is limited to finding strategies to ease voice production.

    Progressive Neurologic Diseases can include voice disorders characterized by reduced loudness and projection, quality and resonance. Patients with these diseases may also have changes in speech articulation as well.

    Presbylarynx, a weakened and often breathier voice associated with normal aging, is characterized by difficulty projecting the voice to achieve adequate loudness.  A combination of voice therapy to strengthen vocal fold muscles and sometimes surgical procedures can make a significant impact on functional communication.

    Paradoxical Vocal Fold Motion (Vocal Ford Dysfunction) – periodic episodes thought to be triggered by irritants and often associated with reflux, in which the vocal folds fully or partially close causing noisy strained breathing, coughing and a sensation of tightness in the throat.   In teenagers, this condition is often associated with stress related to high expectations in competitive sports.  Voice therapy focuses on relaxation and breathing with exercises to promote easy breathing with improved patient control.

     

    Voice Assessment
    A voice evaluation is a noninvasive assessment that includes a thorough case history review, and perceptual and objective evaluation of your voice production.  Acoustic and airflow measures include the use of the Computerized Speech Lab (Kay-Pentax, Inc).  The evaluation provides baseline information about voice function and includes counseling on ways to improve vocal health even before the start of treatment.   A laryngeal examination by an Otolaryngologist (ENT) is required prior to the start of voice therapy.  Videostroboscopic examination of the larynx is available at SBUMC, scheduled through the Otolaryngology Department.

     

    Voice Therapy
    Voice therapy is designed to target your specific vocal weaknesses and concerns and improve voice quality and ease and efficiency of voice production.  Most often, you will receive detailed instruction in various voice and breathing techniques that focus on breath support and airflow, resonant voice production, voice projection and address concerns particular to you.  Over several weeks, exercises gradually incorporate functional speech used in your daily interaction.   For many neurologic voice disorders which cannot be remediated by voice therapy, short term therapy can sometimes provide helpful strategies to ease communication.

    Frequently asked questions:

    Q: Why is my doctor referring me for voice therapy?
    A: Though not all voice disorders can be eliminated through voice therapy, for many voice problems it is the first course of treatment. Functional voice disorders caused by voice misuse or abuse can often be remediated through training in healthful voice production techniques.  Even patients with voice disorders that do not tend to resolve with therapy alone can benefit significantly from voice therapy in addition to medical or surgical treatment.

    Q:What will happen in the voice evaluation? 
    A: The speech pathologist will start by taking your medical history and recording a brief sample of your voice.  You will be asked to speak into a microphone several times and at various pitches for acoustic computer analysis of your voice and sustain sounds for the speech pathologist to time and evaluate.   Some patients are sked to blow into a tube to test lung capacity. The evaluation ends with counseling on healthy voice habits and ways you can begin to improve your voice while you are waiting for your first therapy appointment.

    Q:What is voice therapy and how often will I attend?
    A: Generally, adults meet weekly with the speech pathologist for 40 minutes and children meet twice weekly for shorter sessions.   Most often, the patient learns various exercises related to breath support, laryngeal relaxation, vocal resonance and projection. There are various techniques that are particular to the individual person and their diagnosis.  Daily home practice by the patient is required to achieve the most rapid and significant improvement.

    Q:How long does a course of voice therapy last?
    A: Most patients can achieve significant improvement within 12 weeks of therapy, with some requiring more or less time.  Of course, the duration of therapy is dependent on the individual patient, the type of disorder requiring treatment, and the patient’s response to therapy techniques.

    Q:What can I do to improve my vocal health even before starting therapy?
    A: Most voice patients can benefit from following these Vocal Hygiene Guidelines:

    • Use a moderate vocal loudness and avoid talking in environments that require loud or strained voice use.   Mute or move away from ambient noise for conversation.
    • Avoid habitual or excessive throat clearing and coughing.
    • Quit smoking and avoid environmental airborne irritants.
    • Drink plenty of water and limit caffeine and alcohol.  Generally 6 to 8 cups of water daily with an extra cup of water for each caffeinated or alcoholic beverage is recommended.
    • Be careful to avoid holding your breath during strenuous exercise.  During repetitive exercises, try to exhale on exertion and inhale on relaxation so your airway remains open and relaxed.