Voice Disorders and Voice Therapy

1

Which pathologies/conditions are appropriate for a referral to an SLP?

Voice therapy is most successful in treating patients with normal laryngeal anatomy, which typically carries a diagnosis of muscle tension dysphonia or muscle tension aphonia. Voice therapy can also be highly successful at optimizing patients with mild alterations in anatomy such as vocal fold atrophy, vocal fold nodules, vocal fold polyps, glottic insufficiency, vocal fold scar, vocal fold paralysis, vocal process granuloma, etc.

Voice therapy can enhance treatment outcomes after medical and/or surgical intervention as it improves the efficiency and coordination of the pulmonary, laryngeal, and resonance systems to decrease extralaryngeal tension and optimize vibration patterns. This promotes improved voice quality and consistency and decreases vocal effort.

Neurologic voice disorders such as laryngeal tremor and spasmodic dysphonia may benefit from trial voice therapy to reduce laryngeal tension and effort, but treatment with botulinum toxin (Botox) is considered the standard of care for this population. Voice therapy can be used as an adjunct therapy with Botox to reduce compensatory behaviors, with research indicating that these patients may experience significantly better outcomes when compared to patients who received Botox treatment alone, and patients with hypophonia, as seen most commonly in Parkinson’s disease (PD), can also be good candidates for voice therapy.

2

What medical documentation should an SLP complete for an optimal voice assessment?

Prior to the initiation of SLP evaluation of voice the patient should be evaluated by an otolaryngologist. Reports and findings including the following are essential to complete an optimal voice assessment: detailed medical and surgical history, current medication list, past and current laryngeal diagnoses, still images or videos of the larynx, radiologic image interpretation of the head and neck (if applicable), and results of any swallowing evaluations (if applicable).

3

What intake information is collected during an SLP voice evaluation?

The main goals of the SLP voice evaluation are to:

• 1.

  Determine the etiologic factors relating to the voice disorder

• 2.

  Determine the severity of the voice disorder

• 3.

  Determine the clinical plan of care and the expected prognosis

Case history, instrumental and physical assessment, acoustic analysis, and perceptual ratings are typically collected during speech-language pathology voice evaluation. SLPs aim to discover behaviors, environmental factors, patterns of occupational and social voice use, and relevant medical and surgical history that impact the patient’s voice. The timing and nature of a patient’s voice complaints, for example, are extremely valuable pieces of information that help determine the nature of the patient’s disorder. Was onset gradual or sudden? Is the problem consistent or intermittent in nature? The patient’s vocal hygiene and voice use is also evaluated and discussed.

Physical examination of the head and neck and cranial nerve examination is usually conducted by the referring physician, but can be also performed by the evaluating or treating SLP. SLPs may also conduct an oral mechanism examination such as the Oral Speech Mechanism Screening Examination (OSMSE-3; see chart). This standardized protocol is used to assess the appearance and function of the oral mechanism, including the lips, tongue, jaw, teeth, palate, pharynx, velopharyngeal mechanism, breathing, and diadochokinetic rates. The larynx may also be palpated for the assessment of range of motion.

Assessment of vocal performers requires additional history acquisition and examination. Special attention is given to reported vocal effort, voice production across pitch range, and vocal demands of the patient’s performing schedule, among other factors.

4

Describe the objective measures/evaluation completed during an SLP voice evaluation.

Rigid laryngoscopy or transnasal flexible laryngoscopy with stroboscopy allows the structure and function of the vocal folds to be assessed, imaged, and digitally recorded. In most states, SLPs with expertise in voice can complete either rigid videostroboscopy or transnasal flexible laryngoscopy with stroboscopy with proper training and physician supervision. The American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) and American Speech Language and Hearing Association joint position statement outlines the roles of physicians and SLPs in this context. Laryngoscopy can also be an important tool for determining the presence of compensatory vocal behaviors and can be used as a biofeedback tool. Direct observation of vocal folds and vocal fold vibration is an essential component of evaluation as the laryngeal mechanism can be observed and described.

Quantification of other vocal parameters can be performed using advanced equipment to measure the aerodynamic and acoustic properties of voice. As equipment cost and time can be prohibitive for some SLPs, acoustic analysis of voice offers SLPs a noninvasive and low-cost method for obtaining a significant amount of patient data. For example, the fundamental frequency, pitch range, and vocal intensity can be evaluated. Measurements including rates of airflow during phonation, minimum subglottic pressure, and the frequency of breaths while reading the rainbow passage are frequently used during assessment.

5

Which patient-centered assessments are used during a voice evaluation?

Throughout a voice evaluation, the SLP listens and forms an impression of the patient’s vocal quality, pitch, and vocal intensity (loudness) as a way of describing the patient’s voice and setting a baseline for the patient’s vocal presentation. The use of digital recording equipment to collect patient speech samples is recommended. Standardized perceptual rating scales such as the Consensus on Auditory Perceptual Evaluation of Voice (CAPE-V) are used to help standardize impressions.

Patients’ perceptions of their voice disorder and how it impacts their daily life are important factors that can be quantified using quality of life tools. The Vocal Handicap Index (VHI), Voice Handicap Index-10 (VHI-10), Singing VHI-10 (SVHI-10), and Voice Related Quality of Life Scale (VRQOL) are all subjective quality of life measurements that have been validated for use ( Table 74.1 ).

6

What are the most common symptoms related to voice disorders?

The most common symptoms or patient complaints related to voice disorders include changes in pitch, decreased loudness, rough voice quality, breathy voice quality, increased vocal effort, increased vocal fatigue, decreased vocal range, and inconsistency in voice production.