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Practical Strategies for Treatment of Common Voice Disorders Carol Krusemark, M.A., CCC-SLP Voice Pathologist/Singing Voice Specialist MGH Center for Laryngeal.

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Presentation on theme: "Practical Strategies for Treatment of Common Voice Disorders Carol Krusemark, M.A., CCC-SLP Voice Pathologist/Singing Voice Specialist MGH Center for Laryngeal."— Presentation transcript:

1 Practical Strategies for Treatment of Common Voice Disorders Carol Krusemark, M.A., CCC-SLP Voice Pathologist/Singing Voice Specialist MGH Center for Laryngeal Surgery and Voice Rehabilitation

2 Common Voice Disorders Muscle Tension Dysphonia Muscle Tension Dysphonia PrimaryPrimary SecondarySecondary Vocal pathology associated with abuse/misuse Vocal pathology associated with abuse/misuse NodulesNodules Vocal scarring or loss of vibratory layerVocal scarring or loss of vibratory layer

3 Primary Muscle Tension Dysphonia a posterior glottic chink caused by simultaneous activation of vocal fold closers and openers a posterior glottic chink caused by simultaneous activation of vocal fold closers and openers Can be normal in females Can be normal in females

4 Primary Muscle Tension Dysphonia False vocal fold approximation: medio-lateral supraglottic compression False vocal fold approximation: medio-lateral supraglottic compression

5 Primary Muscle Tension Dysphonia Supraglottic compression in the anterior to posterior axis Supraglottic compression in the anterior to posterior axis

6 Primary Muscle Tension Dysphonia Compression from both the A- P and medio- lateral directions Compression from both the A- P and medio- lateral directions

7 Vocal Nodules Reactive fibrovascular lesions formed at the site of greatest vocal fold contact Reactive fibrovascular lesions formed at the site of greatest vocal fold contact

8 Scar or loss of vibratory layer Loss of superficial lamina propria, resulting in reduced musocal wave Loss of superficial lamina propria, resulting in reduced musocal wave

9 Treatment modalities Facilitating Strategies Facilitating Strategies Reduction of vocal fold and supraglottic hyperfunction Reduction of vocal fold and supraglottic hyperfunction Type I: posterior glottic chink Type I: posterior glottic chink Glottal fryGlottal fry Inhalation phonationInhalation phonation Types II-IV: Supraglottic compression Types II-IV: Supraglottic compression Semi-occluded vocal tract tasksSemi-occluded vocal tract tasks

10 Type I Glottal fry phonation Glottal fry phonation Low subglottal driving pressureLow subglottal driving pressure Reduced tension of the muscle within the vocal folds (thyroarytenoid)Reduced tension of the muscle within the vocal folds (thyroarytenoid) Vocal folds are short and thickVocal folds are short and thick Increased interarytenoid activityIncreased interarytenoid activity Complete vocal fold closure front to backComplete vocal fold closure front to back Eliminating posterior chink Eliminating posterior chink Isolation/syllables/words/etc.Isolation/syllables/words/etc.

11 MTD: Posterior glottic gap Inhalation Phonation Inhalation Phonation Phonation during inspiratory phasePhonation during inspiratory phase Results in improved vocal fold closure along entire lengthResults in improved vocal fold closure along entire length Vocal tract adjustment can assist with transition from inspiratory to expiratory phonationVocal tract adjustment can assist with transition from inspiratory to expiratory phonation Hierarchy of tasksHierarchy of tasks

12 MTD: Compression Goals: Goals: Reduce supraglottic compressionReduce supraglottic compression Reduce vocal fold medial compressionReduce vocal fold medial compression Task requirements: Task requirements: Complete closure of the vocal folds along their length (coordination of closers)Complete closure of the vocal folds along their length (coordination of closers) Adduction to a just barely touching positionAdduction to a just barely touching position

13 Semi-occluded vocal tract tasks Lowers phonation threshold pressure Lowers phonation threshold pressure Decreases medial compression Decreases medial compression Reduces laryngeal muscular tension Reduces laryngeal muscular tension Improves laryngeal muscular coordination Improves laryngeal muscular coordination squares up vocal fold edges for efficient vibration squares up vocal fold edges for efficient vibration Phonation through a straw (small is better) Phonation through a straw (small is better) Sustained phonation of voiced fricative consonants Sustained phonation of voiced fricative consonants Lip bubbles/trills Lip bubbles/trills Tongue trills Tongue trills Rolled /r/ Rolled /r/ Humming Humming Fringe benefit: highlights oral resonance Fringe benefit: highlights oral resonance

14 Straw phonation Daily exercises program (2-3 times) Daily exercises program (2-3 times) Three Principles: Three Principles: Lips around strawLips around straw Sound through straw onlySound through straw only Vibratory feeling at the lipsVibratory feeling at the lips Four tasks: Four tasks: One long, slow slide from low to high and back againOne long, slow slide from low to high and back again A series of slow slides on a single breathA series of slow slides on a single breath A series of accented slides (revving)A series of accented slides (revving) Song phonationSong phonation

15 From straw to speech Assure correct production through straw Assure correct production through straw Practice phrases before and after straw Practice phrases before and after straw Note auditory and ideally kinesthetic contrast Note auditory and ideally kinesthetic contrast Maintenance of kinesthetic similarity Make it feel like it did after you used the straw Maintenance of kinesthetic similarity Make it feel like it did after you used the straw Gradually fade straw use Gradually fade straw use

16 Circumlaryngeal massage Addresses paralaryngeal resting muscle tension Addresses paralaryngeal resting muscle tension Massage and manipulation of the supporting muscular sling Massage and manipulation of the supporting muscular sling Focuses on muscular attachments to the thyroid cartilage and hyoid bone Focuses on muscular attachments to the thyroid cartilage and hyoid bone Muscle relaxation encourages inferior movement of the thyroid cartilage Muscle relaxation encourages inferior movement of the thyroid cartilage

17 Circumlaryngeal Massage/Evidence Significant changes in patient severity ratings (Roy, 1993) and acoustic voice measures (Roy, 1997) after one session Significant changes in patient severity ratings (Roy, 1993) and acoustic voice measures (Roy, 1997) after one session 93% able to maintain improvement for a week without further treatment (Roy, 1993) 93% able to maintain improvement for a week without further treatment (Roy, 1993) Improved voice was maintained for up to 5 months for 72% of patients (Roy 1997) Improved voice was maintained for up to 5 months for 72% of patients (Roy 1997)

18 Circumlaryngeal Massage/Evidence Professional voice users with moderate to severed muscle tension dysphonia Professional voice users with moderate to severed muscle tension dysphonia 25 sessions25 sessions Improvements in acoustic measurementsImprovements in acoustic measurements Strain Strain Highest frequency Highest frequency Average fundamental frequency Average fundamental frequency Jitter and shimmer Jitter and shimmer Improvements in Dysphonia Severity IndexImprovements in Dysphonia Severity Index

19 Structure identification

20 Muscles of the anterior neck SuprahyoidDigastricMylohyoidGeniohyoidStylohyoidInfrahyoidThyrohyoidSternohyoidOmohyoidSternthyroid

21 Circumlaryngeal Massage Using small circles, massage in the thyrohyoid space, moving horizontally through the space Using small circles, massage in the thyrohyoid space, moving horizontally through the space

22 Circumlaryngeal Massage Use larger circles to massage from the thyrohyoid space to above the hyoid bone and back Use larger circles to massage from the thyrohyoid space to above the hyoid bone and back

23 Circumlaryngeal Massage Massage in the thyrohyoid space moving from back to front Massage in the thyrohyoid space moving from back to front

24 Circumlaryngeal Massage Massage up and down in a C shape from the thyrohyoid space to the cricoid cartilage and back Massage up and down in a C shape from the thyrohyoid space to the cricoid cartilage and back

25 Questions??


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