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

Common Voice Disorders Muscle Tension Dysphonia Primary Secondary Vocal pathology associated with abuse/misuse Nodules Vocal scarring or loss of vibratory layer

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

Primary Muscle Tension Dysphonia False vocal fold approximation: medio-lateral supraglottic compression John Rogers 8/30/11

Primary Muscle Tension Dysphonia Supraglottic compression in the anterior to posterior axis Casavoy August 2 8:42 (1:11

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

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

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

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

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

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

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

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

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

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

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

Circumlaryngeal Massage/Evidence 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) Improved voice was maintained for up to 5 months for 72% of patients (Roy 1997)

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

Structure identification

Muscles of the anterior neck Suprahyoid Digastric Mylohyoid Geniohyoid Stylohyoid Infrahyoid Thyrohyoid Sternohyoid Omohyoid Sternthyroid

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

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

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

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

Questions??