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
Primary
Secondary
Vocal pathology associated with abuse/misuse
Nodules
Vocal 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”
Can be normal in females
Cecchi

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

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

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

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

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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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

19. Structure identification

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

21. Circumlaryngeal Massage
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

23. Circumlaryngeal Massage
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

25. Questions??