practical strategies for treatment of common voice disorders carol krusemark, m.a., ccc-slp voice...
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Practical Strategies for Practical Strategies for Treatment of Common Voice Treatment of Common Voice
DisordersDisordersCarol Krusemark, M.A., CCC-SLPCarol Krusemark, M.A., CCC-SLPVoice Pathologist/Singing Voice Voice Pathologist/Singing Voice
SpecialistSpecialistMGH Center for Laryngeal Surgery and MGH Center for Laryngeal Surgery and
Voice RehabilitationVoice Rehabilitation
Common Voice DisordersCommon Voice Disorders
Muscle Tension DysphoniaMuscle Tension Dysphonia• PrimaryPrimary• SecondarySecondary
Vocal pathology associated with Vocal pathology associated with abuse/misuseabuse/misuse• NodulesNodules• Vocal scarring or loss of vibratory layerVocal scarring or loss of vibratory layer
Primary Muscle Tension DysphoniaPrimary Muscle Tension Dysphonia
a posterior a posterior glottic glottic ““chinkchink”” caused by caused by simultaneous simultaneous activation of activation of vocal fold vocal fold ““closersclosers”” and and ““openersopeners””
Can be normal Can be normal in femalesin females
Primary Muscle Tension DysphoniaPrimary Muscle Tension Dysphonia
False vocal fold False vocal fold approximation: approximation: medio-lateral medio-lateral supraglottic supraglottic compressioncompression
Primary Muscle Tension DysphoniaPrimary Muscle Tension Dysphonia
Supraglottic Supraglottic compression in compression in the anterior to the anterior to posterior axisposterior axis
Primary Muscle Tension DysphoniaPrimary Muscle Tension Dysphonia
Compression Compression from both the A-from both the A-P and medio- P and medio- lateral directionslateral directions
Vocal NodulesVocal Nodules
Reactive Reactive fibrovascular fibrovascular lesions formed at lesions formed at the site of the site of greatest vocal greatest vocal fold contactfold contact
Scar or loss of vibratory layerScar or loss of vibratory layer
Loss of superficial Loss of superficial lamina propria, lamina propria, resulting in resulting in reduced musocal reduced musocal wavewave
Treatment modalitiesTreatment modalities
Facilitating StrategiesFacilitating Strategies Reduction of vocal fold and Reduction of vocal fold and
supraglottic hyperfunctionsupraglottic hyperfunction Type I: posterior glottic Type I: posterior glottic ““chinkchink””
• Glottal fryGlottal fry• Inhalation phonationInhalation phonation
Types II-IV: Supraglottic compressionTypes II-IV: Supraglottic compression• Semi-occluded vocal tract tasksSemi-occluded vocal tract tasks
Type IType I
Glottal fry phonationGlottal fry phonation• Low subglottal Low subglottal ““drivingdriving”” pressure pressure• Reduced tension of the muscle within Reduced tension of the muscle within
the vocal folds (thyroarytenoid)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 Complete vocal fold closure front to
backback Eliminating posterior chinkEliminating posterior chink
• Isolation/syllables/words/etc.Isolation/syllables/words/etc.
MTD: Posterior glottic gapMTD: Posterior glottic gap
Inhalation PhonationInhalation Phonation• Phonation during inspiratory phasePhonation during inspiratory phase• Results in improved vocal fold closure Results in improved vocal fold closure
along entire lengthalong entire length• Vocal tract adjustment can assist with Vocal tract adjustment can assist with
transition from inspiratory to expiratory transition from inspiratory to expiratory phonationphonation
• Hierarchy of tasksHierarchy of tasks
MTD: CompressionMTD: 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 Complete closure of the vocal folds
along their length (coordination of along their length (coordination of ““closers)closers)
• Adduction to a Adduction to a ““just barely touchingjust barely touching”” positionposition
Semi-occluded vocal tract tasksSemi-occluded vocal tract tasks
Lowers phonation Lowers phonation threshold pressurethreshold pressure
Decreases medial Decreases medial compressioncompression
Reduces laryngeal Reduces laryngeal muscular tensionmuscular tension
Improves laryngeal Improves laryngeal muscular coordinationmuscular coordination
““squares upsquares up”” vocal fold vocal fold edges for efficient edges for efficient vibrationvibration
Phonation through a Phonation through a straw (small is better)straw (small is better)
Sustained phonation Sustained phonation of voiced fricative of voiced fricative consonantsconsonants
Lip bubbles/trillsLip bubbles/trills Tongue trillsTongue trills Rolled /r/Rolled /r/ HummingHumming Fringe benefit: Fringe benefit:
highlights oral highlights oral resonanceresonance
Straw phonationStraw 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 One long, slow slide from low to high and back
againagain• 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
From straw to speechFrom straw to speech
Assure correct production through strawAssure correct production through straw Practice phrases before and after strawPractice phrases before and after straw Note auditory and ideally kinesthetic Note auditory and ideally kinesthetic
contrastcontrast Maintenance of kinesthetic similarity Maintenance of kinesthetic similarity
““Make it feel like it did after you used Make it feel like it did after you used the strawthe straw””
Gradually fade straw useGradually fade straw use
Circumlaryngeal massageCircumlaryngeal massage
Addresses paralaryngeal resting Addresses paralaryngeal resting muscle tensionmuscle tension
Massage and manipulation of the Massage and manipulation of the supporting muscular supporting muscular ““slingsling””
Focuses on muscular attachments to Focuses on muscular attachments to the thyroid cartilage and hyoid bonethe thyroid cartilage and hyoid bone
Muscle relaxation encourages inferior Muscle relaxation encourages inferior movement of the thyroid cartilagemovement of the thyroid cartilage
Circumlaryngeal Circumlaryngeal Massage/EvidenceMassage/Evidence
Significant changes in patient severity Significant changes in patient severity ratings (Roy, 1993) and acoustic voice ratings (Roy, 1993) and acoustic voice measures (Roy, 1997) after one sessionmeasures (Roy, 1997) after one session
93% able to maintain improvement for a 93% able to maintain improvement for a week without further treatment (Roy, week without further treatment (Roy, 1993)1993)
Improved voice was maintained for up to 5 Improved voice was maintained for up to 5 months for 72% of patients (Roy 1997)months for 72% of patients (Roy 1997)
Circumlaryngeal Circumlaryngeal Massage/EvidenceMassage/Evidence
Professional voice users with moderate to Professional voice users with moderate to severed muscle tension dysphoniasevered muscle tension dysphonia• 25 sessions25 sessions• Improvements in acoustic measurementsImprovements in acoustic measurements
StrainStrain Highest frequencyHighest frequency Average fundamental frequencyAverage fundamental frequency Jitter and shimmerJitter and shimmer
• Improvements in Dysphonia Severity IndexImprovements in Dysphonia Severity Index
Structure identificationStructure identification
Muscles of the anterior neckMuscles of the anterior neck
SuprahyoidSuprahyoid
DigastricDigastric
MylohyoidMylohyoid
GeniohyoidGeniohyoid
StylohyoidStylohyoid
InfrahyoidInfrahyoid
ThyrohyoidThyrohyoid
SternohyoidSternohyoid
OmohyoidOmohyoid
SternthyroidSternthyroid
Circumlaryngeal MassageCircumlaryngeal Massage
Using small Using small circles, circles, massage in massage in the the thyrohyoid thyrohyoid space, space, moving moving horizontally horizontally through the through the spacespace
Circumlaryngeal MassageCircumlaryngeal Massage
Use larger Use larger circles to circles to massage massage from the from the thyrohyoid thyrohyoid space to space to above the above the hyoid bone hyoid bone and backand back
Circumlaryngeal MassageCircumlaryngeal Massage
Massage in Massage in the the thyrohyoid thyrohyoid space space moving moving from back from back to frontto front
Circumlaryngeal MassageCircumlaryngeal Massage Massage up Massage up
and down in a and down in a ““CC ”” shape from shape from the thyrohyoid the thyrohyoid space to the space to the cricoid cricoid cartilage and cartilage and backback
Questions??Questions??