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19/05/2015

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The Voice Clinic and

Paediatric Voice Disorder

The Voice Clinic

and

Paediatric Voice Disorders

Kate Osland & Sarah Inglis

Speech Pathologists, Voice Clinic

The Children’s Hospital at Westmead

19th May 2015

https://www.surveymonkey.com/s/voicedisorder

19/05/2015


Outline of the session

• What is the Voice Clinic?

• 3 case studies

– Patient journey from assessment to therapy and

follow-up

• Highlighting some of the issues and considerations

when working with the paediatric voice population.

• A description – not a prescription!

What is the Voice Clinic?

• Joint ENT and Speech Pathology clinic

• Fortnightly clinic, 2 patients per clinic

• Referral by GP, ENT, paediatrician, or other specialist

• Each appointment consists of 45 min-1hr speech

pathology assessment, ½ hr for ENT consult &

feedback

• Student involvement

• Purpose of Ax = differential diagnosis and suitability

for therapy

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Who do we see?

• Children referred by medical professionals

• Children from age 3-16

• Children who present with a primary voice complaint

A typical Voice Clinic

assessment

1. Case history

2. Oral-motor assessment

3. Perceptual assessment and acoustic assessment

during functional voice tasks

4. Therapy trial

5. ENT consultation

6. Feedback

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• Unique clinical experience

– Orientation

– Practical voice assessment experience

Student experience

‘Having an experience with child voice is quite rare’

‘We had to think carefully of how we could make the tasks fun and motivating for the client

to participate in. This differed from my experiences in assessing an adult voice client’

‘Through this, I learnt a lot about my own abilities and limitations in terms of carrying out

voice therapy techniques’

‘It was great seeing how speech pathologists can work with medical professionals in the

area of voice.’

What do students say?

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Case Study 1 – S

Background

• Male; 14 years, 11 months

• Presenting concern: Breathy voice, difficulty

achieving volume and projection.

• Voice Hx: Onset approx. 18 months ago, stable.

• Med Hx: Eczema, allergic rhinitis, mild asthma. Uses

steroidal nasal spray.

• Social Hx: Eldest child, attends academically

selective high school, in school choir, interest in

public speaking.

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Results of Scope

• Incomplete closure of the vocal folds (posterior glottic

chink)

• Increased vocal fold tension

• Rise in laryngeal position with phonation

Assessment results

Measure Norm Result

Fundamental frequency Mean 125Hz 223 Hz

Harmonics-to-Noise ratio 20 dB+ 28 dB

Maximum phonation time 22 s (range 9-35s) 11 s

Pitch range 80-724 Hz for post-

pubertal male

146-528+ Hz

• OMA: Significant elevation of larynx on phonation. No other

structural or functional abnormalities detected.

• Perceptual assessment: Mildly breathy and strained, elevated

pitch for age/gender. A deeper vocal quality was noted when S

laughed or cleared his throat.

• Acoustic assessment:

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Therapy trial

• Responsive to therapy trial to lower voice with cues

– Yawn

– Initiation of phonation on ‘oh’ with a glottal stroke onset

– Short phrases

• S did not readily identify with this deep pitch

Diagnosis?

=

Puberphonia

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Puberphonia

• Definition: the persistence of a high-pitched voice beyond the age at

which voice change is expected to have occurred (Desai & Mishra,

2012)

• Aetiology: Increased laryngeal muscular tension leading to excessive

laryngeal elevation, psychosocial factors impacting upon acceptance of

new voice (e.g. social immaturity) (Desai & Mishra, 2012).

• Prevalence: 1 in 900,000 (Banerjee et al, 1995); more common in

adolescent males

• Clinical features:

– High fundamental frequency for age/gender (> 200Hz)

– Pitch breaks

– Hoarseness

– Breathiness

– Difficulty in vocal projection

– Visible laryngeal muscle tension

Puberphonia

• Desai and Mishra’s prospective study (2012)

• Subjects: 30 males aged between 14-18 years of age with a diagnosis

of puberphonia based on ENT/SP assessment using videostroboscopy,

perceptual and acoustic analysis.

• Treatment:

– Humming whilst gliding down a scale

– Phonation of vowels with glottal attack

– Use of vegetative sounds such as cough/throat clear to initiate voicing

– Production of glottal fry

– Digital manipulation of thyroid cartilage

– Counselling

– Relaxation exercises

• Outcome: – All 30 patients showed improvement on acoustic and perceptual measures.

– Majority of patients needed 4 sessions to achieve acceptable outcome.

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Management considerations

• Nature of condition

– Potential for rapid improvement

• Client factors

– Self-awareness

– Motivation

– Secondary gains/limiting variables

Recommendations

• Direct voice therapy indicated

• No scope indicated

• ‘Counselling’ as a part of the therapy process

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Therapy

• Focus on lowering of larynx and increasing control of

voice at lower pitch

– Kinaesthetic feedback

– Use of low vowel with glottal stroke onset

– Giggle to promote release of constriction

– Humming, smooth onset

• Progress

– Initially slipping back into ‘usual voice’

– Generalised well outside of session

– Desired outcome achieved in 4 sessions

Follow-up

• 3 months post therapy

• Clear, effortless voice quality

• More confident speaking in front of class

• Improving control of pitch in singing, working

with singing teacher

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Case Study 2 – A

Background

• 15 year old boy referred following concerns regarding a

prolonged period of aphonia (1.5 years).

• Medical history: ASD diagnosed mid Dec 2013.

• Previous speech pathology/ENT involvement:

– Two ENT investigations prior to Voice Clinic assessment.

– Two blocks of voice therapy between February and March

2013.

• Social history: Lives with mother and 11-year-old brother in a

regional area. Home-schooled.

• Other health professionals: Saw psychologist for anxiety

management.

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Assessment results

• OMA: Nil abnormalities observed, weak prompted

cough noted but spontaneous cough was stronger.

• Perceptual characteristics: ‘Whispered’ and

breathy vocal quality and aphonic voice.

• Acoustic assessment: Acoustic analysis invalid.

Diagnosis?

=

Psychogenic dysphonia

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Psychogenic Dysphonia

• Definition: A type of ‘non-organic’ voice disorder where there is

loss of voice in the absence of structural or neurological

pathology to explain the extent of the patient’s voice loss, and

where this volitional loss of voice is linked to psychological

imbalance (Baker, 2003.)

• Aetiology: Psychogenic voice disorders are the ‘manifestation

of psychological disequilibrium’ (Aronson, 1990.)

• Prevalence: Difficult to ascertain, though psychogenic aphonia

noted more predominantly in women (Martins, Tavares, Ranalli,

Branco, Pessin, 2014,) with a ratio of 8:1 (Baker, 2003.) There is

a low prevalence of conversion reaction (Baker, 2003.)


• Clinical and perceptual features:

- Onset of dysphonia is sudden (Martins, Taveres, Ranalli, Branco &

Pessin, 2014.)

- Patient histories indicate significant emotional stress (Seifert &

Kollbrunner, 2005) and potentially conflict over ‘speaking out’ about

something (Baker, 2003.)

- May have difficulty describing how they feel about their loss of voice

or other traumatic situations/events in their lives.

- Non-speech vocalisations are clear (Seifert & Kollbrunner, 2005.)

- Dysphonia or aphonia can be intermittent (Martins, Tavares, Ranalli,

Branco & Pessin, 2014.)

- Absence of laryngeal pathology under instrumental examination.

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• Treatment available:

- Aim of therapy: maximise function and reduce negative effects of

difficulties on life participation (Seifert & Kollbrunner, 2005.)

- Counselling will be important (Seifert & Kollbrunner, 2005.)

- Shaping non-speech vocalisations into speech gradually over time

(Colton, Casper & Leonard, 2011.)

• Outcomes:

- Multi-disciplinary approach leads to the best results (Martin,

Tavares, Ranalli, Branco & Pessin 2014.)

- High rate of relapse without psychological intervention (Seifert &

Kollbrunner, 2005.)

Considerations for Rx

• A lives in a regional centre.

• A schooling situation.

• A’s limited exposure to individuals outside his

family.

• A’s personal investment in therapy.

• A’s ‘special interests.’

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Recommendations

• Intensive 2-week block of voice therapy - 10 sessions (30 minutes daily)

• Referral to Psychological Medicine

Therapy

• Progress

– A unable to be seen by Psychological Medicine

team during his stay at the hospital.

– A made exponential progress through voicing

hierarchy.

– Performance in remaining 5 sessions = reversion

in volitional voicing.

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Therapy (cont.)

• Outcome

– Making little progress overall and ambivalent

about his personal investment in therapy.

– Clinicians unsure how to treat in future given

psychological component.

– Mother to contact the department to discuss

review assessment and a possible therapy block

in less than a month’s time.

Follow-up Review

• Conducted in presence of mother and younger

brother.

• Reported participating in home practice, with difficulty

voicing in that environment.

• Demonstrated fairly consistent voicing on all levels

trialled apart from scripted interactions.

• A reported that he was ready to engage in therapy

and wanted to start therapy this week.

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Therapy

• Joint SP/Psychological Medicine intervention

recommended: Rehab-style, one week

outpatient block.

• Progress

– A able to use clear, consistent in conversation

beyond the therapy room.

– A more personally invested in therapy.

Therapy (cont.)

• Outcome

– A left therapy block consistently and volitionally

using his voice in naturalistic settings, with some

therapy activities given to increase his volume.

• Plan

– A to contact the clinicians via telephone later in

the year, and arrange a review assessment for

early 2015.

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Follow Up Review (3 months)

• A using clear, audible, and louder voice since

last seen in department.

• Using voice functionally in everyday life.

• More outgoing and happier, with career

aspirations and plans for the future.

• Plan of action: discharge.

Case Study 3 – M

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Background

• 7 year-old female

• Presenting concern:

– Hoarse voice with reduced voice volume

• Voice Hx:

– Unclear onset of voice problem

– Voice stable over time

• Medical Hx:

– Normal birth history and early development

– No major illness or surgeries

– Family history of thyroid abnormalities and hormonal issues

• Social Hx:

– Separation anxiety; psychological involvement

Assessment results

Measure Norm Result

Fundamental frequency 261Hz (range 195-

303Hz)

275 Hz

Harmonics-to-Noise

ratio

20 dB+ 19 dB

Maximum phonation

time

13.7s (range 8.9-18.5s) 6.6 seconds

Pitch range No norms for children 232 – 285 Hz

• OMA: No structural or functional abnormalities detected.

• Perceptual assessment: Mildly breathy, rough and strained

voice quality.

• Acoustic assessment:

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Therapy trial

• +++ encouragement to participate

• Strategies trialled:

– Giggle technique for release of constriction

– Resonant voice with ‘mmm’ to cue smooth onset

to voicing

– Sob

• Limited response to therapy trial

Diagnosis?

=

Hyperfunctional voice

disorder (+ nodules?)

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Hyperfunctional Voice

Disorder

• Definition:

– A condition in which there is excess tension of the muscles within and around the

larynx, a posterior glottic chink, elevation of the larynx with voicing, and frequent

mucosal changes on the vocal cords (Lee & Son, 2005).

• Aetiology:

– Psychological or personality factors that induce tension;

– Suboptimal use of the voice in the context of high vocal demands;

– Compensatory strategy for underlying pathology,

– Learned (mal)adaptive behaviour following a respiratory illness (Morrison et al, 1983).

• Prevalence:

– Nodules - 21.6% in males; 11.7% in females (Kilic et al, 2004)

• Clinical features:

– Hoarseness, strain, breathiness; pitch or phonation breaks; unusually high or low pitch

– In children, there is a lack of reporting of laryngeal discomfort with use, although

there may be detectable deterioration in quality (Lee & Son, 2005)


Disorder

• Treatment options:

- Voice therapy (direct vs. indirect)

- Medical management

- No management/observation alone

• Adult literature indicates that a combination of direct and indirect

therapy is best practice for treating vocal fold nodules (Ruostalainen et

al, 2008). No clear conclusion in children.

• No clear evidence for which treatment is best or how long to implement

it (Pederson & McGlashan, 2012; Ongkasuwan & Friedman, 2013).

• Motivation and behaviour change are important factors to success (Lee

& Son, 2005; Mori, 1999).

• Surgery typically has a reduced role in paediatrics (Sulica & Behrman,

2003).

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Disorder

• Accent method

• Chant talk

• Confidential voice therapy

• Froeschel’s chewing technique

• Giggle technique

• Resonant voice therapy

• Sob quality

• Yell Well

• Yawn sigh

• Vocal hygiene

• Open mouth approach

• Other (trilling, singing, relaxation, twang, pitch exercises… etc etc)


Disorder

• The upshot of this: SPs rely on relatively low levels of

evidence combined with clinical experience to guide

management of this population (Signorelli et al,

2011).

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Management considerations

• What is the recommended treatment given

our hypothesised diagnosis?

• Is scoping strongly indicated?

• Likelihood of compliance with scoping?

• Will M be a suitable therapy candidate?

• Will M’s family engage with therapy process?

Recommendations

• Trial of voice therapy at CHW

• Review by ENT pending progress in therapy,

with view to scope as indicated.

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Therapy

• Progress:

– M attended 6 therapy sessions

– Resonant voice therapy

– Difficult to engage in therapy sessions

– Sensitive to feedback

– Mother and M reluctant to separate

– Intermittent illness disrupting therapy practice

– Not making progress

• Plan:

– ENT review

ENT Findings

Image courtesy of http://www.bbivar.com/vidimg/

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Follow-up

• Joint decision with family to discontinue voice

therapy

• Monitoring of voice quality and follow-up in

one year

Summary

• An ENT diagnosis is not essential before progressing to therapy

– but can be helpful.

• Use the best available evidence and your clinical experience to

guide selection of voice therapy techniques.

• Paediatric voice is a challenging and varied caseload.

• Many factors can impact on progress – it is not always smooth

sailing!

• Important to validate your diagnosis if there is no progress.

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How do I refer?

• Encourage your client to see their GP or other

relevant specialist to obtain a referral

• Referrals should be addressed to:

Dr John Curotta

The Voice Clinic

The Children’s Hospital at Westmead

Fax (02) 9845 2078

References • Aronson, A.E. (1990). Clinical voice disorders: an interdisciplinary approach. New York: Thieme

Inc.

• Baker, J. (2000). Psychogenic voice disorders – heroes or hysterics? A brief overview with

questions and discussion. Logopaedics, phoniatrics, and vocology, 27: 84-91.

• Baker, J. (2003). Psychogenic Voice Disorders and Traumatic Stress Experience: A Discussion

Paper with Two Case Reports. Journal of Voice, 17 (3): 308-318.

• Banerjee, A.B., Eajlen, D., Meohurst, R., & Murty, G.E. (1995). Puberphonia – A treatable entity,

1st World Voice Congress Oporto: Portugal.

• Colton, R. H., Casper, J.K., & Leonard, R. (2011.) Understanding Voice Problems: A

Physiological Perspective for Diagnosis and Treatment (3rd edition.) Baltimore, MD: Lippincott

Williams & Wilkins.

• Desai, V., and Mishra, P. (2012). Voice therapy outcome in puberphonia. Journal of

Laryngology and Voice, 2: 26-29.

• Kilic, M.A., Okur, E., Yildirim, I., Guzelsoy, S. (2004). The prevalence of vocal fold nodules in

school-age children. International Journal of Pediatric Otorhinolaryngology, 68: 409-412.

• Lee, E., & Son, Y. (2005). Muscle tension dysphonia in children: voice characteristics and

outcome of therapy. International Journal of Pediatric Otorhinolaryngology, 69: 911-917.

• Sulica, L., & Behrmann, A. (2003). Management of benign vocal fold lesions: A survey of

current opinion and practice. The Annals of Otology, Rhinology and Laryngology, 112: 827-833.

19/05/2015


References • Martins, R.H.G, Tavares, E.L.M, Ranalli, P.F., Branco, A., & Pessin, A.B.B. (2014). Psychogenic

dysphonia: diversity of clinical and vocal manifestations in a case series. Brazilian Journal of

Otorhinolaryngology, 80 (6): 497-502.

• Mori, K. (1999). Vocal fold nodules in children: preferable therapy. International Journal of

Pediatric Otorhinolaryngology, 49 Suppl 1:S303-6.

• Morrison, M.D., Rammage, L.A., Belisle, G.M. , Pullan, C.B., & Nichol H. (1983). Muscular

tension dysphonia. Journal of Otolaryngology, 12: 302-306.

• Ongkasuwan, J., & Friedman, E.M. (2013). Is voice therapy effective in the management of vocal

nodules in children. The Laryngoscope, 123: 2930-2931.

• Pederson, M., & McGlashan, J. (2012). Surgical versus non-surgical interventions for vocal cord

nodules: Review. The Cochrane Library, Issue 6. John Wiley & Sons, Ltd.

• Ruostalainen, J., Sellman, J., Lehto, L., & Verbeck, J. (2008). Systematic review of the treatment

of functional dysphonia and prevention of voice disorders. Otolaryngology-Head and Neck

Surgery, 138, 557–565.

• Seifert, E. & Kollbrunner, J. (2005.) Stress and distress in non-organic voice disorders. Swiss

Medicine Weekly, 135: 387-397.

• Signorelli, M.E., Madill, C.J., & McCabe, P. (2011). The management of vocal fold nodules in

children: A national survey of speech-language pathologists. International Journal of Speech-

Language Pathology, 13(3), 227-238.

welcome to allied health telehealth · case study 2 – a background • 15 year old boy referred...

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