Translating Voice Evaluation Results to Voice Therapy

Edie Hapner Ph.D CCC-SLP Marina Gilman MM, MA, CCC-SLP

The Emory Voice Center
Department of Otolaryngology, Emory University
Atlanta, Georgia
ASHA Convention November 15-17, 2007

I. Paradigm for understanding benign vocal fold lesions:

TOO MUCH Vocal Over-doer

Phonotrauma resulting from:
A single event causing acute VF hemorrhage
Acute tissue changes that result in VF vibratory change
Long term over use
Pathologies seen under this category:
Nodules Granuloma
Cysts Reinkes Edema
Polyps Hemorrhage
Scarring/Sulcus vocalis Chronic Cough with lesion

TOO LITTLE Vocal Under-doer

Deconditioning or weakness of VF after an illness
Age related changes
VF paresis or paralysis
Pathologies seen under this category
Presbylaryngeus: Age related changes, atrophy
Vocal Fold Paralysis/Paresis
Neurological issues like Parkinsons, other progressive neurological diseases

TOO TENSE Compensatory Muscle Over-doer

Pivotal finding is NO lesion
Hyperfunctional underclosure of the VF
Paralaryngeal or intrinsic muscle imbalance
Sudden unexplained voice loss with no organic etiology
Coughing, choking, throat clearing and resulting voice change
Pathologies seen under this category
Muscle tension dysphonia (MTD)
Mutational falsetto/puberphonia
Hyperfunctional underclosure aka functional dysphonic aka conversion dysphonic
Laryngospasm, chronic cough, PVFD

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2 Hapner and Gilman Translating Voice Evaluation Results to Voice Therapy ASHA Convention 11/2007

II. Voice Hygiene in the Millenium

Vocal dose/ vocal recovery
Room Acoustics
Therapy practice of talking in noise
Cumulative nature of voice problems
Vocal dose measures: quantifying accumulated vibration exposure in vocal fold tissues (Titze
et al, 2003)
Vocal Self image
Sowing Voice Hygiene in the Therapy Plan
Vocal Finances ( Hicks & Milstein, 2007)
Consciousness/Conscientiousness in therapy ( Hicks & Milstein, 2007)
Hydration: Older and newer information (Verdolini, Sivasankar, Solomon Fischer studies
(1994-2003); Roy study ( 2007)
Motivation/stage of change/readiness (van Leer, Connor, Hapner, 2007)

III. THERAPY GOALS

TOO MUCH
Reduce Phonatory Effort by reducing
Compensatory supraglottic hyperfunction
Subglottal pressure
Phonotrauma with each vibratory cycle
Optimize respiratory/phonatory balance
Optimizing function within daily living environment

TOO LITTLE Optimize respiratory/phonatory coordination

Establish balanced oral nasal resonance/reduce compensatory muscle imbalance
Where possible, improve glottal closure
Optimizing function within daily living environment

TOO TENSE Optimize laryngeal postures

Optimize respiratory/ phonatory balance
Reduce compensatory supraglottic hyperfunction
Normalize voice in daily living environment

Therapy protocols:
Vocal Function Exercises Semi-occluded vocal tract exercises
Resonant voice therapy (including LMRVT) Optimizing respiratory/phonatory balance
Voice Building (including LSVT) Breath management

References for Therapy Techniques: LMRVT, LSVT, Vocal Function Exercises and Semi-Occluded
vocal tract exercises.
1. Verdolini Resonant voice therapy. IN Stemple,JC. Clinical Voice Pathology: Theory and
Management 3 rd ed. 2000 Singular Pub.
2. Sabol, J. W., Lee, L., & Stemple, J. C. (1995). The value of vocal function exercises in the
practice regimen of singers. Journal of Voice, 9, 2736.
3. Fox CM. Ramig LO. Ciucci MR. Sapir S. McFarland DH. Farley BG. The science and practice of
LSVT/LOUD: neural plasticity-principled approach to treating individuals with Parkinson disease
and other neurological disorders. [Review] [128 refs] [Journal Article. Review] Seminars in
Speech & Language. 27(4):283-99, 2006 Nov.
4. Titze, IR. Voice Training and therapy with semi-occluded vocal tract: rationale and scientific
underpinnings. JSLHR 49(2):448-59 2006

2007 Hapner and Gilman