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??