Voice Part 1

Questions will be true or false, short answer questions and multiple choice questions.

What are the 4 voice classifications?

Inflammatory, Structural/Neoplastic. Neuromuscular, Muscle Tensions Imbalance

Name the 2 causes of inflammatory disorders and give a specific example of each.

Infective: e.g. viral, bacterial, fungal (HPV example of a chronic infection)

Non-infective: e.g. acute allergic reaction, trauma, reflux, drugs, autoimmune

Name 3 structural abnormalities, describe vocal cord appearance and cause

Vocal cord haemorrhage - blood vessels in the vocal cords burst causing sudden bleeding on either the epithelium or lamina propria.

Vocal cord sulcus - elongated grove along the superficial layer of the lamina propria (Reinkes space). Can occur after a ruptured cyst.

Vocal cord nodule - occurs at the midpoint of vocal cords on the epithelium. Caused by phonotrauma or repetitive over-use and misuse.

Name 3 examples of muscle tension imbalance, describe vocal cord appearance and cause

AP constriction: compression of the laryngeal vestibule from back to front. Both the anterior and posterior part of the vocal cords are obscured.

Lateral constriction: Vocal cords appear long and stretched, the false fold are pulled inwards to assist closure.

Incomplete closure: the vocal cords move towards the midline and then stop, before full closure is achieved.

Define vocal cord palsy and its cause

The vocal cords become paralysed due to damage to the recurrent laryngeal nerve. Because a paralysed fold loses its muscle tone, it may become thinner and more bowed. Associated with an underlying neurological condition.

Define spasmodic dysphonia and its cause

involuntary spasms of the vocal cords, including adductor, abductor and mixed, caused secondary to damage to the superior laryngeal nerve/ associated with an underlying neurological condition.

Briefly summarise the anatomical changes of a total laryngectomy (5 points)

Laryngectomy surgery includes complete removal of the laryngeal cartilage, epiglottis, hyoid bone, sections of the base of tongue and strap muscles of the neck. As the tissue is reconstructed to allow closure of the defect, a neopharynx is formed. The patient has a permanent stoma, no voice and separate food and air passages 

Briefly describe the physical changes and voice changes associated with vocal cord inflammation (3 points).

Swelling (oedema), redness (erythema), and sometimes discomfort pr pain. Swelling makes the vocal cords thicker, heavier and stiffer resulting in a lower pitch and irregular vocal cord vibration (rough voice).

Describe a breathy voice quality and what you might see at vocal cord level (2 points)

Whispery vocal tone with air escape. The air escape adds noise at the glottis resulting in a reduced HNR.

Briefly describe surgical voice restoration (SVR) and how voice is produced (5 points).

SVR is the modification of a laryngectomy to include a trache-oesophageal puncture (TEP). It involves placing a silicone valve prosthesis into the (TEP). When the stoma is covered, the voice prosthesis redirects the pulmonary airstream via a newly formed flap in the neopharynx called the pharyngoesophageal segment (PE). As airflow is directed through this PE segment, the tissue allows for vibration, which allows for a new voice.

Give two examples and brief descriptions of ENT or SLT voice clinics (4 points).

1. Joint voice clinic: a dedicated clinic for patients presenting with voice problems, it is a one-stop clinic where patients access all HCP who may be involved in treating potential underlying causes of the voice disorder.

2. SLT-led clinic: a new patient-clinic led by an experienced SLT for the assessment of patients where the primary mode of treatment is most likely to be voice therapy.

Give 2 examples of the role of the SLT post phonosurgery for benign vocal cord lesions? (2 points)

Vocal care for wound healing.

Direct therapy to improve vibratory characteristics.

Give one pro and one con to using an artifiical larynx post laryngectomy (2 points)

Pro: generally high success rate as the device is easy to use.

Con: the voice quality is considered less natural (mechanical).

How is respiration affected post laryngectomy? How might you best optimise pulmonary rehabilitation? (3 points)

The stoma has no filtering properties and no resistance to air, this can lead to excessive and/or dry mucus, with a risk of increased coughing and chest infections as well as a higher risk of inhaling foreign objects. You could optimise PR with an HME device.

In Janet Baker’s article, Women’s voice, lost or mislaid, stolen or slayed, how is COSO defined?

Conflict that arises when a person is under pressure to say something as a way of continuing to cope with a commitment but is constrained to do so as saying something may make matters worse.

How would you describe an abductor spasmodic dysphonia?

Sudden involuntary spasms that trigger the vocal cords to open. Vibration can’t happen when cords are open so voicing is difficult. The open position of the cords lets air escape during voicing . Voice is weak, quiet and breathy. 

Which of the following is a treatment option for voice feminisation (1 point) MCQ

Glottoplasty; this procedure adjusts the proportions of the vocal cords by reducing the length of the vibrating segment to give a higher pitch. 

Which of the following best describes non-verbal communication post laryngectomy? (1 point MCQ)

Non-verbal communication includes silent articulation, gesture and alternative and augmentative communication.  It is often used immediately post surgery and longer term for patients with extensive anatomical changes post surgery. 

What is the process of referral to SALT for voice concerns?

1. Patient: often hoarseness recovers with home remedies and people won’t attend GP. How quickly a patient seeks help from the GP will depend on their degree of tolerance.

2. GP Consultation: only a small percentage of voice disorders start suddenly; most have a gradual onset. GP gives advice and information, and medication managament.

3. ENT Consultation: Two-week cancer pathway for patients over 45 with persistent unexplained hoarseness, neck lump and/or otalgia/ General ENT clinic for assessment and management of ENT conditions, including minor procedures/ Joint Voice Clinic for voice assessment with both ENT consultant and specialist SLT.

4. SLT Consultation: Parallel/SLT-led clinic for advanced SLT-led assessment with ENT support as required. Patients may have forgotten the initial trigger to their symptoms or symptoms may worsen between onset and the start of treatment.

What is the purpose of the initial patient interview?

1. combine observation and information

2. start to formulate a plan; develop and test tentative hypothesis

3. develop rapport and trust between yourself and the patient

What information do you need to gather in the case history?

What is the problem? (patient and clinician perspective)

Onset (sudden, gradual, specific cause e.g. cold, life event)

Duration (time since onset, improvement/deterioration)

Variables (known causes; does anything ease or exacerbate the problem)

Throat sensation (tight, achy, sore, irritating, SOB, lump/sticking)

Voice use (any excessive use?)

Other contributing factors (environment, emotional issues, medication)

Voice care (fluid intake, voice rest, smoking, alcohol, caffeine)

Known ENT problems (sinus problems, hearing impairment, allergies, reflux)

Other medical problems (neurological problems, trauma, injury, surgery, resp disease, psychiatric problems)

What impact is the problem having? (work, home, social, emotional)

What are the 3 patient reported outcome measures (PROMS)?

Patient questionnaires

Voice Handicap Index (VCI)

Newcastle Laryngeal Hypersensitivity Questionnaire

How can patient questionnaires be used as an outcome measure?

They capture patient-reported symptoms and QoL.

They measure treatment outcomes from the patients perspective.

They track progress pre- and post-treatment to guide care.

They inform service evaluation and improvement.

What are potential challenges to using patient questionnaires as PROM?

Low patient literacy.

Perceived burden.

Questionnaire fatigue; might not be an accurate representation.

Who created the Voice Handicap Index (VHI-10) and how is it used as a PROM?

Jacobson et al., 1997

it is a a validated 30-point scale 0-4 rating.

Covers emotional, functional and physical domains.

Has good correlation.

Score of >11 is abnormal.

Who created the Newcastle Laryngeal Hypersensitivity Questionnaire and how is it used as a PROM?

Vertigan et al., 2014

Measures laryngeal sensory disturbance.

It is a validated 14-item questionnaire, 7-point scale, 3 sub-scales:

Obstruction/ pain/ throat tickle

Lower score = higher impairment (Score <17 is abnormal)

Demonstrates effectiveness of behavioural speech and language treatments

What are the 3 p’s that describe the cause of a voice disorder?

Predisposing factors: biological, social and occupational influences on voice vulnerability e.g. underlying conditions; high vocal demand at work

Precipitating/ initiating factors: events/ behaviours that trigger symptom onset e.g. life event; acute vocal overuse/misuse; surgery; infection; irritant exposure

Perpetuating factors: factors that maintain or worsen voice problems over time e.g. continued high vocal load; unaddressed psychological factors; chronic health conditions

What is GRBAS?

Perceptual analysis

How we grade voice disorders and describe the voice quality.

Outline the different type of hoarseness: rough/ breathy/ asthenia/ strained

Score all areas 0-3, and overall G 0-3

What is a rough voice quality?

Rough hoarseness is a rasping, rattling sounding voice due to Irregular vibration of the vocal cords.

Can be heard in disorders such as Reinke’s oedema (smokers voice); vocal cord polyps; nodules; muscle tension.

What is a breathy voice quality?

A whispery voice quality due to incomplete vocal cord closure (air escape).

Can be heard in disorders such as vocal cord palsy, nodules, laryngeal cancer, muscle tension and vocal cord atrophy.

What is a asthenic voice quality?

A small, weak voice due to weak/slow/small vocal cord movements.

Can be heard in disorders such as psychogenic aphonia; presbyphonia; puberphonia; Parkinsons disease

What is a strained voice quality?

Produced when the throat muscles are constricted, listening for effort.

Can be heard in disorders such as adductor spasmodic dysphonia; dysphonia; muscle tension dysphonia; and secondary to structural, inflammatory and neuromuscular disorders.

What are the benefits of perceptual analysis?

Enables us to organise what we hear into a structure to aid understanding and guide action.

Can be used to evaluate progress over time.

Can be used to organise the feedback to clients.

Can be used to communicate with colleagues.

Can be used to carry out research.

What are the 2 most commonly used perceptual analysis schemes in the uK?

GRBAS

Cape-V

What are the benefits of acoustic analysis?

Confirms our perceptual analysis of voice quality.

Gives more information on normal and pathological voice production, thus supporting diagnosis.

Results are presented on-screen in the form of visual feedback and so can be used for patient biofeedback.

Can be used as a baseline measure/ clinical outcome.

The data is more objective that PA and is replicable and so could be used in research.

However objective data still required subjective interpretation.

What are the methods of acoustic analysis?

Closed Quotient % (CQ%)

Fundamental Frequency

Amplitude

Harmonics to Noise ratio (HNR)

Maximum Phonation Time (MPT)

S/Z ratio

Which method of AA measures the percentage of the vibratory cycle for which the vocal cords are in contact?

Closed Quotient % (CQ%)

The higher the % the longer the closed phase (adductor spasmodic dysphonia).

The lower the % the longer the open phase (vocal cord palsy).

The norm is 50-60% closure.

Which method of AA measures the size of the vocal cord movement?

Amplitude which is perceived as loudness/ volume and measured in dB.

Normal speaking voice is approximately 70dB.

In disordered voice, size of movement can often be impaired with resultant difficulty projecting e.g. vocal cord atrophy, muscle tension imbalance, laryngitis.

Which method of AA measures the number of times the vocal cords vibrate in a second?

Fundamental frequency which is perceived as pitch and measured in Hz.

The norm is between 100-300Hz dependent on gender and age.

Bigger/thicker vocal cords have less tension and elasticity and move slower e.g. Reinke’s causes bulky/flaccid vocal cords which move slower causing a lower pitch.

Smaller/thinner vocal cords have increased tension and elasticity and move quicker e.g. psychogenic voice is high pitch due to thin, tense cords which move quickly.

Which method of AA measures the length of time a person can sustain a ‘s’ and ‘z’?

S/Z Ratio

The ‘s’ time is divided by the ‘z’ time, giving a numerical ratio.

The higher the number, the more likely that difficulty with phonation is indicated.

Normal figure is 1 as people can sustain both sounds for an equal amount a time.

For people with voice problems, the s/z ratio is >1.4 as the lesion/dysfunction will interfere with the vibratory cycle, reducing the length of time the voiced sound can be maintained.

Which method of AA measures the time in seconds in which a person can sustain a vowel sound at a comfortable pitch on one breath?

MPT: Maximum Phonation Time

Normal male MPT = 25-35s

Normal female MPT = 15-25s

The MPT is reduced in cases of vocal dysfunction/laryngeal pathology as the ability to close the vocal cords efficiently is reduced and it is harder to maintain strong vibration during the open and closed phases (reduced glottic efficiency).

Which method of AA measures the amount of random noise (aperiodic wave) that is not harmonic of the glottal signal?

HNR: Harmonics to Noise Ratio as measured in dB on a vowel.

A high HNR indicates a predominantly periodic, clear signal.

A low HNR suggests breathiness, roughness or hoarseness

Noise can include air escape in a breathy voice quality or creak in vocal strain.

Healthy voices typically have HNR values of 20dB or higher

How is laryngeal endoscopy carried out?

The flexible scope is passed up the nose to visualise the larynx and vocal tract = flexible laryngoscopy.

Patient speaks whilst the scope is in situ and therapy techniques can be practiced and the phonation pattern can be observed.

What does Stroboscopy refer to?

Adding a flashing stroboscopic light to the flexible endoscope to illuminate the vocal folds and take multiple snapshots at different phases in the vibratory cycle.

The flashing is synchronised with vocal fold vibration to give a series of snapshots which the brain interprets as movements and gives the illusion that the vocal folds are vibrating in slow motion.

What to look for on laryngeal endoscopy?

Structural abnormalities: lumps and bumps

Inflammation: redness and swelling

Range of movement

Opening and closing of the vocal cords

Mucosal wave

Lengthening and shortening of the vocal cords

Elevation and lowering of the larynx

Excessive movement of surrounding structures

Weakness

Excessive movements/tremor

What would cause limited vibration/mucosal wave of the vocal-cords?

Lesions infiltrating the deeper layers of the cords.

Should you diagnose based off one assessment finding?

No, it is important to integrate all the information from the referral, case history, patient reported outcomes, laryngeal endoscopy, perceptual and acoustic analysis as each will give you different information to aid diagnosis and allow you to avoid red herrings.

What is the aim of indirect voice therapy?

To modify anything that contributes to and maintains a voice disorder in order to eliminate their effects on the voice.

What does indirect therapy include?

Education

Advice

Adaptations

Strategies

What does education involve in terms of indirect therapy?

A clear description of normal voice production

An explanation of their diagnosis

How therapy will help

Other treatment options

The aim is that understanding their diagnosis and treatment plan can aid compliance

What are areas of voice/throat care to provide education on?

Hydration

Irritants

Voice rest

Adapting your environment

Voice abuse/ misuse

What is the importance of hydration? (as if educating a patient)

Hydration helps maintain the protective mucosal lining which coats the vocal cords, protecting them from the natural friction that occurs during phonation.

When dehydrated, the vocal cords become stiff and more viscous causing reduced vocal cord vibration and a feeling of mucus in the throat (due to the viscocity).

What are causes of dehydration?

Lack of fluid (e.g. lack of availability, avoidance due to nausea)

Loss of fluid (e.g. diarrhea and vomiting)

Secondary to underlying health conditions (e.g. Sjogrens and Diabetes)

Side effect to medication (e.g. radiotherapy, blood pressure tablets, cholesterol medications, anti-depressants)

Environment (e.g. dry air, air conditioning, dry heat)

Individual factors (e.g. dislike, high caffeine, alcohol intake)

What does a dehydrated voice sound like?

Rough, with reduced amplitude and pitch and heightened sensory awareness.

What advice would you give for someone experiencing dehydration?

Stay hydrated

Drink 2 litres of non-caffeinated fluid per day

Limit intake of caffeine and alcohol

Try steam inhalation (Mahalingham et al., 2016)

Use a humidifier in your home

Use fine water sprays, mucus retention toothpastes, gels to compensate for dryness, sugar free sweets

What is the effect of irritants on the voice? (as if educating a patient)

Irritants reduce surface moisture of the vocal folds resulting in a thiner or disrupted mucosal lining, increased friction during vibration and greater phonatory effort required to produce voice.

They can trigger a local inflammatory response in the laryngeal tissues resulting in swelling (oedema) of the vocal folds, redness (erythema) and increased vascularity.

Can lead to dryness, excessive mucus in the larynx and pharynx and an urge to cough.

Can cause rough sounding voice with reduced amplitude and pitch and heightened sensory awareness.

What are causes of irritation?

Upper respiratory tract infections

Allergies

Excess mucus or postnasal drip

Acid refluc

Frequent coughing or throat clearing

Chemical exposure

Inhaled irritants

Medications e.g. ACE inhibitors, inhalers, radiotherapy

What advice would you give for someone experiencing irritation?

Cough control strategies

Medication management e.g. rinsing after inhaler use

Protective clothing

Adapting the environment

Mucus management

What is the difference between absolute and relative voice rest?

Absolute voice rest: complete silence, no talking, no singing - generally only advised with acute injury or post-surgical procedures.

Relative voice rest: reducing vocal load relative to vocal output - talk less and give voice a break.

How long is voice rest advised?

No consensus on effective duration of voice rest.

What are examples of environments that contribute to voice disorders?

Extensive background noise: lead to prolonged projection/shouting

Quiet environments: lead to persistent loud whispering which puts strain on the laryngeal muscles

Rooms with bad acoustics: you have to ‘speak up’

Poor air quality: e.g. no humidifier, exposure to chemicals/fumes/dust/smoke/dry air/ hot air/ air con/ dust

What advice would you give to a patient whose environment is contributing to their voice disorder?

Importance of adapting the environment:

Reducing the background noise

Avoiding projection in open spaces

Using amplification to raise the voice

Aiming to work in small groups

Moving to the person you’re talking to rather than shouting across

Turning off the air-con and dry heat appliances

Ventilating and humidifying rooms

Staying hydrated

Wearing a face mask

What is the difference between voice abuse and voice misuse?

Voice abuse: any behaviour that strains/ injures the vocal cords e.g. excessive talking, throat-clearing, coughing, screaming, yelling, inhaling irritants, smoking.

Voice misuse: improper voice usage such as speaking too loudly or at an abnormally high or low pitch.

What strategies could you advise around voice use and vocal demand?

Build awareness of appropriate voice use in different settings e.g. 1:1 vs large groups

Alternative ways to communicate to reduce vocal deman e.g. non-verbal communication, use of a whistle/ clapping hands

Ask someone else to cover some of the vocal load

When would we do direct therapy?

Muscle tension imbalance (primary and secondary)

Primary treatment for structural disorders e.g. vocal cord nodules.

Increasing evidence for treatment of polyps.

When would we not do direct therapy?

When there are restrictions in ability, for example permanent damage to the vocal cord.

What are the aims of direct therapy?

To re-establish optimal muscle balance through…

• breath support

• improving the vibratory cycle

• normalising vocal tone and resonance

• reducing muscle effort

• increasing vocal stamina and range

• normalising throat sensation

How can building awareness be used as direct therapy?

Many patients have poor body awareness; they are unaware of excessive physical tension.

If laryngeal tension has been present for a long time, tightness might be the normal feeling.

Building awareness of tension/tightness supports the patient being able to manage their voice problem independently, preventing relapse.

Building awareness of placement of sound

What strategies can be used in direct therapy to build awareness of tension?

Noticing how the voice works normally.

Contrasted practice: how sensation changes as we alter speaking and breathing patterns

No right or wrong: noticing not correcting

Prior to voice therapy, how would you build awareness of posture?

Common mistakes with posture include slouching, bottom out, flat back, putting your weight through one side, hunched back, poking chin forward, rounded shoulders.

Therapy can start with strategies to optimise posture such as full body relaxation.

Prior to therapy, how would you build awareness of breath support?

Our breath should be quiet, should be slow (12BPM) and we should feel the abdomen rise and fall as we breathe in and then out.

If breathing isn’t at its optimum, we may observe noisy breathing. signs of infection/disease (inspiratory/respiratory wheeze) or dysfunctional breathing (over-breathing in the absence of disease).

Therapy can start with breath support, DIAPHRAGMATIC breathing, relaxation techniques.

What strategies can be used for tension in the shoulders, neck and jaw prior to therapy?

Discrete stretching exercises

Progressive muscle relaxation

What strategies can be used for laryngeal constriction prior to therapy?

Laryngeal manipulation: diagnosis and treatment of muscle tension imbalance using techniques from osteopathic medecine including palpation, postural correction and specific laryngeal stretches to improve vocal function.

What are symptoms of over-breathing?

Air hunger: yawning, signing, gasping

Mouth-breathing

Rapid rate of breathing

Upper chest breathing

Tension/movement in shoulders when breathing

Breath-holding

What are common causes to changes in breathing pattern?

Co-morbidities such as asthma, bronchiectasis, COPD as they restrict airflow.

Locking the abdomen e.g. postural change, sports, anxiety, to look slimmer e.g. in pilates/ ballet

Increased rate of expiration in different emotional states (fight or flight response), face mask, infection.

Increased upper body tension, larynx.

Reduced breath support due to pressed airflow

Mouth-breathing

What direct therapy techniques are used for breathing?

Become aware of breath support to power the voice and the effect of tension/changes in breathing patterns.

Breathing exercises work on the out breath to increase airflow through the vocal cords.

We encourage slow, quiet nose breathing (filters the air, regulates the airflow, reduces risk of hyperventilation and air hunger)

Encourage Diaphragmatic breathing: uses less muscular effort and increases the volume of air to support speech or singing; can be topped-up quickly to replenish the breath

When voicing, we combine the airflow on the out-breath with the vibration of the vocal cords.

What effect does SOVT work on the principles of?

The Bernoulli Effect: Velocity increases as fluid moves through a small space > increase in velocity creates an area of low pressure > systems pull towards areas of low pressure

What is SOVT?

Semi-Occlusion Vocal Tract exercises.

By narrowing the vocal tract at the lips or tongue, we increase intra-oral pressure > slows down the velocity and cushions the vocal cords, leading to more gentle initiation of voice and vocal cord vibration with less effort requires, thus releasing laryngeal constriction.

SOVT focuses on airflow and sound production away from the vocal cords, through the vocal tract.

Holistic direct therapies use SOVT by working on all 3 components of voicing.

What are the 3 components of voicing?

Power

Source

Filter

What are examples of holistic direct therapies which utilise SOVT?

Lax Vox: a straw adds resistance to airflow and lengthens the vocal tract (Markhetta Sivho, 1991).

Accent method: where we coordinate airflow and voicing, adding occlusion with fricatives (Thyme-Frokjaer & Frokjaer-Jense, 2001).

What are examples of discrete direct therapies using SOVT that work on a specific component of voicing/ specific muscle group?

Humming: SOVT technique that focuses on forward placement of sound for resonance.

Yawn: builds upon the muscles changes that yawning naturally brings about > patients get a good sensation of laryngeal opening.

Maintain comfortable vocal effort = Voice Onsets, Sob, Twang, Belt (Estill, 2017)

What psychological approaches might be integrated into direct therapy for muscle tension imbalance?

CBT

Mindfulness

NLP

Solution focused brief therapy

What is the hierarchy of therapy progression?

1. general awareness of breath, tension, effort and placement of voice

2. establish optimum voice using an appropriate vocal gesture

3. CV/VC combinations

4. single words containing the target sound

5. shape techniques to more normal voice

6. automatic speech

7. generalisation

How can you make sure you are giving specific feedback in therapy?

Tell them why… how does it sound/feel/look?

Be encouraging but tell the truth and be accurate

Write it down

Record it

Review their practice first e.g. start of the session,”can you show me how you have been practicing your voice exercises?”

Does one therapy technique fit all patients with the same voice disorder?

NO: PATIENT-LED THERAPY

The same disorder can occur with a different cause.

Different patients will find different therapy techniques easier/ more comfortable

Try different techniques to find out which approach works best and alter techniques in response to what we see and hear

Is direct or indirect therapy more effective?

There is no universal consensus

Some studies favour direct and some favour indirect.

Often in treatment, we use a combined approach (CARDING ET AL., 2008)

What is the typical goals formula for a combined approach to treatment?

1. increase understanding of normal voice and nature of their voice problem

2. indirect advice e.g. vocal hygiene, environmental adaptation, internal/external triggers, psychological factors, medications

3. Direct voice exercises e.g. work on vocal tract postures, decrease maladaptive vocal tract behaviours, voice resonance and projection

What is a GIC and what is it’s purpose?

Gender Identity Clinic

A specialist MDT centre of excellence with the remit to provide treatment for the safe and sustainable alleviation of gender dysphoria, and exploration of gender identity

Offer voice modification therapy in combination with other treatments

What is an SLT’s role in trans voice?

We deliver voice modification therapy to assist trans and gender-diverse people in creating and sustaining their authentic voice, congruent with their sense of self (Mills & Stoneham, 2017)

Treatment involves voice coaching and changing vocal parameters such as…

• pitch

• breath support

• resonance

• volume

• articulation

• intonation

• non-verbal communication

Psychological approaches to support voice change process, including self-efficacy and confidence and the transfer of skills into social situations (Mills & Stoneham, 2017).

what is gender dysphoria?

Describes a sense of unease that a person may have because of a mismatch between their biological s*x and their gender identity > can lead to depression and anxiety

What is voice feminisation surgery?

The perception of voice change from masculine to feminine

It is considered an essential part of care for transgender women

Trans women trying to feminise their voice represent the largest group seeking SLT services

Works on pitch and resonance

What does voice modification for trans men involve?

The lowering of the speaking fundamental frequency (pitch)

Voice therapy is generally not required for trans men as the effects of hormone therapy often result in a deeper pitch

What is the voice quality of a patient with Primary Muscle Tension Imbalance?

Rough, Breathy, Strained, harsh

hard glottal attack

excessively high/low habitual pitch

extreme/ reduced intonation patterns

reduced pitch range

excessively loud or quiet

What is a psychogenic voice disorder?

Dysphonia/aphonia resulting from psychosocial stress, triggered by emotional conflicts (Andersson & Schlalen, 1998)

Unable to produce phonation voluntarily, despite vocal folds that look normal and fully mobile and achieve full closure and phonation for vegetative functions (Harris et al., 2018)

When does voice change become a psychogenic disorder?

When the change is not in he moment of overt emotional distress

When the patient isn’t aware of emotion/ unable to express emotion

When the patient is mentally coping and just getting on with it

When they perceive emotion as a weakness