Treatment of Voice Disorders: Voice Therapy Notes

Treatment Planning and Issues

Evaluation identifies if voice production issues are Structural, Behavioral, or both. Treatment employs Counseling, Motivational Interviewing, and Lifestyle Modification to improve function and change maladaptive vocal patterns.

Vocal Health and Hygiene

  • Systemic Hydration: What is consumed (drinking).

  • Surface Hydration: Steam inhalation or the use of a humidifier.

  • Dehydration (Verdolini): Results in increased subglottic pressure and vocal effort, deteriorates voice quality, and increases phonotrauma risk. Water intake is referenced relative to the figure 721721.

Reflux and Behavioral Management

Reflux is a mechanical problem managed via:

  • Eating Habits: Avoiding triggers like spicy, greasy, acidic foods, chocolate, and carbonation.

  • Medication: PPI or H2 Blocker.

  • Physical Strategies: Bed wedges or elevating the head of the bed.

  • Stress management.

Behavioral management focuses on reducing vocally traumatic habits (e.g., chronic coughing/clearing). Handouts should be simple and use positive "Do" language for lifestyle modification.

Voice Therapy and SOVT Exercises

Therapy aims to coordinate respiration, phonation, and resonance. Most techniques use a Semi-Occluded Vocal Tract (SOVT) (Titze, 2006):

  • Function: Narrows the vocal tract to maximize interaction between the sound source and filter, providing steady back pressure to reduce tension and collision force.

  • Exercise Hierarchy (High to Low Resistance): Straw phonation, Humming, Voiced fricatives, Lip/tongue trills, Nasal consonants, and High vowels.

  • Straw Phonation: Narrows/lengthens the tract; resistance varies based on straw length and diameter.

  • Lip Trills: Improve breath support and provide oral cavity pressure signals to reduce "pushing."

Resonant Voice and Airflow Facilitators

  • Resonant Voice Therapy (RVT): Focuses on vibrations in the oral cavity (lips, face) to improve efficiency.

  • Lessac-Madsen Resonant Voice Therapy (LMRVT) (Verdolini): A packaged program transitioning from basic gestures to conversation.

  • Vocal Function Exercises (Stemple): A set of 44 systematic exercises (warm up, stretching, contraction, adductory power) to coordinate laryngeal function.

  • Lax Vox / Cup bubble: Phonation into water.

  • Twang (Estill method): Increases intensity and efficiency with low effort via vocal tract narrowing.

  • Stretch and Flow Phonation (Stone & Casteel): Focuses on steady air release and biofeedback (e.g., tissue) to treat hyperfunction.

  • Flow Phonation (Gardner-Schmidt): A modified version of stretch and flow that maintains a normal speaking rate.

Specialized Facilitators

  • Confidential Voice: A quiet, breathy, temporary voice used to prevent waking others.

  • Yawn-Sigh: Widens the throat and mouth to produce gentle glottal attack.

  • Chewing/Open-Mouth: Reduces jaw tension and improves resonance.

  • Redirected Phonation: Uses vegetative sounds (coughing, laughing, gargling) to establish phonation in cases of functional aphonia.

  • Glottal Fry/Inhalation Phonation: Relaxed modes used to reduce hyperfunction or treat aphonia.

Strengthening and Breathing

  • Strengthening (Closure/TA and Pitch/CT): Do not attempt if excessive strain exists.

  • Lee Silverman Voice Treatment (LSVT): "Think Loud!" for Parkinson’s.

  • SPEAK OUT!: Speaking with intent for Parkinson’s.

  • PhoRTE (Hapner & Zeigler): High intensity vocal exercise for presbyphonia.

  • Breathing: Low-centered abdominal/diaphragmatic breathing (Inhale = inflate; Exhale = deflate/support).

Therapy Delivery (Verdolini)

The "un-scared voice therapy" approach follows:

  1. Scan: Identify what needs changing.

  2. Gel: Encourage the patient to feel the desired vibration or change.

  3. Show: Modeling and tactile cues.

  4. Tell: Specific verbal instructions to modify production.