Management of Voice Disorders

Objectives

  • Be aware of the types of management options available.

  • Understand the difference between direct and indirect techniques.

  • Describe the logical hierarchy in therapy delivery.

  • Have a basic knowledge of therapy techniques.

  • Apply the above to a range of case studies.

Possible Treatment Options

  • Discharge from therapy when appropriate.

  • Reassurance when the problem is resolved or if the patient is not motivated for therapy.

  • Treatment options include:

    • Advice which may involve:

    • Vocal hygiene.

    • Medication.

    • Guidance for patient-initiated follow-up- soft discharge.

    • Review of progress leading to discharge.

    • Direct therapy.

    • Surgical interventions, potentially involving pre- or post-operative therapy.

Surgical Intervention

  • Surgical procedures are generally reserved for specific lesions or structural issues. Examples include:

    • Vocal fold palsy or paresis.

    • Presence of cysts, polyps, or nodules.

    • The condition of sulcus or atrophy.

    • Surgical assessment may require better imaging techniques and tactile examination for lesions or mucosal changes.

    • Procedures may take place in an operating room or in an office setting.

    • Microlaryngoscopy:

    • An intervention that can be performed under general anesthesia or sedation.

    • Used for diagnostic purposes, biopsy, and potentially therapeutic action.

    • Techniques like laser surgery, cold steel, debridement, or steroid injections may be utilized.

    • Implants may also be used for vocal fold paralysis.

    • In-office procedures usually utilize local anesthetic for vocal fold injections (e.g., Botox), which are typically temporary.

    • Trans-nasal oesophagoscopy (TNO) involves accessing the esophagus via a nasal passage.

  • Can be done as temporary measures.

Medicinal Management

  • Laryngopharyngeal reflux (LPR):

    • Treatment typically includes Alginate suspension (e.g., Gaviscon Advance), recognized as effective (O’Hara et al., 2020).

    • Historically, proton pump inhibitors (PPIs) such as Lansoprazole or Omeprazole have been utilized.

    • Lifestyle modifications involving dietary and behavioral changes are recommended.

  • HPV vaccine:

    • Administered to reduce the risk of recurrence in cases of Recurrent Respiratory Papilloma (RRP).

  • Antibiotics and steroids:

    • May be utilized for chronic laryngitis, infections, or edema associated with voice disorders.

Voice Therapy

  • Voice therapy is characterized by two major approaches: Indirect and Direct techniques.

Indirect vs. Direct Therapy

  • Indirect Therapy:

    • Focuses on overall education, vocal hygiene, maintaining a voice diary, awareness of vocal effort, relaxation, counseling, and making environmental changes.

    • Incorporating aids such as amplification.

  • Direct Therapy:

    • Encompasses techniques like posture and alignment adjustments, techniques for stretch and release to promote relaxation, managing airflow and breath patterns, and specific exercises for glottic closure and safe projection.

    • Emphasis on a mixture of both indirect and direct therapies has been shown to yield significant improvements (Carding, 2017).

Indirect Therapy: Vocal Hygiene

  • Hydration:

    • The vocal folds' uppermost layer comprises mucosal epithelium needing lubrication for effective sound production.

    • Dehydration risk includes irritation and potential cyst formation.

    • Systemic hydration is achieved through fluid consumption (2-2.5 liters recommended daily, increased if on drying medications or experience high vocal load).

    • Direct hydration via steam or nebulizer is beneficial for softening tense muscles and provides opportunities for voice rest.

  • Throat Clearing:

    • Often a response to irritation from reflux or allergens, but this can become habitual.

    • Management suggestions include sipping water, inhaling through the nose, and exhaling through pursed lips.

  • Irritants:

    • Identification of irritants:

    • Smoke, vaping, industrial dust, pet hair, and various fumes contribute to laryngeal discomfort.

    • Recommendations are to reduce exposure by limiting sprays, quitting smoking, using inhalers correctly, and wearing masks when necessary.

  • Reflux Management:

    • Understanding different types of reflux (GORD, LPR, and silent reflux) and their management through medicinal, dietary, and behavioral methods.

    • Suggestions for dietary changes include avoiding late meals, reducing alcohol/caffeine intake, and promoting stress management.

  • Vocal Load:

    • Assessment of vocal demands is crucial, especially for professional users.

    • Techniques include managing background noise and promoting voice rest to prevent habitual overexertion.

Direct Therapy Techniques

  • Posture and Alignment:

    • Correct alignment minimizes tension and impacts voice production positively.

  • Stretch and Release:

    • Targeting tension through physical activities such as shoulder rolls and neck stretches to promote ease of voice production.

  • Airflow & Breath Techniques:

    • The role of efficient breathing patterns in optimal voice production.

    • Diaphragmatic breathing techniques to improve lung capacity and overall vocal performance.

    • Biofeedback- having to re-train them to do this.

  • Release of Constriction:

    • Strategies to reduce tension in the vocal tract, involving various exercises and approaches to alleviate tension throughout the body.

    • Bootstrap it to something that you already do e.g. when making a phonecall.

  • Resonant Voice Therapy (Stemple, 2007):

    • Focus on creating oral and facial vibrations that lead to an easier phonation process.

    • Incorporates a range of activities aimed at achieving resonance with minimal vocal strain.

Additional Therapy Approaches

  • Recognition of various methods for treating hyperfunctional or hypofunctional voice disorders, emphasizing the significance of understanding anatomical and physiological principles along with creative exploration in therapy.

Voice Therapy in Practice

  • Patient Referral Example (Case Study: Sarah):

    • Referral to speech-language therapy (SLT) for intermittent hoarseness and discomfort.

    • Assessment reveals:

    • Normal larynx structure but signs of muscle tension.

    • Identified issues: Poor vocal hygiene, stress, high vocal load, and neck/shoulder tension.

  • Assessment Summary:

    • Observed dehydration, potential laryngeal reflux, anxiety impacts, and functional issues leading to poor phonation and airflow constraints.

  • Therapy Options for Sarah:

    • Combined indirect and direct approaches to address vocal hygiene and alignment, utilizing techniques like mindfulness, relaxation, and integration of respiratory exercises.

Conclusion

  • Addressing voice disorders requires a comprehensive understanding of both theoretical and practical elements in voice management and a flexible therapeutic approach that can adapt to individual patient needs.