Sunday, April 28, 2013

Questions to Ask

Being diagnosed with a voice disorder can be devastating, it can greatly impact one's life emotionally, socially and professionally.

It is important to know what questions or information to ask your physician or speech therapist to acquire as much information as possible about your diagnosis. The following suggestions and questions may be helpful:

In a conversation with your physician, ask about:
  • Whether your voice disorder coincides with another illness.
  • Is it temporary or permanent?
  • The genetics and familial heredity that may be linked to your voice disorder.
  • Long term verses short term outcomes?
  • Medications I can take to help my voice improve?
  • The possibility of using Botox treatment?
  • Is surgical intervention necessary? If so, what are the risks and expected outcomes?

In a conversation with your Speech Pathologist, make sure you discuss the following:

  • Vocal hygiene
  • Vocal misuse
  • Stressors: physical or emotional
  • Supplemental treatments: massage, progressive relaxation techniques, breathing, etc.
  • Expected outcomes of treatment
  • Your responsibilities outside of treatment, e.g., a home program

Coping with your Voice Disorder

It is important that one receives therapeutic counseling regarding your a disorder whether, it is mild or severe. Our voice is a major communication tool in our daily life and to have it altered or lost permanently in any way can be devastating. 

Many feelings may arise when dealing with a voice disorder, such as:
  • frustration
  • inadequacy
  • self doubt
  • isolation
  • fear
  • disappointment
  • isolation
  • alone
  • loss of their identity

It is essential that you give yourself an outlet for these feelings so you can cope with your disorder in a healthy and helpful way. There are a variety of people whom you can speak to about the emotions that come with the diagnosis of a voice disorder, such as a speech and language pathologist, a physician, a counselor, or a therapist. Local support groups may also be a helpful way to connect with other people who may be sharing your experiences and finding support. Ask your physician or speech and language pathologist for information about local support groups or therapists who they recommend.



Monday, April 22, 2013

Laryngitis: A Teacher's Take


Overview:

Laryngitis is one of the most common conditions identified in the larynx. Laryngitis, as its name implies, is an inflammation of the larynx. Symptoms of laryngitis can include some or all of the following:
  • Hoarseness
  • Weak voice or voice loss
  • Tickling sensation and rawness of your throat
  • Sore throat
  • Dry throat
  • Dry cough

It comes in both acute and chronic forms. Acute laryngitis has an abrupt onset and is usually self-limited. The causes of acute laryngitis include vocal misuse, exposure to noxious agents, or infectious agents leading to upper respiratory tract infections. These infectious agents are most often viral, however they can also be bacterial in nature. Chronic laryngitis takes longer to develop and involves a longer duration of symptoms. Chronic laryngitis may be caused by environmental factors such as cigarette smoke, polluted air, irritation from asthma inhalers, reflux disease, or vocal misuseVocal misuse causes the vocal folds to come together with excessive force, and this friction causes swelling.
Although acute laryngitis is usually not a result of vocal abuse, vocal abuse is often a result of acute laryngitis because the underlying infection or inflammation results in a hoarse voice. Typically, the patient exacerbates this by misusing their voice in an attempt to maintain premorbid phonating ability.
The following are recommended home remedies for the symptoms associated with laryngitis:
  • Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate, e.g., from a cool mist humidifier
  • Complete voice rest is suggested, although this recommendation is nearly impossible to follow. If the patient must speak, soft sighing phonation is best. Avoidance of whispering is best, as whispering promotes hyper-functioning of the larynx.
  • Inhaling steam, e.g., from a hot bath or shower

Laryngitis in Schools:

An ATL survey, conducted in March, 2008, surveyed 490 teachers working in maintained and independent schools in England, Wales, Northern Ireland and Scotland.
Overall 60% of the respondents had experienced voice problems, with 68%of teachers working in maintained schools experiencing voice problems compared to 57% in independent schools.
However, 42% of the teachers who had experienced voice problems shared that their school had offered "little or no support" when problems occurred. 20% said that their school had shown them no support, and an additional 22% had found their school to be quite unsupportive.

A Teacher's Take:

Caren Sowa is a first grade teacher at Carver Elementary School in Carver Massachusetts. Here is a guest blog with her perspective on the condition:

Every December, like clockwork, I find myself with an upper respiratory infection. Within days, I am battling laryngitis as well, with a sore throat and an increasingly hoarse voice. Eventually my voice will turn from hoarse to completely gone. As a first grade teacher of 25+ loud, enthusiastic, and energetic students, this is always an issue as I use my voice for hours each day.

My school was built in the 1950s, when "pod-style" schools were popular. Without permanent walls, classrooms could be combined and co-taught as necessary. While that style of teaching may have been effective at the time, we are no longer collaborating and co-teaching. The once-flexible design is now a hinderance as we are constantly battling background noise from neighboring classrooms and the noise from children and staff in the hallways. I have done my best to insulate my classroom with rugs, curtains, and tall bookshelves where a wall does not exist. However, the heightened sound level affects my speaking style every moment I am teaching.

Our school curriculum uses center-based activities for many of our subjects. My already-noisy classroom turns into an even louder environment at this time, as my students collaborate with their classmates at several different stations around the classroom. When it is time to alert them to switch, I am using my voice to project over this noise. This is just one example of the strain I put my voice through. While I have been told by my physician that my laryngitis is caused by my upper respiratory infections and not the vocal strain, I am also aware that how I use my voice while I have laryngitis does not make matters better. 

For the first couple of times I had laryngitis, I did my best to battle it, and used my loudest, whisper of a voice possible. Eventually I adopted a few tricks that may be helpful to other teachers (or those of other occupations who rely on their voice). Here are a few of them:
  • Use bells, timers, or other mechanisms to get your students' attention
  • Keep hydrated- I make sure to drink extra water at this time, but also prefer tea
  • Use a humidifier at home- I have one in my home office and bedroom, and have started using them as soon as the weather gets cold and dry
  • Come up with clever, reward based systems to get your students to help you- I usually promote a helper at the end of each day (based on behavior or other factors) who will help me the following day. I will sometimes give this student directions to dictate to the class. (It can also be a fun way to incorporate reading if you are a first grade teacher... try writing out simple directions on a small dry erase board for them to read to the class!)
  • Keep classroom noise as low as possible so that you do not have to strain your voice even more to talk
My best piece of advice is to take some time to recover and get well. The vocal rest will aid in your throat's recover, and the time off will help with the underlying ailment that caused the laryngitis in the first place. My second piece of advice is to advantage of your resources right in your building, and talk to your speech and language pathologist. They are trained to deal with voice problems such as this and can give you more great advice on how to implement strategies to deal with your laryngitis when it arises. They may also help with vocal preservation, or learning to use your voice appropriately to prevent general vocal abuse.

Psychogenic Disorders

Cause:

Conversion Dysphonia/Aphonia , this disorder can manifest when there is a psychological trauma or event that occurs. These events can cause a person to lose their ability to speak (Aphonia) or change their voice quality (Conversion Dysphonia).  Events can include: death or an accident.
The event can also be a long term psychological event, something that the person experiences in the past or in a chronic fashion such as, sexual or emotional abuse, and neglect, or depression and anxiety/stress-  which can cause an alteration of the voice Conversion Dysphonia) or cause the person to lose their voice (Aphonia).

Symptoms:

The voice can have varying characteristics and symptoms unique to each person, some symptoms may not be mentioned:

  • pitch: high to low
  • volume: loud to soft
  • breathy
  • strained
Click here for a sample of this disorder.
 
Treatment:

Functional voice therapy can be helpful, but often times the voice disorder will not resolve unless the person undergoes functional voice therapy in addition to counseling. Sometimes surgery will be helpful or Botox injections, however then it may be another cause for the disorder


References:

Aronson, A.(1990) Clinical Voice Disorders an interdisciplinary approach (3rd Ed.) Thieme Medical Publishers Medical Inc.: New York

 Koufman JA, Isaacson G. The spectrum of vocal dysfunction. Otolaryngol Clin North Am. Oct 1991;24(5):985-8.

Baker, J. (2003).   Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports. Journal of Voice. 17(3)     308-318

http://www.edgarcayce.org/are/holistic_health/data/prapho3.html

http://www.lionsvoiceclinic.umn.edu/page3b.htm
 
http://www.pediastaff.com/resources-dysphonia-muscle-tension-dysphonia-pediatric-implications--october-2009



Other Neurogenic Voice Disorders

Overview & Cause:


Other Neurologic Diseases may cause voice disorders or voice problems may develop as a symptom of the following disorders:
  • Parkinson's Disease (PD): a degenerative disorder of the central nervous system, symptoms include motor impairments due to death of dopamine generating cells in the mid brain. Motor impairments include: shaking, rigidity, slowness of initiation to start moving or speaking. Can see tremor in the hands or entire body and gait when walking. The voice can become dysphonic or in severe cases aphonic. The voice may be hoarse and breathy, monopitch and monoloud.
  • Myasthenia Gravis (MG): chronic autoimmune disease causing weakness and fatigue. Can affect voluntary muscles of the body such as: the eyes, the mouth, the throat and the limbs. Voice may be breathy, monotone. monoloudness, voice fatigues with use- recover with rest.
  • Amyotrophic Lateral Sclerosis (ALS, a.k.a. Lou Gherig's disease): neurodegenerative disease that affects nerve cells in the brain and spinal cord, upper motor neuron (UMN) or lower motor neuron (LMN). Symptoms include: LMN symptoms: atrophy, fasciculations, weakness and UMN symptoms: tight, stiff muscles, spasticity/rigidity and exaggerated reflexes (Hypereflexia) dysphagia (swallowing difficulty),  and difficulty speaking. These patients can exhibit pseudobulbar affect or "emotional lability". Voice quality can present in a mixed fashion since this is characterized as a Mixed Dysarthria: the voice can be hypernasal, strain/strangled, slow effortful, monopitch, monoloudness, decreased range of motion.
  • Stroke (Cerebrovascular Accident CVA): limited or no brain function due to loss of blood supply to the brain. This can be due to Ischemia - lack of blood flow caused by, a blockage (Thrombosis or Arterial Embolism or hemorrhage. Symptoms of strokes vary as does severity but they include inability to move one side of the body, inability to understand or formulate speech and inability to see one side of the visual field. Voice qualities and problems can vary dependent on the stoke, lesion location and severity.
  • Traumatic Brain Injury (TBI): this is a closed or penetrating injury to the brain which can have varying symptoms and outcomes. It can be widespread  or focal damage. It is a major cause of disability and death. It is more common in males than females. Voice disorders concomitant with TBI vary depending on each patient. Often times a voice disorder that coexists with these disorders is termed as dysarthria.


Symptoms:

Parkinson's Disease:

The following symptoms may be present:
  • Breathy voice
  • Monopitch
  • Monoloudness
  • Short, fast rushes of speech
  • Trouble with initiating speech

Myasthenia Gravis:

The following symptoms may be present:
  • Monotone
  • Monoloudness
  • Fatigue with vocal use

Amyotrophic Lateral Sclerosis:

The following symptoms may be present:
  • Strained and strangled sounding voice
  • Hyponasal vocal quality
  • Slow and effortful speech
  • Monoloudness (reduced volume)
  • Monopitch
  • Breathy voice

Stroke/CVA:

The quality of voice and symptoms depend on the location and the severity of the stoke.

Traumatic Brain Injury:

The quality of voice and symptoms depend on the location and the severity of the injury.

Treatment:


In regards to these neurogenic disorders treatment varies depending on the person and how they are affected. The treatment given may help the primary disease or disorder and in addition a voice treatment will be given such as Botox injections or surgery.  See the Treatment sections on Spasmodic Dysphonia and Paralysis/Paresis for some applicable information.

Functional Voice Therapy will be helpful for all these types of Neurogenic Disorders- depending on the symptoms presented voice therapy would work on: pitch, rate, timing, prosody, volume, stress (word and sentence), word finding, vocabulary and several different communication modalities: sign language, communication boards, Alternative Augmentative Communication devices (AAC) would also be an option for a patient who loses their ability to speak or if it becomes effortful over time. You can find more information here.


Parkinson's Disease, patients with voice disorders with PD have benefitted from the Lee Silverman Voice Treatment (LSVT ). This treatment is specifically directed toward PD and focuses on intensive high effort speech exercises and increasing vocal loudness in a healthy way. For more information on LSVT, click here.

Here are two videos that may be helpful:

       Video 1: Think Big

       Video 2: Think Big, 2 Years Later

Myasthenia Gravis (MG) can be treated in different ways. As fatigue is an associated symptom that affect both gross motor movements and speech productions, oral medications that reduce fatigue are helpful. ALS, stroke & traumatic brain injury are all treated in various different ways, as the symptoms themselves are treated depending on their severity.

References:


Ramig, L., Verdolini, K. (1998). Treatment Efficacy Voice Disorders. Journal of Speech, Language and Hearing Research, (41), S101-S116.


Ramig, LO., Fox, C., Sapir, S. (2004). Parkinsons disease: speech and voice disorders and their treatment with the Lee Silverman Voice Treatment. Semin Speech Language. (2) 169-80.


Watts, C., Vanryckeghem, M. (2001).Laryngeal Dysfunction in ALS: a review and case report. BMC Ear, Nose and Throat Disorders. 1;1.




Sunday, April 21, 2013

About Us

Who are we?

Lindsey Sowa and Erin Carroll are Master's students in the communication disorders program at the University of Massachusetts Amherst. This blog was created as a counseling resource for their fellow classmates and future students of their program. Lindsey and Erin are not professionals, so this blog is not meant to be a diagnostic tool, rather an informative site for one to gather information and relevant sources of information.

Lindsey and Erin can be reached via email through this blog. Any questions or feedback are welcome.


Saturday, April 20, 2013

References:

For additional information, please see the following websites and journals that we have found informative:

Contact Ulcer:

Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. Aug 2009;13(8):1422-9. 

Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52.

Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas.Laryngoscope. Feb 1999;109(2 Pt 1):301-6.

Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3.



Vocal Fold Cyst:

Beham AW, Puellmann K, Laird R, Fuchs T, Streich R, Breysach C, et al. A TNF-regulated recombinatorial macrophage immune receptor implicated in granuloma formation in tuberculosis. PLoS Pathog. Nov 2011;7(11):e1002375. 


Jackson C. Contact ulcer of the larynx. Ann Otol Rhinol Laryngol. 1928;37:227-30.


Jackson C, Jackson CL. Contact ulcer of the larynx. Arch Otolaryngol. 1935;22:1-15.

Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest SurgAug 2009;13(8):1422-9.

Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52.


de Lima Pontes PA, De Biase NG, Gadelha EC. Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope. Feb 1999;109(2 Pt 1):289-94.


Gould WJ, Rubin JS, Yanagisawa E. Benign vocal fold pathology through the eyes of the laryngologist. In: Rubin JS, ed. Diagnosis and Treatment of Voice Disorders. New York, NY:. Igaku-Shoin;1995:146-9.


Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas.Laryngoscope. Feb 1999;109(2 Pt 1):301-6. 


Nasri S, Sercarz JA, McAlpin T, Berke GS. Treatment of vocal fold granuloma using botulinum toxin type A. Laryngoscope. Jun 1995;105(6):585-8. 


Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3.


Wenig BM, Heffner DK. Contact ulcers of the larynx. A reacquaintance with the pathology of an often underdiagnosed entity. Arch Pathol Lab Med. Aug 1990;114(8):825-8.


Paralysis/Paresis of the Vocal Folds:

Bastian RW; Delsupehe KG. Indirect larynx and pharynx surgery: a replacement for direct laryngoscopy. Laryngoscope 1996 Oct;106(10):1280-6
Boone, D., McFarlane, S., Von Berg S. (2005). The voice and voice therapy (7th ed.). New York: Allyn & Bacon

Colton, R, Casper J., Leonard, R. (2006). Understanding voice problems: A physiological perspective for diagnosis and treatment (3rd ed.). New York: Lippincott Williams and Wilkins

Roth, F.P and Worthington, C.K. (2001). Intervention for voice and alaryngeal speech. InTreatment resource manual for speech-language pathology, 2nd ed. Albany, NY; Singular Thomson Learning.



Vocal Fold Nodule:

Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The Clinicopathologic Spectrum of Benign Mass Lesions of the Vocal Fold due to Vocal Abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.


Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol. Sep 1995;104(9 Pt 1):698-703. 


Hogikyan ND, Appel S, Guinn LW, et al. Vocal fold nodules in adult singers: regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing. J Voice. Mar 1999;13(1):128-42.


Gray SD, Titze I, Lusk RP. Electron microscopy of hyperphonated canine vocal cords. J Voice. 1987;1(1):109-115.


Kuhn J, Toohill RJ, Ulualp SO, et al. Pharyngeal acid reflux events in patients with vocal cord nodules.Laryngoscope. Aug 1998;108(8 Pt 1):1146-9. 


Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of Vocal Fold Polyps With Conservative Treatment. J Voice. Nov 12 2011


Ragab SM, Elsheikh MN, Saafan ME, et al. Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol. Dec 2005;119(12):961-6. 




Vocal Fold Hemorrhage:

Postma GN, Courey MS, Ossoff RH. Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol. Jun 1998;107(6):472-6. 


Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.


Hochman I, Sataloff RT, Hillman RE, et al. Ectasias and varices of the vocal fold: clearing the striking zone.Ann Otol Rhinol Laryngol. Jan 1999;108(1):10-6. 


Ivey CM, Woo P, Altman KW, et al. Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study. Ann Otol Rhinol Laryngol. May 2008;117(5):353-8. 


Burns JA, Friedman AD, Lutch MJ, Zeitels SM. Subepithelial vocal fold infusion: a useful diagnostic and therapeutic technique. Ann Otol Rhinol Laryngol. Apr 2012;121(4):224-30. 


Franz P, Aharinejad S. The microvasculature of the larynx: a scanning electron microscopic study.Scanning Microsc. Mar 1994;8(1):125-30; discussion 131. 


Frenzel H, Kleinsasser O. Ultrastructural study on the small blood vessels of human vocal cords. Arch Otorhinolaryngol. 1982;236(2):147-60. 


Hsiung MW, Kang BH, Su WF, et al. Clearing microvascular lesions of the true vocal fold with the KTP/532 laser. Ann Otol Rhinol Laryngol. Jun 2003;112(6):534-9. 


Lin P, Stern JC, Gould WJ. Risk factors and management of vocal fold hemorrhages. J Voice. 1991;5:74-7.





Muscle Tension Dysphonia:



Spasmotic Dysphonia(SD)/Laryngeal Dystonia

SW., Baxter, M., Oates, J., Yorston, A,. (2009). Long term results of Type II Thyroplasty for adductor spasmodic dysphonia. The Larygoscope. V 114 (9) 1604-1608.

De Conde,A., Long,J., Armin, B., Berke, G. (2012). Functional reinnervation of vocal folds and selective laryngeal adductor denervation-reinnervation surgery for spasmodic dysphonia. Journal of Voice. V 25(5), 602-603.
Hajioff, D., RatenburyH., Carrie, S., Carding, P., Wilson, J. (2001). The effect of Isshiki type 1 thyroplasty on quality of life and vocal performance. Clinical Otolaryngology and Allied Sciences. Vol 25, Issue 5, 418-422.

http://www.pluralpublishing.com/media/media_vtcs_SamplePages.pdf


Benign Essential Voice Tremor: