Flashcards
Medical Voice Assessment and Treatment
Cards in this deck (36)
- 1How to specialize in voice-Obtain CF at voice center or medical setting
-Summer Vocology Institute
- Join ASHA's SIG3 voice list
-Visit and observe laryngologists and voice clinicians at voice centers
-Attend national voice centers
-Take workshops or classes in theater oriented voice methods - 2General ENT vs. LaryngologistFellowship trained laryngologists are specialized in voice and airway disorders
- 3Voice Evaluation Includes:-Case History
-Perceptual analysis (FITQ)
-Assessment of vocal hygiene
-Acoustical analysis
-Videostroboscopy exam
-Assessment of respiratory support, upper body tension, stimulability
-Swallowing screen - 4Case History Includes:-Medical/Surgical history review
-Patient Interview (vocal symptoms/complaints; onset/duration of problem; history of previous problems)
-Clinical observation
-Stress/anxiety
-Social History - 5Perceptual Evaluation Types1. GRBAS
2. CAPE-V
3. FITQ - 6Perceptual Evaluation: GRBASScale from 0 (wfl) to 3 (severe)
Grade roughness, breathiness, aesthenia, strain - 7Perceptual Evaluation: CAPE-VDeveloped by ASHA Sig3
Variety of tasks: sustained vowels, sentence production, spontaneous speech
Rate parameters on a 100 point scale, indicating consistent or inconsistent (overall severity, roughness, breathiness, strain, pitch, loudness)
Allows for commentary on additional features and resonance - 8Perceptual Evaluation: FITQFrequency (too low, too high, monotone, pitch breaks)
Intensity (too soft, too loud, monotone, phonation breaks)
Timing (rhythmic changes too slow or too fast; late voice onset; early voice onset
Quality: Roughness, aesthenia, breathiness, constriction, hoarseness, harshness, haviness, falsetto, muffled, hyper/hyponasality, back-focused
*Rating 0 = normal; 1= abnormality to professional; 2= abnormality to untrained observer when pointed out; 3 = abnormality noticed by anyone - 9Acoustic Analysis: Acoustic Signs of Voice ProblemsFundamental Frequency (mean F0, frequency variability, phonation range, perturbation)
Amplitude (average SPL. amplitude variability, dynamic range, perturbation
Signal to Noise Ratio
Voice Tremor
Phonation Time
Voice Stoppages
Frequency Breaks
Cepstral analysis (connected speech) - 10Voice Hygiene InventoryHydration? (water; caffeinated vs. non beverage intake)
Use of dehydrating agents? (Antihistamines, decongestants, diuretics)
Inhaled Steroids?
Reflux? - 11Assessing Vocally Abusive BehaviorCoughing, throat clearing, shouting/yelling/cheering, loud talking, prolonged voice use (vocational/avocational/rest breaks?), talking over ambient noise, singing
- 12Evaluating Respiratory Supports/z ratio (can also measure phonatory ability)
Maximum phonation times
Observation of respiratory zones
Vital capacity (when available)
Spirometry (when available)
**Can evaluate perceptually - 13Respiratory Patterns: TypesClavicular
Thoracic
Diaphragmatic
Mixed
Paradoxical - 14Assessing Upper Body TensionLook at hyperkinetic muscular behaviors (shoulders, neck, larynx, base of tongue, jaw, abdomen, facial)
Posture
At rest/during phonation - 15PhonationRapid, periodic opening and closing of the glottis
Steadiness of vocal fold vibration on prolonged vowel tasks
Appropriate medial compression of VFs - 16VideostroboscopyAccurate interpretation is critical for accessing valuable information
Necessary in establishing or clarifying diagnoses
Valuable for pre and post documentation
Useful in evaluating effectiveness and impact of treatment procedures - 17Assessing StimuabilityLook at what they can do with minimal cues
Shows prognosis for improvement
Guides the decision making process for therapy progression or medical treatment - 18Physiologic vs. Symptomatic TherapyPhysiologic methods possess strongest support
Efficacy of hygiene training is inconclusive
Lack of evidence for symptomatic therapy - 19Physiologic Voice Therapy-Modification of underlying physiology of voice producing mechanism
-Coordinate/balance vocal subsystems (respiration-breath support, phonation-laryngeal muscle strenght + control + stamina, resonation- supraglottic modification of laryngeal tone/resonance) - 20Planning Physiologic Voice Therapy: ProtocolsUse a combo of methods
1. Establish within normal limits efficient phonation in absence of tension
2. Extend normalized physiology into conversational speech
3. Combinations of Resonant Voice Therapy (RVT), Vocal Function Exercises (VFEs), Semi-occluded vocal tract, and stretch & flow - 21Semi-Occluded Vocal Tract ExerciseOften used as stimulability indicator or warm-up technique
Primarily used for therapeutic purposes
Optimizes vocal subsystems (lip trills, tongue trills, straw, hums/continuants)
Can be difficult to generalize - 22Resonant Voice Therapy: Basics-Teaches patient concept of forward tone focus
-Sensory and Auditory feedback
-Similar approaches for voice restoration and enhancing normal voice
-Training is to mastery
-Singular training focus
-Training is results driven
-Greatest possible precision during perceptual tasks is vital for success - 23Resonant Therapy: Process1. Hum in isolation
2. When hum is consistent and correct move to hum + molm, molm, molm or have patient slowly open mouth while maintaining frontal focus
3. Produce molm-molm-molm as speech/nonsense phrase varying rate, pitch, and loudness
4. Advance along hierarchical speech talks
5. Use chant talk, all voice or voiced/voiceless
6. Advance to normal pitch inflection
7. Have patient attend to linking/connecting words - 24Resonant Voice Therapy: Generalization-Read paragraph with phrase markers and separate each phrase only by natural inhalation of air
-If patient has difficulty, break down sentence by sentence and then put back together
-Begin to use resonant voice in simple spontaneous speech tasks - 25Vocal Function Exercises: DefinitionSeries of systematic voice manipulations, similar to PT for vocal folds
Designed to strengthen, balance, and coordinate laryngeal musculature
Enhance relationship between three subsystems of voice productions - 26Vocal Function Exercises: TypesWarming Up
Stretching
Contracting
Adductory Strengthening - 27Vocal Function Exercises: Warm-UpSustain vowel /i/ for as long as possible on musical note F
F above middle C for females and below middle C for males - 28Vocal Function Exercises: StretchingGlide from lowest to highest pitch on the word "knoll", "whoop", hum, tongue trill, lip trill
GOAL: no voice breaks - 29Vocal Function Exercises: ContractingGlide from a comfortable high not to lowest note on the word "knoll", "boom", tongue trill, lip trill
GOAL = no voice breaks - 30Features that must be assessed and addressed during vocal function exercisesPosture
Breathing
Placement
Onset - 31It is important to know...YOUR LIMITS
if you are not comfortable, you can do more harm than good
get trained! - 32Vocal Fold Nodules: TreatmentVOICE THERAPY FOCUSED ON:
Vocal Hygiene
Management and pacing of vocal demands
Minimizing vocal abuse and misuse
Decreasing upper body tension
Optimizing coordination of vocal subsystems (stretch and flow, resonant voice therapy, generalization!) - 33Vocal Fold Polyp:VOICE THERAPY FOCUSED ON:
Vocal hygiene
Eliminating vocal abuse, overuse, and misuse
Management and pacing of vocal demands
Decreasing upper body tension
Optimizing coordination of vocal subsystems
Generalization of optimal voice to conversational speech
MICROFLAP TECHNIQUE - 34Microflap TechniqueIncision created lateral to pathology: preserves mucosa along medial edge and minimum scarring effect on vibration
Microflap is lifted
Pathology is removed
Microflap is redraped
Observe 5-7 days of complete voice rest and then patient follows schedule for graduated return to voicing - 35Injection LaryngoplastyAKA: Injection augmentation
Used to improve glottic closure
Typically with VF paralysis, VF paresis, VF atrophy, VF scar, sulcus vocalis, soft tissue loss of the VFs
Can be used as a temporary treatment to improve glottic insufficiency (trial vocal fold augmentation) - 36ThyroplastyMedialization laryngoplasty with implant
Implant is inserted medial to thyroid cartilage at level of VFs, pushing them medially
Medium-grade silastic wedge is used and carved to fit
Gained popularity due to simplicity, potential for reversibility, predictability of outcome