Medical Voice Assessment and Treatment

Questão	Responda
How 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
General ENT vs. Laryngologist	Fellowship trained laryngologists are specialized in voice and airway disorders
Voice 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
Case 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
Perceptual Evaluation Types	1. GRBAS 2. CAPE-V 3. FITQ
Perceptual Evaluation: GRBAS	Scale from 0 (wfl) to 3 (severe) Grade roughness, breathiness, aesthenia, strain
Perceptual Evaluation: CAPE-V	Developed 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
Perceptual Evaluation: FITQ	Frequency (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
Acoustic Analysis: Acoustic Signs of Voice Problems	Fundamental 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)
Voice Hygiene Inventory	Hydration? (water; caffeinated vs. non beverage intake) Use of dehydrating agents? (Antihistamines, decongestants, diuretics) Inhaled Steroids? Reflux?
Assessing Vocally Abusive Behavior	Coughing, throat clearing, shouting/yelling/cheering, loud talking, prolonged voice use (vocational/avocational/rest breaks?), talking over ambient noise, singing
Evaluating Respiratory Support	s/z ratio (can also measure phonatory ability) Maximum phonation times Observation of respiratory zones Vital capacity (when available) Spirometry (when available) **Can evaluate perceptually
Respiratory Patterns: Types	Clavicular Thoracic Diaphragmatic Mixed Paradoxical
Assessing Upper Body Tension	Look at hyperkinetic muscular behaviors (shoulders, neck, larynx, base of tongue, jaw, abdomen, facial) Posture At rest/during phonation
Phonation	Rapid, periodic opening and closing of the glottis Steadiness of vocal fold vibration on prolonged vowel tasks Appropriate medial compression of VFs
Videostroboscopy	Accurate 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
Assessing Stimuability	Look at what they can do with minimal cues Shows prognosis for improvement Guides the decision making process for therapy progression or medical treatment
Physiologic vs. Symptomatic Therapy	Physiologic methods possess strongest support Efficacy of hygiene training is inconclusive Lack of evidence for symptomatic therapy
Physiologic 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)
Planning Physiologic Voice Therapy: Protocols	Use 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
Semi-Occluded Vocal Tract Exercise	Often 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
Resonant 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
Resonant Therapy: Process	1. 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
Resonant 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
Vocal Function Exercises: Definition	Series 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
Vocal Function Exercises: Types	Warming Up Stretching Contracting Adductory Strengthening
Vocal Function Exercises: Warm-Up	Sustain vowel /i/ for as long as possible on musical note F F above middle C for females and below middle C for males
Vocal Function Exercises: Stretching	Glide from lowest to highest pitch on the word "knoll", "whoop", hum, tongue trill, lip trill GOAL: no voice breaks
Vocal Function Exercises: Contracting	Glide from a comfortable high not to lowest note on the word "knoll", "boom", tongue trill, lip trill GOAL = no voice breaks
Features that must be assessed and addressed during vocal function exercises	Posture Breathing Placement Onset
It is important to know...	YOUR LIMITS if you are not comfortable, you can do more harm than good get trained!
Vocal Fold Nodules: Treatment	VOICE 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!)
Vocal 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
Microflap Technique	Incision 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
Injection Laryngoplasty	AKA: 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)
Thyroplasty	Medialization 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

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Medical Voice Assessment and Treatment

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	Criado por Linnea Larson quase 8 anos atrás