Linda Rammage

Diagnostic criteria in functional dysphonia

One thousand consecutive patients seen in a multidisciplinary voice clinic are reviewed. The incidence and relative severity of diagnostic features in each of five assessment areas are calculated and compared. The five areas include: 1. history, 2. laryngoscopic examination, 3. perceptual‐acoustic assessment, 4. voice related musculoskeletal, and 5. psychological evaluations. Feature prevalence is presented for patients we have classified as having muscular tension dysphonia, which can be primary, or associated with vocal nodules, chronic laryngitis, or polypoidal degeneration; or as having a psychogenic “functional” dysphonia. Following review of the data, we present a suggested list of diagnostic criteria that should be present before using a specific diagnostic label. These criteria have been further broken down into those that will be present to make a diagnosis, and those that may be present.

The Management of Voice Disorders

1 Evaluation of the voice disordered patient.- 2 Classification of muscle misuse voice disorders.- 3 Medical aspects of voice disorders.- 4 Approaches to voice therapy.- 5 Psychological management of the voice disordered patient.- 6 Psychological and neurological interactions in dysphonia.- 7 Pediatric voice disorders: special considerations.- 8 Voice disorders in the elderly.- 9 The singing teacher in the voice clinic.- 10 Anatomy and physiology of voice production.- 11 Basics of singing pedagogy.- Appendix A Antireflux instructions.- Appendix B Vocal rehabilitation exercises.- B.1 Vocal hygiene: how to get the best mileage from your voice.- B.2 Gravity and relaxation.- B.3 Dynamic alignment: optimizing posture for movement.- B.4 Specific relaxation: liberating the speech articulators.- B.4.1 Face.- B.4.2 Jaw.- B.4.3 Tongue.- B.4.4 Lips.- B.4.5 Throat.- B.5 Coordinated voice onset.- B.6 Feeding the resonators and mmmaking the mmmost of resonance.- B.7 Extending your dynamic pitch range.- B.7.1 Bubbling and frilling.- B.7.2 Vocal siren.

Injection Laryngoplasty With Hyaluronic Acid for Unilateral Vocal Cord Paralysis. Randomized Controlled Trial Comparing Two Different Particle Sizes

The objective was to determine if particle size affects durability of medialization in patients undergoing injection laryngoplasty (IL) with hyaluronic acid (HA) for unilateral vocal cord paralysis (UVCP). We hypothesized that large particle-size HA (LPHA) persists longer after injection to produce a more durable vocal result. The study design used was a prospective randomized controlled single-blind trial. Patients underwent IL with Restylane (small particle-size HA, SPHA) or Perlane (LPHA) (Q-Med AB, Uppsala, Sweden). Injections were performed transcutaneously in the outpatient clinic. The Voice Handicap Index (VHI) at 6 months postinjection was the primary outcome measure. Secondary outcomes included videostroboscopic findings, and objective acoustic and aerodynamic measures. Seventeen patients (eight SPHA, nine LPHA) were available for follow-up at 6 months. Normalized VHI scores at 6 months after IL were significantly lower in the LPHA group compared to the SPHA group when not adjusted for age and sex (P=0.027). After adjustment, the difference was not significant (P=0.053) but the LPHA group trended toward lower normalized VHI scores. The findings support the hypothesis that the larger particle-size of LPHA makes this material more durable than SPHA for IL. This material may be considered for temporary medialization in patients with UVCP in whom medium-term improvement of at least 6 months is desirable. The transcutaneous route can be used safely in the office setting in non-anticoagulated patients.

Voice disorders in the elderly

A review of the literature clearly shows that connective tissue degeneration in the larynx, particularly of elastic and collagen fibers, is more prevalent in males than in females. Reinkes edema or polypoidal degeneration of vocal cords may or may not be more common in females. Whether or not the above statements are true, tissue atrophy causes a problem in males because the voice becomes higher pitched, weak or reedy, less masculine, whereas polypoidal change in the older female larynx results in a lower pitch, husky voice that would be acceptable in a male but makes the female voice more male-like and undesirable. Functional misuses of laryngeal muscles come into play when patients try to compensate for these changes. The etiology of dysphonia in the elderly gets even more confusing when psychological factors such as loneliness and depression add their effects to laryngeal muscle misuse. Laryngeal cancer is still probably the most common cause of hoarseness in older persons. Unfortunately the biopsy to rule out cancer in a person who is hoarse from degenerative or functional causes will often greatly worsen the dysphonia and render voice therapy less effective.

Aerodynamic, laryngoscopic, and perceptual-acoustic characteristics in dysphonic females with posterior glottal chinks: A retrospective study

Summary The relationships of posterior glottal chink magnitude and nodule size with phonatory flow rate, resistance, and breathiness were investigated in 70 women in a retrospective study. Results demonstrated a strong relationship between chink size airflow, but no relationship between nodule size and airflow. Resistance and nodule size were moderately correlated. Breathiness was not explained by airflow, nodule size, or chink magnitude. Subjects in therapy demonstrated concurrent reductions in airflow and chink size. For the laryngeal magnitude measures, visual-perceptual ratings were compared with computer-based measurements. The discussion includes a critical analysis of measurement methods and directions for future research.

Treatment of laryngeal contact ulcers and granulomas: a 12-year retrospective analysis.

Multiple etiological factors including gastroesophageal reflux, hyperfunctional voice use, and endotracheal intubation have been implicated in the development of posterior laryngeal ulcers and granulomas. The optimal approach to treatment of these lesions remains controversial. The mainstay of treatment at Vancouver General Hospital has been aggressive medical management of gastroesophageal reflux, with complimentary voice therapy offered to patients suspected of having significant hyperfunctional phonation. The authors reserve Botulinum toxin injection or surgical excision for patients who fail initial therapy. They conducted a retrospective analysis of their voice clinic records from 1985-1997 to examine the efficacy of this approach. They identified 76 patients with the diagnosis of contact ulcer or granuloma. Fifty-two patients had follow-up data available for review. Ninety-four percent of patients were treated nonsurgically: 35 patients were treated solely by dietary and medical therapy to control gastroesophageal reflux, 10 patients were treated by a combination of medical gastroesophageal reflux control and voice therapy, 3 patients had Botox injections, 2 patients had surgical excision of granuloma, 1 patient had a Kenalog injection, and 1 patient underwent laparoscopic fundoplication. Overall, 77% of patients had complete resolution, whereas 11% had partial resolution and another 11% had no significant improvement. The data supports control of gastroesophageal reflux as a central component in treatment of posterior laryngeal ulcers and granulomas.

Interdisciplinary Approach to Functional Voice Disorders: The Psychiatrisf's Role

A review is given of the experience obtained over 6 years of having a psychiatric consultant available as part of the staff of the Voice Clinic, to which more than a thousand patients have been referred. The presenting features in a case that should alert the otolaryngologist to the need for psychiatric consultation and possible treatment are noted. Suggestions are made as to how to prepare the patient for the referral to a psychiatrist with the appropriate Interests and willingness to collaborate closely with the otolaryngologist and the speech pathologist.

Selective denervation: reinnervation for the control of adductor spasmodic dysphonia.

OBJECTIVES The objective of this study was to evaluate the efficacy of a new surgical procedure for adductor spasmodic dysphonia (AddSD). This surgery involves the bilateral selective division of the adductor branches of the recurrent laryngeal nerves with immediate reinnervation of the distal nerve trunks with branches of the ansa cervicalis (selective denervation-reinnervation). METHODS Our first six patients to undergo this procedure were enrolled in the study. All patients suffered from AddSD and had previously received botulinum toxin A (Botox, Allergen, Markham, ON) therapy. Patients were recorded preoperatively and all underwent the same surgical procedure performed by the same lead surgeon. All patients were surveyed postoperatively and then re-recorded. Expert and untrained judges undertook perceptual evaluation of voice quality. Voice samples were also objectively evaluated for aphonic voice breaks. RESULTS No major surgical complications were noted. Patient satisfaction was excellent, and five of the six patients no longer require botulinum toxin therapy. In five of the six patients, the majority of untrained and expert listeners perceived the postoperative voice to be superior. Objectively, the rate of aphonic voice breaks was also reduced in five of the six patients.

Does singing and vocal strengthening improve vocal ability in people with Parkinson’s disease?

Abstract Background: Ninety percent of people with Parkinson’s disease (PD) develop voice problems and many consider poor verbal communication skills to be one of their most serious concerns. Method: The purpose of this exploratory study was to determine whether a combined vocal pedagogy and voice therapy approach that emphasizes vocal effort and includes singing as half of each treatment session, improves the vocal ability of people with PD. The protocol consisted of 12 group sessions involving vocal, speech and singing exercises. Measures were taken with a stopwatch and the Visipitch® before and after 12 treatment sessions. Results: With correction for multiple variables, differences in pre–post measures of maximum intensity (loudness) range (dB) and average frequency or pitch (Hz) in oral reading were statistically significant. Conclusion: Group vocal strengthening activities that include singing may help maintain vocal skills and slow the vocal deterioration that often accompanies PD.

Psychological management of the voice disordered patient

The function of voice is principally to communicate with other people. It is thus seen to have a major social component that serves to disperse feelings of psychological isolation. In order to speak, one requires an organic apparatus capable of producing sound, a psychological intent to communicate, and a social context in which one feels the desire to talk, since most people do not talk much to themselves, they think instead. Voice production, therefore, clearly rests upon the outcome of the interaction of factors that can be conceptualized as being at organic, psychological, and social levels. These assertions are obvious and hardly warrant mention. What does require emphasis is the principle underlying all our work in the voice clinic. Namely, that human beings are constituted so that their functioning is the outcome of the constant interplay of thoughts, emotions and actions, the last being mediated by the voluntary musculature.