1514 treatment of functional voice disorders historical perspective and clinical approaches

8/17/2019 1514 Treatment of Functional Voice Disorders Historical Perspective and Clinical Approaches

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CURRENT EVIDENCE WITH A HISTORIC PERSPECTIVE

Treatment of severe functional

voice disorders

Vrushali Angadi, M.S., CCC-SLP ip

Rebecca L. Hancock, M.Ed. CCC-SLP

The University of Kentucky Clinical Voice Center


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There are no financial interests, relationshipbenefits for the presenters associated with this talk

its content in any fashion. The purpose ofpresentation is for purposes of clinical educa

DISCLOSURE STATEMENT


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Overview

Definitions

A place in the history of medicine

Pathophysiology

Diagnosis and clinical features

Treatment approaches from then to now

Case Presentations


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Definitions,Background and

Basics


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Normal Anatomy

Pictures courtesy of Bluetree publishing


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Terminology

•

Classification Manual of Voice Disorders – I (Verdolini, Rosen, & Br2006)

– Primary muscle tension dysphonia

– Secondary muscle tension dysphonia

•

“Clinical differentiation of specific psychogenic versus muscular indis rarely pursued and there are no empirical data to substantiatepresumed muscular or functional adaptations that underlie dysphproduced in the absence of organic etiology.” (CMVD-I)


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Normal Voicevideostroboscopy


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Normal VoiceHigh speed imaging,2000fps

• Videos removed


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Functional Dysphonia

• The presence of voice disturbance in the absence ofstructural, neurologic, or mucosal impairment

• Herrington-Hall et al. (1988) out of 1262 voice patients7.9% had functional dysphonia.

• Coyle, Weinrich, Stemple (2001) noted this to be higheincidence, 12.2% of their sample termed “functional”

• Common early treatments include URI medication, reflmedication, voice rest (but seldom resolve the issue)


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What is Functional DysphFrequently quoted

• Morrison and Rammage (1993

– Patients with structurally nlarynges with muscle misularynx, with several interacincluding habituated musc

•

Roy (2003) – Voice disturbance in the ab

structural or neurologic pa

– Caused by poorly regulatedthe intrinsic and extrinsic lamusculature

• Aronson’s criteria (1964)

– There is no apparent alteration instructure

– Normal laryngoscopy butabnormal stroboscopy

– Disproportionately severe voicequality to laryngeal inflammation

– Disorder of nervous origin*

– Reversible

– Motor utilization is incorrect

– Desire exists in patient to beignorant to the cause


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An archival approachRET REA T I N G T O M O V E F O RWA RD


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“Muscle Tension DAn Evolution in Te

• “The hysterical larynx” (1877)

• Hysterical aphonia (1930)

• Psychophonasthenia (1938)-abnormalvocalization with normal verbalization, adeviant of stuttering

• Hyperphonia (1944)

• War aphonia (1944)-seen in both soldiers andcivilians after WWII

• Psychosomatic aphonia (1949)

• Vocal cord neurosis (1953)

• Psychogenic/Conversion aphonia (Aronson,1964)

• Functional dysphonia

• Psychogenic dysphonia

• Vocal abuse/misuse syndrome

• Hyperfunctional dysphonia

• Hyperkinetic dysphonia

• Mechanical voice disorder

• Laryngeal isometric dysphonia

• Muscle tension dysphonia “MT

• Laryngeal tension-fatigue synd(Koufman/Blalock) (1998)


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Historic Reports

• Whitefield Ward (1877)

– ENT, former clinical assistant toLondon Throat Hospital

– “the disease takes women as itfinds them: blondes, brunettes,stout, thin, weak, ruddy, or pale,there is no choice”

– “Hysterical aphonia is most liableto occur in the single female”

• Cortlandt MacMahon, MD

– Instructor for Voice Proin the ENT DepartmentBartholomew's Hospita1911. Instructor for SpeDefects in 1913, and re1938

– “It is remarkable how spersons possessed of hintelligence and wondefluency are content to voice which is distressihear”


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Further reports

•

Chevalier Jackson, MD (1949) – (1865-1958) Laryngologist from Pennsylvania, spent ti

London. Responsible for poison control labeling on boReferred to as the “greatest laryngologist of all time”

– Described “ephemeral adductor paralysis” where patie

are “struck dumb”


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Making the

Diagnosis

Integrating the 5 domains of voiceassessment

• Acoustic

•

Aerodynamic• Visualization

• Perceptual

• Patient Perception


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Clinical Questions Case History

– Nature of Onset

• Sudden vs progressive

• Associated with change in voiceuse or demand

– Describe what the voice presentlycan do

• Intermittent voice loss vs totalaphonia

• Pain with palpation or phonation

– Premorbid medical conditions

• Medications

• Surgeries

• Medical conditions

– Social History

• Caffeine, carbonation, ETO

tobacco, Dietary factors

– History of psychosocial stressenvironmental change

– Typical for multiple medicalappointments prior to clinic v

–

Patients often unaware ofimprovements in voice qualit


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It’s all about perception

• Completion of the VHI

– Psychosocial measure of the impact of quality of life based on the prvoice disorder

– Gauging progress in treatment (Jacobson, Johnson, Grywlski, et al, 1

• Perceptual Assessment

– CAPE-V (Barkmeier, Verdolini, & Kempster, 2002)

•

CAPE-V: general dysphonia, roughness, breathiness, strain, pitchloudness, secondary features including glottal fry, spasm, issues

– GRBAS Scale (Hirano, 1981)

• general dysphonia, roughness, breathiness, asthenia, strain, list sfeatures

– Importance Differentiating MTD from SD (Morrison et al, 1986; Roy

– Incorporate trial therapies for stimulability


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Laryngeal Function Studies

• Acoustic Assessment

– ADSV (Kay Pentax) cepstral peak analysis• Analysis of dysphonia in speech and voice- able to analyze

severely dysphonic voices

• Analyses during running speech

– MDVP will give irregular values for sustained /a/

• Will see elevated jitter, pitch perturbation quotient, shimmvariations in peak-peak amplitude

– Often reduced MPT and pitch range


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Laryngeal Function Studies: Aerodynamicanalysis

Aerodynamic parameters Hyperfunction: Excessive

medial compression

Hyperfunctional

under-closure

Hypofunct

Laryngeal airway

resistance (LAR)

30-60 cmH2O (L/s)

Increased (>60) Decreased (8) Increased (5) Decreased/ Increased * Decreased/

*variable depending upon patient’s compensatory pattern


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Laryngeal Imaging

• Normal laryngoscopic assessment with abnormal

stroboscopy• Tight mediolateral glottic/supraglottic contraction

• Incomplete glottic closure/hyperfunctionalunderclosure

•

Enlarged posterior glottic gap• Ventricular phonation

– (Roy 2008)

Images courtesy o


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Manual Palpation

• Aronson (1990) Theories include chronic superior

larynx posture leads cramping and stiffness ofhyolaryngeal complex

• Roy (2008)- used to assess laryngeal mobility

• Lowell et al (2012)-patients with MTD elevate thehyolaryngeal complex with phonation more so than

age matched peers• Angusuwarangsee, Morrison (2002) Emphasize release

of the thyrohyoid membrane during release

Images courtesy of R


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Treatment

Interventions


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Historic approaches

• Cortlandt MacMahon (1940)

– Humming or producing /m/ sounds

– nasal breathing exercises

– placing the middle finger of the right hand on the back of the tongue and placresistance while placing the left hand on the thyroid cartilage, and asking the pcough

– Progress strong cough to /ah/

– Patient asked to depress the tongue 100/x’s for maintenance

• James Sonnet Green (1938)

– Psychiatric treatment- hypnotherapy

– “The effects of shock therapy are almost always transitory, because frighteningpatient into vocalization does not counteract his neuroticism”


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More historic approaches

• Gold et al (1940) Procedure to Treat Aphonia

– Stimulation with electric vibrator to muscles of the neck coupled with hypno

– Thorough coating of patient’s pharynx with oil of cloves

– Injection of sodium pentathol (barbituates)

– Scratch the soles of the patient’s feet with sharp stones

• William Lell (1941)

– Falsetto voice to “reeducate” voice production


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Chevalier Jackson’s Surprisingly AccurateApproach to Aphonia

• “The next step is to get the patient to make a sound in some way othan an effort to say a word.”

• “When the patient produces a phonatory grunt by bringing his elbdown with a thump against his sides, he can be easily convinced thhas started learning a new way of talking.”


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Less has changed than you’d expe

T H E M O DERN A G E


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Manual Reposturing

• Can be effective in patients who

have phonation, as well as thosethat don’t

• Described by Aronson; (1964) Royet al(1997); Mathieson et al(2007)

•

“Bieber Fever” – Case of a 13 year old female with

normal laryngoscopy, aphonic withsudden onset after a concert withscreaming

• Video removed


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If no phonation is achieved(dig into your bag of tricks)

•

Vegetative sounds (cough, gargle,startle, laugh)

• White noise/auditory masking

• Kazoos

•

Flow mode with PAS forbiofeedback or a tissue

• Can use stroboscopy to elicit agag response (last resort)


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Pack a tool box(if the patient can vocalize…)

• Semioccluded vocal tract (Titze, 2006)

– Straw phonation

– Lip trills, lip + Tongue Trills

• Flow mode phonation (Titze, 2002)

• Yawn-Sigh Approach (Boone and McFarlane, 1988)

• Resonant Voice therapy (Verdolini, Burke, Lessac, et al, 1995)

• Falsetto phonation to break cycle (Stemple, 2009)


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Holistic Approaches

• Myofascial Release (find a localpractitioner, may be able to see sameday)

• Lingual and mandibular stretches

• Neck and shoulder stretches

• Progressive relaxation

• Video removed


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Thinking outside the box…

• At some point they may require psychologicassessment

– Secondary gain; Stemple (2009)

• Intraoral muscle release

• Introduction of lidocaine or botulinum toxintranscricothyroid membrane if behavioraltherapy fails (Dworkin et al, 2000)

– In some cases, causes immediate change

– Laryngeal “wash” of nebulized lidocaine hasproven effective clinically


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Case Study

• 50 year old woman with 35 year history of 2

pack/day smoking

• Complaint of voice loss and pain withspeaking

• Referred to clinic for consideration of botoxfor questioned spasmodic dysphonia

• Stroboscopy positive for small rightsubmucosal lesion, however hyperfunctionalunderclosure and supraglottic hyperfunctionon exam

• Loud phonation

• Video removed


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46 year old female

• Prior history of voice loss, functional,responsive to behavioral intervention

• Normal laryngoscopy, phonationachieved on vegetative sounds

• Voice to diplophonia after 1 hour

• 2 follow up sessions with limitedgeneralization

• Now speaking normally aftermotivational interviewing session todiscuss cost benefit ratio


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Case Study• 21 year old female, aphonic after upper respirato

• Would not speak for face video, deferred to larynand stimulability probes

• Voice restored in 1 hour using vegetative sounds /woo/

• Glottal fry addressed in later sessions

• Videos removed


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Counseling after voice restoration

• Reassure and insure patients are familiar with the techniques to maintain

sustain good voice quality

• Insure patient recognizes their control over voice quality and are motivatemaintain voice

• Maintenance

– Vocal Function Exercises

• Do not blame the patient, utilize terminology such as:

– Reprogramming motor behaviors of voice production

– Tension/Adverse event had a temporary muscle imbalance, which has bcorrected

– Patient should demonstrate with negative practice prior to d/c from clin


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Wisdom of the Ages

– Do not become angry with these patients.

– Do not dismiss these patients with some trite remark lis all in your head.” Do not tell them “to snap out of it.

– Do not delve too deeply into their psychologic difficultunless you are prepared to handle any eventuality whimight arise. Superficial inquiries are desirable and arelikewise perfectly safe.

• Louis H. Clerf, M.D. and Francis J. Braceland, M.D., 1942


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Thank you!!! Questions?

• [email protected]

• [email protected]

The University of Kentucky Clinical Voice Center

859-257-0143

mailto:[email protected]:[email protected]:[email protected]:[email protected]


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References• Angusuwarangsee, T., Morrison, M. (2002). Extrinsic laryngeal muscular tension in patients

disorders.

• Altman, K. (2005). Current and emerging concepts in muscle tension dysphonia: 30 month

•Aronson, A., Peterson, H., Litin, E. (1964). Voice symptomatology in functional dysphonia a

• Asherson, N. A test for functional aphonia and for detection of complete unilateral feigned

• Bridger, M. et al (1983). Functional voice disorders.

• Dworkin, J., et al (2000). Use of Topical Lidocaine in Treatment Muscle Tension Dysphonia.

• Harris, C. et al (1992). Functional aphonia in young people.

• House, A., Andrews, H. (1988). Life events and difficulties preceding the onset of functiona

• House, A., Andrews, H. (1987). The psychiatric and social characteristics of patients with fudysphonia.

• Karkos, P. et al (2007). Is laryngopharyngeal reflux related to functional dysphonia?

• Lowell, S., et al, (2012). Position of the hyoid and larynx in people with muscle tension dysp

• Maryn, Y. et al (2003). Ventricular dysphonia: clinical aspects and therapeutic options.

•MacMahon, C. A note on treatment of functional aphonia.


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References• Mathieson, L., et al (2007). Laryngeal manual therapy: preliminary study to examine its treatment e

the management of muscle tension dysphonia.

• Morrison, M., et al. (1986). Diagnostic criteria in functional dysphonia.

• Morrison, M., Rammage, L. (1993). Muscle misuse voice disorders: description and classification.

• Rasch, T., et al (2005). Voice related quality of life in organic and function voice disorders.

• Roy, N., Bless, D., Heisey, D., Ford, C. (1997). Manual Circumlaryngeal Therapy for Functional Dysphevaluation of short/long term treatment outcomes.

• Roy, N., Bless, D. (2000). Personality traits and psychological factors in voice pathology: a foundatioresearch

• Roy, N. (2003). Functional dysphonia.

• Roy, N., et al (2005). Task specificity in adductor spasmodic dysphonia versus muscle tension dysph

• Roy, N. (2008). Assessment and treatment of musculoskeletal tension in hyperfunctional voice diso

• Ruotsalainen, J., et al (2008). Systematic review of treatment of functional dysphonia and preventidisorders.

• Sama, A. et al (2001). The clinical features of functional dysphonia.


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References• Sokolowsky, R., Junkermann, M. (1944). War Aphonia.

•Van Houtte, E. (2011). An examination of surface EMG for the assessment of muscle tensio

• Van Houtte, E, et al (2009) Pathophysiology and treatment of muscle tension dysphonia: a current knowledge.

• Van Lierde, K et al (2010). The treatment of muscle tension dysphonia: comparison of two techniques by means of an objective multiparameter approach.

• Van Lierde, K., et al (2004). Outcome of laryngeal manual therapy in four Dutch adults withmoderate to severe vocal hyperfcuntion: a pilot study.

• Van Mersbergen, M.,et al. (2008). Functional dysphonia during mental imagery: Testing tradisorders.

• Vertigan, A., et al (2006). Involuntary glottal closure during inspiration in muscle tension dy

• Voerman, M. et al (1984). Retrospective study of 116 patients with non-organic voice disormental imagery and laryngeal shaking.

• Historical Articles and Paper dated prior to 1940 borrowed from the private library of Josep

1514 treatment of functional voice disorders historical perspective and clinical approaches

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