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Overview Steam, Straws & Stroboscopy: An Update on Vocal Health
Elizabeth SavinaSpeech Pathologist, Brisbane Voice Clinic
Chunky Harmonies Choir
Red Hot ChilliParkies(As part of Asia Pacific Sing to Beat Parkinsons’Research Project 2017)
Overview 1. Making sure there is enough
moisture inside and out
2. Balancing Rest and
Rehabilitation
3. Red Flags requiring
Laryngeal Stroboscopy
4. Laryngopharyngeal Reflux
5. Medications and Your Voice
Out there on the interweb…
Is it really so?
1. Making Sure
there is enough
moisture inside
and out
NNasendoscopy/ Laryngoscopy with labelling of the anatomy.
Hi Speed Digital Imaging >8000 frames/ second
Fluid within the Vocal Folds –
•Needs to be just right •Too much – bass guitar string
• Lower pitch • Harder work to set them in
vibration.
•Too little – thinner vocal folds• More work to get them to meet
in the midline
Caffeine & Voice(Hartley et al 2014)
• Caffeine 250mg-480mg – no changes to acoustic, perceptual, PTP (but extremes of range weren’t tested)
Caffeine Doses•Expressso 47-75mg•Instant: 27-175mg•Black tea: 14-70mg•Green tea: 24-45mg
Surface Hydration
• Glands just above VF + surface cells secrete
• Mucous dries out -> cycle of sticking, pushing (imagine talking wi
• If you can feel it, it is possibly: • Too dry• From post-nasal drip that needs treatment• Or your larynx is hypersensitive.
When weswallow:
The voice box is closed off by the epiglottis so food & drink shouldn’t be touching or coating the vocal folds.
Vocal folds
How to get moisture to the surface of the Vocal Folds.
Steam- Heat - Moisture might
never make it to the vocal folds
- Still standard recommendation
Nebulised Isotonic Saline
- Smaller particles/- Matches body fluids- No heat involved - Not a standard
recommendation in Aus
Another thought•Another benefit of “steaming” may be the warmth -> Muscle relaxation
•Alternate sensory input for the hypersensitive larynx
•Increased blood flow -> larynx secretes more?
•Allows someone to rest
Take Home Messages - 1
•Hydration is important for body, brain and larynx
•Steaming might still be useful
•Might use nebulized saline in the future
2. Balancing Rest and Rehabilitation
When I trained (18 years ago)
•Common to hear of 2 weeks - 1 month of Voice Rest
•“Total Voice Rest”
But!!!!!
• Do we put patients in bed for 2 or 4 weeks post hip surgery???
“Good” Vibrations and Movement of Vocal Folds
Heal the Vocal Folds(Verdolini et al 2012, Kaneko 2017) )
Good Vibrations (Verdolini et al 2012)
•3 College Students•Vocal load task = 15 min loud talking, 5 minute rest x3 –> acute inflammation
•Random -> •Spontaneous speech, •Rest •Resonant Voice
Good Vibrations (Verdolini et al 2012)
Pro-Inflammatory Mediator: interleukin (IL)-1β
Post Surgical Research (Kaneko 2017)
•31 Patients Randomised Control•(3 vs 7 day voice rest) + therapy•3 days did better on acoustic and patient self-report at 1 and 3 months
What about STRAWS?
1 type of Semi-Occluded Vocal TractExercises SOVT-E
Just Right Closure
•Overclosure -> damage (e.g. nodules)
•Under closure -> breathy, dry out, ↓volume
•Just Right Closure ~0.6 0.7 mm
SOVT-E (Verdolini 2011)
•↓↑closure of the vocal folds
SOVT-E (Verdolini 2011)
•↑Amplitude of VF vibration•↑loudness without ↑collision forces
•best for healing
Different SOVT (Andrade 2014)
Narrowing/Lengthening
•m, n, ng•v, z, dʃ, w, y•Straw into airTend to be less effortful
2nd Source of Vibration
•Lip Trills•Tongue Trills•Straw into water (- ?massage)
What other changes occur(Guzman et al 2016)
- ↑diameter of the vocal tract - Good for amplification
Narrower Straw -> wider vocal tract (Guzman et al 2016)
No Straw 5mm Straw 2.7mm Straw
Lowering of the larynx (sometimes) (Guzman et al 2016)
Aryepiglottic Narrowing (sometimes)(Guzman et al 2016)
Amplifies the formants/harmonics in 2-4000Hz rangeSounds Bright, a part of Twang, Opera, rural singing
Newer Trends in Voice Therapy•Intensive Treatment (e.g. 6 hours in 1 week)
•Telehealth (treatment by equivalent of skype)
•Massage of the anterior neck •Vocal Unloading•Myofascial Release
Reusable Straws
•2 main diameters •Metal, Silicone (Ihave found Glass can break a bit more easily)
•Ebay/Kmart
Take Home Messages 2
•Rest or reduce use if voicing is feeling effortful/strained or lower pitched.
•Follow ENT advice, but Total Voice Rest > 3 days or a week is rare now
•Often best to have Voice Therapy pre as well post Surgery
3. Red Flags requiring Laryngeal Stroboscopy
Lary
ngos
copy
Stro
bosc
opy
Stroboscopy
•Details of the surface of the vocal folds that can’t be seen with standard laryngoscopy•Scars, sulcus, stiffness – pre nodular swelling
•Much more available now
Hint
•When booking an ENT appointment, it is helpful to say you want stroboscopy done, as ENTs often work out of multiple offices, but only have stroboscopy available at some of them.
What can go wrong with a voice?
Lesions of the Vocal Folds Benign•Nodules•Polyp•Cyst•Granuloma•Leukoplakia Voice Therapy 1st
Cancerous - Most commonly associated with smoking/alcohol
Cancerous, smaller lesion, would expected to have less change to the voice.
• Not cancerous, but very large lesion, so would be expected to cause massive change to the voice.
Degree of voice change does not necessarilyindicate the seriousness of the issue
Other Issues Neurological- Paralysis- Tremor- Dystonia (Spasmodic Dysphonia)
- Progressive –MS, Parkinson’s
Joint or Connective Tissue Disorders - Rheumatoid Arthritis
Autoimmune/Inflammatory
Guidelines for Hoarseness (Dysphonia) 2018•Voice changes lasting > 4 weeks should be investigated•Earlier if specific concerns
•High voice use, No URTI, Sudden Voice Loss •Laryngoscopy (with stroboscopy) before Voice Therapy
Take Home Messages 3•Stroboscopy is essential for complete evaluation
• Seek help if voice changes last > month, or earlier if •High vocal demands•No URTI •Sudden loss of voice
Reflux!!! •Acid & Pepsin of stomach ->
larynx and pharynx = Larngopharyngeal Reflux (LPR) • → ssue damage• → muscles tensing to guard
the area.
Reflux Symptom Index (RSI) for LPR
RSI
•Only 35% also have “heartburn”Franco 2015
Reflux and Singing
Managing Reflux Shaw (2010)
Sports Drinks Cochrane et al(2012)
Managing Reflux Shaw (2010)
and Singing
Take Home Messages 4
•Laryngopharyngeal reflux can have a significant effect on the voice
•Avoid large meals/large amounts of water before lying down OR singing
5. Medications and Your Voice
Several classes of medications are known to affect the voice in different ways
The National Centre for Voice and Speech in America has a great resources to check your medications.
National Centre for Voice and Speech
Take Home Message 5
•Many medications can have a significant effect on the Voice
•Start with GP or pharmacist if concerned
National Voice/Laryngological Organisations
•Australian Voice Association•Laryngology Society of
Australasia
•The Voice Foundation (USA)•British Voice Association
Good Sources of Health Information
•Better Health Channel •Mayo Clinic•Cleveland Clinic•John Hopkins
Overview Thankyou!
Elizabeth SavinaCertified Practising Speech Pathologist