International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013
ISSN 2278-7763
277
VOICE THERAPY: MANAGEMENT OF BENIGN VOICE
DISORDERS *
1
Dr. Sachender Pal Singh, 2Dr. Smrity Rupa Borah Dutta, 3Dr. Aakanksha Rathor
1
Postgraduate Trainee, Otorhinolaryngology Department, Silchar Medical College & Hospital,Silchar, India; 2Assistant Professor, Otorhinolaryngology Department Silchar Medical College & Hospital,Silchar, India; 3Postgraduate Trainee, Otorhinolaryngology Department, Silchar Medical College & Hospital,Silchar, India.
Email: Sachender123@gmail.com
ABSTRACT
Voice disorders are universal problems & have significant affect on the patients’ emotional, psychological, physical, social, personal & professional well being. This is a prospective study done in the department of Otorhinolaryngology, Silchar Medical
College & Hospital from June 2012 to July 2013.
Thirty consecutive dysphonic patients with benign voice disorders underwent a course of voice therapy with or without undergoing surgical procedures. Pre therapy-versus-post therapy comparisons were made of self-ratings of Voice Handicap Index,
Auditory-Perceptual Ratings, as well as, Visual -Perceptual Evaluations of laryngeal images.
Voice therapy is an essential & effective tool to manage benign voice disorders, and provide both objective and patient-centered
outcomes. To be precise, the role of voice therapy is not only therapeutic but it also helps to encourage healthy voice habits &
prevent recurrence of disease after a very delicate surgery.
Keywords : Dysphonia, Benign Voice Disorders, Voice therapy, Voice Handicap Index.
1 INTRODUCTION
Dysphonia can be defined as any impairment of the voice or
difficulty in speaking. Various dysphonic patients were diagnosed on the basis of history, clinical examination & laryngoscopy as having benign voice disorders followed by their proper management with voice therapy with or without phonomicrosurgery.
Data on the prevalence of voice disorders is scarce and have
ranged from 0.65 to 15 percent in the general population [1],
[2]. Benign voice disorders impair communication and have
important affect on public health. Roy et al reported that
29.9% of the general public had at least one voice disorder in
their lifetime, 6% had a current voice disorder, and 7.2%
missed one or more work days [3]. In addition to health care
costs related to treatment and lost work productivity, benign
voice disorders impair patients’ quality of life [4]. There has
been an ideological shift in health care from 'curing' disease to
'minimizing the impact of illness on everyday activities' [5].
Voice pathologists have been using Transnasal Flexible Laryngoscopy (TFL) in their clinical practice for over 20 years [6].
The main purposes of TFL examination by a voice pathologist
are to confirm the medical diagnosis [7], [8], to understand the
physiological phonatory characteristics [9], [10], and to assist
Plica Ventricularis (1 pt.), Parkinson’s disease (1), Puberphonia
(1), Vocal Cord Paralysis (2).
2.3 Patients excluded from the study were: patients with malignant lesions, infective pathology or speech defect due to CNS
lesions. All the excised tissues were sent for histopathological
examination.
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in the design of appropriate voice therapy treatment [11], [12].
1.1 AIMS OF VOICE THERAPY
• To achieve better voice quality, this is stable, reliable and
less effortful to produce.
• To make better use of vocal resonance and tonal quality;
• To increase the flexibility of the voice by improving the pitch
range and loudness without undue effort;
• To increase the stamina of the voice.
2.4 T REATMENT PROGRAMS
•
Explanation of normal vocal physiology to the patients.
•
Explanation of the disorders.
•
Help the patient to assume responsibility
•
Help the patient to understand vocal hygiene
•
Teaching the patients about vocal function exercises
•
Teaching the patients about laryngeal massage
•
To treat the associated laryngopharyngeal reflux
•
Where indicated, we considered the surgical procedures & removed the abnormal tissue giving maximum respect to the normal superficial lamina propria.
•
Regular follow up
Vocal function exercises & laryngeal massage were chosen
according to the patient’s voice disorders.
2.5 TREATMENT GOAL
Primary goal of voice therapy was to maximize the efficiency
of phonation & to eliminate maladaptive vocal behaviors that
exacerbate these benign voice disorders
1. Auditory-Perceptual Ratings: Subjects were asked to
read ‘The Rainbow passage’ (Operating Techniques in
2 MATERIALS AND METHODS
Laryngology) or to count 1 to 20 & voice was record-
This study is a prospective study during the period of June
2012 to July 2013 carried out at Deptt. Of Otorhinolaryngology, at Silchar Medical College, Silchar, Assam.
ed. Perceptual ratings of voice quality were conduct-
2.1 SUBJECTS
2.1 Thirty consecutive subjects with benign voice disorders
were recruited for the study after making a proper diagnosis
on the basis of history, clinical examination & laryngoscopic
examination. The patients were in the age group of 20-70
years.
2.2. Patients included in the study were: Vocal Cord Nodule (9
patients), Vocal Polyp(6 pts.), Primary Muscle Tension Dysphonia (6 pt.), Sulcus Vocalis (2 pts.), Presbylaringis(2 pts.),
Copyright © 2013 SciResPub.
ed with the ‘GRBAS scale’ [13].
The GRBAS scale is considered by many authors to be
the most reliable auditory perceptual scale currently
available for use as an outcome measure [14], [15].
2.
Quality Of Life Measures: ‘Voice Handicap Index’
was used to assess the impact of the voice in terms of
physical complaint and restriction in participation in
daily activities & response to treatment [16], [17], [18],
[19], [20].
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International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013
ISSN 2278-7763
3.
Visual-Perceptual Ratings: It was based on comparison of Transnasal flexible laryngoscopy (TFL) done
before & after the voice therapy
3 RESULTS
SV
PL
PMTD
PMTD
PMTD
DPV
VCP
PU
N
N
N
N
P
P
P
20
10
0
BEFORE VOICE THERAPY
AFTER VOICE THERAPY
Fig1.GRBAS SCORE
0
SV
SV
PL
PL
PM…
PM…
PM…
PM…
PM…
PM…
DPV
PD
PU
VCP
PU
100
BEFORE VOICE THERAPY
AFTER VOICE THERAPY
Fig2.VOICE HANDICAP INDEX
[Abbreviations: Sulcus Vocalis (SV), Presbylaryngis (PL), Primary Muscle Tension Dysphonia (MTD), Dysphonia Plica
Ventricularis (DPV), Parkinson’s Disease (PD), Vocal Cord
Paralysis (VCP), Puberphonia (PU), Vocal Cord Nodule (N),
Vocal Polyp (P)]
278
apy which shows level1 evidence [21]. Voice therapy doesn’t
only involve the behavioral voice therapy & laryngeal massage but also involve the vocal hygiene which covers a vital
area.
4.1 VOCAL POLYP
A vocal polyp never resolves with therapy alone and should
be surgically removed. In one study of 24 subjects with polyps,
48 percent of patients exhibited a moderate degree of dysphonia and this was more severe in patients with polyps than in
subjects with any other laryngeal lesions who were examined
[22].
Different treatments are recommended for polyps that consist
of a combination of phonomicrosurgery and voice therapy
[23], [24], [25], [26].
In our study we gave 2 months voice therapy before the surgery but there were no improvement in symptomatology. So
we went for phonomicrosurgery followed by voice therapy to
prevent recurrence & till now we have not encountered any
recurrence.
4.2 VOCAL CORD NODULE
The etiology of vocal nodules is not known, but traditionally
they are thought to be due to voice abuse [27] rather than
overuse [28]. A double-blind study into an evaluation of hydration against placebo as a treatment for vocal nodules was
also convincing [29]. There is no evidence for advising absolute voice rest as this is usually too difficult as patients will not
be able to do his work & have to seclude himself [30].
Treatment by voice therapy and laryngoscopic review is preferable to treatment by surgery followed by therapy [31].
In our study most of the patients were having problem with
their mouth opening & posture while talking & history of
voice misuse & abuse. We advised proper vocal hygiene, good
posture during talking & behavioral voice therapy & in some
laryngeal massage to treat hyperfunction, before the surgery &
then after 2 days of absolute voice rest we continued with the
same. We started the therapy before the surgery to prevent
damage to the vocal cords immediately postoperatively with
the faulty trials of voice therapy techniques by the patients.
With this we got no recurrence & all of the patients are doing
well. In early vocal cord nodules we didn’t plan phonomicrosurgery & they had showed very good results with only voice
therapy.
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Fig3.Dysphonia plica ventricularis (before & after voice
therapy), laryngoscopic view
4.3 PRESBYLARINGIS
Such patients don’t want voice therapy but usually requires
only reassurance that the disorder is self limited. If treatment
is indicated, then the vocal hygiene, behavioral voice therapy
& laryngeal massage are advised to make the laryngeal musculature strong and to improve vocal control. In our study we
did the same & a very good result was achieved.
Fig4.Primary muscle tension dysphonia (before & after voice
therapy), laryngoscopic view
Fig5. Vocal cord nodule (before & after voice therapy),
laryngoscopic view
4 DISCUSSIONS
In the literature, there are few reports of efficacy of voice therCopyright © 2013 SciResPub.
4.4 SULCUS VOCALIS
Voice therapy helps in preventing hyperfunction & mild dysphonic patients can be managed with voice therapy alone. In
our study we got 2 cases which were having slight phonatory
gap. We tried voice therapy first & they did well with that.
4.5 PRIMARY MUSCLE TENSION DYSPHONIA
It is often a 'diagnosis of exclusion', i.e. 'the vocal cords look
and move normally'. Management includes techniques to reduce vocal fold, laryngeal & pharyngeal regions muscle tension [32].
In our study we got only 6 cases of MTD & have managed
them with the vocal hygiene, behavioral voice therapy & laryngeal massage & achieved satisfactory results. One of them
was very interesting case, as he develops the dysphonia after
an incident of cut throat. We managed the pt. primarily for cut
throat & after that we gave him voice therapy & he improved
a lot with that. On laryngoscopy he was not having any trauIJOART
International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013
ISSN 2278-7763
ma in the larynx.
•
279
To relax the excessively tense musculature which inhibits normal phonatory function & to reduce ody-
4.6 DYSPHONIA PLICA VENTRICULARIS
We got only one such case. True vocal cords were normal &
there was no associated pathology with them. But at the time
of onset of symptoms he was having anxiety & depression due
to failure in exams. We tried voice therapy & psychotherapy
and patient has improved satisfactorily.
4.7 PUBERPHONIA
We got only 1 case of puberphonia. We advised him voice
therapy programe & he improved with that to his satisfaction.
nophonia.
•
Manual Laryngeal Musculoskeletal Reduction Technique was first discussed by Aronson (1990). He described that, on giving massage the muscle tension of
the extrinsic laryngeal musculature decreases & massage eliminates the inappropriate muscle activity during phonation.
INTRODUCTION TO SOME OF THE TECHNIQUES:
4.8 VOCAL FOLD PARALYSIS
In unilateral or bilateral vocal cord paralysis we should wait
for 9-12 months for spontaneous recovery, but if the patient is
experiencing serious degree of aspiration of food or fluids or is
very sick or terminally ill then phonosurgery may be considered to reduce the problem.
We got only 2 cases of unilateral vocal cord paralysis with no
significant aspiration. We advised them the appropriate vocal
function exercise with regular follow up & now the patient is
having less dysphonia & his transnasal flexible laryngoscopy
is having significant changes.
RESONANT VOICE:
Titze (2003) states, “resonant voice engages the vocal tract for
maximum transfer of power from glottis to lips & ultimately
all the way to the listener”.
Glottic configuration observed in the resonant voice was, in
fact, the glottic configuration known to produce maximum
transfer of sound through the vocal tract.
Humming: It results in easy, relaxed voice production by increasing proprioceptive feedback from oronasal resonance &
decreasing feedback from laryngeal resonances (Colton &
Casper 1990).
4.9 VOICE THERAPY
CHEWING:
Chewing while phonation results in the most natural & basic
mode of voice production & restrict any inappropriate muscle’s action [Froeschels (1943, 1952)].
• Reduces pitch & muscle tension in voice production
VOCAL HYGIENE: It includes the methods to alter the inappropriate voice use adapted by the patient. The methods include patients’ education and their awareness, training &
abuse identification. Last but not the least hygiene program
must sum up with the modification stage, to reduce the occurrence of inappropriate behaviors (Andrews, 2001).
• Encourages mouth opening & reductions of mandibular tensions.
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SYMPTOMATIC VOICE THERAPY (Daniel Boone, 1971):
Based on modification of systems:
1. Appropriate tongue position,
2. Alteration of loudness,
3. Chewing exercise,
4. Digital manipulation,
5. Ear training,
6. Elimination of abuses,
7. Elimination of hard glottal attack
8. Explanation of the problem,
9. Open mouth exercises
10. Pushing approach,
11. Relaxation
12. Respiration training,
13. Voice rest,
14. Yawn sigh approach
PSYCHOGENIC VOICE THERAPY:
 Focuses on identification and modification of the
emotional and psychosocial disturbances associated
with the onset and maintenance of voice problem.
PHYSIOLOGIC VOICE THERAPY:
Voice disorders are best treated by modifying the underlying
physiology of voice production (stemple, 2000; stemple et al
2000)
Three key components:
1. Improves the balance between the respiration, phonation & resonance.
2.
Improves the strength, balance, tone & stamina of the
laryngeal muscles.
3.
Develops a healthy mucosal covering of the true vocal
folds.
Examples: vocal function exercises, resonant voice therapy
and the accent method of voice therapy
CIRCUMLARYNGEAL MASSAGE & LARYNGEAL MANUAL THERAPY:
Copyright © 2013 SciResPub.
• Reduction of hard glottal attacks
YAWN –SIGH APPROACH (Boone):
Performing a yawn just prior to phonation would result in
phonation with a relax vocal tract as it expands the pharynx &
stretches & then relaxes the extrinsic laryngeal muscles, thus
lowering the larynx in the neck to a more neutral position &
permit a more forward placement of the tongue in the oral
cavity.
ACCENT METHOD (Svend Smith (Harris, 2000)):
Accentuated vowel productions with abdominodiaphragmatic
breathing optimize the respiratory phonatory balance & bring
about proper patterns of vocal cord closure (kotby, Shiromoto,
& Hirano, 1993).
It is based on the myoelstic aerodynamic theory of vocal fold
vibration proposed by van den berg in 1958(Harris, 2000)
It addresses pitch, loudness & timbre simultaneously rather
than focussing separately upon each of these vocal parameters.
CONFIDENTIAL VOICE (Colton & Casper (1990):
It reduces the vocal intensity, muscular tension & collision
impact of vocal cord during phonation as well as eliminates
the strained or tight breathing pattern (Casper, 1997).
VOCAL FUNCTION EXERCISES:
These exercises strengthen & rebalance the subsystems involved in phonation (Respiration, Phonation & Resonance)
(stemple 1993).
Used in: vocal fold lesions, muscle tension dysphonia, hypofunctional voice disorders.
PLACE THE VOICE (Boone, 1988):
He proposed that individuals with vocal hyperfunction
should be trained to shift the vocal tone away from the neck &
into the midface region using nasal sounds to enhance the patients’ awareness of resonance in the facial area.
PUSHING EXERCISE:
These are based upon the premise that the rapid & voluntary
contraction of 1 set of muscles would result in the contraction
of other groups of muscles (Froschels et al 1955).
Boone (1971) noted the tendency for the larynx to undergo
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International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013
ISSN 2278-7763
reflexive closure during moments of heavy exertion. It results
in increase in glottal closure & loudness.
ABDOMINAL BREATHING:
1. To maintain appropriate subglottal air pressure.
2.
To avoid shallow, upper chest breathing.
3.
To avoid phonation on residual air.
280
Muscle tension
dysphonia
To alter the state of
tight vocal tract muscles
and to improve the range
of movement of the laryngeal joints
Correction of
posture,
abdominal breathing, open mouth
approach, circumlaryngeal massage
technique, chewing exercise, yawn
sigh
approach,
resonant voice
Puberphonia
Phonate at a low pitch, to
fully utilize the phonatory &
respiratory musculature
Dysphonia
plica
ventricularis
Restore true vocal fold
health,
Resolve the false fold
phonation
Unilateral
vocal
fold
paralysis
To improve glottal closure
& at the same time to avoid
undesirable
compensatory
behaviours, progressive development of optimal breathing, abdominal support, &
gentle improvement of intrinsic muscle strength &
agility, without supraglottal
hyperfunctional compensation
Parkinson’s
disease
To improve glottal closure, to increase effort & coordination, to increase fundamental frequency range &
to increase overall loudness
Resonance,
phonation of vowel with glottal attack,
chewing,
relaxation
techniques,
half
swallow
boom
techniques,
use of vegetative sounds like
cough or throat
clearing to initiate
voice,
digital manipulation of thyroid
cartilage during
vowel production
.
Relaxation,
whistling & blowing techniques,
inspiratory
phonation,
yawn
sigh
method,
Laryngeal manipulation & circumlaryngeal
manual therapy,
Psychotherapy
Abdominal
breathing,
resonant voice,
yawn sigh method,
half
swallow
boom technique,
lip & tongue
trill,
pushing exercises,
accent method,
manual laryngeal muscle tension
reduction
techniques
Lee Silverman
Voice Treatment
HALF – SWALLOW BOOM TECHNIQUE:
 The swallow procedure maximizes closure of the larynx

“Boom” is a single word composed of voiced sounds
that is able to be produced as air is released from the
constricted larynx and the oral opening is minimized

Produces posterior pressure on the larynx

This technique is a slow progression to get the patient
to lower their pitch

Used to improve glottal closure.
INHALATION PHONATION:
Boone (1966) held that phonation during inhalation results in
adduction of the true vocal cords without associated false vocal folds adduction.
CHANT-TALK:
 Encourages an easy flow of phonation & reduces laryngeal & vocal tract tensions.

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Reduces the tendency towards hard glottal attack &
increased force of vocal fold contact.

Increases proprioceptive feedback as vibrations are
felt through the nose & cheek areas, thus helping the
patient to reduce focus on the larynx.
Table 1 Voice therapy for different voice disorders
VOICE
DISOR
ORDERS
Early
vocal
cord
nodule/poly
p
Pres
bylaryngis/
Sulcus
vocalis
AIMS AND GOALS
VOICE THERAPY PROGRAM
To minimize detrimental
vocal behaviors & learn
healthy voice production,
use the pts. natural pitch,
reduces hoarseness, ensure
relaxed & easy movements of
vocal cords, to increase
breath support, to decrease
the head & neck muscles
tension (compensatory behaviors)
To improve vocal fold closure,
to strengthen & rebalance
the laryngeal musculature
and co-ordinate the subsystems of voice production
Vocal hygiene,
correct
posture,
confidential voice,
resonant voice,
vocal function
exercise program
Copyright © 2013 SciResPub.
Respiratory retraining,
Relaxation
techniques ,
laryngeal adduction exercises,
vocal
function
exercise program
5 CONCLUSION
Voice therapy is an essential & effective tool to manage benign
voice disorders, and provide both objective and patientcentered outcomes. Improvements in perceptual and functional outcomes were related to improved vocal efficiency resulting from simultaneous altering of all phonatory subsystems
(i.e., Phonation, Resonance and Respiration). Although immediate treatment effects were encouraging, long-term follow-up
are needed to sustain the results. To be precise, the role of
voice therapy is not only therapeutic but it also helps to enIJOART
International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013
ISSN 2278-7763
courage healthy voice habits & prevents recurrence of disease
after a very delicate surgery.
Although there is inter & intra observer grading differences in
Auditory-Perceptual Ratings & Quality Of Life Measures and
there may be mismatch between the two methods but clinically these variations are small enough to permit practical evaluation of the patient’s voice & are very useful during follow up
to both the patient as well as the trainer. Voice therapy is a
need, today, to manage the different benign voice disorders
encountered in daily life.
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Author Profile
Dr. Sachender Pal Singh passed M.B.B.S degree
from Mahrishi Markendeshwar Institute of
Medical Science & Research, Haryana in 2011
and is presently pursuing M.S degree in Otorhinolaryngology (2011-2014) from Silchar Medical
College, Assam, India.
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ISSN 2278-7763
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