Practical Strategies for
Treatment of Common
Voice Disorders
Carol Krusemark, M.A., CCC-SLP
Voice Pathologist/Singing Voice
Specialist
MGH Center for Laryngeal Surgery and
Voice Rehabilitation
Common Voice Disorders

Muscle Tension Dysphonia
• Primary
• Secondary

Vocal pathology associated with
abuse/misuse
• Nodules
• Vocal scarring or loss of vibratory layer
Primary Muscle Tension Dysphonia


a posterior
glottic “chink”
caused by
simultaneous
activation of
vocal fold
“closers” and
“openers”
Can be normal
in females
Primary Muscle Tension Dysphonia

False vocal fold
approximation:
medio-lateral
supraglottic
compression
Primary Muscle Tension Dysphonia

Supraglottic
compression in
the anterior to
posterior axis
Primary Muscle Tension Dysphonia

Compression
from both the AP and mediolateral directions
Vocal Nodules

Reactive
fibrovascular
lesions formed at
the site of
greatest vocal
fold contact
Scar or loss of vibratory layer

Loss of superficial
lamina propria,
resulting in
reduced musocal
wave
Treatment modalities
Facilitating Strategies
 Reduction of vocal fold and supraglottic
hyperfunction
 Type I: posterior glottic “chink”

• Glottal fry
• Inhalation phonation

Types II-IV: Supraglottic compression
• Semi-occluded vocal tract tasks
Type I

Glottal fry phonation
• Low subglottal “driving” pressure
• Reduced tension of the muscle within
the vocal folds (thyroarytenoid)
• Vocal folds are short and thick
• Increased interarytenoid activity
• Complete vocal fold closure front to
back

Eliminating posterior chink
• Isolation/syllables/words/etc.
MTD: Posterior glottic gap

Inhalation Phonation
• Phonation during inspiratory phase
• Results in improved vocal fold closure
along entire length
• Vocal tract adjustment can assist with
transition from inspiratory to expiratory
phonation
• Hierarchy of tasks
MTD: Compression

Goals:
• Reduce supraglottic compression
• Reduce vocal fold medial compression

Task requirements:
• Complete closure of the vocal folds
along their length (coordination of
“closers)
• Adduction to a “just barely touching”
position
Semi-occluded vocal tract tasks





Lowers phonation
threshold pressure
Decreases medial
compression
Reduces laryngeal
muscular tension
Improves laryngeal
muscular coordination
“squares up” vocal
fold edges for efficient
vibration







Phonation through a
straw (small is better)
Sustained phonation
of voiced fricative
consonants
Lip bubbles/trills
Tongue trills
Rolled /r/
Humming
Fringe benefit:
highlights oral
resonance
Straw phonation


Daily exercises program (2-3 times)
Three Principles:
• Lips around straw
• Sound through straw only
• Vibratory feeling at the lips

Four tasks:
• One long, slow slide from low to high and back
again
• A series of slow slides on a single breath
• A series of accented slides (revving)
• Song phonation
From straw to speech
Assure correct production through straw
 Practice phrases before and after straw
 Note auditory and ideally kinesthetic
contrast
 Maintenance of kinesthetic similarity
“Make it feel like it did after you used
the straw”
 Gradually fade straw use

Circumlaryngeal massage
Addresses paralaryngeal resting
muscle tension
 Massage and manipulation of the
supporting muscular “sling”
 Focuses on muscular attachments to
the thyroid cartilage and hyoid bone
 Muscle relaxation encourages inferior
movement of the thyroid cartilage

Circumlaryngeal
Massage/Evidence



Significant changes in patient severity
ratings (Roy, 1993) and acoustic voice
measures (Roy, 1997) after one session
93% able to maintain improvement for a
week without further treatment (Roy,
1993)
Improved voice was maintained for up to
5 months for 72% of patients (Roy 1997)
Circumlaryngeal
Massage/Evidence

Professional voice users with moderate to
severed muscle tension dysphonia
• 25 sessions
• Improvements in acoustic measurements
 Strain
 Highest frequency
 Average fundamental frequency
 Jitter and shimmer
• Improvements in Dysphonia Severity Index
Structure identification
Muscles of the anterior neck
Suprahyoid
Digastric
Mylohyoid
Geniohyoid
Stylohyoid
Infrahyoid
Thyrohyoid
Sternohyoid
Omohyoid
Sternthyroid
Circumlaryngeal Massage

Using small
circles,
massage in
the
thyrohyoid
space,
moving
horizontally
through the
space
Circumlaryngeal Massage

Use larger
circles to
massage
from the
thyrohyoid
space to
above the
hyoid bone
and back
Circumlaryngeal Massage

Massage in
the
thyrohyoid
space
moving
from back
to front
Circumlaryngeal Massage

Massage up
and down in a
“C” shape
from the
thyrohyoid
space to the
cricoid
cartilage and
back
Questions??