Piper Doering
Organic Voice Disorders
Spring, 2013
Assignment 1
1. Do you think the patient has PVFM? Do you think he has a voice disorder? Provide
information from the case that supports your answer.
Yes, the patient appears to have strong indications of PVFM. His symptoms include:
moderately-high blood oxygen level despite low pulmonary function tests, abnormal inspiratory
flow volume loop (FVL), exposure to irritants, and high stress.
As Vertigan, Theodoros, Gibson, and Winkworth (2006) stated, patients with PVFM can still
have normal oxygen saturation in their blood despite variability in pulmonary function tests. This
is true for the described patient, as his blood oxygen saturation was moderately-high (96%)
whereas his pulmonary function tests (i.e., forced expiratory volume, forced vital capacity,
forced inspiratory flow) were less than predicted, especially during forced inspiratory flow.
His case is differentiated from asthma because of the marked abnormal inspiratory component of
the FVL. “The FVL in people with PVFM has been shown to have a normal expiratory phase but
attenuation in the inspiratory phase” (Vertigan et. al, 2006, p. 469). Patient self-reports of
shortness of breath and difficult inspiration confirms this finding.
Other factors that indicate PVFM include environmental and psychological aspects. This patient
was previously exposed to a massive bleach exposure and has a history of smoking. Inhaled
irritants, such as bleach and cigarette smoke, have been a reported cause of PVFM.
Psychologically, this patient is dealing with challenging life situations, both work and health
related. This stressful lifestyle could be increasing his laryngeal and overall body tension, thus
increasing breathing and voice challenges.
Whether or not this patient’s medications are increasing his symptoms of PVFM are unknown.
Based on his case description, a specific voice disorder, if any, cannot be confirmed. However,
this patient does have voice difficulties, including a soft gravelly voice, supraglottic
hyperfunction, and an elevated jitter and shimmer. These findings could be related to PVFM or
to his specific lifestyle (e.g., smoking, stress, tension, etc.). A stroboscopy would be helpful in
making this clinical decision.
2. What do you believe the contributing factors may be for his breathing difficulties and his
voice problems? Why do you believe this?
This patient’s breathing difficulties and voice problems are likely due to the narrowing of his
glottis upon inspiration, lifestyle factors, and increased tension. When the glottis narrows upon
inspiration, the space available for air to enter, in turn, decreases. This could be causing the
patient to feel like he is forcing air in through a restricted area, like “trying to breathe in through
a small straw” as he described. Lifestyle factors including the inhalation of toxins as well as
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work- and medical-related stress could also be contributing to his breathing difficulties and voice
problems. The inhalation of toxins can directly damage the physical respiratory and laryngeal
structures, whereas work- and medical-related stress can increase psychological strain and
overall tension. Finally, this increased tension is likely causing strain and restriction to the
respiratory cycle and limited movement to the laryngeal musculature.
3. What are your general recommendations for this patient? Provide support for these
recommendations.
I would first recommend that this patient participates in education about vocal hygiene and
causes of vocal damage. This would increase his awareness of everyday life situations that
impact voice quality and breathing (e.g., hydration, environmental toxins, stress, tension,
possible medications, etc.)
Second, I would recommend that this patient receives speech services with a focus on laryngeal
tension (e.g., Muscle Tension Reduction Exercises [MTREs] and/or Circumlaryngeal Massages
[CLMs]), increased respiratory control/exercise, and possibly relaxation techniques. It would be
the aim that these techniques would increase his breathing control and increase vocal quality.
As for the patient’s psychological factors, journaling may be an effective technique and
counseling can be incorporated as needed. However, dealing with unemployment and his wife’s
cancer may require a referral to a licensed counselor.
4. Outline your behavioral intervention plan. Provide support for your plan based on the
literature you have read.
Behavioral intervention for this patient would include:
a. An explanation of the patient’s vocal fold functioning to increase his awareness of the
paradoxical behavior he is experiencing, allowing him to take greater responsibility for
his condition. This aspect of therapy would also focus on initial counseling and training.
According to Koufman & Block (2008), patients should receive counseling and training
on their first visits regardless of the underlying cause of PVFM. This would also be time
for patient reassurance, a reoccurring theme within this behavioral intervention.
b. MTREs and CLMs to reduce tension in laryngeal musculature. Techniques to reduce
muscle tension have had positive outcomes for many patients with PVFM (Martin et. al,
as cited in Vertigan et. al, 2006).
c. Respiratory control and exercise techniques. Interventions that focus on respiratory
control have been found effective in reducing and eliminating symptoms of PVFM
(Vertigan et. al, p. 477). Respiratory control would focus on relaxed and abdominal
breathing. One respiratory exercise technique would be the “quick-sniff/slow-blow
technique” as an introductory respiratory exercise that focuses on expiration. “Sniffing
with flaring of the nostrils is linked with brisk vocal fold abduction and is a brainstem
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reflex” (Koufman & Block, 2008, p. 330). Pursed-lip breathing would also be introduced.
d. Relaxation, journaling, and counseling techniques. Relaxation techniques would help the
patient develop an awareness of his musculature, with an emphasis placed on learning to
relax his neck and shoulders. The journaling and counseling components fit into the
relaxation aspect of therapy as a means for this patient do increase psychological health
(counseling referral may be required). As an added component, journaling will
potentially increase further awareness and responsibility for his breathing disorder
(Sandage & Zelazny, 2004). This journal would include daily occurrences of stress,
tension, diet, and event triggers.
Reference List
Koufman, J.A. & Block, C. (2008). Differential diagnosis of paradoxical vocal fold movement.
American Journal of Speech-Language Pathology, 17, 327-334.
Sandage, M.J. & Zelazny, S.K. (2004). Paradoxical vocal fold motion in children and
adolescents. Language, Speech, and Hearing Services in Schools, 35, 353-362.
Vertigan, A.E., Theodoros, D.G., Gibson, P.G., & Winkworth, A.L. (2006). The relationship
between chronic cough and paradoxical vocal fold movement: A review of the literature.
Journal of Voice, 20 (3), 466-480.
Below is a description of the case:
The patient was referred from local pulmonologist for a second opinion about the PVFM.
Patient’s vitals:
57 years old
211 pounds
Respirations = 18 rpm
Pulse = 76 bpm
Oxygen Saturation = 96%
Blood pressure = 132/80
Medications:
HCTZ
Lipitor
Aspirin
Albuteral p.r.n.
Advair - one puff b.i.d.
Tylenol
Multivitamin
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History:
Patient was seen initially by a pulmonologist for restrictive lung disease secondary to a
massive bleach exposure. Increases in humidity make it harder for him to breathe. He was
previously diagnosed with PVFM at the U of M Lion’s Clinic (1 ½ years previously). He had
voice therapy to work on tension reduction and breathing after the PVFM diagnosis. Has sleep
apnea and uses CPAP for that. He quit smoking about 1 ½ years ago. His wife was diagnosed
recently with breast cancer and is undergoing chemotherapy. He is unemployed and has been
unable to find work. He began having more difficulty breathing approximately three weeks
before he saw the doctor. He complained of SOB and having problems breathing in…says it’s
like trying to breathe in through a small straw.
Pulmonary Function Tests:
FEV1 is 61% of predicted
FVC is 60% of predicted
Forced inspiratory flow is 41% of predicted
Marked abnormal inspiratory component of the flow volume loop
Voice Evaluation Findings:
Neck tension bilaterally
Soft gravelly voice
Supraglottic hyperfunction
Elevated jitter and shimmer; reduced pitch sigma
Narrowing of glottis on inspiration, especially on forced inspiration
Sniffing through the nose reduced the narrowing of the glottis
Humming improved his voice quality
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