Laryngology seminar
Voice therapy
R3 戴安修
Successful behavioral treatment of voice disorders includes
1. The effectiveness of treatment designed to teach reduction of vocal misuse,
hyperfunction and muscular imbalance.
2. Compensation or correction for the effects of a medical or physical condition on the
larynx.
3. Optimum voice production in the presence of a psychogenic disorders.
Dysphonic patients  hyperfunctional sets toward phonation. They work to talk in
most situations.
The exaggerated effort related to a generalized tension  may become more acute in
particular situations, such as when they speak to authority figures or when they try to
make favorable impressions on their listeners.
The primary task of voice clinicians is to explore with patients the various therapy
techniques that might produce that ‘good’ voice.
A young man who exhibits hard glottal attack might profit from learning to reduce his
rate of speech, opening his mouth a bit more, and practicing vocal chanting. Help
facilitate easy, smoothing style of voicing.
Voice therapy facilitating techniques
The selected therapy technique facilitates a more optimal vocal response by the
patient.
1. Counseling
§ Counseling the patient is highly individualized.
§ Most voice patients want to understand what their problems are and what they can
do about them.
§ Helping the patient to put his or her voice problem in its proper perspective.
§ Patients with hyperfunctional voice disorders profit from hearing the clinician
describe the voice problems in words they can understand.
§ For patients with structural changes of the vocal folds, such as nodules or polyps, 
explain that the organic pathology may well be the result of prolonged misuse, and
that by eliminating the misuse, the patient well eventually experience a reduction of
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vocal fold pathology.
§ Motivating the patient to eliminate the abusive behavior.
§ Therapy cannot be successful until contributory vocal abuse-misuse can be
drastically reduced.
§ For some patients, the voice problem is the cause of all of their ills, such as poor job
performance, social inadequacy, or general unhappiness.
§ A more generalized anxiety might best be treated through counseling or
psychological therapy.
2. Auditory feedback
§ Voice improvement is often enhanced by listening closely to one’s voice.
§ Auditory feedback is often an important step in therapy for articulation, language,
fluency, and voice disorders.
§ Real-time amplification, loop playback.
§ A holistic approach to correcting a voice disorder is often preferred over
fractionating various voice components (breathing, pitch, loudness) with separate
practice for each component.
Visual feedback
§ Real-time visual feedback of patient posture, head position, mouth opening, and
body position can be view in a mirror.
3. Relaxation
Stress  dry throat and mouth, harshness, elevated pitch, functional dysphonia and
shortness of breath.
4. Head positioning
§ Head position may change pharyngeal-oral resonating structures  change in vocal
quality
§ Basic to good vocal performance is good posture and head positioning.
§ Patients with vocal hyperfunction often profit most from neck flexion with the chin
tucked down toward the chest. Such downward carriage of the head seems to
promote greater vocal tract relaxation.
§ Patients with unilateral vocal fold paralysis will sometimes demonstrate a stronger
by lateralizing head position, with or without digital pressure on the lateral lamina
of the thyroid cartilage.
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5. Open-mouth approach
§ Encouraging the patient to develop more oral openness often reduces generalized
vocal hyperfunction. Opening the mouth more and while speaking and learning to
listen with a slightly open mouth allow the patient to use the vocal mechanism more
optimally.
§ The open-mouth approach promotes more optimum approximation of the vocal
folds, and helps correct problems of loudness, pitch, and quality.
§ Increase oral resonance and improve overall voice quality. Use the vocal
mechanism with less effort and strain.
§ It requires a lot of self-practice to overcome the habit of talking through a restricted
mandible.
6. Yawn-sigh
§ One of the most effective therapy techniques  minimizing the tension effects of
vocal hyperfunction.
§ In vocal hyperfunction, larynx raise, tongue lifted high and forward, the vocal folds
tightly compressed, pharynx constricted.
§ Yawn-sigh  larynx drops to a low position, slightly opening between the vocal
folds, pharynx dilated. When the patient is asked to sigh an /i/ or /a/, the voice
comes out with little effort and sound relaxed.
7. Respiratory training
§ Training in breath support.
§ Increasing abdominal muscle participation while the patient is sitting or standing
§ A slight increase of inspiratory volume may produce an immediate effect of
reducing vocal strain and improving overall vocal quality.
8. Digital manipulation
§ Light pressure anteriorly on the thyroid cartilage appears to nudge the thyroid
cartilage back slightly, shortening the overall length of the vocal folds, thickens the
folds.
§ Another is placing the fingers lightly on the thyroid cartilage and monitoring the
vertical positioning of the larynx.  Good technique for whom appears to have
excessive laryngeal vertical movement
Laryngeal massage
§ First step is to screen for a high larynx and probable excessive laryngeal-neck
muscle tension. The approach is recommended for patients with functional voice
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disorders, muscular tension dysphonia.
§ Manual circumlaryngeal therapy offers gentle laryngeal manipulation and massage,
resulting in lower laryngeal carriage and greater intrinsic-extrinsic laryngeal muscle
relaxation.
9. Nasal stimulation
§ Certain stimulus sounds seem to facilitate an easier-produced, often better sounding
voice. Using nasal consonants as therapy stimuli is particularly useful for patients
with functional dysphonia, spasmodic dysphonia, and dysphonia related to cord
thickening, nodules, polyps.
9. Change of loudness
§ Inappropriate loudness of voice is most often not the primary causative factor of a
voice problem, but rather a secondary.
§ Reducing of increasing the loudness of voice lends itself well to direct symptom
modification through exercise and practice.
§ Voice 1: Whisper. 2: not want to awaken a sleeping person. 3: normal voice to use to
talk to family. 4: Talk to someone across the room. 5: Yelling voice to call some one
outside.
11. Establishing a new pitch
§ Speaking at very bottom or the top of one’s pitch range requires too much force and
effort.
§ No absolute optimum pitch on which a particular person should speak, some people
with voice problems my profit from speaking at a different pitch level.
12. Focus
§ Good focus of the voice is characterized by the voice coming from the middle of the
mouth, just above the surface of the tongue.
§ Respiration training and placing the voice in the facial mask  Improve respiratory
control and resonance.
References
1. Boone DR, McFarlane SC, Von Bery SL (2005). The voice and voice therapy.
Boston: Allyn and Bacon.
2. Ramig LO, Verdolini K (1998). Treatment efficacy: Voice disorders. Journal of
speech, language and hearing research, 41, S101-S106.
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