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296 The Voice and Voice Therapy
colleagues, 2021). Oates and Dacakis (2015) reported that voice femininization should target
increasing fundamental frequency to approximately 180 Hz and increasing formant frequencies
close to cisgender female levels. VFAs that we have found effective in helping transgender women
uncover a healthy and natural pitch and pitch range while avoiding hyperfunction include open
mouth, establishing a new pitch, pitch inflections and relaxation, among others.
Resonance: Davies (2017) cited studies that suggested raising both average speaking fundamental frequency (SFF) and the resonances of the vocal tract may be the most important factor
in voice feminization. To this end, we introduce the VFAs of focus, nasal-glide stimulation, and
tongue protrusion /i/. These exercises help bring the client’s attention forward to the facial mask,
allowing the voice to fully resonate through the supralaryngeal structures and into the pharynx and
oral cavity. Tongue protrusion /i/ pulls the tongue forward, opening the laryngeal aditus (Edwards,
2003). Similar techniques intended to create a more feminine sounding resonance include lip
spreading and forward tongue carriage described by Carew and colleagues (2007).
Voice presentation is closely linked to one’s identity, and a mismatch between voice and
the person’s inner perception can create tension, stress, and anxiety (Davies et al., 2017). This
mismatch puts individuals at risk for developing functional voice disorders that may complicate
gender-affirming voice therapy. In a review of 25 TGD voice and communication cases, 28% had
voice disorders, including dysphonia, vocal tension, and strain (Hancock & Garabedian, 2013).
For these clients, we review vocal hygiene regimens and relaxation techniques. We also review
their breathing patterns both in clinic and by asking them to replicate breathing and voice to the
best of their ability during daily scenarios (work, typical conversations, and high stress demands).
We explain the differences between clavicular, thoracic, and diaphragmatic-abdominal breathing,
showing that the latter entails very little upper chest movement and is the preferred method of
respiration, especially for those with heavy vocal demands. Preferred VFAs for this population are
respiration training, relaxation, and yawn-sigh, the latter which gently widens the oral cavity and
oropharynx and lowers the larynx, leading to a more relaxed voicing mechanism.
Gender-Affirming Intervention for Transmasculine Individuals
Congruence of voice and gender identity is not just a significant concern for transgender women;
it is also for transmasculine individuals. A common misperception is that androgenic cross-sex
hormones result in lowering pitch, which eliminates the necessity of voice treatment. While
hormone therapy indeed increases testosterone levels, thus adding mass to the vocal folds and
lowering pitch, it does not necessarily influence changes to other aspects of voice and speech,
such as intonation, volume, and nonverbal communication (ASHA, 2019). These gender markers
remain problematic, as evidenced by as many as 31% of transmasculine individuals reporting
dissatisfaction with their voice masculinity after hormone therapy (Brown et al., 2020).
Azul and colleagues (2018) investigated self-evaluations of 14 German-speaking transmasculine individuals. Of those 14, almost 80% presented with indications of gender-related voice
problems. Problems included dissatisfaction with gender-related voice features, difficulties with
control of vocal gender presentation, and mismatch between desired gender attribution and
gender attributions received from others. Thus, gender-affirming voice and speech intervention is
warranted for this population. A good place to begin might be introducing the concepts shown in
Figure 8–1 and adapting them into voice therapy that provides the transmasculine client the tools
CHAPTER 8 Therapy for Specific Patient Populations 297
to explore and develop healthy voice strategies that feel congruent with their gender and sense
of self. Another promising approach appears to be group therapy. Beneficial outcomes of group
therapy were documented by Mills and colleagues (2019), who investigated 10 participants identifying as transgender men who received voice and communication group therapy between 2017
and 2018. These participants reported high levels of satisfaction with the voice group program,
reporting significant positive shifts in voice skills and self-perception. The authors suggested that
the findings be replicated and that a transmasculine voice modification protocol be pursued.
In summary, gender-affirming health care is a rapidly evolving interdisciplinary field with
an unprecedented increase in the number and visibility of TGD individuals seeking support and
gender-affirming voice and communication intervention. The voice clinician is instrumental in
acting as a guide based on the clients’ stated concerns and priorities toward achieving a voice that
is authentic, comfortable, and safe (ASHA, 2019). The voice clinician incorporates strategies that
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directly target pitch and pitch variation, resonance, and forward focus speech, among others.
Stimulability probes as described in Chapter 7 are instrumental in uncovering the healthy voice
that feels congruent with the client’s gender and sense of self.
Voice Therapy for Respiratory-Based Voice Problems
Respiratory problems often influence how a child or adult can use their voice. Severe problems
in respiration, such as bilateral vocal fold paralysis (see Chapter 5), often require life-saving
medical–surgical intervention. In milder breathing problems, the voice clinician can often play
both a diagnostic and therapeutic role, working closely with the pulmonologist and the respiratory
therapist. Let us consider a few respiratory problems and their overall management, including
voice therapy.
Airway Obstruction
The voice clinician may encounter children and adults with voice problems related to airway
obstruction. Although obstructive airway problems require medical–surgical intervention and
management, the SLP may play an important part in both identification and management of the
disorder. Airway obstruction has two basic contributing causes (O’Hollaren, 1995): (a) structural,
lesion mass, and foreign body airflow interference and (b) abnormal laryngeal movement interference. See Igarashi and colleagues (2019) for an investigation into foreign body airway obstruction.
Airflow Interference
Laryngeal and supralaryngeal mass obstruction to airflow can have both infectious and noninfectious causes. Severe involvement of the epiglottis and supraglottal structures is almost always the
result of a bacterial infection, treatable with appropriate antibiotic therapy. Depending on the
size of the supraglottal swelling, inspiratory and expiratory breathing can be seriously compromised. Subglottal obstruction from disease is most often seen in croup, a viral disease that is
usually characterized by “barky” cough and inhalation stridor (Hester et al., 2019). Once croup
is differentiated from problems such as induced laryngeal obstruction (which is often confused
298 The Voice and Voice Therapy
with asthmatic stridor), effective treatment includes racemic epinephrine and corticosteroids
(Asmundsson et al., 2019; Mora et al., 2023; O’Hollaren & Everts, 1991).
Airway obstruction can be caused by space-occupying lesions such as papilloma, granuloma,
carcinoma, or large cysts — all described in Chapter 4. Once such lesions are identified as compromising the airway, effective medical management may include radiation therapy to reduce the
lesion size or surgical reduction or removal of the lesion. The obstructive lesion is watched closely;
when it becomes too large, such as is often observed in juvenile papilloma, a surgical approach
restores required airway competence. The voice clinician often plays an important role with the
postsurgical, mass lesion patient, establishing the best voice possible with voice therapy (despite a
scarred and abnormal glottal margin).
Vocal Fold Paralysis
The most common laryngeal movement obstruction to air movement within the airway is laryngeal paralysis, unilateral or bilateral. In Chapter 5, we looked at the possible causes of vocal fold
paralysis, and surgical and voice therapy management; thus, we do not repeat that information
here. Suffice it to say that while unilateral vocal fold paralysis contributes to some compromise
of the open airway, bilateral abductor paralysis produces a life-threatening obstacle to air passage,
requiring immediate surgical intervention.
Asthma
According to the Centers for Disease Control and Prevention (https://www.CDC.gov), approximately 25 million Americans have asthma; including about 4.5 million young people under the
age of 18 years, making it the leading chronic disease in this population. In asthma, the patient
experiences a narrowing of airway tubes, particularly in the bronchi and bronchioles, which limits
the free passage of air. Spasms of the airway can be caused by the external smooth muscles going
into spasm, causing a narrowing of the opening (Berkow et al., 1997). This causes the inner lining
of mucosa tissue to become compressed and inflamed, resulting in mucosal swelling and irritation,
and causing production of mucus (which further obstructs the passageway). The patient struggles
to take in a breath. Asthma is no longer thought of as a single disease. It is often categorized into
different types, which include allergic, aspirin induced, cough variant, exercise induced, nighttime,
steroid resistant, and occupational (American Lung Association, n.d.). The asthmatic symptoms
may be chronic (they come and go) or part of a sudden and severe reaction that may require
immediate medical intervention. In the asthmatic patient, the primary management is treating the
spasms and inflammation that interrupt the patient’s natural breathing. Glucocorticoids (GCs),
both inhaled and oral, are considered effective treatment in asthma because they control symptoms
and prevent exacerbations (Ora et al., 2020). Reduced airway inflammation appears primary for
increasing airway dilation and thus allowing a greater passage of air into and out of the lungs.
Asthma intervention depends on age, symptoms, asthma severity, and medication side effects. For
a full review of asthma medications and indications, see the Mayo Clinic website (https://www
.mayoclinic.org/diseases-conditions/asthma/diagnosis-treatment/drc-20369660).
The voice clinician does not usually encounter the patient during severe respiratory obstruction. Patients with asthma sometimes complain of voice symptoms, which are usually attributed to
CHAPTER 8 Therapy for Specific Patient Populations 299
treatment with inhaled corticosteroids (Naunheim et al., 2023; Stanton et al., 2009). Asnaashari
and colleagues (2012) evaluated the quality of phonation in a group of 34 adults with untreated
mild to severe persistent asthma and compared these participants to a group of nonasthmatic,
age- and sex-matched healthy controls. These clinical researchers found that lower airway diseases
such as asthma can impair voice quality. When dysphonia is chronic and interferes with quality
of life, patients may seek the help of the voice clinician.
Vertigan and colleagues (2021) investigated laryngeal functioning in patients with a confirmed
diagnosis of severe asthma. They found a high prevalence of respiratory and phonatory dysfunction, which improved after a combination of speech pathology intervention and improved asthma
control. Speech intervention was based on principles commonly used in inducible laryngeal
obstruction (ILO)/exercise-induced laryngeal obstruction (EILO) and chronic cough (refer to
these sections in this chapter). Intervention included educating the patient about laryngeal functioning in asthma, strategies for reducing or eliminating irritation triggers, and symptom control
exercises such as cough suppression strategies. Laryngeal dysfunction and subjective symptoms as
measured by the Asthma Control Questionnaire improved after speech intervention. The authors
suggested that speech intervention did not alter pulmonary function but rather improved patients’
perceptions of their asthma symptoms.
When respiratory symptoms are under some control, the voice clinician may help the patient
develop and use a functional voice. Phonation can often be helped by reducing the number of
syllables the patient says on one breath. A baseline measurement should be taken. The patient
should then be instructed to cut the total number in half. For example, if a patient says 20 syllables
on one expiratory phrase, the patient should be instructed to limit utterances to half that number,
or 10 syllables per breath. This seems to prevent vocal fold squeezing, which makes the last words of
the phrase or sentence sound squeezed or dysphonic. Help the person to develop methods
of renewing breath while speaking. Good posture with the head not tilted upward or downward,
the open-mouth approach, vocal hygiene, and the yawn-sigh approach have all been found helpful
for the asthmatic patient who wishes to improve vocal efficiency (see Chapter 7).
Chronic Obstructive Pulmonary Disease
Emphysema and Chronic Bronchitis
Among various chronic pulmonary diseases experienced by the adult population, COPD is the
most common (Centers for Disease Control). Emphysema is a type of COPD involving damage
to the air sacs (alveoli) in the lungs. As a result, the body does not get the oxygen it needs. The
primary cause of emphysema is smoking, although it is now recognized that COPD/emphysema
occurs in nonsmokers and that cigarette smoking accounts for 50% to 70% of COPD cases.
Other exposures are air pollution, occupational exposures, poorly controlled asthma, environmental tobacco smoke, infectious diseases, and low socioeconomic status (Yang et al., 2022).
The continuous exposure to these elements in the lungs causes the alveolar walls to lose their
elasticity, collapsing on pulmonary expiration (Berkow et al., 1997). This collapse of the alveoli
in turn causes the bronchioles (the airway conduits to and from the alveoli) to collapse. Indeed,
most people with emphysema also have chronic bronchitis. The result of this alveoli-bronchiole
collapse is difficulty in emptying the lung during expiration (Sataloff, 1997). Consequently, the
high residual air volumes preclude taking in adequate oxygen renewal on inspiration. The patient
300 The Voice and Voice Therapy
with moderate to severe emphysema struggles to get sufficient breath to sustain their life. Da Silva
and colleagues (2022) investigated voice-related quality of life in 37 individuals diagnosed with
COPD. Results revealed an impact on the quality of life in the voice of the analyzed individuals,
which the authors suspected may be due in part to the vocal alterations resulting from the disease.
Because the primary cause of emphysema is cigarette smoking, the first mandatory treatment
step is to stop smoking. Mild emphysema can begin to show after only 5 or 7 years of continuous,
heavy smoking. It is the mildly involved patient, often a professional user of voice, whom we
often see with a voice problem. Formal respiratory therapy for these patients is better off left in
the hands of the respiratory therapist or other pulmonary specialists. For example, the patient
might be using prescribed bronchodilators, inhaled steroids, or even supplemental oxygen. The
voice clinician often begins intervention by taking voice measurements specific to air volume
and available pressures for voicing, measures of duration, and sound pressure level of the voice.
Observation of the patient during speaking, oral reading, and singing tasks may also reveal some
unnecessary postural-skeletal behaviors the patient is using to maintain breathing, movements that
may be inefficient and counterproductive to good voice control.
Desjardins and Bonilha (2020) investigated 12 studies looking at the effectiveness of several
respiratory interventions to improve respiratory and voice outcomes in individuals with COPD.
Exercises included expiratory muscle strength training, inspiratory muscle strength training,
incentive spirometry, isocapnic hypernea, respiratory effort treatment, abdominal directives, easy
breathing, stimulation training, and vocalization with abdominal breath support. Respiratory
improvements were reported for subjects in each of the 12 studies reviewed, and 9 of the 12
reported some voice improvement, although these were limited to subsets of participants. In our
own clinics, we have found that vertical positioning strategies and attention to diaphragmaticabdominal breathing may be useful as well as practice in counting syllables per utterance in an
attempt to become more aware of when to renew breath. Shortening the length of phonation can
help the patient have more control over voice loudness. The patient with COPD can sometimes
improve voice quality by speaking at a slightly higher voice pitch. Other VFAs, such as focus,
glottal attack changes, masking, and pitch inflections, might be attempted in the search for a
stronger functional voice (see Chapter 7).
Faulty Breath Control
Many children and adults appear in the clinic with faulty breath control, caused by some organic
disease or from functional misuse, or both. That is, there may be a functional overlay to an organic
respiratory disease that can be treated directly to improve overall respiratory function as well as
provide better breath support for voice. There are an endless number of respiratory diseases, most
of which may have some impact on voice. The voice clinician who works with voice patients soon
learns to consult with physicians and therapists who work with patients with respiratory diseases.
What we do with voice problems related to respiratory problems must be consistent with the
limitation imposed by various respiratory diseases and the treatments the patient may be receiving
from other professionals. The clinician should not be preoccupied with the presenting disease
problem but face the patient more holistically, as a person with a voice disorder that shows itself
in various pitch–loudness–quality dimensions. In fact, faulty breath control may show itself more
as a functional problem than as an organic one. For most patients, the voice clinician should assess
CHAPTER 8 Therapy for Specific Patient Populations 3 01
respiratory-voice function following many of the evaluation procedures presented in Chapter 6.
The voice evaluation should supplement any other respiratory assessment information. We use
the management and therapy suggestions developed in the VFAs called respiration training for
developing better breath support for patients with faulty breath control (see Chapter 7).
Induced Laryngeal Obstruction and
Exercise-Induced Laryngeal Obstruction
ILO and EILO have been described in the past using several different terms, the most common
being paradoxical vocal fold movement (PVFM) or vocal cord dysfunction (VCD). As our
understanding of the condition has evolved, so has the nomenclature. A joint statement from
the European Respiratory Society and the European Laryngological Society proposed use of the
term ILO to better describe the clinical entity that is characterized by inappropriate, transient,
reversible narrowing of the larynx in response to external triggers (Glasson et al., 2024; Halvorsen
et al., 2017).
ILO is characterized by vocal fold adduction on inhalation and/or exhalation resulting in
respiratory distress that mimics lower airway dysfunction (Clemm et al., 2022). ILO that occurs
because of exertion is known as EILO. ILO/EILO symptoms can occur in the absence of a
known cause or continue despite thorough medical management. The disorder is recognized in
the medical community as a disorder to consider when symptoms of respiratory distress do not
respond to treatment for asthma (see Case Study 3 in Chapter 6). Health care use and comorbidities in this population are high, with the dominant comorbidities being asthma and reflux
(Haines et al., 2024). Shay and colleagues (2020) investigated comorbidities in a large group
of patients under the age of 26 years with EILO. Of the 112 patients, 91 were female and 21
were male. Most patients (93%) participated in organized sports, most of them at a competitive
level. Almost 60% of patients presented with a prior diagnosis of asthma, the majority of whom
had failed asthma treatment. The most common symptoms reported were dyspnea, wheezing
and stridor, and throat tightness. Flexible laryngoscopy revealed that almost 80% of patients
showed PVFM with 24% showing supraglottic involvement, “with patterns of obstruction
similar to those observed in children with laryngomalacia” (p. E401). See Chapter 4 for Organic
Voice Disorders. These authors suggested a variety of potential triggers for ILO, including odors,
temperature changes, irritants, stress, and exercise.
Vance and colleagues (2021) reviewed charts of 40 individuals with confirmed ILO over a
12-year period. The average age was 30.25 years, and 45% were under the age of 18 years. Eighty
percent were female, 25% were serious athletes, and 40% were students. A previous history of
asthma was reported for 65%, with 36% of those being confirmed by pulmonary function testing.
Laryngopharyngeal reflux (LPR) was reported for 78%, 8% had a history of obstructive sleep
apnea, 18% had a body mass index over 30, and 48% had a history of allergic rhinitis. Thirteen
percent worked in a job requiring extensive voice use (singer, music teacher), and one-third of the
individuals had concurrent psychiatric diagnosis.
ILO/EILO can be considered manifestations of laryngeal hypersensitivity syndrome, described
by Baker and colleagues (2021). These researchers suggest that VCD may be associated with
aberrant involuntary learned behavior rather than primarily due to ongoing disease or damage,
but not necessarily in the presence of or as a result of psychological distress (Baker et al., 2021).
302 The Voice and Voice Therapy
Sandage and colleagues (2023) identified several other conditions that can mimic ILO/EILO.
These additional conditions include laryngeal edema, angioedema, anaphylaxis, extra thoracic
obstruction, and bronchopulmonary dysplasia. See Sandage and colleagues (2023) for an expanded
list of conditions that can mimic ILO/EILO.
SLPs receive referrals for ILO and EILO from several different medical specialists, among
them pulmonologists, allergists, and sports medicine. Thus, it is paramount that SLP-voice clinicians who assess and treat ILO/EILO have a solid understanding of the conditions that may mimic
this disorder before initiating intervention (Sandage et al., 2023).
With respect to treatment, Vance and colleagues (2021) assessed the efficacy of several
approaches to ILO/EILO in 40 patients over 12 years. Twenty-three percent underwent botulinum
toxin type A (BTX-A) treatment, 80% underwent voice therapy, 93% underwent LPR therapy,
and 30% underwent psychotherapy. Patients who received BTX-A, voice therapy, and LPR treatment had a 90% subjective improvement rate and a significant improvement rate over just voice
therapy and LPR. These researchers suggested that current management of ILO/EILO include
LPR control when indicated and laryngeal control therapy by a SLP-voice clinician. They also
cautioned that although many feel that ILO/EILO has a psychogenic basis, that misdiagnosis of
psychopathology must be considered in the full differential diagnosis.
Behavioral interventions by the voice clinician include vocal hygiene education, anti-LPR
counseling, recognizing and reducing triggers, respiratory training, and laryngeal relaxation.
Trudeau (1998), Blager (1995), Von Berg and colleagues (1999), Mathers-Schmidt (2011), Case
(2002), Murry and colleagues (2004), Shaffer and colleagues (2018), Fujiki and colleagues (2024),
and Barillari and colleagues (2024) have reported good success in their respective vocal hygiene
and laryngeal control programs geared toward minimizing the triggers of, and subsequent airway
obstruction experienced by, the patient with ILO. Many programs place emphasis on helping the
patient to become aware of aberrant and normal vocal fold positioning during both inspiration
and expiration. Some of these programs use flexible videoendoscopic feedback. In our clinical
practice, we use flexible videoendoscopy to illustrate correct and abnormal vocal fold postures for
both phonation and quiet respiration for the patient to both observe and produce. Patients become
aware of how to produce vocal fold configurations in their own larynx, showing them what to do
to “open the airway when you take in a breath.” We have found the use of the yawn-sigh to be
a useful technique for opening the vocal folds and creating a more open airway (see Chapter 7).
Other approaches described by Trudeau (1998) include nasal inspiration, working on /s/ duration
(not to maximum levels), and the use of diaphragmatic-abdominal breathing.
Chronic Refractory Cough
The act of coughing allows breathing to occur without obstruction and is necessary to protect
the lower airways; it is considered a normal life-sustaining physiological reflex (Driessen et al.,
2020; Murgia et al., 2020). However, when the cough persists for years with little to no relief from
medical treatment, it is considered a chronic, or refractory, cough (CRC). The diagnosis of CRC is
made once the main diseases that cause chronic cough have been excluded and the cough remains
refractory to medical treatment. CRC is seen in 20% to 46% of patients presenting to specialist
cough clinics, and it has substantial impact on quality of life and health care utilization (Gibson
& Vertigan, 2015; Vertigan et al., 2019).
CHAPTER 8 Therapy for Specific Patient Populations 303
CRC is associated with laryngeal hypersensitivity syndromes and chronic pain syndromes.
Its pathophysiology is complex and includes cough reflex sensitivity, central sensitization, and
peripheral sensitization (Gibson & Vertigan, 2015). Triggers may be induced laryngeal obstruction, also known as PVFM, LPRD, and muscle tension dysphonia, or it may be independent of
these conditions. Chronic cough has physical side effects, such as laryngeal trauma (Colton et al.,
2011), dysphonia, globus, and dyspnea; social consequences, such as embarrassment and negative
impact on quality of life (Ma et al., 2009; Vertigan et al., 2019); and financial consequences,
such as expensive medications and lost work productivity. For a full review of the multiple factors
influencing cough function and complex mechanism underlying cough disorders, see Novaleski
and colleagues (2024).
Several treatments are available for CRC, both medical and behavioral. Pharmacological interventions include neuromodulators, with gabapentin as the first choice (Visca et al., 2020). BTX-A
injections are also reported to be effective (Campbell et al., 2023) There is growing recognition
of the beneficial role of speech therapy for disordered cough (Novaleski et al., 2024). Behavioral
approaches by the SLP-voice clinician are similar to those approaches to the treatment of functional voice disorders (Blager et al., 1988). The voice clinician helps the patient understand the
nature of their disorder, recognize key triggers that stimulate their urge to cough, and then devise
techniques to reduce or eliminate the typical responses to those triggers. A comprehensive CRC
reduction program targets the higher cognitive components of cough and includes educating the
patient about the nature and anatomy of the cough, identifying triggers of the cough, introducing
strategies to suppress the cough, vocal hygiene education, and encouraging patients to believe in
their own self efficacy. For tutorials on the role of the voice clinician in the management of patients
with CRC, see Baker and colleagues (2021), Novaleski and colleagues (2023), and Vertigan and
colleagues (2019).
Kapela and colleagues (2020) studied the effects of prerecorded videos featuring exercises
to reduce CRC. Two groups received speech intervention for CRC, but the experimental group
also received supplementary videos to use at home. Participants in the experimental group were
asked to rate the accuracy of their ability to demonstrate the cough suppression exercises. Other
outcome measures were the Symptom and Severity Rating Scale, Leicester Cough Questionnaire,
and CAPE-V. The authors reported a significant pre- to post-treatment improvement in both
groups, but the degrees of improvement were not significantly different between the two groups.
Tracheostomy
A tracheostomy, or external opening into the trachea, may be necessary when an individual
experiences respiratory difficulty due to an obstruction of the upper airway, has problems with
pulmonary toilet (managing secretions), or requires mechanical ventilation to maintain adequate
respiration. A tracheostomy fundamentally alters the physiology of voice and swallow because the
stoma is below the level of the larynx, thereby bypassing the upper airway. Decisions regarding
the type and size of the tracheostomy tube will be made by the ENT, pulmonologist, and multidisciplinary airway team, based on the individual’s diagnosis, physical status, and medical needs.
The SLP-voice clinician trained in tracheostomy and ventilator care plays an important role in
decision-making, cuff deflation, tracheal decannulation and management of swallowing, voice,
and establishing a means of communication (Divya et al., 2020; Kazandijian & Dikeman, 2008).
304 The Voice and Voice Therapy
Depending on the type of tracheostomy tube the individual receives, the individual may or
may not be able to use a tracheostomy speaking valve, which is a one-way removable valve that is
attached to the open end of the tracheostomy tube. The valve allows air through the tracheostomy
tube on inhalation and closes on exhalation to force air up through the vocal folds and into the
upper airway so that subglottic pressure is restored, and the patient can articulate the sound source.
As a team, the pulmonologist, respiratory therapist, critical care nurse, and SLP-voice-clinician
work together to determine when the patient is or will be ready for speaking valve trials. Specific
indications and therapy for children and adults with tracheostomy are discussed by Mason (1993),
Barnes and Toms (2021), and Chorney and colleagues (2021). In addition to providing direct
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services, SLPs are also responsible for patient and family counseling and investigation of support
services. Several organizations provide support to specific tracheostomy and ventilator-dependent
populations.
Summary
In this chapter, we presented voice disorders in children and adolescents, older adults, those
with hearing impairment, those who are seeking gender-affirming voice therapy, and those with
a variety of respiratory-based conditions. We also discussed the professional voice user and the
management of dysphonia in this population of patients, whose numbers are increasing. While
patients from the aforementioned groups may also have primary or concomitant functional,
organic, or neurogenic contributors to their dysphonia, they each present unique management
challenges (see Chapter 7 for case studies).
CLINICAL CONCEPTS
The following clinical concepts correspond with many of the objectives at the beginning of
this chapter:
1. In the older adult patient with dysphonia, the voice problems are sometimes due
to normal age-related changes, while other times the voice problems are sometimes
due to pathological changes that are more a consequence of disease process. You may
see a speaker with Parkinson’s disease who has a soft voice (see Chapter 5); a speaker
with weak respiratory muscles who has to take more frequent breaths during talking;
a speaker with hearing loss who has difficulty monitoring and adjusting their voice,
resonance, and speech output; and a speaker with dysarthria who cannot control
the flow of air through the glottis, resulting in changes in pitch, loudness, and voice
quality (see Chapter 5).
2. Many voice-disordered patients will come to you because of changes to the voice
related primarily to vocal hyperfunction. Some examples include a preschool-age
child who is in a noisy daycare center and has to raise their voice to be heard;
an elementary-age child who participates in extracurricular activities such as
CHAPTER 8 Therapy for Specific Patient Populations 305
cheerleading, glee club, or debate team and uses their voice excessively throughout
and beyond the school day; and an adolescent in high school who cannot participate
in extracurricular activities such as being on a sports team because of their dysphonia
and the social stigma that it brings.
3. Some voice-disordered patients will come to you because they are professional voice
users. Some examples include a schoolteacher whose voice does not hold up throughout the day and who uses a lot of her sick days because of chronic dysphonia; a singer
who overuses or misuses his voice and whose performances thus suffer; a call center
operator whose dysphonia interferes with her effectiveness in helping callers and who
thus misses out on potential job advancement opportunities; a salesperson whose
dysphonia is distracting and a barrier to closing deals successfully; and a minister
whose “message is lost in the messenger” because of a distracting voice quality.
4. Individuals seeking gender-affirming intervention may come to you seeking to
modify their voice and communication. The voice clinician is instrumental in acting
as a guide based on the client’s stated concerns and priorities toward achieving a voice
that is authentic, comfortable, and safe.
5. Some voice-disordered patients will come to you because they suffer from PVFM,
with or without chronic cough. Voice therapy can be an important adjunct to
medical management and may include the use of many of the VFAs outlined in
Chapter 7.
GUIDED READING
Read the following articles:
Bottalico, P., Murgia, S., Mekus, T., & Flaherty, M. (2023). Classroom acoustics for
enhancing students’ understanding when a teacher suffers from a dysphonic voice.
Language, Speech, and Hearing Services in Schools, 54(4), 1195–1207. https://doi.org/10
.1044/2023_LSHSS-22-00158
Describe the challenges to both teachers and children in elementary school classrooms who
experience high listening difficulty due to poor classroom acoustics. How might you go
about suggesting changes to modify these noise levels and increase teacher intelligibility?
Leyns, C., Papeleu, T., Tomassen, P., T’Sjoen, G., & D’haeseleer, E. (2021). Effects of speech
therapy for transgender women: A systematic review. International Journal of Transgender
Health, 22(4), 360–380. https://doi.org/10.1080/26895269.2021.1915224
Analyze the improvements in pitch elevation, oral resonance, self-perception, and listener
perception as a result of speech therapy for transgender women. Why do you think these
behaviors in particular were selected by the researchers as variables of interest?