Учебники / Voice Disorders and Their Management Freeman 2000

in environments which are often dusty; dust and materials leaking from set designs and stage pyrotechnics should be carefully considered. Those who work with actors and singers are well aware that they will frequently evidence dust and pollution as contributing to voice disorders, but will also refer to the lack of importance given to this by theatre management. Dealers on the Stock Exchange work in areas where fumes from fax and photocopying machines and teleprinters pollute the atmosphere. The clergy may preach in damp, musty and poorly ventilated spaces.

The effect of ageing

The vocal changes associated with ageing are well documented but it is important for those working with professional voice users to consider the effects of ageing on the voice. With demographic changes, many professional voice users will be working until they are quite old in chronological and physiological terms, even if they feel and look younger. A recent directive in the United Kingdom has effectively prevented teachers retiring early, whereas many were previously able to take advantage of an early retirement package. Now many teachers, unless retiring on the grounds of ill health, will work until they are 60 years old. A similar age profile exists for the clergy and salespeople, while several well-known actors and singers appear to rapturous applause, at an age far beyond that of statutory retirement. Providing of course that the voice remains flexible, and attention is paid to postural, respiratory and vocal health, then vocal quality can be maintained.

The effect of acoustics

Classrooms, lecture halls, theatres, drama studios, sales rooms, bond markets and churches vary enormously in size and design. Teachers often find that they may have to work in a variety of spaces throughout the day, endeavouring to compensate vocally for the different acoustics within each space. Similarly actors, singers, salespeople and the clergy are equally affected by the structure of buildings and the materials used inside them which determine the acoustic properties of the specific space. It is important to look at the space within which an individual is working and assess the demands that this will impose on their voice.

Achieving change

There is every reason to suggest that the professional voice training given to actors or singers should be, in some way, replicated for those professional voice users already identified in this chapter, including teachers, the clergy, salespeople, lawyers. Regrettably, there appears to be little likeli-

hood of this occurring. This means that the approach to working with this client group must in part be dictated by the client’s own need, as has been discussed above, to identify:

•specific external environmental factors which may have contributed to the voice disorder;

•specific factors which may maintain poor vocal practice;

•specific changes which the individual may make to establish new and less abusive voice use.

In working with the professional voice user the clinician should at all times keep a very clear vision of the specific needs of the individual, but also the needs that differentiate this group from those patients who are not professional voice users. It is important to demonstrate to the patient an understanding of the specific requirements of their professional role and to recognize that these requirements are different from those required by a more general dysphonic population. There are cogent arguments on each side for clinicians to have additional specialist training before working with this client group; but currently the jury is still out on this issue.

Professional voice users, in the main, demonstrate a noticeable desire to ‘get their voice back as quickly as possible’. The clinician needs to respond to this, by keeping in mind the clear agenda that professional voice users need voices which have both stamina and quality, in order to complete their professional roles. For many singers and actors this can be very difficult; many of the less ‘high profile’ professionals do not have the benefit of enlightened management companies, which allow them to take sufficient time off to effect permanent and consistent improvement. Teachers are equally conscious that any time off work during the term creates considerable financial pressure for the school, because of the need to employ a supply teacher at high cost.

The pressure to obtain results in a few sessions can also be considered in relation to the costing of voice therapy, either in terms of health insurance or in relation to the current limited provision by the NHS within the UK. This is not to suggest unwarranted speed is an essential component of all work with professional voice users, but simply to signal the implications of voice problems within this clinical group. Intervention with this group should, in the words of Morrison and Rammage (1994), ‘address all the lifestyle, emotional and technical issues that are represented in a complex system of symptom formation’.

As we have seen above, work with professional voice users, as with other client groups, must begin with the sharing of information regarding the structure and function of the vocal tract, the physiology of voice and

speech and the way in which this may be affected by physical and psychological stress. It is increasingly recognized that the way in which information is processed is highly individual (Ley, 1989; Ogden, 1996). Clinicians should try to maximize learning opportunities by offering information in a way that is most accessible to the individual. For example, some individuals learn best within a visual, rather than an aural modality; for some a mixture of both will prove most effective (see Freeman, Chapter 8). Clinicians are recommended to look at recent theories of learning, to ensure that they are delivering information in as appropriate a manner as possible (Verdolini et al., 1998). For some, too much information too soon will be confusing, so the educational aspect of intervention should be delivered in easily digestible amounts.

The impact of the external environmental factors

Specific external environmental factors may have contributed to the voice disorder. It is important to recognize that it may not be possible to change some of these environmental factors, but it is appropriate to look at ways in which to modify the environment. This can be much more successful than we first think, and the following strategies are offered.

1.Make sure that individuals are encouraged to think about the acoustics of the room in which they work. It is important to provide professional voice users with at least introductory information about the way the voice can be affected by the local acoustic environment, an area explored by Howard and Angus (1996).

Teachers, for example, may be able to change the acoustic from one which is vocally hard work, to one which supports the voice and minimizes the effort needed to produce voice. Recommended and fairly low cost solutions are, for example: (a) changes to wall and floor coverings; (b) repositioning of the desks to allow the teacher to move to a different part of the room when teaching; (c) if necessary the teacher may have to use a microphone.

2.Working with the acoustic of the room, rather than against it, can be achieved by experimenting with different pitch levels. It is always important to encourage the teacher to do this with guidance as imposed alterations in pitch can be vocally abusive. Actors and singers tend to work instinctively with the acoustic of the stage or space in which they are performing. Again, it is important to highlight this aspect of potential vocal strain. Often, it is possible to discuss this with the producer or director and encourage them to restrict difficult positions on stage to movement only positions.

3.Working in well-ventilated and well-hydrated surroundings is particularly important and again comparatively simple low cost solutions are available; water containers placed near radiators, covering radiators with damp cloths, goldfish in bowls, flowers and plants can all be used to introduce moisture to a room. Damping down a stage before a performance is important to reduce dust, as is the need to restrict exposure by performers to the use of stage ice or pyrotechnics if possible. If actors or singers are going to have to perform in adverse conditions then it is important to encourage them to steam just before and just after their performance to mitigate some of the dehydrating and vocally irritating effects (Verdolini-Marston et al., 1994).

4.Masks and protective clothing must be worn, where possible, if individuals are working in, for example, laboratory or workshop conditions. Breathing in the fumes of fixatives, glues or some paint material is not helpful. While individuals are often not happy about making this change it is important and compliance can sometimes be achieved if one uses the ‘setting a good example to students’ approach.

5.Seating and postural changes can bring about quite dramatic changes which impact on vocal tract positioning and laryngeal setting. It is important to examine these aspects with the patient and to identify how postural changes may be achieved. This may be by instigating comparatively small changes, like altering the height of a chair in relation to the desk or indeed moving furniture to encourage, rather than detract from, effective vocalization.

Focus on these aspects often prompts the patient to look more carefully at all aspects of their environment. It can also have the effect of making connections for the individual between previously unrelated aspects of their life, encouraging the identification of potentially harmful environmental features. For example, actors may need to maintain voice in demanding physical positions, on a raked stage or in restricting costumes. If they also work part-time in a smoky pub, then the combination is potentially vocally lethal. Understanding the link, however, allows change to be incorporated.

Specific factors which maintain poor vocal practice

The clinician needs to be aware of factors readily identifiable from the case history which are potentially abusive, but also of less transparent factors, particularly those which are discussed in health psychology references as influencing compliance (following the advice and instructions of the practitioner – Ley, 1988) or adherence (accepting an active share in the decision

making – and believing that one’s own actions will make the change possible – Stanton, 1987). It can be uncomfortable for the clinician to recognize that the relationship between clinician and patient may actively prevent improvement and change. The intimate link between emotion and voice is recognized; so too is the ‘Sharma’ effect, often seen in voice work when an individual is convinced that it is the special gifts and skills of the master clinician that have effected change. The obverse of this is that for some, fortunately few, patients the relationship with the clinician prevents, rather than facilitates change. Recognizing that intervention with a specific patient may be maintaining rather than changing poor vocal practice is a critical element in our evaluation of therapy practice and outcomes.

Specific treatment regimes

In structuring a therapy task, it is important to remember that individuals have preferred thinking and preferred learning styles. Work on learning and memory (Rose, 1985; Buzan, 1989) suggests that if individuals can tap into their preferred modality for learning, then new information is absorbed and retained with much greater speed and consistency. For example, patients who are more visual learners may be more comfortable with therapy which relies on visual display from the Laryngograph (Fourcin, 1974; Carlson, 1993) or Visipitch (Kay Elometrics) while other patients may respond better to a more auditory or kinaesthetic approach (Filter, 1980).

Notwithstanding this, there are specific areas which form the bedrock of intervention with voice patients. Work on general relaxation is an essential starting position for work on voice and many professional voice users find that once they have been introduced to the principles of relaxation, they can very effectively continue to work on their own. Work either on a stretch and release method or an image-based method is recommended (Jacobson, 1938; Martin and Darnley, 1992, 1996). It is also important to look at relaxation exercises which address specific areas of tension, for example the jaw, the neck, the face (Martin and Darnley, 1992).

Work on posture and alignment can mitigate against some of the problems identified earlier as a result of fixed occupational postures. General exercises for posture and work utilizing the Alexander Technique (Barlow, 1973; MacDonald, 1994) are of considerable benefit and indeed it is important to review conditions within the working environment with colleagues as this can often identify previously overlooked bad practice. It is easy to become habituated to particular conditions and, in effect, no longer see them. It is also true that individuals became ‘posturally entrenched’, often failing to ‘feel’ a position which is, in fact, potentially vocally abusive: voice is a physical skill and there is a need to consider the whole body in intervention.

Breathing exercises are very much part of the voice therapists’ repertoire and breath support and control are essential prerequisites, particularly with those who need to project their voices. Working with the professional singer or actor, it quickly becomes evident that for many, breathing exercises are utilized for their professional life, but there is little carry-over into offstage work. For the professional voice user, coordinating breath with voice onset is very important and so ‘teaching’ effective breath support and control can later be supplemented with work on what Morrison and Rammage (1994) term coordinated voice onset, thus optimizing the opportunity for easy voicing and the reduction of hard attack.

The mouth is the only truly moveable resonator and it is important for it to be as relaxed and flexible as possible. In order to maximize resonance, designated jaw exercises are very often a useful starting point for more detailed work on the articulators, and certainly work on the lips and tongue should be part of the repertoire of exercises for voice patients.

Specific vocal problems

When teachers were asked to specify the vocal problems they experience (Martin and Darnley, 1996) the range of responses was:

•insufficient volume;

•constant need to swallow;

•sounding strained at the end of the day;

•tight feeling in the throat;

•hoarse every time I have a cold;

•cuts out in the middle of sentences;

•husky voice;

•unable to sing;

•voice collapsed;

•complete voice loss.

These responses came from a random sample of teachers, many of whom had never sought any professional help for their voice problems. However, they emphasize the range and extent of the voice problems experienced by teachers and, indeed, these problems are symptomatic of those experienced by most professional voice users.

Generalization

The acid test of the success of any clinical intervention must be whether the individual acquires the ability to monitor their voice on an ongoing basis, learning to recognize and accurately predict situations which are potentially vocally abusive. The clinician must encourage this skill and also

ensure that the patient is fully aware of the various factors which influence vocal performance. It is imperative that intervention offers professional voice users the skills to maintain voice, even when severely vocally challenged, and offers them strategies to monitor their own voice and recognize factors which may precipitate vocal abuse and misuse.

The success of any programme of intervention depends on the individuals’ ability to incorporate therapy techniques into their working environment and to build on what has been learned within the supportive clinical environment, so that they can achieve effective voice at all times, and in a variety of different environmental conditions, to differing groups of people. The challenge of voice work with the professional voice user is precisely that intervention fulfils these criteria and allows the individuals to feel secure in their ability to maintain voice and thus their professional role at all times. It is therefore useful to put the voice under pressure to replicate situations which may challenge the voice and to monitor carefully how well the voice responds. Techniques such as easy safe shouting should be taught, while ways in which to protect and care for the voice must be incorporated into daily living.

As with many other treatment programmes, group work as part of a maintenance programme can be most successful. Indeed, group voice work with professional voice users can be particularly helpful once the individual’s needs have been evaluated.

Summary

Working with professional voice users is both a challenging and a rewarding experience. Challenging because the professional voice users expect and deserve to achieve vocal skills which fully meet their professional requirements and rewarding because successful intervention allows the individual not only to retrieve their modus vivendi as far as their professional status is concerned, but also to reinstate that unique characteristic which gives us our identity – our voice.

Preoperative assessment

Before any phonosurgical procedure the patient undergoes a complete phoniatric assessment. This consists of:

1.A videolaryngostroboscopy recording. This is made using a rigid endoscope coupled to a videocamera. The vocal folds are first filmed in normal light in order to study laryngeal morphology, and then in stroboscopic light in order to study alterations in the vibratory behaviour of the vocal folds (assessment of the significance of faults of closure, localized rigidity, modification of the mucosal wave, etc.). We prefer to use a rigid endoscope rather than a fibreoptic nasendoscope, as the latter produces a smaller, less well-defined image, which makes precise assessment of detail more difficult. A good quality videorecorder incorporating both a slow-motion mode and a good freezeframe image is important in order to get the maximum information from the recording. Good quality still photographic prints may also be produced by downloading direct from the videotape to a videoprinter.

2.A full vocal assessment. First, a tape recording of the voice is made while the subject is reading, speaking spontaneously and singing. A phonetogram is then performed, and when practicable the examination is completed by a full instrumental study (electrolaryngography, frequency analysis, sonography, etc.) in order to provide data on the various voice parameters for subsequent detailed analysis.

Maintenance of good acoustic and visual records is important in order to make an objective assessment of any modifications produced by phonosurgery.

The operation

This is performed as a suspension microlaryngoscopy and is always carried out under general anaesthesia with endotracheal intubation and full muscle relaxation. Full laryngeal relaxation allows for optimum positioning of the laryngoscope and hence nearly always gives excellent exposure of the whole glottis. Under these conditions the surgeon can operate safely, performing whatever surgical manoeuvres may be necessary in an unhurried manner. Patients usually remain in hospital for 48 hours following operation.

The equipment comprises:

1.a binocular operating microscope with a focal length of 350 or 400 mm;

2.two operating laryngoscopes of different sizes, together with a suspension arm;

3.relatively few instruments, most of which are angled to right or left: curved forceps, microscissors, dissectors, fine microforceps, fenestrated heart-shaped tissue-holding forceps, an arrowhead knife, a needle for injection, and a point monopolar diathermy electrode. All these instruments are approximately 22 cm long;

4.finally, the CO2 laser. Use of the laser is strongly advocated by some practitioners although we prefer to use micro-instruments, which are even more precise in practice and are better suited to the size of lesions to be treated.

Postoperative follow-up

In the immediate postoperative period the patient must maintain complete vocal silence for eight days until reviewed at the first postoperative follow-up appointment.

Medication is routinely prescribed postoperatively. The patient is given an injection of a depot preparation of steroids, a laryngeal steroid spray and mucolytics. In addition, antibiotic cover may also be supplied in cases where infection is thought to be a significant factor or when fibrin glue has been used during the operation. When the phoniatrician sees the patient for the first postoperative follow-up appointment the full preoperative workup is repeated. A period of intensive speech therapy then begins, and sessions continue throughout a month of convalescence. Subsequently the frequency of sessions is reduced and the patient returns to work between four and six weeks after operation. Going back to work is always a vulnerable time for patients when their work demands extensive voice use, teachers being particularly at risk. The phoniatrician makes a final assessment at the end of the course of speech therapy.

Indications for operation: techniques and results

Acquired benign lesions of the vocal folds

Nodules

A nodule is a mucosal thickening situated at the junction of the anterior and mid-third of the vocal fold, slightly under the free border. The thickening is of variable size and is usually elongated, although occasionally it may be rounded. A nodule may be pink or whitish in colour where there is old surface keratinization, and may on occasion also present as a small, pearly-white, pointed heap, this latter appearance being generally seen in singers. The lesion is normally bilateral.