Учебники / Voice Disorders and Their Management Freeman 2000

The muscle groups are initially examined statically, to assess their tone and quality. Fibrosis and permanent shortening associated with prolonged contraction will be noted. The musculature is then assessed dynamically to establish the range of joint movement and efficiency of their habitual use. Where there has been damage to the larynx or suspensory mechanism (e.g. through paralysis or surgical division from such operations as thyroidectomy), the compensatory patterns are assessed. Many patients who have normal laryngeal mechanisms and normal muscle tone in the extrinsic laryngeal muscles at rest, produce hypertonic muscle patterns as soon as they begin to phonate. These cases are usually associated with emotional difficulties that are expressed in increased musculo-skeletal tension.

Other important measurements can be carried out either at a session with the speech therapist prior to the voice clinic, or by a technician either before or after the clinic examination. These measures might include audio recording, EGG, Phonetograms, airflow studies and spectrography, as available and appropriate. If they can be carried out before the examination, the results are available to the clinic team. However, it may be more appropriate to decide on which will be the most useful for individual patients after the laryngeal examination. The results can then be reviewed and added to the patient notes at the end of the clinic.

Administrative issues

There is no right way to run a voice clinic, but there are two definite approaches. The first is to assess all voice patients coming through the ENT department in the voice clinic, and the second is to see only those who present with complex problems or who have failed in conventional therapy.

The first approach has the advantage of providing a full assessment at the initial interview, ensuring the most effective use of clinic time and maximizing patient co-operation. The disadvantages are that some patients do not require a multidisciplinary approach and therefore may be considered as wasting clinical time. Also, hoarse patients need to be given priority in order to exclude malignancies. Voice clinics running only once a month will not be able to provide this service quickly enough. Finally, this approach often requires close co-operation between the hospital consultants, and where the voice clinic is staffed by a registrar or senior registrar, this may not always be possible.

The second approach has the advantage that screening of hoarse patients is carried out prior to their referral to the voice clinic, eliminating those with malignancies or who require primary surgery and selecting patients most likely to benefit from a multidisciplinary approach. It also

allows time to arrange for the relevant team members to be present or to select special patient groups for certain clinics. The disadvantages are that patients may be selected for surgery rather than voice therapy unnecessarily and concomitant medical or psychosocial factors may be missed, with the attendant problems discussed earlier in the chapter.

Number of patients per clinic

Once the referral style has been decided, it remains necessary to work out the probable case load so that the number of clinics per month can be agreed. Most departments seem to decide to run voice clinics once a month initially, increasing or decreasing the frequency according to the case load demand and financial constraints. Once the team is experienced, new patients seem to need a maximum of half an hour while repeat patients can be seen in 15–20 minutes. Most clinics may have to manage between 7 and 12 patients in a session. More than 12 patients per session becomes impracticable.

History taking and clinical records

Case history forms can either be sent to patients to fill in prior to their clinic visit, be given to patients to complete in the waiting room or dealt with in clinic. Collecting the information prior to the clinic examination saves time, but there is a danger that patients may fail to understand some questions, or fail to recognize and report symptoms accurately without careful questioning. Where information is collected by questionnaire, it is recommended that the history is briefly recapped in clinic to prevent misunderstandings or omissions. The case history questionnaires can be kept in the notes along with the assessment check lists for stroboscopy and laryngeal palpation. They have the advantage that they are in the patient’s own hand and confirm agreement of the case history facts that may be useful in the event of medico-legal disputes.

Video and audiotapes are usually stored in the clinic in date order. It is imperative that the dates of the patients’ attendance at clinic are carefully recorded, in order to be able to access their previous recording(s) quickly. Ideally, long standing patients should have their own tapes, but this tends to be costly and increases the need for storage space. Once recordings are kept on CD or DVD ROMs it will be easier to access past recordings as it will be possible to file them under the patient’s name.

Explanations

A significant part of the time allowed for clinical assessment is spent on explanation to the patient. It is very important that the patient under-

stands the diagnosis and the proposed management plan and takes part in the decision-making process. It ensures that they take responsibility for the voice problem and for carrying out the voice therapy.

Support staff

Voice clinics require the usual administrative support and staff need to be clear about who is responsible for booking appointments, finding notes, typing the letters and reports and keeping the necessary statistics. Inevitably there are cost implications. If the clinic is run in the ENT department, it is usually the case that the voice clinic can be treated as another ENT clinic and the same support staff can be used for both. Where the clinic runs in the Speech Therapy department, it may be more difficult to negotiate and sometimes the speech therapist or speech therapy secretary will need either to collect notes from the ENT administrative staff or organize the appointments and typing themselves.

The voice clinic that runs in the ENT department will often be provided with a clinic nurse and allowed to share the receptionist. If it is run in speech therapy, sometimes a volunteer can be trained to act as receptionist. It is important that someone is responsible for welcoming patients, checking that their personal details are correctly recorded in the notes and making sure they know where to find other departments for tests when required.

Outcome and audit

In these days of financial restrictions, it is more important than ever that clinicians measure the outcomes of therapy and the clinic keeps accurate statistics. Records need to be kept of how many patients were seen per clinic, the number of new patients versus follow-up patients, how many failed to attend and the referral source. It is also useful to record the diagnosis and management for each patient, together with the number of clinic and therapy visits before discharge. The patient’s age, sex and occupation may also be useful for research purposes.

It is up to each member of the voice clinic team to take their own measures of the patient’s voice preand post-therapy. Usually, one good tape recording will be made at the beginning, at certain points during treatment (for example, before and after surgery, or after certain aims have been achieved, and at the end of the treatment period). The speech therapist may wish to carry out EGG, airflow measures or spectrography, while the singing teacher may decide to record the patient singing and carry out a phonetogram, depending on the technology available to the clinic. The clinic osteopath may have an assessment sheet grading muscle tone levels across a number of scalar degrees.

Questionnaires of patient satisfaction with the service they received in the voice clinic, together with their rating of their original problem and the final result, are also helpful (Harris et al., 1986). Recent work carried out by Enderby (1997) and Carding (2000) suggests that a valid way to measure outcome for the speech, language and voice impaired population is to rate the impairment (i.e. the severity of the hoarseness); the disability (how much the hoarseness prevents the patient from communicating effectively); the amount of handicap this creates (how much impact the hoarseness has on the patient’s work and social activities) and the patient’s own rating of the degree of distress the problem is causing. This seems a valid way of measuring the more subtle effects of voice therapy, such as psychological or attitude change, and the use of compensatory communication techniques.

Finally, it is important that one of the team collates the outcome measures either on to a computer spreadsheet or on to a single sheet to be included in the patient’s discharge report.

Voice clinic research

Between 1990 and 1992 research was undertaken at the Voice Clinic at Queen Mary’s Hospital, Sidcup into the association between head, neck and shoulder girdle dysfunction and dysphonia. The project was funded by Guy’s Hospital Primary Care and Development Fund with the aim of establishing:

1.whether manual therapy/osteopathic techniques provide an effective alternative to speech therapy for dysphonic patients;

2.whether speech therapy, manual therapy or a combination of both is most effective in resolving dysphonia;

3.the existence of specific patient characteristics that could be used to determine the therapy mode most likely to benefit individual patients.

Dysphonic patients identified at their voice clinic assessment as needing voice therapy were offered the opportunity to take part in the research. Patients requiring surgery prior to their voice therapy and patients whose dysphonia/aphonia was judged to be predominantly emotional in aetiology were excluded. Sixty patients agreed to take part in the study and were randomly allocated to one of two therapy conditions: a sixsession course of speech therapy, carried out by one of the two voice clinic speech therapists, or a six session course of manual therapy carried out by the voice clinic osteopath.

At the end of the six sessions, the assessment procedure was repeated, following which the patients completed six sessions of the alternative

treatment before a final re-assessment. At the end of the study 39 patients had completed six sessions of speech therapy, six sessions of osteopathy and had been assessed three times – prior to therapy, after the first therapy condition and after the alternative therapy condition. The analysis was based on the data provided by these patients and carried out at Nottingham University Psychology Department by Dr David Clarke and Ms Louise Maskill.

The following measures were used for the initial and re-assessments.

1.Videostrobolaryngoscopy to monitor the patient’s pre-therapy vocal fold posture, symmetry and vocal health. The videos for each subject were then edited randomly by the speech therapist and rated blind by the voice clinic surgeon, using a protocol designed for the study. An independent surgeon experienced in voice work also rated 10% of the subjects, chosen at random, using the same protocol, to act as a reliability check.

2.A digital tape recording of the patient reading a phonetically balanced passage was analysed, using pitch extraction techniques, by Dr David Howard, Lecturer in Music Acoustics at York University.

3.Vocal Profile Analysis (Laver, 1980) was carried out by an independent speech therapist experienced with the technique from the DAT tape recordings of the reading passage. A random 10% of the subjects were re-rated by a second speech therapist experienced in the same technique to act as a reliability check.

4.A phonetogram was carried out by the clinic therapists in order to provide an assessment of the patient’s pre-therapy vocal frequency and intensity ranges. The loudest and softest notes and the frequency ranges were used to represent changes produced in the therapy conditions, ensuring that the analysis could be presented in a simple way compatible with the other measures.

5.A five-point rating scale was completed by each patient in order to assess his or her perception of their own vocal pitch, volume, quality, comfort and stamina prior to the onset of the dysphonia and prior to therapy. In this way patients who reported themselves as always having hoarse or weak voices could be identified. The same scales were repeated after each therapy condition.

6.A series of 17 neck and laryngeal variables were palpated and rated for position/muscular tension by yes/no answers on 3–5 point scales (as appropriate) by the clinic ENT surgeon, osteopath and speech therapist. The three independent ratings were then averaged together for the statistical analysis. This also allowed for practitioner agreement to be monitored.

7.A photo profile was made of each patient standing against a grid with a complex arrangement of mirrors allowing simultaneous views of the patient’s posture from above, front, behind and side. The grid measurements were recorded to monitor changes in the patient’s physical posture with treatment.

Analysis of variance carried out on the data found over half of the variables measured show statistically significant differences between the preand post-therapy mean scores. Where statistically significant differences were found for the treatment sequence (in three cases), all instances favoured the sequence: osteopathy followed by speech therapy. Although the number of cases analysed is quite small and needs to be interpreted with caution, the data appear to lend support to the hypothesis that osteopathy does provide an effective form of treatment for dysphonic patients. This does not, however, provide sufficient evidence that either speech therapy or osteopathy is the preferred mode of treatment for dysphonics. If anything the data seem to suggest that both forms of treatment produce similar improvements in the symptoms and the possibility that they may work in different ways on the same variables needs further research.

This pilot study has broken some new ground and as a result, a new perspective on voice production is beginning to emerge, particularly in the way we regard the significance of vocal postures and the importance of the vocal tensioning mechanism (cricothyroid visor) (Harris and Lieberman, 1993; Harris et al., 1998). It will hopefully pave the way for further research into the efficacy of manual therapy/osteopathic techniques for the treatment of dysphonia and the development of new tools to provide accurate measurements of variables such as laryngeal position, height and visor opening, which are, at present, only possible to assess subjectively with palpation.

Andrews ML, Summers A (1991) Voice Therapy for Adolescents. San Diego, CA: Singular Publishing Group.

Andrews S, Warner J, Stewart R (1986) EMG biofeedback and relaxation in the treatment of hyperfunctional dysphonia. British Journal of Disorders of Communication. 21: 353–69.

Ardran G, Kinsbourne M, Rushworth G (1966) Dysphonia due to tremor. Journal of Neurology, Neurosurgery and Psychiatry 29: 219–23.

Argov Z, Mastaglia FL (1979) Drug therapy – disorders of neuromuscular transmission caused by drugs. New England Journal of Medicine 301(8): 409–13.

Aring C (1965) Supranuclear (pseudobulbar) palsy. Archives of International Medicine 115: 198–-9.

Arnold GE (1961) Physiology and pathology of the cricothyroid muscle. Laryngoscope 71: 658–65.

Arnold GE (1962) Vocal nodules and polyps: laryngeal tissue reaction to habitual hyperkinetic dysphonia. Journal of Speech and Hearing Disorders. 27: 205–17.

Aronson AE (1971) Early motor unit disease masquerading as psychogenic breathy dysphonia: a clinical case presentation. Journal of Speech and Hearing Disorders 36: 116–24.

Aronson AE (1980) Clinical Voice Disorders: An Interdisciplinary Approach. New York: Thieme-Stratton.

Aronson AE (1985a) Adductor spastic dysphonia: abductor spastic dysphonia. In Aronson AE (ed.) Clinical Voice Disorders: An Interdisciplinary Approach 2nd edn. New York: Thieme-Stratton.

Aronson AE (1985b) Clinical Voice Disorders: An Interdisciplinary Approach 2nd edn. New York: Thieme-Stratton.

Aronson AE (1990) Clinical Voice Disorders: An Interdisciplinary Approach 3rd edn. New York: Thieme-Stratton.

Aronson AE, DeSanto L (1983) Adductor spastic dysphonia; three years after recurrent laryngeal nerve resection. Laryngoscope 36: 116–24.

Aronson AE, Hartman DE (1981) Adductor spastic dysphonia as a sign of essential (voice) tremor. Journal of Speech and Hearing Disorders 46: 52–8.

Aronson AE, Brown JR, Litin EM, Pearson JS (1968a) Spastic dysphonia I: voice, neurologic and psychiatric aspects. Journal of Speech and Hearing Disorders 33: 203–18.

Aronson AE, Brown JR, Litin EM, Pearson JS (1968b) Spastic dysphonia II: Comparison with essential (voice) tremor and other neurologic and psychogenic dysphonias. Journal of Speech and Hearing Disorders 33: 220–31.

Aronson AE, Ramig L, Winholtz W, Silber S (1992). Rapid voice tremor or ‘flutter’ in amyotrophic lateral sclerosis. Annals of Otology, Rhinology and Laryngology 101: 511–18.

Asbury A, McKhann G, McDonald W (1992) Diseases of the Nervous System. Clinical Neurobiology. Philadelphia, PA: WB Saunders.

Aten J (1983) Treatment of spastic dysarthria. In Perkins WH (ed.) Current Therapy of Communication Disorders: Dysarthria and Apraxia (pp. 69–78). New York: Thieme-Stratton.

Audelman JU, Hoel RL, Lassman FF (1970) The effect of L-dopa treatment on the speech of subjects with Parkinson’s disease. Neurology 20(4): 410–11.

Austin SF, Titze IC (1997) The effects of subglottal resonance upon vocal fold vibration. Journal of Voice 11: 391–402.

Bagnall A (1995) ‘Yell Well’. (Videocassette) North Adelaide, South Australia: AB Voice International.

Bakal DJ (1979) Psychology and Medicine. London: Tavistock.

Baken RJ (1987) Clinical Measurement of Speech and Voice. San Diego, CA: College Hill Press.

Baken RJ, Cavallo SA (1981) Pre-phonatory chest wall posturing. Folia Phoniatrica 33: 193–202.

Baker J (1997) Psychogenic dysphonia: peeling back the layers. Journal of Voice 12: 527–35.

Baker DC, Savetsky L (1966) Congenital partial atresia of the larynx. Laryngoscope 77. Baker K, Ramig L, Freed C, Johnson A (1997) Preliminary voice and speech analysis following fetal dopamine transplants in 5 individuals with Parkinson disease. Journal

of Speech and Hearing Research 40: 615–26.

Bamford KA, Caine ED, Kiddo KK et al. (1989) Clinical pathological correlation in Huntington’s disease: a neuropsychological and computed tomography study. Neurology 39: 796–801.

Barchi R, Furman RE (1992) Pathophysiology of myotonia and periodic paralysis. In Ashbury AK, McKhan GM, McDonald WI (eds) Diseases of the Nervous System: Clinical Neurobiology 2nd edn (pp. 146–63). Philadelphia, PA: WB Saunders.

Barlow W (1973) The Alexander Technique. New York: Warner Books.

Barnes C (1992) Evaluating the efficiency of Botox in the treatment of spasmodic dysphonia. Metropolitan University of Manchester 1992. Unpublished BSc thesis.

Bassich CJ, Ludlow CL (1986) The use of perceptual methods by clinicians for assessing voice quality. Journal of Speech and Hearing Disorders 51: 133–41.

Bastian RW, Keidar AK, Verdolini-Marston K (1990) Simple vocal tasks for detecting vocal fold swelling. Journal of Voice 4: 172–83.

Bastian RW, Nagorsky MJ (1987) Laryngeal image biofeedback. Laryngoscope 97: 1346–9.

Beck K (1918) Uber Erfahrungen mit Stimmstoerungen bei Kriegsteilnehmen. PassowSchaefer Beitrage. Annat Ohjres Usw 11: 130.

Beck AT (1970) Depression: causes and treatment. Philadelphia, PA: University of Pennsylvania Press.

Beery QC (1991) Psychosocial aspects of adolescent dysphonia: an approach to treatment. Language, Speech, and Hearing Services in Schools 22: 163–7.

Belisle GM, Morrison MD (1983) Anatomic correlation for muscle tension dysphonia. Journal of Otolaryngology 12: 319–21.

Benjamin H (1966) The Transsexual Phenomenon. Julian Press: New York.

Bennett S, Bishop S, Lumpkin S (1987) Phonatory characteristics associated with bilateral diffuse polypoid degeneration. Laryngoscope 97: 446–50.

Benninger MS, Schwimmer C (1995) Functional neurophysiology and vocal fold paralysis. In Rubin JS, Sataloff RT, Korovin GS, Gould WJ (eds) Diagnosis and Treatment of Voice Disorders (pp. 105-21). Tokyo: Igaku-Shoin.

Benninger MS, Crumley RL, Ford CN, Gould WJ, Hanson DG, Ossoff RH, Sataloff RT (1994a) Evaluation and treatment of the unilateral paralyzed vocal fold. Otolaryngology Head and Neck Surgery 111: 497–508.

Benninger MS, Gillen J, Thieme P, Jacobson B, Dragovich J (1994b) Factors associated with recurrence and voice quality following radiation therapy for T1 and T2 glottic carcinomas. Laryngoscope 104 (March): 294–8.

Berendes J (1938) Zur Enstehung und Behandlung der Dysphonia Spastica. Z Hals. Usw Heilk 44: 78–84.

Bernstein DA, Borkovec TD (1973) Progressive Relaxation Training: A manual for the helping professions. Illinois: Research Press.

Berry WR (1983) (ed.) Clinical Dysarthria. San Diego: College-Hill.

Bielamowicz S, Kreiman J, Gerratt B, Dauer M, Berke G (1996) Comparison of voice analysis systems for perturbation measurement. Journal of Speech & Hearing Research 39: 126–34.

Biever DM, Bless DM (1989) Vibratory characteristics of the vocal folds in young adult and geriatric women. Journal of Voice 3(2): 120–31.

Blair RG (1965) Vagitis Uterinus: Crying in Utero. Lancet 11: 1164–5.

Bless DM (1991) Measurement of Vocal Function. Otolaryngologic Clinics of North America 24: 1023–33.

Bless DM, Hirano M, Feder, R (1987) Videostroboscopic evaluation of the larynx. Ear, Nose and Throat Journal. 66: 289–96.

Blitzer A, Brin M (1991) Laryngeal Dystonia: a series with botulinum toxin therapy. Annals of Otology, Rhinology and Laryngology 100: 85–9.

Blitzer A, Brin M (1992) The dystonic larynx. Journal of Voice 6: 294–7.

Blitzer A, Lovelace RE, Brin MF, Fahn S, Fink ME (1985) Electromyographic findings in focal laryngeal dystonia (Spastic Dysphonia). Annals of Otology, Rhinology and Laryngology 94: 591–4.

Blitzer A, Brin MF, Fahn S, Lovelace RE (1988) Clinical and laboratory characteristics of laryngeal dystonia: a study of 110 cases. Laryngoscope 98: 636–40.

Blitzer A, Brin MF, Stewart C et al. (1992) Abductor laryngeal dystonia: a series treated with botulinum toxin. Laryngoscope 102: 163–7.

Bloch P (1965) Neuro-psychiatric aspects of spastic dysphonia. Folia Phoniatrica 17: 301–64.

Boliek CA, Hixon TJ, Watson PJ, Morgan WJ (1996) Vocalisation and breathing during the first year of life. Journal of Voice 10: 1–22.

Boliek CA, Hixon TJ, Watson PJ, Morgan WJ (1997) Vocalisation and breathing during the second and third years of life. Journal of Voice 11: 373–90.

Boltezar IH, Burger ZR, Zargi M (1997) Instability of voice in adolescence: pathologic condition or normal developmental variation? Journal of Paediatrics 130(2): 185–90.

Bonduelle M (1975) Amyotrophic lateral sclerosis. In Vinten PJ, Gruyn GW (eds) Handbook of Clinical Neurology (pp. 281–338). Amsterdam: North Holland.

Boone DR (1966) Modification of the voices of deaf children. Volta Review. 68: 686–92.

Boone DR (1971) The Voice and Voice Therapy. Englewood Cliffs, NJ: Prentice Hall. Boone DR (1977) The Voice and Voice Therapy 2nd edn. Englewood Cliffs, NJ:

Prentice-Hall.

Boone DR (1983) The Voice and Voice Therapy 3rd edn. Englewood Cliffs, NJ: Prentice Hall

Boone DR (1991) Is Your Voice telling on You? San Diego, CA: Singular Publishing Group.

Boone DR (1993) The Boone Voice Program for Children 2nd edn. Austin, TX: Pro-Ed. Boone DR (1997) The three ages of voice: the singing/acting voice in the mature adult.

Journal of Voice 11(2): 161–4.