Voice Treatment and Therapy

VOICE TREATMENT AND THERAPY
Traditional voice therapy consists of two primary avenues: Vocal Hygiene and Voice Therapy.Vocal hygiene is a daily regimen to achieve and maintain a healthy voice. Vocal hygiene includes maintaining adequate hydration (6-8 glasses of water per day), minimizing exposure to noxious chemicals, no smoking of cigarettes, and the avoiding of excessive shouting, screaming or other loud voice use.Voice therapy is a behavioral intervention technique that makes use of vocal exercises, speaker awareness and proper postures and alignment when using the voice. Please click to the left for a more detailed look at the specific types of voice therapies offered at the Voice & Swallowing Center.

Care of the Performing and Professional Voice
Many people rely on their voice in order to perform the essential functions of their job. This includes performers, teachers, salespeople, and numerous others. Ironically, people in such professions are more likely to experience vocal problems due to the strain of frequent use. Preventative care and prompt evaluation of problems can help patients avoid the development of more serious conditions.

Voice Pathologist

What does a voice pathologist actually do?
Services include laryngeal videostroboscopy (magnified “slow motion” imaging of the larynx) with differential diagnostic support and interpretation of laryngeal functioning as well as perceptual and objective voice assessment and treatment. Voice therapy is designed to improve vocal function and quality, including exercises for vocal fold strength, flexibility, endurance, coordination and balance of the sub-systems (respiration, phonation and resonation) needed for healthy voice production. The goals of any voice therapy program are to return the voice to normal or as near normal sounding as possible. Voice therapy is usually short term, 4-10 sessions, over a 6-8 week period. Length of therapy is determined by diagnosis, the condition of the vocal folds, vocal habits, motivation and compliance with the therapeutic program.

Behavioral Voice Therapy
Behavioral Voice Therapy consists of two main parts, Vocal hygiene and exercises, to change the biomechanics of voice production. Vocal hygiene is similar to dental hygiene, a daily program to keep the voice functioning at its highest level. Maintaining good nutrition and hydration is a key to vocal hygiene. Avoiding vocal abuse such as shouting, smoking, excessive alcohol intake and noxious chemicals are all part of vocal hygiene.

Voice therapy is a behavioral program to adjust the biomechanical forces that produce the sound of the voice. Exercises include breathing techniques, vocalizing exercises, proper placement of the vocal structures and adjustment of force or effort at the oset of the voice. Since hoarseness may evolve from various diagnoses, the type of therapy to use is determined by the diagnosis.

Hoarseness may occur due to a number of underlying causes:

Neoplastic Neurologic:

• Vocal fold polyp Vocal fold paralysis (unilateral)
• Vocal fold nodules Spasmodic dysphonia
• Vocal fold granulomas Neuromuscular disorders such as
• Parkinson's Disease
• Vocal fold papilloma Essential tremor
• Reinke's Edema
• LAryngeal cancer Stroke (Cerebral vascular accident
•  

Inflamatory

• Gastroesophageal reflux
• Laryngopharyngeal reflux
• Post viral vagal neuropathy
• Fungal laryngitis
• Allergic laryngitis

Miscellalneous:

• Voice misues
• Muscle tension dysphonia
• Vocal fold atrophy
• Vocal fold scar/sulcus vacalis
• Pharmcological side effects

Adapted from: Rosen, C.A. , Anderson, D. and Murry, T. : Evaluating Hoarseness: Keeping Your Voice Healthy American Family Physician Vol 57, 11, 2775-2782, 1998

Dietary Therapy
Dietary treatment for voice disorders starts with eating a balanced diet in the appropriate amounts in order to keep one's weight at an ideal level and one's energy at a level for proper voice use.

Excessive weight may lead to faulty use of the respiratory muscles extremely important for generating the power of the voice. In addition, proper hydration including 6-8 glasses of water per day (60-72 ounces) is necessary to maintain adequate tissue lubrication.

Singers, especially must be careful not to eat excessively prior to or right after a performance - especially if the performance is late at night and they go to bed right afterward.

Pharmacotherapy
Recently the use of injectable medicines as well as traditional prescription medicines and certain health foods have been used to treat voice disorders that in the past have been resistant to traditional behavioral therapies or surgeries.

Botox
Botulinum Toxin (Botox) is a drug made from the bacterium known as Clostridia Botulinum. This is actually a toxin produced by this bacterium which causes muscle paralysis. Used in a diluted dose, this toxin can be useful for certain disorders. Botox injections reduce the tight, squeezed phonation and disruption of voice breaks caused by spasmodic dysphonia.

Below, is a Botox injection procedure with posterior (L) and anterior (R) views.

Taking Herbal Medicines: What Singers Should Know
By Jason B. Surow, M.D. , F.A.C.S.

(The following information was collected by Jason B. Surow, MD, during a recent survey of singers. Please note that the use of herbal medicines and their effects on voice is not yet well understood.)

Herbal Medicine with Possible Anticoagulation Results (Blood thinning effect)

Dong Quai- "contains coumadin"*
Willow bark- "contains salicylates" *
Primrose
Cowslip
Jack-in-the-Pulpit -
Red root- "causes clotting disorders
"Garlic- "in high dose worsens anticoag" "inhibits platelet aggregation and has fibrinolytic activity"***

Vitamin E - "in high doses"
Gingko Biloba-"inhibits platelet aggregation"***
Feverfew-"inhibits components of the clotting cascade and may inhibit platelet aggregation"***
Ginger-"reduces platelet aggregation"

*coumadin (warfacin) is a powerful blood-thinning agent
** salicyate= aspirin
***this can cause prolonged bleeding

Herbal Medicines with Possible Inhalant Allergy Cross-Reactivity with Ragweed:

Chamomile- "long term use can lead to ragweed allergy"
Goldenseal
With Sunflower:
Echinacea
Photosensitization Concerns From Herbal Medicine (skin rash and sensitivity to sunlight)
St. John's Wort
Celery
Dong Qua
iYarrow

Herbal Medicine with Possible Diuretic Effects (water losing effect)

Elder "strong diuretic"
Feverfew
Dandelion
Nettles

Herbal Medicine with Possible Blood Pressure Concerns:

St. John's Wort*- MAO inhibitor effect. "Don't take with amphetamines, amino acids, asthma inhalers, caffeine, decongestants, beer, wine, yogurt, fermented or smoked foods." [avoid amino acid tyramine] Avoid narcotics due to high incidence of high fever with coma.
Ma Huang (ephedra)*- "avoid in MAO inhibitor use (often used in depression), glaucoma, anxiety, heart problems"
Goldenseal
Ginseng
Licorice root- causes fluid retention.
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*MAO inhibitor is a class of drugs that are commonly used for the treatment of depression
Herbal Medicines with Possible Immune Dysregulation Effects
Echinacea- "may overstimulate immune system and lead to immune suppression" "Increases tumor necrosis factor" "Don't use in HIV" Don't use for more than 2 weeks in a row. Certain herbs should not be used in autoimmune problems like Multiple Sclerosis, arthritis, and others.

Problems with Production of Herbal Products

L-Tryptophan - l 989 contamination led to several hundred cases of eosinophilia- myalgia syndrome, and at least one death.
Anticholinergic poisoning from herbal tea yerba de mate (Paraguay tea) contaminated by Belladonna alkaloids from weeds overgrowing in the field
Vitamin Toxicity
Vitamin C- cramps, flatulence, bloating, diarrhea
Vitamin E- "thins blood" "reduces effectiveness of thyroid replacement" "avoid high doses with high blood pressure, congestive heart failure, insulin, dependent diabetes, heart problems"
Uterine Stimulants
yarrow
lady's mantle
dong quai
chamomile
cinnamon
myrrh
yam
licorice root
many others

Herbal Medicines with Possible Hormonal Effects (the vocal folds are known to change due to some hormones; this can be permanent)

Dong Quai- "increases effects of ovarian and testicular hormones".
Used to treat hormonal problems

Yam- "progesterone-like " chemicals

Licorice root- "has estrogen and progesterone effect. May change pitch of voice"

Hops- "high proportion of estrogens and can lead to loss of libido in men"

Primrose- "natural estrogen promoter"

Melatonin- "major role in production of estrogen & progesterone & other hormones." "acts as contraceptive in high doses"

Yohimbe- "may increase testosterone. Women shouldn't use"

Other Cautions:

Don't use with fever- astragalus(huang qi), goldenseal, others.

Chewing leaves of feverfew is a folk remedy but can cause mouth sores.

Lobelia has "nicotine-like" effects and >50 gms can suppress breathing and depress BP and even lead to coma.

Ginseng lowers blood sugar so shouldn't be used if hypoglycemic.

Nutmeg is toxic in high doses

Sage has chemical (thujone) that can trigger seizures in epileptics.

Melatonin- don't use if severe allergy, immune disorder, or cancer

Peppermint relaxes smooth muscle and can promote gastric acid reflux into the throat.

Surgery
Surgery for benign vocal fold lesions or for vocal fold paralysis is done only when the patient cannot achieve the desired voice use or when there is a surgical need to prevent aspiration of food and liquids.

Two types of surgery are most common. The first, Phonosurgery, is surgery directly on the vocal folds to remove a polyp, cyst or edematous tissue (known as Reinke's edema). The second type, Laryngeal framework surgery, is surgery on the larynx which houses the vocal folds. This is usually done when there is a vocal fold paralysis or partial paralysis in order to move the paralyzed vocal fold closer to the functioning one in order to achieve improved vocal fold closure for voice and swallowing.

Surgery may also be performed to remove papillomas, a viral wart-like growth on the vocal folds.

Laryngeal Framework Surgery:
Laryngeal Framework Surgery, is surgery on the larynx which houses the vocal folds. This is usually performed when there is a vocal fold paralysis
or partial paralysis in order to move the paralyzed vocal fold closer to the functioning one in order to achieve improved vocal fold
closure for voice and swallowing.

Phonosurgery:
Phonosurgery, is surgery directly on the vocal folds to remove a polyp, cyst or edematous tissue (known as Reinke's Edema).

Special Types of Therapy

Accent Method
Accent method is a voice therapy popular in Europe, which focuses on breathing as the control mechanism of voice production. Accentuated and rhythmic movements are coupled to various vocalizations to encourage an easy flow of the voice. This technique helps to relieve tension in the muscles around the larynx and neck.

Confidential Voice Method
Confidential voice therapy focuses on increasing the flow of air. The therapy begins with a "breathy voice quality" and then builds to normal voice while maintaining a sufficient amount of airflow. This technique is used when excess vocal tension is diagnosed and the muscles of the voice do not relax sufficiently.

Lee Silverman Voice Treatment
The Lee Silverman Voice Treatment was developed for patients with Parkinson's disease and has been applied to various types of disorders in which the vocal folds fail to close. The focus is on increasing breath support to maintain loudness at a preset level.

Other voice therapy techniques also exist. The technique used depends on the patient's disorder, his or her ability to identify changes in the voice with the technique used and the interpersonal relationship between the patient and the voice specialist. Voice therapy should always be done by a licensed and certified speech-language pathologist. In some instances, patients, especially singers, are also referred to singing teachers for special help with repertoire and techniques to aid in the recovery of the voice problem.

Resonant Voice Therapy
Resonant voice therapy is a method of treatment which focuses the voice in a frontal position in which the vocal folds are brought together with less force so that they produce better closure along the length of the vocal folds. The use of humming or chanting is an integral part of this approach.

Respiratory Retraining
Respiratory Retraining focuses on coordinating breathing with vocalization. This technique has been shown to be useful for patients with excessive cough, paradoxical vocal fold motion disorder, vocal spasm or laryngeal irritation. It is often used in conjunction with the treatment of reflux.

Vocal Massage
In the technique of Vocal Massage, a series of specific massage exercises are used to bring the voice into a more efficient posture. This technique is also referred to as "manipulation voice therapy" since it requires the therapist to manipulate the muscles in the neck and around the larynx.