Perceptual-physiologic approach to evaluation and treatment of dysphonia

[Application of the biofeedback method in the treatment of dysphonia (literature review)]

The literature review describes the experience of using the biofeedback method in the treatment of dysphonia of various etiologies. Indications for the use of this method and its effectiveness in a certain contingent of patients are discussed.

The role of diode laser in the treatment of ventricular dysphonia

OBJECTIVES

The treatment of ventricular dysphonia (VD) should be based on confirming the true folds pathology. In some patients, the ability of the true folds vibration remains unclear and decision making for performing aggressive surgical interventions can be difficult.

STUDY DESIGN

A retrospective study of surgery by chart review.

METHODS

Eight cases with suspicious compensatory type of VD were analyzed in this study. They were all symptom free until a history of endotracheal intubation for laryngeal irrelevant surgery. Their false fold adducted and constricted the supraglottic region sphincterically during phonation. Laser ablation of redundant false folds was performed. After confirming the true folds condition, a second procedure was carried out accordingly within 3 months. The outcome was determined by comparing the difference of the perceptual examination and acoustic parameters before and after each procedure.

RESULTS

Postoperation laryngoscopy revealed the underlying vocal atrophy in five cases and vocal fold palsy in the other three patients. Six of them were treated by medialization thyroplasty or fat augmentation. No significant change in the perceptual evaluation and maximum phonation time was found after laser ablation surgery. Meanwhile, there was no complication such as choking or aspiration after the laser ablation surgery. There was no recurrence of redundant false fold within the mean follow-up of 40 months.

CONCLUSIONS

The role of diode laser microlaryngosurgery is not to improve vocal quality but to offer a better visualization of underlying vocal behavior. This facilitated the subsequent prime vocal fold correction surgery. Therefore, we recommend this two-stage treatment modality for patients with compensatory VD.

Effects of biofeedback in phonatory disorders and phonatory performance: a systematic literature review

The purpose of this article was to systematically review the literature on the effects of biofeedback therapy in the domain of phonatory disorders and phonatory performance, using studies in peer-reviewed journals. An extensive definition of biofeedback is given and its place in voice treatment is defined. Eighteen group or case studies or reports considering the effects of electromyographic, laryngoscopic and acoustic biofeedback in dysphonic patients (hyperfunctional voice disorders, hypofunctional voice disorders, psychogenic voice disorder, laryngeal trauma, total laryngectomy, vocal cord dysfunction) and participants with normal voices are included and an analysis of procedure as well as research design and results is presented. The usefulness of biofeedback in phonatory disorders and performance was to be interpreted based on tendencies, since there is a lack of randomized controlled efficacy studies. In only 3 of 18 studies (16.7%) did biofeedback therapy fail to improve voice quality or not result in better results than other forms of therapy. Recommendations for improved methodologies are made, which include the use of acoustic voice quality parameters.

Ventricular dysphonia: clinical aspects and therapeutic options

OBJECTIVE/HYPOTHESIS

Ventricular dysphonia, also known as dysphonia plica ventricularis, refers to the pathological interference of the false vocal folds during phonation. Despite its low incidence and prevalence, Vd is a well-known phenomenon in voice clinics. The present report reviews symptoms, etiology, diagnosis, and therapeutic options regarding this voice disorder.

STUDY DESIGN

Literature review and case studies.

METHODS

The literature pertaining to all clinical aspects of V(D) was reviewed to define diagnostic and therapeutic clinical decision making.

RESULTS

Ventricular dysphonia is characterized by a typical rough, low-pitched voice quality resulting from false vocal fold vibration. Ventricular dysphonia may be compensatory when true vocal folds are affected (resection, paralysis). Noncompensatory types may be of habitual, psychoemotional, or idiopathic origin. Because perceptual symptoms may vary considerably, diagnosis should rely on a meticulous voice assessment, including laryngeal videostroboscopic, perceptual, aerodynamic, and acoustic evaluation. Various therapeutic approaches for the noncompensatory type of ventricular dysphonia may be considered: voice therapy, psychotherapy, anesthetic or botulinum toxin injections, or surgery.

CONCLUSION

The study presents the state of the art with respect to ventricular dysphonia and may be helpful in diagnosis and therapeutic decision-making.

The association of laryngoceles with ventricular phonation

Laryngoceles represent dilatations of the laryngeal saccule that may extend internally into the airway, or externally through the thyrohyoid membrane. Unilateral laryngoceles are uncommon clinical entities and bilateral laryngoceles are rare. Certain activities like glass blowing and playing a wind instrument are associated with laryngocele development, as is laryngeal carcinoma in the ventricular area. This case describes development of bilateral laryngoceles in a patient who chronically uses ventricular phonation during speech. The pathogenesis involves repetitive elevation of intralaryngeal pressure during false vocal cord approximation, exposing the ventricles to abnormally high air pressures. The pathogenesis in this case, as well as in laryngoceles associated with occupational or anatomic risk factors, is discussed.

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.

The effectiveness of voice therapy for patients with non-organic dysphonia

Forty-five patients diagnosed as having non-organic dysphonia were assigned in rotation to one of three groups. Patients in one group received no treatment and acted as a control group. Patients in the other two groups received a programme of either 'indirect' therapy or 'direct with indirect' therapy, respectively. A self-report questionnaire of vocal performance, observed ratings of voice quality, and computer-derived acoustic measurements (signal-to-noise ratio, pitch perturbation and amplitude perturbation) were carried out on all patients before and after treatment to evaluate the changes in voice quality over time. There was a significant difference between the three groups on the self-report questionnaire, voice quality ratings and pitch perturbation measurements (P = < 0.05). Thirteen out of 15 control patients showed no significant change on any of the measures. Seven patients who received indirect treatment showed significant improvement in voice quality following treatment. Fourteen out of 15 patients who received direct treatment showed significant improvement in voice quality.

Acoustic and physiologic characteristics of inspiratory phonation

Voice produced on inhaled air is a form of phonation that has received relatively little attention despite its apparent usefulness in the assessment of vocal function. This preliminary investigation was designed to describe the general characteristics of vocalization driven by an ingressive phonatory airflow. Vocal fundamental frequency (F0), electroglottographic (EGG), and airflow measures were examined in 16 normal men and women, who alternated between inspiratory and expiratory voice. Mean F0 routinely increased during inspiratory voice segments, shifting on average 5.1 semitones above the subjects' comfortable expiratory voice frequency. EGG data showed inspiratory voice to be associated with a more symmetrical pattern of vocal fold contact characterized by a prolonged interval of increasing contact. Both short-term F0 variability (jitter) and EGG amplitude perturbation were significantly higher during inspiratory voice. Stroboscopic examination of four of the subjects showed caudal displacement of the larynx and lengthened vocal folds associated with inspiratory phonation. The absolute airflow rate was significantly greater for inspiratory phonation, on average 48.5% higher than during normal expiratory voice. It was also found that both inspiratory pulse and falsetto vibratory patterns could be produced by at least some of the subjects, indicating some control over the mode and frequency of vocal fold vibration when driven by an ingressive airflow.

An interdisciplinary approach to the treatment of a hyperfunctional voice disorder

The purpose of this article is to describe the treatment of a 45-year-old male with a hyperfunctional voice disorder by a biofeedback therapist and a speech-language pathologist. The interdisciplinary approach to the treatment of this voice disorder involved the combined use of traditional voice therapy techniques and EMG biofeedback procedures together with cognitive behavioral therapy. Voice therapy was facilitated through the use of a computer-based, speech-monitoring system. The remediation of this voice disorder was attributed to the collaborative efforts of two professionals representing diverse professional training and treatment protocols. The results showed reductions in muscle activity in the infrahyoid and laryngeal areas as well as improved use of proper breathing and voicing onset behaviors. Follow-up at 10 and 15 months posttreatment intervals indicated that the client had retained all target voice skills and the tension reduction/biofeedback skills. Results suggest that interdisciplinary, collaborative efforts using biofeedback and voice therapy can prove beneficial in the treatment of hyperfunctional voice disorders.