eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Voice Therapy

Author: Ryan C Branski, PhD, CCC/SLP, Assistant Attending Scientist, Speech and Hearing Center, Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center
Coauthor(s): Thomas Murry, PhD, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Clinical Director, Voice and Swallowing Center; Clark A Rosen, MD, Director, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh Voice Center; Associate Professor, University of Pittsburgh School of Medicine
Contributor Information and Disclosures

Updated: Jan 17, 2008

Introduction

Voice therapy encompasses a myriad of techniques employed in the management schema for patients with voice disorders. These techniques may seek to eliminate potentially harmful vocal behaviors, alter the manner of voice production, and/or enhance vocal fold tissue healing following injury. Emerging data suggest that voice therapy is an effective and appropriate method of therapy either in itself or as a compliment to other treatment modalities (eg, surgery, medications).

The particular therapeutic regimen employed for a particular patient is highly variable and based on several key issues including: (1) vocal fold tissue health, (2) vocal demands of the patient, (3) baseline phonatory behaviors, and (4) patient compliance. Once these 4 factors have been evaluated, a customized voice therapy program is developed and contoured to address the vocal complaints and the demands of the patient. For example, a voice therapy program for a 70-year-old housewife is likely to vary significantly from that for a 30-year-old attorney, even in the presence of similar laryngeal appearance.

Simplistically, voice disorders may be divided into the following 3 categories: hyperfunctional, hypofunctional, and dysfunctional. In each of these cases, a vocal fold lesion and/or neurological abnormality may contribute to the voice disorder.      

Hyperfunctional voice disorders, regardless of the presence of a vocal fold lesion, involve increased laryngeal and/or supralaryngeal muscle tension. The goal of therapy for these disorders is to decrease laryngeal and supralaryngeal muscle tension during voice production in an attempt to improve vocal efficiency. A benign vocal fold lesion may likely accompany hyperfunctional voice disorders. Therapy must not only target improved vocal efficiency but also enhanced resolution of the lesion. Evidence is emerging that "exercise" in the broad sense may alter wound healing events and facilitate lesion resolution. Therefore, customized therapies must be designed to treat patients who present with benign vocal fold lesions (eg, nodules, polyps) because these lesions are likely the manifestation of the wound healing response to phonotrauma.

In contrast, hypofunctional voice disorders (eg, unilateral vocal fold paralysis, parkinsonian dysphonia) typically respond to behavioral voice therapy techniques that improve glottal closure or augment vocal tract dynamics to enhance vocal output.1

Voice therapy is also widely believed to be effective with patients who do not fall into either of the above categories. These patients have a dysfunctional voice disorder (eg, psychogenic dysphonias, conversion dysphonia, puberphonia) in that they are capable of producing a normal voice but do not use the vocal mechanism in a functionally appropriate manner. In addition, several populations of patients may benefit from voice therapy. As described in the following section, a unique form of voice therapy called "respiratory retraining" has been shown to be effective in the management of patients with a condition referred to as paradoxical vocal fold movement disorders. In this condition, the vocal folds inappropriately close during breathing, causing shortness of breath and/or cough. In addition, voice therapy may be beneficial in the transgender population in which the voice must be manipulated to correspond with the patient's gender identity. 

Accurate Diagnosis

A prerequisite to voice therapy is a referral from a voice care team, which typically involves an otolaryngologist and speech pathologist. This referral should evolve from a complete evaluation of the vocal mechanism including rigid and/or flexible laryngeal endoscopy. Stroboscopy may also be indicated for many patients to visualize vibratory motion. This thorough evaluation process permits for the customization of a voice therapy program based on vocal physiology. 

Indications for Behavioral Voice Therapy

Functional voice disorders

Functional voice disorders are characterized by the presence of vocal symptoms without anatomical laryngeal abnormality. Muscle tension dysphonia (MTD) is the most common disorder in this category. Most literature suggests that a course of indirect and direct voice therapy is very effective in decreasing laryngeal hyperfunction associated with MTD (see Voice Therapy for therapeutic techniques for MTD).

During evaluation, it is often helpful to determine if the patient is able to improve voice quality with trials of direct voice therapy techniques. This is a strong indicator of future voice therapy success. However, the longer the patient has had dysphonia, the more guarded the prognosis for success with therapy. Psychogenic dysphonias, such as conversion dysphonia, also fall into the category of functional voice disorders. Combinatory therapy with a trained SLP and a mental health specialist is believed to treat these disorders effectively.

Organic vocal fold disorders

Organic vocal fold disorders include, but are not limited to, vocal fold nodules, cysts, and polyps. Vocal nodules are small, commonly bilateral lesions of the superficial layer of lamina propria, usually located at the junction of the anterior third and posterior two thirds of membranous vocal fold. Voice therapy is usually the sole treatment indicated for vocal nodules if they are not long-standing in duration and not extremely fibrotic in nature.

Cysts and polyps are also lesions of the superficial layer of the lamina propria. Phonomicrosurgery and voice therapy are usually indicated in the treatment of cysts and polyps. Voice therapy is indicated prior to and following surgery and can improve the outcome. In these cases, voice therapy combined with surgery is thought to decrease the likelihood of lesion recurrence due to poor vocal technique and vocal misuse.

Neurological voice disorders

Neurological voice disorders can often affect a patient's voice. The most common disorders resulting in dysphonia include PD, essential tremor (ET), and spasmodic dysphonia (SD). LSVT has been demonstrated to be effective for treating the communication disorder associated with PD. Treatment is intensive, requiring 4 sessions a week for 4 weeks. The purpose of treatment is to increase loudness, and in addition to improved voice, patients may develop increased respiratory output, decreased glottal incompetence, improved articulatory precision and mobility, and improved overall intelligibility. In follow-up studies, LSVT has been shown to be effective without continued treatment for 3-5 years.

Spasmodic dysphonia is a focal dystonia affecting the laryngeal musculature, most commonly treated with localized injections of botulinum toxin A (BOTOX®). These injections temporarily weaken the muscles, thereby decreasing dystonic laryngeal muscle activity. The duration of weakness varies from patient to patient and often from injection to injection. Murry and Woodson (1995) suggested that behavioral voice therapy used in combination with BOTOX® injection therapy increases the effectiveness and duration of the BOTOX® therapy.4

Unfortunately, there is little literature concerning the efficacy of voice therapy with other neurological disorders. Patients with vocal tremor are often referred for voice therapy. Patients need to be informed that while speech language pathology may improve voice, tremor or other neurological symptoms are not commonly resolved with voice therapy alone; therefore, medical treatment may be indicated. Voice therapy may help the patient compensate for the neurologic problem and improve other components of voice that are not directly affected by the disorder.

Vocal fold immobility

Success of voice therapy in patients with unilateral vocal fold immobility is dependent on the position of the paralyzed vocal fold, the remaining vocal fold bulk, the tension present in the immobilized fold, the duration of the disorder, and surgical correction if performed. Patients with a paralyzed vocal fold in a medial position are more likely to have successful therapy than are patients with an immobile vocal fold in a lateral position.

Historically, voice therapy for vocal fold paralysis involved rigorous pushing/pulling exercises, which actually induced laryngeal hyperfunction. Resultant hyperfunction is often more detrimental to the patient's voice than the paralysis itself. These types of pushing/pulling exercises have no role in modern voice therapy. Vocal function exercises, resonant voice therapy, challenge therapy (modified LSVT), postural/position alterations, or a combination of these are indicated. In cases in which the paralyzed vocal fold is extremely lateral (>3 cm), voice therapy usually follows surgical correction.

Paradoxical vocal fold movement disorder 

PVFMD is a poorly understood disorder that involves inappropriate closure of the vocal folds during respiration. Patients may report dyspnea, cough, or globus sensation. As described above, a combined modality treatment involving respiratory retraining and reflux therapy appears to be an effective treatment option.

Caveats of Voice Therapy

Voice therapy should only be performed by a licensed speech pathologist with training in voice disorders. Many speech pathologists focus on one area of treatment, such as aphasia, dysarthria, dysphagia, cognition, or voice. Referring a patient to a speech language pathologist (SLP) with little experience or interest in voice is not favorable for therapeutic success. 

Voice therapy is individualized. Every patient presents with a completely different syndrome, regardless of the physiology. Individual therapists may approach the same disorder very differently but still achieve the same level of success. However, not every patient with a voice disorder is successful in therapy. The success of therapy is dependent upon many factors, including patient compliance.  

Summary

Voice therapy is an essential component of treatment for many patients with voice disorders. In many cases, voice therapy is the primary treatment recommended for many patients. This article is far from a comprehensive review of all voice therapy techniques, but rather a cursory outline of some of the more salient issues involved in the therapeutic process. Voice therapy is individualized; the type of therapy can vary greatly from patient to patient and from clinician to clinician with similar levels of success. In conclusion, when performed by a certified speech language pathologist (SLP) with specific training and experience in voice disorders, voice therapy can be effective in helping many patients with voice disorders.  

Keywords

voice therapy, behavioral voice modification, behavioral voice therapy, voice rehabilitation, dysphonia, voice therapy program, hyperfunctional voice disorder, hypofunctional voice disorder, dysfunctional voice disorder, functional voice disorder, phonotrauma, vocal function exercises, VFEs, direct voice therapy, indirect voice therapy, confidential voice therapy, resonant voice therapy, accent method voice therapy, Lee Silverman voice treatment, LSVT, respiratory retraining, Muscle tension dysphonia, MTD, psychogenic dysphonia, conversion dysphonia, organic vocal fold disorder, neurological voice disorder, vocal fold immobility, paradoxical vocal fold movement disorder, PVFMD

 


More on Voice Therapy

References
[ CLOSE WINDOW ]

References

  1. Trani M, Ghidini A, Bergamini G, Presutti L. Voice therapy in pediatric functional dysphonia: a prospective study. Int J Pediatr Otorhinolaryngol. Mar 2007;71(3):379-84. [Medline].

  2. Branski RC, Perera P, Verdolini K, Rosen CA, Hebda PA, Agarwal S. Dynamic Biomechanical Strain Inhibits IL-1beta-induced Inflammation in Vocal Fold Fibroblasts. J Voice. Aug 11 2006;[Medline].

  3. Behrman A. Facilitating behavioral change in voice therapy: the relevance of motivational interviewing. Am J Speech Lang Pathol. Aug 2006;15(3):215-25. [Medline].

  4. Murry T, Woodson GE. Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy. J Voice. Dec 1995;9(4):460-5. [Medline].

  5. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice. Mar 1999;13(1):72-104. [Medline].

  6. Case J. Clinical Management of Voice Disorders. 3rd ed. Austin: Pro-Ed; 1996.

  7. Colton RH, Casper JK. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. 2nd ed. Baltimore: Williams & Wilkins; 1996.

  8. Dromey C, Ramig LO, Johnson AB. Phonatory and articulatory changes associated with increased vocal intensity in Parkinson disease: a case study. J Speech Hear Res. Aug 1995;38(4):751-64. [Medline].

  9. Fawcus M. Voice Disorders and Their Management. London: Croom Helm; 1986.

  10. Bassiouny S. Efficacy of the accent method of voice therapy. Folia Phoniatr Logop. 1998;50(3):146-64. [Medline].

  11. Morrison M, Rammage L. The Management of Voice Disorders. San Diego: Singular Publishing Group Inc; 1994.

  12. Ramig LO, Countryman S, O'Brien C, Hoehn M, Thompson L. Intensive speech treatment for patients with Parkinson's disease: short-and long-term comparison of two techniques. Neurology. Dec 1996;47(6):1496-504. [Medline].

  13. Ramig LO, Pawlas AA, Countryman S. The Lee Silverman Voice Treatment: A Practical Guide for Treating the Voice and Speech Disorders in Parkinson Disease. Iowa City: National Centre for Voice and Speech; 1995.

  14. Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice. Sep 1997;11(3):321-31. [Medline].

  15. Roy N, Leeper HA. Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: perceptual and acoustic measures. J Voice. Sep 1993;7(3):242-9. [Medline].

  16. Sapir S, Spielman JL, Ramig LO, Story BH, Fox C. Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson disease: acoustic and perceptual findings. J Speech Lang Hear Res. Aug 2007;50(4):899-912. [Medline].

  17. Schindler A, Bottero A, Capaccio P, Ginocchio D, Adorni F, Ottaviani F. Vocal improvement after voice therapy in unilateral vocal fold paralysis. J Voice. Jan 2008;22(1):113-8. [Medline].

  18. Speyer R. Effects of Voice Therapy: A Systematic Review. J Voice. May 15 2007;[Medline].

  19. Stemple JC. Clinical Voice Pathology. New York: Macmillan; 1984.

  20. Stemple JC, Lee L, D'Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice. Sep 1994;8(3):271-8. [Medline].

  21. Verdolini K. Guide to Vocology. Iowa City: National Center for Voice and Speech; 1998.

  22. Verdolini K, Druker DG, Palmer PM, Samawi H. Laryngeal adduction in resonant voice. J Voice. Sep 1998;12(3):315-27. [Medline].

  23. Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E. Preliminary study of two methods of treatment for laryngeal nodules. J Voice. Mar 1995;9(1):74-85. [Medline].

  24. Verdolini-Marston K, Sandage M, Titze IR. Effect of hydration treatments on laryngeal nodules and polyps and related voice measures. J Voice. Mar 1994;8(1):30-47. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

voice therapy, behavioral voice modification, behavioral voice therapy, voice rehabilitation, dysphonia, voice therapy program, hyperfunctional voice disorder, hypofunctional voice disorder, dysfunctional voice disorder, functional voice disorder, phonotrauma, vocal function exercises, VFEs, direct voice therapy, indirect voice therapy, confidential voice therapy, resonant voice therapy, accent method voice therapy, Lee Silverman voice treatment, LSVT, respiratory retraining, Muscle tension dysphonia, MTD, psychogenic dysphonia, conversion dysphonia, organic vocal fold disorder, neurological voice disorder, vocal fold immobility, paradoxical vocal fold movement disorder, PVFMD

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ryan C Branski, PhD, CCC/SLP, Assistant Attending Scientist, Speech and Hearing Center, Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Murry, PhD, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Clinical Director, Voice and Swallowing Center
Thomas Murry, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Clark A Rosen, MD, Director, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh Voice Center; Associate Professor, University of Pittsburgh School of Medicine
Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: UST Grant/research funds Consulting

RELATED MEDSCAPE ARTICLES
Articles
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.