Patient L received 5 hours of voice therapy, conducted by 4 voice patholo- gists per day for 3 consecutive days. Pretherapy and post-therapy measure- ments were performed at the beginning and end of each therapy day with stro- boscopy, high-speed digital imaging, acoustic, aerodynamic, and auditory perceptual analysis of voice quality. The therapy regimen consisted of 4 differ- ent goals focusing on reducing hyper- functional behaviors, improving glottal closure, building vocal endurance, and increasing hydration. During the 3 days of intensive treatment, patient L was not provided with additional home practice of the voice exercises.
The above voice therapy goals were achieved using a combination of voice therapy techniques. Patient L’s
130 Voice Therapy: Clinical Case Studies
first therapy session each day consisted of performing the vocal function exer- cises, abdominal breathing, and neck relaxation exercises. During the subse- quent sessions, each day the goal was to systematically progress toward use of resonant voice at conversation level. For this, techniques of resonant voice and flow mode phonation were used at syllable, word, sentence, marked para- graph reading level, paragraph read- ing level, structured conversation, and conversation.
Patient L attended all scheduled voice therapy sessions. Team meetings were conducted prior to the initiation of voice therapy each day to discuss the patient’s response to the targeted voice therapy activities and highlight the ther- apy plan for each day. During the team meetings, the team leader also summa- rized the results of the pretherapy and post-therapy voice measurements for the voice pathologists participating in the patient’s care.
Patient L had a breakthrough ses- sion with one of the voice pathologists during the early afternoon of the second day, in which the patient was able to maintain resonant voice during struc- tured tasks at sentence and paragraph reading levels. Goals for day 3 were changed to accommodate the progress made during day 2 of the intensive voice treatment. During day 3, patient L was provided with increased opportu- nities to practice carryover of the newly learned skills in the voice therapy ses- sion to unique situations like order- ing at the cafeteria and conversation at the hospital cafeteria with high levels of background noise. The last session during day 3 was geared toward pro- viding a written home practice plan for the patient.
Results of Therapy
Pretherapy and post-therapy measure- ments performed each day consistently revealed significant improvement of voice quality at the end of an intensive voice therapy day. The results from the last therapy session of a 3-day intensive voice treatment regimen are summa- rized below:
n Laryngeal imaging: Both stroboscopic
and high-speed digital imaging re- vealed improved glottal closure compared to an irregular incomplete glottal closure that was observed dur- ing pretreatment recordings. Glottal closure during complete adduction was now characterized by a small posterior phonatory gap. Healthy vibratory amplitudes and mucosal wave were appreciated along the right vocal fold and minimal reduc- tion in mucosal wave was observed along the left vocal fold. Lateral and anterior posterior compression of the glottis was not observed. High-speed analysis inconsistently revealed phase asymmetry between the vocal folds.
n Acoustic analysis: The patient reduced
jitter and shimmer measurements and increased the signal-to-noise ratio. Post-test acoustic measurements were grossly within expected norms for the patient’s age and gender.
n Aerodynamic analysis: Mean airflow
rate was 180 cc/s and mean phona- tory threshold pressure was 5.2 cm/ H2O, which are within the expected
limits.
n Auditory perceptual analysis: Conver-
sational speech was rated to have an overall normal grade (G), mild rough- ness (R), with no evidence of breathi- ness and asthenia. The patient’s voice
Primary and Secondary Muscle Tension Dysphonia 131
quality improved markedly as judged by the patient. Even at the end of a 3-day intensive voice therapy regi- men, patient L did not complain of vocal fatigue and hoarseness.
Subsequent follow-up was con- ducted once every 2 weeks by means of e-mail and by video-voice interface through the World Wide Web. The team leader discussed the maintenance plan with the patient’s voice therapist in Ice- land by e-mail. Subsequent follow-up at 6 months revealed that patient L had continued to maintain the improvement achieved during the initial course of intensive voice treatment. At this time, a follow-up in 1 year was recommended. The positive outcome of this treatment is attributed to the rigorous concen- trated practice of structured therapeutic tasks to bring about a change in target vocal behavior. Intensive short-term therapy with a number of voice clini- cians inherently created opportunities for differential practice, which facili- tated transfer of learned skills. Because the patient had a long-standing voice problem, the intensive nature of voice treatment also aided in reducing the patient’s frustration with the therapeu- tic tasks and enhanced compliance with the voice exercises, by demonstrating success within a short duration.
Though controversy continues to surround the actual prevalence of voice disorders associated with laryngopha- ryngeal reflux (LPR), patients continue to be referred with this diagnosis. In the following case, Sandy Schwartz discusses both medical and behavioral management of a case of MTD second- ary to LPR.
Case Study 16
Sandra A. Schwartz
Medical and Therapeutic
Management of Laryngopharyngeal Reflux With Resulting
Secondary MTD