Eficacia y seguridad de dispositivos de ozono para la

Patient D received 7 sessions of voice therapy over the course of 3 months and attended 2 follow-up sessions at 1 and 3 months following treatment. At the final session (approximately 6 months from initial diagnosis), we collected post-treatment data.

Visual-Perceptual

Patient D’s vocal fold nodules resolved as judged by the patient and her voice pathologist from visual records of her pretreatment and post-treatment strobo- scopic recordings. The otolaryngologist confirmed this judgment during a fol- low-up indirect mirror examination that revealed no evidence of any midline vocal fold lesion or supraglottic hyper- function. Under stroboscopic light, vibratory movement exhibited normal phase closure, with normal mucosal wave and amplitude. Phase symmetry and periodicity were still irregular. Acoustic Analysis

Using the same sustained vowel /i/ pro- tocol measured at pretesting, patient D reduced jitter to 0.89% and shimmer to 0.31 dB. She also increased signal-to- noise ratio to 25 dB SPL. Her maximum

pitch increased to 547 Hz. All of these post-test acoustic measures were within expected norms for her age. Habitual pitch and loudness tasks did not change. Aerodynamic Measures

Mean airflow rate decreased to a final mean rate of 150 cc/s, which was within expected normal limits. Mean intraoral pressure was measured at 5.7 cm H2O,

which is also decreased from initial measures and within expected limits. Audio-Perceptual

Patient D’s voice quality improved markedly as judged perceptually by the patient, her mother, and the voice pathologist. She eliminated pitch breaks and intermittent aphonia entirely dur- ing a repeat perceptual assessment using the CAPE-V. Both the patient and thera- pist rated conversational voice produc- tions as normal overall with only mild, intermittent evidence of roughness (11 mm), and no evidence of breathiness, or strain. She sang “Happy Birthday to You” again without any pitch breaks.

The positive outcome of this treat- ment plan is attributable to the patient and family compliance with the home programming effort. The concurrent family counseling process undoubtedly assisted with creative problem-solving strategies to mitigate angry or emotional vocal outbursts. During the course of voice treatment, patient D developed a sense of self-awareness and responsi- bility toward her voice problem, as evi- denced by her willingness to report her weekly progress and to display some of her creative journal entries when she came to therapy. The behavioral modi- fication program of effort and reward did seem to reinforce her “control” over

72 Voice Therapy: Clinical Case Studies

vocally abusive behaviors. Certainly, not all children can eliminate vocally aggressive behaviors. Fortunately, pa- tient D enjoyed the positive attention and support she received from her mother and brother for her compliance with vocal exercises and voice conser- vation strategies. Thus, her decisions about good voice use were motivated by her own sense of self-determination and satisfaction, and the entire house- hold benefitted from improved com- munication patterns. Both she and her mother were pleased with the outcome.

In the following case of a 10-year-old with MTD secondary to a vocal fold cyst, Carissa Portone-Maira uses vocal hygiene counseling, vocal function exercises, and resonant voice therapy to improve vocal function.

Case Study 8

Carissa Portone-Maira

Eclectic Voice Therapy for

Secondary MTD in a 10-Year-Old With a Vocal Fold Cyst

Case History

History of the Problem

GG presented as a pleasant 10-year-old boy who was a good fourth-grade stu- dent and had recently become interested in acting. His mother reported that over the past 3 years, GG had developed pro- gressively worsening vocal difficulties. The specific complaints were a rough and breathy voice, decreased vocal stam- ina, decreased pitch flexibility, decreased

loudness, inability to project his voice, and voice loss after attempts to raise the voice (such as calling across the football field). GG reported that he had to repeat himself frequently to be understood, and he agreed that he had problems with losing his voice.

Medical History

GG underwent adenotonsillectomy in 2010. He had asthma and seasonal aller- gies but otherwise was a healthy boy. He used an Asmanex inhaler and Nasonex for allergy management. He was a full- term infant, and there were no reported hospitalizations. He had seen a general- practice otolaryngologist, who diag- nosed him with vocal fold nodules. Social History

GG lived with his mother, father, and younger sister (age 4). He attended a public elementary school and was audi- tioning for roles in commercials and local community theatre productions. There was no tobacco exposure in the home. He had no history of speech therapy in early childhood, and he was not receiving speech therapy services at school.

Voice Evaluation

Audio-Perceptual Assessment

The CAPE-V,90 _{a 100-mm visual ana-}

log scale, was utilized to assess overall severity of voice quality and to quantify aberrant perceptual features identified in the voice. The overall severity score was 72/100, indicating a moderate- severe dysphonia. The aberrant percep- tual features identified in the voice were

Primary and Secondary Muscle Tension Dysphonia 73

moderate breathiness, moderate rough- ness, and severe strain. GG frequently spoke with excessive hard glottal attacks, but overall vocal intensity was reduced. There was a low laryngeal tone focus. Locus of respiration was primar- ily thoracic. Vocal pitch and prosody were normal for age and gender. Articu- lation and language skills were within the normal range for age and gender. Instrumental Assessment

Laryngeal Imaging. Multidisciplinary voice evaluation was conducted. Laryn- geal videostroboscopy was performed transorally with a 70-degree endo- scope. Arytenoid motion was brisk and symmetric. There was a right-sided subepithelial lesion that led to moder- ate reduction in mucosal wave. There was also a contralateral softer reactive lesion that did not impact mucosal wave. The larger right vocal fold lesion fit into the left lesion with a cup-and- saucer appearance. Glottic closure was incomplete with an hourglass superior configuration. This was particularly prominent in higher pitches. There was normal amplitude of vibration on the left, but reduced amplitude on the right side. This led to consistent phase asym- metry. Vibration was frequently aperi- odic, but periodic cycles were observed. There were no vascular abnormalities, and no other lesions noted in his phar- ynx or the remainder of his larynx. The laryngologist’s diagnosis was right- sided subepithelial cyst with a reactive lesion on the contralateral (left) vocal fold. The laryngologist referred GG for voice therapy but stated that if there were ongoing limitations after com- pleting voice therapy, he would likely require surgical excision of the right- sided cyst.

Aerodynamic Measures. Maximum pho nation times were as follows: /a/ = 6.8 seconds, /s/ = 12.6 seconds, /z/ = 7.5 seconds. The s/z ratio was 1.68, indicative of glottal incompetence. Instrumental aerodynamic assessment was conducted with the KayPENTAX Phonatory Aerodynamic System. Mean flow rate on sustained vowels was 0.17 L/s, on the highest end of the normal range. Mean peak air pressure on the voicing efficiency task (an estimate of subglottic pressure) was 11.45 cm H2O,

on the high end of the normal range. Phonation threshold pressure was ele- vated at 6.93 cm H2O, consistent with

the perceptual assessment of hard glot- tal attacks.

Acoustic Measures. Laryngeal func- tion studies were completed utilizing the KayPENTAX Computerized Speech Lab. A headset microphone was placed at a 45-degree angle at 2 cm from the mouth for data acquisition. Speak- ing fundamental frequency (SF0) was

within the normal range at 260.57 Hz with a standard deviation of 28.41 Hz. Physiological pitch range was 204 to 655 Hz, with a midrange gap from 350 to 500 Hz. When asked to produce a pitch glide with reduced loudness, high- est F0 was limited to 400 Hz. Fundamen-

tal frequency on sustained vowels was 249.845 Hz. Vocal instability was evi- denced by elevated pitch perturbation (jitter) of 3.593% and intensity perturba- tion (shimmer) of 10.352%. An elevated noise-to-harmonic ratio (0.321%) was consistent with the perceptual assess- ment of roughness.

Patient Self-Assessment

Pediatric Voice Handicap Index score was 60/120. When asked to rate his

74 Voice Therapy: Clinical Case Studies

voice on a scale from 1 to 10 (10 = best), GG rated his voice as a 3/10. At its best, he would rate it at 7.5. At worst, he would rate it a 1. On a self-rating scale of 1 to 7 for talkativeness and loud- ness (1 = quiet and introspective; 7 = loud and talkative), GG rated his innate talkativeness as 5/7 and loudness as 5/7.

Voice Therapy

Therapy was planned for 6 weekly sessions. The primary goal of therapy was to improve the efficiency of vocal mechanics sufficient to enable GG to participate fully in his normal activi- ties, including sports and acting, with- out voice loss. A secondary goal was to avoid the need for surgical remedia- tion. GG agreed at the time of the ini- tial evaluation to refrain from yelling or raising his voice until he was taught methods for healthy vocal projection in voice therapy. One of his parents was present for the entire evaluation and for all therapy sessions to promote carry- over of therapy techniques to the home environment.

Therapy targeted vocal hygiene education, forward-focused resonance to improve the efficiency of vocal tract posturing, and coordination of abdom- inal respiration with phonation to improve vocal quality and efficiency and reduce hard glottal attacks. Reso- nant voice therapy91 _{and Vocal Function}

Exercises92 _{were the primary treatment}

paradigms used in order to balance the 3 subsystems of voice (respiration, pho- nation, and resonance). Semi-occluded vocal tract exercises93 _{were incorporated}

into Vocal Function Exercises to reduce phonatory impact during practice and facilitate optimal vocal tract configura-

tion. During the evaluation, there was a notable improvement in GG’s percep- tual voice assessment as well as normal- ization of perturbation measures with cues for forward-focused resonance and increased transglottal airflow. GG’s age and stimulability to improvement with forward focus would support use of the

Adventures in Voice program94 _{(for more}

information on Adventures in Voice, see Hersan’s Treating a Child with Second- ary MTD using concepts from Adven-

tures in Voice, Chapter 3). However,

GG’s high maturity level did not neces- sitate full immersion into Adventures

in Voice, which creates a make-believe

adventure for the voice patient, com- plete with passport to travel to “lands” where various skills are mastered. Still, some specific therapy tasks from the program were used advantageously.

The first treatment session intro- duced coordination of respiration with phonation specifically targeting reduc- tion of hard glottal attacks. Forward- focused resonance was introduced as well. Both concepts were incorporated into a semi-occluded vocal tract exer- cise: GG phonated into a drinking straw placed within a cup of water. Using this exercise, he was able to avoid a hard glot- tal attack (sudden splash of water in the face). He increased his awareness of for- ward focus versus vocal tract straining by attending to sensations. During the session, he was able to identify effortful versus easy phonation in his mother’s voice as well as the clinician’s voice. He was able to demonstrate introductory awareness of the same in his own voice by the end of the session. Vocal hygiene recommendations from the evaluation session were reviewed, and he was able to independently recall recommenda- tions for hydration and elimination of coughing/throat clearing.

Primary and Secondary Muscle Tension Dysphonia 75

At the second voice therapy ses- sion, GG reported daily homework practice between visits. He expressed low confidence in his ability to identify target versus nontarget voice during his practice, but his mother stated that she thought his voice already sounded bet- ter. GG described tension in his upper back, a new complaint. Because tension in the upper back could refer and create tension within the vocal tract, therapy began with stretches for the back of the neck/upper back to promote more relaxed postures of the laryngeal mech- anism. Attention was then turned to coordination of abdominal respiration with phonation. Elimination of high chest breathing was easily established simply by cueing “easy inhalation” and shifting the focus to exhalation rather than inspiration. Ideal transglottal air flow (flow phonation)95 _{was established}

on sustained and pulsed /S/ and /m/. The nasal sound /m/ was then gen- eralized to “m-hm” for use as a self- cueing mechanism (carrier phrase) to achieve forward focus in conversation. The use of self-cueing on “m-hm” was incorporated into a game of Memory with m-initial words. Negative prac- tice was contrasted with the target to increase awareness. GG noted a sensa- tion of reduced laryngeal effort using the techniques as compared to negative practice, and he expressed increased confidence in his awareness of target versus nontarget vocal quality. To pro- mote ease of home practice, GG was advanced from phonation into a straw within a cup of water to phonation into a straw without water. Modified Vocal Function Exercises (VFEs) were intro- duced. The VFE tasks were performed as described by Stemple (for more infor- mation on Vocal Function Exercises, see Case Study 13 by Joseph Stemple, Use

of Vocal Function Exercises in the Treat- ment of an Adult With Secondary MTD, later in this chapter), but the sound used for all tasks was phonation into a straw, as GG was already familiar with straw phonation.

Unfortunately, at this point, GG did not return for over 1 month. When he returned for his third therapy session, he reported inconsistent homework prac- tice. He cited after-school activities and overload of academic homework as the causes for his lack of practice. Therefore, therapy began with identifying a moti- vator to practice, and we agreed that he would receive a prize of chocolate if he practiced every day before his next ses- sion. Stretches for the back of the neck/ upper back were reviewed. Awareness and production of forward focus with- out vocal tract straining were targeted at the sentence level during a game of 20 Questions. Chanting and negative prac- tice were incorporated on a limited basis as needed to achieve target voice and to ensure a contrast between habitual voice versus forward focus. GG noted a sensation of reduced laryngeal effort using the techniques. Vocal Function Exercises (modified with straw phona- tion) were reviewed, and considerable time and attention were paid to ensure there was no vocal tract straining dur- ing the exercises.

The fourth treatment session was 1 week later. GG reported consistent daily homework practice and was re- warded with a chocolate bar as prom- ised. Awareness and production of for- ward focus without vocal tract straining were targeted at the paragraph level during story reading. Semi-occluded vocal tract techniques between para- graphs were helpful as a facilitating technique. Forward focus was also tar- geted at an increased loudness level.

76 Voice Therapy: Clinical Case Studies

Phonation into a very narrow straw (coffee stirrer) was helpful to internal- ize the amount of breath needed to phonate loudly without strain during a game of “Mother, May I?” in the clinic hallway. When acting as the “mother,” GG would reply to requests with either “m-hm, Yes you may” or “m-mm, No you may not.” Asking GG to base his answer of yes or no on whether or not the opposing player utilized forward- focused resonance simultaneously tar- geted awareness of forward focus. The clinician intermittently demonstrated laryngeal tone focus as a foil to ensure GG’s awareness. When acting as a player rather than the “mother,” GG had the option of producing target voice with increased loudness to make his request or to engage in negative prac- tice followed by self-correction. Phonat- ing into the coffee stirrer intermittently through the game promoted increased success in performance. Modified Vocal Function Exercises were reviewed and were continued with phonation into a straw as in the previous session. GG was encouraged to produce one produc- tion of each VFE exercise into the coffee stirrer and one into a standard straw. We agreed that chocolate reinforcement would again be provided if homework was completed each day prior to the next session.

GG again did not return for 1 month between sessions. When he arrived for his fifth therapy session, he reported inconsistent homework practice. Voice recording was compared to the ini- tial pretreatment recording. Hearing the improvement in his voice led to immediate stated motivation to return to more consistent practice. Awareness and production of forward focus with- out vocal tract straining were reviewed

in modified Vocal Function Exercises, on carrier phrase (m-hm), and in sen- tences. GG was successful in imple- menting target voice independently at these levels but still questioned his own awareness. Awareness and production were targeted in a monologue being prepared for audition, at conversational and stage/projected loudness levels. After each sentence, GG was asked for a self-assessment of forward versus laryn- geal tone focus, and his confidence in his awareness improved. Vocal Function Exercises were advanced to the stan- dard protocol to help generalize therapy skills to new sounds. Standard nasal /i/ was used for the warm-up sound and kazoo buzz for the stretch, contraction, and power phase. Care was taken to avoid straining with the new sounds. GG agreed to follow through with prac- ticing Vocal Function Exercises twice daily. He expressed understanding that he needed to begin paying attention to speaking with forward focus, and he elected to begin by using forward focus when speaking with his parents. Note that both parents had attended suf- ficient therapy sessions to be aware of forward versus laryngeal tone focus in GG’s speech.

At the sixth therapy session, 2 weeks later, GG reported consistent twice daily homework practice; however, he was not sure if he was using target voice when attempting to do so. After ensur- ing Vocal Function Exercises were being performed accurately, the remainder of the session was spent targeting aware- ness of forward focus without vocal tract straining. GG was consistently able to produce target voice, despite his res- ervations. Given the repeated failure to maintain awareness between treatment sessions, a new approach was needed.

Primary and Secondary Muscle Tension Dysphonia 77

Awareness was targeted via recording and playing back the voice in a “quiz” format. Grant would mark each pro- duction as “+,” “−,” or “±,” while the clinician did the same. We then com- pared scores, and GG was in agreement with the clinician over 80% of the time. His confidence improved as he saw the answers on his quiz being graded as correct consistently. His real-time self- assessment was then targeted by first judging the clinician’s voice in real time, then his own voice in a slow counting task, then a sentence-level reading task, still using the quiz format. Awareness remained accurate with greater than 80% success. The session improved GG’s confidence in identification and production of target voice during play- back and in real time to such a degree that only one final discharge session was planned for the next week.

Therapy Outcomes

Audio-Perceptual

At the seventh treatment visit, GG pre- sented with a mild dysphonia character- ized by mild breathiness, intermittent mild roughness, and occasional laryn-