Patient K was a 21-year-old female col- lege student and avid singer. She pre- sented to an active Midwestern voice center at the suggestion of her director in a regional musical production. She was seen in the Department of Otolar- yngology and was diagnosed with bilat- eral vocal fold nodules.
Patient K complained of daily hoarseness and throat pain after talk- ing and singing. She had struggled with voice breaks in her high notes and roughness in her speaking voice inter- mittently for approximately 9 months. Initial evaluation included flexible videostrobolaryngoscopy, perceptual voice evaluation using the CAPE-V,90,138
and patient self-assessment including the Voice Symptoms Scale (VoiSS),139
the Singing Voice Handicap Index (S-VHI),140 and an unpublished clinical
questionnaire about voice, which que- ries patients about their level of concern about voice and speaking effort (scale of 1 to 7), the amount of time they can talk without vocal difficulties, and their per- ception about their voice in relation to “normal voice,” expressed as a percent.
Baseline Observations
The overall impression was a recurring voice problem that ranged from mild- moderate (eg, on the day of the initial evaluation) to moderately severe follow- ing extended voice use. For K, the most functionally distressing aspects of her condition were the debilitating effects it had on her singing performance and an inability to speak without fatigue and pain in everyday activities.
As noted, the initial otolaryngo- logical diagnosis was bilateral vocal fold nodules. Following treatment, a post hoc review of both baseline and post-treatment stroboscopic exams was obtained from a second board-certified laryngologist, who was otherwise unin- volved in K’s care and was unaware of the purpose of the ratings or even that the images were from the same patient. For the baseline exam, the confederate described bilateral vocal fold edge irreg- ularities, mildly reduced amplitude of
144 Voice Therapy: Clinical Case Studies
vibration and moderately reduced muco- sal waves bilaterally, and the classic hourglass-shaped glottis characteristic of nodules. A still image captured from the pretherapy exam is shown in Figure 3–8.
Perceptual evaluation of the patient’s voice at baseline was completed by the
treating speech-language pathologist using the CAPE-V protocol. Findings indicated mild-moderate overall grade of dysphonia, mild-moderate rough- ness, mild-moderate breathiness, mild- moderate strain, mild-moderate high pitch in speech, and normal loudness. Similar to the procedure for stroboscopic ratings, after therapy termination, post hoc auditory-perceptual evaluations of K’s pretherapy and post-therapy voice recordings were obtained, using the CAPE-V, from 2 additional speech-lan- guage pathologists with extensive expe- rience in perceptual ratings of voice. Also these clinicians were otherwise uninvolved in the patient’s care, the pre- post status of the recordings, or the pur- pose of the evaluations. Results aver- aged across all 3 clinicians are shown in Figure 3–9, together with the range of
FIguRE 3–8. Pretherapy still image of vocal folds.
FIguRE 3–9. Average pretreatment ratings of voice quality across 3 clinicians using the CAPEV (for each dimension 100 is the worst possible score). Ranges across 3 raters were as follows: overall grade: 10 to 30; roughness 6 to 25; breathi ness: 1 to 20; strain: 1 to 13; pitch 0 to 24 (too high); loudness: 0 to 1.
Primary and Secondary Muscle Tension Dysphonia 145
ratings across clinicians for each voice quality parameter in the CAPE-V. These ratings show that the clinicians were in agreement that K’s voice was patently impaired. Additionally, not shown in Figure 3–9, both the treating clinician and one of the blinded clinicians noted trem- ulousness during sustained /a/, and the treating clinician also noted intermittent vocal fry in connected speech.
Results for the baseline VoiSS and S-VHI are displayed in Figures 3–10 and 3–11, which reveal clear abnormalities. On the third, as yet unvalidated, ques- tionnaire tool, K rated her concern about her voice at 5/7 and vocal effort during speech at 4/7. She rated her voice as 32% of normal voice on a visual analog scale (data not shown).
History and observations sug- gested that the most obvious contribu-
tor to K’s physical pathology and voice problems was voice use patterns, which by clinical observation included both adducted and nonadducted hyper- function. Adducted hyperfunction was noted especially in singing. The bio- mechanical result would be large inter- cordal impact stresses, which increase susceptibility to nodules and attendant voice changes.141–146 In contrast, what
appeared to be reactive nonadducted hyperfunction, which can also consti- tute vocal dysfunction and even epi- sodic voice loss,1 was held to charac-
terize K’s speaking voice, along with a chronic “throaty resonance” and vocal fry. A second factor thought to be con- tributory to K’s voice problems was relative dehydration. This possibility was based on the patient’s frequent throat clearing apparently to remove
FIguRE 3–10. Pretreatment results for Voice Symptom Scale (VoiSS).139 Worst possible scores are total score = 120; impairment
146 Voice Therapy: Clinical Case Studies
FIguRE 3–11. Pretreatment results for Singing Voice Handicap Index (SVHI).140 Worst possible scores are total score = 144; func
tional domain = 40; physical domain = 40; emotional domain = 64.
thick mucus from the larynx, and her acknowledgement that she drank very little water. The literature indicates that dehydration may predispose laryngeal tissue to injury or slow recovery from injury, while also increasing the sub- glottic pressure required for phonation, especially for high pitches.146–148