Voice Evaluation. Area of Concern:

Transcription

1 Name : Lilly Tulip File Number : 1002 Age : xx years D.O.B. : Address : th St NW D.O.E. : Minot, ND Referral : Dr. Andrew Hetland Phone : (701) Code : Area of Concern: Voice Evaluation LT was referred for voice therapy at Minot State University Communication Disorders Clinic (MSU CDC) by Otolaryngologist, Dr. Andrew Hetland, from the Mid Dakota Clinic PrimeCare Center in Bismarck, ND. A voice evaluation to assess the structure and function of her vocal folds post adductor spasmodic dysphonia diagnosis, voice therapy, and Botox injection was conducted to determine appropriate therapy methods. LT expressed concerns with the quality of her voice, as she perceived her voice as sounding scratchy and breathy when speaking. This was LT s first voice evaluation conducted at MSU CDC. Background Information: LT s voice problem was first noticed by her family doctor, Dr. Teri Hurley, approximately five years ago. LT was diagnosed with adductor spasmodic dysphonia and attended voice therapy from May through August, 2012 to improve spasticity. Therapy focused on laryngeal massage, resonant voice activities, and breathing/strengthening techniques to improve voice quality. After little improvement in vocal quality, LT received a Botox injection to her vocal folds on October 22, 2012 from Dr. Hetland. After the injection, her vocal quality improved for approximately three weeks, reducing her pressed voice; however, her voice became severely breathy immediately after the injection, but the breathy quality subsided within three weeks. Her vocal tremor/voice breaks returned approximately 4-6 weeks post injection. LT reported she experienced tension in her voice while speaking, and her voice varied from day to day. According to the case history, LT expressed her voice symptoms became worse in fall 2011, and she sought medical treatment. She experienced this level of functioning for approximately months before she received the Botox injection. LT reported her voice problems worsen in the afternoon and evenings, as she experiences fatigue from increased effort, as well as throat pain and oral dryness. LT stated she has difficulty communicating in noisy and

2 Voice Evaluation LT 2 quiet environments, and others have difficulty understanding her when she speaks. Additionally, LT reported her voice appears typical while whispering, when she uses short sentences with pauses, or when she has small amounts of alcohol. LT was employed in a professional setting requiring frequent telephone usage before she retired on October 13, Although she did not retire due to her voice problem, others noticed her vocal issues. LT reported using her voice in everyday activities was somewhat important following retirement. She stated her voice had a small negative effect on the activities she participates in, such as socializing with others. LT also reported she sometimes does not want to speak to others unless they are aware of her vocal issues, and she avoided activities such as talking on the telephone and volunteering during the presidential election due to her voice. LT was previously diagnosed with Tinnitus and experiences frequent headaches/migraines and sinusitus. She reported using blood pressure medications for migraine prevention, as well as Estradial for hormone replacement. With the exception of these symptoms, LT reported her health was in good condition. LT s home environment was reported to have high amounts of dust due to ongoing construction in the surrounding area. Furthermore, she noted high levels of noise from the construction; however, this noise level has not affected her ability to communicate. The humidity levels in her house were reportedly at a comfortable level. Testing and Results: Perceptual Evaluation: The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was administered to obtain information regarding LT s vocal quality. Results of the CAPE-V (0=normal, 100=severe): Task Conversation Consistency Overall Severity 40/100 (moderately deviant) Consistent Roughness 10/100 (mildly deviant) Consistent Breathiness 30/100 (mild-moderately deviant) Inconsistent Strain 10/100 (mildly deviant) Consistent Pitch 0/100 (normal) Consistent Loudness (soft) 50/100 (moderately deviant) Consistent Resonance 0/100 (normal) Consistent Tremor 70/100 (moderate-severely deviant) Consistent LT s vocal quality was judged to be mildly-moderately deviant in breathiness and loudness as she maintained a soft voice throughout the assessment. Strain and roughness were mildly present, and resonance and vocal pitch were normal; however, LT had significant difficulty gliding up and down the pitch range. A consistent vocal tremor/voice break was observed during sustained vowels, sentences, and conversation. The Voice Handicap Index (VHI) was completed prior to the evaluation to assess LT s perception of her voice. The VHI measured physical components of vocal function, which looked at laryngeal discomfort and voice output characteristics (i.e., vocal pitch, hoarse quality). The index also measured functional components which looked at the impact of the voice disorder on every day activities (i.e., I miss work due to my voice problem ) and the emotional

3 Voice Evaluation LT 3 component was based on statements regarding emotional responses to the disorder (i.e., I feel annoyed when people ask me to repeat ). LT s scores are as follows: Subscale Functional Physical Emotional Total LT s Scores 23/40 (severe) 26/40 (severe) 16/40 (moderate-severe) 65/120 (severe) LT s functional and physical scores were considered severe, and her emotional score was considered moderately severe. According to the mean values for VHI subscale and total scale scores of 65/120, LT indicated her voice severely impacted her daily life activities and prohibited her from engaging in volunteer work and other social activities. Acoustic Evaluation: The results of the perceptual evaluation were supported by acoustic information and norms taken from the VisiPitch Multidimensional Voice Program (MDVP) and Real Time Pitch Program (RTPP). Microphone gain was set at number 4 for all recorded signals. Results from MDVP: Task Average Fundamental Frequency (Normal range= ) WNL = within normal limits ONL = outside normal limits Shimmer Percent (Normal range= ) Jitter Percent (Normal range= ) Noise to Harmonic Ratio (Normal range= ) 15 /i/s WNL ONL ONL ONL /a/ Habitual ONL ONL ONL ONL Pitch /u/ Habitual Pitch ONL ONL ONL ONL On the MDVP analysis, LT s average fundamental frequency (vocal pitch) was within normal limits for the /i/ task, but outside normal limits for the /a/ and /u/ tasks. Her shimmer (amplitude perturbation measures variation in vocal intensity), jitter (frequency perturbation measures variation in pitch), and noise to harmonic ratio were outside normal limits on all tasks. These results indicated instability of the vocal folds during vibration, inadequate mobility of the vocal folds, and a possible air leak through her vocal folds upon closure, which were consistent with the acoustic findings of her moderately deviant vocal quality and vocal tremor/voice breaks. Furthermore, analysis of the adductor and abductor sentences revealed tremor/voice breaks were present during production of vowels, but the tremor improved during moments of laughter and production of voiceless sounds (e.g., /h, k, p/).

4 Voice Evaluation LT 4 Multiple analyses regarding LT s breath support and glottal closure were obtained. While reading the Rainbow Passage, LT s average syllables per breath was 15, which was outside of the expected norms (7-10 breaths) for respiratory control. /S/ to /Z/ ratio calculations resulted in a score of 3.8 seconds, indicative of insufficient vocal fold closure, as scores greater than 1 were outside the normal range. LT s average maximum phonation for sustained /a/ was 4.3 seconds and /i/ was 5.2 seconds. She was outside of the normal range of seconds for both tasks, which may suggest incomplete vocal fold closure or lack of respiratory support during phonation. The acoustic findings were impacted by the tremor/voice breaks heard in LT s voice, as the vocal folds do not move in a typical pattern when the voice is unsteady. Physical Findings: A videolaryngostroboscopic evaluation was conducted using a 70-degree rigid endoscope to evaluate vocal fold appearance and function. LT reported a variable gag reflex; therefore, throat-numbing spray was used. A view of her true vocal folds was obtained, and no lesions were noted. Left and right vocal folds appeared smooth and straight and on plane (i.e., when the vocal folds come together and do not overlap one another). Additionally, vocal fold closure patterns appeared to be incomplete, as a consistent gap was observed from the posterior portion to the anterior portion of the vocal folds, and at times an hourglass closure pattern was observed. The mucosal wave and supraglottic activity appeared aperiodic (i.e., non-rhythmic), and tremor was observed in structures surrounding the true vocal folds during sustained vowels (e.g., epiglottis, false vocal folds, and the posterior pharyngeal wall). LT had significant difficulty gliding from the mid to high pitch range and mid to low pitch range due to the voice breaks. Additional Observations: LT was a very kind woman who was willing to participate in all evaluation tasks. She was especially patient and cooperative, even in moments of high emotional distress. LT was considerate to the student clinicians and was excited to help them learn. Based on LT s explanation of her vocal problems and her physiological responses, her voice problem clearly impacted her participation in daily life. She reported drinking approximately one quart of water and three caffeinated beverages per day, in addition to four ounces of wine each night. LT refrained from tobacco use; however, she stated alcohol consumption improved her vocal quality. An informal oral-motor evaluation was conducted to assess LT s structure and function of the oral mechanism for speech production. LT s tongue, lips, and palate were examined for the presence of a tremor. Her tongue, lips, and palatal movement and strength appeared typical, and no tremor-like symptoms were noticed. Summary: LT presented with abnormal vocal fold function. Her vocal quality was soft with moderate breathiness, mild roughness and strain, and normal resonance. Vocal tremor was evident in all structures surrounding the vocal folds during production of vowels. Physical findings revealed incomplete glottal closure patterns and smooth and straight vocal folds. LT s

5 Voice Evaluation LT 5 vocal fold movement was non-rhythmic, and no lesions were noted. Acoustic results and perceptual findings supported the moderate vocal issues heard during the evaluation. Recommendations: 1. LT would benefit from enrollment in voice therapy services to improve vocal fold closure patterns and the breathy vocal quality focusing on: a. A trial of Vocal Function Exercises 2. Use vocal hygiene strategies to improve vocal quality. 3. Refer to the following resources for tips and strategies on proper voice care: a. The National Center for Voice and Speech - b. University of Iowa Voice Academy - XXX, B.S. Graduate Student Clinician Lisa Roteliuk, MS, CCC-SLP Clinical Supervisor XXX, B.A., B.G.S. Graduate Student Clinician This evaluation was completed by Graduate Student clinicians under the supervision of an ASHA certified and ND License Speech-Language Pathologist.

6 Voice Evaluation LT 6 Home Programming 1. Get sufficient sleep and drink plenty of water (6-8 eight ounce glasses per day). For every caffeinated beverage consumed, try to drink 2-3 times the amount in water. 2. When your throat feels dry, use cough syrup with Guaifenesin as the only active ingredient (avoid cough syrups with decongestants as they will be drying to the vocal folds) often found in brands such as Tussin or Mucinex. Chewing gum and sucking on hard candy or lozenges without menthol will also help increase the secretions/saliva in your mouth. The goal is to increase the natural secretions in your mouth to improve the moisture surrounding the laryngeal area. 3. Steam the vocal mechanism by taking deep breaths in the shower, using a facial steamer, or learning over the sink with hot running water. Placing a towel over your head (like a tent) and taking in deep breaths will help focus the steam on the facial area. These techniques will hydrate the vocal folds and increase relaxation. 4. Consider using the following relaxation strategies: a. Wall Exercise: Stand with your back against the wall with your feet under your hip and your knees unlocked. Walk your feet forward and allow your knees to bend so you are leaning against the wall. Keep the back of your head and upper back in contact with the wall. Walk your feet back under your body and walk away from the wall with your new alignment. b. Shoulder Blade Squeeze: Stand with your feet under your hips and knees unlocked. Spread your arms out at either side of your body at shoulder height with your palms facing the ceiling. Allow your shoulders to drop away from your ears while maintaining your arm and palm position. c. Head and Neck Stretch: Clasp your hands behind your head and cradle the base of your skull. Push back against your hands with your head. Tuck your chin in and lead with the muscles that join the upper back-of-the-neck to the base of the skull. Relax the rest of your body during the exercise. Hold this posture for about 30 seconds. When you re done, inhale and let your hands go at the same time. You may feel a head rush, which is typical.