Posts filed under Practical Therapy

5 Tips on Treating Vocal Nodules in Kids & Teens

It's always a challenge to find fun and creative materials to help children and young adults want to take care of their voices. With recent research backing a behavioral approach to treating vocal nodules, versus surgical excision, it's even more important we keep these clients engaged. 

1. Start Simple: You don't want to overwhelm your young client with too much information at first, because there's a possibility of being "tuned out." Try bubbles in a cup at first to get them interested. This is a very inexpensive way to make voice rehabilitation very fun. First take a cup filled with 1-2 inches of water and put a narrow-diameter straw in it. Make sure no air comes out the nose, and blow bubbles in the water. Slowly add voice until you have the client vocalizing and making bubbles at the same time. This creates inertive reactance (back pressure at the level of the vocal folds) and helps re-educate the muscles during voice production. Need ideas? Try these easy to print interactive products:

 Straw Phonation characters for decreasing phonotrauma

Straw Phonation characters for decreasing phonotrauma

 Bubbles in Hot Chocolate!

Bubbles in Hot Chocolate!

 Bubbles in a Cup for introducing Semi-occluded vocal tract exercises.

Bubbles in a Cup for introducing Semi-occluded vocal tract exercises.

2. Remember Breathing and Hygiene: It is important once your client is engaged, that you stress the importance of no stress! Two ways you can do this are by teaching diaphragmatic/abdominal breathing and good vocal hygiene. Breaths supported from the abdomen are much more likely to decrease upper body tension than breaths from the chest and shoulders. You're fighting gravity when you breathe from your upper body. Staying hydrated by drinking enough water and avoiding caffeine, ceasing yelling at sporting events or on the playground, and resting your voice are all easy ways to keep good vocal health. Get started with these fun additions to your toolkit: 

 Elephants Don't Forget Good Vocal Hygiene

Elephants Don't Forget Good Vocal Hygiene

 Voice-O-Poly: Challenge your Vocal Health Knoweldge

Voice-O-Poly: Challenge your Vocal Health Knoweldge

3. Vocal Resonance: Humming at the front of your face is a type of semi-occluded vocal tract exercise, but it can get boring quickly. To keep kids engaged find materials that are applicable to lesson plans that they are already doing in the regular classroom. You might also find that sending home fun "hum" activities to try during meal times can help the child remember to practice. Yummy! The following materials can dovetail humming into fun games during your sessions:

 Halloween Themed Resonance for Voice

Halloween Themed Resonance for Voice

 My Mom Makes Lemon Muffins: Vocal Resonance 

My Mom Makes Lemon Muffins: Vocal Resonance 

 For the boys! Resonance Football

For the boys! Resonance Football

4. Use Flow Voice when the laryngeal squeezing is intense. Some clients have struggles with producing sound with "humming" in a healthy way after developing a voice disorder. Flow voice, with roots with Casper, Stone and Casteel, can help break the habit of vocal overcompensation. Kleenex tissue can also be used as great visual feedback to let the client know if the airflow is coming out at the same time as the voice. Find out more and use the following products to teach this type of voicing. 

 Stretch your vowels and flow with Frogs and leaping!

Stretch your vowels and flow with Frogs and leaping!

 Flow phonation with tissues!

Flow phonation with tissues!

 

5. Straw phonation is the newest craze! Cheap, easy, fun and full of benefit. Ingo Titze has done an amazing job with researching benefits that come from phonating or making noise through a narrow straw. This is so perfect for children because they can take their straws anywhere and improve their voicing while letting their friends join in. This is even great for your whole classroom, and for teachers to share on the vocal benefits. I take straw phonation breaks all the time. Keep kids interested with these: 

 Climb mountains with straw phonation

Climb mountains with straw phonation

 Fly your airplanes with straw phonation

Fly your airplanes with straw phonation

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Diagnoses Are Changed...There Must Be Something in the Water

It's Research Tuesday again! There may be "Something in the Water" for Carrie Underwood for her to be changed, and the same is true for the diagnosis of many voice disorders following videostroboscopic evaluation. In this recent article in the Laryngoscope, Seth Cohen (no not the one from the OC), Nelson Roy, Mark Courey and others take a look at how important Videolaryngostroboscopy (VLS) is as an evaluation tool. They did this retrospectively for patients from 2004-2008, who had been evaluated by an otolaryngologist and then had a specialty voice evaluation with a VLS component within 90 days. Findings? Half of the patients had a change in diagnosis following a VLS. HALF! That's insane. I love examining vocal folds with my strobe light and rigid endoscope, and now I love it even more. If this examination can correctly identify disorders that would have been misdiagnosed otherwise, I'll shout it from the mountain tops! Strobes matter!

Think about the otolaryngologist. He sees 20-30 patients per day, and voice complaints usually result in a quick look with a flexible endoscope through the nose. This is to determine if there is something scary or not, and to determine the depth of evaluation necessity. The ENT will then usually refer the patient to a voice specialist for a videostroboscopic examination, or do it himself if he has the training, technology and time. He makes the best call he can for the technology and time he has, and when he knows the patient will benefit from further analysis, he refers. This is efficient.

What makes a videostroboscopy so much more comprehensive?

  1. It can be recorded and reviewed multiple times to educate the patient and to share with other care providers.
  2. It is magnified greater than a flexible endoscope, so you see the laryngeal vestibule in greater detail.
  3. The strobe light allows the vocal folds to be seen in motion. This helps us evaluate the vocal folds in five ways, as well as for color and structure.

This saves us money, it saves the patient money, and it saves insurance companies money. In this study, 83% of 125 individuals who had the diagnosis of acute laryngitis had their diagnosis changed to something different. This was not the only initial diagnosis, but it showed the biggest change. Difference in diagnosis means that there were differences in treatment patterns as well. This means that PPI's were only used when necessary, surgery wasn't performed if it wasn't necessary and voice therapy may have helped in many cases. I like the otolaryngologists I work closely with because they are very conservative when they treat. We provide voice therapy and wait and watch. Vocal folds are so delicate and unnecessary surgery could make a voice quality worse than what the person was complaining of. Each case is different, but many times voice therapy can make a huge difference and even help avoid surgery.

So what was being over diagnosed? Acute laryngitis and vocal fold paresis had a higher chance of being changed as a diagnosis than chronic laryngitis. Cancer and nonspecific dysphonia had less of a chance than chronic laryngitis. The article also states that ENT's are less comfortable with diagnosing specific voice disorders unless they are very visual in presentation, so even more reason for our specialty to shine. Get out there, stay educated on interpreting and strobe, people!

Source: Change in diagnosis and treatment following specialty voice evaluation: A national database analysis. Cohen, Seth; Kim, Jaewhan; Roy, Nelson; Wilk, Amber; Thomas, Steven, & Courey, Mark. Laryngoscope, 13 Feb 2015, doi: 10.1002/lary.25192

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Yodel-ay-i-ay-i-OMG!

Have you ever had a singer on your caseload? Ever had a yodeler? Vocal Hyperfunction can occur in regular singing as well as in yodeling. Classically trained singers and musical theatre style singers use many of the same vocal techniques. Both styles depend on smooth transitions between notes. Rosenberg and LeBorgne refer to a "hybrid singer" in their 2014 publication "The Vocal Athlete," and most singers these days are that. It is important to know about the different types of singing your client might be doing to treat in the most comprehensive way. Treating folks in the south, I get a small group of those who yodel. You are not just born knowing how to yodel, just like you are not born knowing how to sing. Yodeling is an art. It is difficult to do without practice. Just try it! Better yet, try to do what this 12 year old yodeler can do:

So how does one yodel? Yodeling is oozes with heritage because it actually was used to communicate in the extremely tall mountains, where it was difficult to hear because of wind and other climate factors. Yodeling transitioned from this communication option, to being popular in country music. Up until the 1950's, it was prevalent in this scene.

Yodeling is actually the exact opposite of a smooth transition between notes. In classical singing training, we are taught that we should float to notes, never scoop up to them, and definitely never land on them hard. We are instructed to make clean transitions and be thoughtful with where we place the different pitches. Register breaks are seen as improper technique and are discouraged. Yodeling opposes all of that teaching; It is changing your vocal fold tension from high to low registers and actually allowing the break to occur. EMBRACE THE BREAK. It doesn't always have to be in octaves. This goes against all I was taught in my classical voice lessons, but it is relatively easy to mimic if you try it. You deliberately have to break vibratory smoothness, by relaxing. Ha.

So what does yodeling look like? It might help you to see what vocal folds do when yodeling occurs. Here is an examination of the vocal folds, via videostroboscopy. We can see the true vocal folds switch from chest to falsetto registers during the pitch changes. They shorten and lengthen quickly as they do this.

Yodeling, just like any other type of singing, can develop laryngeal tension when it isn't necessary. Make sure when you are yodeling, you keep a relaxed larynx at all times, just like when you are singing in any other style. Make sure you are using enough breath support so you have enough gas in your tank and you don't begin to squeeze those laryngeal muscles.  Hey, if that 12 year old can learn from a tape, maybe you and I can too? And maybe we can give this guy a run for his money.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Can it be...MTD? Muscle Tension Dysphonia Defined.

Completely over diagnosed. Wrongly diagnosed. Underdiagnosed. What the heck is MTD?

Muscle Tension Dysphonia is a term that describes a certain type of voice problem or voice disruption with massive underlying tension, and no other pathological cause. So you have an odd vocal quality or hoarseness, and you are as wound up as Lindsay Lohan's newest attorney. This tension can be found in the upper body area, like the shoulders, neck, jaw, base of tongue and the larynx. The tension can be painful, and many times there are concomitant conditions like stress and emotional conflict making the symptoms worse. There are 2 types of muscle tension dysphonia according to Clinical Voice Pathology by Stemple et al, and 3 according to the voice doctor, Dr. James Thomas.

Do you see cases of MTD in your practice? MTD can often be confused with Spasmodic Dysphonia, so it is important to correctly identify each. I see a lot of vocal hyperfunction, and it's a mix on the cause. Most of the time it is easy to see that there is overcompensation for lack of true vocal fold mass, movement, etc. You must make sure you are taking into consideration the type of examination when making a diagnosis. No one likes a rigid scope in the mouth, so some laryngeal tension could be caused from the exam itself. 

Three Types of MTD:

  1. Primary MTD (Non-organic hyperfunction)
  2. Primary MTD (muscle tension gap)
  3. Secondary MTD (hyperfunction in presence of vocal disturbance)

Stemple and colleagues describe Primary MTD as excessive tension affecting the voice with no other cause. Dr. Thomas agrees, and elaborates on two different types of Primary MTD. He divides the primary category into two: Non organic dysphonia/hyperfunction and muscle tension gap. Primary MTD can present as hyperfunction on a videostroboscopy examination with complete closure of the true vocal folds, however there is some type of superior constriction present. That means that you will see anterior-posterior or medial compression above the true vocal folds. The false vocal folds may be squeezing together so tightly that your view of the true folds is almost completely obscured. This might make it hard to see if there is underlying weakness. This type of patient may have developed this excessive hyperfunction gradually and now it has become the new normal for making sound. Voice therapy can ease the tension with upper body relaxation stretches, circumlaryngeal massage and tension-free phonation training.

Muscle tension gap is different, Thomas argues. He states that the vocal folds can remain open secondary to abductor and adductor muscles simultaneously contracting during phonation. Like the non-organic MTD, this can be learned and compensatory. It could be a muscular habit that will not die, like if vocal nodules are removed. Vocal nodules can be improved and eradicated usually by voice therapy alone, but some surgeons still operate. The patient has learned the way to make sound with the nodules present, a little like playing football with a poorly inflated football. (You can do it successfully after a learning curve, but it's probably going to cause some trouble. Sorry Tom Brady.) An hourglass vocal fold closure is all that can be achieved. The adductor muscles only have to bring the vocal folds together to a certain degree before the nodules prohibit any further contact with the remaining free edges of the folds. Fast forward to the nodules being suddenly removed by a surgeon, the muscles may maintain that same pattern, and only come together so closely. Voice therapy can teach the patient how to phonate completely (and achieve that full closure again) by teaching new motor patterns.

Secondary MTD involves a pathology of some kind like paralysis or lesions, where the patient is overcompensating for the deficit. Secondary MTD is dubbed hyperfunction representing hypofunction by Thomas. With a pathology present, the patient is utilizing hyperfunction to compensate for lack of true vocal fold use. You need to look beyond the superior constriction here to notice why the patient is squeezing. Is there a paralyzed vocal fold? Is there bilateral atrophy and bowing? Is there a polyp? Is there recurrent laryngeal nerve damage? Voice therapy can be beneficial here, but it would be best to address the underlying issue first. If it is atrophy, the patient's ENT might consider implants or injectables. If it is paralysis, the ENT might recommend waiting about 9 months to see if it is true paralysis before laryngoplasty.

Dr. Thomas has this nice educational video to aid in any persisting confusion.

So when you see a patient with laryngeal hyperfunction, make sure you are determining what is causing the hyperfunction. If you're coming up empty handed (not to be confused with a deflated football in hand), perhaps it is true MTD.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

The Theme is Scream: Can You Scream-Sing Properly?

Have you heard those heavy metal screaming bands? They may not be your cup of tea, but you might end up with a lead-singer from this type of genre on caseload someday. These singers growl and grunt on a nightly basis when on tour, so how is the voice not completely wrecked? Screaming is not only hard on some people's ears, it is hard on the vocal folds as well. There is, however, a ray of hope for those suffering from vocal issues as a direct result from their love affair with screaming metal music.

As Melissa Cross explains, proper screaming technique can be taught. She instructs singers to scream properly so they can avoid damage to their vocal folds. These screaming performances night after night will take a toll, so without proper training, she warns, it could end a career. You can scream using your true vocal folds and/or your false vocal folds. Your true folds are more delicate than your false, and they have no nerve endings. They vibrate together about 500 times per second, and can swell with overuse and misuse. This swelling is what causes roughness and hoarseness in the vocal quality, because the true vocal folds can no longer vibrate efficiently with increased weight.

Enter, the false vocal folds, sometimes called vestibular folds. The false folds are located right above the true folds and can vibrate together much like the walls of the throat would vibrate for a laryngectomee with a tracheoesophageal prosthesis. This man has had his voice box and vocal cords removed and is using a hands-free prosthesis to inhale air from his stoma. The air does not exit the way it entered, and is forced up through the throat tissue. That is why he sounds the way he does. This is also different from the electrolarynx. Have you seen that tobacco commercial? The electrolarynx is held against the outside of the neck and sends vibrations through the tissue that can be shaped by your mouth, tongue, teeth and lips to produce words and sentences.

Growling is utilized in mainstream music too, but much more infrequently. Artists like Carrie Underwood and Christina Aguilera both use their false vocal folds to add intensity to some of their phrasing. Here, Carrie growls at 1:23 on "fight" and here Christina does it on "My" at 0:03 and on "touch" at 2:38 here.

Ms. Cross is interesting to me because she is a classically trained voice teacher and she is educating a select population on how to effectively use their mechanism for the sound of choice for their music style. She aims for multiple overtones in the screams she teaches, which I would hope would decrease any resultant hyperfunction from too low or too high of a scream. She warns not to utilize both folds simultaneously, for fear of overuse as well.

There is information that is erroneous out there too. Here is someone saying that the epiglottis is responsible for the growl. Um, no. We have this video, I don't know why she is teaching the student to vibrate his palatal arches, but she is. Perhaps she is trying to eradicate any accidental use of the true vocal folds? But why not educate the student on the whole mechanism? The diagram gives me shivers.

Ms. Cross is due to discuss her techniques on a NATS Chat in February, and I'm very interested to hear what she has to say. Her techniques are unusual, but obviously encourage a balanced vocal subsystem of equal parts air, sound and resonance. Your opera singing vocal teacher might cry blasphemy, but it is all the same mechanism, and I haven't run across anyone else who has taken on this niche. Very cool.

 

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.