Terminating...Why Words Matter

In an age where we are all faced with political correctness, it proves beneficial to be well versed in all the ways a person could describe something. Lately we have been how to describe very delicate subjects such as the transgender policy on bathrooms, ISIS driven hatred and even touchy terminology from our presidential candidates. Everyone has a platform on the internet, and now more than ever we must be very careful with our words.

Also introducing, Blake Shelton's creative new song about how (presumably Gwen Stefani) has a Way With Words. 

I find it very important to try my best to use the most appropriate terminology in life and in my vocal rehabilitation sessions. I want to address the movement to terminate the word "vocal abuse" and use "phonotrauma" in its stead.

 What we've been using for a while to describe screaming, pressed talking, throat clearing, etc.

What we've been using for a while to describe screaming, pressed talking, throat clearing, etc.

 Where we're headed.

Where we're headed.

The idea, brought forth to me by Kittie Verdolini Abbott in her latest lecture I attended in February, suggests that using the term "vocal abuse"  is detrimental to the vocal rehabilitation process.  Vocal abuse describes behaviors like pressed talking, screaming/shouting, coughing, singing loudly, and excessive talking. She suggests using "phonotrauma" instead, so as not to describe a person's habits with such negative context. This can help with the process of shaping and creating new and efficient vocal habits because people want to know what they're doing well, and they may tend to focus on the bad and hear nothing else you say. (And a lot of beneficial information is given during an evaluation or session.)

I relate this to ASHA's policy to refer to speech therapy as intervention or sessions. To me, that says we are moving away from the idea that the services SLP's provide are therapy. However, I find that much of what I do when working with voice and swallowing patients is therapeutic. I can understand and also like considering Speech-Language Pathology as more professional and holding our skilled services to higher standards. 

Other terms I'd like your input on:

  • Calling a person gender ambiguous or gender neutral. What's appropriate?
  • Vocology instead of Voice Disorders. Do you think it will cause confusion referring to an SLP as a Vocologist instead of a Speech Language Pathologist?
  • Laryngeal Dystonia or Vocal Dystonia instead of Spastic/Spasmodic Dysphonia. Does Vocal sound like Focal? Will it be similar to telling the difference between Dysphagia and Dysphasia?

I would love to hear your thoughts and input.

-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.

 

Posted on June 16, 2016 .

Advice Post-Slice: Voice Recommendations After Surgery

How much voice rest is necessary after surgery to the vocal folds? When I had voice surgery 10 years ago, I was instructed to rest my voice strictly for 1 week. No talking, singing, throat clearing, grunting, you get the picture. It was unclear, however, how I was to get back to singing normally again. So what do I tell patients? It varies depending on the extensiveness of the laryngeal surgery, but I pull my recommendations from studies.

The Rat Pack

Leydon et al 2014 describes how forty rats, (I know they're not people,  but I'm sure the experimenters formed relationships with their little buddies for the duration of the trial) had the mucosal layer of the vocal folds removed. (That's the top layer.)  Then the rats' larynges were examined between 3-90 days at 5 different times. 

 This image is pulled from Springer online: Operative Techniques in Laryngology

This image is pulled from Springer online: Operative Techniques in Laryngology

 

Researchers found that a vocal fold tissue structure regenerated quickly (like, within 5 days) with intercellular junctions and multi layered epithelium (the tissue on the very outside of the vocal folds that receives the biggest impact during vibration). 

However, atypical permeability of this layer of the TVF's was seen up to 5 weeks after surgery. This means that if you have vocal surgery, you should be sure to keep tabs on your vocal use for many weeks following surgery, as there is a very elevated risk for further damage as your body continues to rebuild where the surgeon worked. Intact structure does not necessarily mean you can demand vocal use you were using before surgery.

Scarring Woes

Scarring is frequently seen after surgery and results in issues with phonation. So obviously we want to minimize scarring. We can't exactly massage the vocal folds to soften this scar tissue, but perhaps gentle vocal exercises that stretch and contract the tissues, as well as utilize resonant voice can help

Another study by Branski et al from 2006 really looks at how a vocal fold wound heals, including inflammation and swelling, as well as scarring. Again, we're talking our animal friends' vocal folds. Scarring develops when there is an increased inflammatory response following an injury. The study discusses differences in lesions to the vocal folds, including nodules, polyps and cysts. Particularly interesting to me, was the suggestion that a cyst, especially one at the midpoint of the vocal fold, might be due to injury associated with impact stress. (Which further convinces me that my vocal fold cyst from years ago was likely a product of a poorly coached belting role I performed during High School.)

Lesions and Surgery

The Branski article suggests that vocal fold lesions are probably the body's way of healing a wound, much in the way a scar results from a cut. Applicable to many of my patients is the discussion of chemical vocal fold injury from LPR, and that 50% of patients with voice disorders also have LPR or GERD, or both. We must also consider the effect of reflux on the healing process after surgery.

So, how long should a person realistically expect to be on complete vocal rest after surgery? For 2 weeks-5 weeks post injury, epithelium remains permeable and impacted by the wound healing process. I say impacted and not weakened, because epithelialization (restoring structural integrity) occurs rapidly between 3-5 days after injury.  Complete rest during this rapid healing time with a very strict ease back into phonation over 2-5 weeks appears to win here. 

We're still learning so many things about how this delicate tissue heals itself, we can only recommend based on the information we have now. Every patient heals differently, and the degree of surgical manipulation will vary case to case. 

Resources:

Leydon, Ciara, Imaizumi, mitsuyoshi, Yang, David, Thibeault, Susan L., & Fried, Marvin P. Structural and functional vocal fold epithelial integrity following injury. Laryngoscope 2014, Dec. 124 (12) 2764-2769

Branski, Ryan C, Verdolini, Katherine, Sandulache, Vlad, Rosen, Clark A., & Hebda, Patricia. Vocal fold wound healing: A review for clinicians, Journal of Voice, 2006 Vol 20, No 3, pp 432-442

 

A Pumice Stone for Your Vocal Folds? Of Nodules and Intervention

There are many factors that can cause an individual to be hoarse. Vocal fold swelling from sickness or overuse affects the ability for vocal folds to vibrate. Lesions, like polyp, cysts or nodules, can impact closure patterns and vibratory abilities with weight and stiffness. This can greatly affect vocal quality and pitch control. So if a person is diagnosed with one of these issues, is there effective treatment? 

It is important for each healthcare provider involved with a patient's case to weigh all factors when considering surgery like direct microlaryngoscopy. Whenever you are making cuts or removing portions of the vocal fold epithelium, you risk damaging the delicate tissue that is responsible for vibrating and displacing to make sound. Vocal folds are made up of 5 layers, the epithelium on top, the lamina propria (Superficial, intermediate and deep layers) and the thyroarytenoid muscle underneath. Surgeons must be conscious of each layer and do their best to prevent any excess damage, as this tissue will not regenerate with the same chemical makeup. Any surgical intervention will cause swelling, or edema, and can possibly result in worse vocal quality than before. Surgery can be very effective in vocal fold lesion cases, but should be carefully considered. 

Vocal fold nodules are very common benign vocal fold lesions. Nodules are unique in that they are usually bilateral, located on the portion of the vocal folds that creates the greatest movement when vibrating, and they are usually symmetrical. They can be gelatinous or hard fibrotic callouses. They occur from overuse of the voice that has caused the vocal fold mucosa to change composition in response to constant abuse. Vocal nodules can actually respond to behavioral voice therapy and can lessen or even disappear. Dr. Lesley Childs discusses why surgery for this is a last resort following conservative behavioral voice sessions. It is very important for patients to understand why they developed vocal fold nodules in the first place, so they can reverse bad vocal behaviors and prevent them from reoccurring. 

A case for conservative treatment can be made because often times money, time and tissue can be saved if the patient will commit to changing abusive vocal behaviors in therapy sessions. There is also the very likely chance of recurrence if nodules are surgically removed without the patient receiving voice rehabilitation therapy. Communicate with your referring surgeons and work together with them to determine the best and most comprehensive plan of care for each patient with nodules.

The key to the best patient care is communication and being open to suggestions. In my practice I operate as transparently as possible and with education with the patient in mind. A patient of mine asked me if I was like a "pumice stone for the vocal folds," and I had to laugh as I told her yes. What a gift to be able to help a person in the way a pumice stone does---aesthetically and functionally. 

 

-ATVC

Sources: Clinical Voice Pathology: Theory and Management 4th Edition, Stemple, Glaze & Klaben. Plural Publishing.

 

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.

Posted on September 14, 2015 .

Singing in Chest Have You Stressed? Compared With Falsetto, What's Best?

Whether a professional singer or a singer for hobby, if you are developing a professional voice you should have a goal for maximum output with minimal effort. Acoustic output should be easily attained with very little physiological effort, so why do we feel like we have to push to get some sounds?

Source-Filter Theory should begin the discussion. You ask yourself, "Where did I learn about that first? Was it just something I memorized for a test?" It's actually quite easy to explain and the actions are in the name. Remembering that you have a source of sound (your vocal fold vibrations) and that the sound is modified by the filter of your vocal tract is all you have to know. The shape of your throat and mouth take the sound signal and dampen some formants and amplify others, creating your unique sound.

Think of your singing as training the intrinsic muscles of the larynx to strengthen your chest voice. This does not mean that you will always need to sing in your chest voice, but it is important to have control of your whole range, low and high, to master using each when appropriate. There is also the issue of correctly defining chest/belt and head/falsetto voice. I was at a conference at UTSW last month where Dr. Stephen F. Austin spoke regarding this issue. As a singer, you have to remember that your vocal cords or folds are not the only things working in your throat to make sound. He reminded the audience that firm phonation is a full contact sport, furthering the image that one must really commit to working out the voice muscles daily, as any athlete would, to avoid injury and have the best and most efficient working mechanism.

Chest voice can be created by increasing motor signals to the thyroarytenoid muscles (vocal folds). As the vocal folds contract, they bulge toward the middle (medially) and down (inferioraly). If you exercise your TA muscle, it will respond to the exercise because it is a skeletal muscle. Your aim is for creating a square glottis when you have phonation, or vocal fold vibration. With a larger area of contact during vibration comes a stronger sound.

Falsetto, or head voice, is created by decreasing the engagement of the thyroiarytenoid muscles, or the vocal folds. At the same time, you increase the cricothyroid and lateral crycoarytenoid muscles. When beginning your singing training, make sure there is a strong enough chest voice to have an audible break into falsetto. Once this is established, work begins on smoothing out between registers.

Yodeling, interestingly enough, is transitioning between the two types of voice very quickly. One has to relax the larynx enough to perform the switch to each octave along with coordinating the articulators (lips, teeth and tongue) to sprinkle /l/ and /d/ throughout different vowels.

Chest voice is always a "dangerous" subject, as most vocal training programs are tailored for classical singing. Dangerous  because it is like the plague and no one wants to touch it. Reality is, though, chest and belting voice is the most common vocal style in contemporary commercial music (CCM). That means most people with singing careers don't have formal training, but can have real problems that need an experienced teacher. Leborgne and Rosenberg state that 34% of university level teachers who train non-classical singers have never been trained in commercial music. So, why are we putting singers at risk by not being well trained in both classical and contemporary styles of singing? Just with chest singing, falsetto voice can be abused if not trained properly, so it is important to learn to do each the proper way to avoid injury. 

So don't let belting and chest voice singing stress you out. Just like falsetto singing, belting and chest voice singing needs to be taught correctly to avoid injury to the vocal mechanism. Remember, registration is a choice and with proper practice in each, you can keep an efficient larynx in good working order. Dr. Austin reminds us that everything we do can't be beautiful, we must experiment with our instruments.

 

References: Lecture by Dr. Stephen F. Austin at UTSW Singers Symposium 2015
The Vocal Athlete. Ronenberg, Marci & Leborgne, Wendy D. Plural Publishing 2014.
 
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.
Posted on July 7, 2015 .

A Voice That Makes Others Feel Vulnerable?

Diane Rehm has been a radio figure since 1973, and in 1998 she was diagnosed with Spasmodic Dysphonia (SD). If you have ever wondered why she sounds the way she does, it is because of this rare neurological condition. Some people don't know she has SD, and wonder why she talks so slowly and shakily. I want to remind folks what spasmodic dysphonia is and how Diane utilizes Botox treatments to keep her radio career alive.

 

Diane has written books and has created a YouTube video through the National Spasmodic Dysphonia Association (NSDA) to help others better understand Spasmodic Dysphonia. Her condition began with a cough which impacted her ability to speak. Tremor also affected her and she went off the air for 4 months to deal with the emotional and psychological impact of the disorder. Diane was diagnosed with SD and began receiving Botox injections bilaterally (into both vocal folds) to reduce the impact of the spasms on her vocal quality.

Spasmodic Dysphonia is a type of focal dystonia in the central motor system. The two types of SD differ in the abnormal involuntary movements. Adductor SD spasms the vocal folds inward causing a strained, strangled sounding voice and Abductor SD spasms the vocal folds outward causing a very breathy sounding voice, usually on voiceless consonants.

Spasmodic Dysphonia does not favor a specific gender, nor does it have a pattern of onset that stays consistent. Treatment success varies, and usually consists of Botulinum toxin (Botox) injections paired with voice therapy to prolong its effects. Botox usually lasts from 3-6 months before the spasms return. Voice therapy centers around increased pitch, breathy voice quality, /h/ onsets and relaxation. Great care is taken to decrease the hyperfunction some patients have developed as a compensatory measure to their condition.

A nice article by the Washingtonian describes the spitfire confidence that Diane exudes despite her diagnosis and voice troubles. She is an inspiration to all people, especially those who share her diagnosis. SD can easily send a person in to a deep depression and cause reclusive, anti-social behavior and even thoughts of suicide. Rehm doesn't let SD define her, instead she uses her position of influence to help educate listeners about SD and its treatment options.

Diane says that some listeners cannot stand to listen to her, and others feel vulnerable and more human after listening to her on the air. Whatever your position, it is interesting to note that this condition could affect any one of us. The more we understand it, the more accepting we can become.

 

Sources: Clinical Voice Pathology:Theory and Management 4th Edition. Stemple, Joseph; Glaze, Leslie; Klaben, Bernice.

 

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.

Posted on May 11, 2015 .

Beware...Don't Get Scammed by "Patients"

I received an email about a week ago requesting my services. Here is the email:

Hello,

My name is Rebecca Horton; I will be going on my annual leave on the 27th
of March and my daughter & I will be coming to Texas on holiday for 1
month. We will be staying from Sunday 29th of March 2015 to Wednesday 29th
of April 2015. I require the services of a Speech-Language Pathologist,
though this could be done rather flexibly for the entire period of our
stay. I will require your services for 2days each week and for 1 session
of 1hour or 90mins each depending on your availability.

I am a single mother and my daughter (Susan Horton) who is 5years old has
a speech-language disorder. Over the past 5months her stuttering has
become very severe each time she is talking. As a result of her severe
stuttering each time she’s trying to speak, she seems to have developed a
sense of shyness and feels ashamed of talking when she’s in public. I have
taken her to my doctor for a thorough medical check-up and was informed
she is physically and medically okay. My doctor says that the severe
stuttering could be as a result of anxiety or stress from the death of her
father and advised me to see a speech-language pathologist who specialize
in communication disorders. Over the past 1 month I have hired the
services of a speech-language pathologist and I’ve noticed that she finds
each therapy session very relaxing, energizing and it has helped improve
her speaking ability.

Since we are going on a 1 month holiday I would like my daughter to have a
speech therapy program during our stay in Texas. Her speech-language
pathologist here in the UK recommends she takes at least 2 therapy
sessions each week while she’s on holiday in order for her to continue her
rapid progress. I believe the more time she spends with you, by the end of
our holiday’s her speaking ability would have significantly improved. I
would greatly appreciate your thoughts, recommendation and the total costs
for your services (number of sessions required: 8).

I’m 44 years old and a senior accountant, working with Corona Foods
Limited here in the United Kingdom. I will be happy to pay in advance of
our visit to guarantee your services during our stay. I will bring my
daughter to your clinic/practice for each therapy sessions. I look forward
to hearing from you, many thanks.

Best regards,
Rebecca Horton
54 Leopold Road
London, SW19 7JD
United Kingdom

Sounds pretty legitimate right? As I began to reply, I noticed that she revealed many details that were almost too personal, but were appropriate for a fluency diagnosis. This included the death of a parent (an even so traumatizing, it might contribute to stuttering onset) as well as the public shame and shyness. I thought, why is this woman trying to prepay? That is not a normal thing. "To the Google!" I shouted, and sure enough came up with a practically identical email with only names changed. The email was published with a warning about scamming SLP's.

So what's the scam? Apparently, these people are targeting private practice Speech Language Pathologists, and our human qualities. These people want you to agree to provide the services in advance (seems okay), and then they send you a check for WAYYYYY over the amount for the specified number of services, and then request a reimbursement for the difference. Meanwhile, they demand the difference quickly so you send them a check before their check has a chance to clear. (Which it obviously doesn't, and then you just paid someone a bunch of money for nothing.)

So friends, do not fall victim to this scam. Spread this blog around so that other, less tech savvy SLP's are aware. This is a scam, don't get duped.

 

-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.

Posted on March 24, 2015 .

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.

Shine Bright Like a Voice Analysis

Why does a voice sound disordered? Does it sound harsh? Does it sound breathy? Does it sound too high pitched? We can hear a voice and perceptually tell that it sounds unnatural. How do we prove this? There are perceptual scales, like the CAPE-V and the GRBAS, and I use the Vanderbilt FITQ scale. (It's a rating scale for Frequency, Intensity, Timing and Quality on a 0-3 rating.) There are self-perception measures like the Vocal Handicap Index and the Reflux Symptom Index. Unfortunately, we can't just say someone sounds dysphonic and expect the service to be covered. Insurance companies tend to prefer hard numbers and measurable data. The perceptual scales are measurable, however they are subject to intra and inter rater reliability issues because on any given day each of us hears things differently.

Many clinicians utilize acoustic measures like Jitter and Shimmer, as well as noise-to-harmonic ratio when they gather data. Jitter is displacement in frequency periods or pitch variations, and shimmer is changes in intensity or amplitude. Noise-to-harmonic ratio is simply comparing the relationship of good sounds to bad ones, and if the noise outweighs the harmonies, then there is dysphonia. These measures are limited because they require the person to sustain a vowel to capture data, and that can be difficult for some voice patients. While it is important to measure sustained vowel productions, but it is vital to measure the voice in connected speech as well. There are reasons for this: 1) Adductor spasmodic dysphonia sounds relatively normal during a sustained "ahh" but is very apparent during connected speech. 2) Sustained vowels are not as multidimensional as speech. Speech contains rapid voice onsets, offsets, inflections, stress, pauses, voiced and non voiced sounds.

What if we could somehow combine how we measure both connected speech and prolonged vowels? Youri Maryn, Marc De Bodt and Nelson Roy developed a protocol that is multifaceted, like a diamond. The voice has many layers and dimensions, so shouldn't it be analyzed the same way? It's called the Acoustic Voice Quality Index. It takes into consideration 6 parameters:  shimmer local, shimmer local dB, harmonics-to-noise ratio, general slope of spectrum, tilt of regression line through the spectrum and smoothed cepstral peak prominence. If these are unfamiliar terms, that's okay. Just know that the sound signal is being analyzed in different ways and tested to determine if the numbers accurately reflect what is heard perceptually. The testers in this article are making sure that if a voice quality sounds disordered, the numbers consistently reflect this when compared with numbers from a normal sounding voice. 

Cepstral peak prominence is an emerging measure for acoustic analysis. (Cepstrum is spectrum with the letters rearranged, but it the calculations to find it are a bit more involved.) The more periodic a sound signal is, the more you will see a prominent cepstral peak, so we are looking for a low number to represent a dysphonic voice. The great thing about cepstral peak is that it is the only acoustic metric that shows dysphonia in sustained vowel productions and connected speech. Jitter, Shimmer and NHR are limited to the former.

Simply by using PRAAT, a free program, you can easily obtain data in a non-invasive way. Maryn et al 2010 says that there are other similar models of voice data analysis, but none utilize continuous speech and sustained vowels to determine how severe a person's dysphonia is. Maryn and team cross-validated the AVQI in 2009 with 251 subjects. This 2010 study looked at 72 voice samples, as well as 33 other samples to determine the AVQI's responsiveness to change. Acoustic measures were taken using James Hillenbrand's "SpeechTool" (another free program) and PRAAT.

AVQI was developed specifically to be widely available to those providing voice therapy with limited budgets. It's super nice to have CSL software from Kay Pentax, but for the vast majority of clinicians in hospitals, private practices, schools and clinics, budgets are tight. PRAAT can be downloaded on Mac or PC, so it is easily accessible. If you were like me, you might have been collecting data with PRAAT and SpeechTool, but with this measure you can streamline your data collection and use only one program. This saves you time and money, as well as provides you with better data. Excellent... The script necessary to complete calculations can be found in the appendix data for Maryn 2014.

So why the AVQI? Maryn and Weenink found that listeners rate sustained vowels more severely than connected speech when there is dysphonia present. I can vouch for this because my patients usually can only hear a target production in isolated sustained vowels, not in connected speech when I demonstrate both. The AVQI has also been tested across multiple languages, like Dutch and German. Studies have found that despite language differences, the measure remains reliable and valid.

The 2014 article cautions for clinicians to make sure they are accounting for environmental noise in the room as well as mobile phone interference. Recommendations are for a head-mounted condenser microphone with XLR connection as well as an external mixer soundcard to improve the quality of the audio signal and to keep it the same across patients. Remember to tilt the microphone away from the mouth and record voice sounds with a sampling frequency of at least 26kHz.

Using the AVQI has allowed me to streamline my evaluations by a few minutes, as well as show a picture representation of the voice to my patients. Visual is always good. Minutes of each day all are precious because they add up, so I hope you will read up on this available and easy-to-use option for acoustic measurements.

-ATVC

Resources: The Acoustic Voice Quality Index: Toward improved treatment outcomes assessment in voice disorders Youri Maryn, Marc De Bodt, Nelson Roy. Journal of Communication Disorders 43 (2010) 161–174

Objective Dysphonia Measures in the Program Praat: Smoothed Cepstral Peak Prominence and Acoustic Voice Quality Index. Marin, Youri & Weenink, David. J Voice. 2015 Jan;29(1):35-43. doi: 10.1016/j.jvoice.2014.06.015. Epub 2014 Dec 9.

 

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.