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Given that certain occupations are more at risk for developing dysphonia (e.g. teachers) research into prevention studies have been conducted. Research into the effectiveness of prevention strategies for dysphonia have yet to produce definitive results, however, research is still ongoing. Primarily, there are two types of vocal training recognized by professionals to help with prevention: direct and indirect. Direct prevention describes efforts to reduce conditions that may serve to increase vocal strain (such as patient education, relaxation strategies, etc.), while indirect prevention strategies refer to changes in the underlying physiological mechanism for voice production (e.g. adjustments to the manner in which vocal fold adduction occurs, respiratory training, shifting postural habits, etc.).
A combination of both indirect and direct treatment methods may be used to treat dysphonia.
There are a number of potential treatments for spasmodic dysphonia, including botox, surgery and voice therapy. A number of medications have also been tried including anticholinergics (such as benztropine) which have been found to be effective in 40-50% of people, but which are associated with a number of side effects.
This condition is most often treated using voice therapy (vocal exercises) by speech-language pathologists (SLPs) or speech therapists who have experience in treating voice disorders. The duration of treatment is commonly one to two weeks.
Techniques used include:
- Cough: The patient is asked to apply pressure on the Adam's apple and cough. This results in the shortening of the vocal folds which is the physiological mechanism that reduces pitch. The patient can thus practice voicing at a lower pitch.
- Speech range masking: This procedure is based on the theory that when speaking in noisy backgrounds, people speak louder and more clearly in order to be heard. The patient practices speaking while a masking noise is playing. Then, the patient listens to a recording of his/her voice during the masking session and tries to match it without the masking. By doing this, the patient practices their 'loud and clear' voice.
- Glottal attack before a vowel: A glottal attack is when the vocal folds are fully closed and then pushed open by the air pressure from breathing out or making a sound. In this technique, the patient breathes in and then makes a vowel as he/she breathes out.
- Laryngeal musculature relaxation techniques: Laryngeal muscles surround the vocal folds and by relaxing them, there is reduced pressure on the vocal folds. This can be done by yawning and subsequently sighing, exaggerated chewing while speaking, and speaking or singing the 'm' sound.
- Lowering of larynx to appropriate position: The larynx is lowered by the patient by putting pressure on the Adam's apple. By lowering the larynx, the vocal folds relax, and thus pitch is lowered. The patient does this while speaking to practice speaking with a lower pitch.
- Humming while sliding down the scale: The patient starts humming at the highest pitch that they can reach and then keeps lowering the pitch while humming. This allows the patient to practice using a lower pitch and also to relax the laryngeal muscles.
- Half swallow Boom technique: The patient says 'boom" just after swallowing. This is repeated with the patient turning his/her head to either side and also while lowering the chin. After practice, the patient adds more words. This technique helps to close the vocal folds completely.
Indirect Voice Therapy
Indirect treatment options for puberphonia focus on creating an environment where direct treatment options will be more effective. Counselling, performed by the S-LP, a psychologist, or counsellor, can help patients identify the psychological factors that contribute to their disorder and give them tools to address those factors directly. Patients may also be educated about good vocal hygiene and how their behaviour could have long term effects on their voice.
Audiovisual feedback:
In puberphonia, the use of audiovisual feedback allows the patient to observe graphic and numerical representations of their voice and pitch. This allows the patient to determine an ideal pitch range based on normative data on age and gender, and incrementally work through speech tasks while working in that desired pitch range. As the patient improves, speech tasks progress to become more natural, involving tasks such as reciting automatic information, to reading, to spontaneous speech and conversation. Incorporating audiovisual feedback in speech and voice therapies has been successful in intervention by improving motivation and guidance.
Surgery:
In some cases when traditional voice therapy is ineffective, surgical interventions are considered. This can occur in situations where intervention is delayed or the patient is in denial, causing the condition to become resistant to voice therapy.
There are different types of surgical interventions which have been successful in lowering the vocal pitch in men with puberphonia who had previously received ineffective voice and psychotherapy. The first surgical intervention developed, called "Relaxation Thyroplasty" or "Retrusion Thyroplasty", involves a bilateral excision of 2 to 3 mm vertical strips of thyroid cartilage which lowers the vocal pitch through anteroposterior relaxation and shortening of the vocal folds. It can be performed under local or general anesthesia.
"Relaxation Thyroplasty by a medial approach" is a modified approach of traditional "Relaxation Thyroplasty". This version involves lowering the vocal pitch by creating an incision bilaterally in the thyroid lamina and then depressing the anterior segment of the thyroid cartilage.
A more recent, less invasive intervention is the "Window Relaxation Thyroplasty". This approach involves creating a window at the anterior commissure which is then displaced posteriorly.
Clinicians can also request a self-assessment, in which the client describes their symptoms and their effects on activities of daily living. The clinician may direct this self-assessment to include the identification of personality traits that may maintain the disorder, the social and emotional consequences of the symptoms experienced, and whether the client has any access to their modal voice register.
A complete assessment for puberphonia or any other voice disorder may require a referral to another healthcare professional, such as a psychologist or a surgeon, to determine candidacy for different treatment options.
Voice therapy appears to be ineffective in cases of true spasmodic dysphonia, however as it is difficult to distinguish between spasmodic dysphonia and functional dysphonias and misdiagnosis is relatively common, a trial of voice therapy is often recommended before more invasive procedures are tried. Some also state that it is useful for mild symptoms and as an add-on to botox therapy and others report success in more severe cases. Laryngeal manual therapy, which is massaging of the neck and cervical structures, also shows positive results for intervention of functional dysphonia.
In most cases the cause is unknown. However, there are various known causes of speech impediments, such as "hearing loss, neurological disorders, brain injury, intellectual disability, drug abuse, physical impairments such as cleft lip and palate, and vocal abuse or misuse."
The list of treatments mentioned in various sources for presbylarynx includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.
- Voice therapy
Medical often works in conjunction with behavioral approaches. A pulmonary or ENT (otolaryngologist) specialist will screen for and address any potential underlying pathology that may be associated with VCD. Managing GERD has also been found to relieve laryngospasm, a spasm of the vocal cords that makes breathing and speaking difficult.
Non-invasive positive pressure ventilation can be used if a patient's vocal cords adduct (close) during exhalation. Mild sedatives have also been employed to reduce anxiety as well as reduce acute symptoms of VCD. Benzodiazepines are an example of one such treatment, though they have been linked to a risk of suppression of the respiratory drive. While Ketamine, a dissociative anesthetic, does not suppress respiratory drive, it has been thought to be associated with laryngospasms.
For more severe VCD cases, physicians may inject botulinum toxin into the vocal (thyroarytenoid) muscles to weaken or decrease muscle tension. Nebulized Lignocaine can also been used in acute cases and helium-oxygen inhalation given by face mask has been used in cases of respiratory distress.
Psychological interventions including psychotherapy, cognitive behavioural therapy (CBT), Biofeedback, and teaching self-hypnosis are also suggested to treat VCD. Intervention is generally targeted at making the client aware of stressors that may trigger VCD symptoms, to implement strategies to reduce stress and anxiety, and to teach techniques for coping with their symptoms.
CBT can focus on bringing awareness to negative thought patterns and help reframe them by focusing on problem solving strategies. Psychologists may also use relaxation to reduce distress when a patient is experiencing symptoms. Biofeedback can be a helpful addition to psychotherapy. The aim of Biofeedback is to educate the client on what happens to the vocal cords during breathing and to help them learn to control their symptoms.
Choosing an intervention strategy needs to be assessed by a multidisciplinary team and individualized therapy planned carefully, keeping the characteristics of each patient in mind.
Bogart–Bacall syndrome (BBS) is a voice disorder that is caused by abuse or overuse of the vocal cords.
People who speak or sing outside their normal vocal range can develop BBS; symptoms are chiefly an unnaturally deep or rough voice, or dysphonia, and vocal fatigue. The people most commonly afflicted are those who speak in a low-pitched voice, particularly if they have poor breath and vocal control. The syndrome can affect both men and women.
In 1988 an article was published, describing a discrete type of vocal dysfunction which results in men sounding like Humphrey Bogart and women sounding like Lauren Bacall. BBS is now the medical term for an ongoing hoarseness that often afflicts actors, singers or TV/radio voice workers who routinely speak in a very low pitch.
Treatment usually involves voice therapy by a speech language pathologist.
Many of these types of disorders can be treated by speech therapy, but others require medical attention by a doctor in phoniatrics. Other treatments include correction of organic conditions and psychotherapy.
In the United States, school-age children with a speech disorder are often placed in special education programs. Children who struggle to learn to talk often experience persistent communication difficulties in addition to academic struggles. More than 700,000 of the students served in the public schools’ special education programs in the 2000-2001 school year were categorized as having a speech or language impediment. This estimate does not include children who have speech and language impairments secondary to other conditions such as deafness". Many school districts provide the students with speech therapy during school hours, although extended day and summer services may be appropriate under certain circumstances.
Patients will be treated in teams, depending on the type of disorder they have. A team can include SLPs, specialists, family doctors, teachers, and family members.
Some practitioners believe there would be evidence indicating anxiolytics to be helpful in treating children and adults with selective mutism, to decrease anxiety levels and thereby speed the process of therapy. Use of medication may end after nine to twelve months, once the person has learned skills to cope with anxiety and has become more comfortable in social situations. Medication is more often used for older children, teenagers, and adults whose anxiety has led to depression and other problems.
Medication, when used, should never be considered the entire treatment for a person with selective mutism. While on medication, the person should be in therapy to help them learn how to handle anxiety and prepare them for life without medication.
Antidepressants have been used in addition to self-modeling and mystery motivation to aid in the learning process.
If a child finds it difficult to blow, pinching the nose can help regulate airflow. The child should then practice speech sounds without pinching the nose.
These exercises only work as treatments if hypernasality is small. Severe deviations should be treated surgically.
Dysprosody, which may manifest as pseudo-foreign accent syndrome, refers to a disorder in which one or more of the prosodic functions are either compromised or eliminated completely.
Prosody refers to the variations in melody, intonation, pauses, stresses, intensity, vocal quality, and accents of speech. As a result, prosody has a wide array of functions, including expression on linguistic, attitudinal, pragmatic, affective and personal levels of speech. People diagnosed with dysprosody most commonly experience difficulties in pitch or timing control. Essentially, people diagnosed with the disease can comprehend language and vocalize what they intend to say, however, they are not able to control the way in which the words come out of their mouths. Since dysprosody is the rarest neurological speech disorder discovered, not much is conclusively known or understood about the disorder. The most obvious expression of dysprosody is when a person starts speaking in an accent which is not their own. Speaking in a foreign accent is only one type of dysprosody, as the disease can also manifest itself in other ways, such as changes in pitch, volume, and rhythm of speech. It is still very unclear as to how damage to the brain causes the disruption of prosodic function. The only form of effective treatment developed for dysprosody is speech therapy.
Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-modeling should be shown over a spaced out period of time of approximately 6 weeks.
Aphonia is defined as the inability to produce voiced sound. A primary cause of aphonia is bilateral disruption of the recurrent laryngeal nerve, which supplies nearly all the muscles in the larynx. Damage to the nerve may be the result of surgery (e.g., thyroidectomy) or a tumor.
Aphonia means "no sound". In other words, a person with this disorder has lost his/her voice.
In cases of muscle weakness or cleft palate, special exercises can help to strengthen the soft palate muscles with the ultimate aim of decreasing airflow through the nose and thereby increasing intelligibility. Intelligibility requires the ability to close the nasal cavity, as all English sounds, except "m", "n", and "ng", have airflow only through the mouth. Normally, by age three, a child can raise the muscles of the soft palate to close to nasal cavity.
Without the use of a technological aid, nasal emission is sometimes judged by listening for any turbulence that may be produced by the nasal airflow, as when there is a small velopharyngeal opening and there is some degree of mucous in the opening. More directly, methods recommended include looking for the fogging of a mirror held near the nares or listening through a tube, the other end of which is held in or near a nares opening.
There have been many attempts to use technological augmentation more than a mirror or tube to aid the speech pathologist or provide meaningful feedback to the person attempting to correct their hypernasality. Among the more successful of these attempts, the incompleteness of velopharyngeal closure during vowels and sonorants that causes nasal resonance can be estimated and displayed for evaluation or biofeedback in speech training through the nasalance of the voice, with nasalance defined as a ratio of acoustic energy at the nostrils to that at the mouth, with some form of acoustic separation present between the mouth and nose. In the nasalance measurement system sold by WEVOSYS, the acoustic separation is provided by a mask-tube system, nasalance measurement system sold by Kay-Pentax, the acoustic separation is provided by a solid flat partition held against the upper lip, while in the system sold by Glottal Enterprises the acoustic separation can be by either a solid flat partition or a two-chamber mask.
However, devices for measuring nasalance do not measure nasal emission during pressure consonants. Because of this, a means for measuring the degree of velopharyngeal closure in consonants is also needed. A commercially available device for making such measurements is the Perci-Sar system from Microtronics. The Nasality Visualization System from Glottal Enterprises allows both the measurement of Nasal Emission and Nasalance. In the presence of a cleft palate, either of these systems can be helpful in evaluating the need for an appliance or surgical intervention to close the cleft or the success of an appliance or a surgical attempt to close the cleft.
The presbylarynx is a condition in which age-related atrophy of the soft tissues of the larynx results in weak voice and restricted vocal range and stamina. In other words, it is the loss of vocal fold tone and elasticity due to aging which affects voice quality.
Articulation problems resulting from dysarthria are treated by speech language pathologists, using a variety of techniques. Techniques used depend on the effect the dysarthria has on control of the articulators. Traditional treatments target the correction of deficits in rate (of articulation), prosody (appropriate emphasis and inflection, affected e.g. by apraxia of speech, right hemisphere brain damage, etc.), intensity (loudness of the voice, affected e.g. in hypokinetic dysarthrias such as in Parkinson's), resonance (ability to alter the vocal tract and resonating spaces for correct speech sounds) and phonation (control of the vocal folds for appropriate voice quality and valving of the airway). These treatments have usually involved exercises to increase strength and control over articulator muscles (which may be flaccid and weak, or overly tight and difficult to move), and using alternate speaking techniques to increase speaker intelligibility (how well someone's speech is understood by peers). With the speech language pathologist, there are several skills that are important to learn; safe chewing and swallowing techniques, avoiding conversations when feeling tired, repeat words and syllables over and over in order to learn the proper mouth movements, and techniques to deal with the frustration while speaking. Depending on the severity of the dysarthria, another possibility includes learning how to use a computer or flip cards in order to communicate more effectively.
More recent techniques based on the principles of motor learning (PML), such as LSVT (Lee Silverman voice treatment) speech therapy and specifically LSVT may improve voice and speech function in PD. For Parkinson's, aim to retrain speech skills through building new generalised motor programs, and attach great importance to regular practice, through peer/partner support and self-management. Regularity of practice, and when to practice, are the main issues in PML treatments, as they may determine the likelihood of generalization of new motor skills, and therefore how effective a treatment is.
Augmentative and alternative communication (AAC) devices that make coping with a dysarthria easier include speech synthesis and text-based telephones. These allow people who are unintelligible, or may be in the later stages of a progressive illness, to continue to be able to communicate without the need for fully intelligible speech.
Muteness or mutism () is an inability to speak, often caused by a speech disorder, hearing loss, or surgery. Someone who is mute may be so due to the unwillingness to speak in certain social situations.
Historically, to temporarily alleviate symptoms, patients have tried positional maneuvers, such as tilting their head to one side or upside down, lie down on their backs, or sit in a chair with their head between their knees. Similarly, a routine of lying down four times per day with legs elevated to around 20 inches for at least two weeks has been attempted as well. Depending on the underlying cause of the disorder, the individual may need to remove caffeine from their diet, reduce exercise, or gain weight. It may be the case that the symptoms are induced by anxiety; anxiolytic drugs or supplements (e.g., GABA) combined with the removal of caffeine from the diet could offer a simple strategy to determine if anxiety is the root cause.
Estrogen (Premarin) nasal drops or saturated potassium iodide have been used to induce edema of the eustachian tube opening. Nasal medications containing diluted hydrochloric acid, chlorobutanol, and benzyl alcohol have been reported to be effective in some patients, with few side effects. Food and Drug Administration approval is still pending, however.
In extreme cases surgical intervention may attempt to restore the Eustachian tube tissues with fat, gel foam, or cartilage or scar it closed with cautery. These methods are not always successful.
In 2006, the U.S. Department of Education indicated that more than 1.4 million students were served in the public schools' special education programs under the speech or language impairment category of IDEA 2004. This estimate does not include children who have speech/language problems secondary to other conditions such as deafness; this means that if all cases of speech or language impairments were included in the estimates, this category of impairment would be the largest. Another source has estimated that communication disorders—a larger category, which also includes hearing disorders—affect one of every 10 people in the United States.
ASHA has cited that 24.1% of children in school in the fall of 2003 received services for speech or language disorders—this amounts to a total of 1,460,583 children between 3 –21 years of age. Again, this estimate does not include children who have speech/language problems secondary to other conditions. Additional ASHA prevalence figures have suggested the following:
- Stuttering affects approximately 4% to 5% of children between the ages of 2 and 4.
- ASHA has indicated that in 2006:
- Almost 69% of SLPs served individuals with fluency problems.
- Almost 29% of SLPs served individuals with voice or resonance disorders.
- Approximately 61% of speech-language pathologists in schools indicated that they served individuals with SLI
- Almost 91% of SLPs in schools indicated that they servedindividuals with phonological/articulation disorder
- Estimates for language difficulty in preschool children range from 2% to 19%.
- Specific Language Impairment (SLI) is extremely common in children, and affects about 7% of the childhood population.
Dysprosody is an impairment in the prosodic elements such as rhythm, timing, melody, stress, pitch and intonation. It primarily results from neurological damage that can be caused by tumors, stroke, or severe head injury. There have been several hypotheses proposed discussing the area of the brain responsible for prosodic control, but since prosodic elements are so diverse, its organization in the brain is still unclear. There are different types of dysprosody, including linguistic and emotional, which present different symptoms. The only course of treatment proven to be effective is speech therapy, although normal speech may naturally resume. Currently, there has been more research regarding dysprosody's link to other diseases, in particular Parkinson's disease, but also Huntington's disease, and gelastic epilepsy to name a few.
Voice disorders are medical conditions involving abnormal pitch, loudness or quality of the sound produced by the larynx and thereby affecting speech production. These include:
- Puberphonia
- Chorditis
- Vocal fold nodules
- Vocal fold cysts
- Vocal cord paresis
- Reinke's edema
- Spasmodic dysphonia
- Foreign accent syndrome
- Bogart–Bacall syndrome
- Laryngeal papillomatosis
- Laryngitis