Case Scenario: Which Voice Therapy Approach Should I Use?
In your clinical setting, your supervisor made you responsible for receiving and treating the referrals of individuals with voice disorders. Your primary responsibilities have been treating individuals with neurological speech and language disorders, and your experience with voice is limited.
Mr. A is a 54-year-old salesperson, referred to therapy with a unilateral, left true vocal fold paralysis secondary to a thyroidectomy. The paralyzed fold, located near the midline, leaves the patient with a mild dysphonia, characterized by a breathy, weak, rough voice that fatigues with use. These vocal symptoms make it very difficult for him to work, as he makes many of his daily sales contacts by phone.
Possible Treatment Approaches
As you explore possible therapy approaches, it appears as though the leading texts and articles offer a wide variety of possible treatment approaches including:
- Phonation while pushing and pulling to increase vocal fold adduction
- Counseling regarding vocal conservation strategies
- Direct laryngeal manipulation (head turning, manual techniques)
- Systematic vocal exercise (resonant voice therapy, Vocal Function Exercises)
- Surgical treatments (injection laryngoplasty, thyroplasty).
With so many choices, how do you choose? I would suggest that your choice is made simpler if you always consider three simple words: Evidence, Need, and Ability.
Evidence
The clinical literature suggests several different therapeutic approaches, but which are supported by evidence?1 Before you recommend and apply an approach, it might be wise to use Google Scholar to search for supportive evidence. Search for the above case scenario, unilateral vocal fold paralysis. You will find good support for exercise therapies and surgical intervention, and limited support for other types of therapies in this patient population. SLPs should always strive to use therapeutic approaches that the evidence supports.
Need
In making your therapy decisions, you must take into account the needs and desires of the patient. This particular individual works as a salesperson and finds it difficult to sustain his daily work activities because of his voice problem. He needs immediate assistance.
Consequently, since the paralyzed vocal fold is near the midline, and the evidence supports the use of injection laryngoplasty for this diagnosis,2 consulting with a laryngologist regarding recommendation for this approach might be best. Immediate voice improvement from surgery could then be supported by another evidence-based approach such as Vocal Function Exercises.3-5 These would reestablish the balance of the three subsystems of voice, respiration, phonation, and resonance.
Ability
What do we mean by ability? First, does the patient have the cognitive and physical ability to follow through with the prescribed therapy approach? Many of the evidence-based voice therapy approaches used by SLPs seem a bit silly to patients and others are somewhat complicated to perform. Prior to committing to an approach, the SLP must judge the patient’s ability to understand the reason for the approach and to perform the appropriate tasks necessary for improvement. Equally important is the clinician’s confidence in the approach and ability to model the approach as intended. Believing in the chosen therapeutic method and selling it to the patient is a big part of voice therapy success.
Choices, Choices, Choices
Therapeutic choices should never be made using a cookbook approach. In this case of a unilateral vocal fold paralysis, a clinician may find many different management approaches. I strongly suggest that finding techniques to use is only a first step. The next steps are to:
- Determine whether there is evidence to support the selected approach
- Take into account the patient’s needs and desires
- Determine the patient’s and your abilities associated with teaching, learning, and performing the desired approaches.
- Thomas, L.B., & Stemple, J.C. (2007). Voice therapy: Does science support the art? Communicative Disorders Review, 1(1), 51-79.
- Prendes, B.L., Yung, K.C., Likhterov, I., Schneider, S.L., Aljurf, S.A., and Courey, M.S. (2012). Long-term effects of injection laryngoplasty with a temporary agent on voice quality and vocal fold position. Laryngoscope, 122:10, 2227-2233.
- Stemple, Lee, L., D'Amico, B., & Pickup, B. (1994). Efficacy of vocal function exercises as a method of improving voice production. J Voice, 8(3), 271-278.
- Roy, Gray, S. D., Simon, M., Dove, H., Corbin-Lewis, K., & Stemple, J. C. (2001). An Evaluation of the Effects of Two Treatment Approaches for Teachers With Voice Disorders: A Prospective Randomized Clinical Trial. J Speech Lang Hear Res, 44(2), 286-296.
- Kaneko, M., Hirano, S., Tateya, I., Kishimoto, Y., Hiwatashi, N., Fujiu-Kurachi, M., & Ito, J. (2015). Multidimensional Analysis on the Effect of Vocal Function Exercises on Aged Vocal Fold Atrophy. J Voice. 29:5, 638-634.
