Question
I am working with an adult male patient who is experiencing difficulty with phonation following a 3 month intubation and subsequent vocal fold paralysis. Can you give me some therapy ideas for establishing functional phonation?
Answer
Although spontaneous recovery often occurs in vocal fold paralysis within six months to a year following injury, many clinicians support early voice therapy because it is unknown whether therapy may play a part in facilitating spontaneous recovery. Another benefit to early therapy may be that it helps prevent the adoption of undesirable compensatory vocal habits such as hyperfunctioning from occurring. However, if therapy is initiated during the spontaneous recovery timeframe, it must be noted that vocal recovery cannot be attributed to therapy with any confidence.
Clinicians often report success with behavioral treatment for vocal fold paralysis, however, frequently there may be a negative aspect to the treatment, which must be considered or resolved. In addition, it should be noted, that Colton, Casper, and Leonard (2006) argue that there is little evidence to support the idea that the folds can be encouraged to cross midline by means of behavioral treatment.
For clients who do not experience satisfaction with therapy, the clinician should consider counseling them regarding the possibility of medical/surgical management designed to medialize the cords. Medical management, however, is strongly discourage until after the client is certain that spontaneous recovery will not occur, that is, at least 18 months post injury, and after voice therapy has been attempted.
Having said all that, I assume that your client suffered a unilateral adductor vocal fold paralysis since medical procedures are often indicated for bilateral paralysis. Most behavioral techniques that have been used for unilateral paralysis of the vocal fold are designed to achieve approximation between the intact fold and the paralyzed fold.
Boone, McFarlane and Berg (2005) have suggested several techniques that might be attempted to improve unilateral adductor vocal fold paralysis. Two behavioral techniques they suggested are (1) the use of digital pressure to one side or the other of the thyroid lamina and (2) head turning to either the right or left. The use of these techniques requires some experimentation to determine the optimum combination of digital pressure and head turning that is needed to produce the most productive voice. Try the following:
- Have the client phonate the best he/she can on a vowel (baseline). Then,
- Have the client look forward. Apply digital pressure to the right thyroid lamina and phonate. Determine if the voice is better.
- Have the person turn their head to the right, press on the right thyroid lamina and phonate. Determine if the voice is better.
- Have the person turn their head to the right, press on the left thyroid lamina and phonate. Determine if the voice is better.
- Have the person turn their head to the left, press on the right thyroid lamina and phonate. Determine if the voice is better.
- Have the person turn their head to the left, press on the left thyroid lamina and phonate. Determine if the voice is better.
- Determine if and with what procedure the most productive voice is produced.
- Try to produce words, sentences, etc., with the most productive procedure.
Remember also that if at any time your client achieves some voicing, a personal voice amplifier might be beneficial. Many inexpensive amplification devices can be obtained over the internet.
A technique mentioned by Colton, Casper, and Leonard (2006) involves establishing a high pitch voice. This technique tends to stretch and tense the affected cord and thereby causes it to medialize. Although some have tried to move the voice into the modal or mid-voice, Colton, et al., report that attempts to do this are unsuccessful. Some clinicians, however, have used a hard glottal attack to try to get the voice in the mid register. Considering the above, this technique may have disappointing results.
Another technique which has been used successfully by some, but which currently has fallen into disfavor, involves pulling and pushing techniques while phonating. Expert clinicians strongly discouraged casually using these techniques due to the fatiguing effects of the procedure, and because the technique may cause an even weaker voice for a short period following the use of the technique (Colton, Casper, & Leonard, 2006). Supposedly, the pushing and pulling techniques are designed to increase the tension in the laryngeal area and thereby cause the folds to medialize. The procedure used to increase the tension involves grasping the sides of the chair and pulling up while phonating or pushing against a desk or chair seat while phonating to achieve voice. If you try this technique, use extreme caution, paying particular attention to any hyperfunctioning of the client. If you note that your client has acquired some bad habits such as increasing phonatory effort to compensate for the paralysis, you may need to engage in therapy designed to decrease this effort.
References
Colton, R, Casper J., Leonard, R. (2006). Understanding voice problems: A physiological perspective for diagnosis and treatment (3rd ed.). New York: Lippincott Williams and Wilkins
Boone, D., McFarlane, S., Von Berg, S. (2005). The voice and voice therapy (7th ed.). New York: Allyn & Bacon
Dr. Harmon is an Associate Professor on the graduate faculty at Mississippi University for Women. She currently teaches graduate courses in Fluency Disorders, Phonological and Articulatory Disorders, and Voice Disorders. Dr. Harmon has been an invited speaker in the area of stuttering therapy with state and regional associations and with Northern Speech Services across the country.
