6/11/2014 Presentation Material influenced by Dr. Nelson Roy PhD., - PDF document

6/11/2014 Presentation Material influenced by Dr. Nelson Roy PhD., CCC-SLP University of Utah • Anatomical Diagrams/pictures/many slides courtesy of Dr. Nelson Roy What are Manual Circumlaryngeal Swallowing Management Techniques? Indications • Odynophagia • Guesses? • Dysphagia complaints in the absence of • When are they used? significant oropharyngeal findings • How are they employed? • Food “sticking” • What diagnoses can benefit from their use? • Complaints of effortful swallowing • With or without presence of dysphonia What is Muscle Tension Dysphonia? (MTD) Voice Management Indications • Laryngeal or Extralaryngeal hyperfunction • Excess or dysregulated/imbalanced activity of the • Painful voicing/singing intrinsic and extrinsic laryngeal muscles is the • Complaints of throat soreness/pain primary cause of the voice disturbance. • Tight throat musculature • A voice disorder in the absence of visible structural or neurological laryngeal pathology (or where the • Strangled sensation vocal fold pathology is insufficient to explain the • Throat “knots”/lumps degree of the dysphonia). • Muscle Tension Dysphonia 1

6/11/2014 Sources of excessive/dysregulated dysregulated Sources of excessive/ MTD: Broad Conceptualization laryngeal muscle activity… … laryngeal muscle activity Psychological &/or personality factors induce � Psychological &/or personality factors induce � � Key feature is laryngeal and paralaryngeal laryngeal tension. laryngeal tension. hypertonicity � No particular voice quality or glottic configuration is � Technical misuses of the vocal mechanism. Technical misuses of the vocal mechanism. � uniquely identified with MTD. � Learned adaptations following upper respiratory Learned adaptations following upper respiratory � � Extrinsic and intrinsic laryngeal muscle infection. infection. dysregulation contributes to the abnormal voice. � Extreme compensation for underlying vocal Extreme compensation for underlying vocal fold fold � � Muscle tension pulls larynx out of “natural” position. pathology. pathology . � Larynx is suspended high in the neck & the entire Increased laryngeal tone secondary to LPR. � Increased laryngeal tone secondary to LPR. hyoid-laryngeal sling is stiff. � Symptoms of Excess Laryngeal Arnold Aronson (1990) Muscle Tension “ All patients with voice disorders, regardless of � Laryngeal tenderness, soreness, pain, tightness which intensifies with extended voice use (especially with the etiology should be tested for excess palpation) musculoskeletal tension, either as a primary � Unilateral symptoms are more common or secondary cause of the dysphonia” � Pain radiates to one or both ears/fullness of the ears � Vocal fatigue, increased effort, “swellings” in the tongue base/neck regions • Dr. Roy expanded on Aronson’s writings and � Dynamic range restricted (decreased loudness/pitch) developed this “family” of manual � May be seen/witnessed in our voice and or dysphagic circumlaryngeal techniques . patients SPEECH SAMPLES Examples of Muscle Tension Dysphonia (Voice samples) � Pre-Treatment Samples (Rainbow Passage) � Notice the varying degrees of severity and the disparity of vocal symptoms 2

6/11/2014 Muscle Tension Voice Disorders Muscle Tension Voice Disorders Why so many Examples? � Manual Circumlaryngeal Techniques serve as powerful diagnostic and treatment tools… � Full range of different voices in connected speech � Focal Palpation � Severity and quality � Manual Laryngeal Reposturing Maneuvers *** � Circumlaryngeal Massage � Perceptual Clusters? � Determining the contribution of excessive or � Not isolated Cases, often misdiagnosed as ADDSD dysregulated laryngeal muscle activity is critical to or ABSD proper diagnosis and the selection of appropriate � Age range/No age boundaries treatments. � As much as 40% of voice tx caseloads are MTD. � Avoid unnecessary medical or surgical management Focal Palpation of the Laryngeal Area � Pressure is directed over the: � Major horns of the hyoid � Superior border of the thyroid cartilage � Anterior border of SCM � Suprahyoid musculature � Determine size of the thyrohyoid space Assess the Voice Effect of Laryngeal Assess the Voice Effect of Laryngeal Assess the Voice Effect of Laryngeal Assess the Voice Effect of Laryngeal Reposturing Reposturing/Repositioning /Repositioning Reposturing/Repositioning (Cont) /Repositioning (Cont) Reposturing � Brief manual displacement, sustained pressure &/or downward traction applied to the larynx can reveal valuable � Want to keep the patient’s neck in a neutral position information re: potential for improved voice (i.e., voice with no extension. Usually support the occiput of stimulability testing). the head to keep patient from moving back. � While the patient vocalizes, repositioning or stabilizing the � May see patient’s who suspend/elevate their larynx larynx can interfere with habituated patterns of muscle misuse. even at rest, may appear as if they’re holding their � Brief “moments” of voice improvement can be identified, breath; however, it’s actually a “holding” pattern of shaped and reinforced with digital cueing. the suprahyoid muscles. � Digital Cues faded, patient relies on vibrotactile, kinesthetic, and auditory feedback to maintain improved voice, muscle balance and laryngeal positioning. 3

6/11/2014 Observe the Voice Effect of Three “Push-Back” Maneuver (#1) Laryngeal Resposturing Maneuvers 1. Digital compression in posterior direction within region of the hyoid bone. � Hyoid “Push-back technique”. � Vary height and pressure, i.e., suprahyoid (BOT), hyoid, infrahyoid, T-H space, thyroid notch, and thyroid prominence. “Pull-Down” Maneuver (#2) Group Practice with these three Reposturing Techniques 4

6/11/2014 Indications of Improvement Voice Samples of Muscle Tension (Single Session) Dysphonia before and after Manual Circumlaryngeal � Voice quality (should improve) Techniques � Pain reduction/relief � Normalized laryngeal height & mobility � Pre- and Post-Treatment Speaking Samples (Roy & Ferguson, 2001). (Rainbow Passage) � Reduced muscle nodularity � May consider use of Myofascial Release with patients as well. 5

6/11/2014 Case Illustrations: MTD Case Illustrations: MTD � Case Number 1 � 37 year old female � Case Number 1 � Sudden onset of dysphonia following � Patient resurfaced in October URI 2013 with recurrence of MTD following stressful time and � Unable to work sinus infection with URI during this time � Presentation not as severe as � Treated with 3 voice prior in 2011 therapy sessions � Treated for 6 voice therapy between 5/25/11 to 6/10/11 sessions between 10/21/13 to � Patient d/c’d self 1/22/14 from work because she felt back to “herself” Case Illustrations: MTD Case Illustrations: MTD � Case Number 2 � 22 year old male � Case Number 3 � Extensive medical history � 32 year old female � Sudden onset of dysphonia with left unilateral vocal fold paralysis following a left acoustic neuroma surgery � Evaluated by another SLP with � Had CSF leak following surgery, Radiesse injection in the vocal fold, was NPO. videostroboscopy and sent to Voice Center Candidate for permanent thyroplasty for therapy � Dysphagia-received OP dysphagia therapy- resumed PO diet � Dx: Moderate MTD � Unable to work during this time � First two samples on initial therapy date � Treated with 2 voice therapy sessions between 5/21/12 to 6/4/12 � D/C’d self for return to work and school before and after Manual CLM � Treated with 6 voice therapy sessions between 5/14/12 to 10/10/12 Case Illustrations: MTD Case Illustrations: MTD � Case Number 4 � 70 year old female � Sudden onset of dysphonia following cardiac ablation � Traumatic intubation; patient with TMJ history � Treated with 5 voice therapy sessions between 10/13/10 to 11/15/10 6

6/11/2014 Pre-MCT Post-MCT Pre-MCT Post-MCT � � � M � � � � � � � M � � � Pre-MCT Post-MCT Manual Circumlaryngeal Techniques Using Manual Circumlaryngeal (including Larynx Reposturing probes) Techniques in Cases of Benign Mucosal Disease � Determine the contribution of laryngeal and extralarngeal muscle dysregulation to the • “ All voice patients should be tested for dysphonia and/or dysphagia symptoms. excess tension, regardless of the presumed � “unloading” the larynx provides a distilled etiology. The degree of voice improvement version of the dysphonia. should be proportional to the reduction of � Assures proper diagnosis and management. muscle tension.” (Aronson, 1990). 7