This case study is an adolescent singer. This performer is a 14-year-old female; the oldest of four siblings. She presented to the ENT clinic with persistent hoarseness, reported a loss of vocal range, vocal loudness, pitch breaks and long periods of complete voice loss. A typical week would involve rehearsing with three different choirs and participating in her church choir weekly as a soloist. During case history interview she reported her voice would be “normal and serviceable” until Wednesday or Thursday in the week, then her voice would begin to get “hoarse and breathy.”
Course of Referral
This patient routinely lost her voice due to social and extracurricular school activities. Her parents, along with her school choir director, recommended a medical examination of the larynx due to chronic laryngitis. She was first seen by her primary care physician and then referred to an ENT. Following the completion of a vocal fold examination, via laryngeal mirror, the patient was referred to a team of speech-language pathologists for videolaryngostroboscopy and vocal function studies.
She was in overall good health. She was not taking any prescribed medications, and had no history of substance abuse. She had a history of chronic sinus infections but no known allergies.
She sang with her church choir and school choral group for six years. She was involved with a vocal coach intermittently from age XXX and reported having an average
amount of vocal training. As the oldest sister, she routinely baby sat her three younger siblings and was responsible for after school care and activities in her family. It is relevant to comment on her family unit as a whole due to the loud environment and active family gatherings. In fact, both her mother and father have reported periods of complete loss of voice and “hoarse/breathy” symptoms.
Evaluation: The results of the mirror exam revealed a lesion (sessile polyp) along the anterior one third of the right true vocal fold and possible nodular formation on the opposite vocal fold.
Initial Office Visit
Upon arrival to our office for a voice evaluation, her vocal quality was moderately breathy with frequent voice breaks (approximately two per five word phrase) and hard glottal attacks on back consonants (/i/, /g/, /k/, / /).
Results of the Videolaryngostroboscopic Examination:
- Vocal fold edge: A large polyp existed on the middle one half of the right true vocal fold with light tissue change (possible nodular formation) on the opposite vocal fold.
- Glottic closure: Glottic closure was observed to be hourglass unless hyperfunctional compensatory mechanisms were employed.
- Phases closure: Open phase predominated
- Vertical level: Equal
- Amplitude: Vibratory amplitude was severely limited and decreased in the right true vocal fold and judged to be slightly limited in the left true vocal fold.
- Mucusal wave: The mucosal wave was severely limited in the right true vocal fold and judged to be slightly decreased in the left.
- Vibratory behavior: The vibratory behavior of the right vocal fold was judged to be nearly absent and partially absent in the left.
- Phase symmetry: Judged to be always irregular
- Hyperfunction: Hyperfunction was present occasionally with the arytenoid complex moving anteriorly.
A behavioral voice therapy program was initiated immediately following the examination. This program focused first on modifying maladaptive vocal behaviors and factors in her social life which appeared to relate to the etiology of the vocal pathology. For a young adolescent, these factors were centered on her daily encounters at school. For example, talking with friends during classroom changes and talking in the lunch room in an extremely loud environment. We discussed how to deal with her peers pressuring her and the concept of vocal rest. We discussed the importance of staying off the telephone unless it’s extremely urgent, how to continue being active socially without injuring her voice and how to inform and build an understanding with her classroom teachers about her voice use so that she was not penalized for not participating orally in class discussion and projects.
We considered these are all extremely important factors to address in an initial counseling session. We felt that if these factors were not addressed the success of any further treatment may be compromised.
Treatment of the entire family unit was also essential for carryover of good vocal habits for this adolescent patient. Her parents routinely participated in our treatment sessions as well as occasional visits with her younger siblings. The home environment was addressed in terms of its contribution to vocal use and abuse. Strategies for gathering her families attention involved utilizing instruments to gain attention (i.e. a whistle, or clapping hands) as well as a voice monitoring system that allowed the younger siblings to signal their sister when she was talking too loud or too long. The general strategies at the onset of the behavioral program included identifying and eliminating any other forms of vocal abuse, initiating a modified voice rest program (no more than 10-15 minutes of talking per day for approximately one week), use of a therapeutic voice, tone focus, breath support/management and laryngeal relaxation strategies as previously described in the Case 1.
Results of Therapy
Surgical Procedure and Result
The patient was brought to the operating room and put under general anesthesia brought about by oral endotracheal intubation. The surgical procedure was successful with no interoperative or post-operative reactions.
Perceptual Impressions Following Surgery
Following the four days of complete voice rest followed- up with three weeks of a modified voice rest (no more than fifteen minutes of talking per day) using a relaxed vocal production, good vocal hygiene and no vocal abuse, she presented back to our office for a post-operative follow-up examination. Her voice was still slightly breathy however, this is due in part to the low impact voice she was using and the surgical healing process. There was no evidence of hard glottal attacks or strained-pressed voicing observed.
Videolaryngostroboscopic Results Following Surgery:
- Vocal fold edge: smooth bilaterally; free of laryngeal lesion
- Glottic closure: Complete
- Phase closure: normal
- Vertical level: Equal
- Amplitude: normal
- Mucusal wave: normal
- Vibratory behavior: fully present
- Phase symmetry: Regular
- Hyperfunction: Not present
Behavioral Voice Therapy Following Surgery
The goal of the voice therapy program post-surgery was geared towards addressing the same issues of healthy voice use versus vocal abuse in the home, at school, in social settings and choir rehearsals or performances.
Additionally, speaking voice therapy was strongly emphasized since her singing voice was very well trained given her age and vocal maturity. Again, just like we discussed before the surgery, these are the crucial areas that best characterize the majority of her vocal abuse. If this was to happen to one of your students you will need to re-emphasize the importance of maintaining optimum pitch, loudness and quality especially in the speaking voice. (see peggy’s section of speaking voice therapy).
A vocal “endurance/stamina” program was implemented, similar to what was described in case one. If you are going to lead your student down this path, you must ensure that your student understands the balance between the respiratory system, and the interaction of phonation and resonance. Be careful not to assume that she is aware especially with this adolescent age group. Too often performers young performers like her do not have any interest or are not secure enough to develop their own style; rather she may mimic a sound off the radio.
She was able to make a full return to all of her daily and extracurricular activities. She has gained a tremendous amount of education regarding vocal health that will benefit her career for years to come. Her insight into her own vocal production and the ability to self-monitor her own vocal production is outstanding.