Consensus Statement on the Use of Voice Therapy in the Treatment of Dysphonia

Consensus Statement on the Use of Voice Therapy in the Treatment of Dysphonia

This statement regarding the use of voice therapy in the treatment of dysphonia has been developed by the American Academy of Otolaryngology- Head and Neck Surgery Committee on  Speech, Voice,  and Swallowing and the Special Interest Division 3, Voice and Voice Disorders of the American Speech-Language-Hearing Association.

Summary

It is the consensus of these committees that voice therapy by a licensed speech language pathologist is important for effective medical and surgical treatment of the patient with dysphonia. Voice therapy should be an integral part of the treatment plan of the patient until optimal patient response is achieved.

Background 

Dysphonia is defined as an impairment of the speaking or singing voice. Dysphonia arises from an abnormality of the structures and or functions of the voice production system and can cause bodily pain, a personal communication disability, or an occupational or social handicap. The cause of dysphonia is generally multifactorial. Genetic and psychological factors may predispose an individual to voice disorders.1 Chronic and acute variables may precipitate dysphonia. These include occupational vocal demands, medications, health problems, environment, trauma, and lifestyle choices. Dysphonia is as disruptive to quality of life as angina, sciatica and chronic sinusitis.2 The communicative problems associated with dysphonia can lead to social withdrawal, occupational handicaps, and depression.3

Voice disorders are a widespread and significant problem. Estimates of prevalence range from 3% to 7%of the general population. 4 Individuals with heavy occupational voice use, a significant risk factor for dysphonia, may comprise from 5-10% of the U.S. workforce.5 The largest epidemiologic study of the prevalence of voice disorders in the United States revealed that approximately 43% of adults surveyed experienced voice problems at some point during their life.6  Approximately 23% of those individuals visited a physician or speech-language pathologist for treatment for dysphonia. The cost of untreated voice disorders total billions of dollars in treatment and lost productivity costs.6  In teachers alone, the cost of dysphonia approaches $2.67 billion annually in the United States. 7

The overall goal for the dysphonic patient is optimal long-term voice quality and communication function with minimal recurrence. Treatment should be both efficient and effective. Voice therapy is an integral component of intervention and contributes to both its efficacy and efficiency. Evidence from clinical trials documents the efficacy of voice therapy for a spectrum of voice disorders. 8-14 Even in patients with a long history of dysphonia, voice therapy can be highly effective.15 Efficiency includes cost-effective and prompt intervention provided over a time period most suitable for achieving optimal outcome.

Voice therapy is the treatment of choice for muscle tension dysphonia and there is evidence to support its utility in these cases.16-22 In complex disorders such as paradoxical vocal fold motion, voice therapy prevents long-term costs of treatment by helping reduce expensive emergency room visits and hospitalizations.23 Voice therapy techniques have been shown to improve voice in individuals without voice disorders, suggesting a role for therapy in the prevention of voice disorders.24-26

Benign vocal fold lesions are a common cause of dysphonia.27 Many studies document excellent outcome after voice therapy in patients with a variety of benign lesions.28-35 In cases in which surgery is necessary, pre- and post-operative voice therapy may shorten the postoperative recovery time, allowing faster return to work and limiting scar and permanent dysphonia.36

Many laryngologists consider voice therapy essential for patients with unilateral vocal fold paralysis, as definitive treatment or as adjunctive to surgery.37-40  Evidence suggests that preoperative voice therapy improves voice outcomes for greater than 50% of patients with unilateral vocal fold paralysis and may render surgery unnecessary.41 In other neurological-based dysphonia such as Parkinson’s disease, voice therapy has yielded significant improvement in overall communication.42-45

In conclusion, research data and expert clinical experience support the use of voice therapy in the management of patients with acute and chronic voice disorders. Voice therapy contributes to increased effectiveness and efficiency in the treatment of voice disorders. When surgery is necessary, adjuvant voice therapy can improve surgical outcomes, prevent additional injury, and limit additional treatment costs.

Adopted: September 28, 2005

References

  1. Gray SD, Hammond E, & Hanson DF. Benign pathologic responses of the larynx. Ann Otol Rhinol Laryngol; 104; 13-18.
  2. Benninger MS, Ahuja AS, Gardner G, et al. Assessing outcomes for dysphonic patients. J Voice; 12: 540-50.
  3. Smith E, Verdolini K, Gray S, et al. Effect of voice disorders on quality of life. J Med Speech Lang Path 1997;4: 223-244.
  4. Healy WC, Ackerman BL, Chappell CR, et al. The Prevalence of Communicative Disorders: A Review of the Literature.  American Speech-Language-Hearing Association, Rockville, MD.
  5. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: A preliminary report. J Voice; 11(3): 254-259.
  6. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, & Smith EM. (2004) Prevalence of Voice Disorders in Teachers and the General Population. J Speech Lang  and Hearing Research, 47, 281-293.
  7. Ramig O, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hearing Disord 1998; 41: S101-16.
  8. Verdolini K, Ramig L. Logopedics Phoniatrics Vocology; 26: 37-46.
  9. Speyer R, Weineke G, Hosseini EG, Kempen PA, Kersing W, & Dejonckere PH (2002). Effects of voice therapy as objectively evaluated by digitized laryngeal stroboscopic imaging. Ann Otol Rhinol Laryngol; 111, 902-8.
  10. Sellars C, Carding PN, Deary IJ, MacKenzie K, & Wilson JA. (2002). Characterization of effective primary voicetherapy for dysphonia. J Laryngol Otol; 116, 1014-8.
  11. Roy N, Bless DM, Heisey D, et al. Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice; 11: 321-331.
  12. MacKenzie K, Millar A, Wilson JA et al.  Is voicetherapy an effective treatment for dysphonia? A randomised controlled trial. BMJ; 323: 658-61.
  13. Bassiouny S. Efficacy of the accent method of voicetherapy. Folia Phoniatrica et Logopedica; 50:146-64.
  14. Verdolini-Marston K, Burke MK, Lessac A  et al. Preliminary study of two methods of treatment for laryngeal nodules. J Voice; 9:74-85.
  15. Xu JH, Ikeda Y, Komiyama S. Bio-feedback and the yawning breath pattern in voicetherapy: a clinical trial. Auris, Nasus, Larynx; 18: 67-77.
  16. Speyer R, Wieneke GH, Dejonckere PH. Documentation of progress in voice therapy: perceptual, acoustic, and laryngostroboscopic findings pretherapy and posttherapy. J Voice;18: 325-40
  17. Mary Y, De Bodt MS, and Van Cauwenberge P. Ventricular dysphonia: clinical aspects and therapeutic options. Laryngoscope; 113: 859-66.
  18. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice; 13: 72-104.
  19. Fex B, Fex S, Shiromoto O, et al. Acoustic analysis of functional dysphonia: before and after voicetherapy (accent method). J Voice; 8:  163-7.
  20. Roy N, Gray SD, Simon M, et al. 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: 296-296.
  21. Kitzing P, Akerlund L. Long-time average spectrograms of dysphonic voices before and after therapy. Folia Phoniatrica; 45:53-61.
  22. Andrews S, Warner J, Stewart R. EMG biofeedback and relaxation in the treatment of hyperfunctional dysphonia. Br J Disord Commun; 21:353-69.
  23. Martin RJ, Blager FB, Gay ML, Wood RP Paradoxic vocal cord motion in presumed asthmatics. Sem Respir Med. 1987; 8:332-337
  24. Stemple JC, Lee L, D’Amico B, et al.  Efficacy of vocal function exercises as a method of improving voice production. J Voice; 8: 270-8.
  25. Kotby MN, Shiromoto O, Hirano M. The accent method of voice therapy: effect of accentuations on F0, SPL, and airflow. J Voice; 7: 319-25.
  26. Boone DR, McFarlane SC. A critical view of the yawn-sigh as a voice therapy technique. J Voice; 7: 75-80.
  27. Gould WJ, Rubin JS, & Yanagisawa E. (1995). Benign vocal fold pathology through the eyes of the laryngologist. In: JS Rubin, R Sataloff G Korovin, WJ Gould, eds. Diagnosis and Treatment of Voice Disorders. New York: Igaku-Shojin; 137-151.
  28. Holmberg EB, Hillman RE, Hammarberg B, et al. Efficacy of a behaviorally based voice therapy protocol for vocal nodules. J Voice; 15: 395-412.
  29. McCrory E. (2001). Voice therapy outcomes in vocal fold nodules: a retrospective audit. Intl J Language & Communication Dis; 36, Suppl:19-24.
  30. Ylitalo R, Hammarberg B. (2000). Voice characteristics, effects of voice therapy, and long-term follow-up of contact granuloma patients. J Voice, 14, 557-66.
  31. Gordon MT, Pearson L, Paton F, & Montgomery R. (1997). Predictive assessment of vocal efficacy (PAVE): a method for voice therapy outcome measurement. J Laryngol Otol; 3, 129-33.
  32. Leddy M, Samlan R, and Poburka B. (1997). Effective treatments for hyperfunctional voice disorders. In: A. Shoemaker, Advance for Speech-Language Pathologists and Audiologists, 7, 18.
  33. Murry T, and Woodson GE. (1992). A comparison of three methods for the management of vocal fold nodules. J Voice, 6, 271-276.
  34. Lancer M, Syder D, Jones AS, et al.. The outcome of different management patterns for vocal cord nodules. J Laryngol and Otol; 102: 423-432.
  35. Smith S and Thyme K. (1976). Statistic research on changes in speech due to pedagologic treatment (the accent method). Folia Phoniatricia, 28, 98-103.
  36. Woo P, Casper J, Colton R, et al. Diagnosis and treatment of persistent dysphonia after laryngeal surgery: a retrospective analysis of 62 patients. Laryngoscope; 104:1084-1091.
  37. Benninger MS, Crumley RL, Ford CN, Gould WJ, Hanson DG, Ossoff RH, Sataloff RT. Evaluation and treatment of the unilateral paralyzed vocal fold. Otolaryngol Head Neck Surg. 1994 Oct; 111(4):497-508.
  38. Anderson T, Sataloff RT. The power of voice therapy. Ear Nose Throat J;. 81:433-4. 39. Pedersen, M., Beranova, A., Moller, S. (2004).
  39. Dysphonia: medical treatment and a medical voice hygiene advice approach. A prospective randomised pilot study. European Arch Oto-Rhino-Laryngology, 261, 312-5
  40. Sulica L, Behrman A. Management of benign vocal fold lesions: a survey of current opinion and practice. Ann Otol, Rhinol Laryngol; 1112: 827-33.
  41. Heuer RJ, Sataloff RT, Emerich K, et al. Unilateral recurrent laryngeal nerve paralysis: the importance of "preoperative" voice therapy. J Voice; 11: 88-94.
  42. Spielman JL, Borod JC, Ramig LO. The effects of intensive voice treatment on facial expressiveness in Parkinson disease: preliminary data. Cognitive & Behavioral Neurology; 16: 177-88.
  43. Ramig O, Countryman S, O’Brien C, Hoehn M, & Thompson I. (1996) Intensive speech treatment for patients with Parkinson disease: short- and long-term comparison of two techniques. Neurology, 47, 1496- 1504.
  44. Smith ME, Ramig LO, Dromey C, Perez KS, & Samandari R. (1995). Intensive voice treatment in Parkinson disease: laryngostroboscopic findings. J Voice, 9, 453-9.
  45. de Angelis EC, Mourao LF, Ferraz HB, Behlau MS, Pontes PA, & Andrade LA. (1997). Effect of voice rehabilitation on oral communication of Parkinson's disease patients. Acta Neurologica Scandinavica, 96, 199-205.
Important Disclaimer Notice

Position Statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery, Inc. or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing policy statement library. In no sense do they represent a standard of care. The applicability of position statements as guidance for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical policy statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.