CHARLES VAN RIPER LANGUAGE, SPEECH AND HEARING CLINIC

Department of Speech Pathology and Audiology

Unified Clinics, Western Michigan University

Kalamazoo, Michigan 49008 269-387-7000

INITIAL VOICE CONSULTATION

DATE OF EVALUATION: September 13, 2005 FILE NO:

CLIENT: X X BIRTHDATE: AGE:

ADDRESS: , Kalamazoo, MI 49001

TELEPHONE: OCCUPATION: Receptionist

REFERRED BY:

EXAMINERS: SUPERVISOR: Dr. Stephen Tasko

Presenting Complaint

Chronic episodes of intermittent voice loss.

Background Information

X X first experienced voice problems three years ago after having an episode of bronchitis. Mrs. X saw Dr. XX otolaryngologist on XX. Evaluation performed ??? failed to reveal any laryngeal abnormalities and she was referred for a voice evaluation.

Currently, XX experiences voice problems 4-5 times a year, for 6-10 days at a time. The episodes occur suddenly and without warning. Vocal symptoms range from total voice loss to a rough voice. Her voice doesn’t improve with rest. She does not report pain associated with producing voice, but does experience tension in the throat during an episode. Some other symptoms she has during an episode are: non-productive throat clearing, excessive coughing, feeling of dry or scratchy throat, dry mouth, post-nasal drip, a tickling sensation in the throat and intermittent difficulties swallowing. She does not choke on food, but reports that she has occasional difficultly initiating a swallow. Like their onset, the resolution of voice symptoms is typically sudden. However, following her most recent episode, Ms. X reports a persistent roughness in her voice. Ms. X notes that although she does not observe a pattern to her voice problems, she does associate them with times of elevated stress.

Ms. X currently works in a physical therapist’s office as a receptionist. She is still able to work during her voice loss, but it is difficult because her job requires a lot of talking. She was previously employed as a restaurant manager, but changed jobs because the long hours prevented her from seeing her family. Ms. X describes herself as a very talkative person and finds it distressing when she is unable to do so.

When Ms. X was in High School, she had severe acid reflux, but has not had problems with it recently. Four years ago Ms. X had a transient ischemic attack, reportedly related to anxiety. The following year she suffered a stroke that affected the vision in her left eye. She reports occasional tinnitus. She has pain from TMJ and protruding discs in her lower back, and manages that pain with Ibuprofen. Ms. X reports that she has been diagnosed with an anxiety disorder, clinical depression and most recently bipolar disorder. She is currently taking a number of medications: Aspirin as a blood thinner, Lamictal for Bipolar Disorder, Xanax for Anxiety, Lexapro for Depression, and Calcium+D for general bone health. She is a nonsmoker and social drinker.

Ms. X and her husband have two sons, aged four and five. She and her family moved to the Kalamazoo area in May, 2001. She moved from XX, Michigan, where she was raised. During the psychosocial interview, she reported having a number of stressors, a significant portion of which stems from marital problems. Ms. X reports that she and her husband have attended marital counseling. She currently does not attend individual counseling.

Clinical Observations and Impressions

On the day of the evaluation, Mrs. XX presented with a mild to moderate voice quality disturbance that was evident across all tasks. Voice quality was characterized by mildly reduced loudness, breathiness that was more pronounced at the end of phrases and during voiceless contexts, roughness that appeared to be limited to sustained vowel contexts, minimal strain, and a pitch that was appropriate for her age and gender. Mrs. XX’s voice quality disturbance was more pronounced during singing. She exhibited difficulties with pitch control and increased levels of roughness and breathiness.

Samples of Ms. X’ voice were submitted to acoustic analysis and are summarized below. Ms. X’ speaking fundamental frequency was 175 Hz, which is near the lower end of the expected range for her age and gender. Analysis of phonatory variability during the production of a sustained “ah” revealed mildly elevated measures of cycle-to-cycle frequency (jitter) variability. Signal-to-noise ratio was also found to be just below the range for normal speakers. Phonational frequency range was found to be 31 semitones, which is just below the expected range of 36 semitones. Maximum phonation time was 13.5 seconds, which is shorted than that expected given her age and gender. Overall, the acoustic results are consistent with a mild deviation from normal vocal function.

Speaking Fundamental Frequency
Oral Reading / Normal / Spontaneous Speech / Normal
Mean F0 (Hz)
SD F0 (semitones)
Maximum Phonational Frequency Range / Sustained “ah”
Client / Normal / Client / Normal
Min (Hz) / Mean F0 (Hz) / NA
Max (Hz) / Jitter (%) / <1 %
Range (semitones) / Shimmer (%) / NA
Signal-Noise Ratio / >15

A manual assessment of laryngeal musculoskeletal tension was performed. There was evidence of elevated tension and pain/tenderness during palpation of the region of the hyoid bone, along the superior border of the thyroid lamina and in the thyrohyoid space. These findings are consistent with elevated laryngeal musculoskeletal tension.

An oral videolaryngendoscopic examination of vocal function was performed. The procedure was tolerated and the vocal folds were observed under halogen light conditions only. The vocal folds and surrounding structures were unremarkable. No asymmetries were noted during vocal fold adduction, abduction, or vocal fold lengthening and shortening. Phonation at low, habitual and elevated pitch levels was characterized by incomplete closure along the entire length of the glottis. There was not evidence of supraglottic compression. Representative images of vocal fold adduction during phonation and abduction during inspiration are attached.

Screening of the oral mechanism suggested normal structure of the tongue, lips, jaw, hard palate, and velum. Ms. X exhibited a normal range of motion in her tongue, lips and jaw. Tongue, lip and jaw strength were adequate. The soft palate elevated symmetrically during phonation. Her diadochokinetic rates appeared within normal limits.

During hearing screening, Ms. X identified 25 dBHL tones at 1000 Hz, 2000 Hz, and 4000 Hz in each ear.

Summary and Recommendations

X X presents with history of intermittent dysphonia characterized by a sudden onset and offset of the symptoms, signs and symptoms of elevated laryngeal musculoskeletal tension, and an absence of laryngeal abnormalities during videolaryngoendoscopy. Although, Ms. X was largely asymptomatic on the day of the evaluation, these findings, combined with Ms. X’ report of a variety of sources of stress and anxiety, support a diagnosis of muscle tension dysphonia. As a result of this evaluation, the following is recommended:

1.  Ms. X should attend voice therapy with the general goal of reducing laryngeal musculokeletal tension. If she has another episode, she should be evaluated during the episode to confirm the diagnosis and provide symptomatic voice therapy.

2.  Ms. X should seek individual counseling to help her cope with her personal problems. Her stressors can negatively impact her progress in voice therapy.

3.  Given her history of tinnitus, a formal hearing evaluation should be considered.

Ms. X should be re-evaluated in approximately three months to evaluate progress. Prognosis for voice improvement is fair to good provided she seek professional counseling for stress.

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Student 1, B.A., Graduate Clinician Student 2, B.S., Graduate Clinician

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Stephen Tasko, Ph.D., CCC-SLP

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Date

Cc: Dr. MD