CDIS 700CDIS 700

Management and Therapy for Special ProblemsManagement and Therapy for Special Problems

Paradoxical Vocal Fold Paradoxical Vocal Fold Motion (PVFM)Motion (PVFM)

What is PVFM?What is PVFM?

The vocal folds adduct during inhalation and/or The vocal folds adduct during inhalation and/or exhalation, causing an upper airway obstruction.exhalation, causing an upper airway obstruction.

Known by a variety of names:Known by a variety of names: Vocal cord dysfunctionVocal cord dysfunction Paradoxical vocal cord motionParadoxical vocal cord motion Episodic laryngeal dyskinesiaEpisodic laryngeal dyskinesia Episodic paroxysmal laryngospasmEpisodic paroxysmal laryngospasm Factitious asthmaFactitious asthma Munchausen’s stridorMunchausen’s stridor Psychogenic stridorPsychogenic stridor Aductor laryngeal breathing dystoniaAductor laryngeal breathing dystonia

Signs and SymptomsSigns and Symptoms

Asthma-like breathing difficultiesAsthma-like breathing difficulties Asthma may co-occur in up to 50% of PVFM Asthma may co-occur in up to 50% of PVFM

cases.cases.

Sensation of tightness or choking in the Sensation of tightness or choking in the laryngeal arealaryngeal area

StridorStridor

At Risk PopulationsAt Risk Populations

The average person with PVFM is:The average person with PVFM is: A A womanwoman who is who is Between the ages of 20-40Between the ages of 20-40 and and HasHas at least 12 years of education at least 12 years of education andand Works in health careWorks in health care

Children and adolescents with the disorder Children and adolescents with the disorder are likely to be high achievers and athletes.are likely to be high achievers and athletes.

EtiologyEtiology

There are several possible etiologies, There are several possible etiologies, including:including: Upper airway sensitivity to laryngeal Upper airway sensitivity to laryngeal

irritants irritants Neurological causes at the level of the Neurological causes at the level of the

brainstem or the upper or lower motor brainstem or the upper or lower motor neuronsneurons

Psychological conditions Psychological conditions 

Differential DiagnosisDifferential Diagnosis

Should be based on multidisciplinary Should be based on multidisciplinary evaluations, including the patient’s clinical evaluations, including the patient’s clinical history, pulmonary function and lab test history, pulmonary function and lab test results, laryngoscopic findings, speech-results, laryngoscopic findings, speech-language pathology evaluation, and language pathology evaluation, and psychological evaluation.psychological evaluation.

Medical TreatmentMedical Treatment

Patient educationPatient education

Termination of unnecessary medicationsTermination of unnecessary medications

CPAP may be used to reduce the effort needed CPAP may be used to reduce the effort needed for inspiration. for inspiration.

Sedatives or anti-anxiety drugs can be temporarily Sedatives or anti-anxiety drugs can be temporarily used, but this is rare. used, but this is rare.

Laryngeal nerve sectioning and Botox injections Laryngeal nerve sectioning and Botox injections are sometimes used (little evidence base) are sometimes used (little evidence base)

As a last resort, a tracheotomy may be warranted. As a last resort, a tracheotomy may be warranted.

PsychotherapyPsychotherapy

Could be considered if medical factors Could be considered if medical factors have been ruled out and the PVFM is have been ruled out and the PVFM is diagnosed as a conversion disorder. diagnosed as a conversion disorder.

Speech therapy is more often Speech therapy is more often recommended as the first line of recommended as the first line of treatment.treatment.

Speech TherapySpeech Therapy

The SLP should be ready to refer to voice The SLP should be ready to refer to voice specialists, neurologists, or psychologists if specialists, neurologists, or psychologists if indicated by the assessment.indicated by the assessment.

Treatment consists of patient education, Treatment consists of patient education, supportive counseling, instruction in tension supportive counseling, instruction in tension identification and control, and instruction in identification and control, and instruction in relaxed throat breathing. relaxed throat breathing.

More research needs to be conducted related to More research needs to be conducted related to the effectiveness of therapeutic treatments for the effectiveness of therapeutic treatments for PVFM.PVFM.

PVFM ReferencesPVFM References

Koester, M.C., & Amundson, C.L. (2002). Seeing the Koester, M.C., & Amundson, C.L. (2002). Seeing the forest through the wheeze: A case-study approach to forest through the wheeze: A case-study approach to diagnosing paradoxical vocal fold dysfunction. diagnosing paradoxical vocal fold dysfunction. Journal of Journal of Athletic Training, 37, Athletic Training, 37, 320-324. 320-324. 

Sandage, M.J., & Zelazny, S.K. (2004). Paradoxical Sandage, M.J., & Zelazny, S.K. (2004). Paradoxical vocal fold motion in children and adolescents. vocal fold motion in children and adolescents. Language, Language, Speech, and Hearing Services in Schools, 35, Speech, and Hearing Services in Schools, 35, 353-362.353-362.

Mathers-Schmidt, B.A. (2001). Paradoxical vocal fold Mathers-Schmidt, B.A. (2001). Paradoxical vocal fold motion: a tutorial on a complex disorder and the speech-motion: a tutorial on a complex disorder and the speech-langauge pathologist’s role. langauge pathologist’s role. American Journal of American Journal of Speech-Language Pathology, 10, Speech-Language Pathology, 10, 111-125.111-125.

Transgender VoiceTransgender Voice

Transgender ClientsTransgender Clients

TransTransgendergender can be loosely defined as anything can be loosely defined as anything or anyone that falls outside of typical gender or anyone that falls outside of typical gender roles or norms.roles or norms.TranTransexualsexual most often refers to men and women most often refers to men and women who feel that their biological sex doesn’t match who feel that their biological sex doesn’t match their feelings of maleness or femaleness on the their feelings of maleness or femaleness on the inside.inside.Transitioning is the process of beginning to live Transitioning is the process of beginning to live life according to one’s internal feelings about life according to one’s internal feelings about gender. Watch a “time capsule” video about one gender. Watch a “time capsule” video about one person’s journey person’s journey here..

Transitioning, Hormone Therapy, Transitioning, Hormone Therapy, and Voice and Voice

Biological women who live as men often do not Biological women who live as men often do not receive voice therapy.receive voice therapy. The female larynx can generally go lower without The female larynx can generally go lower without

creating too much voice strain.creating too much voice strain. Hormones may also deepen the voice.Hormones may also deepen the voice.

Most transsexual/transgendered clients who Most transsexual/transgendered clients who seek out speech therapy will be biological men seek out speech therapy will be biological men who are living as women (male-to-female who are living as women (male-to-female transsexuals). transsexuals). Strain on the voice results when a “male” larynx is Strain on the voice results when a “male” larynx is

forced into too high of a pitch.forced into too high of a pitch.

What Makes for a Feminine Voice?What Makes for a Feminine Voice?

Vocabulary!Vocabulary!A breathier voice qualityA breathier voice qualityMore facial expressionsMore facial expressionsGreater articulatory precision Greater articulatory precision Higher pitchHigher pitchMore pitch inflections with greater Fo variabilityMore pitch inflections with greater Fo variabilityDecreased loudness/volumeDecreased loudness/volumeVowel prolongationVowel prolongationWatch a Watch a video clip of a MTF transgender person of a MTF transgender person describing how she obtains a more feminine describing how she obtains a more feminine voice.voice.

Therapy and Other OptionsTherapy and Other Options

Work on obtaining frontal focus. Do nasal/glide Work on obtaining frontal focus. Do nasal/glide work that emphasizes increased vowel duration work that emphasizes increased vowel duration at the word level.at the word level.

Counsel the client that a feminine “voice” is not Counsel the client that a feminine “voice” is not reliant on just pitch. Gestures, facial reliant on just pitch. Gestures, facial expressions, and word choice are very important expressions, and word choice are very important components.components.

Thyroplasty or other types of surgery may Thyroplasty or other types of surgery may permanently stretch the vocal folds, leading to a permanently stretch the vocal folds, leading to a higher pitch.higher pitch.

Transgender/Transsexual Voice Transgender/Transsexual Voice ResourcesResources

Adler, R.K., Hirsch, S., & Mordaunt, M. (2006). Adler, R.K., Hirsch, S., & Mordaunt, M. (2006). Voice and communication therapy for the Voice and communication therapy for the transgender/transsexual client.transgender/transsexual client. San Diego: San Diego: Plural.Plural.

““Voice and Communication Therapy for Voice and Communication Therapy for Transgender/Transsexual Clients” (Transgender/Transsexual Clients” (http://www.asha.org/public/speech/disorders/TGTS.htm))

See the March 3, 2009 ASHA Leader for more See the March 3, 2009 ASHA Leader for more resources.resources.