Phoniatry is the science that examines the diagnosis and treatment of voice and speech disorders. Although studies on phoniatry, also known as communication disorders, are not very recent in our country, the interest of ENT specialists in this subject has been very limited until recently. Many classifications have been made for voice disorders that fall under the subject of phoniatrics, but different terminology problems arise here as well. In order to eliminate terminology problems, it would be appropriate to examine voice disorders in a classification order. Dysphonias will also be examined according to this classification.
If we examine the human voice according to its basic characteristics, four features attract attention: quality, resonance, pitch and intensity. Wilson (11) examines voice disorders by dividing them into four main groups according to those who are primarily affected by these features:
(1) Sound quality disturbances
(2) Resonance disturbances
(3) Curtain disorders
(4) Violent disorders
In order to produce a normal voice, the phonation organs must be perfect both anatomically and functionally. Voice disorders involving the larynx are called dysphonia. Dysphonia is a disorder of sound quality. The first disorders that come to mind when talking about voice disorder or hoarseness are in this group. In this group, the sound is absent (aphonia) or voice breaks (phonation break, voice break) except that it is breathy (breathy), irregular (rough, harsh), hoarse (muffled, hoarse).
Resonance disorders can be examined in two groups as nasal resonance disorders (rhinophonies) and oral-pharyngeal resonance disorders.
There is no deterioration in sound quality or resonance in voice disorders that fall into pitch disorders. Disorders such as the average fundamental frequency of the person’s speaking voice is not suitable for his age or gender, pitch breaks and narrowing of the pitch range are examined in this group.
In Loudness disorders, there is a narrowing of the intensity range as well as the loudness of the sound being too high or too low.
In this section, sound quality disorders and dysphonias will be explained. Benign laryngeal lesions that cause dysphonia and the treatment approach are explained in detail in the “Benign Larynx Lesions” section of this book. In this section, the approach to functional dysphonias will be given in more detail. In addition, vocal cord paralysis, which is included in the neurologic dysphonia group, and treatment principles will be mentioned.
Audio Quality Disorders:
Sound quality is the general auditory impression that the voice of a person speaking makes on another listener, and is an acoustically multidimensional property. Perceptual features related to voice quality are irregularity (harshness, roughness), breathlessness (breathiness) and hoarseness (hoarseness). Hoarseness is actually a combination of disorganization and pallor. Isshiki (3) also states that insufficient treble harmonics are also effective in perceiving the sound as low. The acoustic equivalent of disorder is perturbation parameters such as jitter, shimmer and derivatives. The acoustic equivalent of breathability is the sound turbulence index.
Voice quality problems can be examined in three main groups according to their etiology as organic disorders, functional disorders and secondary pathological lesions:
I.Organic Disorders: If the cause of the voice disorder can be detected by examination or laboratory tests, it is an organic voice disorder. These disorders can be examined under the following headings:
A. Congenital malformations:
1. Sulcus vocalis (Sulcus glottidis)
2. Congenital laryngeal web
3. Down syndrome (Mongolism)
B. Laryngeal traumas:
1. Mechanical traumas: Lesions that occur in the larynx due to blunt traumas such as traffic accidents or penetrating-cutting tools take place in a wide spectrum ranging from mild edema to laryngotracheal separation. Here, Kittel’s classification of mechanical laryngeal traumas has been modified by adding a laryngotracheal separation agent:
a) Concussion: There is no visible pathology other than mild edema in the larynx.
b) Contusion: There are visible traumatic lesions in the laryngeal soft tissue. Lesions can be open or closed.
c) Distortion: There is trauma to the cricothyroid or cricoarytenoid joint capsule or ligaments.
d) Subluxation/luxation: Subluxation or luxation may occur in the cricoarytenoid joint due to trauma.
e) Fracture: Fractures can be seen in the cartilages forming the larynx skeleton due to traumas.
f) Laryngotracheal separation
2. Iatrogenic traumas: Voice disorders in this group emerge as a complication due to surgical interventions. Causes of iatrogenic trauma:
a) Excision of lesions such as nodules, polyps, papillomas
b) Decortication (Strippingii)
c) Glottoplasty
d) Laryngeal roof surgery
e) After high tracheotomy
f) Intubation trauma
g) After thyroid surgery
3. Burns:
a) Thermal burns
b) Chemical burns
c) Radiation burns
C. Voice disorders resulting from surgical interventions: In such interventions performed for the excision of malignant lesions or for respiratory relief, voice disorder is not a complication but a natural consequence of the intervention. Initiatives in this group:
1. Cordectomy
2. Arytenoidectomy
3. Partial laryngectomies
4. Total laryngectomy (Alaryngeal aphonia)
5. Tracheotomy
D. Inflammations of the larynx:
1. Acute laryngitis
a) Acute simple laryngitis
b) Influenza acute laryngitis
c) laryngotracheobronchitis (Croup)
d) Acute laryngitis seen in rash diseases
e) Subglottic and stridulous laryngitis
2. Chronic nonspecific laryngitis: Generally, smoking, alcohol and other irritation factors play an important role in the etiology of the problems in this group. It has three different forms according to the changes in the mucosa:
a) Chronic simple laryngitis
b) Chronic hypertrophic laryngitis
c) Chronic atrophic laryngitis (Laryngitis sicca)
3. Chronic specific laryngitis:
a) Tuberculous laryngitis
b) Syphilitic laryngitis
c) Laryngeal scleroma
d) Leprosy
e) Laryngeal sarcoidosis
f) Laryngeal mycosis
4. Reflux laryngitis (Gastroesophageal reflux, laryngopharyngeal reflux, phonasthenia [Kotby(5)]): It is the reflux of stomach contents through the esophagus to the pharynx and larynx and related non-infectious laryngitis. Kotby6, intermittent hoarseness, excessive mucus and sore throat, sore throat He calls the problem in which complaints such as frequent throat clearing are seen together as phonasthenia.The fact that this problem resembles laryngopharyngeal reflux in terms of symptoms suggests that it is the same entity.
5. Cricoarytenoid arthritis
E. Laryngeal allergy:
1. Allergic laryngitis
2. Angioneurotic edema
F. Xerolarynx: It is the drying of the laryngeal mucosa due to the effect of some drugs or sympathetic hyperactivation.
G. Larynx neoplasms:
1. Benign neoplasms:
a) Papilloma
b) Adenoma
c) Hemangioma
d) Lipoma
e) Granular cell myoblastoma
f) Chondroma
g) Fibroma
2. Malignant neoplasms:
a) Carcinoma in situ
b) Squamous cell carcinoma
c) Verrucous carcinoma
d) Carcinosarcoma
e) Adenoid cystic carcinoma
f) Chondrosarcoma
g) Fibrosarcoma
3. Dysplasias:
a) Leukoplakia: Clinically, it is a white lesion on the vocal folds and when examined pathologically, it is seen to be composed of hyperkeratotic cells.
b) Erythroplasia: It is in the form of an irregular red spot.
c) Pachyderma (Pachyderma laryngis): It is a hyperplastic process involving posterior commissure and posterior 1/3 of vocal folds.
d) Keratosis: It is an irregularity of red color on one or both vocal folds, slightly higher than the surrounding mucosa.
H. Laryngeal pseudotumors:
1. Cysts:
a) Congenital cysts
b) Epidermoid cyst
c) Retention cysts other than intrachordal cysts
2. Varicose lesions
3. Laryngoceles:
a) External laryngocele
b) Internal laryngocele
4. Granulomas:
a) Intubation granuloma
b) Wegener’s granulomatosis
c) Foreign body (Teflon) granuloma
d) Reflux granuloma
5. Sarcoidosis
6. Amyloidosis
I. Neurological disorders: Aronson (1) classifies neurological voice disorders as follows:
1. Lower motor neuron, neuromuscular junction and muscle disorders: In neurological disorders that fall into this group, the voice is pale and the intensity is reduced. Subgroups:
a) Vagal nerve lesions:
I. Lesions above the level of the pharyngeal branch: Cause adductor paralysis and palatopharyngeal paralysis.
ii. Lesions below the level of the pharyngeal branch: All intrinsic laryngeal muscles are affected. There is no problem with the palatopharyngeal muscles.
iii. Lesions affecting only the superior laryngeal branch: The voice is slightly pale and hoarse due to cricothyroid muscle paralysis. Also, the ability to change pitch has decreased.
iv. Lesions involving only the recurrence branch: Abductor paralysis is seen. Respiratory distress is prominent in bilateral cases. In unilateral cases, the voice is breathy.
b) Myasthenia gravis
c) Botulinum toxin injection for therapeutic purposes
2. Upper motor neuron disorders: Spastic paralysis of the larynx is seen in upper motor neuron disorders such as pseudobulbar paralysis.
3. Cerebellar system disorders:
a) Cerebellar ataxia
b) Arnold Chiari malformation
4. Extrapyramidal system disorders:
a) Parkinson’s
b) Korea
c) Myoclonus
d) Gilles de la Tourette’s syndrome
e) Athetosis
f) Dystonia
g) essential tremor
5. Multiple motor system disorders:
a) Amyotrophic lateral sclerosis
b) Multiple sclerosis
c) Wilson’s disease
J. Endocrinopathies:
1. Thyroid dysfunctions: In myxedema, hoarseness is seen due to the accumulation of myxedema material in the vocal folds.
2. Pituitary dysfunctions: In acromegaly, the vocal folds are lengthened due to overgrowth of the larynx, and the curtain thickens. Hoarseness is also common.
3. Premenstrual voice changes: Edema in the vocal folds due to the effect of estrogen hormones can cause hoarseness.
K. Senile changes in the larynx (Presbylarynx, presbyphonia): Deterioration in voice quality is observed due to atrophy in the vocal folds.
II. Functional (Nonorganic) Disorders: These are voice disorders that occur as a result of malfunctioning of the larynx. In some of the disorders in this group, organic lesions such as nodules and polyps occur in advanced stages.
A. Dysphonias due to laryngeal dystonia (Phonoponosis, voice abuse-functional voice disorder-type 4 [Koufman (1982)] (6), voice abuse syndromes-functional voice disorder-type 4 [Koufman (1991)](7): The syndromes that Koufman named tension-fatigue syndrome in non-professionals and Bogart-Bacall syndrome in professionals fall into this group.
1. Juvenile hyperfunctional dysphonia (Hyperfunctional childhood dysphonia [Kotby5]): It is the most important cause of childhood dysphonia.
2. Hyperfunctional dysphonia (Hyperkinetic dysphonia): Due to the hypertonia in the intrinsic and extrinsic laryngeal muscles, there is usually an irregularity in the voice. It has three different shapes:
a) Laryngeal isometric contraction (Muscle tension dysphonia-type 1 [Morrison1110(1983)], muscle tension dysphonia-type 1* [Koufman9(1991)], muscle misuse dysphonia-type 1 [Morrison(9)])
b) Lateral contraction (ventricular band phonation, functional dysphonia-ventricular band [Morrison(9)], muscle tension dysphonia–type 2* [Koufman (6)]muscle misuse dysphonia-type 2 [Morrison(9)])
c) Anteroposterior contraction (AP impingement, muscle tension dysphonia-type 3* [Koufman(7)], muscle misuse dysphonia-type 3 [Morrison(9)])
3. Hypofunctional dysphonia (Hypokinetic dysphonia, phonasthenia, voice weakness, vocal asthenicity): There is hypotonia in the larynx and resonator organs. In the vocal folds, a spindle-shaped gothic opening (excavation, bowing) is often seen during phonation, and therefore the voice is breathy. In addition to the deterioration in voice quality, thickening of the pitch, decrease in the volume of the voice, narrowing of the pitch and pitch range, and hyperrhinophonia are observed.
4. Mixed type functional dysphonia (Voice fatigue, vocal fatigue): Here, the hypertonia in the laryngeal muscles is partially replaced by hypotonia after a while. Depending on the continuation of the sound effort for a long time, the sound quality deteriorates in the following hours, and the sound improves with rest. In addition to the deterioration in sound quality, there is also a decrease in sound intensity and a narrowing of the pitch range.
B. Spastic dysphonia (Spasmodic dysphonia): It may be of psychogenic origin or it may be of neurological origin. It has two different forms:
1. Adductor spastic dysphonia
2. Abductor spastic dysphonia
C. Habitual aphonia/dysphonia (Functional voice disorder-type 2 and type 5 [Koufman(6)], functional voice disorder-type 2 and type 5 [Koufman(7)], muscle misuse dysphonia-type 5 [Morrison(9)] )]): It is the condition in which aphonia/dysphonia persists after viral laryngitis or a minor laryngeal operation, despite the disappearance of the cause of the voice disorder.
D. Conversion aphonia/dysphonia (Conversion mute, hysterical aphonia/dysphonia, psychogenic aphonia/dysphonia, phononeurosis, functional voice disorder-type 1 [Koufman(6)], functional dysphonia-hypoadduction [Morrison(8)], functional voice disorder- type 1 [Koufman(6)], muscle misuse dysphonia-type 4 [Morrison(9)]): In this situation, which is generally seen in women, it is observed that the vocal folds come to the midline during vegetative sounds such as coughing, while the vocal folds do not come to the midline during phonation. Spontaneous resolution of aphonia/dysphonia may be observed from time to time.
III. Secondary pathological lesions (Muscle tension dysphonia-type 2 [Morrison(8)], minimally associated pathological lesions [Kotby(5)]):
A. Intrachordal hemorrhage: It occurs due to acute vocal trauma.
B. Vocal fold polyp: They are mass lesions that occur on the free edge of the vocal folds due to vocal trauma.
C. Vocal fold nodules (Muscle tension dysphonia-type 2a [Morrison(8)]): This lesion, which is seen at the free edge of the vocal folds and at the junction of the anterior 1/3 and middle 1/3 parts, has two stages:
1. Immature nodule (Prenodular swelling): It is a hyperemic lesion with edema around it.
2. Mature nodule: It has a more definite border and is gray-white in color.
D. Reinke’s edema:
1. Early stage: Vocal folds are swollen and translucent due to edema fluid collected at Reinke’s distance.
2. Late stage (Polypoid degeneration, chronic polypoid corditis, chronic edematous hypertrophy, polypoid vocal fold, muscle tension dysphonia-type 2c [Morrison(8)]):
E. Contact ulcer/granuloma: It is usually seen on the vocal process of the arytenoid cartilage in middle-aged and older men with low pitched speech.
F. Intrachordal cysts: These are retention cysts seen on the free edge or upper surface of the vocal folds. If care is not taken, it can be confused with a nodule due to the lesion it creates in the contralateral vocal fold.
G. Traumatic corditis (Functional chronic laryngitis, muscle tension dysphonia-type 2b [Morrison(8)]): It is hyperemia and thickening of the mucosa in the vocal folds due to bad use of the voice.
APPROACH TO DYSPHONIA AND PHONIATRIC EDUCATION
In order for reeducation to be successful, the diagnosis must be well established and the patient must be well evaluated. In order to clinically evaluate laryngeal and phonatory function, talk to the patient should be started as soon as he enters the outpatient clinic. A full assessment consists of determining how the speaker typically uses his or her voice and the patient’s vocal capacity. Thus, these values will be compared with the physical examination findings to be made later, and it will be possible to find the most accurate diagnosis(10).
The subjective assessment of voice production, especially hoarseness, is difficult to describe in measurable terms. However, in voice training, it should be distinguished from objectively measuring the degree of dysphonia by listening to different sound qualities and making subjective evaluations.
During this sound evaluation, attention is paid to the patient’s breathing while speaking, singing and shouting. It is necessary to pay attention to contractions in the cervical area, excessive laryngeal movements, swelling of the superficial cervical veins during phonation and excessive muscle activity. Throat clearing is a common sign of local irritation in functional dysphonia.
The diagnosis of the vast majority of patients can be easily made by indirect laryngoscopy and their identification can be made with a good ear. However, the definitive diagnosis is made by laryngovideostroboscopy. It is of great importance to record the voice and evaluate the degree of pathology. Sounds can be recorded and listened to by using a simple sound blaster card and the “wave studio” program, one of the routine programs of this card, in treatment units equipped with a computer for recording sound. If computer facilities are not available, the sounds can be recorded on a tape recorder.
In addition, the quality of the patient’s voice can be evaluated with perceptual scales. It is important to evaluate the sound subjectively. However, many different scales have been proposed for the perceptual evaluation of sound. In our department, the GRBAS scale of GREL, of which we are a member, is used. This scale, which is very easy to apply, evaluates the degree of dysphonia, frequency consistency, airiness, and hyperkinetic or hypokinetic features by giving 0-3 points. Here, 0 represents the good sound and 3 the worst sound (10).
In addition, the patient’s anamnesis and examination information should be carefully recorded. Although reeducation techniques can vary greatly depending on the patient, even in the same pathologies, some techniques can be beneficial for all patients. However, the most important point to be considered here is to determine the etiology of the pathology that creates the dysphonia. However, the etiology cannot be determined as healthy in every patient. Close monitoring of patients whose etiology cannot be determined is of great benefit. After a thorough examination of the larynx in patients with dysphonia, revealing the occupational characteristics and providing a good explanation for the psychology of the person, inflammatory and allergic pathologies should be corrected first.
The effectiveness of phoniatric reeducation depends on the organic attitude of the laryngeal mechanism and the motivation of the patient to the treatment.
In phoniatric reeducation effective for these disorders:
1- Determining the behaviors that lead to abuse and misuse of the voice and the environment in which they are used.
2- Systemic reduction of the formation of bad voice habits
3- Using various phoniatric reeducation techniques to enable the patient to create a voice in the easiest way possible.
One of the most important factors in voice training is informing the patient. The patient is told about how long the training will take and the success rate after the training, in a language that he can tell the patient how often he will come to the treatments. Here, it will be of great benefit to explain the pathology to the patient through an anatomical diagram or to show the pathology in the video if possible. It is important to review the formation of the voice before moving on to the basic techniques of voice training. The main source of sound is air. Therefore, for a good voice, a correct and effective breathing technique should be used. In addition, the sound formed by vibration in the vocal cords should be formed in a healthy way with resonators. Therefore, all of the patients who apply to phoniatrics benefit from the exercises such as turning, stretching and chewing, which relax the neck muscles while starting the exercise, and a better phonation can be achieved with the diaphragm breathing technique.
As one of the most essential components of good voice formation is appropriate respiratory support, patients should be provided with respiratory support. Generally, when shallow breathing is used in respiration, it is tried to continue speaking by using residual air and this may be insufficient. The most effective method of respiratory support for sound formation is diaphragmatic breathing. This method is applied by diaphragm contraction, which causes the lower rib cage and abdomen to swell. Thus, it provides maximum air intake for sound formation.
In order to increase the lung capacity, the patient is told to stand upright and place one hand on the chest and the other on the abdomen. The patient is asked to breathe quickly and deeply. It is reported that the hand on the chest should move very little, while the hand on the abdomen should move outward together with the abdominal muscles. The patient is then instructed to relax the abdominal muscles and exhale slowly. By repeating these procedures, it is ensured that the patient’s abdomen moves outward in inspiration and inward in expiration.
Then, according to the pathology, exercises that reduce or increase the tension of the larynx muscles are performed. The patient should be taught a slow relaxed stretch by prolonging the inspiratory and expiratory phases. We recommend this technique to be applied by mostly patients lying on their back. It is easier to practice this technique lying down. In addition, the patient can be protected from dizziness due to alkalosis, which will occur due to taking plenty of oxygen for a long time.
Stretching exercises and speaking techniques such as singing are also useful in reeducation (2).
In another exercise, the patient is seated in front of the mirror and told to pretend to chew something. He is told to do this with his mouth open loosely and to turn the imaginary food inside the mouth with exaggerated tongue movements. It should not be rushed. Because this process forms the basis of the technique. While the patient is doing this exercise, he is told to start speaking slowly. It is important to create different sounds rather than a single voice. If the patient makes the same vowel, it means that the patient does not move his tongue in the mouth, but keeps it placed on the floor. The patient should be encouraged. This chewing technique was developed by Froeschel. The chewing technique not only reduces glottal attack, but also leads to an improvement in voice quality.
Absolute voice rest is not recommended for patients with hyperkinetic dysphonia.
Instead, patients:
n Limited audio use for 7-10 days
n Use of soft glottal attack while speaking
n Use of low noise is recommended.
In addition, the patient is advised not only to limit the frequency of speech, but also to limit the duration of speech. Each talk time is limited to 10-15 minutes.
In noisy environments (eg, in a crowd, on the street or in a restaurant), the patient should be warned not to speak, because the speaker automatically raises his voice in the surrounding noise. Whispering is thought to be a suitable method for making sounds, as it is often believed by patients to be the easiest and softest sound. However, the whispering sound is often harmful as it increases the contraction on the vocal cord. We do not recommend the whisper sound to our patients.
When the patient begins to form short sentences, he should be told to form longer sentences that begin with vowels and consonants. The patient should continue these chewing exercises until he regains normal speech.
Another strain relief technique is phonation with a sigh. Here, sighing movements are made while lowering and raising the pitch. During sigh attacks, the phonation of words starting with the “H” phoneme is studied.
In exercises aimed at providing soft adduction of cord vocals, the “M” sound is produced without opening the mouth.
One of the most common symptoms seen in patients with voice disorders is glottal attack. This is due to the advanced convergence of the vocal cords and their sudden opening due to the increase in subglottic pressure during the pronunciation of vowels. In addition, contractions in the neck muscles and larynx cause glottal attack.
It is best to tape all therapy sessions and listen to them as needed. Listening to the patient’s own voice can also be used in therapy due to the feedback effect. There are computer programs made for this.
The most effective sound that a person creates with the least laryngeal muscle tension and the most comfortable general physical exertion is the optimal tone and is usually a narrow range of one or two musical notes. Here, the importance of sound analysis emerges. The person’s speech fondamental frequency and optimal vocal range can be determined objectively by computerized techniques, providing us with great benefit in treatment.
Screaming, shouting, loud cheering are bad vocal habits caused by hyperadduction and violent vibration of the vocal folds. Such behaviors cause irritations starting from the increase in vascularity in the larynx and extending to the development of hematoma.
Parents often yell at their children in the neighbor’s house. Using a whistle as a signal to invite children home would be the ideal way to use this kind of bad noise. Another less obvious example of poor voice use is with speaking in an environment with excessive background noise. This is usually the patient’s work environment. It is important for the patient to describe how much yelling there is because of his job or social environment.
Some patients may develop vocal abuse behaviors because of excessive shouting for professional reasons…Sound artists…actors, teachers, lawyers, and other professionals who use their voices are at risk of voice abuse in this way. Many of these patients have good vocal hygiene when they use their voices outside of work. Measures to prevent professional audio users from excessive yelling through landscaping:
1- Using an amplifier
2- Reducing the distance between the listener and the speaker
3- To plan sound rests during the lesson or performance.
The criteria for terminating phoniatric reeducation should optimally be that the patient acquires the habit of effortless, normal voice, and good vocal hygiene. The most important termination should be to learn what happened to the patient’s voice disorder and to prevent the problem from recurring by adopting behaviors that will eliminate or modify the problem.
Phoniatric reeducation is not always successful. The patient may show partial voice improvement and then show no improvement, plotting a plateau at this level. If the patient is unwilling to continue reeducation and does not make the necessary changes, he or she should be removed from therapy.
Psychological factors are associated with sound. Quickness of excitement, irritability, relationship disorder, personal tensions distort the voice. However, portraying every functional dysphonia as a psychic disorder is a bit unfair and exaggerated for our patients. Especially professionals may have a disorder that is not of psychiatric origin. Both hoarseness and psychological disorder should be corrected.
In children with dysphonia, it is important to inform the child and family first. Regardless of age, the vocal organ should be explained and information should be given about the pathology on the vocal cord. It would be appropriate to use diagrams or video documentation here. It should be described with the hand and finger that the cords look like lips, not strings, and this acts like lips playing trumpet. When breathing in, the vocal cords open. Air passes into the lungs, the vocal cords are closed. It contracts like a trumpeter’s lip. In the case of a child, the child’s family should also be informed. The child should not be afraid of his voice. Rather than making a loud sound, the harm of excessive effort is explained.
First, he should be told that his voice caused a problem for him, and then the positive result he will get from this reeducation. If he gets bored and does not show interest, this treatment can be interrupted. They should be told that dysphonia is not a serious disease and that it does not threaten vocal function in the future. It should be known that the difficulty of the voice can cause school and family difficulties. Sometimes psychological and good pedagogical training may be required.
Reeducation in adults can take up to 1 year, but with a child it should not exceed 4-6 months. If there is a residual, the sessions should be started again. If reeducation is prolonged with the child, it can be badly effective.
Dealing with the vocal cords alone in a child does not mean anything. A person cannot control what he says while thinking. Likewise, there is no need to think about the feet while walking. It is forbidden to prevent all reactions to the child’s voice. Children should be warned as a family.
School and family problems should also be considered in reeducation. Children who have the habit of making noise are recommended to make sounds with musical instruments.
These problems are greater in those who use their voice professionally, especially in sound artists, in the application of treatment as well as diagnosis. Therefore, before making the diagnosis and starting the treatment, the vocal artist should be examined very well and in detail.
Anamnesis is very important in hoarseness problems of people who use their voices for professional purposes, especially artists. Their voice training , careers and working conditions should be questioned thoroughly . The onset and duration of hoarseness should be determined in the prepared form. Another important factor is the patient’s expectation from the treatment. After the treatment of a patient with a normal vocal cord nodule is completed, if the patient pays attention to some rules, there will be no more vocal cord nodules. However, if the vocalist does not change the wrong technique or environment he used after the treatment, it is inevitable that the nodule will develop again. Another difficult point encountered in the treatment is that the voice artist wants to return to his job as soon as possible. In some cases, she even wants to go on stage while she has nodules.
After anamnesis, general condition and systemic examination should be performed. After the general examination . Ear, nose and throat examination is done. This examination is very important in terms of revealing whether the important pathology of indirect laryngoscopy and, if possible, stroboscopic examination is due to organic reasons or technical problems. The methods up to this section can be performed in all otolaryngology clinics .
After these examinations, special examination methods are started. Special investigation methods take time . In addition, if there is a large nodule or edema in the vocal cords, a healthy result cannot be obtained. Therefore, the artist should be urgently reeducated or, if necessary, taken to medical treatment, and these additional examinations should be performed as soon as possible. The sound needs to be warmed up with piano and closed and open vocal exercises before proceeding to additional examinations . It is also important that the artist is not tired . Especially for artists coming from outside the city, if they have traveled at night, it is recommended to rest in the morning and have a light meal, and then come to the examinations.
First of all, electroglotographic examinations are performed. Here, the opening and closing of the vocal cords can be viewed with the help of an oscilloscope. With this method , the lowest and highest treble sound that the artist can give in a healthy way can be determined . Thus, the range and type of voice can be determined objectively. With the two-channel computer technique we developed in 1992, audio signals and electrolotographic signals can be transferred to the computer at the same time and examined on the screen. The advantage of this technique is that it can be determined during the exercises whether the transitions of the voice registers are made properly or not. This method is important both in diagnosis and in guiding treatment .
As a result of electroglotographic examination, the sound range given as healthy can be determined. This interval is very important for guiding treatment . Because reeducation needs to be done with voice exercises and the correction of the technique should be started in a healthy voice range and gradually increased to high pitched voices. These exercises should be given with the opportunity pedagogue and the vocal artist should do their exercises under the supervision of a pedagogue.
With this method , register transitions can also be detected . First of all, the treatment is done in the middle register and after obtaining a healthy middle register, it is necessary to work on the register transition. While performing these exercises, attention should be paid to the posture of the artist, use of the diaphragm and articulation. Glottal attack and tension of the neck muscles should not be overlooked. A technical error seen here needs to be corrected immediately .
Voice capacity is evaluated objectively with spectral analyzes and phonetograms and the reeducation to be applied is directed accordingly. One of the most important reasons for the formation of nodules is the inability to give voice with the pianissimo technique, especially in high-pitched voices. This is clearly detectable in phonetograms. Subjective vocal evaluations should also be recorded while these examinations are being performed. These are attack, emission, articulation, homogeneity, agitation volume, vibrito, legato, final and transition tones. In addition, general evaluations and follow-up notes should be carefully stated. These examination methods and evaluations should be done under the supervision of a vocal pedagogue, if possible.
After these evaluations, technical errors can be easily determined in a vocal artist who does not have organic pathology or has not been treated. In addition to this, sound capacity and quality can be evaluated, and works suitable for the sound can be determined by determining the type of sound.
Passive support exercises are started on the postoperative 7th day and active voice exercises are started on the 21st day in patients who are treated for large polyps and vocal cord mucosa undergoing laryngeal microsurgery.
Esophageal voice training is given in reeducation for patients we have operated for laryngeal cancer, and exercises are given to improve voice quality in patients with partial laryngectomy. Here, patients should first be told about the anatomy of the surgery they have undergone and how their next phonation will be, and if possible, patients who have had the same surgery and have achieved their optimal voice with successful reeducation should be cited as examples. The group therapy to be applied here simultaneously provides psychological support to the patient.
In patients with vocal cord paralysis and hypokinetic dysphonia, basic exercises and resonance exercises are applied by giving different positions to the larynx. Laryngeal massage and therapy are also beneficial. If no results can be obtained with resonance therapy, exercises are given with explosive, glotal attack enhancing and cord vocal tensioning and approximating phonemes. Which of these exercises will be applied and their duration are determined by clinical controls. The most important mistake made in patients with vocal cord paralysis is sending the patient to late reeducation. Some patients with vocal cord paralysis partially or completely heal spontaneously within 6 months. This leads the physician who performs thyroid surgery or diagnoses functional paralysis to wait for this period. However, partially healed or non-recovered patients lose a valuable 6 months and benefit partially from the applied reduction. At the same time, the reeducation times are extended. Patients with vocal cord paralysis should be referred for reeducation as soon as the diagnosis is made, and if it is the result of thyroid surgery, reeducation should be started on the 21st postoperative day.
In patients with mutational dysphonia, the pathology is incomplete vocalization, which is 1 octave in men and ½ octave in women, which is due to the development of the larynx at puberty. This group of patients can be easily missed even by otolaryngologists, and laryngitis treatment can be given by looking at the hyperemia in the larynx examination and the opening in the closure of the cords. Or, they are taken for detailed hormonal examinations by the internal medicine physician. The vast majority of patients with mutational dysphonia are falsetto mutations. The main purpose in the reeducation of these patients is to determine the basic speech frequency and to ensure that the patient speaks at this frequency. Here, with the Gultzmann maneuver, the larynx can be pressed backwards and downwards, making the sound quieter. Another similar maneuver can be applied by pressing the base of the tongue with a beeslang.
All the reeducation techniques described above are generally used techniques. Pathologies can often be complex, which changes treatment plans. For example, this pathology of a patient with a nodule due to mutational diphonia cannot be passed without eliminating the primary pathology or it recurs.
In addition to these general techniques, many different reeducation techniques are proposed in the world. Successful results are obtained especially in hyperkinetic dysphonias (4). The person who will apply phoniatric reeducation should determine the reeducation program to be applied according to the patient and should direct this program according to the course of the treatment and should be open to all new applications.
