CDIS 700Management and Therapy for Special Problems
Paradoxical Vocal Fold Motion (PVFM)
What is PVFM?The vocal folds adduct during inhalation and/orexhalation, causing an upper airway obstruction.Known by a variety of names: Vocal cord dysfunction Paradoxical vocal cord motion Episodic laryngeal dyskinesia Episodic paroxysmal laryngospasm Factitious asthma Munchausen’s stridor Psychogenic stridor Aductor laryngeal breathing dystonia
Signs and SymptomsAsthma-like breathing difficulties Asthma may co-occur in up to 50% of PVFM cases.Sensation of tightness or choking in thelaryngeal areaStridor
At Risk PopulationsThe average person with PVFM is: A woman who is Between the ages of 20-40 and Has at least 12 years of education and Works in health careChildren and adolescents with the disorderare likely to be high achievers and athletes.
EtiologyThere are several possible etiologies,including: Upper airway sensitivity to laryngeal irritants Neurological causes at the level of the brainstem or the upper or lower motor neurons Psychological conditions
Differential DiagnosisShould be based on multidisciplinaryevaluations, including the patient’s clinicalhistory, pulmonary function and lab testresults, laryngoscopic findings, speech-language pathology evaluation, andpsychological evaluation.
Medical TreatmentPatient educationTermination of unnecessary medicationsCPAP may be used to reduce the effort neededfor inspiration.Sedatives or anti-anxiety drugs can be temporarilyused, but this is rare.Laryngeal nerve sectioning and Botox injectionsare sometimes used (little evidence base)As a last resort, a tracheotomy may be warranted.
PsychotherapyCould be considered if medical factorshave been ruled out and the PVFM isdiagnosed as a conversion disorder.Speech therapy is more oftenrecommended as the first line oftreatment.
Speech TherapyThe SLP should be ready to refer to voicespecialists, neurologists, or psychologists ifindicated by the assessment.Treatment consists of patient education,supportive counseling, instruction in tensionidentification and control, and instruction inrelaxed throat breathing.More research needs to be conducted related tothe effectiveness of therapeutic treatments forPVFM.
PVFM ReferencesKoester, M.C., & Amundson, C.L. (2002). Seeing theforest through the wheeze: A case-study approach todiagnosing paradoxical vocal fold dysfunction. Journal ofAthletic Training, 37, 320-324.Sandage, M.J., & Zelazny, S.K. (2004). Paradoxicalvocal fold motion in children and adolescents. Language,Speech, and Hearing Services in Schools, 35, 353-362.Mathers-Schmidt, B.A. (2001). Paradoxical vocal foldmotion: a tutorial on a complex disorder and the speech-langauge pathologist’s role. American Journal ofSpeech-Language Pathology, 10, 111-125.
Transgender ClientsTransgender can be loosely defined as anythingor anyone that falls outside of typical genderroles or norms.Transexual most often refers to men and womenwho feel that their biological sex doesn’t matchtheir feelings of maleness or femaleness on theinside.Transitioning is the process of beginning to livelife according to one’s internal feelings aboutgender. Watch a “time capsule” video about oneperson’s journey here.
Transitioning, Hormone Therapy, and VoiceBiological women who live as men often do notreceive voice therapy. The female larynx can generally go lower without creating too much voice strain. Hormones may also deepen the voice.Most transsexual/transgendered clients whoseek out speech therapy will be biological menwho are living as women (male-to-femaletranssexuals). Strain on the voice results when a “male” larynx is forced into too high of a pitch.
What Makes for a Feminine Voice? Vocabulary! A breathier voice quality More facial expressions Greater articulatory precision Higher pitch More pitch inflections with greater Fo variability Decreased loudness/volume Vowel prolongation Watch a video clip of a MTF transgender person describing how she obtains a more feminine voice.
Therapy and Other OptionsWork on obtaining frontal focus. Do nasal/glidework that emphasizes increased vowel durationat the word level.Counsel the client that a feminine “voice” is notreliant on just pitch. Gestures, facialexpressions, and word choice are very importantcomponents.Thyroplasty or other types of surgery maypermanently stretch the vocal folds, leading to ahigher pitch.
Transgender/Transsexual Voice ResourcesAdler, R.K., Hirsch, S., & Mordaunt, M. (2006).Voice and communication therapy for thetransgender/transsexual client. San Diego:Plural.“Voice and Communication Therapy forTransgender/Transsexual Clients” (http://www.asha.org/public/speech/disorders/TGTS.htm)See the March 3, 2009 ASHA Leader for moreresources.