We’re going to start talking about what your authors call “special problems”. Here I am going to cover paradoxical vocal fold motion and transgender voice. Next time we’ll talk about laryngectomy.
So we’ll start first with paradoxical vocal fold motion.
Paradoxical vocal fold motion is an interesting phenomenon. In a way it is kind of like spasmodic dysphonia, in that the vocal folds tend to close when they should be open. But unlike adductor spasmodic dysphonia, in the case of paradoxical vocal fold motion the vocal folds are closed even during breathing. So this is a scary disorder to have, because not only do you have a strangled vocal quality, but you have difficulty breathing. You’ll hear this disorder called by lots of different names, which I’ve listed on your PowerPoint slide. I think that the most commonly used term, especially by doctors, is laryngeal dyskinesia.
Paradoxical vocal fold motion is also often confused with asthma. So sometimes patients are misdiagnosed with asthma, when really they have PVFM. But in about 50% of patients, they actually have both asthma and PVFM. Other symptoms are feeling tightness or choking in the throat and stridor, or that wheeze on inhalation.
There are some interesting statistics on who tends to have PVFM. For some reason the average person who has PVFM tends to be female, between the ages of 20-40, who has at least a high school education, and who works in healthcare. Children and teenagers can also develop PVFM. These children tend to be very high achievers and athletes.
We’re not entirely sure what the cause of PVFM is, but there are probably several causes. Many of these patients have reactions to irritants, such as perfumes or incense at church. There may also be neurological or psychological implication.
Remember that SLPs don’t make medical diagnoses, but we can observe what we see and make suggestions to medical personnel. In order for a person to receive a PVFM diagnosis, they’ll have to have many tests in addition to the speech therapy evaluation. These tests are conducted by pulmonologists, ENTs, and possibly neurologists and psychologists.
So how is PVFM treated by medical personnel? In addition to patient education, sometimes a CPAP machine can help make breathing easier. Sometimes anti-anxiety drugs can be prescribed by doctors if needed. It’s also possible that a doctor or ENT will want to cut the laryngeal nerve or give Botox injections in order to relax the vocal folds, but there isn’t much evidence that these strategies are at all helpful.
Sometimes PVFM is diagnosed as a conversion diagnosis, meaning that it is a functional disorder that results from a psychological issue. In this case, the patient may receive psychotherapy from a psychologist or psychiatrist, but in most cases the cause of PVFM is not entirely psychological, and speech therapy is the first line of treatment.
Speech therapy for treatment of paradoxical vocal fold motion usually consists of patient education and counseling, as well as relaxation exercises to relax the vocal mechanism. When I was at the University of Michigan hopsital, the voice specialist shared with me his technique to help PVFM patients prevent and manage these attacks where they can’t breathe and can’t talk. He called it the “sniff and blow” technique, and I’ll demonstrate it for you here. There are two quick sniffs in through the nose, and then a long breath out through the mouth. So it’s like this [demonstrates]. The two sniffs in opens up the larynx, and the blow out through the mouth begins to regulate the breathing cycle. The key with this technique is to have clients practice it a lot before they need it. They should do it at first when they are doing nothing else, and then they can practice while watching TV or driving in their car. They can then begin to practice in situations in which they have episodes. I’ve had clients who couldn’t sit through a church service because there was incense, and it would set off their PVFM, or athletes who would be playing soccer or swimming and then have an attack. So having them practice the sniff and blow on the soccer field, or in church can be really helpful. The goal is to have clients practice the technique so that it becomes second nature to them, and they begin to have a sense of control over their PVFM symptoms. Hopefully they’ll get to the point where they can ward off and attack before it even starts.
There have been some helpful articles written to help SLPs and other professionals better understand PVFM. I’ve listed them here, and I encourage you to look them up.
So let’s move on now to a discussion about voice issues for transgender clients.
Let’s talk about some terminology here. The word transgender can be applied to anything or anyone who falls outside of typical gender roles or norms. So back in the 1940s and even 1950s, for a woman to wear a pair of pants instead of a skirt or dress would have been considered transgender. Transsexual on the other hand, has a more specific meaning. It applies to men and women who feel that their biological sex doesn’t match their feelings of maleness or femaleness on the inside. Often these feelings are associated with a strong need to change one’s physical appearance to match one’s internal gender. There is a process that many transgender people go through in order to match up their internal feelings of gender with their external appearance, which is called transitioning. This process may include surgeries, cosmetic changes, hormone therapies, and conversations with family, friends, and co-workers.
Many transgender clients may take hormone therapy in order to help them appear more masculine or more feminine. For biological women who are transitioning to a male persona, these hormones, such as testosterone, may naturally deepen the voice. The opposite is not true for biological men, who take estrogen and other hormones. So male-to-female transgendered people are most likely to seek out speech therapy services. We need to help these clients achieve a feminine sounding voice that does not result in strain and vocal abuse.
As many people who seek therapy will be male-to-female transgender clients, we must be aware of and counsel our clients on aspects of feminine voice. There have been many research studies which have pinpointed exactly how the speech and vocal characteristics of women differ from that of men. For example, think about how women might excuse themselves to go to the restroom versus men. There are some definite differences there. Women’s voices also tend to be breathier with greater articulatory precision. They also tend to use more facial expressions, gestures, and pitch range, with longer vowels. Help clients to recognize that it is not only raising pitch which results in a more feminine voice. Have clients analyze their own voices and those of the people around them to see how they can change a lot about how their voice is perceived without introducing the vocal strain that can go along with a higher pitch.
Voice therapy for transgender clients should focus on appropriate resonance with frontal focus. But much of therapy will involve counseling clients on feminine aspects of voice which do not necessarily involve a higher pitch, such as working on appropriate vocabulary, gestures, and greater articulatory contacts. If these things do not allow clients to pass as a woman, laryngeal surgery, or thyroplasty, may help to elevate pitch.
Here are some references for you in order to help you better understand voice therapy for transgender clients.
CDIS 700Management and Therapy for Special Problems
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.