Averting the “Limping Larynx” with a Multidisciplinary Approach

November 28, 2010

Otolaryngologist Ronda Alexander, MD, looks to orthopedic surgery as an analogy to explain the treatment of voice disorders.  “After a knee replacement or an ACL repair, the surgeon prescribes physical therapy to teach patients how to use the joint safely so that the replacement or repair lasts as long as possible,” says Dr. Alexander, who is director of the Texas Voice Performance Institute and an assistant professor in the Department of Otorhinolaryngology-Head and Neck Surgery at The University of Texas Medical School at Houston.  “Voice disorders demand the same rehabilitative treatment.  As laryngologists we provide the medical therapy.  A good voice rehabilitation program is equally important to the patient’s long-term success.”

We use our voices to inform, persuade and connect with other people.  An estimated 28 million Americans also rely on their voices to make a living, including singers, teachers, physicians, attorneys, ministers, nurses, salespeople and public speakers.  Among them is Carrie P., a 42-year-old saleswoman who saw Dr. Alexander when she developed hoarseness after suffering a neck injury in an automobile accident.

“We started with a comprehensive voice evaluation,” the otolaryngologist says.  “The good news was also the bad news.  She had no lesions or irregularities in the larynx causing the hoarseness.  But when I examined the muscles of her neck around the larynx, I noticed tension.”

Physician and patient established a treatment goal of learning to use the larynx safely and effectively.  Working with Jade Alexander, CCC-SLP, a speech pathologist at Memorial Hermann-Texas Medical Center, Carrie learned to massage, stretch and relax the muscles of her shoulders, neck and jaw.  They also worked on reducing tension in the larynx through resonant voice therapy focused on shaping sounds using the lips.  “This type of therapy helps reduce tension of the larynx and tongue base by opening the jaw and placing more focus on the lips,” Alexander says.

Three weeks into voice therapy, Carrie had changed the position of her shoulders, neck and head and was producing smoother sounds more easily.  “When we injure a leg, we limp to avoid pain and further damage, but once the injury has healed, limping becomes maladaptive behavior,” Dr. Alexander says.  “The same thing can happen with the voice.  Once the medical issue has been resolved, the compensatory behavior that allowed the patient to use the voice during healing can cause damage in the long run.  To help patients recover from what I call the “limping larynx” – a voice characterized by a great deal of tension and altered sound – we combine the skills of the members of our multidisciplinary treatment team.”

Both otolaryngologist and speech pathologist stress the importance of good vocal hygiene.  “Hydration can affect how the voice sounds,” Alexander says.  “A good voice also requires good breath support.  It’s important to notice how you talk, when you yell, whether you’ve talked for hours and need to rest your voice or whether you’re straining your voice by talking in noisy places.”

“Many factors converge to affect voice performance, which is why we can’t effectively treat voice disorders in isolation,” Dr. Alexander adds.  “Having a multidisciplinary team available in the same facility helps ensure convenience for patients, good physician-therapist communication and better outcomes.”

Dr. Alexander’s clinical interests include the evaluation of hoarseness, spasmodic dysphonia, vocal tremor, vocal cord paralysis, extra-esophageal reflux and swallowing disorders.  She is specially trained to manage the unique needs of professional voice users.  She also has interests in neuromuscular disorders of the head and neck, including tension and migraine headache.

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