When you encounter someone who speaks with a strangled, hoarse, or breathy-sounding voice you may assume they’re simply getting over a bad cold.
“I’m sorry, I’m not sick—it’s just my voice,” college student Mia* got used to saying when she entered the University of Minnesota as a freshman.
Mia suffers for Spasmodic Dysphonia (SD), a voice disorder in which the vocal folds don’t move the way they should when speaking. At minimum this disorder affects around 50,000 people in North America, but experts suspect the number is higher. It’s possible that some cases continue to go unresolved for many years before an accurate diagnosis is made.
As a speech-language pathologist you will be called in to help patients with SD through voice therapy. You will usually be one of a team of professionals working together to help improve the ability of individuals like Mia to communicate on the job and at home.
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Spasmodic Dysphonia Presents Challenges When it Comes to Getting the Diagnosis Right
Unfortunately many individuals have to work through a wrong diagnosis before stumbling on the right one.
Blogger Eric Y shares that his ENT initially treated him surgically for a deviated septum and acid reflux, with no change in symptoms. After some internet research and a long trip from Honolulu to Chicago for an evaluation Eric officially had his diagnosis: Spasmodic Dysphonia.
Because there isn’t a straightforward test for SD, it is believed to be one of the most misdiagnosed conditions in the speech world. Usually it takes a team of professionals focusing on their area of expertise to arrive at a diagnosis. A preferred team will look something like this:
- Speech-Language Pathologist: evaluates voice production and quality
- Otolaryngologist (ENT): evaluates the vocal cords and how they move
- Neurologist: checks for signs of dystonia or other neurological conditions
Unclear Origins and a Debate
If you’re looking for definitive answers for what caused a patient’s SD, you’re probably out of luck. Based on available evidence, most experts think that it’s a brain problem: the nervous system regulator in the basal ganglia starts producing inaccurate signals, impacting the timing and intensity of how the muscles contract and relax.
Many patients, like Mia, note that the change happened after a specific event. For Mia, it was surgery to remove a benign tumor. Others point to head trauma, infections, illness, or stressful events as the triggering incident.
Members of the medical community disagree on whether or not these events can induce the kind of brain changes that result in SD, although ongoing research may bring about clarity in the coming years. While understanding origins might improve future treatment, the good news is that current treatments can be surprisingly effective.
Treatment Options for Spasmodic Dysphonia
As mentioned before, SD evaluation and treatment requires a team approach. It is highly unusual for speech therapy alone to provide adequate support.
- The most common treatment at this time is Botox injections in the vocal cords, combined with voice therapy.
- Speech Therapy. Focused therapy is given before and after Botox injections, which happen 3-4 times a year. Your work will generally focus on helping the patient to control their breath and manage tongue placement to speak more efficiently.
- Selective laryngeal adduction denervation and reinnervation(SLAD/R) surgery involves clipping away the laryngeal nerve and then reattaching the related muscles to a nerve that isn’t associated with the patient’s SD. Most patients see significant improvement 6-12 months after the surgery, and most will never need the Botox treatments again once they have healed from the surgery. Roughly 80% of patients are satisfied with the results, however some patients’ voices are permanently altered.
Advising Patients on Options When Their Careers Are Impacted
Although there are no clear statistics anecdotally there appears to be a large number of individuals with SD who work in careers that put high demands on their voices. Whether they are in radio, education, members of the clergy or just find themselves on the phone much of the day, this voice illness can dramatically affect their careers.
As a speech-language pathologist part of your role will be to help individuals with SD manage their symptoms and find ways to decrease voice strain while on the job. Sometimes standard SD treatment is enough to keep an individual in their current job, but if not you may want to discuss some other possible approaches with your patient. These could include:
- Ask the employer for grace period: some people respond very well to treatment and after a series of months can return to their previous tasks with little difficulty.
- Ask the employer to adjust job responsibilities so they can focus on less vocally-straining tasks.
- As the employer if they will accept the use of a voice amplifier.
- Explore some work-arounds so that more vocally demanding tasks happen during optimum times within the Botox treatment schedule.
- Ask for a transfer within the company to a position that doesn’t require a high level of vocal energy.
Initially your patient may resist assistive technologies, but using products that reduce strain on their voices can actually improve their overall quality of life. Whether it’s making themselves heard and understood with less frustration or reducing talk time so they can save their voices for when really needed, these assistive technologies are worth considering.
- Voice Amplifiers: Voice amplifiers like this one can help your patient project their voice without as much vocal strain. They can choose from a variety of microphone options including handheld, headset, and collar microphones.
- Text-to-Speech Apps: These apps allow your patient to make phones calls and communicate in real-time with individuals using text-to-speech technologies. The individual will simply type what they want to say, and the app converts the text to speech so the person on the other end can hear them.
- Operator Assisted Speech: These services are similar to the text-to-speech apps, but instead of a computer generated voice an operator plays the middle-man. So your patient types and the operator speaks out their message. These can vary from state to state, but most systems are similar to this one offered in North Carolina.
Specializing in the Treatment of Spasmodic Dysphonia
You won’t find any industry certifications specific to Spasmodic Dysphonia, but because it is a neurological disorder you may want to consider pursuing board certification from the Academy of Neurologic Communication Disorders and Sciences (ANCDS).
In order to be eligible for this certification, you’ll need to fulfill the following requirements:
- Be a fully certified CCC-SLP
- Have five years of clinical experience with neurologic communication disorders
- Submit your CV or resume with three letters of recommendation from health care professionals familiar with your skills
- Complete the Board Certification Candidacy Application and pay applicable fees
The certification process involves submitting two case studies, giving an oral presentation, and taking part in a discussion following your presentation. The reviewers will then give you a “Pass” or notify you that your work “Does not meet standards.”
Additional Ways to Specialize Your Focus
In working with spasmodic dysphonia you’ll find yourself drawing on methods from various speech-language methods you may want to get additional training in something called Expiratory Muscle Strength Training (EMST). This method uses a specially calibrated device combined with specific exercises to increase respiratory strength of the patient. The company that created a commonly used device for this training offers periodic workshops for professionals.
You can also improve your ability to treat SD by attending workshops or webinars on voice therapy subjects. Some of the places you can find these trainings include:
- National Spasmodic Dysphonia Association: Periodic workshops and conferences; join the newsletter list for information as the events portion of the website doesn’t always have the earliest posting for these events.
- Mayo Clinic School of Continuous Professional Development: Offers conferences and online workshops.
- University of Wisconsin Voice and Swallow Clinics Lecture Series: Online lectures available to ASHA members for CEU’s.
- The Voice Foundation: Annual symposium and various conferences and events. Many SLP’s specializing in voice issues are members of this foundation.
- Northern Speech Services: Online workshops on speech related topics for CEU’s.
- National Center for Speech and Voice: Summer intensives on Vocology.