What are the voice therapy options for treating voice disorders?

Voice Therapy Options for Treating Voice Disorders

Voice therapy should be strongly advocated as the first-line treatment for dysphonia amenable to behavioral intervention, delivered by certified speech-language pathologists (SLPs) after diagnostic laryngoscopy confirms the underlying pathology. 1

Prerequisites Before Voice Therapy

Diagnostic laryngoscopy must be performed before prescribing voice therapy, with results documented and communicated to the SLP. 1 This ensures appropriate patient selection and allows the therapist to tailor interventions to the specific laryngeal pathology identified.

Core Voice Therapy Approaches

Voice therapy encompasses both direct symptomatic techniques and indirect behavioral modifications, typically delivered in 1-2 sessions weekly for 4-8 weeks. 1

Direct Symptomatic Techniques

These hands-on exercises directly modify vocal production:

• Vocal function exercises including pitch glides, sustained phonation on vowels, and controlled breathing patterns 1
• Resonant voice therapy using humming, nasal consonants (/mm/), and forward-focused tone production 1
• Laryngeal manipulation with circumlaryngeal massage during phonation to reposition and relax the larynx (requires patient consent before neck contact) 1
• Postural maneuvers such as phonating while bending forward or looking at the ceiling to facilitate voice return 1
• Attention redirection techniques including bubble blowing with vocalization, amplification devices, or electroglottography biofeedback 1
• Automatic speech tasks like counting, reciting days of the week, or singing familiar songs to bypass conscious vocal control 1

Indirect Behavioral Modifications

These address underlying contributing factors:

• Vocal hygiene education emphasizing adequate hydration, avoidance of tobacco and alcohol, and appropriate vocal rest 2, 3
• Communication counseling addressing predisposing, precipitating, and perpetuating psychosocial factors 1
• Identification and modification of harmful vocal behaviors such as excessive throat clearing, shouting, or speaking over noise 1, 3
• Psychological support for anxiety, avoidance patterns, or social phobia related to voice use, with referral to mental health professionals when needed 1

Condition-Specific Applications

Muscle Tension Dysphonia (MTD)

Voice therapy is highly effective as primary treatment compared to vocal hygiene alone, targeting abnormal muscle patterns without anatomic laryngeal changes. 1

Vocal Fold Nodules and Polyps

Voice therapy is the first-line treatment for phonotraumatic lesions, often eliminating the need for surgery entirely, as many are self-limited or reversible with behavioral modification. 1, 3, 4 Surgery is reserved only when satisfactory voice cannot be achieved conservatively. 3

Parkinson's Disease Hypophonia

Lee Silverman Voice Treatment (LSVT LOUD®) is the most effective specialized method for treating reduced vocal intensity and monotone speech in Parkinson's disease. 1, 5 This addresses the characteristic low-volume, low-energy voice pattern.

Unilateral Vocal Fold Paralysis

Voice therapy helps patients compensate for altered laryngeal physiology and can be used alone or combined with injection laryngoplasty or framework procedures. 1, 2

Spasmodic Dysphonia and Laryngeal Dystonia

Voice therapy serves as useful adjunct to botulinum toxin injections, addressing compensatory behaviors and maximizing functional outcomes. 1, 5

Functional (Psychogenic) Dysphonia/Aphonia

Combined direct and indirect approaches with psychological counseling are essential, as outcomes improve when patients understand psychosocial connections and have coping strategies. 1 Referral to mental health professionals may be necessary for long-standing anxiety, depression, or medicolegal issues. 1

Evidence Quality and Treatment Effectiveness

Moderate-to-good evidence supports voice therapy efficacy for functional dysphonia, with systematic reviews demonstrating effectiveness across the lifespan from children to older adults. 1, 6 Recent multidimensional studies show significant improvements in perceptual voice quality, acoustic parameters, maximum phonation time, and Voice Handicap Index scores. 4

Critical prognostic factors include:

• Adherence to therapy (attending >4 sessions) yields 87% effectiveness versus 64% with poor adherence 4
• High occupational vocal demand correlates with 90% effectiveness versus 70% for routine vocal demand 4

Important Clinical Caveats

• Children under 2 years may not participate effectively in many voice therapy forms; family education and counseling become primary interventions 1
• Pediatric vocal nodules and polyps typically resolve during normal development; voice therapy remains primary treatment with surgery having limited role 3
• Duration of therapy depends on dysphonia origin, severity, concurrent medical therapy, and critically, patient commitment to practicing new vocal behaviors outside sessions 1
• Pre- and post-operative voice therapy enhances surgical outcomes for procedures like vocal fold injection, laryngoplasty, and thyroplasty 1
• Insurance coverage: Medicare generally covers voice therapy when provided by certified/licensed SLPs, ordered by physicians, and deemed medically necessary; Medicaid varies by state but typically covers up to age 18 1

Finding Qualified Providers

Certified and licensed SLPs are the appropriate professionals to deliver voice therapy. 1 Locate qualified voice-specialized SLPs through ASHA's ProFind search engine (www.asha.org/profind) or by contacting ASHA's Action Center at 800-498-2071. 1