Can Voice therapy lead to optimal vocal fold physiology in cases with vocal nodules? Namita Joshi*, Gauri Belsare**, Jayashree Jagtap*** *Associate professor, BVDU’s Medical College School of Audiology & Speech Language Pathology Pune

Effect of Vocal Nodules on vocal fold physiology Incomplete closure (hour glass pattern) Absent (at site) or Irregular vocal fold vibration Mucosal wave is absent at site Symmetrical vocal fold vibration except at site Hoarse voice Diplophonia in cases with ventricular fold hypertrophy Colton & Casper(2000)

Goals in Voice therapy Optimal vocal fold physiology is the ultimate goal. Physiological voice therapy-widely accepted approach Reduction in Nodule size is secondary Vocal hygiene program Resonant voice therapy (Boone, 1995, Stemple, 2001, Verdolini et al 2001,Chen et al 2007) Effect of voice therapy in Indian scenario not much explored. (Boominathan 2003, Savithri & Rajsudhakar 2005, 2010)

Aim To explore the effect of Voice therapy on vocal fold vibration in clients with vocal nodules. Objectives To study the effect of voice therapy on closure of vocal folds in clients with vocal nodules. To study the effect of voice therapy on mucosal wave of the vocal folds in clients with vocal nodules. The study the effect of voice therapy on quality of voice of clients with vocal nodules. Null Hypotheses There will be no effect of voice therapy on closure of vocal folds of clients with vocal nodules. There will be no effect of voice therapy on mucosal wave of the vocal folds of clients with vocal nodules. There will be no effect of voice therapy on voice quality of clients with vocal nodules.

Method . (H/0 vocal abuse since at least six months) Females between 20-40 years of age Pre post design Three clients diagnosed with vocal nodules minimum of 6 sessions Followed structured voice therapy programme Stoboscopy evaluation & MDVP evaluation GRBAS prescribed same dosage of anti-inflammatory medicines Clients were evaluated by same professionals On visual analog scale Post therapy evaluations Voice evaluations done at regular intervals .

Voice therapy Hydration vocal function exercises Resonant voice therapy Dietary modification Environmental modifications Sessions were of 30 mins each thrice a week.

Results Objective 1: To study the effect of voice therapy on closure of vocal folds in clients with vocal nodules. Pre therapy Post therapy Client 1 Client 2 Client 3 Inter rater reliablity r=0.6 ( Rating done by two SLPs and one ENT)

Results Objective 2: To study the effect of voice therapy on mucosal wave of vocal folds in clients with vocal nodules SN Category Client 1 Pre Post Client 2 Pre Post Client 3 Pre Post 1 Closure Hourglass Complete Post chink 2 Mucosal wave + on right Reduced on left + on both VF -ve at site + both, full length VF -ve at site + ve complete VF 3 Symmetry -ve on left + 4 Periodicity -ve on Left 5 False cords hypertrophy Reduced Normal Pre therapy video – post therapy video (Inter rater reliability r=0.6) kruscal Wallis test was done, significant difference was found only for Mucosal wave pattern and Closure pattern(p˂0.05)

Results Objective 3: To study the effect of voice therapy on quality of voice in clients with vocal nodules Client 1 Client 2 Client 3

Results Objective 3: To study the effect of voice therapy on quality of voice in clients with vocal nodules Category Client 1 Client 2 Client 3 Pre Post Grade overall 2 1 3 Roughness Breathiness Asthenic Strain (Inter rater reliability r=0.6) Significant positive correlation (r= 0.7 , (p˂0.05) was found between closure pattern and overall grade of voice quality

Conclusion Null hypotheses are rejected. There was a significant effect of voice therapy in achieving optimal vocal fold vibration, in terms of improving vocal fold closure, mucosal wave pattern, and improving quality of voice. Voice therapy should be recommended irrespective of the size of the nodule prior & post to surgery. Efficacy of voice therapy in larger sample should be explored.

References Verdolini-K,M; M.K. Burke, Lessac, A; Glaze E; Caldwell E; (1995); ‘Preliminary study of two methods of treatment for laryngeal nodules; Journal of Voice, Volume 9, Issue 1, March, Pages 74-85 Sheng Hwa Chen, Tzu-Yu Hsiao, Li-Chun Hsiao, Yu-Mei Chung, Shu-Chiung Chiang (2007); “Outcome of Resonant Voice Therapy for Female Teachers With Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements.Journal of Voice, Volume 21, Issue 4, Pages 415-425. Stemple J.C; (2001) “ Principles of Voice therapy” Plural Publishing ltd. Rajsudhakar & Savithri (2010), “ Vocal load in teachers’, JISHA, vol 30.  

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