Case Study: A Physiologic Approach to Voice Disorder Treatment

Do different pathologies have distinctive audio-perceptual features? Can you hear and distinguish voice differences in a patient with vocal nodules as opposed to a cyst or a polyp or papilloma? Are there specific treatments for each voice pathology?

Prior to the use of instrumentation to help assess voice disorders, clinicians used their clinical ears to describe a voice disorder. Patients were said to have a mild, moderate, or severe dysphonia characterized by hoarseness, harshness, stridency, breathiness, or any other descriptive term. Therapy would then be planned specifically to the pathology and symptoms heard. Breathiness was treated by laryngeal compression. High pitch was lowered and low pitch was raised. Tension was reduced through relaxation exercises. The problem with this approach is that pathologies do not have distinctive audio-perceptual features and treatment of the symptom may not positively impact the underlying cause of the voice problem.

Case Example

Tommy is an eight-year-old student with vocal fold nodules. He was referred to his public school SLP to treat vocal nodules. Since phonotraumatic behaviors, such as shouting, loud talking, and screaming, cause nodules, the SLP determined that a behavior modification vocal hygiene approach would be most appropriate for Tommy. The SLP created a daily vocal behavior chart of all Tommy’s vocally abusive behaviors and asked both Tommy’s mother and teacher to place a checkmark beside each behavior when noticed. Reduced behaviors were rewarded with prizes.

After several weeks, the approach worked to reduce Tommy’s abusive vocal behavior, but his voice quality remained dysphonic. Tommy’s SLP then made a point to observe Tommy in the classroom and on the playground. While the incidence of phonotraumatic events decreased, Tommy’s voice could still be heard above the playground and classroom noise. It was concluded that Tommy was just a loud child. Hygienic voice therapy did not work and both the SLP and Tommy became frustrated.

Missing Element

While shouting and loud talking resulted in the development of the vocal nodules, do those behaviors also maintain the presence of the nodules? I would suggest that the presence of the nodules actually maintained the perceived symptoms of increased loudness and dysphonia. Even with the reduction of the abusive behaviors, the underlying physiology related to the pathology remained unaddressed.

Vocal nodules are bilateral mass lesions that increase the mass of the vocal folds and cause the closure of the vocal folds to demonstrate an hourglass closure pattern, thus an air leak. Since normal voicing depends on complete vocal fold closure to build normal subglottic air pressure, the presence of the nodules caused Tommy to work harder to build the necessary air pressure. This led to vocal hyperfunction even when speaking at normal intensity. The increased effort often required that he speak louder to keep the vocal folds vibrating without phonation breaks. Talking loudly and shouting led to the development of the nodules but the presence of the nodules also required that Tommy talk louder to maintain phonation. Applying a physiologic approach to voice therapy, along with a vocal hygiene approach, would be the appropriate treatment for this case.


This is one example of why it is important to consider the underlying physiology of voice production and not just the behaviors that caused the disorder. The underlying physiology may be similar across many different voice pathologies. Attending to the physiology of voice production will often reduce or eliminate the symptoms of the voice disorder and simplify therapeutic choices.

Questions to Ask when Planning Therapy

Here are a few questions to ask prior to planning therapy. These will help choose the most effective approach:

  • What are the causes of the disorder?
    • Are the causes still present, and do they need to be modified or eliminated?
  • What is the underlying physiology associated with the voice disorder?
    • What is the relationship of the three subsystems of the voice: respiration, phonation, and resonance?
    • How have the subsystems compensated for the presence of the disorder?
    • Which specific physiologic voice therapy approach will best address the problem?

Inherent in all voice disorders is an imbalance in the three subsystems of voice production. The goal of voice therapy is to improve the natural balance, thus improving voice production.

  1. Stemple, J (2005) A Holistic Approach to Voice Care.  In Seminars in Speech and Language, Holland A (Ed.) New York: Thieme Medical Publishers, Inc. 26:2, 131-138.