Lee, Stemple, Glaze, & Kelchner
Voice Disorders in Schools: Facilitating Progression from Screening to IEP
ASHA Convention, San Antonio, 1998
Our Chat tonight, November 19th, 2001, is hosted by Dr. Leslie Glaze,  who
will address the topic of Voice Disorders.  Leslie Glaze, Ph.D., is
the Director of Clinical Programs in the Department of Communication Disorders
at the University of Minnesota.  Her primary interests include the utility
of instrumental and perceptual measurements of voice and medical pathologies of voice,
laryngectomy rehabilitation, and other disorders of speech production.  Dr. Glaze will
be one of the guest panelists for the Institute, Neurogenic Dysphonias: No Motion, Too
Much Motion, at the upcoming ASHA Convention.  Additional resources
provided by Dr. Glaze can be found at the bottom of this transcript.

<Robin> We are so pleased to welcome Dr. Leslie Glaze who will chat with us tonight
    about voice disorders.
<Leslie Glaze> Happy to be here, Adrienne -- got a question for me?
<Adrienne> I was supposed to do my first voice diagnostic next week but the client
<Leslie Glaze> Good for you Adrienne -- do you have protocol in mind for assessment?
<Adrienne> We had talked about using the Visi Pitch
<Leslie Glaze> Excellent choice.  The way I usually proceed is to consider the history
<Leslie Glaze> In the history I try to consider all medical/physical factors, then voice
    uses (demands and social preferences) and then finally, psychosocial or emotional
<Adrienne> her history questionnaire said she had vocal nodules previously
<Leslie Glaze> Most clients are surprised that there is a connection between voice and
    the psyche, but I try to compare it to other psychophyscial responses, like migraine
    headaches, lower back pain, and other stress
<Adrienne> she just wanted to get back into therapy, but since it was more than a year
    ago we have to do an eval
<Leslie Glaze> Yes, things can often change in a year
<Adrienne> and shouldn't the therapy have prevented further nodules?
<Leslie Glaze> Yes, you'd think so, but perhaps she wasn't able to be compliant, or
    perhaps her previous nodules are so large that they cannot shrink easily
<Leslie Glaze> She may even have some permanent scarring if she's had them a long
<Leslie Glaze> Nonetheless, your goal is to maximize her potential to balance airflow
    (breath support) to relaxed phonation to good vocal tract resonance.
<Leslie Glaze> With vocal nodules you'll want to see how MUCH she needs to
    talk and how much she WANTS to talk.
<Leslie Glaze> It helps if she's pretty motivated, of course
<Leslie Glaze> That Visi Pitch biofeedback will help, too...
<Robin> How long should the course of therapy last for a case of vocal nodules?
<Leslie Glaze> I usually suggest that voice therapy (with compliance) is QUICK -- 6-12
    weeks maximum
<Leslie Glaze> You should see change early, especially if you include not ONLY vocal
    hygiene, but also active voice exercises
<Leslie Glaze> I have a mini bias here -- can you tell?  I'm a big believer in voice
    exercise, not just LIMITING voice use.
<Leslie Glaze> When I give folks long lists of things they CAN'T do (no yelling, no
    screaming, no coffee, no alcohol), I'm almost certain that they are going to drop
    therapy becasue it's just too darn hard to keep all those rules
<Robin> what do you mean by voice exercise?
<Leslie Glaze> Um, for voice therapy, I usually consider Stemple's Vocal Function
    Exercises (sustained tones)
<Leslie Glaze> Or, pitch glides, relaxed vocal sighs (Haaaa, Heee, Hoooo) to
    coordinate good breath support and relaxed voice
<Leslie Glaze> I like the concept of doing a short (ten minute) warm up and cool down
    morning and evening. 
<Leslie Glaze> It really helps relax voice.
<Leslie Glaze> Adrienne, do you happen to know if this client has any occupational
<Adrienne> she's a student
<Adrienne> not sure what her major is
<Leslie Glaze> Former cheerleader?  Restaurant waitstaff? Camp counselor?
    Daycare teacher?
<Adrienne> don't know
<Leslie Glaze> These are the types of jobs or interests that seem to ALWAYS get in
<Leslie Glaze> Oh -- here's another: aeorobics instrucotrs. 
<Leslie Glaze> IN any case -- I'd check out what are the number 1, 2,3, things she
    really WANTS to change about her voice quality
<Adrienne> What if she just wants to get rid of the nodules?
<Leslie Glaze> Sometimes nodule speakers (especially female) have trouble with the
    idea of changing voice quality because some like the sound of that low pitched
    "sexy" voice, you know?
<Leslie Glaze> Will you be able to do endoscopy to look at the nodules?
<Adrienne> no
<Leslie Glaze> OK -- well then, here are some other easy tasks to represent the "size"
    or better, the severity of the nodules:
<Leslie Glaze> Voice range profile -- are you familiar with that?
<Adrienne> no
<Leslie Glaze> VRP is taking the minimum and maximum pitch at minimum and
    maximum loudness, so that you can identify the four courners of her dynamic and pitch
<Leslie Glaze> As nodules get smaller, she'll be able to get LOWER and HIGHER in
    pitch; SOFTER and even LOUDER in loudness
<Adrienne> what do the four corners tell you?
<Leslie Glaze> The four corners tell you about pitch and dynamic range. 
<Leslie Glaze> A patient with healthy vocal fold has more pitch and loudness range
    than a speaker with lesions (nodules)
<Leslie Glaze> Yes, Adrienne, the square should get bigger. 
<Adrienne> got it
<Leslie Glaze> In fact, you might try a few mid-range pitches, too, to assess that
    flexibility, too.
<Leslie Glaze> Great -- another thing that's kind of important for an indivodual with
    nodules is to learn to LISTEN to their own vocal behaviors.
<Leslie Glaze> So, you might have her keep a voice journal, too
<Adrienne> now how do I do that as a clinican?
<Leslie Glaze> For the journal, just have her keep a diary of the amount of heavy voice
    use, and note self-reflections of how her voice sounds, also what's happening
    (stressed, rushed?) during those times.
<Robin> what type of equipment do you use to assess pitch?
<Leslie Glaze> Oh, Robin, to assess pitch, Adrienne can use the Visipitch.
<Robin> ok, but what if you are a clinician who doesn't have access to a Visipitch?
<Leslie Glaze> If you don't have access to a Visipitch you can certainly use a piano
    keyboard, an inexpensive pitch pipe, or even a Fo meter (from Radio Shack)
<Leslie Glaze> Loudness can be measured using a sound level meter (I borrow them
    from the Audiologists)
<Robin> The sound level meter I have from Radio Shack is very helpful and affordable
<Erika-URI> Hi everyone...
<Anonymous2161> My question is about hard glottal attacks, they seem to be at the
    root of my client's voice disorder.  She is 7 yrs with nodules., a good deal of
    tension in her breathing
<Leslie Glaze> Hard glottal attacks can be lessened somewhat if your client will use
    breathier voice.
<Leslie Glaze> I try to teach "gliding" into sounds. 
<Leslie Glaze> For example, can you sense the difference between screaming
    ARGHHH! and calling HHHHHEEEYYYY!
<Anonymous2161> I have tried, the sigh into easy onset, do you have any good tricks
    to help a young child grasp this?
<Leslie Glaze> I would actually PRACTICE loud calling with a good long HHHH easy
    onset -- even if it's a LOUD voice, as long as the onset or voice isn't strained. 
    Make sense?
<Leslie Glaze> Young kids can practice this with easy songs (nursery rhymes) or even
    what I call "mad pseech!"
<Leslie Glaze> Mad speech allows the kid to try to say some "no nos" in a vocally
    healthy way.  Examples:
<Leslie Glaze> HHHEEEY!  That's MIIIINE!
<Leslie Glaze> NNOOOO!  I don't waaaant toooo!
<Leslie Glaze> If the kids use a gentle or prolonged onset, prolong the vowels (not
    the consonant transitions, open their mouths widely, and use good breath
    support -- then it's all vocally SAFE!
<Anonymous2161> that helps, every program I read just stresses the vocal
    abuse, I think it is making her paranoid!
<Anonymous4794> I have a sulcus vocalis on my right vocal fold, any suggestions???
<Leslie Glaze> Sulcus vocalis is tricky.  When and how was it diagnosed?
<Leslie Glaze> Sulcus is usually representative of some permanent (?) scarring.  They
    may be congenital or acquired.
<Anonymous4794> Well, I've had it for at least 3 years, but we learned in class that it is
    congenital. My professor went to a convention in July and learned that they are usually
    not curable.
<Anonymous4794> My voice sounds intermittently hoarse and breathy and I don't think
    therapy will help.
<Anonymous4794> If I'm tired, you can tell... the quieter I try to talk, the more hoarse
    and breathy I sound. If I talk loudly, it is less noticable. It sounds like I used to
    be a cheerleader (I wasn't).
<Leslie Glaze> You are correct that therapy is not usually so helpful, except to
    maximize your potential for best voice use.
<Anonymous4794> that's what we figured, I tried it for a little while but got tired of it--
    with school and internship, it was too much
<Leslie Glaze> Understand about therapy -- another idea -- have you tried an
    amplifier?  They're cooler than ever -- allow headset use, and REALLY help preserve
    and amplify voice
<Leslie Glaze> The best amplifier I've ever seen is the Chattervox -- we give it to school
    teachers and they LOVE it..  You wear it on a fanny pack and it lasts all day.
<Anonymous4794> have you heard about any surgeries?
<Leslie Glaze> Yes, they are mostly limited in success, to be truthful.  Some recent
    good results injecting GORTEX into the sulcus to plump it up.
<Leslie Glaze> Have you had a strobe exam, then?
<Anonymous4794> yes, and my professor and an ENT diagnosed me
<Adrienne> 4794, you are an slp student?
<Anonymous4794> yes
<Leslie Glaze> Did the ENT have suggestions?
<Anonymous4794> not really, he said he doesn't specialize in voice, but knew it was a
<Leslie Glaze> About sulcus, I would be VERY careful to select a strong laryngologist
    with some experience in phonosurgery -- if you wish to tell me the region or locale I
    might be able to recommend a source
<Anonymous4794> my professor has heard of a Dr. in NY
<Anonymous4794> I am in Greenville, NC
<Leslie Glaze> North Carolina -- there is a FINE phonosurgeon in NC
<Anonymous4794> thanks, do you know him/her personally?
<Leslie Glaze> Yes, I just presented with him at ASHA -- very very skilled. 
<Anonymous4794> I was there, but I didn't think there was anything on sulcus, did you
    have a good time?
<Adrienne> Robin, wasn't Bernard's poster on sulci?
<Adrienne> I didn't get to see it, but he told me about it
<Anonymous4794> what do you know? adrienne?
<Robin> let me check
<Leslie Glaze> No -- didn't see anything on sulcus, porbably because it's such an
    unresolved area
<Anonymous4794> that's my luck :(
<Leslie Glaze> Another phonosurgical option is thyroplasty medialization -- pushes the
    true vocal fold over to midline and gets rid of the scalloped edge
<Adrienne> 4794- have you thought about being your own subject and doing some
<Robin> Bernard's poster session addressed laryngeal scarring
<Robin> an investigation to see if topical adhesive could be used to induce stiffness in
    the porcine larynx
<Leslie Glaze> Hmmm...induce stiffness, or perhaps -- reduce stiffness?  I don't have
    the program in front of me, but usually, with sulcus and scarring -- stiffness is the
    major problem.
<Leslie Glaze> The ENT / Laryngologist I am thinking of is James Koufman.
<Leslie Glaze> Laryngeal scarring and sulcus might be in the same family of threats to
    the vocal folds and vibration
<Adrienne> sorry 4794, I just remember him saying sulcus and me thinking- like the
    sulci in the brain
<Anonymous4794> that's ok
<Leslie Glaze> Yes, sulcus means "furrow" and that's just a visual description of the
    midline furrow in the vocal fold.
<Anonymous4794> it looked like a "furrow" - indention in the fold
<Anonymous4794> my professor thinks it may have been a cyst that ruptured
<Leslie Glaze> Good call -- that's often the case with acquired sulci. 
<Anonymous4794> that's true
<Leslie Glaze> When a submucosal cyst bursts, sometimes the capsule is left and the
    delicate membranous portion is "sucked in"
<Leslie Glaze> Just checking -- you haven't had a poor voice all your life, have you?
<Anonymous4794> not at all, I have a twin sister and we used to sound just alike
<Leslie Glaze> Aha!  A twin -- well, that's as conclusive as it gets.  Definitely acquired,
<Leslie Glaze> There's a whole new line of voice research devoted to family traits and
    voice characteristics. 
<Anonymous4794> I'm sure of it.., it's very frustrating
<Anonymous4794> my name is Karen, by the way
<Leslie Glaze> I'm sure it is 4794, and I wish I had more good news for you.  Sulcus is
    one of the few disorders that I feel may always require a guarded outcome.
<Leslie Glaze> Hi Karen.
<Robin> The laryngologist is Dr. James Koufman is from Wake Forest University in
    Winston Salem, NC
<Karen> that's close!!! do you know more about him?
<Leslie Glaze> He has an EXTENSIVE website under the The Voice Center, I think...
<Robin> I am familiar with that website...great info
<Karen> what is it?
<Leslie Glaze> Yes, very very aggressive (and CONFIDENT) laryngologist -- I would
    recommend that you see him, consider his recommendations (it WILL inlcude
    surgery), then WAIT..
<Leslie Glaze> Why wait?  To see if you feel the same wish to have surgery in a
<Karen> so, James Koufman at Wake Forest--- THANKS!!!
<Robin> we have the link to the Center For Voice Disorders of Wake Forest University
    on the Resource Link page here on this website
<Leslie Glaze> Phonosurgery for sulcus is just simply not as clear cut as other
    varieties...no matter what anyone tells you.
<Karen> I know, I guess I want to see what my options are
<Karen> do you think it's worth it?
<Leslie Glaze> I would advise you to ask him the same questions I encourage all of
    my clients to ask before a phonosurgery..
<Leslie Glaze> Yes, check out your options, but ask him:
<Leslie Glaze> How many of these have you done?
<Leslie Glaze> May I speak with one of your patients who has had a similar surgery?
<Leslie Glaze> What is the BEST and WORST case scenario as an outcome?
<Karen> don't worry, I heard it may get worse, possibly better, but with any voice
    surgeries, it may come back..
<Karen> this is very different though....
<Leslie Glaze> Yes, all true....I like to remind folks that phonosurgery is a cosmetic
    surgery --
<Karen> it sounds scary
<Leslie Glaze> I am not opposed to it at all -- it's TREMENDOUSLY helpful for many
<Karen> but it won't hurt to ask
<Leslie Glaze> Absolutely NOT!  Great to ask!
<Leslie Glaze> Not trying to scare you -- ask him to describe exactly what he'll do. 
<Karen> ok-- thanks for your help!! you've both been great!
<Karen> I'll keep you posted!
<Leslie Glaze> It's just unfortunate that sulcus -- it that's what it really is...is hard to
<Karen> that's what I've been told :-(
<Leslie Glaze> Happy to hear from you -- email me if you have more questions:
<Karen> Thanks SOOOOO much!
<Leslie Glaze> You are entirely welcome!
<Robin> That was a very interesting exchange of information!  Good luck with
    everything Karen!
<Leslie Glaze> Other questions out there?
<Robin> Erika and anonymous chatters, do you have any questions for Dr. Glaze?
<Erika-URI> it was informative :)
<Erika-URI> But I haven't had any exp. with voice
<Leslie Glaze> No problem -- would you like to work in a school or in clinical setting?
<Leslie Glaze> Many school SLPs feel unprepared to handle kid voice cases
<Leslie Glaze> We've developed a child based "Quick Screen for Voice" that helps
    school SLPs identify and treat voice disorders in kids
<Robin> I'd like to hear about that!
<Leslie Glaze> Linda Lee, Joe Stemple, Lisa Kelchner and I put it together -- it
    includes screening items to look at respiration, voice, resonance, and other risk
    factors for kids.
<Robin> what a great idea!
<Leslie Glaze> It's published in our text (not pushing that), but we are hoping to submit
    to AJSLP this year.
<Leslie Glaze> Say folks -- before the hour is up -- I need to ANNOUNCE that our own
    host, Robin, has quite extensive experience with kid voice, too!
<Robin> which text is it in?
<Leslie Glaze> Clincical Voice Pathology, Stemple, Glaze, and Klaben
<Leslie Glaze> It's worked well -- we've piloted it in Minnapolis and Cincinnati districts.
<Robin> LOL, Leslie!
<Adrienne> Robin, you studied under Diane Bless right?
<Leslie Glaze> Yes, Robin and I BOTH studeied under Diane -- we're both former
<Adrienne> neat
<Leslie Glaze> In fact, Robin's data helped me launch my own doctoral program -- my
    first study used some of her data!
<Leslie Glaze> Thanks, Robin!
<Robin> and thanks to Dr. Glaze, we are both published in the Journal of Voice!
<Robin> Do you use any instrumentation with the assessment?
<Leslie Glaze> Nope -- purposefully observational, task based, but instrument FREE
    for school clincians
<Robin> this sounds like a wonderful assessment/screening tool!
<Robin> is it only available in the text?
<Leslie Glaze> I really like the Quick Screen. 
<Leslie Glaze> Now, it is, but of course I'm happy to send you an online version.
<Leslie Glaze> We also have some handouts that include "Voice Tips for Teachers"
<Leslie Glaze> and an "At Risk" checklist for kids voice problems
<Leslie Glaze> Also a "functional indicators of voice disorders "checklist for kids and
<Adrienne> do you do many inservices Dr. Glaze?
<Leslie Glaze> A few each year -- but I have a busy family so it's tricky to travel...
<Leslie Glaze> Love speaking to new groups, though!
<Robin> any more questions for Dr. Glaze?
<Leslie Glaze> Thanks everyone, for your kind attention and for those good questions!
<Adrienne> Thanks for all your insights and information!!
<Leslie Glaze> Adrienne -- if you are still there -- hope your voice diagnostic goes well!
<Robin> Well, thank you so much, Dr. Glaze...this chat has been VERY
    informative...from sulci to hard glottal attacks
<Leslie Glaze> Happy to be here.  Fun!!
<Robin> We appreciate your time and expertise!
<Leslie Glaze> My absolute pleasure.
<Robin> If you don't mind sending me some of the vocal tips for teachers, we can add
    it to this chat transcript
<Leslie Glaze> Certainly -- will do this tomorrow!
<Robin> Thank you!
<Adrienne> maybe when the school-based clinican chat starts you can come back and
    chat with them
<Leslie Glaze> Yep -- I'd be happy to!
<Robin> Great idea, Adrienne!
<Adrienne> :~)
<Robin> Thanks again and good night!
<Leslie Glaze> Good night, then!
<Adrienne> goodnight

Leslie Glaze and co-authors have supplied the following additional information. Click them to view!

Lee, Stemple, Glaze, & Kelchner
Voice Disorders in Schools: Facilitating Progression from Screening to IEP
ASHA Convention, San Antonio, 1998