Case study seminar 1 (voice)

Martine is a 60 years old lady who presents at the SLT, with a functional dysphonia (at least:
that is what the ENT-prescription says). So we can assume that the voice problem is not a
consequence of an organic vocal fold leasion. The lady presents with a moderate dysphonia,
with as well a breathy as a rough component. There are voiceless episodes during speech
and pitch is rather low.

Vocal behavior shows a superficial breathing pattern, inappropriate breathing pauses,

(visible) hypertension of the m. sternocleidomastoideus during phonation, insufficient
lowering of the jaw and limited rounding of the lips while speaking, insufficient forward
focus. Both dynamic and pitch range are limited.

Martine herself reports the following secondary complaints: mucus in the throat, frequently
throat clearing, perceptive tension (sometimes pain) in the neck and shoulder area (mainly
at the left side). The medical history shows that she had stomach complaints at a regular
base. At a previous ENT visit PPI’s (i.e. anti-reflux medication) were prescribed and Martine
says that the medication had a positive effect on voice (going from aphonia to dysphonia).

Our patient is a single, she works as a nurse at a home nursing service. The vocal demands,
both professional and social, are rather limited. She has an irregular work schedule and
works partially at the moment to take care of her two grandchildren and her mother who
has a beginning dementia. Martine says that particularly taking care for her mother causes a
lot of frustration and stress. She likes looking after her grandchildren, but the combination of
her job and all the care giving is very heavy. Nevertheless she continues doing all this,
because she feels responsible and a bit guilty, and because she does not see another
solution.

The patient herself addresses her voice problems to fatigue. After a busy week the voice is
remarkably worse than in a calmer period. Besides she says that, considering the past, she
has never had a really good voice and she was often a bit hoarse having a cold. Only in the
last six months the voice problems have increased, incidentally having no voice at all, what
made her look for help. The complaints started at the same time as the care for her mother
increased.