Kristine Tanner, PhD, CCC-SLP, Brigham Young University, Provo, Utah
Work Setting: Health Care Work Setting: Private Practice
An interprofessional team collaborated across specialties to diagnose a 20-year-old college student with muscle tension dysphonia and paradoxical vocal cord dysfunction. After the student returned to college, the initial team worked with a local speech-language pathologist (SLP) and with a college voice coach to continue her treatment. After 6 weeks, the student’s speaking voice returned to normal limits, and her singing voice and vocal endurance returned to baseline levels.
Megan is a 20-year-old woman majoring in music, dance, and theater at a small liberal arts college. She wants to be a professional singer and actress with a touring musical theater company. Megan was on her first 2-week tour with her college performing group when she experienced sudden-onset breathing problems and hoarseness. She was rushed to the emergency room at the local hospital, where she received pulmonary, cardiology, and otolaryngology workups.
The results of these tests were unremarkable, and the otolaryngologist on call referred her to the outpatient multidisciplinary voice clinic. She was discharged with normal breathing and oxygen saturation levels but persistent hoarseness. The clinical nurse coordinator contacted the otolaryngologist to obtain medical records and to ensure continuity of care.
The interprofessional practice (IPP) team consisted of the following professionals:
Two days after her emergency room visit, Megan had an appointment with the IPP team at the outpatient voice clinic. At the meeting to discuss Megan’s case, the team agreed on their individual assessment roles and responsibilities.
When the SLP and laryngologist assessed Megan, they found that her breathing was normal, but her voice quality was aphonic. A standard head and neck examination revealed no significant findings. Symptom provocation trials were unsuccessful, and flexible videolaryngostroboscopy, laryngeal function studies, and stimulability testing revealed no structural or neurological changes. The singing voice specialist assessment was postponed, given Megan’s aphonic voice quality.
Afterwards, during the IPP team briefing, the SLP discussed medical options with the laryngologist, and they determined that Megan would benefit from a lidocaine rinse procedure. The SLP suggested that the singing voice specialist do a consultation afterwards, and the team discussed the pros and cons of this approach. Collectively, they agreed to perform the laryngeal visualization evaluation as a team.
The SLP performed a flexible laryngoscopy while the laryngologist administered topical lidocaine to the larynx. The endoscope was left in place to provide visual biofeedback to Megan. The SLP and the singing voice specialist performed therapeutic probes, and Megan began demonstrating normal voicing during syllables and during short phrases. The team employed negative practice so that Megan could alternate old and new voice production. The singing voice specialist determined that negative practice also helped Megan with her singing voice at that time.
Megan was diagnosed with muscle tension dysphonia and, likely, paradoxical vocal cord dysfunction. The IPP team members educated Megan on these diagnoses, including teaching her several voice therapy, rescue breathing, and singing voice techniques.
Because Megan’s college is located in a different state from the outpatient voice clinic, the team worked to develop a treatment plan with local professionals in Megan’s college town. Once she returned home, the IPP team was expanded to include a local SLP and Megan’s college voice coach. The assessing SLP and the singing voice specialist were selected as team facilitators. They obtained a HIPAA release so that they could share findings with the local SLP and with the local voice coach.
Via IPP phone meetings, the two SLPs and the two voice coaches recommended an initial trial of five voice sessions. They also reflected upon techniques to provoke vocal cord dysfunction symptoms, given that Megan’s initial assessment had failed to reproduce the symptoms.
The local SLP and the college voice coach used the IPP team’s initial plan to work with Megan and continue the improvements established during her initial assessment. They periodically reached out to the assessing SLP and singing voice specialist to discuss treatment and report progress.
Megan’s symptoms diminished during day-to-day conversation after three treatment sessions with the SLP. However, it took 6 weeks of working with the local voice coach for Megan’s speaking voice quality to return to normal and for her singing voice and vocal endurance to return to baseline levels.
After Megan participated in five appointments over the course of 2 months with the local SLP, she was discharged. The local SLP sent the discharge summary to the assessing IPP team. The local voice coach continues to work with Megan on healthy singing and theater voice production during their regularly scheduled sessions at the college. No further SLP voice treatment was indicated. The IPP team has instructed Megan to contact either her local SLP or the original assessment team should her symptoms recur.