T. 8-year-old boy came to my office upon referral from his speech therapist. The reason for the consultation was chronic hoarseness accompanied by intermittent aphonia. His speech therapist had already seen him for three sessions. After the third session he began to question the effectiveness of his treatment due to a lack of progress. T. came to me accompanied by his mother, who was very useful for the clinical history.
T.'s voice has always been hoarse, in memory of his mother. What he had noticed differently was a gradual increase in the effort that T. used to produce the voice, with no particular seasonal correlations. According to Mom, T. didn't seem overly concerned about his ailment, but every now and then she complained that her throat was dry and tired and occasionally, it was hard for him to get his voice out.
An otolaryngologist, who performed a laryngeal rhinoendoscopy before referring it to the speech therapist, reported fullness at the medial margin of both vocal cords in the anterior third, and at the junction of the posterior two-thirds. Furthermore, the phonation was accompanied by an anterior-posterior 'squeezing'.
T. is the fourth of five children. No other siblings have voice disturbances. T. is a very active kid with both games and sports, he also loves to sing. As for school and sports performance, the mother stated that T. has always put a lot of pressure on himself to excel, he has always been very competitive. As for the family environment, not considering the many children in the house, the home environment is not very noisy.
Regarding birth and development, these have been described as 'clinically perfect, very fast delivery'. The mother does not speak of T. as a child usually crying or screaming. As a child he did not have colic. he only reported one episode of high fever associated with flu symptoms at age 4, which required short-term hospitalization. He has never had any surgery or head or neck injuries.
At the time of the visit, T. was in good health. His story was negative for allergies, nasal drip, tonsillitis or adenoids and gastroesophageal reflux. Her fluid intake is good. He sleeps well.
The speech therapist's therapeutic goals have focused on reducing effort, decreasing vocal abuse, and improving vocal hygiene.
On instrumental analysis, the spoken fundamental frequency was estimated at 275Hz, which is within normal limits for her age and gender. When he was then asked to sing a scale, the phonatory range was 262-466Hz, about eleven semitones, which is outside the normal limits. When he was asked to imitate a siren the difficulty was to maintain the phonation, due to multiple unvoiced interruptions.
Overall severity was rated as 4 on a 5-point scale (moderate to severe). Hissing and straining were classified as 4, while hoarseness was classified as a 2. There were many unvoiced pauses, lasting from one syllable to several consecutive words. For 1 minute of reading, 10 unvoiced pauses were found out of a total of 103 words (10%). Similarly, eight unvoiced interruptions (16%) occurred over the course of a required 1 minute monologue of 50 words. most of the pauses occurred towards the extremities of the respiratory groups. Hard glottal attacks have also been highlighted.
At rest T. had normal breathing patterns. The breath hold for the speech, however, was shallow with focus on the upper chest. The maximum phonation duration for sound / a / was on average 14 seconds, which is within normal limits for age.
On palpatory evaluation, the speech therapist had found a prominence of the laryngeal girdle muscles, in particular of the SCOM, especially during phonation. He had tried applying Aronson's laryngeal massage which produced a marginal change in voice quality.
Osteopathically I found skull base compression ++ right condylar portion with left lateral strain, complete asynchrony of: phonatory tripod, laryngeal structures (with somatic c.thyroid dysfunction in right rotor superiority, c.cricoid in posterior tilt), hyoid (dysfunction in bilateral superiority and posteriority), thoracic outlet and thoracic diaphragm, plurisegmentary dysfunction D1-D4 segment). I therefore started to treat osteopathically with CS, FU, articulatory and BLT techniques, collaborating with the speech therapist for 5 sessions which was then followed by a new phonatory evaluation that gave normalized parameters.
At the end of the OMT sessions, the speech therapist closed everything with a respiratory re-education work.
To date, 2 years have passed since the treatment period and T. has no longer presented the disorders that accompanied him from birth.