terapias para trastornos de la voz
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TERAPIA DE VOZ PARA EL MANEJO DE TRASTORNOS DE LA VOZUNIVERSIDAD AUTONOMA DE SINALOA
HOSPITAL CIVIL DE CULIACAN
CENTRO DE INVESTIGACIN Y DOCENCIA EN CIENCIAS DE LA SALUD
OTORRINOLARINGOLOGIA Y CIRUGIA DE CABEZA Y CUELLODR. ANGEL CASTRO URQUIZOR1 ORL
CULIACAN SINALOANOVIEMBRE 2016
10481
Introduccin
El otorrino suele ser el primero en el camino de un paciente con trastornos de vozEs necesario un manejo conjunto 2
Introduccin
Importante Abstenerce de decir: Quiero que pruebe la terapia de voz - plantan la semilla del fracaso.
Explicar que es algo muy prolongado--< es la premisa bsica para el EXITO
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Introduccin
illustrates the key categoriesof any voice therapy program: increase vocal hygiene,decrease phonotrauma. and increase coordinated voice production.Although the circles delineate separate entities, they are not mutually exclusive
Ver en que categora esta el paciente,
The third circle, increase coordinated vocal production,represents a direct approach to voice therapy; here,the speech-language pathologist directly alters the patient'sspeaking technique in an attempt to increase vocal qualityand efficienc4
Introduccin
Introduccin
Higiene vocalBase de la terapia de voz
Autocuidado de cuerdas vocales
Hidratacin e irritantes
Control activo
Disminucin de cicatrices
HidratacinRLF1
Hidratacin
Research has shown that hydrated vocal folds vibrate withless subglottic pressure than do nonhydrated vocal folds,especially at high pitches ( 10-14). Hydrated vocal folds areless predisposed to trauma than dry vocal folds and showmore resilience from trauma than dry vocal folds8
Initiating voice therapy with the healthiest vocal foldspossible is the launch pad of therapy.
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Reflujo laringofarngeo
Initiating voice therapy with the healthiest vocal foldspossible is the launch pad of therapy.10
Disminucin de fonotraumaVoz producida con esfuerzo por tiempo incrementado o volumen alto resultando en patologa de cuerda vocal.2
The second circle is entitled decrease phonotrauma(vocal abuse/overuse) and is defined as a voice producedwith too much effort for increased durations of time orat an inordinately high volume, often resulting in organicallybased vocal fold pathology. Phonotraumatic vocalbehaviors may result in benign vocal fold lesions (e.g.,nodules, cysts, fibrous mass, polyps) and scar. Suchvocal behaviors as screaming, yelling, throat clearing,continued voicing while sick, vocalization during vigorousexercising, vocal overuse, and speaking over backgroundnoise are examples. Although modem-day voicetherapy is much more than a '"do/don't" list. the prevailing"don't" recommendation in voice therapy is "don'tscream. High-pitched screaming may result in vocalfold hemorrhage. Vocal overuse may also cause vascularchanges (i.e., vascular permeability) in the vocal folds,which may predispose patients to have small and largehemorrhages, often recurrent in nature. Cumulativemicrotrauma to the vocal fold tissues may result in scarring,sulcus vocalis, or both. Voice therapy is often usedin conjunction with surgical intervention for phonotraumaticlesions in this circle.
Educar en las primeras dos sesiones
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Coordinacin de la vozVoz no coordinada: Sonido anormal resultante de desequilibrio de la respiracin, fonacin y resonancia. 3
Tcnicas de compensacin inapropiadas
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Abordajes en terapia de voz
No hay acuerdo general entre los patlogos del habla y el lenguaje Acerca de qu terapias de voz utilizar con voz especfica Trastornos.Most speech-language pathologists usea combination of the therapies listed and do not use onetherapy in particular. Although the following list defineseach specific therapy, voice therapy is not cookbook care. ..Each patient presents with individual needs, and sometherapies work better with some patients than others.13
Mtodo del acento
Proponents of this method report that patients acquire optimal respiratorysupport, coordination of exhalation and phonatory onset..and phonatory effort (19). Research investigating the efficacyof the accent method shows good outcomes ( 19 ,20).14
SOPORTE RESPIRATORIO OPTIMO
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EXPLICACION: APRENDEN NUEVOS PATRONES DE COMPORTAMIENTO,APLICACIN EN LESIONES BENIGNAS: NODULOS; DISFONIA TENSIONAL, FUNCION PARADOJICA
The accent method may be used to treat benign lesions,MID, vocal fatigue. paradoxical vocal fold motion, andmild glottal incompetence(cierre inadecuado).16
Voz confidencial
which results in smaller amplitudes of vibrationand decreased collision force/stress impact.MAS QUE NADA ES PARA DARLE TIUEMPO A SANAR
Aplicacion: LESIONES BENIGNAS; POSOPERATORIO; PERIODOS CORTOS DE TIEMPO, MTD
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EXPLICACION: LIGERA ABDUCCION CON MENOS TRAUMA Y PROTECCION DE NUEVA LESIONAPLICACIN: LESIONES BENIGNAS; POSOPERATORIO; PERIODOS CORTOS DE TIEMPO
Confidential voice therapy may be used to treat benignlesions, MTD, and it can be used during the postoperativeperiod of voice reinstatement It is not appropriate forpatients with voice problems related to glottal incompetence.Also, confidential voice is only used for a period oftime to promote vocal fold healing; once that period is finished,the voice production is shaped into a healthy vocalproduction by other therapies mentioned in this chapter.A soft, breathy voice is not an appropriate goal of any voicetherapy technique.18
Lee Silverman
EXPLICACION: LAS IDEAS MEJOR ESTRUCTURADAS SE DICEN EN SILENCIOAPLICACIONES: PREsBILARINGEA PARKINSON; NEUROLOGICAS
patients with Parkinson disease. The aging voice, and other conditions including stroke, multiplesclerosis, cerebral palsy. and Down sndrome
When patients are asked to speak loudly, not onlydoes vocal fold closure increase but articulatory precisionalso improves.19
LSVT LOUD
LSVT BIG
Tcnicas manuales crico-laringeasReposicionamiento manual directo de la laringe
Observacin de los cambios en voz durante fonacin
Usar cuando los Msculos contribuyen a anormalidades de voz
Tensin muscular desva laringe de posicin neutral
These techniquesare used when extrinsic and intrinsic laryngealmuscle dysregulation (imbalance) contribute to an abnormal-sounding voice.
AREAS dolorosas : TIROHIODEA CARTILAGO TIROIDES Y BORDE INF DE HIOIDES
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EXPLICACION: SE REACOMODA LARINGE A POSICION NEUTRAM MASAJE RELAJA LOS MUSCULOSAPLICACIONES: DISFONIA TENSIONAL; FUNCIONAL E HIPERFUNCIONAL; LESIONES ORGANICAS CON COMPENSACIONES INADECUADAS
The "push-back" maneuver uses digital compression in theposterior direction within the region of the hyoid bone.23
Roy and Leeper reportaron mejora en 93% de 17 pacientes con disfona hiperfuncional en 1 sesin
The "push-back" maneuver uses digital compression in theposterior direction within the region of the hyoid bone.The "pull-down" maneuver impedes laryngeal elevationby applying downward traction over the superior border ofthe thyroid cartilage. The medial compression and downwardtraction maneuver puts pressure directly over the posterioraspect of the thyroid cartilage and thyrohyoid space.Circumlaryngeal massage may directly stretch the laryngealmuscles and effect relaxation.24
Voz resonanteProduccin de sonidos nasales, zumbidos, fricativos
The Lessac-Madsen Resonant Voice Therapy (LMRVT) FisiologaAprendizajeApego 8 sesiones semanales
NASALES HUM, FRICATIVOS ZZZ O VVV PRODUCE UN HABLA BUCAL Y MEJORA LA RELACION DE FINACION CON ESFUERZO
Several studies show that easy, resonant voice is producedwith vocal folds that are barely touching or barely separatedvocal folds, which tend to optimize the relation betweenvoice output intensity and vocal fold impact intensityConsonantefricativa. Una consonantefricativaes la que se produce por un estrechamiento o constriccin de dos rganos articulatorios que modifican la corriente de aire, originando una friccin turbulenta25
Resonant voice may be used with patients who have benignvocal fold lesions, mild glottal incompetence, and hyperfunctional(e.g., MID) voice disorders.26
Reentrenamiento respiratorio
Usado en paradoxical vocal fold motion disorder (PVFMD)27
Open-throat breathingcan be achieved by inhaling through the nose with arelaxed tongue posture or inhaling with pursed lips (e.g.,like sucking a thick milk shake up through a straw) andprolonging audible exhalation through pursed lips on anunvoiced /u/ or by producing a voiceless fricative like /s/,If/ or "sh." Patients are taught both "rescue breathing techniques"when in an attack, as well as rhythmic breathingto "prevent" an attack28
Fonacin de flujoAdaptada de: Stretch and Flow PhonationAprender a no sostener respiracin durante el habla.
4 habilidades bsicas1.- Liberacin de flujo areo2.- Fonacin respirando 3.- Fonacin de flujo4.- Precisin de articulacin
patients recognize that they are not holding their breath is the key
Flow phonation may be used with patients with functionalaphonia. MTD, and mild atrophy and it also may be effectivein patients with benign vocal fold lesions.
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Ejercicios de funcin vocal1950, Briess
Tcnicas de fortalecimiento y coordinacin de cuerdas y msculos larngeos.
Equivalente de terapia fsica para cuerdas vocales
Mejoran la eficacia y relacin de fonacin/esfuerzo por flujo de aire, resonancia y vibracin vocal
Ejercicios de funcin vocal2 repeticiones 2 veces al da
1: EE EL MAYOR TIEMPO POSIBLE2:GLIDING DE NOTA MAS bAJA A MAS ALTA CON PALABRA KNOLL 3.-GLIDING DE LA NOTA MAS ALTA A LA MAS BAJA CON KNOLL4.-SOSTENER KNOLL EN CADA NOTA MUSICAL EL MAYOR TIEMPO POSIBLE
a) vocal warm-up by sustaining the vowel ee" for as long as possible, (b) stretching of the laryngeal muscles by gliding from the lowest note to thehighest note on the word '"knoll (c) contracting of the laryngeal muscles by gliding from the highest noteto the lowest note on the word "knoll," and (d) buildingmuscular power by sustaining musical notes for as long aspossible on the word "knoll" minus the "kn."31
VFEs may be used on patients with benign vocal fold lesions, mild glottal incompetence, and MTD.
EXPLICACION: MEJORA FUERZA Y DESEMPEO DE MUSCULOS Y COORDINACION DE RESPIRACION Y FONACIONAPLICACIONES: LESIONES BENIGNAS, DISFONIA POR TENSION MUSCULAR
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Terapias de tracto vocal semi-ocluido
Zumbido labio Burbujas, trinos de la lengua, fonacin de popote , fricativas sostenidas (/ Z /, / v /), etc.33
Almost all voice disorders can be helped by this generalgrouping of therapies, as well as the nonspecific complaintof vocal fatigue.34
Referencia apropiadas para terapia de voz
A QUIEN REFERIRMUCHOS PX TIENEN MEJORIA CON DOS SESIONESPACIENTE: MOTIVACION; GANAS DE MEJORAR; ACTITUD; APEGOLARINGE: ESTADO FUNCIONAL, En ocasiones con disminuir fonotrauma y humectar bastaPatient factors refer to such things as motivationfor change, positive attitude, compliance to behavioralmodification, adherence to homework, hearing loss, andaccepting responsibility for change.
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