[Psychogenic Aphonia - Succesfull Multiprofessional Treatment of a 13-Year-Old Girl - A Case Report]. / Psychogene Aphonie ­ erfolgreiche multiprofessionelle Behandlung eines 13-jährigen Mädchens ­ ein Kurzbeitrag aus der Praxis.

Psychogenic Aphonia - Succesfull Multiprofessional Treatment of a 13-Year-Old Girl - A Case Report Psychogenic aphonia is a rather rare disorder with a point prevalence of 0.4 %. It appears more frequently in females than in males. There are only few reports in the scientific literature about children affected by psychogenic aphonia. The diagnostical and therapeutical approach must be multimodal. The case reported here describes a 13 year-old girl with a psychogenic aphonia, the course of her illness und the efforts of treatment until full recovery of voice and speech.

Management of aphonic patients following total laryngectomy and trachea esophageal puncture.

BACKGROUND: Trachea esophageal puncture (TEP) is performed following total laryngectomy to allow speech and communication. The most common reason for long-term speech failure in this population is hypertonicity of the constrictor muscle. OBJECTIVES: To present our experience with the treatment of aphonic patients after total laryngectomy and TEP and suggest a protocol for treatment. METHODS: Of 50 patients who underwent total laryngectomy and TEP, 6 suffered from aphonia after surgery. All patients underwent radiotherapy with or without chemotherapy. Delay in speech continued for more than 6 months after surgery. The patients received percutaneous lidocaine injection to the neopharynx in different locations around the stoma in order to map the hypertonic segments in the neopharynx. RESULTS: Lidocaine injection immediately enabled free speech in five patients. One patient (patient 6) suffered from aphonia and from severe dysphagia and required a feeding tube. This patient succeeded to pronounce abbreviations after lidocaine injection. Another (patient 4) gained permanent ability to speak following a single lidocaine injection; this patient was not injected with botolinium toxin (BTX). For the other five, lidocaine had a transient effect on speech. These patients received BTX percutaneous injections. After BTX injections four regained free speech within 14 days. The fifth patient (patient 6) gained a conversational voice and his swallowing improved only after additional intensive speech therapy. CONCLUSIONS: Percutaneous lidocaine and BTX injections represent first-line treatment in this population, with good success and minimal complications.

[A single appointment with a speech therapist can release a patient, even from a long-term aphonic status! Three clinical cases]. / Consulter un(e) phoniatre peut "Libérer" d'une "aphonie rebelle"! Trois cas cliniques évoqués.

Those three clinical cases involved aphonic female patients without any laryngeal disorders for their ENTs. 1) The first one had been out of work since 11/2 year because of her aphonia. She was still suffering from it in spite of a weekly speech therapy session and a monthly psychotherapy appointment. 2) The second patient had been aphonic for 3 weeks. Three different ENTs had renewed her prescription of work stoppage, even with normal laryngeal exam. 3) The third had lost her singing voicing ability during a performance in a national festival of songs and had to cancel the followings events. Even if all of them were waiting for a "miracle pill" they recorded their training session and left this single phoniatrician appointment with their restored voicing ability.

[Hysterical mutism]. / Le mutisme hystérique.

BACKGROUND: Conversion disorders comprise many clinical pictures, including hysterical mutism. Hysterical mutism has emerged as a clinical entity that remains difficult to diagnose, and whose treatment is poorly codified. Hysterical mutism is a disorder of the vocal function without changing the integrity of the body, resulting in loss of voice. Identified at all times, hysterical mutism entered the medical field in the late nineteenth century, under the direction of Jean-Martin Charcot (Salpêtrière School). Since then, although the disorder has emerged as a clinical entity, it remains little known. METHOD: A systematic review of the literature. We performed electronic literatures search of relevant studies using Medline, SUDOC, and BIUM. Search terms used were mutism, functional aphonia, conversion disorder, hysteria. RESULTS: The epidemiology of hysterical mutism is difficult to assess. The first limitation is the lack of consensensual diagnostic criteria. An estimate of its frequency may be advanced through registries consultation of otolaryngology-head and neck surgery. Through a literature review, emerges a rare disorder, about 5% of functional dysphonia. The sex-ratio is in favour of women. Regarding age of onset of disorder, functional aphonia mainly concerns adults with an average around the age of 30-40 years. The onset of the disorder typically involves a sudden onset and a recent stressful event. The duration of the disorder is difficult to specify. It appears that this dysfunction is rapidly reversible and that the majority of patients are in remission of this disorder within three months. The recurrence of dysfunction seems to be frequent. The existence of psychiatric comorbidity did not appear to be the rule. The natural history of this disorder is not known making it tricky to evaluate the efficiency of therapeutic approaches. CONCLUSION: Today the term hysterical mutism does not appear as an entity in either international classification. It belongs to the category of conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Identified as a medical entity described by the school of the Salpêtrière, this disorder has raised little interest. The medicalization of the condition remains difficult because of the importance of stigma associated with it, which contributes to the rejection rather than support of patients with mutism. To better understand this disorder and improve the care of patients who suffer, renewed interest is warranted.

A historical vignette (23). A voiceless poet at Bourbon - l'Archambault: Nicolas Boileau.

In 1687, the poet was stricken by an aphonia that would last six months. He underwent a cure at a spa in the Massif Central, but without result. The correspondence between Boileau and his friend Racine allows us to relive the atmosphere of being a spa guest in the 17th century (Figure 1). Boileau's aphonia seems to have been functional for the larger part.

[Rehabilitation after total laryngectomy--vision and realization]. / Rehabilitacja chorych po laryngektomii--wizja a realizacja.

Universality, early initiation, complexity and continuity - should be the main attributes of rehabilitation in patients after laryngectomy. The authors discuss the problem of universality and accessibility of rehabilitation in Poland. A great role in realization of this attributes played since 20 years the Polish Society of Laryngectomees. Till now the governmental help and the participation of the National Health Fund for the patients after laryngectomy is very limited. The early rehabilitation should be started before the operation and a particular note must be taken to the patient's changed vital situation after the surgical treatment. The complexity of the rehabilitation must cover the whole spectrum of rehabilitation; it means voice and speech therapy, the improvement of respiratory system function, the problems of respiratory air conditioning and the psychological as well as social psychological aspects. The authors describe a model of such a complex rehabilitation that can be provided in health resorts. In the postoperative period the role of the laryngectomee clubs and associations is very important to assure the continuity of rehabilitation.

[Management and therapy in functional aphonia: analysis of 500 cases]. / Postepowanie i leczenie w afonii psychogennej: analiza 500 przypadków.

INTRODUCTION: The article reviews current opinions on etiopathogenesis and management of functional total loss of the ability to produce loud voice. Psychogenic aphonia refers to involuntary whispering despite a basically normal larynx. MATERIAL AND METHODS: [corrected] The longitudinal study was carried out on 500 patients treated for psychogenic aphonia during 32 years (1972-2004). Of the facilitating techniques, the following were useful for phoniatric therapy: relaxation and respiration, gargle, chewing, pushing, inhalation phonation, masking, phonetic exercises. RESULTS: During the first day of vocal exercises the voice return to 410 patients (82%). The others required carrying on vocal therapy. CONCLUSIONS: The basic importance of phoniatric therapy is recovering the voice during the first day of vocal exercises. Sometimes the aphonic patient profits most from symptomatic voice therapy concurrent with psychotherapy.

Development of a Low-Cost, Noninvasive, Portable Visual Speech Recognition Program.

OBJECTIVES: Loss of speech following tracheostomy and laryngectomy severely limits communication to simple gestures and facial expressions that are largely ineffective. To facilitate communication in these patients, we seek to develop a low-cost, noninvasive, portable, and simple visual speech recognition program (VSRP) to convert articulatory facial movements into speech. METHODS: A Microsoft Kinect-based VSRP was developed to capture spatial coordinates of lip movements and translate them into speech. The articulatory speech movements associated with 12 sentences were used to train an artificial neural network classifier. The accuracy of the classifier was then evaluated on a separate, previously unseen set of articulatory speech movements. RESULTS: The VSRP was successfully implemented and tested in 5 subjects. It achieved an accuracy rate of 77.2% (65.0%-87.6% for the 5 speakers) on a 12-sentence data set. The mean time to classify an individual sentence was 2.03 milliseconds (1.91-2.16). CONCLUSION: We have demonstrated the feasibility of a low-cost, noninvasive, portable VSRP based on Kinect to accurately predict speech from articulation movements in clinically trivial time. This VSRP could be used as a novel communication device for aphonic patients.

Aphonia and dysphagia after gastrectomy.

A 67-year-old male was referred to our otolaryngological clinic because of aphonia and dysphagia. His voice was breathy and he could not even swallow saliva following a total gastrectomy for gastric carcinoma performed 2 weeks previously. Laryngeal fiberscopy revealed major glottal incompetence when he tried to phonate. However, both vocal folds abducted over the full range during inhalation. The patient could not swallow saliva because of a huge glottal chink, even during phonation. Based on these findings, he was diagnosed as having bilateral incomplete cricoarytenoid dislocation after intubation. The patient underwent speech therapy; within 1 min his vocal fold movement recovered dramatically and he was able to phonate and swallow. There have been few case reports of bilateral cricoarytenoid dislocation, and no effective rehabilitation has been reported. We believe that our method of vocal rehabilitation serves as a useful reference for physicians and surgeons worldwide.

Spastic dysphonia.

130 cases of spastic dysphonia are reviewed with special emphasis on the etiology of the disorder. An analysis of the circumstances surrounding the onset of the disease points strongly to a psychogenic origin of the disease in, at least, the vast majority of the cases.

Visual feedback of vocal intensity in the treatment of hysterical aphonia.

This case report describes the successful though temporary removal of a hysterical aphonic symptom in a 49-year-old male patient by using visual feedback of changes in vocal intensity. Following symptom removal the patient experienced considerable emotional distress due to a number of factors. His aphonia returned and has proven resistant to subsequent intervention. At a 1-year follow-up his condition was found to be unchanged. The case is discussed in relation to the common controversy over the wisdom of symptomatic treatment for hysterical reactions, and a practical means of resolving the disagreement is considered.

Functional aphonia in young people.

The study reviewed the case histories of 14 young aphonics. A questionnaire was completed by the five speech therapists involved with these cases. The patients were all initially examined by E.N.T. specialists and then treated by speech therapy. All the patients were 'cured' by speech therapy, that is the voice returned to its premorbid state. This study looks at common characteristics of presentation, different approaches to management, and the patterns of voice return.

Functional voice disorders. A review of 109 patients.

The records of 109 patients, presenting with functional voice disorder during the years 1977-1981, have been reviewed. The mean age was 45 years and the F : M ratio is 2 : 1. Excess voice use was not obviously an aetiological factor. Sixty-one of the 109 patients (56 per cent) were cured by speech therapy, in that their voices returned to their pre-morbid state, and a further 28 (26 per cent) were improved by therapy; seven patients (6 per cent) did not improve and 13 (12 per cent) were lost to follow-up. Of the patients that were 'cured', 54 per cent were discharged after three months' treatment and 72 per cent after six months' treatment. Eight per cent required treatment for more than a year.

Botulinum toxin injection for failed tracheo-oesophageal voice in laryngectomees: the Sunderland experience.

Spasm of the pharyngo-oesophageal segment is one of the important causes of tracheo-oesophageal voice failure. Traditionally it has been managed by either prolonged speech therapy, surgical pharyngeal myotomy or pharyngeal plexus neurectomy with varying degrees of success. Botulinum neurotoxin has been found to be effective in relieving pharyngo-oesophageal segment spasm. Since 1995, we have used botulinum toxin injection on 10 laryngectomees with either aphonia or hypertonicity due to pharyngo-oesophageal segment spasm. Early results were analysed by the Sunderland Surgical Voice Restoration Rating scale. Seven of the 10 patients, who were previously completely aphonic, developed voice following this therapy and are using their valve choice as their only method of communication. Out of the three patients who were treated for hypertonic voice, two did derive some benefit from the procedure. One patient developed a hypotonic voice, which lasted for a few months.

Cough offset schwa as a means of eliciting initial phonation in functional aphonia: two case reports.

The use of the schwa vowel at cough offset is an automatic production that can be easily prolonged and modified as a phonation-producing device without requesting initial voluntary phonation on the part of the patient. It is presented as a clinical method that was successful for the author with two female patients presenting functional aphonia. The technique lends support to the suggestions by Aronson (1969) and Boone (1971) that the symptomatic approach can be successful with the functional aphonic patient. The clinician should be mindful of the fact that in certain cases of functional aphonia an appropriate referral might be needed to deal with emotional aspects after voice is regained.

The modification and generalization of voice loudness in a fifteen-year-old retarded girl.

A fifteen-year-old severely disturbed girl was treated for aphonia. Because of the extent of her withdrawal, the subject was conditioned in a laboratory setting and received tokens for speaking loudly enough to operate a voice-operated relay. Conditioning at first consisted of saying 100 monosyllabic words, with the possibility of reinforcement on each word. Later, the subject was required to say a polysyllabic word, and finally, five or six words per token. The subject was shaped to speak with normal loudness in the laboratory, and generalization to a reading situation in the laboratory was measured and observed to occur, at first for a few minutes, and later for a longer period. Generalization to a reading situation in the classroom did not occur, but the subject's voice loudness also increased in the classroom when several new reinforcement contingencies were put into effect there.

Short-term strategic treatment in traumatic conversion reactions.

The therapists applied the strategic approach in four cases that demonstrate a variety of traumatic and conversion reactions. The therapists accepted the definition of the problem as presented by the patients or their families at the overt level, and were able to treat the conversion symptoms. At the latent level, however, there were additional system-focused goals. In the first stage, the therapists strove to understand the inner world and cultural background of their patients, their dynamics and the circumstances surrounding the event that led to the conversion reaction, or the traumatic significance of the event when it was a posttraumatic conversion. It was then possible to develop a strategy for treatment and to decide which treatment techniques were appropriate. The therapists created situations that encouraged change and pushed the patients to abandon the symptom. This therapy model is composed of behavioral and paradoxical techniques based on the understanding of the dynamic material and cultural content.

[Psychogenic aphonia; an effective and rapidly treatable conversion]. / Psychogene afonie; een goed en snel behandelbare conversie.

Psychogenic aphonia is a conversion symptom which is quite annoying to the patient. This article concentrates on the treatment of psychogenic aphonia. The literature contains only few articles on this subject. We present in detail a very efficient way of treatment with directive and biofeedback aspects. Central to the treatment is a direct approach of the symptom, based on the idea that due to the time factor the aphonia has become dissociated from the unconscious psychological conflict. The treatment starts with a double cough so that the vocal chords close. At the same time the ear, nose and throat specialist looks with the laryngoscope and corrects directly which gives an optimal learning effect. In 1988 and 1989, 23 patients were treated with this method. The duration of the aphonia varied from two weeks to two years. In eight of the patients the aphonia recurred. Patients were treated for a total of 45 episodes of aphonia. In all cases the voice returned within an hour.