122 Voice Disorders and their Management

Where there are medical conditions such as laryngopharyngeal reflux,

chronic sinusitis, allergic reactions of the vocal tract and chronic airways
disease which predispose the client to vocal hyperfunction and coughing or
throat clearing, referral for medical and, possibly, surgical management is
warranted (Sataloff, 1987c). Laryngopharyngeal reflux, for example, may be
controlled with high doses of H2-receptor agonists such as omeprazole and
lifestyle modifications (e.g. avoidance of foods which trigger reflux, avoid-
ance of eating close to bedtime, elevation of the head of the bed by 12 cm
during sleep, use of antacids) (Morrison and Rammage, 1994; Koufman et
al., 1996). It should be remembered, however, that many medications used
to treat other conditions such as allergies and sinusitis may have a negative
effect on the vocal fold cover and that these conditions are also notoriously
difficult to resolve (Reed Thompson, 1995; Colton and Casper, 1996).
In cases where laryngeal irritants are likely to underlie vocal hyperfunc-
tion, the client will work with the clinician to either remove those irritants
or to reduce their effects on vocal behaviour. Tobacco and marijuana
smoking and the use of other recreational drugs such as cocaine will be
discouraged, but referral to a formal programme for elimination of such
drug use may be necessary because many clients need considerable
support and counselling in order to abandon the habit. Similarly, clients
who have a high caffeine intake will be advised to reduce the number of
drinks containing caffeine and to increase water intake to compensate for
the dehydration which can be associated with caffeine. The client will also
be advised to avoid environments which are excessively dry, dusty or
polluted or to minimize their potential harm by increasing oral hydration
and environmental humidity levels. Although cessation of medications for
medical conditions such as asthma, hypertension and depression will be
contraindicated, consultation with the client’s medical practitioner may
allow for changes in medication and modification of dose levels which will
reduce the negative effects of the medication on vocal functioning.
When hyperfunctional voicing appears to result from faulty learning
mechanisms, an aetiological approach will also be required. A common
example is the person who adopts a low pitch and glottal fry in an effort to
convey authority (Stemple et al., 1995a). This pattern was once almost
exclusive to men, but with recent sociocultural changes (Pemberton et al.,
1998), women may also demonstrate such learned hyperfunction. In this
case, effective intervention will involve counselling which focuses on the
client’s vocal image and the vocal damage which may result, as well as
teaching the client to use alternative means of conveying the desired
image (e.g. altering prosodic patterns and non-verbal behaviour).
Although psychogenic factors can underlie vocal hyperfunction (Rollin,
1987; Aronson, 1990; Goldman et al., 1996), there is considerable contro-