Introduction
Facial-Flex^® is a lightweight, mouthpiece sized device which provides dynamic resistance during oral motor exercises. It has been shown to strengthen the circumoral facial muscles when used in a program to maintain constant resistance with daily use. 1,2 Facial-Flex^® is currently under study as an adjunct to speech therapy in patients with disorders of both muscular weakness and hyperfunction that effect voice. The following case report demonstrates early results in a patient with both of these problems.

Case report

The patient is a 57 year old male with a 4-5 month history of hoarseness, hypernasality and strain with voice use. Otolaryngologic examination including strobovideolaryngoscopy revealed a right superior laryngeal nerve paresis, muscle tension dysphonia, and gastroesophageal reflux laryngitis. He was referred for speech therapy evaluation and treatment.

Initial examination of the oral mechanism revealed slight weakness of the lips and circumoral muscles on the left side, slight left sided tongue weakness and spasms of the left neck and cheek. During conversational speech and reading passage, throat jaw and tongue tension was evident and placement of the tone was generally posterior. His vocal quality was slightly hoarse.

The patient completed an eight-week course of therapy including four, biweekly, 30-45 minute speech therapy sessions and exercise with the Facial-Flex^®. He successfully progressed for 60 repetitions daily with 6 ounce resistance to 300 repetitions daily with 8 ounce resistance during the study period. At the completion of the therapy course both the patient and the therapist noted complete resolution of the asymmetric left facial weakness and of the cheek and neck spasms. Questionnaires completed by both patient and therapist separately reveal that they both felt that the Facial-Flex^® made the speech therapy easier to complete and more successful. The patient has had improvement in vocal quality, strength stamina, pitch range and ease of use.

Discussion

This is a single case report of the subjective findings of a therapist and patient with regard to use of Facial-Flex^® as an adjunct to a program of speech therapy. These early results are exciting because they demonstrate the safe and efficacious use of Facial-Flex^® in a patient with voice problems secondary to both muscle weakness and compensatory muscle tension.

Voice disorders result from a variety of local and systemic conditions. Some patients have poor vocal quality or strength due to lesions such as a laryngeal neoplasm or injury, neuromuscular weakness, voice abuse or psychological stress. Diseases of neuromuscular weakness, abnormal muscle motion and disorders of central neurologic control can cause poor speech articulation and weak voice quality.

Many voice disorders are associated with a weakness, incoordination or abnormal use of facial and cervical muscles. Normal voice production requires movement and stabilization of the larynx by the extrinsic laryngeal muscles in the neck. The facial musculature is effected as an extension of the cervical muscles and is a primary component in the formation of language. Tone of the facial and cervical muscles also has an influence on vocal resonance in the oral cavity and pharynx. Weakness of these muscle groups may result in complaints such as hoarseness, breathiness, loss of vocal volume, loss of pitch range, vocal fatigue dysarthria and slurred speech. Conditions causing such weakness include cerebrovascular accident (stroke), chronic neuromuscular diseases (i.e. multiple sclerosis, ALS), myasthenia gravis, surgical trauma, Bell's palsy, and any chronic debilitating disease.

Speech therapy provided by a Speech-Language Pathologist trained in voice care and singing voice training provided by a voice teacher is beneficial in the treatment of almost all patients with disorders of voice secondary to related neuromuscular dysfunction. Strengthening exercises are utilized to correct weakened muscle groups and provide balanced muscular effort. Specific exercises and maneuvers are taught to promote relaxation in muscle groups with demonstrated hyperfunction. Additionally the promotion of general vocal hygiene and proper speaking and singing technique will result in more balanced and proper use of the cervicofacial muscles.

Facial-Flex^® is under study and an adjunct to speech therapy for all disorders of cervicofacial muscle strength or spasm causing dysphonia.

1.Grove GL, Rimdzius SW, Grove MJ, Changes in f'acial skin biornechanics due to a mechanically aided resistance exercise program Clinical Research, 40(2):442, 1992.

2.Grove GL, Rimdzius SW, Zerweck CR, A mechanically aided resistance exercise program for sagging facial muscles, Journal of Geriatric Dermatology, 2(5):152-158, 1994