Chapter 5 Voice Evaluation

SLP Function in Voice Assessment Voice diagnosis Analyze acoustic, perceptual, and physiological factors I.e., what is the pt. doing relative to respiration, phonation, and resonance? Includes strobovideolaryngoscopy and videoendoscopy Plan voice treatment

Voice Screening Decide whether or not voice evaluation is indicated Compare performance to peers of same age and gender on the following parameters: Loudness Pitch Nasal resonance Oral resonance Quality Boone recommends - N + scale; adds s/z ratio

Team Approach Laryngologist Speech Pathologist Pediatrician Plastic Surgeon Neurologist Orthodontist Prosthodontist Psychologist

Evaluation Case history Respiration-Phonation-Resonance observations Test data ENT exam results Defer decision re voice therapy pending ENT results

Endoscopy and Mirror Laryngoscopy Used by both Laryngologist and SLP Laryngologist - assesses laryngeal disease SLP - assesses laryngeal function related to clinical stimulation Refer to ASHA Guidelines for Vocal Tract Visualization and Imaging (1992b) and Roles of Otolaryngologists and SLPs in the Performance and Interpretation of Strobovideolaryngoscopy (1998)

Instrumental vs. Perceptual Evaluations Good evaluation can be done with or without instrumentation Instrumentation documents and quantifies data, but will not make up for weak powers of observation, modest clinical skills, or lack of knowledge Crucial factor is the ability to listen critically, and think objectively

Elements of a Voice Evaluation Case History Evaluation of Pitch ……………. Frequency Loudness ……... Intensity Quality ……….. Waveform complexity Air wastage ….. Airflow rate Analysis of ENT report Clinical facilitation techniques Analyze videoendoscopic data Observe patient behavior Analyze electroglottographic data

Case History General Description of problem and cause Establish rapport Avoid leading questions Ask questions in different ways Description of problem and cause Reveals pt conceptualization and possible “Reality distance” Dysphonia different in severity/character than warranted by lesion may indicate psychogenic component

Case History - 2 Onset and duration of problem Variability of problem Acute & sudden poses threat to pt Slow onset can suggest gradually developing laryngeal pathology or neurological disease Variability of problem Identify situations of best and worst voice e.g. GERD Abuse Allergies What situations aggravate the problem

Case History - 3 Description of Vocal Use (Misuse/Overuse/Abuse) Use of larynx in daily environment May require environmental observation, e.g. playground behaviors in children Medical Information Previous therapy Family voice patterns e.g. resonance or vocal tremor Medication; hormone therapy Use of smoking, alcohol, drugs Daily fluid intake

Observation of the Patient Describe behavior, don’t just label Consider degree of social adequacy What is the pt most concerned about?

Testing Voice Rating Scale - forces SLP to focus measurements and observations Parameters may include: Pitch Loudness Quality Nasal and Oral Resonance Speaking Rate Variability of Inflection

Testing - 2 Scale used may vary Qualities to observe include Breathiness Hoarseness Thinness Tightness Tremor Strained-strangled

Oral Evaluation Oral peripheral structure and function Cranial nerve examination Observe sites of potential hyperfunction Neck tension Mandibular restriction Laryngeal excursion Thyroid tipping forward with high notes Tongue placement

Endoscopy - use to study vocal tract anatomy and physiology, e. g Endoscopy - use to study vocal tract anatomy and physiology, e.g., mucosal wave Oral Scope - solid/rigid glass rod --> excellent picture Nasal Scope - flexible fiberoptic cable used to view connected speech Stroboscope - flashing light source --> slow motion-like observation of vocal pathology

Advantages of Videostroboscopy Permanent record Studies laryngeal function during typical and clinically manipulated production Aids in pt counseling Aids in compliance with therapy tasks Share pictures with referral source Compare pre and post TX Frame-by-frame analysis of abnormal physiology/mucosal wave Treatment, research, and teaching

Respiration Spirometer - measures lung volume in cc or liters Pressure measuring gauges Manometer Airflow - volume of air passed through glottis in fixed pd, e.g. 100 cc per second on vowel Phonatory Function Analyzer Pneumotachometer Aerophone Use of air supply is more important than lung volume Make judgements about adequacy of respir-ation in speaking and singing tasks wastage of air duration of phona-tion; s/z ratio > 1.4 Pulse hand on abdomen during phonation Wet spirometer - displaces container floating in water, floating higher in proportion to volume of air introduced. Has greater clinical and volume accuracy. Dry - flexible container enlarges with air volume increase Normal subject have ration of 1.0. Patients with glottal margin pathologies have elevated s/z ratios in excess of 1.4, indicating marked reduction in voiced duration values.

Respiration - 2 Visual observation of breathing patterns: Clavicular elevates shoulders on inhalation, tenses strap muscles --> too much effort for too little breath Abdominal-Diaphragmatic abdominal or lower thoracic expansion on inspiration Thoracic no upper or lower thoracic mvmt Respiration - 2 Pneumograph - records thoracic and abdominal mvmt Respiratrace X-ray

Pitch Best pitch - pitch level that produces the most pleasing quality and least amt of hoarseness or roughness, produced with an economy of physical effort and energy Jitter < .6% Shimmer < 2.4% Habitual pitch - pitch used most often

Pitch-2 Perceptual judgement re: Relaxed phonation Efficiency for mechanism Appropriate for age and gender Relaxed phonation yawn-sign “uh-huh” Ability to vary pitch SLN paralysis Virilizing drugs Glandular-metabolic changes Fundamental Frequency (F0) and Frequency range Visipitch Phonatory Function Analyzer Computerized Speech Lab Piano/keyboard Pitch pipe Chromatic Tuner

Loudness Perceptual judgement re: efficiency of level for environment Soft voice Feelings of inadequacy Conductive hearing loss Neurological disorder Loud voice Hyperfunction Sensorineural hearing loss Lack of variation Loudness Sound pressure level meter Visipitch Computerized speech lab Phonatory Function Analyzer Myasthenia larynges - functional loss of muscle strength without a neurological basis. Represents a ‘tired’ larynx. Cords may bow.

Quality Spectrogram shows: --> Periodicity of vocal tone reduced; aperiodicity or noise increased --> Aperiodicity across spectrum, often with abrupt onset; reduced F0 --> increased noise across spectrum; heavier concentrations in first formant Quality Breathiness - audible air escape as approximating edges of glottis fail to make contact Harshness - unpleasant hard, rough, or metallic quality Hoarseness - harshness + breathiness Rheumatoid arthritis meds to relax muscles may produce breathy voice quality

Other Perceptual Judgements of Quality Glottal fry - slight hoarseness noted at bottom of range Register variations - fold approximation incompatible with desired pitch level Pitch breaks - noted in voices pitched too high or low Phonation breaks - sudden loss of voice Sudden abduction of folds Phonatory arrest --> overadduction