Voice evaluation

TOpics Definition of the terms assessment, evaluation and diagnosis The screening process for voice disorders Medical Evaluation for Voice Disorders Assessment, Evaluation and Diagnosis for Voice Disorders by the clinician

Definitions

Definition Assessment Evaluation Diagnosis The process of collecting relevant data for clinical decision making Evaluation It’s an appraisal of the implications and significance of the assessment Diagnosis Making a decision as to whether a problem exists, and if so, differentiating it from other similar problems.

The screening process

Screening forms The Boone Voice Program for Children (Boone, 1993) Addresses respiration, phonation and resonance Is appropriate for students in all grades Natural samples of voice and speech Simple three-point system

Screening forms The Quick Screen for Voice (Lee, Stemple and Glaze, 2005) Addresses respiration, phonation and resonance Is appropriate for students from preschool through high school Samples of spontaneous conversation, picture description, imitated sentences, recited passages, counting and other natural samples of voice and speech

Medical Evaluation for Voice Disorders

Medical Evaluation for Voice Disorders All patients/clients with voice disorders must be examined by a physician. The physician’s examination may occure before or after the voice evaluation by the clincian.

Medical Evaluation for Voice Disorders Only the decision about whether to begin voice therapy need be deferred until all medical information is obtain. On completion of the medical examination, its is equally important for the laryngologist to communicate the findings to bout the patient and the referring clinician.

Medical Evaluation for Voice Disorders Physical examination should include: General physical condition A thorough ear, nose and throat evaluation Visual inspection of the larynx !!! Mirror laryngoscopy Endoscopic laryngoscopy

Assessment, Evaluation and Diagnosis for Voice Disorders by the clinician

Assessment, Evaluation and Diagnosis The clinician’s role: Describe the structure and function of the larynx Make recommendations regarding Further testing needed to understand the etiology of the voice problem Maintenance of the voice problem Treatment

Assessment, Evaluation and Diagnosis The clinical process of the voice assessment: Review of auditory and visual status Relevant case history Standard and nonstantndardized methods Use of noninstrumental and/or instrumental measures Perceptual ratings, acoustic analysis, aerodynamic measures, electroglottography and imaging tech

Assessment, Evaluation and Diagnosis The clinical process of the voice assessment: Selection of standardized measures for documented ecological validity Monitor voice status and ensure support for patient

1. Case history

Case history Description of the problem and cause directly The patient’s reality distance Onset and duration of the problem Acute or gradual Long or short Variability of the problem Timetable of the consistency of patient’s problem Important for treatment Description of vocal use (daily use-misuse) In most life situations Additional case history information Previous voice therapy Family voicing patterns

2. Noninstrumental assessment

Noninstrumental assessment Includes: Behavioral observation The oral-peripheral mechanism examination Auditory-perceptual assessment Quality of life in persons with voice disorders

1. Behavioral observation This tells more about patients than their histories and assessment data. We can see: Extremely sweaty palms Avoid eye contact with people Use excessive postural changes Demonstrate facial tics

2. The oral-peripheral mechanism examination Examination of the face, oral and nasal cavities and pharynx is also required. Mandibular restriction (下颌回缩) Unusual downward or upward excursion of the larynx during the production of various pitches

3. Auditory-perceptual assessment Factors might influence judgment The natural of the speaking task Listener experience and training The type of rating method used GRBAS CAPE-V(the Consensus Auditory Perceptual Evaluation of Voice)

3. Auditory-perceptual assessment GRBAS(Hirano, 1981) G(grade):the overall severity of voice abnormality R:rough B:breathy A:aesthenic(weakness) S:stain A four-point system

3. Auditory-perceptual assessment CAPE-V(Kempster,Gerratt, 2008) 2 specific psychometric properties: Visual analog scales Unanchored 6 aspects of voice: Overall severity Roughness Breathiness Strain Pitch loudness

4. Quality of life in persons with voice disorders Includes: Overall health-related quality of life Communication-related quality of life

3. instrumental assessment

instrumental assessment Includes: Laryngoscopy Acoustic analyses Aerodynamic measurements Electroglottography

1. Laryngoscopy Appropriately trained clinicians may employ indirect laryngoscopy and other laryngeal visualization techniques

2. Acoustic analyses Valid acoustic measurements can: Discrimination Positive correlation Sufficient stablilization

2. Acoustic analyses 5 acoustic properties of the vocal signal: Frequency Intensity Perturbation Sound spectrography Signal(or harmonics)-to-noise ratio

2. Acoustic analyses Frequency Speaking fundamental frequency(SFF) Average F0 Frequency variability F0.SD Phonational frequency range(PFR) Maximum phonational frequency range(MPFR) Voice range profile(VRP)

2. Acoustic analyses Intensity Habitual intensity Intensity variability Int.SD Intensity(dynamic)range From softest nonwhisper to loudest shout Voice range profile(VRP)

2. Acoustic analyses Perturbation Short-term cycle-to-cycle Jitter Shimmer Short-term cycle-to-cycle Nonvolitional variability

Jitter

Shimmer

2. Acoustic analyses Sound spectrography Harmonic structure of the glottal sound source Resonant characteristics Narrow-band filtering Good frequency resolution Wide-band filtering Good time resolution

2. Acoustic analyses Signal(or harmonic)-to-Noise Ratio: The lower the HNR, the more noise there is in the voice Correlates well with the perception of dysphonia

3. Aerodynamic Measurements 5 acoustic properties of the vocal signal: Lung volumes and capacities Air pressure Airflow Laryngeal resistant Durational measures

3. Aerodynamic Measurements Lung volumes: Tidal volume Inspiratory reserve volume Expiratory reserve volume Residual volume

3. Aerodynamic Measurements Lung capacities: Inspiratory capacity Vital capacity Functional residual capacity Total lung capacity

3. Aerodynamic Measurements Air pressure: cm H2O Inside lungs Below the vocal folds Indirect measure by /p/ Inside oral cavity

3. Aerodynamic Measurements Airflow: CC or mL Glottal resistance to airflow Breathy vowel – higher airflow Strained-strangled voice - lower airflow Laryngeal resistance: Repeat /pi/ at a rate of 1.5 syllables/sec Peak intraoral pressure - /p/ Peak airflow - /i/

3. Aerodynamic Measurements Durational measures MPT S/Z ratio

4. Electroglottogrphy EGG: Noninvasive Tech An estimate of VF contact patterns

EGG Hardware

Use of EGG Hardware

Stroboscopy vs. EGG wave

Normal EGG wave

Acoustic & EGG Assessment A Complete Example

Real-time Two-channel Recording

Perturbation of Acoustic Signal

Perturbation of EGG Signal

Advanced Assessment

Signal, Harmonic & Noise

Vocal Function Estimates

Its all for today!