Chapter 5

1. Chapter 5 Voice Evaluation

2. 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

3. 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

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

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

6. 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)

7. 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

8. 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

9. Case History • General • 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

10. Case History - 2 • Onset and duration 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

11. 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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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 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 Respiration

19. 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 Pneumograph - records thoracic and abdominal mvmt Respiratrace X-ray Respiration - 2

20. 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

21. Perceptual judgement re: 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 Pitch-2

22. 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 Sound pressure level meter Visipitch Computerized speech lab Phonatory Function Analyzer Loudness

23. Breathiness - audible air escape as approximating edges of glottis fail to make contact Harshness - unpleasant hard, rough, or metallic quality Hoarseness- harshness + breathiness 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

24. 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