Voice Evaluation

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

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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, dont 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 --gt excellent
  picture
• Nasal Scope - flexible fiberoptic cable used to
  view connected speech
• Stroboscope - flashing light source --gt slow
  motion-like observation of vocal pathology

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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
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 gt 1.4
• Pulse hand on abdomen during phonation

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Respiration - 2

• Visual observation of breathing patterns
• Clavicular
• elevates shoulders on inhalation, tenses strap
  muscles --gt 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

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 lt .6
• Shimmer lt 2.4
• Habitual pitch - pitch used most often

21
Pitch-2

• 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

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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

• Sound pressure level meter
• Visipitch
• Computerized speech lab
• Phonatory Function Analyzer

23
Quality

• Spectrogram shows
• --gt Periodicity of vocal tone reduced
  aperiodicity or noise increased
• --gt Aperiodicity across spectrum, often with
  abrupt onset reduced F0
• --gt increased noise across spectrum heavier
  concentrations in first formant

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

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 --gt overadduction