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• 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• 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., 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 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 - 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

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:• 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

Sound pressure level meter

Visipitch Computerized

speech lab Phonatory

Function Analyzer

Quality

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

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