Chapter 5 Voice Evaluation
Dec 23, 2015
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