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Voice Assessment

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Voice Evaluation• Evaluation: Assessment of the

characteristics of a disorder or problem.

• Three primary objectives:

1) Describe type and severity of disorder for baseline,

2) Identify and interpret abnormal voice for differential diagnosis,

3) Determine if voice therapy is necessary.

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What should you achieve from the evaluation?

1) Complete description of client’s voice,

2) A hypothesis as to probable cause or etiology,

3) Data regarding all parameters of voice, including perceptual, acoustic, aerodynamic and kinematic data.

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Evaluation Components• Medical evaluation

• Patient interview

• Instrumental evaluation of voice including aerodynamic & acoustic analyses

• Functional evaluation of vocal fold movement

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Professionals Concerned• Medically oriented team-

-Physician, otolaryngologist, neurologist, orthodontist, radiologist, respiratory therapist, plastic surgeon, voice scientist, SLP, psychologist.

• Educationally oriented team--Teacher, school psychologist, SLP, school nurse, coach, music/drama teacher, physician, audiologist, counselor.

• Professional voice team--Otolaryngologist, nurse, singing teacher, drama coach, voice scientist, allergist, pulmonary specialist, SLP.

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Medical Evaluation

Otolaryngologic examination-

1) Detailed history of the problem

2) Examination of entire head & neck region

3) Pertinent medical history gathered

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Medical ExaminationExamination includes-

1) Otoscopic observation of ears

2) Examination of oral & nasal cavities

3) Palpatation of salivary glands, lymph nodes, and thyroid gland

4) Visual examination of larynx (indirect laryngoscopy (mirror; light source; images reversed)

5) Fiberoptic laryngoscopy

6) Radiographs of head, chest & neck

7) Diagnosis & recommendations for treatment

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Voice Pathology Evaluation• Perceptual:

1) Referral

2) Patient interview/ history

3) Oral-peripheral examination

4) Evaluation of voice components: phonation, resonation, pitch, loudness & rate

5) Diagnostic therapy

6) Impressions

7) Prognosis & recommendations

8) Hearing screening

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Referral• Establish the identity of referral source

• Reasons for referral

• Establish patients understanding of referral

• Develop patient knowledge of voice disorder

• Establish credibility of examiner

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Patient Interview/ History• Case history information: Written & verbal

information from client, physicians, family members, other therapists & teachers.

• Basic questions of any case history:

1) Identifying information

2) Family history

3) School/ work history

4) General health and voice health

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Content of Interview1) Problem-

-Nature of problem

-Awareness of patient

-Open-ended questions

-What caused the problem

-Establish initial client-patient relationship

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Content of Interview2) Effect of voice problem-

-Life changes, impact of disorder,

-Severity of reaction,

-Feelings, emotions.

3) History of the problem-

-Onset; gradual or sudden,

-Duration; how long condition has been present,

-Variability in voice throughout day.

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Content of Interview4) Voice usage -

-Habits (smoking, drinking, shouting, etc.)

-Where & how they use voice (work, recreation)

-Professional use; social history

5) Medical history-

-Present status

-Neurological, allergy-related, gastrointestinal, respiratory or other problems

-Past health history

-Drug history

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Content of Interview

6) Psychological state-

-Emotional state

-Current or past pressures effecting

communication

-Stress-related voice usage

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Oral-Peripheral Exam-Determine physical condition of oral mechanism,

-Observe laryngeal tension area,

-Check for swallowing difficulties,

-Check for laryngeal sensations,

-Routine oral-peripheral examination along with: *whole body tension, *digital manipulation of the thyroid

cartilage (should rock back & forth).

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Evaluation of voice components: Perceptual

1) Critical listening & Description- -Tape record interview: baseline & future review, -Use of rating scales during interview (i.e. General Voice Profile etc.):

1. Is voice variable or stable?2. Normal pitch for age, sex?3. Normal rate, quality, loudness?4. Judgment relates to environment5. Back-up with objective data if possible

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Perceptual Terms1) Tone: a manner of speaking, a vocal sound (normal,

breathy, hoarse)

2) Breathy: term to describe excessive airflow during phonation or if someone runs out of air

3) Hoarse: aperiodic vibration of folds, rough o raspy sounding

4) Tension: a balancing of forces in opposition, mental or nervous strain

-Hyper- excessive above normal-Hypo- below normal

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Perceptual Terms

5) Abuse: Activities above & beyond what is considered normal to the vocal folds (shouting, screaming etc.)

6) Loudness: Subjective correlate to intensity

7) Pitch: Subjective correlate to frequency

8) Inflection: Any change in tone or pitch

9) Pitch breaks: Other than puberphonia

10) Diplophonia: Existence or perception of 2 vibrating frequencies (“double voice”)

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Perceptual Terms11) Resonance: Determination of sound as prescribed by

the size and mechanical properties of a cavity (nasal, oral. hypo-, hyper)

12) Emission: Excessive nasal airflow

13) Aphonia: Absence of voicing which is consistent

14) Tremor: Rhythmic variations in pitch & loudness, not under voluntary control

*Rating scales usually differ as little as 10% to as much as 70%.

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Noninstrumental Objective Measurements1) Maximum Phonation Time (MPT):

-Ability to sustain phonation maximally,

-Information about respiratory function, glottal efficiency & laryngeal control,

-Designed to test limits of phonation & uncover other weaknesses,

-Patient is instructed to sustain the vowel /a/ for as long as possible at comfortable pitch & loudness (3 Trials):

• Adult Women: 15 Seconds

• Adult Man: 20 Seconds

• Children: 10 Seconds

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2) S/Z Ratio: • Patient should maximally sustain /s/ than /z/, repeated

twice: Greater ratio than 1.4 suggests disorder

-Used to differentiate deficits in respiratory support vs. laryngeal insufficiency,

-Normal individuals: sustain voiced sound as long as unvoiced producing a ratio close to 1,

-Respiratory insufficiency should reduce both productions equally, producing a ratio of 1,

-Reduced vibratory efficiency results in air wastage (reduction in the ability to sustain phonation) ratio greater than 1 (z shorter than s),

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3) Evaluation of pitch characteristics:

-Total Phonation Frequency Range: Ascending & descending pitch slides; lowest to highest ranges,

-Habitual Pitch: Patient says:”I live in Alabama_a_a” -prolonging final vowel, match pitch on keyboard or tape recording,

-Conversational Range: Patient can describe furniture in room, clinician later determines high & low pitch (judgment of variability),

- Pitch Fluctuations: During prolongation's of vowels, pitch breaks are noted.

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4) Loudness:

-Observe during interview,

-Test ability to increase subglottal air pressure by having patient shout “Hey”,

-Positive sign to override dysphonia with intensity (getting improved closure),

-Have patient count up to 10 and you highlight 2 numbers within that sequence which you want produced with an increased intensity,

-Look for glottal closure & efficiency

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5) Rate:

- Description of rate (slow, normal, fast) during interview,

-Excessive rate can cause pathologic condition (misuse),

-Diagnostic therapy to see if rate can be altered.

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Diagnostic therapy• Depends on the clients symptoms,

• Client may have excessive laryngeal tension:• Digital manipulation to reduce tension

• Easy onset speech productions with single words & sentences

• Client may exhibit respiratory problems, excessive breaths or not enough, not enough replenishing breaths during speech:

• See if client can consciously inc./dec. breaths, inc. breaths at appropriate location etc.

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Diagnostic therapy

• Object is to identify problems in quality, rate, loudness and pitch and use therapeutic techniques to see if client is stimulable for changing these patterns,

• If client is not stimulable, the prognosis for improvement is poor,

• Need to be very familiar with voice deviations including respiratory and laryngeal abnormalities.

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Diagnostic therapy

• Production of Reflexive Sounds: – Coughing, laughing, clearing throat, vocalized

pause “Uh-Huh”

– Compare spontaneous examples with elicited

– Used to determine quality in non-speech task

• Altering Pitch:– Change pitch up & down (not range)

– Physical or discrimination problem• If imitation difficult; try animal sounds (“meow”)

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Diagnostic therapy

• Sustained Phonation:

– Practice before taking measurements (timed = tension)

– Observe preparation of how client carries out task

• Strained, length, steadiness

– Rationale; ability to control & sustain phonation and respiration

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Diagnostic therapy• Altering Vocal Loudness:

– Increment loudness in steps (model)

– Rationale: further test limits of voice production, explore ability to manipulate isolated vocal parameters, match a model

• Phonation w/ Effortful Glottal Closure:

– ONLY with patients for whom activity is not harmful

– Grunting, isometric pushing of hands together, raise chair while seated

– Phonate while producing tension

– Rationale: Attempt to force vocal fold adduction; Elicit a nonspeech sounds that is difficult to control voluntarily

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Impressions, Prognosis & Recommendations

1) Summarize etiologic factors associated with development & maintenance of individual’s voice disorder:

• list in order or perceived importance!

2) Analyze probability of improvement through voice therapy:

• include motivation, interest, time availability

3) Outline management plan:• outline the etiologic factors discovered during the

evaluation, therapy approaches & other referrals.

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Readings

• Colton & Casper: Ch. 2 & 7

• Directed Reading (9/16/99): – Eckel, F.C., & Boone, D.R. (1981). The s/z ratio as

an indicator of laryngeal pathology. Journal of Speech & Hearing Disorders, 46, 147-149.

– Colton, R,H. & Hollien, H. (1972). Phonational range in the modal and falsetto registers. Journal of Speech & Hearing Research, 15, 708-713.