EVALUATION OF VOICE DISORDERS.pptx

7/30/2019 EVALUATION OF VOICE DISORDERS.pptx

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DR.N.KUMAR M.S ENT PG



Laryngeal AnatomyThree surrounding structures- pharynx,

trachea and esophagus

Three levels - supraglottis, glottis andsubglottis

Three fixed structures - hyoid, thyroid and

cricoidThree mobile structures -epiglottis, false vocal cords and true vocal cords (folds)



Laryngeal Anatomy



Laryngeal PhysiologyThree main functions – Protection of airway,

respiration and voice

Three criteria for voice- generator, vibratorresonator

Three components for high quality glottic

voice - closure, pliability and symmetry



Production of normal voiceFor production of normal voice, vocal cords

should:

1. Be able to approximate properly witheach other.

2. Have a proper size and stiffness.

3. Have an ability to vibrate regularly inresponse to air column



What is Voice? Vocal fold vibration that provides sound source

for spoken language

Phonation: humans set their vocal folds into a vibratory pattern (say “oooo”)

Vocal folds are adducted (closed), air is exhaled upwardsand blows apart the vocal folds setting them into a rapid

vibratory pattern

Voice is further modified by the processes of

resonation and articulationThree vocal characteristics: frequency, intensity,

and phonatory quality



Frequency Rate of vocal fold vibration (pitch)

Fundamental frequency (F0) – basic vibratory rate of the vocal folds (in Hertz)

Kindergarten girls and boys = 250 Hz

Adult women = 180 – 220 Hz

Adult men = 120 – 140 Hz

F0 relates to three characteristics:

Vocal fold length, mass, and tension

Fundamental frequency changes as we age, especially between birth and puberty



Pitch Important concepts:

Habitual pitch: pitch one uses normally

Optimal pitch: best pitch voice can produce

Basal pitch: lowest pitch one can produce

Ceiling pitch: highest pitch one can produce Vocal range: difference between basal and ceiling

Disordered pitch:

Habitual pitch differs significantly from optimal

Extremely limited vocal range



IntensitySound pressure reported in decibels

(loudness)Relates to two features of vocal production:

Amount of airflow from the lungs

Amount of resistance to the airflow by the vocal folds (which contributes to theirexcursion, or how far apart the vocal folds

move and come back together)Every person has a baseline intensity level

that characterizes his/her conversational

speech



LoudnessOver-loudness: air pressure builds up under

vocal folds and produces wide excursion of folds

Under-loudness: lack of respiratory force

because of… Neurological injury and disease

Social or psychogenic factors



Phonatory Quality How well the two vocal folds work together during the

vibratory cycle

If vocal folds work symmetrically and harmoniously, voice is pleasant and clear

If compromised in some way (e.g., growth on one of thefolds), phonatory quality is affected

Also influenced by the resonation of the voice into theoral and nasal cavities (e.g., nasal voice quality)

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Communication Sciences and Disorders: An Introduction

Copyright ©2006 by Pearson Education, Inc.

Upper Saddle River, New Jersey 07458 All rights reserved.



Describing Voice Quality Dysphonia: umbrella term for a voice that is

disordered in some way

Aphonia: total loss or lack of voice

Many other, mostly subjective terms…

Pitch and frequency: jitter or diplophonic Loudness and intensity: pressed or strident

Resonance: nasal or ringing

Phonatory quality: flutter or creak

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Describing Vocal Fold Functioning Hypofunction: vocal folds are under-functioning and

have inadequate tension, so air escapes through Breathiness or hoarseness, or no voice at all

Hyperfunction: vocal folds are overly tense andcompress too tightly together

Too loud, too high, and/or too strained

Sometimes spasticity of the voice

Diplophonia: vocal folds produce two different pitches

simultaneously

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What is a Voice Disorder?

Pitch, loudness, or phonatory quality differssignificantly from persons of a similar age, gender,cultural background, and racial and/or ethnic group,and

Vocal quality detracts from the ability to function andachieve in society

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arac er s cs o ce sor ers

it is not audible, clear or stable in a wide range of acoustic settings;

it is not appropriate for the gender and age of thespeaker;

it is not capable of fulfiling its linguistic andparalinguistic functions;

it fatigues easily; it is associated with discomfort and pain on phonation.



Key definitions Dysphonia: Any impairment of the voice or difficulty speaking.

Dysarthria: Difficulty in articulating words, caused by impairment of the muscles used in speech.

Dysarthrophonia: Dysphonia in conjunction with dysarthria, forexample after a cerebrovascular accident,head injury or part of adegenerative neurological condition, such as motor neuronedisease.

Dysphasia: Impairment of the comprehension of spoken or

written language (sensory dysphasia) or impairment of theexpression by speech or writing (expressive dysphasia),especially when associated with brain injury.

Hoarseness: A perceived rough, harsh or breathy quality to the voice.



Most Common Voice Disorders muscle tension dysphonia;

laryngitis/muscle tension dysphonia secondary to poor

vocal hygiene, dietary and lifestyle issues; extraoesophageal reflux (laryngopharyngeal reflux);

vocal fold nodules;

vocal. fold polyps;

vocal fold cysts;

vocal fold palsy and paresis;

arytenoid granulomas.



Less frequently seen sulci and mucosal bridges;

spasmodic dysphonia;

papillomatosis;

microvascular lesions; laryngeal trauma, including post-surgical causes;

other neuromuscular causes;

hyperkeratosis, dysplasia and carcinoma;

endocrine causes; amyloid;

other laryngeal tumours.

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Prevalence and Incidence:

Voice Disorders in Adults Prevalence = 29%, Incidence = 6%

Higher prevalence for women, peak ages of 40-60 years

Higher prevalence among people with frequentallergies, asthma, colds, and sinus infections

Higher prevalence among professions reliant on

voice Common causes: vocal nodules, edema/swelling,

polyps, carcinoma, and vocal fold paralysis

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Prevalence and Incidence:

Voice Disorders in Children 25% of children exhibit significant vocal problems,

with 40% of these cases ongoing, not transient,problems

For some it is a congenital problem, but most casesresult from overuse or misuse of voice

Most common cause: vocal nodules that impedesmooth meeting of folds, resulting in breathy or

hoarse voice

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IV. How are Voice Disorders

Identified? A. The Voice Care Team

Close collaboration of a variety of professionals

Medical professionals: primary carephysician (PCP), otolayrngologist

Allied health professionals: speech-language

pathologist, psychologist or psychiatrist

Possibly educators or voice coaches also

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B. The Assessment Process Identification of warning signs

Assessment Protocol:

Case history and interview Oral-motor examination

Clinical voice observation

Instrumental voice observation

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Warning Signs for Voice Disorders

Children and adolescents:

Vocally abusive behaviors

Underlying medical conditionPsychological well-being

Adults:

Change in phonatory quality for morethan two weeks, consult physician

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Case History and Interview

the nature and chronology of the voice problem;exacerbating and relieving factors;

lifestyle, dietary and hydration issues;

contributing medical conditions or the effects of their

treatment; the patient's voice use and requirements;

the impact on their quality of life, social andpsychological well-being;

their expectations for outcome of the consultation andtreatment.

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Oral-Motor Examination Identify conditions of structures involved with

producing voice

Study amount of tension and sensation involved inspeech and voicing

Examine possible swallowing problems Study the appearance and functioning of the velum

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Clinical Observation Perceptual observation of characteristics of voice

during a variety of speaking and vocal activities Example activities: counting from 1 to 40 softly then

loudly, sustaining a vowel sound for as long aspossible, engaging in normal conversation

Also studies systems that support vocal production,like respiration

Relies heavily on the listener, so need to be properly trained and experienced

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Instrumental Observation Objective measures of vocal functioning:

Acoustic assessment: measures frequency, intensity, andresonance characteristics

Aerodynamic assessment: measures airflow, air pressure,and vocal fold resistance

Electroglottography: measures vocal fold contact during voicing

Videostroboscopy: examines laryngeal system andmeasures vocal fold movement

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Overview of methods of objective evaluation of voice

used in clinical practice

1-Perceptual evaluation of the voice:using rating scales to grade the presence

and severity of defined qualities of the voicethat we can hear, e.g. hoarseness, roughness,breathiness.



1-Perceptual evaluation of the

voice: process of assessing and grading the severity of these

distinctive qualities in a speaker's voice by an'expert/trained' listener

:



GRADES Grade (of hoarseness), rough, breathy, aesthenic,

strained -GRBAS Grade (of hoarse ness), rough, breathy, aesthenic,

strained, instability -GRBASI Rau higke it (roughness),Behauchtheit (breathiness.

Hei serke itsgrad (hoarseness) method Consensus auditory perceptual evaluation of voice-

CAPE V Hammarberg evaluation scheme Voicing evaluation scheme Vocal profile analysis



GRBASGrade (G) -Overall rating of severity of

abnorm ality of voice

Roughness R-Irregular perturbation of pitchand amplitude, noise in low frequency region and the presence of spectral

subharmonics



Breathiness (B) - Noise below the midfrequencies, incomplete closure of vocal folds

resul ting in high expiratory flow rate Aesthenia A- Less harmonic content in the

high frequency region, irregularity of pitch

and amplitude, a fading amplitude contour



STRAIN S- Reflects higher pitch, noisein the higher frequencies, increased

amplitude of the higher harmonics andincreased pitch and amplitudeperturbation



2-Acoustic analysis: extracting andobjectively evaluating various factors related

to the acoustic waveform recorded using amicrophone placed near the mouth e.g.fundamental frequency, intensity,

perturbation measures



“Typical” acoustic measures Fundamental frequency and variability

mean Fo F 180-250 Hz M 100-150 Hz Vocal intensity and variability Mean 60-80 dB SD 10 dB

Perturbation measures (many ways to measure)

Analysis must be limited to a phonated segment Jitter- frequency (0.2-1 %) Shimmer-intensity (0.5 dB – norms not well

established)

Harmonic to noise ratio (> 15)



Typical acoustic measuresPhonational frequency range

~ 3 octaves

Dynamic range50-115 dB

30 dB range



Electrolaryngography/electroglottography: indirectmeasures of vocal fold vibration (e.g. fundamentalfrequency, degree of contact, perturbation measures)

determined by measuring changes in high frequency electrical conductance between two electrodes placedon the skin over the thyroid cartilage.



Electroglottography (EGG)• Human tissue = conductor

• Air: conductor

• Electrodes placed on each sideof thyroid lamina

• high frequency, low currentsignal is passed between them

• VF contact = impedance

• VF contact = impedance



Electroglottogram



Muscle Activity

Electromyography (EMG) is a way of recordingmuscle activity

Electrodes (needle or hook wire) inserted in the

muscle Used to

Evaluate neuromuscular function

Discriminating paralysis from arytenoid dislocation

Verify location of needle for injecting BOTOX intointrinsic laryngeal muscles

SPPA 6400 Voice Disorders



Visual assessment: inspection of the structure anddynamic function of the larynx and rest of the vocaltract together with the vibratory patterns of the vocal

folds during phonation (e.g. using endoscopiclaryngoscopy including stroboscopy,videokymography and high-speed digital cinematography).



HSDI AND KYMOGRAPHY Laryngeal motion is imaged

Gives permanent record of actual cycle to cycle motionof vocal folds



Aerodynamic measures: indirect measuresof the forces that initiate and maintain

vocal fold vibration e.g. subglottalpressure,airflow and air volume




Mean flow rate (MFR) Measures thought to reflect laryngeal valving

↑ = poor laryngeal valving

↓ = excessive laryngeal valving




Subglottal Pressure (Psg) Estimate

Repeated /pi/ with intraoral pressure transducer

Can measure for conversational loudness (5-10 cm water)

Can measure threshold (3-5 cm water)



Quality of life measures: using self-administered, validated disease-specific or generic questionnaires toassess the patient's perception of the impact of the

voice condition on their quality of life, in terms of physical complaints and restriction in participation indaily activities (e.g. Voice Handicap Index, Voiss).



Patient questionnaire of vocal performance (VPQ)

Voice handicap index (VHI)

Voice-related quality of life (V- RQOL) Voice activity and participation (VAAP)

Voice symptom scale (Voiss)

Voice handicap index- 10 (VH 1-10)



Voice accumulator and tests of vocalloading: these are means of sampling the

voice or aspects of vocal function either overa prolonged period of time or before andafter a specified vocal stress test.



Instrumented Evaluation Videolaryngostroboscopy

Acoustic Evaluation

Selected Instruments




Laryngoscopy Direct

Indirect Mirror examination

Rigid laryngeal endoscopy Constant light

Stroboscopy

Flexible fiberoptic laryngeal endoscopy

Constant light Stroboscopy




Components Endoscope (rigid or flexible)

Light source (constant or strobe)

Camera Recording device (VHS, computer)

If strobe light is used, a neck mounted microphone (orelectroglottograph) is used for tracking F o




Constant light vs. strobe light Constant light source allows viewing of basic

structure and function Identify lesions

Identify abnormalities in ab/adduction Identify supraglottic activity

Strobe light source allows a view of “simulated” vibration allows assessment of the vibratory function of the vocal

folds

May reveal structural abnormalities not seen duringconstant light endoscopy




VLS Examination Evaluate structural integrity

Evaluate gross mobility of structures

Evaluate (inferred) vibratory patterns




VLS ExaminationRelevant structures

True vocal folds

Ventricular folds Arytenoids

Interarytenoid area

Epiglottis

Glottic closure




Typical VLS Examination A task list

Normal, loud and soft phonation

Pitch glide Cough

Normal & deep breathing


Stroboscopy



An examination in which a strobe light is combined with rigid or

flexible laryngoscopy, allowing an examination of vocal fold vibrationand vocal fold closure

Laryngeal stroboscopy involves controlled high-speed flashes of lighttimed to the frequency (opening and closing cycles of vf’s per/ sec.) of the patient's voice. Images obtained during these flashes provide a slow

motion-like view of vocal fold vibration during sound production.

Stroboscopy

ey ea ures n e n erpre a on



ey ea ures n e n erpre a onof laryngostroboscopic images

1-Glottal closure pattern-Anterior or posteriorgap,Hourglass or spindle shaped ,Irregular orregular,Closed phase

2-Mucosal wave (right/left) in response to changesin pitch and loudness-Symmetry,Periodicity (regularity), Degree of change



Contd3-Description of lesion- Colour,Shape,Multiple/single,Surface

4-Vocal fold opening/closing pattern (right/left)-Rangefull/reduced,Normal/lag,Presence of spasm/tremor

5-Supraglottic appearance-

False cords medial constriction: right/Ieft/both

Anteroposterior constriction (arytenoid-epiglotticapproximation)



6-Symmetry of arytenoids (vocal processes and apices/corniculate cartilages)-Prominence/lesion(s)SaggitaI/coronaI/axiaI planes



Advantages of Instrumentation: These technologies provide both the practitioner and the patient with

valuable information. They allow images to be recorded on video orother media formats, allowing examiners to review the images of thelarynx frame by frame,

In addition it captures still and close-up images, and allows membersof the voice care team to re-review images that were captured. Patientscan also view the recorded images and see the reason(s) for their voiceproblems.

Stroboscopy: this can provide a series

of images

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Some Instruments for acoustic analysis

Real-time analysisExamples Sound level meter Visi-pitch

Real-time spectrograms Nasometer

“Off -line” analysis (analysis after data is collected) Examples Computerized speech Lab (CSL), MDVP Cspeech (tf32) Praat




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