Voice 3 - Evaluation

prior to evaluation (3)

• patient questionnaire

• patient surveys

• visualization of the larynx

what is the most important part of the physical exam?

visual inspection of the larynx

what should a physical exam include (not us)

assessment of general physical condition and. athorough ENT eval

evaluation elements (us)

• review of auditory and visual status

• case history

• behavioural observation

• auditory-perceptual ratings

• voice related QoL

• laryngoscopy

• acoustic analysis

• aerodynamic analysis

• phonatory-respiratory efficiency

• voice dosage

assessment is conduced to identify

• impairments in body structure and function

• co-morbid deficits that can affect voice (like health conditions and meds)

• limitations in activity and participation

• contextual (environmental and personal) factors

• impact of QoL

why screen for voice disorders in children?

dysphonia negatively impacts:

• educational dev

• psychosocial dev

• emotional health

• physical health

what is really important about the client-clinician relationship?

good relationship = better buy in

client empowerment is often highly correlated with

perceived control

stages of change

1. precontemplation

2. contemplation

3. preparation

4. action

5. maintenance

why motivational interviewing?

• activate the patient’s motivation

• debunk the myths

• embrace a skillful clinical style (guide more than direct)

• collaborative

tenants of motivational interviewing

• ask open-ended questions

• affirming

• reflective listening

• summarizing

• eliciting change talk

case history elements

• description of problem and cause (patient’s own description is revealing)

• variability of the problem

• onset and duration of the problem

• description of vocal demands

• any previous voice problems? how was it treated

perceptual assessment/behavioural observation elements

• oral mech

• reading sample, conversational sample, singing sample, sustained /a/ (record!!)

• Cape-V

what to look for during behavioural observation

• respiration

• vocal quality and stability

• rate. of speech

• resonance

• articulation

• posture

• musculoskeletal tension during phonation and rest (may need to palpate)

excessive tension in disordered individuals (MTD) noted via palpation where?

• over the major horns of the hyoid bone

• over the superior cornu of the thyroid cartilage

• along the anterior border of the sternocleidomastoid muscle

• throughout the suprahyoid musculature

• high position of larynx has been observed in many patients with voice disorders

true or false: lots of standardized rating scales have been developed for palpation

false: only. a few: ex. Anggsuwarangsee and Morrison, Mathieson

pros of perceptual assessment

• quick and non invasive

• easy to use

• no electronic equipment needed

• often accurate and meaningful

• supports therapy goals and tracks progress

• ex: cape-v, grbas

which perceptual measurement tool is more sensitive to small differences within and among patients?

cape-v

breathy

incomplete glottal closure, increased turbulence, decreased intensity

rough

aperiodic vf vibration, spectral noise, increased intensity

strained

increased medial compression of true (and maybe false) vfs, aperiodic vf vibration, spectral noise, increased intensity

harsh

strained and rough

hoarse

strained rough and breathy

critiques of VHI

• items developed without patient involvement

• normed only on voice patients

• not a true QoL measure (handicap)

why use objective measures?

• consistency within and between the judges is from mild to moderate

• depends on the training, type of stimulus, task instruction, and judge experience

are acoustic measures diagnostic?

NO!!! But they can be supportive

acoustic measures are:

indirect and offer a brief vocal snapshot that may or may not be representative

true or false: sustained vowels represent connected speech

false

acoustic measures

• cepstral peak prominence (vowel and speech)

• mean vocal frequency (Hz)

• habitual vocal SPL (dB)

• Vocal frequency standard deviation (Hz)

• Max and min vocal SPL (dB)

• Max and min vocal frequency (Hz)

• Acoustic Voice Quality Index (AVQI)

why can’t we get rid of perceptual eval?

• relationships between acoustic and perceptual eval are largely inconclusive

• our perception is so complex, we haven’t figued out how to model it mathematically yet

laryngeal mirror is

laryngeal mirror

videostroboscopy: what to look for

• vocal fold adductor/abductor movement

• vibratory movement of VFs themselves (can’t see these on endoscopy without light)

videostroboscopy: what it allows for

• an image of the apparent motion of VFs to. berecorded

• simulated slow motion image of VFs

• useful quantitative info re: nature of vibration

  
  

videostroboscopy: basic instrumentation

• endoscope: rigid or flexible

• microphone: used to trigger the stroboscopic light source

• light source: stroboscopic in order to visualize vibration

• electronic control unit

• foot pedal

stroboscopy is an optical illusion based. on

talbot’s law

what is talbot’s law

sequential images produced at intervals shorter than 0.2 seconds persist on the retina and fuse with successive images to produce the optical illusion of apparent motion

risks of rigid oral endoscopy

• minor side effects

• mucosal abrasion or laceration may occur (more of a risk in patients without teeth)

• trauma to teeth

• if anesthesia is applied then this should be done in a medically supervised setting

performing endoscopy

• signing of consent

• thorough patient history

• conversational sample - record

• acoustic measurements

• anesthetize (if appropriate)

• set- up equipment

• place laryngeal microphone

• position the patient

• gentle tongue hold

• sustained /i/, sniff /i/, high pitch, low pitch, ascending and descending glissandos, singing/conversation (flexible only)

does a universal rating system for endoscopy exist?

no

glottic closure

• complete

• incomplete

• spindle gap/bowed

• hourglass

• anterior gap

• posterior gap

VF edge

• recognition of pathology/irregularity impacting the free edge of each fold

• smooth

• rough

• irregular

• excrescence

• edema

• erythema

• any combo of these

amplitude

• extent of lateral displacement from midline

• R/L judged separately

• ballpark for normal: 1/3 width of visible portion of the VF

• presence of lesion, edema, stiffness, hyperfunction can affect amplitude

• will vary depending on pitch and volume

mucosal wave

• the longitudinal flexibility of the fold, seen as a traveling wave on vibration

• reflects the pliability of the phonatory mucosa (epithelium and superficial lamina propria)

• R/L judged separately, compared

phase symmetry

• based on the degree to which the two folds appear as mirror images of one another (shape-changing relationship)

• consider timing of opening, closing, approach to midline, excursion

• any differences with respect to position, mass, tension, elasticity will cause asymmetrical vibratory movements

phase closure

• describes the ratio of open to closed phase

• open phase may be increased in cases of presbylarynx, glottal lesion, paralysis

• closed phase may be increased in cases of hyperfunction

in the closed phase, VFs should meet where?

in the same vertical level

what is vertical level approximation often affected by?

unilateral paralysis, CA joint injury

what is supraglottic activity?

compensatory vs. functional muscle activity of supraglottic structures to increase the vibratory function of the glottis

• may partially or fully obstruct view of vocal folds during phonation

what are the most common supraglottic activity patterns?

medial and antero-posterior

when is supraglottic activity rated?

during phonation

true or false: aerodynamic measures are diagnostic

false but they can be supportive

aerodynamic measures

• average glottal airflow rate (L or ml/s)

• average interpolated air pressure (cmh2O or KPa)

• mean vocal SPL (dB) and vocal frequency (Hz) during the task

• average glottal airflow rate (L or ml/s)

phonatory-respiratory efficiency

• max phonation time

• S:Z ratio

assessing stimulability is critical to

patient compliance (empowerment/buy in)

stimulability testing gives you the opportunity to

immediately train awareness of behaviour(s) that you want to change

creating voice goals with your client

• providing regular but realistic homework

• carefully consider timing of hw and pt’s current vocal load

• record the exercises for the patient and write out detailed instructions

• discuss expectation of voice therapy and prognosis