Diagnostic Evaluation

What is a voice disorder?

• An individual’s quality, pitch, or loudness differs from voice characteristics typical of speakers of similar age, gender, cultural background, & geographic location

• Etiologies vary…

  • Structural

  • Medical

  • Neurologic

  • Psychological

• Predisposing, precipitating (inciting), & perpetuating factors

(Prevalence of Voice Disorders) What factors influence the prevalence of voice disorders?

• Age

• Gender

• Occupation

(Prevalence of Voice Disorders) Largest epidemiology study of voice disorders undertaken…

• 7% of adults (aged 21-66 yrs) reported a “current” voice disorder

• 30% of adults reported a voice disorder at some point during their “lifetime”

(Prevalence of Voice Disorders) Who are chronic voice disorders more common among?

• Women

• Individuals 40-59 years of age

• History of…

  • Heavy voice demands

  • Reflux symptoms

  • Chemical exposures

  • Frequent upper respiratory infections

What are the primary objectives of a voice evaluation?

• Identify the causes

  • Etiologic, physiologic, or behavioral factors

• Describe the present vocal components

• Evaluate the effect of the disorder on respiration, phonation, and resonance

• Develop the management plan

What are the secondary objectives of a voice evaluation?

• Patient education

• Patient motivation (educate on reasoning behind exercises like lip trills)

• Establish credibility of voice pathologist

Who can serve as a referral source for voice disorders?

• Otolaryngologists

• Other medical specialists

• SLP

• Vocal coaches

• Singing teachers

• Former patients

• Family

• Friends

• Pulmonologist

• Cardiologist

• GI

• PCP

• Allergy/asthma specialist

Professional Relationships:

• Evolution of the voice team

• Complementary relationships

Voice problems are describe as abnormalities in:

• Quality

• Pitch

• Loudness

• Resonance

What should a voice evaluation be comprised of?

• Reason for the Referral

• History of the Problem

  – Medical and Surgical History

  – Social history

• Oral Mechanism Examination

• Auditory-Perceptual Voice Assessment

  – Respiration, Phonation, Resonance, Pitch, Loudness, Rate

• Visualize the larynx!

• Diagnostic Probes (Stimulability)

• Patient Self-Assessment (PRO)

• GRBAS

Evaluation Form:

• Referral:

  1. Establish referral source

• Reason for Referral:

  1. Establish exact reason for patient referral

  2. Establish patient understanding for referral

  3. Develop knowledge of the voice disorder

  4. Establish credibility of examiner

History of the Problem:

1. Establish the chronology of the problem

2. Seek etiologic factors associated with the history

3. Determine patient motivation

Medical History:

1. Seek medically-related etiologic factors

2. Establish awareness of patient personality

What is an informal aerodynamic measure to look at respiratory support?

• /s/ → voiceless

• /z/ → voiced, if there’s laryngeal pathology, stiffness, or scarring → you will not be able to sustain phonation as long as you should be

Social History:

1. Identify work, home, recreational environments

2. Discover emotional, social, family, occupational activities, challenges, difficulties

3. Seek more etiologic factors

Oral-Peripheral Examination:

1. Determine physical condition of oral mechanism

2. Observe whole body tension

3. Observe laryngeal area tension

4. Check for swallowing difficulties

5. Check for laryngeal sensations

What should a perceptual evaluation include?

• General Quality

• Respiration

• Phonation

• Resonance

• Pitch

• Loudness

• Rhythm & Rate

• Non-speech Phonotrauma

General Quality:

1. Describe voice quality using descriptive terms (May use scale system, GRBAS, CAPE-V)

2. Examine inappropriate use of voice components

Respiration:

1. Describe type of breathing pattern (supportive/non-supportive)

2. s/z ratio

3. Maximum phonation time

Phonation:

1. Hard glottal attacks

2. Glottal fry

3. Breathiness

4. Diplophonia (2 pitches @ the same time)

Resonance:

1. Hypernasal

2. Hyponasal

3. Assimilative nasality

4. Cul de sac nasality

5. Inappropriate tone focus

Pitch:

1. Test present pitch range (how low vs. low)

2. Describe conversational inflection (monotone?)

3. Make subjective judgement of appropriateness

Loudness:

1. Too loud, soft, approrpiate (HEY!)

2. Check ability to shout/talk softly

Rhythm & Rate:

1. Too fast

2. Too slow

3. Interrupted (Spasm, Tremor)

Non-speech Phonotrauma:

1. Throat clearing

2. Coughing

3. Unusual laugh

What are perceptual signs of voice problems?

• Quality → Roughness or Hoarseness

• Pitch → F0 (fundamental frequency)

• Loudness → Intensity

• Other behaviors → stridor, excessive throat clearing

• Aphonia → loss of voice

What should patient self-assessment incorporate?

• Patient perspective related to the voice disorder

• Describes the physical, functional, and emotional implications

What are some assessment tools for assessing the impact of a voice disorder on a patient’s daily life?

• Voice Handicap Index (VHI)

• Voice Handicap Index-10 (VHI-10)

• Voice-Related Quality of Life (V-RQOL)

• Voice Activity and Participation Profile (VAPP)

• Voice Symptom Scale (VoiSS)

• Aging Voice Index (AVI)

What should the voice pathology evaluation consist of?

• Patient interview

• Perceptual voice assessment

• Instrumental assessment of vocal function

• Laryngeal videostroboscopy

(The Voice Pathology Eval) What is crucial for accurate diagnosis of voice pathology?

• visualization of the larynx! History can only give us clues into diagnosis

(The Voice Pathology Eval) When can indirect laryngoscopy be conducted?

• In the clinic, while the patient is awake

  • Flexible fiberoptic endoscopy

  • Rigid endoscopy

  • High-speed imaging

(The Voice Pathology Eval) When can direct laryngoscopy be conducted?

• while the patient is under anesthesia

What are the types of laryngeal imaging?

• Flexible Fiberoptic Endoscopy

• Rigid Endoscopy

• Halogen or Stroboscopic Lighting

Flexible Fiberoptic Endoscopy:

• Variety of sizes

• Distal chip

• Almost any patient can be visualized with this

  technique

Rigid Endoscopy:

• 70-degree scope

• 90-degree scope

• 4mm, 10 mm

What are the advantages of rigid endoscopy?

• increased clarity for assessing erythema, vascularity, tissue changes

• Closer view

What are the disadvantages of rigid endoscopy?

• Difficult to conduct w/ some patients

• Gag reflex

• Cannot assess other structures

What are the advantages of flexible endoscopy?

• can assess velopharyngeal function, adenoid tissue, palatal structure

• resting breathing & connected speech

• can usually assess subglottis

What are the disadvantages of flexible endoscopy?

• clarity is often diminished

• numbing of nares

Stroboscopy:

• Studying the motion of a body, especially during rapid revolution or vibration, by making the motion appear to slow down or stop

• Intermittent flashes of light “frame” the action

• Produces extremely short, brilliant bursts of light for synchronization with a camera having a high shutter speed in order to photograph a rapidly moving object

Videostroboscopy:

• Video imaging of the larynx is standard and critical

• Videostroboscopy provides information on both laryngeal function & structure

• Allows recording of apparent vocal fold motion

• Specialized equipment & training is necessary

• Videostroboscopy scoring instruments are available

What is Talbot’s Law?

• The eye cannot perceive more than 5 distinct

images per second

When a series of images are produced at more than 1/5 of a second, one image persists long enough to fuse with the subsequent image & an optical illusion occurs that is called apparent motion (Talbot’s Law)

What are laryngoscopic observations?

• Supraglottic closure

• VF movement

• Tissue changes

• VF edge

What are stroboscopic observations?

• Degree of glottal closure

• Periodicity

• Phase symmetry

• Mucosal wave

• Amplitude of excursion

• Phase closure

What may supraglottic activity indicate?

• Muscle tension dysphonia

• Poor respiratory support

• Compensatory movements for pathology

• Medio-lateral (side to side)

• Antero-posterior (posterior squeezing)

Vocal fold edge:

• smooth & straight

• rough & irregular

Glottal closure:

• Complete closure

• Spindle gap

• Posterior gap

• Irregular closure

• Anterior gap

• Hourglass

• Incomplete closure

• REFER TO IMAGES ON PDF!!!

Phase Symmetry:

• Degree to which the VFs appear as mirror images of each other

• Assessed during normal pitch & loudness

What is a mucosal wave?

• Affected by disease processes that stiffen the mucosal cover of the vocal folds

• Vertical movement of the mucosa over the body of the vocal fold during phonation

• Fundamental frequency & intensity affect mucosal wave

Amplitude of Excursion:

• Refers to how far the vocal folds move laterally during phonation

• Assessment is made at normal pitch & loudness

• Normally, the fold should travel approximately ½

  (50%) of the visible width of the vocal fold

Phase Closure:

• Assessed during normal pitch & loudness

• Open Phase

• Closed Phase

• Should be equal

  • Hyperfunction = longer closing

  • Breathy = longer opening

Summary:

• IMPRESSIONS: Summarize the etiologic factors associated

  with the development and maintenance of the voice disorder

• PROGNOSIS: Analyze the probability of improvement through voice therapy

• RECOMMENDATIONS: Outline the management plan