Voice Disorders Exam 1

What is a voice disorder

Individuals whose pitch, loudness, quality, and/or effort to produce voice differs significantly from that of persons of a similar age, gender, cultural background, and racial or ethnic group. Changes in the voice parameter(s) draw attention to itself

What are the components of voice evaluation?

Perceptual, Acoustic, Aerodynamic, Stroboscopic, Self-report, palpate/observe

What does a comprehensive voice assessment that includes videostroboscopy determine?

The nature, severity, and/or extent of a voice disorder

Abduction

movement away from the midline

Adduction

Movement toward the midline

Endoscopy ("underlined endoscope")

visual examination of vocal folds through canal using a specialized lighted instrument called an \__________

Stroboscopy

a light or rapedly shuttered camera resulting in the illusion of slow-motion video image of vocal fold vibration. • Matches vibratory cycle; if cycle is off the images look like a blur

What does a flexible, fiberoptic transnasal endoscope (halogen light) assess?

Connected speech or singing, ab/adduction (coup, /ihi/, sniff, /i/, breathing at rest), supraglottic behavior, non-speech tasks (whistle, cough, throat clear, breath hold)

Rigid stroboscopy

Inserted into the mouth, this procedure sheds light on structure at key points in the waveform to give the illusion of movement. Closer look at vocal folds and oscillation (function)

When would you use rigid stroboscopy?

• Must use /i/ vowel to get epiglottis out of way!
• vocal folds closely
• Assess vocal fold oscillation parameters (e.g. amplitude, mucosal wave)
• Effect of any abnormalities on oscillation
• Can only use sustained phonation on /i/ and reverse phonation
• Gag
• Pitch tracking!

high speed digital imaging

◦ High-speed equipment can record 2000 to 5000 frames per second, allowing each individual cycle of vocal fold vibration to be recorded and analyzed

Drawbacks include:
• Expense
• Can only store a few secs (large files)
• Up to recently, only black and white

Advantages include:
• No need to track pitch (remember aperiodicity) so you can see aperiodic voices
• Higher time resolution
• Can measure exact onset of phonation (don't have to wait to track)
• Studies: more accurate diagnosis
• Observe details such as discreet spasmodic events in SD

what does it mean if one of my vocal folds starts much later than the other and stops earlier:

scarring!!!

What info do we get from a visual assessment of larynx (stroboscopy parameters)

• Describe at rest (abducted)
• Color of vocal folds (pearly white?)
• Color of surrounding tissues (pink; red may indicate irritation; erythema\= visible blood vessels; edema\=swelling)
• Secretions
• Vocal fold edges (normal aka smooth/straight, full vs bowed (think hammock), irregular aka lesions, rough)
• Assessment of vocal fold function
• Ab and adduction
• Symmetry
• Complete or Partial
• Strobe: Oscillation parameters (use VALI sheet)
• Amplitude of vibration,
• glottal closure (e.g. gaps, symmetry),
• mucosal wave
• adynamic segments,
• phase closure (does closing or opening phase predominate),
• phase symmetry (do the folds both come together at the same time)

What tasks help measure ab/adduction?

• phonation,
• sniff/i/ reps or /hihihi/
• glottal coup

Acronym for Vali stroboscopy

No CAMPSS
Nonvibratory portion

Closure
Amplitude
Mucosal wave
Periodicity
Symmetry(vertically and phase)
Supraglottic pressure

Vocal cord positioning

"Fully abducted"
9.5 mm from center
"Partial abduction"
7mm from center
"Intermediate (cadaver)
3.5mm from center
"paramedian" (paralysis/paresis)
1.5mm from center
"median" or midline

Glottic closure (shape of glottis during closed phase)

Complete:
• Touching along entire edge of vocal folds

Anterior gap
• Apart anteriorly only (near anterior commissure)

Posterior gap:
• apart near arytenoids
Hourglass:
• lesions touch in the mid 1/3 portion of the membranous glottis

Medial gap ("spindle")
• Gap in the mid 1/3 portion of membranous glottis
• Not "complete" and not "Bowing"

Irregular:
• lesions different on both sides at different points

Incomplete:
• Not touching along entire length including vocal processes.

Which phase predominates in phase closure?

Typically open predominates 60:40

Mucosal wave "ripple"
Amplitude of vibration

mucosa in a wave like motion
moves medial to lateral
made possible because of flexibility. Rate at normal pitch and loudness
Normal is 50% lateral movement

Vertical phase symmetry

Rating the symmetry of VF

Non-vibration portion (adynamic segment)

identification of portions of the vocal fold that are non-moving during phonation

supraglottic activity

the degree of anteroposterior and lateral compression during phonation. Vali scale

Vertical plane

height symmetry

What vocal quality does a predominant open phase or no closed phase lend to

Breathy voice

What phase predominates in pressed voice/severe vocal hyperfunction, and vocal fry

closed phase

What are the 3 qualities most reliably judged?

Breathiness
• Excessive air escape in voice quality
Roughness
• Irregularity in voice quality, aperiodicity in vibration
Strain
• Excessive effort in voice production

Breathiness

• Incomplete closure or gaps
• Lesions in the way of complete closure
• Open phase predominates
• Phase asymmetry
Audible air escape in the voice

Strain

• Closed phase predominates
• Excessive amplitude and pressure
• Supraglottic compression (false vocal folds)
Excessive vocal effort (hyperfunction)

Roughness

• Irregular vibration i(strobe can't lock on)
• Lesions causing irregular vibration

Other aspects influencing voice quality

Vocal tract shaping( body of guitar)
• Cul-de-sac or "back/pharyngeal" resonance or "hootie" like owl
• Oral resonance
• Anterior placement of articulation (green aliens toy story)
• Twang (the nanny, whiney)

Pitch
• Fry, modal, falsetto (TA not part of vibrating mass)

Loudness
• Psub, amplitude of vibration

Pitch (CAPE-V)

Perceptual correlate of fundamental frequency. This scale rates whether the individual's pitch deviates from normal for that person's gender, age, and referent culture. The direction of deviance (high or low) should be indicated in the blank provided above the scale.

Loudness (CAPE-V)

Perceptual correlate of sound intensity. This scale indicates whether the individual's loudness deviates from normal for that person's gender, age, and referent culture. The direction of deviance (soft or loud) should be indicated in the blank provided above the scale

Adduction continua

Breathy --\> Normal --\> Pressed/Strained

Pitch continua

Fry --\> Modal --\> Falsetto

Resonance continua

Back/paryngeal/cul-de-sac --\> oral --\> anterior twang

Perceptual rating of vocal quality

may be described as the psychological representation of a physical stimulus

One's perception is difficult to define as it is often formed based on their world

Influenced by many variables
• Non-linear
• interaction

What factors influence how we perceptually judge voices?

- age
- sex
- language
- culture
- what you just heard
- experience

What has been developed to minimize the error in determining voice characteristics when listening to voice

Systematic scaling techniques and specific strategies for completing perceptual analysis of voice

What are some perceptual measure tools of voice quality?

GRBAS
CAPE-V

What is the ordinal scale?

where numbers are assigned to attributes.
- 0 \= normal
- 1 \= mild...etc

What is the visual analog scale?

a tool where a line is used with two defined end points and ratings can be placed on the line to define the magnitude of a sensation

Clear\_________________________________________Severe

What is the GRBAS scale?

• The GRBAS scale uses a 4-point rating system where:
• "0" indicates a normal voice quality
• "1" indicates a mildly deviant voice quality
• "2" indicates a moderately deviant voice quality
• "3" indicates a severely deviant voice quality

GRBAS scale e.g "G2R1B2A0S1"
• G\= Grade or a judgment of how dysphonic the voice sounds
• R \= Roughness is a judgment of how irregular and noisy the voice sounds; it should relate to aperiodicity in the vibratory cycle
• B \= Breathiness is a judgment of how much additional airflow is perceived; it should relate to higher minimum airflow during the glottal cycle
• A \= Asthenia is a judgment of how weak the voice sounds; it should relate to the sound pressure level of the voice
• S\= Strain is a judgment of how compressed or hyperfunctional the voice sounds

Drawbacks of GRBAS

• No measure for "profound"
• No resonance aspects
• Ordinal structure doesn't allow tracking within-number change
• Improvement of severity within level mild à improved but still mild is not accounted for we still mark mild.

What is the CAPE-V

• CAPE-V - Consensus on Auditory Perceptual Evaluation of Voice
• Task 1: Sustained /a/ and /i/ 3-5 sec each 3x
• Task 2: Six sentences
• The blue spot is on the key again (three vowels: /u/ /a/ /i/
• How hard did he hit him (voiceless to voiced transitions)
• We were away a year ago ( all voiced)
• We eat eggs every easter (elicit hard glottal attacks)
• My momma makes lemon muffins (nasals for hyponasality)
• Peter will keep at the peak (plosives, no nasals, nasal air emission)
• Task 3: Running speech (e.g. PB&J, not voice problem)
• Rate Pitch, loudness, consistent/intermittent
• Rate Overall severity, roughness, breathiness, strain

Line goes from 0-100 and you rate based on severity

What are the objective acoustic measures?

Mean Fo in conversation and range (lowest to highest)

dB in conversation and range (quietest to loudest)

Quality-related measures:
jitter and shimmer (perturbation), Harmonics to Noise ration (HNR), Cepstral Peak Prominence

What do acoustic measures tell us?

• Capture some aspects of voice objectively
• Useful:
• Compare to norms
• Compare pre and post therapy or surgery
• Objective, but limited

What is F0?

fundamental frequency; the frequency at which vocal chords vibrate in voiced sounds

What do aerodynamic measures tell us?

• How much subglottal pressure do they use when producing voice?
• How much airflow is used up during voice production? Eg. Breathy vs pressed

Flap analysis

• Flap your hand back and forth 3x/sec

• Fo \=2Hz \= how many flaps per second

• Each flap takes about \______sec to complete. How long a cycle takes to complete \= "Pitch Period" or "t"
• Each flap moves out about 8 inches this is the Amplitude or dB

• There is slight variation in cycle to cycle (flap by flap, step by step) pitch period (step or flap duration) and distance of moment (amp). This is called "jitter" and "shimmer"
• Without jitter and shimmer, the movement would be perfect

Properties of sound waves: Period

Period \= duration of one cycle \= t

• If Fo \= 100 Hz
then t \= 1/ 100 \= .01

• If t\=.01 frequency (Hz) is 1/.01\=100 Hz
• If t \= .005, then Frequency \= 1/.005 \= 200 Hz

• The higher the frequency, the shorter the period.

• The lower the frequency, the longer the period.

What is an acoustic waveform?

• a plot of the change in
amplitude of the pressure wave over time.

What is the power spectrum

• aka line spectrum a "snapshot" of the
energy of each frequency component of the pressure wave.
Shown as a vertical line

What are harmonics?

whole number multiples of the fundamental frequency
• So: 100 Hz wave
• also has 200 Hz, 300 Hz, 400 Hz, etc.
• We perceive the 100 Hz distance between them as F0

What leads to wider-spaced harmonics?

A higher fundamental frequency (F0)

Vocal tract filter amplifies certain harmonics in source spectrum resulting in?

Formants

What are formants?

frequency peaks which have a high degree of energy (concentration of acoustic energy around a particular frequency) in the spectrum or speech wave

narrow band spectrogram

displays harmonics of the speech sounds with less distinct formants

wide band spectrogram

Shows formants clearly as opposed to harmonics

complex wave

Composed of two sine waves at different frequncies such as 100 Hz and 500 Hz for example

Fourier theorem states that:

every complex periodic wave can be decomposed into its harmonic series

What does PRAAT display?

raw waveform, power spectrum, spectrogram

Digital measurement considerations when recording

• Use mic with flat frequency response
• Sampling rate at least 2x highest frequency of speech spectrum
• (Nyquist rule) 44.1 kHz
• Keep set-up constant (mouth to mic distance)
• Mic at 45 degree angle
• Don't breathe on mic!

What is physiological pitch range

• Entire range from lowest to highest Fo (does not include fry)

What task gets the pitch range?

• Glide or step to highest pitch, hold it, capture and calculate Fo
• Glide or step down to lowest note, hold it, capture and calculate Fo
• Exclude Fry! Lowest "regular" pitch

Describe vocal folds of low pitch

VF are shorter, thicker, less stiff--vibrate more slowly

Describe vocal folds of high pitch

VF are stretched, thinner, stiffer--vibrate faster

How do you measure fundamental frequency?

• F0 in sustained phonation (/a/)
• Must be "regular" to be accurate
• "Type 1 signal"
• Can't measure Fo when:
• Type 2 signal: Fo splits in two bands on spectrogram.

What type signal (1, 2, and/or 3) results from dysphonic patient? fry?

• When patient very dysphonic:
• Type 2 and 3 signals
• Fry: Often type 2 signal

What is jitter?

• Jitter\= F0 Perturbation \= cycle to cycle irregularity of the period of vibration
• Irregularity of pitch period
• Perceived as slight dysphonia
• Normal if less than 1 % (but not 0)
• Abnormal if elevated

What task measures jitter

• Sustained phonation, needs normal FO, not for Type 2-3 signal
• NOT FOR CONNECTED SPEECH (b/c no stable F0)

What is intensity?

• Amplitude of vibration
• Determined by Psub
• Relates to vocal fold motion
(Amp of vibration
and Glottal closure)
• Height of waveform
• Steepness of spectral slope
• Reflects sound pressure level (SPL) in dB
(Measure with sound level meter)
Loudness is perceptual correlate

How to get dynamic range?

Go from quietest "ah" to loudest shout

What is shimmer?

• Cycle to cycle variation in amplitude
• Perceptual roughness
• Only valid in regular F0 (not Type 2-3, tremor, speech)

Jitter and Shimmer

• For slightly dysphonic voices only
• Because you need stable Fo: type 1 signals only
• Sustained phonation task only (no tremor or speaking)
• So, a dysphonia measure for not-too-dysphonic voices...
• Higher values indicate worse quality

What measures allow type 2 and 3 signals?

Harmonics to Noise ratio (HNR)
Cepstral Peak Prominence (CPP)

Harmonics to Noise ratio (HNR)

• Harmonic energy (dB) compared to noise

• Must use sustained phonation
Spectral measure
• not cycle to cycle
• Does not require very stable Fo
• Can have energy that's not harmonic (not multiples of Fo)

Noise results from
• incomplete glottal closure
• (air that is not valved)
• irregularity of vibration
• (aperiodic vibration: not a multiple of the fundamental)

Higher is better

Cepstral Peak Prominence (CPP)

• Rharmonic energy (dB) in "cepstrum"

the extent to which the F0 stands out from the background noise (irregular VF vibration and excessive airflow) in the voice

What are the theoretical steps of Cepstral Peak Prominence (CPP)?

Mathematically transform raw waveform to spectral display
• "Fourier transform"
• Gets power spectrum (speech spectrum) or spectrogram

Do another Fourier transform!
• Get "cepstral" display:
• Also gives idea of harmonic energy concentration
• Harmonics called "rhamonics"

No longer requires F0 or sustained phonation task

Can use in connected speech

Are there norms for Cepstral Peak Prominence (CPP)?

• No true norms
• Higher values: clearer and/or louder voice
• Lower values: rougher or breathier voice • Perception:
• Correlated positively r\=.8 with overall clarity of voice (G in GRBAS)
• Inversely correlated with breathiness, roughness

AVQI: Acoustic Voice Quality Index

• Need free script in PRAAT
• Combines several measures including Shimmer calculated 2 ways, HNR, spectral slope, CPPs
• Task includes speaking and sustained phonation; voiced information extracted and analysed

ADSV (analysis of dysphonia in speech and voice)

• Software in CSL (Kay Pentax, $600)
• Cepstral peak prominence and its standard deviations ("spectral moments")

Voice Range Profile

physiologic frequency and intensity range

What nerve innervates the Superior laryngeal nerve (SLN) and the recurrent laryngeal nerve (RLN)?

Vagus nerve (CN X)

Which laryngeal nerve has an external and internal branch?

Superior laryngeal nerve (SLN)

What does the external branch of the SLN do?

motor to cricothyroid muscle and joint

What does the internal branch of the SLN do?

Sensory for touch above the VF

What does the recurrent laryngeal nerve do?

Sensory below VF
innervates motor function of 5 intrinsic muscles (excludes cricothyroid muscle)

What are the intrinsic muscles?

Thyroarytenoid
Posterior Cricoarytenoid
Lateral cricoarytenoid
Oblique and transverse arytenoid
Cricothyroid

posterior crico arytenoid

abducts vocal folds

Lateral crico-arytenoid

adducts vocal folds bringing the vocal processes together

What are the interarytenoids?

oblique and transverse arytenoids

What do the interarytenoids do?

- adducts arytenoid cartilage providing medial pressure to VF
transverse and oblique

cricothyroid muscle

- in the front primary tensor of vf pulls thyroid cartilage down when it contracts with hep from ct joint. Tightens vf increases pitch

Thyroarytenoid muscles

Primary muscle of the vocal folds (next to vocalis muscle)

What are aerodynamic tasks?

• S:Z ratio and maximum phonation time (MPT)

• After adduction, vocal folds are pushed apart by\__________

increased subglottal pressure

How do the VF open?

folds do not open all at once, but rather the lower part first begins to open and at a later point in time the upper portion of the folds separate.

Maximum phonation time (MPT)

on /a/
• How long someone can sustain phonation on a given pitch
• Gives an idea of vital capacity, glottal valving efficiency
• "Hold out an /a/ as long as you can on a comfortable speaking pitch."
• "one two three for fiiiiive"
• coach duration.
• 3 trials
• Let's try that

S:Z ratio

-person is asked to sustain an /s/ as long as possible then to do the same with /z/
s phonation time divided be z phonation times
Sustained /s/ gives idea of lung capacity
• Rules out the glottis as source of inefficiency

s:z should be about 1

s/z \> 1 \= breathy, high flow, \>1.3 suggests disorder

s:z

What can you get from the patient's Pulmonary Function Testing (PFT)?

Vital Capacity- VC is 3-5 liters or 3000-5000 cubic centimeters
Divide by MPT seconds
• Eg 3000/10\=300 cc/sec
Phonation quotient