Voice Assessment and Disorders

Voice Assessment

What is a Voice Disorder?

• According to Van Riper and Irwin (1958), a voice or speech is considered defective if it:

  • Interferes with communication.

  • Draws undue attention to itself.

  • Causes concern to the speaker or listener.

    • not communicating authentically

    • may not be disorder but difference

    • if it causes speaker concern we will help.

The Importance of Listening

• Researchers emphasize the critical role of the ear in voice labs.

• Key skills include critical and careful listening, and objective analysis (Boone, 2005).

  • what do we hear, nasal, where am i hearing something different.

Describing Voice Disorders: Vocal Quality Disturbances

• Occur at the laryngeal level (phonatory).

• Dysphonia: (dys) + (phonia)

  • Any abnormal vocal quality suggesting an interruption of normal production/vibration.

• Aphonia: (a) + (phonia)

  • Lacking voice, no true vibratory voicing.

• Aphonic break:

  • A break or interruption in the vibration or phonation.

• Functional Aphonia

  • no voice, the way you use it, its not structural its functionally(not using the part.)

Describing Voice Disorders: Pitch and Tremor

• Pitch breaks:

  • An interruption in the frequency of vibration of the vocal folds or a shift in vocal register during singing. what level we are vibrating at of the vocal cords shift, often seen in singing.

• Tremor:

  • Involuntary variations in pitch and/or loudness when trying to produce a steady, sustained tone, usually of a CNS origin.

    • not hearing steady tone.

Describing Voice Disorders: Hoarseness, Breathiness, Harshness

• Hoarseness (husky):

  • Excessive ‘noise’ in the signal creating an unpleasant, rough vocal quality.

• Breathiness (Jitter: frequency variation, Shimmer: amplitude variation):

  • An audible escape of air or a ‘weak’ vocal tone suggestive of glottal insufficiency.

• Harshness (strident, unpleasant, grating, rasping, rough, guttural, raucous, metallic):

  • Irregular vocal fold vibrations creating a ‘raspy’ or unmusical tone; a combination of hoarseness and breathiness.

Describing Voice Disorders: Diplophonia, Strained-Strangled, Glottal Attack, Glottal Fry

• Diplophonia

  • The presence of two tones or pitches heard simultaneously during phonation.

• Strained-Strangled

  • Perceived strain or pushed vocal quality at the onset of and during phonation.

• Glottal attack

  • Hyperadduction of the vocal folds at the onset of phonation. Consider the break in “uh-oh”.

• Glottal fry

  • Use of the lowest register during phonation (also called pulse register), resulting in an increased closed phase of the vibratory cycle.

Voice Disorders – Benign Essential Tremor (BET)

• Tremor (Benign Essential Tremor) –BET is a disorder that causes shaking of the voice.

  • Benign means that the disorder will not harm your health.

  • Essential means that the tremor is not associated with any other disease state, such as the tremor associated with Parkinson's Disease.

• When Benign Essential Tremor affects the voice, vocal fold vibration is normal, but the entire larynx shakes slightly, causing an extra vibration, or tremor, at about $5-7$ cycles per second.

• Sometimes the larynx can be seen to tremor even at rest, but usually the tremor begins when the person begins to speak.

• Benign Essential Tremor tends to occur in older persons, though persons in their 50's may also be afflicted.

Voice Disorders - BET: Sound and Complaints

• Sound of voice

  • A steady shaking or wobbling of the voice, ranging from gentle and continuous to a staccato, almost hiccuping sound.

  • tremor is often rhythmic and steady, at $5-7$ cycles per second, and it occurs in all speech contexts. It may vary in intensity with changes in pitch or volume, and, like all voice disorders, tends to get worse in stressful situations.

• Complaints

  • May include:

    • Poor voice quality, with "old-sounding" characteristics

    • Vocal weakness and low volume

    • Vocal fatigue increasing with voice use

    • Embarrassment

Describing Voice Disorders: Vocal Fatigue, Voice Deterioration, Vocal Tension

• Vocal fatigue

  • A ‘tired’ voice or feeling of excessive effort to phonate

• Voice deterioration

  • Reduction of volume or vocal quality with prolonged use

• Vocal tension

  • A tightness of the laryngeal musculature during voicing

Describing Voice Disorders: Resonance

• Resonance: Occurs supra-glottically--above laryngeal level

• Nasality:

  • Hypernasality: Excessive nasality resulting from increased sound diverted into the nasal airway. Hypernasality may suggest pharyngeal weakness or VPI

  • Hyponasality: Insufficient nasality (e.g.: denasal voice) resulting from a reduction in nasal resonance. Hyponasality may suggest enlargement of the tonsils/adenoids and/or a nasal obstruction.

Classifying Voice Disorders

• Functional: using a normal vocal mechanism in a faulty manner, not functioning the way ot should.

  • vocal nodules*

  • polyps

  • functional aphonia

  • muscle tension dysphonia*

  • ventricular phonation

  • traumatic laryngitis*

  • falsetto (puberphonia)

  • Reinke’s edema

  • phonation breaks

  • pitch breaks

• Organic: faulty voice related more to a physical cause than misuse, something is not working or is missing, biological(structures).

  • vocal nodules*

  • sulcus vocalis*

  • contact ulcers

  • cancer

  • infectious laryngitis

  • leukoplakia

  • hyperkeratosis

  • granuloma

  • reflux*

  • webbing

  • papilloma

Neurogenic Voice Disorders

• Voice disorder is a result of damage to the neurological system

  • vocal fold paralysis*

  • myasthenia gravis

  • Guillaine-Barre

• Dysarthrias: most from stroke or TBI

  • unilateral upper motor neuron dysarthria

  • spastic dysarthria

  • hypokinetic dysarthria (Parkinson’s)*

  • Hyperkinetic dysarthria (spasmodic dysphonia*, essential tremor)

  • ataxic dysarthria

  • Mixed (ALS, TBI, MS)

The Voice Assessment

• Case History: job, social habits, hobbies, family history,

• Medical History: relevant surgeries, as it relates to voice, allergies, asthma, tonsillitis, strep throat.

• Observing the client: tremors, 3 systems, respiration, vibration, strained, nasal, muffled,

• Evaluating the Voice: instrumentation, nasometer, measures,

• Oral peripheral examination: tonsils, palate, redness, tumours,

• ENT Report

• Audiology Report

Case history Description

• Description of problem

• Date/type of onset

• Course of problem (variability)

• Concurrent events

• Emotional factors

• Reactions of others

• Personal reactions

• Perceived cause

• Previous dysphonia and/or treatment

• Voice use and needs at home

• Voice use and needs at work

• Coping strategies

Case History (Cont.)

• Exposure to smoke, dust, chemicals

• Dysphagia (swallowing) (acid reflex= burned vocal cords)

• Alcohol/coffee consumption (drying)

• Vocally abusive behaviors

• coughing after each swallow or cough

Voice Evaluation Tools

• CAPE V

• Vocal Handicap Index

• GRBAS

• Experience

• Apps available on iPad

• Visi-pitch

• Agencies may develop their own case history format, or use a standard form such as the CAPE-V , GRBAS scale or the Voice Handicap Index (VHI)

Medical History Questions

• What is your general health situation?

• Have you had any (vocal related) surgeries in the past?

• What medications are you currently taking?

• Do you have any allergies

Observe the Client

• What is their overall posture?

  • Sitting?

  • Standing?

  • Hunched?

• How are they breathing?

  • clavicular

  • thoracic

  • diaphragmatic

• Is there tension in: face, neck, shoulders, body/posture

Clinical Voice Evaluation

• Maximum phonation time (MPT)

  • /a/

  • 6 yrs: $10.5$ sec.

  • young adults: $28$ sec.

  • elderly: $13$ sec. (Boone 2005)

• s/z ratio (s/z voiced and voiceless)

  • $1.0$ normal, $1.4$ + glottal valving insufficiency

• Speech rate

  • C+ $6-8$ yr: $119-130$ wpm

  • Adults (speaking): $160-170$ wpm

  • adults (reading) $140 -185$ wpm

Clinical Voice Evaluation 2 Pitch

• Range varies $2-3$ octaves for non-singers(Gallena, 2007)

  • gliding up and down, yawn-sigh, /i/ Boone)

• Habitual pitch: pitch used most often in everyday speech

• Optimal pitch: pitch where voice is produced with least amount of effort and laryngeal tension; about $1/4$ of the way up the pitch range; some challenge the concept

• VisiPitch useful instrument

• Intensity

  • Visipitch, sound level meter, counting conversational loudness average $70-80$dB (SPL)

Clinical Voice Evaluation 3

• My Grandfather , Rainbow passage Reading passage

• Informal: counting $1-100$ (expect 2 breaths)

• Boone: how a voice patient uses their air is more important than lung volumes

• lung volumes measured by spirometry, airflow (Phonatory Function Analyzer)

• Respiration: breath support for speech

Clinical Voice Evaluation 4

• Diagnostic therapy

  • Exploration of techniques which may facilitate improved voicing

  • Why?

    • May provide more information about what is contributing to the voice problem

    • Gives an early indication of possible effectiveness of voice therapy

ENT Evaluation

• Endoscopy

• Stroboscopy

• Essential for any voice patient to rule out laryngeal pathology

• may use: indirect laryngoscopy endoscopy: flexible (nasal) or rigid (oral)

  • Endoscopy stroboscopic evaluation

  • Stroboscopy

Audiology Assessment

• Recommended to rule out any hearing impairment contributing to voice problem

• How does hearing impact voice?

STUDY QUESTIONS

• Define the terms used to describe voice disorders.

• What is the difference between a functional and organic voice disorder?

• What is a neurological voice disorder?

• Give examples of each of the types of voice disorders.

• Describe the elements of a voice assessment.

• What are some standard instruments/questionnaires used for collecting case history information?

Study Questions 2

• Give examples of the types of questions that might be asked on a case history. Why would you want to ask these questions?

• What is meant by the s/z ratio? How does it give us information about a client’s vocal functioning?

• What medical evaluation is critical for a voice patient? Why?

• What instrumental and non-instrumental techniques could be used to evaluate respiration?

Study Questions 3

• What does testing a client’s respiration tell us about their ability to use voice?

• What is MPT and why is it important?

• Know the values for MPT, s/z ratio, speech rate, pitch, and intensity