Voice Evaluation & Oral Mechanism Examination – Detailed Study Notes

Recording & Case-History Interview

• Always audio-record the interview portion (≈ 15 min) so you can re-listen for missed details.
  • Use a small digital recorder rather than a phone when possible.
  • After recording, download and relabel the file with a neutral numerical code + patient initials + date.
  • Keep all audio under lock or encrypted storage to remain HIPAA-compliant; never store full identifiers.

Types of Voice/Swallow Assessments

• Non-instrumental = Clinical examination (e.g.
  bedside swallow, clinical voice eval).
• Instrumental (e.g.
  MBSS, FEES, stroboscopy) provides objective images or measures.
• The terminology mirrors dysphagia practice: “clinical” vs “instrumental” swallow evaluation.

Initial Behavioral / Perceptual Observations

• Document vocal signal qualities (breathiness, roughness, strain, stridor, etc.).
• Note extra-laryngeal or psychological behaviors:
  • Visible tension, tics, repetitive rubbing, anxiety cues.
  • Opening statement may describe general appearance (e.g.
    "well-nourished, alert").

Oral Peripheral / Oral Mechanism Examination (OME)

Purpose

• Examine the entire speech production mechanism—lips to larynx.
• Identify structural anomalies and establish functional baselines.

Guiding Principles

1. Go in fixed order (outside → inside) so nothing is missed.
2. Observe structure first, THEN function—repeat this mantra.
3. Constantly ask why each task is performed; relate findings to voice.

External Inspection

• Face symmetry, ear height, eyebrow level—could reveal syndromes or stroke.
• Observe neck & shoulder posture; tension can affect laryngeal position.

Intra-Oral Structural Check

• Color & tissue integrity: healthy mucosa = uniform pink, smooth.
• Dentition / bite: neutral bite vs overbite, underbite; note malocclusion.
• Tongue: size, fasciculations, midline deviation; lift tongue with depressor to view ventral surface.
• Palate: contour, possible torus palatinus, midline raphe.
• Buccal cavity: look for white plaques or lesions (possible oral cancer).
• Oropharynx: with light source, evaluate tonsils, uvular deviation, signs of submucous cleft (bifid uvula, blue zone).

Breathing Instruction During Inspection

• Tell patient to mouth-breathe; nasal breathing drops the soft palate and obscures view.

Functional Oral Motor Tasks

Five Muscle-Function Dimensions

{\text{Strength, Range\ of\ Motion (ROM), Speed, Accuracy, Coordination}}

Palate

• Say “ah-ah-ah” ×3; look for symmetrical velar elevation.
• Puff-cheek test: take deep breath, seal lips, blow cheeks; examiner presses cheeks to test palatal & lip strength.

Lips

• Seal, pucker, retract ("ōō → ēē").
• Observe for air escape or asymmetry.

Tongue

• Protrude and hold straight out (don’t rest on lip).
• Side-to-side as fast as possible while tongue remains outside.
• Up-and-down touches of upper/lower lip.
• Strength test: push tongue against depressor; intra-cheek resistance (tongue in cheek, press outward).

Diadochokinetic (DDK) Rates

• Useful only if articulatory coordination is suspected (e.g.
  neuro disease).
• Example syllables: pa\, ta\, ka individually and sequentially pa\, ta\, ka.
• Case example: Abnormal DDK revealed undiagnosed ALS; rapid neuro referral is critical (ALS survival ≈ 90 days–2 yrs after Dx).

Laryngeal Palpation & Posture

• Fingers at top, mid, and lower thyroid cartilage; gently slide side-to-side to assess mobility/stiffness.
• Feel hyolaryngeal excursion during swallow (thyroid notch should elevate to touch superior finger).
• Palpate suprahyoid tension from behind patient.
• Asymmetrical tension (dominant-side tightness) can laterally displace the larynx, reducing glottal efficiency → patient compensates with excess effort.

Simple Resonance Probe

• Have patient say “My sister wears fuzzy shoes.”
  • Nasal (/m, n/) vs oral segments help judge resonance balance.

Core Components of a Comprehensive Voice Evaluation

1. Case history (recorded).
2. OME (structure + function just detailed).
3. Perceptual voice tasks
   • Sustain vowels: lax /ɑ/, /u/ for quality.
   • CAPE-V or K-V sentences for standardized ratings.
   • Short connected passage (e.g.
     Grandfather, Rainbow).
   • ≥ 5 min spontaneous conversation.
4. Acoustic/Aerodynamic measures (if devices available): Visi-Pitch, sound level meter, airflow.
5. Palpation/posture analysis.
6. Patient-reported outcome scales (e.g.
   VHI-10).

Specific Acoustic/Physiologic Tasks & Numbers

• Habitual vs comfortable pitch: verify with frequency analyzer.
• Optimal pitch via three “uh-huh” responses; hold the last.
• Loudness range: measure softest → loudest “hey”.
• Pitch matching: usually only for singers.
• s/z ratio
  • Inhale deeply, sustain /s/, then /z/ as long as possible ×3.
  • \text{Ratio} = \frac{\text{Longest }s}{\text{Longest }z}; >1.4 may indicate glottal insufficiency.
• Maximum Phonation Time (MPT) & Counting Task
  • Sustain /ɑ/ or /u/ after deep breath; time with handheld timer, not wristwatch glare.
  • Count "1…20" on one breath: note seconds & final number—guides breath-group length in therapy.

Documentation & Rating

• Provide qualitative descriptors:
  • Quality: breathy, rough, strained, tremulous, etc.
  • Pitch: within expected range? too high/low? variability?
  • Loudness: adequate, reduced, excessive.
  • Resonance: hypo- or hyper-nasal.
• Identify tension sites, posture faults, and any behaviors influencing phonation.

Referral & Advocacy

• If OME reveals red-flag neuro signs, phone the PCP or neurologist immediately; do not simply mail a report.
• Example: early ALS suspected from weak clear-throat, abnormal DDK.

Therapy-Planning Hierarchy

1. Respiration (foundation): breath support, coordination.
2. Laryngeal mechanics: tension reduction, efficient closure.
3. Resonance balancing.
4. Articulation if needed.
5. Vocal hygiene begins day 1—safe to teach pre-medical clearance and gives patient immediate value.

• Always target the factor “contributing most to dysfunction.”

Patient & Customer Service Tips

• End every session with tangible take-home strategies (e.g.
  hydration log, resonant humming drill) so patients feel progress.
• Maintaining satisfaction increases compliance & follow-up attendance.