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Chapter 5. Voice Evaluation. SLP Function in Voice Assessment. Voice diagnosis Analyze acoustic, perceptual, and physiological factors I.e., what is the pt. doing relative to respiration, phonation, and resonance? Includes strobovideolaryngoscopy and videoendoscopy Plan voice treatment.

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chapter 5

Chapter 5

Voice Evaluation

slp function in voice assessment
SLP Function in Voice Assessment
  • Voice diagnosis
    • Analyze acoustic, perceptual, and physiological factors
    • I.e., what is the pt. doing relative to respiration, phonation, and resonance?
    • Includes strobovideolaryngoscopy and videoendoscopy
  • Plan voice treatment
voice screening
Voice Screening
  • Decide whether or not voice evaluation is indicated
  • Compare performance to peers of same age and gender on the following parameters:
    • Loudness Pitch
    • Nasal resonance Oral resonance
    • Quality
      • Boone recommends - N + scale; adds s/z ratio
team approach
Team Approach
  • Laryngologist
  • Speech Pathologist
  • Pediatrician
  • Plastic Surgeon
  • Neurologist
  • Orthodontist
  • Prosthodontist
  • Psychologist
evaluation
Evaluation
  • Case history
  • Respiration-Phonation-Resonance observations
  • Test data
  • ENT exam results
  • Defer decision re voice therapy pending ENT results
endoscopy and mirror laryngoscopy
Endoscopy and Mirror Laryngoscopy
  • Used by both Laryngologist and SLP
  • Laryngologist - assesses laryngeal disease
  • SLP - assesses laryngeal function related to clinical stimulation
  • Refer to ASHA Guidelines for Vocal Tract Visualization and Imaging (1992b) and Roles of Otolaryngologists and SLPs in the Performance and Interpretation of Strobovideolaryngoscopy (1998)
instrumental vs perceptual evaluations
Instrumental vs. Perceptual Evaluations
  • Good evaluation can be done with or without instrumentation
  • Instrumentation documents and quantifies data, but will not make up for weak powers of observation, modest clinical skills, or lack of knowledge
  • Crucial factor is the ability to listen critically, and think objectively
elements of a voice evaluation
Elements of a Voice Evaluation
  • Case History
  • Evaluation of
    • Pitch ……………. Frequency
    • Loudness ……... Intensity
    • Quality ……….. Waveform complexity
    • Air wastage ….. Airflow rate
  • Analysis of ENT report
  • Clinical facilitation techniques
  • Analyze videoendoscopic data
  • Observe patient behavior
  • Analyze electroglottographic data
case history
Case History
  • General
    • Establish rapport
    • Avoid leading questions
    • Ask questions in different ways
  • Description of problem and cause
    • Reveals pt conceptualization and possible “Reality distance”
    • Dysphonia different in severity/character than warranted by lesion may indicate psychogenic component
case history 2
Case History - 2
  • Onset and duration of problem
    • Acute & sudden poses threat to pt
    • Slow onset can suggest gradually developing laryngeal pathology or neurological disease
  • Variability of problem
    • Identify situations of best and worst voice
      • e.g. GERD Abuse Allergies
    • What situations aggravate the problem
case history 3
Case History - 3
  • Description of Vocal Use (Misuse/Overuse/Abuse)
    • Use of larynx in daily environment
    • May require environmental observation, e.g. playground behaviors in children
  • Medical Information
    • Previous therapy
    • Family voice patterns e.g. resonance or vocal tremor
    • Medication; hormone therapy
    • Use of smoking, alcohol, drugs
    • Daily fluid intake
observation of the patient
Observation of the Patient
  • Describe behavior, don’t just label
  • Consider degree of social adequacy
  • What is the pt most concerned about?
testing
Testing
  • Voice Rating Scale - forces SLP to focus measurements and observations
  • Parameters may include:
    • Pitch
    • Loudness
    • Quality
    • Nasal and Oral Resonance
    • Speaking Rate
    • Variability of Inflection
testing 2
Testing - 2
  • Scale used may vary
  • Qualities to observe include
    • Breathiness Hoarseness
    • Thinness Tightness
    • Tremor Strained-strangled
oral evaluation
Oral Evaluation
  • Oral peripheral structure and function
  • Cranial nerve examination
  • Observe sites of potential hyperfunction
    • Neck tension
    • Mandibular restriction
    • Laryngeal excursion
    • Thyroid tipping forward with high notes
    • Tongue placement
endoscopy use to study vocal tract anatomy and physiology e g mucosal wave
Endoscopy - use to study vocal tract anatomy and physiology, e.g., mucosal wave
  • Oral Scope - solid/rigid glass rod --> excellent picture
  • Nasal Scope - flexible fiberoptic cable used to view connected speech
  • Stroboscope - flashing light source --> slow motion-like observation of vocal pathology
advantages of videostroboscopy
Advantages of Videostroboscopy
  • Permanent record
  • Studies laryngeal function during typical and clinically manipulated production
  • Aids in pt counseling
  • Aids in compliance with therapy tasks
  • Share pictures with referral source
  • Compare pre and post TX
  • Frame-by-frame analysis of abnormal physiology/mucosal wave
  • Treatment, research, and teaching
respiration
Use of air supply is more important than lung volume

Make judgements about

adequacy of respir-ation in speaking and singing tasks

wastage of air

duration of phona-tion; s/z ratio > 1.4

Pulse hand on abdomen during phonation

Spirometer - measures lung volume in cc or liters

Pressure measuring gauges

Manometer

Airflow - volume of air passed through glottis in fixed pd, e.g. 100 cc per second on vowel

Phonatory Function Analyzer

Pneumotachometer

Aerophone

Respiration
respiration 2
Visual observation of breathing patterns:

Clavicular

elevates shoulders on inhalation, tenses strap muscles --> too much effort for too little breath

Abdominal-Diaphragmatic

abdominal or lower thoracic expansion on inspiration

Thoracic

no upper or lower thoracic mvmt

Pneumograph - records thoracic and abdominal mvmt

Respiratrace

X-ray

Respiration - 2
pitch
Pitch
  • Best pitch - pitch level that produces the most pleasing quality and least amt of hoarseness or roughness, produced with an economy of physical effort and energy
    • Jitter < .6%
    • Shimmer < 2.4%
  • Habitual pitch - pitch used most often
pitch 2
Perceptual judgement re:

Efficiency for mechanism

Appropriate for age and gender

Relaxed phonation

yawn-sign

“uh-huh”

Ability to vary pitch

SLN paralysis

Virilizing drugs

Glandular-metabolic changes

Fundamental Frequency (F0) and Frequency range

Visipitch

Phonatory Function Analyzer

Computerized Speech Lab

Piano/keyboard

Pitch pipe

Chromatic Tuner

Pitch-2
loudness
Perceptual judgement re: efficiency of level for environment

Soft voice

Feelings of inadequacy

Conductive hearing loss

Neurological disorder

Loud voice

Hyperfunction

Sensorineural hearing loss

Lack of variation

Sound pressure level meter

Visipitch

Computerized speech lab

Phonatory Function Analyzer

Loudness
quality
Breathiness - audible air escape as approximating edges of glottis fail to make contact

Harshness - unpleasant hard, rough, or metallic quality

Hoarseness- harshness + breathiness

Spectrogram shows:

--> Periodicity of vocal tone reduced; aperiodicity or noise increased

--> Aperiodicity across spectrum, often with abrupt onset; reduced F0

--> increased noise across spectrum; heavier concentrations in first formant

Quality
other perceptual judgements of quality
Other Perceptual Judgements of Quality
  • Glottal fry - slight hoarseness noted at bottom of range
  • Register variations - fold approximation incompatible with desired pitch level
  • Pitch breaks - noted in voices pitched too high or low
  • Phonation breaks - sudden loss of voice
    • Sudden abduction of folds
    • Phonatory arrest --> overadduction
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