Ax of voice

Question 1

Components of Voice Ax for all patients according to Dejonckere et al. (2001)

Answer 1

◼ Perceptual assessment
◼ Videostroboscopy
◼ Acoustic assessment
◼ Aerodynamic assessment
◼ Subjective rating by the patient

◼ All assessments should be maximally objective (use blinding of raters where possible: like you would with an AIDS)
◼ Use high-quality voice recording

Question 2

Voice ax for paeds according to Cohen et al. (2012a, 2012b)

Answer 2

◼ Get ENT exam
◼ Take case history
◼ Be aware of differences between paediatric and adult larynx
and how these change through adolescence
◼ Otherwise; same as Dejonckere et al. (2001), but paediatric
tools

Question 3

Voice ax for adults according to
Jesus et al. (2021)

Answer 3

◼ Auditory-perceptual analysis (GRBAS or CAPE-V)
◼ Aerodynamic measures (breath control, MPT, S/Z)
◼ Global evaluation (oral cavity, palpation of larynx & neck,
posture, impact)
◼ Acoustic evaluation (F0, jitter, shimmer, HNR)

Question 4

full voice examination

Answer 4

1. Case History
2. Observation & Listening
3. Recording
4. Voice Sample
5. Perceptual Analysis
6. Videostroboscopy
7. Acoustic Assessment
8. Aerodynamic Assessment
9. Self-rating scale
10. Formulating a diagnosis

Question 5

5 P’s of case history (Macneil et
al., 2012)

Answer 5

Presenting problem: Identify difficulties from the client’s perspective
(usually activity- and participation-related)

Predisposing factors: Examine what may be contributing to the problem
(e.g. risk factors, environmental exposure)

Precipitating factors: Significant events that preceded the onset

Perpetuating factors: Things that maintain the current difficulties (e.g.
anxiety disorder)

Protective factors: Things that mitigate the voice disorder (e.g. awareness of preventing vocal strain)

Question 6

screening people for laryngopharyngeal reflux

Answer 6

reflux symptom score

Question 7

medical history for voice problems

Answer 7

◼ Medical conditions may affect voice e.g.
◼ Tremor
◼ Parkinson’s Disease
◼ Benign Essential Tremor
◼ Adductor/Abductor Dysphonia (or Dystonia in general)
◼ Fatigue
◼ Myasthenia Gravis
◼ Hyperthyroidism and hypothyroidism
◼ Intubation, physical trauma
◼ Any conditions causing dysarthria can affect voice
◼ Note: Menstruation, menopause and testosterone insufficiency
contribute to voice changes also (Abitol & Abitol, 2014)

Question 8

medications in case history for voice problems

Answer 8

◼ Look at what medications the client is taking
◼ Watch out for:
◼ Anti-reflux medication
◼ May indicate LPR/GORD
◼ Inhalers
◼ May cause drying and other adverse effects in the larynx
(Gallivan et al. 2007)
◼ Advise: gargling, drinking water post-same
◼ Is there a pattern of voice difficulties worsening when new
medications were started or when doses changed?

Question 9

taking voice sample

Answer 9

Dejonckere (2001)
◼ Record /a:/ three times (Maximum Phonation Time)
◼ Record /a:/ slightly louder to evaluate changes
◼ Record single sentence or short, simple passage

Cohen (2012a, 2012b)
◼ Connected speech sample

• can do all including pitch glides and S:Z ratio

Question 10

perceptual analysis: validated scales

Answer 10

◼ Most common scales in use in Ireland (Kenny, 2017) are:
◼ GRBAS (80%)
◼ Vocal Profile Analysis/VPA (20%)
◼ Consensus of Auditory-Perceptual Evaluation of Voice/CAPE-V
(20%)
◼ But also…
◼ “Your own verbal descriptors e.g. creaky/hoarse” (76%)
◼ A “mild/moderate/severe” scale (43%)
◼ McAlister & Yanushevskaya (2019): Similar perceptual findings to Kenny (2017)

Question 11

barriers to instrumental evaluation

Answer 11

McAlister & Yanushevskaya (2019)
◼ Poor access to equipment
◼ Limited knowledge
◼ Lack of CPD
◼ Lack of time
◼ Low priority for voice in a mixed caseload

Question 12

GRBAS

Answer 12

◼ Grade (the overall grade of the voice)
◼ Roughness (a gravelly quality)
◼ Breathiness (a kind of breathy, airy sound)
◼ Asthenia (weakness)
◼ Strain (sounding like a forced voice)
◼ Developed by Hirano (1981)
◼ The most widely used scale in the literature
◼ A version called the GRBASI also exists (I=instability)

Question 13

GRBAS instructions

Answer 13

◼ GRBAS Instructions
◼ Listen to a sample of a patient’s voice. Can be a prolonged /a:/, or
reading/conversation or all of the above.
◼ Rate each individual feature of the voice on a scale
◼ 0=absent
◼ 1=mild
◼ 2=moderate
◼ 3=severe
◼ The highest number in the RBAS part gets assigned to the G. In
other words, your overall severity is never more severe than any
individual feature
◼ Write your findings in subscript after each letter, like this:
◼ G2R2B1A0S1

Question 14

Consensus Auditory-perceptual evaluation of voice (CAPE-V)

Answer 14

◼ Developed by ASHA and the University of Pittsburgh
◼ Measures much the same as GRBAS, but not asthenia and
adds a few more features

Question 15

videostroboscopy

Answer 15

◼ An endoscopic procedure used to visualise the pharynx and larynx.
◼ Light is shined on the vocal cords in pulses.
◼ The rate (frequency) of the pulses is related to the fundamental frequency (F0) of the voice.
◼ Each pulse of light is shone on the vocal folds at an increased point in the adduction/abduction cycle.
◼ This gives the illusion of vocal fold opening and closure, it is not true movement.

Question 16

rigid vs flexible videostroboscopy scope

Answer 16

rigid scope:
- higher quality image
- poorly tolerated - gagging
- doesn’t allow speech tasks

flexible scope:
- poorer image
- better tolerated (via nose)
- allows speech tasks

Question 17

advantages and disadvantages of videostroboscopy

Answer 17

advantages:
- direct visualisation
- degree of muscle tension
- natural speech/singing tasks
- education/therapy tool

disadvantages:
- expensive
- no training available
- relies on experience
- somewhat subjective

Question 18

acoustic hardware equipment

Answer 18

◼ Computerised Speech Lab (CSL) by KayPentax
◼ Sound Pressure Level (SPL) meter
◼ Pitch meter

Question 19

acoustic software

Answer 19

• Praat
• LingWAVES

Question 20

advantages and disadvantages of acoustic ax

Answer 20

advantages:
- objective
- breakdown of voice components
- instills confidence
- easily replicable and controlled
- complements other axs
- picks up change before ear

disadvantages:
- can be quite technical
- results can vary through machines and softwares (Maryn et al., 2009)
- doesn’t assess connected speech
- good/bad day
- multiple samples needed

Question 21

measuring loudness

Answer 21

Loudness measures using the Sound Pressure Level meter
(you can get apps to measure this on your phone/tablet).
◼ Measure at a consistent distance (e.g. 30cm)
◼ Useful in cases of presbyphonia, vocal fold palsy/paralysis,
neurogenic voice disorders e.g. Parkinson’s

Question 22

measuring pitch

Answer 22

◼ Pitch tuners can be used to measure pitch ranges – apps
available too
◼ Be aware of pitch control needed for speech vs singing
◼ Reduced pitch range may indicate vocal fold inflexibility
◼ Examine client for pitch breaks

Question 23

what is aerodynamic ax?

Answer 23

◼ Designed to assess the efficiency of the airflow stream, which
influences voice production
◼ In theory, the less efficient the stream, the less efficient the
voice
◼ In particular, measures “valving” of air at the glottis

Question 24

bedside axs for aerodynamic ax

Answer 24

◼ S/Z Ratio (should be holding each for ratio of 1:1
◼ Maximum Phonation Time

Question 25

S/Z ratio for aerodynamic ax

Answer 25

◼ S/Z Ratio
◼ Evaluates efficiency in voicing by taking two identical phonemes (except for the absence and presence of voicing) and compares
durations between the two
◼ Developed originally by Eckel & Boone (1981)
◼ Tested on 28 adult dysphonic patients with laryngeal pathology
(nodules or polyps), 36 dysphonic patients with no pathology and 86 normals
◼ Discovered that 95% of the time, those with a laryngeal pathology had a ratio in excess of 1.4

Question 26

S/Z Ratio instructions

Answer 26

◼ “Take a breath and say /s/ for as long as you can…like this…[SLT models]”
◼ Record timing measure and repeat until you have three measures
◼ “Take a breath and say /z/ for as long as you can…like this…[SLT models]”
◼ Record timing measure and repeat until you have three measures
◼ Divide longest /s/ duration by longest /z/ duration
◼ Note: Importance of maintaining vocal intensity at 60dB ± 2dB
with microphone at a distance of 12 inches per Gelfer & Pazera
(2006)

Question 27

how to interpret S:Z results for adults

Answer 27

◼ Approximately equal /s/ and /z/ durations indicate normal, healthy adult larynx per Eckel & Boone (1981), Gelfer & Pazera
(2006)
◼ >1.4 in adults may indicate laryngeal pathology (Eckel & Boone, 1981)…BUT!…
◼ Healthy adults in a study of 20 men and 20 women by Gelfer & Pazera (2006) found a range of 0.46 to 1.47…AND!…
◼ They found that 10 trials were necessary for accurate results…SO!…

Question 28

maximum phonation time (MPT) for aerodynamic ax

Answer 28

A measure of the efficiency of glottal valving by evaluating how long an individual can hold an /a:/

Question 29

instructions for MPT

Answer 29

◼ “Take a breath and hold /a/ for as long as you can, even if your
voice changes…like this…[SLT models]”
◼ Record timing measure and repeat until you have (at least) three
measures
◼ Take the longest duration of the three attempts as the value
◼ Note: Ensure modal voice (Goy et al., 2013)
◼ Note: Differences exist between patients with respiratory
conditions and those without e.g. Dogan et al. (2005) list norms for
asthmatics

Question 30

instrumental ax

Answer 30

◼ Typically used to evaluate airflow during various phonation tasks
like MPT and repeating /papapapapa/
◼ Measures include: peak expiratory airflow, subglottic pressure,
vital capacity, expiratory volumes
◼ Also provides loudness measures

Question 31

self-rating and impact scales

Answer 31

◼ Designed to capture the client’s own perspectives on their
voice disorder in terms of:
◼ Self-perceived severity
◼ Self-perceived impact

examples:
Voice Handicap Index (VHI)
Paediatric Voice Handicap Index (pVHI)

Question 32

VHI

Answer 32

◼ 30 question survey
◼ Example: “My family has difficulty hearing me when I call them
throughout the house”
◼ Rate each answer as never (0) to always (5)
◼ Questions divided into physical, emotional and functional aspects

Question 33

pVHI

Answer 33

◼ Pediatric Voice Handicap Index (pVHI)
◼ Identical to the adult one, but reduced to 21 questions to reflect a
pediatric population