Diagnosis and Evaluation of Voice Disorders (Ch. 4) Flashcards
Primary aims of voice eval
-determine existence of problem
-discover cause of problem
(respiratory, laryngeal, digestive, social, emotional)
-describe symptoms
-assess severity
-investigate effects on pt’s life
-determine most effective way to treat
Quality of Life Measures
- impact on pt’s life
- helps provide best treatment
- serves as good outcomes measure
Voice Handicap Index
-most widely used; translations available
-30 item questionnaire
- scale of 1 for never to 4 for always
-120 points total
-0-30 low
-31-60 moderate
>60 severe
-proven validity
Voice-Related Quality of Life (V-RQOL)
- assesses impact on
- social/emotional
- physical
- perception-2 wks prior
- partner also completes
- 10 questions
- 5-pt scale (poor to excellent)
- developed for effect of VF paralysis
Voice Disability and Coping Questionnaire (VDCQ)
- assesses how pt copes w/effects of disorder
- is pt problem-focused or emotion-focused? Do they try to change enviro or change the stress?
- 15 items
- 6-pt rating (never to always)
- 4 coping strategies:
1. social support
2. info seeking
3. passive coping
4. avoidance - can ID maladaptive strategies
Auditory-Perceptual Eval
- requires clinical expertise
- “professional listening”
- gold standard because it’s real life: pt’s perceptions are important
A-P Eval: Vocal Activities
- MPT
- Pitch Range
- Loudness Range
- S/Z Ratio
- Vocal endurance
- Reflexive glottal valving
Maximum Phonation Time (MPT)
-deep breath as possible
-sustain “ah” for as long as possible 3x:
comfortable pitch
high pitch
low pitch
-health = >20 sec
-measures glottal efficiency
S/Z Ratio
-deep breath as possible
-sustain /s/ as long as possible
-deep breath
-sustain /z/ as long as possible
-divide /s/ time by /z/ time
-normal = 1-1.4
->1.4 indicates inability to sustain voicing due to glottal inefficiency
BUT wide variability and overlap b/w normal and impaired
Pitch range
- sing scales, comfortable to lowest (excl pulse) & comfortable to highest (incl falsetto)
- normal = 2 1/2 octaves
Loudness range
count from soft as possible (not whisper) to loud as possible
Vocal endurance
- count vigorously to 100
- listen to hard glottal attacks in 80s-90s
- listen to phonation breaks in 60s-70s
- look for increased tension
- listen for loss of voice
Reflexive glottal valving
- cough forcefully/clear throat
- say “uh-huh”
- laugh
- Pt can have normal reflexive valving but impaired phonation
- weak cough may be VF paralysis
A-P Eval: Rating Scales
- Equal-appearing interval scales
- Semantic differential scales
- Visual analog scale
- GRBAS Voice Rating Scale
- CAPE-V
- Patinent self-perception scales
Interval Scales
- numbers rep level of severity
- can be used for variety of vocal aspects
- pitch, loudness, quality
Semantic differential scales
polar opposites on ends of scale: normal/abnormal pleasant/unpleasant strong/weak high/low
Visual analog scale
- 100 mm line for each area rated
- normal on L, abnormal on R
- rater marks their perception
- number of mm used as score
GRBAS Voice Rating Scale
- from Japan
- equal-appearing interval scale
- used in voice research
- proven reliability
- grade/roughnes/breathiness/asthenic/strain
- 0-3
Consensus Auditory-Perceptual Eval of Voice (CAPE-V)
- developed by ASHA SIG3: voice
- standardized
- vocal tasks reflect minimal set of clinically meaningful parameters
- procedures/results: easy & efficient to obtain; applicable to broad range of paths
- ratings reliable within and between clinicians
- protocol: examines vocal features in different contexts
- vowel prolongations, sentence repetition, connected speech
- vocal features evaluated on 100mm line min-mod-severe
- overall severity: roughness, breathiness, strain, pitch, loudness, other
- uses visual analog scale
Patient self-perception scales
Glottal Function Index
- 5 pt equal appearing interval scale
- > 4 = problem in vocal function
A-P Eval Caveats
- What do definitions mean?
- inter-rater communication - Voice quality is multidimensional
- interdependence of pitch, loudness, clarity, rate, resonance - Clinical opinions does not analyze vocal path
Instrumental measures
- determine existence of problem
- assess severity or stage of progression
- ID source of problem
- allow quantitative documentation
types of instrumental measures
- laryngeal mirror
- direct laryngoscopy
- rigid endoscopy
- flexible endoscopy
- videostroboscopy
Acoustic Analysis
- Visi-Pitch
- C-Speech System
- Computerized Speech Lab
- Multidimensional Voice Program (MDVP)
Acoustic analysis - types of measures
- Frequency
- fundamental
- Maximum Phonational Frequency Range - Frequency variability
- Intensity
- Vocal perturbation and noise
Frequency measures
- FO/Avg FO
- perceived as pitch
- adult female - 210ish
- adult male = 180ish
Maximum Phonational Frequency Range
Female = 135-1000Hz
Male = 80-700 Hz
highly variable due to health more than age
Frequency variability
- variations in sustained tone or connected speech
- expressed as SD of FO in Hz
- sustained tone <10Hz
- conversation 20-35 Hz
- very sensitive indicator of disease
intensity measures
-perceived as loudness
-ave intensity (single words):
females = 65-77 dB
males = 70-80 dB
-dynamic range: normal = 30dB
Vocal perturbation and noise measures
-jitter & shimmer
-jitter = frequency/pitch
normal is 0.2-1 %
-shimmer = intensity (loudness)
normal is <5% (.5 dB)
-HNR
normal voice has more harmonics
Acoustic analysis: caveats
- Analyzing severely aperiodic voices may be impossible
- highly sensitive to outside noise
- quality of hardware, calibrations, microphones
- skill of clinician in collecting data
- lack of correspondence of data and perception
Electroglottography (EGG)
- indirect measure of glottal competency
- used when laryngeal paralysis is suspected
- Lx waveform is interpreted based on shape and ratios of opening, closed, closing phases
- better for highly dysphonic patients b/c acoustic measures can be derived
EGG caveats
- waveform does not indicate degree of closure or width of glottal opening
- wouldn’t detect gaps
- wouldn’t detect restrictions to opening - no specific norms exist to interpret waveforms
- no standardization of waveforms
tasks/findings in endoscopy
phonatory tasks:
- normal respiration
- /i/
- /hi/ /hi/ /hi/
- glissando /i/
videostroboscopy evaluation
- VF edge
- glottic closure
- extent of opening
- -phase closure
- mucosal wave
- amplitude of vibration
- phase symmetry
- vertical approximation
- supraglottic activity
- periodicity/regularity
endoscopy/videoendoscopy caveats
- vibratory patterns of severely dysphonic patients not captured
- strobe is set to FO, so if FO is variable, so are images - some optic devices distort image
- phonation not truly representative
- relies on visual interpretation
- large amount of normal variability
aerodynamic measures
- air volume
- VC
- TV - airflow rate
- subglottal air pressures
- oral pressure as pt says /p/
caveats for aerodynamic measures
no established norms for airflow
not useful in tracking small changes
laryngeal electromyography (LEMG)
invasive: insert needles into laryngeal muscles to measure activity
differentiates b/w
- unilateral vs. bilateral paralysis
- paralysis vs. CT joint problems
- paralysis vs. muscle tension dysphonia
Case history
- interview should be broad - all aspects of pt’s life affect voice
- pt’s perception of problem
- medical history (surgeries, Rx, OTCs)
- social/professional life
- SLP listens to voice qualities
Components of comprehensive voice eval
- Case history
- Quality of Life
- Auditory-Perceptual
- Laryngeal exam
- Acoustic analysis
- Aerodynamic analysis
