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Assessment of Disorders of Speech, Voice, Fluency and Swallowing > L11 Voice > Flashcards

L11 Voice Flashcards

1
Q

five components of a voice assessment according to Dejonckere et al. (2001)

A
  • Perceptual assessment
  • Videostroboscopy
  • Acoustic assessment
  • Aerodynamic assessment
  • Subjective rating by the patient
  • As well as this all assessments should be maximally objective (use blinding of raters where possible: like you would with an AIDS)
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2
Q

components of a paeds assessment according to Cohen et al. (2012a, 2012b)

A
  • Get ENT exam
  • Take a case history
  • Be aware of the differences between paediatric and adult larynxes and how these change through adolescence
  • Otherwise the same as Dejonckere et al. but paediatric tools
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3
Q

ten components of a full voice assessment

A
  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 (using Baker classification system, not diagnosing a disease - none of our business)
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4
Q

personal section of case history

A
  • Age & sex
  • Medical history
  • Medications
  • Smoking
  • Drinking
  • Drugs
  • Asthma/COPD
  • Allergies
  • Intubation
  • Head/neck injury
  • Reflux
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5
Q

home section of case history

A
  • Who’s at home
  • Loud at home
  • Dry/hot/dusty
  • Use of chemicals
  • Pets
  • Kids
  • Family dynamics
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6
Q

work section of a case history

A
  • Occupation
  • Environment
  • Dry/hot/dusty
  • Phone use
  • Presentations
  • Ergonomics
  • Use of chemicals
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7
Q

school section of case history

A
  • Group play
  • Boisterous
  • Vocal demands
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8
Q

social section of a case history

A
  • Social life
  • A talker
  • Lonely
  • Play sports
  • Support sports
  • Acts when drunk
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9
Q

reference for the 5 ps

A

(Macneil et al., 2012)

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10
Q

what are the 5 ps

(Macneil et al., 2012)

A
  • presenting problem
  • predisposing factors
  • precipitating factors
  • perpetuating factors
  • protective factors
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11
Q

presenting problem

A

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

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12
Q

predisposing factors

A

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

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13
Q

precipitating factors

A

Significant events that preceded the onset

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14
Q

perpetuating factors

A

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

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15
Q

protectivr factors

A

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

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16
Q

why is client insight important when taking a case history

A
  • During your case history taking be aware of your client’s insight into their voice difficulties
  • Poor insight or understanding of key concepts (e.g. strain, pitch) may need to be addressed first to make progress in therapy
  • Insight is key to becoming aware of voice difficulties
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17
Q

asking about stress in a voice assessment

A
  • NB: Ask about the onset of the voice problem
  • Can often co-occur with events that are perceived as
    significantly stressful for the patient (Holmqvist et al., 2013) or at a time of a major life event (Baker et al., 2013)
  • Increased stress may lead to increased laryngeal muscle tension
  • If the stress is still there or not dealt with
    • Consider referral to psychology
    • Consider delaying your intervention until resolved
    • Best practice is SLT and psychological intervention happening in tandem this may not always be practica
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18
Q

MDTV

A
  • In those with muscle tension voice disorders and with lesions like nodules, you expect a temporal pattern
  • Voice is better at start of day than end (except perhaps on waking)
  • Voice is better at start of week than end of week
  • This is especially true of teachers
  • Always consider the onset and progression of the dysphonia when taking a case history (part of the 5 Ps)
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19
Q

LPR

A
  • Laryngopharyngeal reflux disease (LPR)
  • Pepsin is refluxed into the oesophagus, pharynx and larynx.
  • “Sticky” and difficult to remove
  • Activates in the presence of acid (even in the atmosphere)
  • Damages the vocal folds
  • Causes hoarse voice and other upper airway problems
  • Often diet-related (Review: Koufman, 2014)
  • Can be managed by SLT (Lechien et al., 2020 on BB)
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20
Q

examples of medical conditions that can affect the voice

A
  • Tremor
  • Parkinson’s Disease
  • Benign Essential Tremor
  • Adductor/Abductor Dysphonia (or Dystonia in general)
  • 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)
  • In the case of medical conditions, voice symptoms usually worsen with time, in-line with disease progression
  • Don’t forget that a simple chest infection can be a trigger for dysphonia!
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21
Q

examples of medications that can cause voice problems

A
  • 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
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22
Q

body posture observations

A
  • Misalignment of the spine (especially cervical spine) can lead to voice disorders (Wilson Arbodela & Frederick, 2008)
  • A framework exists to evaluate and measure this (Bruno et al., 2009)
  • Effects are mainly through changes in resonance
  • Early intervention (as always) is best
  • Seek the advice of a physiotherapist!
23
Q

dememour observations

A
  • Quiet
  • Nervous/Fidgety
  • Excessively talking
  • Stand off-ish
24
Q

recording necessities according to Dejonckere et al. (2001)

A
  • deally a sound-treated room
  • …or at least a quiet one (<50dB ambient noise)
  • Record digitally
  • Sampling frequency of 20,000Hz
  • Mic-to-mouth distance of 10cm
  • Place mic at 45-90° degrees off axis of mouth to reduce noise
  • Video recordings are probably even better, as they allow you to capture posture, movement, visual strain, etc.
25
Q

what should a voice sample include

A
    • Record /a:/ three times (Maximum Phonation Time)
  • Record /a:/ slightly louder to evaluate changes
  • Record single sentence or short, simple passage
  • Pitch glides
  • S:Z ratio
26
Q

what are the most used perceptual analysis scales in ireland

according to kenny (2017)

A
27
Q

what are barriers to instrumental evaluation

according to McAlister & Yanushevskaya (2019)

A
  • Poor access to equipment
  • Limited knowledge
  • Lack of CPD
  • Lack of time
  • Low priority for voice in a mixed caseload
28
Q

describe the GRBAS

A
  • 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)
29
Q

how to grade GRBAS

A
  • 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
30
Q

Describe the CAPE-B

A
  • Consensus Auditory-Perceptual Evaluation of Voice (CAPEV)
  • Developed by ASHA and the University of Pittsburgh
  • Measures much the same as GRBAS, but not asthenia and adds a few more features
31
Q

GRBASvs CAPE-V

A

GRBAS:

  • Very quick to administer
  • Widelt used, so transferrable results
  • Lacks specific instructions

CAPE-V

  • Longer to administer
  • Commonly used
  • Gives detailed instructions

******Both are reliable and both have good cross-correlation with one another (Nemr et al, 2012)******

32
Q

describe videostroboscopy

A
  • 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.
  • Typically uses a rigid or flexible scope
33
Q

use of a rigid rod for videostroboscopy

A
  • Higher quality image
  • More poorly tolerated (gagging)
  • Does not allow speech tasks
34
Q

use of a flexible rod for videostroboscopy

A
  • Poorer image
  • Better tolerated (passed via nose)
  • Allows speech tasks
35
Q

advantages of videostroboscopy

A
  • Direct visualisation
  • Degree of muscle tension
  • Natural speech/singing tasks
  • Education/therapy tool
36
Q

disadvantages of videostroboscopy

A
  • Expensive
  • Lack of training availablity
  • Relies on experience
  • Somewhat subjective
37
Q

what is acoustic assessment

A

the use of hardware/software/apps to breakdown voice componenets

38
Q

advantages of acoustic assessment

A
  • Objective results
  • Breakdown of voice components (Pitch, fundamental frequency, noise in the signal)
  • Instills confidence in the patient
  • Easily replicable and controlled
  • Complements other assessments
  • Picks up change before the ear will
39
Q

disadvantages of acoustic assessment

A
  • Can be quite technical
  • Results may vary from machine to machine and software to software (Maryn et al, 2009)
  • Doesn’t assess connected speech
  • Speaker could be having a particularly good or bad day
  • Multiple samples needed
  • What does it actually tell me
40
Q

resonance

A
  • Not typically an issue in normal populations or those presenting to a regular voice clinic
  • May be a feature in neurogenic illnesses e.g. MND
  • Certainly a feature in cleft palate (Kummer, 2011)
  • Can be measured using Nasometer
  • Prostheses (e.g. palatal prosthesis) can be used to address
  • Surgery can address
  • May require articulation therapy
41
Q

aerodynamic assessment

A
  • 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
42
Q

bedside aerodynamic assessments

A
  • S/Z Ratio
  • Maximum Phonation Time
43
Q

S/Z ratio

A
  • 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)
  • Approximately equal /s/ and /z/ durations indicate normal, healthy adult larynx per Eckel & Boone (1981), Gelfer & Pazera (2006)
44
Q

maximum phonation time

A

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

45
Q

breath support for voice

A
  • Purports to examine for “clavicular breathing” and to change these patterns to an “abdominal breathing” pattern
  • In reality, you cannot only breathe with your upper lungs
  • Very little evidence for abdominal breathing as a therapy
    technique
  • In fact, it’s been found to be ineffective, especially vs
    laryngeal manual therapy (van Lierde et al., 2010)
  • There may be some rationale in patients with lung
    dysfunction e.g. asthma/COPD/Parkinson’s
  • Some (effective) therapy approaches do incorporate it e.g. The Accent Method (Kotby & Fex, 1998)
  • I would suggest that any efficacy of “breathing work” comes from reducing strain in the larynx by taking the focus away from that area e.g. concentrating on introducing accessory muscles of breathing during singing
  • Inadequate breath support may be an issue for elite voice users
  • Singers especially need to learn to avoid a SPLAT breath
    (Chapman, 2017) Singers Please Loosen Abdominal Tension
  • This is common in dancers, especially ballet dancers
46
Q

self rating and impact

A
  • Designed to capture the client’s own perspectives on their voice disorder in terms of:
    • Self-perceived severity
    • Self-perceived impact
47
Q

voice handicap index VHI

A
  • Jacobsen et al. (1997)
  • 30 question survey
  • Rate each answer as never (0) to always (5)
  • Questions divided into physical, emotional and functional aspects
48
Q

Pediatric Voice Handicap Index (pVHI

A
  • Zur et al. (2007)
  • Identical to the adult one, but reduced to 21 questions to reflect a pediatric population
49
Q

advantages of VHI

A
  • Very widely used
  • Translated to many langauges
  • Quick to administer
50
Q

disadvantage of VHI

A

less robust

51
Q

Voice Symptom Scale (VoiSS)

A
  • Deary et al. (2003)
  • 30 item questionnaire
  • Went through rigorous piloting and review before publication, very robust test
  • Items are rated 0 (never) to 4 (always)
  • Divided into subdomains of ‘impairment’, ‘emotional’, ‘physical’
52
Q

advantages of VoiSS

A
  • Highly robust
  • Quick to administer
53
Q

disadvantages of VoiSS

A
  • Less widely used
  • Less widely translated

Assessment of Disorders of Speech, Voice, Fluency and Swallowing (8 decks)

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