Laryngology evaluation

Question 1

One of the first patient-based, voice-specific out-
come measures was the Voice Handicap Index.
This is a 30-question assessment that focuses on
which three domains?

Answer 1

Functional, physical, and emotional aspects of voice

disorders

Question 2

Which voice-specific patient-reported outcome
measure uses 10 questions to assess the physical
functioning and social–emotional status of a
patient with voice disturbance, and how is it
measured?

Answer 2

The V-RQOL. Each question is given 1 to 5 points, with 5
representing a severe problem, and 1 representing no
problem. An equation is then used to generate a score out
of a total of 100, with a higher score representing better
quality of life.

Question 3

Name three important voice parameters.

Answer 3

● Frequency (pitch)
● Intensity (loudness)
● Quality (i.e., timbre)

Question 4

What term refers to the number of repeating

cycles per second (Hz) in the acoustic waveform?

Answer 4

Frequency

Question 5

Define the fundamental frequency of the voice

and the ranges for adult men and women.

Answer 5

The predominant pitch component of speech
● Normal adult men into their 70s: 100 to 125 Hz
● Normal adult women: 190 to 225 Hz

Question 6

What describes the quality of a sound determined

by its frequency (or fundamental frequency)?

Answer 6

Pitch

Question 7

What acoustic term defines the loudness, or sound

pressure level, of speech?

Answer 7

Intensity (normally 70 dB for both male and female

conversational speech)

Question 8

What factors most often influence loudness, or

intensity?

Answer 8

Subglottic pressure, frequency, speech sample, glottal
resistance, and airflow rate
Type of equipment used, distance from the sound source,

and ambient noise can also influence loudness measure-
ments.

Question 9

In acoustic analysis of voice, what are the most

common parameters used to assess frequency?

Answer 9

● Average speaking fundamental frequency

● Maximum phonational frequency range

Question 10

What describes the quality or character of voice,

separate from pitch, intensity, and prosody?

Answer 10

Quality (timbre): Roughness, breathiness, and strain

Question 11

What is the perceptual correlate of the frequency

of a sound wave?

Answer 11

Pitch (perceptual correlate of frequency)

Question 12

What is the perceptual correlate of the amplitude

of a sound wave?

Answer 12

Volume is the perceptual correlate of amplitude.

Question 13

In acoustic analysis of voice, jitter is defined as cycle-to-cycle variation in what parameter?

Answer 13

Frequency of a wave (normal = 0.40%)

Question 14

In acoustic analysis of voice, shimmer is defined as

cycle-to-cycle variation in what parameter?

Answer 14

Amplitude of a wave (normal = 0.50 dB).

Question 15

What are the most common measurements used

to assess voice quality in acoustic analysis of voice?

Answer 15

Short-term perturbation measures (only reliable for nearly
periodic signals):
● Jitter: Cycle-to-cycle variation in frequency
● Shimmer: Cycle-to-cycle variation in amplitude
Note: No single test has been identified to reliably assess
voice quality.

Question 16

The GRBAS scale is an assessment tool, which
attempts to standardize the auditory perceptual
evaluation of voice quality. What does GRBAS
represent, and how is this assessment scored?

Answer 16

G Grade: Overall severity
R Roughness: Psychoacoustic impression of irregular vocal-
fold vibration
B Breathiness: Psychoacoustic impression of air leakage
through the glottis
A Asthenia: Weakness or lack of power in the voice
S Strain: Psychoacoustic impression of hyperfunctional state
of phonation
0: No deficit in parameter
1: Mild deficit
2: Moderate deficit
3: Severe deficit

Question 17

What is the major weakness of the GRBAS scale?

Answer 17

It does not offer a specific protocol for administration or

guidelines for analysis.

Question 18

Which auditory-perceptual evaluation tool uses a
visual analog scale (100-mm line; increasing
distance from the left indicates increasing severity)
to assess six parameters of voice: overall severity,
roughness, breathiness, strain, pitch and loudness,
and how is it scored?

Answer 18

Consensus Auditory-Perceptual Evaluation-Voice (CAPE-V):
The score is based on two sustained vowels, six standard
sentences, and 20 or more seconds of natural running
speech. The six parameters are evaluated for resonance
differences and whether the parameter is constant or
intermittent.

Question 19

Define the following terms:

1. Aphonia
2. Breathy voice
3. Diplophonia
4. Dysphonic
5. Flutter
6. Hoarse voice
7. Hypernasal (honky, nasal)
8. Hyponasal
9. Resonant
10. Strained (harsh, strangled)
11. Tremor

Answer 19

1. The inability to set the vocal folds into vibration either
   consistently or intermittently. Note: Arrest of phonation
   describes sudden stops.
2. Containing the sound of breathing (expiration) during
   phonation
3. Phonation with two independent pitches
4. Abnormal phonation
5. Phonation with amplitude or frequency modulations in
   the 8- to 12-Hz range
6. The combination of a rough and breathy voice
7. Voice quality when excessive acoustic energy is coupled
   to the nasal tract through opening of the velar port
8. Voice quality when inadequate acoustic energy is
   coupled to the nasal tract
9. A voice quality that rings on or “carries” well
10. A voice quality that appears effortful
11. A 1- to 15-Hz modulation of a cyclic parameter (e.g.,

amplitude or fundamental frequency), either neuro-
logic in origin or interaction between neurologic and

biomechanical properties

Question 20

An important adjunct to the auditory-perceptual
evaluation of the dysphonic patient is the visual-
perceptual evaluation, which evaluates visible and
physical facets of voice production related to
cause, maintenance, or effect of dysphonia. What five categories are evaluated?

Answer 20

● General appearance
● Posture, breathing, musculoskeletal tension
● Neurologic dysfunction
● Physical dysmorphology
● Clinical manifestations of disease

Question 21

When assessing a patient who has dysphonia
suspicious of muscle tension or muscle misuse
dysphonia, what tactile-perceptual tests can be
completed in the office to provide a clinical
assessment of dysfunction?

Answer 21

● Palpation of the suprahyoid, thyrohyoid, cricothyroid, and
pharyngolaryngeal muscles both at rest and during
phonation
● Assessment of the thyrohyoid space for anterosuperior
supraglottic compression
● The clinician should assess for tension, muscle “knots,”
decreased space between thyroid cartilage and hyoid, or
discomfort on mobilization.

Question 22

What is the aerodynamic assessment that meas-
ures the length of time a patient can sustain a

vowel after having taken a maximum inspiration?

Answer 22

Maximum phonatory time (indicates breath support and
phonatory efficiency
The longest of three trials should be reported. Typically,
adult women range between 15 and 25 seconds, adult men
between 25 and 35 seconds.

Question 23

The subglottic air pressure (force/unit area) can be
evaluated clinically by measuring the intraoral air
pressure during a voiceless consonant. What influences the magnitude of normal pressure peak
variation, and what are normative values for men and women?

Answer 23

Loudness, age, gender, consonant, and speech context
● Men: 7.52 cm H2O
● Women: 6.43 cm H2O

Question 24

What term describes the minimal subglottic pressure needed for vocal fold vibration?

Answer 24

Phonation threshold pressure

Question 25

Define transglottic airflow and its gender-specific

ranges.

Answer 25

Transglottic airflow is the volume of air that passes through
the glottis during a specific period. It can be traced during
sustained phonation or connected speech and is associated
with breathiness.
● Men: 100 to 183 mL/second
● Women: 91 to 156 mL/second

Question 26

What is the term given to the ratio of trans-
laryngeal air pressure to translaryngeal airflow?
What are the normative values in each gender, and
what is the perceptual correlate?

Answer 26

Laryngeal airway resistance
● Men: 25 to 45 cm H2O/L/second
● Women: 27 to 51 cm H2O/L/second
Phonatory effort, vocal strength, strain

Question 27

What test measures the conductance of low-frequency electrode signals between two surface
electrodes on the neck to assess vocal fold vibration?

Answer 27

Electroglottography

Question 28

What is the maximum number of images the

retina can distinguish per second, and how does this compare with the rate of vocal fold vibration?

Answer 28

● Retina: Five images per second (Talbot’s law)
● Vocal cords: 75 to 1,000 cycles per second
Therefore, vocal-fold vibration cannot be seen by the naked
eye.

Question 29

Videostroboscopy uses a xenon light with rapid
on-and-off bursts to view the larynx in brief
snapshots, fusing images, and “slowing” the
motion of the vibration. This allows for visual-
ization by the human retina. Why does video-
stroboscopy require a microphone?

Answer 29

The microphone is placed on the patient’s neck to sense
laryngeal vibration, which in turn controls the rate of xenon
light firing. Light activation must be out of phase with
laryngeal vibration to identify movement.

Question 30

What five important criteria are used to grade videostroboscopy?

Answer 30

● Symmetry
● Periodicity
● Amplitude
● Mucosal wave
● Closure

Question 31

Define the following terms:
● Symmetry
● Periodicity
● Amplitude
● Mucosal wave
● Closure

Answer 31

● Symmetry: Mirrorred appearance of the two vocal folds
● Periodicity: Regularity of successive glottal cycles
● Amplitude: Lateral excursion of the midmembranous cord
● Mucosal wave: Vertical and horizontal movement of the
cover (SLP) over the body (thyroarytenoid muscle)
● Closure: Closure of the cartilaginous and membranous portions of the glottis

Question 32

During videostroboscopy on a normal patient, the

mucosal wave will be seen traveling over what fraction of the superior portion of the true vocal fold?

Answer 32

From the inferior lip of the true vocal fold up the medial
edge and across approximately one-half of the superior
surface

Question 33

True or False. Videostroboscopy is an excellent tool
in the evaluation of all voice pathologies, including
those without periodic vibration of the true vocal
folds.

Answer 33

False. Videostroboscopy can analyze only periodic vocal-fold

vibration.

Question 34

What is the main advantage of videokymography

over videostroboscopy?

Answer 34

Videokymography captures multiple images of a single
glottic cycle, allowing for analysis of aperiodic vocal-fold
vibration.
Videostroboscopy is effective only in the setting of periodic
vocal-fold vibration and provides an averaging of images.

Question 35

What describes altered vocal quality, pitch, loud-ness, communication, or voice-related quality of life?

Answer 35

Dysphonia

Question 36

What are common risk factors for dysphonia

(hoarseness)?

Answer 36

● Upper respiratory tract infection
● Recent or current infection
● Significant voice use, misuse, or abuse
● Recent neck trauma
● Recent surgery (e.g., airway, neck or thoracic surgery)
● Recent intubation
● Tobacco and alcohol use
● Reflux
● Neurologic disorders
● Psychiatric illness or stress
● Hypothyroidism
● Recent choking or foreign-body aspiration/ingestion

Question 37

What type of stridor would be seen in (1)
supraglottic, (2) glottic, (3) subglottic, or (4)
tracheobronchial airway obstruction?

Answer 37

1. Inspiratory
2. Inspiratory or biphasic
3. Biphasic
4. Expiratory

Question 38

When a suspected aspiration event has occurred,
describe the most important aspects of the history
and evaluation in a stable patient.

Answer 38

SPECS-R*
S: Severity of obstruction on clinical exam
P: Progression of obstruction
E: Eating difficulty, failure to thrive
C: Cyanotic episodes
S: Sleep disturbance
-
R - Radiographic abnormalities (only obtain if information
will change management and patient is not in acute
distress)
*Clinical suspicion: Witnessed aspiration, etc.