Voice Flashcards
Multidisciplinary roles in voice evaluation
- ENT evaluation completed first: provides laryngeal diagnosis and medical management plan
- SLP provides voice therapy plan
What are the components of a voice evaluation?
- Medical exam
- Patient interview
- Perceptual evaluation
- Patient self-evaluation
- Acoustic/aerodynamic measurements
- Vocal fold movement/function
What are the goals of a voice assessment?
- Determine etiology, physiology, or behavioral factors that created the disorder
- Describe the voice symptoms
- Evaluate how the disorder impacts each subsystem
- Develop a management plan
- Educate and motivate
What information does an SLP collect during the case history?
- Description of problem/cause (associated factors, time of onset, duration/consistency of problem)
- Medical history
- History of previous voice disorders
- Occupational/social voice use
- Phonotrauma checklist
- Vocal use habits
- Family support
- General health habits
- Emotional state/stress level
- Hearing
What “checklist” or “index” should complete during a voice eval? Provide rationales for selecting each one.
Reflux Symptom Index
- This helps identify whether reflux may be contributing to voice problems.
Vocal Behavior Checklist
- Evaluates vocal behaviors and habits that could negatively impact the voice, such as excessive talking, loud talking, throat clearing, or smoking. It provides insight into factors that may be contributing to vocal strain or injury, guiding recommendations for voice therapy or lifestyle changes.
Vocal Handicap Index
- The VHI measures the perceived impact of voice problems on a person’s daily life, including their social, emotional, and physical well-being.
Vocal Fatigue Index-2
- The VFI-2 evaluates the level of vocal fatigue or strain a person experiences, including symptoms like vocal tiredness, discomfort, or reduced endurance during speech. It assists in identifying individuals who may be overusing their voice or experiencing signs of vocal overexertion, which can inform treatment plans for preventing further vocal damage.
What should SLP observe throughout case history?
- Anxiety/tension
- Neck or laryngeal tension
- Signs of hand, limb, or head tremor
- Respiratory behavior during speech
What is the CAPE-V? Rationale for administration
- Standardized tool used to assess auditory-perceptual characteristics - overall severity, pitch, loudness, roughness, breathiness, strain.
- SLP rates these qualities based on spoken samples (vowel, sentences, conversational sample)
- Establishes a baseline assessment of voice & allows for monitoring changes over time
What does each CAPE-V attribute indicate? What additional features should an SLP listen form?
Roughness: irregularity in the voicing source
Breathiness: audible air escape
Strain: hyperfunction
Additional –> diplophonia, vocal fry, asthenia, aphonia, pitch instability, tremor, wet/gurgly
What are two measures to collect during eval that assess laryngeal function?
S/Z ratio: estimate of laryngeal efficiency
- Sustain /s/ as long as possible; /z/ as long as possible
- Divide longest /s/ by longest /z/
- Indicated of efficient airflow during phonation
Maximum phonation time: respiratory capacity during speech
- Longest sustaining of /a/ at comfortable pitch & loudness
What additional parameters should be measured during a voice eval? (4)
Pitch
- Pitch glides
- Compare to average range
Volume
- Use sound level meter (compare to conversational level 60-65 dB)
Rate
- May contribute to laryngeal pathology
Resonance
- Assess presence of hyper/hyponasality
- Nonasal/nasal phrases
What is the ADSV? What values does it provide?
Analysis of Dysphonia in Speech and Voice: program that performs cepstral and spectral analyses
- Noise-to-harmonics ratio: identifies dysphonic voice if harmonic energy doesn’t stand out from noise elements
- Spectral slope: amplitudes of high frequency energy in a signal
- Cepstral peak prominence: amplitude of peak relative to amplitude of overall signal energy
- Cepstral-spectral Index of Dysphonia (CSID): represents acoustic dysphonia severity (higher score = dysphonic)
- Fo: rate at which VFs vibrates during voiced speech sounds
Endoscopy
Direct visualizzino of vocal folds and laryngeal area
Flexible vs rigid endoscopy
Flexible (nasolaryngoscopy):
- Visualization of nasal cavity, soft palate, pharyngeal walls
- VFs during connected speech
Rigid:
- Light source brighter than flexible
- Better visualization of VF tissue (lesions)
- CANNOT visualize VFs during connected speech
- Often used with stroboscopy
Stroboscopy
Vocal fold movement patterns & mucosal wave
Samples different parts of the vibratory cycle (slow motion movement of VFs)
Assesses vibratory function:
- Regularity, amplitude, mucosal wave, symmetry, vertical level, glottal closure, supra glottal activity, VF edge, VF mobility
List/explain vibratory function parameters
(Hint –> F, S, M, R, A, M, S, V, GC, PC)
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- Free edge contour: smoothness of free edge (**non-linear edge contour can interfere with glottal closure)
- Supra-glottic activity: constriction of supraglottic structures
- VF mobility: movement of each VF toward and away from midline (normal, reduced, absent)
- Regularity: consistency of cycles
- Amplitude: magnitude of lateral movement of VFs (**reduced amplitude due to INCREASED mass/stiffness, incomplete glottal closure)
- Mucosal wave motion: magnitude of movement of the mucosal membrane
- Phase symmetry: symmetry of motion during phonation
- Vertical level: whether VFs meet on same vertical plane during closed phase
- Glottal closure: appearance of glottis during closed phase of vibration
- Phase closure: duration of different phases during glottal cycle
What does Color High-Speed Video Endoscopy record? List advantages/disadvantages.
Records every vibratory cycle (accurately represents aperiodic vibration) and provides highly detailed views of VF vibration
Advantages:
- Valid for ALL voices
- Detailed assessment of symmetry/periodicity
- Detailed view of lesions
Disadvantages:
- Uses memory/storage
- Limited recording time
- Costly
- Requires use of rigid endoscope
What does Videokymography record?
- 2-dimensional display of HSV data
- Tracks changes in 2D image over time
Explain Electroglottography - What does it measure
- Small, high frequency electrical signal passed between 2 electrodes
- Measures varying VF contact patterns
- Extracts fundamental frequency
What does Electromyography measure?
- Functioning of laryngeal muscles
**Analysis of VF paralysis
What instrument can be used to assess aerodynamic measures?
Pneumotachograph: airflow mask w/built in pressure sensors; determines change in pressure across a known resistance
Define the following aerodynamic measures - airflow, pressure, laryngeal resistance
Airflow: at midpoint of vowel, flow across glottis
Pressure: measure at lips, estimate subtotal pressure
Laryngeal resistance: pressure/airflow
What tool is used to assess nasality?
Nasometer:
- Measures amount of air escaping through nasal passages while a person speaks
- Compares acoustic energy coming from nose to energy coming from mouth
- Ratio provides insight into how much nasal resonance is present
**hypernasal: too much air escapes through noise
**hyponasal: too little air passes through nose
What tool can be used to measure lung volume?
Plethysmography: estimates lung volume levels during speech from chest wall excursion
List 4 common pediatric voice etiologies
- Laryngomalacia: immature laryngeal cartilage (most common cause of infant inspiratory stridor)
- Laryngeal webbing: membranous tissue connecting VFs
- Laryngeal cleft: opening between larynx and esophagus
- Puberphonia: high-pitched voice during puberty
Define functional voice disorder
Voice disorder in the absence of neurologic or structural pathology of larynx
OR
Laryngeal pathology develops secondary to vocal misuse
What is phonotrauma? Provide 3-5 examples
Using phonatory and other systems in an ineffective manner
Examples:
- Hard glottal onsets
- Habitual use of glottal fry
- Excess tension in laryngeal muscles
- Loud talking
- Talking in too high/low pitch
Vocal Nodules - Etiology
Etiology:
- Phonotrauma
- Elevated anxiety OR extraversion
- Caffeine intake
- Allergies
- GERD
Vocal Nodules - Tissue features
bilateral or unilateral?
visual appearance (early vs later)
location
BMZ affected?
Tissue features:
- Bilateral
- White, callous-like swellings on vibratory margin
- Increased mass & stiffness on VF cover
- Located –> juncture of anterior 1/3 and posterior 2/3 of VF margin (point of greatest impact)
- Early = soft/reddish…..Later = white/hard
- BMZ = 3x normal thickness
Vocal Nodules - Vibratory features/Aerodynamics
Vibratory:
- Incomplete GC
- Aperiodic vibration
- (+/-) Decreased amplitude or symmetry
Aerodynamics
- Increased airflow
- Decreased pressure
- (+/-) Changes in laryngeal resistance
Vocal Nodules - Perceptual/Acoustic features
- Breathy, rough
- (+/-) Strained, pressed
- Reduced pitch
- Reduced pitch range & control
- Reduced loudness levels & range
Vocal Polyps - Etiology
Phonotrauma
- Single event of excessive use
- HIGH association w/smoking
OR
Unknown
Vocal Polyps - Tissue features
2 types
unilateral vs bilateral
visual appearance
location
BMZ affected?
Sessile: closely adhering to mucosa, broad based
Pedunculated: attached by a slim stalk
- Pliable fluid-filled sacks (vascular, edematous)
- Unilateral
- Location –> anterior 1/3 of VF
- NO affect on BMZ
Vocal Polyps - Vibratory/Aerodynamic features
Vibratory:
- Incomplete GC
- Aperiodic vibration
- (+/-) Decreased amplitude or symmetry
Aerodynamics:
- Increased airflow
- Decreased pressure
- (+/-) Changes in laryngeal resistance
Vocal Polyps - Perceptual/Acoustic features
- Breathy, rough
- (+/-) Strained/pressed
- Overall pitch & pitch range decreased
- Decreased loudness level & range
- Diplophonia
Reinke’s Space Edema
What is it?
Etiology
Generalized edema along the entire length of the VFs
Etiology:
- Most often associated with smoking (chronic mucosal irritation)
Reinke’s Space Edema - Tissue features
- Generalized edema in the superficial layer of lamina proprietary (Reinke’s space)
- Increase in tissue mass
- DECREASED stiffness
Reinke’s Space Edema - Vibratory/Aerodynamic features
Vibratory:
- Incomplete VF closure
- Asymmetry/aperiodicity
Aerodynamics:
(+/-) Changes in airflow
- May see increased laryngeal resistance
Reinke’s Space Edema - Voice features
- Significantly rough, breathy, strained
- LOW pitch
- Decreased pitch & loudness range
Traumatic Laryngitis
What is it?
Etiology
Inflammation of VFs and larynx
Etiology:
- Phonotrauma (screaming, excessive smoking/drinking)
- Inhaled chemical exposure
- Chronic allergies
- GERD
Traumatic Laryngitis - Tissue features
- VFs are edematous and reddish
- Chronic = VF thickening
Traumatic Laryngitis - Vibratory/Aerodynamic features
Vibratory:
- Incomplete VF closure
- Asymmetry and aperiodicity
Aerodynamics
- Increased laryngeal resistance
