Voice Assessment Flashcards
Assessment is a process which includes:
Case history including medical status, socioeconomic, cultural and linguistic backgrounds done through a parent/patient/family interview.
Review of auditory, visual, motor, cognitive (and other s&l) status
Using standardized or non standardized measures of speech, language, voice
True or False. Evaluation is the appraisal of the implications and significance of the assessment.
True
What is the purpose of assessment, evaluation, diagnosis?
- To see if a problem actually exists and differentiate it with similar problems
- To determine the baseline level of the patient
- To determine prognosis in therapy
- To formulate recommendations to other professionals/the family
Case history questions re voice
Do you have any pressing voice commitments
How many voice training have you had?
Under what kinds of components do you use your voice?
Are you aware of misusing or abusing your voice during speaking?
Case History Taking: Some factors to consider
Patient’s perception and description of the problem
Onset and duration of the problem
Variability of the problem/description of vocal use
Patient’s perception of the effects of the disorder
Patient’s perceived cause of the disorder
Other symptoms related to the voice disorder
True or False. During the assessment procedure, a case history is usually done to gather clinically reliable data regarding a patient’s speech, language, and voice capabilities.
False. The purpose of case history is to gather background information
True or False. A doctor’s recommendation letter is primarily used to determine the tests that will be conducted during the assessment proper.
True
Why do we need to look at the larynx?
To have an idea about the current structure and function of the vocal fold
To see the condition of the larynx and its related structures
To support the voice diagnosis that will be made after the evaluation
This is a small laryngeal mirror placed at the back of the patient’s mouth and light is shined on the mirror from a headset.
Mirror laryngoscopy
What are the advantages and disadvantages of a mirror laryngoscopy?
Advantages: quick and easy overview of laryngeal anatomy and physiology, prognostic for either rigid or flexible laryngoscopy
Disadvantages: poorly tolerated by some patients, can only asses sustained vowels and not connected speech or singing, alters typical laryngeal behavior
What is a rigid laryngeal endoscopy?
A rigid fiberoptic scope is placed inside the mouth.
What are the advantages of a rigid laryngeal endoscopy?
Excellent and direct lighting contributing to good photography
Excellent magnification, contributing to good videography
What are the disadvantages of rigid laryngeal endoscopy?
Poorly tolerated by some patients
Can only assess sustained vowels and not connected speech or singing
Cannot assess the entire vocal tract
Alters typical laryngeal behavior
A flexible fiberoptic laryngoscope is passed through the nasal passages.
Flexible (nasal) laryngeal endoscopy
What are the advantages and disadvantages of flexible laryngoscopy?
Advantages: well-tolerated by almost all patients, minimal alteration of typical laryngeal behavior, can assess connected speech and singing across the vocal range, can assess the entire vocal tract
Disadvantages: optics and magnification inferior to that of rigid (oral) laryngoscopy
Used to visualize vocal fold vibration by using a synchronized, flashing light passed through a flexible or rigid laryngoscope. The flashes aer synchronized to the vibration at a slightly slower speed, allowing the vocal folds to be observed in slow motion
Videostroboscopy
What are the advantages and disadvantages of stroboscopy?
Advantages: allows for examination of vocal fold vibratory behavior
Disadvantages: requires the patient produce a steady fundamental frequency, requires additional technical skills of the examiner
The use of devices and instruments to measure the following:
Frequency
Intensity
Perturbation
Signal to noise ratio (SnR)
This is a widely used instrument to extract acoustic parameters during speech production (pitch, loudness, and dynamic range). It utilized a visual screen to present parameters (self-monitoring)
Visi-Pitch IV (KeyPENTAX)
More comprehensive hardware and software than Visi Pitch IV. Software and hardware modifications: auditory feedback tools, disordered voice database, games, MDVP (with jitter, shimmer, HnR)
Computerized speech lab
Other similar software that are utilized:
PRAAT (Paul Boersma & David Weenink)
Audacity
How can we get F0 or average fundamental frequency?
This is during sustained phonation of the vowel /a/. During that instance, this is where we get the F0.
What type of speaking task should I use to measure SFF (sustained fundamental frequency)?
Connected speech
True or False. Average fundamental frequency is correlated with the perception of habitual pitch.
True
Average fundamental frequency depends on the following:
Age, gender, and race
What type of speaking task should I use to measure F0?
Connected Speech
This is the fundamental frequency measured during connected speech
Speaking fundamental frequency
What is frequency variability? Value during speaking and sustained phonation?
F0SD
Pitch variability perceived as an acceptable change in prosody (pitch is rising and falling in prosody)
Can be obtained through the sample used in messing F0 and SF0
This is also defined as the standard deviation from the F0
Standard range from F0 is around 20-30 Hz during speaking and around 3-6 Hz during sustained phonation.
What does an F0SD higher than the usual value entail?
A higher-than-usual F0SD means that the pitch of the person’s voice changes a lot more than normal during speech.
The individual might not be aware that his pitch varies or changes during speech (involuntary)
There might be vocal pathologies
What is the maximum phonational frequency range (MPFR)? Standard value?
Range of phonational frequencies from the lowest sustainable tone to the highest (falsetto included)
Layman’s term: pitch range
Can be measured in hertz, semitones or octaves
3 full octaves (36 semitones) is the standard for adults
What are the norms for sustained phonation in male and females? Plus minus?
Male: 125.8 ±23.4
Female: 196.3 ±23.0
What are the norms for speech in male and females? Plus minus?
Male: 122.6±15.6
Female: 194.8 ±19.0
What is the normative value of the SF0 range for male and females?
Male: 85.8 - 269.3
Female: 97.1 - 309.6
What is habitual intensity?
Average loudness level for the majority of vocalization (should be loud enough to be heard over background noise but not so loud that it causes distraction)
Standard range is 65-80 dB SPL (~70 dB SPL) for male and female adults
Older adults use a slightly less intense conversational voice (~50 dB SPL)
What is intensity variability?
Defined as the standard deviation from the habitual intensity during speaking
Intensity SD of a neutral sentence is ~10 DB (-/+ 5); it could be higher depending on the speaker’s mood
Can be obtained from habitual intensity sample
Kung gaano ka nagiiba yung intensity ng speech ng isang tao
What is dynamic range?
Refers to the physiologic range of intensities
From a softest non whisper to the loudest shout without physical strain
What is perturbation? Derived from? Can be a sign of?
General definition: Variability or irregularity in a system
In voice: the cycle to cycle variability in the vocal signal
Short term, nonvolitional variability of the vocal features
Can only be derived from sustained vowel phonation
Perturbation refers to small, irregular variations in the voice’s frequency or amplitude during sustained vocal production. These fluctuations are typically unintended and can be signs of vocal instability or pathology.
True or False. Perturbation can be derived from connected speech.
False. It can only be derived from sustained vowel phonation.
There are two types of perturbation. What are they?
Jitter (Frequency perturbation)
Shimmer (Amplitude perturbation)
What is jitter?
Short term variability (irregularity) in fundamental frequency
What is shimmer?
Short term variability in intensity
True or False. You can use shimmer and jitter as a diagnosis for voice
False. Standardization is almost nonexistent and it is not indicative of impairment; thus it is best interpreted in combination with other data.
True or False. According to Titze (1994), generally, jitter of less than 1.0% and shimmer of less than 0.5 dB are considered normal.
True
What is harmonics to noise ratio? Normal value? In terms of VF pathology?
Since the voice is not a pure tone, it has a harmonic component, and an inharmonic (aperiodic) component, but our voice should be predominantly harmonic. HnR tells us how much of the voice is made up of harmonic sound vs noise. This is the ratio of energy in harmonics to the aperiodic noise component of the vocal signal; measured in dB HL.
Normal value: >20 dB
However this is also not conclusive of vocal pathologies
What is spirometry? Measured in terms of?
Used to measure respiratory capabilities
Often measured in terms of cubic or liters (depicted as % in results, compared to reference value)
Has two types: wet and dry
What is a wet spirometer?
A small container floats in water
Patient blows into the container
Container floats higher
Respiration is measured in ml
Maybcontainer na nakalutang tapos dapat patataasin ng pasyente through pagblow
What is a dry spirometer?
Patient blows into a flexible container
Container enlarges and deflates
Can be digitized for easier viewing
How do you perceptually assess respiration? What are the types of breathing patterns.
- Observation of breathing behavior during conversation/reading
- Engaging the patient in a normal conversation. Alternatively, a reading task can also be conducted.
Take note of the following:
(1) how many words before he/she takes a breath
(2) breathing patterns
1. Diaphragmatic
2. Apico-diaphragmatic
3. Thoracic
How is his/her posture during speaking tasks?
What task can you ask the patient to do to check the patient’s respiration? (Besides observation of conversation and reading)
(1) **MPT ** - longest period of a vowel prolongation using a single breath
Practically, an average of three trials should be representative of MPT
Adults should be able to maintain an MPT of 14-20 seconds;
Children should maintain an MPT for approximately 10 seconds
(2) S/z ratio : Task to individually assess and differentiate phonation and respiration.
S/z ratio has the same procedure with MPT, but replace /a/ with /s/ and /z/
S/z ratio can be done in whatever order
3 trials – longest of each is used to calculate the s/z ratio
Normal value for s and z is 20-25 seconds for adults and ~10 seconds for children
s/z > 1 = laryngeal pathology (pag mas mataas z sa s)
True or False. For the s/z ratio and normal vocal fold: /s/ and /z/ should be about the same length ~1
True
True or False. s/z ratio may be used to distinguish respiratory support deficits from inefficient vocal fold vibration.
False. Cannot be used to distinguish respiratory support deficits from inefficient VF vibration
True or False. S/z ratio only signifies its claims, and is not confirmatory of respiratory/vocal issues. Elevated ratios may be a red flag to check VF edges, lesions, or possible VF paralysis.
True
How do we assess the strength of glottal closure?
The clinician will instruct the patient to: produce a sharp cough, perform a throat clear, and produce a vowel with a hard glottal attack.
A mushy cough, weak throat clear or a soft glottal attack may indicate neuromuscular weakness.
What are the steps when a clinician assesses special pitch problems?
Gutzmann Technique
- Ask the patient to sustain a hum
- Place your fingers on the patient’s thyroid cartilage
- Gently press downward
- The patient’s pitch should lower normally
Note: For patient’s with psychogenic falsetto, this technique will cause the pitch to rise suddenly then return to the original pitch.
hum-press thyroid- lower pitch
How do you assess special pitch problems (diplophonia)?
Instrumental assessment is crucial to assess where the secondary vibration is happening
The source of the second site vibration must be established through cine-radiographic techniques and removed surgically before any form of therapy
If no secondary site of vibration is found, the case may be UCFP or vibration of ventricular folds
Non Phonatory OPM Behavior
In addition to a standard OPM examination, the following areas must also be considered:
(1) Signs of anxiety
(2) Visible neck tension (supralaryngeal muscles)
(3) Mandibular restriction → Vocal hyperfunction
(4) Abnormal laryngeal excursion –rapid upward excursion, forward rocking
ANeVAlex
For the perceptual assessment in voice quality, how to know the prognosis of a breathy voice?
Ask the patient to phonate while:
(1) Lifting the body out of a chair with the hands
(2) Linking the fingers of both hands together and pulling in opposite directions
(3) Pushing against a wall
Other perceptual assessment in the vocal quality that an SLP can observe is the vocal/glottal fry: crackling or frying sound during phonation. What are the areas that should be looked at?
- Frequency
- Average duration
- Context -This is related to fatigue and stress (the more likely the person is stress and fatigued, he/she will exhibit glottal fry)
What are the vocal tremors?
Any shaky voice quality that are neurogenic in nature
This uses a 4-point, equal appearing interval rating scale of 0 (Normal) to 3 (Extreme). Developed in Japan to provide a rating scale for vocal quality pathologies.
GRBAS (Grade, Roughness, Breathiness, Aesthenia, Strain)
Developed in America during a conference held by ASHA. It uses visual analog scales or rating and is unanchored. It shares parameters of GRBAS but adds pitch: overall severity, roughness, breathiness, strain, pitch, loudness
CAPE-V
What is VAP?
Developed by Haynes and Pindzola
For evaluation of normal vs non normal voice
Parameters of VAP: pitch, loudness, quality, breath features, rate rhythm
What assessments can you use for quality of life measures (how voice can affect their quality of life)?
Voice Handicap Index
Pediatric Voice Handicap Index
Vocal Performance Questionnaire
Voice Symptom Scale
Voice-Related Quality of Life (V-RQOL)
What are the factors to see for Videostroboscopy?
- Glottic closure
- Supraglottic activity
- Extent of opening
- Vertical level approximation
- Vocal fold edge
- Vocal fold mobility
- Amplitude of vibration
- Mucosal wave
- Nonvibrating portion
- Phase closure
- Phase symmetry
- Periodic/regularity
This is the degree of medial or anteroposterior compression of the ventricular/false folds.
Supraglottic activity
Degree of vocal fold opening when maximally adducted
Extent of opening
Degree to which both vocal folds are on the same plane
Vertical level approximation
Ability of vocal fold to abduct and adduct
Vocal fold mobility
Factors to consider in selecting and assessment tool
- Medical diagnosis (is it functional, organic, neurological, etc.,)
- Current medication taken
- Effect of the disorder on the quality of life
True or False. A patient reported that his severely breathy voice and vocal nodules started one week before the voice evaluation. From a clinical standpoint, this information is most likely factual.
FALSE. Vocal nodules are not sudden onset. They are a result of continuous and repetitive trauma in the VF. It most likely happened one week before.
True or False. A patient reported that his intracordal cyst started about 4 months ago. He reported that the condition became more severe 3 months ago, and again increaed in severiity about 2 months ago.
True
