Voice Assessment

Question 1

Voice Eval Summary

Answer 1

MD report of VF status
Medical hx
Respiratory capabilities
Strength of glottic closure
Optimum/habitual/range of pitch
Intensity & Vocal quality
Endurance
Sites of vocal hypertension
Motor/sensory eval of CN 9, 10, 12
Audio/video recorded sample

Question 2

Voice Eval: Medical Hx

Answer 2

Birth & neonatal period
Illnesses, allergies, accidents
Hospitalization medications
Previous ENT evals
Previous speech/psychiatric contact

Question 3

Voice Eval: Behavioral Hx

Answer 3

Biographical info
Pt description of voice d/o
Other reactions
Effects of voice on personal life
Pt explanation of cause
Onset & course of d/o

Question 4

Physician Eval of VF Status:

Answer 4

Flexible Endoscope Nasendoscopy (also like FEES–same procedure w/o food), Nasendoscopy, Mirror laryngoscopy (reversal in image to keep in mind)

Question 5

Respiratory Difficulties & Voice

Answer 5

SOA, reduced speech endurance, emphysema, PD, CP, clavicular breathing–>increased laryngeal tension
Speaking on residual air
Clavicular: tension in neck
Other: shallow breathing

Question 6

Extraneous Respiratory Noises (Stridor)

Answer 6

Asthma, nasal blockage, laryngeal neoplasms, laryngeal webs, abductor paresis or paralysis of VFs

Question 7

Voice Eval of Respiration:

Answer 7

For vegetative purposes
Adequate lung capacity for sustaining speech
Efficiency of respiration
s/z ratio
Respiratory pattern
Take a deep breath and say /a/ and time them; if they don’t, give them example
Hold /i/ at normal voice as long as they can

(Note from Baker: Embarrassment: don’t show embarrassment in front of pt; doesn’t show confidence either)

Question 8

S-Z Ratio

Answer 8

If there’s a problem w/ voice, it’ll show up on /z/
/z/ will be much shorter
Prepubertal children 10 seconds
Adults 20 to 25 seconds (this is long; Baker calls 15 seconds normal)
No pathology ratio of 1.0
Reduced vital capacity ratio of 1.0 but reduced length for both
Vocal fold pathology 2:1 ratio poor laryngeal control for /z/

Question 9

Maximum Phonation Time (MPT)

Answer 9

Efficiency of glottal closure & efficiency of respiratory system
Adults: 15-20 seconds
Elementary school system: 10 seconds
Deep breath and count out loud as long as you can on that breath (don’t rush though)
If they let breath out at the beginning, they’re inefficient
If people are good, can sometimes count to 35-40 on 1 breath

Question 10

Decreased MPT

Answer 10

1. Inefficient glottal control: breathiness, glottal lesions (Anything that causes a leak (not able to keep glottal control), interarytenoidal lesions, paralysis or paresis of cnx
2. Inefficient respiratory functioning: insufficient respiration pattern, neurologic involvement faculty learned pattern of speaking

Question 11

Eval of Muscle Coordination for Respiration Activities

Answer 11

1. Maintain slow, gradual inspiration
2. Maintain slow, gradual expiration
3. Sustain production of an isolated vowel
4. Read aloud sentences & phrases of varying length
5. Pant like a dog
6. Speak while engaging in some strenuous motor activity (lift something, etc.)

Question 12

Eval of Loudness

Answer 12

Audiometric Eval (check hearing)
Optimum loudness-subjective loud enough to be heard over background noise but not uncomfortable to listener

Question 13

Etiologies of Loudness

Answer 13

VF paralysis
Neurogenic d/o's
Mass lesions of the VFs
Personality disturbance
Deafness

Reduced loudness—paralysis?

Question 14

Procedures for Eval of Loudness

Answer 14

Speak in presence of music
Speak while performing different levels of physical activity
Project voice across room or large lecture hall
Move away from examiner at 10 feet distance

Trouble projecting voice?

Question 15

Eval of Pitch

Answer 15

Sing down scale to lowest note
Sing up scale to falsetto
Determine pitch range
Describe in range of musical note (E3-C5) or as a frequency range (165-523 Hz)
Adequate for age & sex
Everyone has an optimal pitch for their larynx & a habitual pitch
Sing from lowest to highest note they can—you count the notes; give example first (may have to do “do each note after me”)
May decide it’s 2 notes & count 2 notes
Cant tell if voice sounds better lower and strain higher, etc.

Question 16

Evaluation of Optimal Pitch

Answer 16

Voice produced most efficiently; does habitual match optimum?
3 Methods:
1. Fairbanks 1/4 or 1.3: from bottom of range
2. Uh-huh: say uh-huh 2x, then hold it out, then count to 5; habitual is counting; optimal is holding ‘huh’
3. Yawn-sigh: most relaxed a larynx can get is out of a yawn; sigh out of yawn; then count to 5; optimal is sigh

Question 17

Eval of Habitual Pitch

Answer 17

Modal frequency level or pitch use in everyday speech
Method 1: Conversational speech or reading; passage tape recorded stop tape at various place-match pitch to a pitch pipe
Method 2: Toner II Visi- pitch
Use rainbow passage
Aphonic never has a voice; not breathy
Tension will be observed: facial grimacing, tension in neck, etc.

Question 18

Eval of Voice Quality

Answer 18

Tape record conversation of interview
Read a standard passage
Determine quality disorders of phonation or resonance

Question 19

Eval of Breathiness

Answer 19

Asynchronous vibration of VF, paralysis of VF, bowed VF
Can it be reduced?: Phonate different vowels while lifting, Phonate different vowels by pushing, Phonate different vowels while pulling
Spastic: harsh; Flaccid: breathy

Question 20

Eval of Harshness

Answer 20

Neurological disease, hard glottal attack, hypertension of pharynx, use severity rating scale

Question 21

Eval of Hoarseness (breathiness + harshness)

Answer 21

Neurological disease
Interference of the mass, compliance, & elasticity of VF
Laryngeal edema
Severity rating of degree

Question 22

Eval of Glottal Fry

Answer 22

Frying sound @ bottom of pitch range; Everyone has a little fry when they talk at times

1. Determine frequency of occurrence during reading & conversation
2. Avg. duration in seconds
3. Where fry occurs? End of word, phrase, sentence, etc.
4. More frequently on upward or downward inflection
5. Elevate pitch level

Question 23

Eval Sites of Vocal Hypertension

Answer 23

1. Elevation of the larynx
2. Elevation of the hyoid bone
3. Posterior tongue position (do they talk w/ tongue back?)
4. Muscles standing out from the neck
5. Strained vocal quality
6. Hard glottal attack
7. Pain in the presence of normal VFs

Question 24

Hyperfunctional Respiration Patterns

Answer 24

Quick, shallow inhalation; inspiratory voicing
Inefficient control of exhalation: talks on residual air, doesn’t take replenishing breaths
Runs out of air
Air escapes in a rush @ beginning of utterance

Question 25

Hypofunctional Respiration Patterns

Answer 25

Difficulty maintaining erect head, neck, & thorax Inhalation insufficient in depth & timing Exhalation weak & short Inadequate control of exhaled air Weak muscle tone & movement Inadequate use of replenishing breaths Reduced prolongation of /s/

Question 26

Hyperfunctional Phonation Patterns

Answer 26

Abrupt initiation of phonation Folds approximated too tightly, voice is squeezed Constriction of trachea, adduction of false folds Arrhythmic short words & phrases Observable tension sites Inappropriate or uncontrolled loudness & pitch Phonation breaks & nonintentional pitch changes Uses laryngeal valve to control exhaled air Voice sounds hoarse, harsh, diplophonic, ventricular, jerky, & arrhythmic

Question 27

Hypofunctional Phonation Patterns

Answer 27

``` Inconsistent or breathy voice onset Inadequate, irregular laryngeal valving Reduced laryngeal DDK rates Excessive air escape during phonation Voice sounds weak, aphonic, cuts in & out, fades Limited audibility & endurance Minimal vocal variation ```

Question 28

Hyperfunctional Resonance Patterns

Answer 28

Tension in supraglottal resonators Voice sounds strident; has an "edge" Lack of reverberation of sound on facial bones Minimal mouth opening; tight jaw Inappropriate balance of oral nasal resonance Tense, posterior tongue carriage

Question 29

Hypofunctional Resonance Patterns

Answer 29

Inadequate oral resonance & nasal resonance Minimal movement of lips & tongue to shape cavity Vibrating column of air not projected forward Voice sounds thin, weak, muffled Lack of resonance may affect intelligibility of speech sounds Inadequate or imprecise velopharyngeal closure

Question 30

CAPE-V Stands for _____

Answer 30

Consensus Auditory-Perceptual Evaluation of Voice Developed by Special Interest Division 3, Voice and Voice Disorders, of the American Speech-Language-Hearing Association

Question 31

CAPE-V Purpose & Application

Answer 31

Developed as a tool for clinical auditory-perceptual assessment of voice Primary purpose: describe severity of auditory-perceptual attributes of a voice problem Secondary purpose: contribute to hypotheses regarding anatomic & physiological bases of voice problems & to evaluate need for additional testing Not intended for use as the only means of determining nature of voice d/o Not to be used to exclusion of other tests of vocal function Not expected to demonstrate a 1:1 relation to results from other tests of vocal fx

Question 32

CAPE-V Overall Severity

Answer 32

Global, integrated impression of voice deviance

Question 33

CAPE-V Roughness

Answer 33

Perceived irregularity in the voicing source; see hoarseness

Question 34

CAPE-V Breathiness

Answer 34

Audible air escape in the voice; degree perceived relates to degree of VF closure

Question 35

CAPE-V Strain

Answer 35

Perception of excessive vocal effort (hyperfunction); harshness

Question 36

CAPE-V Pitch

Answer 36

Perceptual correlate of fundamental frequency; rates whether the individual's pitch deviates from normal for that person's gender, age, & referent culture

Question 37

CAPE-V Loudness

Answer 37

Perceptual correlate of sound intensity; indicates whether the individual's loudness deviates from norms as well

Question 38

Harshness (associated with strain)

Answer 38

Perceived excessive effort, tension, & constriction in vocal tract; aperiodicity of vibratory pattern diffused across spectrum; hard onsets, visible tension, overadduction of VFs, staccato or jerky phrasing may be present

Question 39

Hoarseness (associated with roughness)

Answer 39

Perceived leakage of air & aperiodicity of vibration (noise) present

Question 40

Severe Hoarseness

Answer 40

Includes voice breaks or aphonic episodes during connected speech

Question 41

Wet Hoarseness

Answer 41

Related to the presences of excessive &/or thick secretions in the vocal tract

Question 42

Aphonia

Answer 42

Severe breathiness; complete absence of sound

Question 43

Vocal Fry or Pulse Register

Answer 43

Basal pitch; relaxed, syncopated vibratory mode produced below lowest note of musical pitch range; likened to popcorn popping or door creaking; note frequency & location (end of breath group or sentence) of fry

Question 44

Difference b/t Aphonia & Breathiness

Answer 44

Aphonia has no voice; breathiness has some voice/sound

Question 45

Voice Attributes on the CAPE-V AKA

Answer 45

Positive Signs

Question 46

CAPE-V Data Collection

Answer 46

Audio record individual's performance on 3 vowels, sentences, & conversational speech

Question 47

CAPE-V Task 1: Sustained vowels: 2 vowels selected

Answer 47

1 is lax vowel (/a/) & the other tense (/i/); /i/ is sustained vowel used during videostrobe; use of /i/ offers auditory comparison Clinician should say to the individual, “The first task is to say the sound, /a/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” (provide model if necessary) Client performs this task three times for 3-5 sec each.“Next, say the sound, /i/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” Client performs this task three times for 3-5 sec each. Lax vowel will bring out breathiness; high tense vowel: can get you closure: is there a difference b/t two vowels

Question 48

CAPE-V Task 2: Sentences:

Answer 48

Designed to elicit various laryngeal behaviors & clinical signs Present client with flashcards that show the target sentences one at a time and say, “Please read the following sentences one at a time, as if you were speaking to somebody in a real conversation.” With difficulty reading, the clinician may ask client to repeat sentences after verbal examples. (Note on CAPE-V form.)

Question 49

CAPE-V Sentences

Answer 49

(a) The blue spot is on the key again; (b) How hard did he hit him? (c) We were away a year ago; (d) We eat eggs every Easter; (e) My mama makes lemon jam; (f) Peter will keep at the peak.

Question 50

What sounds CAPE-V sentences elicit

Answer 50

Sentence 1: provides production of every vowel sound in the English language Sentence 2: emphasizes easy onset with the /h/ Sentence 3: all voiced Sentence 4: elicits hard glottal attack Sentence 5: incorporates nasal sounds Sentence 6: weighted with voiceless plosive sounds.

Question 51

CAPE-V Task 3: Running Speech

Answer 51

Elicit at least 20 seconds of natural conversational speech using standard interview questions such as, “Tell me about your voice problem." or "Tell me how your voice is functioning.” (probably more than 20 seconds)

Question 52

CAPE-V Data Scoring

Answer 52

Client should perform all tasks before completing form; If performance is uniform across all tasks, the clinician should mark the ratings indicating overall performance for each scale. If a discrepancy is noted in performance across tasks, clinician should rate performance on each task separately, on a given line. Only one CAPE-V form is used per individual being evaluated. In the case of discrepancies across tasks, tick marks should be labeled with the task number. If discrepancies within task further divide: 1a, 1b, 2a, 2b Unlabeled tick marks indicate uniform performance After all ratings are complete, physically measure the distance (mm) from the left end of the scale. Write the mm score in the blank space to the far right of the scale, relating the results in proportion to the total 100 mm length of the line.

Question 53

CAPE-V Results Reporting

Answer 53

Reported in 2 ways: 1. indicate distance in mm to describe the degree of deviancy, for example “73/100” on “strain.” 2. Use descriptive labels, for example “moderate-to-severe” on “strain.” Strongly suggested to use both forms of reporting

Question 54

CAPE-V Recommendations

Answer 54

Recommended to compare new CAPE-V with any done previously with the same client. Rate subsequent examinations based on direct comparisons between earlier and current audio recordings. (would optimize internal consistency/reliability for assessing tx outcomes) Make every effort to minimize bias in all ratings Indicate prominent observations about resonance under “Comments about resonance.” hyper/hyponasality, cul-de-sac resonance, etc.

Question 55

CAPE-V Cautions

Answer 55

Intra- and inter-judge agreement varies widely Attempted to limit sources of variability in the present tool, but its reliability and validity have not yet been assessed.