1. Voice Assessment

2. Voice Evaluation
Evaluation: Assessment of the characteristics of a disorder or problem.
Three primary objectives:
1) Describe type and severity of disorder for baseline,
2) Identify and interpret abnormal voice for differential diagnosis,
3) Determine if voice therapy is necessary.

3. What should you achieve from the evaluation?
1) Complete description of client’s voice,
2) A hypothesis as to probable cause or etiology,
3) Data regarding all parameters of voice, including perceptual, acoustic, aerodynamic and kinematic data.

4. Evaluation Components
Medical evaluation
Patient interview
Instrumental evaluation of voice including aerodynamic & acoustic analyses
Functional evaluation of vocal fold movement

5. Professionals Concerned
Medically oriented team-
-Physician, otolaryngologist, neurologist, orthodontist, radiologist, respiratory therapist, plastic surgeon, voice scientist, SLP, psychologist.
Educationally oriented team-
-Teacher, school psychologist, SLP, school nurse, coach, music/drama teacher, physician, audiologist, counselor.
Professional voice team-
-Otolaryngologist, nurse, singing teacher, drama coach, voice scientist, allergist, pulmonary specialist, SLP.

6. Medical Evaluation 1) Detailed history of the problem
Otolaryngologic examination-
1) Detailed history of the problem
2) Examination of entire head & neck region
3) Pertinent medical history gathered

7. Medical Examination Examination includes-
1) Otoscopic observation of ears
2) Examination of oral & nasal cavities
3) Palpatation of salivary glands, lymph nodes, and thyroid gland
4) Visual examination of larynx (indirect laryngoscopy (mirror; light source; images reversed)
5) Fiberoptic laryngoscopy
6) Radiographs of head, chest & neck
7) Diagnosis & recommendations for treatment

8. Voice Pathology Evaluation
Perceptual:
1) Referral
2) Patient interview/ history
3) Oral-peripheral examination
4) Evaluation of voice components: phonation, resonation, pitch, loudness & rate
5) Diagnostic therapy
6) Impressions
7) Prognosis & recommendations
8) Hearing screening

9. Referral Establish the identity of referral source
Reasons for referral
Establish patients understanding of referral
Develop patient knowledge of voice disorder
Establish credibility of examiner

10. Patient Interview/ History
Case history information: Written & verbal information from client, physicians, family members, other therapists & teachers.
Basic questions of any case history:
1) Identifying information
2) Family history
3) School/ work history
4) General health and voice health

11. Content of Interview 1) Problem- -Nature of problem
-Awareness of patient
-Open-ended questions
-What caused the problem
-Establish initial client-patient relationship

12. Content of Interview 2) Effect of voice problem-
-Life changes, impact of disorder,
-Severity of reaction,
-Feelings, emotions.
3) History of the problem-
-Onset; gradual or sudden,
-Duration; how long condition has been present,
-Variability in voice throughout day.

13. Content of Interview 4) Voice usage -
-Habits (smoking, drinking, shouting, etc.)
-Where & how they use voice (work, recreation)
-Professional use; social history
5) Medical history-
-Present status
-Neurological, allergy-related, gastrointestinal, respiratory or other problems
-Past health history
-Drug history

14. Content of Interview 6) Psychological state- -Emotional state
-Current or past pressures effecting communication
-Stress-related voice usage

15. Oral-Peripheral Exam -Determine physical condition of oral mechanism,
-Observe laryngeal tension area,
-Check for swallowing difficulties,
-Check for laryngeal sensations,
-Routine oral-peripheral examination along with:
*whole body tension,
*digital manipulation of the thyroid cartilage (should rock back & forth).

16. Evaluation of voice components: Perceptual
1) Critical listening & Description-
-Tape record interview: baseline & future review,
-Use of rating scales during interview (i.e. General Voice Profile etc.):
1. Is voice variable or stable?
2. Normal pitch for age, sex?
3. Normal rate, quality, loudness?
4. Judgment relates to environment
5. Back-up with objective data if possible

17. Perceptual Terms
1) Tone: a manner of speaking, a vocal sound (normal, breathy, hoarse)
2) Breathy: term to describe excessive airflow during phonation or if someone runs out of air
3) Hoarse: aperiodic vibration of folds, rough o raspy sounding
4) Tension: a balancing of forces in opposition, mental or nervous strain
-Hyper- excessive above normal
-Hypo- below normal

18. Perceptual Terms
5) Abuse: Activities above & beyond what is considered normal to the vocal folds (shouting, screaming etc.)
6) Loudness: Subjective correlate to intensity
7) Pitch: Subjective correlate to frequency
8) Inflection: Any change in tone or pitch
9) Pitch breaks: Other than puberphonia
10) Diplophonia: Existence or perception of 2 vibrating frequencies (“double voice”)

19. Perceptual Terms
11) Resonance: Determination of sound as prescribed by the size and mechanical properties of a cavity (nasal, oral. hypo-, hyper)
12) Emission: Excessive nasal airflow
13) Aphonia: Absence of voicing which is consistent
14) Tremor: Rhythmic variations in pitch & loudness, not under voluntary control
*Rating scales usually differ as little as 10% to as much as 70%.

20. Noninstrumental Objective Measurements
1) Maximum Phonation Time (MPT):
-Ability to sustain phonation maximally,
-Information about respiratory function, glottal efficiency & laryngeal control,
-Designed to test limits of phonation & uncover other weaknesses,
-Patient is instructed to sustain the vowel /a/ for as long as possible at comfortable pitch & loudness (3 Trials):
Adult Women: 15 Seconds
Adult Man: 20 Seconds
Children: 10 Seconds

21. 2) S/Z Ratio:
Patient should maximally sustain /s/ than /z/, repeated twice: Greater ratio than 1.4 suggests disorder
-Used to differentiate deficits in respiratory support vs. laryngeal insufficiency,
-Normal individuals: sustain voiced sound as long as unvoiced producing a ratio close to 1,
-Respiratory insufficiency should reduce both productions equally, producing a ratio of 1,
-Reduced vibratory efficiency results in air wastage (reduction in the ability to sustain phonation) ratio greater than 1 (z shorter than s),

22. 3) Evaluation of pitch characteristics:
-Total Phonation Frequency Range: Ascending & descending pitch slides; lowest to highest ranges,
-Habitual Pitch: Patient says:”I live in Alabama_a_a” -prolonging final vowel, match pitch on keyboard or tape recording,
-Conversational Range: Patient can describe furniture in room, clinician later determines high & low pitch (judgment of variability),
- Pitch Fluctuations: During prolongation's of vowels, pitch breaks are noted.

23. -Look for glottal closure & efficiency
4) Loudness:
-Observe during interview,
-Test ability to increase subglottal air pressure by having patient shout “Hey”,
-Positive sign to override dysphonia with intensity (getting improved closure),
-Have patient count up to 10 and you highlight 2 numbers within that sequence which you want produced with an increased intensity,
-Look for glottal closure & efficiency

24. 5) Rate:
- Description of rate (slow, normal, fast) during interview,
-Excessive rate can cause pathologic condition (misuse),
-Diagnostic therapy to see if rate can be altered.

25. Diagnostic therapy Depends on the clients symptoms,
Client may have excessive laryngeal tension:
Digital manipulation to reduce tension
Easy onset speech productions with single words & sentences
Client may exhibit respiratory problems, excessive breaths or not enough, not enough replenishing breaths during speech:
See if client can consciously inc./dec. breaths, inc. breaths at appropriate location etc.

26. Diagnostic therapy
Object is to identify problems in quality, rate, loudness and pitch and use therapeutic techniques to see if client is stimulable for changing these patterns,
If client is not stimulable, the prognosis for improvement is poor,
Need to be very familiar with voice deviations including respiratory and laryngeal abnormalities.

27. Diagnostic therapy Production of Reflexive Sounds: Altering Pitch:
Coughing, laughing, clearing throat, vocalized pause “Uh-Huh”
Compare spontaneous examples with elicited
Used to determine quality in non-speech task
Altering Pitch:
Change pitch up & down (not range)
Physical or discrimination problem
If imitation difficult; try animal sounds (“meow”)

28. Diagnostic therapy Sustained Phonation:
Practice before taking measurements (timed = tension)
Observe preparation of how client carries out task
Strained, length, steadiness
Rationale; ability to control & sustain phonation and respiration

29. Diagnostic therapy Altering Vocal Loudness:
Increment loudness in steps (model)
Rationale: further test limits of voice production, explore ability to manipulate isolated vocal parameters, match a model
Phonation w/ Effortful Glottal Closure:
ONLY with patients for whom activity is not harmful
Grunting, isometric pushing of hands together, raise chair while seated
Phonate while producing tension
Rationale: Attempt to force vocal fold adduction; Elicit a nonspeech sounds that is difficult to control voluntarily

30. Impressions, Prognosis & Recommendations
1) Summarize etiologic factors associated with development & maintenance of individual’s voice disorder:
list in order or perceived importance!
2) Analyze probability of improvement through voice therapy:
include motivation, interest, time availability
3) Outline management plan:
outline the etiologic factors discovered during the evaluation, therapy approaches & other referrals.

31. Readings Colton & Casper: Ch. 2 & 7 Directed Reading (9/16/99):
Eckel, F.C., & Boone, D.R. (1981). The s/z ratio as an indicator of laryngeal pathology. Journal of Speech & Hearing Disorders, 46,
Colton, R,H. & Hollien, H. (1972). Phonational range in the modal and falsetto registers. Journal of Speech & Hearing Research, 15,