2. SPPA 6400 Voice Disorders Structure and Function of Larynx

3. SPPA 6400 Voice Disorders

4. Some questions  What is a voice disorder?  How does it differ from speech disorder?  How does if differ from a resonance disorder?  How common are voice disorders?  Who gets a voice disorder?  Why might someone have a voice disorder?  How do you know if someone has a voice disorder?

5. SPPA 6400 Voice Disorders Voice Disorders: Simple Taxonomy  Organic  Neurogenic  Functional

6. SPPA 6400 Voice Disorders Prevalence vs. Incidence Source: Manitoba Centre for Health Policy

7. SPPA 6400 Voice Disorders From Roy et. al (2004) JSLHR 47 281-93. Epidemiology

8. SPPA 6400 Voice Disorders From Roy et. al (2004) JSLHR 47 281-93. Epidemiology

9. SPPA 6400 Voice Disorders From Roy et. al (2004) JSLHR 47 281-93.

10. SPPA 6400 Voice Disorders From Roy et. al (2004) JSLHR 47 281-93. Epidemiology

11. SPPA 6400 Voice Disorders Voice/laryngeal disorders is often a multidisciplinary effort  Speech Language Pathology  Otolaryngology  Voice Scientists  Vocal Instructors  Neurology  Gastroenterology  Pulmonology  Psychology

12. SPPA 6400 Voice Disorders Assessment What are the goals of assessment?

13. SPPA 6400 Voice Disorders Assessment: Aims  Etiology  Diagnosis  Prognosis  Planning

14. SPPA 6400 Voice Disorders Signs vs. Symptoms

15. SPPA 6400 Voice Disorders Common Voice Symptoms (Table 2.1)  Hoarseness  Vocal fatigue  Breathy voice  Reduced phonational range  Aphonia or voice loss  Pitch breaks/inappropriately high pitch  Strain/struggle  Tremor  Pain & other physical sensations

16. SPPA 6400 Voice Disorders Primary components of Assessment  Chart Review  Case History  Clinical Evaluation Non-instrumented evaluation Instrumented evaluation Quality of life Indicators  Experimental/diagnostic therapy

17. SPPA 6400 Voice Disorders Case History  Voice Symptom History  Voice Use History  Health History  Social/Vocational History  Psychosocial History

18. SPPA 6400 Voice Disorders Voice Symptom History  The Voice Problem  Effect of the Voice Problem  History of the Voice Problem

19. SPPA 6400 Voice Disorders Voice Use History  Establish voice use patterns  On the job  At home  In social settings Look for,  Environmental factors (noise, air quality)

20. SPPA 6400 Voice Disorders Health/Medical History  Current health problems & past history  Specific areas to probe Respiratory problems Gastrointestinal problems Neurological problems Allergies Head and neck trauma, surgery, disease Prescription and OTC drugs Substance use: alcohol, tobacco, drugs, caffeine Exercise/diet considerations

21. SPPA 6400 Voice Disorders Social/Vocational History

22. SPPA 6400 Voice Disorders Psychosocial Interview  “The voice is often a sensitive to our emotional well being…”  Ask about, Stress/emotional problems  Chronic or episodic Hx of counseling

23. SPPA 6400 Voice Disorders Clinical Evaluation  Non-instrumented evaluation Auditory perceptual evaluation of voice Maximal effort tasks Assessment of laryngeal musculoskeletal tension  Instrumented evaluation Videolaryngostroboscopy Acoustic evaluation Other selected instruments  Quality of life indicators Voice Handicap Index

24. SPPA 6400 Voice Disorders Critical listening during history  How do signs match symptoms?  Signs of other communication impairment  Variability in signs as a function of Duration of session (change over time) Periods of improvement/resolution Automatic behaviors (e.g. cough, throat clear, laugh) Conversational content  Atypical vocal signs such as stridor (noise during respiration), tics, grunts, barks

25. SPPA 6400 Voice Disorders Critical observation during history  Signs of pain/discomfort  Signs of tension/strain  Respiratory patterns (“clavicular breathing”)  Level of comfort (or anxiety) over the course of the interview  Signs of tremor, unusual movements of the body

26. SPPA 6400 Voice Disorders Auditory Perceptual Evaluation  Standardized to clinic/profession  Standardized with respect to Data collection procedures (e.g. Alvin Clinic) Data evaluation procedures (e.g. CAPE-V) Data reporting procedures (be consistent)

27. SPPA 6400 Voice Disorders GET HIGH QUALITY RECORDINGS OF VOICE!!! You need High quality recording device High quality microphone Easy access to recordings

28. SPPA 6400 Voice Disorders Auditory Perceptual Signs  Pitch  Loudness  Quality  Aphonia  Other Behaviors

29. SPPA 6400 Voice Disorders Pitch  Monopitch  Inappropriate pitch  Pitch breaks  Diplophonia  Reduced pitch range Females Male

30. SPPA 6400 Voice Disorders Loudness  Monoloudness  Excessive loudness variation  Reduced loudness range

31. SPPA 6400 Voice Disorders Quality  Roughness  Breathiness  Strain/struggle/tension  Tremor  Sudden interruption of voicing (voice break)  Hoarseness

32. SPPA 6400 Voice Disorders Aphonia  Aphonia vs. dysphonia  Consistent vs. intermittent/episodic

33. SPPA 6400 Voice Disorders Other Behaviors  Stridor  Excessive throat clearing/coughing

34. SPPA 6400 Voice Disorders Scaling perceptual features of voice

35. SPPA 6400 Voice Disorders Definitions of Vocal Attributes: OVERALL SEVERITY: Global, integrated impression of voice deviance. Roughness: Perceived irregularity in the voicing source. Breathiness: Audible air escape in the voice. Strain: Perception of excessive vocal effort (hyperfunction). Pitch: Perceptual correlate of fundamental frequency. This scale rates whether the individual's pitch deviates from normal for that person's gender, age, and referent culture. The direction of deviance (high or low) should be indicated in the blank provided above the scale. Loudness: Perceptual correlate of sound intensity. This scale indicates whether the individual's loudness deviates from normal for that person's gender, age, and referent culture. The direction of deviance (soft or loud) should be indicated in the blank provided above the scale. From ASHA Consensus on Auditory Perceptual Evaluation of Voice (CAPE-V) Scaling perceptual features of voice

36. SPPA 6400 Voice Disorders Other Tasks  Phonational frequency range  Loudness range  Maximum phonation time repeat 3 times, take largest value  S/Z ratio repeat 3 times, take largest value  Laryngeal diadochokinesis (quickly repeated /a/ and/or /ha/)  Voluntary cough

37. SPPA 6400 Voice Disorders Assessment of Laryngeal Musculoskeletal Tension “All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990)

38. SPPA 6400 Voice Disorders Instrumented Evaluation  Videolaryngostroboscopy  Acoustic Evaluation  Selected Instruments

39. SPPA 6400 Voice Disorders Laryngoscopy  Direct  Indirect Mirror examination Rigid laryngeal endoscopy  Constant light  Stroboscopy Flexible fiberoptic laryngeal endoscopy  Constant light  Stroboscopy

40. SPPA 6400 Voice Disorders Components  Endoscope (rigid or flexible)  Light source (constant or strobe)  Camera  Recording device (VHS, computer)  If strobe light is used, a neck mounted microphone (or electroglottograph) is used for tracking F o

41. SPPA 6400 Voice Disorders Constant light vs. strobe light  Constant light source allows viewing of basic structure and function Identify lesions Identify abnormalities in ab/adduction Identify supraglottic activity  Strobe light source allows a view of “simulated” vibration allows assessment of the vibratory function of the vocal folds May reveal structural abnormalities not seen during constant light endoscopy

42. SPPA 6400 Voice Disorders Videolaryngostroboscopy (VLS)  Why do it?

43. SPPA 6400 Voice Disorders VLS Examination  Evaluate structural integrity  Evaluate gross mobility of structures  Evaluate (inferred) vibratory patterns

44. SPPA 6400 Voice Disorders VLS Examination Relevant structures  True vocal folds  Ventricular folds  Arytenoids  Interarytenoid area  Epiglottis  Glottic closure

45. SPPA 6400 Voice Disorders Typical VLS Examination A task list  Normal, loud and soft phonation  Pitch glide (glissando)  Cough  Normal & deep breathing

46. SPPA 6400 Voice Disorders Glottal closure patterns (Hirano & Bless,1993)

47. SPPA 6400 Voice Disorders Stroboscopic observations Parameters for evaluating the stroboscopic image  Symmetry of VF motion  Periodicity  Glottal closure configuration  Horizontal excursion of the VFs  Mucosal wave  Phase closure  Vocal fold edge  Vibratory behavior

48. SPPA 6400 Voice Disorders Example of a VLS evaluation form

49. SPPA 6400 Voice Disorders Poburka BJ, Bless DM (1998) A multi-media, computer-based method for stroboscopy rating training JOURNAL OF VOICE 12 (4): 513-526 Methods of training individuals to rate stroboscopic examinations vary widely … Consequently, problems occur in both inter- and intrajudge agreement … This study attempted to determine if CAI could train individuals to make accurate and reliable visuo- perceptual judgments of stroboscopy… Following 4 to 5 hours of CAI training, the subjects with no previous experience demonstrated improved interjudge agreement with a panel of expert raters. The training was not effective for the experienced group. Regardless of the rater's experience, the parameters that required evaluation of movement were more difficult to rate than those requiring only an assessment of structure.

50. SPPA 6400 Voice Disorders VLS Considerations  Level of training (ASHA, 2004)  Cleaning/Universal precautions  Use of topical anesthetic

51. SPPA 6400 Voice Disorders “Typical” acoustic measures  Fundamental frequency and variability mean Fo F 210 Hz M 110 Hz SDFo ~ 2-4 semitones  Vocal intensity and variability Mean 60-80 dB SD 10 dB  Perturbation measures (many ways to measure) Analysis must be limited to a phonated segment Jitter (0.2-1 %) Shimmer (0.5 dB – norms not well established)  Harmonic to noise ratio (> 15) NOTE: these are ballpark figures. Always check actual tables for normative values.

52. SPPA 6400 Voice Disorders Synthetic Continuum Varying in Jitter 0.0%2.0% 0.2%2.5% 0.4%3.0% 0.6%4.0% 0.8%5.0% 1.0%6.0% 1.5%

53. SPPA 6400 Voice Disorders Typical acoustic measures  Phonational frequency range ~ 3 octaves  Dynamic range 50-115 dB 30 dB range NOTE: these are ballpark figures. Always check actual tables for normative values.

54. SPPA 6400 Voice Disorders Some Instruments for acoustic analysis  Real-time analysis Examples Sound level meter Visi-pitch Real-time spectrograms Nasometer  “Off-line” analysis (analysis after data is collected) Examples Computerized speech Lab (CSL), MDVP Cspeech (tf32) Praat

55. SPPA 6400 Voice Disorders Other Measures  Aerodynamic Measures  Electroglottography (EGG)  Electromyography (EMG)

56. SPPA 6400 Voice Disorders Mean flow rate (MFR)  Measures thought to reflect laryngeal valving  ↑ = poor laryngeal valving  ↓ = excessive laryngeal valving

57. SPPA 6400 Voice Disorders Subglottal Pressure (P sg ) Estimate  Repeated /pi/ with intraoral pressure transducer  Can measure for conversational loudness (5- 10 cm water)  Can measure threshold (3-5 cm water)

58. SPPA 6400 Voice Disorders Average glottal resistance  P sg /Mean Flow Rate  ↑ = hyperadducted state  ↓ = hypoadducted state

59. SPPA 6400 Voice Disorders Links to sites related to aerodynamic analysis http://www.kayelemetrics.com/ Aerophone II http://www.glottal.com/ Glottal enterprises pneumotachograph

60. Electroglottography (EGG) Human tissue =  conductor Air:  conductor Electrodes placed on each side of thyroid lamina high frequency, low current signal is passed between them VF contact  =  impedance VF contact  =  impedance

61. Electroglottogram

62. SPPA 6400 Voice Disorders Muscle Activity  Electromyography (EMG) is a way of recording muscle activity  Electrodes (needle or hook wire) inserted in the muscle  Used to Evaluate neuromuscular function Discriminating paralysis from arytenoid dislocation Verify location of needle for injecting BOTOX into intrinsic laryngeal muscles

63. SPPA 6400 Voice Disorders Quality of Life Indicators  Voice Handicap Index (VHI)  Voice-Related Quality of Life (V-RQOL)

64. SPPA 6400 Voice Disorders Assessment Report Key Components  Covers key components of assessment Need good description  However, need to go beyond description Voice diagnosis (or reason why not) Prognosis (or reason why not) Recommendations (it’s OK not to recommend Tx)