2. Clinical Assessment SPPA 6400 Voice Disorders: Tasko

3. Voice Disorders: A Multidisciplinary Effort Speech Language Pathology Otolaryngology Voice Scientists Vocal Instructors Neurology Gastroenterology Pulmonology Allergy Psychology SPPA 6400 Voice Disorders: Tasko

4. Medical Evaluation (Otolaryngology) The otolaryngologist establishes medical status of the head and neck. Otolaryngologist will view the larynx in some manner. – Indirect mirror exam – Rigid or flexible endoscopic examination – Direct laryngoscopy – Some combination of the above SPPA 6400 Voice Disorders: Tasko

5. Some Aims of Assessment Etiology Diagnosis Prognosis Planning SPPA 6400 Voice Disorders: Tasko

6. Signs vs. Symptoms

7. SPPA 6400 Voice Disorders: Tasko Common Voice Symptoms Hoarseness Vocal fatigue Breathy voice Reduced phonational range (pitch & loudness) Aphonia or voice loss Pitch breaks/inappropriately high pitch Strain/struggle Tremor Pain & other physical sensations Colton et al. (2010)

8. SPPA 6400 Voice Disorders: Tasko Primary components of Assessment Chart Review Case History Clinical Evaluation – Non-instrumental evaluation – Instrumental evaluation (later) Experimental/diagnostic therapy

9. SPPA 6400 Voice Disorders: Tasko Case History Voice Symptom History Voice Use History Health/Medical History Social/Vocational History Psychosocial History

10. SPPA 6400 Voice Disorders: Tasko Voice Symptom History The Voice Problem Effect of the Voice Problem History of the Voice Problem Example

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

12. SPPA 6400 Voice Disorders: Tasko Health/Medical History Current & past health problems Specific areas to probe – Respiratory problems – Gastrointestinal problems – Neurological problems – Endocrine problems – Allergies – Head and neck trauma, surgery, disease – Other Chronic Illness – Prescription and OTC drugs – Substance use: alcohol, tobacco, drugs, caffeine – Exercise/diet considerations Example

13. Social/Vocational History Home environment Work environment Social/recreational activities SPPA 6400 Voice Disorders: Tasko Example

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

15. SPPA 6400 Voice Disorders: Tasko 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

16. SPPA 6400 Voice Disorders: Tasko Critical observation during history Signs of pain/discomfort Signs of tension/strain Function of other vocal components Level of comfort (or anxiety) over the course of the interview Signs of tremor, unusual movements of the body

17. SPPA 6400 Voice Disorders: Tasko Non-instrumental Evaluation Oral-Peripheral Examination Auditory perceptual evaluation of voice Selected maximal effort tasks Assessment of laryngeal musculoskeletal tension Self-report measures

18. SPPA 6400 Voice Disorders: Tasko Auditory Perceptual Evaluation Standardized to clinic/profession Standardized with respect to – Data collection procedures – Data evaluation procedures – Data reporting procedures

19. GET HIGH QUALITY RECORDINGS OF VOICE!!! You need – High quality recording device – High quality microphone – Ability to adjust recording settings – Easy access to recordings SPPA 6400 Voice Disorders: Tasko

20. Auditory Perceptual Signs Pitch Loudness Quality Dysphonia vs. Aphonia Other Behaviors – Resonance – Rate – Articulation

21. SPPA 6400 Voice Disorders: Tasko 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) Auditory Perceptual Disturbances

22. SPPA 6400 Voice Disorders: Tasko Pitch & Pitch Disturbances Monopitch Inappropriate pitch Pitch breaks Diplophonia Reduced pitch range Females Male

23. SPPA 6400 Voice Disorders: Tasko Loudness Monoloudness Excessive loudness variation Reduced loudness range

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

25. SPPA 6400 Voice Disorders: Tasko Aphonia Aphonia vs. dysphonia Consistent vs. intermittent/episodic

26. SPPA 6400 Voice Disorders: Tasko Other Behaviors Stridor Throat clearing Coughing

27. SPPA 6400 Voice Disorders: Tasko Consensus on Auditory Perceptual Scaling of Voice (CAPE-V)

28. SPPA 6400 Voice Disorders: Tasko Other Tasks Maximum phonation time (MPT) s/z ratio Voluntary cough

29. SPPA 6400 Voice Disorders: Tasko 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)

30. SPPA 6400 Voice Disorders Tasko Manual Assessment of Laryngeal Musculoskeletal Tension Pressure is directed over the – Major horns of the hyoid bone – Superior border of the thyroid cartilage – Anterior border of sternocleidomastoid and into the suprahyoid muscles Determine size of the thyrohyoid space Digital pressure should be just enough to blanche (lighten in color) your nail bed

31. SPPA 6400 Voice Disorders Tasko Aronson (1990) Manual Assessment of Laryngeal Musculoskeletal Tension

32. SPPA 6400 Voice Disorders Tasko Roy et al. (1996) Manual Assessment of Laryngeal Musculoskeletal Tension

33. SPPA 6400 Voice Disorders: Tasko Self-Report of Vocal Disturbance Voice Handicap Index (VHI) Voice-Related Quality of Life (V-RQOL)