Voice Assessment

Front 1

What are the goals of a voice evaluation?

Back 1

1. obtain comprehensive info re: voice disorder and the patient's previous medical and voice history
2. Perform instrumental assessment (perceptual, acoustic, aerodynamic, physiologic)
3. ID possible underlying factors that may be responsible for voice pathology, determine severity of voice pathology, determine stimulability for improved vocal quality/production
4. explain findings to patient and compare with normal voice production
5. obtain client's perception of voice and their perceived handicap to establish realistic goals
6. determine if patient is mentally and physically able to engage in therapy
7. outline treatment plan
8. address client concerns & develop good relationship

Front 2

Can and SLP make a medical diagnosis?

Back 2

NO, the ENT makes the diagnosis (though we may aid ENT in differential diagnosis as well as identification of contributing and precipitating factors)

Front 3

What are the components of a voice evaluation?

Back 3

1. medical history
2. vocal history
3. perceptual evaluation
4. videostropic exam
5. acoustic evaluation & aerodynamic evaluations
6. evaluation of breath support, posture, muscle tension
7. voice surveys
8. stimulation probes

Front 4

What kinds of questions are asked during medical history?

Back 4

1. prior surgeries
2. current medical conditions or diseases
3. physical disabilities - hearing, vision, sensory, postural (back, neck, shoulder problems)
4. allergies
5. current medications, supplements, herbs,etc.
6. respiratory conditions, cardiac conditions or surgery, history of reflux or allergies, surgeries involving the nexk, thoracic activity, oral cavity, pharynx, palate, nasal cavities, abdominal musculature, back or shoulders, lung lobectomies, neurological problems

Front 5

What kinds of questions are asked during vocal history?

Back 5

1. prior voice problems or voice therapy
2. prior voice training for speech or singing
3. current daily vocal demands
4. onset & duration of vocal problem - gradual or sudden?
5. sensory symptoms
6. changes in voice over the course of the day/week or during different types of usage or duration of usage
7. what are coping strategies?
8. vocal hygiene
9. laryngeal pain

Front 6

What do voice surveys do?

Back 6

They give us information regarding patient's perception of severity of vocal handicap
1. voice quality of life index
2. vocal handicap assessment

Front 7

What is the Reflux Symptom Score Survey?

Back 7

It gives information regarding the presence and severity of reflux symptoms

Front 8

What are the 6 aspects of perceptual evaluation?

Back 8

1. quality
2. pitch
3. loudness
4. register
5. resonance
6. miscellaneous

Front 9

What are different types of voice quality?

Back 9

hoarse, breathy, strained, raspy, tremor, pressed, weak, strangled, diplophonia, phonation breaks?

Front 10

What are different types of voice pitch?

Back 10

appropriate, too high, too low, pitch breaks, sporadic uncontrollable changes in pitch

Front 11

What are the types of voice loudness?

Back 11

soft, inappropriately loud, sporadic uncontrollable change in loudness

Front 12

What are the types of register?

Back 12

fry, modal, falsetto

Front 13

What are the types of voice resonance?

Back 13

hypernasal, hyponasal, front tone focus, throaty

Front 14

What are miscellaneous qualities define voice?

Back 14

hard glottal attacks, throat clearing, coughing

Front 15

Under what two conditions are vocal quality assessed?

Back 15

1. spontaneous speech
2. reading

Front 16

What is the GRBAS scale and how is it rated?

Back 16

Grade
Roughness
Breathiness
Asthenia (weakness)
Strain

rated 0-1-2-3

Front 17

What do you use to evaluate perceptual aspects of speech?

Back 17

1. spontaneous/written vocal sample
2. GRBAS
3. written description
4. rating of severity - slight, mild, moderate, severe (or use 7-pt scale)
5. instrumental assessment - voice spectrogram, acoustic analysis - results should correlate with what you hear

Front 18

Name different kinds of breath support.

Back 18

1. clavicular
2. thoracic
3. abdominal
4. variable

Front 19

Name some things you should be looking for during a breath support assessment.

Back 19

1. abdominal wall excursion on inhalation, should raising, or neck tension on inhalation
2. small, inadequate breaths, shallow breaths
3. speaks too long on one breath, pushing voice beyond breath support
4. poor coordination between respiration and phonation - exhalation before speaking or holding of breath before phonation

Front 20

What are two ways to observe breath support?

Back 20

1. observe patient's breathing pattern while engaged in spontaneous conversation during voice history intake and during assessment tasks. Also observe while sitting quietly.
2. have patient stand and speak sponataneously, place hands on abdominal wall, then place hands on lateral ribs

Front 21

During laryngeal palpation, the following are checked:

Back 21

1. laryngeal height
2. thyrohyoid space
3. thyrohyoid muscles
4. suprahyoid muscles -FOM muscles
5. laryngopharyngeal constrictors

* jaw tension - palpate masseter
* neck and shoulder tension - check ROM and palpate muscles

Front 22

What are the two ways to assess muscle tension?

Back 22

1. at rest
2. during phonation

Front 23

What is proper laryngeal height?

Back 23

thyroid space should be two fingers

Front 24

What is proper thyrohyoid space?

Back 24

It should be 1/2" wide or a finger's width wide

Front 25

Should the larynx move freely when rocked laterally?

Back 25

yes

Front 26

Should the thyrohyoid and suprahyoid muscles be soft?

Back 26

yes

Front 27

How do you check for neck tension?

Back 27

turn head left and right, look up at 45 degree angle, look down, chin to chest

Front 28

How should observe SCM?

Back 28

Touch patient's shoulders, neck, observe SCM during respiration and during phonation

Front 29

What are the instrumental assessments?

Back 29

1. acoustic assessment
2. aerodynamic assessment
3. videostroboscopy
4. electroglottography
5. electromyography

Front 30

What is measured in an acoustic evaluation?

Back 30

1. fundamental frequency - habitual pitch during reading, counting 1-15, spontaneous conversation
2. pitch range - between highest and lowest pitches, pitch variability (inflection)
3. average intensity - during spontaneous conversation
4. average intensity during spontaneous conversation
5. max & min intensity: intensity variability
6. measurement of acoustic parameters (such as frequency & intensity pertubations, noise levels, VFo -variation in ff, frequency tremor, amplitude tremor

Front 31

What is jitter?

Back 31

frequency pertubation

Front 32

What is shimmer?

Back 32

intensity pertubation

Front 33

How are noise level in voice measured?

Back 33

1. noise to harmonics ratio
2. voice turbulence index
3. soft phonation

Front 34

What is measured in an aerodynamic evaluation?

Back 34

1. subglottal pressure - measured indirectly and estimated via a measure of the intraoral pressure during repetitions of /pi/ and /pae/
2. transglottal airflow - usually measured during sustained phonation on /a/.

Front 35

How are aeodynamics assessed?

Back 35

1. Ps and Airflow are measured via instrumentation - using Kay Elemetrics 'Aerophone' or Glottal Enterprises systems, or other computer analysis system
2. Rothenberg Mask - mask with both pressure airflow transducers attached that measure air pressure and air flow. Signals are sent to computer which has software that enables us to calculate airflow in L/sec and subglottal pressure in cm H2O

Front 36

What is an esophogeal balloon?

Back 36

a second indirect method of measuring subglottal pressure; assumes esophogeal pressure is a good estimate of subglottal and tracheal pressure; invasive; used for research

Front 37

What is a tracheal puncture?

Back 37

it directly measures subglottal pressure via tracheal puncture; invasive, used primarily for research

Front 38

What is inverse filtering of the airflow signal?

Back 38

it is a way to measure aerodynamics by removing the resonant effects of the vocal tract (F1 and F2); it is a more accurate estimate of the airflow waveform produced at the level of the vocal folds; it can be performed on the acoustic sound pressure wave (audio) or on the airflow waveform

Front 39

What is AC flow versus DC flow when measuring the airflow signal?

Back 39

AC flow - alternating flow, i.e., the amount of airflow that is 'vibrated' during VF vibration. Peak and average airflow during vibration

DC flow - airflow leakage, i.e., amount of air leakage during vibration (unvibrated air) when VFs are supposed to be closed. Peak and average

Front 40

When filtering the airflow signal, what is Max. Flow Declination Rate (MFDR)?

Back 40

the rate of decline in airflow reflects the closing rate of the VFs. Related to vocal intensity

Front 41

What is electroglottography (EGG)?

Back 41

It assesses relative contact area of VFs during a cycle of vibration; it is often done concurrently with a strobe.

Front 42

How does an EGG in the larynx work?

Back 42

it measures changes in electrical impedance and conductivity associated with opening and closing of VFs. When VFs are closed, greater current flows across them than when they are open.

Front 43

What are two indirect measures of glottal closure?

Back 43

1. Maximum Phonation Time - sustained /a/ - time duration of sustain with stopwatch - repeast 3xs and take the best time; normal female range is 16-26 seconds; normal male range is 19-30 seconds

2. S/Z ratio - 1) take the time duration to sustain /s/ 2x and average them; 2) time duration of sustained /z/ 2x and average them; 3) divide average time for /s/ by average time for /z/. Normal is .80 to 1.40 for adults

Front 44

How do you use a sound level meter (SLM) to measure intensity?

Back 44

1. measure during a spontaneous conversation
2. measure maximum intensity during a yell
3. measure minimum intensity during a very quiet sustained /a/

Front 45

What are the rationales for instrumental assessment?

Back 45

1. perceptual signs should be verified and supported by acoustic/aerodynamic methods (instrumental analysis)
2. noninvasive (acoustic & aerodynamic)
3. good availability and relatively low cost
4. correspondence with the underlying physiology of voice disorders
5. good applicability to future therapy goals
6. pre-, mid- and post-therapy comparisons
7. objective documentation of change for insurance reimbursement purposes
8. allows for comparison of vocal performance to normative data

Front 46

What equipment is needed for acoustic and aerodynamic analysis?

Back 46

1. computer
2. acoustic and aerodynamic analysis software
3. aerodynamics hardware (Rothenberg Mask/filters)
4. a good quality microphone
5. a sound level meter (SLM)
6. a stopwatch
7. ruler/tape measure
8. good quality digital recorder

Front 47

Name some voice stimulation probes:

Back 47

1. stimulate diaphragmatic breathing
2. decrease intrinsic and extrinsic muscle tension
3. improve vocal quality
4. increase/decrease pitch
5. improve vocal fold adduction
6. improve vocal resonance
7. increase vocal loudness

Front 48

Non-instrumental Evaluation of Voice

Back 48

1. pitch - subjective judgement or 1, 2,3 method
2. pitch range - use keyboard, pitch pipe, or ear
3. intensity - subjective judgement or use SLM
4. glottic competence and coordination & interaction of respiratory and phonatory systems - MPT and s/z ratio, have pt. cough, clear throat, use hard glottal attacks

Front 49

What is electromyography?

Back 49

Fine wires or needle electrodes are inserted into laryngeal muscles to measure electrical activity of muscles

Front 50

Is electromyography invasive?

Back 50

Yes, it requires expertise of knowledge of head and neck anatomy; interpretation requires experience and practice

Front 51

Why is electromyography used?

Back 51

1. It is used to differentiate VF paralysis from arytenoid cartilage fixation or dislocation
2. it is used to verify excessive muscle activity or verify site injection for Botox therapy for spasmodic dysphonia.