Voice Kasa

Front 1

Acoustic output

Back 1

/p/ in voiceless plosive
--complete occlusion of the vocal tract then a burst of air as the occlusion is released
--listener perception of voiceless stop requires 30-80 ms VOT

/^/—voiced monophthong
pure vowel with single, unchanging sound quality
Average F1: 720 Average F2: 1240

/m/—voiced nasal
-- weaker acoustic energy than vowels
-- region of low frequency energy around 500 Hz or less due to the longer/larger vocal tract resulting from the addition of the nasal cavity
-- listener perception of nasals involves
-- nasal murmurs between 200-300 Hz
-- antiresonances which occur due to the occlusion of the oral cavity and its function as a cul-de-sac resonator
-- /m/ distinguished from other nasals (/n/ and /ng) by formant transitions (mainly F2) which are shorter in duration and lower in frequency for /m/.

Front 2

How is it different for velopharyngeal incompetence?

Back 2

--p/ and /^/ affected
--hypernasality due to open VP port
--Difficulty w/stop /p/ because no build up oral pressure for plosive
--audible nasal emission: air leaks through VP port
--Will have compensatory strategies articulations in attempts to produce proper phonemes which include laryngeal or pharyngeal stops for oral stops

Front 3

Racial Voice Use Patterns
Quality, pitch, loudness, resonance

Back 3

A. Vocal quality
1. Studies of listener perception of black vs. white (unseen speaker)
a. correct racial ID was made
b. glottal fry: more in black
B. Pitch
1. For all ages, black lower F0 than whites
2. black have greater flexibility above their mean modal frequencies while white Americans tend to have greater flexibility below their mean modal frequencies.
C. Loudness and resonance
1. One study of voice use in black preachers described their style as including:
a. use of vocal harshness
b. varying speech rate (from rapid to slowed and chanting)
c. use of loud falsetto shrieks
d. rushing many syllables into a single breath group
e. loud gasping inhalations
f. inhalatory stridors

Front 4

Incidence/prevalence of voice/resonance disorders

Back 4

A. Squamous cell carcinoma
1. higher in black and white men than in women for all subsites
2. black men had a higher incidence of all subsite laryngeal cancers, most notably cancer of the glottis
3. black and Native American women are at a greater risk for laryngeal cancer and have a lower 5-year survival rate than white women
B. Vocal nodules
1. slightly more prevalent in Asian men than Asian women AND
2. higher incidence in black women than black men
C. Laryngomalacia
1. equal prevalence among Asian men and women AND
2. higher incidence among black women than black men
D. Cleft palate
1. highest incidence (per 1000 population) among Chinese (4.04%)
2. second highest among Native Americans (0.79-3.62%)
3. third highest among Japanese (0.82-2.41%)
4. fourth highest among blacks (0.80-1.67%)
E. Cancer
1. higher among blacks (men+women) than any other race/ethnicity
2. lower among American Indian men and women (New Mexico) than any ethnicity except Filipino women

Front 5

What recommendations might you make regarding vocal hygiene?

Back 5

I. Vocal hygiene
A. Case history:
1. daily fluid intake
2. use of caffeine
3. meal/snack habits (how often and how much)

B. Recommendations:
1. increase fluid intake to 64 oz/day (if it were not that high already)
a. especially important on lecture days
b. might decrease dry coughing by thinning respiratory secretions
2. maintain nutritionally balanced diet
a. reduce dietary caffeine
b. GERD: smaller meals/snacking throughout day
c. limit/avoid certain foods like milk, ice cream, chocolate, etc., which tend increase viscosity of respiratory secretions and irritate the mucosal lining, causing coughing

3. adequate sleep
4. exercise (as appropriate during pregnancy)

Front 6

What recommendations might you make regarding voice conservation?

Back 6

II. Voice conservation
A. Voice exercises (warm-up/-down)
1. Stemple’s vocal function exercises
B. Vocal rest (between lectures and at home)
C. Vocal amplification
D. Limit talking in noisy environments as much as possible

Front 7

b. What non-instrumental clinical assessment tasks would you choose to evaluate her vocal function? Provide a rationale for each task. What might her results be? General, Acoustic and Physiological

Back 7

A. VHI (Voice Handicap Index)
1. Rationale: get client self-rating of functional, physical, and emotional strain

B. CAPE-V
1. Rationale: clinician’s professional judgment; provides benchmark for judging progress in terms of: overall severity, roughness, breathiness,strain,pitch

Acoustic
A. Average fundamental speaking frequency
1. Counting task
a. Rationale: compare to norms for age and sex

B. Pitch Range
1. Keyboard
a. Rationale: compare to norms for age and sex

Conversational loudness
1. Sound Level Meter
a. Rationale: compare to norms for age and sex

Physiological
A. Tasks
1. Maximum Phonation Time (to screen for adequate approximation, e.g., lesions)
a. Phonation of /a/ (or /i/ or /u/) three times and taking the longest one
b. compare to norms for women in same age range
2. s/z Ratio (to screen for adequate approximation, e.g., lesions)
a. /s/ and /z/ three times each as long as possible and dividing the longest /s/ by the longest /z/
b. compare to norms for women in same age range
3. high quiet phonation (to screen for edema)
a. Not compared to norms (subjective rating)
4. Laryngeal DDK (to screen for neural control)
a. Repetition of puh-tuh-kuh in any combo as many times as possible in 7 seconds
b. Listen for strength, rate, and consistency
c. Compare to norm (5 sounds/second for 7 seconds)

Front 8

c. Describe (1-2 paragraphs) options for instrumental assessment for visual-perceptual, acoustic, aerodynamic, and physiologic aspects of vocal function. What trends would you expect in these measures

Back 8

I. Visual-perceptual
A. Instrument options for assessment
1. indirect laryngoscopy
2. direct laryngoscopy
a. flexible scope
b. rigid scope
3. direct stroboscopy
B. Expected trends: LOOKING FOR GLOTTAL SHAPE, MUCOSAL WAVE, PHASE SYMMETRY, AMPLITUDE, ETC

II. Acoustic
A. fundamental frequency (average, maximum, and minimum)
B. perturbation (jitter and shimmer)
C. harmonics-to-noise ratio
III. Aerodynamic
A. subglottal pressure (measured intraorally)
1. expected trend: higher pressure with hyperfunctional use (evidenced by muscle tension and effortful phonation)
B. inverse filtered flow
(leak or no leak)

IV. Physiologic
A. electroglottography
(closing patterns)

Front 9

d. Based on the reported information and your expected results from additional assessment, what etiological factors may be causing her compromised vocal function? Which clinical signs/symptoms led you to your conclusion?

Back 9

I. GERD, evidenced by:
A. arytenoid edema
B. poor morning voice
C. bitter acid taste upon waking
D. dry coughing
II. Beginning of nodules, evidenced by:
A. bilateral, pre-nodular swellings
B. perception of effortful phonation
C. increasing vocal fatigue throughout the day
D. moderately hoarse vocal quality
E. mild breathiness
F. frequent phonatory breaks
III. hyperfunctional use of vocal mechanism, evidenced by:
A. the significant jaw/neck muscle tension
B. effortful phonation
C. mild strained-strangled voice quality
IV. suboptimal breathing pattern, evidenced by:
A. shallow breathing
B. rounded shoulders
C. forward head carriage

Front 10

e. State your primary goals and objectives to address her problems. What management procedures/strategies might you use to address these goals and objectives? Include appropriate referrals to other clinical professionals.

Back 10

Implementation of vocal hygiene program??? (hydration, caffeine)
Implementation of voice conservation plan??? (vocal rest, amplification, etc.)

I. Goal: To improve vocal quality
A. Objective: Mrs. K will use either an easy voice onset or confidential voice technique on isolated words with vowels in the initial position with 90% accuracy as measured across two consecutive sessions in the treatment room setting as measured by the clinician.
1. Management strategy: use of easy voice onset or confidential voice technique
II. Goal: To improve breathing patterns
A. Objective: Mrs. K will inspire to a count of five and expire to a count of five for five minutes in the therapy room as measured across two consecutive sessions.
1. Management strategy: use of soothing voice and progressive relaxation to encourage the client to deepen her breathing pattern. I would record my voice on a tape or CD to facilitate home practice.
III. Goal: To reduce muscular tension
A. Objective: Mrs. K will use a modified progressive relaxation program for 10 minutes, twice per day for one week.
1. Management strategy: Use of soothing voice and progressive relaxation to encourage the client to reduce jaw and neck tension. I would record my voice on a tape or CD to facilitate home practice.
IV. Referrals:
A. PCP: confirm a possible diagnosis of GERD
B. ENT for further examination of the pre-nodular swellings

Front 11

f. Your patient speaks Japanese in many professional and social contexts, using a perceptually high fundamental frequency and low vocal intensity. In order to be heard in the classroom, she uses both English and Japanese with a higher vocal intensity, but with much perceived effort. Would you try to lower the Fo in her Japanese and/or English speech to a more “optimum pitch”? Provide a rationale for your response. Cite the findings of relevant research literature in your rationale.

Back 11

• UNSUPPORTED CLAIM
o optimal pitch is where aerodynamic power is most efficiently converted into acoustic power
o Research has NOT shown this efficient conversion exists.
• Evidence AGAINST changing FO:
o Minifie (1983): argues against the existence of an “optimal pitch”
o DeJarnette & Holland in Battle (2002): differences in average pitches exist between different racial and ethnic groups, so it is not wise to impose what is considered a normal pitch in mainstream American culture if that is not normal in Japanese culture.
•ALTERNATIVE REMEDIATION
o INFORM:
 Educate client about the risks of using high fundamental frequency combined with high vocal intensity during lecture, which could cause larynx to be overworked
o VOICE AMPLIFICATION
 Roy et al. (2003): teachers reported high treatment effects from the use of these low cost devices

Front 12

g. In facilitating and habituating new vocal production habits, what principles of perceptual motor skill learning are vital to effective learning? What are your options for cueing the client to attend to sensory information?

Back 12

I. Relevant principles of motor skill learning:
A. Augmented feedback
1. information that learners receive about their performance relative to the goal
2. Some augmented feedback is necessary, or practice will not improve performance, however, research shows that less frequent feedback is more conducive to learning than more frequent feedback
B. Variability of practice tasks
1. Varying practice tasks initially depresses immediate performance, but learners who receive practice variability perform better on retention and transfer tests than learners who have no variability in their practice.
C. Task distribution
1. Types:
a. Blocked practice (completing all the trials on any particular task at one time)
b. Random practice (varying the practice order by combining two or more tasks into one practice session and combining them in nonrepetitive or unsystematic ways
2. Research shows that immediate performance is better with blocked practice, but that greater learning takes place with random practice

A. “Scan, Gel, Show, Tell” Framework
1. Allows for attention to be focused on neuromuscular sensation rather than decoding verbal information
2. Hierarchy of Framework from most desirable to least: