• Assessment
• Evaluation
• Diagnosis
• Evaluation and treatment overlap
• Use both intrumentation & perceptual judgements

2. Laryngoscopic Exam

• Indirect laryngoscopy(IL)
• Endoscopy
• Flexible - nasoendoscopy
• Rigid
• Videostroboscopy - camera, recording unit & strobing light source
• Falls within the scope of appropirately-trained SLP
• Interpretation varies
• ENT - identification of vocal pathology
• SLP - describe vocal folds under clinical stimuluation

3. Essential Elements

• Case hx, background info, speech mechanism results
• Pitch/Frequency evaluation
• Loudness/Intensity evaluation
• Quality/wave complexity of voice
• Duration - Respiratory/Phonatory control
• Evaluation of Muscle Tension dysphonia

4. Background and/or Referral Information

• Basic identifying informaiton
• Medical history
• Results of laryngoscopic exam
• Referrals as needed
• Results of screening(s)
• Fig.  5.1, pg 124, Boone & McFarland

5. Case History Interview

• Description of problem/cause
• Onset & duration
• Variability & consitency
• Description of vocal use
• Health history
• Social history
• Patient attitudes/feelings about voice
• Observations of patient - non-verbal cues

6. Speech & Hearing Mechanism Exam

• Minimally, use tasks that assess laryngeal function
• Sharp cough
• Vocal fold DDK
• Head turn during phonation
• Full Oral Mechanism Exam if indicated
• Hearing screening

7.  Perceptual Assessment of Voice

• Categorical ratings
• Mild, moderate, severe
• Equal appearing scales/visual analog scales
• Direct magnitude estimation
• Wilson voice Profile
• Perceptual Evaluation of Voice (Awan)

8. Perceptual Assessment of Pitch

• Habitual pitch level
• Modal (most used) or average pitch level
• Judged as appropriate for age & gender
• Pitch variability
• Can patient vary pitch levels during speech?
• Listen for normal intonation patterns
• Pitch stability
• Can patient maintian a steady pitch?
• Shakiness in voice, pitch breaks, diplophonia, vocal tremor
• Total pitch range
• Range between lowest pitch in modal register and highest pitch in falsetto

• Mean speaking frequency
• Reading sample or spontaneous speech
• Standard deviation/pitch sigma
• Both continuous speech or sustained vowel
• Given in Hz but converted to semitones
• Frequency ranges
• Speaking range
• Maximum (Total) phonational frequency range (MPFR)

10. Rationale for Frequency Measurements

• Inappropriate pitch levels may have contribulted to the development of the voice disorder
• Determining “best pitch” gives starting point for facilitation techiniques
• Some vocal fold pathologies produce change in f0 due to weighting and increased mass-size
• Reflects integrity of laryngeal mechanism (especially range measurements)

11. Perceptual Assessment of Loudness

• Habitual loudness
• Loudness variability
• Evaluate loudness contributions to normal stress and intonation
• Loudness instability in sustained tones
• Sudden drops in loudness or noticable decreases at ends of utterances
• Loudness range

12. Measurement of Intensity

• Using the sound level meter
• Using computer programs
• Habitual intensity level
• Continuous speech sample
• Two methods
• Total intensity range (dynamic range)
• Phonetegram
• High-quiet singing task

13.  Rationale for Intensity Measurements

• Low intensity may be associated with:
• vocal fold paralysis,
• increases in mass as in vocal nodules
• bowed vocal folds due to over use, presbylaryngeus or Parkinson’s
• High intensity may be associated with hearing loss or hyperfunctinal voice patterns
• Inability to change intensity (monoloudness) may be indicative of:
• neurological problems
• respiratory inadequacy
• often accompanies lack of variablity in pitch

• Also called Voice Range Profile
• Looks at intensity range over a variety of frequencies
• Client will sustain vowels (usually /a/) at fixed intervals within their MPFR at soft and loud intensities
• Intensity (dynamic) range is greatest in middle of f0 range
• More useful for singers
• Identification of potential voice problems
• Measurement of voice changes post-training

15. High-Quiet Singing Task (Verdolini, 1994)

• Individuals with mass changes (nodules) have more difficulty singing or speaking softly
• Voice quality is better when intensity is increased
• Possible explanations
• Mass lesion prevents high-frequency phonation
• Increased PTP due to increases in mass and/or damage or dehydration of the mucosal cover
• How to do it (pg 74, Awan)

• Key component of voice assessment
• Standard to which acoustic and physiological measures will be related and interpreted
• Gauge by which therapy recommendations will be made
• Quality is the characteristics of sound that distinguish it from other sounds of similar pitch, loudness and duration
• Normal vs.  Dysphonic voice quality
• Rate voice quality on three samples: sustained vowel, spontaneous speech, reading passage

18. Common Descriptors for Voice Quality

• Breathy
• Audible escape of air due to failure of glottal edges to make optimum contact
• Whispery or airy voice
• Harsh
• Describes vocal roughness, tension in the voice associated with forcefully
• adducted vocal folds or voice that is pushed through a constricted glottis
• Coarse, strident, raspy, grating, metallic
• Hoarse
• Combination of irregularity of vocal fold vibration and turbulent airflow through the glottis
• Can have breathy, harsh, wet, dry

19. Glottal Fry

• If used excessively, may affect perception of voice quality
• Note the following:
• How often it occurs
• Avg.  Duration in seconds
• Where it occurs( end of word, phrase, sentence)
• Upward or downward inflections?
• How easily it can be eliminated by using higher pitch and/or loudness

20. Quantitative Evaluation of Voice Quality

• Voice quality deviations are result of addition of noise or aperiodic energy to the quasiperiodic glottal waveform
• Results in disruptions of:
• Period of vibration (frequency)
• Amplitude of vibration
• Profile or complexity of the waveform
• Above variations are called perturbations
• Quantification of above include measures of jitter, shimmer and HNR

21. Measures of Jitter

• Measures the cycle-to-cycle variations in vocal periods
• This is short-term variability that is not voluntary or intended
• The acoustic correlation of erratic vibratory patterns
• Indicates diminished control over the laryngeal system
• Sensitive to pathological changes and severe respiratory insufficiency

22. Various Methods for Quantifying Jitter

• Mean absolute jitter
• Jitter percent or jitter factor
• Relative average perturbation (RAP)
• Can be given in terms of ms, Hz or percent
• Clinical utility
• Correlates with ratings of roughness & hoarseness
• Correlates with overall severity ratings of voice
•  Degree of correlation varies - not perfect measure

23. Factors Affecting Jitter Measurement

• Jitter is greater at initiation and termination of voicing
• Some jitter measures increase as frequency increases others decrease
• Some jitter measures decrease as vocal intensity increases
• Jitter may vary systematically across vowels
• Some studies indicate increased jitter in adult females - at least for some vowels

• Measures the cycle-to-cycle variations in peak amplitude
• Analogous to f0 perturbations or jitter
• Acoustic correlation of noisy, breathy voice
• Tends to be higher in cases of vocal pathology including mass lesions such as nodules
• Also elevated at low intensities or low f0

25. Various Methods for Quantifying Shimmer

• Absolute shimmer given in dB
• Shimmer (dB) RAP
• Shimmer percent RAP
• Clinical utility
• Correlates with judgements of breathiness and hoarseness
• Correlates judgements of severity of dysphonia

26. Harmonic to Noise Ratio

• Compares the amplitude of the periodic portion of the signal to the amplitude of the aperiodic component
• Also called SNR or NHR depending on method of computation
• Clinical utility
• Some indications that this measure predicts perceptual severity better than isolated jitter and shimmer measurements
• Correlates with judgements of degree of hoarseness/roughness
• Combined with jitter and shimmer, identifies breathy voices

• Lung capacity exceeds amount of air needed for speech or singing
• Therefore it is the use of air that is more important to us diagnostically than the actual lung volumes
• If ability to generate and control exhalation for speech is disrupted, you may see:
• Short phrase length and frequent pauses
• Effortful speech/voice as result of excessive tension in laryngeal structures
• Eventual vocal fatigue

28. Observation of Respiratory/Phonatory Control

• Use 7 point rating scale and note respiratory patterns during reading or conversational speech
• May also want to stress the system by having client read or count as far as they can go on one breath
• Observe frequency of breaths, tendency to talk on respiratory reserves, stridor
• Three basic types of respiratory patterns
• Clavicular breathing
• Thoracic breathing
• Diaphragmatic-abdominal breathing

29. Measurement of Subglottic Pressure

• Invasive measurements include:
• Needle inserted in subglottal space
• Balloon in esophagus
• Body plethysmograph
• 5 For 5 Task gives an estimate of ability to produce sufficient air pressure for speech
• Described on pg 123

30. Quantitative Evaluation of Respiratory/Phonatory Control

• Vital capacity
• Basic indicator of respiratory ability & amount of air available for phonation
• Should be 3500 - 5000 cc (ml) dependent on age, gender, size, respiratory & other health factors
• Can also compare to predicted vital capacity
• Mean Flow Rates (MFR)
• Measure volume of air/ second exhaled during phonation
• Direct measurement is made using a pneumotachometer
• Phonation Quotient (PQ) &  EMFR
• Indirect measures based on VC and MPT
• Correlate with MFR though usually overestimate

31. Maximum Performance Tests for Voice

• Dependent on airflow & pressure therefor give us indication of adequacy of both
• Maximum phonation time
• Measures efficiency of glottal closure & adequate function of the respiratory system
• Ratio of MPT to predicted MPT
• Ratios less than .70 may indicate problems
• S/Z ratio
• Allows clinician to distinguish respiratory deficits from problems with laryngeal valving of airflow

32. Evaluation of Muscle Tension Dysphonia

• Excessive musculoskeletal tension may be
• Cause of the voice problem
• Accompanying factor in a voice disorder
• Outcome or result of voice dysfunction
• Symptoms include
• Variable voice quality deviations
• Restriction in both pitch and loudness ranges
• Dull to severe ache in neck, larynx & shoulders
• Lump, ball or tension in larynx, pharynx
• Tension/restriction extending to jaw, tongue, thoracic region
• Secondary pathological conditions such as nodules, polyps, etc.

33. Causes of Excessive Tension

• Technical misuse of vocal mechanism especially under conditions of extensive vocal demands
• Psychological and/or personality factors
• Learned adaptation occurring after organic triggers such as reflux, upper respiratory infection, allergies, asthma
• Compensatory adaptation for underlying organic or neurologically based dysfunction

34. Evaluating Presence of MTD

• Laryngeal reposturing
• Downward pressure over superior border of thyroid
• Anterior-posterior compression
• Medial compression
• Circumlaryngeal Massage
• Specific instructions pg 147 - 148
• Used both as a diagnostic and therapeutic technique
• Abdominal Press
• Client sustains /i/
•  Place hand on abdomen and pulse
•  Voice should also pulse - if not indicates excessive tension