Clinical Assessment
SPPA 6400 Voice
Disorders: Tasko
Voice Disorders: A
Multidisciplinary Effort
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Speech Language Pathology
Otolaryngology
Voice Scientists
Vocal Instructors
Neurology
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Gastroenterology
Pulmonology
Allergy
Psychology
SPPA 6400 Voice
Disorders: Tasko
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
Some Aims of Assessment
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Etiology
Diagnosis
Prognosis
Planning
SPPA 6400 Voice
Disorders: Tasko
Signs vs. Symptoms
SPPA 6400 Voice
Disorders: Tasko
Common Voice Symptoms
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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)
SPPA 6400 Voice
Disorders: Tasko
Primary components of
Assessment
• Chart Review
• Case History
• Clinical Evaluation
– Non-instrumental evaluation
– Instrumental evaluation (later)
• Experimental/diagnostic therapy
SPPA 6400 Voice
Disorders: Tasko
Case History
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Voice Symptom History
Voice Use History
Health/Medical History
Social/Vocational History
Psychosocial History
SPPA 6400 Voice
Disorders: Tasko
Voice Symptom History
• The Voice Problem
• Effect of the Voice Problem
• History of the Voice Problem
Example
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
SPPA 6400 Voice
Disorders: Tasko
Health/Medical History
• Current & past health problems
• Specific areas to probe
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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
SPPA 6400 Voice
Disorders: Tasko
Example
Social/Vocational History
• Home environment
• Work environment
• Social/recreational activities
Example
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
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
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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
SPPA 6400 Voice
Disorders: Tasko
Critical observation during
history
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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
SPPA 6400 Voice
Disorders: Tasko
Non-instrumental
Evaluation
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Oral-Peripheral Examination
Auditory perceptual evaluation of voice
Selected maximal effort tasks
Assessment of laryngeal musculoskeletal
tension
• Self-report measures
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
SPPA 6400 Voice
Disorders: Tasko
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
Auditory Perceptual Signs
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Pitch
Loudness
Quality
Dysphonia vs. Aphonia
Other Behaviors
– Resonance
– Rate
– Articulation
SPPA 6400 Voice
Disorders: Tasko
Auditory Perceptual
Disturbances
From ASHA Consensus on Auditory Perceptual
Evaluation of Voice (CAPE-V)
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.
SPPA 6400 Voice
Disorders: Tasko
Pitch & Pitch Disturbances
• Monopitch
Females
• Inappropriate pitch
• Pitch breaks
• Diplophonia
• Reduced pitch range
SPPA 6400 Voice
Disorders: Tasko
Male
Loudness
• Monoloudness
• Excessive loudness variation
• Reduced loudness range
SPPA 6400 Voice
Disorders: Tasko
Quality
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Roughness
Breathiness
Strain/struggle/tension
Tremor
Sudden interruption of voicing (voice break)
Hoarseness
SPPA 6400 Voice
Disorders: Tasko
Aphonia
• Aphonia vs. dysphonia
• Consistent vs. intermittent/episodic
SPPA 6400 Voice
Disorders: Tasko
Other Behaviors
• Stridor
• Throat clearing
• Coughing
SPPA 6400 Voice
Disorders: Tasko
Consensus on Auditory Perceptual
Scaling of Voice (CAPE-V)
SPPA 6400 Voice
Disorders: Tasko
Other Tasks
• Maximum phonation time (MPT)
• s/z ratio
• Voluntary cough
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)
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
SPPA 6400 Voice
Disorders Tasko
Manual Assessment of Laryngeal
Musculoskeletal Tension
SPPA 6400 Voice
Disorders Tasko
Aronson (1990)
Manual Assessment of Laryngeal
Musculoskeletal Tension
SPPA 6400 Voice
Disorders Tasko
Roy et al. (1996)
Self-Report of Vocal
Disturbance
• Voice Handicap Index (VHI)
• Voice-Related Quality of Life (V-RQOL)
SPPA 6400 Voice
Disorders: Tasko