Voice Assessment
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Voice Evaluation
• Evaluation: Assessment of the
characteristics of a disorder or problem.
• Three primary objectives:
1) Describe type and severity of disorder for
baseline,
2) Identify and interpret abnormal voice for
differential diagnosis,
3) Determine if voice therapy is necessary.
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What should you achieve from the
evaluation?
1) Complete description of client’s
voice,
2) A hypothesis as to probable cause or
etiology,
3) Data regarding all parameters of
voice, including perceptual, acoustic,
aerodynamic and kinematic data.
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Evaluation Components
• Medical evaluation
• Patient interview
• Instrumental evaluation of voice
including aerodynamic & acoustic
analyses
• Functional evaluation of vocal fold
movement
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Professionals Concerned
• Medically oriented team-Physician, otolaryngologist, neurologist,
orthodontist, radiologist, respiratory therapist,
plastic surgeon, voice scientist, SLP, psychologist.
• Educationally oriented team-Teacher, school psychologist, SLP, school nurse,
coach, music/drama teacher, physician, audiologist,
counselor.
• Professional voice team-Otolaryngologist, nurse, singing teacher, drama
coach, voice scientist, allergist, pulmonary specialist,
SLP.
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Medical Evaluation
Otolaryngologic examination1) Detailed history of the problem
2) Examination of entire head & neck
region
3) Pertinent medical history gathered
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Medical Examination
Examination includes1) Otoscopic observation of ears
2) Examination of oral & nasal cavities
3) Palpatation of salivary glands, lymph nodes, and
thyroid gland
4) Visual examination of larynx (indirect
laryngoscopy (mirror; light source; images reversed)
5) Fiberoptic laryngoscopy
6) Radiographs of head, chest & neck
7) Diagnosis & recommendations for treatment
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Voice Pathology Evaluation
• Perceptual:
1) Referral
2) Patient interview/ history
3) Oral-peripheral examination
4) Evaluation of voice components: phonation,
resonation, pitch, loudness & rate
5) Diagnostic therapy
6) Impressions
7) Prognosis & recommendations
8) Hearing screening
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Referral
• Establish the identity of referral source
• Reasons for referral
• Establish patients understanding of
referral
• Develop patient knowledge of voice
disorder
• Establish credibility of examiner
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Patient Interview/ History
• Case history information: Written & verbal
information from client, physicians, family
members, other therapists & teachers.
• Basic questions of any case history:
1) Identifying information
2) Family history
3) School/ work history
4) General health and voice health
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Content of Interview
1) Problem-Nature of problem
-Awareness of patient
-Open-ended questions
-What caused the problem
-Establish initial client-patient
relationship
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Content of Interview
2) Effect of voice problem-Life changes, impact of disorder,
-Severity of reaction,
-Feelings, emotions.
3) History of the problem-
-Onset; gradual or sudden,
-Duration; how long condition has been present,
-Variability in voice throughout day.
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Content of Interview
4) Voice usage -
-Habits (smoking, drinking, shouting, etc.)
-Where & how they use voice (work, recreation)
-Professional use; social history
5) Medical history-Present status
-Neurological, allergy-related, gastrointestinal,
respiratory or other problems
-Past health history
-Drug history
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Content of Interview
6) Psychological state-Emotional state
-Current or past pressures effecting
communication
-Stress-related voice usage
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Oral-Peripheral Exam
-Determine physical condition of oral mechanism,
-Observe laryngeal tension area,
-Check for swallowing difficulties,
-Check for laryngeal sensations,
-Routine oral-peripheral examination along with:
*whole body tension,
*digital manipulation of the thyroid
cartilage (should rock back & forth).
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Evaluation of voice components: Perceptual
1) Critical listening & Description-Tape record interview: baseline & future
review,
-Use of rating scales during interview (i.e.
General Voice Profile etc.):
1. Is voice variable or stable?
2. Normal pitch for age, sex?
3. Normal rate, quality, loudness?
4. Judgment relates to environment
5. Back-up with objective data if possible
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Perceptual Terms
1) Tone: a manner of speaking, a vocal sound (normal,
breathy, hoarse)
2) Breathy: term to describe excessive airflow during
phonation or if someone runs out of air
3) Hoarse: aperiodic vibration of folds, rough o raspy
sounding
4) Tension: a balancing of forces in opposition, mental
or nervous strain
-Hyper- excessive above normal
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-Hypo- below normal
Perceptual Terms
5) Abuse: Activities above & beyond what is considered
normal to the vocal folds (shouting, screaming etc.)
6) Loudness: Subjective correlate to intensity
7) Pitch: Subjective correlate to frequency
8) Inflection: Any change in tone or pitch
9) Pitch breaks: Other than puberphonia
10) Diplophonia: Existence or perception of 2 vibrating
frequencies (“double voice”)
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Perceptual Terms
11) Resonance: Determination of sound as prescribed by
the size and mechanical properties of a cavity (nasal,
oral. hypo-, hyper)
12) Emission: Excessive nasal airflow
13) Aphonia: Absence of voicing which is consistent
14) Tremor: Rhythmic variations in pitch & loudness,
not under voluntary control
*Rating scales usually differ as little as 10% to as much
as 70%.
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Noninstrumental Objective Measurements
1) Maximum Phonation Time (MPT):
-Ability to sustain phonation maximally,
-Information about respiratory function, glottal efficiency &
laryngeal control,
-Designed to test limits of phonation & uncover other
weaknesses,
-Patient is instructed to sustain the vowel /a/ for as long as
possible at comfortable pitch & loudness (3 Trials):
• Adult Women: 15 Seconds
• Adult Man: 20 Seconds
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• Children: 10 Seconds
2) S/Z Ratio:
• Patient should maximally sustain /s/ than /z/, repeated
twice: Greater ratio than 1.4 suggests disorder
-Used to differentiate deficits in respiratory support
vs. laryngeal insufficiency,
-Normal individuals: sustain voiced sound as long as
unvoiced producing a ratio close to 1,
-Respiratory insufficiency should reduce both
productions equally, producing a ratio of 1,
-Reduced vibratory efficiency results in air wastage
(reduction in the ability to sustain phonation) ratio
greater than 1 (z shorter than s),
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3) Evaluation of pitch characteristics:
-Total Phonation Frequency Range: Ascending &
descending pitch slides; lowest to highest ranges,
-Habitual Pitch: Patient says:”I live in Alabama_a_a”
-prolonging final vowel, match pitch on keyboard or
tape recording,
-Conversational Range: Patient can describe furniture
in room, clinician later determines high & low pitch
(judgment of variability),
- Pitch Fluctuations: During prolongation's of vowels,
pitch breaks are noted.
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4) Loudness:
-Observe during interview,
-Test ability to increase subglottal air pressure
by having patient shout “Hey”,
-Positive sign to override dysphonia with
intensity (getting improved closure),
-Have patient count up to 10 and you highlight
2 numbers within that sequence which you
want produced with an increased intensity,
-Look for glottal closure & efficiency
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5) Rate:
- Description of rate (slow, normal,
fast) during interview,
-Excessive rate can cause pathologic
condition (misuse),
-Diagnostic therapy to see if rate can
be altered.
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Diagnostic therapy
• Depends on the clients symptoms,
• Client may have excessive laryngeal tension:
• Digital manipulation to reduce tension
• Easy onset speech productions with single words &
sentences
• Client may exhibit respiratory problems, excessive
breaths or not enough, not enough replenishing
breaths during speech:
• See if client can consciously inc./dec. breaths, inc.
breaths at appropriate location etc.
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Diagnostic therapy
• Object is to identify problems in quality, rate,
loudness and pitch and use therapeutic techniques to
see if client is stimulable for changing these patterns,
• If client is not stimulable, the prognosis for
improvement is poor,
• Need to be very familiar with voice deviations
including respiratory and laryngeal abnormalities.
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Diagnostic therapy
• Production of Reflexive Sounds:
– Coughing, laughing, clearing throat, vocalized
pause “Uh-Huh”
– Compare spontaneous examples with elicited
– Used to determine quality in non-speech task
• Altering Pitch:
– Change pitch up & down (not range)
– Physical or discrimination problem
• If imitation difficult; try animal sounds (“meow”)
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Diagnostic therapy
• Sustained Phonation:
– Practice before taking measurements (timed
= tension)
– Observe preparation of how client carries
out task
• Strained, length, steadiness
– Rationale; ability to control & sustain
phonation and respiration
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Diagnostic therapy
• Altering Vocal Loudness:
– Increment loudness in steps (model)
– Rationale: further test limits of voice production, explore
ability to manipulate isolated vocal parameters, match a
model
• Phonation w/ Effortful Glottal Closure:
– ONLY with patients for whom activity is not harmful
– Grunting, isometric pushing of hands together, raise chair
while seated
– Phonate while producing tension
– Rationale: Attempt to force vocal fold adduction; Elicit a29
nonspeech sounds that is difficult to control voluntarily
Impressions, Prognosis & Recommendations
1) Summarize etiologic factors associated with
development & maintenance of individual’s voice
disorder:
• list in order or perceived importance!
2) Analyze probability of improvement through voice
therapy:
• include motivation, interest, time availability
3) Outline management plan:
• outline the etiologic factors discovered during the
evaluation, therapy approaches & other referrals.
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Readings
• Colton & Casper: Ch. 2 & 7
• Directed Reading (9/16/99):
– Eckel, F.C., & Boone, D.R. (1981). The s/z ratio as
an indicator of laryngeal pathology. Journal of
Speech & Hearing Disorders, 46, 147-149.
– Colton, R,H. & Hollien, H. (1972). Phonational
range in the modal and falsetto registers. Journal
of Speech & Hearing Research, 15, 708-713.
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