What are the primary objectives of the voice evaluation?
- Identify the causes
- Describe the present vocal components
- Develop the management plan
What are the secondary objective of the voice evaluation?
-Patient education
-Patient Motivation
-Establish credibility
True or False Voice Therapists diagnose the pathology
False
True or False Voice Therapists diagnose the treatment
true
What is the most optimal type of voice referral?
Self referral
What is the most important part of the diagnostic evaluation?
Patient interview
Resonance
-Nose, throat, mouth
-Unique in each person
-What gives each person their unique voice
What is the order of events in the voice evaluation?
1. Referral
2. Referral source
3. History of problem
4. Medical History
5. Social History
6. Oral-Peripheral examination
7. Perceptual Evaluation
What is included in the referral section of the voice evaluation?
Establishing the referral source
What is included in the "Reason For Referral" section of the voice evaluation?
-Exact reason for referral
-Establish patient understanding of referral
-Develop knowledge of voice disorder
-Establish credibility
What is included in the "History of the problem" section of the voice evaluation?
-Establish chronology of the problem
How long has this been going on?
-Seek historical etiologic factors
How has this progressed?
-Determine motivation
How much does it bother you?
What is included in the "medical history" section of the voice evaluation?
-Seek medically related etiologic factors
Have you had any surgeries? Hospitalizations? Smoke? Drink? Medications?
-Establish awareness of patient personality
Last question: on a day to day basis, how do you feel?
What is included in the "Social History" section of the voice evaluation?
-Identify home, work, recreational environments
-Discover emotional, social, family difficulties
-Seek more etiological factors
Hobbies, who are you around on a daily basis? Married? Divorced?
What is included in the "Oral-Peripheral Examination" section of the voice evaluation?
-Determine physical condition of oral mechanism
-Observe whole body tension
-Observe laryngeal tension
-Check for swallowing difficulties
-Check for laryngeal sensations (dryness, tickling, burning, lump, thickness)
This is where you scope the patient
What is included in the perceptual evaluation?
-General quality (voice quality, inappropriate use of voice components)
-Resperation
-Phonation
-Resonance
-Pitch
-Loudness
-Rhythym and rate
-Non speech abuses
A client with shallow breathing or vocal nodules causing poor s:z ratio has an impairment in ______________
Respiration
A client who shows 1. Hard glottal attacks 2. Glottal fry 3. Breathiness or 4. Diplophonia is experiencing a deficit in ______________
Phonation
A client exhibiting Hypernasality, hyponasality, assimilative nasality, or inappropriate tone focus is having difficulty with _____________
Resonance
A client with a reduced range, poor conversational inflection this person is experiencing a deficit in __________
Pitch
If a client is speaking too loud, they probably have a
sensorineural hearing loss
If a client is speaking too soft, they probably have....
a Conductive hearing loss
If a big man comes in with a high voice he most likely has a __________
sulcus
If a person is unable to shout, they most likely have some sort of _________
lesion
Name 3 non-speech abuses
-throat clearing
-coughing
-Unusual laugh
Identifying the existence of a voice problem is
Detection
Assessing the stage of progression of the voice problem is
Severity
Identifying the differential source of the voice problem is the
diagnosis
Videostroboscopy
View of the gross structure of VF and how they move and their vibratory characterisitics
High Speed Digital Imaging
How VF move, their vibratory characteristics, and onset/offset
Acoustic Recording and analysis
Qualitative picture with objective measures for pitch and intensity (fo, intensity, signal-to-noise ratio, pertubatoon measures, spectral features)
Aerodynamic Assesment
Interaction between breath support and voice production (airflow rat and volume, buglottal pressure, phonation threshold pressure, laryngeal resistance)
Inverse Filter
Glottal waveforms of acoustics or airflow
Electroglottography
Acoustic recording (measure of VF contact area)
Electromyography
Only direct measure of muscle activity (needle straight to muscle)
Advantages of Rigid Endoscopy
-Close view of larynx
-Large magnification
-Stable lens
Disadvantages of Rigid Endoscopy
-Limited sample (sustained /i/)
-Not good for those with hyperactive gag reflex
-Not a realistic sample of the patient's speech
-Not good for viewing supraglottic region
Advantages to flexible endoscopy
-View of larynx during connected speech
-Broad view of vocal tract and supraglottic region
Disadvantages of Flexible Endoscopy
-Darker Image
-Limited by movement of velum
-Difficult to acheive stable image
What is Talbots Law?
-Images linger on eye for .2 seconds after exposure
-Eye can perceive no more than 5 images/second
-For stroboscopy, video picks up images at different points in cycle and puts them together (simulated slow motion, not real time)
what is the purpose of having a client say /i/ at regular pitch?
Assess glottic closure
What is the purpose of having a patient glide up
Assess CT and external branch of SLN
What is the purpose of having a client glide down
Assess TA
What is the purpose of having the client o diadochokinesis? "he, he, he"?
Assess IA, LCA, PCA and the RLN
What is the purpose of having the client doing inhalation phonation?
to view lesions beneath the surface
What would "the left arytenoid is locked in the lateral position" mean?
Left VF paralysis
Anterior/posterior compression is a sign of
hyperfunction
Scissoring assumes damage to....
CT and SLN
T/F Stroboscopy is measured in real time
False
T/F High Speed Digital Imaging is measured in real time
True
What is the main disadvantage to using HSDI?
-There are so many images that it takes a long time to look at all of them
-Cannot see adduction and abduction
-Can only use rigid endoscope
-Light is very hot
Advantages to HSDI
-Records in real time
-Not dependant on fo- so no tracking errors
-Effective with VF vibratory features
What measurement would be effective in measuring whether or not a patient is dysphonic?
Acoustic Recording analysis
(measures pitch and intensity)
T/F Acoustic Recording Anaysis tells you waht is happening at the true VFs
FALSE
Which measurement is used for pitch?
Routine voice acoustic measures
(fo)
Normal pitch for men and women
Men: 100-150 Hz
Women: 180-250 Hz
Ways to mesure fo
-sustained vowels
-reading
-conversation
Standard deviation for Fo
Pitch sigma
A higher standard deviation in pitch means
more dysphonic voice
Measured in Hx or semitones
Phonation Range
What is the phonation range of normal young adults?
3 octaves (may be more for a singer)
Jitter
Frequency Perturbation
High Jitter=
Dysphonic Voice
What is Jitter/Frequency Perturbation?
change of frequency from one successive period to the next
How to measure jitter
sustained vowels
This directly reflects the sound pressure level (SPL) of voice
Intensity
Direct correlate of loudness
Intensity
Indication of strength of the VF vibration
Overall SPL dB
Norms- 75-80 dB for normal conversation
Amplitude Variability
Standard Deviation of SPL during connected speech from the loudness
Range of loudness vocal intensities a person can produce
Dynamic range
Norms 50-115 dB SPL
What is Shimmer?
Amplitude Perturbation
(peaks)
cycle-to-cycle changes of amplitude
Norm- <.35 dB
Do we want high or low harmonics to noise ratio?
high
Excessive high subglottal pressure points to
hyperfunction
excessive low subglotti pressure points to
hypofunction
Describe Subglotic Pressure, Phonation Threshold Pressure, Laryngeal Airway Resistance, and Airflow rate for someone with Poor Subglottic Closure
Psub- unaffected
PTP- increased to initiate phonation
LAR- low
Airflow rate- high
Describe Subglotic Pressure, Phonation Threshold Oressure, Laryngeal Airway Resistance, and Airflow rate for someone with Muscle Tension Dysphonia
Psub- increased
PTP- increased
LAR- high
Airflow rate- low
Describe Subglotic Pressure, Phonation Threshold Oressure, Laryngeal Airway Resistance, and Airflow rate for someone with Vocal Fold Nodules
Psub- increased
PTP- increased
LAR- low because of hourglass opening
Airflow rate- high
Describe Subglotic Pressure, Phonation Threshold Oressure, Laryngeal Airway Resistance, and Airflow rate for someone with Papilloma/Carcinoma
-Psub:tricky—depends on if they are compensating or not
