Hi everyone. Let’s go ahead and get started with out discussion about conducting voice evaluations.
So we can think of there being two objectives to conducting a voice evaluation. The first thing we’re trying to accomplish is to figure out from the clients voice quality and from their symptoms if the client really has a voice disorder and could benefit from our services, especially if they don’t come with a diagnosis from an ENT. Of course we’re also trying to figure out the potential causes of the client’s symptoms. An as a secondary objective, we’re trying to do a number of things. We’re trying to assess the client’s motivation to change their voice, to educate them about the voice mechanism and good vocal hygiene, and we also want to establish that we are knowledgeable professionals and can help clients achieve their voice goals.
So now we can talk about some of the questions and important points that we have to establish as a result of clinical interviewing during the voice evaluation. We want to know who referred the patient, and if the patient knows why they’ve been referred to us. This goes along with the patient education piece. We have to gauge where our clients are in their understanding of their voice problem in order to help them resolve their voice issues.
One of the first questions you can ask a client when you meet them is “what brings you in to see me today?” You’ll want to ask this in a friendly way that conveys your interest in the client and what they have to say. Again, this is a good way to figure out who sent the client to you, and what the client thinks is the problem. It’s possible that your client is there because they recognize their voice problem and want to change it, or it could be the case that your client is under duress from family, friends, or another health care provider, and don’t recognize that there is a true problem with their voice.
Okay, so continuing on with the types of questions you ask in a voice evaluation, it’s really important that you ask questions that will give you a sense of how these voice symptoms developed over time, how the client has tried to manage his/her symptoms, and any contributing factors, such as abuse or misuse. So asking questions like “how would you describe your voice?” “How long has your voice been like this?” “Has it gotten better or worse since you first started having problems?” is really necessary to understand the nature of the voice disorder. Your textbook authors do a nice job of identifying other questions you can ask clients.
We also want to consider the patient’s medical history. We want to know if they have any conditions that can cause changes in the voice, such as respiratory conditions, neurological disorders, or resonance disorders, like cleft palate. Surgeries which may affect the functioning of the laryngeal muscles, infections, or overall illnesses should all be reported in a diagnostic report. Another consideration is whether the client takes any medications, particularly those that are known to have a negative effect on the voice. In the PPT presentation I’ve given you a link to a very nice webpage which gives a pretty thorough list of medications and their probable effects on the voice. It’s not uncommon for over the counter decongestants and allergy medications to have a drying effect on the voice, so be sure you ask the client to describe all prescription as well as over the counter medications.
Along with a thorough medical history, we also want to figure out how the client uses his or her voice, and the ways in which the client may be affected by their voice disorder. So be sure to ask about a client’s job, hobbies, and social habits. In the diagnostic report, you’d really only want to report on those aspects of a client’s life which may affect the voice, and you’d want to do so in a professional and nonjudgmental way. For example, it’s better to write, “Mr. Smith reports moderate alcohol intake on a regular basis and smokes two packs of cigarettes each day,” than “Mr. Smith drinks and smokes excessively.” You’ll also want to see if the client recognizes a connection between poor vocal hygiene and his/her voice symptoms.
Okay, so moving on to the oral mech exam. If I had to guess, I’d say that this is the part of a voice eval that many clinicians skip unless there is an obvious neurological or physiological reason to do the exam. At the very least, you’ll want to closely observe the client for signs of excessive tension in the oral or layrngeal musculature, or signs of neurological impairment, like asymmetry of the facial features. When doing a full oral mechanism exam, you may see if you can elicit the gag reflex or if the client is sensitive to cold at the back of the throat by using a frozen cotton swab. Otherwise, the oral mech exam you do for a voice client isn’t different than what you would do for any other type of client.
When you’re writing a voice report, you’ll need to make sure you describe what you hear and observe about the client’s symptoms and voice mechanism. So you’ll want to describe the complaint, note how the client is producing voice (such as with a lot of tension), note their respiration, and use a variety of techniques to assess voice quality. We’ll talk about voice quality in just a moment, but let’s take a minute to focus on respiration. Be sure that you note if the client seems to be using clavicular breathing or has obvious shortness of breath. You can use instruments like a spirometer to get a measure of the client’s respiratory functioning, or you can use some non-instrumental measures like the s/z ratio and maximum phonation duration to see if there is air wastage at the level of the laryx. We’ll talk about these last two in a bit.
So moving on, there are lots of ways to assess voice quality. What we mean by quality is an overall sense of the pitch, intensity, clarity, and smoothness that we perceive in someone’s voice. There are some rating scales, like the CAPE-V and GRBAS that allow SLPs to assess quality through auditory perceptual means. That is, the clinician listens to the client speak and fills out the rating form based on their perceptions of voice quality. So you don’t need fancy equipment to do a good assessment of someone’s voice quality if you are a skilled clinician. There are a few other techniques that are commonly used because they are effective, simple, and cost-effective. The first of these non-instrumental measures we’ll talk about is maximum phonation duration, also known as maximum phonation time. It may be helpful for you at this point to get a stopwatch or watch with a second hand, as these are the tools that a voice clinician should have handy. We’ll practice MPD first. Maximum phonation duration helps to determine whether there are problems with respiratory status or glottic insufficiency. You simply ask the client to produce the vowel sound “ah” for as long as they can at a comfortable pitch and loudness level and without strain. You’ll want to model saying “ah” for as long as you can to the client, and give verbal encouragement as the client begins to phonate. Let me do an example and you time me. AH------------. By my watch I was able to produce that ah for 17 seconds. You as the clinician would write this number down, then ask me to do it again, and then a third time. You’d take the best of the three times, and this would be my maximum phonation duration. Normative data for typical speakers indicate that adult men should be able to produce “ah” for 25-35 seconds, and women for 15-25 seconds. Try it for yourself and see what your maximum phonation time is. Now, for s/z ratio, this is another simple measure in which the clinician asks the client to produce an extended /s/ for as long as possible and then a /z/ sound for as long as possible. Again, these productions should be at a comfortable pitch without strain. The clinician may ask the client to produce both iterations of /s/ and /z/ twice, and then notes the number of seconds for the longest trial for each sound. The clinician then divides the /s/ time by the /z/ time to get the S/Z ratio. A ratio of 1.0, in which the voiced z sound is held out as long as the voiceless s sound means that there is probably no air wastage. A ratio of 1.4 or greater has typically indicated that there is air wastage, as in the case of nodules. I’ll pretend to have a voice disorder, and you can calculate my s/z ratio: here is /s/ - 13 seconds and here is /z/ : 8 seconds. My s/z ratio turns out to be 1.6. This means that I have air wastage. While no one would ever be diagnosed with a voice disorder solely on the basis of their maximum phonation duration and the s/z ratio scores, these measures can mean that some type of vocal pathology is involved.
Okay. So if you are following along in the PPT, you’ll see that there are lots of way that we can describe voice quality. You can have a hoarse or breathy voice, one that sounds strained or tight or tense, a tremulous voice, etc. I also want to note that it’s quite possible to have several of these qualities all within the same person. Having both a hoarse and a breathy voice often go together. So take a look at the hyperlinks I’ve added in the PowerPoint slide for voice quality and see if you can train your ear to detect some of these aspects of voice quality.
We can move on now from a discussion of the perceptual aspects of voice assessment to the types of assessment that you can do if you have the right equipment. For example, with training, SLPs can quote on quote “scope” their patients. This means that we can perform laryngoscopy with a flexible or rigid endoscope and visualize the larynx. The equipment is very expensive and the training is specialized, so if you are in the schools, or a smaller hospital, it’s unlikely you will have access to this equipment. That’s okay, as hopefully you would have access to an ENT’s report, or you can refer to an ENT. I’ve given you some video samples of the flexible laryngoscopy procedure in which a small flexible tube goes through the nasal passages to observe the vocal folds, and the rigid endoscope, which is angled toward the back of the pharynx. In both cases, the ENT can visualize the vocal folds and is often able to record video footage. Note that the clinician actually holds the end of the scope with the camera, and that the camera doesn’t actually go into the nose or mouth. For a cheaper but probably less effective technique, clinicians can take a small mirror, almost like the kind that dentists use, and angle that down toward the larynx for a visual of the vocal folds. It’s really neat to see the vocal folds using mirror laryngoscopy, but you can’t see the level of detail you can with a scope. There are lots of other machines that we can use for acoustic, muscular, and aerodynamic assessment of voice, like the electroglottograph, visi-pitch, and the nasometer. You’ll learn more about these instruments when you practice with them in our on campus lab.
As an FYI, here are ASHA’s guidelines, statements, and reports related to laryngoscopy for SLPs. Read at your leisure, especially if you are interested in specializing in voice and would like to learn how to perform laryngoscopy.
To summarize voice evaluation, I’d like to stress a few things. Note that we are not trying to make a medical diagnosis, but instead to determine if a voice problem exists and how we might treat the patient if therapy isn’t contraindicated by medical professionals. In other words, we can do an eval for someone , but we can’t start treatment until an ENT or physician has ruled out disorders like cancer, polyps, myasthenia gravis, etc. So if a client comes to you without a referral from a physician or ENT, it’s okay to do the eval and to educate them about good vocal hygiene. But you can’t make any treatment recommendations until they receive clearance from a medical doctor. That’s all for now. We’ll talk more about voice evals at our next on campus class.
Unit 6: Voice Evaluation
Voice Evaluation CDIS 700
Objectives of Voice Evals <ul><li>Primary objective- Discover whether the client has a voice disorder, and to evaluate the present symptoms. </li></ul><ul><li>Secondary objective- Patient education and motivation, as well as establishing your own credibility. </li></ul>
Referral Source <ul><li>Who referred the patient </li></ul><ul><ul><li>ENT </li></ul></ul><ul><ul><li>Neurologist </li></ul></ul><ul><ul><li>Physician </li></ul></ul><ul><ul><li>SLP </li></ul></ul><ul><ul><li>Family, friends, or self </li></ul></ul><ul><li>Will want to know if the patient understands why they have come or if they realize there is a problem. </li></ul>
Establish the reason for the referral <ul><li>Establish the exact reason for the patient referral. </li></ul><ul><li>Establish if the patient understands the reason for the referral. “What brings you to see me?” </li></ul><ul><li>Develop patient knowledge of the problem. </li></ul>
History of the Problem <ul><li>When was the onset of the problem? </li></ul><ul><li>What has the course of the problem been? </li></ul><ul><li>How does it change over time? </li></ul><ul><li>How does the patient define the problem? </li></ul><ul><li>How do others define the problem? </li></ul><ul><li>What is their motivation for change? </li></ul><ul><li>Identifying vocal abuses and misuse. </li></ul>
Medical History <ul><li>What illnesses may be related to the present voice problems? </li></ul><ul><li>Any known etiological factors? </li></ul><ul><li>Any medications that may be involved? </li></ul><ul><ul><li>http://www.uiowa.edu/~shcvoice/rx.html </li></ul></ul>
Social History <ul><li>Gather knowledge about patient’s work, home and social environment. </li></ul><ul><li>Discover emotional, social and family difficulties. </li></ul><ul><li>Establish an understanding of the patient’s personality. </li></ul><ul><li>Questions: </li></ul><ul><ul><li>What is the home and work environment? </li></ul></ul><ul><ul><li>Any social or emotional difficulties related to the voice? </li></ul></ul><ul><ul><li>Does the patient perceive any relation between the problems? </li></ul></ul>
Oral Mechanism Exam <ul><li>Determine the physical condition of the oral mechanism. </li></ul><ul><li>Observe the laryngeal area for tension. </li></ul><ul><li>Check for any physiological difference or signs of neurological involvement in the oral cavity. </li></ul><ul><li>Check for laryngeal sensations. </li></ul>
Voice Evaluation <ul><li>Describe the present vocal properties. </li></ul><ul><li>Examine inappropriate use of the voice. </li></ul><ul><li>Assess respiratory status </li></ul><ul><li>Note voice quality </li></ul><ul><ul><li>Self-report </li></ul></ul><ul><ul><li>Clinician observation </li></ul></ul><ul><ul><li>Non-instrumental measures </li></ul></ul><ul><ul><li>Instrumental measures </li></ul></ul>
Quality Assessment <ul><li>A multitude of scaling procedures </li></ul><ul><li>Reading, conversational speech, singing </li></ul><ul><li>Maximum phonation time /duration (MPT/MPD) </li></ul><ul><li>s/z ratio </li></ul><ul><li>Sorry my MPT and s/z ratios are so quiet on the audio narration – my video editing software dampened the sound. </li></ul>
Quality Assessment <ul><li>Quality during sustained vowels and speaking: </li></ul><ul><ul><li>Hoarse or raspy– warnings for language in this video; consider how you might educate this person </li></ul></ul><ul><ul><li>Breathy – voice is also a bit hoarse </li></ul></ul><ul><ul><li>Tremulous </li></ul></ul><ul><ul><li>Strained or tense </li></ul></ul><ul><ul><li>Diplophonia – I found a clip! </li></ul></ul><ul><ul><li>Aphonia – lack of voice/whisper </li></ul></ul>
Instrumental Assessment <ul><li>Laryngoscopy </li></ul><ul><ul><li>Flexible (nasal) – also see here for longer video </li></ul></ul><ul><ul><li>Rigid (oral) - a bit strange, but you can see pics of the scope </li></ul></ul><ul><ul><li>Note: stroboscopy is just the light source that can be attached to flexible or rigid scopes. It slows down the motion of the vocal folds so our eyes can see; otherwise they move too fast. </li></ul></ul><ul><ul><li>Mirror laryngoscopy – wear gloves! </li></ul></ul><ul><li>Electroglottograph </li></ul><ul><li>Visi-Pitch </li></ul><ul><li>Nasometer </li></ul><ul><li>Others </li></ul>
Direct Laryngeal Observation: <ul><li>Vocal Tract Visualization and Imaging: Position Statement </li></ul><ul><ul><li>http://www.asha.org/docs/html/PS2004-00121.html </li></ul></ul><ul><li>Knowledge and Skills for Speech-Language Pathologists With Respect to Vocal Tract Visualization and Imaging </li></ul><ul><ul><li>http://www.asha.org/docs/html/KS2004-00071.html </li></ul></ul><ul><li>Vocal Tract Visualization and Imaging: Technical Report </li></ul><ul><ul><li>http://www.asha.org/docs/html/TR2004-00156.html#r5 </li></ul></ul>
Keep in Mind… <ul><li>Rely on what you hear, not solely on instrumentation data. </li></ul><ul><li>During an evaluation, you are making a diagnosis of how the voice is performing, not a medical diagnosis. </li></ul><ul><li>Delay making recommendations for treatment unless an ENT has performed a medical evaluation and voice therapy is not contraindicated. </li></ul><ul><li>You can always educate patients on good vocal hygiene, even if you may not be able to make specific voice therapy recommendations. </li></ul>