The assessment of voice in professional voice users is different considering the fact that they have unique vocal needs.This is a brief introduction outlining how assessment of voice should be done.

1. Soorya
BASLP
V sem

2. The professional voice user is any person
whose voice is the primary instrument for
performing his or her work.
The need for voice performance and vocal
endurance is high in professional voice
users.

3. Koufman (1998) identified four levels of
professional voice users based on the
professional demands and vocal load:
The elite vocal performer (Level I) is a person
for whom even a slight deviation of voice may
have dreadful consequences. Most singers and
actors would fall into this group.
The professional voice user (Level II), is a
person for whom a moderate vocal problem
might prevent adequate job performance.
Teachers, lecturers and clergy would fall into
this group. 11

4.  The non-vocal professional (Level III), is a
person for whom a severe vocal problem would
prevent adequate job performance. This group
includes lawyers, businessmen and physicians.
 The non-vocal non-professional (Level IV)
includes clerks and other laborers, where the
vocal quality is not a prerequisite for adequate
job performance.

5. QUALITY LOAD PROFESSIONS
HIGH HIGH ACTORS,SINGERS
High Moderate Radio and tv journalists
moderate high school and kindergarten
teachers (), telephone
operators
Moderate Moderate bank, business and
insurance personnel (),
physicians,
lawyers, nurses
low high foremen, welders,
platers

6. Voice problems in singers include:
i. Dryness in throat
ii. Tightness
iii. Vocal fatigue
iv. Discomfort
v. Hoarseness
vi. Reduced pitch range
vii. Loss of high notes
viii. Pain (Sapir,1993;Sapir etal ,1996)

7. Heavy demands on voice
GERD
Hectic work schedules
Stage Fear
Need to rise their voice above the
instrumental music

8. 1.Phonotrauma: Microvascular
lesions;Resulting from Voice
overuse,misuse and abuse
2.Altered VF movement:With associated
fibrovascular sequelae;include
polyp,cyst,etc
3.Technical imperfections:Failure to meet
expectations of self,style of music,and
audience

9. Vocal endurance is much more important
compared to voice quality in case of
teachers
 Voice problems in teachers have been observed to
lead to severe personal, social, vocational and
economic consequences (Thomas, de Jong,
Kooijman, Donders & Cremers, 2006).

10.  Studies have reported prevalence of voice
problems in teachers as
 16.3% (Fritzell, 1996)
 75% (Rusell, Oates, & Greenwood, 1998),
 32% (Smith, Lemke,Taylor, Kirchner &
Hoffman, 1998),
 69% (Kowalska, Bogusz, Fiszer, Spychaska,
Kotylo, Przygocka & Modrzewska, 2006)
 49% (Boominathan, Rajendran, Nagarajan,
Seethapathy & Gnanasekar, 2008)

11.  Teachers experience increased vocal fatigue
compared to other professional voice users .
Reasons could be:
(a) intensity and frequency of speech:
 The aim of improving message transfer in noisy
situation is achieved by increasing SPL. Raised
SPL further raises the fundamental frequency
(F0) of voice. According to Jiang and Titze,
(1994) the force with which the vocal folds collide
increases as a function of F0, SPL and adduction
increased mechanic loading on vocal fold tissue
pathological changes in the vocal fold tissue
(Mann, McClean, Gurevich-Uvena, Barkmeier,
McKenzie-Garner, Paffrath and Patow, 1999)

12.  (b) type of teachers: A few group of teachers
seem to be at greater risk of developing voice
problems than others. Verdolini-Marston
(2001) reported that physical education and
sports teachers were at a greater risk of
developing voice problems. Owing to the
nature of their work and their working
environment these teachers face high vocal
demands.
 Other researchers have identified music
teachers to be prone to develop vocal
symptoms (Fritzell, 1996) than pre-school
teachers (Sala et al., 2001).

13. (c) gender: 76% of teachers seeking medical
treatment due to voice problems were females
(Fritzell, 1996).
Russel at al. (1998) reported that females are
twice likely to suffer from voice problems than
males. The reason is because of differences in
the anatomical structure of the vocal organ.
There is a greater percentage of collagenous
fibers and hyaluronic acid in the male vocal
folds than in females (Hirano, 1983).

14. The other risk factors for vocal fatigue
include, (d) smoking, allergy, respiratory
infections, (e) hearing loss, (f) stress, and
(g) posture.

15. 1. INDIVIDUAL FACTORS
2. VOCAL LOADING /OTHER FACTORS

16. Weak voice
Poor/incorrect techniques
Poor voice habits
Talkative personality
Vocally loading hobbies
Poor life habits
Other general conditions
Food habits

17. Background Noise
Poor room acoustics
Long speaking distance
Air quality,dryness,dust
Poor working posture
Stress
Inadequate Equipment
Vocal loading(Song and Speech)

18. Primary Risk factors in teachers :Need for
prolonged use of voice. Prolonged voice
use is called ‘vocal loading’.
Each repeated vibration Of VF
Repeated Collision btw Vocal
Mucosa Repeated damage to VFs

19. Other professional voice users include
mimicry artists,call center
workers,actors,telemarketers,salesmen etc

20.  Telemarketers
• Boredom and fatigue along with psychological problems of
constant rejection
• Poor posture from sitting in inappropriate chairs with no
headset
• No training in breath support
 Broadcasters
• Worked in fixed head/body position
• Lower-pitched voice to sound forceful
• In dirty and dusty studios for long stressful hours
 Salesmen
• Perform under pressure: no sales=no income
• Spend hours in loud background noise

21.  Named after Humphrey Bogart and Lauren
Bacall
 Condition most common in singers, actors, and
radio and TV personalities
 These people speak with a fundamental
frequency that is too low, poor breath support,
and laryngeal muscle tension
• Causes muscle tension dysphonia

22. Professional Voice Users

23. ONE SIZE FITS ALL
DOESN’T
WORKASSESSMENT MUST TAKE INTO CONSIDERATION:
•Individual professional’s needs
•Working conditions
•Impact of voice in his/her life
•Eg.A reduced pitch range may not affect a teacher much
but it could affect the career of a singer.

24.  SCREENING
 Screeningmaybeconductedifavoice
disorderissuspected.Whendeviations
fromnormalvoicearedetectedduring
screening,furtherevaluation iswarranted.
 Screeningincludesevaluationofvocal
characteristicsrelatedtorespiration,
phonation,andresonance,aswellas
vocalrangeandflexibility(e.g.,pitch,
loudness,pitchrange,andendurance).
 Clinicians mayuseaformalscreening
tool(Leeetal.,2004)orobtaindatausing
informaltasks.Standardizedself-report
questionnairescanbeincludedforamore
thoroughscreening(e.g.,Deary,Wilson,
Carding,&MacKenzie,2003;Hogikyan&
Sethuraman,1999;Jacobsonetal.,
1997).
 COMPREHENSIVE
 A comprehensive assessment is
conducted for individuals
suspected of having a voice
disorder, using both
standardized and
nonstandardized measures

25. Consistent with the World Health Organization's (WHO) International
Classification of Functioning, Disability and Health (ICF) framework
(ASHA, 2016b; WHO, 2001), comprehensive assessment is
conducted to identify and describe
•impairments in body structure and function, including
underlying strengths and weaknesses in speech sound production
and verbal/nonverbal communication;
•co-morbid deficits such as other health conditions and
medications that can affect voice;
•the individual's limitations in activity and
participation, including functional status in communication and
interpersonal interactions;
•contextual (environmental and personal) factors that serve as
barriers to, or facilitators of, successful communication and life
participation;
• and the impact of communication impairments on quality of
life and functional limitations relative to premorbid social roles
and abilities for the individual and the impact on his or her
community.

26. 1.CASE HISTORY
2.SELF ASSESSMENT
3.OPME
4.Assessment of Respiration
5.Auditory-Perceptual Assessment
6.Instrumental Assessment

27. Could include-
 Demographic Details.
 Individual's description of voice problem,
including onset and variability of symptoms
 Medical status and history, including
surgeries, chronic disorders, and medications
 Previous voice treatment
 Daily habits related to vocal hygiene
 Vocational habits
 Voice use/day.
 Voice demands for vocational and non
vocational activities

28. Singing history
 Type of singing in which
he/she is involved
 Training related- whether
they are trained or
untrained singers—How
many hours of training
per day.
 Posture while singing
 Current difficulties

29. In which grade
he/she is teaching
Years of teaching
No.of subjects
No.of classes per
work day
No.of students in a
class
Age of students
Environment of
class-(?)dusty
Use of any assistive
aids(eg.amplification
devices)
Noise in class frm
inside
/outside(fan,light,ac,
steps nearby)

30. Individual's assessment of how voice
problem affects
• emotions and self-image; and
• ability to communicate effectively in everyday
activities and in social and work settings (e.g.,
Hogikyan & Sethuraman, 1999; Jacobson et al.,
1997; Ma & Yiu, 2001).

31.  VHI(Jakobson et al,1997)
 VHI -10(shortened version of Voice handicap
index),Amir et al,2006a,2006b.
 Voice Symptom Scale (VoiSS)(Mackenzie et
al,2003)
 Voice related quality of life(Karnell et al,2007)
 In teachers-Test material by Rantala,Vilkman,and
Bloiger(2002)
 In singers—EASE(Evaluation of the Ability to Sing
Easily)(Phyland et al,2013), VHI-singer,Modern
singing handicap Index(Moreti et al,2011),Classical
singing handicap Index (Avila et al,2010)

32.  Assessment of structural or motor-based deficits
that may affect communication and voice, including
strength, speed, and range of motion of oral
musculature
 Assessment of symmetry and movement of
structures of the face, oral cavity, head, neck, and
respiratory system during rest and purposeful
speech tasks
 Testing of mechano-sensation of face and oral
cavity
 Testing of chemo-sensation (i.e., taste and smell)
 Assessment of laryngeal sensations (dryness,
tickling, burning, pain, etc.) and palpation of
extrinsic laryngeal musculature

33. Respiratory pattern (abdominal, thoracic,
clavicular)
Coordination of respiration with phonation
(breath-holding patterns, habitual use of
residual air, length of breath groups)
Maximum phonation time
s/z ratio to assess for glottal insufficiency,
which may be indicative of laryngeal
pathology

34. Voice Quality
 Consensus features assessed during production of
sustained vowels, sentences, and running speech
• Roughness—perceived irregularity in voicing source
• Breathiness—audible air escape in voice
• Strain—perception of excessive vocal effort
• Pitch (perceptual correlate of fundamental frequency)—deviations
from normal relative to age, gender, and referent culture
• Loudness (perceptual correlate of sound intensity)—deviations from
normal relative to age, gender, and referent culture
• Overall severity—global, integrated impression of voice deviance
 Additional perceptual features
• Diplophonia, aphonia, pitch instability, tremor, vocal fry, falsetto,
wet/gurgly
 (Kemper, Gerratt, Abbott, Barkmeier-Kraemer, & Hillman,
2009; ASHA, 2002; ASHA , n.d.)

35. Resonance
Assess resonance quality (normal,
hyponasal, hypernasal, cul-de-sac).
If abnormal, assess stimulability for normal
resonance.
If normal, evaluate the focus of resonance
(oral, pharyngeal/laryngeal, nasal).

36. Phonation
Voice onset/offset (e.g., delayed voice
onset; quality of voice at onset)
Ability to sustain the voice to achieve
appropriate phrasing during speaking
Ability to demonstrate strong and
consistent rate of vocal fold valving during
diadochokinesis

37. Rate
Deviations from normal relative to age,
gender, and referent culture

38. GRBAS
BUFFALLO III Voice profile
Vocal profile analysis
Stockholm Voice evaluation Approach
CAPE V
Voice Rating Scale
In singers-Solo voice performance
evaluation-Wapnick et al,1997;Auditory
Perceptual Rating Instrument for operatic
singing voice,Kenny etal.

39. Laryngeal Imaging
 Measures of structure and gross function (using
videoendoscopy) and measures of vocal fold
vibration during phonation (using
videostroboscopy)

(*Adapted from Recommended Protocols
for Instrumental Assessment of
Voice (ASHA, 2015))

40. • Videolaryngoendoscopy
Vocal fold edges—appearance of
superior vocal fold edges during
abduction
Vocal fold mobility—movement of vocal
folds toward and away from midline at
level of cricoarytenoid joint during
laryngeal diadochokinetic task
Supraglottic activity—degree of
compression of supraglottic structures
during sustained phonation

41. • Videolaryngostroboscopy
 Regularity—consistency of successive glottic cycles
 Amplitude—lateral movement of the vocal fold medial plane
 Mucosal wave—independent lateral movement of mucosa over
vocal fold
 Left/right phase symmetry—symmetry of vocal folds (opening,
closing, maximum lateral–medial excursion) during glottic cycle
 Vertical level—level difference in vertical plane between vocal folds
during maximum closed phase of glottic cycle
 Glottal closure pattern—glottal configuration during maximum
closure
 Glottal closure duration—relative proportion of glottal cycle in which
glottis is closed

42. Acoustic Assessment
Objective measures of vocal function
related to vocal loudness, pitch, and
quality

43. • Vocal amplitude
 Habitual sound pressure level (SPL) in decibels (dB)—
typical sound level of voice during connected speech
(standard reading passage)
 Minimum and maximum vocal SPL (dB)—softest and
loudest sustainable phonation

44. • Vocal frequency
 Mean vocal f0 (Hz)—average of the estimates of the
f0 for acoustic signal recorded during connected speech
(standard reading passage)
 Vocal f0 standard deviation (SD; Hz)—SD of the
estimates of the f0 for acoustic signal recorded during
connected speech
 Minimum and maximum vocal f0 (Hz)—f0 values for the
lowest and highest pitched sustainable phonations

45. • Vocal signal quality
 Vocal cepstral peak prominence (CPP; dB)—relative
amplitude of the peak in the cepstrum that represents
the dominant rahmonic of the vocal acoustic signal
(sustained vowels and connected speech samples)

46. Aerodynamic Assessment
Measures (using noninvasive procedures)
of glottal aerodynamic parameters required
for phonation

47. • Glottal airflow
 Average glottal airflow rate (L/sec or mL/sec)—
estimated from oral airflow rate during vowel production

48. • Subglottal air pressure
 Average subglottal air pressure (cm of water [cmH2O]
or kilopascals [kPa])—estimated for intraoral air
pressure produced during repetition of stop consonants
in syllable strings

49. • Mean vocal SPL and f0—extracted from
simultaneously recorded acoustic signal; facilitates
interpretation of airflow and air pressure
measurements

50. In case of singers,while doing flexible
fiberoptic laryngoscopy,
We may follow:
Protocol For examination In
singers(Beninger and murray,2008)
Protocol for examination in singers
(Ravikumar,Bhoominathan
&Mahalingam,2014)

51. Teaching voice can be assessed based
on:loading time and factors affecting voice
production.

52. Vocal dose measures are also used in
assessment of professional voice;
Titze et al(2003) reported of 3 doses in
voice production-Time dose,Distance
dose,cycle dose

53. Time dose:total phonation time
Distance dose: total distance travelled by
the vocal fold during the vibration,
considers the amplitude of such distance,
which changes the intensity of the voice
Cycle dose:total number of oscillatory
periods performed by the vocal folds in
time and is measured in thousands of
cycles per second1

54. INSTRUMENTS FOR MEASURING
VOCAL DOSES:
1. Voice Dosimeter(Titze,Svec and
popolo,2003;Popolo et al,2005)-
Quantifies all 3 doses

56. 2.AMBULATORY PHONATION MONITOR
Developed by KayPentax

58. Assessment may result in
diagnosis of a voice disorder;
clinical description of the characteristics
and severity of the disorder;
statement of prognosis and
recommendations for intervention;
identification of appropriate treatment or
management options; and
referral to other professionals, as needed.

59. THANK YOU