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Flashcards in Voice Assessment Deck (55):
1

Voice Eval Summary

MD report of VF status
Medical hx
Respiratory capabilities
Strength of glottic closure
Optimum/habitual/range of pitch
Intensity & Vocal quality
Endurance
Sites of vocal hypertension
Motor/sensory eval of CN 9, 10, 12
Audio/video recorded sample

2

Voice Eval: Medical Hx

Birth & neonatal period
Illnesses, allergies, accidents
Hospitalization medications
Previous ENT evals
Previous speech/psychiatric contact

3

Voice Eval: Behavioral Hx

Biographical info
Pt description of voice d/o
Other reactions
Effects of voice on personal life
Pt explanation of cause
Onset & course of d/o

4

Physician Eval of VF Status:

Flexible Endoscope Nasendoscopy (also like FEES--same procedure w/o food), Nasendoscopy, Mirror laryngoscopy (reversal in image to keep in mind)

5

Respiratory Difficulties & Voice

SOA, reduced speech endurance, emphysema, PD, CP, clavicular breathing-->increased laryngeal tension
Speaking on residual air
Clavicular: tension in neck
Other: shallow breathing

6

Extraneous Respiratory Noises (Stridor)

Asthma, nasal blockage, laryngeal neoplasms, laryngeal webs, abductor paresis or paralysis of VFs

7

Voice Eval of Respiration:

For vegetative purposes
Adequate lung capacity for sustaining speech
Efficiency of respiration
s/z ratio
Respiratory pattern
Take a deep breath and say /a/ and time them; if they don’t, give them example
Hold /i/ at normal voice as long as they can

(Note from Baker: Embarrassment: don’t show embarrassment in front of pt; doesn’t show confidence either)

8

S-Z Ratio

If there’s a problem w/ voice, it’ll show up on /z/
/z/ will be much shorter
Prepubertal children 10 seconds
Adults 20 to 25 seconds (this is long; Baker calls 15 seconds normal)
No pathology ratio of 1.0
Reduced vital capacity ratio of 1.0 but reduced length for both
Vocal fold pathology 2:1 ratio poor laryngeal control for /z/

9

Maximum Phonation Time (MPT)

Efficiency of glottal closure & efficiency of respiratory system
Adults: 15-20 seconds
Elementary school system: 10 seconds
Deep breath and count out loud as long as you can on that breath (don’t rush though)
If they let breath out at the beginning, they’re inefficient
If people are good, can sometimes count to 35-40 on 1 breath

10

Decreased MPT

1. Inefficient glottal control: breathiness, glottal lesions (Anything that causes a leak (not able to keep glottal control), interarytenoidal lesions, paralysis or paresis of cnx
2. Inefficient respiratory functioning: insufficient respiration pattern, neurologic involvement faculty learned pattern of speaking

11

Eval of Muscle Coordination for Respiration Activities

1. Maintain slow, gradual inspiration
2. Maintain slow, gradual expiration
3. Sustain production of an isolated vowel
4. Read aloud sentences & phrases of varying length
5. Pant like a dog
6. Speak while engaging in some strenuous motor activity (lift something, etc.)

12

Eval of Loudness

Audiometric Eval (check hearing)
Optimum loudness-subjective loud enough to be heard over background noise but not uncomfortable to listener

13

Etiologies of Loudness

VF paralysis
Neurogenic d/o's
Mass lesions of the VFs
Personality disturbance
Deafness

Reduced loudness—paralysis?

14

Procedures for Eval of Loudness

Speak in presence of music
Speak while performing different levels of physical activity
Project voice across room or large lecture hall
Move away from examiner at 10 feet distance

Trouble projecting voice?

15

Eval of Pitch

Sing down scale to lowest note
Sing up scale to falsetto
Determine pitch range
Describe in range of musical note (E3-C5) or as a frequency range (165-523 Hz)
Adequate for age & sex
Everyone has an optimal pitch for their larynx & a habitual pitch
Sing from lowest to highest note they can—you count the notes; give example first (may have to do “do each note after me”)
May decide it’s 2 notes & count 2 notes
Cant tell if voice sounds better lower and strain higher, etc.

16

Evaluation of Optimal Pitch

Voice produced most efficiently; does habitual match optimum?
3 Methods:
1. Fairbanks 1/4 or 1.3: from bottom of range
2. Uh-huh: say uh-huh 2x, then hold it out, then count to 5; habitual is counting; optimal is holding ‘huh’
3. Yawn-sigh: most relaxed a larynx can get is out of a yawn; sigh out of yawn; then count to 5; optimal is sigh

17

Eval of Habitual Pitch

Modal frequency level or pitch use in everyday speech
Method 1: Conversational speech or reading; passage tape recorded stop tape at various place-match pitch to a pitch pipe
Method 2: Toner II Visi- pitch
Use rainbow passage
Aphonic never has a voice; not breathy
Tension will be observed: facial grimacing, tension in neck, etc.

18

Eval of Voice Quality

Tape record conversation of interview
Read a standard passage
Determine quality disorders of phonation or resonance

19

Eval of Breathiness

Asynchronous vibration of VF, paralysis of VF, bowed VF
Can it be reduced?: Phonate different vowels while lifting, Phonate different vowels by pushing, Phonate different vowels while pulling
Spastic: harsh; Flaccid: breathy

20

Eval of Harshness

Neurological disease, hard glottal attack, hypertension of pharynx, use severity rating scale

21

Eval of Hoarseness (breathiness + harshness)

Neurological disease
Interference of the mass, compliance, & elasticity of VF
Laryngeal edema
Severity rating of degree

22

Eval of Glottal Fry

Frying sound @ bottom of pitch range; Everyone has a little fry when they talk at times
1. Determine frequency of occurrence during reading & conversation
2. Avg. duration in seconds
3. Where fry occurs? End of word, phrase, sentence, etc.
4. More frequently on upward or downward inflection
5. Elevate pitch level

23

Eval Sites of Vocal Hypertension

1. Elevation of the larynx
2. Elevation of the hyoid bone
3. Posterior tongue position (do they talk w/ tongue back?)
4. Muscles standing out from the neck
5. Strained vocal quality
6. Hard glottal attack
7. Pain in the presence of normal VFs

24

Hyperfunctional Respiration Patterns

Quick, shallow inhalation; inspiratory voicing
Inefficient control of exhalation: talks on residual air, doesn't take replenishing breaths
Runs out of air
Air escapes in a rush @ beginning of utterance

25

Hypofunctional Respiration Patterns

Difficulty maintaining erect head, neck, & thorax
Inhalation insufficient in depth & timing
Exhalation weak & short
Inadequate control of exhaled air
Weak muscle tone & movement
Inadequate use of replenishing breaths
Reduced prolongation of /s/

26

Hyperfunctional Phonation Patterns

Abrupt initiation of phonation
Folds approximated too tightly, voice is squeezed
Constriction of trachea, adduction of false folds
Arrhythmic short words & phrases
Observable tension sites
Inappropriate or uncontrolled loudness & pitch
Phonation breaks & nonintentional pitch changes
Uses laryngeal valve to control exhaled air
Voice sounds hoarse, harsh, diplophonic, ventricular, jerky, & arrhythmic

27

Hypofunctional Phonation Patterns

Inconsistent or breathy voice onset
Inadequate, irregular laryngeal valving
Reduced laryngeal DDK rates
Excessive air escape during phonation
Voice sounds weak, aphonic, cuts in & out, fades
Limited audibility & endurance
Minimal vocal variation

28

Hyperfunctional Resonance Patterns

Tension in supraglottal resonators
Voice sounds strident; has an "edge"
Lack of reverberation of sound on facial bones
Minimal mouth opening; tight jaw
Inappropriate balance of oral nasal resonance
Tense, posterior tongue carriage

29

Hypofunctional Resonance Patterns

Inadequate oral resonance & nasal resonance
Minimal movement of lips & tongue to shape cavity
Vibrating column of air not projected forward
Voice sounds thin, weak, muffled
Lack of resonance may affect intelligibility of speech sounds
Inadequate or imprecise velopharyngeal closure

30

CAPE-V Stands for _____

Consensus Auditory-Perceptual Evaluation of Voice
Developed by Special Interest
Division 3, Voice and Voice Disorders, of the American Speech-Language-Hearing Association

31

CAPE-V Purpose & Application

Developed as a tool for clinical auditory-perceptual assessment of voice
Primary purpose: describe severity of auditory-perceptual attributes of a voice problem
Secondary purpose: contribute to hypotheses regarding anatomic & physiological bases of voice problems & to evaluate need for additional testing
Not intended for use as the only means of determining nature of voice d/o
Not to be used to exclusion of other tests of vocal function
Not expected to demonstrate a 1:1 relation to results from other tests of vocal fx

32

CAPE-V Overall Severity

Global, integrated impression of voice deviance

33

CAPE-V Roughness

Perceived irregularity in the voicing source; see hoarseness

34

CAPE-V Breathiness

Audible air escape in the voice; degree perceived relates to degree of VF closure

35

CAPE-V Strain

Perception of excessive vocal effort (hyperfunction); harshness

36

CAPE-V Pitch

Perceptual correlate of fundamental frequency; rates whether the individual's pitch deviates from normal for that person's gender, age, & referent culture

37

CAPE-V Loudness

Perceptual correlate of sound intensity; indicates whether the individual's loudness deviates from norms as well

38

Harshness (associated with strain)

Perceived excessive effort, tension, & constriction in vocal tract; aperiodicity of vibratory pattern diffused across spectrum; hard onsets, visible tension, overadduction of VFs, staccato or jerky phrasing may be present

39

Hoarseness (associated with roughness)

Perceived leakage of air & aperiodicity of vibration (noise) present

40

Severe Hoarseness

Includes voice breaks or aphonic episodes during connected speech

41

Wet Hoarseness

Related to the presences of excessive &/or thick secretions in the vocal tract

42

Aphonia

Severe breathiness; complete absence of sound

43

Vocal Fry or Pulse Register

Basal pitch; relaxed, syncopated vibratory mode produced below lowest note of musical pitch range; likened to popcorn popping or door creaking; note frequency & location (end of breath group or sentence) of fry

44

Difference b/t Aphonia & Breathiness

Aphonia has no voice; breathiness has some voice/sound

45

Voice Attributes on the CAPE-V AKA

Positive Signs

46

CAPE-V Data Collection

Audio record individual's performance on 3 vowels, sentences, & conversational speech

47

CAPE-V Task 1: Sustained vowels: 2 vowels selected

1 is lax vowel (/a/) & the other tense (/i/); /i/ is sustained vowel used during videostrobe; use of /i/ offers auditory comparison
Clinician should say to the individual, “The first task is to say the sound, /a/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” (provide model if necessary) Client performs this task three times for 3-5 sec each.“Next, say the sound, /i/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” Client performs this task three times for 3-5 sec each.
Lax vowel will bring out breathiness; high tense vowel: can get you closure: is there a difference b/t two vowels

48

CAPE-V Task 2: Sentences:

Designed to elicit various laryngeal behaviors & clinical signs
Present client with flashcards that show the target sentences one at a time and say, “Please read the following sentences one at a time, as if you were speaking to somebody in a real conversation.” With difficulty reading, the clinician may ask client to repeat sentences after verbal examples. (Note on CAPE-V form.)

49

CAPE-V Sentences

(a) The blue spot is on the key again; (b) How hard did he hit him? (c) We were away a year ago; (d) We eat eggs every Easter; (e) My mama makes lemon jam; (f) Peter will keep at the peak.

50

What sounds CAPE-V sentences elicit

Sentence 1: provides production of every vowel sound in the English language
Sentence 2: emphasizes easy onset with the /h/
Sentence 3: all voiced
Sentence 4: elicits hard glottal attack
Sentence 5: incorporates nasal sounds
Sentence 6: weighted with voiceless plosive sounds.

51

CAPE-V Task 3: Running Speech

Elicit at least 20 seconds of natural conversational speech using standard interview questions such as, “Tell me about your voice problem." or "Tell me how your voice is functioning.” (probably more than 20 seconds)

52

CAPE-V Data Scoring

Client should perform all tasks before completing form; If performance is uniform across all tasks, the clinician should mark the ratings indicating overall performance for each scale.
If a discrepancy is noted in performance across tasks, clinician should rate performance on each task separately, on a given line. Only one CAPE-V form is used per individual being evaluated. In the case of discrepancies across tasks, tick marks should be labeled with the task number.
If discrepancies within task further divide: 1a, 1b, 2a, 2b
Unlabeled tick marks indicate uniform performance
After all ratings are complete, physically measure the distance (mm) from the left end
of the scale. Write the mm score in the blank space to the far right of the scale, relating the results in proportion to the total 100 mm length of the line.

53

CAPE-V Results Reporting

Reported in 2 ways:
1. indicate distance in mm to describe the degree of deviancy, for example “73/100” on “strain.”
2. Use descriptive labels, for example “moderate-to-severe” on “strain.”
Strongly suggested to use both forms of reporting

54

CAPE-V Recommendations

Recommended to compare new CAPE-V with any done previously with the same client.
Rate subsequent examinations based on direct comparisons between earlier and current audio recordings. (would optimize internal consistency/reliability for assessing tx outcomes)
Make every effort to minimize bias in all ratings
Indicate prominent observations about resonance under “Comments about resonance.”
hyper/hyponasality, cul-de-sac resonance, etc.

55

CAPE-V Cautions

Intra- and inter-judge agreement varies widely
Attempted to limit sources of variability in the present tool, but its reliability and validity have not yet been assessed.