Transcript Pitch

Structure and Function of
Larynx
SPPA 6400 Voice Disorders
SPPA 6400 Voice Disorders
Some questions
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What is a voice disorder?
How does it differ from speech disorder?
How does if differ from a resonance disorder?
How common are voice disorders?
Who gets a voice disorder?
Why might someone have a voice disorder?
How do you know if someone has a voice
disorder?
SPPA 6400 Voice Disorders
Voice Disorders: Simple Taxonomy
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Organic
Neurogenic
Functional
SPPA 6400 Voice Disorders
Prevalence vs. Incidence
Source: Manitoba Centre for Health Policy
SPPA 6400 Voice Disorders
Epidemiology
From Roy et. al (2004) JSLHR 47 281-93.
SPPA 6400 Voice Disorders
Epidemiology
SPPA 6400 Voice Disorders
From Roy et. al (2004)
JSLHR 47 281-93.
From Roy et. al (2004) JSLHR 47 281-93.
SPPA 6400 Voice Disorders
Epidemiology
SPPA 6400 Voice Disorders
From Roy et. al (2004) JSLHR 47 281-93.
Voice/laryngeal disorders is often a
multidisciplinary effort
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Speech Language Pathology
Otolaryngology
Voice Scientists
Vocal Instructors
Neurology
Gastroenterology
Pulmonology
Psychology
SPPA 6400 Voice Disorders
Assessment
What are the goals of assessment?
SPPA 6400 Voice Disorders
Assessment: Aims
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Etiology
Diagnosis
Prognosis
Planning
SPPA 6400 Voice Disorders
Signs vs. Symptoms
SPPA 6400 Voice Disorders
Common Voice Symptoms (Table 2.1)
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Hoarseness
Vocal fatigue
Breathy voice
Reduced phonational range
Aphonia or voice loss
Pitch breaks/inappropriately high pitch
Strain/struggle
Tremor
Pain & other physical sensations
SPPA 6400 Voice Disorders
Primary components of Assessment
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Chart Review
Case History
Clinical Evaluation
 Non-instrumented evaluation
 Instrumented evaluation
 Quality of life Indicators
Experimental/diagnostic therapy
SPPA 6400 Voice Disorders
Case History
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Voice Symptom History
Voice Use History
Health History
Social/Vocational History
Psychosocial History
SPPA 6400 Voice Disorders
Voice Symptom History
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The Voice Problem
Effect of the Voice Problem
History of the Voice Problem
SPPA 6400 Voice Disorders
Voice Use History
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Establish voice use patterns
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On the job
At home
In social settings
Look for,
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Environmental factors (noise, air quality)
SPPA 6400 Voice Disorders
Health/Medical History
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Current health problems & past history
Specific areas to probe
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Respiratory problems
Gastrointestinal problems
Neurological problems
Allergies
Head and neck trauma, surgery, disease
Prescription and OTC drugs
Substance use: alcohol, tobacco, drugs, caffeine
Exercise/diet considerations
SPPA 6400 Voice Disorders
Social/Vocational History
SPPA 6400 Voice Disorders
Psychosocial Interview
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“The voice is often a sensitive to our
emotional well being…”
Ask about,
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Stress/emotional problems
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Chronic or episodic
Hx of counseling
SPPA 6400 Voice Disorders
Clinical Evaluation
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Non-instrumented evaluation
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Instrumented evaluation
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Auditory perceptual evaluation of voice
Maximal effort tasks
Assessment of laryngeal musculoskeletal tension
Videolaryngostroboscopy
Acoustic evaluation
Other selected instruments
Quality of life indicators
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Voice Handicap Index
SPPA 6400 Voice Disorders
Critical listening during history
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How do signs match symptoms?
Signs of other communication impairment
Variability in signs as a function of
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Duration of session (change over time)
Periods of improvement/resolution
Automatic behaviors (e.g. cough, throat clear, laugh)
Conversational content
Atypical vocal signs such as stridor (noise during
respiration), tics, grunts, barks
SPPA 6400 Voice Disorders
Critical observation during history
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Signs of pain/discomfort
Signs of tension/strain
Respiratory patterns (“clavicular breathing”)
Level of comfort (or anxiety) over the course of the
interview
Signs of tremor, unusual movements of the body
SPPA 6400 Voice Disorders
Auditory Perceptual Evaluation
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Standardized to clinic/profession
Standardized with respect to
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Data collection procedures (e.g. Alvin Clinic)
Data evaluation procedures (e.g. CAPE-V)
Data reporting procedures (be consistent)
SPPA 6400 Voice Disorders
GET HIGH QUALITY
RECORDINGS OF VOICE!!!
You need
High quality recording device
High quality microphone
Easy access to recordings
SPPA 6400 Voice Disorders
Auditory Perceptual Signs
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Pitch
Loudness
Quality
Aphonia
Other Behaviors
SPPA 6400 Voice Disorders
Pitch
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Monopitch
Inappropriate pitch
Pitch breaks
Diplophonia
Reduced pitch range
Females
SPPA 6400 Voice Disorders
Male
Loudness
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Monoloudness
Excessive loudness variation
Reduced loudness range
SPPA 6400 Voice Disorders
Quality
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Roughness
Breathiness
Strain/struggle/tension
Tremor
Sudden interruption of voicing (voice break)
Hoarseness
SPPA 6400 Voice Disorders
Aphonia
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Aphonia vs. dysphonia
Consistent vs. intermittent/episodic
SPPA 6400 Voice Disorders
Other Behaviors
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Stridor
Excessive throat clearing/coughing
SPPA 6400 Voice Disorders
Scaling perceptual features of voice
SPPA 6400 Voice Disorders
Scaling perceptual features of voice
Definitions of Vocal Attributes:
OVERALL SEVERITY: Global, integrated impression of voice deviance.
Roughness: Perceived irregularity in the voicing source.
Breathiness: Audible air escape in the voice.
Strain: Perception of excessive vocal effort (hyperfunction).
Pitch: Perceptual correlate of fundamental frequency. This scale rates whether
the individual's
pitch deviates from normal for that person's gender, age, and referent culture. The
direction of
deviance (high or low) should be indicated in the blank provided above the scale.
Loudness: Perceptual correlate of sound intensity. This scale indicates whether
the individual's
loudness deviates from normal for that person's gender, age, and referent culture.
The direction of
deviance (soft or loud) should be indicated in the blank provided above the scale.
SPPA 6400 Voice Disorders
From
ASHA Consensus on Auditory Perceptual
Evaluation of Voice (CAPE-V)
Other Tasks
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Phonational frequency range
Loudness range
Maximum phonation time
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S/Z ratio
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repeat 3 times, take largest value
repeat 3 times, take largest value
Laryngeal diadochokinesis (quickly repeated /a/
and/or /ha/)
Voluntary cough
SPPA 6400 Voice Disorders
Assessment of Laryngeal Musculoskeletal Tension
“All patients with voice disorders, regardless of
etiology should be tested for excess
musculoskeletal tension, either as a primary
or secondary cause of dysphonia”
(Aronson, 1990)
SPPA 6400 Voice Disorders
Instrumented Evaluation
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Videolaryngostroboscopy
Acoustic Evaluation
Selected Instruments
SPPA 6400 Voice Disorders
Laryngoscopy
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Direct
Indirect
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Mirror examination
Rigid laryngeal endoscopy
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Constant light
Stroboscopy
Flexible fiberoptic laryngeal endoscopy
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Constant light
Stroboscopy
SPPA 6400 Voice Disorders
Components
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Endoscope (rigid or flexible)
Light source (constant or strobe)
Camera
Recording device (VHS, computer)
If strobe light is used, a neck mounted
microphone (or electroglottograph) is used for
tracking Fo
SPPA 6400 Voice Disorders
Constant light vs. strobe light
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Constant light source allows viewing of basic
structure and function
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Identify lesions
Identify abnormalities in ab/adduction
Identify supraglottic activity
Strobe light source allows a view of “simulated”
vibration
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allows assessment of the vibratory function of the vocal
folds
May reveal structural abnormalities not seen during
constant light endoscopy
SPPA 6400 Voice Disorders
Videolaryngostroboscopy (VLS)
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Why do it?
SPPA 6400 Voice Disorders
VLS Examination
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Evaluate structural integrity
Evaluate gross mobility of structures
Evaluate (inferred) vibratory patterns
SPPA 6400 Voice Disorders
VLS Examination
Relevant structures
 True vocal folds
 Ventricular folds
 Arytenoids
 Interarytenoid area
 Epiglottis
 Glottic closure
SPPA 6400 Voice Disorders
Typical VLS Examination
A task list
 Normal, loud and soft phonation
 Pitch glide (glissando)
 Cough
 Normal & deep breathing
SPPA 6400 Voice Disorders
Glottal closure patterns (Hirano & Bless,1993)
SPPA 6400 Voice Disorders
Stroboscopic observations
Parameters for evaluating the stroboscopic image
 Symmetry of VF motion
 Periodicity
 Glottal closure configuration
 Horizontal excursion of the VFs
 Mucosal wave
 Phase closure
 Vocal fold edge
 Vibratory behavior
SPPA 6400 Voice Disorders
Example of a VLS evaluation form
SPPA 6400 Voice Disorders
Poburka BJ, Bless DM (1998) A multi-media, computer-based
method for stroboscopy rating training JOURNAL OF
VOICE 12 (4): 513-526
Methods of training individuals to rate stroboscopic examinations
vary widely … Consequently, problems occur in both inter- and
intrajudge agreement … This study attempted to determine if
CAI could train individuals to make accurate and reliable visuoperceptual judgments of stroboscopy… Following 4 to 5 hours of
CAI training, the subjects with no previous experience
demonstrated improved interjudge agreement with a panel of
expert raters. The training was not effective for the experienced
group. Regardless of the rater's experience, the parameters that
required evaluation of movement were more difficult to rate than
those requiring only an assessment of structure.
SPPA 6400 Voice Disorders
VLS Considerations
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Level of training (ASHA, 2004)
Cleaning/Universal precautions
Use of topical anesthetic
SPPA 6400 Voice Disorders
“Typical” acoustic measures
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Fundamental frequency and variability
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Vocal intensity and variability
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Mean 60-80 dB
SD 10 dB
Perturbation measures (many ways to measure)
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mean Fo F 210 Hz M 110 Hz
SDFo ~ 2-4 semitones
Analysis must be limited to a phonated segment
Jitter (0.2-1 %)
Shimmer (0.5 dB – norms not well established)
Harmonic to noise ratio (> 15)
NOTE: these are ballpark figures. Always check actual tables for normative
values.
SPPA 6400 Voice Disorders
Synthetic Continuum Varying in Jitter
0.0%
2.0%
0.2%
2.5%
0.4%
3.0%
0.6%
4.0%
0.8%
5.0%
1.0%
6.0%
1.5%
SPPA 6400 Voice Disorders
Typical acoustic measures
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Phonational frequency range
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~ 3 octaves
Dynamic range
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50-115 dB
30 dB range
NOTE: these are ballpark figures. Always check
actual tables for normative values.
SPPA 6400 Voice Disorders
Some Instruments for acoustic analysis
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Real-time analysis
Examples
 Sound level meter
 Visi-pitch
 Real-time spectrograms
 Nasometer
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“Off-line” analysis (analysis after data is collected)
Examples
 Computerized speech Lab (CSL), MDVP
 Cspeech (tf32)
 Praat
SPPA 6400 Voice Disorders
Other Measures
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Aerodynamic Measures
Electroglottography (EGG)
Electromyography (EMG)
SPPA 6400 Voice Disorders
Mean flow rate (MFR)
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Measures thought to reflect laryngeal valving
↑ = poor laryngeal valving
↓ = excessive laryngeal valving
SPPA 6400 Voice Disorders
Subglottal Pressure (Psg) Estimate
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Repeated /pi/ with intraoral pressure
transducer
Can measure for conversational loudness (510 cm water)
Can measure threshold (3-5 cm water)
SPPA 6400 Voice Disorders
Average glottal resistance
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Psg/Mean Flow Rate
↑ = hyperadducted state
↓ = hypoadducted state
SPPA 6400 Voice Disorders
Links to sites related to aerodynamic
analysis
http://www.kayelemetrics.com/
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Aerophone II
http://www.glottal.com/
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Glottal enterprises pneumotachograph
SPPA 6400 Voice Disorders
Electroglottography (EGG)
• Human tissue =  conductor
• Air:  conductor
• Electrodes placed on each side of
thyroid lamina
• high frequency, low current
signal is passed between them
• VF contact  =  impedance
• VF contact  =  impedance
Electroglottogram
Muscle Activity
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Electromyography (EMG) is a way of recording
muscle activity
Electrodes (needle or hook wire) inserted in the
muscle
Used to
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Evaluate neuromuscular function
Discriminating paralysis from arytenoid dislocation
Verify location of needle for injecting BOTOX into
intrinsic laryngeal muscles
SPPA 6400 Voice Disorders
Quality of Life Indicators
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Voice Handicap Index (VHI)
Voice-Related Quality of Life (V-RQOL)
SPPA 6400 Voice Disorders
Assessment Report
Key Components
 Covers key components of assessment
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Need good description
However, need to go beyond description
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Voice diagnosis (or reason why not)
Prognosis (or reason why not)
Recommendations (it’s OK not to recommend Tx)
SPPA 6400 Voice Disorders