DR.N.KUMAR M.

S ENT PG

Laryngeal Anatomy
Three surrounding structures- pharynx,

trachea and esophagus Three levels - supraglottis, glottis and subglottis Three fixed structures - hyoid, thyroid and cricoid Three mobile structures -epiglottis, false vocal cords and true vocal cords (folds)

Laryngeal Anatomy

Laryngeal Physiology
Three main functions Protection of airway,

respiration and voice Three criteria for voice- generator, vibrator resonator Three components for high quality glottic voice - closure, pliability and symmetry

Production of normal voice

For production of normal voice, vocal cords

should: 1. Be able to approximate properly with each other. 2. Have a proper size and stiffness. 3. Have an ability to vibrate regularly in response to air column

What is Voice?
Vocal fold vibration that provides sound source

for spoken language Phonation: humans set their vocal folds into a vibratory pattern (say oooo)
Vocal folds are adducted (closed), air is exhaled upwards

and blows apart the vocal folds setting them into a rapid vibratory pattern

Voice is further modified by the processes of

resonation and articulation Three vocal characteristics: frequency, intensity, and phonatory quality

Frequency
Rate of vocal fold vibration (pitch) Fundamental frequency (F0) basic vibratory rate of

the vocal folds (in Hertz)

Kindergarten girls and boys = 250 Hz Adult women = 180 220 Hz Adult men = 120 140 Hz

F0 relates to three characteristics: Vocal fold length, mass, and tension Fundamental frequency changes as we age, especially

between birth and puberty

Pitch
Important concepts: Habitual pitch: pitch one uses normally Optimal pitch: best pitch voice can produce Basal pitch: lowest pitch one can produce Ceiling pitch: highest pitch one can produce Vocal range: difference between basal and ceiling Disordered pitch: Habitual pitch differs significantly from optimal Extremely limited vocal range

Intensity
Sound pressure reported in decibels

(loudness) Relates to two features of vocal production: Amount of airflow from the lungs Amount of resistance to the airflow by the vocal folds (which contributes to their excursion, or how far apart the vocal folds move and come back together) Every person has a baseline intensity level that characterizes his/her conversational speech

Loudness

Over-loudness: air pressure builds up under

vocal folds and produces wide excursion of folds Under-loudness: lack of respiratory force because of Neurological injury and disease Social or psychogenic factors

11.13

Phonatory Quality
How well the two vocal folds work together during the

vibratory cycle
If vocal folds work symmetrically and harmoniously,

voice is pleasant and clear If compromised in some way (e.g., growth on one of the folds), phonatory quality is affected

Also influenced by the resonation of the voice into the

oral and nasal cavities (e.g., nasal voice quality)

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Copyright 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

11.15

Describing Voice Quality

Dysphonia: umbrella term for a voice that is

disordered in some way Aphonia: total loss or lack of voice Many other, mostly subjective terms
Pitch and frequency: jitter or diplophonic Loudness and intensity: pressed or strident Resonance: nasal or ringing Phonatory quality: flutter or creak

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11.16

Describing Vocal Fold Functioning

Hypofunction: vocal folds are under-functioning and

have inadequate tension, so air escapes through

Breathiness or hoarseness, or no voice at all

Hyperfunction: vocal folds are overly tense and

compress too tightly together

Too loud, too high, and/or too strained Sometimes spasticity of the voice

Diplophonia: vocal folds produce two different pitches

simultaneously

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11.14

What is a Voice Disorder?

Pitch, loudness, or phonatory quality differs

significantly from persons of a similar age, gender, cultural background, and racial and/or ethnic group, and Vocal quality detracts from the ability to function and achieve in society

Justice Communication Sciences and Disorders: An Introduction

Copyright 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Characteristics Of Voice Disorders

it is not audible, clear or stable in a wide range of

acoustic settings; it is not appropriate for the gender and age of the speaker; it is not capable of fulfiling its linguistic and paralinguistic functions; it fatigues easily; it is associated with discomfort and pain on phonation.

Key definitions
Dysphonia: Any impairment of the voice or difficulty speaking. Dysarthria: Difficulty in articulating words, caused by

impairment of the muscles used in speech. Dysarthrophonia: Dysphonia in conjunction with dysarthria, for example after a cerebrovascular accident,head injury or part of a degenerative neurological condition, such as motor neurone disease. Dysphasia: Impairment of the comprehension of spoken or written language (sensory dysphasia) or impairment of the expression by speech or writing (expressive dysphasia), especially when associated with brain injury. Hoarseness: A perceived rough, harsh or breathy quality to the voice.

Most Common Voice Disorders

muscle tension dysphonia;
laryngitis/muscle tension dysphonia secondary to poor

vocal hygiene, dietary and lifestyle issues; extraoesophageal reflux (laryngopharyngeal reflux); vocal fold nodules; vocal. fold polyps; vocal fold cysts; vocal fold palsy and paresis; arytenoid granulomas.

Less frequently seen

sulci and mucosal bridges; spasmodic dysphonia; papillomatosis; microvascular lesions; laryngeal trauma, including post-surgical causes; other neuromuscular causes; hyperkeratosis, dysplasia and carcinoma; endocrine causes; amyloid; other laryngeal tumours.

11.18

Prevalence and Incidence: Voice Disorders in Adults

Prevalence = 29%, Incidence = 6%

Higher prevalence for women, peak ages of 40-60 years

Higher prevalence among people with frequent

allergies, asthma, colds, and sinus infections Higher prevalence among professions reliant on voice Common causes: vocal nodules, edema/swelling, polyps, carcinoma, and vocal fold paralysis
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11.19

Prevalence and Incidence: Voice Disorders in Children

25% of children exhibit significant vocal problems,

with 40% of these cases ongoing, not transient, problems For some it is a congenital problem, but most cases result from overuse or misuse of voice Most common cause: vocal nodules that impede smooth meeting of folds, resulting in breathy or hoarse voice

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11.45

IV. How are Voice Disorders Identified?

A. The Voice Care Team

Close collaboration of a variety of professionals Medical professionals: primary care physician (PCP), otolayrngologist Allied health professionals: speech-language pathologist, psychologist or psychiatrist Possibly educators or voice coaches also
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11.46

B. The Assessment Process

Identification of warning signs
Assessment Protocol: Case history and interview Oral-motor examination Clinical voice observation Instrumental voice observation

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Copyright 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

11.47

Warning Signs for Voice Disorders

Children and adolescents:
Vocally abusive behaviors Underlying medical condition

Psychological well-being

Adults:
Change in phonatory quality for more

than two weeks, consult physician

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11.49

Case History and Interview

the nature and chronology of the voice problem;

exacerbating and relieving factors; lifestyle, dietary and hydration issues; contributing medical conditions or the effects of their treatment; the patient's voice use and requirements; the impact on their quality of life, social and psychological well-being; their expectations for outcome of the consultation and treatment.
Copyright 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

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11.50

Oral-Motor Examination
Identify conditions of structures involved with

producing voice Study amount of tension and sensation involved in speech and voicing Examine possible swallowing problems Study the appearance and functioning of the velum

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Copyright 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Clinical Observation

Perceptual observation of characteristics of voice

during a variety of speaking and vocal activities Example activities: counting from 1 to 40 softly then loudly, sustaining a vowel sound for as long as possible, engaging in normal conversation Also studies systems that support vocal production, like respiration Relies heavily on the listener, so need to be properly trained and experienced

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11.52

Instrumental Observation
Objective measures of vocal functioning: Acoustic assessment: measures frequency, intensity, and resonance characteristics Aerodynamic assessment: measures airflow, air pressure, and vocal fold resistance Electroglottography: measures vocal fold contact during voicing Videostroboscopy: examines laryngeal system and measures vocal fold movement

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Overview of methods of objective evaluation of voice used in clinical practice

1-Perceptual evaluation of the voice:

using rating scales to grade the presence and severity of defined qualities of the voice that we can hear, e.g. hoarseness, roughness, breathiness.

1-Perceptual evaluation of the voice:

process of assessing and grading the severity of these

distinctive qualities in a speaker's voice by an 'expert/trained' listener

:

GRADES
Grade (of hoarseness), rough, breathy, aesthenic,

strained -GRBAS Grade (of hoarse ness), rough, breathy, aesthenic, strained, instability -GRBASI Rau higke it (roughness),Behauchtheit (breathiness. Hei serke itsgrad (hoarseness) method Consensus auditory perceptual evaluation of voiceCAPE V Hammarberg evaluation scheme Voicing evaluation scheme Vocal profile analysis

GRBAS
Grade (G) -Overall rating of severity of

abnorm ality of voice Roughness R-Irregular perturbation of pitch and amplitude, noise in low frequency region and the presence of spectral subharmonics

 Breathiness (B) - Noise below the midfrequ

encies, incomplete closure of vocal folds resul ting in high expiratory flow rate Aesthenia A- Less harmonic content in the high frequency region, irregularity of pitch and amplitude, a fading amplitude contour

 STRAIN S- Reflects higher pitch, noise

in the higher frequencies, increased amplitude of the higher harmonics and increased pitch and amplitude perturbation

 2-Acoustic analysis: extracting and

objectively evaluating various factors related to the acoustic waveform recorded using a microphone placed near the mouth e.g. fundamental frequency, intensity, perturbation measures

Typical acoustic measures

Fundamental frequency and variability mean Fo F 180-250 Hz M 100-150 Hz Vocal intensity and variability Mean 60-80 dB SD 10 dB Perturbation measures (many ways to measure) Analysis must be limited to a phonated segment Jitter- frequency (0.2-1 %) Shimmer-intensity (0.5 dB norms not well established) Harmonic to noise ratio (> 15)

Typical acoustic measures

Phonational frequency range
~ 3 octaves

Dynamic range
50-115 dB
30 dB range

 Electrolaryngography/electroglottography: indirect

measures of vocal fold vibration (e.g. fundamental frequency, degree of contact, perturbation measures) determined by measuring changes in high frequency electrical conductance between two electrodes placed on the skin over the thyroid cartilage.

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
Electromyography (EMG) is a way of recording muscle activity Electrodes (needle or hook wire) inserted in the muscle Used to
Evaluate neuromuscular function Discriminating paralysis from arytenoid dislocation Verify location of needle for injecting BOTOX into

intrinsic laryngeal muscles

SPPA 6400 Voice Disorders

 Visual assessment: inspection of the structure and

dynamic function of the larynx and rest of the vocal tract together with the vibratory patterns of the vocal folds during phonation (e.g. using endoscopic laryngoscopy including stroboscopy,videokymography and high-speed digital cinematography).

HSDI AND KYMOGRAPHY

Laryngeal motion is imaged
Gives permanent record of actual cycle to cycle motion

of vocal folds

 Aerodynamic measures: indirect measures

of the forces that initiate and maintain vocal fold vibration e.g. subglottal pressure,airflow and air volume

Mean flow rate (MFR)

Measures thought to reflect laryngeal valving
= poor laryngeal valving = excessive laryngeal valving

SPPA 6400 Voice Disorders

Subglottal Pressure (Psg) Estimate

Repeated /pi/ with intraoral pressure transducer
Can measure for conversational loudness (5-10 cm

water) Can measure threshold (3-5 cm water)

SPPA 6400 Voice Disorders

 Quality of life measures: using self-administered,

validated disease-specific or generic questionnaires to assess the patient's perception of the impact of the voice condition on their quality of life, in terms of physical complaints and restriction in participation in daily activities (e.g. Voice Handicap Index, Voiss).

 Patient questionnaire of vocal performance (VPQ)

Voice handicap index (VHI) Voice-related quality of life (V- RQOL)

Voice activity and participation (VAAP)

Voice symptom scale (Voiss) Voice handicap index- 10 (VH 1-10)

 Voice accumulator and tests of vocal

loading: these are means of sampling the voice or aspects of vocal function either over a prolonged period of time or before and after a specified vocal stress test.

Instrumented Evaluation
Videolaryngostroboscopy
Acoustic Evaluation Selected Instruments

SPPA 6400 Voice Disorders

Laryngoscopy
Direct Indirect Mirror examination Rigid laryngeal endoscopy

Constant light Stroboscopy

Flexible fiberoptic laryngeal endoscopy Constant light Stroboscopy

SPPA 6400 Voice Disorders

Components
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

Constant light source allows viewing of basic structure and function
Identify lesions Identify abnormalities in ab/adduction

Identify supraglottic activity

Strobe light source allows a view of simulated vibration

allows assessment of the vibratory function of the vocal

folds May reveal structural abnormalities not seen during constant light endoscopy
SPPA 6400 Voice Disorders

VLS Examination
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 Cough Normal & deep breathing

SPPA 6400 Voice Disorders

Stroboscopy
An examination in which a strobe light is combined with rigid or

flexible laryngoscopy, allowing an examination of vocal fold vibration and vocal fold closure Laryngeal stroboscopy involves controlled high-speed flashes of light timed to the frequency (opening and closing cycles of vfs per/ sec.) of the patient's voice. Images obtained during these flashes provide a slow motion-like view of vocal fold vibration during sound production.

Key features in the interpretation of laryngostroboscopic images

1-Glottal closure pattern-Anterior or posterior gap,Hourglass or spindle shaped ,Irregular or regular,Closed phase 2-Mucosal wave (right/left) in response to changes in pitch and loudness-Symmetry,Periodicity (regularity), Degree of change

Contd
3-Description of lesion- Colour,Shape,Multiple/single, Surface 4-Vocal fold opening/closing pattern (right/left)-Range full/reduced,Normal/lag,Presence of spasm/tremor 5-Supraglottic appearanceFalse cords medial constriction: right/Ieft/both Anteroposterior constriction (arytenoid-epiglottic approximation)

6-Symmetry of arytenoids (vocal processes and apices/ corniculate cartilages)-Prominence/lesion(s) SaggitaI/coronaI/axiaI planes

Advantages of Instrumentation:
These technologies provide both the practitioner and the patient with

valuable information. They allow images to be recorded on video or other media formats, allowing examiners to review the images of the larynx frame by frame, In addition it captures still and close-up images, and allows members of the voice care team to re-review images that were captured. Patients can also view the recorded images and see the reason(s) for their voice problems.

Stroboscopy: this can provide a series of images

Some Instruments for acoustic analysis

Real-time analysis
Examples Sound level meter Visi-pitch Real-time spectrograms Nasometer

Off-line analysis (analysis after data is collected)

Examples Computerized speech Lab (CSL), MDVP Cspeech (tf32) Praat

SPPA 6400 Voice Disorders

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