CHAPTER 1

Introduction: The Voice Diagnostic Protocol and Initial Stages of the Diagnostic Process

The goal ofthis book is to provide detailed information re­ • It is not a book dealing with the method and interpreta­ garding the rationale and procedures for an array ofrelatively tion of laryngoscopy or stroboscopy. Although these are low-cost and readily available methods ofvoice analysis that important elements of a voice diagnostic, most clini­ will be collectively referred to as the Voice Diagnostic Pro­ cians do not have the trainingInc. and/or the equipment to tocol (VDP). A protocol may be defined as a set of methods carry out these procedures. In addition, when done for or procedures by which a clinical study may be carried out. diagnostic purposes, it is essential that visualization of By stressing the use of relatively low-cost methods, it is the larynx be carried out by an otolaryngologist familiar the intention of this book to provide detailed information with laryngeal disorders, who will then make an ap­ and instruction on methods that can be used by any speech propriate medical diagnosis and recommendations. It is pathologist in any situation or environment. Although it is expectedPRO-ED, that the clinician reading this book will seek hoped that all readers interested in the study of voice evalu­ appropriateby referral sources for laryngoscopic evalua­ ation procedures will benefit from the content of this book, tion (as well as stroboscopy, ifnecessary). it is particularly designed as a resource for (1) graduate • This is not a book dealing with instrumentation methods students in speech-language pathology and (2) practicing such as electroglottography (EGG), advanced aerody­ speech-language pathologists interested in expanding their namic assessment, or electromyography (EMG). Al­ skills in voice diagnosis. though these methods may add valuable information The VDP provides the clinician with a detailed and com­materialto our assessment of vocal function, they require an prehensive assessment of voice function, incorporating ele­ expense and expertise with instrumentation that may ments of patient history, perceptual assessment, acoustic make them clinically unfeasible in many situations. methods, and important estimates of physiological activity. By focusing solely on voice diagnostic procedures, it is the Although many ofthe tasks discussed in this protocol will intention of this book to illuminate methods that are often appear "simple" or uncomplicated on the surface, review of "buried" or discussed in a cursory manner in more general the theoretical background ofthese tasks, descriptions in the voice texts. However, focus on acopyrighted single topic necessarily literature, issues of validity and reliability, etc., make even means that certain associated© areas of study will not be "simple" procedures quite complex in terms of clinical use included: and interpretation. Therefore, the background information provided in this book is believed to be necessary if the • This is not a book dealing with resonance-based disor­ clinical information gathered from these tasks is to be rea­ ders such as velopharyngeal inadequacylincompetence sonably interpreted and used with maximum effectiveness. and associated speech characteristics such as hypema­ Even though many of the tasks incorporated in the VDP use sality and hyponasality and nasal emission. This book instrumentation methods, they cannot really be judged to deals with "voice" as a phonatory event, with focus be objective in nature. True objective measures would be primarily on laryngeal and respiratory mechanisms. independent ofhuman error, judgment, perceptions, and bias • Although aspects ofthis book will necessarily deal with of the clinician (Behrman & Orlikoff, 1997; Nicolosi, Har­ elements of laryngeal anatomy, phonatory physiology, ryman, & Kresheck, 1989). In addition, an ideal objective and acoustic principles, it is not an anatomy or speech test would also be independent of influence from patient science text. behavior (i.e., the patient would not be able to influence 2 THE VOICE DTAGl\OSTIC PROTOCOL test results as a function of his or her immediate behavior). sures of voice and the underlying physiology of phonation. In the case of many instrumental tasks of vocal function, It is not enough to simply recognize that a patient has a the ways in which measures are obtained and interpreted rough-sounding voice, higher than expected fundamental are subjective in nature and affected by both clinician and frequency, or short maximum phonation time-the clinician patient (Behrman & Orlikoff, 1997). must develop a rational hypothesis as to why the patient has certain characteristics. This is where application of our THE CONCEPT OF DIAGNOSIS VS. ASSESSMENT! knowledge ofthe underlying physiology or pathophysiology EVALUATION affecting voice production comes into play. A number of previous works dealing with diagnosis of voice disorders The title of this book clearly indicates that the procedures have also stressed this point. Murry (1982) stated that "the described herein are to be components of a diagnostic pro­ assessment of the vocal mechanism ...encompasses a de­ tocol. The term diagnostic has been specifically used to tailed analysis of the abnormal physiologic behavior of indicate that the outcome ofthis process will achieve several the laryngeal mechanism, specifically, and the relationship important goals: between the behavior of the laryngeal mechanism and the patient's general speech and voice production" (p. 478). 1. Our diagnostic decisions will be based on a synthesis Bless and Hicks (1996) stated that "assessment of vocal ofinformation from diverse areas all dealing with as­ function has evolved to mean deriving a description of voice pects of voice function, such as anatomy and physiol­ production...that allows clinicians to make inferences about ogy, acoustics, perception, psychometrics, and knowl­ the functioning of the underlying anatomical and physi­ edge of norms and testing techniques. Inc. ological condition of the larynx" (p. 124). Behrman and 2. The final diagnosis will be derived from the ability Orlikoff (1997) go so far as to stress that "the underlying to distinguish the patient's problem from a large field pathophysiology is [italics added] the voice disorder that the ofpossibilities (Haynes, Pindzola, & Emerick, 1992). clinician must seek to understand" (p. 10). This process is referred to as dijJerential diagnosis, a Once the clinician can hypothesize the possible causative process that takes into account all significant variables factors (behavioral or organic) underlying the patient's voice contributing to the disorder and attempts to differenti­ PRO-ED, disorder, the development of treatment goals becomes evi­ ate the presenting problem from related or dissimilar dent. A physiological approach to diagnosis should lead problems (Weinberg, 1983). by to physiological voice therapy, in which "the management 3. The final diagnosis will actually be the beginning of approach is a direct modification ofthe inappropriate physi­ a continuous venture that will be open to revision on ologic activity" (Stemple, 1993, p. 4). It is clear that the the basis ofthe patient's future behavior. success of voice therapy is highly dependent on the skill Some may object to the use of the term diagnosismaterial or and inferences ofthe voice clinician derived from the initial diagnostic as used by speech-language pathologists, perhaps diagnosis. because of (1) the association of the term with the medical profession and (2) the possible implication that the speech­ AVOIDANCE OF MEDICAL DIAGNOSTIC TERMS language pathologist will be carrying out a medical proce­ dure. Some would prefer the use of terms such as assess­ The focus of the speech pathologist involved in the voice ment or appraisal to describe our methods. However, these diagnostic should be to assess voice production, identify terms are not synonymous with diagnosis and describe only possible underlying factors (behavioral and/or organic) that the procedures used within the overallcopyrighted diagnostic method. may be responsible for the cause and maintenance of the In contrast, "diagnosis requires© placing measurements and voice problem, and determine the severity ofthe voice prob­ other observational data into context and perspective in order lem (Behrman & Orlikoff, 1997; Colton & Casper, 1996; to decide whether a problem exists and to differentiate one Murry, 1982). Itis not the speech pathologist's responsibility problem from others which may have similar performance to determine the specific existence and type of pathological aspects" (Peterson & Marquardt, 1990, p. 4). It is my belief condition that may be affecting the phonatory function ofthe that the term diagnosis is a universal term that describes patient (Behrman & Orlikoff, 1997; Murry, 1982). Although a process of investigation and deduction that cannot be the literature is ripe with the perceptual and acoustic de­ reserved for a particular field or profession. scription of various pathological states, the voice clinician should focus his or her diagnostic conclusions on possible A PHYSIOLOGICAL VIEW OF VOICE DIAGNOSIS physiological mechanisms that may be responsible for the various perceptual, acoustic, and other signs observed in The various sections of this book will stress the possible the particular patient rather than on diagnostic labels. This relationships between perceptual, acoustic, and other mea­ description is much more informative and potentially useful Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 3 to the speech pathologist and the patient than applying a in conjunction with a measure of the average devia­ medical term or label to the patient's disorder. The use of tion. Unfortunately, perceptions cannot be compared medical diagnostic terminology should be avoided for the with measurable norms in any valid manner. following reasons: 3. Progress in therapy sessions may not be gauged ef­ fectively with perceptions alone. Perceptual judg­ 1. It is outside the realm of the speech pathologist to ments may not detect relatively small but significant make medical diagnoses. An appropriate referral must changes in voice characteristics that may indicate that be made to the attending physician or otolaryngolo­ a treatment procedure is having a positive effect on gist, who will apply the "label" to the patient's organic the patient. In addition, perceptual judgments alone pathological condition. may not provide the data required to justify continua­ 2. A multitude ofdifferent disorders with different labels tion of therapy and reimbursement for treatment. can result in similar perceptual, acoustic, etc., char­ acteristics. As an example, vocal nodules, polyps, It can be seen that the effective gauging of the patient's and other lesions that affect the margin(s) of the voice characteristics in both diagnosis and treatment is fold(s) and restrict glottal closure may all have some somewhat lacking if perceptual judgments are used alone. degree of breathiness. Therefore, it can be seen that Therefore, a key component of the VDP is the addition the chance for error in applying a medical diagnostic of instrumental measures wherever possible. Behrman and term solely on the basis ofperceptual and/or acoustic Orlikoff (1997) define instrumental measures as "those ob­ information is a strong possibility. tained using electronic or computer-based equipment" (p. 9). 3. As in other areas of speech pathology, we do not There are several key reasons Inc.why the addition ofinstrumen­ treat labels. Instead, we must treat each patient as tal measures strengthens our diagnostic protocol (Behrman a unique entity with his or her own unique physi­ & Orlikoff, 1997): ological disturbances (both primary and secondary [i.e., compensatory] in nature). Therefore, diagnosis 1. Rapid evolution of the environment in which speech­ should accentuate the underlying physiology of the language pathologists' practice has demanded greater patient and the voice disorder rather than a particular sophisticationPRO-ED, from the clinician in terms of diagnos­ label or category to which they may belong. bytic methods. 2. Health-care delivery and reimbursement issues have THE USE OF INSTRUMENTATION: OBJECTIVE required the voice clinician to quantify patient char­ EVALUATION OF THE VOICE WITH acteristics both in diagnosis and through the course METHODOLOGY AVAILABLE TO ALL VOICE oftherapy. CLINICIANS 3. Instrumentation procedures may be able to tell the material clinician how a patient is making use of and coordi­ Traditionally, the major component of a voice evaluation nating the various subsystems (respiratory, phonatory, dealt solely with a perceptual description ofvoice character­ articulatory) of the speech mechanism. istics. Although perceptual characterization of the voice is 4. Instrumental measures may help form a more solid still an essential component of any voice diagnostic, it can foundation for clinical judgments. no longer be the only parameter to be included in a complete 5. Instrumental measures allow for the comparison of voice diagnostic. There are several important reasons why vocal performance to appropriate normative data. perceptual judgments alone are notcopyrighted adequate: 1. Variability in training and© experience between thera­ It can be seen that instrumental measures help to verify pists inevitably leads to a lack of reliability and valid­ clinical judgments and hypotheses. If clinical experience, ity in the perceptual judgments that are made. Discus­ expertise, and perceptual judgments form the basis of diag­ sion with colleagues will often reveal that even such nostic hypotheses, then instrumental measures are a key commonly used severity terminology such as mild, factor in the acceptance or rejection of these hypotheses. moderate, and severe may have very different mean­ ings for different therapists. RATIONALE FOR ACOUSTIC METHODS 2. Perceptual judgments alone do not allow for objec­ tive comparison with normative groups. One of the A key element of the VDP is that perceptual signs of the fundamental diagnostic decisions made in any evalu­ voice will be verified and supported by means of acoustic ation is one of "normal" vs. "abnormal." One of the methods. Acoustic analysis of the voice represents an area valuable aids we have in making this decision is a of instrumental analysis that presents a number of distinct measure ofthe average performance for a target group advantages to the clinician. 4 THE VOICE DIAGNOSTIC PROTOCOL

Clinician Experience and Familiarity ence that most patients, even relatively young children, are able to easily understand (in a simple, but effective manner) All master's degree-level speech-language pathologists many of the measures displayed in voice analysis programs generally have one or more courses in basic speech science (e.g., jitter values "should go down"; Fo values "should and acoustic methods as part of their academic training. go up"; displayed Fo contours should flatten). In this way, Therefore, many of the concepts of frequency, intensity, acoustic methods provide a valuable link between the voice periodicity vs. aperiodicity, etc., that underlie the acoustic diagnostic and voice therapy. methods used in the voice diagnostic will be relatively fa­ miliar to the clinicians using them. Wide Body of Literature

~oninvasive Acoustic analysis methods have an extensive history of use with a wide range ofvoice-disordered populations. This Acoustic methods are noninvasive and therefore may be provides the clinician with a vast body of literature that used with all patients by any clinician. In addition, most may be accessed to aid in the interpretation of diagnostic patients are relatively familiar with the use of microphones findings. and will be comfortable speaking into them. These benefits do not necessarily extend to other instrumental methods of voice analysis. THE VOICE DIAG~OSTIC PROTOCOL DEFINED The VDP provides the voice clinician with an array of Good Availability and Relatively Low Cost test procedures by which reasonableInc. and accurate diagnostic The equipment necessary for high-quality acoustic analy­ hypotheses may be made regarding the presenting voice sis is readily available to most clinicians for a relatively disorder. The VDP incorporates a wide range of analysis modest cost. The advent of low-cost multimedia computers methods (perceprual, acoustic, and selected physiological in recent years, in conjunction with the proliferation of methods) that meet the following criteria (Hirano, 1991): software for acoustic analysis, has made acoustic analysis PRO-ED, methods widely available. • They present minimum discomfort to the patient. • Theyby are noninvasive techniques. • In most cases, they require minimal amounts oftime to Correspondence with the Underlying Physiology ofVoice complete the procedure. Disorders • They provide relatively immediate test results. The acoustic signal is the by-product of phonation (the • They require minimum expense. oscillation of the vocal folds as determined by aerodynamicmaterial and myoelastic forces). Because the acoustic signal is deter­ The various procedures in the VDP are shown in Figure mined, in part, by movements of the vocal folds, "there is 1-1. a great deal of correspondence between the physiology and The VDP can be described as a method of voice profiling. acoustics, and much can be inferred about the physiology Voice profiling allows the clinician the opportunity to derive based on acoustic analysis" (Colton & Casper, 1996, p. 21). influences regarding the underlying anatomical and physi­ It must be noted that the relationships between phonatory ological starus ofthe phonatory mechanism (Bless & Hicks, physiology and acoustics are certainly not perfect. The voice 1996). An accurate profile of voice function requires the signal "is a complex product of copyrightedthe nonlinear interaction acquisition of multiple measures and observations derived between aerodynamic and biomechanical© properties of the from a wide range ofmethods. Several important reasons for voice production system" (Behrman & Orlikoff, 1997, p. this method of voice profiling are shown below. 10). Because this interaction is nonlinear, accurate predic­ tions regarding underlying phonatory physiology cannot • Bless and Hicks (1996) state that single tests or mea­ always be made on the basis of the acoustic signal alone. sures must be considered as part of a larger battery of However, when acoustic analysis results are placed within tests of vocal function. Diagnostic hypotheses should the context of a complete VDP, very powerful inferences not be made on the basis of one test or measure because may be made. "one cannot look at an isolated phenomenon without running the risk of misinterpreting results" (Titze, 1991 Good Applicability to Future Therapy in Bless & Hicks, 1996). • Colton and Casper (1996) believe that the most com­ Acoustic methods lend themselves well to both diagnostic plete information regarding the patient's vocal function­ procedures and treatment methods. It has been my experi­ ing cannot be obtained by means of only one or two Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 5

Assessment Areas of the VDP

Background Information Presession information Case history re: patient dysphonia -o Speech and hearing mechanism results (.) Pitch/Frequency o Perceptual determination (habitual pitch, pitch variability) .. Mean speaking Fa o Fa variability (Fo standard deviation/pitch sigma)Inc. t.. Fa range (total phonatlonal range and speaking a.. range) Loudness/Intensity (.) Perceptual determination (habitual loudness, loudness variability) -- Meanhnodal speaking IntensityPRO-ED, .. IntenSity range-phonetogram (f) by o "High-quiet" phonation Quality c Perceptual determination (primary quality deviations, instability, strain, diplophonia) en Quantitativematerial analysis of perturbation and noise Oitter, --CO shimmer, HNR) Duration-Respiratory/Phonatory Control C Perceptual determination (Including "five for five" testing and reading of a standard passage on one CD breath) Vital capacity (.) copyrightedMaximum phonation time -- © S/Z ratio o Phonation quotient

> Evaluation of Muscle Tension Dysphonia (MTD) Effects of laryngeal reposturing and massage CD Effects of sustained speech production (rapid .c counting) I-

Figure 1-1 Outline of the Tasks Incorporated into the mice Diagnostic Protocol 6 THE VOlCE DIAGNOSTIC PROTOCOL

procedures. "Each procedure adds to our understanding of nonnal voice production and the deviations that alter the nonnal state" (Colton & Casper, 1996, p. 197). • Kent, Kent, and Rosenbek (1987) state that "particularly when perfonnance is deficient compared to nonns, data should be taken from repeated trials, or other tasks should be used to complete the interpretative frame­ work" (p. 383). In addition, Kent et al. (1987) indicate that the relationship and consistency of test results within a category of testing may tell the clinician some­ thing about the type and severity of a disorder. • Gerratt and Kreiman (in Orlikoff et aL, 1999) state that acoustic measures of vocal quality may be accounted for by many physiological conditions and affected in similar ways by various types of laryngeal behavior and pathological conditions. This fact exemplifies the notion that acoustics must be part of a comprehensive Figure 1-2 Standard Recording and Playback Equipment Used diagnostic protocol that includes detailed case history in Voice Evaluation. (A) Speaker for Playback; (8) Amplifier; (C) infonnation, perceptual assessment, and physiological Cassette Deck; (D) Digital CompactInc. Cassette (DCC); (E) Preampli­ measures. fier Mixer; (F) Unidirectional Microphone. • Hirano (1991) notes that voice function is multidimen­ sional in nature, and, therefore, we need a set oftests to evaluate vocal function in its entirety. cassette, DAT (Digital Audio Tape), DCC (Digital Com­ REQUIRED EQUIPMENT AND MATERIALS FOR pact Cassette),PRO-ED, and MD (MiniDisc) decks do not have THE VDP microphone inputs. Therefore, the microphone can be inputby into the preamplifier mixer and then fed into the The following items are necessary to complete the various line input of the recording deck. In addition, a mixer is tasks incorporated in the VDP (see Appendix A): useful to input the signal into the computer. Although most sound cards have a microphone input, the line • A Pentium-level multimedia computer, incorporating input of the sound card often provides better quality Microsoft Windows 95 or higher (Microsoft Corpo­materialrecording (Huang, Lin, & O'Brien, 1995). Therefore, ration). A multimedia computer generally includes a the microphone would be plugged into the microphone 16-bit sound card and speakers necessary for the record­ input of the mixer, and the line out from the mixer ing and playback of speech samples. would be connected to the line in of the sound card. • Voice analysis software. Several of these packages are • A sound level meter (SLM). This is necessary to make available for use on a Windows-based Pc. Examples are measurements of vocal intensity. Most Radio Shack CSpeechSP (P. Milenkovic, Madison, WI); Dr. Speech stores carry low-cost SLMs in either analog (Model (Tiger DRS Inc., Seattle, WA); EZVoicePlus (VoiceTek 33-2050) or digital (Model 33-2055) models. The digi­ Enterprises, Nescopeck, PA); copyrightedand Multi-Speech Model tal display is often easier to read than the meter display 3700 (Kay Elemetrics Corp.,© Lincoln Park, NJ). All of the analog model. The SLM may also be used as these programs will use the sound card already installed a microphone by connecting its line out to the mixer in a multimedia computer for recording and playback. microphone input. When obtaining voice analysis software, make sure • A spirometer. This is necessary for measurements of that the program is able to provide perturbation and vital capacity and estimates of airflow. A number of noise analyses from sustained vowel samples, as well relatively low-cost hand-held models are available. as continuous speech analysis (some programs require • Stopwatch. add-on packages to provide all these analysis options). • Ruler (for measuring mouth-to-microphone distance). • A good quality microphone (unidirectional dynamic • Good quality cassette, OAT, or MD. Most voice record­ or condenser). Ideally, this microphone will have a ing in the VDP is done directly into the computer. In frequency response between 50 Hz and 15 kHz. fact, this is preferable because it removes possible det­ • Microphone preamplifier or mixer (see Figure 1-2). rimental effects of tape noise, multiple external amplifi­ This item is not a necessity but is useful because many ers, etc. However, in the event that a portable recorder is Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 7

necessary for voice recording away from the computer However, in the case ofdiagnostic testing as discussed here, (e.g., case history interviews that may take place in a the redundant addition of observations to our overall voice room different from that which houses speech/voice profile is done according to slightly different procedures. instrumentation), I suggest the use of a portable MD Redundant data are not collected as exact copies but as as­ unit. MD is a digital recording medium that provides sociations ofan underlying behavior or process. De Callatay many benefits over standard recording methods (no tape (1986) states, "Because there are slight variations in possible noise; no need for tape bias setting; no tape deteriora­ solutions, there will be an increase in the number of pattern tion; ability to index samples for immediate recall; recognitions, increasing the chances offinding a best choice" samples may be erased, combined, moved, named; up (p. 97). In this form ofredundancy, (1) a larger weight will be to 148 minutes of mono recording time on a single given in the development of clinical hypotheses to signs of disc). In addition, portable MD units generally contain a underlying behaviors that have been frequently repeated, and microphone input, removing the necessity for a pream­ (2) a more comprehensive view of the underlying behavior plifier mixer. A study by Winholtz and Titze (1998) in­ will be provided. dicated that MD units are more than adequate for voice Redundancy is used for improved development of clinical analysis purposes and do not introduce any significant hypotheses and for reliability (Le., repeatability) purposes. distortions into the record/playback process. However, redundancy in diagnostic testing does not have to be inefficient. Many of the redundant tests used in the The most expensive item in this equipment list will most voice diagnostic protocol are conducted on the same speech probably be the computer. However, because most clinical sample. As an example, the sameInc. continuous speech sample settings (hospital, school, private office) will already have may be analyzed perceptually and acoustically. In terms of access to a computer with multimedia capabilities, the actual acoustics, several different but associated procedures can be costs for the equipment used in the VDP are relatively low. conducted on the same recorded speech sample (e.g., com­ Figure 1-3 shows a standard equipment setup as may be putations of jitter, shimmer, and harmonics-to-noise ratio). used during voice diagnostic testing. Therefore, redundancy can be incorporated as a beneficial aspect of clinicalPRO-ED, decision making without impeding the THE BENEFITS OF REDUNDANCY efficient completion ofthe voice diagnostic. Voice profiling as conducted by means of the VDP in­ by corporates an extremely important facet of accurate diag­ KEY PARAMETERS FOR CONSIDERATION nostic decision making~redundancy. Most would consider BEFORE BEGINNING THE DIAGNOSTIC redundancy a form of inefficiency, in which procedures and SESSION observations are simply repeated in an identical manner. materialBefore beginning the voice diagnostic, the clinician must be clear on three particular parameters that will be evalu­ ated during the case history interview and throughout the diaguostic session:

• What is normal vs. disordered voice? • If a voice is disordered, how may we describe its sever­ ity? copyrighted • Once we have identified a disordered voice, what are © the primary voice disorder types by which we may categorize it?

Normal vs. Disordered Vocal Quality

To distinguish between normal and disordered behaviors, it is essential that we define our terms. Unfortunately, there is difficulty in actually defining what a normal voice is, even though most people, laypersons as well as profession­ als, are often able to identity voices that "sound different." Figure 1-3 Voice Recording Equipment Set Up Next to a Pentium­ This point was emphasized in a study by Anders, Holben, Level Personal Computer. Digitization and analysis of voice sam­ Hurme, Sonninen, and Wendler (1988), in which trained ples will be conducted by use of the computer. practitioners in clinical voice analysis (speech-language 8 THE VOICE DIAGNOSTIC PROTOCOL pathologists, speech scientists, phoneticians) and laymen voice signal and, most probably, has a significant effect on controls were asked to identify samples ofnormal vs. hoarse patient and listener alike. phonation and also rank the severity of the disordered sam­ Several methods have been described by which the sever­ ples. Anders et al. (1988) observed that the disordered sam­ ity ofvoice deviations may be described or quantified (Krei­ ples could be easily identified and ranked by trained and man, Gerratt, Kempster, Erman, & Berke, 1993): untrained groups alike-the hypothesis that training could 1. Categorical ratings: In this method, voice samples are enhance the accuracy of perceptual identification was not assigned to discrete categories such as mild, moder­ supported. ate, severe. Fex (1992) states that "normal voice quality is a concep­ 2. Equal-appearing interval (EAI) scales: The severity of tion based on subjective opinion, may vary with different a perceived voice characteristic is assigned a number cultures, and certainly is difficult to define; a vast number (most commonly between 1 and 7), with the higher of people are supposed to have normal but nevertheless numbers representing increased amounts ofperceived individually differentiated voice" (p. 155). So, what is it disruption in the voice signal. that the listener detects in the voice signal that allows for 3. Visual analog (VA) scales: Instead ofscaling the voice the discrimination between normal and disordered voice? by use of specified incremental levels of voice dis­ It appears that there are a number of characteristics (age, ruption (as in EAI scales), VA scales provide the gender, racial type, body size/type, etc.) that determine a judge with an undifferentiated line on which a mark range for normal voice type and quality. As we are exposed is placed to indicate the level of voice severity or to the range of normal voice types throughout our lives, we Inc. deviation. Only the extremes of the line are labeled gain experience as to the limits ofnormal voice and, thereby, (e.g., minimal vs. extreme). The use of this type of develop a mental scale by which normal is gauged. As long scaling procedure may be helpful in reducing bias in as a particular voice does not deviate substantially from the rating process. this internal gauge in terms ofparameters such as pitch, 4. Direct magnitude estimation (DME): In this method, a loudness, quality, and duration, it will be considered within number is assigned to indicate the degree ofvoice de­ the normal range. When a voice is perceived as deviating viation.PRO-ED, Numbers may be assigned in an unrestricted from the normal range, it may be characterized as being manner (i.e" any number possible) or restricted fash­ dysphonic. The term dysphonia literally means "abnormal/ by ion (anchored DME in which numbers are assigned difficult/impaired voice." in relation to a reference voice sample with a preas­ signed magnitude). METHODS FOR RATING SEVERITY OF 5. Paired comparison: Two voice samples are judged DYSPHONIA material as to the extent of difference on single or multiple dimensions ofthe voice signal. Having some definition by which we may distinguish normal from disordered/dysphonic voices, the clinician should also enter the diagnostic situation with some working Pros and Cons of Perceptual Assessment of knowledge ofbasic terminology by which we will categorize Disordered Voice our patient's characteristics and communicate them to others. Various methods have been described by which the se­ In each ofthe following chapters ofthis book, the reader will verity of a deviant voice type may be documented. How­ be introduced to definitions for primary voice characteristics copyrighted ever, there has been considerable controversy as to the over­ and disturbances that have been well established and can be all benefit and usefulness of perceptual assessment of the agreed on by most voice scientists© and clinicians. However, voice. An article by Orlikoff et al. (1999) presents various much of the difficulty in accurately defining the perceptual viewpoints dealing with the appropriate use of auditory­ attributes of the voice comes not in applying the categorical perceptual judgments ofvoice (and in particular, voice qual­ label but in accurately describing the severity ofthe observed ity) in the assessment of dysphonia. The pros of perceptual disorder. When we judge the severity of a disorder, we are assessment may be summarized as shown below. recognizing that the condition may exist along a continuum. This continuum extends in growing proportions from an • Perceptual assessment methods are available to all absence or minor amount of the observed deviant voice clinicians and may provide a global measure of characteristic to an extreme amount. The lower end of this vocal performance. continuum should probably be best acknowledged as being a • Perceptual judgment and assessment are of primary "minimal" level, because even normal voice signals are not relevance to most voice patients. The patient is often necessarily perfect. On the other end of the continuum, an most concerned with how others perceive hislher extreme level of voice deviation may overpower the normal voice. Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 9

• The perceptual severity and quality of the voice are The variability in ratings may be due to several factors: often the impetus for the voice evaluation in the first place and, therefore, must be confirmed, evaluated, • The severity of the perceived voice disturbance may and described by the clinician. affect intra-judge and inter-judge reliability. Kreiman et • Perceptual rating is the "gold standard" for assess­ al. (1993) have observed that quality ratings vary more ing the clinical relevance of subsequent acoustical for pathological than normal voices and more for mid­ analyses. scale voices (i.e., mild to moderate voice disturbances) • Perceptual judgments provide a comprehensive im­ than for voices at scale extremes (i.e., normal or severe pression of the voice that includes aspects of voice voices). not captured by acoustic measures. • The type of scaling procedure used may result in vari­ • Perceptual judgments are important in determining ability in ratings, with EAI scale ratings observed to the ultimate success or failure of voice therapy. produce more drift in test-retest comparisons than VA scales. Unfortunately, a number of factors are involved with the • Because judges are exposed to more and different ex­ perceptual assessment of the voice that may make the pro­ amples of voice productions, their internal gauge of cess nebulous (Murry, 1982) and error prone. The cons of what defines normal versus disordered may change, perceptual assessment of the voice may be summarized as resulting in a lack of precision in their test versus retest shown below (Orlikoff et aI., 1999). ratings of voice quality. It should be recalled that reliabilityInc. does not ensure valid­ • Perceptual assessment of the voice appears to be af­ ity of measurement procedures but is a necessary prerequi­ fected by problems of scale validity and reliability. site for validity (Schiavetti & Metz, 1997). Therefore, the • Perceptual assessment does not provide an aware­ aforementioned factors affecting reliability of perceptual ness of the physiological details that result in the assessment also contribute to the next section dealing with acoustic product. factors that affect the validity of perceptual assessment of • Perceptual quality may be difficult to characterize the voice. and communicate in terms of quantified results and, PRO-ED, therefore, may not be as credible as numerical test Validityby procedures. In this regard, results of perceptual as­ The validity of a test procedure refers to the ability to sessment may not be sufficient for medicolegal pur­ measure what we intend to measure. Validity implies a sat­ poses. isfactory and consistent definition or set of definitions for the characteristic behavior we are attempting to measure or Although more pros than cons have been presented,material the rate. In terms of perceptual assessment of the voice, if the possible deficiencies in the perceptual assessment process characteristics we are attempting to identify and rate are are important for us to consider in more detail. In particular, poorly defined, defined differently from person to person, we will focus on a discussion of the reliability and validity or have shifting definitions, then validity will be affected issues involved with perceptual assessment of the voice. in addition to reliability. Several issues possibly affecting Reliability the validity of perceptual judgments of the voice may be summarized as follows: Reliability ofan assessment procedure focuses on the abil­ ity to repeat one's measurements orcopyrighted observations. The ability • Quality judgments that attempt to rate the severity of to repeat measurements is directly© related to the precision the voice deviation are characteristically poorly defined. and accuracy of measurements (Schiavetti & Metz, 1997). Although it is common for working definitions or ex­ Kreiman et al. (1993) provide a comprehensive review of amples to be provided for scale anchors (normal and studies that have been concerned with the assessment of severe), there is generally little or no definition provided speech and voice quality. Their review indicates that, al­ for the mid-scale ratings. With this in mind, it is no though average levels of intra-judge and inter-judge reli­ wonder that mid-scale ratings have been seen as the lo­ ability are generally high, average reliability measures tend cation of greatest variability and disagreement between to mask considerable variability in perceptual judgments. judges rating voice quality (Kreiman et aI., 1993). In addition, the use of correlational statistics to substantiate • Quality judgments that are unidimensional in nature the presence of reliability only indicates that judgments may have poor content validity because they do not (whether intra-judge or inter-judge) may vary in a consistent account for the multidimensional nature of voice. It manner; they do not necessarily indicate that judgments are has been said that, "The voice is a multi-dimensional in agreement (i.e., judgments were exactly the same). phenomenon, comprised of a number of elements that 10 THE VOICE DIAGNOSTIC PROTOCOL

contribute to overall voice quality and voice effective­ ment terms and (2) variation in experience of the listeners. ness" (Orlikoff et aI., 1999, p. 90). Hammarberg, Frit­ These factors may be seen to change the calibration of the zell, Gauffin, Sundberg, and Wedin (1980) showed that judge on test-retest measurements or to affect the similar samples of pathological voices could be perceptually calibration of different judges (remember that calibration summarized in terms of five bipolar factors: (l) unsta­ can refer to observers or scorers in addition to machines/ ble-steady, (2) breathy-overtight, (3) hyperfunctional­ instruments). These changes in calibration produce changes hypofimctional, (4) coarse-light, and (5) head vs. chest in the obtained measurements (Le., voice ratings) (Campbell register. Gelfer (1993) indicated that five dimensions & Stanley, 1966). Both validity and reliability may be af­ of the voice signal accounted for the similarity or dis­ fected by changes in calibration. similarity of normal female voices. The perceptual cor­ relates of the five dimensions were: (I) perceived pitch, HOW TO DO IT: RATING DYSPHONIC SEVERITY (2) perceived loudness, (3) perceived age and rate, (4) variability in perceived pitch, and (5) perceived voice Perhaps the challenge in selecting a method of per­ quality. With this in mind, rating the voice by use of ceptual assessment of voice quality is to find one that is a single scale factor (e.g., "roughness") may not ac­ complex enough to portray the multidimensional nature count for other key voice characteristics that should be of voice quality deviation and yet be understandable included in the description. enough that (1) clinicians may easily learn and use • In addition to various voice characteristics, our percep­ the system with limited training, and (2) results may tual measurements may be swayed by other extraneous be communicated easily amongInc. colleagues and other sources. For example, severity of vocal roughness may professionals. This book proposes that the severity of be influenced by coexisting hypemasality or some other a particular voice disruption (pitch, loudness, quality, nonvoice source information (de Krom, 1994). etc.) be rated on a 7-point categorical/EAI rating scale ranging from a to 6. A a rather than a 1 is suggested as Overall, two key factors can be seen that may be the the lower anchor of the scale to represent the absence sources of reduced validity and reliability in perceptual as­ or minimal PRO-ED,nature of the perceived voice disorder. (See sessment ofthe voice: (1) variation in definition for measure­ Appendix B.) by

Normal Mild materialModerate Severe Extreme

I Minimal I I Aphonic* I

*Lack of phonation-may be due to extremes of hypofunction or hyperfunction.

copyrighted ©

Within this scale, certain pOints (1, 3, 5) are labeled amount of variation in definition from person to person. with the commonly used severity terminology of mild, Of course, lack of agreement in definition is one of moderate, and severe. These are our severity catego­ the key elements that results in reduced reliability and ries, which are ranked on an EAI scale of increasing agreement in perceptual judgments of voice quality. magnitude. These terms are freely used by speech Review of the voice literature finds very little in terms of pathologists to describe various disorders. Yet, the next definition for these commonly used severity terms. It is time a colleague uses one of these terms or you use common that definitions are provided for the end points one yourself, ask yourself, "What does mild, moderate, of the severity continuum, but not for the intermediate or severe really mean?"You will probably find (1) great points. As an example, de Krom (1994) describes a difficulty in defining these terms and (2) a substantial 1a-point EAI scale in which the left side of the scale Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 11

(number 1 in this example) represented "not present causes phonation to be mainly absent or extremely ef­ at all," and the right side of the scale (number 10) fortful. represented "maximally present." Askenfelt and Ham­ marberg (1986) used a 5-point EAI scale, with 0 repre­ The clinician is encouraged to closely compare the per­ senting no deviance and 4 representing a high degree ceived abnormal voice characteristic(s) to all parts of these of deviance from normal. In studies using both 7-point definitions. It may be that a disordered voice does not show EAI scales and VA scales, Kreiman et al. (1993) only all the characteristics mentioned under each definition, or provide definitions of the end points of each scale it may show characteristics crossing definitions. In these (e.g., "not rough at all" versus "extremely rough"). It is cases, intermediate ratings (e.g., mild-to-moderate) may this lack of definition, particularly for the intermediate be appropriate. In addition, certain dysphonia types (e.g., pOints of the severity continuum, that contributes to inappropriately high pitch) may be considered abnormal but the increased variability and decreased reliability and not necessarily disrupt the ability to phonate. agreement in perceptual ratings. Kreiman et al. (1993) It can be seen that these severity definitions emphasize confirm the variability or ratings in the midrange of the noticeability and communicative effectiveness of the vocal quality scales and conclude that "If the quality to patient. These factors get to the heart of what may be con­ be rated is poorly defined or lacks perceptual reality, sidered "abnormal" voice production. As previously stated, listeners will not be able to rate it consistently" (p. 32). the degree of deviation from our internal gauge of what normal voice should be is one ofthe key factors that signals Severity Terminology Defined the disordered voice. Therefore,Inc. in the severity definitions presented here, we range from a barely noticeable deviation It seems that one ofthe major problems in judging voice is (mild) to one that is so extreme (severe) that the normality its multidimensional nature. Voice is composed of numerous of the voice signal is overwhelmed. In addition, these sever­ characteristics that may be weighted differently by different ity definitions take into account the overall effects on com­ judges (de Krom, 1994; Higgins, Chait, & Schulte, 1999). munication. As the voice deviation becomes more notice­ As an example, while listening to the same disordered voice able, communicationPRO-ED, between the speaker and the listener sample, one judge may be focusing on aspects of pitch, will become increasingly impeded. The listener becomes so whereas the other puts more emphasis on vocal quality. In distractedby by the voice deviation that he or she has trouble addition to the perceptual characteristics ofthe voice, sever­ focusing on and processing the underlying linguistic mes­ ity definitions should also take into account "the impact the sage. Orlikoff et al. (1999) agree that it is especially impor­ voice problem may have on the speaker's ability to commu­ tant that the attention ofthe listener is not deviated from the nicate and obtain employment" (Higgins et al., 1999, p. 103). content ofthe message by a "disturbing voice quality." Prater The following severity terminology attempts to incorporatematerial and Swift (1984) indicated that judgments of intelligibility a number ofthe possible diverse effects of dysphonia. should be made in addition to judgments of voice severity and aesthetic quality. Andrews (1995) also includes effects • Mild: Although the listener experienced in the per­ on intelligibility in her definitions for mild, moderate, and ceptual characteristics of the disordered voice would severe ratings for vocal tremor. Although the listener is af­ consider the voice abnormal, the untrained listener may fected by the presence of a voice disorder, the speaker also consider the voice to be only unusual in nature and may have increased awareness ofthe difficulty in communi­ within normal expectations. The voice characteristic is cating and attempt to compensate for the deficit in various not distracting, and the abilitycopyrighted to effectively communi­ ways (behavioral, psychological, social, etc.). Overall, we cate is not affected. The© dysphonia does not interfere have the development of a handicapping condition (Haynes with phonation. et aL, 1992) in which the lack of communicative effective­ • Moderate: Both trained and untrained listeners would ness begins to have a significant impact on the patient's day­ consider the voice abnormal. There may be intermit­ to-day activities. tent periods in which the voice characteristic is highly To account for the multidimensional view of voice pro­ distracting. The ability to effectively communicate is duction that appears to be so important in describing overall noticeably affected under certain conditions (e.g., noisy voice character and effectiveness (Gelfer, 1993; Orlikoff environments). The dysphonia may occasionally cause et al., 1999), these severity definitions will be applied to phonation to cease or become highly effortful. all key characteristics of the voice signal (pitch, loudness, • Severe: Both trained and untrained listeners would quality, and duration). As an example, we may state that a consider the voice extremely abnormal. The voice char­ patient has a "mild dysphonia characterized by abnormally acteristic is highly distracting. The ability to effectively low pitch and breathiness." The severity term (in this case, communicate is consistently affected. The dysphonia mild) describes the effect of the voice disorder on both 12 THE VorCE DIAGNOSTIC PROTOCOL listener and speaker-the supporting statements (pitch, qual­ voice; limited pitch range and variability; consistent/ ity, etc.) will emphasize the primary characteristics that dis­ stable voice dysfunction. This patient also typically tinguish this patient's dysphonia. The result is a composite has a nonnal laryngoscopic examination and no sig­ definition (Bless & Hicks, 1996) that accounts for commonly nificant associated symptoms. observed voice signal deviations in addition to factors such -Type 4. Voice Abuse: This patient reports chronic as consistency, noticeability, and effects on communication. voice problems, although dysphonia may be intennit­ tent. Vocal abuse or misuse characterized by over­ VOICE DISORDER TYPES use, inappropriate pitch level, and use of excessive muscle tension are common characteristics. Pain Having identified a possible dysphonia and assigned it or discomfort in the laryngeal region that worsens a severity rating, the clinician should also fonn a working with increased voice use may be reported. Laryngos­ hypothesis regarding the type of voice disorder that the copy may be nonnal or show a secondary pathologi­ patient may have. Traditionally, voice disorders have been cal condition. Voice quality is variable; the patient separated in two main groups. may initiate voicing with abrupt onsets (hard glottal attack). Functional Voice Disorders -Type 5. Postoperative Dysphonia: This patient re­ ports dysphonia after an operation. Laryngoscopy Commonly, the tenn functional dysphonia has been used may be nonnal or show ventricular fold compression, to describe those voice disorders in which dysphonia was ulcers, or granulomas. Presence ofpain or discomfort observed in the absence of organic pathological condition. Inc. in the laryngeal region and voice characteristics are However, the tenn "functional" has been challenged as being similar to the Type 4 patient; however, ventricular vague, with relatively little agreement on criteria by which fold use may be prominent in this patient. inclusion into the functional dysphonia category is made • Boone (1980) stipulated that functional dysphonias (Goldman, Hargrave, Hillman, Holmberg, & Gress, 1996). were those in which the voice problem was "related Numerous varied opinions on what defines this type ofvoice to faulty vocal fold approximation" (p. 315) in the disorder are found below. PRO-ED, absence oforganic disease. Patients who were seen with • Koufman and Blalock (1982) believed that functional dysphoniaby but nonnal vegetative function of the larynx dysphonias are primarily due to abuse and misuse of (e.g., nonnal coughing, throat clearing) were referred a nonnal laryngeal mechanism, with prolonged abuse to as psychogenic. resulting in the development ofconditions such as nod­ • Boone and McFarlane (1988) indicate that the patient is ules, polyps, ulcers, or granulomas of the vocal folds. directly responsible for a functional dysphonia by using However, it is characteristic that the observed dyspho­materialthe laryngeal mechanism in a faulty manner. In these nia is disproportionately poor compared with the status cases, the patient "may approximate the vocal folds in of the laryngeal mechanism. From a review of 52 func­ a lax manner," "in a tight manner," "or shut the voice tional dysphonia patients, these authors delineated five off by bringing the ventricular folds together" (p. 52). types of functional dysphonia: In addition, the patient is often observed to have nonnal -Type 1. Hysterical AphonialDysphonia: This type laryngeal structures, although "complete supraglottal is distinguished by a sudden onset often associated shutoff (ventricular and aryepiglottic fold adduction)" with a distinct precipitating event. The patient typi­ (p. 53) is often observed. cally has a nonnal laryngoscopiccopyrighted examination, no • Aronson (1990a) sees "functional" as synonymous with significant associated symptoms,© and no history of "psychogenic:' with all associated voice problems at­ prior .laryngitis. Voice is characterized by aphonia or tributable to some underlying "psychoneuroses, per­ whisper, limited pitch range, and variability ("pitch­ sonality disorders, or faulty habits of voice usage" (p. locked" p. 372); consistent/stable voice dysfunction. 8). In addition, Aronson (l990a) believes that the tenn 2. Habituated Hoarseness: This patient reports "psychogenic" has "the advantage of stating positive­ persistent hoarseness usually after a preceding bout Iy ...that the voice disorder is a manifestation of one ofviral laryngitis. The patient typically has a nonnal or more types of psychological disequilibrium, such as laryngoscopic examination and no significant associ­ anxiety, depression, conversion reaction, or personality ated symptoms. Voice is characterized by breathy, disorder, that interfere with nonnal volitional control raspy, diplophonic quality; limited pitch range and over phonation" (p. 121). variability; consistent/stable voice dysfunction. • Unlike Aronson (l990a), Morrison and Rammage -Type 3. Falsetto: This patient reports a sudden or de­ (1993) do not believe that "functional" and psycho­ velopmental onset with an abnonnally high-pitched genic" are synonymous. These authors describe a sub­ Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 13

type of functional dysphonia that they refer to as in a review of the personality and psychological char­ "muscle misuse voice disorders" (MMVDs, p. 428). acteristics of 25 female functionally dysphonic (FD) MMVDs may be associated with factors such as misuse patients. The overall conclusion by Roy et al. (l997b) of extralaryngeal musculature, poor laryngeal posture was that FD patients "display an array of problems and misalignment, poor coordination between respi­ including multiple somatic complaints, diffuse anxiety, ratory and phonatory functions, and excessive or in­ and dysphonia" (p. 449). adequate laryngeal valving. The term "psychogenic" disorder is associated only with those functional dys­ On the basis of the aforementioned opinions, functional phonias in which the observed dysphonia is a direct voice disorders are those voice disorders in which (I) the result of a psychoemotional origin as documented by patient's use ofthe voice mechanism is the underlying cause means offormal psychological testing. of the voice problem(s), and (2) the laryngeal mechanism • Peppard (in Stemple, 1993) indicates that certain types appears normal or shows the development of a secondary offunctional dysphonias may be related to altered feed­ pathological condition (i.e., a pathological condition that back mechanisms (e.g., hearing impairment). has developed because of the patient's abuse/misuse of the • Titze (1994) states that functional dysphonias may be larynx). The faulty use of the laryngeal mechanism may be related to improper use of the voice, although "some related to separate or combined factors of habituated muscle prefer to label all functional dysphonias as idiopathic, tension and vocal inefficiency, compensatory behaviors, indicating that there is no known cause" (p. 307). andior psychological stress. In effect, the patient's use of the • In a review of functional dysphonias in adolescents, vocal mechanism has resultedInc. in the dysphonia-its origin Peppard (1996) implies that cases of functional dys­ is not attributable to some underlying physical or disease phonia (such as functional aphonia or puberphonia) process. are caused by inappropriate use/misuse ofthe larynx­ "These two non-organically based voice pathologies involve the use by adolescents of relatively simple, Organic Disorders often less efficient, modes of phonation" (p. 258). In PRO-ED, addition, Peppard (1996) believes that not all functional Compared with functional disorders, the definition of dysphonias have a psychogenic base, because "some an organicby voice disorder seems to be relatively clear-cut. cases ... may be the result of habituated patterns that, Organic voice disorders are those in which the underlying although inappropriate, were not caused by some un­ cause is a specific lesion affecting the laryngeal mechanism derlying psychogenic disorder" (p. 259). According itself or within the neuromotor pathways serving the pho­ to Peppard (1996) key characteristics associated with natory mechanism. An underlying physical disruption is functional dysphonia are (1) complete aphonia withmaterial responsible for the observed dysphonia, not faulty voice use. very little attempt or struggle to produce phonation, Commonality in definition for this term is reflected in the (2) little or no indication of effort, and (3) relatively following statements: normal prosodic patterns. Similar to the report ofBoone (1980), Peppard (1996) also reports that substantial • Boone (1980) states that organic problems are "related discrepancies between speaking and vegetative voice strictly to organic disease or structural problems" (p. use are often observed. In conclusion, Peppard (1996) 319) . states that functional dysphoniacopyrighted in adolescents may • Boone and McFarlane (1988) identify organic disorders originate from psychogenic causes, efforts to cope with as those in which "the faulty voice is usually related other communicative disabilities,© andior an habituated, more to a physical condition than to a vocal abuse­ inefficient manner ofvoice production. misuse per se" (p. 64). • The multifactorial origins offunctional dysphonia were • Titze (1994) states that "organic voice disorders are stressed by Roy, Bless, Heisey, and Ford (1997a), who those for which a specific lesion can be identified in state that, "a disordered voice in the context of a struc­ some organ of the body" (p. 307). turally normal larynx is the product ofa complexiblend of psychological, social, and physiological factors" (p. Although the underlying physical disruption is key in 322). identifying organic disorders, it must be remembered that • Roy, McGrory, Tasko, Bless, Heisey, and Ford (1 997b ) the effects of the physical lesion extend beyond perceptual state that, "functional implies a disturbance of physi­ and acoustic consequences. Bless and Hicks (1996) observe ological function rather than in anatomical structure" that "organic voice problems are multifarious" with effects (pp. 433-444). However, the heterogeneous nature of that are "biological, psychological, and sociocultural" (p. functional dysphonia was observed by these authors 120). 14 THE VOICE DIAGNOSTIC PROTOCOL

Alternative Categories Presession The terms functional versus organic are not necessarily Information completely separate entities, because organic disorders can result in improper voice use, and improper voice use can 1 result in organic lesions (Titze, 1994). For reasons such Basic Identifying Information as this, several authors have chosen to categorize voice General Medical History disorders in alternative categories rather than adhere to the traditional functional versus organic distinction as shown Results of Laryngological below. Examination

• Weinberg (1983) categorizes voice disorders in terms of (1) abuse/misuse of the larynx; (2) voice disorders re­ Key Areas of sulting from organic disease, physical trauma, or struc­ Case History tural change; (3) voice disorders resulting from psycho­ Questioning genic factors; and (4) undetermined causes. 1 • Titze (1994) prefers to classify voice problems in terms The Nature of the Problem of (1) congenital (structural) disorders; (2) disorders related to tissue change; (3) disorders related to neuro­ DevelopmentInc. of the Problem logical or muscular change; and (4) vocal fatigue. • Verdolini (1994) distinguishes between physical (or­ Variability and Consistency ganic) and not strictly physical (nonorganic) causes. Within this framework, Verdolini (1994) categorizes Description of Voice Usage voice disorders in terms of (1) discrete mass lesions of Effects of Dysphonia on the Patient the vocal folds; (2) voice disorders caused by distrib­ PRO-ED, uted vocal fold tissue changes; (3) organically based Current Health movement disorders; and (4) nonorganically based dis­ by orders. Possible Causes

ogical Screening OUTLINE FOR THE CASE HISTORY SESSION

Having reviewed the basic approach to voice diagnosis, materialSpeech and Hearing equipment preparation, and definitions ofkey parameters by Mechanism which we will describe the disordered voice, we are now Examination ready to begin the diagnostic process. Figure 1-4 presents a 1 flowchart summarizing the key elements of the case history Focus on Laryngeal Function session. The VDP starts with the gathering ofbackground informa­ Hearing Evaluation tion and significant information regarding the patient's pos­ sible voice problem(s) in the casecopyrighted history interview. The Figure 1-4 Flowchart Outlining the Key Areas of Information following are a number ofkey ©areas that should be explored Regarding Possible Voice Dysfunction Obtained from the Patient's with the patient. Wherever possible, it is best to incorporate General Background, Case History, and Speech and Hearing Mech­ these issues into a conversation with the patient/caregiver anism Examination rather than in a "form-filling" exercise. In addition, the clini­ cian will follow the interview with an examination of the speech and hearing mechanisms to identify any significant characteristics ofform or function that may be related to the access to information about the prospective patient may be patient's voice deficits. affected by the particular setting in which one works, with the range ofinitial information extending from simple refer­ Presession Information ral slips with next to nothing in terms of information about the patient's condition to extensive information obtained Before seeing the patient, it is generally advised to obtain from medical charts and reports. It must be kept in mind that as much background information as possible. Immediate background information can present something of a double­ Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 15 edged sword to the clinician. On one hand, background A review of most general case history fonns reveals many infonnation allows the clinician to develop initial hypotheses areas of questioning that often have no significance to the regarding the patient's condition and underlying deficits. On current patient or the presenting voice disorder. The clini­ the other hand, the clinician must be wary of being biased cian must not waste time with this material. The clinician toward a particular clinical hypothesis before the actual must select key areas of questioning that are pertinent to collection of patient signs and symptoms has taken place the possible disorder at hand and should always be prepared in the diagnostic session. Clinical bias refers to factors that to answer why they are asking certain questions. This is may predispose the clinician to select a particular diagnosis especially important in certain sensitive areas of health his­ regardless of the actual data observed. The clinician must tory (e.g., sexual development, illicit drug use). balance the possibilities presented by background infonna­ tion with the realities of the actual diagnostic session. The The Need for Laryngeal Examination Information background infonnation should spur the clinician on to develop clinical hypotheses, carry out any necessary re­ In voice disorders, the underlying laryngeal structures search regarding the patient's condition before evaluating may appear nonnal (as in many functional disorders), the patient, and prepare any special tests that may need to be show the presence of discrete or distributed benign lesions carried out (e.g., although we are focusing on voice evalua­ (e.g., nodules, polyps), or be affected by conditions that tion, voice disorders may coexist with other communicative have significant, even life-threatening, effects on the pa­ deficits that may also need to be evaluated). However, the tient's overall health (e.g., progressive neurological disease, clinician must always be prepared for the possibility that the carcinoma).Unfortunately, allInc. these conditions may have patient may have characteristics that are quite different than quite similar perceptual and acoustic characteristics. Colton background infonnation has led us to believe. and Casper (1996) demonstrate this fact quite effectively in their reviews of voice disorders related to abuse/misuse, ner­ Basic Identifying Information and General Medical vous system involvement, and organic disease and trauma. History The same perceptual and acoustic signs of hoarseness, in­ creased perturbationPRO-ED, levels, and increased spectral noise are Before the case history interview, the patient should be reported for disorders as diverse as laryngeal carcinoma, given a general case history fonn to fill out. Numerous ex­ unilateralby vocal fold paralysis, laryngitis, and vocal nodules amples of these fonns are available; however, in using these (Colton & Casper, 1996). Peppard (1996) also reports the fonns, the clinician is primarily interested in documenting same perceptual and acoustic signs as possible characteris­ two aspects ofthe patient's history that do not and should not tics of functional dysphonia (with apparently nonnal laryn­ have to be discussed at length in the interview setting: ges in most cases). Of course, perceptual and acoustic signs materialmust be interpreted in light of significant infonnation regard­ 1. Identifying infonnation (name, age, date of birth, ing the patient's health, vocational/social/recreational voice address, physician name, and contact infonnation, use, etc., obtained by means of the case history interview etc.) and medical background. However, the point is clear that the 2. General medical background; developmental history voice clinician (particularly one with relatively little experi­ (in the case of a child patient). ence) could easily mistake a potentially life-threatening voice problem for one that is functional in nature. With this It is strongly suggested that the patient (or caregiver) fill in mind, I believe that it is essential that referral be made out this general case history fonncopyrighted before the interview. The to an otolaryngologist for all voice-disordered cases, with general case history fonn can© be reviewed by the speech­ particular emphasis on those in which voice quality devia­ language pathologist and, if necessary, key infonnational tions are primary characteristics. The referral should occur, points pertinent to the patient's voice disorder can be brought ideally, before the voice diagnostic session but definitely up for clarification in the interview session. The voice clini­ before initiation of any voice therapy. cian is encouraged to carry out a conversation with the Several authors have made valuable comments on the patient regarding the key areas of case history questioning topic of when and why referral to the otolaryngologist and not tum this into a fonn-filling exercise. It has been my should take place; these are found below. experience that a clinician paying more attention to fonns than to the patient appears amateurish. A clinician who ap­ • Weinberg (1983) described the importance ofthe laryn­ pears comfortable with the fonn and content of the case geal examination in identifying the possible cause of history interview will be viewed with greater confidence by the voice problem, detennining the need for medical the patient; with greater confidence, the patient will be more treatment, and identification of physical factors that willing to impart infonnation to the clinician. may limit voice change with treatment. The impor­ 16 THE VOICE DIAGNOSTIC PROTOCOL

tance of this referral was emphasized by stating that speech-language pathologist for diagnostic purposes. The "a(n) ... essential part of the diagnostic process for all primary identification and treatment of laryngeal pathologi­ patients with voice disorders is the completion of a cal conditions are the clear responsibility of the laryngolo­ general examination of the head and neck, including gist (Boone & McFarlane, 1988). The speech pathologist the larynx" (p. 159). should review the laryngological examination report for a • Boone and McFarlane (1988) defer voice therapy until specific medical diagnosis, description of possible underly­ after medical examination because voice therapy may ing organic pathological condition, and physician recom­ be contraindicated in some cases (e.g., papilloma, car­ mendations. Although the laryngeal examination report will cinoma). "In such cases, the delay of accurate diagnosis (generally) provide a diagnostic label for the patient's condi­ ofthese pathologies could be life-threatening" (p. 80). tion, this does not eliminate the need for the voice diagnostic • Haynes et al. (1992) emphasize the medical-legal impli­ by the speech-language pathologist. Effective voice therapy cations and benefits of medical referral. These authors recommendations will be made primarily on the basis of the state that "the need for medical diagnosis cannot be detailed description ofthe patient's voice characteristics and overestimated because ofthe lifelhealth implications for voice use described in the speech-language pathologist's the client, the legal implications for the practicing clini­ diagnostic report. cian, and the requirement of third-party reimbursement agencies that services provided be medically necessary" The Nature of the Problem (p.285). • Verdolini (1994) states a preference for otolaryngo­ It is suggested that the clinician start the diagnostic inter­ logical referral for every voice patient seen. However, view with a general open-endedInc. question such as "What "adults older than 50, primarily men, who are hoarse can I do for you today?" or "Can you tell me why you are or who have any change in voice for a period of two here today?" Several reasons exist for this type of opening weeks or more that cannot be reasonably explained ... question: are clearly at risk and should be referred to an otolaryn­ gologist immediately" (p. 290). I. A general open-ended question provides the patient • In particular reference to child patients, Case (1996) with PRO-ED,the opportunity to describe the possible voice states that "any child with a voice disorder stemming problem(s) in his or her own words. If the clinician from abnormal functioning of the vocal folds that pro­ bybegan the interview with a closed statement such duces a difference in voice quality, or in any way makes as "I see here that you have had a hoarse voice," breathing difficult should be evaluated medically before the result would quite possibly be (I) a very limited management by a speech-language pathologist" (p. 72). response from the patient (perhaps even a single word Case (1996) also stresses that "it is better to err on the response) and (2) possible clinician and patient bias side of over-referral" (p. 73) rather than nonreferral,material (the clinician is expecting a certain response, whereas particularly in the situation of the relatively inexperi­ the patient may feel that he or she should provide the enced voice clinician. expected response). • Even in cases of suspected functional dysphonia (voice 2. Colton and Casper (1996) have said that patients are disorders in which there is no apparent underlying or­ often quite accurate in describing their problems. ganic pathological condition and the vocal mechanism Therefore, we must allow the patient the opportunity appears normal), Peppard (1996) stresses that "ethical and time to describe the problems he or she has been practice requires that before anycopyrighted management of voice experiencing. pathology is started, an otolaryngologist© skilled in la­ 3. As the patient is speaking, the clinician is provided ryngeal examination and voice disorders must perform a with (1) the first opportunity to observe some of thorough (laryngeal) examination to rule out any possi­ the perceptual characteristics of the voice and (2) ble organic base for the voice disorder" (pp. 259-260). a chance to begin verifying some of the patient's complaints (both verbal and what may have been A complete laryngological examination should involve reported in referral statements). Patient complaints detailed medical history, head and neck examination, and are referred to as symptoms. One of the primary goals visual examination of the larynx, with the final result being of the voice clinician is to verify as many patient a medical diagnosis of the problem and recommendations symptoms as possible. Once symptoms are verified for treatment (Stemple, 1993). Although some speech-Ian­ (i.e., directly observed by the clinician), they become gnage pathologists have acquired skills in laryngeal exami­ signs (Colton & Casper, 1996). Perceptual judgments nation techniques such as mirror laryngoscopy and video­ regarding the patient's voice characteristics are often stroboscopy, laryngoscopic methods must not be used by the the first signs collected by the clinician during the Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 17

voice diagnostic~the initial descriptions of the pa­ answer. The clinician has responded with a follow-up ques­ tient about his or her voice problem(s) provide an tion that guides the patient to a more descriptive answer that excellent opportunity for these observations to take verifies the probable presence of a voice disorder. In the place. event that the patient is still unable to provide a reasonable 4. As the patient is speaking, the clinician is also pro­ description ofthe problems he or she has been experiencing, vided with the opportunity to visualize characteris­ it is also useful to ask if the way the voice sounds today (Le., tics that may be accompanying the patient's speech! during the interview) is the way the voice sounds when he voice characteristics. These characteristics may in­ or she is having the voice problems. Ifnot, ask the patient to clude excessive tension in the extralaryngeal region, demonstrate the disordered voice. limited oral movements, and rigidity in the mandibu­ In addition to the nature ofthe patient's voice problem, ob­ lar region. servation of other patient symptoms (i.e., associated symp­ 5. The clinician may start to get some inclination regard­ toms) may provide important information in reaching an ing the patient's personality traits and their possible appropriate diagnosis. Changes in associated symptoms over relationship to the perceived voice characteristics and time may also be indicators of change in response to treat­ patient symptoms. ment (Colton & Casper, 1996). A number of neurological and stress-related symptoms may be associated with factors This initial aspect of the voice diagnostic interview is such as type of voice disorder and onset: often described as an assessment ofthe nature ofthe problem • Dysphagia (i.e., what is the problem and what are its characteristics). • Nasal regurgitation of foodInc. and liquids The patient's description of the characteristics of his or her • Weakness (either bilateral or unilateral) in other parts voice problem(s) allows "the clinician to better understand of the body the disorder as the patient sees it" (p. 28, Prater & Swift, • Neurologically related speech and language deficits 1984). In many cases, the patient's description of the voice • Characteristics of increased musculoskeletal tension problem (e.g., "My voice has had a raspy sound to it for the • Increased fatigue last few weeks"; "It gets hard to speak at the end ofthe day.") • HeartburnPRO-ED, will correspond closely to the perceptions of the clinician. • Dryness in the mouth and throat However, other cases may show a lack ofagreement with the by views of the speech-language pathologist, with discrepan­ After initial questioning about the nature of the voice cies caused by factors such as (l) patient misunderstanding problem at hand, the patient must also be questioned in ofthe problem (i.e., reflecting a possible lack ofawareness of several other key areas so that a complete description of the disorder), (2) an inability of the patients to deal realisti­ the presenting patient and his or her voice deficit may be cally with their voice deficits (Prater & Swift, 1984), ormaterial (3) acquired. intermittent voice problems with variable characteristics that may not be in evidence at the time ofthe interview. Development ofthe Problem It is hoped that the voice clinician is presented with a One of the most natural questions after the description of patient who is willing to impart information regarding the the initial complaint is "How long have you had this prob­ voice problem(s) relatively freely. However, some patients lem?" or "When did you first notice your voice problem(s)T' will require various cues so the nature of their deficits may The description of the onset of the voice disorder can be an be grasped. As an example, see below. essential component of case history for both diagnosis and copyrighted prognosis (Prater & Swift, 1984). The onset of the disorder Clinician: "Can you please© tell me why you are here may be characterized in terms of (I) long duration, gradual today?" (general, open-ended question) onset versus (2) those with sudden onsets. Voice disorders Patient: "I have been having trouble speaking lately." that have developed over a relatively long time generally do Clinician: "Do you have trouble with the way your not have a specific date of onset that the patient can recall. speech sounds or in finding the right words to say?" Various types of voice disorders (organic and functional) (Focused, leading question) may develop over weeks, months, or years. Types of voice Patient: "With the way it sounds." disorders that may have a gradual onset are progressive Clinician: "Can you describe for me how your voice neurological diseases and most laryngeal growths that affect sounds when you are having trouble speaking?" vocal fold vibration (Colton & Casper, 1996). Patients who Patient: "It sounds hoarse." have had a slow, gradual onset to their voice problem may show less concern about their voice and/or less overall effect In this example, the patient has answered the initial ques­ on their daily life because they have learned to cope with and tion regarding the nature of the problem with a short, vague compensate for their deficits. Boone and McFarlane (1988) 18 THE VOICE DIAG!'IOSTIC PROTOCOL state that gradually developing dysphonias may suggest de­ tion earlier in the day, with increasing dysphonia with in­ veloping pathological conditions and that these patients may creased voice use. Voice that is worse in the morning versus have a poorer overall prognosis for voicelbehavior change. later in the day may be a symptom of postnasal drip or In contrast to gradual onset disorders, those with a sudden gastroesophageal reflux disease (Boone & McFarlane, 1988; onset are often more disturbing to the patient. Acute, sudden Colton & Casper, 1996). Haynes et al. (1992) state that fac­ onset problems may pose a severe threat to the patient, tors such as personal habits (smoking, alcohol use), work certainly in terms of ability to carry out daily activities and conditions, or medical conditions may affect the variability possibly in terms of overall health (Boone & McFarlane, of a voice disorder. Colton and Casper (1996) report that 1988). The patient may be able to describe the date and patients with psychologically based disorders often report details of the onset of the voice disorder with great detail. considerable variability in their vocal function. Voice disorders that develop over a very short time (1 to 2 days or less) may be due to conditions such as severe laryn­ Description o/Voice Use gitis; psychogenic episode (conversion reaction); specific Many voice disorders arise not from definitive underly­ neurological insult (e.g., cerebrovascular accident, closed ing organic pathological conditions but from the manner in head injury); trauma to the larynx (external [e.g., blunt which the patient uses the phonatory mechanism. Therefore, trauma to the neck region] or internal [e.g., sudden trauma it is essential that the clinician get a comprehensive view of to the vocal fold mucosa from a singular shouting/screaming how the patient uses his or her voice in various situations episode]); voice disruption as a result of surgery (e.g., vocal that may be found within his or her lifestyle. A description fold paresis resulting from thyroid surgery; vocal fold ulcer­ of voice use in vocational, social,Inc. and recreational settings ation resulting from intubation). Colton and Casper (1996) is of great importance, with abuse, misuse, and overuse indicate that sudden voice change in the absence of symp­ of the voice in these various situations often the cause of toms suggestive ofan organic pathological condition is often many functional voice problems (Boone & McFarlane, 1988; a key component ofthe psychogenic diagnosis. Colton & Casper, 1996). Because it is not always possible for the clinician to directly observe the patient in all the Variability and Consistency aforementionedPRO-ED, situations, the patient may be encouraged to It is important for the clinician to discem whether the demonstrate the voice use in these various settings for the patient's voice deficits have been relatively consistent over clinicianby (Boone & McFarlane, 1988). Haynes et al. (1992) time or have shown degrees of fluctuation. Fluctuation back state that the clinician must determine the vocal demands and forth between better versus poorer voice function is of the patient's profession and also determine whether the the hallmark of variability and differs from those patients patient must produce speech under adverse conditions. Sev­ who report consistent change in the voice in terms of steady eral types of voice use and/or setting have been commonly improvement or worsening of symptoms (Colton & Casper,material associated with the development ofvoice disorders: 1996). Disordered voices that periodically return to normal or near-normal characteristics may be functional in nature. • Any work setting that requires the patients to use their On the other hand, most disorders that have underlying voices for their livelihood (Le., professional voice users neurological dysfunction or definitive changes in vocal fold [Colton & Casper, 1996]) may be potentially harmful structure (e.g., mass lesions) generally do not improve spon­ in terms ofthe development ofvoice disorders, particu­ taneously (Prater & Swift, 1984). An exception to this is larly if these patients have not had any professional the case of myasthenia gravis, a deficit of neural transmis­ voice training. sion affecting the myoneural junction.copyrighted This disorder is vari­ • Social settings such as gatherings at parties or in bars able over time, with patients showing© progressive weakness may present a potentially abusive environment. with muscle use, followed by periods of improvement after • Sporting events present a potentially abusive situation rest. In those conditions in which dysphonia fluctuates, it is for both spectator and participant. Forceful phonation important to question the patient regarding the conditions that is potentially damaging to the vocal fold mucosa that are associated with voice change (environmental effects; may accompany strenuous exercise (Colton & Casper, effects of vocational, social, recreation situations; specific 1996). periods ofthe day associated with poor vs. improved voice). • Singing in various situations (choir, theater, recreational In particular, the patient should be questioned about periods musician) presents a potentially abusive condition for of emotional stress (personal, familial, work-related) that many, particularly if they have not had professional may cause the voice to worsen. voice training (e.g., high-intensity voice in the presence Several authors have commented on the variability of of high levels of background noise; possibly under voice disorders. Boone and McFarlane (1988) indicate that adverse conditions such as singing in bars in a smoky hyperfunctional patients often report improved voice func­ atmosphere; poor monitors). Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 19

Effects ofDysphonia on the Patient Possible Causes

Colton and Casper (1996) stated that "the severity of the The voice clinician should ask the patient directly what (patient's) reaction is not always proportional to the severity he or she believes may have been the possible cause(s) of the voice problem" (p. 190). This may be because voice of the voice problem( s) (Boone & McFarlane, 1988). Com­ disorders that affect the patient's vocation or draw negative parison of the patient's response to descriptions of possible reactions from others will be of more concern to the patient causes described by referral sources (e.g., physician, previ­ than those voice disorders that do not adversely affect daily ous speech-language pathologist) may reflect on the knowl­ life. When asked about the effects of the dysphonia, some edge and insight the patient has regarding his or her voice patients may be apprehensive about discussing what may be problem. Differing views on the possible cause of a voice a potentially humiliating effect on their lifestyle. However, disorder between the patient, referral sources, and family the clinician should ensure that expressions ofdenial regard­ members may reflect (1) an inability to adequately under­ ing effects of the dysphonia are fully explored (Colton & stand what may have been explained to the patient, (2) an Casper, 1996; Prater & Swift, 1984). It should be remem­ inability to recognize inner causes of the voice problem, or bered that it may not be the actual reactions to the patient's (3) an inability to accept and cope with the problem. Prater dysphonia that are as important as how a patient feels about and Swift (1984) believe that differences in perception of the reactions of others (Prater & Swift, 1984). Feelings what has caused the voice problem versus opinions offered of stress, tension, and development of possible negative by referral sources must be addressed ifthe patient is to have psychological outlook may arise as a result of reactions to a positive prognosis for improvement in voice therapy. dysphonia. Inc. Issues Dealing with Psychological Screening Health Status Several authors have stressed the fact that voice disorders The patient's health history should be assessed to de­ may be symptomatic of factors such as (1) inability to hold termine any possible relationship to the presenting voice satisfactory interpersonal relationships (Boone & McFar­ disorder. Voice characteristics reflect not only the emotional lane, 1988), PRO-ED,(2) struggle with social aspects of communica­ state and personality of the patient but also the overall physi­ tion (Praterby & Swift, 1984), and (3) psychological stress cal status (Colton & Casper, 1996). The voice clinician is arising from diverse (financial, marital, personal, profes­ particularly interested in health history in the following sional, physical, mental, or emotional) sources (Dworkin & areas: Meleca, 1997). In order that these sources are fully investi­ gated, psychological screening must be a critical aspect of o Current health status. voice diagnosis, particularly in the case of "functional" dys­ o Injuries or trauma to the head and/or neck region. materialphonias. Aronson (1 990b) stresses that a psychosocial his­ o Neurological problems. tory is crucial for successful diagnosis and therapy because o Respiratory deficits. it often uncovers "a disturbance in the patient's psychologic o Allergy-related problems. equilibrium" (p. 288) that underlies the patient's dysphonia. o History of frequent upper respiratory tract infections. • Surgeries, particularly in which the patient may have "Functional" patients often have the following character­ been intubated. istics (Aronson, 1990b ): • Smoking, alcohol use, illicit drug use. 1. They describe the development of their voice prob­ o Ingestion of caffeinated beveragescopyrighted (coffee, tea, soft drinks). © lems in conjunction with the development ofpersonal • Use of prescription and over-the-counter medications problems. (e.g., antihistamines, decongestants, diuretics). 2. They are often reluctant to verbally express their • Endocrine imbalances. conflicts. • Previous occurrences of voice dysfunction or "loss" of 3. They are patients with whom no one has bothered to the voice. take a psychosocial history. • Hydration status-Degree of internal hydration may In addition, evidence of psychological stress may be re­ affect the viscosity of mucus secretions and aids in flected in the following nonverbal cues (Andrews, 1995; lubrication of the vocal fold cover (Stemple, 1993). A Boone & McFarlane, 1988; Dworkin & Meleca, 1997; Prater well-lubricated cover protects the vocal fold during the & Swift, 1984): vibratory cycle and aids in heat dissipation. Ingestion of six 8-ounce glasses of water or fruit juice per day is o Sweaty palms generally recommended. o Avoidance ofeye contact 20 TUE VOICE DIAGNOSTIC PROTOCOL

• Excessive postural adjustments were not observed in the normal control subjects. Can­ • Facial tics nito (1991) concluded that the identification and relief • Masked facial expression of emotional disorders in SD patients were critical for • Head and neck muscle tension their effective management, and that any behavioral • Head and/or hand tremors voice therapy gains would be temporary in patients who remained clinically anxious and depressed. Although it is not within the purview of the speech-lan­ • Goldman et al. (1996) compared measures of psycho­ guage pathologist to conduct formal personality testing, it logical stress, anxiety, voice use, and somatic com­ is essential that the clinician derive at least an impression plaints in groups of women with vocal nodules. In regarding the patient's psychosocial behavior and basic addition, results were compared with women with func­ adjustment to life (Aronson, 1990b; Haynes et al., 1992; tional dysphonia (Le., presence of dysphonia in the Murry, 1982). Psychological screening of the patient should absence of an organic pathological condition), as well involve three key areas of questioning: as a group of normal controls. The Schedule of Recent Experience was u!\ed to obtain estimates of psycho­ • Influence of stressors: Stressors are events that neces­ logical stress, and the State-Trait Anxiety Inventory sitate changes in how an individual conducts his or her was used to assess levels ofanxiety. Results indicated that life (Holmes & Rahe, 1967 in Goldman et al., 1996). both dysphonic groups (nodules and functional dys­ Examples of stressors may be changing jobs, moving phonia patients) had greater than normal levels ofanxi­ to a different part of the country, or going through a ety (both state and trait) Inc.and a significantly greater inci­ divorce. dence of somatic complaints than the normal controls. • Influence of anxiety: Anxiety refers to the presence of In addition, the functional dysphonia group showed an unpleasant emotional state or condition (Spielberger, a greater level of adjustment-related stress than the Gorsuch, Lushene, Vagg, and Jacobs, 1983 in Goldman normal controls. These authors concluded that there ap­ et al., 1996). Goldman et al. (1996) state that "different pears to be "evidence ofan association between selected individuals may inherently experience different levels psychosocialPRO-ED, factors and hyperfunctional voice disor­ of anxiety and/or may react to a given stressor (e.g., ders" (p. 51). The assessment of psychosocial variables life event) with different degrees of anxiety" (p. 45). wouldby appear to be an important component ofa battery Anxiety may be separated in two components: state of tests used to assist in differential diagnosis and may anxiety versus trait anxiety. State anxiety refers to the be useful in identifYing those patients who may benefit patient's present feelings of anxiety; trait anxiety refers from counseling or formal psychological evaluation. to an individual's persistent or personality-related level • Roy et al. (1 997b ) reported on results from the Min­ ofanxiety (Goldman et al., 1996). Examples of anxietymaterial nesota Multiphasic Personality Inventory (MMPI) ob­ could be feelings ofworry or inadequacy. tained from groups ofFD women and a group ofcontrol • Somatic complaints: These are physical complaints, subjects without voice disorders. Results showed that illnesses, weaknesses, etc. (e.g., headaches, heartburn). only 32% of the FD patients had "normal" profiles on In some patients psychological stress and/or anxiety the MMPI compared with 90% of the controls. In addi­ may manifest itself in the development of physical tion, the FD patients were significantly different from symptoms. Exhibit 1-1 provides an example ofa simple the control subjects on 7 of 10 personality scales. Two survey developed by Goldman et al. (1996) that may be scales were observed to sufficiently discriminate the given to the patient to gathercopyrighted background information FD subjects from the controls: (1) a general index of regarding common somatic© complaints. frequency of somatic complaints and (2) a measure of diffuse anxiety. Roy et aL (1997b) concluded that Several studies have directly examined the presence of somatic complaints and anxiety may be characteristic factors such as stress, anxiety, and somatic complaints in a traits of FD patients. These traits "may constitute a per­ variety of voice disorders as shown below. sistent vulnerability (diathesis) for the development of tensional or somatic symptoms when under conditions • Cannito (1991) examined psychometric measures ofde­ of psychological distress" (p. 449). Failure to recognize pression, anxiety, and somatic complaints in 18 female the possible presence ofunderlying psychological stress patients with spasmodic dysphonia (SD) and a group and tension in FD patients may limit the long-term of matched normal controls. Results showed that 56% prognosis ofthese patients. of the SD patients were either clinically anxious or depressed. In addition, the SD subjects demonstrated Psychological factors may be associated with voice dis­ abnormally elevated levels of somatic complaints that orders as (1) an underlying cause and/or (2) a result of Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 21

Exhibit 1-1 Somatic Complaints Survey

I. Do you ever have trouble with heartburn, gastric reflux, or stomach upset?

Never _ Infrequently _ At least once per month _At least once per week

2. Do you ever have headaches?

Never Infrequently _At least once per month At least once per week

3. (when not exercising) Do you have pain in the chest or does your heart seem to pound or race?

Never _ Infrequently At least once per month _At least once per week

4. Fainting or dizziness?

Never Infrequently _At least once per month At least once per week

5. Trouble sleeping?

Never Infrequently _ At least once per month _ At least once per week Inc. 6. (when not exercising) Do you have shortness of breath?

Never _ Infrequently _ At least once per month __ At least once per week

7. Hot or cold spells? Are you easily chilled? Never Infrequently _ At least once perPRO-ED, month _ At least once per week 8. Numbness or tingling? by Never Infrequently __ At least once per month _ At least once per week

9. Poor appetite, associated weight loss?

Never _ Infrequently _ At least once per month _ At least once per week material 10. Overeating, associated with weight gain?

Never Infrequently _ At least once per month _ At least once per week

II. Do you ever feel uncomfortable about eating or drinking in public?

Never _ Infrequently _ At least once per month _ At least once per week

12. Do you ever feel like you have acopyrighted lump in your neck or throat?

Never ©_ Infrequently _ At least once per month _ At least once per week

13. Do you notice any tenderness in your back or shoulders?

Never Infrequently _ At least once per month At least once per week

14. Do you have any pain or trouble swallowing?

Never _ Infrequently _ At least once per month __ At least once per week

Source: Reprinted with pennission from S. Goldman et aI., Stress, Anxiety, Somatic Complaints, and Voice Use in Women with Vocal Nodules: Preliminary Findings, American Journal o.f Speech-Language Pathology, Vol. 5, No.1, pp. 44-53, © 1996, American Speech-Language Hearing 22 THE VOICE DIAGNOSTIC PROTOCOL coping with an incapacitating voice disorder (Roy et al., of arresting one motor impulse and substituting in its 1997b). In this view, psychological factors should be consid­ place a movement that is diametrically opposed" (p. ered with all voice disorder types (organic and functional! 74). Patients may be asked to produce the syllable /?A/ psychogenic), because "all disease processes carry compo­ (i.e., initiation of a centralized vowel with a glottal nents of emotional stress" (Colton & Casper, 1996, p. 196). stop production [Verdolini, 1994]) or the syllable /hA/ Although the clinician may believe it necessary to refer the (Renout et al., 1995). Use of the syllable /hAl may be patient for formal psychological testing (Murry, 1982), it preferable because it requires the patient to shift rapidly would appear valuable to include questions dealing with the between abducted and adducted positions. Patients are presence of stressors, anxiety, and somatic complaints in asked to repeat the selected syllable as fast as possible the case history interview. Although the clinician may be on one uninterrupted breath (Renout et al., 1995). The met with some degree of patient resistance to this line of patient's production will ideally be recorded and then questioning (Aronson, I 990b ), the possible value obtained closely reviewed for the number ofrepetitions within a in terms ofdiagnostic accuracy and success in treatment will 5-second (Renout et al., 1995) or 7-second (Verdolini, be well worth the effort. 1994) time period. The VF-DDK is then generally re­ ported as the number of syllable repetitions per second. SPEECH MECHANISM EXAMINATION-BASIC Verdolini (1994) mentions three characteristics of OVERVIEW AND FOCUS ON ASPECTS OF VF-DDK that should be observed by the clinician: LARYNGEAL EVALUATION 1. The rate of glottal plosivesInc. per second During a voice evaluation, our attention is primarily fo­ 2. The strength ofthe plosives cused on the function of the respiratory/laryngeal complex. 3. Steadiness (i.e., ability to produce rhythmic repeti­ However, it is important that the speech clinician also assess tions) over time the form and function ofthe other components ofthe speech mechanism (face and lips, mandible, velar function, etc.). In In terms of rate, normal VF-DDK for adults has been re­ particular, the clinician should pay close attention to signs ported in thePRO-ED, range offive to six syllables per second (Canter, of possible neurological deficits in which abnormalities 1965; Shanks, 1966 in Renout et al., 1995) or similar in (unilateral or bilateral) in muscle strength, speed, range, natureby to the expected diadochokinetic rate for the syllable accuracy, steadiness, and/or tone may be present (Darley, /kA/ (Verdolini, 1994). Aronson, & Brown, 1975). Neuromuscular deficits affecting one part of the speech mechanism may also be reflected • Head twisting during phonation: The action oftwisting! in phonatory function. The clinician is directed toward a turning the head sharply to the side has the effect of comprehensive oral-facial mechanism examination outlinematerial compressing the pyriform sinus on the side to which the such as the Dworkin-Culatta Oral Mechanism Examination patient is turning. In addition, this movement may serve (Dworkin & Culatta, 1980) for an extensive assessment of to push the vocal fold on the side to which the patient speech mechanism function. is turning more toward the midline of the glottis. This Several key components of the speech mechanism exami­ may be an effective technique of improving voice func­ nation are focused on laryngeal function. Detailed evaluation tion, particularly for those patients who show some of factors such as pitch, loudness, quality, and durational degree ofunilateral vocal fold paralysis/paresis (Boone capability will be discussed in substantial detail throughout & McFarlane, 1988; Hutchinson, Hanson, & Mecham, the following chapters and, therefore,copyrighted will not be considered 1979; Logemann, 1998). The patient should be asked here: © to twist/turn the head toward the right shoulder and then phonate (sustain the vowel /o/)-the procedure • The sharp cough: During the speech mechanism evalu­ should be repeated by having the patient turn toward ation, the patient should be asked to produce a sharp the left shoulder. The clinician should listen closely for cough. Laryngeal weakness may be indicated by the changes in voice quality. If unilateral paralysis/paresis presence of a weak, "mushy" cough (Prater & Swift, is present, the patient may be able to achieve better 1984) . quality voice with the head twisted toward the weak • Vocal fold diadochokinesis: Observation of the pa­ side. tient's capability to carry out vocal fold diadochokinesis (VF-DDK, a.k.a. laryngeal diadochokinesis [L-DDK]) In addition to the aforementioned laryngeal tasks, the refers to the repetition of rapid adductory-abductory clinician should be aware of signs of excessive muscle ten­ movements over time. Renout, Leeper, Bandur, and sion that may be affecting voice production. Characteristics Hudson (1995) described diadochokinesis "as the action consistent with increased muscle tension may be head or Introduction: The Voice Diagnostic Protocol and Initial Stages ofthe Diagnostic Process 23 hand tremors, abnormal breathing patterns, visible tightness vocal loudness as compensation. With these possibilities in in the neck or jaw region, or unusual downward or upward mind, hearing screening is certainly a necessary aspect ofthe excursions of the larynx during speech (Andrews, 1995; voice diagnostic. Referral for a full audiological examination Boone & McFarlane, 1988; Stemple, 1993). The reader is may also be necessary in some cases. referred to Chapter 6 for a detailed description of evaluation procedures and the possible effects of excessive musculo­ SUMMARY skeletal tension on voice production. The Voice Diagnostic Protocol is a set of clinical methods Hearing Evaluation and procedures by which a comprehensive evaluation of phonatory voice disorders may be carried out. We begin In addition to evaluating the integrity of the peripheral the VDP with the gathering of background information and speech mechanism, it is also important to assess the hearing significant information regarding the patient's possible voice mechanism. Murry (1982) stresses that "under no circum­ problem(s) in the case history interview. During this inter­ stances should the voice evaluation be completed without view, the clinician should always be listening/observing so information about the patient's hearing ability" (p. 485). the statements that the patient/caregiver is providing may Difficulty controlling vocal loudness or use of appropriate be verified. In this way, a number of the descriptions that loudness levels in speech may result secondary to hearing we are provided with (symptoms) become verifiable facts loss (Colton & Casper, 1996; Murry, 1982; Stemple, 1993). (signs) (Colton & Casper, 1996). The clinician will follow Dworkin and Meleca (1997) state that abnormally quiet/soft the interview with an examinationInc. of the speech and hear­ voices may accompany cases of conductive hearing loss, ing mechanisms to identify any significant characteristics whereas sensorineural hearing loss may cause the patient to of form or function that may be related to the patient's speak in an abnormally loud voice. In the case of a conduc­ voice deficits. Finally, initial hypotheses dealing with the tive hearing loss, bone conduction is better than air conduc­ differential diagnosis of the voice problem are being formed tion. Therefore, the patient may believe that he or she is at this point. These hypotheses will eventually be proved producing an adequately loud voice when it is, in fact, too or disprovedPRO-ED, through (1) the addition of the formal obser­ quiet. In sensorineural losses, both air and bone conduction vations we will be making in our application of specific are detrimentally affected, causing the patient to increase tests/proceduresby and (2) comparisons with normative data.

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