Clinical Voice Assessment Methods

Study Notes

GRBAS Scale: A simple rating tool for voice quality, assessing overall severity, roughness, breathiness, asthenia, and strain.
Each parameter (G, R, B, A, S) is scored on a 4-point scale (0 = no deficit, 1 = mild, 2 = moderate, 3 = severe).
No standardized utterance type is recommended for GRBAS, so specific testing conditions must be documented.

The CAPE-V is a rating tool assessing six core parameters of voice quality on a 100-mm line.
Parameters assessed include overall severity, roughness, breathiness, strain, pitch, and loudness.
Additional parameters can be added at the discretion of the examiner.
Parameters can be categorized as consistently or intermittently present.
The CAPE-V uses sustained vowels, standard sentences, and natural running speech (at least 20 seconds) for scoring.
Recommendations on testing environments are included in the reference publication.

Assessment includes speech breathing, speech production, and resonance.
Speech breathing factors include breath group length, average loudness, loudness variability, and inspiratory duration.
Speech production factors include articulation precision, resonance, and prosody.
Resonance evaluations include terms such as hypernasal, hyponasal, and cul-de-sac.
Prosody features are speech rate, repeated/prolonged syllables, speech rushes, intonation (monopitch/monoloudness), and stress patterns.

Evaluation considers visible aspects of voice production related to etiology and/or outcomes of dysphonia.
Factors include physical appearance (age, height/weight, facial expression, skin/hair/nails, hygiene, and dress), which indicate systemic diseases, previous treatment, or emotional problems.
Posture and musculoskeletal tension are analyzed.
Musculoskeletal tension can include abnormal jaw motion, chin jut, neck extension, visible neck muscle bulges/raised shoulders, and contribute to muscle tension dysphonia (MTD).
Neurological dysfunction indicators include unsteadiness, asymmetry, rigidity, hesitation, slowness, weakness, incoordination, inconsistency, and extraneous movements (especially in tongue, jaw, lips, or soft palate).

Focal dystonias (writer's cramp, blepharospasm, torticollis, oromandibular dysphonia) are correlated with neurologically-based voice disorders like spasmodic dysphonia.
Physical dysmorphology, like syndromic features or orofacial differences, may relate to resonance or speech intelligibility deficits.

Certain systemic diseases impacting the larynx and voice may manifest physically (examples: rheumatoid arthritis, lupus, Sjögren's syndrome).

Muscle imbalance (intrinsic and extrinsic laryngeal muscles) is a key characteristic of muscle tension dysphonia (MTD), which MTD is assessed manually.
Manual examination of laryngeal musculoskeletal tension quickly assesses muscle tension contributions to voice quality.
Assessment typically involves palpation of suprahyoid muscles, hyoid bone, thyroid cartilage, thyrohyoid space, and sternocleidomastoid muscle.
Assessments include palpation at rest and during phonation with a focus on lateral mobility.
Recommended further palpation includes thyrohyoid, cricothyroid, and pharyngolaryngeal muscles (inferior constrictor, posterior cricoarytenoid).
Normal findings include palpable space between hyoid and thyroid cartilage, and mobility of the laryngeal complex.

Currently, no intra- or inter-examiner reliability data exist for manual laryngeal tension examination.
Sensitivity and specificity of abnormal findings remain unknown.

A radiographic study of laryngeal position in MTD patients found no difference in hyoid or thyroid cartilage location at rest between control and MTD groups.
During phonation, controls lowered the hyoid more than MTD participants, and MTD participants raised the thyroid cartilage more than controls.