Voice Assessment: Jitter, Shimmer and Questionnaires

• Normal changes in pitch (jitter) should be less than 1.04.
• Normal changes in amplitude (shimmer, loudness) should be less than 3.8.

Patient Reported Outcome Measures:

• Reflux Symptom Index (RSI)
• Vocal Tract Discomfort Scale (VTDS)
• Singing Voice Handicap Index (SVHI)
• Voice Related Quality of Life (V-RQOL)
• Voice Handicap Index (VHI-30)
• Voice Handicap Index (VHI-10)
• Pediatric Voice Handicap Index (pVHI)
• Communicative Participation Item Bank (CPIB)
• Patient-Reported Outcomes Measurement Information System (PROMIS)

GRBASI Scale:

• GRBASI stands for:
  • Grade (G): degree of hoarseness of voice.
  • Roughness (R): impression of irregularity of vibration of vocal folds.
  • Breathiness (B): degree of air escaping from between the vocal folds heard by the examiner.
  • Asthenia (A): degree of weakness heard in the voice.
  • Strain (S): extent to which strain or hyperfunctional use of phonation is heard.
  • Instability (I): changes in voice quality over time.
• Each component is rated on a four-point integer scale: 0 (normal), 1 (slight), 2 (moderate), and 3 (severe).
• Limitations include:
  • Limited granularity of ratings with only 4 Likert scale options.
  • Challenges of inter- and intra-rater reliability, particularly for abnormal voices.
  • These challenges can be mitigated by rater training.

VTDS

• Vocal Tract Discomfort Scale is used to assess symptoms or sensations one may feel in their throat as part of a voice problem.
• The frequency and severity of each symptom/sensation is indicated by circling a number in the appropriate column.

SVHI

• Singing voice handicap index.

V-RQOL Assessment

• It assesses how a voice impacts daily activities over the past two weeks.
• There are no right or wrong answers.
• Individuals rate each item on a scale of 1 to 5:
  • 1 = None, not a problem
  • 2 = A small amount
  • 3 = A moderate (medium) problem
  • 4 = A lot
  • 5 = The problem is "as bad as it can be"

VHI-30 and VHI-10

• These use statements that many people use to describe their voices and the effects of their voices on their lives.
• The respondent circles the response that indicates how frequently they have the same experience.
• Scales rate from 0-4
  • 0 = Never
  • 1 = Almost never
  • 2 = Sometimes
  • 3 = Almost always
  • 4 = Always

PVHI

• Pediatric Voice Handicap Index, statements describe voices and effects on children's lives.
• Respondents circle the response indicating their child's frequency of experiencing symptoms.

CPIB

• Communication Participation Item Bank describes a variety of situations in which someone might need to speak to others.
• For each question, people mark how much their condition interferes with their participation in that situation.
• "Condition" includes anything that affects communication, including speech conditions, health conditions, or environmental factors.
• Rate for an average day.

PROMIS

• Patient-Reported Outcomes Measurement Information System is a system of health-related quality-of-life measures.
• PROMIS measures physical, mental, and social well-being and is designed for neurological conditions and populations. Both are developed by the National Institutes of Health (NIH).

PVQD

• Perceptual Voice Qualities Database

Auditory-Perceptual Voice Evaluations

• GRBAS and CAPE-V are two auditory-perceptual evaluations of voice.
  • CAPE-V (consensus auditory-perceptual evaluation of voice) is a widely used tool for assessing voice quality.
  • CAPE-V evaluates perceptual voice characteristics, including Roughness, Breathiness, Strain, Pitch, Loudness, and Overall Severity.
  • Assessment includes sustained vowels /a/ and /i/, sentence production, and spontaneous speech.
  • Ratings can be categorized into signal-based, rater-based, and task-based effects.

Harmonics-to-Noise Ratio

• Lower values indicate more noise in the voice, which contributes to roughness.
• HNR >18-20 dB generally suggests good vocal quality.
• Lower HNRs suggest more "noise" or hoarseness in the signal.
• The task involves sustained vowel phonation only.

CAPE-V

• Primary purpose is to describe severity of auditory-perceptual attributes of a voice problem for communication among clinicians.
• Secondary purpose is to contribute hypotheses regarding anatomic and physiological bases of voice problems and evaluate the need for additional testing.
• Not the exclusive means for determining the nature of a voice disorder.
• Not to be used exclusively, and unable to provide a 1:1 relation.

Cepstral Peak Prominence Smoothed (CPPS)

• Lower values indicate more breathiness; about 11 dB and lower indicates voice getting worse.
• Assessment tasks can be sustained vowels or connected speech.
• Norms vary by task (vowel/connected speech) and sex.

Average Fundamental Frequency

• Determined by the rate of vocal fold vibration.
• The perceptual correlate of F0 is pitch.
• assessment tasks include Sustained vowel and connected speech.

Pitch in Voice Report

• Mean pitch.
• Pitch range.
• Standard deviation.

Standard Deviation in Sustained Vowel Task

• The standard deviation should be 10-15% or lower of the mean F0 value.

Standard Deviation in Connected Speech Task

• Standard deviation should be 2-4% of the mean F0 value.

Interpreting Pitch Measures

• Measures of pitch (average, standard deviation, range) must be interpreted as a function of task, sex, and age of the speaker.

Jitter

• Measures cycle-to-cycle variations in F0 (short-term measure of pitch stability).
• The norm is < 1.04%.
• Tasks include Sustained vowel task only.

Shimmer

• Measures cycle-to-cycle variability in intensity (loudness).
• The norm is < 3.80%.

Average Fundamental Frequency

• Males: 110-120 Hz
• Females: 200-220 Hz

Vocal Nodules

• Primarily affect the superficial layers of the lamina propria.
• Nodules form due to repetitive mechanical stress, leading to localized swelling and eventual thickening of this layer.
• Over time, with persistence, vocal nodules can become more fibrotic, making the vocal folds stiffer, reducing their ability to vibrate efficiently, resulting in hoarseness and vocal fatigue.

Voice Disorders

• Adductor spasmodic dysphonia refers to a voice disorder where the vocal cords involuntarily close too tightly during speech, causing a strained or strangled sound.
• Abductor spasmodic dysphonia refers to a less common type where the vocal cords involuntarily open too much, leading to a breathy or whispery voice.

Laryngoscopy

• Allows visualization of structures, but not assessment of vocal fold vibration.
• A rigid (top image) or flexible (bottom image) scope can be used.

Videostroboscopy

• System detects fundamental frequency (F0) and triggers light flashes to create the appearance of slow-motion vibration.
• Allows for visualization of vocal fold movement.
• Can be performed using a rigid (top image) or flexible (bottom image) scope.

Laryngoscopy and Videostroboscopy Exam

• Sustaining vowels (e.g., /i/, /a/) at different pitches and loudness levels.
• Assess connected speech using a flexible scope (inserted through the nose).
• Record tasks like coughs, throat clears, and pitch glides for a comprehensive evaluation.

Endoscopic Observation: Assessing Laryngeal Integrity

• Can use continuous light source or strobe light for ratings (except VF edge ratings).
• Looks at erythema, edema, varices, mucus, arytenoid mobility, vocal fold edge, supraglottic compression.

Stroboscopic Observation: Assessing Laryngeal Function

• The integrity of laryngeal structures (movement) can be assessed.
• Videostroboscopy cannot be used when vocal fold vibration is irregular (asymmetry between VFs).
• Assessment protocol involves:
  • Sustained /i/.
  • Typical pitch and loudness for speaker.
  • A pitch and/or loudness level where the patient reports difficulty (if applicable).
  • Gliding from habitual to highest pitch possible and then habitual to lowest pitch possible.
  • Producing a quiet voice and then a loud voice.
• Observation focuses on regularity, amplitude, mucosal wave, nonvibrating portion, vertical level, glottal closure pattern, left/right phase symmetry, glottal closure duration.

Laryngeal Findings:

• Erythema (redness due to capillary dilation): Reflects inflammation and/or irritation of the laryngeal structures and is often seen in chronic laryngitis or vocal misuse/abuse.
• Erythema of posterior commissure and arytenoid = LPR (Laryngopharyngeal reflux)
• Edema (fluid below the epithelium): Etiologies include smoking, LPR, vocal misuse/abuse, radiation therapy.
  • May add mass to VF, decreasing pitch.
  • In severe cases, VF "bulge" with a convex edge.
  • Added mass reduces lateral movement.
  • Asymmetrical vibration is often present if edema differs between VFs.
• Varices (dilated vessels): Run near the VF surface parallel to the VF edge.
  • Etiologies include hormonal fluctuations, repeated trauma, and inflammation.
  • Often located in mid-membranous region where greatest impact occurs.
  • May result in hoarseness or be asymptomatic.
• Mucus (presence of thick, adherent mucus (white pockets)):
  • Lubricates the VFs, but thick and adherent mucus is associated with dysphonia (particularly hyperfunctional).
  • Inflammation of VF alters mucus consistency.
  • Thick mucus may also suggest dehydration.
• Arytenoid mobility is assessed by saying "eee" and "ahhh". - paralysis with thyroidectomy = Right - paralysis with heart surgery from damage to recurrent laryngeal nerve = Left

Reduced VF Mobility

• May be reduced due to unilateral/bilateral paresis or paralysis

Types of VF Edges

- Smooth/straight
- Irregular
- Rough
- Bowed
- Convex

Vocal Fold Edges

• These must be rated with continuous light while VFs are fully abducted (during breathing).
• They are the free edge/margin of the membranous portion of the VF (common site of lesion development- phonotrauma).
• A non-linear edge prevents VF closure, which affects loudness and voice quality.
• Mobility may also be compromised by sulcus vocalis (a groove along the length of the free edge).

Compresssion

• Mediolateral compression: The ventricular folds move medially.
• Anteroposterior compression: The aryepiglottic muscles contract decreasing the space between the arytenoids and epiglottis.
• Supraglottic compression: Associated with strain and increased vocal effort.
  • Minor compression may not signal hyperfunction.

Videostroboscopic Glottal Cycle

• Regularity is the degree to which one cycle is consistent with successive cycles. Tells if the strobe is tracking cycles properly.
• increases commensurately with loudness and varies inversely with pitch
• Amplitude: Extent of lateral movement from the midline during phonation.
  • Can be reduced due to increased mass, increased stiffness, or incomplete glottal closure.
  • Measures lateral movement of the vocal fold body, rating distance of travel from the midline in 25% increments.
• Based on normal pitch and loudness.
• Reduced in VF nodules, polyps, edema, and sulcus vocalis.

Mucosal Wave

• Starts on the inferior surface of the vocal folds and travels upwards over the free margin, then moves laterally across the superior surface of the vocal folds.
• It represents lateral movement of the mucosal cover.
• The behavior of the wave tells about the pliability of the vocal fold cover.
• Conditions that stiffen the cover (e.g. lesions, scarring) reduce the wave and increase the phonation threshold pressure.
• It's perceived by the speaker as increased effort to phonate.
• Glottal Gap - Posterior Gap is common in young and elderly females and is also encountered in adults without dysphonia. May be present in males. - Anterior gap, hour-glass closure, and complete closure.
• The degree to which glottal closure pattern contributes to dysphonia depends on the involvement and size of the abnormality.

Asymmetry

• Occurs when there is a timing difference between the right and left vocal folds.
• May be caused by a mismatch in the physical properties of the vocal folds (e.g. tension, mass) causing them to respond differently to aerodynamic forces.
• For example, a unilateral lesion such as cyst or polyp adds mass and stiffness to the affected VF causing it to vibrate at a different rate.
• Unilateral denervated VF (paralysis) leads to differences in tension and mass.
• Severe asymmetry has a larger effect on vocal quality than mild asymmetry, some speakers (without a pathology) have mild asymmetry
• Nonvibrating portion is typically seen in VF carcinoma, VF scarring, and VF papilloma.
• Vertical level is caused by structural differences between VF (atrophy from unilateral paralysis causing one VF to become thinner than the other. Air can leak where the vocal folds fail to meet along the vertical plane.

Glottal Closure Duration

• Short closed phase = breathy voice.
• Long closed phase = pressed/hyperfunctional voice.
• and muscle tension dysphonia: predominantly closed phase
• and polyps: predominantly open phase.
• Strobe Lights: Xenon and Halogen.
• Granuloma: Forms at back or around the vocal process of the arytenoid.

Laryngoscopy

• The process of examining the larynx (voice box).
• The larynx is positioned deep in the throat, the larynx is not as easily examined with a flashlight, as the mouth and nose are. Special instruments needed to evaluate it.
• Light connected to a mirror or special tool (laryngoscope) to visualize the larynx.

Mirror Laryngoscopy

• Performed by placing an angled mirror into the back of the mouth.
• Light is shone into the mouth and reflects off the mirror and downward towards the larynx.
• Utilized since the late 1800s, requiring a mirror, light source, and gentle steady hand.
• May be challenging for both the physician and the patient. Provides the most accurate color representation of the larynx, which is helpful in diagnosing and monitoring treatment of disease that affects the larynx.

Flexible Laryngoscopy

• The most commonly performed procedure for visualizing the larynx.
• A flexible endoscope (flexible laryngoscope) is inserted into one nostril, into the back of the nose, behind the palate, and placed above the larynx.
• Anesthetic and decongestant medications are used for patient comfort.
• Provides an excellent birds-eye-view of the structures and functions of the voice box while allowing the patient to speak, swallow, and breathe naturally.
• Directed vocal tasks allow for the clinician to fully assess the larynx.
• Gives information about movement and abnormalities (masses, injuries, swelling).

Rigid Laryngoscopy

• The endoscope is placed through the mouth with the tongue held slightly out.
• The physician inserts the scope to the back of the tongue.
• The scope end points down to visualize the larynx.
• The patient is asked to say "e" and the function of the larynx is assessed.

Videostroboscopy

• Conducted if laryngoscopy is insufficient.
• Vocal folds vibrate too quickly to be seen by the naked eye so a special light is used to observe.
• This procedure helps detect subtle abnormalities in voice and other throat problems.
• Performed with either a flexible laryngoscope or a rigid laryngoscope, placed painlessly in the mouth.
• The examination is viewed on a video screen and recorded for later review and analysis.