PERCEPTUAL EVALUATION

OVERVIEW ON INSTRUMENTAL
EVALUATION VOICE

Prakash Boominathan
Associate Professor
Sri Ramachandra University, Chennai

Components of diagnostic voice evaluation:

™ Medical evaluation.

™ Patients interview

™ Psycho acoustic evaluation of voice

™ Instrumental evaluation of voice including acoustic

and aerodynamic analysis

™ Functional evaluation of vocal fold movement.

Some procedures used in voice evaluation process include:

•Obtain audio-recorded sample of the patient’s
voice.

•Description of the patient’s vocal fold

structure and function from a laryngologist

•Evaluate:
Æ Respiratory capabilities

Æ Strength of glottal closure

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 Æ Voice quality

Æ Pitch range, optimal pitch and habitual

pitch
Æ Vocal loudness level
Æ Endurance for speech production
Æ Sites of vocal hyperfunction
Æ Oral peripheral, motor and sensory
aspects of the patient’s speech musculature.

Evaluation could be done by following methods:

• Auditory and visual perceptual assessment.

• Objective / instrumental assessment.

• Patient’s judgment of their own voice problems.

The patient with voice problem tend to present 9 major

symptoms. They are:

* Hoarseness
* Vocal fatigue
* Breathy voice
* Reduced Phonation range
* Aphonia
* Pitch break or Inappropriate high pitch
* Strain
* Tremor
* Pain and other physical sensation

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 Patient may report several symptoms but the symptom first
mentioned or emphasised should be considered as the primary
symptom and evaluated.

Evaluation of vocal function may be divided into six categories:

ÆAssessment of the vibratory function, which gives us
information about the leading edge of the vocal fold.

Æ Aerodynamic measurement reveals the ability of the lungs

and abdomen to provide power to the voice and the ability of the
glottis to release air efficiently.

Æ Measures of phonatory function to quantify the limits

of vocal frequency, intensity and duration.

Æ Acoustic analysis to detect and document numerous

subtleties in the vocal signal.

Æ Laryngeal electromyography to confirm the presence

or absence of appropriate neuromuscular function.

Æ Psycho acoustic evaluation

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HOWEVER, THE HUMAN EAR AND BRAIN ARE

STILL THE BEST EQUIPMENT WE HAVE

AVAILABLE. (Sataloff et. al, 1990).

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 PERCEPTUAL VOICE
EVALUATION

EVALUATION OF
RESPIRATORY SYSTEM

Voice production begins with respiration (breathing). Air is

inhaled as the diaphragm (the large, horizontal muscle below the
lungs) lowers.

The volume of the lungs expands and air rushes in to fill this
space. We exhale as the muscles of the rib cage lower and the
diaphragm raises, essentially squeezing the air out.

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 ¾ It is necessary to analyze breathing habits as the abnormalities
related to respiratory system may lead to voice problem as they
affect the expiratory air necessary for speech.
Type of breathing: Thoracic, clavicles, abdomen and
diaphragmatic.

¾ Maximum duration of sustained blowing: Maximum

length of time an individual can maintain an oral flow of air and
can be measured by asking the patient to take a deep breath and
blow the air out slowly. The amount of time taken to expel the
air out will be maximum duration of sustained blowing.

Normal maximum duration of sustained blowing is 10 – 12 sec.

¾ Reading aloud a passage: Patient is asked to read as much

of standard passages as possible on a single breathe. Record

the number of words and the duration of time in second that

the patient is able to read.

EVALUATION OF
PHONATORY SYSTEM

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 • The patient will be asked to talk and his speech will be observed or
recorded and the analysis will be made by the clinician based on his
auditory perception.

• Pitch ÆPitch is the perceptual correlate of fundamental frequency

Pitch can be evaluated in different ways they are Monopitch,
Inappropriate pitch, Pitch break and Reduced pitch range.
* Monopitch: This term refers to lack of variation of pitch
during speech. There will be a marked absence of inflectional
variation and inability to voluntarily vary pitch. This can be one of
the many signs charecteristics of neurological impairment or simply
a reflection of ones personality or psychiatric disability

* Inappropriate pitch: This refers to the voice that is

judged to exceed the range of acceptable pitch for age or sex,
being either too low or high. The pitch reflects the
underdevelopment or immaturity of the larynx based on the
endocrinological factors or perhaps a congenital anomaly.
* Pitch break: This refers to unexpected or uncontrolled
sudden shifts of pitch in either an upward or downward
direction. They are associated with the changing voice of
adolescent male and are usually a temporary stage that resolves
with time. Pitch breaks occur as a result of a laryngeal
pathology or loss of neural control of phonation.

* Reduced Pitch range: This is usually at the high end of the

range and inability to produce pitch without excessive strain.
• Loudness Æ Loudness is perceptual quality of intensity.
Lodness can be evaluated in different ways they are
Monoloudness, loudness variation, and Reduced loudness
range.
* Monoloudness: This term refers to lack of variation of
loudness level during speechThis can be one of the many signs
charecteristics of neurological impairment or simply a reflection
of ones personality or psychiatric disability

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 * Loudness Variation: This term refers to the variation of
loudness that is soft / normal / loud. Appropriate loudness level
are dependent on specific speaking situation. Voice that are too
soft or too loud may be reflection of auditory dysfunction, of
personality or of habit. This can be attributed to either problem
in the neural control of phonatory or respiratory mechanism or a
reflection of psychological problems.
* Reduced Loudness Range: This term refers to reduction
in patients loudness range usually involves a loss of ability to
produce loud sounds. Many times reduced phonation range and
reduced loudness range occur in same patient.

•Quality Æ Voice quality can be perceptually evaluated in

different ways. They include hoarse, Breathy, Tension, Tremor,
Strain/ Stuggle, Sudden Interruption in voicing and Diplophonia
•MAXIMUM PHONATION DURATION (MPD)

The patient will be asked to sustain phonation after a deep

inhalation. This reveals the interaction of respiratory system and
laryngeal system. Normal MPD is 15 – 30 seconds.

• S/Z ratio

This is the ratio between the duration of sustained /z/

and /s/. Subject will be asked to sustain /s/ and /z/ as
long as possible and the time will be determined using
a stopwatch. This measure provides information about
laryngeal system as for the production of /s/ vocal fold
vibration doesn’t occur whereas for /z/ vocal fold
vibration occurs.

Normal /s/ & /z/ ratio is 0.9 to 1.1.

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 EVALUATING
RESONATORY SYSTEM

This provides information about resonator system.

• Hypernasality can be assessed by asking the patient to blow

the checks, blow a balloon, suck through a straw, phonate /i/ and
sustain /s/ and nasal emission during the act can be checked.
The patient can also be asked to read and the clinician can
perceptually assess the nasality. Asking the patient to sustain a
nasal continuant can assess.
• Denasality/Hyponasality/Cul-de-sac: If there is any nasal
passage obstruction then it will result in the failure of
sustaining a nasal continuant.

A very simple test can be done to determine resonance using a

straw, preferably a bending straw or a piece of tubing. The
examiner should place one end of the straw at the entrance to
the child's nose and the other end at the examiner's ear.
The patient will be asked to produce the following types of
speech samples:
• Prolongation of single vowels

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 • Repetition of syllables with pressure-sensitive phonemes,
and high and low vowels (papapapa; pipipipi; sasasasa;
sisisisi; etc.)
• Prolongation of /s/
• Sentences that are loaded with pressure-sensitive phonemes
• Counting from 60-70
• Repetition of nasal consonants (mamamama; nananana)
• Prolongation of /m/

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If sound is heard through the straw on vowels sounds or voiced

plosives, this indicates hypernasality.

If air is heard loudly through the straw on oral consonants, this

indicates nasal emission. If there is not much sound coming
through the straw on nasal consonants, this may indicate
hyponasality or cul-de-sac resonance.

GRBAS

This is a standardized perceptual rating of vocal functioning.

This was introduced by Hirano (1981). GRBAS is a five-point
classification scheme for perceptual ratings of vocal functions, this
includes:

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 G Grade, the severity of hoarseness is quantified under the
parameter. The overall voice quality, integrating all
deviant components. The clinician rates the overall level
of dysphonia where 0 = normal, 1 = mild dysphonia, 2 =
moderate dysphonia, and 3 = severe dysphonia

R Roughness, audible impression of turbulent air leakage

through an insufficient glottic closure may include short
aphonic moments (unvoiced segments). The clinician
rates the level of vocal roughness where 0 = normal, 1 =
mild roughness, 2 = moderate roughness, and 3 = severe
roughness

B Breathiness audible impression of irregular glottic pulses,

abnormal fluctuations in Fo, separately perceived acoustic
impulses (as in vocal fry), includes diplophonia and register
breaks. When present, diplophonia can be additionally
recorded as " d ". The clinician rates the level of vocal
breathiness where 0 = normal, 1 = mild breathiness, 2 =
moderate breathiness, and 3 = severe breathiness
A Asthenia is defined as weakness, lack of energy and
strength, loss of strength. The clinician rates the level of
vocal asthenia (weakness) where 0 = normal, 1 = mild
asthenia, 2 = moderate asthenia, and 3 = severe asthenia

S Strain; The clinician rates the level of

vocal strain where 0 = normal, 1 = mild
strain, 2 = moderate strain, and 3 =
severe strain

0 = normal or absence of deviance

1 = slight deviance
2 = moderate deviance
3 = severe deviance.
GRBAS is auditory perceptual assessment of voice quality.

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 Consensus Auditory-Perceptual
Evaluation of Voice
(CAPE-V)

The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-

V) was developed as a tool for clinical auditory-perceptual
assessment of voice.

Purpose:

• To describe the severity of auditory- perceptual attributes of a

voice problem, in a way that can be communicated among
clinicians.

•To contribute to hypotheses regarding the anatomic and

physiological bases of voice problems and to evaluate the need for
additional testing.

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 The CAPE-V indicates salient perceptual vocal attributes,
identified by the core consensus group as commonly used and
easily understood. The attributes are:

•Overall severity: Global, integrated impression of voice

deviance.

•Roughness : Perceived irregularity in the voicing

source.

•Breathiness : Audible air escapes in the voice.

•Strain : Perception of excessive vocal effort

(hyperfunction).

•Pitch : Perceptual correlate of fundamental frequency.

This scale rates whether the individual's pitch deviates from normal
for that person's gender, age, and referent culture. The direction of
deviance (high or low) should be indicated in the blank provided
above the scale.

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•Loudness : Perceptual correlate of sound intensity. This

scale indicates whether the individual's loudness deviates from
normal for that person's gender, age, and referent culture. The
direction of deviance (soft or loud) should be indicated in the
blank provided above the scale.

In CAPE-V, “MI” refers to "mildly deviant," “MO” refers to

“moderately deviant,” and “SE” refers to "severely deviant."

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 The clinician may place tick marks at any location along the line:

• Ratings are based on the clinician’s direct observations of the

patient’s performance during the evaluation, rather than patient
report or other sources.

•To the right of each scale are two letters, “C” and “I” the clinician
circles the letter that best describes the consistency of the judged
parameter.

•“C” represents “consistent” a judgment of “consistent” indicates

that the attribute was continuously present throughout the tasks.

•“I” represents "intermittent" a judgment of “intermittent”

indicates that the attribute occurred inconsistently within or
across tasks

•The clinician can indicate prominent observations about

resonance phenomena under “Comments about resonance.”

The individual should be seated comfortably in a quiet

environment. The clinician should audio record the individual’s
performance on three tasks: vowels, sentences, and conversational
speech.

In the case of discrepancies across tasks, tick marks should be

labeled with the task number:

• Tick marks reflecting vowel prolongation should be labeled #1

• Tick marks reflecting running speech should be labeled #2.
• Tick marks reflecting story retelling should be labeled #3.

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 Scoring:

After the clinician has completed all ratings, he or she should

measure ratings from each scale.

This can be done by physically measuring the distance in mm from

the left end of the scale. The mm score should be written in the
blank space to the far right of the scale, thereby relating the results
in a proportion to the total 100 mm length of the line.

The results can be reported in two possible ways:

• Distance in mm to describe the degree of deviancy.

• Second, results can be reported using descriptive labels that

are typically employed clinically to indicate the general
amount of deviancy.

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INSTRUMENTAL EVALUATION

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 Naso- VOICE EVALUATION
endoscopy

Imaging Rigid
Techniques endoscope

Voice
Evaluation
MRI

Laryngoscopy Stroboscopy

Imaging
Micro- C T Scan
Techniques
X Ray
laryngoscopy

Ultra
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VOICE EVALUATION
• Essential part of the assessment
• Flexible nasoendoscopy (available in size 3 mm or
smaller) should be a routine part.
• laryngeal anatomy
• vocal fold function

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 • Rigid endoscopes and stroboscopy (with flexible or rigid endoscopes)
• Obtains quantitative and qualitative data on vocal fold function

www.sgh.com.sg

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www.pluralpublishing.com www.laryngograph.com www.kayelemetrics.com

Microlaryngoscopy under general

anesthesia

www.ghorayeb.com, Otolaryngology Houston

www.ghorayeb.com, Otolaryngology Houston

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http://en.wikipedia.org/wiki/Laryngoscope

Laryngoscopy

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www.aic.cuhk.edu.hk www.pennhealth.com

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 VOICE EVALUATION
• Imaging
• PA and lateral neck x-rays
• Ultrasound
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI) of the larynx
• Objective analysis.

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www.glasgowchiropractic.com/digitalxray.htm

Ultra sound

pdb.cc.nih.gov/research/3dultrasound.htm pdb.cc.nih.gov/research/3dultrasound.htm
Prakash Boominathan 50

C T Scan

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www.kuleuven.be/cltr/nl/larynx/ct_overzicht.htm

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 MRI
• Nasal cavity
• Nasopharynx
• Pharynx
• Larynx
• Tongue
• Spinal column
• Spinal cord
• Epiglottis
• Cricoid cartilage

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www.emedicine.com/ent/topic392.htm

VOICE EVALUATION
• Essential part of the assessment
• Flexible nasoendoscopy (available in size 3 mm or smaller) should be a routine part.
• laryngeal anatomy
• vocal fold function
• Rigid endoscopes and stroboscopy (with flexible or rigid endoscopes)
• Obtains quantitative and qualitative data on vocal fold function
• Microlaryngoscopy under general anesthesia
• Imaging
• PA and lateral neck x-rays
• Ultrasound
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI) of the larynx
• Objective analysis.

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PRINCIPLES OF INSTRUMENTAL MEASUREMENT

Speech and voice measure rely on three events, these include

signal detection, signal manipulation and signal reconversion,
the physical phenomenon of these three process are:

1) Detected & input by a device, such as a microphone,

pressure transducer, flow meter/electrode.

2) Manipulated in some form, such as filtering, amplification

or editing for use with a specific type of equipment/analysis.

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 3) Reconverted for output and display in readable form such as
numerical value, oscilloscope tracing/ output through speakers.

For acoustic measurements signal detection generally begins

with the microphone.

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INSTRUMENTAL MEASURES IN THE VOICE

LABORATORY
TECHNIQUE INFORMATION

Stroboscopic imaging of Gross structure

Larynx Gross movement
Vibratory characteristics

Acoustic recording and Fundamental frequency

analysis Intensity
Signal/harmonic to noise ratio.
Perturbation measures
Spatial features.

Airflow rate and volume

Sub glottal (INTRA ORAL)
pressure
Laryngeal resistance
Aero dynamic measurement Phonation threshold pressure.
Electro- Measure of vocal fold contact
glottography area
(EGG)
Photoglottography Measure of glottal area
(PGG)

Electromyography Direct measure of muscle

(EMG) activity used for localization of
muscle.

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 Some of the acoustic parameters that are analyzed include :

• Fo
• Amplitude
• Fo /Amplitude
• Waveform
• Spectrum
• Glottal waveform
• Dynamic aspect.

ACOUSTIC
MEASUREMENTS

Vocal fold movement results in periodic interruption of the

air stream at rates appropriate for the perception of sound.
Acoustics being the study of sound and voice acoustics can
provide important information on vocal fold movement.

Acoustic parameters are easy to record and to analyze

objectively. Acoustic parameters can be measured by
various instruments such as Visi-Pitch or several other
computer programs such as CSL, Dr Specch, SuperScope II
etc

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 Many acoustic signs are associated with a given pathology. Some
are unique and some are redundant. For example, jitter and noise
spectrum may reflect the basic aperiodicity of the basic aperiodicity
of the vibrating vocal folds.

The basis of acoustic analysis is Digital Signal Processing(DSP)of

speech signal. Voice and speech are analogue signals that means its
continuous and time varying.

In DSP (Digital Signal Processing) analogue signal will be

divided into small discrete bits of information that can be
represented numerically. This process is called digitization and
this is achieved by a device called analog to digital (A/D)
converter.
The digital representation is a series of numbers. When an
analogue signal is digitized in two operations is performed
simultaneously. They are:

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1) Discretization in time (i.e.) sampling in the analogue form. They

are sampled at certain time, usually periodically spaced.

2) Discretization of signal amplified (i.e.) Quantization. In which

the continuous amplitude variation of signal is divided into series
of level/step.

There are five steps in analogue to digital process (Kent and read,
1933). These steps include signal conditioning (fitting) and
signal conversion (sampling and quantization).

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 SIGNAL CONDITIONING

• Pre emphasis: Low frequency energy tends to be greater than

high frequency energy in speech signal. Pre emphasis is done
to normalize the strength of acoustic energy across all
frequency so that low frequency energy does not
disproptionally dominate the analysis.

• Pre sampling Filter: A low pass filtering procedure designed

to reject high frequency energy above a specific level and limit
the threat of under sampling the acoustic signal and the
resulting aliasing artifacts.

SIGNAL CONVERSION

• Sampling: Division of time unit of continues signal

into finite units for numerical assignment.

• Quatization: Division of amplitude height in to discrete

steps/level for numerical representation.

• Encoding: The process of assigning numerical value to

discrete points.

Acoustic analysis also includes perturbation measurement,

harmonic to noise ratio, fundamental frequency, phonetogram,
Nasalance, voice onset time, and long term average spectrum.

A Advantages of acoustic measures are its effect of

rehabilitation plan and Indirect influence about severity of
voice pathology. Disadvantages of acoustic measure are that
it does not differentially diagnosis of the source of voice
pathology.

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 The Dysphonia Severity Index (DSI)

The Dysphonia Severity Index (DSI) is designed as an objective

and quantitative correlate of voice quality.

The Dysphonia Severity Index calculates a combination of weights

variables such that the different types of voices according to the
perceived voice quality were optimally identified.

This analysis only four voice characteristics:

• Maximum phonation time (MPT, sec.)

• Highest frequency (Fo-high, Hz)
• Lowest intensity (I-low, dB(A))
• Jitter (%).

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 The DSI is calculated using the following expression:

DSI = (0.13*MPT) +(0.0053*Fo-high)

–(0.26*I-low)– (1.18*jitter) + 12.4.
The DSI is a continuous measure with two anchor points: +5 for
normal voice and -5 for severely bad voice (poor quality). It can
exceed these anchor points in case of respectively excellent or
extreme bad voices.
When the DSI is above 1.6, it can be considered as being normal,
given the wide range of normal voices.

Therapy Outcome Measure DSI

0 Severe persisting aphonia: patient has no voice, is unable to < 4.3
phonate
1 Constant dysphonia: Sporadic periods of phonation, aphonic - 4.2 to –2.3
periods may be present
2 Moderate dysphonia: patient can produce voice, but there are -2.2 to –0.4
frequent periods of dysphonia
3 Slight to moderate dysphonia: less frequent periods of dusturbed - 0.3 to 0.7
phonation or slight persisting dysphonia
4 0.8 to 1.7
Slight dysphonia: sporadic dysphonic moments for short periods

> 1.8
5 No dysphonia

VOICE HANDICAP INDEX

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 The Voice Handicap Index (VHI) was development and validated
was done by Jacobson et al
Patient will be asked to circle the response in the scale of 0 to 4 that
indicates how frequently they have the same experience. 0 indicates
that they have never experienced it followed by
1 - almost never
2 - sometimes
3 - almost always
4 - always

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There are 30 total items that represent 3 areas of concern:

–Emotional impact of voice problem
–Physical impact of voice problems
–Functional impact of voice problems

Each of the subheadings has 10 statements, which describes the

patient’s voices and the effects of their voices on their lives.

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• Outcome measurements of voice disorders are an important new

area for both the evaluation of voice-disordered patients and
evaluation of treatment efficacy.
• A Voice Handicap Inventory is a valid and reliable self-
assessment tool for use by patients to determine their perception of
the severity of their voice.
• The VHI is most often used to measure the changes of the
patient's perception following treatment for four different voice
disorders.
• The VHI shows a significant change following treatment for
unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension
dysphonia.
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 • VHI is a useful instrument to monitor the treatment efficacy for
voice disorders.

• Patients generally differ in their response to cancer and to the

therapeutic interventions used in its treatment.

• Even patients with a similar oncologic site and stage who receive
identical treatment can differ in their own assessment of quality of
life.

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SCORES:
0 to 30 = These are low scores, and indicate that most likely
there is a minimal amount of handicap associated with
the voice disorder.
31 to 60 = Denotes a moderate amount of handicap due to the
voice problem.
60 to 120 = These scores represent a significant and serious
amount of handicap due to a voice problem

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