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146 The Voice and Voice Therapy
individuals with PD. Subjects were individuals with PD without DBS, individuals with PD
with DBS, and neurologically healthy controls. Results suggested that the individuals with DBS
demonstrated similar speech movements to their healthy control peers in terms of distance and
speed; however, changes in speaking rate, as measured by sentence duration, appeared to be similar
to individuals without DBS.
Check Your Knowledge
1. Describe the underlying deficits of PD.
2. Why is a holistic approach to PD advocated by the authors? What is
meant by the term holistic?
Cerebrovascular Accident
Cerebrovascular accident (commonly referred to as stroke) is the fifth leading cause of death in the
United States, behind heart disease, cancer, COVID-19, and unintentional injuries, according to
the Centers for Disease Control and Prevention (n.d.). It affects as many as 5% of the population
over 65 years old, and this number is growing annually due to the aging population. A significant
portion of stroke patients who initially survive are faced with the risk of aspiration as well as
quality-of-life issues relating to impaired communication (Chleboun et al., 2021; Feigin et al.,
2003).
Voice and connected speech changes in CVA are complex and highly dependent on the nature
and site of lesion. Vocal fold paralysis as a direct result of stroke is rare and is most commonly
associated with brainstem stroke, lateral medullary syndrome, Wallenberg syndrome, and Horner
syndrome (Sawalha et al., 2021). Vasan and colleagues (2023) investigated the prevalence of vocal
fold paralysis after ischemic and intracerebral hemorrhagic stroke in inpatient populations over
a span of 20 years. They found that both CVA types accounted for 0.1% of in-hospital vocal
fold paralysis.
In the absence of vocal fold paralysis, voice quality is characterized principally as either spastic
or flaccid. Spastic voice changes are common with UMN lesions, as seen in bilateral CVAs (Duffy,
2020). Speech is characterized by slowed articulation, strained voice quality, and hypernasality (see
Video 5–3). In contrast, flaccid voice changes result from a LMN lesion in the brainstem, principally
from loss of muscle tone and reflexes. Speech is characterized by a breathy voice quality with diminished loudness and air wastage, hypernasality, and distorted articulation (Aronson, 1985; Lévêque
et al., 2022).
Laryngeal stroboscopy is a key procedure in the diagnosis of laryngeal dysfunction in CVA.
Stroboscopy provides an assessment of the mucosal wave, which is abnormal in subtle paresis or
atrophy of the vocal folds (Altman et al., 2007). Sensation can also be tested by touching the endoscope tip to the arytenoids bilaterally, where a strong vocal fold closure should be elicited. Pooling
of secretions in the hypopharynx suggests impairment of sensation or secretion management.
CHAPTER 5 Neurogenic Voice Disorders 147
Though not as commonly used, laryngeal electromyography (LEMG) is helpful in the assessment
of immobility of one or both vocal folds (Chadwick & Sulica, 2020; Munin et al., 2003).
Treatment of laryngeal dysfunction in stroke encompasses four major areas: (a) tracheotomy/
airway management, (b) dysphagia/aspiration, (c) secretion management, and (d) dysphonia.
Review of the first three areas is beyond the scope of this text; the interested reader is referred to
Altman and colleagues (2007) for an overview. Treatment of dysphonia involves managing glottic
incompetency due to vocal fold paralysis, a topic covered earlier in this chapter.
Traumatic Brain Injury
TBI is the result of external forces acting on the head. Most TBIs are caused by motor vehicle accidents, falls, assaults and explosion injuries experienced by members of the armed forces (Norman
et al., 2021; Shively & Perl, 2012). These injuries can cause focal or diffuse lesions, axonal shearing,
and hypoxia, all of which can be secondary to vascular or tissue damage.
Dysarthria associated with TBI may be temporary or chronic, mild or severe, and accompanied or not by other language and cognitive disorders. Most dysarthrias are of the mixed type, and
variability in the nature and severity of the physiological impairment calls for custom treatment
programs based on a clear appreciation for the subsystems of respiration, phonation, resonance,
articulation, and prosody. For example, patients presenting primarily with pontocerebellar axonal
injuries may demonstrate ataxic symptoms of paradoxical breathing patterns and velar mistiming.
For these patients, we emphasize the voice facilitating approaches of auditory feedback, counseling, and respiratory training (see Chapter 7). Other patients with more involved injuries of
the motor system bilaterally may present with spastic dysarthria and have lower vital capacities
than nondisabled speakers (Murdoch et al., 1994). Kinematics of the group studied by Murdoch
and colleagues revealed that the speakers with TBI have problems coordinating the actions of the
rib cage and abdomen during speech. This lack of coordination is apparent in patients with TBI,
many of whom take replenishing breaths at inappropriate phrase junctures during conversational
speaking and oral reading tasks. For these patients, we advise intervention focusing on altering the
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pitch (usually slightly upward) and reducing vowel duration within words. Auditory and visual
biofeedback is critical for this population to increase meta-awareness of speaking deficits and
strategies that increase naturalness of conversational speech.
Summary
At the beginning of this chapter, we looked at the neurological bases of human laryngeal function.
We reviewed the latest research in behavioral, pharmacological, and surgical management of neurogenic voice disorders and listed a number of voice facilitating approaches that have been effective
for many patients presenting with dysarthria (see Chapter 7). The key to effective behaviorbased intervention for patients presenting with static or progressive neurogenic dysphonia is
an understanding of the nature of deficits in the subsystems of speech and knowing how to
address them.
148 The Voice and Voice Therapy
CLINICAL CONCEPTS
The following clinical concepts correspond with the objectives at the beginning of this
chapter.
1. Changes in speech can be the first or only manifestation of neurogenic disease.
Recognition of these changes can have a significant impact on medical diagnosis and
care. The SLP may be the first professional to recognize the breakdown of a single
system, such as in idiopathic UVFP, or multiple subsystems, such as ALS.
2. In many cases, strengthening the vocal muscles and improving voicing technique in
UVFP result in very good voice quality. The voice facilitating approaches of head
positioning, establishing a new pitch, focus, and auditory feedback (see Chapter 7)
should be explored in patients with UVFP.
3. Holistic approaches to the hypokinetic reductions in many of those with PD are
effective in increasing respiration, phonation, and articulatory range of motion and
accuracy. Auditory feedback and visual feedback are effective strategies for helping to
maintain these improvements.
4. Laryngeal dystonias (SD and vocal tremor) originate from neurogenic etiologies,
whereas MTD is of a functional nature. SLPs are skilled in the differential diagnosis
of each of these disorders and often work collaboratively with ENTs to identify and
manage these patients.
5. Voice and speech problems originating from TBI are multifactorial in nature and call
for custom treatment programs based on a clear appreciation of the subsystems of
respiration, phonation, resonance, articulation, and prosody.
GUIDED READING
Read the following articles:
Marques, J. A. S., Marronnier, A., Crampon, F., Lagier, A., & Marie, J. P. (2020). Early
management of acute unilateral vocal fold paralysis: Update of the literature. Journal of
Voice, 6, 924–926.
Sano, D., Matsushima, K., Isono, Y., Ikui, Y., Kinutani, Y., Chiba, Y., & Oridate, N. (2020).
Long-term treatment outcome of type 1 thyroplasty using novel titanium medicaliza-
tion thyroplasty implant combined with arytenoid adduction for unilateral vocal cord
paralysis: Single arm interventional study at a single institution. Laryngoscope Investiga-
tive Otolaryngology, 5(5), 895–902.
Torrecillas, V. F., Hoffman, M. R., Schiffer, B., Keefe, K., & Smith, M. E. (2024). Long-
term outcomes and revision rates in laryngeal reinnervation. Laryngoscope, 134(7),
3187–3192.
Compare and contrast the three current approaches to UVFP.
CHAPTER 5 Neurogenic Voice Disorders 14 9
Read the following article:
Bouhabel, S., & Hartnick, C. J. (2018). Current trends in practices in the treatment of
pediatric unilateral vocal fold immobility: A survey on injections, thyroplasty and nerve
reinnervation. International Journal of Pediatric Otorhynolaryngology, 109, 115–118.
Compare and contrast approaches to UVFP between adult and child populations.
Read the following article.
Parveen, S. (2020). Parkinson disease bootcamp: An education program for individuals with
Parkinson disease and their families. Perspectives of the ASHA Special Interest Groups, 5,
654–657.
Describe how you would go about organizing an educational program in your community
for individuals with PD and their families.
PREPARING FOR THE PRAXIS
Directions: Please read the case study and answer the five questions that follow.
John is a 60-year-old high school teacher who presented to our clinic with a 14-month
history of a progressive dysphonia following removal of his thyroid gland. A suspected
vocal fold paralysis had been ruled out by his ENT. We performed a follow-up rigid
endoscopy at our clinic and observed normal vocal fold mobility. Our endoscopic findings
further revealed that the ventricular vocal folds tended to move toward the midline upon
phonation, thus damping the vibration of the true vocal folds and interrupting the mucosal
wave. Thick, sticky mucus was seen throughout the laryngeal vestibule, and pachydermia
was observed at the posterior commissure. The patient presented with a strained voice
that was occasionally choked off during the clinical interview. He reported that at times
the voice improved, during singing or whistling, but otherwise, it was becoming harder
and harder to force the voice out. The dysphonia was threatening his job as a teacher and
coach, and he could no longer enjoy normal outings with his family. Voice facilitating
approaches of focus and inhalation phonation resulted in easier vocal quality for a few
phonatory attempts, but the strained quality and vocal arrests soon returned.
1. Based on the patient’s history and perceptual findings, respond to the following:
Aunilateral vocal fold paralysis was originally suspected in this case because of
surgical intervention in the vicinity of cranial nerve:
A. X
B. V
C. XII
D. XI
150 The Voice and Voice Therapy
2. The involvement of the ventricular vocal folds during voicing attempts is most likely
associated with a(n):
A. Maladaptive behavior adopted to try to compensate for the irregular vocal
fold arrests
B. Result of laryngopharyngeal reflux
C. Ataxic dysarthria
D. Precursor to hypokinetic dysarthria
3. The voice facilitating approach of focus was probed in an attempt to:
A. Move voiced energy from the larynx to the face
B. Increase vocal amplitude
C. Increase pitch
D. Increase vocal fold closure
4. This patient is most likely presenting with:
A. Adductor spasmodic dysphonia
B. Myasthenia gravis
C. A primary muscle tension dysphonia
D. Essential tremor
5. The gold standard medical approach to this disorder calls for:
A. BTX-A injections
B. Vocal fold augmentation
C. Medialization thyroplasty
D. Laryngeal massage
CHAPTER 6
EVALUATION
OF THE VOICE
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Describe the screening process for voice disorders.
●
Identify the components of the medical evaluation of the voice-disordered patient.
●
Explain the importance of the case history.
●
Describe the noninstrumental assessment of voice.
●
Describe the instrumental assessment of voice.
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152 The Voice and Voice Therapy
hen encountering a patient presenting with a voice disorder, the clinician begins a
systematic process of assessment, evaluation, and diagnosis. Assessment is the process
W
the implications and significance of the assessment. Diagnosis calls for the clinician to make a
decision about whether a problem exists and, if so, differentiating it from other, similar problems.
In a medical model, diagnostic emphasis is on identification of possible causes and maintaining
factors (Paul, 2014).
such, the voice evaluation must be a carefully and scientifically validated procedure performed by
a competent clinician. Ideally, the voice assessment should follow examination of the patient
by a laryngologist (an ear, nose, and throat [ENT] physician with special knowledge of the larynx
and voice). In instances where a patient is assessed prior to examination by the laryngologist, the
speech-language pathologist (“clinician”) should reserve diagnosis and treatment planning until
results of the medical assessment can be evaluated. While it is the province of the laryngologist
to make a laryngeal diagnosis, and to establish and oversee a medical management plan, it is the
province of the clinician to make a voice diagnosis and to establish and carry out a voice therapy
plan. Although we present the comprehensive voice evaluation here as a separate chapter, it is
important for the reader to appreciate that effective voice therapy requires continuous assessment
and evaluation. While we believe in the value of using appropriate instrumentation for assessment,
the knowledgeable and skilled clinician is the one who is of ultimate value in the evaluation,
diagnosis, and treatment of the patient with a disordered voice. We begin this chapter with a
brief discussion about screening individuals for voice disorders. An overview of the laryngologist’s
evaluation of the larynx follows. We then present detailed information about the comprehensive voice evaluation, emphasizing the role of the speech-language pathologist (SLP). We
conclude with three case studies that will help the reader put the information in this chapter into
clinical context.
of collecting relevant data for clinical decision-making. Evaluation is an appraisal of
The results of the voice evaluation serve as the foundation for a sound treatment plan. As
Screening for Voice Disorders
As discussed in Chapter 1, the actual prevalence of voice disorders in children is difficult to
determine. A number of researchers have concluded conservatively that approximately 5% to
10% of school-age children may have a voice disorder (Almero et al., 2021; Balakrishnan et al.,
2023). Dysphonia may be more prevalent in children with adenotonsillar issues (Lee et al., 2021)
and in children who are vocally untrained singers (Pribuisiene et al., 2020). Kahane and Mayo
(1989) suggest that the majority of children with voice disorders are not seen by a clinician.
A number of studies indicate that children with voice disorders make up less than 5% of any
given school-based clinician’s caseload (Marcus et al., 2013; Şenkal & Çiyiltepe, 2013; Teten
et al., 2016).
Individuals other than the school clinician often identify the majority of children with voice
problems (Davis & Harris, 1992). Typically, the child’s teacher, nurse, or family member first
notices a vocal feature such as harsh quality. The ability of such individuals to make accurate judgments about the normalcy of voice is not quite as good, however, as that of an experienced clinician
CHAPTER 6 Evaluation of the Voice 15 3
(McFarlane et al., 1991). Therefore, rather than relying on other well-meaning individuals to refer
children for therapy, the clinician should develop screening procedures for the early identification
of children with voice problems.
Most public and private schools have screening programs to identify speech and language
disorders in new students and those in certain grades at specified times of the year. By using some
kind of voice screening form, clinicians are better able to identify and document those children
in need of voice assessment and potential treatment. With very little additional testing time per
child (5 min or so), a voice screening can be added to existing speech and language screening
protocols. The importance of identifying and managing voice disorders in children cannot be
overemphasized because dysphonia can have an impact on a child’s educational and psychosocial
development, as well as the child’s physical and emotional health (Brower et al., 2020; Connor
et al., 2008).
Clinicians in various settings have developed different voice screening forms. The items on
the screening form usually represent the aspects of voice that the clinician considers important
for identifying children who may be having voice problems. The screening form helps clinicians
focus, organize, and report their listening observations.
The Quick Screen for Voice (Lee et al., 2004, 2005) assesses respiration, phonation, and reso-
nance within approximately 10 min and suits students from preschool to high school. During its
administration, clinicians make observations based on spontaneous conversation, picture descriptions, imitated sentences, recitations, counting, and other vocal activities. If a student displays one
or more production disorders in any section, they fail the screening. Field tests on 3,000 children
across kindergarten, first, and fifth grades, plus 47 preschoolers, showed about 10% of preschool
students failed, aligning with prevalence rates in existing literature. A checklist directs parents,
teachers, and caregivers to identify functional indicators of voice disorders. This approach increases
awareness of potential causes for voice issues and provides SLPs with vital identification information. The third tool, a brochure, offers essential insights into voice disorders and emphasizes the
importance of medical examinations, particularly laryngeal exams, for those identified with voice
problems. By distributing this brochure, SLPs take an active role in educating parents about the
critical need for professional evaluation and management of voice disorders.
The Dysphonia Risk Screening Protocol (DRSP) (Nemr and colleagues, 2016) has 18 questions designed to evaluate an individual’s risk of dysphonia by analyzing vocal assessments and
risk factors in different age groups. With 365 participants across children, adults, and seniors,
the protocol includes a set of 18 questions and utilizes a visual analog scale for risk calculation. The questions cover self-assessment of voice quality, history of voice disorders, signs and
symptoms related to voice, voice use outside of work, dietary habits, hydration levels, medication
use, exposure to smoking, sleep quality, history of illnesses affecting the voice, any treatments
or surgeries undergone, family history of voice problems, dynamics within the family, physical
activity levels, and leisure activities that involve voice use. Speech samples and 6-month followup acoustic analyses provide confirmation of dysphonic or nondysphonic classification. The
findings reveal distinct mean total scores between dysphonic and nondysphonic groups across
all samples, with high sensitivity and specificity. This suggests that the protocol is a valuable
tool for identifying dysphonia risk, supporting its use in voice clinics for early detection and
intervention.
154 The Voice and Voice Therapy
Hseu and colleagues (2023) explored the link between dysphonia history, vocal assessments,
and laryngeal findings to improve referral practices. A review of 459 pediatric patients from a
clinic over 4 years included evaluations of symptoms, examinations, CAPE-V, and pVHI scores.
Most patients were boys, with the average first visit at 8.6 years old. Boys also tended to have more
severe dysphonia scores. Longer symptom duration correlated with higher severity scores. Over
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two-thirds of patients were advised to undergo treatment, indicated by higher CAPE-V scores.
The study suggests referrals to voice clinics for children with dysphonia lasting over 3 months or
those with severe symptoms.
Medical Evaluation of the Person With a Voice Disorder
Sataloff (2017) has written extensively about the history taking and physical examination of
patients with voice disorders. They suggest the use of a history questionnaire (often completed in
advance) to help the patient document all the necessary information, sort out and articulate their
problems, and save office time in recording information (p. 138). Figure 6–1 lists the essential
items covered in such a questionnaire. Depending on the nature of the patient’s chief complaint
and symptoms, the clinician may pursue additional areas of questioning.
A detailed history and interview often suggest the cause of a voice disorder; however, a comprehensive physical examination is still necessary to confirm or rule out certain medical conditions
that may require the laryngologist to consult with specialists such as neurologists, pulmonologists, endocrinologists, psychiatrists, internists, physiatrists, and others with special knowledge of,
and interest in, voice disorders. Physical examination should include an assessment of general
physical condition, and a thorough ear, nose, and throat evaluation. Depending on the patient’s
age and observed signs, additional areas of examination may be pursued (McMurray, 2003; Pontes
et al., 2006).
Visual inspection of the larynx is perhaps the most important in terms of understanding
the cause of a voice disorder and its potential for treatment. There is a rich history of research
supporting the importance of laryngoscopy in the diagnosis of voice disorders (see Kendall and
Leonard [2011] for a historical perspective). Office-based visual examination of the larynx traditionally takes one of two forms: mirror laryngoscopy or endoscopic laryngoscopy (more commonly
referred to as laryngeal endoscopy). In mirror laryngoscopy, a small laryngeal mirror is placed at
the back of the patient’s mouth, and light is shone on the mirror from the physician’s headset.
If the mirror is angled properly, a reflected view of the hypopharynx can be seen. In laryngeal
endoscopy, either a rigid fiber-optic scope is placed in the mouth or a flexible fiber-optic scope is
passed through one of the nasal passages. The rigid laryngoscope has a prism at the end that directs
light and receives images at an angle of either 70° or 90°, permitting optimum visualization of the
normal inverted-V position of the vocal folds. Figure 6–2 lists the advantages and disadvantages
of these indirect laryngeal examination methods.
The information gained from laryngoscopic visualization of the larynx has often been the most
important information gained during the diagnostic assessment (Sulica, 2013). When coupled
with the other information, visualization of the larynx has greatly improved our accuracy of
diagnosis and set the foundation for successful voice therapy plans.
FIGURE 61. Sample medical history questions.
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