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156 The Voice and Voice Therapy
FIGURE 62. Advantages and disadvantages of laryngeal examination methods.
Source
ment of the Committee on Speech, Voice, and Swallowing Disorders of the American
Academy of Otolaryngology-Head and Neck Surgery.
Surgery
: Modified from Koufman (2002), Laryngopharyngeal Reflux: Position State-
Otolaryngology-Head and Neck
,
127
(1), 32–35.
CHAPTER 6 Evaluation of the Voice 157
Roles of the Voice Clinician and Physician and Need for a
Medical Evaluation of the Person With a Voice Disorder
The American Speech-Language-Hearing Association (ASHA) Preferred Practice Patterns for the
Profession of Speech-Language Pathology (2004d) state:
A physician, preferably in a discipline appropriate to the presenting complaint, must
examine all patients/clients with voice disorders. The physician’s examination may occur
before or after the voice evaluation by the clinician. (p. 99)
If a patient arrives for treatment for dysphonia but has not had a previous medical examination, the clinician should wait to make treatment recommendations until they have obtained all
necessary medical information. The voice evaluation by the speech-language pathologist may
begin, however, even in the absence of all the medical information. A case history can be taken,
and assessment of respiration, phonation, and resonance can be conducted — only the decision
about whether to begin voice therapy need be deferred until all medical information is obtained.
This deferment is necessary because a patient’s voice may sound a particular way for a number of
reasons, some more serious and complicated than others. For example, a particular patient’s vocal
symptoms may include decreased speaking pitch, pitch variability, and pitch range; decreased
loudness, loudness variability, and loudness range; increased breathiness; voice breaks; and vocal
fatigue. Such complaints are common when there is an additive vocal fold mass. However, such a
mass lesion may take the form of a nodule, for example, which is benign, or it may take the form
of an invasive malignant tumor. Without a complete medical examination, including imaging,
the clinician does not know the etiology of the voice disorder.
The roles of the laryngologist and clinician differ in regard to evaluation of the voice-disordered
patient, although the assessments conducted by each may overlap. In general, the laryngologist’s
primary role is to identify and manage those conditions or diseases that interfere with normal
voice production, while the clinician’s primary role is to evaluate and facilitate voice production
given the known medical status of the patient. Optimally, both professionals work together in
evaluating and managing the patient.
In larger urban cities, patients may have ready access to a voice care team in settings such
as local hospitals and clinics, private otolaryngology practices, or academic medical centers. In
smaller cities or rural areas, however, access may be quite limited. In such cases, patients may have
to travel a considerable distance to see a laryngologist. In such cases, it is important for patients to
understand why they need to see the laryngologist. A brief written note from the referring clinician
can often help facilitate communication between the patient and laryngologist. If the patient is
a child who failed a voice screening, for example, inclusion of the voice screening form may help
the parents to discuss their child with the laryngologist and help focus the child’s examination.
Upon completion of their medical examination, it is equally important for the laryngologist to
communicate the findings to both the patient (or parent, where applicable) and the referring
clinician. Depending on the nature of the medical examination, a variety of written forms may be
used. These written forms may include a narrative/descriptive note stating the medical diagnosis
and findings, record forms for specific types of assessment (such as laryngoscopy), and copies of
photos or videos of the laryngeal and related findings.
158 The Voice and Voice Therapy
Speech-Language Pathology Evaluation of
the Person With a Voice Disorder
In an interview with Thibeault (2007), Bless describes the speech-language pathologist’s role in
the evaluation of persons with voice disorders as follows:
The clinician’s role is to describe the structure and function of the larynx and make recommendations regarding further testing needed to understand the etiology or maintenance of
the voice problem and to make recommendations for treatment. (p. 4)
The ASHA published a comprehensive document titled Preferred Practice Patterns for Speech-
Language Pathology (ASHA, 2004d). Based on this document, consensus guidelines from the
European Laryngologic Society (Lechien et al., 2023) and our many decades of clinical experience,
we present in Figure 6–3 a list of the major components in the evaluation of the voice. We recognize that not every patient will need to undergo all the assessments listed in Figure 6–3, and we
recognize that not every voice clinician will have access to, and be comfortable with, the equipment
needed to conduct all the assessments. It is our intent here to provide sufficient breadth and depth,
knowing that the individual clinician will have the final “voice” in evaluating any given patient.
Review of Auditory and Visual Status
Hearing acuity is important in monitoring and regulating one’s own voice production (Lee, 2012;
Lee et al., 2013, 2015). Thus, hearing loss has the potential to alter respiration, phonation, reso-
FIGURE 63. Components of the comprehensive voice evaluation.
CHAPTER 6 Evaluation of the Voice 15 9
nance, and prosody (Boone, 1966a; Choi, 2014; Guerrero Lopez et al., 2013). For example, an
older patient may have a hearing loss and/or their spouse may have a hearing loss. In this clinical
scenario, there is potential for the patient to develop a functional dysphonia characterized by the
use of inappropriate pitch or loudness and/or glottal attack. Other clinical scenarios include a child
with a congenital hearing loss or a teen or adult with noise-induced hearing loss. It is estimated
that in 2019, about 8% of adults in the United States had hearing loss, which may vary from mild
loss of sensitivity to total loss of hearing (NORC, 2024). The prevalence of hearing loss accelerates
dramatically with age (Yamasoba et al., 2013). It is estimated that 20% of children under the age
of 18 years in the United States have hearing loss (Lieu et al., 2020). When evaluating the patient
with a voice disorder, a hearing screening should be conducted by the clinician when hearing
difficulty is suspected (either by patient self-report or behavioral observation of others) (Bogardus
et al., 2003). Conducting hearing screenings in such a situation is within the ASHA (2016) Scope
of Practice for Clinicians and is addressed in the ASHA (2004d) Preferred Practice Patterns for
Speech-Language Pathology. Cohen and Turley (2009) investigated the co-prevalence of voice
problems and hearing loss in 248 older adult residents living independently in two retirement
communities and reported that nearly 20% had dysphonia, 50% had hearing loss, and just over
10% had both. Persons with hearing loss were more likely to have dysphonia than those without
hearing loss, and persons with both dysphonia and hearing loss had greater depression scores than
those with neither symptom (p. 1987). Park and colleagues (2022) explored the co-occurrence of
presbycusis (age-related hearing loss) and presbyphonia (age-related voice disorder) and assessed
how presbycusis influenced adherence and effectiveness of voice therapy in older adult patients.
The researchers screened individuals aged 65 years and older for both conditions using audiometry,
voice assessments, the Voice Handicap Index-10 (VHI-10), and laryngoscopic exams. Among
221 patients, 56% had presbyphonia, 49% had presbycusis, and 39% were diagnosed with both.
The study further evaluated voice therapy outcomes in 40 presbyphonia patients, comparing
those with and without presbycusis. It was reported that patients with both conditions showed
less improvement in voice function and maximum phonation time after therapy compared to
those with only presbyphonia. However, the presence of presbycusis did not significantly impact
therapy adherence. The authors concluded that a significant number of older adult individuals
experience both presbycusis and presbyphonia, affecting their voice therapy outcomes. Despite
this, adherence to voice therapy remains unaffected by the presence of presbycusis. What remains
unknown in the literature is whether there is a relationship between hearing loss and dysphonia
in younger adults or children. However, there is a wealth of literature that suggests a relationship
between hearing loss and resonance disorders (see Chapters 8 and 10).
Visual acuity is also an important consideration when assessing the person with a voice
disorder. Decreased visual acuity may lead a patient to misjudge their distance from the listener
and to alter their voice in ways that are detrimental. If visual feedback is provided by a mirror
reflecting the patient’s head and body posture, or a computer monitor showing a voice tracing,
it is important that the patient be able to see well. In the case of the alaryngeal speaker who is
learning to use an electrolarynx, visual acuity is important in learning to place the electrolarynx
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in the right location. More than 8 million Americans are estimated to experience blindness, low
vision, or an age-related eye disease, with persons older than age 65 years being the most affected
(Flaxman etal., 2021). This number is expected to double by 2050 (Varma et al., 2016).
160 The Voice and Voice Therapy
Case History
During the case history, the clinician must establish rapport with the patient so that there is an
open and honest sharing of information, and so that the patient will ultimately feel empowered to
change their behavior if called on to do so (van Leer et al., 2008). Behrman (2006) and de Almeida
and colleagues (2013) have written about the concept of motivational interviewing, which centers
on eliciting the patient’s motivation to adhere to behavioral change in a nonthreatening manner.
Behrman also describes certain clinical considerations that may affect resistance, and therefore
adherence, to voice therapy. Such considerations may include a history of controlling interactions
with medical professionals; previous exposure to exaggerated vocal hygiene messages; confusion
regarding vocal identity; failure of other treatment modalities, including voice rest and medical
management; prior experience with nonadherence in voice therapy; and lack of support from individuals in the patient’s life, including business colleagues, friends, and family members (p.216).
The clinically astute clinician monitors their own verbal and nonverbal behaviors during the case
history interview in order to elicit clinically relevant information from the patient in a supportive
and motivating manner.
In the following sections, we provide an overview of the key areas in the case history and
interview. Depending on the particular clinical scenario, one may pursue other areas.
Description of the Problem and Cause
It is valuable to ask patients directly what they feel are the problems and what might have caused
them. It is often effective to ask the same questions of family members, a spouse, or teachers. The
different views about what the problem may be and the various guesses about probable causation may offer tips for management. Patients’ descriptions often reveal much about their own
conceptualization of the problem. What a patient feels the problem is may not be consistent with
the opinions of the referring physician or the clinician, a discrepancy that may be due to what we
call the patient’s reality distance. This distance may be the result of the patient’s lay background
and inability to understand adequately what had been explained. Often, we hear highly discrepant
reports of “what the doctor said” as a patient recounts the diagnoses of previous clinicians. More
often than not, this distance is primarily the result of the patient’s reluctance to accept and cope
with the real problem. An individual’s defenses may force them to describe the problem in a way
that is not consistent with the perceptions of others. What a patient says about a problem, however,
may provide the clinician with insights that no amount of observation or testing can match.
Onset and Duration of the Problem
How long patients believe they have had the voice problem is important. A problem of acute
and sudden onset of a dysphonia usually poses a severe threat to a patient. That is, it keeps the
patient from carrying out their customary activities (playing, singing, acting, selling, preaching,
teaching, campaigning). Sudden onset of aphonia or dysphonia deserves thorough exploration
by both the laryngologist and the clinician. Sometimes dysphonia develops very gradually. Such
a gradual, fluctuating dysphonia is often related to varying situations in which patients may find
themselves; sometimes it occurs only during moments of stress or after fatigue. A history of slow
CHAPTER 6 Evaluation of the Voice 161
onset sometimes suggests a gradually developing pathology, such as the development of Reinke’s
edema or dysphonia that is an early developing symptom of some kind of progressive neurological
disease. Voice therapy, like other forms of remedial therapy, is usually more successful with those
patients who are motivated to overcome their problems. Patients with a long history of indifference toward their dysphonia usually present an additional challenge to the clinician and a more
unfavorable prognosis than the patients who have recently acquired the disorder, depending, of
course, on the type and etiology and relative extent of the pathology involved.
Variability of the Problem
Most voice patients can provide rather accurate timetables of the consistency of their problem. If
the severity of a voice problem is variable, a clinician may be able to identify those vocal situations
in which the patient experiences the best voice and the worst voice. The typical patient with vocal
hyperfunction reports a better voice earlier in the day, with increasing dysphonia later in the day
after more voice use. For example, a high school social studies teacher reported a normal-sounding
voice at the beginning of the day; toward the end of a day, after 6 hours of lecturing, he reported
increasing hoarseness and a feeling of fullness and dryness in the throat. Voice rest and then dinner
at the end of the day usually restored his voice to its normal pitch and quality. Obviously, such
fluctuation in the daily quality of the voice enables the clinician to identify easily the situations
contributing to the patient’s vocal abuse. Another patient, whose dysphonia was related closely to
allergy and postnasal drip experienced during sleep, presented this variation in hoarseness: severity
in the morning on awakening, decrease in severity with use of the voice, complete disappearance
by late afternoon, and severity again the next morning. This pattern is also closely associated with
nighttime laryngopharyngeal reflux.
The variation of the voice problem can reveal which situations tend to aggravate the disorder.
A heavy metal rock band singer reported that she had no voice problem during the day in conversational situations or while practicing with her band. She developed hoarseness only on those nights
she performed. Observation of her performances revealed that the adverse factors were the cigarette
smoke around her, to which she was unusually sensitive, and the noise of the crowd, above which
she had to increase her volume in order to be heard by the audience. Her singing technique was
satisfactory. Adherence to a strict vocal hygiene program that included voice use reduction on the
days of her performances (Zraick et al., 2009) provided her with immediate relief. She was also
encouraged to invest in a more sophisticated and powerful sound system.
Description of Vocal Demand
Abuse, misuse, and overuse of the voice, referred to by some as phonotrauma, cause most functional voice problems. It is important for clinicians to determine how voice patients are using
their larynges in most life situations. The voice a child or adult exhibits in the clinician’s office
may not represent the voice used on the playground, in the classroom, or in other settings. Sometimes patients can re-create some of their aversive laryngeal behaviors as a demonstration for the
clinician, but more often, a valid search for aversive vocal behaviors requires the clinician to visit
the environment where the abuse or misuse occurs. Successful voice clinicians must thus build
into their schedules actual visits to classrooms, playgrounds, theaters, churches, courtrooms, or
162 The Voice and Voice Therapy
other work and social environments. Individuals who may require particularly high vocal demand
include schoolteachers (Nusseck et al., 2022), university professors (Gomes et al., 2020), those in
the performing arts (Franca & Wagner, 2015; Zuim et al., 2021), cheerleaders (Case, 2002), and
fitness instructors (Hamdan et al., 2021; Venkatraman et al., 2023).
Additional Case History Information
It is important to determine at the time of the voice evaluation if the patient has ever had previous
voice therapy. If the patient has, what type of past therapy would have obvious relevance to present
management? When previous voice therapy attempts have failed to improve the vocal quality
or have been unsuccessful in reducing a vocal pathology, the knowledge of previous therapy is
important. We must make every effort, however, to present the appearance of a fresh and different
approach to the patient who has experienced failure in previous voice therapy; even if we use the
same goals of therapy as before, we must redirect the new approach to voice therapy in a manner
that appears to the patient to be headed down a completely different road. Determining whether
other members of the family have similar voice problems is helpful. We have had particular
patients present a certain voice problem, only to interview members of the family and find that all
or many of them have the same voicing patterns. Once a patient is comfortable with an examiner,
or perhaps after voice therapy has begun, a social history should be taken to provide the clinician
with useful information about the patient as a person. One patient spoke with two completely
different voices, constantly shifting between one voice and the other. When we asked why she
used these two voices, she said her first voice was “my voice before I died.” Further case history
questioning revealed that she had been a patient in a mental hospital on two occasions. It became
clear as the interview progressed that she was still having psychological problems and that her voice
disorder was a symptom of a more serious unresolved disorder. She was convinced that she had
died and that she was now a channel for another person who had also died. The different voices
represented different people.
Behavioral Observation
One should keep in mind that observation of our patients often tells us more about them than their
histories and assessment data. Clinicians must become critical observers, attempting to describe
behavior they see rather than merely labeling it. Writing observations about a patient is one of the
few ways clinicians can note what they observe (audio and video recordings are two other means).
Even here, however, it is important for clinicians to minimize any subjectivity by describing only
what they see and hear and not adding interpretation to the observation.
Because voice difficulties are often symptomatic of the inability to have satisfactory interpersonal relationships, it is imperative that the clinician consider the patient’s degree of adequacy as
a social being. Patients who exhibit extremely sweaty palms; who avoid eye contact with people to
whom they are speaking; who speak through clenched teeth; who use excessive postural changes
or demonstrate facial tics; who sit with a masked, nonaffective facial expression; or who exhibit
obvious shortness of breath may be displaying behaviors frequently considered as symptomatic of
anxiety. The struggle to phonate may reflect a struggle to maintain a conversational relationship.
CHAPTER 6 Evaluation of the Voice 16 3
Such observed behavior in the voice patient may be highly significant to the voice clinician planning
a course of voice remediation. The decision about whether to treat a problem symptomatically
(that is, by voice therapy) or by improving the patient’s potential for interpersonal adjustment
(perhaps by psychotherapy) is often aided by a review of the observations of the patient. A patient
who demonstrates friendly, normal affect is telling the clinician, at least superficially, that they
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function well in a two-person relationship; such information may well have clinical relevance. Such
observations are extremely valuable to clinicians planning treatment approaches. Note, however,
that in our experience, very few voice patients require referral for psychotherapy.
Auditory-Perceptual Ratings
Clinicians appear to prefer auditory-perceptual measures to instrumental measures when assessing
dysphonia and documenting therapy progress (Barsties & De Bodt, 2015; Bassich & Ludlow,
1986; Carding et al., 2000). Behrman (2005) surveyed voice clinicians regarding common diagnostic practices in patients referred for therapy with the diagnosis of muscle tension dysphonia.
Each respondent reported that perceptual assessment of voice quality was very important for
therapy tasks such as defining overall therapy goals, defining specific therapy session goals, helping
the patient to achieve a target production, providing reinforcement to the patient, and measuring
treatment outcome. The clinician’s perceptual assessment of voice quality occurred significantly
more commonly than stroboscopic, acoustic, aerodynamic, and electroglottographic assessments.
Behrman concluded that “efforts to make voice quality assessment standard and strengthen perceptual scaling methods appear well justified, given its dominant role in voice evaluations” (p. 468).
When performing an auditory-perceptual evaluation of voice quality, clinicians should consider
a number of factors that might influence their resulting judgments (Kent, 1996). According to a
seminal paper by Kreiman and colleagues (1993), these factors include the nature of the speaking
task (Chaves et al., 2017; Law et al., 2012; Zraick, Birdwell et al., 2005; Zraick, Wendel et al.,
2005), listener experience and training (Chan & Yiu, 2006; Eadie & Baylor, 2006; Eadie, Kapsner,
et al., 2010; Eadie, Van Boven, et al., 2010; Misono & Merati, 2012), the use of anchors (Awan
& Lawson, 2009; Chan & Yiu, 2002; Eadie & Kapsner-Smith, 2011), the type of rating method
used (Eddins & Shrivastav, 2013; Feinstein et al., 2023; Patel et al., 2010) and the language used
to describe aspects of the human voice (Kreiman, 2024). A number of different voice perceptual
scales are available for clinical use, but two seem to be used most in current clinical practice. The
first is the GRBAS scale (Hirano, 1981), and its revision, the GRBAS-Extended (Ricci-Maccarini
et al., 2022), and the second is the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V)
(Kempster et al., 2009).
The GRBAS scale was developed by the Committee for Phonatory Function Tests of the
Japanese Society of Logopedics and Phoniatrics. Each parameter on the GRBAS scale represents
a dimension of phonation: G (grade) represents the overall severity of voice abnormality, R represents roughness, B represents breathiness, A represents aesthenic (weak), and S represents strain.
The GRBAS uses a four-point, equal-appearing rating scale of 0 (normal) to 3 (extreme) for all
five parameters.
The Extended GRBAS scale (Ricci-Maccarini et al., 2022) builds on the standard GRBAS
scale by adding eight perceptual parameters, aimed at providing a more complete assessment
164 The Voice and Voice Therapy
of voice changes, particularly after phonosurgery. The eight added perceptual parameters were
found to be valuable for the assessment of dysphonia, with significant correlations found between
perceptual evaluations and acoustic analysis. The Extended GRBAS scale is a useful and reliable
tool for clinicians for a comprehensive perceptual evaluation of dysphonia, offering improvements
over the standard GRBAS scale by including additional parameters for a more nuanced voice
assessment.
The CAPE-V was drafted following the Consensus Conference on Auditory-Perceptual
Evaluation of Voice held at the University of Pittsburgh in June 2002. The conference, sponsored
by ASHA’s Special Interest Group 3 (Voice and Voice Disorders), brought together researchers
and clinicians interested in the problem of measuring voice quality. A working group drafted
the instrument known as the CAPE-V following the conference (Kempster et al., 2009). The
CAPE-V shares several of the parameters of the GRBAS scale. Judges rate six aspects of voice
(Overall Severity, Roughness, Breathiness, Strain, Pitch, and Loudness) by placing a tick mark
on a 100-mm horizontal line. The instrument includes two unlabeled scales in the event a voice
includes other significant features (e.g., tremor).
Zraick and colleagues (2007, 2011) validated the CAPE-V for use with adults in a national,
multicenter study sponsored by ASHA. This study examined agreement for expert clinicians’
ratings of dysphonia using the CAPE-V and the GRBAS. There was also an assessment of interrater and intrarater reliability across both scales. It was reported that expert clinicians’ perceptions
of dysphonia appeared to be reliable and unaffected by rating instrument, and that the CAPE-V
appeared to be more sensitive than the standard GRBAS to small differences within and among
patients. Additional studies have further examined the clinical use of the CAPE-V (Chen etal.,
2018; Helou et al., 2010; Karnell et al., 2007; Kelchner et al., 2010; Khoramshahi et al., 2018;
Mozzanica et al., 2013; Nagle, 2022; Narea-Veas et al., 2023; Núñez-Batalla et al., 2015; Solomon
et al., 2011). Clinicians are urged to administer the CAPE-V following instructions that can be
downloaded (https://prep.asha.org/siteassets/uploadedfiles/asha/sig/03/cape-v-procedures-andform.pdf), as there is a recent report of lack of fidelity that may affect ratings (Lodhavia &
Kempster, 2024). Clinicians are also cautioned to use the official version of the CAPE-V form
that can be downloaded for noncommercial use (https://www.asha.org/form/cape-v/). Use of the
nonofficial version of the CAPE-V may influence the ratings obtained (see Nagle et al., 2014).
Figure 6–4 shows a CAPE-V form completed for a 37-year-old woman with primary muscle
tension dysphonia.
Fujiki and colleagues (2022) investigated if SLPs can use auditory-perceptual voice assessments to predict the medical urgency of voice disorders. SLPs assessed 25 voice samples, covering
a spectrum of dysphonia severity and diagnoses, including benign lesions, laryngeal cancer, and
various forms of laryngeal dysfunction. Particularly urgent cases were defined as those involving
laryngeal cancer and severe unilateral laryngeal paralysis. Initially blinded to patient information,
SLPs judged the severity of voice quality, guessed the diagnosis, and decided on the urgency of
a laryngologist consultation. Once provided with basic medical histories, they reevaluated the
medical urgency. Findings showed that without patient information, SLPs correctly identified
65% of urgent and 87% of nonurgent cases. These figures significantly improved for urgent
cases with added medical history, though accuracy slightly declined for nonurgent cases. Notably,
SLPs were more accurate with severe dysphonia in urgent cases and mild dysphonia in nonurgent
cases. Factors like smoking history and dysphonia severity significantly influenced their decisions,
although their diagnostic accuracy for specific conditions was low. In conclusion, combining
FIGURE 64. A CAPE-V form. Reprinted with permission from Consensus Auditory-Perceptual
Evaluation of Voice: Development of a Standardized Clinical Protocol by G. B. Kempster, B.
R. Gerratt, K. Verdolini Abbott, J. Barkmeier-Kraemer, and R. E. Hillman.
of Speech Language Pathology
Language-Hearing Association. All rights reserved. Figure courtesy of Nancy Solomon, PhD.
, 18(2), 124–132. Copyright 2009 by the American Speech-
American Journal
165