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186 The Voice and Voice Therapy
TABLE 69. Voice Range Profile Measures for Adult Females With
Dysphonic Voices Versus Adult Females With Normal Voices
Measures Dysphonic (n = 90) Normal Voice (n = 35)
Frequency Measures Mean SD Mean SD
Lowest frequency (Hz) 127.65 20.99 115.01 12.00
Highest frequency (Hz) 854.98 251.25 1232.85 221.42
Total number of semitones 32.36 6.39 40.89 3.73
Intensity Measures Mean SD Mean SD
Lowest intensity (in dB) 60.64 7.41 48.91 3.12
Highest intensity (in dB) 109.28 5.18 105.66 6.12
Total intensity range (in dB) 48.63 8.06 56.74 6.29
Source: Measures as reported by Ma and colleagues (2007).
example, Figure 6–14 shows electroglottograms for a prolonged /i/ vowel produced with
a normal voice quality, a breathy voice quality, and a hoarse voice quality.
By standardizing the collection, recording, and analysis of acoustic data, the recommended protocols aim to improve the reliability and comparability of vocal assessments. This, in turn, enhances
the evidence base for the management of voice disorders, enabling more effective evaluation and
treatment strategies.
Intensity Variability
Intensity variability is the range of intensities used in connected speech. Normal voices have
some intensity variability, perceived by the listener as acceptable changes in intonation. In
some dysphonic speakers, however, intensity can be either more or less variable than expected
or tolerated by the listener. In connected speech, decreased intensity variability may be perceived as monoloudness. Abnormal intensity variability may have either a physiological etiology
(such as Parkinson’s disease, vocal fold paralysis, or hearing loss) or may result from learned
behavior. Intensity variability is measured in terms of the SD from the average intensity. This
SD reflects the range of intensities around the average intensity (measured in dB SPL). Intensity
SD for a neutral, unemotional sentence is around 10 dB, but it can be higher depending on the
speaker’s mood.
Dynamic Range
Dynamic range is the physiological range of intensities, from the softest nonwhisper to the loudest
shout, that the patient can produce without undue physical strain. Speakers rarely speak at either
CHAPTER 6 Evaluation of the Voice 187
A
B
C
FIGURE 614. Electroglottograms. These three
electroglottograms are productions of the /i/
vowel with normal vocal quality (A), breathy
quality (B), and hoarse vocal quality (C). The
normal trace (A) demonstrates a sharp vertical
rise, a narrow peak, an even return to baseline,
and a substantial closed phase. Trace B, the
breathy voice quality, is represented in the
sloping voice onset, rather than the vertical
rise seen in the normal trace and the long open
phase. Trace C, the hoarse voice, is indicated by
the lack of a uniform waveform from one cycle
to the next.
end of their dynamic range (approximately 40 to 115 dB) for extended periods. Therefore, the
clinician should focus attention on the dynamic range available to the patient around their habitual
loudness. Table 6–10 presents data on select lung volumes and capacities across the lifespan (Siupsinskiene & Lycke, 2011). The dynamic range depends on the F0 produced. It tends to be greatest
for F0 in the midrange and less for F0 that is much lower or higher (Ferrand, 2007). The fact
that F0 and intensity co-vary leads some to propose the use of the VRP to assess some patients.
Aerodynamic Analysis of the Voice
Aerodynamic analysis of the voice is also becoming increasingly more possible and common in
clinical practice. Aerodynamic measures reflect the patient’s ability to use the larynx to regulate
the flow of air for phonation. Prior to quantitatively assessing respiration, we suggest carefully
188 The Voice and Voice Therapy
TA BLE 6 10. Group Means of Seven Age Groups of Subjects for
Some Lung Volumes and Capacities (in Cubic Centimeters)
Subjects’
Age Group 7 10 13 16 25 50 75
Males
TLC 2120 3140 4330 6200 6740 7050 6630
VC 1670 2510 3550 5080 5350 5090 4470
FRC 980 1400 1970 2940 3120 3460 3440
ERV 530 770 1180 1810 1730 1500 1280
Females
TLC 2070 2980 3740 4980 5030 5310 4860
VC 1580 2340 2999 3780 3930 3600 2940
FRC 970 1430 1690 2560 2420 2930 2590
ERV 480 780 940 1350 1320 1220 670
Note: ERV = expiratory reserve volume; FRC = functional residual capacity; TLC = total lung capacity;
VC = vital capacity.
Source: Adapted from Hoit and Hixon (1987); Hoit, Hixon, Altman, and Morgan (1989); and Hoit,
Hixon, Watson, and Morgan (1990).
observing the patient’s breathing patterns. An inefficient breathing pattern or a lack of coordination
between inspiratory and expiratory movements can contribute to dysphonia. For example, the
patient may have to take more frequent breath groups or may adopt increased musculoskeletal tension resulting in vocal hyperfunction. There are three basic types of breathing patterns:
clavicular, thoracic, and diaphragmatic-abdominal, as described here:
●
Clavicular breathing. This inefficient type of breathing is probably the easiest to
identify. The patient elevates the shoulders on inspiration, using the neck accessory
muscles as the primary muscles of inspiration. This upper chest breathing, characterized
by noticeable elevation of the clavicles, is unsatisfactory for good voice for two reasons.
First, the resulting weak and shallow inspiration does not provide adequate respiratory
support for speech and voice. Second, overuse of many of the neck accessory muscles
for respiration (particularly the sternocleidomastoids) may cause an increase in laryngeal
tension (Prater et al., 1999).
●
Thoracic breathing. This type of breathing is characterized by expansion of the thorax
and contraction of the abdomen during inspiration, reversed during expiration. It is the
normal breathing pattern for most people. In some cases, however, thoracic breathing
can be characterized by shallow breathing punctuated by breath holding or gasping.
CHAPTER 6 Evaluation of the Voice 18 9
●
Diaphragmatic-abdominal breathing. This may well be the preferred method of
respiration, especially if the patient has heavy vocal demands, as in singing or acting.
This breathing pattern is characterized by abdominal and lower thoracic expansion
on inspiration, with little noticeable upper chest movement, and a gradual decrease in
abdominal and lower thoracic prominence on expiration.
Hixon and Hoit (1998, 1999, 2000) have written extensively about the clinical evaluation of
speech breathing and have also published a comprehensive text on the evaluation and management
of speech breathing disorders (Hixon & Hoit, 2005). In their writings, these authors emphasize
the role of the speech breathing case history in the evaluation of patients. The speech breathing
case history described by Hixon and Hoit (2005) includes the following sections: (a) alerting
signs and symptoms; (b) airway risk factors; (c) medical evaluations, diagnoses, and treatments;
(d)breathing and speaking experiences; and (e) client perceptions of speech breathing. Figure 6–15
lists some of the alerting signs and symptoms described (p. 196), and Figure 6–16 lists some of
the abnormal client perceptions of speech breathing (pp. 200–201).
Our clinical protocol includes assessment of (a) lung volumes and capacities, (b) air pressure,
(c) airflow, and (d) laryngeal resistance. In the sections that follow, we briefly describe each measure
and the equipment needed.
Lung Volumes and Capacities
Part of evaluating respiratory adequacy is measuring the patient’s lung volume. Lung volumes
refer to the amount of air in the lungs at a given time and how much of that air is used for various
purposes, including speech (Solomon & Charron, 1998). Only a small amount of the air in the
lungs is exchanged during a single quiet respiratory cycle. The total volume of the lungs can be
divided into volumes and capacities (see Table 2–1). Lung volumes, also known as respiratory
volumes, refer to the amount of air in the lungs at a given time and how much of that air is
used for various purposes, including speech (Solomon & Charron, 1998). Respiratory volumes
FIGURE 615. Alerting speech breathing signs and symptoms.
190 The Voice and Voice Therapy
FIGURE 616. Abnormal client perceptions of speech breathing.
include tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual volume.
Lung capacities combine two or more of the respiratory volumes and include inspiratory capacity,
vital capacity, functional residual capacity, and total lung capacity. These volumes and capacities are useful for diagnosing problems with pulmonary ventilation (Bajc et al., 2004; Moini,
2012). Respiratory volumes and capacities vary depending on the patient’s age, gender, level
of physical exertion, and vocal training. Data reported by Hoit and Hixon (1987) and Hoit
and colleagues (1989, 1990) indicate that, in general, lung volumes and capacities increase from
infancy through puberty and then remain stable until advancing age, when they decrease slightly
(see Table 6–10).
Air Pressure
Various air pressures are necessary for speech, including pressure inside the lungs, pressure below
the vocal folds, and pressure inside the oral cavity. Air pressure is measured and expressed in
units of cm H
or more, yet the pressure needed for conversational speech is only around 5 to 10 cm H
O. The total pressure that a person can generate may be as high as 50 cm H2O
2
2
O.
Greater pressures than this may be required, however, depending on syllable stress and loudness
demands (Stathopoulos & Sapienza, 1997). Pressure below the vocal folds is estimated indirectly
by measuring oral pressure during production of the closed portion of a voiceless bilabial consonant such as /p/. When producing this consonant, the lips are closed, the velopharyngeal port
CHAPTER 6 Evaluation of the Voice 191
is sealed, and the glottis is open; thus, pressures throughout the system are equal. Oral pressure
is measured by a pressure transducer connected to a small tube placed just inside the mouth
(Smitheran & Hixon, 1981).
Laryngeal Airflow
Laryngeal airflow is the volume of air passing through the glottis in a fixed period. It is measured
in cubic centimeters (cc) or milliliters (mL) per second. For example, the /a/ vowel produced with
a normal voice quality is characterized by an approximate laryngeal airflow of 100 cc/s (Baken,
1996). That same vowel produced with a breathy voice quality (perhaps by a patient with large
bilateral nodules) would be characterized by a laryngeal airflow of higher than 100 cc/s due to
excessively decreased glottal resistance to airflow. At the opposite end of the continuum, that
same vowel produced with a strained-strangled voice quality (perhaps by a patient with adductor
spasmodic dysphonia) would be characterized by a laryngeal airflow of less than 100 cc/s due to
excessively increased glottal resistance to airflow. Peak airflow (i.e., greatest flow) can be considerably higher than 100 cc/s and depends on articulatory demands; for example, peak airflow during
production of fricatives and stop consonants may exceed 500 cc/s (Stathopoulos & Weismer,
1985). Children and older adults tend to demonstrate higher laryngeal airflows than younger
adults (Stathopoulos & Sapienza, 1997).
Laryngeal Resistance
Laryngeal resistance is a measure derived from peak intraoral pressure and peak airflow during
production of the /pi/ syllable repeated at a rate of approximately 1.5 syllables per second. Peak
intraoral pressure is estimated from the /p/ portion of the syllable, and peak airflow is measured
from the /i/ portion of the syllable. A breathy voice would suggest decreased laryngeal resistance,
while a strain-strangled voice would suggest increased laryngeal resistance. When interpreting
laryngeal resistance values, the clinician must examine the relative contribution of air pressure
and airflow to that value.
The capacities and volumes we need to measure can be determined by using wet or dry
spirometers. In the wet spirometer, a container floats in water placed in a larger container. As air
is introduced into the smaller floating container, it floats higher in proportion to the volume of
air introduced. The distance or rise of displacement is measured in terms of cubic centimeters or
liters. Some spirometers are of the dry type. A flexible container enlarges on inspiratory tasks and
decreases in volume on expiratory tasks, in both instances measuring the volume of displacement.
Recent advances in technology have resulted in miniaturization and digitization of dry spirometers, allowing for ease of use and reduced cost compared to the wet spirometers.
Relatively inexpensive pressure measuring gauges and manometers are available for the
measurement of airflow pressures. For example, Hixon and colleagues (1982) described a simple
water manometer test that can be used to estimate the ability to generate respiratory driving
pressure sufficient for voice and speech. The test requires a drinking glass that is 12 cm deep or
deeper, filled with water, and calibrated in centimeters by a marker pen. A plastic straw is attached
to the cup with a paper clip. The bottom tip of the straw is anchored at 10 cm below the rim.
The patient is instructed to blow bubbles through the straw. If the patient maintains a stream of
192 The Voice and Voice Therapy
bubbles for 5 s with the straw at a depth of 10 cm, 10 cm H2O, the authors suggest that breath
support is adequate for conversational speech.
The Phonatory Aerodynamic System (PAS) (PENTAX Medical Corp., Montvale, New
Jersey), shown in Figure 6–17, is the latest pneumotachograph-based system for aerodynamic
analysis of the voice. The PAS is a noninvasive device that can simultaneously capture sound
intensity, intraoral pressure, airflow rate, and fundamental frequency and has an auxiliary port to
allow for the collection of electroglottography. It also includes protocols for common phonatory
measurements including vital capacity, air pressure screening, comfortable sustained phonation,
vocal efficiency, and running speech analysis (Huth et al., 2020). Zraick, Smith-Olinde, and Shotts
(2012) reported the first adult normative data for this system, obtained from 157 speakers over the
age of 18 years. Weinrich and colleagues (2016) reported pediatric normative data for this system,
obtained from 60 children whose ages ranged from 6 to 17 years. Both studies discovered ageand gender-related differences. This information can aid the voice clinician in the interpretation
of developmental changes that occur in male and female respiratory and laryngeal systems, and
disclose whether the results are age or gender dependent (Schaeffer, 2017). There currently are no
substantive normative data for geriatric speakers. Awan and colleagues (2013) found the system
to be highly reliable in a 1-week test-retest reliability measure for the majority of aerodynamic
measures in 60 healthy adults between the ages of 18 and 31 years. Schaeffer (2017) reported that
the system was sensitive to the effects of stimulation training (before and after stimulation) on
20participants with vocal complaints.
FIGURE 617. The Phonatory Aerodynamic System. Used with the
permission of Pentax Medical.
CHAPTER 6 Evaluation of the Voice 19 3
Maximum Phonation Time
MPT is the longest period during which a patient can sustain phonation of a vowel sound,
typically /a/, at their most comfortable pitch and loudness. Historically, MPT (also referred to
ɑ
as maximum phonation duration) of sustained phonemes (/
/, /i/, /u/) has been used as a simple
clinical test to distinguish the disordered voice (initially defined as weak and breathy voice) from
normal voice (Ptacek & Sander, 1963). Eckel and Boone (1981) postulated that reduced MPT
in individuals with benign vocal pathologies was “due to inefficient regulation of the airstream”
(p 147). Maslan and colleagues (2011) describe knowledge about the effect of age, gender, and
number of trials on MPT values. They report that (a) children tend to have shorter MPTs, require
more trials to learn how to maximally phonate, and show more variation than young adults; (b)
young adults have less variability in MPT as a group and can phonate for a comparatively longer
time than either children or older adults; (c) older adults have shorter MPTs; and (d) across all age
groups, men can sustain a longer MPT on average than women. If laryngeal airflow is high, MPT
is shorter than normal; if laryngeal airflow is low, MPT may be longer than normal. As Kent and
colleagues (1987, p. 368) note, however, MPT by itself cannot be used to distinguish a deficit in
respiratory support (reduced phonation volume) from an inefficiency in vocal fold vibration (high
airflow). This is particularly the case with older adult speakers (Matsuzaki & Makiyama, 2017).
Table 6–11 presents select normative MPT data for adults and children.
When eliciting MPT, the clinician should give standardized instructions regarding depth
of inhalation, and the clinician should provide a visual and auditory model and visual feedback
about performance. There is some disagreement in the literature about how many trials should
be elicited (one vs. three to five), and whether one should take the longest utterance or an average
of the utterances (Johnson & Goldfine, 2016). Practically speaking, an average of three trials
should result in a representative MPT for most patients. A timer and audio recorder are the only
equipment needed to measure MPT. Speyer and colleagues (2010) have shown that an individual’s
MPT is highly consistent over a period of 6 weeks, and that clinician intrarater reliability is
high for repeated measurements of the same trial. Perhaps one of the most efficient uses of MPT
is as a baseline against which future comparisons can be made during and at the conclusion of
voice therapy.
S/Z Ratio
The s/z ratio is also an indirect index of laryngeal airflow. To obtain the s/z ratio, the clinician
asks the patient to first sustain the /s/ as long as possible, and then to sustain the /z/ as long as
possible, each at normal pitch and loudness following a maximal inhalation. Verbal encouragement is usually given, and the longest /z/ and longest /z/ from one of three alternating /s, z/
trials is used to calculate the ratio. Boone (1977) proposed that evaluating vocal function should
go beyond just the sustained phonation of vowels. He introduced the idea that comparing the
duration of producing a sustained voiceless /s/ sound to that of a voiced /z/ sound could offer
indirect clues about glottal resistance, as this comparison is influenced by airflow duration. Boone
theorized that if there is a mass on the glottal margin, it would likely lower glottal resistance. This
decrease in resistance would lead to an increase in airflow, resulting in a shorter phonation time for
the voiced /z/ sound, while the duration of the voiceless /s/ sound, which involves resistance at the
194 The Voice and Voice Therapy
TA BL E 611. Select Maximum Phonation Time (MPT) for Normal Speakers
Producing /a/
Standard
Age Range
Source
Finnegan (1984) 3–5 Male 9.3 2.4 4.5–14.1
(years) Sex Mean (s)
Female 8.5 2.1 4.5–12.6
6–9 Male 15.5 4.1 7.5–23.6
Female 14.8 3.6 7.7–21.9
10–13 Male 21.1 5.6 10.2–23.1
Female 16.3 4.1 10.4–24.3
14–17 Male 18.5 5.9 11.6–34.8
Female 15.6 5.1 10.5–30.9
Deviation or
Standard Error Range (s)
Tavares and
colleagues (2012)
Ma and Yiu
(2006)
Maslan and
colleagues (2011)
4–6 Male 6.0 1.8 Not reported
Female 6.2 2.0
7–9 Male 8.1 2.0 Not reported
Female 7.9 2.0
10–12 Male 9.2 2.3 Not reported
Female 9.1 2.0
20–55 Combined 22.9 8.9 Not reported
61–70 Male 26.2 1.2 16.0–35.0
Female 18.8 2.5 8.0–60.0
71–80 Male 23.1 1.7 7.0–58.0
Female 22.8 1.4 12.0–45.0
81–90 Male 21.7 1.5 10.0–50.0
Female 21.0 0.9 5.0–60.0
teeth, would remain unchanged. Boone hypothesized that persons with normal vocal folds could
be expected to prolong the voiceless /s/ and the voiced /z/ phonemes for about the same length of
time, resulting in an s/z ratio approximating 1.
Eckel and Boone (1981) studied three groups of adult and pediatric speakers (those with
vocal fold nodules or polyps, those with functional dysphonia, and those with normal larynges
and voices) and reported s/z ratios greater than 1.40 in 95% of those speakers with nodules or
CHAPTER 6 Evaluation of the Voice 19 5
polyps (p. 147). The s/z ratios for those speakers with functional dysphonia or normal voices
were approximately 1.0 and did not significantly differ from each other. Across groups, however,
there was a wide range of s/z ratios obtained: Some speakers with nodules or polyps or functional
dysphonia exhibited s/z ratios less than 1.0, while some speakers with normal voices exhibited s/z
ratios greater than 1.0. A number of subsequent studies of the s/z ratio with adults and children
have been conducted, with most reporting quite variable results both within and across dysphonic
and normal speakers. A review of the literature by Gelfer and Pazera (2006) confirmed a considerable overlap in the s/z ratios in normal subjects and those with laryngeal disorders, which called
into question the diagnostic validity of the ratio. (Fendler & Shearer, 1988; Gelfer & Pazerra,
2006; Hufnagle & Hufnagle, 1988; Larson et al., 1990; Mohammadzadeh & Sandoughdar, 2017;
Rastatter & Hyman, 1982; Soman, 1997; Sorenson & Parker, 1992; Tait et al., 1980; Treole &
Trudeau, 1997; Trudeau & Forrest, 1997; Van der Meer et al., 2010). Despite the lack of reliability
evidence and normative data, the s/z ratio continues to be used both in research and clinically.
Johnson and Goldfine (2016) suggested that measures such as MPT and the s/z ratio should not
be used at all as evaluative tools, due to lack of consistency and reliability. However, while Gilman
(2021) agrees that these tasks cannot determine the level of impairment or course of therapy by
themselves, they provide additional insight into the vocal capabilities and functional abilities of
the patient when taken together with the other metrics including airflow, pitch, overall quality,
and endurance that are taken or observed during the initial evaluation process. Table 6–12 presents
select normative s/z duration data for adults and children.
By standardizing the collection, recording, and analysis of aerodynamic data, the recommended protocols aim to improve the reliability and comparability of vocal assessments. This, in
turn, enhances the evidence base for the management of voice disorders, enabling more effective
evaluation and treatment strategies.
Analysis of Voice Dosage
Many voice disorders are chronic or recurring conditions that result from faulty and/or abusive
vocal behaviors. Such behaviorally based disorders are difficult to assess and rehabilitate because
patient self-reporting and self-monitoring are subjective and often unreliable. Instrumentation is
available that gives clinicians and researchers quantitative data on a patient’s voice use throughout
the day.
Voice dosimeters are innovative tools akin to fitness trackers but for vocal health. They
provide precise measurements of vocal usage, quantifying this in terms of vocal load or dose.
Designed for versatility, they can be utilized across various settings, including everyday environments (Popolo et al., 2005). These devices are designed for ambulatory use, allowing individuals
to carry on with their daily activities while the dosimeter collects data on the number of vocal
fold vibrations as well as average frequency and amplitude of vocalization. Advances in technology
now enable the analysis of voice quality through dosimeter data, including aspects such as clarity,
perturbation, and resonance.
A voice dosimeter measures a person’s voice use by using a special sensor, called an accelerometer transducer or contact microphone, which is placed on the neck. This sensor is excellent
at picking up vibrations from the voice because it is tuned to catch skin vibrations while ignoring