CODI 504  VOICE DISORDERS
Writing the Report  Due By Friday Nov 8 by 2:00 pm

To complete your project, you will need to compile your results into a written report.

1.    Make a copy of the record form in appendix C of your text and fill in the appropriate data from your lab assignments 2 - 5.  In the comments sections, look at your data and determine if it is within normal limits for your client.

2.    Use the following headings to organize the report of the results of your assessment of your partner's voice.  I am particularly interested in the sections that deal with the quantitative data you gathered in the lab.  You may leave the other sections out if you like or include them with hypothetical information if you wish (or the real thing if you know your partner that well ) to complete your report.  I have included a sample write-up for you to use as a guide.
 
 

Voice Evaluation Report







Referral and Background Information

The patient, a 29 year old female, was referred today by Dr. Bratton (ENT).  The patient is status post  surgical removal of a vocal fold papilloma in 1996.  The patient also had a neurofibroma removed 11/97 and has a history of Muscle Tension Dysphonia (MTD III) as per ENT report of 5/5/98.  Endoscopic examination today revealed no masses and bilateral vocal fold movement but with continued hoarseness.  The patient complained of consistent hoarseness and dryness since two weeks after surgery.  She currently experiences sinus drainage and stated that she runs out of air for speaking.  She was observed coughing aggressively throughout the session.  She stated that she coughs in this manner frequently.  The patient reported that her voice is better in the morning and deteriorates throughout the day.  when questioned about vocal abuse, she reported that she experiences a great deal of stress and fatigue in her daily routine.  She also complained of having to strain to produce voice.

Voice Handicap Index

The VHI (Jacobson) was administered in order to determine self-perceived severity of voice symptoms.  The patient's functional subscale score was 25 which places her in the severe range (mean 18.30, S.D. 1.50).  The patient's physical subscale score was 26.  This score also falls within the severe range (mean 22.78, S.D. 1.48).  The patient's emotional subscale score of 18 fell within the moderate range for this scale (mean 13.33, S.D. 1.61).  The patient's total score of 69 also placed her within the severe range (mean 61.39, S.D. 4.21).  According to these results, the patient feels that her voice problem is severe and greatly affects the functional, emotional and physical aspects of her life.

Perceptual Assessment of the Voice

Using the Wilson Voice Profile, the patient's voice was rated as throaty (-2), tense (+2), low in pitch (-2) and slightly monotone (-1).  The patient's voice was moderately hoarse-rough throughout the session.  The quality of the voice remained constant during oral reading and counting with only slight fatigue noted towards the end of the tasks. The patient's cough was very aggressive.  During sustained phonation of /a/, voice quality was severely rough throughout and short in duration.

Musculoskeletal Tension Assessment

During digital manipulation of the larynx, the patient reported pain especially in the left thyrohyoid space.  The larynx was found to be slightly elevated which reduces the thyrohyoid space.  Her larynx was manipulated with slight resistance and she reported tightness in the extrinsic laryngeal muscles.  After laryngeal massage and tone focus, the patient's phonation of /a/ improved slightly.  Reduction in laryngeal elevation and voice improvement after massage are indicative of excessive musculoskeletal tension.

Aerodynamic Assessment

An assessment of durational aspects of the patient's voice was performed to determine the patient's glottal adduction/abduction efficiency and use of respiratory capacity for normal speech production.  Predicted Forced Vital Capacity, which is based on the patient's age, height and gender was 3159 cc.  Actual Forced Vital Capacity (FVC), measured using a dry spirometer, was 2900 cc.  The predicted Maximum Phonation Time (MPT) for this patient, based on actual measured FVC was 18.6 sec.  Observed MPT  for sustained /a/ was 5 sec for a ratio (observed/predicted) of .27.  Ratios less than .70 are indicative of problems controlling exhalation through the vocal folds during phonation.  She was able to sustain an /s/ for 10 sec and /z/ for 6 seconds for an s/z ratio of 1.67.  Ratios greater than 1.4 are considered indicative of poor laryngeal valving and/or vocal fold pathology.  The Phonation Quotient (PQ) was 580 ml/sec and Estimated Mean Flow Rate (EMFR) for this patient was 213.88 cc/sec.  The norms for women are 125 cc/sec (PQ) and 107 cc/sec for EMFR (Rau and Beckett, 1984).

Frequency (Pitch) Assessment

The CSL-Pitch program ( Kay Elemetrics) was used to assess frequency during continuous speech.  Mean speaking fundamental frequency during a reading of "The Rainbow Passage" was 186.35 Hz with a pitch sigma of 2.12 ST.  Maximum phonational frequency range was 22 ST with a range from 113 Hz to 420 Hz.  Norms for the patient's age would indicate a mean speaking F0 of 207.52 Hz (S.D. 15.68), pitch sigma of 2.79 ST and a maximum frequency range of 25.8 ST (S.D. 4.87).

Intensity (Loudness) Assessment

Intensity measures were made during reading of the standard reading passage, using a Radio Shack (Model XXX) sound level meter with a microphone-to- mouth distance of approximately 12 inches.  Mean speaking intensity was 65 dB with a maximum intensity during reading of 72 dB and a minimum of 63 dB.  Total intensity range during a counting task was 20 dB (61 dB - 81 dB).  Phonation during the high/quiet singing task were rated 5 on a scale of 1 - 10 with 1 representing delayed phonation, discontinuous phonation and failure to phonate quietly and 10 representing immediate phonation onset and continuous, quiet phonation.

Results of MDVP Assessment

The Multidimensional Voice Program (Kay Elemetrics) was used to assess quality-related measures of the voice including jitter, shimmer and noise-to-harmonic ratio.  During sustained phonation of the vowel /a/,  the following jitter measurements were elevated ( RAP, JITT, JITA, PPQ).  Average jitter (RAP)  across 3 repetitions was 2.35 %.  Shimmer was also elevated with average shimmer (APQ) of  3.76 %.  The NHR was within normal limits.

Interpretation and Clinical Impressions

The patient's forced vital capacity was within normal limits (compared to predicted FVC), however the ratio MPT/PMPT was below normal.  This observation tends to indicate that the patient has inadequate control over laryngeal valving and is releasing air too quickly.  The patients high PQ and EMFR as well as the elevated s/z ratio are also indications of inefficient laryngeal valving.  The hoarse voice quality, mildly restricted frequency range (restricted in high end of range) and report of pain upon laryngeal manipulation are indicative of muscle tension in the laryngeal area.  These observations are consistent with the patient's diagnosis of MTD.  The combination of laryngeal tension and inability to regulate exhalation during speech increases the demands on the vocal mechanism, reducing its efficiency, maintaining poor vocal quality and leading to vocal fatigue.  The slight improvements of voice quality on sustained /a/ after laryngeal manipulation and tone focus exercises serve as positive prognostic indicators for intervention.  The high scores of the VHI also indicate that therapy is warranted and would improve the patient's quality of life as well as her voice.

Recommendations

Voice therapy is recommended with an emphasis on reduction of  laryngeal tension, education with regard to vocal hygiene, maximum breath support through the use of frequent replenishing breaths, vocal function exercises to strengthen and balance laryngeal musculature and respiratory effort and tone focus exercises to improve vocal quality.