Discord

Describe "normal pitch."

A normal pitch is 2-3 octaves; women's pitch is typically higher than men's. Speaking fundamental frequency is our ability to manipulate pitch and pitch range is what could our vocal folds actually make.

What do we mean by "pre-assessment?"

Before the patient walks in the door you want to see what information they already have such as reviewing medical reports. Look at their diagnosis; what prescriptions were they given? Were they given a medical diagnosis? Do they have vocal folds paralysis? Etc. You also want to go over the general evaluation setup. Do you need to set evaluation up in a certain way for a particular patient? Do they have a chronic cough? Paralyzed VF? Nodules or polyps?

Explain Jitter vs. Shimmer vs. Noise to Harmonics ratio (NHR).

Jitter and shimmer represent variation or perturbations in voice. i. Jitter (rap=relative average perturbation): indicates variability of fundamental frequency (cycle to cycle variation of frequency); mainly affected due to lack of VF control. Shimmer: perturbation measure; measurement of intensity; cycle to cycle variation of amplitude Noise-to-harmonic range (NHR): general evaluation the noise presence is analyzed, meaning how much additional noise/unnecessary sound is in the voice in relation to how many nice smooth pitches/harmonics are heard

List 5 "personal factors" which may negatively affect vocal hygiene?

Occupation Medication/Drug Use Smoking/tobacco products Alcohol intake Weight Nutrition Sleep deprivation Dehydration Allergies

What are some diet changes that patients can make to reduce acid reflux?

Patients can reduce consumption of foods high in sugar, high in fat, acidic foods such as tomatoes, avoid eating a food such as an orange first thing in the morning when they have nothing in their stomachs because it is just adding acid to acid, avoid caffeine, and avoid alcohol.

What information does the s/z ratio give you?

The S/Z ratio are minimal pairs that differ only by voicing. You want the patient to do active participation to find out what their voice sounds like in isolation. You want the patient to hold /s/ for as long as they can by telling them to take in a nice deep breath then going for as long as they can. You time it and they do this 3 times and you take the highest of the 3. It is to check is they can control the amount of air leaving, if they can control the amount of air they are inhaling to then exhale to do this task. They you do the same with /z/. By doing /z/ you are checking if they have any vocal fold pathologies if they cannot hold /z/. You then take the highest /s/ and divide it by the highest /z/ and the goal is to have it equal 1. What is their breath support in relation to vocal function? If it is over 1 then there is a VF pathology and if it is under 1 their breath support is very bad. NOTES FROM CLASS: measures the length of time a person can sustain the sound 's', the length of time they can sustain the sound 'z', and then divides the two figures to obtain a numerical ratio.

8. Compare/contrast LMN vs UMN lesions based on TYPE

UMN=spasticity LMN=paralysis; falccidity a. With UMN it can be unilateral or bilateral b. UMN is typically involved in organization or impulses so you will get spasticity because there is less organization of those impulses c. 3 types of UMN lesions: i. Hyperkinetic: too much movement 1. Spasmodic dysphonia 2. Essential tremor ii. Hypokinetic: too little movement 1. Parkinson's Disease (PD) iii. Ataxic Dysarthria 1. Cerebellar lesion d. With LMN disorder there are the following types: i. Recurrent Laryngeal Nerve Paralysis: 1. It innervates everything but cricothyroid (this means if there is paralysis, no information gets to these muscles inside of larynx) 2. Unilateral Paralysis: a. Hoarse b. Breathy c. Weak d. Aphonia e. Normal f. Paresis Degree-maybe normal? 3. Bilateral Paralysis: a. Abducted- don't get much voicing b. Paramedian (semiabducted)-some passive vibration for some voicing c. Adducted-(might need tracheostomy;can't make voice or breathe because they're closed) ii. Superior Laryngeal Nerve Paralysis 1. Weakness and breathy voice 2. Limitations in pitch range and variability

Define vocal hygiene. What are 4 aspects of vocal hygiene that are typically reviewed with patients?

Vocal hygiene includes the things we want our patents to do and not do for the betterment of their voice. The 4 factors of vocal hygiene include: avoid abuse and misuse, vocal rest, hydration, and diet. Other subfactors can include maintaining a healthy weight, exercising, reducing exposure to smoke, avoid yelling, limiting caffeine intake, and diaphragmatic breathing focusing on breath support.

How does stroboscopy work?

What are the pros and cons of flexible and rigid scopes? Stroboscopy uses intermittent light flashes that are time relative to the fundamental frequency (pitch). The use of the interrupted light makes objects (the VF) appear to move in slow motion. Helps us to see how the VFs are doing: are they coming together? how far apart are they moving? Are they stretching or contracting? Is there excess mucous on them? The pros of the rigid scope is that some patients find it more comfortable to go through the mouth as opposed to transnasally like the flexible scope and there is a larger view because there is a bigger camera. There are also cons: the quality is not as good, can only check for sustained vowel phonation, the ENT pulls the tongue out and the person says /i/ and /a/; it can be difficult and uncomfortable. The pros of the flexible scope is that some patients find it more comfortable to go transnasally instead of orally. This camera quality is better. The patient can fully speak with this scope in allowing the patient to do pitch glides, speech tasks, what the VFs look like during regular phonation, what the glottal closure looks like, etc. You can see the supraglottic cavities better than with the rigid scope and also vertical approximation of VFs and you can see velopharyngeal closure. If they have allergies you can see the edema in the nose. The cons is that the view is not as large and that some patients can find it more uncomfortable to have the scope go in transnasally instead of orally.

What are the differences between functional and perceptual assessment?

With functional assessment we look at: i. Respiratory capacity: 1. Are they expanding all the way? Are they bringing shoulders up? Are they not really taking an inhale at all? 2. -low capacity: not taking deep breath 3. -medium capacity: kind of taking a deep breath 4. -high capacity: taking deep inhale ii. Speech breathing pattern: 1. Is their stomach going in and out=diaphragmatic? Is it more thoracic and you only see their ribcage going in and out? Is it clavicular? 2. -are they tensing the entire time they are phonating? How loud are they speaking? Can they get loud or is it breathy? 3. -is their vocal quality great but they are straining? Is it horrible and they have strain and stress as well? iii. S/Z ratio (minimal pairs that differ only by voicing); want the ratio to be 1 iv. Max Phonation Time (MPT) (say "ahhhh" for as long as they can) v. Count 1-5 (1 being the quietest 5 being the loudest) vi. Count on 1 breath as high as they can go Perceptual assessment: i. Standardized 1. Clinician based: a. CAPE-V: measure of quality and severity b. GRBAS (GRBASI): Grade, roughness (how rough does their voice sound), breathiness, asthenia, strain, instability; aids in reducing error in judging characteristics in voice 2. Client based: a. VHI (voice handicap index): checks their quality of life; how they rate their own voice/severity of impact on physical, emotional, and functional aspects.

What does it mean to have variability in a person's vocal function? What are the factors?

You are looking at the ability to change the voice for your intended purposes; looking at the respiration, pitch, loudness, and quality of the voice when talking about variability. You do not want to have too much variability in the voice because you want someone to be able to have some control over the changes and to be consistent. The factors include: i. Respiration: breath support; how much can we increase or decrease our breath support for an intended speech outcome such as getting loud or whispering ii. Pitch: can we increase or decrease as we need to express emotion and prosody? iii. Loudness: increasing amplitude and decreasing amplitude without strain. Can you get loud or quiet? This helps us to change our emphasis iv. Quality: how smooth is their voice? Can they change their quality to change meaning such as exaggerating voices to tell a story

2. Define Organic, Structural/Functional, and Neurogenic disorder classifications.

a. An organic voice disorder is physiological in nature with alterations in respiratory, laryngeal, or vocal tract mechanisms. i. Structural can result from physical changes in the voice mechanism such as nodules on VFs. b. A functional disorder is improper or inefficient use of the vocal mechanism when the physical structure is normal such as muscle tension dysphonia or aphonia, diplophonia/ventricular phonation, and vocal fatigue) c. Neurogenic/neurological: There is an issue with CNS innervating the muscles of the larynx or an issue with the PNS innervating the muscles of the larynx such as vocal tremor, paralysis or VFs, or spasmodic dysphonia

1. Describe voice disorder the incidence and Prevalence as per ASHA.

a. As per ASHA, incidence of voice disorder in the U.S. ranges from 3% to 9% and of those 0.98% sought treatment. b. Prevalence: i. Voice disorders are higher in females than in males with a ratio of 1.5/1 female/male. In children it is more prevalent in males than females. When it comes to age it is higher in the elderly ranging from 4.8% to 29.1%. Pediatric voice disorders ranges from 1.4% to 6.0%. ii. When it comes to occupation the most at risk populations include: teachers, manufacturing/factory workers, salepersons, and singers. For teachers there is a higher prevalence: 11% than non-teachers at 6.2%. A prevalence at a single point in time is 9% to 37% and at some point in time it is 50% to 80%. iii. Etiologies: 1. In men it is usually chronic laryngitis and typically men 40 years and older have a higher prevalence of laryngeal cancer. 2. Adults between 19 years old and 60 years old are diagnosed with functional dysphonia (20.5%), acid reflux, laryngitis (12.5%), and vocal polyps (12%). Those 60 years evaluated are commonly diagnosed with presbyphonia, reflux and inflammation, paralysis or paresis, Reinke's edema, and laryngeal cancer. Pediatrics are commonly diagnosed with nodules and in school-age children it is two times as likely for males to be the ones with nodules. 3. Occupation includes functional voice disorders at 41%, vocal fold nodules/hypertrophy at 15%, and reflux/laryngitis/inflammation at 11%.

6. How are functional disorders different from organic disorders?

a. Functional disorders include improper or inefficient use of the vocal mechanism when the physical structure is normal such as vocal fatigue, muscle tension dysphonia, or aphonia, and/or diplophonia/ventricular phonation. i. The structure looks fine upon examination (looks functional), but we are not using it efficiently b. Whereas with organic disorders it is physiological in nature and there are structural issues. There are alterations in respiratory, laryngeal, or vocal tract mechanisms. i. It can be structural which results from physical changes in the voice mechanism or neurological which results from problems with CNS or PNS innervation to larynx causing vocal tremor, spasmodic dysphonia, or paralysis of vocal folds.

7. Describe SLP role for patients who are transgender/transexual transitioning

a. Help with pragmatics, language and vocal intensity: b. Male to female- Feminization- increased fundamental frequency c. Female to male- Masculinization- decrease fundamental frequency d. Use of various therapy programs along with associated hormone therapies e. May need to also work on pragmatics, language, vocal intensity f. Typically males are louder, so we are trying to help FTM get louder g. Help with intonation and prosody h. Pragmatically: how they are using their voice (smooth out vocal gymnastics, make them more monotone) i. Females stereotypically use different language than males j. We need to teach MTF and FTM the differences in stereotypical language that males and females use so they can use it to sound more like the gender they identify with k. We can only take them so far, they need assistance biologically (hormones/surgery) to get them where they need to go

4. How do hemorrhage and cancerous lesions differ?

a. Hemorrhage: It is vascular; there is leakage of blood resulting in damage to surrounding areas. It is caused by (etiology) phonotrauma, trauma due to surgery, or medications such as blood thinners. It involves red patches, increase in VF mass and stiffness, irregular VF vibrations, reduced amplitude, and hoarseness. Depending on the hemorrhage size, it can cause mild to severe aphonia. b. Cancerous: lesions; can expand and grow to other areas; involves a white/reddish color due to hypervascularization, plaque, mass, and irregular tissue. Can start off as non-malignant (dysplasia) and then become malignant (laryngeal cancer) which can be caused by many things such as heavy smoking, drinking, or LPR. The signs and symptoms include hoarseness and rough voice, sore throat, cough, and respiratory issues if the cancer is large enough. The location of the lesion can be subglottic, supraglottic, or glottic. Location and size determine severity/types of issues.

9. How does the voice of a Parkinson's patient present?

a. Hypokinetic (too little movement). b. The voice is too quiet, monopitch, monoloudness, flat affect (expressionles)s, breathy, rough, and hoarse, tremor in the voice, slow rate, difficulty with starting and stopping, ventricular phonation, and widespread hypotonicity and rigidity.

10. Define chronic cough. (habit cough, irritable larynx)

a. NOT an autoimmune disease or neurological disease by nature; in its own category -not related to disease or virus; no cause unless a side effect of medication b. It is a dry/irritated vocal tract causing cough occurring throughout the day but no mucous comes up c. Acutely (chronic cough (constant) for an acute phase of time after being sick) d. Chronic: more than 8 weeks, no benefit to any respiratory intervention, not related to infection or disease e. The duration can be months to years f. Trigger vs no trigger (vocal hygiene needs to be gone over extensively because something in the environment is causing the cough) g. Some people it sounds like a tick, but it is not as severe and uncontrollable; so for some people it could be when they get nervous h. Could be from going from a hot temperature, to cold temperature, changing of seasons, and/or drying/lack of hydration, change in altitude (whether going from below sea level to a mountain or when sitting versus laying down (might need a wedge pillow). i. Could be an attack that lasts a few minutes or small coughs that happen throughout the day

5. Sulcus Vocalis is defined by three types: Type I, Type IIa and Type IIb. Define each.

a. Sulcus Vocalis is a groove along one or both VFs and can stretch the entire length of VFs. It results in abnormal vibration because when the vocal folds come together there is now a big groove preventing the VFs to come together fully. The etiology is congential which is unknown or acquired which is due to smoking. Symptoms include hoarse and weak voice, vocal effort increases, vocal fatigue, and the depth of the lesion affects the quality of the voice so the deeper the lesion, the worse the voice. b. Type I: sulcus is along entire length of VF, into the (superficial) lamina propria, but does not reach vocal ligament (intermediate and deep layers of lamina propria); only affects gelatinous layer; may just have some hoarseness c. Type IIa: sulcus is along entire length of VFs, but it goes up to the vocal ligament (reaches at least the intermediate layer); moderate dysphonia d. Type IIb: sulcus is along the entire length of the VFs, it extends into the vocal ligament (reaches deep layer); severe dysphonia

3. Compare/ contrast: Vocal Nodules vs Vocal Polyps vs Vocal Cysts vs. Ulcer/Granuloma

a. Vocal nodules are benign and can be unilateral or bilateral. They occur on the anterior 1/3 or 2/3 of VFs. There are 3 types including: acute (trauma, hyperfunctions (soft gelatinous part of VF: superficial LP), chronic (firm callus like nodule, fixed), and reactive nodular change (develops because of contact with other nodules). Etiology is due to phonotrauma or edma of superficial LP. In the later stages the nodules can harden making the voice rough and it can cause vocal fatigue. Nodules and vocal polyps can come back if you continue to use the voice inappropriately. Vocal polyps are fluid filled and benign (like nodules) with working blood supply. (not callus like, like nodules). They occur on the middle 1/3 of the VFs and they are typically unilateral. There are 2 types: cecil and pedunculated. The etiology is sudden onset due to some trauma and/or acute vocal trauma due to a single incident such as yelling at a concert. The symptoms include mild to moderate dysphonia, hoarse/breathy quality, rough like with nodules, and stridor if it is pedunculated. Vocal cysts are also benign but they are surrounded by membrane. They occur near the VF surface and under the lining of the superficial LP at the midline of the glottis. The etiology is due to phonotrauma like with polyps and nodules or it can be congenital which is rare. The symptoms include hoarseness like with nodules, clearing of the throat/coughing, an a globous sensation. An ulcer/granuloma is also a benign growth like nodules, polyps, and cysts but it occurs along the vocal process of arytenoid. It is unilateral or bilateral like with nodules but occurs on the posterior portion of VFs. The granuloma occurs over the contact ulcer and can outgrow the blood supply and it is blood-filled. The etiologies include phonotrauma just like with nodules, polyps, and cysts, intubations, and loud speech.