voice quiz 2

To obtain best possible recording avoid 2 possible errors.

Clinician must be careful to avoid peak clipping 1. Recording fails to use the available if quantization level adequately.

9. Statement profile 9B:Advocating for voice therapy: clinicians should advocate voice therapy: clinicians should advocate voice therapy for patients with dysphonia from a cause amendable to voice therapy: strong recommendations based on systematic review and randomized trials with a preponderance of benefit over harm.

1. Quality improvement opportunity: to promote effective communication with patients and to promote the most effective prevention and treatment practices for patients with dysphonia. National quality strategy domains: person and family-centered care; prevention and treatment of leading causes of morbidity and mortality; making quality care more affordable. 2. Benefit: improve voice-related QOL; prevent relapse; potentially prevent need for more invasive therapy 3. Risks-harms, costs: no harm rereported in controlled trials; cost of treatment 4. Benefits-harm assessment: preponderance of benefit over harm

12. Statement profile 12: Education/prevention: clinicians should inform patients with dysphonia about control/preventive measures: recommendations based on observational studies, small-sample RCTs, expert opinion, and a preponderance of benefit over harm.

1. Quality improvement opportunity: to provide guidance to clinicians in educating patients on behavioral strategies and environmental measures that may prevent or decrease the risk of dysphonia. National quality strategy domains: person and family centered care; prevention and treatment of leading causes of morbidity and mortality. 2. Benefit: possible decreased risk for recurrence of dysphonia; improved vocal hygiene may reduce dysphonia; possible prevention of dysphonia for personas at high risk 3. Risks, harms, costs: time of education; cost of potentially ineffective interventions 4. Benefits-harm assessment: preponderance of benefit over harm

Maximum flow declination rate

a. Relationship between glottal airflow and the mechanics of phonation i. Maximum flow declination rate represents rate at which the glottal airflow shuts off. ii. Its relationships perceptual differences in vocal quality, particularly vocal loudness b. Maximum flow declination rate i. Measured as the maximum negative peak from the first derivative of the glottal airflow wave form. ii. Can be used to define hypo and hyper functional glottal configurations. c. Hypofunctional voice cases i. Would predictably yield a low maximum flow declination rate value because of the disability in completely closing the VF and the slowness in the return of the weakened VF toward midline. d. Hyper functional voice cases i. Would yield a higher maximum flow declination rate due to an increase in subglottal pressure and greater vibrational amplitudes. ii. Those with hyper functional can also experience increased VF stiffness.

Electroglottography

i. A noninvasive technique that provides information about the degree of VF closure by measuring the electrical resistance between two electrodes that are placed on the neck at the level of thyroid notch. ii. Mild electronical current passes between electrodes, and voltage from the EEG instrumentation can be displayed visual so the measured can be used to see degree of closure. iii. More contact VF make the easer for the current to pass between vocal fold tissue, resulting in a higher displayed peak of EGG waveform. iv. VF opening periods (i.e., inspiration) would be seen as valleys on single output.

Goals of acoustic analysis

i. Acoustic analysis is one means used in the evaluation of voice, allowing clinicians to gather significant amounts of data in a noninvasive and cost-effective mane. ii. One must use good judgment in gathering tools to assess patient's voice. iii. Precautions for clinical decision making. iv. Tools use in evaluating voice must be guided by nature of the info necessary for making clinical diagnosis or to aid in rehab for patient.

Laryngeal aerodynamic as a function of aging

i. Aging in anatomic and physiologic changes to the larynx 1. Degeneration of the cartilaginous framework, VF tissue, and motor innervation to the larynx ii. Changes affect the biomechanics function of the larynx affecting laryngeal aerodynamics.

Precautions for clinical decision making

1. Acoustic measures can easily be affected by variable other than the voice itself. 2. Factors include recording procedures, elicitation instructions, and environmental interference.

Laryngostroboscopy

i. Pros 1. Oral and flexible laryngoscopic techniques can be used with this equipment if the vibration of the VF requiring assessment. 2. With the vibration referred to as mucosal wave 3. Additionally, with this equipment, VF opening, and closure can be assessed, whether the VF open fully and shut tightly, and whether the VF move together as a unit. 4. Allow the structure and function of the VFs to be imaged and preserved. Digitally using specialized instrumentation

Consensus on auditory perceptual evaluation of voice

1. Not intended to be used alone of other means for determining the nature of a voice disorder. 2. CAPE-V should be complemented by a visual exam of the larynx and other tests of vocal function to arrive at the best evaluation and most comprehensive impression of voice disorder.

airflow measures are useful because.

their modest to high correlation with breathiness

Peak glottal airflow

a. Relates to the maximum glottal area during VF vibration. b. Increased stiffness decreased mucosal wave, or any other pathologic condition or phonation type that restricts the maximum displacement of the VF (pressed voice) can alter peak airflow during phonation.

Lack in stability in VF vibration

Will result in frequent changes in the pattern.

Aerodynamics:

branch of science concerned with the study of gas motion in objects and the forces that are created Study of airflow and pressure produced during voice production and considered an essential tool in the voice laboratory of clinical voice evaluation.

Oral endoscope

- placed in the back of the mouth - advantage of increased magnification - Sustained /i/ only a. Passed into the body. b. Placed into the back of the mouth. c. Sits in same position (near soft palate) as mirror but has increased advantage in magnification. d. Pros i. Light is carried by fiberoptic bundle and. Directed down onto the larynx. ii. Light is then reflected back to the examiner providing an image of VF. iii. Should not cause great deal of discomfort for patients. 1. Some experience gagging as scope is placed about 2/3 into back of mouth. e. Cons i. If pt. can't tolerate it because of gagging, use a topical anesthesia to desensitize reflex but some don't use it because it may affect. Normal function of exam structured. ii. Only sustained vowels can be produced and not articulation.

electromyography

1. An office-based procedure to evaluate the integrity of the neuromuscular system in the larynx by recording action potential generated in laryngeal muscles during voluntary and involuntary contraction. ii. Invasive procedure and must be performed by a neurologist and/or otolaryngologist. iii. Purpose is to help the physician differentiate various causes of movement abnormalities within the laryngeal mechanism (disorders affecting the neural innervation to the larynx) and to differentiate between UMN and LMN, peripheral nerves, the neuromuscular junction, muscle fibers, and the laryngeal cartilages and joints. iv. It Should be an extension of physical exams, not isolated. v. LEMG abnormalities are interpreted within the context of the clinical impression and are used to guide the diagnosis and treatment of VF mobility disorders. vi. During this, the pt. is asked to sniff or phonate with an /eeeee/ to activate muscles of interest to measure both onset and offset, document delays in muscle activation, determine specific neuromuscular response to stimuli and correct the change in muscle activity with therapeutic agent (Botox) i. Most common use is differentiating paralysis vs. paresis vs. cricoarytenoid joint fixation. ii. Surface electromyography (sEMG) is a noninvasive method to assess muscle function that is readily performed by the voice pathologist. 1. Nonspecific to muscle group and can generalize increased or decreased activation of muscles during vocal activity (louder voice->increased EMG activity)

It is essential to classify into three types in acoustic analyses of voices.

1. Because many of acoustic measures. Will only be valid for signals that are classified as type 1. a. For example, frequency and amplitude perturbation can only be calculated in type 1 (2 & 3 don't have fundamental freq. don't convey meaningful information) 2. Most acoustic analyses software cannot automatically distinguish between the three types of voice segments.

MPT (maximum phonation time)

1. Can be useful and general measure of lung capacity and laryngeal valving abnormality. 2. Task must be performed correctly and may be susceptible to interpretation when laryngeal valving abnormalities are severe.

Several extraneous factors that may affect short-term perturbation measures, and care must be taken to control theses adequately.

1. Different software packages offer different methods to compute perturbation. a. When making computations it's important to distinguish valued before and after a period, to ensure they are comparing numbers from same algorithm. 2. Perturbation values are often affected by the type of microphone used, distance and angle of microphone placement, as well as recording environment such as noise and reverberation. 3. Short-term perturbation values should only be measured from steady phonation and not from running speech. Conversational and reading tasks are not appropriate. 4. Perturbation values are only meaningful when a distinct fundamental frequency can be identified in the analysis segment. Only for type 1 signals

vowel spectrum precaustions

1. Easily obtained for the vowel /ae/ because the formant frequencies for this vowel are widely separated. 2. These measures are difficult to compute from vowels that do not have clear harmonic or if there is a lot of aspiration noise. a. Lack of clearly visible harmonics makes it difficult for the user to select appropriate peaks. 3. These values can be easily biased by the vowel formant frequency. 4. Each speaker and vowel can have different formant frequencies; the user needs to correct for these differences before comparing data across speakers.

Pts with voice disorders, their FFT spectra may not always look as clear.

1. Higher level of aspiration noise observed in many patients tend to mask the harmonic structure, in the higher frequencies. 2. Harmonic structure can be visibly seen in lower frequencies but diminished in high frequency.

Ordinal scale

1. Numbers are assigned to attributes: 1 = normal, 2 =mile etc. 2. Buffalo rating voice profile and the GRABAS scale uses a 5-point and a 4-point rating system (voice quality tool) a. 4-point rating system: 0= normal voice quality - 3 an extremely deviant voice quality b. GRBS includes the elements: i. G= grade or a judgment of how rough the voice sounds ii. R= roughness is a judgment of how irregular a noisy the voice sounds; it should relate to aperiodicity in the vibratory cycle iii. B= breathiness is a judgment of how much additional airflow is perceived; it should relate to higher minimum airflow during the glottal cycle iv. A= asthenia is a judgment of weak voice sounds; it should relate to the sound pressure level of the voice v. S= strain is a judgment of how compressed or hyper-functional the voice sounds 3. Stimuli elicited are a sustained vowel or a few short phrases. 4. Vowel allows listeners to focus on phonatory quality with less influence e from articulatory dynamics that could influence the perception of the disorder. 5. Passage to use is rainbow passage, which can be used to make judgments of voice quality pre/post-treatment.

11. Statement profile 11: Botulinum toxin: clinicians should offer, or refer to someone who can offer, botulinum toxin injections for the treatment of dysphonia caused by SD and other types of laryngeal dystonia. Recommendation base on RCTs with minor limitations and preponderance of benefit over harm

1. Quality improvement opportunity: to expediate referral for suspected SD. National quality strategy domains: person and family centered care; prevention and treatment of leading causes of morbidity and mortality. 2. Benefit: improved voice quality and voice related QOL 3. Risks, harms, costs: dysphagia, airway obstructions, breathy voice, direct costs of treatment, time off word, and indirect costs of repeated treatment 4. Benefits-harm assessment: preponderance of benefit over harm

4A. Statement profile 4A: clinicians may perform a diagnostic laryngoscopy at any time for a patient with dysphonia:

1. Option: based on observational studies, expert opinion, and a balance of benefit and haram 2. Quality improvement opportunity: to highlight the important role of visualizing the larynx and vocal folds in treating a patient with dysphonia. National quality strategy domains: prevention and treatment oof leading causes of morbidity and mortality; effective communication and care coordination; patient safety benefit: establishing the underlying diagnosis, possible reduction in cost, improved diagnostic accuracy, appropriate referrals and 1. treatment, avoidance of missed or delayed diagnosis, reduced anxiety by establishing diagnosis. 3. Risk, harms, costs: patient discomfort, cost of examination, procedure-related morbidity. 4. Benefits-harm assessment: balance of benefit and harm 5. Purpose: highlight important role of visualizing the larynx and VF to establish a diagnosis of a patient with dysphonia

methods for directly viewing the larynx

1. Oral endoscope 2. Trans nasal flexible laryngoscopy 3.Laryngostroboscopy 4.Strobolaryngoscopy

types of measures (aerodynamics)

1. Phonatory aerodynamic system model 6600 1. Circumferentially vented pneumotachograph face mask: 1. Differential pressure transducers 1. Average airflow 1. Estimated Subglottal pressure. 1. Estimated laryngeal airway resistance. 1. Inverse Filtering 1. Airflow open Quotient 1. Maximum flow declination rate 1. Peak glottal airflow Minimum glottal airflow

10. Statement profile 10: Surgery: clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that to not respond to conservative management, or glottic insufficiency: recommendation base on observational studies demonstrating a benefit of surgery in these conditions and preponderance of benefit over harm.

1. Quality improvement opportunity: to advocate that clinicians discuss and consider surgery as a therapeutic option for patients with dysphonia whose underlying etiology is amendable to surgical intervention. National quality strategy domains: personal and family centered care; prevention and treatment of leading causes of morbidity and mortality. 2. Benefit: potential for improved voice outcomes among carefully selected patients 3. Risks, harms, costs: none 4. Benefits-harm assessment; preponderance of benefit over harm

8. Statement profile 8: Antimicrobial therapy: clinicians should not routinely prescribe antibiotics to treat dysphonia: strong recommendation against prescribing based on systematic reviews and randomized trails showing ineffectiveness of antibiotic therapy and a preponderance of harm over benefit.

1. Quality improvement opportunity: to discourage the misuse of antibiotics. National quality strategy domains: prevention and treatment of leading causes of morbidity and mortality; patient safety; making quality care more affordable. 2. Benefit: avoidance of ineffective therapy, unnecessary cost, and antibiotic resistance 3. Risks, harms, costs: potential for failing to treat bacterial, fungal, or mycobacterial causes of dysphonia. 4. Benefits-harm assessment: preponderance of harm over benefit if antibiotics are prescribed.

9A. Statement profile 9A: Laryngoscopy prior to voice therapy: clinicians should perform diagnostic laryngoscopy or refer to clinician who can perform diagnostic laryngoscopy before prescribing voice therapy and document/communicate the results to the SLP. Recommendation: based on observational studies showing benefit and preopereance of benefit over harm

1. Quality improvement opportunity: to encourage the routine use of diagnostic laryngoscopy for patient with dysphonia (hoarseness) before initiation of voice therapy to promote the most effective treatment practice for patients with dysphonia. National quality strategy domains: effective communication and care coordination; prevention and treatment to leading causes of morbidity and mortality. 2. benefit: avoid delay in diagnosing laryngeal conditions not treatment with voice therapy, optimize voice therapy by allowing targeted therapy. 3. risks, harms, costs: delay in initiation of voice therapy; cost of the laryngoscopy and associated clinician visit; patient discomfort 4. benefits-harm assessment: preponderance of benefit over harm

13. Statement profile 13: Outcomes: clinicians should document resolution, improvement, or worsened symptoms of dysphonia or change in QOL among patients with dysphonia after treatment or observation. Recommendation based on randomized trials and cohort studies with preponderance of benefit over harm.

1. Quality improvement opportunity: to ensure that patients with dysphonia are followed until the dysphonia has improved or resolved or the underlying condition has been diagnosed and appropriately managed. National quality strategy domain: effective communication and care coordination 2. Benefit: document the final status of dysphonia, communicate with referring clinicians, document favorable outcomes or failure of treatment 3. Risks, harms, costs: cost of follow-up visits. Benefits-harm assessment: preponderance of benefit over harm

5: Statement profile 5: Imaging: clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) among patients with a primary voice complaint prior to visualization of the larynx: recommendation: against imaging based on observational studies of harm, absence of evidence concerning benefit, and a preponderance of harm over benefit

1. Quality improvement opportunity: to reduce variations of care and unnecessary expense as well as harm from radiation and/or contrast exposure. National quality strategy domain: making quality care more affordable. 2. Benefit: avoid unnecessary testing and overdiagnosis; minimize cost and adverse events; maximize the diagnostic yield of CT and MRI when indicated; avoid radiation 3. Risks, harms, costs: potential for delayed missed diagnosis. 4. Benefits-harm assessment: preponderance of benefit over harm 5. Purpose: not to discourage the use of imaging in the comprehensive workup of dysphonia but rather to emphasize that it should be appropriately used to assess for specific pathology after the larynx has been visualized. Imaging may be more appropriate after diagnosis has been made with laryngoscopy.

6. Statement profile 6: Antireflux medication and dysphonia: clinicians should not prescribe anti-reflux medications to treat isolated dysphonia based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. Recommendations against prescribing based on randomized trials with limitations and observational studies with a preponderance of haram over benefit.

1. Quality of improvement opportunity: to limit widespread use of anttireflux medications as empiric therapy for dysphonia without symptoms of GERD or seeing changes in the larynx associated with LPR or laryngitis, given limited evidence of the medications. National quality strategy domains: prevention and treatment of leading causes of morbidity and mortality; patient safety; making quality care more affordable. 2. Benefit: avoidance of unnecessary therapy; reduced cost; avoidance of complication from proton pump inhibitors; avoidance of diagnostic and treatment delay due to course of PPI therapy 3. Risks, harms, costs: potential withholding of therapy from patients who may benefit. 4. Benefits-harm assessment: preponderance of benefit over harm

2. Identifying underlying cause of dysphonia: Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management.

1. Recommendation: based on observational studies with a preponderance of benefit over harm a. Quality improvement opportunity: to guide the expediency and nature of recommended treatments/investigations through identification of potential underlying causes of dysphonia. National quality strategy domains: prevention and treatment of leading causes of morbidity and mortality; effective communication and care coordination b. Benefit: to identify potential causative factors of the dysphonia, increase awareness of underlying causes of dysphonia, identify patients at risk for serous underlying conditions, and identify underlying cause to allow for targeted treatment c. Risks, harms, costs: none d. Benefits-harm assessment: preponderance of benefit over harm e. Purpose: to help clinician identify underlying cause of dysphonia. Careful history and physical examination provide important clues to the underlying etiology and can help direct management. f. Potential etiologies: include traumatic, infections, inflammatory, neurologic, metabolic, neoplastic, congenital, and behavioral factors. g. History should include reviewing duration of dysphonia, type of onset (sudden, gradual), potential inciting events, how the condition is affecting the patient, associated symptoms, modifying factors, current medications habits, concurrent medical conditions, and prior surgery. i. Allows for categorize dysphonia severity, develop treatment plan, and prioritize patients who may need escalated care.

4B. Statement profile 4B: Need for laryngoscopy in persistent dysphonia: clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serous underlying cause is suspected.

1. Recommendations: based on observational studies, expert opinion, and a preponderance of benefit over harm 2. Quality improvement opportunity: to high light the important role of visualizing the larynx and vocal folds in treating a patient with dysphonia, especially if the dysphonia fails to improve withing 4-week onset. National quality strategy domains: prevention and treatment of leading causes of morbidity and mortality; Effective communication and care coordination 3. Benefit: avoid missed or delayed diagnosis of serous conditions among patients without additional signs and/or symptoms to suggest underlying disease; permit prompt assessment of the larynx when serous concern exists. 4. Risks, harms, costs: potential for delay in diagnosis; procedure-related morbidity; procedure-related expense; patient discomfort 5. Benefits-harm assessment: preponderance of benefit over harm Purpose: highlight important role of visualizing the larynx and VF in establishing a diagnosis for a patient

Precautions to be taken when making and interpreting this measure relative noise level

1. Relative noise level (like signal perturbation measures) may be computed using several different algorithms. a. Including: signal-to-noise ratio (SNR), harmonics-to-noise ratio (SNR), the harmonics-to-noise ratio (HNR), normalized noise energy (NNE), and glottal noise energy (GNE) b. But should not be compared because different algorithms are not similar. 2. The absolute noise level in voice is highly variable and provides little information by itself, the noise level is typically reported by normalizing it to the harmonic or period energy. a. Normalization requires estimating the power of harmonic part of the vocal signal. b. Difficulty to do if the vocal fold vibration is highly irregular and does not result in a clear harmonic structure. c. Measures of relative noise levels can't be made accurately from type 2 & 3 signals. d. Users should analyze signals and interpret results with knowledge that the algorithms used for computing relative noise levels may not be accurate when acoustic signals become highly aperiodic.

Strobolaryngoscopy

1. Results should be viewed and interpreted by a laryngologist with training in the in the stroblaryngoscopic procedure. 2. Purpose of procedure is to assess voice production and vocal function. 3. May also used as a biofeedback tool for voice therapy.

Considerations when recording voices for acoustic analyses are. (acoustics)

1. Sample rate a. Reflects how often the voice signal is sampled in time. b. Number of snapshots that one may take of the signal. c. The more snapshots taken, or higher sample rate, the better the original signal can be approximated. i. The rate should be no less than 20 kHz (20,000 per second) 2. Quantization level a. Reflects number steeps that may be used to represent changes in the amplitude of signal.

3. Statement profile 3: escalation of care: clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include but are not limited to recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user.

1. Strong recommendation: based on observational studies with preponderance of benefit over harm. 2. Quality improvement opportunity: to encourage early referral of patients with dysphonia whose history, symptoms, or physical examination is concerning for a serious underlying etiology. National quality strategy domains: prevention and treatment of leading causes of morbidity and mortality; effective communication and care coordination; patient safety. 3. benefit: to identify factors early in the course of management that could influence the timing of diagnostic procedures, choice of interventions, or provision of follow-up care; to identify risk factors; to identify populations for whom early or more aggressive intervention may be warranted. 4. risks, harms, costs: time in assessment 5. benefits-harm assessment: preponderance of benefits over harm 6. purpose: encourage early laryngoscopy and/or referral for specialty care with laryngoscopy for patients with dysphonia whose history, symptoms, or physical examination is concerning for a serious underlying etiology. 7. Several conditions exist which can minimize morbidity and mortality and reduce the negative quality of life consequences. 8. Early referral to a laryngologist should also be offered for professional voice users and singers or other occupations/positions where delay may risk extensions of injury or other occupations where a delay may risk extension of injury.

Vocal acoustic can be classified into three types of segments by observing narrowband spectrograms.

1. Type 1: when narrowband spectrogram shows clearly visible structure period of harmonic structure. 2. Type 2: voices that show subharmonics. Subharmonics: two or more light-colored horizontal lines between each dark line. Subharmonics are in the vowel spectrum. 3. Type 3: segments in pts. Voice showing a complete lack of a clear harmonic structure.

Acoustic analysis of voice is usually used to obtain info of two kinds.

1. Vocal fold physiology 1. Perception of voice

s/z ratio

1. another classic and simple measure used to define respiratory function and laryngeal pathology. 2. measures length of time a person can sustain the sound /s/ and the length of time they can sustain the sound /z/, and the divides the 2 figures to obtain numerical ratio. 3. the higher the figure, the greater the possibility the person is experiencing with phonation (vibrating the VFs) a. make sure it is done correctly by having the person take their largest possible breath before attempting to sustain sound.

7. Statement profile 7: Corticosteroid therapy: clinicians should not routinely prescribe corticosteroid for patients with dysphonia prior to visualization of the larynx. Recommendation against prescribing based on randomized trials showing adverse events and absence of clinical trial demonstrating benefits with a preponderance of harm over benefit for steroid use.

1.Quality improvement opportunity: to discourage the empiric use of steroid for dysphonia prior to laryngeal examination. National quality strategy domains: prevention and treatment of leading 1. causes of morbidity and mortality; patient safety; making quality care more affordable. 2. Benefit: avoid potential adverse events associated with unproven therapy 3. Risks, harms, costs: none 4. Befits-harm assessment: preponderance of harm over benefit for steroid use.

Estimated Subglottal pressure

A. Subglottal air pressure a. Measured in H20 b. Is the amount of pressure directly below VF developed by respiratory system for voice production? B. To measure this: a. Pressure transducer is connected to. a thin, short piece of polyethylene tubing i. This is then attached to a hypodermic needle inserted into the cricothyroid membrane. b. The only issue with this is discomfort and anxiety during collection. C. Direct way to measure direct subglottal pressure a hypodermine needs is placed into subglottal airway through puncture into the cricothyroid space in front of neck. C. Indirect measurement of subglottal pressure occurs by a. Placing a small piece of polyethylene tubing between lips which is attached to a differential pressure transducer. b. With tube between lips, pt. is asked to produce string of bilabial syllables consisting of the voiceless stop /p/ followed by the vowel /I/ at a constant pitch and at a rate of 1.5 syllables per second. i. During /p/ production the VF were open, but lips are closed giving the opportunity for pressure to reach a state of equilibrium throughout the upper airway. ii. Must maintain syllable ratee. iii. Must be at a 1.5 rate per second but somewhat higher is okay but no slower if the data are to be valid. D. Differential pressure transducer a. Measures difference between 2 or more pressures. In the case of the differential pressure transducer described here, pressure 1 = atmospheric pressure; pressure 2= pressure sensed in the oral cavity

Use of aerodynamics indexes for documenting changes in laryngeal status

Is relevant for reporting treatment outcome for a variety of populations with disordered voice production.

Minimum glottal airflow

a. Relates to the amount of airflow through the glottis during the closed phase of VF vibration. b. Higher minimum airflow i. Reflects a greater degree of incomplete glottal closure. ii. This measure provides a way to document hypofunctional component of vocal pathologies, such as 1. Vocal fold paralysis or spasmodic dysphonia, or other cases were glottal incompetence. c. Glottal airflow waveform i. Will be different just deponing on the phonation type. 1. For breathy voice a. Glottal pulse will be more symmetric with a higher open quotient and a higher peak airflow. 2. Creaky or pressed voice a. Glottal airflow pulses are more irregular, and the OQ will be low.

Clinicians when evaluating patients with Parkinson's

disease based on airflow declination and lung volume expended per syllable to avoid depending on an acoustic signal.

Visual analog

Tool was. Line is used with two defined endpoints, and ratings can be placed on the line to define the magnitude of a sensation.

Vital capacity

Total amount of air that can be exhaled after a maximum inspiration.

Perception of voice

Use of any took helping to identify and quantify changes in perceived vocal characteristics can help evaluate voice a. disorders and document outcome of rehab goals of pts with voice disorders. b. Although using rating scales can give subjective evaluation of voice, acoustic analysis of voice holds promise in standardizing measurement tasks and in minimizing the variability associated w/ subjective evaluation.

1. Identify the special populations in the article (eg, pediatrics, professional voice users, head and neck cancer) that may need specialized care considerations.

a. (Prior laryngeal surgery, recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, history of radiation treatment to the neck, direct laryngeal trauma, craniofacial abnormalities, velopharyngeal insufficiency, and dysarthria (impaired articulation) b. Voice disorders affect all ages, but some evidence suggests that risks are higher in pediatric and elderly (> 65 years of age) c. Higher prevalence in boys and those 8-14-year range d. Among older adults with presbylarynx (age-related laryngeal changes) e. Those in adults aged 60-69 f. Most common diagnosis coded in this cohort were acute and chronic laryngitis, non-specific dysphonia, and laryngeal lesions. g. Adult and geriatric

Circumferentially vented pneumotachograph face mask:

a. Allows oral airflow to be collected at the mouth. b. This transduction system works on the principle of impedance to produce a measurable drop-in pressure proportional to airflow. c. Mesh on the mask create an air pressure drop equivalent to flow that is approximately no more than 10% of lung pressure used to produce sounds. d. Circumferential design minimizes sound distortion and loss of high-frequency fidelity compared to funnel-type pneumotachographs. e. Comes with noninvasive instruments to extract oral and nasal airflow, estimate subglottal air pressure, and assist the clinician in calculating laryngeal airway resistance. f. Cons: i. Discussion on effects on breathing and the accurate representation of airflow signal during voice production.

Describe what they recommended.

a. Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces the quality of life. b. Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. c. Clinicians should perform laryngoscopy or refer to a clinician who can perform laryngoscopy when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. d. Clinicians should perform diagnostic laryngoscopy before prescribing voice therapy and document/communicate the results to the SLP e. Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention. Such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. f. Clinicians should offer or refer to someone who can offer botulinum toxin injections for the treatment of dysphonia about control/preventative measures. g. Clinicians should document resolution, improvement, or worsening symptoms of dysphonia or change in the quality of life of patients with dysphonia after treatment or observation.

Describe what they recommended against

a. Clinicians should not routinely prescribe antibiotic to treat dysphonia. b. Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. c. Clinicians should not prescribe antireflux medications to treat isolated dysphonia based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. d. Clinicians should not routinely prescribe corticosteroid for patients with dysphonia prior to visualization of the larynx.

But vocal intensity is notoriously difficult

a. Ex: ambient noise, microphone placement, sensitivity, or adjustment made on analog or digital electrons such as preamplifier b. Preamplifier gain will have to be adjusted to account for very low signals or to avoid peak clipping.

Recording fails to use the available if quantization level adequately.

a. If the microphone gain is set too low, the entire signal may be recorded using small number of quantization level. b. This error fails to utilize the full amplitude resolution available and may limit the accuracy of specific acoustic measures such as amplitude perturbation. c. Can be avoided by making sure microphone gains are set highest values possible that doesn't result in peak clipping.

Phonatory aerodynamic system model 6600

a. Integrated PC-based hardware and software system measuring airflow and air pressure parameters during voice. b. Has software routines with which to calibrate equipment and normative data bases built in the data management of its output for easy comparison. c. Allows for collection of oral airflow and oral pressure.

Differential pressure transducers

a. Measures the pressure by calculating the difference between the pressure before a resistance and the pressure after a resistance. b. Measuring pressure difference before and after resistance, the flow velocity can be calculated.

Clinician must be careful to avoid peak clipping.

a. Peak clipping: occurs when the signal intensity is so high that it can't correctly be represented within the quantization level available for recording. b. To avoid peak clipping: microphone gain needs to be adjusted such that the highest peaks in the signal do not exceed maximum input levels.

Airflow open Quotient

a. Provides information about length of time the glottis is open relative to the duration of the entire cycle of VF vibration. b. This is useful when cases in which glottal closure is deemed inadequate or incomplete. i. Or in other cases where a high glottal resistance is suspected 1. Meaning an obstruction, spasm hyperfunction, or loud voice production c. Open quotient i. Can help define the degree of glottal adduction from aa pressed (harsh) to breathy voice. 1. However, care must be taken to measure the subglottal pressure developed during voice production because it is influential on measure of open quotient.

Estimated laryngeal airway resistance.

a. This requires the accurate measurement of average airflow and estimated subglottal pressure as determined from the intraoral pressure signal during /pi/ syllabled described above. b. You calculate by dividing value of estimated subglottal pressure by the average airflow value. c. Can use resistance measures to differentiate muscle tension dysphonia from healthy adults.

Inverse Filtering

a. To get an estimate of the airflow modulated by the VFs during voicing, Inverse filtering of the oral airflow waveform must be completed to obtain an estimate of airflow. b. Relies on the accurate identification of the formant frequencies from the oral airflow signal. c. Benefits of Rothenberg's circumferentially vented mask designed. i. The preserving of the vowel quality because of the high bandwidth of system, on the order of 3 kHz. D. Criteria for deriving accurate information using a pneumotachograph. i. Output must be linear function of the volume velocity. ii. Airflow resistance of the mask should be. Low enough so no negligible disturbance of the pressure and airflow occurs during speech. Adhering to the low airflow resistance criteria ensure that there is no distortion to the acoustic signal. iii. The response time of pneumotachograph should be small compared to the glottal period.

Vocal fold physiology

a. Voice disorders generally originate from some change in VF structure or vibratory characteristics. Any tool used to quantify and identify changes help voice and development of rehab goals. b. Acoustic analysis is superior to laryngostroboscopy or aerodynamic assessment because it is easy to quantify, less time consuming, less expensive, and more comfortable to patient.

Average airflow

a. With a healthy laryngeal condition: Average airflow during sustained vowel production ranges from i. 40 to 320 cc/sec in men ii. 50 to 220 cc/sec in women iii. With average data reported as 119 cc/sec and 115 cc/sec b. Sustained vowel production is used to measure. i. Average airflow, as the vocal tract is relatively unrestricted. c. This provides general idea of laryngeal function but does not give detail about flow modulated (regulated) at level of glottis. i. When extracted from a voicing signal other than sustained vowel prolongation glottal airflow is averaged with the other airflow modulated by articulators within the oronasal and pharyngeal cavities. D. With the medialization procedures i. There is a potential decrease in airflow from pre- to post surgery. ii. Caution should be read when interpreting its use as a fine measure and should be recognized as a gross measure of laryngeal function change. e. Can be combined with measures of estimated subglottal airway resistance. f. Studies have found that those with spasmodic dysphonia produced varying airflow. i. This may be a source of error due to the variability in flow rate that occurs because of chaotic nature of VF vibration associated with spasmodic dysphonia. Results must be read with caution. g. Glottal airflow: i. Finer measure of airflow

Trans nasal flexible laryngoscopy

a. passed through nasal cavity. b. Awake for procedure. c. Water based gel is used to help ease movement of scope through nasal passage. d. Pros: i. Pts typically don't experience pain. ii. Anesthetic spray used to minimize discomfort but doesn't totally eliminate sensation. iii. Allows assessment of VF function during more complex vocal tasks iv. Connected speech and song production can be sampled while using the flexible scope. Providing more functional behaviors associated with voicing that can be used in reaching aa diagnosis. v. Can assess the presence or absence of compensatory behaviors. 1. If they exist, they exist they can be documented and treated in rehab program. 2. Can see ventricle (false) VF movement during voice product ion. 3. During voice production the VFs do not participate in generating sound productions. But when the pathology exists, the FVF movement may compensator for the impaired VF movement. a. This happens when thee FVF move toward middle of larynx during voicing. This is a sign of muscle tension. e. Cons i. Sense of mechanical discomfort as scope passes through nose.

Voice range profile (phonetogram)

i. Also known as phonautograms ii. Method of gathering comprehensive data about the entire range of fundamental frequencies and intensities that a patient can produce. 1. When a pt. is asked to phonate a wide range of fundamental frequencies, spanning the lowest to the highest note possible 2. Pure tone audio signal is usually provided as a target the client is in need to match their fundamental frequency of phonation. 3. May be given visual feedback to help them monitor their vocal output. 4. At each intensity, they are to vary intensity from low to as high as possible. i. For a person with healthy voice typically shows an elliptical shape, with the smallest range of intensity produced toward the lowest and highest fundamental frequencies. ii. Patients with voice disorders may have overall reduction in the range of fundamental frequency and/or intensity that can produce. iii. May show a notch or specific areas within the VRP at which they are unable to produce voicing. iv. It can be fatiguing and timely it is not usually part of clinical assessment can provide valuable information regarding voice production capabilities for speaker. v. Used for evaluating professional voice users (singers)

Fundamental frequency

i. Basic measure made from acoustic signal. ii. Most software for acoustic analysis of speech will provide one or more algorithms for computing fundamental frequency. iii. Most software packages will display fundamental frequency contour for analyzed signal and report mean and SD for the contour. iv. This measure typically reflects number of vibratory cycles completed per second. v. It's clearly estimated for type 1 signals. vi. Related to pitch. vii. As the FF increases, so does pitch, but the relationship is not linear. 1. Ex: doubling FF does not lead to doubling pitch viii. Errors that come when estimating fundamental frequency 1. Algorithms may double or half of the actual FF. 2. When the algorithm accidently reads the first formant of frequency as the FF a. This occurs in vowels where the first formant frequency is close to the FF. b. Always visually inspect the FF contour accuracy c. If FF contour is abrupt changes should be matched against the time waveform to confirm accuracy of FF output. Can be easily corrected by limiting the algorithm to search for candidate FF with narrow range. ix. Great promise in this measure to clinical assess dysphonia as the numbers are more robust to variations in signal types than the more conventional algorithms.

vowel spectrum

i. Changes in vowel spectrum are related to a specific aspect of VF closure. ii. Measuring the difference in the amplitude of the second harmonic relation to the amplitude of the first Hamonic, one can estimate a change in the open quotient iii. Greater open quotient = a greater H1-H2 ratio iv. Spectral tilt: the amplitude of the harmonic closest to the third formant relative to the amplitude of the first harmonic (H1-A3) 1. As spectral tilt is affected by the degree of abruptness during VF closure, H1-A3 reflects the rate at which the vocal fold closure is achieved. 2. H1-A3 is related to the speed of glottal closure within a cycle of VF vibration. 3. Greater H1-A3 reflects greater spectral tilt. v. Amplitude of the harmonic closest to the first formant relative to that of the first harmonic (H1 to A1) is associated with the first formant frequency bandwidth. 1. As the first formant bandwidth increases for incomplete glottal closure, H1-A1 may be used as a measure of glottal closure. 2. Larger H1 -A1 values reflect a lack of glottal closure. 3. These measures are associated with the presence of breathy voice quality. vi. For a person who is observed with a breathy voice quality 1. Is typically observed when there is incomplete glottal closure, greater spectral tilt, and longer open quotient; these voices have higher H1-A3, H1-H2 values. vii. In contrast, strained or pressed voices are typically generated with very rapid adduction of the vocal folds. Resulting in lower H1-H2 values i. These measures are typically classified as type 1 signals.

Laryngeal aerodynamic of developing larynx.

i. Children's smaller laryngeal size 1. Limits glottal area and VF vibrational amplitude. 2. Which then affects aerodynamic to acoustic energy conversion? ii. Tang et al predicted aerodynamic measure, as function of development would reflect the known changes in laryngeal anatomy. iii. Functional differences between children and adults 1. 14 yr. old boys and adult men a. Showed comparable aerodynamic influence on voice. 2. Women and all other children showed. a. Similar function 3. Data corresponds with developmental anatomy of larynx. a. Which shows laryngeal size for women and children to be more similar than women compared to men?

Indices obtained by combining measurements.

i. Dysphonia Severity Index (DSI) 1. A combination of measurements 2. Used to describe the severity of a patient's dysphonia augment perceptual assessment of voice, and it is considered a more objective method of voice analysis. 3. Provides an additional measure of noise components without being limited by the lack of identification of a fundamental frequency. 4. This is an algorithm that combines a small subset of weighted acoustic variables. ii. Thee more negative the index result after applying the algorithm to the patients voicing signal, the more dysphonic voice. iii. The more positive the index result after applying the algorithm to the voicing signal, the more dysphonic the voice. iv. Cepstral/Spectral Index of Dysphonia (CSID) 1. This measure combines cepstral measures of voice. Such as CPP. Other voice parameters, such as the spectral tilt, to develop more holistic measure of dysphonia severity. 2. Sensitive to voice quality changes in dysphonia 3. These measurement tools are available thru Pentax and are called the Analyses of dysphonia in speech and voice (ADSV) v. Clinicians should begin voice analyses by a careful study of the narrow band spectrogram. 1. This allows clinician to classify the signal into three segments: mainly period (Type 1), signals with subharmonics (type 2), or signals with no clear harmonic structure (type 3) 2. Type 1 segments may then be submitted for computing other measures, such as FF, short-term perturbation, relative noise levels, or CPPa. 3. Type 2 and 3: signals may be best described using spectrograms or LTAS.

Laryngeal aerodynamic changes as a function of speech tasks

i. Each task has different effect on measurement outcome. 1. For example, is it just a sustained vowel task vs connected speech task. ii. Glottal airflow parameters during vowel productions, syllable production, & reading 1. Found statistical significance between vowels produced in is isolated compared to vowel produced in syllables and reading. 2. Differences were found in airflow amplitude measures and time-based airflow measures. a. Although had statistical significance, numeric differences were small causing speculation as to whether the difference would resulting perceptually distinct voice quality.

Cepstral peak

i. Is obtained by analyzing the spectrum of a vowel. ii. The spectrum shows the distribution of energy across different frequencies for the same waveform. iii. To determine cestrum, another analysis (which is akin to computing a spectrum from a waveform) is completed. 1. computing a spectrum from another spectrum 2. wee then obtain a measure of energy over a period. iv. Cestrum: an inverse of the word spectrum, reflecting the nature of the computation that reverses the signal representation from the frequency domain back to the time domain. v. cepstral measures have increasingly been used to describe the degree of severity of dysphonia. vi. ^ Cepstral peak prominence (CPP) 1. CPP is calculated by first estimating the height of the cepstral peak that corresponds to the FF and comparing it to the noise in the same frequency region. 2. Difference between the two reflects the degree to which the energy in the region of the FF is visible or prominent over the noise in the same frequencies. i. CPP is reported in a unit of dB. ii. Normal voices typically have a higher CPP value. iii. CPP trends lower as the severity of dysphonia increase iv. CPP values correlated with perceptual judgments of breathiness as well as that overall severity of dysphonia v. CPP is another way to estimate relative noise levels in a vowel and behaves like metrics such as HNR or GNE vi. CPP is not as prone to errors from FF estimation, making it more accurate and consistent across measurements. vii. Good index of overall change in voice quality, particularly for type 1 voices

Voice handicap index

i. Measures how a voice problem influences a patient's quality of life. ii. Three major areas are represented on this index. 1. Physical subscale a. Includes questions about how his voices disorder affects other physical functions such as (breathing, or breath control, how voice sounds, and whether sound quality is consistently impaired or varies in the day) 2. Functional subscale a. Includes questions related to how the voice disordered impacts other daily activities, such as (work, family life, and interactions with friends. 3. Social subscale a. Emotional subscale. Questions related to how the patient feels about having the voice disorder. iii. When using the VHI to document change in voice handicap following treatment, a difference score of 18 points would be considered statistically significant and potentially clinically relevant. iv. Factor analysis: a statistical test that determines the smallest number of factors required to explain a pattern of relationship. For example, the analysis helps to determine which factor makes the change in voice more positive or more negative and/or which factor has no role in changing the voice.

Auditory-based measures of voice quality

i. Most acoustic measures used in voice clinic are not directly related to perceptual attribute of voice. ii. Perception of vocal quality is believed to be highly complex, involving multiple acoustic cues that often have a nonlinear relationship with the percept they elicit. iii. These measures are computed from the auditory representation of the acoustic signal. 1. Signal is recorded by a high-fidelity microphone and first passed through a computer program that stimulates transduction process in the peripheral auditory system. a. The simulated output of the auditory system is then used to identify features or cues that may reflect change in voice quality. iv. Perception of breathiness may be related to thee extend to which the harmonic components in a voice are masked or overshadowed by noise in the same voice. v. Pitch strength: reflects the robustness of pitch sensation in a sound stimulus. 1. Voices with greater pitch strength are generally perceived to be less breathy than those with lower pitch strength. 2. Roughness and observed roughness are primarily related to the amplitude modulations or rapid changes in the intensity of vowel waveform. vi. Strain: related to distribution of energy in the vowels 1. Vowels tend to be perceived as more strained if they have more energy in the midd to high frequency regions.

Spectrograms

i. Not a specific measure, but it is a visual representation of the speech acoustic signal. ii. Allows a clinician to inspect how the acoustic signal changes over time. iii. Represents speech in three dimensions. 1. Ordinate or horizontal axis shows time. 2. The abscissa or the vertical axis shows frequency. 3. Darkness of the plot shows intensity of various frequencies. 4. May also show intensity by different colors on the plot. iv. 2 types are commonly used for speech analyses. 1. Wider windows for analysis (darker) a. Creating a wideband spectrogram b.Averaging signals in wider windows, a wideband spectrogram gives very good time resolution, but lacks good frequency resolution. c. Allows clinicians to clearly observe how acoustic signal changes over time but can't resolve neighboring frequency components distinctly. d. Clearly distinguish beginning and end of a consonant but fails to show individual harmonics in the vowel. e. Ideal for studying the formant struct or consonant-vowel boundaries. 2. Shorter windows (lighter) a. Creates a narrowband spectrogram. b. Much better frequency resolution but lacks the time resolution of the wideband spectrogram. c. Shows individual harmonics at cost of losing the fine temporal structure. d. An excellent way to inspect the vocal acoustic signal in patients with voice disorders. e. Inspecting changes in the harmonic structure of the voice, clinician can observe the stability of the patients VF vibration. i. Harmonic: a structure that is an integral multiple of the fundamental frequency. If the patient has a stable VF vibration pattern, the narrowband spectrogram shows clear and steady harmonics.

Acoustic analysis of voicei.

i. Once the voice sample is recorded, it is submitted for a variety of analyses. ii. Different algorithms and procedures for voice analyses are included in 7 major categories. 1. Spectrograms, fundamental frequency, intensity, short-term perturbation, relative noise levels, cepstral peak, and measures made from short-or long-term spectra.

Perceptual rating scale

i. One's perception is difficult to define s it is often formed based on their words (age, sex, language, culture, intrinsic and extrinsic bias) ii. Clinician is to listen and form an impression of patient's vocal quality, pitch, and loudness to describe the voice and determine the baseline i. impression with which to compare a form of treatment (i.e., surgical, pharmacologic, or behavioral iii. Can assign terms to voice quality. iv. Physiological process of the voice disorder does not show a one-to-one correspondence with the perceptual description of the voice quality. 1. Listene4rs don't always agree with each other very well. 2. Systematic scaling techniques and specific strategies for completing perceptual analysis of voice should be used to minimize errors in determining voice characteristics when listening to voice. v. Standardized rating scales and attending to specific aspects of vocal quality. 1. An organized manner for assessment of voice quality 2. Rating scales for objectifying perception take the form of an ordinal or visual angle scale. vi. Ordinal scale is the preferred scale because it is easier to use (but should not be the benchmark)

1. Identification of abnormal voice: clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces QOL.

i. Recommendation: based on observational studies with a preponderance of benefit over harm ii. Action statement profile: 1 1. Quality improvement opportunity: to promote awareness of dysphonia by all clinicians as a condition that may require intervention. National quality strategy domain: prevention and treatment of leading causes of morbidity and mortality from treatment; discourage the perception of dysphonia as a trivial condition that does not warrant attention. 2. Risk, harms, costs: potential anxiety related to diagnosis; time, expended in diagnosis, documentation, and discussion. 3. Benefits-harm assessment: preponderance of benefits over harm 4. Purpose: to promote awareness of dysphonia as a condition that may decrease a patient's quality of life. Proposed diagnosis is based strictly on clinical criteria and does not require testing. 5. Clinician should assess quality of voice. For example, breathy voice may signify vocal paralysis or another cause of incomplete closure. Strained with alerted pitch or pitch breaks is common in SD.

Recording voice acoustic analysis

i. Recorders must meet certain minimum standards for the acoustic measures to be accurate. ii. Minimum standards include being careful to use recording equipment that has a wide frequency response, high sensitivity, and good signal-to-noise ration. 1. Most recording system designed specifically for voice analyses or primarily for music meet or exceeds the minimum requirements. iii. Modern instrumentation for acoustic recording relies on digital technology that represents the acoustic waveform as a series of numbers. 1. These digital recordings represent acoustic signals by taking snapshot (sample) of signal from time to time. i. 1 bit signal 1. Can only 2 possible levels or steps ii. 2-bit signal 1. May have four possible steps. iii. Higher bit rates 1. Allow the acoustic signal to be more accurately reflected improving the accuracy of acoustic analysis. 2. It is recommended acoustic signals have at least 12-bit resolution, but new software packages now use 16-bit or higher quantization levels.

Short-term perturbation

i. Reflect cycle-to-cycle in speech acoustic signal. ii. Sound generated by VF vibrations not perfectly periodic and varies slightly from ones preceding it. iii. Successive cycle may differ in their amplitudes and their time-period or fundamental frequency. iv. Measures of frequency perturbation and amplitude perturbation v. Algorithms that have been proposed to quantify each of the two aspects of vocal acoustic signal. vi. Amplitude perturbation 1. Frequently referred to as shimmer vii. Frequency perturbation 1. Labeled to as jitter. viii.Shimmer and jitter have specific meaning as they describe one method for computing amplitude and frequency perturbation. ix. Algorithms used to compute short-term perturbation. 1. Absolute shimmer 2. Amplitude perturbation quotient 3. Directional perturbation factor 4. Directional shimmer factor 5. Least mean square jitter and shimmer x. Physiologically it reflects variability in the VF vibration. xi. Thus, with individuals who have highly aperiodic VF vibration are likely to show greater perturbation values. 1. These values only be correctly computed for type 1 value segments. 2. Therefore, it may be misleading perturbation values if the type of signal being analyzed is not classified accurately. But will produce output whether the type. xii. Increased perturbation values correspond closely with change in voice quality such as increase in breathiness or roughness. xiii. These measures only help to quantify aa specific change in the vocal acoustic signals, and such changes may or may not have a clear perceptual correlate.

Intensity

i. Reflects the acoustic power in the voice and is related to pts. ability to generate and maintain adequate subglottal pressure. ii. Is related to loudness of the voice but the acoustic-perceptual relationship is not linear. iii. Although greater intensity reflects greater loudness, the two don't increase proportionally. iv. Most software generates an intensity contour & provide some means for summarizing it statistically. v. Will include the average intensity, measured in decibels and its SD. vi. Free of errors and straightforward vii. But vocal intensity is notoriously difficult. 1. Because it is easily affected by externals facts. a. Ex: ambient noise, microphone placement, sensitivity, or adjustment made on analog or digital electrons such as preamplifier b. Preamplifier gain will have to be adjusted to account for very low signals or to avoid peak clipping.

Laryngeal aerodynamic differences as a function of Sex

i. Reports of distinctions in aerodynamic parameters between young women and young men (this documented higher values for amplitude-based parameters such as mean, peak, and alternating flow) 1. Maximum flow declination rate in men versus women 2. Longer open phases of the airflow duty cycle in women vs men ii. Results relate well to the perception that. 1. Female voice is weaker and breathier than the adult male voice.

spectral measures

i. Shows how the energy is distributed across various frequencies in a signal. ii. Computing makes it easy to compute the spectrum of a signal and can quantify various aspects of the spectrum. iii. Measures may be obtained either from a short-term spectrum or a long-term averaged spectrum. iv. Small-term spectrum: computed by analyzing a small part of the vocal acoustic signal. 30 to 50 ms in duration. v. Long-term average spectrum (LTAS): computed by averaging energies in much longer utterances (seconds to few minutes)

Fast Fourier Transform (FFT)

i. Software packages can generate a FFT or. A linear predictive coefficients (LPC) spectrum 1. FFT spectra are useful for voice. 2. LPC spectra are typically used to identify vowel formants. ii. FFT spectrum for a vowel 1. Shows a series of equally spaced peaks on the horizontal frequency axis. a. Each peak represents a harmonic component. b. Harmonic components that lie close to a Forman frequency can be identified by their greater intensity. C. Otherwise, intensity of the harmonics tends to decline with increasing frequency. Type 3 may show no harmonic structure

relative noise level

i. The level of noise relative to the level of the harmonics or the periodic signal generated by VF vibration. ii. The outputting from this periodicity is measured as noise and may arise from two factors. 1. Irregularities in vocal fold vibration (short-term perturbation) results in the presence of noise in the Vocal acoustic signal 2. An incomplete glottal closure results in the generation of turbulence at the glottis, which adds noise to the vocal acoustic signal. 3. On overall noise it is difficult to isolate the effects 4.Most measures of noise reflect change in short-term perturbation as well as the presence of turbulence or aspiration noise in vocal acoustic signal iii. Relative of noise increases as the VF vibration becomes irregular and/or if the VF fail to complete close the glottis. 1. Perceptually, Relative noise levels have been associated with breathiness, roughness, and hoariness. a. Perception of these vocal qualities appears to be more complex and is likely elicited by a combination of various acoustic changes in the vocal signal. 2. Although relative noise levels are correlated w/ the perception of dysphonic voice quality, this measure is neither specific to a particular voice quality type nor highly sensitive to changes in the vocal quality.i.

Voice handicap scales and quality of live scales

i. This helps improve clinician awareness because we really don't know how disorder impacts them. ii. Must be completed at the beginning of initial assessment to gauge the influence of the disease or disorder. iii. Also fill out throughout the course of treatment as an indicator of improvement or deteriorating in status iv. Be careful of placebo effect where a patient may indicate perceived improvement in handicap while thee disordered voice changes very little. v. Show better sense of patient perception of the voice problem/ vi. Pts with high core and mild hoarseness are likely to be better candidate for therapy than a patient with severe problem who is not hampered by voice quality. i. When selecting an instrument to use it is important to consider the validity, reliability, and practicality. ii. Ease from both clinician and client should be taken into consideration.

long term average spectrum

i. Typically obtained from reading or a conversational speech sample ii. Restating spectrum can be used to study the distribution of energy across frequency. iii. As the distribution of energy across several vowels and consonants, it does not show harmonic structure associated with the vowel FFT spectrum iv. It typically shows a smoother contour, with the greatest energy at the lower frequency regions. i. Typically obtained from reading or a conversational speech sample ii. Restating spectrum can be used to study the distribution of energy across frequency. iii. As the distribution of energy across several vowels and consonants, it does not show harmonic structure associated with the vowel FFT spectrum iv. It typically shows a smoother contour, with the greatest energy at the lower frequency regions. v. Commonly used measures obtained from the LTAS include. 1. Computing the ratio of energy within different frequency bands as well as computing various spectral moments a. Ex: users may calculate the ratio of energy between 0 - 1 kHz and 1 to 5 kHz or that between 0 to 2 k Hz and 2 to 4 kHz. i. Alpha-ratio ii. To compute spectral moments, the LTAS is treated like a bell curve, and its first four moments are calculated. 1. Mean, SD, skewness, and kurtosis (used to describe the overall energy distribution in the speech signal iii. This measure is best treated as an approach to describing and studying the speech acoustic signal. iv. Is simply used in a descriptive manner to compare two or more speech samples. v. Valid for all signal types- types 1, 2 and 3 vi. Aspiration noise can alter various LTAS measures to some degree. vii. Note spectral characteristics (the slope) are dependent on the overall intensity level, which must be controlled or accounted for when interpreting spectral measures.

Using aerodynamics for examination of voice disorders

i. Vital capacity 1. Total amount of air that can be exhaled after a maximum inspiration. ii. MPT (maximum phonation time) 1. Can be useful and general measure of lung capacity and laryngeal valving abnormality. 2. Task must be performed correctly and may be susceptible to interpretation when laryngeal valving abnormalities are severe. iii. s/z ratio 1. another classic and simple measure used to define respiratory function and laryngeal pathology. 2. measures length of time a person can sustain the sound /s/ and the length of time they can sustain the sound /z/, and the divides the 2 figures to obtain numerical ratio. 3. the higher the figure, the greater the possibility the person is experiencing with phonation (vibrating the VFs) a. make sure it is done correctly by having the person take their largest possible breath before attempting to sustain sound.

Voice Related Quality of Life Scale

i. a 10-item instrument, adapted from the adult VRQOL instrument. ii. 2. parents or guardian in the care of pediatric voice problem should not be underestimated as parents play a major role in monitoring their child, modifying their child's environment to promote vocal hygiene, practicing good vocal habits and vocal homework exercises with child, and providing the clinician with updates on progress or departures from the therapeutic goals

How is an acoustic or aerodynamic measure different from the auditory-perceptual measures we learned about last week?

i. aerodynamic measures 1. Used in the object clinic assessment of how the larynx is functioning. 2. Is more of an invasive measurement. 3. Used to monitor change in voice over time (following therapy, before and after surgery, or with the progression of the disease) 4. Should produce quantitative results. i. acoustics 1. Acoustic is cost-effective. 2. Acoustics can be affected by variables other than its voice itself. 3. Factors include recording procedures, elicitation instructions, and environmental interference. 4. Easy to quantify changes, less time consuming, most comfortable to the patient. 5. Can give a subjective evaluation of voice. Acoustic analysis of voice holds promise in standardizing measurement tasks and in minimizing variability associated with subjective evaluation. 6. Consist of 7 major categories i. Auditory perceptual 1. Produce subjective results based on reports or SLP judgments. 2. Not intended to be used alone or other means for determining the nature of a voice disorder. 3. CAPE-V should be complemented by a visual exam of the larynx and other tests of vocal function to arrive at the best evaluation and most comprehensive impression of voice disorder.

acoustic-aerodynamic measures

spectrograms, fundamental frequency, intensity, voice range orofile, short-term perturbation, relative noise-level, spectral measuyres, fast fourier transform, vowel spectrum, long-term average spectrum, cepstral peak, electroglottography, electromyography, auditory-based measures of voice quaaality, oral rigid laryntowdopy, transnasal fllexibllel laryngoscopy. etc.