55 

55
Voice Evaluation and Therapy
Robin A. Samlan

KEY POINTS The Voice Handicap Index was designed to assess handicap,
“a social, economic, or environmental disadvantage resulting from
• The voice is multidimensional, so voice assessment an impairment or disability.”5 The instrument consists of 30
should be multidimensional. statements that patients rate on a five-point equal-appearing interval
scale that reflects frequency of occurrence. The total possible
• Auditory, visual, and tactile perceptual examinations are score is 120, with higher scores reflecting greater handicap.
key components of a voice evaluation. Although functional, physical, and emotional subscales can be
• It is important to characterize the patient’s perception of reported,6 it has been suggested that the total score is more
the problem and the impact of the voice disorder on the meaningful.7 Since its publication in 1997, the Voice Handicap
patient’s life. Several published scales can be used to Index has been widely used to show voice handicap in specific
report various aspects of handicap or quality of life. groups of patients, comparisons between handicap and vocal
• Specific measurements can be used to better understand function measures, and change with treatment. It has been translated
voice production and to document aspects of voice into numerous languages and has been used as a model for a
quality. A group of measures provides a more complete shortened version, (VHI-10),7 a singing handicap index8 and its
description of the voice than any measure alone. 10-item version,9 a child’s version,10 a vocal fatigue index,11 and
an aging voice index.12
• Vocal function measurements are less “objective” than The Voice-Related Quality of Life13 is a 10-item scale divided
they sound, and their relation to voice quality is into physical and social-emotional functioning subscales. Each
complicated and incompletely understood. item is scored on a five-point interval scale that reflects the severity
• Voice therapy helps patients learn efficient and healthy of the problem. For each subscale and for the total score, 100 is
technique to enhance voice quality and loudness, the highest possible score, which reflects the highest quality of
minimize voice-related handicap, improve life. A child’s version of this scale is also available.14 The Voice
communicative effectiveness, and restore vocal identity Symptom Scale1,15 is a psychometrically sound 30-item scale that
and health. represents physical impairment, emotional response, and related
physical symptoms. Each question is rated using a five-point scale
that represents frequency of occurrence.
Several other PRO scales are related to concerns of patients
in an otolaryngology practice. These include the Reflux Symptom
Index,16 Speech Handicap Index for patients with head and neck
Voice is produced by interactions among the respiratory, laryngeal, cancer,17 Cough Severity Index,18 and the Dyspnea Index.19
and resonance systems. The speech-language pathologist assesses
each system in addition to the overall speech output. This chapter
describes the typical components of a voice evaluation and how
PERCEPTUAL ASSESSMENT
to interpret the results, including patient-reported outcomes
(PROs), perceptual evaluation, instrumental assessment of the
Auditory Perceptual Assessment
voice-production mechanism and resultant sound wave, and Voice pitch, loudness, and quality are generally assessed during
diagnostic therapy. The chapter concludes with an introduction auditory perceptual evaluation. Pitch, pitch variability and range,
to voice therapy. Videostroboscopy is detailed in Chapter 54. loudness, and loudness variability and range are assessed in relation
to the speaker’s age, sex, gender, and the testing environment.
Voice quality is more difficult to define and measure, although it
PATIENT-REPORTED OUTCOME INSTRUMENTS is important because the ultimate goal of intervention is often to
Individuals have different requirements and expectations of their improve voice quality. Clinicians should consider cultural variability
voices as well as different emotional responses to voice disorders; when determining whether quality is impaired. Traditionally, voice
thus, the same degree of dysphonia will differentially limit participa- quality is rated as a series of pseudo-independent features (e.g.,
tion in typical daily activities or alter a person’s sense of self. As breathiness, roughness, and strain), but strong evidence suggests
part of a complete voice evaluation, the effect of the voice problem that the overall pattern is more than the sum of these features.20
on each individual’s life should be assessed. PRO instruments are Raters often disagree when rating voice quality; this is based on
questionnaires completed by the patient that measure symptoms several factors, including difficulty isolating individual features or
and participation as well as more complex constructs such as health, dimensions, differing and inconsistent internal representations of
quality of life, or handicap. Several PRO questionnaires specific the parameters and severity, inadequate scale resolution, and the
to voice have been published and, as with all PROs, they differ magnitude of the target parameter.20
with respect to the rigor of their construction, validation process, Perceptual rating tasks that control these factors—such as
psychometric properties, questionnaire length, and domains determining whether two stimuli are the same or different, rating
assessed.1–4 In general, PROs are an important component of a the degree of dissimilarity of two productions, and adjusting a
voice evaluation that provides information not captured elsewhere. synthetic copy of a voice to match an original—lead to more
The questionnaires can be used to guide discussion between health reliable voice quality assessment.20–22 The method-of-adjustment
care providers and patients and to determine functional treatment task quantifies the perceived quality by the level of a particular
goals. Several of the most commonly used scales are introduced feature (e.g., noise-to-signal ratio) that the rater sets to perceptually
in this section. match the two stimuli.20 A sort-and-rate task can be used when
819
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 CHAPTER 55  Voice Evaluation and Therapy 819.e1

Abstract Keywords
55
Voice evaluation includes the patient’s perception of the problem, Patient-reported outcomes
perceptual assessment, instrumental measures, and diagnostic auditory perceptual
therapy. This chapter reviews each part of the voice evaluation acoustic
and introduces the reader to common behavioral therapy techniques aerodynamic
for voice and laryngeal airway disorders. voice therapy

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820 PART V  Laryngology and Bronchoesophagology

comparisons of multiple stimuli are required. Listeners place icons information regarding underlying systemic disease, previous
that represent stimuli on a line so that items that sound most treatment, or emotional disorders. Inattention to personal hygiene
similar are placed closest to one another.23–25 The distances among and dress, for example, can be indicative of an emotional disorder
stimuli are organized as dissimilarity matrices and are analyzed or dementia.
using multidimensional scaling.23,26,27 Posture and musculoskeletal tension are thought to contribute
Two rating scales that are used clinically are the GRBAS to muscle tension dysphonia (MTD), which alters vocal pitch,
(grade, roughness, breathiness, asthenia, and strain)28 scale and loudness, and quality. Assessment involves evaluation of the align-
the Consensus Auditory-Perceptual Evaluation–Voice (CAPE-V).29 ment of the head, neck, torso, pelvis, and legs. Musculoskeletal
The GRBAS scale is a simple rating tool by which the overall tension is visible as abnormal extent of jaw motion, chin jut, neck
severity and five dimensions of voice quality are rated on four- extension, bulging of the neck muscles while talking, or raised
point scales. The letter G represents the grade or overall quality, shoulders.
R is roughness, B is breathiness, A is asthenia (weakness), and Neurologic dysfunction is indicated by observations such as
S is strain. Each parameter is rated; the score is zero if no unsteadiness, asymmetry, rigidity, hesitation, slowness, weakness,
deficit is present, 1 if the deficit is mild, 2 if it is moderate, and incoordination, inconsistency, and extraneous movements. Weak-
3 if the deficit is severe.28 No standard recommendation has ness, asymmetry, and incoordination of the tongue, jaw, lips,
been established for the type of utterances to use with GRBAS, or soft palate are especially noteworthy. The presence of focal
so specific information about testing conditions should be dystonias, such as writer’s cramp, blepharospasm, torticollis,
documented. and oromandibular dysphonia, usually leads the examiner to
The CAPE-V is a rating tool by which six core parameters— consider a neurologically based voice disorder, such as spasmodic
overall severity, roughness, breathiness, strain, pitch, and loudness— dysphonia.
are rated by marking severity along a 100-mm line.29 These Physical dysmorphology, particularly syndromic features or
parameters may be supplemented with additional examiner-selected evidence of orofacial difference or resection, should be noted for
parameters. Each parameter is also flagged as occurring consistently possible relation to a resonance or speech intelligibility deficit.
or intermittently. The CAPE-V is scored based on two sustained Many systemic diseases that can affect the larynx and voice have
vowels, six standard sentences, and at least 20 seconds of natural visible physical symptoms, among which are rheumatoid arthritis,
running speech. Recommendations about testing and recording lupus, and Sjögren syndrome. For a detailed discussion of the
environments are included in the reference publication. visual perceptual examination, the reader is encouraged to refer
Additional features assessed in the auditory perceptual evaluation to the works of Koschkee and Rammage.30
include speech breathing, speech production, and resonance.
Auditory perceptual correlates of speech breathing include length
of breath group, average loudness, loudness variability, and inspira-
Tactile Perceptual Assessment
tory duration. These provide important information about lung Intrinsic and extrinsic laryngeal muscle imbalance is thought to
volume expended, adequacy and consistency of alveolar pressure, be the primary characteristic of MTD.31 Manual examination of
and shape of the rib cage and abdominal walls during talking. laryngeal musculoskeletal tension is a powerful technique to rapidly
Several other aspects of speech production, such as imprecise assess the contribution of muscle tension to the observed voice
articulation, resonance, and prosody disturbances, can indicate quality. Teasing apart muscle tension from other components of
structural or neurologic disorders that affect voice production. the dysphonia can help ensure proper diagnosis and management.
Resonance is described using the terms hypernasal, hyponasal, and Several protocols for manual examination have been recommended,
“cul-de-sac.” Prosody refers to speech rate, presence of repeated and assessment typically includes palpation of the suprahyoid
or prolonged syllables, rushes of speech, intonation (i.e., monopitch muscles, major horns of the hyoid bone, superior cornu and lateral
or monoloudness), and stress patterns. aspects of the thyroid cartilage, thyrohyoid space, and anterior
border of the sternocleidomastoid muscle. Suprahyoid tension
and thyrohyoid space are assessed both at rest and during phonation,
Visual Perceptual Assessment and lateral mobility is also assessed.32–34 Fig. 55.1 depicts this
The visual perceptual assessment refers to visible and physical aspects evaluation. Some authors also recommend palpating the thyrohyoid,
of voice production related to the etiology, maintenance, or result cricothyroid, and pharyngolaryngeal muscles (inferior constrictor
of dysphonia. General appearance features such as apparent age and posterior cricoarytenoid).35,36 Normal findings include palpable
compared with chronologic age; height and weight; facial expres- space between the hyoid bone and the superior border of the
sion; skin, hair, and nails; personal hygiene; and dress provide thyroid cartilage and mobility of the laryngeal complex. Findings

Greater cornu of
hyoid bone

Superior cornu and

posterior ridge of
thyroid cartilage Anterior
thyrohyoid
membrane

Superior ridge of
thyroid cartilage

A B C
Fig. 55.1  Manual musculoskeletal tension evaluation. (A) Palpation of suprahyoid musculature.
(B) Palpation of greater cornu of the hyoid bone, superior cornu of the thyroid cartilage, and lateral aspects
of the thyroid cartilage. (C) Palpation of the thyrohyoid space.

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 CHAPTER 55  Voice Evaluation and Therapy 821

indicative of excessive musculoskeletal tension include pain with

palpation that is frequently more severe on one side, decrease or
Source Measures 55
absence of thyrohyoid space at rest or with phonation, muscle The voice “source” is the output of vocal fold vibration (glottal
“knots,” high carriage of the hyoid bone and thyroid cartilage, area) and its interaction with the pressures of the subglottal and
and difficulty lateralizing the larynx.32–36 supraglottal vocal tract (glottal flow). Two techniques are used to
Currently, no intraexaminer or interexaminer reliability data estimate the source: electroglottography (EGG) and inverse
are available for the manual tension examination, and the sensitivity filtering.
and specificity of abnormal findings are unknown. In a radiographic
study of laryngeal position in people with MTD, Lowell and
colleagues37 found no difference between control participants and
Electroglottography
people with MTD in hyoid or thyroid cartilage location at rest. EGG measures the conductance of a low-frequency electric signal
During phonation, control participants lowered the hyoid more across the neck between two surface electrodes.39–41 The conduc-
than those with MTD, and participants with MTD raised the tance of the signal varies with the vibration of the vocal folds:
thyroid cartilage more than controls.37 when the vocal folds contact each other, conductance increases,
and the slope of the resultant EGG trace is positive; as vocal folds
separate, conductance decreases, and slope is negative. The results
INSTRUMENTAL ASSESSMENT are relative rather than absolute and do not measure glottal area
Instrumental source, aerodynamic, and acoustic assessments are or closure. The waveform’s shape is potentially meaningful for
used to document the voice disorder and the status of the voice- describing the pattern of vocal fold vibration, and many quotients
production system, including the respiratory system, voice source, to quantify the waveform have been proposed (e.g., open, skewing,
and the supraglottal vocal tract. Vocal function studies are sometimes and contact).42–45 Techniques for quantifying the waveform have
used to define treatment goals or as visual feedback during voice not yet been standardized, largely because of technical challenges
therapy, and repeated testing over time allows clinicians to monitor and difficulty relating the EGG waveform to vocal fold motion.43,44
and document changes that result from treatment or disease
progression. Instrumental assessments are also used to improve
our understanding of how particular aspects of physiology and
Inverse Filtered Flow
production generate the acoustics that evoke voice quality percep- Inverse filtering is a signal-processing technique that removes the
tion in the listener. effects of the vocal tract (formants) from the acoustic or the
It is tempting to consider instrument-based tests “objective,” aerodynamic waveform, leaving the glottal flow (i.e., source signal).
because they generate numbers, but it is important to remember Several measures can be made from the inverse-filtered flow
that examiners influence results and that factors other than laryngeal waveform; these include the skewing quotient, the ratio of increasing
status can affect measurements. To maximize its usefulness, vocal to decreasing flow, and the open quotient, the ratio of the increasing
function testing must be performed using standard protocols, plus decreasing flow to the period of the waveform.46 Measures
recording procedures, patient instructions, and test environments. of the slope of the flow spectrum are thought to be important to
A tutorial was recently published recommending protocols and overall voice quality.23,47 Unfortunately, inverse filtering is techni-
technical specifications for instrumental voice assessment.38 If cally challenging,48 and the results are difficult to validate.
adopted by researchers and clinicians, the protocols might improve Because glottal flow varies with different vocal fold vibration
our ability to compare patient outcomes and study results across patterns, and because it is important to voice quality, approaches
voice centers. Note that no single measure explains voice production to estimating the glottal flow waveform continue to evolve. Alku
or portrays the differences among voices, and most speech-language and colleagues49–51 analyzed sources of error in inverse filtering
pathologists select a subset of the measures described in the and proposed and tested a new algorithm. Kreiman and colleagues52
following sections based on their philosophy and education. The took a different approach and used a custom synthesizer to spectrally
measures described here are grouped as vocal respiratory measures, modify the inverse-filtered voice to perceptually match the original
source measures, aerodynamic measures, measures of velopharyngeal production.
function, and acoustic voice measures.
Aerodynamic Measures
Respiratory Measures Aerodynamic evaluation involves measuring air pressures and
Most people with voice-related concerns do not require full airflows. Although it is difficult to separate respiratory from
pulmonary function testing. Several measures of respiratory capacity laryngeal contributions to measures of air pressure and airflow
or use during speaking are useful in describing voice disorders during voice production, aerodynamic measures provide valuable
and planning treatment. These include maximum inspiratory and information in understanding voice production. Measurements
expiratory pressures, vital capacity, and the percent vital capacity are listed in Table 55.1 along with their hypothetical perceptual
at which patients initiate and terminate speech. correlates and normative values.

TABLE 55.1  Perceptual Correlates of Aerodynamic Measures

Normative Mean Normative Mean
(Standard Deviation) (Standard Deviation)
Measure Perceptual Correlate for Women for Men
Subglottal or intraoral air pressure Phonatory effort and strength of pressure consonants 7.52 (2.17) cm H2Oa 6.43 (1.07) cm H2Oa
Phonation threshold pressure Effort to initiate phonation ≈3 cm H2O modal, ≈8 cm H2O high pitchb
Airflow Breathiness 91–156 (16–71) mL/sc 101–183 (16–77) mL/sc
Laryngeal airway resistance Phonatory effort, vocal strength, and strain 27–51 cm H2O/L/s 24–45 cm H2O/L/sc
a
Data from Subtelny JD, Worth JH, Sakuda M: Intraoral pressure and rate of flow during speech. J Speech Hear Res 9:498, 1966.
b
Data from Verdolini-Marston K, Titze IR, Druker DG. Changes in phonation threshold pressure with induced conditions of hydration. J Voice 8:30, 1994.
c
Data from Baken RJ, Orlikoff RF. Clinical Measurement of Voice and Speech, 2nd ed., San Diego, 2000, Singular Publishing Group.

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822 PART V  Laryngology and Bronchoesophagology

scores are considered normal or not normal based on a threshold.

Intraoral Air Pressure Thresholds vary slightly from one study to the next; hypernasality
Relatively constant subglottal pressure is required to sustain vocal is generally perceived when nasalance is more than 25% to 33%
fold vibration. Because measuring subglottal pressure directly for a standard nonnasal passage, and hyponasality is perceived
requires a tracheal puncture, intraoral air pressure during a voiceless when nasalance falls below 50% during nasal sentences.70–73 Given
stop consonant (usually a “p”) is used as an estimate.53 Reports of that resonance patterns vary by dialect, regional normative data
peak pressure vary with loudness, age, gender, consonant, and should be used when possible.70
speech context.40 Abnormal values can indicate a lack of driving
pressure, an incompetent or insufficient velopharyngeal or laryngeal
valve, or increased vocal fold mass or stiffness.
Acoustic Voice Measures
The acoustic speech signal is the vocal system’s output, and it is
rich in information about pitch, loudness, and quality. Acoustic
Phonation Threshold Pressure measurements are best made from signals recorded on high-quality
The subglottal pressure necessary to initiate vocal fold vibration equipment in a quiet environment with a constant mouth-to-
is called phonation threshold pressure (PTP).46 At high pitch, PTP microphone distance and standard instructions. Data should be
is sensitive to increased viscoelasticity of the vocal folds, and the interpreted in light of the subject’s age and gender, interactions
measure has been useful in demonstrating subtle changes after among parameters, and the speech sample selected for analysis.
dehydration, vocal fatigue, and vocal warm-up.54–60 PTP might It is also important to know whether the samples analyzed were
correspond to a patient’s perception of increased effort to phonate, representative of the patient’s typical voice.
a common symptom of patients with voice disorders. In voice and speech production, vocal fold vibration and its
interaction with the air pressures just above and below the vocal
folds produce a signal (source) with acoustic energy at a fundamental
Airflow frequency, multiples of that frequency (harmonics), and noise
Airflow is measured as volume (mL or L) per unit of time (second (inharmonic energy).74 The source signal is modified as it passes
or minute). Mean airflow is commonly assessed during sustained through the supraglottal vocal tract (filter). Altering the shape of
phonation, and values are influenced by gender, age, fundamental the vocal tract—for example, raising the tongue—changes the
frequency, and intensity. Mean airflow is typically elevated when location of the resonant peaks (formants) and produces different
glottal closure is poor, such as in vocal fold motion impairment,28,61 vowels. The source is particularly influential in determining voice
and can be elevated or reduced with hyperfunction.39,61a quality, and it is often desirable to examine aspects of the source
signal without direct visualization of the vocal folds (e.g., via
high-speed video).
Laryngeal Airway Resistance
Laryngeal airway resistance is the ratio of translaryngeal air pressure
to translaryngeal airflow.53 Higher laryngeal airway resistance can
Frequency
indicate increased vocal intensity, a long-closed phase of the glottal Fundamental frequency (F0) is the number of repeating cycles per
cycle, or a higher force of glottal closure.39 second present in the acoustic waveform. Pitch is the primary
perceptual correlate of frequency, although many additional factors
contribute to the perception of pitch. Altered pitch and restricted
Maximum Phonation Time pitch range are common symptoms of voice disorders and can
Maximum phonation time (MPT) has long been used to quantify represent a significant concern for patients. Average speaking
the poorly defined concepts of breath support and phonatory fundamental frequency and maximum frequency range can be
efficiency. The maximum length of time a patient can sustain measured using a variety of free and commercially available software
phonation, however, is not fully explained by either vital capacity packages, and output varies across packages based on the algorithm
or laryngeal function.62 Respiratory capacity and function, phonatory used for calculation.75 The acoustic signal must be nearly periodic
function, resonance, practice, frequency, intensity, instructions, for the software to identify the fundamental frequency, a feature
and vowel choice all influence MPT,39,62–67 and the normal range that limits accurate assessment of many impaired voices.76 Norma-
for healthy young adults is 6.6 to 69.5 seconds.40 Thus the utility tive values are influenced by intensity, speech sample, vowel type,
of MPT is severely limited by poor validity and reliability. If MPT age, and gender,40,77 and an average speaking fundamental frequency
is used, it should be collected using standard instructions and ranges from 100 to 125 Hz for adult men in their 70s and 190 to
coaching, the longest of three trials should be reported, and results 225 Hz for adult women.40 The maximum frequency range is
should be interpreted cautiously. often reported using the octave-based semitone scale, with 12
semitones in an octave. The maximum range for men and women
is typically two-and-a-half to three octaves, or approximately 29
Measures of Velopharyngeal Function to 36 semitones.40
Inadequate velopharyngeal function leads to nasal air emission
and weak pressure consonants. These aspects of speech production
can be quantified by measuring nasal airflow and intraoral air
Intensity
pressure. High nasal airflow and low intraoral air pressure for Sound pressure level measured in decibels (dB SPL), or intensity,
pressure consonants indicate velopharyngeal incompetence or is the primary acoustic correlate of loudness, although many factors
dysfunction. When nasal cavity pressure is also measured, the influence the perception of loudness. Sound pressure level is
velopharyngeal orifice area can be calculated.68,69 influenced by frequency, vowel, speech sample, equipment, distance
Oronasal resonance balance (e.g., hypernasality during vowels from the sound source, and ambient noise.77 The most common
and hyponasality during nasal consonants) can be assessed acousti- measures are average speaking and minimum and maximum sound
cally using a commercial program such as the Nasometer (Kay- pressure levels. On average, men and women speak at approximately
PENTAX, Montvale, NJ). This instrument computes nasalance, a 70 dB SPL (at a distance of 6 inches),40 although variability in
ratio of nasal sound energy to total (oral plus nasal) energy. conversational speech is significant. Minimum intensity is typically
Correlation of nasalance to perceived hypernasality is not high, less than 60 dB, and maximum intensity is greater than 110 dB.39,78
and nasalance is often considered in a binary manner, such that Intensity measures are used to document patient symptoms of

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 CHAPTER 55  Voice Evaluation and Therapy 823

inadequate loudness, such as might occur with Parkinson disease 55.00 Fundamental frequency (Hz) 1661.22
or vocal fold motion impairment, or difficulty speaking quietly, 55

125
Sound pressure level (dB)
which can occur with scarring or lesions.

Voice Range Profile

A frequency-by-intensity plot for an individual’s total range is
called a voice range profile, or phonetogram. The minimum and
maximum intensities an individual can produce are plotted for
every frequency in that person’s range (see Fig. 55.1). Typically,
the highest frequencies are produced at a greater SPL than the
lowest frequencies. The profile is useful for tracking change and C2 C3 C4 C5 C6

for documenting difficulty with specific pitch and loudness combina- Fig. 55.2  Sample voice range profile of a nonsinger showing a total
tions (e.g., trouble singing particular notes quietly). frequency range of 131 Hz (C3) to 1318 Hz (E6), which is 40
semitones or 3.3 octaves. The intensity range is 53 dB SPL.
Perturbation and Noise Measures
Acoustic measurement of voice quality is more difficult than pitch
or loudness. Measures that document variability in the sound wave to as spectral tilt, indicate whether low or high frequencies dominate
or noise in the spectrum have been thought to indicate roughness, the spectrum.87 Increased spectral tilt (i.e., less high-frequency
breathiness, and strain. Unfortunately, these measures do not information) is associated with a breathy voice.88
correspond strongly with voice quality.77,79–86 The best-known A cepstrum is a spectrum of a spectrum. The cepstral peak
perturbation measures are jitter, cycle-to-cycle variation in fre- prominence (CPP) is a measure of signal periodicity that does not
quency, and shimmer, cycle-to-cycle variation in amplitude; yet rely on fundamental frequency extraction but instead corresponds
changes in these measures must be significant before listeners can to the regularity of harmonic peaks. The measure has been found
perceive them,21 and perturbation measures can be reliably to correspond with breathiness and overall dysphonia ratings.89–91
completed only for nearly periodic signals. Perturbation analysis A higher CPP reflects regular harmonics and better voice quality,
is not appropriate if the signal has no single fundamental frequency whereas a lower CPP is consistent with worse voice quality.
or if it has qualitative changes, which are features common
in disordered voices.76 Notably, the measures are specifically
excluded from the recommendations for acoustic analysis of voice
DIAGNOSTIC THERAPY
by the American Speech-Language-Hearing Association (ASHA) Diagnostic therapy, or probe therapy, is used to determine whether
expert panel.38 voice quality can be modified. Response to therapeutic probes
Several estimates of the periodic (harmonic) versus aperiodic can guide intervention decisions and may even help determine
(noise) components of a signal have been proposed, and one or the diagnosis. Therapy probes often include modification of extrinsic
more of these measures is typically included in acoustic analysis laryngeal muscle tension or posture. They also include techniques
software packages. Normative values depend on the particular to modify the breath, phonation, and resonance subsystems.
measure and the algorithm used for calculation, and no standard
has emerged. Additionally, variants of the harmonics-to-noise ratio, INTRODUCTION TO THERAPY FOR VOICE AND
such as perturbation measures, depend upon accurate fundamental
frequency extraction and are prone to error for disordered voices.
LARYNGEAL AIRWAY DISORDERS
Similar to perturbation measures, they were excluded from the
acoustic analysis recommendations of the ASHA expert panel.38
Therapy for Voice Disorders
Speech-language pathologists work with patients to use the
most efficient and healthy voice-production mechanism possible
Spectral and Cepstral Assessment to improve voice quality and loudness, minimize voice-related
The acoustic waveform contains information about both the source handicap, improve communicative effectiveness, and restore vocal
and filter. Analysis techniques can be used to highlight source and identity and health. Voice therapy generally involves indirect and
filter components. direct therapy to improve the patient’s voice-production technique.
A spectrogram displays the frequencies present in the sound The number of voice therapy sessions and prognosis for improve-
wave over time, with the magnitude of the energy at a given ment vary and depend on individual patients and their goals.
frequency evident by pigmentation on a gray or color scale. Therapy is generally short term (one to eight sessions) and is
Changing the bandwidth of the analysis window allows us to view more successful for those who demonstrate the capacity for
details of either the source or the filter. A wide-band spectrogram improved voice early in the process. It is important to note that
has higher time resolution and highlights the formants, which are voice therapy requires behavioral changes, and patients only improve
components of the filter.40 A narrow-band spectrogram has higher with therapy when they actively participate by incorporating the
frequency resolution and emphasizes the fundamental frequency new skills into their daily lives. An overview of voice therapy for
and the harmonics (Fig. 55.2). Narrow-band spectrograms are dysphonia is presented first, followed by therapy for laryngeal
used to visualize features such as relative noise and harmonic airway disorders.
energy, tremor, phonation breaks, and pitch shifts. The indirect component of voice therapy, counseling to optimize
A spectrum displays frequency by amplitude and allows precise the laryngeal environment and voice use, is typically brief. It
examination of the energy present at all frequencies that comprise involves appropriate and relevant “vocal hygiene,” in which the
a waveform (Fig. 55.3). Long-term average spectra show the amount speech-language pathologist reinforces physician recommendations
of energy at each frequency summed over a long time period, regarding the internal laryngeal environment (e.g., hydration, reflux
such as a standard reading. Because the measure is averaged over precautions, and compliance with prescribed medication regimen)
such a long sample, the effects of speech context are minimized. and appropriate and relevant “phonotrauma reduction,” in which
Measures of spectra typically compare the magnitude of energy patients are guided to modify the amount and type of voice use. For
in different frequency bands. The resultant values, often referred some patients, the primary treatment recommendations are medical,

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824 PART V  Laryngology and Bronchoesophagology

0.5 0.2
Audio

Audio
0 0
-0.2
-0.5

5000 5000

4000 4000
Frequency (Hz)

Frequency (Hz)
3000 3000

2000 2000

1000 1000

0 0
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
A Time (sec.) B Time (sec.)
Fig. 55.3  Narrow-band spectrograms for a woman saying “zah zay zee zoh zoo” using her normal (A) voice
quality and a breathy (B) voice quality. The horizontal striations are harmonic energy and the low-amplitude
(blue or green) fuzzy-appearing energy is noise. Note that there are higher-frequency harmonics in the normal
production than the breathy production. The harmonics in her normal production are of higher amplitude
(orange and red) than those in the breathy production (green and yellow).

surgical, or involve compensatory strategies (e.g., amplification). In generalization. The patient focus is on articulatory precision,
this case, one or two sessions of indirect voice therapy might be articulatory movements, and voice quality during conversation
the only services they require from a speech-language pathologist. (Gartner-Schmidt et al., 2016).
Typically, however, most voice therapy is devoted to direct work
on voice-production technique (described later), because direct
voice therapy leads to greater improvement in voice quality and
Laryngeal Muscle Balance
symptoms than vocal hygiene alone.92–94 Excessive tension in extrinsic laryngeal and strap muscles can
precipitate, exacerbate, or maintain a voice disorder. Directly
targeting these muscles through manual tension reduction and
General Comments massage can interrupt disordered voicing patterns and rapidly
The voice therapy technique that is used varies based on patient improve voice quality, often with long-term improvement.32,33,98
strengths and needs and clinician strengths and training. No gold Common maneuvers that include hyoid pushback and lowering
standard technique or “recipe” for voice therapy works for all the thyroid cartilage are depicted in Fig. 55.4.
patients and clinicians, even within a diagnosis, and patients respond
to different types and levels of feedback and instruction. The
choice of therapy technique is often independent of the underlying
Coordination of Respiratory-Laryngeal Valving
medical diagnosis, because patients with the same medical diagnosis Patients sometimes use inefficient coordination of respiration and
produce very different vocal behaviors. Most of the time, the goal laryngeal valving. For example, they might use too little airflow
of intervention is to engender change across the resonance, (“breath holding”), produce tight vocal fold adduction during
laryngeal, and respiratory systems, and the speech-language phonation, or produce incomplete vocal fold closure with too
pathologist uses a combination of many techniques to produce much airflow at the beginning of phonation. Several strategies
this change. The following section is an overview of several can be used to work toward coordinated airway valving before
techniques organized by system, followed by additional consid- and during speech. In stretch and flow, or flow phonation, patients
erations for specific populations. are taught to manage airflow during a progression of voiceless
and then voiced tasks, until they can identify the sensation of
airflow energy at the front of the mouth while maintaining
Supraglottal Vocal Tract decreased throat constriction.99,100 Coordination of breath and
Several techniques used in voice therapy capitalize on the nonlinear phonation is also addressed using sustained vowels produced with
interactions of the time-varying glottal area and the supraglottal nasal or oral twang101 or through straws. The productions are
vocal tract.95,96 As a group, they are considered “resonant” or generally sustained quietly and the approach is often called vocal
“semioccluded vocal tract” techniques, and they involve altering function exercises. Modification of glottal attack (i.e., hard or breathy
the length of the vocal tract through laryngeal height changes or onsets) can be used to normalize voice production, and visual
lip rounding and changing the diameter of the vocal tract through feedback with endoscopy or stroboscopy is useful when patients
constrictions or expansions of the laryngeal vestibule (i.e., supraglot- require help learning to attend to subtle feelings and linking them
tal larynx or epilarynx), pharynx, or mouth. Resonant techniques to physiologic changes in laryngeal function.
can alter voice quality by influencing patterns of vocal fold vibration
and enhancing the harmonic structure.96 Patients are taught to
feel vibration in the mouth or face and to decrease laryngeal
Breath
tension or effort.97 Sometimes, external devices such as straws or For most patients, working with breathing simply involves discuss-
kazoos are used early in these therapies to help the patient establish ing and practicing appropriate timing for inhalation (i.e., breath
the perceptual target. Conversation training therapy (CTT) is a groups) and using the target range of vital capacity (i.e., initiating
different type of approach in which patient focus is also on the at 60% and terminating at 40% of vital capacity). Stiff vocal folds,
supraglottal structures. Here, therapy sessions and practice occur poor glottal closure, or the patient’s need to use a loud voice might
in conversational speech from the first day of treatment to facilitate necessitate additional instruction. Patients who need to talk loudly,

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 CHAPTER 55  Voice Evaluation and Therapy 825

55

B
A
Fig. 55.4  Manual maneuvers to improve disordered voicing patterns include hyoid pushback with a finger
(A) and lowering the thyroid cartilage (B).

for example, might need instruction to inhale to a larger lung tract resonances might need to be addressed in addition to speech
volume (i.e., up to 80% vital capacity), use additional muscular precision, intonation and prosody, rate, and language. Therapy
effort to resist recoil during the beginning of expiration, and might also include awareness and modification of body posture,
facilitate continued exhalation near the resting expiratory level.102 gestures, and the social use of language.32
The Accent Method is a therapy technique in which the patient
focuses on coordinating abdominal movement with sound produc-
tion.103,104 The technique does not simply alter breath, but holisti-
Therapy for Laryngeal Airway Disorders
cally alters all levels of voice production. Chronic cough and paradoxical vocal fold motion have been
described as being on a continuum of symptoms that share
common etiologic factors.110–112 As professionals who work with
Posture and Alignment the larynx and laryngeal airway, speech-language pathologists also
When musculoskeletal features are contributing to MTD, provide therapy for irritable larynx syndrome. These disorders
they might need to be directly addressed in voice therapy. are assessed and managed by a team, and the team members will
When appropriate, patients are taught to eliminate jaw jut and vary depending on the patient’s needs and the philosophies of
improve neck alignment, shoulder position, and mandible movement the members.
during speech.31
Chronic Cough
Additional Considerations Treatment by the speech pathologist might be indicated for chronic
Although the previously described techniques often form the basis coughs refractory to adequate medical treatment. Treatment themes
of voice therapy, additional considerations and specialized tech- are similar to voice therapy, with a counseling component that
niques are necessary for some patient populations. includes education about the causes of cough and learning to
Age-Related Dysphonia: Several of the previously described increase the moisture in patients’ internal and external environments
techniques have been shown to improve voice in older adults.105–107 (e.g., sipping water; inhaling steam; altering ambient humidity;
A therapy designed specifically to treat the respiratory and and decreasing caffeine, alcohol, and smoke) and reduce exposure
laryngeal deficits of presbyphonia through vocal exercise has also to irritants (e.g., allergies, reflux, and fumes). There is also a
been described and is called phonation resistance training exercise behavioral component, and strategies are taught to delay, inhibit,
(PhoRTE).108 or replace the cough with another behavior. Patients should learn
Singers, Actors, and Professional Speakers: Professional speakers to break the irritation/cough cycle so that they cough less hard,
and singers require care coordination with managers, directors, less often, and for less time.113,114
singing teachers, voice coaches, or others. Voice therapy to prevent
and remediate speaking voice disorders is within the scope of
practice for speech-language pathologists, whereas optimizing the
Paradoxical Vocal Fold Motion
use of voice for acting, public speaking, and singing is typically Treatment for paradoxical vocal fold dysfunction begins with
in the domain of voice trainers, teachers, and coaches.109 Some establishing that the patient has undergone appropriate assessment
speech-language pathologists are also trained in another arena of and treatment by the relevant team members. This is followed by
voice care and might function in dual roles to rehabilitate injured education about the disorder, which often includes a review of
voices and improve healthy ones. the endoscopic evaluation with the patient, if the patient was
Transgender Communication: To facilitate perception of a different symptomatic during the examination. The counseling segment of
gender role, communication therapy generally includes more than therapy involves identifying and determining a plan to control
modification of vocal pitch. Loudness, voice quality, and vocal environmental and psychologic triggers. The behavioral component

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826 PART V  Laryngology and Bronchoesophagology

involves implementing a breathing and relaxation program to the patient develop breathing strategies to prevent and interrupt
improve the patient’s control over breathing and reduce the the symptoms of vocal fold dysfunction.115–117
discomfort and anxiety that naturally occur with shortness of breath.
Patients are taught to attend to early signs of breathing difficulties
to prevent attacks and to interrupt attacks when prevention is not
CONCLUSIONS
possible. The techniques are practiced, reviewed, and adjusted Voice evaluation and therapy are dynamic, and they evolve as our
over several therapy sessions. Visual feedback with endoscopy is understanding of voice production, measurement, and quality
often useful in learning to visualize the vocal fold position to use evolves. Improved knowledge of the links between production
strategies to break the attacks of paradoxical vocal fold motion. and perception will drive future assessment and management
On occasion, the speech-language pathologist must travel to the techniques.
environment where the attacks occur (a treadmill, pool, or training
center) or must create such an environment in the office to help   For a complete list of references, visit [Link].

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 CHAPTER 55  Voice Evaluation and Therapy 826.e1

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