6.1.3 Physical Examination Including Respiration and Velopharyngeal Competence

Any ENT examination should routinely pay special attention to the morphology of the vocal organ. Predominantly, palpation of the neck should be performed, with respect to the position of the larynx in relation to the other anatomical structures. The laryngeal skeleton and the surrounding structures should be palpated on respiration, phonation and swallowing. In particular, one should observe the formation of the thyroid cartilage and the laryngeal prominence, commonly known as the Adam’s apple, more apparent in men. Furthermore, the neck examination includes observing any enlarged thyroid gland as well as the laryngeal vertical mobility (e.g. upwards on swallowing). The Bresgen grip is a frontal pressure on the thyroid cartilage notch. In cases of mutational falsetto, as a result of compression of the flexible thyroid cartilage, the voice drops immediately about an octave down into the chest register owing to relaxation of the overtensed vocal folds. It does not occur when the cartilage is calcified, e.g. due to age or hormonal disorders.

The physical examination assessing vocal functions of the larynx should include a routine examination of the larynx (see Sect. 6.3); voice emission technique including breathing; body posture; voice projection strategies; coordination between respiration, phonation and articulation; the indication of aerodynamic parameters (in particular, the maximum phonation time); and voice self-assessment (see Sect. 6.2). The examination of the larynx with an endoscope or a laryngeal mirror as indirect laryngoscopy should be performed at the very beginning. For phoniatric purposes, attention should be focused on the oropharynx – the valleculae epiglotticae and the shape of the epiglottis; on the hypopharynx – its shape, the size and symmetry of piriform sinuses and the glossoepiglottic and aryepiglottic folds; and on the larynx – the arytenoids cartilage region, vestibular folds, ventricles, colour, length, width and movement of the vocal folds, the shape of the glottis during phonation and the subglottal area, as well as the colour, moisture of the mucosa and the presence of any abnormal tissue.

In the process of voice assessment, it is essential to examine not only the larynx but the whole vocal tract: the oral and nasal cavities and naso-, oro- and hypopharynx. These cavities significantly contribute to the timbre and the proper resonance of the voice. The closure of the nasopharynx due to muscle obstruction of the soft palate on articulation of oral consonants prevents pathological nasality. The evaluation requires the estimation of the size of these cavities, the condition of the mucosa and any possible morphological changes. One should observe the following criteria:·the shape, symmetry and mobility of the tongue; the symmetry and mobility of the lips; the arrangement of the teeth and occlusion; the mobility of jaws and the mandible; the condition and the relationship of the hard and soft palate; the presence of abnormal movements as myoclonus; the symmetrical mobility of the soft palate and the uvula; the size and symmetry of the palatine tonsils, hypertrophy and signs of possible inflammation; the size of the adenoids; the condition of the nasal cavity and nasal turbinates; possible nasal obstruction; the presence of allergic symptoms including swelling and bruising of the turbinates; colour and moisture of the mucosa; and any pathological contents in the nasal cavities or in the nasopharynx.

The evaluation of conditions by means of the phonation technique should first assess the activity of extrinsic and intrinsic laryngeal muscles. One should assess whether the voice is produced freely without any hypercontraction of muscles. In case of vocal hyperfunctionality, there is an excessive, pathological muscle tension and distension of the veins of the neck. In the opposite condition, i.e. vocal hypofunction, phonation is carried out with a weakening of the laryngeal muscle activity (Sataloff 2005b).

6.1.4 Examination of Types of Respiration

Proper breathing technique is an essential condition for the normal voice, in particular for professional voice users. Significant also is the use of the appropriate manner of respiration (inhalation/exhalation). There are three patterns of breath support: upper thoracic/clavicular, abdominal/diaphragmatic and mixed thoracic/abdominal.

The upper thoracic/clavicular breathing involves the expansion of mainly the upper part of the chest. Ribs and abdomen are at relative rest. This type of breathing allows only partial filling of the lungs with air and the breath is defective. Breathing with a predominance of costal track called mixed thoracic/abdominal breathing consists of the ribs moving apart on the outside and slightly upwards, while the chest expands in the lateral dimension. The most appropriate and the most efficient, optimal manner for phonation is abdominal/diaphragmatic breathing. This type of breathing with a predominance of abdominal track occurs when the duration of the inspiration movement of the lower ribs is minimal and the diaphragm contracts and moves downwards. It increases the size of the chest forwards and backwards (Pruszewicz 1992). In singing, the deepest and most appropriate breath is characterised by high amplitude movements of the diaphragm, allowing a deep breath, and ample work of the muscles of the ribs guarantees the correct support breathing (appogio) (Fig. 6.1).

A properly produced voice should manifest the ability to use the whole resonator of the vocal tract. On clinical examination it is possible to evaluate the function of head resonators on phonation of memoranda combined with a vowel phonation [mmae], [mmo], and [mmi].

6.1.5 Examination of Velopharyngeal Competence

The assessment includes velopharyngeal competence. This plays an important role in the presence of a normal nasal resonance in the voice. Normally, only on emission of nasal vowels (e.g. /m/, /n/) is the function of the velopharyngeal sphincter physiologically incomplete, and the airstream enters the nose (Fig. 6.2).

On phonation of oral sounds, when the velopharyngeal valving is not properly controlled and the airflows into the nose, the vowels and nonnasal consonants have an improper hypernasal resonance (open nasality). In hyponasality, the velopharyngeal valving is also improperly controlled, which results in the absence of a nasal resonance on nasal consonants. The closed nasality (rhinophonia clausa—hyponasality) arises as a consequence of a difficult passage of air through the nose. Most frequently, this happens as a consequence of mucosal oedema or polyps in the nose as well as adenoid hypertrophy. The nasal sounds /m/ and /n/ sound like /b/ and /d/, and the voice becomes muted. If there is both velopharyngeal insufficiency and nasal obstruction, the nasality can be mixed.

Otoscopy, performed as part of the ENT examination, may indicate possible changes in the middle ear, which as a possible cause of hearing loss may be the cause of abnormal phonation by means of its insufficient self-control. A pure tone audiogram should be performed in all cases of voice disorders owing to the feedback of hearing and voice.

6.1.6 Perceptual Evaluation of Voice Quality

The clinical evaluation of phonation (non-instrumental) should be started by identifying the timbre of spoken voice in the perceptual examination. Voice quality is a subjective concept from the auditory point of view. During the first contact with the patient, the assessment of voice disorders, as well as the evaluation of the efficacy of the treatment, is performed on the basis of the perceptual psychoacoustic evaluation of the voice (Bassich and Ludlow 1986). Hoarseness is the most common word that describes the quality of the voice characterised by noticeable noise components. It is a non-specific symptom caused mainly by irregularities of the normally almost periodic vibration of the vocal folds or lack of closure and most frequently accompanies organic diseases of the larynx (De Krom 1995). It can also be a symptom of innervation disorders of the larynx and occurs as a result of disturbed mechanisms of phonation in functional dysphonia. In addition, voice qualities are often described by the following words: harsh, breathy, rough, strained or squeezed.

It is important to mention that the same disease may lead to quite different manifestations in voice quality, and the same voice quality may have quite different causes of the underlying pathology (Kreiman et al. 1992, 1993). Thus, any deviant voice requires a complete physical examination (Bless and Baken 1992).

In order to standardise the terminology used to define dysphonia, a variety of perceptual scales have been developed to describe the quality of the voice (Dejonckere et al. 1993). Many phoneticians (Laver 1980), voice and speech physiologists and phoniatricians are convinced that it is necessary to create a universal scale for assessing perceptual voice. Currently, of many scales of subjective evaluation (de Bodt et al. 1996, 1997), e.g. the Stockholm Voice Evaluation Approach (Hammarberg 2000), Buffalo Voice Profile System (Wilson 1987), Laver’s Vocal Profile Analysis Scheme (Laver et al. 1992), Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) (Karnell et al. 2007) and Newcastle Audio Ranking (NeAR) (Gould et al. 2012), the best known and the most widely used is the scale of the Japan Society of Logopaedics and Phoniatrics, the GRBAS scale (Hirano 1989).

The GRBAS scale describes the voice disorder with the use of five well-defined parameters: G, the grade of hoarseness; R, roughness, an audible impression of irregularities of the vibration of the vocal folds; B, breathiness, an audible impression of the air leakage through the insufficient glottal closure; A, an asthenic voice; and S, a strained voice. This scale has four degrees of intensity of disturbances, where ‘0’ indicates a normal voice, ‘1’ mild disturbance, ‘2’ moderate disturbance, and ‘3’ severe disturbance, with respect to all the parameters. Thus, a normal voice is described as follows: G0R0B0A0S0, which means a sonorous voice, without rough elements, produced with a soft attitude, and with a complete glottis closure, produced freely without any excessive muscle tension. Dejonckere et al. (2000) proposed to expand this scale with another parameter: I—instability of the voice (i.e. variability over time)—and then the scale will have the GIRBAS form. The shortened modification of the GRBAS scale excluding A and S owing to the proven low inter- and intra-rater reliability is the RBH scale (Wendler et al. 1986), where /R/ is roughness, /B/ breathiness and /H/ hoarseness. In research the perceptual evaluation should be performed by at least three independent examiners/judges, and then all the results should be averaged (Gerratt et al. 1993; Fang-Ling and Matteson 2014).

Additionally, it should be noted (Bough et al. 1996) that the features of an individual voice depend on the number of certain properties, and therefore apart from the personality and emotional state, one should take into consideration the current body temperature, the degree of rest and rehydration of the body and even the time elapsed from the last meal.

Moreover, the phoniatrician should estimate perceptually whether the pitch of the spoken voice is appropriate for the patient’s age and gender and whether it is stable. The speech tasks for perceptual voice assessment is generally limited to a 5-s sustained phonation of the vowel sounds /ɑ/ and /i/, as well as a short reading of phonetically balanced texts, e.g. the Rainbow Passage for English language. The mean speaking pitch is different in male and female adults, and it changes with age. It is approximately 260 Hz (200–260 Hz, g-c1) and 130 Hz (100–130 Hz, G-c) in younger females and in males, respectively. The vocal pitch range, calculated as the difference between sung sounds at the lowest and highest pitch possible, should cover 1.5–2 octaves, and reaches, depending on the voice type, from d/c¹ to d²/c³ for females and D/c to d¹/c² for males. In running speech, an area of one octave is generally covered. Clinical observations are usually performed with respect to the patient’s habitual pitch while speaking, in order to check whether it is too low or too high. Pitch is of striking importance for all kinds of professional speaking, especially for teachers, lecturers and public speakers. The physiological reference is the so-called indifference level, a pitch that is generated by a well-balanced action of all muscles involved with an optimal relation of muscular tension and vocal output. It is located at the transition area from the lower to the middle third of the pitch range.

This is the pitch that should be kept during speaking as the average or mean speaking pitch or at least to which it should be regularly brought back. Permanent upward deviation does not only mean an overloading of the speakers’ voice apparatus but also that of the listener. As an effect of the so-called functional listening, listeners unconsciously mimic the speakers’ muscular tension, get strained and tired and lose their attention.

For the purposes of complete voice evaluation, it is important to determine the register of the voice. The term ‘register’ means the type of voice, especially while singing, although the term may also refer to the mode of vibration (Niimi and Miyaji 2000). The laryngeal register reflects a specific mode of phonation. The physiological register (modal), called the chest tone, occurs because of the normal vibrations of the vocal folds and is a record of the fundamental frequencies that appear mainly while speaking. The term ‘falsetto’ (head tone) occurs at very high frequencies and is often slightly breathy with an incomplete glottal closure and vibration of the only free edges of the vocal fold, with the tension of the posterior part. A creaky voice, or glottal fry, occurs at very low frequencies by means of the vibration of the frontal parts of the vocal folds and a tight closure of the glottis (see also Sect. 4.​5).

A normal voice is produced with the appropriate loudness, not too loud and not too weak, and indicates the ability of the free and dynamic modulation of the volume.

The most important aerodynamic parameter of phonation is the measurement of the maximum phonation time (MPT) and the s/z ratio (Gelfer and Pazera 2006). MPT is the ability to pronounce the vowel /a/ freely at full exhaustion for as long as possible at a comfortable pitch and volume. According to Kent et al. (1987), for persons aged 17–41 years, on average it fluctuates between 15 s for women and 23 s for men and is reduced with age. Values depending on the age can range as low as 17.25–34.6 s for men and 12.10–26.5 s for women. The s/z ratio makes it possible to compare the ability to control airflow on phonation of the voiceless /s/ and voiced /z/, which is important for establishing the way in which the patient controls exhalation. In individuals with normal voices, the s/z ratio is near 1.0. Vital capacity (VC), measured parametrically by spirometry, is not a direct measurement of phonation but is used indirectly as a measure of lung function indicating the amount of air that can be used for phonation. Vital capacity is a combination of inspiratory reserve volume, expiratory reserve volume and tidal volume—this is total volume of air that can be inspired after total expiration (see Sect. 6.7). The average values of the normal vital capacity reach approximately 4800 mL for men and 3500 mL for women.

The phonation quotient (PQ) indicates the amount of air consumed on phonation and is obtained by division of the vital lung capacity by the maximum phonation time: PQ = VC/MPT. The normal values for this parameter vary from 145 to 269 mL/s for men and from 137 to 233 mL/s for women. Raes and Clement (1996) in their work presented the following results: for adult men at MPT 22.2 s and VC 4.800 mL, the PQ value was 269 mL/s; for women at MPT 18.4 s and VC 3.500 mL, the PQ was 233 mL/s.

The next issue to examine is voice attacks. There are three kinds of attack: the preferred soft mode—simultaneous, when the breath and the vibration occur at the same time; glottal, when vocal folds push against each other too strongly, making it difficult for them to vibrate; and breathy, when the breath occurs first and then the vocal folds begin to vibrate, but a gap in the incompletely closed glottis causes a portion of the air to be converted to the noise, rather than to the acoustic wave.

6.1.7 Articulation

Owing to the permanent interaction between vocal tract configuration and glottal function, proper articulation is also part of the specific technique of producing a normal voice. It should be characterised by a distinctive pronunciation of vowels and consonants, a moderate rate of speech and a mouth open wide with a suitable lowering of the mandible. What seems important is the ability of the correct movement of the lips, the palate (lifting and lowering) and the tongue.

6.1.8 Screening Methods

Screening is an investigation carried out in normal individuals to detect diseases in their early, subclinical stages. Screening of voice quality provides assessments to professional voice users, as well as candidates and students for occupations with special voice quality demands, or any lay person experiencing voice problems. Voice screening is also important for identification and early management of paediatric voice disorders, which can affect the child’s education and psychosocial development. A screening method as a first step is usually based on a review of voice history to identify any potential problems or on questionnaire concerning vocal symptoms. It can be administered by health-care personnel in order to select persons for further examination by a phoniatrician and should include the assessment of voice quality and visualisation of vocal fold function. There are screening tests that can be used to measure different aspects of voice rapidly. They are generally based on questionnaire data and voice analysis, i.e. the assessment of the quality of voice, pitch, loudness, maximum phonation time, respiration and resonance. Questionnaires usually contain typical questions concerning voice complaints, duration of intensive voice and speech use, smoking, subjective voice function assessment (e.g. GRBAS scale) and voice self-assessment (e.g. VHI). Both questionnaire and voice analysis are non-invasive multi-parameter monitoring tools for early detection of potential voice disorders and therefore very useful in preventive health care in phoniatrics.

Methods of screening presented by scientists are based on a questionnaire and voice analysis that concern various groups of adults and children, e.g. the Voice Assessment Protocol for Children and Adults (VAP) (Haynes et al. 2006), Boone Voice Program for Children (Boone 1993; Boone et al. 2005), Quick Screen for Voice (Lee et al. 2004) and Screening Index for Voice Disorders (SIVD) (Ghirardi et al. 2013). There are also other voice screening tests based on only one parameter, e.g. the Glottal to Noise Excitation Ratio presented by Spanish scientists (Godino-Llorente et al. 2010). They confirmed that this acoustic parameter is a good choice for screening purposes in discriminating normal and pathological voices. Johnson et al. (2014) presented a voice screening over the telephone; it can differentiate spasmodic dysphonia from other voice disorders. Ohlsson et al. (2012) performed screening in teacher students using questionnaire Screen6 (Simberg et al. 2001) and the Swedish Voice Handicap Index. They found an association between the number of potential vocal risk factors and the number of voice symptoms.

There is no doubt that laryngoscopy is the most important information source for screening voice disorders. Awan et al. (2016) presented voice screening with the Cepstral Spectral Index of Dysphonia (CSID), which contains three reference standards: auditory perceptual estimation, Voice Handicap Index and laryngoscopic description. They suggested that this CSID method with acoustic voice analysis could be used as a potential screening tool for voice disorder identification. Pernambuco et al. (2016a, b) presented in Portuguese (there is not yet an English translation) a new tool for epidemiological screening voice in older adults: the Rastreamento de Alteracoes Vocais em Idosos (RAVI), i.e. Screening for Voice Disorders in Older Adults. This test consists of 16 questions related to sensations and perceptions associated with the voice. The authors emphasise that RAVI is the first voice-related self-reported questionnaire for identifying voice disorders in older adults. Several other countries, e.g. Scandinavian countries and Austria, have introduced many preventive programmes for professional voice users (Vilkman 2004; Schneider-Stickler et al. 2012).

Some of these screening procedures are useful practically and can be recommended, for example, the Quick Screen for Voice (Lee et al. 2004). It is a rapid and widely administered (by SPL) screening test for children that contains many aspects of voice, respiration and resonance; it has been validated in a large group of kindergarten and preschool children and is used as part of a comprehensive speech, language and hearing screening. The Screening Index for Voice Disorders (SIVD) has been proved to be an efficient tool for screening occupational voice disorders and can be used as an instrument of epidemiologic vigilance (Ghirardi et al. 2013).

Voice screening procedures allow early detection of voice disorders in the subclinical stage and the administration of the treatment, rehabilitation and prevention; they can, if necessary, be used to dissuade people with voice dysfunction from the so-called voice professions.

6.2 Self-Administered Questionnaires for the Assessment of Voice Disorders in Normal and Professional Users

6.3 Laryngoscopy, Stroboscopy, High-Speed Video and Phonovibrogram

6.3.2 The Endoscope

An endoscope is defined as an optical instrument that can be used to view a cavity from the inside through a narrow opening. The superposition principle of geometrical optics is utilised, which states that two crossing beams of light do not influence each other. Illumination and observation occur simultaneously in the same optical system. The size of an endoscope is given in ‘mm diameter’ (D) and sometimes in the older Charrière (Ch) unit of measurement, which corresponds to ‘mm circumference’ (conversion: D = Ch/π, with π = 3.14159 … the circle constant). The length of the endoscope is unimportant for laryngeal endoscopy.

There are two main types of endoscope: rigid and flexible.

6.3.2.1 Rigid Endoscopy

Rigid endoscopes with a length of 3–50 cm are these days mainly used for examination of the upper respiratory tract. A typical rigid laryngoscope is a metal tube of 15–25 cm length that contains ‘rod lenses’ (glass cylinders with lens-shaped cavities that direct and focus light) as an imaging system. The light from the light source is directed laterally through a fibre-optic cable coupled to a semi-transparent beam splitter. At the tip of the endoscope, the light is reflected by a mirror and emitted. The reflection angle of this mirror defines the endoscope type (see Fig. 6.3). An angle of 70–90° is suitable for illuminating the larynx (90° is most common in Europe). Ninety degree or 70° laryngoscopes have today replaced the laryngoscopic mirror of the nineteenth century. The old term ‘indirect’ laryngoscopy is kept for this modern technique because the light is redirected at an angle. A 70° laryngoscope can be inserted a little deeper (and therefore be brought closer to the vocal folds), but a more subtle examination technique is required.

The image is observed through a magnifying eyepiece lens through which one can either directly look or to which a video camera can be attached. The eyepiece usually has fourfold magnification.

6.3.2.2 Flexible Endoscopy

In contrast to the rigid endoscope, a flexible endoscope can be directed around a curve. Conventional flexible endoscopes have the same design as rigid endoscopes, except that they have a bundle of flexible fibre-optic cables instead of a rod lens. Flexible laryngoscopes are approximately 40 cm long, and the tip can be directed by control knobs near the eyepiece (see Fig. 6.4). In contrast to a bronchoscope, flexible laryngoscopes do not have a suction tube or working tube next to the light channel, and it is therefore possible to manufacture very narrow flexible laryngoscopes (max. 5 mm, in contrast with the 6–8 mm of a bronchoscope). However, a not insignificant loss of light occurs with fibre optics; the longer the endoscope, the greater the amount of light lost. This loss of light must be compensated for during observation, either by performing observations in a darkened room or by using electronic light amplification within the video chain.

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