NAME
AGE
: Candy Cookie
: 55
ADDRESS
: 201 5th St. NE
PHONE
FILE
D.O.B
:
: 12/21/55
D.O.E
: 9/9/11
REFERRAL : 8/17/11
CODE
: 784.49
:
VOICE EVALUATION
Area of Concern:
CC was referred to Minot State University Communication Disorders Clinic (MSU CDC)
by Dr. B.R. Buell (ENT) in Bismarck, ND on August 17, 2011for an acoustic voice evaluation of
suspected spasmodic dysphonia including a videostroboscopy. Spasmodic dysphonia is
characterized by a strained, jerky or tight voice, vocal spasms, and inconsistent sound breaks. CC
attended the evaluation to obtain more information about the nature of her voice due to a
persistent vocal fatigue and strain, difficulty with loudness, and pressure in her upper chest and
neck area felt during long periods of talking.
Background Information:
CC’s voice problem became apparent approximately six to nine months ago when it was
noticed by her husband and co-workers, and her voice has continued to worsen since the problem
began. According to CC, her voice was consistently strained and never feels normal since the
onset of her voice problem. She stated her voice is worse when she attempts to speak for a
longer duration, in the mornings, and in evenings; however, her voice can become unpredictably
worse any time of day. CC also reported pressure and tightness in her upper chest during long
periods of speaking.
CC reported no co-occurring events such as new medications, stressors, or traumatic
events since the onset of her voice problem. CC has smoked approximately one package of
cigarettes and consumed eight drinks per week for 20 years, which may negatively impact vocal
quality due to their dehydration effects on the vocal folds. CC reported her voice affects her
ability to perform duties at her workplace. This was CC’s first voice evaluation at MSU CDC.
Voice Evaluation
CC
Page 2
TESTING AND RESULTS:
Perceptual Evaluation:
CC reported her voice feels severely strained and “sometimes doesn’t come out,” which
increases her stress levels. She stated her voice did not necessarily improve even after long
periods without speaking, and she had occasional inconsistent swallowing difficulties with
various liquid and solid consistencies. CC has been on medical leave from her job as a
supervisor of food services in a middle school because the environment requires her to use her
voice all day since May/June 2011. Additionally, CC expressed frustration over the impact her
voice had on holding conversations with friends and family. Time spent with her granddaughter
was among her highest concerns, stating she was upset she “could not read her granddaughter a
story.”
CC participated in a hearing screening to ensure adequate hearing for speech and
language and no hearing concerns were evident. On the Voice Handicap Index (VHI), CC’s
overall score was 113/120; her physical score was 38/40, emotional score was 37/40, and
functional score was 38/40; these scores indicated a severe impact on CC’s quality of life.
The measures on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)
included averages of the following tasks: conversational tasks, sustained /a/ and /i/, and sentence
productions. Results revealed CC’s overall vocal quality was 93% and was consistently
perceived as severe. CC scored 72% on a scale of roughness and 100% on strain. Loudness was
rated as inconsistent and severely reduced with a score of 96%. CC reported at times she ‘ran
out of air,’ and there was a cessation of voice in the middle or at the end of speaking where it
appeared air flow was cut off; loudness was observed to fluctuate before and after these
moments. CC’s voice was perceived as being mildly breathy at 12%, and the pitch was mild to
moderately low at 38%. The percentages were derived from experienced listener perceptions
and rated on a scale of 1-100; one being normal and 100 being severely deviant.
Multiple analysis regarding CC’s breath support and glottal closure were obtained. While
reading the Rainbow Passage, CC’s average syllables per breath was 6.8, indicative of
insufficient glottal closure, compared to the normative mean 13.85 (SD +/- 4.3) syllables per
breath. /S/ to /Z/ ratio calculations resulted in a score of 1.4, indicative of insufficient glottal
closure, because scores greater than 1 are outside normal range. CC’s average maximum
phonation for sustained /i/ was 5.4 seconds and /a/ was 5.3 seconds, which was significantly
below the average normative data of 21.34 (SD +/- 5.66). During a diadochokinetic (DDK) two
second syllable rate analysis, CC produced /pΛ/ seven times, /tΛ/ 10 times, /kΛ/ nine times, and
/pΛtΛkΛ/ seven times, which was within normal limits and indicated CC had adequate ability to
sequence sounds to produce words.
Audio recordings gathered additional samples of sentences and speech tasks to assess
CC’s speech for characteristics of abductor spasmodic dysphonia (Ab-SD) and adductor
spasmodic dysphonia (Ad-SD). (see chart on following page)
Voice Evaluation
CC
Page 3
Potential Characteristics Differentiating Ab-SD and Ad-SD
Abductor Spasmodic Dysphonia (Ab-SD)
Adductor Spasmodic Dysphonia (Ad-SD)
 Spasms (in open VF position)
 Spasms (in closed VF position)
 Spasms absent/reduced in laughing,
 Spasms absent/reduced in laughing,
crying, or shouting
crying, or shouting
 Weak voice
 VF stiffen
 Breathy voice
 Words often cut off
 Difficulty with 60-70 series
 Difficulty with 80 series
 Difficulty transitioning from
 Difficulty with onset
voiced to voiceless
 Choppy sounding speech
 Spasms on voiceless consonants
 Strained/strangled quality
 Stress increases severity of spasm
 Spasms on voiced consonants
(www.nicdc.nih.gov/health/voice/spasdysp.html)
Sentences were loaded with either voiced or voiceless consonants for purposes of
differentiating whether vocal spasms occur during abduction (i.e., Ab-SD) or adduction (AdSD). CC produced one voice break in four sentences while reciting six-word sentences involving
many voiceless consonants. In contrast, she produced 13 voice breaks in five open vowel
sentences, seven to ten words in length, which was consistent with characteristics of Ad-SD. To
further assess Ad-SD vs. Ab-SD, tasks including sentences, conversation, counting the 60-80
series, singing, sustained /a/, and laughing were conducted. Voice breaks increased considerably
midway through the task; increases may have been caused by prolonged speech duration or
voicing tasks. During counting tasks, delayed voice onset occurred more frequently on voiced
(i.e., 80 series) in comparison to voiceless consonants (i.e., Ab-SD number series 60-79) which is
consistent with characteristics of Ad-SD. In spasmodic dysphonia singing and laughing may
greatly reduce symptoms, which was reflected in CC’s speech. Singing and laughing appeared
to relieve vocal tension, strain, and roughness in the first few words of a sentence after one of
these tasks, though this had minimal effect on continued speech. CC exhibited no vocal tremor.
A consistently strained vocal quality was present throughout the recording which is suggested of
Ad-SD.
Acoustic Evaluation:
The VisiPitch Multidimensional Voice Program (MDVP) was used to obtain acoustic
measurements of CC’s vocal quality and pitch. The microphone gain was set at four to record all
samples. CC’s shimmer percent (amplitude perturbation-measures variation in vocal intensity)
was 11.5% which was below normal limits; typical shimmer percent was 1.9 with a standard
deviation (STD) of 0.79. CC’s jitter percent was 7.9% which was below normal limits; typical
jitter percent (frequency perturbation-measures variation in pitch) was 0.63 with a STD of 0.35.
Jitter and shimmer values were consistent with perceptual findings of severe strain on the CAPEV. CC’s mean or average fundamental frequency (Mfo) was 288.16 Hz, which was outside
normal range of 214 Hz for her age and gender.
Voice Evaluation
CC
Page 4
Physical Findings:
A videolaryngostroboscopic evaluation was conducted using a 70-degree rigid endoscope to
evaluate vocal fold appearance and function. Several large protrusions at the base of the tongue
precluded view of vallecular area on most of the video clips, which may warrant further
investigation. During vocal fold closure, reduced movement or weakness of the left vocal fold
was noted and the right vocal fold was observed to cross midline to achieve vocal fold closure.
The arytenoid prominences on both sides were observed to open and close suggesting no
paralysis was evident. The posterior commissure between the arytenoids appeared rough and
had an off-white appearance. Intermittent lock-up of the true vocal fold was observed during
sustained phonation of /i/. No interference from the false vocal fold was observed. On the
Stroboscopy Evaluation Rating Form (SERF), amplitude and mucosal wave of the right vocal
fold were rated at 40%, and 20% for the left vocal fold indicating reduced movement of the
tissues on the surface of the vocal fold. Approximately 23% of the right vocal fold and 73% of
the left vocal fold were non-vibratory. Both vocal folds appeared smooth with irregular edges
related to the bowing of the left vocal fold above level six and the right vocal fold above level
seven (see picture below for reference to levels), irregular and hourglass glottal closures, and the
right vocal fold crossing midline was visible during phonation. Vertical level closure of the
vocal folds appeared on-plane. Some mucus pooling was observed at the posterior portion of
both the left and right vocal folds. An exam using a rigid endoscopic strobe may interfere with
the display of symptoms characteristic of spasmodic dysphonic, specifically laryngeal muscle
spasms may be masked by pulling of the tongue. However, a more reliable exam using the
flexible nasal laryngoscope was unable to be used due current laws which would require a
physician to be present. Upon palpitation of the neck, laryngeal movement was not restricted;
however, tension was noted on superior portion of sternocleidomastoid, located directly below
ear.
Voice Evaluation
CC
Page 5
SUMMARY:
CC’s vocal quality was characterized as severely strained and rough with voice breaks
intermittently audible during initial onset and occasionally during medial and final voiced
consonants. These symptoms are characteristic of spasmodic dysphonia, primarily adductor
spasmodic dysphonia. A strained quality was present during both conversational and phonation
tasks. Upon palpitation of the neck, laryngeal movement was not restricted; however, tension
was noted on superior portion of sternocleidomastoid, located directly below ear. Normal speech
was triggered during laughing and increased with the yawn-sigh technique; however, relief
continued into speech for a short duration with strained vocal quality returning after 3-5 seconds.
Insufficient glottal closure and spastic locked movements were intermittently evident during
sustained phonation as observed through the videostroboscopy. CC may be a candidate for
medical intervention and/or possible therapeutic intervention.
RECOMMENDATIONS:
1. Follow-up with Dr. Buell to review recent findings and discuss possible medical options.
2. Trial Resonant Voice Therapy to determine if positive voice changes could be obtained
prior to other medical options.
___________________________
MM, B.A.
Graduate Student Clinician
__________________________
Lisa Roteliuk, M.S., CCC-SLP
Clinical Supervisor
___________________________
KS, B.Sc.
Graduate Student Clinician
This evaluation was completed by graduate student clinicians under the supervision of an
ASHA certified and ND Licensed Speech-Language Pathologist