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artykuł poglądowy / review article
Diagnostic protocol in voice disorders
Postępowanie diagnostyczne w zaburzeniach głosu
Sielska-Badurek Ewelina, Niemczyk Kazimierz
Chair and Department of Otolaryngology, Medical University of Warsaw, Head of the Department – Prof. Kazimierz Niemczyk, MD PhD
Article history: Received: 20.04.2015 Accepted: 05.05.2015 Published: 30.06.2015
ABSTRACT: iagnostic protocol in voice disorders should be multidimensional, since voice production is a multifaceted pheD
nomenon. Most voice disorders are of functional (57%) origin characterized by a lack of organic changes in indirect
laryngoscopy. Comprehensive assessment of the vocal tract is necessary in those patients in order to state a diagnosis.
Diagnostic protocol suggested by European Laryngological Society in 2001 includes diagnostic tools that enable
comprehensive assessment of the vocal tract. Beside medical history and examination, it recommends performing
a auditory-perceptual assessment, a videolaryngostroboscopic examination (VLS), aerodynamic assessment, acoustic
parameters, as well as voice quality self-assessment test. A DSI index is a promising new diagnostic tool designed to
objectively assess the severity of dysphonia.
KEY WORDS:
Diagnostic protocol, dysphonia, auditory-perceptual assessment, videolaryngostroboscopy, maximal phonation time,
acoustic study, DSI index
STRESZCZENIE:
Postępowanie diagnostyczne w zaburzeniach głosu powinno mieć charakter wielowymiarowy, ponieważ tworzenie
głosu jest zjawiskiem wielopłaszczyznowym. Większość zaburzeń głosu ma podłoże czynnościowe (57 proc.); w laryngoskopii pośredniej nie ma zmian organicznych w obrębie krtani. Do postawienia prawidłowego rozpoznania u tych
pacjentów konieczna jest kompleksowa ocena narządu głosu.
Protokół diagnostyczny zaproponowany przez Europejskie Towarzystwo Laryngologiczne z 2001 r. obejmuje
narzędzia diagnostyczne, dzięki którym można kompleksowo ocenić trakt głosowy. Poza wywiadem i badaniem
przedmiotowym Towarzystwo zaleca wykonanie oceny odsłuchowej głosu, badania wideolaryngostroboskopowego (VLS), oceny aerodynamicznej, badań akustycznych oraz samooceny jakości głosu. Obiecującym, nowym
narzędziem diagnostycznym jest współczynnik DSI, który ma za zadanie obiektywnie określić stopień nasilenia
dysfonii.
SŁOWA KLUCZOWE:
postępowanie diagnostyczne, dysfonia, ocena percepcyjna, wideolaryngostroboskopia, maksymalny czas fonacji,
badanie akustyczne głosu, współczynnik DSI
INTRODUCTION
We live in a society based on communication, where operational vocal organ is important for maintaining interpersonal
relationships, expressing our emotions and feelings. It is also
a working tool for most vocations. It is estimated that at the
beginning of the 20th century, voice constituted a working tool
for about 10% of occupations, while nowadays it is a crucial
factor in most professions (1).
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DOI:10.5604/20845308.1152198
Voice production depends on proper coordination of three
structures. Respiratory system supplies a stream of air to the
larynx. At the level of the larynx, airstream is transformed into
an acoustic wave due to vocal fold vibrations. During propagation through the so-called vocal resonators (epiglottal region,
throat, oral cavity, nasal cavity) the laryngeal tone generated
at the level of the glottis acquires individual timbre.
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artykuł poglądowy / review article
In a view of a multitude of ways human voice is generated,
diagnostics of voice disorders should not be limited to laryngoscopy. Even more so, in the view of the fact that most of the
currently diagnosed voice disorders are functional – 57% (2) and
are characterized by the lack of organic changes in the larynx.
Diagnostic protocol proposed by European Laryngological
Society in 2001 encompasses diagnostic tools that allow for
comprehensive assessment of the voice tract (3). Aside from
medical interview and physical examination, the Society recommends performing a auditory-perceptual assessment,
videolaryngostroboscopic study (VLS), aerodynamic assessment, acoustic parameters and voice quality self-assessment.
Auditory-perceptual assessment and voice quality self-assessment are subjective tests and are performed by the patient.
Videolaryngostroboscopy is a study bordering on objective
(video recording of vocal folds) and subjective (interpretation
performed by a doctor) evaluation. Aerodynamic and acoustic
assessments are considered objective tests.
AUDITORY-PERCEPTUAL EVALUATION
Voice perception assessment consists of auditory evaluation of
patient’s voice quality. The result depends on assessing physician’s auditory training. There are many scales dedicated to
evaluating the quality of patient’s voice utilized by many centers worldwide.
The most common scale for voice perception is the GRBAS
scale created by Hirano (4). Hirano recommends conducting
the assessment during medical interview. Voice is evaluated
based on 5 parameters (Table 1), assessing each one on a 4-point
scale: 0- normal voice, no disturbances; 1 – mild disturbance;
2 – moderate disturbance; 3 – great disturbance.
timbre (without hard attacks). Score G1 R0 B1 A0 S1 signifies
somewhat changed voice, with mild component of breathiness and little strain.
VIDEOLARYNGOSTROBOSCOPIC ASSESSMENT
Videolaryngostroboscopic examination allows for endoscopic
evaluation of vocal fold vibrations. VLS assessment is considered
a major tool in the diagnostics of voice disorders. Stroboscopic
light enables examination of vocal fold vibrations. In women
vocal folds vibrate with a mean frequency of 256 Hz, i.e. 256
cycles per second, while in men with a mean frequency of 128
per second. Human eye is able to register 5 cycles per second.
Thanks to illumination of vibrating vocal folds with intermitting
light with a frequency 1 Hz higher than the frequency of vibration, we acquire an apparent image of phonative vocal fold vibrations. Stroboscopic effect enables assessment of regularity,
symmetry and amplitude of vocal fold vibrations, presence of
mucosal wave and the characteristics of glottal closure during
phonation. Assessment of mucosal wave was particularly useful determining the advancement of organic lesions within the
larynx. For example, presence of mucosal wave in a region affected by vocal fold nodules allows for qualifying them as soft
vocal nodules, while absence of mucosal wave qualifies them as
hard nodules (Fig. 1). In the presence of hypertrophic changes,
lack of mucosal wave signifies greater progression, i.e. deeper
vocal fold infiltration than absent or limited margin movement
(Fig. 2). Irregularity, asymmetry, or abnormal amplitude of vocal
fold vibration may indicate functional voice disorders.
Possibility to store and replay the study multiple times is a great
advantage of VLS examination.
Table 1. Voice quality parameters assessed acc. to GRBAS scale
ABBREVIATION
PARAMETERS
TRANSLATION TO POLISH
G
Grade of hoarseness
Stopień chrypki
R
Roughness
Szorstkość
B
Breathiness
Powietrze w głosie
A
Asthenic
Osłabienie głosu
S
Strained
Napięcie głosu
The G parameter, or grade of hoarseness, relates to the advancement of overall voice change.
Result G0 R0 B0 A0 S0 designates normal voice, without roughness, breathiness, of normal intensity, generated with soft
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 2 (2015), s. 12-18
Figure 1. Soft vocal fold nodules – mucosal wave is visible in VLS assessment
along the entire length of both vocal folds.
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artykuł poglądowy / review article
hyperfunctional mechanisms accompanying prolonged
phonation appear.
MPTa depends on patient’s vital capacity (VC), while VC values
depend on age (lower in children), sex (lower in women than in
men), or possible lower respiratory tract disorders. In order to
eliminate the influence of VC on the differences in a vowel MPT,
it is recommended to establish the phonation quotient (9). PQ
value is a ratio of VC obtained in spirometry and a vowel MPT:
PQ = VC (mL) / MPT (s).
Mean PQ values are 135 mL/s for men and 125.8 mL/s for
women (9).
Figure 2. Hypertrophic lesion in the anterior part of the right vocal fold. Absence
of mucosal wave along the entire length of the right vocal fold.
ACOUSTIC STUDY
AERODYNAMIC ASSESSMENT
Acoustic study provides description of physical voice parameters. Short-term analysis for the a vowel is most often performed. The above-mentioned analysis assesses the following
parameters:
Aerodynamic assessment is dedicated to basic functional assessment of the respiratory tract and proper coordination
between phonation and respiration.
Assessment of maximal phonation time for a vowel (MPT a)
is the simplest aerodynamic study. Obtaining plausible effect
depends on properly instructing the patient on the importance
of taking a deep breath and sustaining phonation of a vowel
at suitable volume and tone for the longest possible time (5).
Patient should be standing during the examination. Measurements are repeated thrice and the best result is selected (5). A
vowel MPT score is reported in seconds.
• F0 – mean fundamental frequency
• Jitter – fundamental frequency change parameter
• Shimmer - relative amplitude modulation
• NHR – noise to harmonic ratio
Most programs immediately interpret the obtained results of
short-term acoustic analysis of a vowel. Abnormal results are
Short assessment time, wide availability (stopwatch is the only
necessary tool) and, as emphasized on multiple occasions, its
objectivity, undoubtedly constitute advantages of MPT examination. One should remember that the result of examination
depends on patient’s motivation and cooperation.
A vowel MPT score below 10 seconds is interpreted as pathological. It is widely believed that the desirable result should
oscillate around 20 seconds and more. However, one should
remember that Carroll in her studies conducted on 40 professional singers acquired shorter mean MPT results (men:
22.64 seconds; women: 18.98 seconds) (6) than previous authors obtained in patients without vocal training (a vowel
MPT: 30.2 seconds (7), or 34.6 seconds (8)). These results
are explained by the fact that persons who care about proper
voice emission terminate vowel phonation at a point when
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Figure 3. Normal result of MDVP (multi-dimensional voice program). MDVP
software is the most prevalent for analysis of short-term a vowel assessment.
Acoustic parameters within the green circle are considered normal.
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Figure 4. Normal result of short-term a vowel examination using the Polish
DiagnoScope software. Parameters of acoustic analysis labeled in green are
normal. Parameters designated in dark blue depend on individual mass of vocal
folds (Fo) and shape of resonators (formants – F1, F2, F3, F4).
Figure 6. Abnormal result of acoustic analysis in a patient with vocal fold
nodules.
questionnaires (Fig. 7) (10). The result, also known as VHI
coefficient, equal to 0 indicates patient’s satisfaction with
the quality of their voice. Values between 0 and 30 are considered normal. The greater the value of VHI coefficient,
the greater is patient’s dissatisfaction with the quality of
their voice.
Patient self-assessment may be also conducted with a so-called
visual analogue scale (VAS) as an alternative to VHI questionnaire. Assessment is conducted using a 100-milimiter tape
measure (Fig. 8) or by asking the patient to evaluate the following parameters on a scale from 0 to 100 (assuming that 0
indicates the norm):
•
•
Figure 5. Abnormal result of MDVP. Most parameters of acoustic analysis
(including jitter and shimmer) are anomalous (indicated by red color and coming
out of the green circle).
usually designated in red (Fig. 3,4,5,6). It is believed that three
and more values above normal for analyzed parameters indicate abnormal result of a vowel acoustic analysis.
SELF-ASSESSMENT OF VOICE QUALITY
There are many questionnaires dedicated to voice self-assessment. They are designed by many centers to fit a multitude
of languages. Voice handicap index (VHI), translated and
validated to Polish in 2004, is one of the most often used
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 2 (2015), s. 12-18
quality of their voice,
impact of voice disorders on everyday life and career.
DYSPHONIA SEVERITY INDEX
Figure 8. A diagnostic tool for voice assessment using visual analogue scale
The above-described diagnostic protocol was proposed by
European Laryngological Society in 2001. Since then, scientists
and clinicians have been searching for new tools that would enable
more credible examination of the voice organ. DSI (dysphonia
severity index) is one of such tools. The value of DSI is considered
an objective result. DSI coefficient is obtained from parameters of
acoustic and aerodynamic analyses, such as: a vowel MPT, max15
artykuł poglądowy / review article
First and last name:………………………………………………………………… 0 =never
1= almost never
Date:………………
Voice Handicap Index (VHI)
2 = sometimes 3 = almost always
0
1 4 =always
2 3 4
1. People have trouble understanding me in a noise room
2. My family has difficulty hearing me when I call them throughout the house
3. I use the phone less often than I would like to
4. I tend to avoid groups of people because of my voice
5. People ask me to repeat myself when speaking face-to-face
6. I tend to avoid contact with friends, neighbors and relatives because of my voice
7. My voice is weak and difficult to hear
8. My voice difficulties restrict my personal and social life
9. I feel left out of conversations because of my voice
10. My voice problem causes me to loose income
2 3 4
0
1 1. I run out of air when I talk
2. People ask me what is wrong with my voice
4. I try to change my voice to sound different
5. My voice is worse in the evening
6. I use a great deal of effort to speak
7. My voice is creaky and dry
8. I feel as though I have to strain to produce voice
9. The sound of my voice varies throughout the day
10. My voice “gives out” on me in the middle of speaking
2 3 4
3. The clarity of my voice is unpredictable
0
1 1. People seem irritated with my voice
2. I find other people don’t understand my voice problem
3. My voice problem upsets me
4. I am less outgoing because of my voice problem
5. My voice makes me feels handicapped
6. I feel annoyed when people ask me to repeat
7. I feel embarrassed when people ask me to repeat
8. My voice makes me feel incompetent
9. I am ashamed of my voice problem
10. I am tense when talking to others because of my voice
Score: ……………………………………..
Figure 7. Voice handicap index questionnaire
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artykuł poglądowy / review article
imal voice frequency (Fmax), minimal voice intensity (Imin) and jitter (Fig. 9) (11):
DSI = 0.13 x MPT a + 0.0053 x F max – 0.26 x I min – 1.18 x Jitter + 12.4
Value of the coefficient is supposed to unequivocally determine the severity of dysphonia (Table 2).
Table 2. Degree of severity of dysphonia depending on the value of DSI
coefficient
DEGREE OF SEVERITY
DSI
0 = no signs of dysphonia
> 4.2
1 = mild
1.81 – 4.2
2 = moderate
-1.21 - 1.8
3 = severe
≤ -1.2
SUMMARY
The presented protocol of diagnostic management contains
basic tools that will allow for reliably determining etiology,
diagnosis and prognosis of voice disorders, as well as planning treatment and monitoring the course of therapy in a majority of patients.
Figure 9. A voice chart used by DIVAS software to identify Fmax and Imin
parameters used for determination of DSI coefficient
It should be emphasized once more that most voice disorders
are of functional background. Such conditions, if diagnosed late,
may lead to development of organic changes in the larynx (vocal fold nodules, polyps, laryngeal cysts, or chronic laryngitis).
Limiting the diagnostics to performing indirect laryngoscopy
in voice disorders does not enable comprehensive evaluation
of dysphonic patients.
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Word count: 1365 Tables: 2 Figures: 9 References: 11
Access the article online: DOI: 10.5604/20845308.1152198 Full-text PDF: www.otorhinolaryngologypl.com/fulltxt.php?ICID=1152198
Corresponding author: Ewelina Sielska-Badurek, Katedra i Klinika Otolaryngologii WUM, [email protected]
Copyright © 2015 Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o. All rights reserved Competing interests: The authors declare that they have no competing interests.
Cite this article as: Sielska-Badurek E., Niemczyk K.: Diagnostic protocol in voice disorders. Pol Otorhino Rev 2015; 4(2): 12-18
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