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Case Example 2: PediatricCase Intake/VHIAuditory‐Perceptual 9‐year‐old female with a longstanding history of araspy voice quality, currently in musical theater andstrains during singing. Prior medical history of central apnea with PICUhospitalization and intubation for 1 day of a week longstay, aspiration of a carrot (2 yrs), and tonsillectomy &adenoidectomy (4 yrs). Normal gestation and twin birth (twin has no voiceproblems). Receives twice weekly (20 min) SLP schoolspeech services /r/, "sh, ch, j" during the past year. Reports vocal fatigue with prolonged voicing, frequentthroat clearing, MPT of 6 s, nasal rustle andhypernasality. pVHI Total Score 28/120 Current Voice Function rated as 30‐40% Normal SustainedPhonation ConnectedSpeechSLP Voice Assessment ComponentsCPT 92524 Behavioral and qualitative analysis of voiceand resonance (non‐instrumental)Case IntakeFacilitative Voicing Techniques Used to explore whattherapy methodsimprove voicing Indicates whetherpatient is a candidate forvoice treatment Gives direction to besttreatment methods forfirst session(Yiu et al, 2012; Boone et al., 2014; Gillespie& Gartner‐Schmidt, 2016; Smith & Titze,2017)ArSHA 2021 Examples of my favorites– Semi‐Occluded Vocal TractTechniques Lip/Tongue raspberry Phonation into a straw Kazoo or “Lip Buzz” during“ooh”– Resonance Adjustments Forward voice resonanceTongue protrusionChantingOpen‐mouthHead positioning (also for vocalfold paralysis/paresis)– Yawn‐sign (stretch and relax)– Vegetative voicing (e.g. throatclear, laughter)– Respiratory training– Laryngeal ManipulationPatient Self‐ReportCranialNerve Exam(AKA tionStudiesLaryngealImagingPhysical Exam andVoicing Facilitation Laryngeal palpation andmanipulation can beinformative– Palpable tension– Tenderness or pain– Voicing changes withmanipulation Facilitative voicingmethods can informabout effective therapymethods7

Voice Stimulability & LaryngealManipulation Case Example Consistent voice quality:––––StrainedBreathyReduced loudnessNot phoneme specific Normal vegetative voicing Stimulable for improvedvoiceAdult Case ExampleFacilitative Voicing Laryngeal Manipulation Semi‐occluded vocal tracttechniques– High/Low pitch– Loud phonation Resonant voiceOutcomes Voice quality improved during:– high pitch– Resonant/forward focused voicing– Thyroid cartilage adduction Increased breathy‐rough voicequality:– Lower pitches– At end of utterances Aperiodicity inconsistent withfunctional voice problemDO NOT AUDIO‐, VIDEO‐RECORD, OR PHOTOGRAPHBehavioral Voice AssessmentDiscussionEvaluation of Voice and VoiceDisorders Across PracticeSettings, Part 2Julie Barkmeier‐Kraemer, PhD, CCC‐SLP,ASHAFUniversity of UtahJulieB.Kraemer@hsc.utah.eduVoice Assessment ToolsSLP Voice Assessment ComponentsCPT 92524 Behavioral and qualitative analysis of voiceand resonance (non‐instrumental)Case IntakeArSHA 2021Patient Self‐ReportCranialNerve Exam(AKA tionStudiesLaryngealImaging8

Voice Assessment ParametersAuditory‐Perceptual Pitch Loudness QualityAcoustic/AerodynamicPhysiological Fundamentalfrequency (Fo) Intensity (dB SPL) Spectral components(CPP) Vocal fold (VF) vibrationrate Subglottal pressure, VFclosure degree/duration VF configuration,symmetry resonanceCompleted Using InstrumentationRecommended Acoustic Tasks andMeasures (Patel et al, 2018)MINIMUM RECOMMENDEDRECORDING TASKS Sustained Phonation Tasks [Repeateach task 3 times]MEASURES Sustained phonation of /a/– Average f0– Average SPL– Cepstral Peak Prominence (CPP)from at least 1 second of middlesustained portion of each of 3trials– Sustain /a/ for 3‐5 seconds atcomfortable pitch and loudness on 1breath– Loudness Range Sustain /ɑ/ as softly as possible forat least 2 seconds withoutwhispering Sustain /ɑ/ as loudly as possible forat least 2 seconds – Lowest SPL value sustained for atleast 1 second– Highest SPL value sustained for atleast 1 second– Pitch Range Sustain /a/ at the highest note thatcan be sustained for 2 seconds Sustain /a/ at the lowest note thatdoes not include glottal fry/pulseregister possible for 2 seconds May use a glide to achieve thehighest and lowest notesRecommended Acoustic Tasks andMeasures (Patel et al, 2018)MINIMUM RECOMMENDEDRECORDING TASKS Connected Speech Tasks– Read a paragraph usingcomfortable pitch andloudness Adults: The RainbowPassage Children: The Trip to the Zoo Pitch Range– Minimum vocal f0 sustained for atleast 1 second– Maximum vocal f0 sustained for atleast 1 second– Determine f0 rangeCan I do instrumental assessment?MEASURES Measures are either obtainedfrom the entire passage orminimum of 5 secondsduration of the passage1.2.3.4.ArSHA 2021Loudness RangeHabitual vocal SPLMean/modal vocal f0Vocal f0 Standard Deviation(SD)Cepstral Peak Prominence(CPP)9

Laryngeal Function Studies:Acoustic MeasuresLow Budget Acoustic Equipment Quantify the auditory‐perceptual parameters ofpitch, loudness, andquality Enable pre‐ and post‐treatment comparisonKeyboard ( 20–X)Pitch Pipe ( 9– 20)Stopwatch ( 2–X)Recording Device(smartphone, cassetterecorder) Elucidate thepathophysiology of vocalfold vibration on voiceproduction(Barsties & De Bodt, 2015; Awan et al., 2016)Affordable Acoustic EquipmentTwo keys to the audio recording Need a High Quality Microphone– Frequency Response:Computer with an audio cardMicrophoneSound Level MeterAudio Interface (mic pre‐ampand A/D converter) Acoustic recording/measurement software Flat (i.e., variation of 2 dB) across the frequency range between the lowest expectedf0 of voice and the highest spectral component of interest (approximately 50–8,000Hz)– Type: Condenser microphone – head mounted Dynamic microphone – tripod or stand– Placement: 4‐5 cm from mouth to microphone Condenser mic should be 45 degrees off‐axis Dynamic mic needs to be directly in front of mouth Environment– Quiet room Ideal if ambient noise is 20 dB SPL lower than recorded voice– Acoustic treatment or considerations (e.g., carpet, sound panels)Examples of two types of micsConnecting your mic to the ‐audio‐interface/Condenser MicrophoneDynamic Microphone 99 220‐ 500You will need: 1501. High quality mic2. Preamp amplifies the mic signalAudiointerface provides3.theAnalog‐to‐digitalpre‐amp, A/D converterAKGC420Frequency ResponseShure SM58Frequency Response transforms audio signal into digitalconverter,and digitalsignal for computerinterface(examples4. Digital interface (e.g. USB,pictured)Firewire, Thuderbolt) 180‐330 communicates with computer5. Computer with sound cardZoom H6 Handy RecorderTASCAM DR‐40X Handheld RecorderArSHA 202110

Sound Level Meter (SLM)Acoustic Analysis Software Type 1 SLM:– Precision grade (most accurate)FREE SOFTWARE Type 2 SLM: Praat (www.praat.org) rfer/)– General grade (less accurate) Use C‐weighting to calibratemeasures of intensity Recommended Reference:– Švec & Granqvist (2018) Tutorial and Guidelines onmeasurement of sound pressure level in voice andspeech, JSLHR, 61: 441‐461.Type 1Type 2Fundamental Frequency (fo) andSound Pressure Level (SPL) Support perceptual correlates– Pitch Fundamental Frequency (fo)– Loudness Sound Pressure Level (SPL)– Quality Cepstral Peak Prominence (CPP) Characterize typical vocal usage duringconversation Characterize maximum performance rangesAmplitude SPLAcoustic Measures Should fo cycles per second 9 cycles/.05s 180 Hertz (Hz)SPL Sound pressure level or acoustic pressure level is alogarithmic measure of sound pressure relative to a reference value– amplitude dimension of the acoustic signal above measured as 62dBMeasures of Voice Quality (Patel et al, 2018) Signal to noise ratiomeasures reflectedlevels of periodic andaperiodic energy in thevoiceWhat is a cepstrum?The Cepstrum The Cepstrum a Fourier transform of the power spectrum of thevoice signal Graphic display of the degree to which the dominant rahmonic canbe identified from the background noise level Crazy terms: spectrum – cepstrum frequency – quefrency filter – lifter Jitter and ShimmerRequire periodicity harmonic – rahmonic Can be obtained from: Sustained vowels Connected speechArSHA 202111

Compare these two CepstraCepstral Peak Prominence (CPP) CPP (circled): Difference inamplitude between the dominantrahmonic (i.e., cepstral peak) andthe cepstrum background (i.e.linear regression line (black)(Hillenbrand et al., 1994, 1996)Typical Voice QualityAberrant Voice Quality13 dB6 dB The CPP measure indicates thedegree of periodic signal in a voice The unit of measure is dB The greater the CPP value, thestronger the periodic signal of thevoice.Recommended measure of voice quality:Cepstral Peak Prominence (CPP) (Patel et al, 2018)CPPs measure: Praat (praat.org) Shown to be a strongpredictor of voicequality (Maryn et al., 2009)– for both vowels andspeech (r .81‐.96)(Awan et al., 2010; Sauder et al,2017) Can be used as atreatment outcomemeasure (Awan & Roy, 2006;Step 1: Load fileStep 2: Analyze Periodicity – to PowerCepstrogramStep 3: Query – Get CPPs2009; Peterson et al., 2013;Ongkasuwan et al, 2019)Maryn & Weenink, 2015; Sauder et al, 2017Case Example 1 – AcousticCPPs measure: Praat (praat.org)Step 2: Analyze Periodicity – toPowerCepstrogram ACOUSTICMEASURESMean/modal F0 (Hz)60‐Hz pitch floor2‐ms time step5 kHz max. frequencyPre‐emphasis from 50 Hz/a/ Avg/i/ Avg292276RainbowPassage314F0 SD (Hz)Mean/modal SPL747621168CPPS in dB15156.5LowestHighestRange641788161217434 (21 ST)Step 3: Query – Get CPPs Subtract tilt before smoothing noTime averaging window .01sQuefrency averaging window .001sPeak search pitch range 60‐330 HzTolerance .05Interpolation “Parabolic”Tilt line quefrency range .001‐0 s (noupper bound)Line type StraightFit method RobustWatts et al, 2017; Brockmann‐Bauser et al,2019; Murton et al, 2020ArSHA 2021SPL RangeF0 Range (Hz) NORMS forFEMALES155-334 Hz ( 25% abovelowest note in the VRP) 32.6 Hz70-80 dB SPL for connectedspeech 14.5 dB for sustainedvowels and 9.3 dB forRainbow Passage 30 dB SPL Range 24 semitonesf0 was at the higher normal rangef0 SD was excessive associated with her noisy voice qualityMean SPL was normal, but SPL range was significantly reducedLow CPP values indicated increased noise in the voiceReduced f0 range and a significantly reduced loudness range (SPL range)12

Laryngeal Function Studies:Aerodynamic AssessmentCase Example 2 – AcousticACOUSTICMEASURES/a/ Avg /i/ AvgAll- VoicelessCAPE-VZoovoiced l fo (Hz)264261210266225251268fo SD (Hz)Mean/modal SPL807773615465776055658NACPPS in dB15169.112.57.99.9NAfo Range (Hz)SPL RangeLowest Highest Range8482001048(29 ST)589537 Efficiency of airstreamconversion into voiceproduction Vocal fold functionduring phonation Respiratory integrity forphonation This child has a normal average and range of fo and SPL range CPPs are not known for children, but had values similar to normal adult valuesAerodynamic Measures at Minimum Average Glottal Air Flow Rate (L/s):– Estimated from the mid‐portion of vowel production Average Subglottal Air Pressure (cmH2O or kPa):– Estimated from interpolated intraoral pressuresduring stop consonant production Mean Vocal SPL and f0:– Aids in the interpretation of air flow and air pressuremeasurementsAffordable Clinical AerodynamicMeasuresAffordable Clinical AerodynamicMeasures Estimate of laryngeal efficiency– S/Z ratio (Eckel & Boone, 1981, Gelfer &Pazera, 2006; Van de Meer et al, 2010; Joshi,2019)– Maximum Phonation Time(MPT)AdultsMalesFemales(Hirano, Koike, & Von Leden, 1968; Bless, 1971;Johnson & Goldfine, 2016)Normal MaxPhonation Durations25‐35 s15‐25 sAffordable Clinical AerodynamicMeasures Vital Capacity Estimate of respiratory drivingpressure for speech– Affordable Spirometer 120.00– Around the house “device” (Hixon etal., 1982)http://www.contecmed.com/index.php?page shop.product details&flypage flypage.tpl&product id 108&category id 21&option com virtuemart&Itemid 604– Ability to sustain 5 cm H2O for 5secondsPhoto taken lArSHA 202113

Affordable Clinical AerodynamicMeasures Average airflow volume calculation– Maximum Phonation Time (MPT)– Vital Capacity (mL)– Phonation Quotient (PQ) Vital Capacity (mL) / MPT (s) Estimated MPT calculation:– MPT(s) VC (mL)/Avg airflow (mL)PhonationQuotientVital CapacityMPTMales4.185 ( .875)31.6 ( 7.94)135 ( 19.3)Females3.019 ( .319)24.6 ( 5.45)125.8 ( 16.4)Additional Respiratory Assessment Observations– Quiet breathing (quiet breathingis 15‐20 breaths per minute)– Respiration‐phonatorycoordination during Sustained phonation Reading task Conversation(Rau & Beckett, 1984; Joshi et al, 2020)Problematic Breathing Patterns Exhaling before speakingShallow inhalationsAudible inhalationsSpeaking too long on one breathPoor phrasingRespiratory effortTension in neck, shoulders, chest, jaw, tongue,lips, etc.SLP Voice Assessment ComponentsAerodynamic MeasuresAdult Case Elevated average airflowvalues– .3‐.4 LPS during sustainedvowels and syllable repetition– .13 ‐ .19 LPS across sustainedvoicing and syllable repetition Elevated intraoral pressures Elevated intraoral pressures– 25 cmH2O (norm is 7‐10cmH2O)– 20 cmH2O (norm is 7‐10cmH2O) MPT 6 seconds s/z ratio 3 MPT 15 seconds s/z ratio 1.7Zraick et al, 2013Weinrich et al, 2013Affordable Laryngeal ImagingSpeech PathologistCPT 92524 Behavioral and qualitative analysis of voiceand resonance (non‐instrumental)Case IntakePatient Self‐ReportCranialNerve Exam(AKA oralperipheralexam)ArSHA ngealImagingPediatric Case Normal average airflowvaluesLaryngologist Determine the presence/ EITHER PARTNER WITH ORabsence of disease/pathologyREFER TO A LARYNGOLOGISTIF YOU DO NOT HAVE Medical diagnosisIMAGING EQUIPMENT Monitor and assess treatmentoutcomes14

Laryngeal ImagingLaryngeal Imaging Contribution Videoendoscopy– Evaluation of gross laryngealand pharyngeal motion andstructure (halogen light) Videostroboscopy– Evaluation of vocal foldvibratory characteristics andstructure (xenon or LEDlight)Overall view of laryngeal structureVocal fold structure and symmetryGlottic configuration during vocal fold closureVocal fold vibratory patternsSupraglottal activityLow‐Tech Viewing of the LarynxIndirect Using iPhoneVideo created from https://www.youtube.com/watch?v 5 RbH3uK640 andhttps://www.youtube.com/watch?v 5g6ew1EhOgYAdvanced Technological LaryngealImagingFlexible ScopeArSHA 2021Scope PlacementLaryngeal Imaging: MethodsRigid Scope15

Rigid Scope Placement90oLaryngeal Imaging: Methods Light Source Differences70o– Videoendoscopy Constant halogen light source– Videostroboscopy Xenon or LED strobe light sourceLaryngeal Imaging: High‐TechEquipmentLaryngeal Imaging: METHODS Scopes attach to a lightsource and camera Camera sends images tothe monitor Images are also recorded(digitized) and saved Audio input (mic) Playback speakersLaryngeal Imaging: Methods Consider clinical tasks– Flexible scope vs. rigid scope Observation Sustained phonation Connected speech– Light source– Patient signs and symptomsLIGHT SOURCE DIFFERENCESVideoendoscopy VideostroboscopyRecommended Laryngeal ImagingProtocolSustained phonation––––Comfortable pitchHigh/low pitchesComfortable loudnessLoud/soft phonation Produce /i–i–i–i/ without breaths inbetween using rapid production ofglottal stops Rest breathing (using rigid or flexibleendoscope) Vegetative tasks and panting Inhalation or “sniff” gesture to test thePCA muscle “/i/–sniff . . . . /i/–sniff” (or inhalation)– Maximum range of motion of vocalfoldsArSHA 202116

Laryngeal Imaging: Stroboscopy Measures of vocal fold vibration require at least 3consecutive videostroboscopic glottal cyclesClosed PhaseOpening PhaseClosing Phase12Laryngeal Imaging: InterpretationEvaluation of gross laryngeal & pharyngeal structure & motion Vocal Fold Edges: Appearance of vocal fold marginsduring abduction Vocal Fold Mobility: Movement of vocal folds towardand away from midline Supraglottic Activity: Degree of compression of thesupraglottic structures during sustained phonation3Slide adapted with permission from Rita Patel; taken from Awan et al. (2015)Laryngeal Imaging: InterpretationEvaluation of Gross Laryngeal and PharyngealMotion and Structure: Vocal Fold Edges:– Smooth & straight, bowed, irregular, or rough– Reported for left and right vocal fold separately Vocal Fold Mobility:– Normal, reduced, or absent– Reported for left and right vocal fold separately Supraglottic Activity:– Predominantly lateral compression,anteroposterior compression, or sphinctericcompression and degree (mild, moderate,severe)Slide adapted with permission from Rita Patel; taken from Awan et al. (2015)Laryngeal Imaging: StroboscopyEvaluation of vocal fold vibratory characteristics duringphonationFigure adapted fromPoburka et al. (2015)1.Regularity: Degree of consistency of one videostroboscopic glottal cyclewith successive cycles2.Amplitude: Extent of lateral movement of vocal fold edges3.Left/Right Phase Symmetry: Degree to which the vocal fold are mirrorimages in the timing of opening, closing, and maximum lateral‐medialexcursion4.Vertical Level: Level difference in vertical plane between the vocal foldduring maximum closed phase of the glottal cycle5.Glottal Closure Pattern: Glottal configuration during maximum closure6.Glottal Closure Duration: Relative portion of each glottal cycle that theglottis is closedSlide adapted with permission from Rita Patel; taken from Awan et al. (2015)Laryngeal Imaging: InterpretationLaryngeal Imaging: Interpretation Regularity:– Regular strobe tracking, intermittent strobetracking, irregular strobe tracking– If the strobe tracking is intermittent or irregular,further estimates/ratings are not valid– Amplitude: 0% to 100% in 25%increments Reported for left and rightvocal fold separatelyFigure adapted from Poburka et al. (2015)RegularIrregularFigure adapted from Poburka et al. (2015)Slide adapted with permission from Rita Patel; taken from Awan et al. (2015)ArSHA 2021Slide adapted with permission from Rita Patel; taken from Awan et al. (2015)17

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- ASHA member - Member of ASHA's SIG3: Voice and Upper Airway Disorders - ASHA working group member for CAPE‐V and Instrumental Voice Assessment Protocols Speaker Disclosure Julie Barkmeier‐ Kraemer, PhD, CCC‐SLP University of Utah Upon completion of this course, participants will be able to: 1.