Voice Assessment and Examination

History & Initial Exam - The First Listen

• Voice History:
  • Onset, duration, severity.
  • Associated symptoms: Pain, dysphagia, GERD, cough.
  • Vocal hygiene: Vocal load, smoking, hydration.
  • Med/Surg Hx: Thyroid surg, intubation, neuro.
  • Social/Occ impact: Prof. voice users.
• "First Listen" (Auditory):
  • Pitch, loudness, quality (hoarse, breathy, strained).
• H&N Exam (Voice-Relevant):
  • Oral cavity/oropharynx.
  • Neck: Masses, tenderness, laryngeal crepitus.
  • CN IX, X, XII screen.

⭐ Hoarseness > 3 weeks, esp. in smokers or with red flags (e.g., pain, hemoptysis), mandates laryngoscopy.

Perceptual Evaluation - Ear on Quality

• Subjective assessment of voice quality by listening.

• GRBAS Scale: 📌 Great Rhinos Bellow At Sunsets. Assesses five parameters:

  • Grade: Overall hoarseness severity.
  • Roughness: Perceived vocal fold vibration irregularity.
  • Breathiness: Audible air escape during phonation.
  • Asthenia: Vocal weakness or lack of power.
  • Strain: Perception of excessive vocal effort.
  • Each scored 0 (Normal) to 3 (Severe).

  Score	Description
  0	Normal
  1	Mild
  2	Moderate
  3	Severe

• CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice):

  • More detailed; uses a 100mm Visual Analog Scale (VAS).
  • Parameters: Overall Severity, Roughness, Breathiness, Strain, Pitch, Loudness.

⭐ GRBAS is widely used for its simplicity and speed in clinical settings, making it a valuable tool for initial voice assessment and tracking treatment progress over time based on auditory-perceptual changes noted by the clinician or patient (though primarily clinician-rated).

Laryngeal Imaging - Visual Vibes

Visualizes vocal fold structure & function for diagnosis.

• Videostroboscopy:
  • Principle: Talbot's law (illusory slow motion).
  • Parameters: Symmetry, Amplitude, Periodicity, Mucosal wave, Glottic closure, Non-vibrating portion.
• High-Speed Videoendoscopy (HSV):
  • Actual vocal fold vibration (>2000 fps).
  • Best for aperiodic voices.
• Narrow Band Imaging (NBI):
  • Enhances mucosal/vascular patterns.
  • Detects early dysplasia/malignancy.
• Kymography:
  • Single-line vocal fold vibration over time.

Acoustic & Aerodynamic - Data Driven Diagnosis

Standardized Scales & Special Tests - Holistic View

• Patient-Reported Outcome Measures (PROMs):
  • Voice Handicap Index (VHI): Self-perceived voice handicap.
    • Domains: Functional, Physical, Emotional (📌 FPE).
    • Scoring: 0-30 (Mild), 31-60 (Moderate), 61-120 (Severe).
  • Voice-Related Quality of Life (V-RQOL): Impact on voice-related QOL.
  • Pediatric VHI (pVHI): For children.
• Special Tests:
  • Laryngeal Electromyography (LEMG):
    • Indications: Vocal fold paralysis/paresis, movement disorders.
    • Muscles tested: Thyroarytenoid (TA), Cricothyroid (CT), Posterior Cricoarytenoid (PCA).
  • Auditory Brainstem Response (ABR): Central neurological causes.

⭐ VHI scoring: 0-30 (Mild), 31-60 (Moderate), 61-120 (Severe) indicates perceived handicap severity.

High‑Yield Points - ⚡ Biggest Takeaways

• GRBAS scale is crucial for subjective voice assessment (Grade, Roughness, Breathiness, Asthenia, Strain).
• Videostroboscopy is key for visualizing vocal fold vibration and mucosal wave integrity.
• Maximum Phonation Time (MPT), normally >15 seconds, indicates glottic efficiency.
• An S/Z ratio >1.4 strongly suggests laryngeal pathology over respiratory causes.
• The Voice Handicap Index (VHI) measures patient-perceived disability from voice disorders.
• Acoustic analysis provides objective data: jitter, shimmer, and Harmonics-to-Noise Ratio (HNR).