Auditory Perceptual Assessment of Voice and Speech Disorders

Auditory Perceptual Auditory Perceptual Assessment of Assessment of

Voice and Speech DisordersVoice and Speech Disorders

Tamer Abou-Elsaad, MD,PhDTamer Abou-Elsaad, MD,PhDProf. of Phoniatrics, ORL Dept.Prof. of Phoniatrics, ORL Dept.

Faculty of Medicine, Mansoura UniversityFaculty of Medicine, Mansoura University

EgyptEgypt

22ndnd ESPL conference, Cairo ESPL conference, Cairo

By


Voice and Speech DisordersVoice and Speech Disorders► Auditory perceptual assessment (APA) of

the patient with communication disorders is a basic skill that phoniatricians and speech language pathologists should develop.

► “The clinically well trained ear will always be the primary and most important means of examination ”. [Fex, 1992]

Fex,S (1992): Perceptual evaluation of voice. J. Voice; 6 (2):155-158.


Voice and Speech DisordersVoice and Speech Disorders►The aim of this presentation is to

identify the different protocols of auditory perceptual assessments.

►Voice and speech samples will be presented in order to orient the phoniatricians and speech pathologists with different voice and speech disorders.

Voice Disorders Voice Disorders

Voice disordersVoice disorders

►Dysphonia:Dysphonia: is a perceptually audible is a perceptually audible change of patientchange of patient’’s habitual voice as s habitual voice as self-judged or judged by his/her self-judged or judged by his/her listeners. listeners.

►Aphonia:Aphonia: Loss of voice. Loss of voice.►Phonasthenia:Phonasthenia: Voice fatigue. Voice fatigue.► Dysodia:Dysodia: change of the singing change of the singing

voice, although the speaking voice voice, although the speaking voice is intact.is intact.

Symptomatology of the voice disordersSymptomatology of the voice disorders::

Voice DisordersVoice Disorders Organic causes Non-organic causes

Minimal Associated Pathological Lesions (MAPLs)

Accompainment of neuropsychiatric ailments:1 ) Neural: element of dysarthrophonia.2 ) Psychiatric: element of mood and personality changes.

Kotby, MN (1995): The accent method of voice therapy. San Diego, California: Singular Publishing Group, Inc.

1) Laryngeal web.2) Sulcus glottidis.

1 ) Traumatic.2 ) Inflammatory.3 ) Neoplastic.4 ) Neurologic.5 ) Endocrinopathy.6 ) Status postlaryngectomy.

- Hyperfunctional childhood dysphonia.- Mutational dysphonia.- Hyperfunctional dysphonia.- Hypofunctional dysphonia.- Ventricular dysphonia. - Phonasthenia.- Habitual dysphonia / aphonia.

Habitual PsychogenicCongenital Acquired- Dysphonia.- Aphonia.

1 ) Vocal fold polyp.2 ) Vocal fold nodules.3 ) Reinke’s edema and polypoid degeneration.4 ) Contact granuloma.5 ) Vocal fold cysts.

Voice DisordersVoice Disorders

I - Elementary Diagnostic Procedures .( A ) Patient’s interview .( B ) Auditory Perceptual Assessment

(APA). ( C ) Visual impression of the voice

source (Laryngeal examination).

II - Clinical Diagnostic Aids .

III - Additional Instrumental Measures .

Diagnosis of Voice Disorders : Diagnosis of Voice Disorders : (Kotby, 1986)

Kotby, MN (1986): Voice disorders : recent diagnostic advances. Egypt. J. Otolaryngol.; 3(1): 69.

APA of Voice DisordersAPA of Voice Disorders 0 1 2

3 (normal) (mild) (moderate) (severe)

- Dysphonia grade (G) :

- Character : S Strained

L Leaky B Breathy

I Irregular (rough)

- Pitch : ( increased / decreased / diplophonia).

- Register : Habitual register: modal/ falsetto.

vocal fry ( Y / N ) Register breaks ( Y / N ).

- Loudness: ( excessive – soft – fluctuating )

- Glottal attack: ( normal – soft – hard ).

- Associated laryngeal function (cough/laughter/whisper).

Clinical examples of Clinical examples of APA of Non-organic APA of Non-organic

voice disordersvoice disorders

Non-Organic Voice Non-Organic Voice DisordersDisorders

Habitual CausesHabitual Causes( 1 ) Hyperfunctional childhood dysphonia:( 1 ) Hyperfunctional childhood dysphonia:- Children who are temperamental and - Children who are temperamental and

abusing their voices.abusing their voices.- Boys > girls.- Boys > girls.- - APA :APA : strained leaky , low pitched voice. strained leaky , low pitched voice.

Non-Organic Voice Disorders Non-Organic Voice Disorders (cont.)(cont.)

Habitual Causes (cont.)Habitual Causes (cont.)( 2 ) Mutational voice ( 2 ) Mutational voice

disorder :disorder :- Failure in the change of - Failure in the change of

the high pitched voice of the high pitched voice of the pre-adolescent period the pre-adolescent period to the lower pitched voice to the lower pitched voice of adults.of adults.

- - APA:APA: weak , thin and weak , thin and monopitched voice with monopitched voice with register breaks register breaks (alternating high pitched (alternating high pitched and low pitched voices) .and low pitched voices) .

Post-therapy sessions

Pre-therapy


Habitual Causes (cont.)Habitual Causes (cont.)( 3 ) Hyperfunctional ( 3 ) Hyperfunctional

dysphonia:dysphonia:- - Aet. :Aet. : misuse / abuse of misuse / abuse of

voice (most common).voice (most common).- - APA :APA : Hard glottal attacks , Hard glottal attacks ,

strained leaky low pitched strained leaky low pitched voice with increased voice with increased loudness and sometimes loudness and sometimes transient phases of voice transient phases of voice breaks.breaks.


Habitual Causes (cont.)Habitual Causes (cont.)( 4 ) Hypofunctional dysphonia:( 4 ) Hypofunctional dysphonia:- Start De-novo Or An - Start De-novo Or An

outcome of longstanding outcome of longstanding hyperfunctional dysphonia hyperfunctional dysphonia with reduction of the with reduction of the muscle control of the glottis muscle control of the glottis during phonation.during phonation.

- - APA :APA : soft glottal attack, soft glottal attack, weak breathy voice with weak breathy voice with raised pitch.raised pitch.


Habitual Causes (cont.)Habitual Causes (cont.)

-- Aet. : Aet. : (i) Prolonged exposure to (i) Prolonged exposure to

the laryngeal insulting the laryngeal insulting factors (prolonged factors (prolonged hyperfunctional hyperfunctional dysphonia) ORdysphonia) OR

(ii) In order to (ii) In order to compensate for non-compensate for non-vibrating V.Fs. e.g. V.F. vibrating V.Fs. e.g. V.F. paralysis.paralysis.

- - APA :APA : strained leaky low strained leaky low pitched harsh voice pitched harsh voice with reduced loudness with reduced loudness and diplophonia.and diplophonia.

(5) Ventricular dysphonia:(5) Ventricular dysphonia:

Pre-therapy

Post-therapy


Habitual Causes (cont.)Habitual Causes (cont.)( 6 ) Phonasthenia : - Affects commonly professional voice users .- The phonasthenic manifestations consist of :* Voice fatigue following prolonged voice use and the patient would like to stop talking .* Dryness , tightness and soreness in the throat .* Frequent throat clearing .* Feeling of sticky mucous fixed in the throat which can not be swallowed.* Difficulty in swallowing saliva but not drinks or foods .* Sometimes sense of mass in the throat ( globus sensation ) .- APA : Voice is not changed in most of the cases but it may show variable degrees of hyper - or hypofunctional dysphonia .


Psychogenic dysphonia & aphoniaPsychogenic dysphonia & aphonia- Most of the cases are of habitual nature rather than a real psychiatric illness . The continuation of aphonia results from absent proprioceptive acoustic feedback due to glottal waste .- APA : * Only whisper which may be hypofunctional (breathy) or hyperfunctional (strained). * Non-verbal phonation as coughing , laughing and crying are normal .

Pre- therapy

Post-therapy

Clinical examples of Clinical examples of APA of Some organic APA of Some organic

voice disordersvoice disorders

Unilat. VFP pre-therapy Unilat. VFP post-therapy

Unilateral V.F. Paralysis following thyroidectomy:

APA: breathy, diplophonic.

Spasmodic Dysphonia Spasmodic Dysphonia (SD(SD((Definition :Definition :

It is a disorder of laryngeal motor control to which diagnosis is based almost on APA of voice and characterized by intermittent voice stoppage that manifests almost markedly during production of connected speech .

Types : SD is categorized on the basis of the nature of

the spasms exhibited ( 1 ) Adductor spasmodic dysphonia: associated

with glottal squeezing and a strained-strangled phonatory pattern .

( 2 ) Abductor spasmodic dysphonia: associated with intermitted glottal widening and a breathy phonatory pattern .

( 3 ) Mixed spasmodic dysphonia: characterized by mixed set of symptoms ; moments of breathness occur alternately with moments of strained voice or voice arrest .

ADSD- counting

ADSD- free conv.

APA of rehabilitated APA of rehabilitated laryngectomized patientslaryngectomized patients

)a (Unaided Esophageal speech:

(2) Electronic vibrator voice:

- TE speech in Patient using stoma valve.

- TE voicing with manual stoma occlusion.

(b) Aided Esophageal speech (TE speech):

(1)Pseudo-glottis voice: Produced by vibration of the pharyngo-esophageal segment (PES).

Speech DisordersSpeech Disorders

Speech DisordersSpeech Disorders* Definition:* Definition:

It is a group of communication disorders It is a group of communication disorders which affects the process of production of the which affects the process of production of the individual speech sounds i.e. articulation . individual speech sounds i.e. articulation .

It includes also a group of disorders that It includes also a group of disorders that affect the process of linking the various speech affect the process of linking the various speech sounds in a chain (fluency).sounds in a chain (fluency).

* Categories of speech disorders:* Categories of speech disorders:( 1 ) Articulatory delays (dyslalia).( 1 ) Articulatory delays (dyslalia).

( 2 ) Disturbed nasality (resonance ( 2 ) Disturbed nasality (resonance disorders) . disorders) .

( 3 ) Stuttering.( 3 ) Stuttering.

( 4 ) Dysarthria. ( 4 ) Dysarthria.

Speech DisordersSpeech Disorders ( 1 ) ( 1 ) Articulatory delays

(Dyslalia):* Definition: is the persistence of defective

individual speech sounds in an age at which the sounds should be properly articulated.

* Common types:- Misarticulated /s/ sound: interdental,

lateral, or pharyngeal.- Misarticulated /r/ sound: may be

replaced by /L/, /j/ , /w/, /n/ ..etc sounds.

- Misarticulated posterior plossives (/k/ and /g/) and replaced by anterior plossives (/t/ and /d/).

Pre-therapy

Post-therapy

ϑ ϭήΧ ΔΧήϓ /fær. χæ/ /χα.ru:f/

ΦϴτΑ ΥϮΧ χ/ o χ / /bαt.ti: /χ

/Υ//χ/

Speech DisordersSpeech Disorders Mansoura Arabic Articulation Test Mansoura Arabic Articulation Test

(MAAT)(MAAT)

Mansoura Arabic Articulation Test Mansoura Arabic Articulation Test (MAAT)(MAAT)

Mansoura Arabic Articulation Test Mansoura Arabic Articulation Test (MAAT)(MAAT)

Speech DisordersSpeech Disorders

( 2 ) ( 2 ) Disturbed nasalityDisturbed nasality : :

(a) Hyponasality :(a) Hyponasality :* Definition:

An audible reduced nasal resonance during speech production due to any lesion that may interfere with the airway above the level of velo-pharyngeal valve.

* Effect on speech: The speech of the patient sounds " dead'' and /m/

may become /b/ and /n/ becomes /d/.

Speech DisordersSpeech Disorders( 2 ) ( 2 ) Disturbed nasalityDisturbed nasality: :

(cont.)(cont.)

(b) Hypernasality :(b) Hypernasality :* Definition: An audible excessive nasal resonance

during speech production due to velo-pharyngeal incompetence.

* Effect on speech:a) Excessive nasal resonance

(nasalization of vowels). b) Audible nasal emission of air during

speech.c) Imprecise consonant production . d) Faulty compensatory articulatory

mechanisms as glottal articulation of (/p/, /t/, /k/ ) and facial nasal grimace.

Facial grimace

Distorted consonants

Nasal air escape+ glottal articulation

Nasal air escape

APA of Resonance APA of Resonance disorderdisorder1. Nasality: Type: (Open-closed).

Degree: (mild – moderate – severe)2. Consonants (imprecised – distorted – omitted):

……..3. Compensatory articulatory mechanisms: (glottal /

Pharyngeal).4. Facial grimace ( P / A ).5. Audible nasal air escape ( P / A ).6. Overall intelligibility (good- fair- poor).7. Factors causing unintelligibility ( open nasality /

consonant impression / glottal articulation / pharyngalization of fricatives / nasal emission )

8. Simple clinical tests:- Cold mirror test [ /a/, /i/ , /s/ , /v/] - a/i test ( +ve / -ve )

Speech DisordersSpeech Disorders( 3 ) ( 3 ) Stuttering Stuttering ::* Definition:* Definition:

It is a condition in which the flow of It is a condition in which the flow of speech is interrupted.speech is interrupted.

* Clinical picture:* Clinical picture:(a) Verbal manifestations: (a) Verbal manifestations:

- intra-phonemic disruption (core - intra-phonemic disruption (core behavior). behavior).

- repetitions of certain speech sounds.- repetitions of certain speech sounds.

- prolongation of sounds.- prolongation of sounds.

- tonic blocks.- tonic blocks.

(b) Non- verbal manifestations:(b) Non- verbal manifestations:

(phenomenon of struggle during speech)(phenomenon of struggle during speech)

- avoidance of eye-contact during - avoidance of eye-contact during conversation. conversation.

- associated movements that involve the - associated movements that involve the face muscles, extremities and/or the face muscles, extremities and/or the whole body. whole body.

Pre- therapy sessions

Post- therapy sessions

APA of stutteringAPA of stuttering(1) Rate of speech: ( very slow – slow -

normal – fast – very fast).(2) Spontaneous speech:

- Interphonemic disruption (IPD):- Blocks.- Prolongations.- Interjected speech fragements (ISF):- Associated body movements (BM):

(3) Automatic speech: (IPD / blocks / prolongations / ISF / repetitions / BM).

Speech DisordersSpeech Disorders( 4 ) ( 4 ) DysarthriaDysarthria::* Definition:* Definition: - It is a defective articulation due mainly - It is a defective articulation due mainly

to a disorder of the motor system. to a disorder of the motor system. - The articulation problem may be - The articulation problem may be accompanied with a disturbed phonation, accompanied with a disturbed phonation, a condition referred to as a condition referred to as dysarthrophonia.dysarthrophonia.

* Etiology:* Etiology: - C- Central nervous system lesion (in the entral nervous system lesion (in the cortex, pyramidal system, extrapyramidal cortex, pyramidal system, extrapyramidal system, and/or cerebellar system); system, and/or cerebellar system); - Peripheral nerve and muscle lesions - Peripheral nerve and muscle lesions that affect the articulatory motor system. that affect the articulatory motor system.

APA of APA of DysartherDysarther

iaiaKotby MN; Elsady SR; Khidr AA; Alloush T; Abdel-Nasser NH; Gamal N; Mahmoud H; El-Sharkawi AE and Kamal A (1995): Voice quality in neurological disorders of the larynx : Patho-physiologicalcorrelates. In: Fujimura O and Hirano M (Eds.): Vocal fold physiology. Singular Publishing Group.

Speech DisordersSpeech Disorders( 4 ) ( 4 ) DysarthriaDysarthria: (cont.): (cont.)* Types of dysarthria:* Types of dysarthria:

1. 1. Spastic dysarthriaSpastic dysarthria due to suprabulbar due to suprabulbar lesions (usually bilateral cortical lesions (usually bilateral cortical lesions).lesions).

The patient's speechThe patient's speech is is stressed, stressed, strangled and strangled and characterized by a characterized by a noticeable crying impression. noticeable crying impression.

2 2 . Flaccid dysarthria. Flaccid dysarthria due to a bulbar due to a bulbar lesion (usually multiple cranial nerve lesion (usually multiple cranial nerve lesions). lesions).

The patient's speechThe patient's speech is characterized is characterized by pronounced excessive open by pronounced excessive open nasality.nasality.

3. 3. Spastic-Flaccid dysarthriaSpastic-Flaccid dysarthria due to due to motor neurone disease.motor neurone disease.

Flaccid Dysartheria

Spastic dysartheria

Spastic-Flaccid Dysartheria

Speech DisordersSpeech Disorders( 4 ) ( 4 ) DysarthriaDysarthria: (cont.): (cont.)* Types of dysarthria:* Types of dysarthria: ( cont.) ( cont.)4. 4. Cerebellar dysarthriaCerebellar dysarthria due to cerebellar due to cerebellar

lesions.lesions.The patient's speechThe patient's speech is characterized by is characterized by irregular articulatory breakdowns with irregular articulatory breakdowns with excess equal stress.excess equal stress.

5. 5. Extrapyramidal dysarthriaExtrapyramidal dysarthria:: The lesion is The lesion is usually in the basal ganglia of which two usually in the basal ganglia of which two types may be identified:types may be identified:

i- Hypokinetici- Hypokinetic as in Parkinson's disease. as in Parkinson's disease. The patient's speechThe patient's speech is characterized by is characterized by short rushes of speech at the end of the short rushes of speech at the end of the utterences.utterences.

ii- Hyperkineticii- Hyperkinetic as in chorea and athatosis. as in chorea and athatosis.The patient's speechThe patient's speech is characterized by is characterized by inappropriate stress patterns that varies inappropriate stress patterns that varies from moment to moment. from moment to moment.

6.6. Mixed type of dysarthria Mixed type of dysarthria may be may be encountered with. encountered with.

Parkinson’s Patient

Cerebellar dysartheria

counting

Fat’ha

Fat’ha

counting

Dyskinetic dysartheria

Thank You

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Auditory Perceptual Assessment of Voice and Speech Disorders