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Voice Evaluation Case Study Final Draft2
Voice Evaluation Case Study Final Draft2
Sierra J. Fox
Temple University
Case Study of 21-Year-Old Nickie 2
Abstract
This case study evaluates the condition of 21-year-old Nickie, a female theater major who is
interested in improving her singing voice to be competitive for musical theater roles. She is a
full-time college student nearing graduation, and works as a waitress in a local pub. She
complains of such vocal issues as chronic laryngitis, voice loss, hoarseness (especially at the end
of each day and week), throat discomfort, dryness and a low vocal range. Nickie was seen by a
speech pathologist for a voice evaluation in January 2013, which revealed vocal nodules at the
1/3 posterior 2/3 juncture of the vocal folds, an hourglass shaped glottis closure pattern, a
slightly reduced mucosal wave in the area of the lesions and increased glottic and supraglottic
compression during phonation. She also exhibited reduced pitch range and a relatively low
maximum phonation time (MPT). This case study outlines the steps that I will take to most
effectively evaluate and gather information about the condition of Nickie’s voice, using
information from her speech-language pathologist (SLP), case history, videostroboscoby and
materials such as the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the
Voice Handicap Index (VHI). The paper will then briefly explore potential courses of action,
singing voice to be competitive for musical theater roles. She is a full-time college student
nearing graduation, and works as a waitress in a local pub. She complains of such vocal issues
as chronic laryngitis, voice loss, hoarseness (especially at the end of each day and week), throat
discomfort, dryness and a low vocal range. Nickie was seen by a speech pathologist for a voice
evaluation in January 2013, which revealed vocal nodules at the anterior 1/3 posterior 2/3
juncture of the vocal folds, an hourglass shaped glottis closure pattern, a slightly reduced
mucosal wave in the area of the lesions and increased glottic and supraglottic compression
during phonation. Nickie has recently decided to enter my voice studio to improve her chances
of getting musical theater roles; as her voice teacher, I must evaluate her vocal condition so as to
best assess the appropriate course of action as I work with her to improve her vocal health and
performance.
Case History
To begin my evaluation, I have completed a case history (see Appendix A for completed
case history form). I also had Nickie fill out a Singing Voice Handicap Index (see Appendix B)
and a VHI (See Appendix C), to assess her interpretation of her vocal problems and how they
affect her professionally, emotionally, functionally and physically. This told me that she reports
only moderate physical and functional issues, and mild emotional issues, with her speaking voice;
however, she reports severe issues and unhappiness with her singing voice. I have also inquired
into her specific vocal requirements and exertions, including the type of amplification she uses
for her gigs (varied depending on the gig, but usually minimal), the venues in which she
Case Study of 21-Year-Old Nickie 4
performs (often small theaters, black-box style; her voice problems have prevented her from
getting roles in shows taking place in large venues), any stylistic/aesthetic vocal effects she
chooses to use (she had initially felt that her “husky” sound was a positive thing, but now she
cannot choose to sound different) as well as into her sleep habits (5-7 hours of sleep per night)
(Schwartz, 2013). When I inquired into phonotraumatic behaviors, she admitted that on a scale
from 1-5 she would rate her overall amount and volume of talking (in person and on the phone)
whispering at 3.
Having completed a case history for Nickie, I then performed some assessments of her
voice as her voice instructor (though more specific and medical evaluations required a referral to
an ENT physician or SLP). I then utilized the CAPE-V form as provided and filled out by
Nickie’s SLP (see Appendix D for completed form) to understand Nickie’s ability to produce
sustained vowels, produce a selection of sentences and to describe vocally the functional issues
with her voice. Nickie’s SLP noted her overall severity, roughness, breathiness and strain at 75
(moderately to severely deviant), with a score of 75 also for a decrease in pitch range, and a
score of 60 (just over moderately deviant) for loudness, denoting that she spoke louder than is
normal. I asked Nickie to give me the phone number of the SLP with whom she was working,
and spoke with her to develop a better understanding of her reports. When I asked into the
specifics of her pitch and amplitude abnormalities, I was told that Nickie’s fundamental speaking
frequency was 207 Hz, as compared to the 225 Hz average for females (Schwartz, 2004, p. 26).
I was also told that her amplitude was approximately 73dB, compared to the normal mean of
approximately 65dB SPL (Gerhard and Whittaker, 2013). The SLP also noted that Nickie
Case Study of 21-Year-Old Nickie 5
displayed a slightly higher range when singing than when speaking, and that she exhibited
frequent periods of aphonia and increased musculoskeletal tension throughout the evaluation.
Nickie’s SLP reported that some of the musculoskeletal tension and discomfort was relieved
with circumlaryngial and neck palpitation/massage, which also helped to lower her thyroid bone
This provided me with a greater understanding of Nickie’s speaking voice and range, but
as a voice teacher, I quickly moved on to an aural evaluation of some basic vocal exercises. I
asked Nickie to pick a comfortable note in her range and sustain that pitch on an “ah” vowel; she
was able to maintain the pitch for an average of 12 seconds over three trials. I then had Nickie
sing scales down and particularly up on a hum, to see if I could hear and/or see her self-ascribed
difficulty in her higher register. She was able to sing the F below middle C (F3) to the C above
middle C (C5), which is a relatively small range for someone intending to be a professional
singer, and indeed showed a reduced upper range. Because of her low MPT, as compared to the
average of 15-20 seconds (Schwartz, 2004, p. 32), I hypothesized that her vocal fatigue/exertion
was related to her breath support (or sub-par medial glottal adduction). To see if she is
experiencing possible hyperfunction when phonating, I asked Nickie to sustain an “s” sound for
as long as possible three times, followed by a “z” sound for as long as possible three times
(Schwartz, 2004, p. 34). She was able to sustain the unvoiced consonant for 18 seconds and the
voiced consonant for 15 seconds, making her s/z ration 1.2, and suggesting that there may be
excess air being released when she attempts phonation due to phonatory hyperfunction (Schwartz,
2013).
I then asked Nickie to sing a 5-note scale up and back, on any vowel she chose (she
gravitated towards an “ah” vowel). I noticed that she hyper-extended her neck when singing,
Case Study of 21-Year-Old Nickie 6
more so on ascending scales than descending scales. As descending scales seemed to create less
tension for Nickie, I asked her to perform lip trills on a descending 5-note scale, but we
discovered that she was unable to perform lip or tongue trills of any sort. This suggested to me
that there were significant tension issues preventing the consistent, relaxed flow of breath and
relaxed face necessary for lip/tongue trills. She was able to sing the 5-note descending scale on a
staccato “ah” sound, but I noticed what appeared to be tongue tension, and asked her to repeat
the exercise with her tongue extended. Nickie tried to complete the exercise, but became
frustrated with the difficulty; she laughed uncomfortably, saying that it “felt too weird,” and did
not want to continue. She said that she felt “warmed up,” and wanted to stop the vocal exercises.
I told Nickie that it was great that she was able to be open and honest with me about her feelings
Developing Goals
I asked Nickie what she would most like to get out of her time studying in my voice
studio. She told me that she wants to improve the quality and health of her voice so that she can
be competitive for musical theater roles again. I communicated with her prior to our first lesson
and asked her to prepare a song to sing when she came in, and a recording device to record the
session. She brought in the song “Mama Who Bore Me” from Spring Awakening, which I had
her sing so that we could asses where she was in relationship to her goals of singing musical
theater. “Mama Who Bore Me” sits mostly in the range of A3-A4, with one instance of G3.
This sits well within the confines of Nickie’s range, which we had determined to be F3-C5;
however, Nickie’s approach to belting the A4s, which are plentiful in this song, made the notes
sound uncomfortable in her range. I could see visible tension in her face and neck, which she
hyperextended frequently, especially when singing above E4. When phrases began with “Mama”
Case Study of 21-Year-Old Nickie 7
on the A4, Nickie demonstrated extreme facial tension, releasing a bit when she went lower in
her range. I could hear a lot of breath escaping in her tone, and she exhibited upper thoracic
breathing patterns, which she did not use while speaking. By the last verse of the song, Nickie’s
voice “cracked” several times, and she became tearful and was unable to finish the song. I told
Nickie that her dedication to the music was impressive, and the fact that she was having such an
emotional reaction showed how much she cares about the music. I suggested that we start from
the beginning of the song, but this time replacing the words with a hum. Her ability to sustain
breath when using the hum was much improved, and she was able to access a more resonant tone
on the hum than on text. Having heard the successful resonance on the “m,” I asked her to sing
“mama,” sustaining the “m” both times before moving to the “a,” and trying to carry over the
resonance sound into the vowel; this was, however, not successful- the resonance did not carry
over.
Having heard Nickie’s starting point, I then set about creating some specific goals for our
time together. I mentioned to Nickie that some of her main challenges were currently physical
tension and breathing, and that I would like to focus on those issues for at least several weeks. I
also suggested that she work on developing her resonant voice with her SLP, working on her
ability to carry over the resonance she displays on a hum on to vowels and full words/phrases.
Nickie agreed that tension and breath felt like significant issues, and added that she would like to
increase her range. I also warned her that several of the behaviors covered in her case history
were likely detrimental to her vocal health, and she admitted that her SLP had told her the same
things, and that she was willing to try to change her habits to improve her vocal health and help
the healing process for her vocal nodules. We drafted a goals list (see Appendix E for first
Case Study of 21-Year-Old Nickie 8
lesson goal sheet) with all of this in mind, and I asked her to keep me updated in regards to her
At Nickie’s second lesson, she brought me her schedule of voice use, color-coded in
terms of how much voice use was required of her (as we had discussed). Together, we worked to
revise this schedule to allow for more vocal rest and less over-use of voice. Nickie told me that
her SLP had been more than happy to work with her on resonant voice, and that she had also
been teaching her how to use confidential voice with success (Gerhard and Whittaker, 2013).
We started vocalizing with descending 5-note scales on a hum, and then added the step of
opening up to an “ah” vowel on the last three notes. Nickie was already better able to bring
some of the forward, nasal resonance of the hum into the vowel, and I told her that her practicing
was already paying off. She was still unable to do a lip trill, but in the course of the lesson did
watch herself in the mirror and, though she did often hyper-extend her neck, saw this and fixed it
over half of the time. Nickie told me that she was still struggling with abdominal breathing, and
that she could remember doing it while speaking, but couldn’t seem to do it while singing. She
was able to demonstrate the breaths to me, but when she sang, she reverted to clavicular
breathing. To give her an exercise to practice to improve this, I had Nickie set a metronome and
sing a 5-ntoe scale up and down on eighth-notes, giving herself a half note to take a deep,
diaphragmatic breath in between (making sure to stay in time). When she was thinking about the
breath, she could do it, but she then reverted to hyper-extension of her neck; I reassured her that
this would be a process and that she was already doing very well, and that she should practice
As Nickie continued to work with her SLP, I noticed significant improvements in her
tone and hoarseness. She admitted that she was having trouble quitting smoking entirely, and
kept “slipping up,” but that she was on a quitting regiment of nicotine patches and felt that it was
improving her voice. She also said that she was not always drinking enough water, especially
considering that she still drank several caffeinated beverages a day, but that she was noticing that
she felt better vocally when she was more hydrated. She said that she was working on keeping
the volume of her voice down, and talking less with friends. She also said that she had almost
entirely stopped whispering during classes. Her SLP had also encouraged her to replace her
Claritin with Singular, which has fewer vocal side-effects (www.ncvs.org/rx.html, 2013).
Though we generally began our warm-ups with humming, we began to move on to singing on a
“v,” in hopes of simulating the airflow and vibrations of the lips that would take place with lip
trills, the idea being that the inherent supraglottic pressure might relieve the pressure at the
glottis. (Gerhard and Whittaker, 2013). By the seventh lesson, Nickie began to be able to sing
brief lip trills; she could sing five notes ascending or descending, but ran out of air before being
able to go up and back down. By the tenth lesson, she was able to perform diaphragmatic
breathing 50% of the time while singing without cues, and 80% of the time with cues, and she
By the sixteenth week, Nickie had completed her therapy with her SLP. The SLP
reported that Nickie had decreased the severity, roughness, breathiness and strain of her voice to
25/100 from 75/100, and had raised her fundamental speaking pitch to 225 Hz. Her recent
stroboscopy revealed that her vocal nodules had softened and diminished, though care would be
necessary to make sure she did not re-aggravate them. With me, her singing range had increased
to an E5 in her upper register, using her head voice- she was able to belt to a B with no more
Case Study of 21-Year-Old Nickie 10
tension than in her lower register, but could only access C5-E5 with her head voice, and still with
audible breathiness. We created a new goals list, keeping many of the long term goals (See
Appendix G for mid-year voice goals). I also asked Nickie to look at other repertoire she might
In later weeks, Nickie brought in “Easy to be Hard” from Hair, “Buenos Aires” from
Evita and “I Don’t Know How to Love Him” from Jesus Christ Superstar. We worked on all of
them, but after a couple of weeks working on “Buenos Aires,” I suggested that we focus on the
other songs, as it utilized the very bottom of her range. I found that when she went into that very
low range (F3-A3), Nickie would lose many of the technical skills that we had been working on.
I suggested that we replace it with “Everything’s Coming up Roses” from Gypsy. She was at
first disappointed to stop singing “Buenos Aires,” because it was “easy” and enjoyable for her to
use her low range, but I told her that we could always go back to it. By the time we had reached
a year of lessons, many things had changed in Nickie’s life; she had quit smoking, graduated
college, and had been continuing work at her local pub while auditioning for theater jobs. She
kept her hours minimal at the pub, and had landed several small theater gigs. I suggested that
she wait to audition for musical theater productions until we had developed a very strong
audition packet, and until we knew that she could maintain vocal health in a full musical theater
production. By the one-year mark, I felt that these things were truly the case. Nickie auditioned
for a local company’s production of The Drowsy Chaperone, using “I Don’t Know How to Love
Him” to start and “I Cain’t Say No” and “Mama Who Bore Me” as songs for the judges to
choose from as audition songs. She landed the role of Kitty, and together we worked to assess
her vocal pacing schedule to accommodate her new needs. I suggested that Nickie avoid alcohol
the week or two before the show, and she agreed that it was a good idea. We then worked
Case Study of 21-Year-Old Nickie 11
together to create a new goal sheet as of that point (see Appendix H for one-year goal sheet), and
I agreed that she might be able to work on “Buenos Aires” again. She also expressed a desire to
increase her range to be able to sing in head voice up to G5 and belt to F5, which we worked into
BIBLIOGRAPHY
Gerhard, J., & Whitaker, N. (2013). Voice Disorders: Special Populations. Philadelphia, PA.
McCoy, S. (2012). Your Voice: An Inside View (2 ed.). Delaware, OH, USA: Inside View Press.
Schwartz, S. (2004). The Source for Voice Disorders: Adolescent & Adult. (B. Truman, Ed.)
Schwartz, S. A. (2013, March 4). Professional Voice Considerations for Singers: Therapist Point
The University of Utah. (n.d.). NCVS: The National Center for Voice and Speech. Retrieved
from www.ncvs.org/rx.html
Case Study of 21-Year-Old Nickie 13
Appendix A
Case History Form (Schwartz, 2004, pp. 39-40)
Nickie
21
Student (Theater, Senior Undergraduate), Waitress
Chronic laryngitis, voice loss, hoarseness (especially at the end of each day and week), throat
discomfort, dryness and a low vocal range
Claritin for seasonal allergies, advil for frequent headaches, pepto-bismol for occasional
heartburn and stomach problems
Yes
Case Study of 21-Year-Old Nickie 14
Appendix A
Difficulty singing high notes, “husky” voice, difficulty sustaining notes, pitch “cracking”
Case Study of 21-Year-Old Nickie 15
Appendix B
These are statements that many people have used to describe their singing and the effects of
their singing on their lives. Circle the response that indicates how frequently you have the same
experience in the last 4 weeks.
5) I have no confidence in my 0 1 2 3 4
singing voice.
Appendix C
Appendix D
Appendix E:
Nickie will take 10 diaphragmatic breaths without cues in the course of the second lesson, to
improve breath support and healthy breathing.
Nickie will hum “Mama Who Bore Me” in its entirety at least once every day until the next
lesson, to reinforce the healthy behaviors she exhibits when using a hum, such as resonant tone
and greater breath support.
Nickie will request to work with her SLP to create resonant tone on vowels following an “m,”
perhaps utilizing the Lessac-Madsen technique of Resonant Voice (Gerhard and Whittaker, 2013)
Nickie will perform ascending 5-note scales in front of a mirror, and will decrease hyper-
extension of her neck by at least 50% to improve neck tension and alignment, facilitating breath
flow
Nickie will limit her cigarette use to two cigarettes a day for a week, working towards quitting
entirely, due to their harmful effect on the voice.
Nickie will increase her intake of water to 8 glasses a day, with caffeinated beverages counting
as one negative glass of water (requiring an extra glass to make up the difference) for one week.
Nickie will draft a schedule of her necessary voice use in a normal week for the next lesson, for
us to review together to find ways to reduce over-use of her voice.
Nickie will increase her range from F4-C5 to F4-F5, to be able to sing a wider variety of musical
theater repertoire.
Nickie will replace upper thoracic breathing with low, diaphragmatic breathing 85% of the time
while singing, to improve breath support and healthy breathing..
Nickie will eliminate tension to the extent that she will be able to perform a lip trill on an 8-note
scale.
Nickie will be able to sing “Mama Who Bore Me” from Spring Awakening and “I Cain’t Say No”
from Oklahoma without pitch cracks, to the extent that they could be used as audition songs.
Nickie will quit smoking, because of their harmful effects on vocal health.
Case Study of 21-Year-Old Nickie 19
10:00
Green: requires full voice, Yellow: requires some voice use, Red: no voice use
Green: requires full voice, Yellow: requires some voice use, Red: no voice use
Appendix G:
Nickie will take diaphragmatic breaths without cues 75% of the time when singing “Mama Who
Bore Me” in the course of the lesson, to improve breath support and healthy breathing.
Nickie will continue utilizing the circumlaryngeal/neck massage as taught by her SLP once or
more every day, to improve thyrohyroid space and relieve tightness of neck muscles (Gerhard
and Whittaker, 2013)
Nickie will sing “I Cain’t Say No” with no visible hyper-extension of the neck for 70% of the
song, to improve neck tension and alignment, facilitating breath flow
Nickie will limit her cigarette use to two cigarettes a week, working towards quitting entirely,
due to their harmful effect on the voice.
Nickie will increase her intake of water to 8 glasses a day, with caffeinated beverages counting
as one negative glass of water (requiring an extra glass to make up the difference)
Nickie will increase her range from F4-C5 to F4-F5, to be able to sing a wider variety of musical
theater repertoire.
Nickie will increase her belting range from F4-C5 to F4-E5, to be able to sing a wider variety of
musical theater repertoire.
Nickie will replace upper thoracic breathing with low, diaphragmatic breathing 85% of the time
while singing, to improve breath support and healthy breathing..
Nickie will eliminate tension to the extent that she will be able to perform a lip trill on an 8-note
scale, up and down.
Nickie will be able to sing “Mama Who Bore Me” from Spring Awakening and “I Cain’t Say No”
from Oklahoma without pitch cracks or visible tension, to the extent that they could be used as
audition songs.
Nickie will quit smoking entirely, because of its harmful effects on vocal health.
Case Study of 21-Year-Old Nickie 23
Appendix H:
Nickie will consume no alcoholic beverages for two weeks before the first performance of The
Drowsy Chaperone, to allow for ideal hydration and vocal hygiene.
Nickie will sing through all of her music for The Drowsy Chaperone on lip trills once every day
to facilitate relaxed airflow and good technique.
Nickie will sing through all of her music for The Drowsy Chaperone in her lesson with no visible
hyper-extension of the neck for 80% of the music, to improve neck tension and alignment,
facilitating breath flow
Nickie will bring a new schedule of her vocal pacing for us to review at our lesson, to create a
plan for vocal rest.
Nickie will increase her intake of water to 8 glasses a day, with caffeinated beverages counting
as one negative glass of water (requiring an extra glass to make up the difference).
Nickie will increase her range from F4-C5 to F4-G5, to be able to sing a wider variety of musical
theater repertoire.
Nickie will increase her belting range from F4-C5 to F4-F5, to be able to sing a wider variety of
musical theater repertoire.
Nickie will replace upper thoracic breathing with low, diaphragmatic breathing without cues
90% of the time while singing, to improve breath support and healthy breathing.
Nickie will be able to sing “Buenos Aires” without noticeable tension or hoarseness in the F3-C4
range of the song, to facilitate healthy singing in her lower register.