C o m p o n e n t s o f Vo i c e

E v aluatio n
a b,
Saranya Reghunathan, MD , Paul C. Bryson, MD *

KEYWORDS
 Voice  Laryngoscopy  Stroboscopy  Voice evaluation  VHI  GRBAS  CAPE-V

KEY POINTS
 There are several components to evaluating voice complaints: patient history, perceptual
voice evaluation, physical examination, and videostroboscopic evaluation.
 Voice evaluation requires assessment of the respiratory system, the larynx, and the reso-
nance capabilities of the upper airway.
 Clinicians should develop a system that works for their practice to include patient-derived
surveys that are concise, informative, and repeatable; perceptual analysis of voice that is
easy to obtain before and after treatment; and finally, high image quality laryngoscopy
equipment with stroboscopy that can be recorded, reviewed, and archived.

INTRODUCTION

Voice evaluation requires assessment of the respiratory system, the larynx, and the
resonance capabilities of the upper airway. Normal phonation requires adequate
breath support, approximation of the vocal folds, vocal fold pliability, and control of
vocal fold length and tension.1
The patient’s description of their voice changes as well as the perceived impact on
daily function are critical for the diagnosis and treatment of voice disorders. This article
focuses primarily on the speaking voice, with attention paid elsewhere to singing and
performance voice.

HISTORY

Patients often complain of “hoarseness,” which essentially corresponds to their

perception of altered voice quality. Hoarseness can correspond to both a symptom
and a sign of dysfunction anywhere in the phonatory apparatus. The first element of

Disclosure Statement: The authors have nothing to disclose.

a
Cleveland Clinic, 9500 Euclid Avenue, A-71, Cleveland, OH 44195, USA; b Section of Laryn-
gology, Cleveland Clinic Voice Center, 9500 Euclid Avenue, A-71, Cleveland, OH 44195, USA
* Corresponding author.
E-mail address: brysonp@ccf.org

Otolaryngol Clin N Am 52 (2019) 589–595

https://doi.org/10.1016/j.otc.2019.03.002 oto.theclinics.com
0030-6665/19/ª 2019 Elsevier Inc. All rights reserved.
590 Reghunathan & Bryson

voice evaluation is the interpretation of the patient’s description and perception of the
altered voice and the important personal and subjective considerations that influence
the voice complaint.
The history should include the following components:
 Description of voice problem, including onset and variability of symptoms
 Altered voice quality
 Phonatory fatigue
 Insufficient loudness
 Restricted pitch range
 Increased phonatory effort
 Breathlessness or conversational dyspnea
 Impaired singing quality or ability
 Past voice disorders and any treatments
 Past surgical history
 Past medical history and current medical status, chronic medical conditions
 Medications
 Other environmental factors (home and occupational)
 Voice habits and hygiene2 (daily vocal load)
The purpose of this comprehensive assessment is to identify underlying diffi-
culties or abnormalities in speech production. Oftentimes, other comorbid health
conditions and medications can affect the voice and must be assessed. It is of
special importance to understand the patient’s limitations in vocal activity and
participation, both personal and professional; this is best described as the pa-
tient’s self-assessment. The patient may describe this as a functional limitation
in communication or interpersonal interaction. A critical part of the history includes
understanding which component of voice the patient finds most troublesome. This
is sometimes different than what the clinician perceives as the most obvious ab-
normality to the voice. Patient observations of voice problems tend to be individ-
ual; it is important to understand the environmental and personal factors the
patient identifies as barriers to successful communication. It is also important to
note that some individuals have expectations of their voices that are not absolute
occupational needs but still may be reported as limiting, both professionally and
socially. Understanding the patient’s perspective on how their voice abnormality
impairs quality of life will give the otolaryngologist a sense of potential treatment
options that will be accepted.

VOICE-SPECIFIC PATIENT-REPORTED QUESTIONNAIRES

Several patient surveys/questionnaires have been created and validated to provide

clinicians insight to a patient’s initial disability. Among them, the Voice Handicap
Index-10 (VHI-10)3 and the Voice-Related Quality of Life (VRQoL)4 are the most widely
used. Such inventories help understand patient motivation, so the physician can make
appropriate treatment recommendations. The VHI-10, for example, delivers a multi-
faceted assessment, as it gives information on the functional, emotional, and physical
attributes of a patient’s voice disorder. Another survey, The Glottal Function Index
(GFI), is a validated 4-item self-administered survey used to evaluate glottal insuffi-
ciency.5 The GFI has been used as an alternative to the VHI due to its brevity and
ease in use.5 Applied both before and after treatment, self-assessments can be an
important means for measuring outcomes; these can allow for comparison of interven-
tions, techniques, and studies.
 Components of Voice Evaluation 591

PERCEPTUAL EVALUATION OF VOICE

The auditory perceptual assessment of voice can be both formal and informal. The
informal component occurs during the initial history. It involves engaging the patient
in spontaneous conversation while obtaining relevant information. Voice quality, pitch
range, resonance (normal, hypo- or hypernasal), loudness, prosody, and articulation
can be generally assessed.6
In addition, it is critical to take note of any diplophonia, aphonia, tremor, vocal fry,
falsetto, and wet sounding voice. Diplophonia is characterized by the perception of
2 simultaneous pitches in the voice. It can be seen in a variety of settings such as
mass lesions, vocal fold paresis or paralysis, or other causes of glottic insufficiency.
Vocal fry is described as a pharyngeally focused voice and can be seen in younger
adults attempting to sound more mature or authoritative.
The formal perceptual assessment typically involves the use of a protocol to sys-
tematically describe and quantify various features of the voice. Although there are
many schemes that have been described, 2 main protocols are commonly used.
The first, GRBAS scale, is examiner based and is the gold standard in perceptual anal-
ysis of voice.4 Developed in 1981, this scheme is not a complete perceptual evaluation
protocol but specifically evaluates voice quality. It assesses the following:
 Grade (the overall degree of voice abnormality),
 Roughness (perceived irregularity in voicing source),
 Breathiness (audible air escape in voice),
 Asthenia (voice weakness), and
 Strain (perception of excessive vocal effort).
Each parameter is quantified on a 4-point scale, where 0 5 normal, 1 5 mild,
2 5 moderate, and 3 5 severe.4 Another commonly used scheme is the Consensus
Auditory-Perceptual Evaluation of Voice. Its primary purpose is to describe the
severity of auditory-perceptual attributes of a voice problem, in a way that can be
communicated among clinicians. Its secondary purpose is to contribute to hypotheses
regarding the anatomic and physiologic bases of voice problems and to evaluate the
need for additional testing.6

EXAMINATION

Typically, perceptual voice assessment is initiated before physical examination of the

patient; the physician should already have a diagnostic inclination based on history
and perceptual evaluation of voice. Abnormalities such as mucosal disturbance, glot-
tic insufficiency, or a neurologic movement disorder are often suspected based solely
on the initial history and voice assessment. Any major incongruity between this prelim-
inary impression and subsequent laryngostroboscopic findings should serve as
concern that the evaluation is incomplete.

HEAD AND NECK EXAMINATION

A full head and neck examination should be performed at the time of initial consulta-
tion. This should include assessment of motion and, where appropriate, symmetry of
structures of the face, oral cavity, head, neck, and respiratory system. This should
include a dedicated evaluation of external laryngeal anatomy and extrinsic laryngeal
musculature.
An assessment of respiration is of particular relevance in order to evaluate coordi-
nation of respiration with phonation. This assessment includes noting the respiratory
592 Reghunathan & Bryson

pattern (abdominal, thoracic, clavicular), looking for breath-holding patterns, or any

habitual use of residual air.

LARYNGEAL EXAMINATION

Indirect visualization of the larynx is the hallmark of in-office laryngological evaluation.

It allows the clinician to make observations of laryngeal structure and function while
the patient is awake and reasonably comfortable. For voice evaluation to be compre-
hensive it is imperative to understand both functional deviation and anatomic abnor-
malities noted on examination.
The larynx can be visualized using many different instruments. The most
commonly used instruments are mirror, transnasal flexible fiberoptic endoscopy,
and rigid transoral endoscopy. In modern times, the ability to record and document
an examination is more meaningful than the ease and cost-effectiveness of the mirror
examination. The patient is able to vocalize in a more natural fashion with fiberoptic
endoscopy, thus making flexible or rigid videoendoscopy the current standard of
assessment.
Videoendoscopy offers insight into structure and gross function of the larynx. It will
show any evidence of supraglottic compression during sustained phonation. More-
over, it can evaluate movement of vocal folds during laryngeal tasks to give informa-
tion on gross vocal fold mobility.7 Certain factors may limit the utility of endoscopy.
Image clarity may be suboptimal and patients may be uncomfortable, have anatomy
that makes the examination more difficult, have anxiety about the test, or have a hy-
persensitive gag reflex.

FLEXIBLE LARYNGOSCOPY

The flexible fiberoptic laryngoscope is a valuable tool that is ubiquitously present for
most, if not all, otolaryngologists. It is a well-tolerated examination and is easily per-
formed by otolaryngologists and trainees. Although there are limitations to the exam-
ination, it can provide, at minimum, visualization of the vocal folds through continuous
light. It is least disturbing to the production of speech, which makes it ideal for evalu-
ation of neurogenic voice disorders. However, the low resolution and lack of magnifi-
cation make the flexible fiberoptic laryngoscope suboptimal to view small mucosal
lesions. Newer, contemporary, “chip-tip” laryngoscopes that do away with fibers pro-
vide a clearer picture, especially as imaging quality becomes of higher definition.

RIGID ENDOSCOPY

The rigid endoscope transmits images via a glass rod. Although this offers a higher
resolution picture, it also requires an increased skill level by the examiner. It does,
however, confer the diagnostic advantage of image quality and zoom to evaluate
mucosal abnormalities. This is especially true when videostroboscopy is concurrently
used.

STROBOSCOPY

Stroboscopy can be performed via flexible or rigid endoscopy and uses a pulsed light
source synced to the patient’s vocal frequency to give the illusion of a slow motion
mucosal oscillation. It requires periodic vibration to capture oscillation. It confers
the single best diagnostic instrument in most of the dysphonia cases and is oftentimes
the only method of obtaining information on mucosal pliability. It functions by pulsing
light at a frequency that is incongruent with the glottal cycle, thus generating a series of
 Components of Voice Evaluation 593

still images across different points of the glottal cycle.2 This image seems fluid to the
examiner’s eye due to Talbot’s law, which states that images presented more quickly
than 200 ms (5 images per second) are seen as a constant, smoothly moving image.
Stroboscopy can provide information on the following components of the glottic
cycle:
 Regularity: uniformity of sequential glottic cycles
 Amplitude: lateral movement of the vocal fold in the medial plane
 Mucosal wave: the movement of the mucosal cover of the vocal fold
 Phase symmetry: symmetry of the left compared with the right vocal fold with re-
gard to opening, closing, medial to lateral excursion
 Vertical level: symmetry of the left and right vocal fold in the vertical plane
 Glottic closure: pattern of complete versus types of incomplete glottic closure
patterns7
The standard of care in laryngoscopic evaluation and documentation involves video
recording of these examinations. Stroboscopy also uses the video recording aspect to
enhance the examination by slowing down the play-back to reveal aspects of pathol-
ogy not initially seen. The physician can rewatch the examination in freeze-frame or
slow motion to improve diagnostic accuracy. Moreover, video recording/archiving al-
lows for comparison of examinations across time as well as before and after interven-
tions. Stroboscopy can often delineate abnormalities that were not seen on initial
fiberoptic endoscopy but were clearly present based on patient history and perceptual
examination of the voice. Certain pathologic conditions, such as sulcus and alterations
in mucosal pliability, are most reliably diagnosed with stroboscopy. Patients with ma-
lignant and premalignant vocal fold changes also benefit from stroboscopy because
the physician can compare vascularity and mucosal pliability as part of routine surveil-
lance pre- and posttreatment.
High-speed imaging and videokymography are 2 additional imaging modalities that
allow for even higher definition evaluation of vocal fold vibration. High-speed videoen-
doscopy allows for true vibratory cycle evaluation in each vocal fold due to a dramat-
ically higher frame per second image capture compared with videostroboscopy. It
does not require periodic vibration and can evaluate a periodic vocal fold vibration
that can be seen in pathology such as vocal fold scar. Videokymography is often a
component of high-speed imaging. Videokymography evaluates the vocal folds via
a horizontal plane through the glottis. The images derived allow for evaluation of
left-right asymmetries, mucosal wave propagation, and glottic closure parameters.
At present, these modalities offer great potential for enhanced understanding and
evaluation of laryngeal biomechanics but remain relegated to research institutions
due to expense and incompletely determined day to day clinical utility beyond video-
stroboscopy and high-definition endoscopy.

AERODYNAMIC ASSESSMENT

Aerodynamic assessment can be helpful to analyze vocal function. It involves

measuring glottal aerodynamic parameters required for phonation, including subglot-
tal pressure, airflow, and glottal efficiency.
Subglottal air pressure is necessary to sustain vocal fold vibration. In order to be
assessed directly, pressure below the vocal folds would require a tracheal puncture.
An estimate of this can be made by measuring intraoral pressure during a voiceless
stop consonant. Subglottal air pressure varies widely based on age, gender, loudness,
consonant tested, and speech context. Abnormal pressures can be secondary to
594 Reghunathan & Bryson

velopharyngeal insufficiency, glottic insufficiency, inadequate pulmonary reserve, or

changes in vocal fold stiffness.
Glottal airflow is commonly assessed during sustained phonation and is estimated
from oral airflow rate during vowel production. It can be abnormal with poor glottic
closure from any means, such as vocal fold motion impairment or mass effect.
Another important concept is maximum phonation time (MPT).8 MPT can assess for
glottic insufficiency, which may indicate laryngeal pathology. However, its limitation is
extreme variability with the normal range for healthy young adults as 6.6 to 69.5 sec-
onds.8 Many factors influence MPT including respiratory capacity and function, pho-
natory function, resonance, practice, frequency, intensity, instructions, and vowel
choice.9 If MPT is used, it should be collected using standard instructions and coach-
ing, and the longest of 3 trials should be reported.
An assessment of velopharyngeal airflow is helpful in determining presence of velo-
pharyngeal competence, which can be estimated by intraoral air pressure and nasal
airflow during stop consonants. In contrast, the presence of low intraoral air pressure
and high nasal airflow during nonnasal consonants indicates velopharyngeal incom-
petence.10 Speech pathologists with expertise in voice will be critical to performing
the above testing.

SUMMARY

Each component of voice evaluation plays a critical role in painting the picture of the
patient’s voice disturbance. Any disparity between history, perceptual evaluation, and
laryngoscopic examination should prompt further evaluation and workup. For
example, a fiberoptic examination that does not reveal any pathology in the presence
of vocal disruption should prompt further evaluation with stroboscopic evaluation.
The goal of voice evaluation is to comprehensively assess the voice. This may lead
to the diagnosis of a voice disorder but at minimum involves a clinical description of
the characteristics and severity of the disorder. Ultimately, it is the clinician’s goal to
provide recommendations for intervention with subsequent identification of appro-
priate treatment and management options. This often includes multidisciplinary man-
agement with speech and language pathologists, neurologists, gastroenterologists,
and pulmonary specialists. It is the senior author’s opinion that video archiving is
also critical for surveillance of lesions over time and evaluation of posttreatment out-
comes for vocal fold movement, closure, and biomechanics.

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