HEARING, BALANCE AND COMMUNICATION

2021, VOL. 19, NO. 5, 311–317

https://doi.org/10.1080/21695717.2021.2020509

ORIGINAL ARTICLE

Voice evaluation – contribution of the speech-language pathologist voice

specialist – SLP-V: part A. History of the problem and vocal behaviour data,
self-assessment and auditory perceptual judgement
Mara Behlaua,b , Glaucya Madazioa , Thays Vaianoa , Claudia Pachecoa and Fl
avia Badaro

a
a
Centro de Estudos da Voz – CEV, S~ao Paulo, Brazil; bEscola Paulista de Medicina, Universidade Federal de S~ao Paulo – UNIFESP-EPM,
S~ao Paulo, Brazil

ABSTRACT KEYWORDS
The human voice is the product of a sophisticated interaction of aerodynamic and myoelastic Voice; voice disorders;
forces, a perceptual phenomenon that is greatly influenced by vocal behaviour in interpersonal dysphonia; assessment
relationships. Vocal problems can be overly complex and can require a team approach, whether
for diagnosis or treatment of the patient. This article describes the contribution of the speech-
language pathologist, voice specialist SLP-V in the assessment of patients with vocal complaints.
A clinical evaluation proposal developed in a 40- to 60-min session is presented. This proposal
consists of the following steps: the history of the problem; the patient self-assessment; the audi-
tory perceptual judgement and acoustic analysis; the physical examination; and finally, the cor-
relation of all previously described steps with the medical diagnosis. Part A of this text explores
the history of the problem with the focus to determine the influence of the vocal behaviour on
the case; the self-assessment of the impact of the voice problem to verify the patient experience
in living and coping with dysphonia; and the auditory perceptual judgement to describe the
type and degree of vocal deviation. Worldwide published tendencies and specific comments of
each step highlight the role of the SLP-V.

Introduction vocal quality, pitch, loudness, or vocal effort that

impairs communication and/or quality of life [3].
The human voice is a product perceived aurally,
Dysphonia can significantly impact different aspects
which immediately impacts the relationship with the
of an individual’s life and deserves to be recognised,
listeners. Its production complexity involves three
evaluated, and treated.
brain systems: innate vocalizations, emotional vocal-
One-third of the population will experience a voice
izations, and highly sophisticated and volitional vocal-
problem at some point in their lives [3], many of
izations, such as singing [1]. In addition, the
whom are transient and benign. A voice assessment is
phonation depends on a balance of aerodynamic (sub- essentially multidimensional and multi-professional.
glottic pressure and trans-lingual flow) and muscle The team dedicated to patients with dysphonia is usu-
forces (with highly developed interdependence and ally composed of a physician, mainly an otolaryngolo-
synergy). A third important aspect is the active par- gist or a phoniatrician, and a speech-language
ticipation of the mucosa that covers the vocal folds, a pathologist. A third party who is frequently part of
multi-laminated vibrator with different mechanical this team when a patient is an artist is a singing
properties. Although animal vocalisation is impres- teacher. These three professionals have different per-
sive, with an open-ended, highly modifiable, and cog- spectives, and sometimes, there is an inevitable over-
nitively rich set of meanings [2], the use of voice by lap among them; however, the responsibilities and
human beings is unique. It encompasses physical sur- goals are different, and we highlight the speech-lan-
vival, professional exercise, cultural manifestation, and guage pathologist’s perspective. It is important to
above all, identity. Therefore, having a normal voice highlight the complexity of the interactions among
is critical for human development. A voice disorder, these three professionals, the domain of knowledge,
called dysphonia, is usually characterised by altered and the transdisciplinary attitude needed to be

CONTACT Mara Behlau [email protected] Escola Paulista de Medicina, Universidade Federal de S~ao Paulo – UNIFESP-EPM, Rua Machado
Bittencourt 361, 10th floor, S~ao Paulo 04044-001, Brazil
ß 2022 International Association of Physicians in Audiology
312 M. BEHLAU ET AL.

Table 1. Characteristics of the top three professionals dealing with voice problems.
Characteristics ENT – laryngologist SLP – voice specialist Teacher of singing
Competence Medicine and diseases Vocal function and Vocal pedagogy
physiological impact
Knowledge Anatomy and vocal physiology Anatomy, physiology, perceptual and Music genres and vocal styles
acoustic analysis
Conceptualization Impact of a disease on the voice Vocal dynamic process and all Artistic potential
interrelations
Auditory skills Less developed Functional ear Musical ear
Focus Healthy larynx Adapted voice and several vocal skills Preferred voice for the musical
genre or vocal style
Mental setting Anatomic Functional Artistic
Central concern Health Vocal functionality Performance and vocal aesthetic
Central intervention Treatment Quality of life in voice Artistic aspects and performance
Performance intervention Voice emergency Vocal health Repertoire training
Body assessment General evaluation Muscle tension related to Body alignment
voice production
Breath assessment Anatomy and physiology Functional Artistic
Formal accreditation Prerequisite Prerequisite Usually not needed

successful when dealing with patients with physician or singing teacher. The patient can also be
vocal complaints. evaluated simultaneously by a physician and an SLP-
Speech-language pathologists play a major role in V, which favours integrated work.
the evaluation and treatment of voice disorders, and We consider an SLP-V initial visit for assessment
their unique position in relation to the other two main with an average time of 40- to 60-min. We propose
partners is presented in Table 1. The professional that the voice consultation is a five-step sequence:
name of this health professional varies worldwide
(speech therapist, logopedist, terapeuta da fala, defec-  The history of the problem and behaviour data
tologist) as does the entry educational level required to  Self-assessment of the impact of the voice problem
work in a clinical setting. Therefore, in this paper, we  Auditory perceptual judgement and acous-
use the acronymous SLP-V (Speech-Language tic analysis
Pathologist specialised in the voice area) to identify  Physical examination of the patient
this health professional specialising in assessing and  Correlation of all steps with the medical diagnoses
treating voice problems. We prefer ‘pathologist’ to
‘therapist’, which is usually the most common nomin- The patient sometimes brings the report of a lar-
ation in Europe, to avoid a possible misconception that yngological evaluation with photos and video record-
the professional focus is restricted only to treatment ings. In this situation, we suggest accessing these
delivery. Other essential members of the voice team images after finishing the patient’s evaluation. The
(besides the duo MD and SLP-V) can join this pair, reason is that the impact of visual information is
such as health professionals (neurologists, psychiatrists, powerful, and it can skew the auditory analysis and
psychologists, gastroenterologists, and endocrinologists, the determination of the degree of the problem. Sight
for example) and professionals in the arts (vocal is a superior sense, usually considered the essential
coaches and public speaking teachers). input [6], and it can bias the value of the other evalu-
Many excellent articles written by physicians offer ations. After these five steps, the SLP-V offers a con-
analyses and position a patient’s evaluation compo- clusion of the assessment, which is less laryngocentric
nents with a voice problem [4,5]. The present article and more comprehensive, considering the use of the
offers a proposal for a clinical SLP-V assessment for voice in communication or for artistic expression. It
voice disorders, focussing on the standard voice spe- encompasses habits, functionality and the experience
cialist, with basic equipment usually found in most of living with a voice problem.
offices. There is no intention to present a voice assess- This text, part A, deals with the history, self-assess-
ment for scientific purposes or academic purposes in ment, and perceptual auditory judgement.
school clinics, much less specialised voice laboratories.
The history of the problem and vocal
The clinical SLP routine assessment behaviour data
An individual with a voice problem may seek an SLP- The history of the problem and the behavioural data
V for assessment or may have been referred by a on the use of voice reveal essential aspects of the
 HEARING, BALANCE AND COMMUNICATION 313

vocal condition and must be consciously taken. The dysphonia and unilateral vocal fold paralysis patients
clinician attitude is to look for a guiding axis that jus- do not present any specific psychological aspects [9].
tifies the complaint and the individual’s symptoms. Clinicians can quickly adapt some of the question-
The purpose of a medical anamnesis is to contribute naires offered in many classical textbooks as models
to a medical diagnosis, which is the prerogative of the on the anamneses. Using a clinical investigation script
physician. The history of the vocal problem, taken by adapted to the profile of patients reduces the time
the SLP-V, has the primary objective of understand- spent on this task and helps establish a clinician–pa-
ing the value of the vocal behaviour in the aetiology tient alliance. A good history of the problem directs
and the maintenance of the voice problem. The func- the clinician to a specific semiological analysis to
tionality of the voice is also a central question. In check vocal functionality and the impact of a
simple words, understanding what the patient cannot voice problem.
do with the voice is a fundamental aspect of the his-
tory of the problem. In addition, identifying whether Self-assessment of the impact of the
the patient has lost functionality or has never had it voice problem
drives the next steps.
Generally investigated topics are: patient’s com- The concept of health as a state of complete physical,
plaint and duration; signs and symptoms associated mental, and social well-being and not merely the
absence of disease or infirmity includes the perception
or not with the professional use of the voice; whether
of an individual regarding a condition and the effect
of auditory, kinaesthetic, or discomfort nature; fluctu-
perceived on one or several aspects of life [10].
ation of symptoms throughout the day; use of voice
Therefore, one of the steps of a patient evaluation in
in the family, social, sporting, or professional voice
a voice clinic involves the vocal self-assessment proto-
use; artistic (singers and actors) and non-artistic
cols [11]. These questionnaires are excellent options
(teachers, lawyers, salespeople); vocal habits and use
to assess the impact caused by a voice disorder on
of tobacco and alcohol; communication attitude in
quality of life, professional performance, and general
different interpersonal situations; personality charac-
well-being. They can also point to factors leading to a
teristics; previous episodes of voice problems and
voice problem. The results can distinguish each case
treatments performed; general health; and preced-
or group them, establish a therapeutic program, pre-
ing surgeries.
dict speech therapy outcomes, and identify some cog-
Each item is investigated considering the voice
nitive aspects, such as coping and self-regulation
usage and possible influences of vocal behaviour in
aspects [12,13]. These instruments improve the clini-
the specific case. For example, when searching for cian’s ability to understand the experience of living
signs and symptoms associated with the professional with a voice problem, the kind of relation individuals
use of the voice, the list offered by Roy et al. [7] helps have with their voices, and how they face it.
both the patient reflect on these aspects and the clinic Answering the questionnaire also provides the patient
improve the clinical reasoning skills. The 14 items with the opportunity to consider the spoken and sung
are: hoarseness, voice tires or change in quality after vocal production by valuing the real influence caused
short use, trouble speaking or singing softly, difficulty by changes in voice [14]. The correlation between the
projecting voice, a loss of singing range, discomfort patient’s and the clinical perspective is variable [15],
while using voice, monotone voice – monopitch, and it is not possible to infer a patient’s perception
effort to talk, chronic dryness of throat, chronic sore- based on the clinical impression. By considering only
ness of throat, frequently clear throat, bitter or acid one of these perspectives, the real problem can be
taste, swallowing difficulties, and wobbly or shaky simplified or not fully considered.
voice. For example, hoarseness, voice tires, or changes Many self-assessment questionnaires are used in
in quality after short use and discomfort while using clinical practice related to aspects of voice disorder,
the voice are the three aspects most associated with a complaints, and the aetiology of the problem. They
voice problem in teachers with occupational dyspho- include: voice handicap (VHI by Jacobson et al. [16]),
nia [7,8]. High neuroticism (sensitive/nervous vs. quality of life (V-RQOL by [17]), vocal signs and
resilient/confident individuals) and low extraversion symptoms (VoiSS by [18], vocal tract discomfort
contribute to the development of functional dyspho- (VTD by Mathieson et al. [19]), vocal fatigue (Vocal
nia; however, high neuroticism and high extraversion Fatigue Handicap Questionnaire – VFHQ by Paolillo
favour the development of vocal nodules. Spasmodic and Pataleo [20]; and Vocal Fatigue Index – VFI by
314 M. BEHLAU ET AL.

Nanjundeswaraan et al. [21]), vocal performance choice of the protocol must be a conscious clinical
(Vocal Performance Questionnaire – VPQ by Deary attitude, taking into consideration signs and symp-
et al. [22]), voice handicap for singing (VHI-S by toms, professional voice use and some cogni-
Murry [23]), classical or modern singing (Classical tive aspects.
Singing Voice Handicap Index and Modern Singing
Voice Handicap Index, by Fussi et al. [24]), and some
Auditory perceptual judgement and
particular scales, such as the Evaluation of the Ability
acoustic analysis
to Sing Easily – EASE, which measures changes in the
singing voice as indicators of the effect of vocal load We understand that auditory perceptual judgement
[25]. Some complaints, such as vocal fatigue or vocal and acoustic analysis are sides of the same coin, and
tract discomfort, are symptoms that are difficult to we performed both procedures practically together to
measure employing auditory and acoustic analyses or optimise the patient’s consultation time and to
speech tests. In these cases, the specific self-assess- improve clinical reasoning. Part A of this text will
ment questionnaires for these aspects are an invalu- analyse only the perceptual auditory judgement for
able contribution to the characterisation and of the clinical purposes. The acoustic analysis will be
degree of the manifestation of the problem. explored at part B.
The information given by self-assessment question- The patient had already explained the history of
naires can be neither obtained nor inferred by any the problem and the self-assessment of the impact of
other type of analysis. After analysing the results of the voice problems. In this moment, a good level of
one or more self-assessment questionnaires, the clin- engagement was enough to proceed with collecting
ician has more data to decide what to search and vocal samples. Although the clinician already had an
measure [11,26]. In some cases, the lack of perception informal impression of the patient’s vocal quality aris-
of the negative impact of a voice problem, whether ing from the history of the problem, different acoustic
real or not, can compromise the individual’s adher- samples, such as sustained vowels, connected speech
ence to treatment. This should not be underestimated. and singing were collected and recorded to measure
The many possibilities of selecting instruments to parameters of vocal quality, or to make a descriptive
identify certain aspects of the experience to live with analysis, in the sequence of the same session.
a voice problem and the shortness of time cause a
dilemma that can be solved using a two-question test
Auditory perceptual judgement
for screening [14]. The Brazilian Dysphonia Screening
Tool (Br-DST) is proposed after an extensive analysis Voice is an essentially perceptual phenomenon. An
of the V-RQOL, VHI, and VoiSS, which provided individual with a vocal complaint can present a devi-
results for 139 individuals through a logistic regres- ant or unpleasant vocal quality, an ineffective voice in
sion model. The two items proved to be efficient to terms of performance, and or a sound that is not rep-
identify dysphonia: (1) I feel like I have to force my resentative of physical or psychological characteristics.
speech, and (2) My voice is hoarse. These direct and Clinical auditory perceptual judgement identifies and
straightforward inquiries can be used as a preliminary highlights these aspects that are often why the indi-
voice assessment. vidual seeks help. Perceived changes in the quality of
It is essential to highlight that any questionnaire the voice, pitch, or loudness, and to a lesser extent, in
must be adapted and validated for the specific country feelings of discomfort in the vocal tract are the most
and language where it is being to avoid misinterpret- common complaints. A perceptual judgement is a
ation. Processing the validation of an instrument in a critical component of any vocal assessment, regardless
language different from the original requires further of whether a physician, an SLP-V, a singing teacher,
cultural adaptation to reach the target group. Some or a vocal coach performs it. It is considered the
items of the original instrument may not be valid in most traditional evaluation method in a voice clinic
another culture. Sometimes, the number of total items [28], the ‘gold standard’ for documenting the severity
is different from the original version, which then of voice impairment [29,30]; however, there is a chal-
requires an investigation of the instrument’s power in lenging complexity involved in this process. The voice
the new population [11,14,27]. is not a binary descriptor (normal versus abnormal)
Understanding what needs to emerge from a self- but a variable measure, with many cultural influences
assessment questionnaire helps the clinician decide on the auditory perceptual judgement [31]. Therefore,
which protocol is best for the specific patient. The defining the normalcy of voice is a real challenge. For
 HEARING, BALANCE AND COMMUNICATION 315

clinical purposes, there are four levels of analysis: (1) Later, the parameter I – instability of the quality of
Normal X altered vocal quality; (2) Type of alteration frequency was included to help describe neurological
(roughness, breathiness, strain, asthenia, tremor, cases [38]. Therefore, GRBAS is sometimes called
spasms, among others); (3) Degree of deviation (mild, GRBASI. This scale is used worldwide and in many
moderate, severe); and (4) Adequacy for a specific scientific publications despite its limitations: it is too
professional voice style (adequate, partially adequate, short and focuses mainly on the laryngeal level; there
or inadequate). are no precise definitions of each parameter; there is
The reliability of the auditory perceptual judge- not a standard voice material to perform the percep-
ment is questioned in several publications. It can be tual judgement; G is sometimes used to express the
dependent on the training of the judges, task design, degree of hoarseness instead of the degree of overall
scale of rating, type of stimuli (sustained vowel, con- deviation (hoarseness was used by Japanese colleagues
nected speech, reading, or spontaneous material), and as a general term for voice alteration and not as a
the listener’s experience [29,30,32–34]. Even with reli- type of voice); and asthenia and strain are the oppos-
ability issues, the value of the auditory judgement is ite of the same continuum: tension and therefore
out of the question because voice is a percep- excludents. Moreover, GRBAS does not include pitch,
tual phenomenon. loudness, or resonance data. Regardless of its limita-
Voice quality is the traditional parameter of an tions, it is a quick scale to be applied and is practical
auditory judgement and corresponds to the overall for screening purposes.
impression of a voice. This panoramic impression CAPE-V results from a team effort of clinicians,
results from several aspects, such as glottic and supra- researchers, and specialists in human perception, and
glottic mechanisms, and behavioural adjustments car- the acronym stands for Consensus Auditory-
ried out by the individual. Other factors play a role in Perceptual Evaluation of voice – CAPE-V [37]. The
contributing to a certain quality, and it is essential to SIG-3 of ASHA presented CAPE-V as a result of a
consider the characteristics of personality, spoken lan- long-term discussion with experts in the field and
guage, profession, and cultural aspects. Three types of also based on solid psychometric studies. CAPE-V
voices are universally recognised and yield consistent has six clearly defined parameters: overall deviation,
perceptual judgments: roughness, breathiness, and roughness, breathiness, strain, pitch, and loudness
strain [28]. Strain, that is, vocal tension, can be pro- accompanied by a visual analog scale of 100 mm, cor-
duced at any level of the vocal tract and its assess- responding to 100 measurement points. Each param-
ment is less reliable than the other two [33]. This can eter can be marked as consistent or intermittent. In
be due to cultural preferences regarding this specific addition to these six entries, the protocol offers the
adjustment that can be viewed as a deviation or possibility of registering the patient’s resonance and
not [35]. two other extra items, which are not included in the
Three trends are common in the literature analysis standard format, such as vocal tremors or spasms. In
and in clinical reports over the last two decades: the addition to the description of each parameter, the
use of structured protocols, the reduction of the num- speech tasks used in this protocol are pre-defined.
ber of analysed parameters, and visual-analog scales They include sustained vowels /a/ and /i/ (3–5 s) three
with a larger number of points instead of numerical consecutive times, reading six sentences specific to
ones with few to give visibility to small increments in different phonetic contexts, and spontaneous speech
voice therapy. (for example: ‘tell me about your voice problem’).
The most widespread protocols for the auditory Thus, the scale includes aspects of the glottic source
perceptual judgement of voice are the traditional and filters and automatic and spontaneous speech.
GRBAS [36] and the modern CAPE-V [37]. The amount and the quality of information given by
GRBAS is a proposal of the Japanese Voice the CAPE-V exceed what can be obtained by the
Committee of the Japan Society of Logopaedics and GRBAS. A recent study revealed that, at least in chil-
Phoniatrics [36]. It is a five-parameter scale: G corre- dren, CAPE-V ratings are more strongly correlated
sponds to grade – global degree of vocal alteration, R with acoustic and aerodynamic voice measures than
to Roughness, B to Breathiness, A to Asthenia, and S GRBAS [35].
to Strain. Each parameter is marked using a numer- Finally, there is a recognised influence of the envir-
ical scale of four points (0–4), allowing for a classifi- onment in which the listening task is performed. The
cation according to the degree of deviation: normal/ clinical setting is very different from the researcher–-
absence (0), mild (1), moderate (2), or severe (3). subject dyad present in the research lab [39]. Clinical
316 M. BEHLAU ET AL.

bias is common and needs to be addressed. Training [3] Stachler RJ, Francis DO, Schwartz SR, et al. Clinical
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[4] Dejonckere PH, Bradley P, Clemente P, et al. A
Conclusion basic protocol for functional assessment of voice
pathology, especially for investigating the efficacy of
Patients with vocal disorders may represent multifa- (phonosurgical) treatments and evaluating new
ceted clinical challenges. Evaluating these individuals assessment techniques. Guideline elaborated by the
may require the analysis of several professional per- Committee on Phoniatrics of the European
Laryngological Society (ELS). Eur Arch
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Otorhinolaryngol. 2001;258(2):77–82.
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ical assessment from the perspective of an SLP-V. 589–595.
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Disclosure statement lation behavior and vocal symptoms. J Voice. 2017;
No potential conflict of interest was reported by 31(4):455–461.
the author(s). [14] Oliveira P, Andrade Lima E, Lopes L, Behlau,
et al. Brazilian dysphonia screening tool (Br-DST):
an instrument based on voice self-assessment items.
ORCID J Voice. 2021;13:S0892.
[15] Karnell MP, Melton SD, Childes JM, et al. Reliability
Mara Behlau http://orcid.org/0000-0003-4663-4546
of clinician-based (GRBAS and CAPE-V) and
Glaucya Madazio http://orcid.org/0000-0001-7160-8636
patient-based (V-RQOL and IPVI) documentation
Thays Vaiano http://orcid.org/0000-0003-2169-2723
of voice disorders. J Voice. 2007;21(5):576–590.
Claudia Pacheco http://orcid.org/0000-0002-2928-2158
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Fl
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