Signs and Symptoms of Voice Problems

Definition of Terms
 Symptom
- patient’s report or complaint about the problem and its characteristics
- may or may not be verified objectively
- can be misleading, frequently underreported, may not be the most significant characteristic present in
the voice
- nevertheless has subjective reality for the patient and must be considered
 Sign
- observable characteristics of voice that may be tested and measured
- not all signs are significant (*note: understanding how different signs relate to each other and how they
reflect underlying pathology will assist the clinician in evaluating the importance of each sign)
-

Major Symptoms of Voice Problems

Symptom Description Other Associated Symptom*
1. Hoarseness - “raspy” or “rough”
- aperiodic vibration of the VFs
2. Vocal fatigue - feeling tired after prolonged talking - occasional raspiness or
- continued talking requires a great deal of hoarseness with prolonged
effort voice use
3. Breathy voice - running out of air before completing
sentences
- needing to replenish the air supply to
continue talking
- difficulty being heard, especially in noisy
situations
4. Reduced pitch range - difficulty producing notes that had - tiredness or soreness in the
previously presented no problem throat area
5. Aphonia - absence of voice - dryness in the throat
- speaking with a whisper - soreness
- great deal of effort in
attempting to speak
6. Pitch breaks / - periodic squeakiness and voice cracks
Inappropriately high - voice seems out of control
pitch - often reported by male adolescents
7. Strain / Struggle voice - difficulty talking - fatigue due to effort <---
- inability initiating or maintaining voicing great deal of tension while
speaking
8. Tremor - wobbly or shaky voice that is usually
very regular in rate
- inability to voluntarily produce a steady
sustained sound
9. Pain and other physical - pain varies across patients and locations
sensations - lump in the throat, feelings of strain or
tension, sensation of dryness
Major Signs of Voice Problems

Perceptual Signs
- characteristics of an individual’s voice that are perceived by the listener
- subjective impressions but have psychological reality
- may be assessed objectively and compared across listeners
- serve as initial guideposts in diagnosis (together with the case history)

Perceptual Sign Description Possible Etiologies

~ Pitch ~ - perceptual correlate of fundamental frequency
1. Monopitch - voice that lacks normal inflectional - neurological impairments
variation - personality
- inability to voluntarily vary pitch (in - psychiatric disability
some instances)
2. Inappropriate pitch - exceeds range of acceptable pitch for age Too High
and/or sex (i.e. too low or too high) - underdevelopment of the
- related to the size of the larynx and its larynx due to: delayed
structures development,
endocrinological factors, or a
*note: other characteristics (aside from congenital anomaly
fundamental frequency can affect pitch Too Low
perception) - endocrinological factors (e.g.
hypothyroidism)
- use of male hormone by
women
3. Pitch breaks - unexpected and uncontrolled sudden - changing voice of an
shifts of pitch in either an upward or adolescent male
downward direction - laryngeal pathology
- accompaniment to
conditions that involve some
loss of neural control
4. Reduced pitch range - reduction in pitch range
- inability to produce higher pitches
without excessive strain (or at all)
~Loudness~ - perceptual correlate of intensity
- may also depend on spectrum, vocal tract resonance, environment
5. Monoloudness - lacks variation in loudness level - neurological impairment
- use of increased loudness for emphasis is - psychiatric disability
absent - habit (personality)
- inability to voluntarily vary loudness*
6. Loudness variation - extreme variations (i.e. too soft or - auditory dysfunction
excessively loud for a specific speaking - personality
situation) - habit (loud environment,
- unpredictable and uncontrolled variation relative with HI)
of loudness (i.e. explosive to fading) - neurological impairment
(phonation, respiration)
- psychological
7. Reduced loudness - reduction in loudness range -
range - usually inability to produce loud sounds
~ Quality ~
8. Hoarseness or - lack of clarity, increased noisiness, - laryngeal pathology affecting
 roughness
*Acoustic correlate:
perturbation, noisiness of
the spectrum
9. Breathiness
*Acoustic correlate:
excessive amount of airflow
produced
*Physiologic correlate:
inadequate glottal closure
10. Tension
11. Tremor
12. Strain / Struggle
*Acoustic correlate: slow
voice onset time, silence,
variations in F0 and SPL
*Physiologic correlate:
difficulty initiating
phonation and struggle to
maintain phonation
13. Sudden interruption of
voicing
*Acoustic correlate:
variability in SPL, airflow
changes
*Physiologic correlate:
sudden, unexpected, and
involuntary abduction of
the VFs or delayed
adduction when
transitioning from voiced to
unvoiced phonemes
14. Diplophonia
*Physiologic correlate:
vocal folds are under
differing degrees of tension
or mass ---> diff. F0 each
discordance
- may be paired with breathiness, tension,
or strain
- perception of audible air escape
- lacks clarity of tone
- usually reduced in loudness
- “hard edge” to the voice + hard glottal
attacks
- sometimes observable muscular tension
in the external neck
- involuntary regular rhythmic variations
in pitch and loudness
- unsteady, “wobbly”, or quivering voice
- perception of inability to control voicing
as it fades in and out
- actual voice stoppages may occur
- sudden unexpected drop in loudness
- equally unexpected change in voice
quality to breathy
- breathy voice may last shortly and may
occur repeatedly within an utterance
(alternating with normal voicing)
- “double voice”
- two distinct pitched perceived
simultaneously during phonation
the vibratory behavior of the
vocal folds
- peripheral or central
neurological impairment
- lesion interfering with
closure
- improper use
- hyperfunctional voice usage
- compensatory behavior in
the presence of laryngeal
pathology or neurological
impairment
- neurological dysfunction in
the absence of vocal fold
pathology (mass)
- psychological
- neurological dysfunction
(no consistent pathological
condition)
 ~ Other Behaviors ~
15. Stridor
16. Excessive throat
clearing
~ Aphonia ~
17. Consistent aphonia
18. Episodic aphonia
- noisy breathing (i.e. involuntary sound - blockage of the airway
accompanying inspiration, expiration, or
both)
- frequent and consistent attempts to clear
excess mucus or other secretions from
the VFs
- response to the sensation of “something
in the throat”
- absence of voicing, usually perceived as - bilateral vocal fold paralysis
whispering - central nervous system
- most or always present dysfunction
- psychogenic problem
- presentation 1: unpredictable, - laryngeal pathology
involuntary aphonic breaks lasting for - central nervous system
only a fraction of a second dysfunction (flaccid type, as
- presentation 2: aphonic periods lasting in myasthenia gravis)
minutes, hours, or days - psychogenic problem
- presentation 3: gradual fading of voice to
the aphonic state, particularly with
increased physical fatigue

Acoustic Signs
- acoustics: study of sound
- can provide information about vocal fold movement; the ff. can be inferred:
 biomechanical characteristics of the folds
 magnitude of air pressure beneath the folds
 neural mechanism
- much can be inferred about physiology based on acoustic analysis
- easiest to record and to analyze objectively

Acoustic Sign Description Normal Values

~ Fundamental Frequency~
1. Mean fundamental
frequency
2. Frequency variability
3. Phonational range
- vibrating frequency of the vocal folds -
- average fundamental frequency During Conversation:
- may be affected by laryngeal pathology - 100-150Hz (males)
- 180-250Hz (females)
- standard deviation of frequency for a - pitch sigmas of 2-4
reasonably large time segment or passage semitones (males,
(longer-term variability is computed because females)
frequency and intensity naturally vary
depending on the sounds, the words uttered,
and the intent of the message)
- expressed in semitones (“pitch sigma”)
- range of frequencies that can be produced - three octaves (with
signers a little higher)

*note: decreases with age

4. Frequency perturbation - irregularity of vibration of the VFs See Chapter 15 of Colton,
(Jitter) - “jitter” (irregularity in the time of vibration) Casper, & Leonard (2011)
- variation of glottal period (change in
 frequency from one successive period to the
next)
- expressed as a percentage of the average
fundamental frequency
- Better measure of severity than possible
etiology (possible etiologies: VF growths,
mucosa changes, variations in VF
composition, variations in muscle function,
variations in muscular motor control)
~ Amplitude ~ - strength of the tone produced by the VFs
5. Overall sound pressure - average sound pressure level of an utterance - 70-80 dB (everyday
level (sustained vowel, spontaneous sentence, or conversational speech)
paragraph)
- indication of the strength of VF vibration
6. Amplitude variability - amplitude standard deviation *note: amplitude naturally
varies depending on the
sounds spoken and the
message
7. Dynamic range - range of vocal amplitudes an individual can - 50dB to 115dB
produce (intensities for males
- smaller at the extremes of fundamental slightly higher)
frequency range
8. Amplitude perturbation - reflects the short-term variation of amplitude - See Chapter 15 of
(Shimmer) from one glottal cycle to the next Colton, Casper, &
- could reflect the kind and severity of the Leonard (2011)
pathology (possible etiologies: growths on
the vocal folds or poor neural control of the
VFs)
~ Others ~ -
9. Signal-to-noise ratio - noise: random, aperiodic energy in the voice, - low levels of noise
generated by either: - Harmonics to noise
 noise source at or near the vocal folds ratio = 1
(e.g. air rushing against open VF)
 greater aperiodicity of vibration
- may occur throughout the entire frequency
range of the voice or in certain frequency
bands
- two approaches to analyze noise:
 level of noise near the second formants
of several vowels (using a spectrogram)
 direct analysis of the level of noise (i.e.
harmonics-to-noise ratio, a variant of
signal-to-noise ratio)
10. Vocal rise or fall time - Rise time: time it takes to produce a tone of
full amplitude; associated with vocal attack
- Fall time: time it takes for the VFs to stop
producing a tone
- May be affected by: pathologies or neural
control of laryngeal muscles
11. Voice tremor - Slow regular variation in the F0 or amplitude - Usually 3-5 Hz about
of the voice around the desired constant the mean fundamental

12. Phonation time
13. Voice stoppages
14. Frequency breaks
15. Normal acoustics
frequency or amplitude frequency
- Tremor rate:
- Associated with variations in muscle activity
levels or control fo the muscles used in
phonation (i.e. more of CNS dysfunction
than peripheral motor control problems or
VF pathology)
Maximum phonation time - 20 seconds (adult male)
- time a person can sustain a tone on one - 15 seconds (adult
breath female)
- may vary as a function of trials - 10 seconds (children)
- short maximum phonation time reflect *note: may vary
inefficiency of the phonatory or respiratory considerably between
system people and among age
S/Z Ratio groups
- max sustained phonation time of /s/ divided - s/z ratio of 1 (> 1.4
by the max sustained phonation time of /z/ may indicate a vocal
- /z/ would suggest the presence of disturbed pathology)
VF vibratory behavior
- silences that are usually longer than normal -
or appear unexpectedly
- Observable in the spectrum of the sound
- sudden shifts of F0 (either upward or -
downward)
- some patients with a phonatory problem may -
exhibit normal acoustic features

Physiological Signs
Measurable Physiological Signs
 Aerodynamic Measurements
 Airflow
- 50 - 200 mL/sec (males with higher flows than females)
- average flow over several glottal cycles (peak flow vs. steady airflow rates)
- airflow rates during the presumed closed phase of the VFs are greater for speakers with vocal fold
lesions or poor muscular or neural control
- variability may also be important to measure in patients with vocal pathology
 Air Pressure
- subglottal pressures higher than 0.2 - 0.9 kPa during conversational speech are indicative of either
excessive lung pressure or inefficient valving of the VFs
 Phonation Threshold Pressure
- minimum pressure required to initiate VF vibration; reflects the level of hydration of the VFs
- dependent on the pitch of the phonation
- determined by: 1) degree of VF opening, 2) thickness of the VFs, 3) velocity of the mucosal wave,
4) viscosity of the tissue
 Vibratory Behavior

 Muscle Activity
Observable Physiological Signs
 Stroboscopic Observations
 Laryngoscopic Signs