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NormalAnatomy/PhysiologyofVoice,AssessmentParametersfora

VoiceEvalua=onPartII:Videostroboscopy

ErinGuidera,MS,CCC-SLPMoffiJCancerCenter

LearningObjec=vesAJendeeswillbeableto:•  Haveabasicunderstandingoftheroleofvideostroboscopy

aspartofacomprehensivevoiceevalua=on•  Haveabasicunderstandingofthebenefitsandlimita=onsof

videostroboscopy•  Haveabasicunderstandingofindica=onsfor

videostroboscopy

Waysto“see”thevoice

Indirectmirrorlaryngoscopy Rigidoralendoscopy

Flexibletransnasallaryngoscopy

ASHAPosi=onStatement“Itistheposi=onofASHAthatvocaltractvisualiza=onandimagingforthepurposeofdiagnosingandtrea=ngpa=entswithvoice,resonance/aeromechanical,ordeglu==ondisordersiswithinthescopeofprac=ceoftheSLP.”“throughintensivecon=nuingeduca=on,pre-service,orin-servicetrainingprograms…Thetrainingshouldtakeplaceinaclinicalse[ng,allowingtheprofessionaltoworkwithmoreexperiencedprofessionalsandanumberandvarietyofpa=ents.”ASHASIG3–TrainingGuidelinesforthePerformingofEndoscopyandVideostroboscopyAmericanSpeech-Language-HearingAssocia=on.(2004).Vocaltractvisualiza.onandimaging:Posi.onstatement.Rockville,MD:Author.

Indica=onsforaStrobe•  AssessVFvibratorybehavior•  Clarifythee=ologyofdysphonia•  Persistentdysphonia(>3weeks),unexplainedby

findingsonindirectexam•  Professionalvoiceusers•  Preop/Postopphonosurgery•  Determineop=mummanagementplan(Sx,Rx,VoiceTx)•  Biofeedback

Butfirst,awalkdownmemorylane…

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VFAnatomy/Physiology

•  Cover–  Epithelium–  Superficiallaminapropria

•  Transi=on(vocalligament)–  Intermediatelaminapropria–  Deeplaminapropria

•  Body–  Vocalismuscle

TheoriesofVibra=on•  Body-CoverTheory

–  Hirano,1975–  Vibra=onproducedbydifferenceins=ffnessbetweenthebodyandthecover

•  Myoelas=cAerodynamicTheory–  Muller,1843–  BernoulliEffect:VFsaresuckedtogetherbynega=ve

pressureandblowbackopenbyairpressurethroughglo[s

•  Non-LinearDynamics–  Interac=onbetweenvibra=onandresonance

ViewingVFVibra=on

•  TheVFsvibratetoofastfortheeyetosee– Women:~200Hz(cycles/sec)– Men:~100Hz–  Children:~300Hz–  SingingfalseJo(highC):>1000Hz

ViewingVFVibra=on•  Humaneyeisunabletodiscriminatebetweenseparate

imagesthatoccurfasterthan5=mespersecond(wecanperceive5dis=nctimagespersecond)

•  Avisualimagelingersonthere=nafor0.2secondsakerexposure

•  Talbot’sLaw-If>6images/secondarevisualized,thebrainwill“fuse”theimagestogetherandappeartobemovingàstroboscopicillumina=on

StroboscopicIllumina=on•  Anillusionofmo=on•  Providesarepresenta=onofvibra=on•  VisualizeindividualpointsfromsuccessivegloJalcycles

•  Usepersistenceofvisiontofusetheimagesintoaslowmo=onpicture

WhatAreWeLookingAt-Supraglo[c

•  Larynx/pharynxstructures–  Vallecula,epiglo[s,AEfolds,falseVFs,arytenoids,pyriformsinuses,etc.

–  Interarytenoidpachydermia,erythema,edema,etc.

•  Laryngealsecre=ons–  Pooling,loca=on,aspira=on–  Copious,frothy,thick/s=cky,ropey,inspissated

•  Supraglo[chyperfunc=on

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WhatAreWeLookingAt–VocalFolds

•  Mobility–  WNL,limitedABD,limitedADD,fixa=on,unilateral/bilateral

•  VFappearance–  Edges(smooth,straight,bowed)–  Color(white,erythema,vasculariza=on)

•  Lesions–  Loca=onoflesion–  Translucent/opaque,hard/sok,sessile/pedunculated,smooth/rough,

round/pointed/ellip=cal,hemorrhagic,etc.…

SAPMuC

Pneumonictoremembermostimportantfeaturesofvibratorybehavior

S=SymmetryA=AmplitudeP=PeriodicityMu=MucosalwaveC=Closure

SAPMuC-PhaseSymmetry

•  TheVFshouldmirroreachotherin=mingandamplitude

•  Drawanimaginarylinedownthecenteroftheglo[s

•  Doestheleksidelookliketherightside?

•  AretheVFopeningandclosinginsynchrony?

SAPMuC-Amplitude•  DegreeofhorizontalexcursionoftheVFsduringvibra=on•  1/3ofvisiblewidthofVFs(Hirano&Bless,1993)

SAPMuC-Periodicity•  Referstothecycle-to-cycle=mingofvibra=on•  Periodicvs.aperiodicvs.Inconsistent

–  Periodic=steadyandrhythmicvibra=on–  Aperiodic=shaky

•  Maychangew/pitch,loudness,breathsupport,etc.

SAPMuCMucosalWave•  Absent,reduced,normal,excessive•  Innormalvibra=on,shouldbe>50%acrossthesuperior

surfaceoftheVFs•  Bestvisualiza=onofwave–lowpitchandloud

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SAPMuC-Glo[cClosure

•  Completevs.Incomplete

•  Ifincomplete…–  Hourglass,spindle,anteriorgap,posteriorchink,bowed,irregularclosurepaJern

•  Bewareofpitch=maygetfalseclosurepaJern

Sonowwe’rereadytoscope.

Justafewsugges=ons….

Bridge3eErin

Pa=entPosi=on–RigidScope

•  Slidehipstobackofchair•  Leanforwardfromthewaist•  Armsonkneesorarmrests•  Chinup

HoldingTheTongue•  Horizontally

–  Thumbbeneathtongue–  Indexfingerontopoftongue–  Stabilizescopebetweenindexand

middlefinger

•  Ver=cally–  Thumbontopoftongue–  Indexfingerbeneathtongue–  Stabilizescopeontopofthumb

•  Begentlewithtongue!

•  Don’t“ride”tongue=gag

•  Mayneedtowarmscopeuptopreventfogging

Horizontal

Ver=cal

Say/i/

•  High,frontclosedvowel•  Raiseslarynx•  Tonguemovesforward•  Velumraises•  Haveptsmilearoundthescope

Don’tGetSlimed

Tipstominimizegagging:•  Don’t“ride”tongue•  Don’thitvelum•  Anchorscope•  Keeptongueoutwhenbreathing•  /i/totongueBOT

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SuggestedFlexProtocol•  VPITasks

–  “puhpuhpuh”–  “ssssssssssss”–  Dryswallow–  Hum

•  Respiratory/VFMobilityTasks–  Sniff–  Lightbreathhold–  Tightbreathhold–  Throatclear–  Cough–  Alterna=ngphona=on/inhala=on(/i/-sniff-/i/-sniff)

•  VoicingTasks–  Modal/i/–  Lowpitch/i/–  Highpitch/i/–  Glidinglowtohighpitch/i/–  Short/i/repe==ons–  Loudphona=on–  Connectedspeech(rainbowpassage)–  S=mulability(e.g.,SDtasks,easyonset,humming,etc.)

SuggestedprotocolVideo

BenefitsofaStrobe

•  Bridgefromtheearstotheeyes•  Assesslaryngealanatomy•  AssessVFvibra=onpaJerns•  ProvidesimageofVFpathology•  Permanentvideorecordoftheevalua=on•  Pa=enteduca=on/biofeedback

Limita=onsofaStrobe

•  Op=calillusion,notreal=me•  Aperiodicvibra=oncanbedifficulttoassess•  2-Drepof3-Dprocess•  Coloringandresolu=onvariesfromscopetoscope•  Rigidscopeonlyforsustainedphona=on•  Ar=factualmuscletension•  AssessmentofSAPMuCissubjec=ve

Ques=ons?

References•  AmericanSpeech-Language-HearingAssocia=on.(2004).Vocaltractvisualiza.onand

imaging:Posi.onstatement.Rockville,MD:Author.

•  AmericanSpeech-Language-HearingAssocia=onSIG3,VoiceandVoiceDisorders.(1997).TrainingGuidelinesforthePerformingofEndoscopyandVideostroboscopy,Vol3,395-402.

•  Gartner-Schmidt,J.(DateUnknown).StroboscopyPrinciple,ConceptsandEvalua.on.ContemporaryVoiceCare:APrac.calApproach.PPTPresenta=on.

•  Hapner,E.&Johns,M.(2007).RecognizingandUnderstandingtheLimita.onsofLaryngealVideostroboscopy.SIG3Perspec=veonVoiceandVoiceDisorders.March2007.Vol17,3-7.

•  Hirano,M.&Bless,D.(1993).VideostroboscopicExamina.onoftheLarynx.SingularPublishingGroup.

•  Rosen,C&Simpson,B.(2008).Opera.veTechniquesinLaryngology.Videostroboscopy

andDynamicVoiceEvalua=onwithFlexibleLaryngoscopy,17-20.

•  Stemple,J.,Glaze,L.&Klaben,B.(2000).InstrumentalMeasurementofVoice.ClinicalVoicePathology:TheoryandManagement,ThirdEdi=on,179-255.