Notices to the Professions

Notice to the Professions /
Certificate E: Flexible Endoscopic Evaluation of Voice and Swallowing (FEEVS) for Adults for RSLPs – Appendix

The prerequisite, essential components for the Certificate E: FEEV transition session, to be held at the Delta Burnaby Hotel Thursday on October 24, 2019, are listed below. This is followed by a resource list for registrants. There is an assumption that participants have the knowledge and skills level in voice equivalent to an SLP graduate program course(s) in vocal anatomy/physiology and clinical assessment and management.

1. Anatomy & Physiology

Speech Breathing:

  • Differences between speech breathing and vegetative breathing.
  • Primary systems involved in speech breathing. Passive versus Active speech breathing mechanisms.
  • Speech breathing measurement and evaluation: e.g. respiratory kinematics and dynamics.
  • Anatomical factors in respiratory systems that influence sub-glottal pressures, phonation duration, phonatory dynamics (e.g. intensity, fundamental frequency).
  • Use (e.g. Posture) factors that influence sub-glottal pressures, phonation duration, phonatory dynamics.
  • Effects of development and aging on speech breathing anatomy and function.
  • Gender-based differences in speech breathing anatomy and function.

Laryngeal & Paralaryngeal Anatomy:

  • Laryngeal suspension system: role of extrinsic laryngeal suspension system during voice production.
  • Primary cartilages of the larynx: functional significance for voice production and breathing of structure, shape and location.
  • Intrinsic muscles of the larynx: primary roles of each for voice production, abduction, adduction, medial compression, registration, dynamics of intensity, fundamental frequency (f0).
  • Structures involved in vocal resonance.
  • Vocal Registration mechanisms (e.g. Modal, Falsetto, Glottal Fry).
  • Primary differences in laryngeal structure between infants, children and adults. Effects of development and aging on vocal structure and function. 
  • Primary gender-based differences in laryngeal structure and function.

Phonatory Physiology:

  • Factors that determine sub-glottal pressures and resistance. Phonation threshold pressures.
  • Vocal fold layer-structure of the vocal folds: influence of the layer-structure on vibratory patterns.
  • Vibratory patterns: longitudinal phase difference; vertical phase difference; mucosal wave.
  • Biomechanical-aerodynamic principle of phonation: flow-separation, etc. Primary asymmetrical force factors determining sustained self-oscillation of the vocal folds.
  • Vocal Registration: Unique postural, vocal fold vibratory, biomechanical, aerodynamic, speech-breathing patterns for different vocal registers.
  • Primary mechanisms responsible for pitch change in modal register, falsetto register.
  • Secondary vocal tract adjustments in the vocal tract that may contribute to pitch changes.
  • Mechanical, aerodynamic and acoustic correlates to intensity changes in modal register, falsetto register.
  • Physiological factors contributing to variable vocal quality, e.g. Breathiness, pressed voice/glottal fry.
  • Supra-glottal influences on vocal quality.
  • Resonance mechanisms/factors in larynx and extra-laryngeal structures.
  • Acoustic and aerodynamic principles of phonation, e.g. Source-Filter/Acoustic Theory

2. Causes & Classifications

Anatomical Factors:

  • Examples: tumours; infections; mucosal changes from use/misuse; laryngeal trauma (internal/external); contact ulcer and granuloma; cysts, sulci, and mucosal bridges; congenital and acquired webs; Cricoarytenoid Joint Problems; Neurological Factors: Motor Speech Disorders; occupational diseases; environmental toxins/sensitivities; irritable larynx/laryngeal breathing dysfunction (e.g. chronic cough, laryngospasm-PVFM, Globus).

Lifestyle Factors: 

  • Examples: Vocal dose; environmental; acoustic; ergonomic; occupational; habitual misuses.

Emotional & Psychological Factors:

  • Examples; autonomic and voluntary nervous system responses to emotional stressors; levels of emotional awareness; attachment factors; Conflict Over Speaking Out (COSO); psychiatric disease.

Reflux:

  • Lifestyle, anatomical factors contributing to LPR; responses of laryngeal valve; chronic laryngeal irritability

Technique:

  • Examples; alignment/posture; specific regional muscle misuses, e.g. jaw clenching; laryngeal misuses, e.g. valving; inappropriate speech breathing; misuses related to register/pitch use, intensity use.

3. Assessment of Voice Disorders

  • Speech-breathing measures (e.g. kinematics; dynamics; vital capacity; phonatory flow volumes).
  • Multi-factorial, client-centred history taking for voice/laryngeal dysfunction including standardized self-report protocols.

Perceptual Evaluations:           

  • Auditory perceptual protocols. (E.g. CAPE-V; Vocal Profile Analysis; GRBAS.
  • Other perceptual protocols. (E.g. manual evaluation; visual analysis of posture)

Instrumental Evaluations:

  • Acoustic measures: for intensity; rate; duration measures of typical values and ranges.
  • Spectral-acoustic measures of vocal perturbations, Cepstral measures.
  • Aerodynamic measures of voice production: phonatory flow rates, volumes; estimated sub-glottal pressure and glottal/laryngeal airway resistance measures; phonation threshold pressures.
  • Laryngeal endoscopy: intra-oral; trans-nasal rationale, protocols including stroboscopic assessment of vocal fold vibratory movements.
  • Other instrumental measures: E.g. electro-glottography; slow-motion photography-kymography; laryngeal electromyography

Diagnostic Voice Therapy:

  • Selection process for therapy probes: How do we choose diagnostic therapy approaches based on information obtained from knowledge of normal and abnormal anatomy/physiology, client history and assessment results?

4. Voice Therapy Approaches

  • Focused/symptomatic therapy approaches and applications.
  • Comprehensive therapy approaches and applications.
  • Augmentative/holistic therapy approaches and applications.

Prerequisite Resource Examples for Voice Endoscopy Education

American Speech-Language-Hearing Association (ASHA)

Speech-Language & Audiology Canada (SAC)

SpeechPathology.com

Carolina Speech Pathology

Aronson, A.E. and Bless, D.M. (2009) Clinical voice disorders 4th Edition, New York: Thieme.

Baker J and Lane RD (2009) Emotion Processing Deficits in Functional Voice Disorders. Chapter 7 in

Emotions in the Human Voice, Vol III, K. Izdebski (Ed). San Diego: Plural Publishing: 105-135.

Ferrand, CT (2012) Voice Disorders: Scope of Theory and Practice, Allyn & Bacon

Harris, T. (1998). Laryngeal mechanisms in normal function ad dysfunction. In T. Harris, S. Harris, J. S.

Rubin & D. M. Howard (Eds.), The Voice Clinic Handbook, 64-90. London: Whurr Publishers Ltd.

Hixon, T and Hoit, J. (2005) Evaluation and Management of Speech Breathing Disorders, Reddington Brown LLC

LeBorgne, W (2018) Rating Laryngeal Videostroboscopy and Acoustic Recordings. Plural Publishing.

Morrison, M. D., & Rammage, L. A. (1993). Muscle misuse voice disorders: description and classification. Acta Otolaryngologica, 113, 428-434.

Morrison, M. D., Rammage, L. A. & Emami, A. J. (1999). The irritable larynx syndrome. Journal of Voice, 13(3), 447-455

Morrison M, Rammage L. (2010) The irritable larynx syndrome as a Central Sensitivity Syndrome. Canadian Journal of Speech-Language Pathology and Audiology 2010;4(4):282-289.

Rammage L., Shoja S. and Morrison M. (in press) Muscle Misuse Disorders of the Larynx.  Chapter 93: Ballenger`s Otorhinolaryngology, Head and Neck Surgery, 18th Edition.  J.B Snow and P.A. Wackym, (eds.) BC Decker.

Sapienza C, Hoffman Ruddy, B (2018) Voice Disorders. Plural Publishing.

Sapienza C, Hoffman Ruddy, B Visual Examination of Voice Disorders- DVD Plural Publishing

Titze, IR. Principles of Voice Production

Van den Berg (1960) The Vibrating Larynx.

For further information, please contact Mardi Lowe, Director, Quality Assurance & Professional Practice at Mardi.Lowe@cshbc.ca.

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College of Speech and Hearing Health Professionals of British Columbia

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