A voice disorder is when the loudness, pitch, quality, and resonance are judged to be abnormal . Also known as dysphonia.

When judging voice, always consider…

  • age
  • gender
  • cultural community

Underlying causes include:

  • nodules
    • benign lesions on the vocal folds found on both adult and children caused by continuous use and misuse of voice
      • prevents complete closure of the vocal folds
      • causes breathiness and sounds hoarse
  • polyps
    • similar to nodules, but found unilaterally; slightly deeper lesions; caused by excessive vocal use or a single traumatic event
      • prevents complete closure of the vocal folds
      • breathy and hoarse
  • webbing
    • a web of tissue across the glottis; can be from birth or acquired; connecting at the anterior region
    • if it covers more, it can affect breathing (will need surgery)
  • cancer
    • malignant growth in the laryngeal system (supraglottal, subglottal, or the surface of the vocal folds- glottal)
      • voice production varies depending on location
      • voice disorders can be secondary cause by cancer
        • surgery, radiation,etc.
  • paralysis
    • unilateral or bilateral cause by some neurological lesion (most likely the vagus (X) facial nerve)
      • varies depending on severity and location of lesion
      • could be complete paralysis of voice
      • breathy, hoarse, weak, quiet
      • false vocal folds may compensate
  • spasmodic dysphonia
    • neurological condition
    • really strained, strangled, effortful voice
  • reflux disease
    • acid from stomach can cause an edema
  • laryngitis
    • can be secondary to a viral disease (cold, etc.) or overuse and inflammation of the laryngeal tissue and muscles


  • pitch too high or too low
  • loudness is too quiet, too loud, or does not vary
  • voice quality
    • harsh: grating and unpleasant, excessive tension
    • breathy: too much air leakage
    • hoarse: combination of breathy & harsh; husky; associated with laryngitis
    • strident: shrill; very tense & very high
    • strider: when vocal folds close on inhalation (voicing on breathing in)
    • diplophonia: producing two different pitches at one time
    • pitch breaks: voice cracks (problem in adults)
    • estranged/strangled voice: tight, estranged voice
    • glottal fry: continually or at the end of a breath group
  • resonance
    • hyper nasal: too much air going through the nose
    • hypo nasal: air not going through the nose


Assessment Areas


  • muscle tension
    • strained neck area
  • neurological involvement
    • weakness on one side
    • tremors
  • adequate mouth opening
    • oral resonance
  • loudness
    • too loud? too soft?
  • excessive speaking
  • frequent throat clearing/coughing?
    • excess force created by the vocal folds
  • allergies?


  • see if they have enough respiratory support to produce voice
  • breathing patterns
    • thoracic breathing
    • diaphragmatic breathing
    • clavicle breathing
  • maximum phonation time
    • female ~ 20 seconds
    • males ~ 25 seconds
  • s-z ratio
    • sustain an “s” and then a “z”
      • you want the ratio to be equal
      • if you have growths on vocal folds, “z” will be shorter because it is voiced
      • any ratio greater than 1.4 is not good
  • words per breath
    • no precise norms
    • short phrases typically indicate insufficient breath support
    • should be at least 12+ words per breath


  • use voice software to look at this
    • too high? too low?
    • does it match what their optimal pitch should be?


  • too loud? too soft?
    • if it is too loud, it could be a behavioral problem or a neural involvement (dysarthria)
    • too soft may be because of neurological involvement (ALS, Parkinson’s), structural (paralysis) or cultural (what is considered appropriate)
  • listen and interview family
  • can the client vary their loudness?


  • harsh, breathy, hoarse, strident, strider, diplophonia, pitch breaks, estranged/strangled voice, glottal fry?


  • hyper nasal or hypo nasal?

Interview Questions

  • What are your voice concerns?
  • Did this begin suddenly or develop slowly?
  • Are there specific situations when voice trauma occurs?
  • When is your voice better? When is it worse?

Formal Tests

  • Boone Voice Program for Children- second edition
  • The Boone Voice Program for Adults- third edition
  • Systematic Assessment of Voice (SAV)
  • Voice Assessment Protocol for Children and Adults (VAP)
  • Voice Impact Profile (VIP)
  • Iowa Patient’s Voice Index (IPVI)
  • Dysphonia Severity Index
  • Voice Activity and Participation Profile (VAPP)
  • Computerized Speech Laboratory (CSL)
  • Praat: Doing Phonetics by Computer

Alternative Assessment Measures

  • Case history (including referral input, client interview, client’s own impact ratings)
  • Checklist of Vocal Characteristics
  • Pushing or pulling techniques: the client should attempt to phonate /a/of optimal quality while pushing down or pulling up on his or her chair
  • Yawn-sign: the client should yawn or sigh audibly in a relaxed manner

Initial Treatment Goals

  • The client will demonstrate improved vocal quality for speech at conversational level to communicate basic medical and social needs in a functional living environment.
  • The client will demonstrate less than 2% perturbation for sustained vowel /a/ for 15 seconds via visual feedback.


  • http://www.everydayfamily.com/blog/all-about-childhood-voice-disorders/
    • This website provides families with basic information about children voice disorders. The page provides families with the definition of voice disorders and potential causes. It also gives a basic outline of how a voice disorder is diagnosed and treated. Different steps for prevention of voice disorders are also listed on the website.
  • https://www.allinahealth.org/ahs/ski.nsf/page/10982-JS10842SKRIKKVoiceDisorders.pdf/$FILE/10982-JS10842SKRIKKVoiceDisorders.pdf
    • This page provides a definition of voice disorders, as well as the potential causes. It provides potential signs and symptoms that a child may have a voice disorder. The pages give parents an idea of the next steps and what they need to do to get help for their child if they have a voice disorder. Diagnosis and prognosis information are also provided.
  • http://www.asha.org/public/speech/disorders/NodulesPolyps/
    • This website, from the American Speech-Language-Hearing Association, gives information about vocal cord nodules and polyps, which are directly related to voice disorders. This page provides families with basic definitions, common signs and symptoms to look for, as well as the different potential causes. It outlines the treatments and what therapy may look like for a patient.


  • Andrews, M.L. & Summers, A.C. (2001). Voice treatment for children and adolescents. Cengage Learning.
    • This book is a potential resource for SLPs in the school setting. The text addresses the psychological aspects of childhood voice disorders. It also includes voice therapy for children that emphasizes hands-on treatment strategies.
  • Hartnick, C.J. & Boseley, M.E. (2008). Pediatric voice disorders. Plural Publishing, Inc.
    • This text provides a comprehensive view of voice disorders in children by incorporating basic science, evaluation, and treatment. It includes information on the development of the larynx and voice production. Different perspective are taken into account, including speech pathology and quality of life, to create different treatment approaches.
  • http://www.asha.org/Publications/leader/2013/130301/Strike-the-Right-Cord.htm
    • This article focuses on voice disorders. It outlines the basic difficulties associated with a voice disorder. The page also includes treatment methods that can be incorporated into everyday life. SLPs are challenged to look further into the child’s medical history about the different causes of voice disorders. The SLP role in voice disorders is also clearly stated.


Haynes, W. O., & Pindzola, R. H. (2012). Diagnostics and evaluation in speech pathology (8th ed., pp 215-237). Pearson.

(1997–2014) American Speech-Language-Hearing Association (ASHA)

SPAUD 501: Diagnostics notes; Heather Koole (Calvin College)

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