Journal of Voice - Articles in Press

The Effect of Vocal Fold Adduction on the Acoustic Quality of Phonation: Ex Vivo Investigations - Corrected Proof

2012-05-14

Summary: Objectives: The purpose of this study was to investigate the effect of vocal fold adduction on voice quality in an ex vivo larynx model.Study Design: Prospective, repeated-measures experiments.Methods: Ten excised canine larynges were mounted on an excised larynx phonation system and measurements were recorded for three different vocal fold adduction levels. Acoustic perturbation measurements of jitter, shimmer, and signal-to-noise ratio (SNR) were calculated from recorded radiated sound histories.Results: Ex vivo experiments indicated that statistically significant increases in the means of jitter (P=0.005), shimmer (P=0.002), and SNR (P=0.011) measures decreased with respect to vocal fold adduction as the independent variable. Theoretical results showed that the direct current (DC) and alternating current (AC) component of glottal area increased monotonically with prephonatory glottal area.Conclusions: Acoustic perturbation increased with the degree of vocal fold abduction. Ex vivo larynx measurements suggested that a hyperadducted state may be acoustically best. This may be explained theoretically by an increase in DC/AC ratio as the prephonatory area is increased.

Pregnancy and Voice: Changes During the Third Trimester - Corrected Proof

2012-05-14

Summary: Introduction: From conception to postpartum, pregnancy is a state in which physiologic, metabolic, and anatomic parameters are altered. Pregnancy could affect voice attributes by changing quality and perturbation rates, mainly during the third trimester. The aim of this study was to compare voice attributes between third trimester pregnant and nonpregnant matched women.Study Design: A case-control study was undertaken with third trimester pregnant women attending the antenatal care clinic of the Hospital Italiano in Buenos Aires. We analyzed and compared values of fundamental frequency, maximum phonation time, vocal intensity, perturbation rates, and physical acoustic qualities.Results: Most pregnant women showed abnormal parameters of auditory perceptual evaluation, a higher incidence of gastroesophageal reflux, predominance of clavicular breathing, and a reduction of phonation time.Conclusions: Significant differences found in both groups suggest that physiologic and body changes produced during pregnancy affect voice quality.

Analysis of Male Singers Laryngeal Vertical Displacement During the First Passaggio and its Implications on the Vocal Folds Vibratory Pattern - Corrected Proof

Pedro Amarante Andrade — 2012-05-14

Summary: Objectives: The first voice passaggio in classical western singing is characterized by changes in the vocal tract resonance and configuration around the middle C region (261.62Hz). Many singers agree that something occurs at the level of the vocal folds to aid the demand for higher frequencies. However, although many singers explore this transitional mechanism, little is known about its precise physiology and association with the vertical displacement of the larynx. The objective of this study is to describe the implications of the vocal tract readjustment and the vocal folds vibration during the passaggio.Methods: The study consisted of 11 well-experienced singers performing an ascending scale up to a few notes above middle C while maintaining a consistent vocal tract configuration and finally sustaining the very last note, hence violating the normal passaggio. Subsequently, they reproduced the last sustained note with their traditional configuration of the larynx—western opera singing style. The data were collected with an electroglottography device. A repeated-measures analysis of variance (ANOVA) was applied to analyze the vocal tract length changes, vocal fold contact area (VFCA), and closure quotient before and after the first passaggio. A paired sample t test was implemented to analyze the formants transition.Results: The results show a significant difference of scores for the formants transition, VFCA, and vocal tract length suggesting that the larynx lowers after the passaggio. This displacement of the larynx is associated with changes on the vocal folds vibratory pattern conjecturably altering from essentially isotonic contraction of the thyroarytenoid muscle to isometric contraction.

Rescue Microlaryngoscopy: A Protocol for Utilization of Four Techniques in Overcoming Challenging Exposures in Microlaryngeal Surgery - Corrected Proof

Jeffrey Cheng, Peak Woo — 2012-05-14

Summary: Objective: To discuss four techniques used to overcome the problem of difficult exposure during operative microlaryngoscopy (microdirect laryngoscopy [MDL]). The protocol uses four techniques in escalating fashion. These techniques are: high-frequency jet ventilation (high-frequency positive pressure ventilation [HFPPV]), using a narrow-bore diagnostic laryngoscope (Holinger) with suspension, using the 30° and 70° telescopes with angled instruments, and using a flexible laryngoscope through a laryngeal mask anesthesia (LMA) device.Methods: From 1996 to 2010, endoscopy photographs from 1840 cases of MDL were reviewed. There were 12 cases used with HFPPV. Ten cases were done with the small-bore Holinger laryngoscope. Two cases were done using telescopes, and one case necessitated the use of a therapeutic flexible laryngoscope through the LMA device. Only one case was aborted because of poor ventilation. These 26 cases are reviewed.Results: Most microlaryngoscopy procedures (98.5%) were able to be performed with standard operating laryngoscopes using the microscope. Risk factors that contributed to difficulty in exposure included two cases of prior radiation therapy, one case of morbid obesity, and one case of Pierre Robin anomaly. The rest was unexpected. Switching from endotracheal intubation to HFPPV allowed adequate exposure in 12 patients while preserving magnification and bimanual instrumentation. Ten cases were able to be done with MDL using a diagnostic narrow-bore diagnostic (Holinger) laryngoscope. When the above approaches fail, an angled telescope with an angled cup forceps was able to reach the lesion in two cases. Finally, one patient who could not be intubated was managed with a flexible laryngoscope through the LMA device.Conclusion: Difficult exposure during MDL is unusual but not rare. It is often unanticipated. A proposal for graded use of the four techniques preserves some advantages of MDL. With each escalation, there is a degradation of the advantages afforded by traditional MDL. These include minor increase in movement with HFPPV, loss of binocular visualization with diagnostic laryngoscopes, loss of bimanual instrument manipulation with the telescopes, and loss of stability with flexible laryngoscopy. Having an understanding of each technique and the need for escalation will allow the surgeon to perform rescue laryngoscopy and complete the surgery.

Prevalence of Voice Symptoms and Risk Factors in Teacher Students - Corrected Proof

2012-05-14

Summary: Teacher students seem to have low awareness of the vocal demands in their future professions, and students with vocal symptoms are at risk for developing voice disorders during their professional careers. The purpose of the present study was to determine the prevalence of voice problems in teacher students at the very beginning of their education at the university. Of 1636 students approached in the first couple of days, 1250 (76%) answered two questionnaires about voice symptoms, Screen6 and Swedish Voice Handicap Index (Sw-VHI), and one questionnaire about potential risk factors. A majority of the students were women, and their mean age was 23 years (range, 18–52 years). The results showed that 208 of 1250 students (17%) had voice problems, defined as at least two symptoms weekly or more often in Screen6. The proportion of women was larger in the group with voice problems than in the group without voice problems. Significant risk factors for voice problems were vocal fold problems in childhood and adulthood, frequent throat infections, airborne allergy, smoking, hearing problems, previous work as teacher or leader, voice demanding hobbies, and previous speech therapy or voice training. There was a clear association between the number of potential vocal risk factors and the number of voice symptoms. There was also a strong association between the scores of the two questionnaires, the Sw-VHI and the Screen6. Students with voice problems according to Screen6 scored 23.1 (mean Sw-VHI) compared with 7.8 for students without voice problems.

Laryngoplasty With Hyaluronic Acid in Patients With Unilateral Vocal Fold Paralysis - Corrected Proof

Reiter Rudolf, Brosch Sibylle — 2012-05-14

Summary: Objectives: Augmentation of vocal fold with hyaluronic acid (Restylane; Q-Med AB, Uppsala, Sweden) is used as a therapeutic option for insufficient glottic closure in unilateral vocal fold paralysis (UVP). Analysis of the optimal glottic width, effectiveness (long-term voice improvement as a consequence of longevity of Restylane), and safety of this new method was made.Study Design/Methods: In a prospective clinical cohort study, 19 consecutive patients with UVP who received vocal fold augmentation with hyaluronic acid (Restylane) were examined preoperatively; 6 weeks, 6, and 12 months postoperatively by laryngostroboscopy; and their voice was evaluated by subjective, objective, and self-assessment (Voice Handicap Index).Results: In 11 of 19 (58%) patients, a subjectively and objectively acceptable voice quality was observed in a follow-up of 12 months. Eight of 19 (42%) patients had a considerable impairment of the voice after 6 weeks (range: 1–24 weeks). Therefore, another intervention (eg, injection laryngoplasty or thyroplasty) was recommended. An impairment of voice was mainly observed if the preoperative glottal gap during phonation was more than 1mm.Conclusion: A long duration (up to 12 months) of acceptable quality of voice was achieved by augmentation with Restylane, if the glottal gap was 1mm or less videolaryngostroboscopically during phonation. The authors recommend this therapy for temporary voice improvement and to augment vocal therapy, if spontaneous recovery of voice is likely. Long-term results remain to be seen.

The Impact of Hormone Therapy on Vocal Quality in Postmenopausal Women - Corrected Proof

2012-05-14

Summary: Objectives: The main purpose of this study was to investigate the impact of hormone therapy (HT) on vocal characteristics in postmenopausal women by comparing postmenopausal women with HT (n=59) and postmenopausal women without HT (n=46). The second purpose was to investigate the differences in vocal characteristics between two types of HT: estrogen therapy (ET) and estrogen-progestogen therapy (E-PT).Methods: To determine the vocal characteristics in both groups, objective (aerodynamic measurements, vocal range measurements, acoustic analysis, and a determination of the dysphonia severity index) and subjective assessment techniques (perceptual evaluation, videostroboscopic evaluation, and voice handicap index) were used.Results: The postmenopausal women without HT showed a significantly lower speaking fundamental frequency and were able to phonate lower compared with postmenopausal women with HT. No differences in vocal characteristics were found between postmenopausal women with ET and postmenopausal women with E-PT.Conclusion: HT seems to counteract the vocal changes caused by menopause. The type of HT did not affect the outcome in this study.

Response to: Letter to Editor, HPV and Glottic Cancer - Corrected Proof

Se-Heon Kim — 2012-05-11

I think there is little significance whether my article is a good matching case-control study or not. The prevalence of meaningful human papillomavirus (HPV) infection is very low in both laryngeal cancer (1/95, 1%) and control (0/15, 0%); accordingly, there may be no bias for comparison of HPV prevalence between laryngeal cancer and control groups.

HPV and Glottic Cancer - Corrected Proof

Viroj Wiwanitkit — 2012-05-11

I read the recent publication on human papillomavirus (HPV) and glottic cancer (GC) with a great interest. Lee et al concluded that “HPV infection may not be a causative factor in the oncogenesis and biologic behavior of GC.” I have some discussions on this work. First, this work is not a good matching case-control study. The fewer number and not matching control reflect the possibility of bias. Second, focusing on the chip technique, it is noted that “there is a need to standardize the type-specific sensitivity of genotyping methods and to evaluate their accuracy to detect multiple HPV infections.” Indeed, false-positive and negative results of the chip technique are still reported.

Noninvasive Monitoring of Vocal Fold Vertical Vibration Using The Acoustic Doppler Effect - Corrected Proof

Chao Tao, Jack J. Jiang, Dan Wu, Xiaojun Liu, Ann Chodara — 2012-04-23

Summary: Objectives/Hypothesis: To validate a proposed method of noninvasively monitoring vocal fold vertical vibration through utilization of the acoustic Doppler effect and the waveguide property of the vocal tract.Study Design: Validation case-control study.Methods: In this device, an ultrasound beam is generated and directed into the mouth. The vocal tract, acting as a natural waveguide, guides the ultrasound beam toward the vibrating vocal folds. The vertical velocity of vocal fold vibration is then recovered from the Doppler frequency of the reflected ultrasound. One subject (age 32, male) was studied and measurements were taken under three modes of vocal fold vibration: breathing (no vibration), whispering (irregular vibration), and normal phonation (regular vibration).Results: The peak-to-peak amplitude of the measured velocity of vocal fold vertical vibration was about 0.16m/s, and the fundamental frequency was 172Hz; the extracted velocity information showed a reasonable waveform and value in comparison with the previous studies. In all three modes of phonation, the Doppler frequencies derived from the reflected ultrasound corresponded with the vertical velocity of vocal fold vibration as expected.Conclusions: The proposed method can accurately represent the characteristics of different phonation modes such as no phonation, whisper and normal phonation. The proposed device could be used in daily monitoring and assessment of vocal function and vocal fold vibration.

Re: Misun V, Svancara P, Martin V. Experimental analysis of the characteristics of artificial vocal folds. J Voice. 2011;25:308–318 - Corrected Proof

R.J. Baken, Jan G. Švec — 2012-04-23

In a recent article, Misun et al report on a series of experiments that assess the behavior, and especially the aerodynamic properties, of a physical model of the vocal folds. Experiments using physical models have had a long and reputable presence in vocal research. They have added significantly to our understanding of many aspects of vocal behavior of the larynx and clarified important details of the vocal product. In general, however, this approach to the study of phonation has serious limitations about which researchers need to be (and generally are) forthright. Conclusions drawn from the study of physical models need to be constrained by the specific circumstances of the particular experiment and must not extend beyond what the experimental data can justify. In light of this, we have serious concerns about the report by Misun et al.

Comparison of Efficacy, Safety, and Cost-Effectiveness of In-Office Cup Forcep Biopsies Versus Operating Room Biopsies for Laryngopharyngeal Tumors - Corrected Proof

2012-04-23

Summary: Objective: To compare the diagnostic yield, safety, and cost of biopsies of laryngopharyngeal tumor performed in an office setting with those performed in the operating room (OR) under general anesthesia.Study Design: This was a retrospective review of patients’ records at Boston Medical Center from 2006 to 2008.Methods: In-office biopsies were performed using flexible digital videolaryngoscopy with cup forcep biopsies taken via the working channel in patients in whom cancer was strongly suspected. Patients whose in-office biopsies were nondiagnostic or suspected to be falsely negative were taken to the OR for biopsy under general anesthesia and served as the control group.Results: Twelve patients fit the selection criteria and had in-office biopsies attempted. One patient could not tolerate the in-office biopsy. Seven of the 11 in-office biopsies performed were diagnostic for squamous cell carcinoma. The average cost (facility and professional otolaryngology charges) for an in-office biopsy was $2053.91. Five of these patients required further biopsy in the OR at an average cost (charges for surgeon, OR, anesthesia, and recovery room) of $9024.47. There were no significant complications reported for any of the procedures.Conclusions: In patients with strongly suspected laryngopharyngeal cancer, in-office cup forcep biopsies were 64% diagnostic. When compared with the OR, in-office cup biopsies of laryngopharyngeal tumor are safe and considerably more cost-effective. Although 36% of patients required operative biopsies, the cost would have been considerably higher in this cohort if all patients had gone to the OR for biopsies.

Vocal Warm-Up Produces Acoustic Change in Singers’ Vibrato Rate - Corrected Proof

Lynda Moorcroft, Dianna T. Kenny — 2012-04-23

Summary: Vibrato rate and vibrato extent were acoustically assessed in 12 classically trained female singers before and after 25 minutes of vocal warm-up exercises. Vocal warm-up produced three notable changes in vibrato rate: (1) more regularity in the cyclic undulations comprising the vibrato rate of a note, (2) more stability in mean vibrato rates from one sustained note to the next, and (3) a moderating of excessively fast and excessively slow mean vibrato rates. No significant change was found for vibrato extent. The findings indicate that vocal warm-up may regulate vibrato rate. Thus tone quality, which is strongly linked to vibrato characteristics, may undergo positive change as a result of vocal warm-up.

The Effect of Voice Amplification on Occupational Vocal Dose in Elementary School Teachers - Corrected Proof

Christopher S. Gaskill, Shenendoah G. O’Brien, Sara R. Tinter — 2012-04-23

Summary: Two elementary school teachers, one with and one without a history of vocal complaints, wore a vocal dosimeter all day at school for a 3-week period. In the second week, each teacher wore a portable voice amplifier. Each teacher showed a reduction in vocal intensity during the week of amplification, with a larger effect for the teacher with vocal difficulties. This teacher also showed a decrease in hourly vocal fold distance dose as measured by the dosimeter despite incurring longer phonation times. Fundamental frequency and vocal fold cycle dose did not appear to be affected by the use of amplification during the teaching day. Both teachers showed evidence of a possible moderate effect of adjusting vocal intensity in the week after amplification, possibly as a means to recalibrate their perceived vocal loudness. This study demonstrates the usefulness of both vocal dosimetry and amplification in monitoring and modifying vocal dose in an occupational setting and reinforces previous data suggesting the effectiveness of amplification in reducing the vocal load in schoolteachers. Implications of the data for future research regarding prevention and treatment of occupational voice disorders are discussed.

Perception of Vocal Tremor During Sustained Phonation Compared With Sentence Context - Corrected Proof

Amy Lederle, Julie Barkmeier-Kraemer, Eileen Finnegan — 2012-04-23

Summary: Objectives/Hypothesis: Vocal tremor is an acoustical phenomenon characterized by relatively periodic modulations in fundamental frequency and intensity. Although vocal tremor is considered easier to perceive during sustained phonation than during connected speech, systematic comparison between these speech contexts has not been investigated. This investigation compared vocal tremor perception during sustained phonation and connected speech contexts.Study Design: This is a prospective, controlled study with randomized conditions.Methods: Audio recordings from five speakers diagnosed with essential vocal tremor were used for this study. Twenty-four naive adult listeners rated the overall severity (ie, aberrance) of the voice and the degree of shakiness (ie, tremor) during sustained phonation of /i/. A different group of 21 naive adult listeners rated sentence stimuli consisting of two different sentences, one loaded with voiced and the other with voiceless speech sounds.Results: All speakers were rated by listeners to have similar levels of shakiness and overall severity during sustained phonation. However, significantly higher levels of shakiness and overall severity were perceived during sustained phonation than during sentence context. A nonsignificant trend was shown for higher average ratings for shakiness and overall severity on voice-loaded compared with voiceless-loaded sentences.Conclusions: This study demonstrated that vocal tremor is perceived as significantly more severe during sustained phonation than during connected speech. More importantly, individual speakers differed in their ability to reduce vocal tremor perception during connected speech. Thus, sustained phonation does not necessarily offer a valid estimation of the impact of a vocal tremor on an individual’s connected speech.

Letter to the Editor - Corrected Proof

Vojtěch Mišun — 2012-04-23

The review’s introduction includes a statement that the article is solving “especially the aerodynamic properties of a physical model of the vocal folds.” The reverse is the case: our article intentionally does not use the term “aerodynamic properties” throughout its length at all. On basis of all the examined characteristics included, the authors have not identified any considerable effect of the aerodynamic properties on the vocal folds motion during their phonation. Within the detailed analysis of numerous measurements of the vocal folds motion, there was no effect of the aerodynamic forces proved during the air passage through the vocal folds or their effect on the vocal folds motion and further characteristics.

Evaluation of Vocal Fold Vibration with an Assessment Form for High-Speed Digital Imaging: Comparative Study between Healthy Young and Elderly Subjects - Corrected Proof

2012-04-23

Summary: Objectives/Study Design: We conducted a prospective study with a subjective assessment form for high-speed digital imaging (HSDI) to elucidate the features of vocal fold vibrations in vocally healthy subjects and to clarify gender- and age-related differences.Methods: Healthy adult volunteers participated in this study. They were divided into young (aged 35 and younger) and elderly (aged 65 and older) groups, and the scores of an assessment form for HSDI characteristics elaborated at our institution were statistically analyzed.Results: Twenty-six young subjects (males: 9, females: 17; mean age: 27 years) and 20 elderly subjects (males: 8, females: 12; mean age: 72 years) were assigned to our study. Posterior gap and posterior-to-anterior longitudinal phase difference were characteristic to young females, whereas in young males, mucosal wave, anterior-to-posterior longitudinal phase difference, and supraglottic hyperactivity were frequent. In elderly males, axis shift, asymmetry, supraglottic hyperactivity, increased mucosal wave, lateral phase difference, and anterior-to-posterior longitudinal phase difference were frequent; and in elderly females, high incidence of lateral phase difference, atrophic change, anterior gap, and asymmetry were observed.Conclusions: The results show that the behaviors of vocal fold vibrations were diverse even in healthy subjects with no vocal complaints or history of laryngeal diseases, and hence, the diversity of vocal fold vibrations in normal subjects must be taken into account in evaluating vocal fold vibrations.

Individually Customized Implants for Laryngoplasty—Are They Possible? - Corrected Proof

2012-04-20

Summary: Objective: To standardize the design of individually fitted implants based on computed tomographic (CT) images for use in medialization laryngoplasty without intraoperative voice monitoring.Study Design: Prospective tomographic and anatomical experimental study of 10 human cadaveric larynges.Methods: CT scans of 10 excised human larynges were analyzed to define the shape and size of ideal implants for medialization laryngoplasty. Silicone implants were designed according to CT parameters and used in simulated laryngoplasties in the laryngeal specimens. The efficacy of each implant in providing adequate medialization of the vocal fold was evaluated.Results: Diverse shapes and sizes of implants were obtained, reflecting variations in laryngeal anatomy. The implants enabled regular medialization of the entire extent of the free border of the vocal fold, including its posterior aspect. Medialization was considered adequate in all cases.Conclusions: This method proved to be a simple and efficient way to design individualized implants for medialization laryngoplasty, regardless of the size and shape of the larynx.Level of Evidence: Not available.

Nonlinear Dynamic-Based Analysis of Severe Dysphonia in Patients With Vocal Fold Scar and Sulcus Vocalis - Corrected Proof

Seong Hee Choi, Yu Zhang, Jack J. Jiang, Diane M. Bless, Nathan V. Welham — 2012-04-20

Summary: Objective: The primary goal of this study was to evaluate a nonlinear dynamic approach to the acoustic analysis of dysphonia associated with vocal fold scar and sulcus vocalis.Study Design: Case-control study.Methods: Acoustic voice samples from scar/sulcus patients and age-/sex-matched controls were analyzed using correlation dimension (D2) and phase plots, time-domain based perturbation indices (jitter, shimmer, signal-to-noise ratio [SNR]), and an auditory-perceptual rating scheme. Signal typing was performed to identify samples with bifurcations and aperiodicity.Results: Type 2 and 3 acoustic signals were highly represented in the scar/sulcus patient group. When data were analyzed irrespective of signal type, all perceptual and acoustic indices successfully distinguished scar/sulcus patients from controls. Removal of type 2 and 3 signals eliminated the previously identified differences between experimental groups for all acoustic indices except D2. The strongest perceptual-acoustic correlation in our data set was observed for SNR and the weakest correlation was observed for D2.Conclusions: These findings suggest that D2 is inferior to time-domain based perturbation measures for the analysis of dysphonia associated with scar/sulcus; however, time-domain based algorithms are inherently susceptible to inflation under highly aperiodic (ie, type 2 and 3) signal conditions. Auditory-perceptual analysis, unhindered by signal aperiodicity, is therefore a robust strategy for distinguishing scar/sulcus patient voices from normal voices. Future acoustic analysis research in this area should consider alternative (e.g., frequency- and quefrency-domain based) measures alongside additional nonlinear approaches.

Materials of Acoustic Analysis: Sustained Vowel Versus Sentence - Corrected Proof

Kyung Ray Moon, Sung Min Chung, Hae Sang Park, Han Su Kim — 2012-04-20

Summary: Objectives: Sustained vowel is a widely used material of acoustic analysis. However, vowel phonation does not sufficiently demonstrate sentence-based real-life phonation, and biases may occur depending on the test subjects intent during pronunciation. The purpose of this study was to investigate the differences between the results of acoustic analysis using each material.Study Design: An individual prospective study.Materials and Methods: Two hundred two individuals (87 men and 115 women) with normal findings in videostroboscopy were enrolled. Acoustic analysis was done using the speech pattern element acquisition and display program. Fundamental frequency (Fx), amplitude (Ax), contact quotient (Qx), jitter, and shimmer were measured with sustained vowel-based acoustic analysis. Average fundamental frequency (FxM), average amplitude (AxM), average contact quotient (QxM), Fx perturbation (CFx), and amplitude perturbation (CAx) were measured with sentence-based acoustic analysis. Corresponding data of the two methods were compared with each other. SPSS (Statistical Package for the Social Sciences, Version 12.0; SPSS, Inc., Chicago, IL) software was used for statistical analysis.Results: FxM was higher than Fx in men (Fx, 124.45Hz; FxM, 133.09Hz; P=0.000). In women, FxM seemed to be lower than Fx, but the results were not statistically significant (Fx, 210.58Hz; FxM, 208.34Hz; P=0.065). There was no statistical significance between Ax and AxM in both the groups. QxM was higher than Qx in men and women. Jitter was lower in men, but CFx was lower in women. Both Shimmer and CAx were higher in men.Conclusions: Sustained vowel phonation could not be a complete substitute for real-time phonation in acoustic analysis. Characteristics of acoustic materials should be considered when choosing the material for acoustic analysis and interpreting the results.

The Interrater Reliability of Stroboscopy Evaluations - Corrected Proof

Tadeus Nawka, Uwe Konerding — 2012-04-20

Summary: Objectives/Hypotheses: To investigate the interrater reliability of stroboscopy evaluations assessed using Poburka’s Stroboscopy Evaluation Rating Form (SERF).Study Design: Single-factor experiment with repeated measures on the same element.Methods: Evaluations of nine experts pertaining to 68 stroboscopy recordings and 16 SERF variables were analyzed. For the 14 SERF variables possessing interval scale level, interrater reliability was investigated using the intraclass correlations for absolute agreement (ICC-a) and consistency (ICC-c). ICCs-c were computed for both original values and values standardized with respect to raters’ means and standard deviations (ipsative values). For the two nominally scaled SERF variables, “vertical level” and “glottal closure” interrater reliability was investigated using kappa coefficients.Results: For evaluations of single raters, ICCs-a ranged from 0.32 to 0.71, ICCs-c for original values from 0.41 to 0.72, and ICCs-c for ipsative values from 0.43 to 0.72. For mean evaluations of two raters, the corresponding values were 0.48 to 0.83 for ICCs-a, 0.58 to 0.84 for ICCs-c for original values, and 0.60 to 0.84 for ICCs-c for ipsative values. The interval scale variables with the lowest interrater reliabilities were phase closure, phase symmetry, and regularity. The kappa coefficients for vertical level and glottal closure were 0.15 and 0.38, respectively.Conclusions: The interrater reliabilities for vertical level, glottal closure, phase closure, phase symmetry, and regularity are so low that these variables should not be assessed via stroboscopy. For the remaining variables, adequate reliability can be obtained by aggregating evaluations from at least two raters.

Epidemiology of Voice Disorders in Teachers and Nonteachers in Brazil: Prevalence and Adverse Effects - Corrected Proof

Mara Behlau, Fabiana Zambon, Ana Cláudia Guerrieri, Nelson Roy — 2012-04-20

Summary: Purpose: This epidemiological study compared the frequency and adverse effects of voice disorders in Brazilian teachers and nonteachers.Methods: A standardized interview/questionnaire was administered to 3,265 participants; 1,651 teachers; and 1,614 nonteachers recruited from all 27 Brazilian states.Results: Prevalence of reporting a current voice disorder was 11.6% for teachers and 7.5% for nonteachers, respectively (χ2(1)=16.1, P<0.001). Sixty-three percent of teachers and 35.8% of nonteachers reported having experienced a voice problem at some point during their lifetime (χ2(1)=246.6, P<0.001). Teachers reported a higher number of current (3.7) and past (3.6) voice symptoms as compared with nonteachers (1.7 current, 2.3 past) and more often attributed these symptoms to their occupation (P<0.001). Teachers, as compared with nonteachers (1) more frequently reported that their voice limited their ability to do certain tasks within their current occupation (29.9% of teachers vs 5.4% of nonteachers; P<0.001); (2) experienced more voice-related absenteeism over the past year (12.1% of teachers missed 5 or more days of work vs 2.4% of nonteachers; P<0.001); and (3) more often considered changing occupations in the future because of voice problems (16.7% of teachers vs 0.9% of nonteachers; P<0.001). The magnitude of voice-related dysfunction among teachers was similar across Brazilian states, and regional characteristics did not appear to significantly influence the results.Conclusion: This large epidemiological study comparing teachers and nonteachers confirms that teaching at school is a high-risk occupation for developing voice disorders. These voice disorders contribute to reduced job performance, attendance, and force many Brazilian teachers to consider changing occupations in the future because of their voice.

Reply to Letter to the Editor - Corrected Proof

Sabine Skodda — 2012-04-20

On behalf of all authors, I am extremely glad for Dr Karlsson’s thorough verification and recalculation of the formula we had used to calculate the triangular vowel space area (tVSA) in our article “Vowel articulation in Parkinson’s disease” (J Voice. 2011;25:467–472). After I have revised and recalculated our raw data, there is no doubt that the formula published in the article is incorrect, obviously because of an inexplicable (and inexcusable) erroneous mathematical transformation of the original formula for tVSA calculation (as it is, eg, used by Sapir et al, J Speech Lang Hear Res. 2010;53:114–125). We should have recognized this error, but unfortunately, we did not. The revision made by Dr Karlsson is of inestimable worth.

Functional Reinnervation of Vocal Cords After Selective Laryngeal Adductor Denervation-Reinnervation Surgery for Spasmodic Dysphonia - Corrected Proof

Adam S. DeConde, Jennifer L. Long, Bob B. Armin, Gerald S. Berke — 2012-04-20

Summary: Selective laryngeal adductor denervation-reinnervation surgery (SLAD-R) offers a viable surgical alternative for patients with adductor spasmodic dysphonia refractory to botulinum toxin injections. SLAD-R selectively denervates the symptomatic thyroarytenoid muscle by dividing the distal adductor branch of the recurrent laryngeal nerve (RLN), and preventing reinnervation, by the proximal RLN and maintaining vocal fold bulk and tone by reinnervating the distal RLN with the ansa cervicalis. We present a patient who had previously undergone successful SLAD-R but presented 10 years postoperatively with a new regional dystonia involving his strap muscles translocated to his reinnervated larynx by his previous ansa-RLN neurorraphy. The patient’s symptomatic vocal cord adduction resolved completely on division of the ansa-RLN neurorraphy confirming successful selective functional reinnervation of vocal cord adductors by the ansa cervicalis.

Effects of Dehydration on the Viscoelastic Properties of Vocal Folds in Large Deformations - Corrected Proof

Amir K. Miri, François Barthelat, Luc Mongeau — 2012-04-09

Summary: Dehydration may alter vocal fold viscoelastic properties, thereby hampering phonation. The effects of water loss induced by an osmotic pressure potential on vocal fold tissue viscoelastic properties were investigated. Porcine vocal folds were dehydrated by immersion in a hypertonic solution, and quasi-static and low-frequency dynamic traction tests were performed for elongations of up to 50%. Digital image correlation was used to determine local strains from surface deformations. The elastic modulus and the loss factor were then determined for normal and dehydrated tissues. An eight-chain hyperelastic model was used to describe the observed nonlinear stress-stretch behavior. Contrary to the expectations, the mass history indicated that the tissue absorbed water during cyclic extension when submerged in a hypertonic solution. During loading history, the elastic modulus was increased for dehydrated tissues as a function of strain. The response of dehydrated tissues was much less affected when the load was released. This observation suggests that hydration should be considered in micromechanical models of the vocal folds. The internal hysteresis, which is often linked to phonation effort, increased significantly with water loss. The effects of dehydration on the viscoelastic properties of vocal fold tissue were quantified in a systematic way. A better understanding of the role of hydration on the mechanical properties of vocal fold tissue may help to establish objective dehydration and phonotrauma criteria.

Transoral Laser Microsurgery Elevates Fundamental Frequency in Early Glottic Cancer - Corrected Proof

2012-04-09

Summary: Objective: To evaluate the long-term voice characteristics and quality of life of early glottic cancer patients after definitive treatment.Study Design: Case series with chart review in a tertiary care medical center in Taiwan.Methods: Forty-two consecutive patients who received radiation therapy (RT) or transoral laser microsurgery (TLM) for early glottic cancer over 12 months were evaluated for voice laboratory data and quality-of-life measurements.Results: Twenty-four patients received RT, and 18 underwent TLM. There was no difference between the two groups on acoustic and aerodynamic voice measures except for modal fundamental frequency in males. In the Functional Assessment of Cancer Therapy-Head and Neck survey, the TLM group had better communication than the RT group, but there were no differences in voice quality and strength. There was also no significant difference in the Voice Handicap Index 10 evaluation.Conclusions: Male patients who received TLM have higher modal fundamental frequency than male patients who received RT and norms. Voice-related life quality is similar in patients regardless of RT or TLM treatment for early glottic cancer, but those who receive TLM have better communication abilities than those who receive RT.

Effects of Vocal Intensity and Vowel Type on Cepstral Analysis of Voice - Corrected Proof

Shaheen N. Awan, Ashley Giovinco, Jennifer Owens — 2012-04-05

Summary: Objectives/Hypothesis: The purpose of this study was to specifically examine the effects of vocal loudness/intensity condition and vowel type on cepstral analysis measurements.Study Design: Experimental, mixed design.Methods: Sustained vowel samples of /i/, /ɑ/, /u/, and /æ/ were elicited from 92 healthy male and female subjects between the ages of 18 and 30 years at three different vocal loudness conditions: (1) “Comfortable pitch and loudness,” (2) “As softly as possible without whispering,” and (3) “As loudly as possible, without screaming/straining the voice or tensing of the neck region.” Recordings were made using a calibrated headset microphone and digitized to computer. Vowel samples were analyzed for vocal intensity (decibels), fundamental frequency (F0 in Hertzz), and relative amplitude of the smoothed cepstral peak prominence (CPPs in decibels).Results: Significant main effects of loudness condition (with a significant increase in CPPs from quiet to comfortable to loud voice) and gender (males having significantly greater mean CPPs than females) were observed. In addition, results indicated that vowel type had a significant effect on the CPP (greater CPPs for low vowels [/ɑ/ and /æ/] vs high vowels [/i/ and /u/]).Conclusions: The results of this study indicate that both the loudness/intensity of vowel elicitation and vowel type should be monitored closely in both research and clinical situations. Changes in the mode of phonation, as well supraglottal changes that effect vocal tract resonances and vocal intensity, appear to combine to result in substantial differences in the CPPs for different vocal loudness/intensity conditions and vowel types. These results indicate that separate cepstral norms are necessary for vowel type, as well as for gender, when using cepstral analysis as a clinical tool.

Vocal Release Time: A Quantification of Vocal Offset - Corrected Proof

Ben C. Watson, Rick M. Roark, R.J. Baken — 2012-04-05

Summary: Objective: To determine the vocal release time (VRT) for linguistically unconstrained voice offsets in a healthy young adult population.Study design: Sound pressure (SP) and electroglottographic (EGG) recordings were obtained for 57 female and 55 male subjects while producing multiple tokens of three tasks (sustained /ɑ:/, “always,” and “hallways”) at comfortable pitch and loudness.Methods: SP and EGG signals were digitally time reversed and generalized sinusoidal models of the SP and EGG signals were obtained to compare rates of amplitude change. VRT was computed from the time lag of the cross-correlation function.Results: Adjusted mean VRT values were significantly greater for females than for males. There was no systematic effect of age on VRT. However, 25–29-year old and >40 year old females showed shorter VRT values than the youngest female age group.Conclusions: Normative data are presented for a new measure of the duration of vocal offset, VRT. Acquisition of this measure requires little user intervention, thereby minimizing effects of subjective decision making. Comparison with previously reported vocal attack time (VAT) values for the same population suggests phenomenological differences between linguistically and physiologically constrained voice onsets and unconstrained voice offsets.

Analysis of Pitch Range After Arytenoid Adduction by Fenestration Approach Combined With Type I Thyroplasty for Unilateral Vocal Fold Paralysis - Corrected Proof

2012-03-15

Summary: Objective: The purpose of this study was to determine the postoperative pitch range acquired in cases of unilateral vocal fold paralysis, as well as factors affecting outcomes.Subjects and Methods: We analyzed 39 cases of unilateral vocal fold paralysis for which surgery was performed between January 2006 and January 2009 and for which pitch ranges and the items listed below were measured preoperatively and 1 year postoperatively. Arytenoid adduction (AA) and type I thyroplasty were performed simultaneously in all cases regardless of preoperative severity. AA was performed by the fenestration approach as previously reported. In this procedure, the cricoarytenoid and cricothyroid joints are not released. Correlations between pitch range acquired postoperatively and the following items were examined: (1) pre- and postoperative maximum phonation time (MPT), (2) pre- and postoperative mean airflow rate (MFR), and (3) preoperative pitch range. Furthermore, patients were surveyed regarding their ability to sing after surgery, and the pitch range cutoff value dividing ability and inability to sing was calculated.Results: Pitch range increased significantly from 3±4.47 halftones (mean ± standard deviation) preoperatively to 17.5±5.80 halftones postoperatively. Preoperative MPT, MFR, and pitch range did not correlate with postoperative pitch range. Postoperatively, only MPT correlated with the width of postoperative pitch range. Twenty-three of 39 subjects (59%) responded that they were able to sing, and the pitch range cutoff value dividing the two groups was 22 halftones.Conclusion: AA and type I thyroplasty significantly expanded postoperative pitch range. There was no correlation between preoperative severity and width of pitch range acquired postoperatively.

The Teaching Performer: A Survey of Assets Versus Choices in Voice Use - Corrected Proof

Kathryn Barnes-Burroughs, Michael C. Rodriguez — 2012-02-20

Summary: Despite fine instructional texts in voice hygiene such as those of Sataloff (2005), McCoy (2004), and Bunch Dayme (2009), giant strides in diagnostic assessment of vocal risk factors, and compelling vocal dose studies of Titze (2000–2005) and others, challenges continue to persist for singing voice teachers who are also active performers, or “Teaching Performers.” The purpose of this study was to investigate the voice hygiene and voice use practices of Teaching Performers in and out of performance periods, and to assess the readiness of these individuals to consider hygienic changes in their vocal routines. Volunteers from the National Association of Teachers of Singing (N=727) were recruited to participate in an anonymous online survey. Strong instrument validity and reliability was determined through expert vetting for content validity, internal consistency testing (coefficient alpha), and test-retest reliability measurement. Teaching Performers (N=596) responded to 26 questions, supplying voice hygiene and usage information through a variety of response platforms. Vocal health and hygiene habits of self-described “successful” Teaching Performers were revealed through descriptive and comparative data analyses. Consideration of results focuses on perceived benefits and current practices of calculated voice use in the careers of active Teaching Performers. Notably, a gathering awareness of relevant factors of voice hygiene and voice use was detected in the participant population also. The results of this survey indicate a persistent need for further study and also may provide a basis for continuing investigations into vocal health, hygiene, and vocal dosing. Additionally, the study results may provide a foundation for the development of further recommendations in the field of singing voice pedagogy.

Effects of Hepatocyte Growth Factor Injection and Reinjection on Healing in the Rabbit Vocal Fold - Corrected Proof

2012-02-02

Summary: Objectives/Hypothesis: Hepatocyte growth factor (HGF) is a multifunctional polypeptide that plays various roles in embryogenesis and tissue regeneration and exhibits marked antifibrotic activity. The present study sought to assess the effects of HGF injection and reinjection coinciding with its peak of activity on collagen density, vessel density, inflammatory reaction in the lamina propria, and mean epithelial thickness in the injured rabbit vocal fold.Study Design: Prospective, controlled, experimental animal study.Methods: Fourteen rabbits were subdivided into two groups and underwent injury of the vocal folds. Immediately after injury, animals in group 1 received HGF injections into the right vocal fold (RVF), whereas those in group 2 received bilateral HGF injections and a single reinjection into the RVF 10 days after the first, to coincide with the peak of HGF activity. The left vocal folds (LVFs) served as controls in both groups. Histological assessment of laryngeal specimens was performed at 30 and 40 days, respectively.Results: In both groups, collagen density was lower in the right (treated) vocal folds than in the left (control) folds (P=0.018). Vessel density was higher in the RVFs in group 2 (P=0.018). Differences were found in mean epithelial thickness and inflammatory reaction in the lamina propria but did not reach statistical significance.Conclusions: In the scarred rabbit vocal fold, HGF injection is associated with decreased collagen density in the lamina propria, whereas reinjection after 10 days produces decreased collagen density and higher vessel density.

Formant Frequencies of Malay Vowels Produced by Malay Children Aged Between 7 and 12 Years - Corrected Proof

2012-01-30

Summary: The formant frequencies of Malaysian Malay children have not been well studied. This article investigates the first four formant frequencies of sustained vowels in 360 Malay children aged between 7 and 12 years using acoustical analysis. Generally, Malay female children had higher formant frequencies than those of their male counterparts. However, no significant differences in all four formant frequencies were observed between the Malay male and female children in most of the vowels and age groups. Significant differences in all formant frequencies were found across the Malay vowels in both Malay male and female children for all age groups except for F4 in female children aged 12 years. Generally, the Malaysian Malay children showed a nonsystematic decrement in formant frequencies with age. Low levels of significant differences in formant frequencies were observed across the age groups in most of the vowels for F1, F3, and F4 in Malay male children and F1 and F4 in Malay female children.

The Impact of a Voice Counseling Procedure to Select Students With Normal Vocal Characteristics for Starting a Master Program in Speech Language Pathology: A Pilot Study - Corrected Proof

2012-01-30

Summary: Objective: The purpose of this study is to determine objective vocal quality, vocal characteristics, and vocal habits in future speech language pathology (SLP) students and to evaluate the possible impact of a provided vocal counseling procedure. A comparison of vocal data was done in SLP students who had and who had not undergone vocal counseling procedure. It is hypothesized that counseling results in good vocal quality, adequate vocal performance, and appropriate vocal hygiene.Study Design: Randomized controlled study design.Methods: To determine the vocal quality, questionnaires (Voice Handicap Index [VHI]), subjective (videostroboscopic and perceptual evaluations), and instrumental assessment techniques (aerodynamic, vocal range, acoustic measurements, Dysphonia Severity Index [DSI]) were used. Identical voice assessments were made in 71 students who followed and have not (n=83) followed the vocal counseling procedure.Results: The VHI showed the absence of a psychosocial impact of the vocal quality. Thirty percentage of the subjects mentioned hoarseness as the most common vocal complain. Videostroboscopic evaluations revealed normal vocal anatomy and physiology. A significant difference regarding the DSI value was found between the students with (+3.3, 83%) and without (+1.8, 68%) a followed voice counseling procedure.Conclusion: This vocal counseling procedure is added as a standard procedure when future students gain information about the SLP master program. To what extent the presence and content of the vocal education strategy can influence the choice of the profession as an SLP is subject for further research.

Brain Activity in Aphonia After a Coughing Episode: Different Brain Activity in Healthy Whispering and Pathological Aphonic Conditions - Corrected Proof

Koichi Tsunoda, Sotaro Sekimoto, Thomas Baer — 2012-01-30

Summary: A 48-year-old woman visited the authors’ clinic because of aphonia. Laryngeal fiberscopic examination indicated laryngitis and bronchitis, and the authors recognized glottal incompetence when she tried to phonate. The authors performed a functional magnetic resonance imaging (f-MRI) study on the patient’s first visit to their clinic and a second study 35 days after the first visit (30 days after the bronchitis and coughing had completely resolved). The brain activity shown on f-MRI differed markedly in the ordinary speaking and whispering phonation modes at the second visit. This suggests that whispering and pathological aphonia result from completely different brain activity, at least in this specific patient.

Japanese Version of Voice Handicap Index for Subjective Evaluation of Voice Disorder - Corrected Proof

Aki Taguchi, Kazuyo Mise, Kaori Nishikubo, Masamitsu Hyodo, Osamu Shiromoto — 2012-01-30

Summary: Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient’s perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient’s disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient’s psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.

Type and Severity of Pain During Phonation in Professional Voice Users and Nonvocal Professionals - Corrected Proof

Kristiane M. Van Lierde, Joke Dijckmans, Lara Scheffel, Mara Behlau — 2012-01-30

Summary: Objective: The purpose of this study was to determine the presence, frequency, and intensity of pain during speaking in professional voice users and nonvocal professionals and to determine if the presence of pain is significantly related with the profile of the professional voice user. Based on the available literature, significantly more pain symptoms in professional voice users can be hypothesized.Study Design: Sample survey.Methods: To characterize the presence, type, and degree of pain symptoms during speaking, a questionnaire was used. Pain severity was measured by means of a numerical rating scale.Results: Fifty-five (176/320) percent of the nonvocal professionals and 84% (698/832) of the professional voice users mentioned the presence of one or more pain symptoms during speaking. Throat pain was mentioned as the most common pain in both the professional and nonvocal professional voice users. The professional voice users showed significantly more throat, neck, shoulder, headache, ear, and back pain. Moreover, the intensity of throat pain was significantly increased in the professional voice users.Conclusions: This study showed evidence that several types of pain are present with significantly greater frequency in professional voice users. Vocal screening strategies, diagnostic, and treatment protocols should include the assessment of the type and severity of pain. Currently, the voice clinic is working on improving the diagnostic protocol with the objective of defining the combination of tests, which best diagnose voice problems and related complaints and which evaluate progress in vocal characteristics and pain after rehabilitation.

Evaluation of Dysphonic Patients by General Otolaryngologists - Corrected Proof

Seth M. Cohen, Michael J. Pitman, J. Pieter Noordzij, Mark Courey — 2012-01-30

Summary: Objective: To investigate the instruments used by general otolaryngologists to visualize the larynx, assess the perception of the instruments’ capabilities, and understand their comfort diagnosing specific etiologies of dysphonia.Study Design: Cross-sectional survey.Methods: One thousand randomly chosen general otolaryngologists from American Academy of Otolaryngology—Head & Neck Surgery were mailed a survey.Results: The response rate was 27.8%. Mean years in practice were 19.5. Mirror and fiberoptic laryngoscopy were most commonly used. Approximately 84.1% used stroboscopy and 33.7% reported laryngoscopy could assess vibration. Respondents were more comfortable diagnosing conditions with obvious laryngeal structural abnormalities compared with those without, such as central neurologic disorders (P≤0.001). Approximately 46.5% were concerned about overdiagnosing laryngopharyngeal reflux (LPR).Conclusions: Although 84.1% of general otolaryngologists use stroboscopy, one-third may not appreciate the differences between stroboscopy and laryngoscopy. General otolaryngologists are less comfortable diagnosing voice disorders without obvious laryngeal structural abnormalities, and nearly 50% are concerned that they overdiagnose LPR.

Acoustic Comparison of Vowel Sounds Among Adult Females - Corrected Proof

Maria Claudia Franca — 2012-01-30

Summary: Introduction/Objective: This study consist of an experiment comparing acoustic characteristics of vowel production among females. The aim of this investigation was to explore the stability among vowels with quantification of acoustic changes in the voice related to speech production associated with an ample variety of vowel sounds. An additional goal was to establish a systematic control of variables and standardization of the data collection procedures.Methods: All data were collected in a quiet environment using the Computerized Speech Lab (CSL; Kay Elemetrics, Montvale, NJ), a computer-based system designed to measure characteristics of voice. Jitter and shimmer, measures of perturbation that reflect characteristics of voice, were applied. Two additional acoustic measures were examined: (1) noise-to-harmonic ratio (NHR), a general evaluation of presence of noise in the voice signal; and (2) voice turbulence index (VTI), related to turbulence caused by abnormal adduction of vocal folds. A systematic methodology of data collection was organized, in an effort to establish a research protocol based on relevant literature, involving (1) keeping constant fundamental frequency (F0) and intensity, (2) positioning of participants and recording equipment, and (3) environmental noise.Results and Conclusion: When measured acoustic parameters of vowels were compared, results revealed that the vowel sounds had a significant effect on shimmer and VTI. Furthermore, speech sounds classified as back vowels exhibited less perturbation and noise in the acoustic signal: the high-back vowels [u] and []; and the mid-back vowels [o] and [], demonstrated most of the statistically significant reduced values of shimmer and VTI among the 12 vowels compared. Further comparisons among front and back vowels grouped in clusters associated to more and less variability led to statistically significant differences in shimmer, NHR, and VTI. Overall, speech sounds classified as back vowels exhibited less variability and noise. Based on the results of this study, back vowels of the English language should be used in voice acoustic tasks in females, given the higher stability of their acoustic signal, as compared with other vowels tested.

Fundamental Frequency and Perturbation Measures of Sustained Vowels in Malaysian Malay Children between 7 and 12 Years Old - Corrected Proof

2012-01-13

Summary: Objective: The study is going to investigate the fundamental frequency (F0) and perturbation measures of sustained vowels in 360 native Malaysian Malay children aged between 7 and 12 years using acoustical analysis.Methods: Praat software (Boersma and Weenink, University of Amsterdam, The Netherlands) was used to analyze the F0 and perturbation measures of the sustained vowels. Statistical analyses were conducted to determine the significant differences in F0 and perturbation measures across the vowels, sex, and age groups.Results: The mean F0 of Malaysian Malay male and female children were reported at 240±34.88 and 254.48±23.35Hz, respectively. The jitter (Jitt), relative average perturbation (RAP), five-point period perturbation quotient (PPQ5), shimmer (Shim), and 11-point amplitude perturbation quotient (APQ11) of Malaysian male children were reported at 0.43±0.26%, 0.25±0.16%, 0.26±0.15%, 2.48±1.61%, and 1.75±1.04%, respectively. As for female children, the Jitt, RAP, PPQ5, Shim, and APQ11 were reported at 0.42±0.22%, 0.25±0.14%, 0.25±0.13%, 2.47±1.53%, and 1.75±1.10%, respectively.Conclusions: No significant differences in F0 were reported across the Malay vowels for both males and females. Malay females had significantly higher F0 than that in Malay males at the age of 8, 10, and 12 years. Malaysian Malay children underwent the nonsystematic decrement in F0 across the age groups. Significant differences in F0 were found across the age groups. Significant differences in perturbation measures were observed across the vowels in certain age groups of Malay males and females. Generally, no significant differences in perturbation measures between the sex were observed in all the age groups and vowels. No significant differences in all the perturbation measures across the age groups were reported in both Malaysian Malay male and female children.

Vocal Folds Analysis using Global Energy Tracking - Corrected Proof

Gal Elidan, Josef Elidan — 2012-01-13

Summary: Introduction: Detection and quantification of oscillatory irregularities in laryngeal videostroboscopy can be particularly difficult for the human expert. Accordingly, there is a wide interest in automated methods for recovering the folds' temporal trajectory. Unfortunately, current methods typically provide only crude glottal measurements.Objectives: An automated procedure for consistently tracking the entire vocal folds' boundary in laryngeal stroboscopy videos, even when the glottal opening is closed.Methods: A preprocessing frame-by-frame crude midpoint identification is followed by an active contour evolution to detect the global boundary in each frame independently. A global energy active contour is then jointly defined over the entire video sequence, and the full glottal boundary is detected throughout the video via standard energy minimization.Results: The vocal folds' boundary is accurately tracked in normal and abnormal stroboscopy videos collected in a clinical setting, and that exhibit a varied range of visual characteristics (eg, lighting conditions). A proof-of-concept evaluation based on the analysis of the waveform of the location of points along the boundary separates between a normal and two markedly different abnormal subjects, and automatically provides a hypothesized localization of the abnormality.Conclusion: The first method for automatically tracing the temporal trajectory of all points along the vocal folds' boundary in all frames of a stroboscopy video is presented. The approach opens the door for novel analysis of all regions of the contour, which in turn may lead to automated localization of pathologies.

Comparison of Rater’s Reliability on Perceptual Evaluation of Different Types of Voice Sample - Corrected Proof

2012-01-13

Summary: Objective/Hypothesis: The objective of this study was to determine whether different types of voice samples affect rater reliability and which type of sample can be rated most reliably, with particular reference to two types of connected speech—passage reading and conversational speech.Study Design: Prospective reliability study.Methods: One hundred fifty voice samples from 40 speakers were presented to 14 speech pathologists experienced in managing voice disorders. Each speaker contributed three types of voice samples: sustained vowels, passage reading, and conversational speech. Ratings were made on four vocal parameters—overall severity, roughness, breathiness, and strain—on a 10-point equal-appearing interval scale.Results: Differences in intrarater reliability across the three types of voice samples were noted. Higher intrarater reliability was achieved with connected speech than with sustained vowel samples. Interrater reliability showed no statistically significant difference across the three types but increased with the severity of dysphonia.Conclusions: This study reveals that raters give internally more reliable ratings for connected speech samples. Results also indicate that voices with severe disorders appear to be rated more reliably.

Creating a Mastery Experience During the Voice Evaluation - Corrected Proof

Heather Shaw Bonilha, Amy Elizabeth Dawson — 2012-01-13

Summary: Objectives: Adherence to treatment is a common challenge when working with patients with voice disorders. Improving their self-efficacy through a mastery experience has the potential to improve treatment adherence. An ideal mastery experience gives early and quick evidence that the patient will be successful with the treatment and works for a broad range of patients. This study sought to test whether a brief stimulability trial of forward focused voice could produce sufficient change in acoustic analysis measures to provide visibly improved objective results and, thus, be a potentially useful mastery experience.Study Design: Prospective, repeated measures, pre- and posttreatment.Methods: Twenty-four consecutive patients with varying diagnoses referred for a voice evaluation participated in this study. Acoustic analysis was completed before and after a short stimulability trial of forward focused voice. Acoustic analysis parameters evaluated include fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and voice turbulence index. Data pre- and posttreatment were analyzed for change and compared with normative values.Results: Results demonstrated a significant change from pre- to posttrial, as indicated by the objective measure transitioning from being outside to within normal limits, in 75% of patients (P=0.000). When less rigid criterion of a positive change in one or more of the three acoustic measures of interest is used, improvement was noted in 96% of patients.Conclusion: Pairing a trial therapy with acoustic analysis during a voice evaluation is a possible mastery experience. Future research is needed to determine if this mastery experience improves self-efficacy, treatment adherence, and treatment outcomes.

A New Voice Rating Tool for Clinical Practice - Corrected Proof

James Gould, Jessica Waugh, Paul Carding, Michael Drinnan — 2012-01-03

Summary: Aims: Perceptual rating of voice quality is a key component in the comprehensive assessment of voice, but there are practical difficulties in making reliable measurements. We have developed the Newcastle Audio Ranking (NeAR) test, a new referential system for the rating of voice parameters. In this article, we present our first results using NeAR.Methods: We asked five experts and 11 naive raters to assess 15 male and 15 female voices using the NeAR test. We assessed: validity with respect to the GRBAS scale; interrater reliability; sensitivity to subtle voice differences; and the performance of expert versus naïve raters.Results: There was a uniformly excellent agreement with GRBAS (r=0.87) and interrater agreement (intraclass correlation coefficient=0.86). Considering each GRBAS grade of voice separately, there was still good interrater agreement in NeAR, implying it has good sensitivity to subtle changes. All these results were equally true for expert and naive raters.Conclusion: The NeAR test is a promising new tool in the assessment of voice disorders.

A Model for Treating Voice Disorders in School-Age Children within a Video Gaming Environment - Corrected Proof

Suzanne N. King, Larry Davis, Jeffrey J. Lehman, Bari Hoffman Ruddy — 2012-01-03

Summary: Objective: Clinicians use a variety of approaches to motivate children with hyperfunctional voice disorders to comply with voice therapy in a therapeutic session and improve the motivation of children to practice home-based exercises. Utilization of current entertainment technology in such approaches may improve participation and motivation in voice therapy. The purpose of this study is to test the feasibility of using an entertainment video game as a therapy device.Study Design: Prospective cohort and case-control study.Methods: Three levels of game testing were conducted to an existing entertainment video game for use as a voice therapy protocol. The game was tested by two computer programmers and five normal participants. The third level of testing was a case study with a child diagnosed with a hyperfunctional voice disorder. Modifications to the game were made after each feasibility test.Results: Errors with the video game performance were modified, including the addition of a time stamp directory and game controller. Resonance voice exercises were modified to accommodate the gaming environment and unique competitive situation, including speech rate, acoustic parameters, game speed, and point allocations.Conclusion: The development of video games for voice therapeutic purposes attempt to replicate the high levels of engagement and motivation attained with entertainment video games, stimulating a more productive means of learning while doing. This case study found that a purely entertainment video game can be implemented as a voice therapeutic protocol based on information obtained from the case study.

Surgical Removal Followed by Radiotherapy for Refractory Vocal Process Granuloma - Corrected Proof

Yongli Song, Li Shi, Yu Zhao, Daqing Zhao, Mei Shi, Zhihong Deng — 2012-01-03

Summary: Objective/Hypothesis: Vocal process granuloma (VPG) is a challenging disease because of its multifactorial etiology, irrespective of treatments. Conservative treatments had shown limited effects, while surgical attempts of removing lesions were only indicated in certain conditions for high recurrent rates. However, a group of patients remained with refractory disease. The objective of this study was to describe the use of surgical removal followed by radiation therapy in the management of patients with refractory VPG.Study Design: Retrospective reviews were conducted in patients with refractory VPG to evaluate the effects of surgical removal followed by radiation therapy and compared with that of surgical removal alone.Methods: Twenty-one patients with refractory disease were enrolled in our study. Fifteen patients accepted surgical removal followed by radiation therapy the day after operation in a total dose of 15Gy. Six patients who refused radiation therapy accepted surgical removal alone. All patients were followed up for 3–6 years and laryngoscope results were studied in all patients.Results: All of the 15 patients treated with surgical removal followed by radiation therapy in low dose got the disease eliminated completely with mild complications. Recurrences were observed during the 2 weeks to 3 months after operation in five of the six patients who accepted surgical removal alone, whereas no recurrence was observed in the other one in whom the granuloma was believed to be caused by intubation injury.Conclusion: This initial study showed that surgical removal followed by radiation therapy in low dose was a safe and an effective approach to manage VPG with a potential for clinical application, but further studies in a larger cohort for a longer term were needed.

Coprevalence of Anxiety and Depression With Spasmodic Dysphonia: A Case-Control Study - Corrected Proof

2012-01-03

Summary: Introduction: There is evidence supporting an association between depression and anxiety in patients with chronic disease. Spasmodic dysphonia (SD) is a chronic, incurable, and disabling voice disorder. Reported rates of depression and anxiety in SD range from 7.1% to 72%, with a maximum number of 18 patients. The goal of this study was to define the coprevalence of depression and anxiety with SD.Materials and Methods: A single-institution case-control study was performed from May to July 2010. Consecutive patients with SD and benign voice disorders were enrolled prospectively. On enrollment, patients were asked to fill out a questionnaire that reviewed the duration of the voice disorder and personal history of anxiety and depression, including current and lifetime diagnosis.Results: One hundred forty-six controls with benign voice disorders and 128 patients with SD were enrolled. Patients with SD were no more likely to be diagnosed with depression or anxiety than those of the control group (odds ratio [OR]=0.985, 95% confidence interval [CI]=0.59–1.63; and OR=1.314; 95% CI=0.75–2.3, respectively). Additionally, duration of disease was a risk factor for depression in both the SD group and the control group, and the association was not significantly different between groups.Conclusion: Patients with SD were no more likely to have depression or anxiety than those with other voice disorders. It is important for otolaryngologists to be aware of the increased rates of depression in patients diagnosed with chronic diseases, including voice disorders, and to refer to a psychiatrist when appropriate.

Objective and Subjective Assessment of Tracheoesophageal Prosthesis Voice Outcome - Corrected Proof

2012-01-03

Summary: Objective: To investigate the relationships between objective measures and the results of subjective assessment of voice quality and speech intelligibility in patients submitted to total laryngectomy and tracheoesophageal (TE) puncture.Study design: Retrospective.Materials: Twenty patients implanted with voice prosthesis were studied. After surgery, the entire sample performed speech rehabilitation. The assessment protocol included maximum phonation time (MPT), number of syllables per deep breath, acoustic analysis of the sustained vowel /a/ and of a bisyllabic word, perceptual evaluation (pleasantness and intelligibility%), and self-assessment.Results: The correlation between pleasantness and intelligibility% was statistically significant. Both the latter were significantly correlated with the acoustic signal type, the number of formant peaks, and the F2−F1 difference. The intelligibility% and number of formant peaks were significantly correlated with the MPT and number of syllables per deep breath. Moreover, significant correlations were found between the number of formant peaks and both intelligibility% and pleasantness. The higher the number of syllables per deep breath and the longer the MPT, significantly higher was the number of formant peaks and the intelligibility%. The study failed to show significant correlation between patient’s self-assessment of voice quality and both pleasantness and communication effectiveness.Conclusion: The multidimensional assessment seems to be a reliable tool to evaluate the TE functional outcome. Particularly, the results showed that both pleasantness and intelligibility of TE speech are correlated to the availability of expired air and the function of the vocal tract.

Analysis of High-Pitched Phonation Using Three-Dimensional Computed Tomography - Corrected Proof

2012-01-03

Summary: Objectives/Hypothesis: Our aim was to use three-dimensional computed tomography (3DCT) to examine arytenoid cartilage movement during a high-pitched tone task.Study Design: This was a prospective study.Methods: This study included 14 patients with male-to-female gender identity disorder who had undergone 3DCT imaging for surgical simulation between January 2007 and May 2008. First, to prove that the phonation condition was indeed one of the high-pitched phonation, we confirmed the rotational movement of the thyroid cartilage, horizontal gliding movement of the inferior horn, and vocal fold elongation on a high-pitched tone task. Next, we detected the arytenoid cartilage positions of the joint during a comparison of comfortable and high-pitched phonations. We measured the movement direction and movement distance of the arytenoid cartilage.Results: In all cases, the cricothyroid space became narrower (rotation movement), and we observed anterior gliding movement of the inferior horn. In all cases, elongation of the vocal folds by the high-pitched phonation was confirmed and the arytenoid cartilages were displaced both anteriorly and caudally from the position during comfortable phonation by the high-pitched tone task.Conclusions: The arytenoid cartilages did not move posteriorly to elongate the vocal folds during high-pitched phonation. The arytenoid cartilages were pulled anteriorly and moved caudally because of tension associated with vocal fold elongation because of the task of high-pitched phonation. These results suggest that there are no movements at the cricoarytenoid joint that directly control the length of the vocal folds in accordance with pitch.

Pre- and Posttreatment Voice and Speech Outcomes in Patients With Advanced Head and Neck Cancer Treated With Chemoradiotherapy: Expert Listeners’ and Patient’s Perception - Corrected Proof

2012-01-03

Summary: Objectives: Perceptual judgments and patients’ perception of voice and speech after concurrent chemoradiotherapy (CCRT) for advanced head and neck cancer.Study Design: Prospective clinical trial.Methods: A standard Dutch text and a diadochokinetic task were recorded. Expert listeners rated voice and speech quality (based on Grade, Roughness, Breathiness, Asthenia, and Strain), articulation (overall, [p], [t], [k]), and comparative mean opinion scores of voice and speech at three assessment points calculated. A structured study-specific questionnaire evaluated patients’ perception pretreatment (N=55), at 10-week (N=49) and 1-year posttreatment (N=37).Results: At 10 weeks, perceptual voice quality is significantly affected. The parameters overall voice quality (mean, −0.24; P=0.008), strain (mean, −0.12; P=0.012), nasality (mean, −0.08; P=0.009), roughness (mean, −0.22; P=0.001), and pitch (mean, −0.03; P=0.041) improved over time but not beyond baseline levels, except for asthenia at 1-year posttreatment (voice is less asthenic than at baseline; mean, +0.20; P=0.03). Perceptual analyses of articulation showed no significant differences. Patients judge their voice quality as good (score, 18/20) at all assessment points, but at 1-year posttreatment, most of them (70%) judge their “voice not as it used to be.” In the 1-year versus 10-week posttreatment comparison, the larynx-hypopharynx tumor group was more strained, whereas nonlarynx tumor voices were judged less strained (mean, −0.33 and +0.07, respectively; P=0.031). Patients’ perceived changes in voice and speech quality at 10-week post- versus pretreatment correlate weakly with expert judgments.Conclusion: Overall, perceptual CCRT effects on voice and speech seem to peak at 10-week posttreatment but level off at 1-year posttreatment. However, at that assessment point, most patients still perceive their voice as different from baseline.

A Canonical Biomechanical Vocal Fold Model - Corrected Proof

Pinaki Bhattacharya, Thomas H. Siegmund — 2012-01-03

Summary: The present article aimed at constructing a canonical geometry of the human vocal fold (VF) from subject-specific image slice data. A computer-aided design approach automated the model construction. A subject-specific geometry available in literature, three abstractions (which successively diminished in geometric detail) derived from it, and a widely used quasi two-dimensional VF model geometry were used to create computational models. The first three natural frequencies of the models were used to characterize their mechanical response. These frequencies were determined for a representative range of tissue biomechanical properties, accounting for underlying VF histology. Compared with the subject-specific geometry model (baseline), a higher degree of abstraction was found to always correspond to a larger deviation in model frequency (up to 50% in the relevant range of tissue biomechanical properties). The model we deemed canonical was optimally abstracted, in that it significantly simplified the VF geometry compared with the baseline geometry but can be recalibrated in a consistent manner to match the baseline response. Models providing only a marginally higher degree of abstraction were found to have significant deviation in predicted frequency response. The quasi two-dimensional model presented an extreme situation: it could not be recalibrated for its frequency response to match the subject-specific model. This deficiency was attributed to complex support conditions at anterior-posterior extremities of the VFs, accentuated by further issues introduced through the tissue biomechanical properties. In creating canonical models by leveraging advances in clinical imaging techniques, the automated design procedure makes VF modeling based on subject-specific geometry more realizable.