Journal of Voice - Articles in Press

In Memoriam: Thomas J. Hixon, PhD - Corrected Proof

Raymond D. Kent — 2010-02-08

With the passing of Thomas J. Hixon, we have lost a premier scientist, an outstanding teacher and mentor, and a distinguished university administrator. He passed away on March 21, 2009, in Tucson, Arizona. Hixon was educated at Bloomsburg University in Pennsylvania (Bachelor of Science) and the University of Iowa (Master of Arts and Doctor of Philosophy). He did postdoctoral work in physiology at Harvard University. Hixon held faculty appointments at the University of Wisconsin-Madison (1965–1976) and the University of Arizona (1976 until his death). Hixon and his colleagues developed and refined innovative laboratory methods, systematized clinical assessment and intervention for speech and voice disorders, and advanced the understanding of respiratory, laryngeal, and supralaryngeal aspects of speech and song. He authored more than 100 scientific publications, including several articles in the Journal of Voice, and also wrote several books (among them are Respiratory Function in Speech and Song, Respiratory Function in Singing: A Primer for Singers and Singing Teachers, Evaluation and Management of Speech Breathing Disorders: Principles and Methods, and Preclinical Speech Science: Anatomy, Physiology, Acoustics, and Perception). A popular keynote speaker, he gave addresses to the National Association of Teachers of Singing, Pacific Voice Conference, Voice Foundation, British Voice Association, Canadian Voice Care Foundation, Australian National Association of Teachers of Singing, and the Swedish Royal Institute of Technology. Hixon was Editor of the Journal of Speech and Hearing Research (1974–1978) and Editor of the Speech Section of the Journal of Speech, Language, and Hearing Research (2002–2005). His administrative service at Arizona included: head of the Department of Speech and Hearing Sciences, Dean of the Graduate College, Associate Vice President for Research and Graduate Studies, and Director of Graduate Interdisciplinary Programs. Hixon received a number of awards from the American Speech-Language-Hearing Association (ASHA) as well as from other organizations. He was elected a Fellow of the ASHA in 1977, received the Honors of the ASHA in 1995, and was the recipient of ASHA's Kawana Award in 2007. The last award is given in recognition of sustained scientific contributions. He is survived by his wife and scientific collaborator, Jeannette Hoit, and his children, Todd and Kimberly.

Qualitative Characterization of Elastic Fiber Distribution in the Mouse Vocal Fold: Further Development of an Animal Model - Corrected Proof

Christopher R. Watts, Jeffrey A. Marler, Bernard Rousseau — 2010-02-08

Summary: The purpose of this study was to identify the presence and characteristics of the distribution patterns of elastic fibers in a 15-week-old C57BL/6J mouse vocal fold, to confirm the presence and distribution of collagen fibers, and to describe potential gender differences in staining patterns, with the aim of further developing the mouse model for use in translational research of vocal fold physiological mechanisms. The vocal folds from 12 mice, divided equally into gender categories, were stained for elastic fibers and collagen fibers using conventional staining methods. Qualitative (subjective) visual analyses were performed by identifying the staining density of elastic and collagen fibers in the superficial half and deep half of the vocal fold lamina propria. Analyses revealed the presence of elastic fibers in both male and female vocal folds, although patterns of staining density were heavy in the deep half of the lamina propria, a location that is deeper than the greatest concentrations of elastic fibers in human vocal folds. Collagen fibers were also present in locations similar to those within human vocal folds, consistent with previously published data. The results of this study support the use of the mouse model in translational and basic science research, and this model may be especially useful for research aimed at furthering our knowledge of genetic influences on vocal fold structural development and function.

Discrimination Between Pathological and Normal Voices Using GMM-SVM Approach - Corrected Proof

Xiang Wang, Jianping Zhang, Yonghong Yan — 2010-02-08

Summary: Acoustic features of vocal tract function are used widely in the study of pathological voices detection. Classification of normal and pathological voices by acoustic parameters is a useful way to diagnose voice diseases. In this aspect, mel-frequency cepstral coefficients are proved to be effective with traditional classifiers such as Gaussian Mixture Model (GMM). However, the accuracy of the classification method can be further improved. In this article, a Gaussian mixture model supervector kernel-support vector machine (GMM-SVM) classifier is compared with GMM classifier for the detection of voice pathology. We found that a sustain vowel phonation can be classified as normal or pathological with an accuracy of 96.1%. Voice recordings are selected from the Kay database to carry out the experiments. Experimental results show that equal error rates decrease from 8.0% for GMM to 4.6% for GMM-SVM.

Interarytenoid Muscle Botox Injection for Treatment of Adductor Spasmodic Dysphonia With Vocal Tremor - Corrected Proof

Katherine A. Kendall, Rebecca J. Leonard — 2010-02-08

Summary: Objectives/Hypothesis: Up to one-third of patients presenting with adductor spasmodic dysphonia will have an associated vocal tremor. These patients may not respond fully to treatment using thyroarytenoid (TA) muscle botulinum toxin (Botox) injection. Treatment failures are attributed to the involvement of multiple muscle groups in the tremor. This study evaluates the results of combined interarytenoid (IA) and TA muscle Botox injection in a group of 27 patients with adductor spasmodic dysphonia and vocal tremor and in four patients with severe vocal tremor alone.Study Design: Patient-satisfaction data were reviewed retrospectively. Pre- and postinjection acoustic data were collected prospectively.Methods: Acoustic measures of fundamental frequency and cycle-by-cycle variability in frequency (jitter) and intensity (shimmer) were obtained from 15 patients' sustained vowel productions. Measures were collected after TA muscle injection, alone, and after combined TA and IA (TA+IA) muscle injections. In addition, two experienced voice clinicians blindly assessed tremor severity from recordings made for each patient in the two conditions. Patients were also queried regarding their satisfaction with the results of the injections and whether they desired to continue receiving TA+IA treatment.Results: Significant improvement in all acoustic measures except for % jitter was observed after the TA+IA muscle injections. Listeners identified voice samples after TA+IA muscle injections as demonstrating less tremor in 73% of the paired comparisons. Sixty-seven percent of the patients with spasmodic dysphonia and vocal tremor wished to continue to receive IA muscle injections. Only one patient with severe vocal tremor wished to continue with injections.Conclusions: The addition of an IA muscle Botox injection to the treatment of patients with a combination adductor spasmodic dysphonia and vocal tremor may improve voice outcomes.

Review of the Impact of Voice Training on the Vocal Quality of Professional Voice Users: Implications for Vocal Health and Recommendations for Further Research - Corrected Proof

D.E. Hazlett, O.M. Duffy, S.A. Moorhead — 2010-02-08

Summary: Objective: To review the current published available research into the impact of voice training on the vocal quality of professional voice users, to provide implications for vocal health and recommendations for further research.Design: Literature review with a systematic approach.Methods: A systematic search of the literature was conducted using electronic databases and the following defined search terms: occupational voice or occupational dysphonia or voice and occupational safety and health. To obtain the comprehensive relevant literature, no studies were excluded on the basis of study design. In total, 10 studies that investigated the impact of a voice training intervention on the vocal quality of professional voice users as a potential prevention strategy for voice disorders were selected for this review.Results: The 10 studies ranged in design from observational to randomized controlled trials with mainly small sample sizes (N=11–60). Nine studies showed that voice training significantly (P<0.05) improved at least one voice-related measurement from the several investigated from baseline. Five studies reported that voice training significantly (P<0.05) improved at least one measurement compared with no training.Conclusions: Findings indicate that there is no conclusive evidence that voice training improves the vocal effectiveness of professional voice users, as a result of a range of methodological limitations of the included studies. However, some studies did show that voice training significantly improved the knowledge, awareness, and quality of voice. Therefore, there is a need for robust research to empirically confirm this, with implications for vocal health, and occupational safety and health policies.

The Effect of Initiating Oral Contraceptive Use on Voice: A Case Study - Corrected Proof

Richard J. Morris, Mary M. Gorham-Rowan, Archie B. Harmon — 2010-02-08

Summary: Objective: To examine the effects of initiating oral contraceptive (OC) use on spectrally based acoustic measures.Study Design: Case history.Methods: A 23-year-old female volunteered to participate in the study. Voice recordings were obtained during eight consecutive menstrual cycles: two cycles before the onset of OC use and six cycles after the initiation of OC use. Recordings consisted of three trials of the sustained vowel /æ/ and were obtained during the follicular phase (preovulation, days 9–11) and luteal phase (premenstruation, days 20–22) of each cycle. Measurements obtained included the following: (1) H1−H2, the ratio of the amplitude of the first harmonic to the amplitude of the second harmonic, which correlates to closed quotient duration; (2) H1−A1, the ratio of the amplitude of the first harmonic to the amplitude of the first formant, which correlates to glottal width; and (3) H1−A3, the ratio of the first harmonic to the amplitude of the third formant, which correlates to the abruptness of vocal fold closure. In addition, acoustic measures of voice perturbation, jitter, shimmer, and noise-to-harmonic ratio were measured.Results: The participant exhibited changes in glottal characteristics in conjunction with initiation of OC use. Both the H1−H2 and H1−A1 differences changed with OC use relative to menstrual cycle phase. These two measures have been correlated with the glottal measures of closed quotient and glottal width, respectively. However, there was no significant change in the H1−A3 difference, indicating no effect of OC use on the speed of vocal fold closure.Conclusions: The results of this study indicate that the onset of OC use can result in vocal changes as noted by different patterns of glottal adjustment across menstrual cycle phases.

Acoustic Analysis of Voice in Huntington's Disease Patients - Corrected Proof

2010-02-08

Summary: Background/Objectives: Alterations of voice and speech are frequently observed in Huntington's disease (HD). The aim of this study was to assess the degree of voice and speech abnormalities in a group of patients with HD and to analyze possible correlations with degree of disease severity.Patients/Methods: An observational study was carried out on diagnosed cases and controls. The voices of 20 patients were analyzed and compared with an age- and sex-matched control group. Variables analyzed included subjective voice exploration, analysis of aerodynamic efficiency, acoustic analysis measures, and laryngeal examination descriptions. Results obtained were correlated with degree of disease severity.Results: Changes in the Voice Handicap Index and clinical characteristics of the voice were observed. Maximum phonation time was reduced. Acoustic analysis revealed changes that were analyzed. Uncontrolled adduction-abduction movements were observed by laryngeal examination. All results showed a positive correlation with degree of disease severity assessed by the Unified Huntington's Disease Rating Scale.Conclusions: HD causes alterations in subjective voice features, aerodynamic and acoustic analysis measures that are correlated with disease severity.

Vocal Fold Elasticity in the Pig, Sheep, and Cow Larynges - Corrected Proof

Fariborz Alipour, Sanyukta Jaiswal, Sarah Vigmostad — 2010-02-08

Summary: Elastic characteristics of the pig, sheep, and cow vocal folds were investigated through a series of in vitro experiments. Sample strips of the vocal-fold tissue were dissected from pig, sheep, and cow vocal folds and mounted inside a saline-filled ergometer chamber that was maintained at 37°C±1°C. Sinusoidal elongation was applied on the samples to obtain the passive force measurements. Force and elongation data from the samples were recorded electronically with a dual-servo system (ergometer). Stress-Strain data were compared to characterize the interspecies differences in the elastic properties of vocal folds. Pig vocal folds exhibited the most nonlinear stress-strain relationship, indicating the presence of a high level of collagen fibers. Cow vocal folds had the highest Young's modulus, but the tissue displayed a nearly linear stress-strain profile. Previous studies of phonation in these three species have indicated that pig larynges have the highest range of phonation frequencies, making them a good candidate for animal studies. The current study provides quantitative data for the elastic properties of the oscillating laryngeal tissue in these species and indicates that nonlinear behavior of these tissues may lead to wider oscillation ranges.

Adverse Effects of Long-Term Proton Pump Inhibitor Use: A Review for the Otolaryngologist - Corrected Proof

2010-02-08

Objective: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks.Study Design: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form.Results: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified.Conclusion: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B12 and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.

A Comparison of Trained and Untrained Vocalists on the Dysphonia Severity Index - Corrected Proof

Shaheen N. Awan, Anysia J. Ensslen — 2010-01-25

Summary: The purposes of this study were (1) to compare trained and untrained singers on the Dysphonia Severity Index (DSI) and its component measures, and (2) to contribute to normative DSI data for trained singers. This study included 36 untrained participants (15 males and 21 females) and 30 participants (15 males and 15 females) with singing experience between the ages of 18 and 30 years. Measures of maximum phonation time (MPT), highest phonational frequency, lowest intensity, and jitter were obtained for each subject and incorporated into the previously published multivariate DSI formula. Results indicated that vocally trained subjects have significantly higher DSI scores than untrained subjects (mean DSI: 6.48 vs 4.00, respectively), with significant differences observed between trained and untrained groups for three of the four components of the DSI (F0 high; I low; jitter). The findings of this study are consistent with previous reports that indicate significant increases in the DSI with vocal training, and with various studies that have observed increased vocal capability in trained singers versus their untrained counterparts. The results of this study indicate that alternative normative expectations for the DSI may need to be taken into account when using the DSI with patients who have participated in directed vocal training, such as choral participation and voice/singing lessons.

Vocal Polyps: Clinical, Morphological, and Immunohistochemical Aspects - Corrected Proof

2010-01-25

Summary: Objectives: To study the clinical, morphological, and immunohistochemical characteristics of vocal polyps.Study Design: Prospective and retrospective.Methods: Clinical study: 76 medical charts from patients with polyps were reviewed. Histology study: in 42 slides from surgical specimens, the following were analyzed: epithelium, basal membrane, and lamina propria. In the transmission and scanning electron microscopy (TEM and SEM) studies, eight new cases of polyps were included. An immunohistochemical study was carried out in the 42 specimens, using antibody antifibronectin, antilaminin, and anticollagen IV.Results: Genders—43% males and 57% females; age range—between 21 and 40 years (36.85%); and between 41 and 60 years of age (51.31%); smoking and drinking—reported by 39 and 15 patients, respectively; associated symptoms—vocal abuse (61%), gastroesophageal (47%), and nasosinusal symptoms (32%); occupation—teachers (24.0%) and maids (18.0%). Histology—epithelial hyperplasia (31.71%), hyperkeratosis, (14.28%), edema (100%), vessel proliferation (92.86%), and congestion (83.33%). SEM—reduction in mucous lacing and increase in desquamating cells. TEM—hyperplastic epithelium, enlargement of the intercellular junctions, dense subepithelial network of collagen and basal membrane with adhesion loss. Immunohistochemistry—greater immunoexpression of fibronectin, laminin, and collagen IV around the vessels.Conclusions: In vocal polyps, the morphological analyses show lamina propria with edema, vessel proliferation and inflammation, basement membrane with adhesion loss in some areas and dense network of subepithelial collagen. Immunohistochemistry techniques identify pigmentation of the antibodies anti-fibronectin, anti-laminin, and anti-collagen IV in the endothelium of blood vessels.

Impairment of Voice Quality in Paradoxical Vocal Fold Motion Dysfunction - Corrected Proof

Kursat Yelken, Erdogan Gultekin, Mehmet Guven, Ahmet Eyibilen, Ibrahim Aladag — 2010-01-25

Summary: Objectives/Hypothesis: To compare subjective and objective voice-quality parameters between asymptomatic paradoxical vocal fold motion dysfunction (PVFMD) patients and healthy individuals.Study Design: Prospective.Methods: A total number of 12 patients with PVFMD and 12 healthy control subjects had voice evaluations by means of laryngostroboscopy, acoustic analysis (jitter, shimmer, and harmonics-to-noise ratio [HNR]), aerodynamic measurements (maximum phonation time [MPT], s/z ratio), and perceptual analysis (Grade, Roughness, Breathiness, Asthenicity, and Strain Scale [GRBAS] and Voice Handicap Index-10 [VHI-10] scales). Evaluations were conducted when all the patients were asymptomatic.Results: False vocal cord adduction, anteroposterior constriction of the supraglottic larynx, decreased amplitude, and decreased mucosal wave were observed in the great majority of the PVFMD patients during laryngostroboscopy. Mean jitter and shimmer rates were significantly high in PVFMD patients and there was no significant difference in mean HNR between groups (P<0.05). Mean MPT was significantly long in control subjects (P<0.05) and mean s/z ratio was nearly equal between patients and control subjects. There was a statistically significant difference between groups about GRBAS and VHI-10 scales (P<0.05).Conclusions: Based on the subjective and objective voice parameters, voice quality is significantly impaired in asymptomatic PVFMD patients when compared with the healthy control subjects.

What is “Twang”? - Corrected Proof

Johan Sundberg, Margareta Thalén — 2010-01-18

Summary: A single female professional vocal artist and pedagogue sang examples of “twang” and neutral voice quality, which a panel of experts classified, in almost complete agreement with the singer's intentions. Subglottal pressure was measured as the oral pressure during the occlusion during the syllable /pae/. This pressure tended to be higher in “twang,” whereas the sound pressure level (SPL) was invariably higher. Voice source properties and formant frequencies were analyzed by inverse filtering. In “twang,” as compared with neutral, the closed quotient was greater, the pulse amplitude and the fundamental were weaker, and the normalized amplitude tended to be lower, whereas formants 1 and 2 were higher and 3 and 5 were lower. The formant differences, which appeared to be the main cause of the SPL differences, were more important than the source differences for the perception of “twanginess.” As resonatory effects occur independently of the voice source, the formant frequencies in “twang” may reflect a vocal strategy that is advantageous from the point of view of vocal hygiene.

Acoustic Voice Analysis of Patients with Vocal Fold Polyp - Corrected Proof

2010-01-18

Summary: Objectives: The aim of the investigation was to obtain acoustic correlates of the vocal quality of patients with vocal polyps, before and after the endolaryngeal phonomicrosurgery (EPM).Methods: Acoustic voice tests were carried out on 46 female patients with vocal fold polyp, before the EPM intervention and 3 weeks after its completion. Acoustic voice parameters were compared with the control group without voice pathology. The results of the investigation were analyzed acoustically.Results: The results showed that jitter (%), shimmer (%), fundamental frequency variation (vF0), voice turbulence index (VTI), pitch perturbation quotient (PPQ), amplitude perturbation quotient (APQ), and NHR values significantly differentiate the patients with vocal fold polyps from a control group without any pathological changes in the larynx. All of the analyzed parameters improved significantly (P<0.05) after the phonomicrosurgical intervention and tended to reach normal values.Conclusions: The acoustic voice analysis may be used for presurgical and postsurgical voice-status evaluation.

Patient Tolerance of the Flexible CO2 Laser for Office-based Laryngeal Surgery - Corrected Proof

Stacey L. Halum, Aaron C. Moberly — 2010-01-18

Summary: Objective: The OmniGuide flexible carbon dioxide (CO2) laser can be readily used in the office but patient tolerance has not been established. The aim of this pilot study was to determine patient tolerance of the flexible CO2 laser. As a reference point, the 585-nm pulsed-dye laser (PDL) was selected for comparison because it is the only office-based laser in which patient tolerance has specifically been studied.Methods: Prospective pilot study involving office-based surgery candidates with benign laryngeal pathology. Via flexible laryngoscopy, half of each lesion was treated with the CO2 laser and the remaining half with the PDL, alternating the order of the lasers (to account for potential thermal injury from the first laser) and blinding the patient to treatment. Patients rated their discomfort immediately after each laser treatment and then completed postoperative questionnaires for discomfort and voice quality.Results: Ten patients with benign laryngeal disease were included. All patients tolerated the office-based laser surgeries without difficulty. The CO2 laser was extremely well tolerated, with mean pain and burning scores of 2.0 and 2.3, respectively, on a scale of 1–10 (10 being intolerable pain). Postoperative pain questionnaires demonstrated minimal discomfort after the laser treatment. Those with resolution of laryngeal disease had significant voice improvement.Conclusion: Flexible CO2 laser laryngeal surgery is well tolerated in an office-based setting.

High-Speed Imaging and Electroglottography Measurements of the Open Quotient in Untrained Male Voices' Register Transitions - Corrected Proof

2010-01-18

Summary: Vocal fold oscillation patterns in vocal register transitions are still unclarified. The vocal fold oscillations and the open quotient were analyzed with high-speed digital imaging (HSDI) and electroglottography (EGG) in 18 male untrained subjects singing a glissando from modal to the falsetto register. Results reveal that the open quotient changed with register in both HSDI and EGG. The in-class correlations for different HSDI and EGG determinations of the open quotient were high. However, we found only weak interclass correlations between both methods. In 10 subjects, irregularities of vocal fold vibration occurred during the register transition. Our results confirm previous observations that falsetto register is associated with a higher open quotient compared with modal register. These data suggest furthermore that irregularities typically observed in audio and electroglottographic signals during register transitions are caused by irregularities in vocal fold vibration.

A Preliminary Study of the Effect of Acupuncture on Emotional Stress in Female Dysphonic Speakers - Corrected Proof

Elaine Y.L. Kwong, Edwin M.-L. Yiu — 2010-01-18

Summary: This study investigated the effect of acupuncture on emotional stress in subjects with phonotraumatic injuries. This study used a prospective randomized, placebo-controlled group design. The independent variable included the types of acupuncture (genuine vs sham) and the sampling time points (two pre-needling, one in the midway of needling, and two post-needling measurements). The dependent variable was the concentration of cortisol obtained from subjects' saliva samples. Eighteen female subjects with phonotraumatic injuries were randomized to receive either genuine or sham acupuncture at the same acupoints during a 30-minute session. Saliva samples were collected from each subject at 10 minutes pre-needling, immediately pre-needling, mid-needling, immediately postneedling, and 10 minutes post-needling time points. The findings suggested that the subjects' salivary cortisol concentration did not reduce after acupuncture, and thus, acupuncture may not be able to reduce the emotional stress level in female dysphonic speakers.

Cross-cultural Adaptation and Validation of the Voice Handicap Index Into Italian - Corrected Proof

2010-01-18

Summary: Objectives: To evaluate the internal consistency, reliability, and clinical validity of the Italian version of the Voice Handicap Index (VHI).Study Design: Cross-sectional survey study was carried out.Methods: One hundred and seventy-five patients with voice disorders, divided in four groups according to the etiology of the disease (neurogenic, structural, functional, and inflammatory), and 84 asymptomatic subjects were included in the study. Internal consistency was analyzed through Cronbach α coefficient. For the VHI test-retest reliability analysis, the Italian VHI was filled twice by 56 patients and 56 control subjects. The test-retest reliability was assessed through the Pearson correlation test. For the clinical validity assessment, the scores obtained in the pathological group were compared with those found in asymptomatic individuals through the Kruskal-Wallis test. Also, the correlation between VHI and the grade of voice disorder was assessed. Finally, the effect of age and gender on overall VHI and its three subscales was analyzed.Results: Optimal internal consistency was found (α=0.93); the test-retest reliability in both groups was high (r>0.86). Nonparametric Kruskal-Wallis analysis of variance for the overall VHI score and its three domains revealed a significant main effect for group (P=0.000). The control group scored significantly lower than the four groups of voice-disordered patients. The overall VHI score positively correlated with the grade of voice disorder (r=0.43). In the voice-disorder group, age and gender were not correlated to the overall VHI score and to their three domains.Conclusion: The Italian VHI is highly reproducible, and exhibits excellent clinical validity.

Application of the Mandarin Chinese Version of the Voice Handicap Index - Corrected Proof

Wen Xu, Demin Han, Hongyan Li, Rong Hu, Li Zhang — 2010-01-18

Summary: Objectives: To investigate the characteristics and clinical application of Mandarin Chinese version of the Voice Handicap Index (VHI).Methods: A cross-culture adaptation was used to develop the Mandarin Chinese version of the VHI. The translated version was then administered to 1766 dysphonic patients and 120 control subjects; 210 of the patients were treated with phonosurgery or BOTOX injection. Disorders were chronic laryngitis, benign vocal fold disorders, pathologic sulcus vocalis, benign or malignant tumors of vocal fold, spasmodic dysphonia (SD) and unilateral vocal fold paralysis (UVFP), and functional dysphonia.Results: The Cronbach's α score for the overall VHI was 0.956; the functional, physical, and emotional subscales had values of 0.922, 0.872, and 0.933, respectively. The test-retest reliability coefficient was 0.991 (P<0.01). Correlations between the subscales and the overall VHI as well as among the subscales were all significant (P<0.01) Principal-component analysis revealed six-factor eigenvalues exceeding 1, explaining 75.39% of the total variance. The total VHI scores and subscale scores were statistically higher for dysphonic groups (P<0.001). The order of disease classification from highest score to lowest score was: SD, functional dysphonia, UVFP, sulcus vocalis, benign and malignant tumor, benign vocal fold disorders, and chronic laryngitis. The emotional scores were the highest in SD, and followed by functional dysphonia; the physical scores were the highest in the other groups. Treatment leads to statistically improvement in VHI scores (P<0.05).Conclusion: The Mandarin Chinese version of VHI appears to be a reliable and valid tool in assessing dysphonia in Mandarin Chinese speakers.

Delayed Laryngotracheal Reconstruction With Titanium Plate: Report of 10 Cases - Corrected Proof

Ahmad Daneshi, Shabahang Mohammadi, Fatemeh Hassannia — 2010-01-18

Summary: Background: Subglottic stenosis is congenital or acquired narrowing of subglottic area. The management of subglottic stenosis is still a serious surgical challenge. Although different surgical techniques are accomplished to manage the condition, no standard treatment has been presented yet.Study Design: Titanium mesh was used in the reconstruction of the anterior laryngotracheal wall in 10 tracheostomized patients with laryngotracheal stenosis because of prolonged intubation. The anterior laryngotracheal wall was split, followed by excision of scar tissue. After several weeks, in a second-stage performance, the titanium plate was fixed at the split edges.Results: Finally, all the patients were decanulated. However, one patient developed respiratory distress because of granulation tissue and underwent a second trial of decanulation. In one patient, the titanium plate extruded.

A Pathological Study of Bamboo Nodule of the Vocal Fold - Corrected Proof

2010-01-18

Summary: We examined pathologically a bamboo nodule of the vocal fold by means of immunohistochemical studies and scanning electron microscopic examination. A 38-year-old female showed a high index of antinuclear antibodies without any systemic symptoms but had complained of progressive voice disorder for 9 months. She had used her voice excessively in her occupation and for singing. Hematoxylin and eosin staining showed submucosal edema with lymphocyte and neutrocyte infiltrations and hyaline degeneration. Periodic acid methenamine silver staining showed hypertrophy of the basal lamina of the blood vessels.Immunohistochemical study showed IgG-positive cells in the blood vessel walls. Scanning electron microscopic study demonstrated immune complexes deposited as fine granules of high electrodense materials in the hypertrophic walls of the micro-blood vessels. After surgical resection of the bamboo nodules and advising her to avoid using her voice excessively, her voice improved gradually and the levels of IgG, immune complexes, and antinuclear antibody decreased for 1 year. These findings suggest that the bamboo nodules were not induced by an organ-specific reaction to an autoimmune disease, but mechanical damage to the micro-blood vessels induced by phonation injury of the vocal fold might have caused the deposit of high-molecular weight immune complexes in the damaged micro-blood vessels at the midportion of the vocal folds, which induced secondary inflammatory change at the midportion of the vocal fold.

Histological Asymmetry of the Human Recurrent Laryngeal Nerve - Corrected Proof

2010-01-18

Summary: Histological studies of the human recurrent laryngeal nerves (RLNs) have described differences in fiber length and thickness between the right and left RLNs. This asymmetry is probably involved in the different times of arrival of the stimuli to the laryngeal musculature controlled by each nerve. Histological and structural differences between the right and left RLNs could explain the synchronicity of laryngeal musculature contraction despite the differing nerve lengths. The purpose of this investigation was to shed some light on this paradigm by obtaining estimates of some morphometric parameters, such as intraperineural area, intraperineural perimeter, fiber area, fiber perimeter, fiber density (number of fibers/mm2), and total number of fibers in the right and left RLN of humans. Thus, the right and left RLNs were studied in a total sample of eight human specimens obtained from necropsies. The nerves were analyzed using histology, and the morphometric parameters were measured using Image Pro Plus Software 4.1 (Media Cybernetics, Silver Spring, MD, USA). No statistical differences between the two RLNs were observed in the intraperineural area, intraperineural perimeter, density (number of fibers/mm2), and total number of fibers. However, the area and perimeter of fibers of the right RLN were statistically larger when compared with those of the left RLN—21% and 11%, respectively. In conclusion, we show that in humans, the area and perimeter of the right RLN are larger than those of the left RLN. This morphological finding is probably related to the different time of arrival of the stimulus to the laryngeal musculature.

A Short-Term Investigation of Dysphonia in Asthmatic Patients Using Inhaled Budesonide - Corrected Proof

Han Su Kim, Jin Wook Moon, Sung Min Chung, Ja Hyun Lee — 2010-01-18

Summary: Background: Dysphonia is one of the most common side effects of patients who use corticosteroid inhalers. The aim of this study was to investigate, prospectively, the occurrence of dysphonia in patients who used corticosteroid inhalers.Methods: Outpatients aged 18 years or older initially treated with inhaled corticosteroids were recruited. All patients were prescribed budesonide/formoterol. Questionnaires, perceptual studies, and acoustic analysis were performed five times during the study: at study entry and after 1, 4, 8, and 12 weeks. Videostroboscopy was performed at study entry and at 12 weeks. The data collected were analyzed by repeated-measures analysis of variance tests and Wilcoxon's signed rank test (P<0.01).Results: Sixty-two patients were enrolled and 29 patients (M:F=19:10) completed the study. Seven patients reported that they had problems with their voice; however, there were no statistically significant changes in the perceptual studies or the acoustic analysis. The videostroboscopy showed that “injection” and “increase of mucus” significantly increased by week 12. Vocal fold bowing was not noted in any of the patients.Conclusions: The results of this study showed no significant voice changes in patients using corticosteroid inhalers over a period of 3 months. However, minor mucosal changes were found on videostroboscopy.

An Exploratory Study of Voice Change Associated With Healthy Speakers After Transcutaneous Electrical Stimulation to Laryngeal Muscles - Corrected Proof

Linda P. Fowler, Mary Gorham-Rowan, Edie R. Hapner — 2010-01-18

Summary: Objectives: The purpose of this study was to determine if measurable changes in fundamental frequency (F0) and relative sound level (RSL) occurred in healthy speakers after transcutaneous electrical stimulation (TES) as applied via VitalStim (Chattanooga Group, Chattanooga, TN).Study Design: A prospective, repeated-measures design.Methods: Ten healthy female and 10 healthy male speakers, 20–53 years of age, participated in the study. All participants were nonsmokers and reported negative history for voice disorders. Participants received 1 hour of TES while engaged in eating, drinking, and conversation to simulate a typical dysphagia therapy protocol. Voice recordings were obtained before and immediately after TES. The voice samples consisted of a sustained vowel task and reading of the Rainbow Passage. Measurements of F0 and RSL were obtained using TF32 (Milenkovic, 2005, University of Wisconsin). The participants also reported any sensations 5 minutes and 24 hours after TES.Results: Measurable changes in F0 and RSL were found for both tasks but were variable in direction and magnitude. These changes were not statistically significant. Subjective comments ranged from reports of a vocal warm-up feeling to delayed onset muscle soreness.Conclusions: These findings demonstrate that application of TES produces measurable changes in F0 and RSL. However, the direction and magnitude of these changes are highly variable. Further research is needed to determine factors that may affect the extent to which TES contributes to significant changes in voice.

The Objective Vocal Quality, Vocal Risk Factors, Vocal Complaints, and Corporal Pain in Dutch Female Students Training to be Speech-Language Pathologists During the 4 Years of Study - Corrected Proof

2009-11-09

Summary: The purpose of the present cross-sectional study was to determine the objective vocal quality and the vocal characteristics (vocal risk factors, vocal and corporal complaints) in 197 female students in speech-language pathology during the 4 years of study. The objective vocal quality was measured by means of the Dysphonia Severity Index (DSI). Perceptual voice assessment, the Voice Handicap Index (VHI), questionnaires addressing vocal risks, and vocal and corporal complaints during and/or after voice usage were performed. Speech-language pathology (SLP) students have a borderline vocal quality corresponding to a DSI% of 68. The analysis of variance revealed no significant change of the objective vocal quality between the first bachelor year and the master year. No psychosocial handicapping effect of the voice was observed by means of the VHI total, though there was an effect at the functional VHI level in addition to some vocal complaints. Ninety-three percent of the student SLPs reported the presence of corporal pain during and/or after speaking. In particular, sore throat and headache were mentioned as the prevalent corporal pain symptoms. A longitudinal study of the objective vocal quality of the same subjects during their career as an SLP might provide new insights.

Perceptual Findings on the Broadway Belt Voice - Corrected Proof

Wendy DeLeo LeBorgne, Linda Lee, Joseph C. Stemple, Heather Bush — 2009-11-09

Summary: The present study required raters (casting directors) to evaluate the belt voice quality of 20 musical theater majors who were proficient in the singing style referred to as belting. Two specified vocalizes and six short excerpts from the belting repertoire were used for rating purposes. The raters were asked to judge the belters on a set of seven perceptual parameters (loudness, vibrato, ring, timbre, focus, nasality, and registration breaks), and then report an overall score for these student belters. The four highest and lowest average scores were used to establish the elite and average student belters. A correlation analysis and linear regression analysis provided insight regarding which perceptual judgments correlated most highly with the elite and average scores. The present study found the perceptual ratings of vibrato and ring to be most highly correlated to the elite student belter. In addition, vibrato and ring were found to highly correlate with perceived loudness.

Objective Dysphonia Quantification in Vocal Fold Paralysis: Comparing Nonlinear with Classical Measures - Corrected Proof

Max A. Little, Declan A.E. Costello, Meredydd L. Harries — 2009-11-09

Summary: Clinical acoustic voice-recording analysis is usually performed using classical perturbation measures, including jitter, shimmer, and noise-to-harmonic ratios (NHRs). However, restrictive mathematical limitations of these measures prevent analysis for severely dysphonic voices. Previous studies of alternative nonlinear random measures addressed wide varieties of vocal pathologies. Here, we analyze a single vocal pathology cohort, testing the performance of these alternative measures alongside classical measures. We present voice analysis pre- and postoperatively in 17 patients with unilateral vocal fold paralysis (UVFP). The patients underwent standard medialization thyroplasty surgery, and the voices were analyzed using jitter, shimmer, NHR, nonlinear recurrence period density entropy (RPDE), detrended fluctuation analysis (DFA), and correlation dimension. In addition, we similarly analyzed 11 healthy controls. Systematizing the preanalysis editing of the recordings, we found that the novel measures were more stable and, hence, reliable than the classical measures on healthy controls. RPDE and jitter are sensitive to improvements pre- to postoperation. Shimmer, NHR, and DFA showed no significant change (P>0.05). All measures detect statistically significant and clinically important differences between controls and patients, both treated and untreated (P<0.001, area under curve [AUC]>0.7). Pre- to postoperation grade, roughness, breathiness, asthenia, and strain (GRBAS) ratings show statistically significant and clinically important improvement in overall dysphonia grade (G) (AUC=0.946, P<0.001).Recalculating AUCs from other study data, we compare these results in terms of clinical importance. We conclude that, when preanalysis editing is systematized, nonlinear random measures may be useful for monitoring UVFP-treatment effectiveness, and there may be applications to other forms of dysphonia.

Laser Reduction Glottoplasty for Managing Androphonia After Failed Cricothyroid Approximation Surgery - Corrected Proof

2009-11-09

Summary: Objective: To treat androphonic voice quality after failed cricothyroid approximation (CTA) surgery.Study Design: Prospective case series.Methods: The voices of three male-to-female transsexuals, two constitutional androphonic females, and one patient with ambiguous genitalia assigned to the female phenotype were deemed to be unimproved after CTA. The patients underwent laser reduction glottoplasty (LRG) surgery tailored to each case between 2001 and 2005. Vocal outcomes were evaluated according to fundamental frequency (FF), satisfaction status, voice-related quality of life (V-RQOL) measures, and ratings of recorded voices by 10 blinded listeners after 12 months postoperatively.Results: The LRG provided an additional mean gain of 45.17±8.47Hz (mean±standard deviation) in the FF, equal to 4.36±0.84 semitones. The mean FF increased significantly (P<0.05) from 158.33±12.14Hz preoperatively to 203.50±13.34Hz postoperatively. All patients reported satisfactory female quality in their voices and greetings with female salutations in nonvisual communications. Their voice-related quality of life (V-RQOL) measures were high and significantly elevated (P<0.05) after LRG. The masculine voice-quality ratings significantly shifted to feminine in the listeners' assessment. No major complications were observed during follow-up, with the exception of mild vocal fold edema that disappeared by 8 weeks postoperatively.Conclusions: LRG can be used in androphonic cases that fail to obtain a high-pitched feminine voice after CTA.

A Computational Model to Predict Changes in Breathiness Resulting From Variations in Aspiration Noise Level - Corrected Proof

Rahul Shrivastav, Arturo Camacho — 2009-11-06

Summary: Perception of breathy voice quality is cued by a number of acoustic changes including an increase in aspiration noise level (AH) and spectral slope. Changes in AH in a vowel may be evaluated through measures such as the harmonic-to-noise ratio, cepstral peak prominence (CPP), or via auditory measures such as the partial loudness of harmonic energy and loudness of aspiration noise. Although a number of experiments have reported high correlation between such measures and ratings of perceived breathiness, a formal model to predict breathiness of a vowel has not been proposed. This research describes two computational models to predict changes in breathiness resulting from variations in AH. One model uses auditory measures, whereas the other uses CPP as independent variables to predict breathiness. For both cases, a translated and truncated power function is required to predict breathiness. Some parameters in both of these models were observed to be pitch dependent. The “unified” model based on auditory measures was observed to be more accurate than one based on CPP.

Laryngeal Granulomas Associated with Superior Laryngeal Nerve Paresis - Corrected Proof

Stacey L. Halum, Peter Miller, Keith Early — 2009-11-05

Summary: The association between superior laryngeal nerve (SLN) paresis and laryngeal granuloma formation has not been described earlier. The aim of this study was to present a series of patients with isolated unilateral SLN paresis who developed contralateral vocal process granulomas. The study design was a retrospective chart review including all patients presenting to Indiana University from February 2006 to August 2007 with laryngeal electromyography (LEMG)-documented unilateral SLN paresis and evidence of laryngeal granuloma on videostroboscopy. Patient history, examination, LEMG findings, and response to treatment were recorded. Three cases of unilateral SLN paresis associated with contralateral vocal process granulomas were identified. In all patients, videostroboscopy examination demonstrated shortening of the ipsilateral vocal fold on adduction and asymmetric contact of the vocal processes at the site of granuloma formation. All patients failed to respond to aggressive antireflux therapy. One patient had spontaneous recovery of the SLN paresis, with subsequent resolution of the granuloma. Two patients were successfully treated with surgical laser excision of the granulomas and injection of botulinum toxin into the normal cricothyroid muscle to alter the vocal process contact points. Vocal process granulomas can be associated with unilateral SLN paresis, potentially related to altered contact points between the vocal processes of the arytenoids.

Medical Comorbidities for Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction) in the Military Population - Corrected Proof

2009-11-05

Summary: Objectives/Hypotheses: This study aimed to describe the demographic characteristics of patients diagnosed with paradoxical vocal fold motion (PVFM) at Walter Reed Army Medical Center (WRAMC), and to document common medical comorbidities. The military population was expected to differ from the general population because of a presumed association between high physical demands and PVFM.Study Design: Retrospective chart review of active-duty (AD) military personnel compared with a natural control group of non-AD patients.Methods: Reports of asthma, allergy, gastroesophageal reflux disease (GERD), and postnasal drip (consequent to chronic sinusitis) were recorded for patients referred to the Speech Pathology Clinic at WRAMC with a diagnosis of PVFM from 1996 to 2001.Results: The cohort consisted of 265 patients, 127 of whom were on AD status. The AD group was significantly younger and represented a narrower age range (17–53 years) than the non-AD patients (8–80 years), and had a more balanced sex ratio (1.2:1 vs 2.9:1). Eighty percent of all patients had at least one of the medical comorbidities surveyed, and 51% had two or more factors. GERD and allergies were reported most commonly by both groups; only asthma occurred significantly more in non-AD than AD patients.Conclusions: PVFM referrals of AD personnel of the US military are characterized by younger patients and a smaller female:male ratio as compared with non-AD patients. Based on the preponderance of men in the military, the number of females in the AD group remained disproportionately large. Multiple medical comorbidities were commonly documented by both groups; the only significant difference was a greater prevalence of asthma in the non-AD group. These data reinforce the need for appropriate differential diagnosis in all patients.

Evidence of Return of Function in Patients with Vocal Fold Paresis - Corrected Proof

Sheila V. Stager, Steven A. Bielamowicz — 2009-11-02

Summary: Unilateral vocal fold paresis (UVFP) patients were examined over time for achievement of partial or full functional return or no functional return in the extent of arytenoid movement, clarity of laryngeal articulation, maximum phonation time (MPT), and flow. Effects of treatment type and initial laryngeal electromyography (EMG) results were examined. A retrospective chart review was completed for patients a year or less after onset evaluated between April 1999 and December 2005 and treated between 2 and 20 months after onset. Twenty-one individuals were evaluated (11 males, age: 34–89 years) and subsequently treated (10 by injection and 11 by thyroplasty). Evidence of full functional return was found for the extent of arytenoid movement in 25% of individuals, for clarity of laryngeal articulation in 71%, for MPT in 58%, and for flow in 50%. No evidence of functional return was found for the extent of arytenoid movement in 33% of the individuals, for clarity of laryngeal articulation in 8%, for MPT in 32%, and for flow in 22%. All pairs of outcome measures showed poor agreement in the level to which they functionally returned. More individuals with signs of reinnervation demonstrated MPTs with full functional return than expected. Patients with UVFP, even after treatment and at least 12 months postinjury did not demonstrate full functional return for all measures. Differences across measures in the percentage of individuals demonstrating each level of function and the lack of agreement of function level between measures within individuals suggest the need to use multiple outcome measures.

Toward Improved Ecological Validity in the Acoustic Measurement of Overall Voice Quality: Combining Continuous Speech and Sustained Vowels - Corrected Proof

Youri Maryn, Paul Corthals, Paul Van Cauwenberge, Nelson Roy, Marc De Bodt — 2009-11-02

Summary: To improve ecological validity, perceptual and instrumental assessment of disordered voice, including overall voice quality, should ideally sample both sustained vowels and continuous speech. This investigation assessed the utility of combining both voice contexts for the purpose of auditory-perceptual ratings as well as acoustic measurement of overall voice quality. Sustained vowel and continuous speech samples from 251 subjects with (n=229) or without (n=22) various voice disorders were concatenated and perceptually rated on overall voice quality by five experienced voice clinicians. After removing the nonvoiced segments within the continuous speech samples, the concatenated samples were analyzed using 13 acoustic measures based on fundamental frequency perturbation, amplitude perturbation, spectral and cepstral analyses. Stepwise multiple regression analysis yielded a six-variable acoustic model for the multiparametric measurement of overall voice quality of the concatenated samples (with a cepstral measure as the main contributor to the prediction of overall voice quality). The correlation of this model with mean ratings of overall voice quality resulted in rs=0.78. A cross-validation approach involving the iterated internal cross-correlations with 30 subgroups of 100, 50, and 10 samples confirmed a comparable degree of association. Furthermore, the ability of the model to distinguish voice-disordered from vocally normal participants was assessed using estimates of diagnostic precision including receiver operating characteristic (ROC) curve analysis, sensitivity, and specificity, as well as likelihood ratios (LRs), which adjust for base-rate differences between the groups. Depending on the cutoff criteria employed, the analyses revealed an impressive area under ROC=0.895 as well as respectable sensitivity, specificity, and LR. The results support the diagnostic utility of combining voice samples from both continuous speech and sustained vowels in acoustic and perceptual analysis of disordered voice. The findings are discussed in relation to the extant literature and the need for further refinement of the acoustic algorithm.

Voice Disorders in the Metropolitan Area of San Juan, Puerto Rico: Profiles of Occupational Groups - Corrected Proof

Albert Villanueva-Reyes — 2009-11-02

Summary: Objectives/Hypothesis: Approximately 28 000 000 workers in the United States experience voice problems everyday. In general, voice problems are very common, but they are more frequent among certain occupational groups.Study Design: Descriptive cross-sectional study.Method: We analyzed 129 available records of voice-disordered cases reported during the period of 2000–2005 from the Corporación del Fondo del Seguro del Estado in the Metropolitan Areas of Puerto Rico of Bayamón, San Juan, and Carolina. The following variables were studied: sex, age, occupation, possible job hazards, diagnosis, and type of treatment. Measures of central tendency, including percentage frequencies, were used.Results: The findings revealed that 81% of all the cases of voice disorders available during the study period were females. The average age at diagnosis for different voice disorders was 42 years (±10 years). Vocal problems were reported with a higher frequency by teachers at the elementary and high school levels (72%). The most common complaints were job-related voice overuse (30%) and excessive dust at the workplace. The most frequent medical diagnoses related to voice disorders were rhynopharyngitis (27%), several types of laryngitis (21%), and laryngopharyngitis (10%). The most frequent treatment modality for laryngeal disease and voice problems was the prescription of medication.Conclusions: The most relevant factor of voice disorders for professional voice users is the vocal overload during their job. It is advisable to implement voice disorder-prevention programs for teachers because of the high rate of vocal dysfunction among these professionals.

Implantation of Esterified Hyaluronic Acid in Microdissected Reinke's Space After Vocal Fold Microsurgery: Short- and Long-Term Results - Corrected Proof

Camille L. Finck, Bernard Harmegnies, Angélique Remacle, Philippe Lefebvre — 2009-10-23

Summary: In this study are reported the laryngeal and vocal results obtained after a microflap excision of benign vocal fold (VF) lesions and immediate implantation of esterified hyaluronic acid (EHA) in the surgical wound. In a previous pilot study on 11 cases, we have shown an excellent tolerance of this bioimplant. The objectives are to confirm the innocuity of the technique, to demonstrate the laryngeal and vocal evolution at short and long term, and to evaluate the eventual positive impact of EHA implantation on the pliability of the superficial layer of the lamina propria (SLLP) and on voice. This is a prospective and comparative study on 83 patients suffering from various benign VF lesions. Thirty-three patients were implanted with EHA, whereas 50 patients did not undergo implantation at the end of the microsurgical procedure.All patients undergo rigid laryngoscopy and microflap excision procedure under general anesthesia. After freeing up of the Reinke's space and creation of a mucosal microflap, a few fibers of EHA are inserted in the surgical wound, before closure of the incision with fibrin glue. Serial laryngeal and vocal assessments are performed in all patients using videostroboscopy (Wolff and Xion), perceptual and objective voice evaluation (MDVP software, Kay Elemetrics), and phonatory function measurements (Aerophone II). Pre- and early postoperative means are compared by analysis of variance. Delayed and long-term evolution of laryngeal and vocal data are compared by means of nonparametric statistical methods. The longest follow-up in the implanted group is 4 years. Early postoperative results are similar in both groups: a significant improvement of a majority of laryngeal and vocal data is observed after microsurgery. In the long term, the two groups exhibit a different behavior: further improvement of voice, as an ongoing process, is only observed in the EHA implanted group, together with improvement of some videostroboscopic characteristics. The nonimplanted group remains stable, with no further improvement of the voice quality obtained after microsurgery. Excellent short- and long-term tolerance of EHA implantation is confirmed by this larger series. The use of EHA implant in microdissected SLLP is safe and leads to good laryngeal and vocal outcomes in the treated patients. More interestingly, treated cases exhibit a continuous improvement over a long period of time.

Treatment of Functional Ventricular Fold Phonation by Temporary Suture Lateralization - Corrected Proof

Gerhard Friedrich, Karl Kiesler, Markus Gugatschka — 2009-10-23

Summary: Ventricular fold phonation (VFP) is a phenomenon characterized by phonation using the false vocal folds. Besides a substitution voice due to loss of the true vocal folds—so called compensatory type—the noncompensatory types have a psychogenic, functional, or habitual background. Therapeutic options for these cases so far comprise voice therapy, pharmacological therapy (injection of anesthetics or botulinum toxin), and, in case of failure, surgical resection of the ventricular folds. Indication for aggressive surgical interventions is usually difficult, as there is always a risk of producing an irreversible state with an even worse situation.We present two cases of functional (psychogenic) VFP treatment refractory to conservative treatment. Lateralization of the ventricular folds by an endo-extralaryngeal temporary suture, similar to that used in bilateral vocal fold paralysis, was performed. Immediately after the procedure, a constant phonation at glottic level could be achieved in both cases. Sutures were removed 4 days after surgery, and phonation remained at the glottic level. Vocal fold phonation could be stabilized in the long run, and both patients recovered completely under additional voice therapy.

Vocal Fold Nodules: Morphological and Immunohistochemical Investigations - Corrected Proof

2009-10-23

Summary: The objective of this study was to investigate the morphological and immunohistochemical characteristics of vocal fold nodules. The study design was prospective and retrospective. For the histological study, we reviewed 15 slides from the surgical cases of vocal fold nodules, in which we analyzed epithelium, basal membrane (bm), and lamina propria. For the transmission and scanning electron microscopy (TEM, SEM) studies, five new cases on vocal fold nodules were included. Immunohistochemistry study was carried out in the 15 specimens, using antifibronectin, antilaminin, and anticollagen IV antibodies. The main histological alterations were epithelial hyperplasia (73.33%), basement membrane thickening (86.66%), edema, and fibrosis (93.33%). SEM—reduction in mucous lacing and increase in the desquamating cells, without epithelial erosion. TEM—hyperplasia of the epithelium, enlargement of the intercellular junctions, which was filled by fluid, subepithelial thickening of the lamina reticularis, and break points in the basal membrane. Immunohistochemistry—we identified greater immunoexpression of fibronectin on the basal membrane, on the lamina propria, and around the vessels. Antilaminin and anticollagen IV antibodies showed higher pigmentation on the endothelium of the vessels than that on the basal membrane. In vocal fold nodules, combined assessment using light microscopy, electron microscopy, and immunohistochemistry can reveal important morphological details useful in characterizing these lesions.

Change in Vibrato Rate and Extent During Tertiary Training in Classical Singing Students - Corrected Proof

Helen F. Mitchell, Dianna T. Kenny — 2009-10-22

Summary: Objectives: Vibrato is an integral and desirable feature of the classical singing voice. For elite singing students, achieving and developing vibrato may constitute one of the essential elements of their vocal training, although it is not necessarily a focus of that training.Study Design: In this longitudinal study, we measured vibrato rate (VR) and vibrato extent (VE) and regularity (SD) of VR and VE in student singers over the course of four semesters of tertiary level voice training at a conservatorium of music to determine how these parameters changed during training.Method: Fifteen singers completed four semesters (2 years) of training. Singers performed four sustained pitches across their vocal range. Peaks and troughs of vibrato were isolated from the fundamental frequency trace to calculate VR in hertz and VE in semitones.Results: Analysis using linear mixed models revealed significant increases in VE and decreases in VRSD over time. VR was within expected limits for classical singers in all semesters, and small VR reductions were not statistically significant between semesters over 2 years of training. VE showed significant increases between the start of year 1 and year 2. Periodicity of singers' VR (SD) improved over training, with significant decreases to VRSD over time. There was no significant change to VESD.Conclusions: Future studies will ascertain whether further changes to VR and VE occur over longer training periods, or whether the major changes occur early in tertiary training.

Whispering—A Single-Subject Study of Glottal Configuration and Aerodynamics - Corrected Proof

Johan Sundberg, Ronald Scherer, Markus Hess, Frank Müller — 2009-10-22

Summary: Whisper productions were produced by a single adult male subject over a wide range of subglottal pressures, glottal areas, and glottal flows. Dimensional measurements were made of these three variables, including glottal perimeter. Subglottal pressure was directly obtained by a pressure transducer in a tracheal catheter, and wide-band flow with a pneumotach mask. Four types of whispers were used—hyperfunctional, hypofunctional, neutral, and postphonation—in addition to three levels of loudness (soft, medium, loud). Sequences of the /pae/ syllable were used. Video recordings of the larynx were made. The glottis was outlined by hand with extrapolation for unseen parts, and area and perimeter were obtained through image analysis software. The whisper tokens resulted in the following wide ranges: subglottal pressure: 1.3–17cm H2O; glottal flow: 0.9–1.71L/s; glottal area: 0.065–1.76cm2; and glottal perimeter: 1.09–6.55cm. Hyperfunctional whisper tended to have higher subglottal pressures and lower areas and flows than hypofunctional whisper, with neutral and postphonation whisper values in between. An important finding is that glottal flow changed more for small changes of area when the area was already small, and did not create much flow change when area was changed for already larger areas; that is, whisper is “more sensitive” to airflow changes for smaller glottal areas. A general equation for whisper aerodynamics was obtained, namely, P (subglottal pressure [cm H2O])=C×F (glottal flow [cm3/s]), where C=0.052×A4−0.1913×A3+0.2577×A2−0.1523×A+0.0388, where A is the glottal area (cm2). Another general equation for nondimensional terms (pressure coefficient vs Reynolds number) also is offered. Implications for whisper flow resistance and aerodynamic power are given. These results give insight into whisper aerodynamics and offer equations relevant to speech synthesis.

The Butterfly Procedure: A New Technique and Review of the Literature for Treating Anterior Laryngeal Webs - Corrected Proof

2009-10-22

Summary: Congenital laryngeal webs, subglottic stenosis, and laryngeal atresia result from various degrees of failure of airway recanalization as a spectrum. The symptoms also range from asymptomatic to dysphonia and severe airway obstruction. There are a number of methods for management of symptomatic patients. In this article, we discuss a new procedure that was used in the management of two anterior laryngeal web patients with relatively acceptable results.

Beta-Adrenergic Blockade and Voice: A Double-Blind, Placebo-Controlled Trial - Corrected Proof

Cheryl L. Giddens, Kirk W. Barron, Keith F. Clark, William D. Warde — 2009-10-21

Summary: This study investigated the effects of laboratory-induced stress and beta-adrenergic blockade on acoustic and aerodynamic voice measures. In a double-blind, placebo-controlled trial, 12 participants, six males and six females, underwent cold pressor-induced sympathetic activation followed by placebo or treatment with 40mg propranolol. Aerodynamic and acoustic parameters of voice were collected at baseline, during cold pressor and after treatment with propranolol or placebo. Fundamental frequency, jitter, shimmer, maximum airflow declination rate, voice onset time, speaking rate, and subglottal pressure were measured at baseline, during cold pressor-induced stress, and after treatment with propranolol or placebo. Cardiovascular measures served as indicators of sympathetic nervous system (SNS) activation by cold pressor and antagonism by propranolol, and were collected during all conditions. Cold pressor appeared to adequately agonize the SNS as indicated by significant increases in resting systolic and diastolic blood pressure and heart rate. Propranolol appeared to adequately antagonize the SNS for the participants. Jitter ratio demonstrated a statistically significant increase in the participants treated with propranolol. Speaking rate demonstrated a small but significant increase in the placebo control group during cold pressor. Gender differences were observed in a few measures. Cold pressor adequately agonized and propranolol adequately antagonized the SNS. No statistically significant differences across subjects were observed in the voice parameters during cold pressor-induced stress before treatment. Jitter ratio increased significantly during propranolol treatment and cold pressor. Speaking rate demonstrated a statistically significant increase during cold pressor in the placebo control group. Gender differences were observed, but were few.

The Singer's Voice Range Profile: Female Professional Opera Soloists - Corrected Proof

Anick Lamarche, Sten Ternström, Peter Pabon — 2009-10-19

Summary: This work concerns the collection of 30 voice range profiles (VRPs) of female operatic voice. We address the questions: Is there a need for a singer's protocol in VRP acquisition? Are physiological measurements sufficient or should the measurement of performance capabilities also be included? Can we address the female singing voice in general or is there a case for categorizing voices when studying phonetographic data? Subjects performed a series of structured tasks involving both standard speech voice protocols and additional singing tasks. Singers also completed an extensive questionnaire. Physiological VRPs differ from performance VRPs. Two new VRP metrics, the voice area above a defined level threshold and the dynamic range independent from the fundamental frequency (F0), were found to be useful in the analysis of singer VRPs. Task design had no effect on performance VRP outcomes. Voice category differences were mainly attributable to phonation frequency-based information. Results support the clinical importance of addressing the vocal instrument as it is used in performance. Equally important is the elaboration of a protocol suitable for the singing voice. The given context and instructions can be more important than task design for performance VRPs. Yet, for physiological VRP recordings, task design remains critical. Both types of VRPs are suggested for a singer's voice evaluation.

The Vocal Quality in Female Student Teachers During the 3 Years of Study - Corrected Proof

2009-10-16

Summary: The purpose of the present cross-sectional study was to determine the objective vocal quality and the vocal characteristics (vocal risk factors, vocal and corporal complaints) in 143 female student teachers during the 3 years of study. The objective vocal quality was measured by means of the Dysphonia Severity Index (DSI). Perceptual voice assessment, the Voice Handicap Index, questionnaires addressing vocal risks, and vocal and corporal complaints during and/or after voice usage were performed. Student teachers have a normal perceptual and objective vocal quality corresponding with a DSI% of 76. The analysis of variance revealed a significant improvement of the vocal quality between the first and the third year of study. No psychosocial handicapping effect of the voice was observed, though there are some vocal complaints and almost all student teachers reported the presence of corporal pain during and/or after speaking. Especially sore throat and headache were mentioned as the most present corporal pain symptoms. Due to the decreased awareness and the multifactorial genesis of the potential vocal risk factors, the student teachers are at risk for developing an occupational dysphonia during their teaching career. Because teaching is a high-risk profession for the development of voice problems, the incorporation of a direct vocal training technique to increase vocal endurance during teaching together with a vocal hygiene program, dietetics, and a stress management training program during the 3 years of study is needed to prevent occupational dysphonia.

Investigation of the Impact of Thyroid Surgery on Vocal Tract Steadiness - Corrected Proof

Conrad I. Timon, Shashi P. Hirani, Ruth Epstein, Mark A. Rafferty — 2009-10-16

Summary: Introduction: Subjective nonspecific upper aerodigestive symptoms are not uncommon after thyroid surgery. These are postulated to be related to injury of an extrinsic perithyroid nerve plexus that innervates the muscles of the supraglottic and glottic larynx. This plexus is thought to receive contributing branches from both the recurrent and superior laryngeal nerves.Patients and Methods: The technique of linear predictive coding was used to estimate the F2 values from a sustained vowel /a/ in patients before and 48 hours after thyroid or parathyroid surgery. These patients were controlled against a matched pair undergoing surgery without any theoretical effect on the supraglottic musculature. In total, 12 patients were recruited into each group. Each patient had the formant frequency fluctuation (FFF) and the formant frequency fluctuation ratio (FFFR) calculated for F1 and F2.Results: Mixed analysis of variance (ANOVA) for all acoustic parameters revealed that the χ F2FF showed a significant “time” main effect (F(1,22)=7.196, P=0.014, partial η2=0.246) and a significant “time by group interaction” effect (F(1,22)=8.036, P=0.010, =0.268), with changes over time for the thyroid group but not for the controls. Similarly, mean χ F2FFR showed a similar significant “time” main effect (F(1,22)=6.488, P=0.018, =0.228) and a “time by group interaction” effect (F(1,22)=7.134, P=0.014, =0.245).Conclusions: This work suggests that thyroid surgery produces a significant reduction in vocal tract stability in contrast to the controls. This noninvasive measurement offers a potential instrument to investigate the functional implications of any disturbance that thyroid surgery may have on pharyngeal innervations.

Diagnostic Validity of Voice Handicap Index-10 (VHI-10) Compared With Perceptive-Auditory and Acoustic Speech Pathology Evaluations of the Voice - Corrected Proof

2009-10-16

Summary: Background: The voice handicap index (VHI) questionnaire and its reduced version (VHI-10) have the aim of measuring voice problems from the subject's self-perception. No studies on the predictive value of VHI-10 have been conducted.Objective: To determine diagnostic validity indicators for VHI-10.Method: Four hundred seventy-six elementary and high school teachers working in municipal public schools in Salvador, Bahia, were evaluated. Sensitivity, specificity, positive and negative predictive values, proportion of correct classification, Youden index, and positive and negative likelihood ratios were calculated.Results: VHI-10 presented low rates for sensitivity (29%), proportion of correct classification (44%), positive predictive value (42%), and negative predictive value (33%). The validity indicators for VHI-10 were better in comparisons with perceptive-auditory analysis than with acoustic analysis.Conclusion: Because of the low validity of VHI-10, its use in population-based studies is not recommended. This suggests that it has limitations as a diagnostic support instrument for clinical evaluations.

Unsuspected Intraoperative Finding of Structural Abnormalities Associated With Vocal Fold Polyps - Corrected Proof

2009-10-12

Summary: Objectives: To report the findings of unsuspected underlying concurrent abnormalities of the vocal fold (VF) associated with polyps.Study Design and Setting: Retrospective chart review at tertiary teaching institution.Subjects and Methods: Operative and clinical notes of 81 adults submitted to suspension laryngoscopy for vocal fold polyp (VFP) excision from 1998 to 2007, which had no previous report of associated structural abnormalities.Results: Associated lesions were described in 54 patients (67%) (35 contralateral, 16 ipsilateral, and three bilateral): 18 reactive nodules, 21 sulcus vocalis, five cysts, two microwebs, and eight capillary ectasias. A positive correlation was found between the presence of polyps and associated structural abnormalities (r=0.0035; P<0.05).Conclusions: The high incidence of concurrent previously unsuspected VF lesions suggests that either these minor underlying anatomical deviations render the VF more vulnerable to vocal abuse, or that phonotrauma may cause a number of VF lesions that can lead to dysphonia.

Noise and Tremor in the Perception of Vocal Aging in Males - Corrected Proof

James D. Harnsberger, William S. Brown, Rahul Shrivastav, Howard Rothman — 2009-10-08

Summary: Objective/Hypothesis: To specify a set of acoustic cues for vocal aging and to establish their perceptual relevance.Study Design: Perceptual testing.Methods: To identify the acoustic and perceptual correlates of the aging voice, voice quality [in conjunction with speaking rate and fundamental frequency (F0)] was systematically manipulated using resynthesis to determine its effect on perceived age. Ten young male voices were resynthesized using two levels of noise (random modulation of F0 contour) and two levels of tremor (constant modulation of F0 contour with a low-amplitude wave) under a speaking-rate manipulation (an increase in speaking rate that is common to older male voices). These materials were submitted to 40 naive listeners in an age-estimation task. Two sets of comparison materials were also included for evaluation: unmanipulated samples from a 150 voice database of young, middle-aged, and older voices and disordered voice samples representing natural manifestations of the voice qualities of interest.Results: Speaking rate, highest degree of tremor, and highest degree of noise all shifted, in an additive manner, the mean perceived age of the young male voices by a maximum of 12 years on average; individual voices were observed being shifted by a generation. Fundamental frequency manipulations had no significant effect on perceived age.Conclusions: Voice quality (both tremor and noise) and speaking rate are all perceptually relevant cues of age in male voices.

Differential Effects of Voice Therapies on Neurovegetative Symptoms and Complaints - Corrected Proof

L. Demmink-Geertman, P.H. Dejonckere — 2009-10-07

Summary: In previous studies, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. After voice therapy, there was a highly significant reduction in the amount of autonomic symptoms and complaints (related or not related to voice). The present prospective study with a matched control group is designed to test the hypothesis that a specific kind of therapy is more efficient than the usual approaches in reducing these neurovegetative symptoms and complaints. Two matched groups of 34 patients diagnosed with nonorganic dysphonia and referred for voice therapy answered a questionnaire of 46 questions with 3 subsets and a consistency control. They received either “coordination therapy” (CTh)—a holistic approach addressing functional, personal and emotional aspects—or a conventional voice therapy (approximately 15 sessions). All patients again filled in a similar questionnaire after approximately 6 months. After therapy, there is in general a highly significant reduction in the amount of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than those of healthy controls. Symptoms and complaints of other nature (validity control) are not influenced. When compared with patients receiving conventional therapy, those who received CTh demonstrate a significantly higher reduction for the subset “neurovegetative symptoms/complaints related to voice and speech.”

Voice in Chronic Renal Failure - Corrected Proof

Radish B. Kumar, Jayashree S. Bhat — 2009-10-07

Summary: Chronic renal failure affects various body systems, one of which is the respiratory system. Because respiration is the prime source for speech, vocal dysfunctions are expected to be present in patients with chronic renal failure. The present study attempts to shed light on the changes in acoustic and aerodynamic characteristics of voice, if any, in patients with chronic renal failure. Phonation of sustained vowel /a/ was subjected to acoustic analysis using VAGHMI software (Voice and Speech Systems, Bangalore, Karnataka, India). Sustained phonation of /a/, /s/, and /z/ was recorded for the purpose of aerodynamic analysis. Independent t test was used to find the significant difference between the two groups. Chronic renal failure subjects showed significant deviation in frequency, perturbation, and aerodynamic measures when compared with normal subjects. These results are discussed with respect to the underlying pathophysiology.

Acoustic and Electroglottographic Analyses of Nonpathological, Nonmodal Phonation - Corrected Proof

Heriberto Avelino — 2009-09-25

Summary: Languages where phonation type and tone are contrastive make use of extremely fine and controlled actions of laryngeal structures; hence, there is little opportunity to variation in either phonation or pitch. Nonetheless, many American Indian languages have contrastive nonmodal phonation, which, moreover, is subject to a great deal of variation. There are a few studies addressing the phonetics of nonmodal phonation in American Indian languages, and little is known about the phonetics/phonology interface of laryngeal features within the sound patterns of these languages. This article aims to contribute to the knowledge of nonmodal phonation through the detailed study of the phenomenon in Yalálag Zapotec (YZ) and American Indian language. A series of spectral and electrophysiological analyses contribute to the description of YZ nonmodal phonation and its variability across gender. It is argued that the temporal patterns in realization of laryngealization are a property of YZ speaker's grammar.