Journal of Voice - Articles in Press

Animal Model for Training and Improvement of the Surgical Skills in Endolaryngeal Microsurgery - Corrected Proof

2012-02-02

Summary: Animal models for training of surgical skills were widely used for a long time in the education of medical practitioners. It is recognized, however, that endolaryngeal microsurgery requires highly refined skills to handle the delicate structures of the vocal folds under the microscope. The availability of fresh human laryngeal specimens is markedly restricted by legal and hygienic issues. The aim of this work was to report on the design of a feasible and effective model to provide the much needed skills in an animal laryngeal model that is as close as possible to the human vocal fold structure. In the initial phase of the research, three animal larynges were studied: porcine/pig, bovine/calf, and ovine/sheep larynges. The pig/porcine larynx was chosen for this experimental training model because it closely resembled the human laryngeal/glottal configurations. A study was carried out on 10 porcine/pig larynges to assess the dimensions of the glottis and study the histology of the layered structure of the vocal fold. The study was pursued to confirm the resemblance of this animal specimen to the human vocal fold. A wooden box with a black finished interior was prepared with an acrylic bed at its floor. This bed allows placement of the porcine/pig larynx. The design of the box allows the endoscopic exposure of the porcine/pig larynx through a rubber diaphragm. The darkness and confinement of the box, apart from the light of the endoscope, approximates the situation in live endoscopy. The operating microscope is then used to expose the glottis. Routine fine microlaryngeal instruments were used for training in the prescribed skills.

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.

Sentence Intelligibility Before and After Voice Treatment in Speakers With Idiopathic Parkinson’s Disease - Corrected Proof

2012-01-03

Summary: Objectives/Hypothesis: The purpose of this study was to determine whether sentence intelligibility improves in speakers with idiopathic Parkinson’s disease (PD) as a result of Lee Silverman Voice Treatment (LSVT). It was hypothesized that all the speakers would improve following treatment, in association with increased vocal loudness, which was the primary target of the treatment.Study Design: Prospective study of eight Speakers with PD using a single-blinded, randomized pre-post treatment design, with multiple daily assessments before and after treatment was carried out. Resultant data were corrected for regression to the mean.Methods: Randomized digital recordings of sentences produced by speakers with idiopathic PD before and after the treatment were presented to normal-hearing listeners with equalized intensity at conversational loudness in the presence of pink noise. Percentage of words understood was calculated before and after the treatment. Changes in overall vocal intensity were also analyzed.Results: There was a statistically significant group effect from pre-to-post voice treatment; however, there was also significant interaction of treatment with speakers. Six of the speakers with PD improved significantly following voice treatment, one exhibited no change, and one exhibited a decline in sentence intelligibility post-treatment.Conclusions: LSVT yielded significant improvement in sentence intelligibility for most speakers in the study but was not beneficial for two of the speakers despite the fact that they increased their overall vocal loudness.

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.

The Traditional/Acoustic Music Project: A Study of Vocal Demands and Vocal Health - Corrected Proof

Molly L. Erickson — 2012-01-03

Summary: Objective/Hypothesis: The Traditional/Acoustic Music Project seeks to identify the musical and performance characteristics of traditional/acoustic musicians and determine the vocal demands they face with the goals of (1) providing information and outreach to this important group of singers and (2) providing information to physicians, speech-language pathologists, and singing teachers who will enable them to provide appropriate services.Study Design: Descriptive cross-sectional study.Methods: Data have been collected through administration of a 53-item questionnaire. The questionnaire was administered to artists performing at local venues in Knoxville, Tennessee and also to musicians attending the 2008 Folk Alliance Festival in Memphis, Tennessee.Results: Approximately 41% of the respondents have had no vocal training, whereas approximately 34% of the respondents have had some form of formal vocal training (private lessons or group instruction). About 41% of the participants had experienced a tired voice, whereas about 30% of the participants had experienced either a loss of the top range of the voice or a total loss of voice at least once in their careers. Approximately 31% of the respondents had no health insurance. Approximately 69% of the respondents reported that they get their information about healthy singing practices solely from fellow musicians or that they do not get any information at all.Conclusion: Traditional/acoustic musicians are a poorly studied population at risk for the development of voice disorders. Continued research is necessary with the goal of a large sample that can be analyzed for associations, identification of subpopulations, and formulation of specific hypotheses that lend themselves to experimental research. Appropriate models of information and service delivery tailored for the singer-instrumentalist are needed.

Study of the Influence of Psychological Factors in the Etiology of Vocal Nodules in Women - Corrected Proof

2011-11-16

Summary: Objective: The role placed by certain psychological factors such as stress and personality on the development of vocal nodules has not yet been established. The aim of this case-control type study is to analyze the relationship between these psychological factors and the presence of vocal nodules while also considering the professional and social aspects of the subjects suffering from this pathology.Methods: The case group is made up of 50 patients diagnosed with vocal nodules and with at least 6 months of evolution. The control group is made up of 50 patients diagnosed with nasal respiratory insufficiency. All the patients were examined by laryngeal stroboscopy. For the personality study, the perceived stress, and the voice use, the Minnesota Multiphasic Personality Inventory-2, Levenstein Perceived Stress Questionnaire, and Goldman Voice Use Survey were used, respectively.Results: The subjects with vocal nodules presented a mean perceived stress score of 0.41±0.09, which was higher than that of the control group (0.35±0.06), the differences observed being statistically significant (P<0.001). In the personality study (MMPI-2), the only scale that was associated with the presence of the vocal nodules was that of psychomotor acceleration. The mean score obtained for the scale was 51.64±8.25 in the vocal nodule group and 45.02±0.06 in the control group (P<0.001). In the analysis of voice use, the subjects with vocal nodules scored 9.31±1.36, which was significantly higher than the score of the control group (8.07±1.24; P<0.001). In addition, other variables were associated with the presence of vocal nodules, such as being young and working in professions considered to be of vocal risk.Conclusions: Perceived stress and personality features of hyperactivity and impulsivity are independent factors related to vocal nodules.

The Effect of Experience on Classification of Voice Quality - Corrected Proof

Jessica L. Sofranko, Robert A. Prosek — 2011-11-15

Summary: Objectives/Hypothesis: The purpose of this study was to compare the agreement among several groups of listeners with different types of experience in regard to classifying voice quality.Study Design: This is a retrospective cross-sectional quasi-experimental design.Method: This study compared three groups: speech-language pathologists who specialize in voice, singing voice teachers, and inexperienced listeners. All groups were asked to classify voice samples as breathy, rough, or normal.Results: Results show a significant difference across all groups with speech-language pathologists demonstrating a substantial interrater agreement, κ=0.67, z=103.07 (P<0.01); singing voice teachers demonstrating a moderate interrater agreement, κ=0.53, z=79.10 (P<0.01); and inexperienced listeners demonstrating a fair interrater agreement, κ=0.24, z=35.82 (P<0.01).Conclusions: Experienced listeners demonstrated a higher interrater agreement as compared with inexperienced listeners, with speech-language pathologists demonstrating a superior agreement as compared with all groups.

Resolution of Vocal Fold Polyps With Conservative Treatment - Corrected Proof

Hideki Nakagawa, Makoto Miyamoto, Toshiyuki Kusuyama, Yuko Mori, Hiroyuki Fukuda — 2011-11-15

Summary: Objectives: Vocal fold polyp is generally thought to require surgical removal. However, a certain proportion of polyps resolve with conservative treatment. This study was performed to clarify the frequency of spontaneous resolution of vocal fold polyp and identify features associated with polyps that are likely to resolve without surgery.Study Design: Retrospective study.Methods: A review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008.Results: Of 644 patients with the diagnosis of vocal fold polyp, 132 received conservative treatment, 433 were treated surgically, and 79 dropped out without attending for further consultation after the initial visit. Of those treated conservatively, 55 experienced complete resolution after a mean of 5.1 months of follow-up from the outset, and 29 showed lesion shrinkage after a mean of 4.1 months of follow-up. Polyps that resolved with conservative therapy were more likely than those that remained unchanged or enlarged to occur in women, be smaller, and have a shorter duration of symptoms. We could not determine the superiority of voice therapy.Conclusions: At least 9.7% of vocal fold polyps might resolve without surgery. Conservative treatment should be considered as an option for selected patients with smaller and more recent-onset polyps.

A Transthyroidal Method for Arytenoid Adduction: A Basic Anatomical Study - Corrected Proof

2011-11-15

Summary: Introduction: Arytenoid adduction is a very effective procedure for medializing the posterior part of the vocal fold in vocal fold paralysis. Major drawback of the method is the technically sometimes-difficult access to the arytenoid with increased postoperative morbidity. Aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage through a thyroplasty window. Furthermore, to investigate the feasibility of an arytenoid adduction by fixation of a surgical screw to the arytenoid cartilage by using this approach.Materials and methods: 10 cadaver larynges, six female and four male, were dissected and measured for our points of interest. A standard manufacture-made surgical screw attached to a suture was anchored to the fovea oblonga of the arytenoid cartilage.Results: Our anatomical measurements proved a mean distance from the posterior edge of the thyroid window to the arytenoid of about 8–9mm in male larynges and 7–8mm in female larynges. The distances did not differ significantly between the sexes. Pulling the anchored surgical screw medializes the posterior part of the vocal fold.Discussion: Our data showed that there is a very constant morphometric relation between the thyroplasty window and the arytenoid cartilage. It is known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions. These differences appear to a much lesser extend in the distances from the surface to the depth, as was confirmed in our series. Using these findings led us to identification of the fovea oblonga near the muscular process as the most favorable point for fixation of a surgical screw through a conventional thyroplasty window. Pulling the attached suture medializes the arytenoid cartilage.

Glottal Contact Quotient in Mediterranean Tongue Trill - Corrected Proof

2011-11-15

Summary: Objective: To determine the effect of a Mediterranean tongue trill (Zalghouta) on estimated glottal closed quotient (CQ).Material and Method: A total of 10 female subjects participated in this study. Vocal fold CQ was measured for both sustained vowel [a] and the tongue trill named Zlaghouta using electroglottography. Frequencies and means (±standard deviation) were used to describe categorical and continuous variables, respectively. The Wilcoxon signed nonparametric test was used to determine any significant changes in CQ means pretrill and during trill.Results: There was a significant decrease in the mean CQ during the Mediterranean tongue trill (Zalghouta) versus the sustained vowel [a] (P value of 0.002) by 15.98. When stratified by training status there was a significant decrease for the trained group (P value of 0.031) and a nonsignificant decrease for the untrained group (P value of 0.125).Conclusion: Zalghouta induces a decrease in the vocal fold contact time. The potential benefits of the Mediterranean tongue trill in vocal therapy need consideration.

Laryngeal Manifestations of Relapsing Polychondritis and a Novel Treatment Option - Corrected Proof

2011-11-15

Summary: Objectives: Laryngotracheal involvement in relapsing polychondritis (RP) is rare. However, it is one of the most common causes of death in this patient population. We present three patients who primarily presented with laryngeal manifestations of RP and a novel treatment option for bamboo nodules.Study Design: Retrospective chart review and comprehensive review of the literature.Results: Two patients first presented to an otolaryngologist because of hoarseness and chronic cough that eventually progressed to dyspnea upon exertion. Laryngeal examination revealed subglottic stenoses. Upon rheumatologic workup both were diagnosed with RP. After treatment with steroids and immunosuppressive drugs, one of the patient’s laryngeal symptoms improved, whereas the other required dilation procedures. Neither patient had classic auricular or nasal symptoms upon initial presentation. The third patient was being treated for spasmodic dysphonia and was noted to have bamboo nodules with accompanying dysphonia. Rheumatologic workup revealed RP and systemic treatment ensued. Unfortunately, her symptoms of hoarseness persisted despite systemic treatment. A pulsed-potassium-titanyl-phosphate (KTP) laser was applied to the bilateral bamboo nodules, which eventually caused resolution of her vocal fold lesions and dysphonia.Conclusions: We present three patients with RP, all of whom sought health care by an otolaryngologist primarily. Awareness of this disease entity and the possibility for early laryngeal involvement is crucial for proper care of those with this life-threatening disease.

Differences in Vocal Characteristics Between Cantonese and English Produced by Proficient Cantonese-English Bilingual Speakers—A Long-Term Average Spectral Analysis - Corrected Proof

Manwa L. Ng, Yang Chen, Ellen Y.K. Chan — 2011-11-15

Summary: Objectives: The present study objectively examined the possible difference in vocal characteristics associated with English and Cantonese produced by proficient Cantonese-English bilingual speakers.Subjects and Methods: Forty native speakers of Cantonese (20 males and 20 females) who were proficient in Cantonese and English participated in the study. An array of acoustical parameters, including fundamental frequency (F0) values and first spectral peak (FSP), mean spectral energy (MSE), and spectral tilt (ST) extracted from long-term average speech spectra were obtained from connected speech samples produced in Cantonese and English by the bilingual speakers. Acoustical parameters were measured using Praat (P. Boersma & D. Weenink, Amsterdam, The Netherlands) and used to objectively describe the voice quality.Results: Results indicated that female bilingual speakers had significantly higher F0 values in speaking English than Cantonese. Although exhibiting comparable FSP values, the bilingual speakers showed significantly higher MSE and lower ST values when speaking Cantonese compared with English.Conclusions: The present findings imply that, even with the same phonatory apparatus, language being spoken can have an effect on the speakers’ voice quality.

The Effect of Cochlear Implantation on Nasalance of Speech in Postlingually Hearing-Impaired Adults - Corrected Proof

2011-11-15

Summary: Objectives/Hypothesis: Hypernasality is considered a prevalent speech abnormality that could significantly contribute to the unintelligibility of the hearing-impaired speakers. The aim of this study was to evaluate the effect of cochlear implantation and the duration of hearing loss on nasalance of speech of a postlingually impaired group of Saudi adult patients.Study Design: Retrospective study.Methods: This study included 25 postlingually hearing-impaired patients who underwent cochlear implantation and 25 age-matched control subjects. Patients were divided into three groups according to the duration of hearing loss. The nasometric data of the hearing-impaired group were compared with the control group. Also, the preoperative values were compared with the postoperative values 6, 12, and 24 months after surgery.Results: Significant differences were demonstrated between the preimplantation nasalance scores of the three subgroups and between the patients and control groups. There were statistically significant differences demonstrated between the pre- and the postimplantation nasalance values for the three groups of patients.Conclusion: Cochlear implantation appears to have significant effects on improving the nasalance of the speech of postlingually hearing-impaired adult patients. However, the degree of improvement might vary according to the duration of hearing loss the patients had preimplantation.

Validation and Standardization of the Pediatric Voice Symptom Questionnaire: A Double-Form Questionnaire for Dysphonic Children and Their Parents - Corrected Proof

Verduyckt Ingrid, Morsomme Dominique, Remacle Marc — 2011-11-15

Summary: The aim of our study was to validate a Pediatric Voice Symptom Questionnaire (PVSQ) presenting with a parallel form for children and their parents. The items of the questionnaire were elaborated from the results of structured interviews with dysphonic children (DP) and normophonic children (NP) and their mothers and were tested for feasibility in a pilot study involving 42 normophonic children aged 5–13 years. The items were then administered in a test-retest mode to 333 children and their parents (154 boys and 179 girls with a mean age of 9 years, standard deviation: 1.8); 45 consulting DP, 34 nonconsulting dysphonics (NcDP), 163 NP, and 91 others. Classical statistical analyses and an item response modeling approach were used to analyze the results.High internal consistency and good test-retest stability were found. Significant differences between total score of the NP, DP, and NcDP groups were observed both in the children and the parents and also between parental and child score for the NP and NcDP groups (P<0.001–P=0.014). Correlations between child and parental scores were found only in the DP groups (r=0.478; P<0.001). Based on our results, the PVSQ is a valid and reliable instrument for the autoevaluation of dysphonia in the child population.

Measures of Spectral Slope Using an Excised Larynx Model - Corrected Proof

Fariborz Alipour, Ronald C. Scherer, Eileen Finnegan — 2011-11-07

Summary: Spectral measures of the glottal source were investigated using an excised canine larynx (CL) model for various aerodynamic and phonatory conditions. These measures included spectral harmonic difference H1−H2 and spectral slope that are highly correlated with voice quality but not reported in a systematic manner using an excised larynx model. It was hypothesized that the acoustic spectra of the glottal source were significantly influenced by the subglottal pressure, glottal adduction, and vocal fold elongation, as well as the resulting vibration pattern. CLs were prepared, mounted on the bench with and without false vocal folds, and made to oscillate with a flow of heated and humidified air. Major control parameters were subglottal pressure, adduction, and elongation. Electroglottograph, subglottal pressure, flow rate, and audio signals were analyzed using custom software. Results suggest that an increase in subglottal pressure and glottal adduction may change the energy balance between harmonics by increasing the spectral energy of the first few harmonics in an unpredictable manner. It is suggested that changes in the dynamics of vocal fold motion may be responsible for different spectral patterns. The finding that the spectral harmonics do not conform to previous findings was demonstrated through various cases. Results of this study may shed light on phonatory spectral control when the larynx is part of a complete vocal tract system.

Complications of Injection Laryngoplasty Using Calcium Hydroxylapatite - Corrected Proof

Rima A. DeFatta, Farhad R. Chowdhury, Robert T. Sataloff — 2011-11-07

Summary: Objective: To report the adverse effects of using calcium hydroxylapatite (CaHA) paste as a vocal fold filler.Methods: Approval of this study was obtained through the institutional review board at Drexel University College of Medicine. Sixteen patients had 22 vocal fold injections with CaHA paste to treat glottic insufficiency. The initial procedures were performed at three different institutions between January 2006 and August 2009. Diagnosis and treatment of the complications in all cases were performed at our institution. Pre- and postinjection mucosal waves were assessed using strobovideolaryngoscopy when possible. All stroboscopic examinations were reviewed independently. Decreases in amplitude and waveform were classified as mild, moderate, or severe. Implant location was examined using computed tomography (CT) scan with 1-mm cuts through the larynx in patients suspected of having implant malposition. Vocal fold function was compared before and after injection, as well as after implant removal in selected cases. Histological section of explanted material was obtained. Major and minor complications were noted in 19 vocal folds.Results: Ten major complications were encountered after surgery at three institutions. These included four vocal folds with adynamic mucosa, six with a severely decreased wave, and two granulomas affecting the vibratory margin. CT scanning confirmed six cases of implant malposition (possibly migration). Six implants were removed through endoscopic lateral cordotomy between 2 and 24 months after injection. Mucosal wave function recovered in five vocal folds after explantation. Minor complications were encountered in nine additional vocal folds. These included tissue inflammation marked by edema, erythema, and mild-to-moderate mucosal wave restriction and hypervascularity.Conclusion: Injection laryngoplasty using CaHA paste has been regarded as an effective treatment for glottic insufficiency. In some patients, CaHA can cause an intense inflammatory reaction, potentially migrate, and compromise vocal fold function. It should be used with full understanding of the potential serious adverse reactions and risk of at least minor impairment of vibratory function.

Intracordal Injections with Allogenic Cartilage in a Canine Paralyzed Vocal Fold Model: Long-Term Results - Corrected Proof

Jin-Choon Lee, Byung-Joo Lee, Soo-Geun Wang, Chang-Hun Lee, Dong-Hoon Shin — 2011-10-31

Summary: Objective: To determine whether detergent treated allogenic cartilage can be used as a substitute for autologous cartilage in a canine paralyzed vocal fold model.Material and Methods: Twelve canines underwent a right recurrent laryngeal nerve resection with injections of allogenic auricular cartilage (harvested 7 days prior, treated with detergent, and minced), with a hyaluronic acid hydrogel (0.2mL) into the right thyroarytenoid muscle, and with a pressure syringe under direct laryngoscopy. Two animals were sacrificed and larynges removed at each time point: 1-, 3-, 6-, 12-, 18-, and 24-months post injection. Hematoxylin-eosin and immunohistochemistry for expression of major histocompatibility complex-II (MHC-II) antigen was measured to assess histomorphology and gross volume and loss of antigenicity of the injected allogenic cartilage.Results: Injected allogenic cartilage maintained its position and volume in the vocalis muscle throughout 24 months. Cartilage was characterized with empty lacunae indicating possible loss of viability. Fibrotic changes were noted in the surrounding cartilage. MCH-II antigen was not identified in the perichondrium and/or cartilage. Inflammatory reaction, granuloma, or foreign body reaction was not observed at any time point.Conclusions: These preliminary results suggest that allogenic auricular cartilage grafts treated with detergent are well tolerated and may be an effective material for volumetric augmentation in the paralyzed vocal cord.

Developing Auditory-Perceptual Judgment Reliability in Otolaryngology Residents - Corrected Proof

S. Misono, A.L. Merati, T.L. Eadie — 2011-10-24

Summary: Objectives: To determine how standard residency training and educational background affect otolaryngology resident auditory-perceptual judgments compared with inexperienced listeners. A secondary aim was to assess the impact of a brief training session on the reliability of judgments among otolaryngology residents.Study design: Mixed cross-sectional and cohort study.Methods: Twenty adult dysphonic and four normal speaker samples were selected from a database. Fifteen listeners at various stages of residency in otolaryngology judged all samples for breathiness and roughness using visual analog scales. Fifteen inexperienced listeners judged the same samples. Subsequently, 12 otolaryngology residents underwent a brief training session. During training, listeners were provided definitions of rating dimensions and accuracy feedback while rating 20 novel (training) stimuli. The feedback included averaged responses from experienced clinicians who had previously evaluated the same speech samples. The residents then completed posttraining evaluations.Results: As a group, otolaryngology resident listeners had significantly better interrater agreement for judgments of roughness compared with inexperienced listeners (P<0.05) and trended toward better interrater agreement for judgments of breathiness (P=0.058). Posttraining, no significant improvement in interrater agreement for judgments of roughness was observed; however, a significant improvement was found in interrater agreement of judgments of breathiness (P<0.05).Conclusions: Compared with inexperienced (untrained) listeners, otolaryngology resident listeners had better interrater agreement overall for judgments of dysphonia. A short training module was associated with improved reliability in resident evaluation of breathiness. Results have implications for improving and standardizing resident evaluation of dysphonia.

Letter to the Editor - Corrected Proof

Fredrik Karlsson, Jan van Doorn — 2011-10-17

In a recent article, Skodda et al reported the results from measurements of the acoustic working space of patients with Parkinson disease (PD) and normal controls. Although we commend the authors on their efforts to establish the most effective measures to demonstrate differences between controls and patients with PD, we wish to point out that the article is marred by an error in the formula for calculation of the triangular vowel space area (tVSA). As Skodda et al have pointed out, the most established method for evaluating vowel space is the area of the vowel triangle formed by the vowels /i/, /u/, and /a/ in the F2−F1 plane. This area can be found using a standard geometric calculation of the area of a triangle with coordinates (F2i, F1i), (F2u, F1u), and (F2a, F1a) for its three vertices. Various equivalent formulas for this area can be found in coordinate geometry textbooks. The formula used by Sapir et al is probably the most common:

Effect of Tones on Vocal Attack Time in Cantonese Speakers - Corrected Proof

Estella P.-M. Ma, R.J. Baken, Rick M. Roark, P.-M. Li — 2011-10-07

Summary: Vocal attack time (VAT) is the time lag between the growth of the sound pressure signal and the development of physical contact of vocal folds at vocal initiation. It can be derived by a cross-correlation of short-time amplitude changes occurring in the sound pressure and electroglottographic (EGG) signals. Cantonese is a tone language in which tone determines the lexical meaning of the syllable. Such linguistic function of tone has implications for the physiology of tone production. The aim of the present study was to investigate the possible effects of Cantonese tones on VAT. Sound pressure and EGG signals were simultaneously recorded from 59 native Cantonese speakers (31 females and 28 males). The subjects were asked to read aloud 12 disyllabic words comprising homophone pairs of the six Cantonese lexical tones. Results revealed a gender difference in VAT values, with the mean VAT significantly smaller in females than in males. There was also a significant difference in VAT values between the two tone categories, with the mean VAT values of the three level tones (tone 1, 3, and 6) significantly smaller than those of the three contour tones (tone 2, 4, and 5). The findings support the notion that norms and interpretations based on nontone European languages may not be directly applied to tone languages.

Erratum: “Vowel Articulation in Parkinson’s Disease.” Journal of Voice. 2011;25:467–472 - Corrected Proof

Sabine Skodda — 2011-10-07

Owing to an erroneous mathematical transformation, the formula for the triangular vowel space area (tVSA) and the deriving values in the results section and are incorrect. The correct formula is tVSA=abs((F1_/i/∗(F2_/α/−F2_/u/)+F1_/α/∗(F2_/u/−F2_/i/)+F1_/u/∗(F2_/i/−F2_/α/))/2). After recalculation of the values of tVSA, the accordant data are as follows (corrections are in bold italics):

Vowel- and Text-Based Cepstral Analysis of Chronic Hoarseness - Corrected Proof

2011-09-23

Summary: Objectives/Hypothesis: Automatic voice evaluation is usually performed on stable sections of sustained vowels, which often cannot capture hoarseness properly. The measures cepstral peak prominence (CPP) and smoothed CPP (CPPS) do not require exact determination of the cycles of fundamental frequency like established perturbation-based measures. They can also be applied to text recordings. In this study, they were compared with perceptual evaluation of voice quality and the German roughness-breathiness-hoarseness (RBH) scheme.Study Design: Retrospective data analysis.Methods: Seventy-three hoarse patients (48.3±16.8 years) uttered the vowel /e/ and read the German version of the text “The North Wind and the Sun”. The text recordings were evaluated perceptually by five speech therapists and physicians according to the RBH scale. The criterion “overall quality” was measured on a 4-point scale and a visual analog scale. For the human-machine correlation, the automatic measures of the Praat program (vowels only) and the “cpps” software were compared with the experts' ratings. The experiments were repeated for speakers with jitter ≤5% or shimmer ≤5% (n=47).Results: For the entire group (n=73), the best human-machine results for most of the rating criteria were obtained for text-based CPP and CPPS (up to |ρ|=0.73). For the 47 selected speakers, the correlation was remarkably worse for all measures but still best for text-based CPP and CPPS (|ρ|≤0.50).Conclusions: Cepstrum analysis should be performed on a text recording. Then, it outperforms all perturbation-based measures, and it can be a meaningful objective support for perceptual analysis.

Endoscopic Laser Thyroarytenoid Myoneurectomy in Patients with Adductor Spasmodic Dysphonia: A Pilot Study on Long-Term Outcome on Voice Quality - Corrected Proof

2011-09-23

Summary: Objectives: Adductor spasmodic dysphonia (ADSD) is a focal laryngeal dystonia, which compromises greatly the quality of life of the patients involved. It is a severe vocal disorder characterized by spasms of laryngeal muscles during speech, producing phonatory breaks, forced, strained and strangled voice. Its symptoms result from involuntary and intermittent contractions of thyroarytenoid muscle during speech, which causes vocal fold to strain, pressing each vocal fold against the other and increasing glottic resistance. Botulinum toxin injection remains the gold-standard treatment. However, as injections should be repeated periodically leading to voice quality instability, a more definitive procedure would be desirable. In this pilot study we report the long-term vocal quality results of endoscopic laser thyroarytenoid myoneurectomy.Study Design: Prospective study.Methods: Surgery was performed in 15 patients (11 females and four males), aged between 29 and 73 years, diagnosed with ADSD. Voice Handicap Index (VHI) was obtained before and after surgery (median 31 months postoperatively).Results: A significant improvement in VHI was observed after surgery, as compared with baseline values (P=0.001). The median and interquartile range for preoperative VHI was 99 and 13, respectively and 24 and 42, for postoperative VHI. Subjective improvement of voice as assessed by the patients showed median improvement of 80%.Conclusions: Because long-term follow-up showed significant improvement of voice quality, this innovative surgical technique seems a satisfactory alternative treatment of ADSD patients who seek a definite improvement of their condition.

Vocal Impact of a Prolonged Reading Task at Two Intensity Levels: Objective Measurements and Subjective Self-Ratings - Corrected Proof

Angélique Remacle, Camille Finck, Anne Roche, Dominique Morsomme — 2011-09-23

Summary: Objectives: The objectives of this study are to evaluate the impact on voice of both duration and intensity level of 2 hours of continuous oral reading. Voice modifications accompanying changes in intensity level during prolonged reading tasks are analyzed.Methods: Fifty normophonic women undergo two sessions of voice loading in which the required intensity level of voice varied between 60–65dB(A) for the first session and 70–75dB(A) for the second session. The effects of loading on objective data (average fundamental frequency [F0], jitter%, shimmer%, noise-to-harmonic ratio, maximum phonation time, lowest frequency [F-Low], highest frequency [F-High], frequency range [Range], lowest intensity [I-Low] level, and highest intensity level) and self-ratings (voice quality, phonation effort, vocal fatigue, and laryngeal discomfort) are assessed every 30 minutes during the loading tasks.Results: Results indicate that average F0, F-Low, I-Low, maximum phonation time, feeling of phonation effort, vocal fatigue, and laryngeal discomfort increase during prolonged reading, whereas shimmer% and self-rating of voice quality decrease. Average F0, F-High, and Range are the only parameters influenced by the required intensity of vocal load; they are significantly higher in the 70- to 75-dB session compared with the 60- to 65-dB session. Concerning the subjective self-ratings, similar results for the four ratings used suggest that only one would suffice in future studies.Conclusions: These results confirm the importance of both duration and intensity level as loading factors, even if intensity level affects fewer variables than duration.

Voice Problems Amongst Primary School Teachers in Singapore - Corrected Proof

Tze Choong Charn, Paul Kan Hwei Mok — 2011-09-19

Summary: Hypothesis/Objectives: Teachers are often cited to be at high risk of vocal disturbances. Many studies were performed in the West, but none locoregionally. The aim of this study is to determine the prevalence of voice problems amongst primary school teachers in six schools in Singapore and explore the associated risk factors.Methods: A cross-sectional study was conducted across six primary schools and 214 full-time teachers were surveyed. Teachers were asked to report if they have voice problems at the day of the interview, during the past 1 year and throughout their careers. Teachers who reported having current voice problems were invited for videolaryngostroboscopy. Multivariate analyses were performed to analyze risk factors associated with voice problems.Results: The point prevalence was 13.1% (95% confidence intervals [CI]: 9.3–18.3%). The past year prevalence and career prevalence were 25.4% (95% CI: 20–31.6%) and 32.1% (95% CI: 26.2–38.6%), respectively.Results showed that reflux symptoms (adjusted odds ratio [adj OR]=6.1, CI: 2.5–14.6) and microphone usage (adj OR=5.6, CI: 1.8–17.6) are risk factors for current voice disorders. Allergic rhinitis symptoms (adj OR=2.1, CI: 1.1–4.3), hypothyroid-like symptoms (adj OR=2.6, CI: 1.3–5.1), and microphone use (adj OR=3.4, CI: 1.1–10.0); allergic rhinitis symptoms (adj OR=2.6, CI: 1.4–5.1), reflux symptoms (adj OR=3.1, CI: 1.5–6.5), and the teaching of arts and theater studies (adj OR=2.8, CI: 1.4–5.9) are risk factors for voice problems in past 1 year and throughout the career, respectively.Conclusion: The findings confirm that teaching is a high-risk profession for acquiring voice problems. The risk factors uncovered are statistically and clinically significant and biologically plausible. There is a need for educational authorities and healthcare providers to develop effective and comprehensive prevention programs to arrest vocal attrition and its detrimental effects on the quality of teaching.

Habitual Use of Vocal Fry in Young Adult Female Speakers - Corrected Proof

Lesley Wolk, Nassima B. Abdelli-Beruh, Dianne Slavin — 2011-09-15

Summary: The purpose of this study was to examine the use of vocal fry in young adult Standard American-English (SAE) speakers. This was a preliminary attempt (1) to determine the prevalence of the use of this register in young adult college-aged American speakers and (2) to describe the acoustic characteristics of vocal fry in these speakers. Subjects were 34 female college students. They were native SAE speakers aged 18–25 years. Data collection procedures included high quality recordings of two speaking conditions, (1) sustained isolated vowel /a/ and (2) sentence reading task. Data analyses included both perceptual and acoustic evaluations. Results showed that approximately two-thirds of this population used vocal fry and that it was most likely to occur at the end of sentences. In addition, statistically significant differences between vocal fry and normal register were found for mean F0 minimum, F0 maximum, F0 range, and jitter local. Preliminary findings were taken to suggest that use of the vocal fry register may be common in some adult SAE speakers.

Acoustic Measures of the Voices of Older Singers and Nonsingers - Corrected Proof

Barbara Prakup — 2011-09-02

Summary: Objectives: This study investigated whether there were differences in the acoustic measures of fundamental frequency (Fo), jitter, intensity, and shimmer of older amateur singers and nonsingers and whether there were significant correlations between these acoustic measurements and listener judgments of speaker age.Methods: Acoustic measurements were obtained on 60 speaker participants from a sustained vowel production. Study participants included 30 male and female singers and 30 male and female nonsingers between the ages of 65 and 80 years. In addition, 10 speech-language pathology graduate students were recruited as listener participants to estimate the age of speaker participants from recorded vowel sounds.Results: The results of this study indicate that participants were perceived as significantly younger than their real ages, and male and female singers were perceived to be significantly younger than male and female nonsingers. Significant differences were found between male and female singers and nonsingers regarding jitter and intensity, with singers displaying significantly less jitter and significantly greater intensity than nonsingers. Perceived age was found to be related to jitter in male singers and nonsingers and female singers. Perceived age was found to be related to intensity in female nonsingers. No statistically significant differences were found between singers and nonsingers regarding Fo or shimmer. No significant correlations were found between perceived age and intensity in male singers, male nonsingers, or female singers.Conclusions: Acoustic and auditory-perceptual features of the aging voice appear to be factors associated with participation in amateur singing.

Determination of Fundamental Frequency and Voice Intensity in Iranian Men and Women Aged Between 18 and 45 Years - Corrected Proof

Farzad Izadi, Ramin Mohseni, Ahmad Daneshi, Nazila Sandughdar — 2011-09-02

Summary: Objectives: Acoustic measurements have become an essential aspect of voice assessment during the last few decades, and studies have established that normative data is necessary for acoustic analysis. In this study, two aspects of voice are reviewed. These two factors are fundamental frequency and intensity. This study was designed to establish the normal acoustic analysis parameters in normal Iranian adults.Methods: In this cross-sectional study, 200 healthy randomly selected subjects (100 men and 100 women) were assessed. Data collection was carried out using the Studio Speech software and Laryngograph processor (Laryngograph Ltd, London, UK), type: PCLX at the Larynx and Voice Disorders Clinic of Rasoul-e-Akram Hospital under comfortable phonation.Results: The value of fundamental frequency in reading was greater for women (170–240Hz) than for men (107–140Hz). Also, the value of intensity was greater for women (73.54–84.99dB) than for men (72.40–86.03dB).Conclusion: The present study developed the normal data for fundamental frequency and intensity in Iranian speakers aged between 18 and 45 years. We concluded, fundamental frequency has significant differences between men and women, but intensity has no significant difference between them.

Can Listeners Hear Who is Singing? What is the Pitch Bandwidth of Singer Discrimination in Untrained Listeners? - Corrected Proof

Molly L. Erickson — 2011-09-02

Summary: Objective/Hypothesis: This study sought to determine the pitch bandwidth of singer discrimination based on singer gender, pitch range, and same-different voice category.Study Design: Repeated measures factorial design.Methods: This study used a forced-choice paradigm, where listeners heard two different singers (singer 1 and singer 2) producing /ɑ/ at an identical pitch and an unknown singer (either singer 1 or singer 2) producing /ɑ/ at a different pitch. It was the listener's task to identify which singer (singer 1 or singer 2) was the unknown singer. Two baritones and two tenors were recorded producing /ɑ/ at the pitches C3, E3, G3, B3, D4, and F4. Two sopranos and two mezzo-sopranos were recorded producing /ɑ/ at the pitches C4, E4, G4, B4, D5, and F5. For each group of stimuli, male and female, all possible pairs of singers were constructed for the lowest pitch (C2 or C3, respectively) and highest pitch (F4 or F5, respectively). The unknown singer was varied across the remaining pitches.Results: For between category comparisons, the ability to discriminate singers diminished monotonically with pitch interval, reaching below chance levels between the intervals of the 9th and 11th. For within category comparisons, it was much harder to discriminate singers across pitch, particularly when the voices were female.Conclusion: Timbre is not perceived as invariant across the entire singing range, and the bandwidth of this timbre invariance depends on multiple factors, including pitch range, gender, and same-different voice category.

How Do Teachers With Self-Reported Voice Problems Differ From Their Peers With Self-Reported Voice Health? - Corrected Proof

Viveka Lyberg Åhlander, Roland Rydell, Anders Löfqvist — 2011-09-02

Summary: Objectives: This randomized case-control study compares teachers with self-reported voice problems to age-, gender-, and school-matched colleagues with self-reported voice health. The self-assessed voice function is related to factors known to influence the voice: laryngeal findings, voice quality, personality, psychosocial and coping aspects, searching for causative factors of voice problems in teachers.Methods: Subjects and controls, recruited from a teacher group in an earlier questionnaire study, underwent examinations of the larynx by high-speed imaging and kymograms; voice recordings; voice range profile; audiometry; self-assessment of voice handicap and voice function; teaching and environmental aspects; personality; coping; burnout, and work-related issues. The laryngeal and voice recordings were assessed by experienced phoniatricians and speech pathologists.Results: The subjects with self-assessed voice problems differed from their peers with self-assessed voice health by significantly longer recovery time from voice problems and scored higher on all subscales of the Voice Handicap Index-Throat.Conclusions: The results show that the cause of voice dysfunction in this group of teachers with self-reported voice problems is not found in the vocal apparatus or within the individual. The individual's perception of a voice problem seems to be based on a combination of the number of symptoms and of how often the symptoms occur, along with the recovery time. The results also underline the importance of using self-assessed reports of voice dysfunction.

An Examination of Surface EMG for the Assessment of Muscle Tension Dysphonia - Corrected Proof

2011-09-02

Summary: Objectives: Muscle tension dysphonia (MTD) is the pathological condition in which an excessive tension of the (para)laryngeal musculature leads to a disturbed voice. Surface electromyography (sEMG) was used to investigate differences in extralaryngeal muscles’ tension in patients with MTD compared with normal speakers. sEMG was examined as a diagnostic tool to differentiate between patients with MTD and controls.Methods: Eighteen patients with MTD and 44 normal speakers were included in the study. All subjects were evaluated with videostroboscopy, voice assessment protocol, and sEMG. sEMG was performed on three locations of the anterior neck. Measurements were taken during silence, phonation tasks, and while reading, with comparisons made between both study groups.Results: Patients with MTD did not express higher levels of sEMG during rest, phonation, or reading compared with normal speakers. There were no significant differences in sEMG values between males and females in both study groups.Conclusion: sEMG was not able to detect an increase in muscle tension in patients with MTD. The results of this study do not support the use of sEMG as a diagnostic tool for distinguishing patients with and without MTD. Clinical examination with laryngeal palpation, videostroboscopy, and dysphonia severity index remain the key investigations.

Health Information-Seeking Behaviors Among Classically Trained Singers - Corrected Proof

Brian E. Petty — 2011-08-24

Summary: Understanding health information-seeking behaviors (HISBs) within a particular patient demographic group is an important part of effective clinical outreach and education efforts. Although the community of classically trained singers has long been recognized by specialized health care providers, no studies have yet addressed the processes by which they search for voice-related health information, and little is known about how they use and access medical care. An electronic questionnaire focusing on HISB and voice-related health care issues was administered to 151 self-identified classically trained singers and 49 nonsinger controls. Outcomes of interest were tested for association with groups of singers and controls, followed by tests of association between demographic variables (age, gender, insurance status) with each outcome of interest. Results showed significant differences in specialty care access including point of first contact (P=0.0085), gender-associated delay of treatment initiation (P=0.0324), and use of home remedies for vocal problems (P≤0.0001). Significant differences in HISB were noted as well, including history of having undertaken an information search (P≤0.0001), likelihood of having concerns about information quality (P≤0.0001), and difficulty knowing where to find information (P≤0.0001). Differences were influenced by singing status, age, and gender. The insights provided by these data may inform decision-making processes regarding patient care, patient education, and clinical outreach to the target population.