Journal of Voice - Articles in Press

Objective Vocal Quality in Children Using Cochlear Implants: A Multiparameter Approach - Corrected Proof

Nele Baudonck, Evelien D'haeseleer, Ingeborg Dhooge, Kristiane Van Lierde — 2010-08-27

Summary: Objectives: The purpose of this study was to determine the objective vocal quality in 36 prelingually deaf children using cochlear implant (CI) with a mean age of 9 years. An additional purpose was to compare the objective vocal quality of these 36 CI users with 25 age-matched children with prelingual severe hearing loss using conventional hearing aids (HAs) and 25 normal hearing (NH) children.Study Design: The design for this cross-sectional study was a multigroup posttest-only design.Methods: The objective vocal quality was measured by means of the dysphonia severity index (DSI). Moreover, perceptual voice assessment using the GRBASI scale was performed.Results: CI children have a vocal quality by means of the DSI of +1.8, corresponding with a DSI% of 68%, indicating a borderline vocal quality situated 2% above the limit of normality. The voice was perceptually characterized by the presence of a very slight grade of hoarseness, roughness, strained phonation, and higher pitch and intensity levels. No significant objective vocal quality differences were measured between the voices of the CI children, HA users, and NH children.Conclusions: According to the results, one aspect of the vocal approach in children with CI and using HAs must be focused on the improvement of the strained vocal characteristic and the use of a lower pitch and intensity level.

Long-Term Horizontal Vocal Directivity of Opera Singers: Effects of Singing Projection and Acoustic Environment - Corrected Proof

Densil Cabrera, Pamela J. Davis, Anna Connolly — 2010-08-23

Summary: Vocal directivity refers to how directional the sound is that comes from a singer's mouth, that is, whether the sound is focused into a narrow stream of sound projecting in front of the singers or whether it is spread out all around the singer. This study investigates the long-term vocal directivity and acoustic power of professional opera singers and how these vary among subjects, among singing projections, and among vastly different acoustic environments. The vocal sound of eight professional opera singers (six females and two males) was measured in anechoic and reverberant rooms and in a recital hall. Subjects sang in four different ways: (1) paying great attention to intonation; (2) singing as in performance, with all the emotional connection intended by the composer; (3) imagining a large auditorium; and (4) imagining a small theatre. The same song was sung by all singers in all conditions. A head and torso simulator (HATS), radiating sound from its mouth, was used for comparison in all situations. Results show that individual singers have quite consistent long-term average directivity, even across conditions. Directivity varies substantially among singers. Singers are more directional than the standard HATS (which is a physical model of a talking person). The singer's formant region of the spectrum exhibits greater directivity than the lower-frequency range, and results indicate that singers control directivity (at least, incidentally) for different singing conditions as they adjust the spectral emphasis of their voices through their formants.

The Prevalence of Undiagnosed Thyroid Disease in Patients With Symptomatic Vocal Fold Paresis - Corrected Proof

2010-08-23

Summary: Objective: Vocal fold paresis has a multifactorial etiology and is idiopathic in many individuals. The incidence of thyroid-related neuropathy in the larynx has not been previously described. The purpose of this study was to evaluate the prevalence of previously undiagnosed thyroid disease in patients with laryngeal neuropathy and to compare this prevalence with that in a cohort of patients with a neurotologic neuropathy.Study Design and Setting: Case series with chart review; tertiary care, otolaryngology practice.Subjects and Methods: Charts of 308 consecutive patients with dysphonia and vocal fold paresis and 333 consecutive patients with sensorineural hearing loss, who presented for evaluation during a 3-year period, were reviewed.Results: One hundred forty-six of 308 (47.4%) patients with vocal fold paresis were diagnosed with concurrent thyroid disease, whereas 55 of 333 (16.5%) patients with sensorineural hearing loss were diagnosed with concurrent thyroid disease (P<0.001, Pearson chi-square = 92.896; degrees of freedom = 5). Thyroid diagnoses among those with vocal fold paresis included benign growths (29.9%), thyroiditis (7.8%), hyperthyroidism (4.5%), hypothyroidism (3.6%), and thyroid malignancy (1.6%).Conclusions: Thyroid abnormalities are more prevalent in patients with dysphonia and vocal fold paresis than in patients with symptomatic sensorineural hearing loss, suggesting a greater association between previously undiagnosed thyroid abnormalities and laryngeal neuropathy than that between neurotologic neuropathy and thyroid disease.

Multiparametric Analysis of Vocal Fold Vibrations in Healthy and Disordered Voices in High-Speed Imaging - Corrected Proof

2010-08-23

Summary: Objectives: The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI).Study Design and Methods: Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000Hz (256×256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values.Results: HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis).Conclusion: Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.

The Effect of a Short Voice Training Program in Future Teachers - Corrected Proof

2010-08-23

Summary: The purpose of this study was to investigate if a module consisting of 6 hours of voice training is effective in future teachers. Sixty-five students, enrolled in the academic teaching program at the Vrije Universiteit Brussel, participated in this study. The trained group (n=35) received 6 hours of voice training, whereas the control group (n=30) received no voice training. A multidimensional test battery containing subjective judgments and objective measurements was applied in both groups at the study onset and after 4 months to evaluate the training outcome. No significant differences were observed for the subjective judgments. For the objective measurements, by contrast, several significant differences between the trained and the control groups were found. This outcome favors the systematic introduction of voice training during the schooling of future teachers.

Effects of Vocal Training on Singing and Speaking Voice Characteristics in Vocally Healthy Adults and Children Based on Choral and Nonchoral Data - Corrected Proof

Nora Siupsinskiene, Hugo Lycke — 2010-08-12

Summary: Objectives: This prospective cross-sectional study examines the effects of voice training on vocal capabilities in vocally healthy age and gender differentiated groups measured by voice range profile (VRP) and speech range profile (SRP).Methods: Frequency and intensity measurements of the VRP and SRP using standard singing and speaking voice protocols were derived from 161 trained choir singers (21 males, 59 females, and 81 prepubescent children) and from 188 nonsingers (38 males, 89 females, and 61 children).Results: When compared with nonsingers, both genders of trained adult and child singers exhibited increased mean pitch range, highest frequency, and VRP area in high frequencies (P<0.05). Female singers and child singers also showed significantly increased mean maximum voice intensity, intensity range, and total VRP area. The logistic regression analysis showed that VRP pitch range, highest frequency, maximum voice intensity, and maximum-minimum intensity range, and SRP slope of speaking curve were the key predictors of voice training. Age, gender, and voice training differentiated norms of VRP and SRP parameters are presented.Conclusions: Significant positive effect of voice training on vocal capabilities, mostly singing voice, was confirmed. The presented norms for trained singers, with key parameters differentiated by gender and age, are suggested for clinical practice of otolaryngologists and speech-language pathologists.

Cytochrome c Oxidase Deficiency in Human Posterior Cricoarytenoid Muscle - Corrected Proof

2010-08-05

Summary: Background: Mitochondrial alterations occur in skeletal muscle fibers throughout the normal aging process, resulting from increased accumulation of reactive oxide species (ROS). These result in respiratory chain abnormalities, which decrease the oxidative capacity of muscle fibers, leading to decreased contractile force, sarcopenia, or fiber necrosis. Intrinsic laryngeal muscles are a cranial muscle group that possesses some distinctive genotypic, phenotypic, and physiologic properties. Their susceptibility to mitochondrial alterations resulting from biological processes that increase levels of oxidative stress may be one of these distinctive characteristics.Objectives: The incidence of cytochrome c oxidase (COX) deficiency (COX–) was determined in human posterior cricoarytenoid (PCA) muscle when compared with the human thyrohyoid (TH) muscle, an extrinsic laryngeal muscle that served as “control” muscle. Ten PCA and 10 TH muscles were harvested postlaryngectomy from 10 subjects ranging in age from 55 to 86 years. Differences in COX− were compared within and between muscle types using tissue section staining and standard morphometric analysis.Results and Conclusions: COX− fibers were identified in both the PCA and TH muscles. The PCA muscle had 10 times as may affected fibers as the TH muscle, with significant differences in COX− found between muscle type and fiber type (P=0.003). Almost all of this effect was the result of elevated levels of COX− in type I fibers from the PCA muscle (P=0.002) that showed a strong positive correlation with increased age. These results suggest that increased mitochondrial alterations may occur in the PCA muscle during normal aging.

The Relationship Between Tongue Trill Performance Duration and Vocal Changes in Dysphonic Women - Corrected Proof

2010-07-26

Summary: Objective: To assess the relationship between tongue trill performance duration and auditory perception and acoustic changes in dysphonic women.Study Design: Prospective clinical study, with intrasubject comparison.Methods: Twenty-seven women who had vocal nodules were in the experimental group (EG) (tongue trills), and 10 were also in the control group (CG) (placebo exercises). The voices were recorded before and after experimental and placebo exercises at the first (m1), third (m3), fifth (m5), and seventh (m7) minutes of performance. These recordings were randomized, and the auditory perception analysis was carried out by three judges trained in voice analysis. Individual recordings were analyzed using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) protocol, the randomized pairs of recordings were compared, and the better voice was chosen. VoxMetria software (CTS, Parana, Brazil, www.ctsinformatica.com.br) was used to assess the acoustic.Results: In the EG, the CAPE-V results showed a predominance of vocal improvement, statistically proven, at m5 of tongue trill exercise, with the best overall rating, the least roughness and breathiness, and increase in pitch level. At m7, strain was significantly higher. In the paired comparison analysis, voices at m5 were considered the best of all moments. There was an increase of the F0 and glottal-to-noise excitation after m3 and a decrease in noise as in m1. In the CG, vocal changes were discrete compared with those in the EG.Conclusion: Tongue trill performance duration interfered with the vocal response of dysphonic women, with positive response predominance at m5. At m7, there was an increase of vocal tension and a drop in vocal quality.

Evaluation of Stroboscopic Signs - Corrected Proof

2010-07-23

Summary: Objective: Clinicians interpret the stroboscopic examination by systematically rating several parameters or “signs.” This can be time consuming and experience dependent. The significance of each of these signs is unknown. Some signs may be redundant, whereas others may be more independent, thus reflecting a unique aspect of the exam assessment. We wanted to determine which stroboscopic signs are more independent and clinically relevant. This may lead to a more efficient and reliable method of stroboscopic exam evaluation.Study Design: Retrospective.Method: One hundred and eighty one consecutive adult patients with dysphonia of various pathologies were studied. Severity of dysphonia was judged, and a set of seven stroboscopic signs for each stroboscopic exam was rated by our voice team. A principal component factor analysis was performed, and the two factors that accounted for the most variance in the original rating data were determined. These two independent factors were then investigated for clinical usefulness.Results: Several individual stroboscopic signs of vocal fold vibration correlated with the “Vibration Factor” (VF) (mucosal wave, amplitude, vibratory behavior, and periodicity) and the vocal fold edge correlated with the “Edge Factor” (EF). Scores for VF and EF were used to differentiate between general categories of vocal fold pathology and related to the severity of dysphonia. Severity of dysphonia correlated with the VF to a greater degree than the EF. Furthermore, these two factor scores could be accurately estimated using only three stroboscopic signs (amplitude, vibratory behavior, and edge).Conclusion: The results of the study support the concept that a small set of stroboscopic ratings is an adequate representation of the information derived from the original, more comprehensive sign rating protocol. A focused rating system may provide an efficient method for stroboscopic evaluation, contributing to the differentiation of various vocal fold pathologies and correlating to clinician ratings of severity of dysphonia.

Voice Amplification as a Means of Reducing Vocal Load for Elementary Music Teachers - Corrected Proof

Sharon L. Morrow, Nadine P. Connor — 2010-07-23

Summary: Music teachers are over four times more likely than classroom teachers to develop voice disorders and greater than eight times more likely to have voice-related problems than the general public. Research has shown that individual voice-use parameters of phonation time, fundamental frequency and vocal intensity, as well as vocal load as calculated by cycle dose and distance dose are significantly higher for music teachers than their classroom teacher counterparts. Finding effective and inexpensive prophylactic measures to decrease vocal load for music teachers is an important aspect for voice preservation for this group of professional voice users. The purpose of this study was to determine the effects of voice amplification on vocal intensity and vocal load in the workplace as measured using a KayPENTAX Ambulatory Phonation Monitor (APM) (KayPENTAX, Lincoln Park, NJ). Seven music teachers were monitored for 1 workweek using an APM to determine average vocal intensity (dB sound pressure level [SPL]) and vocal load as calculated by cycle dose and distance dose. Participants were monitored a second week while using a voice amplification unit (Asyst ChatterVox; Asyst Communications Company, Inc., Indian Creek, IL). Significant decreases in mean vocal intensity of 7.00-dB SPL (P<0.001) were found using amplification, along with significant decreases (P=0.001) in cycle dose and distance dose. In addition, mean phonation time was found to decrease using amplification (P=0.023). These data suggest that voice amplification may be an effective intervention to decrease the potentially damaging vocal loads experienced by elementary music teachers in the classroom.

The Impact of Voice Disorders Among Teachers: Vocal Complaints, Treatment-Seeking Behavior, Knowledge of Vocal Care, and Voice-Related Absenteeism - Corrected Proof

Evelyne Van Houtte, Sofie Claeys, Floris Wuyts, Kristiane Van Lierde — 2010-07-16

Summary: Objectives: Teachers are at increased risk for developing voice disorders. Occupational risk factors have been extensively examined; however, little attention has been paid to the consequences of the vocal complaints. The objective of this study was to investigate the knowledge that teachers have about vocal care, treatment-seeking behavior, and voice-related absenteeism.Methods: The study group comprised 994 teachers and 290 controls whose jobs did not involve vocal effort. All participants completed a questionnaire inquiring about vocal complaints, treatment-seeking behavior, voice-related absenteeism, and knowledge about vocal care. Comparisons were made between teachers with and without vocal complaints and with the control group.Results: Teachers reported significantly more voice problems than the control population (51.2% vs 27.4%) (χ2=50.45, df=1, P<0.001). Female teachers reported significantly higher levels of voice disorders than their male colleagues (38% vs 13.2%, χ2=22.34, df=1, P<0.001). Teachers (25.4%) sought medical care and eventually 20.6% had missed at least 1 day of work because of voice problems. Female teachers were significantly more likely to seek medical help (χ2=7.24, df=1, P=0.007) and to stay at home (χ2=7.10, df=1, P=0.008) in comparison with their male colleagues. Only 13.5% of all teachers received information during their education.Conclusions: Voice disorders have an impact on teachers' personal and professional life and imply a major financial burden for society. A substantial number of teachers needed medical help and was obligated to stay at home because of voice problems. This study strongly recommends the implementation of vocal education during the training of teacher students to prepare the vocal professional user.

Vocal Process Avulsion - Corrected Proof

Scott S. Harris, Reena Gupta, Mary J. Hawkshaw, Robert T. Sataloff — 2010-06-28

Summary: Vocal process avulsion is a rare condition in which laryngeal trauma causes a separation of the vocal process from the body of the arytenoid cartilage. Typically symptoms are dysphonia and shortness of breath during phonation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography are helpful in establishing this important and sometimes elusive diagnosis. Several treatment modalities have been reported with varying success. We report four new cases, review four cases reported previously by the senior author, and suggest approaches to diagnosis and optimal treatment of vocal process avulsion.

Biomechanics of the Cricoarytenoid Joint: Three-Dimensional Imaging and Vector Analysis - Corrected Proof

2010-06-25

Summary: Objectives/Hypothesis: Laryngeal framework surgery requires a good understanding of the biomechanics of the cricoarytenoid (CA) joint, the precise function of which is still only poorly understood. The aim of the study was (1) to show that, by superimposing two or more three-dimensional (3D) images, we can visualize the exact position of the arytenoid cartilages within the larynx at different phases of their movement; and (2) to demonstrate that it is possible to analyze the arytenoid cartilage movements mathematically with the help of vector analysis.Study Design: In vitro cadaver study.Methods: Twenty fresh and intact cadaver larynges were scanned by high-resolution computerized tomography with the arytenoid cartilages in “respiratory” position and in “phonatory” position. The two positions were superimposed and rendered in 3D with MIMICS (Materialise Interactive Medical Image Control System, Leuven, Belgium). The spatial trajectory of the arytenoid cartilage movements was calculated with vector analysis.Results: The movement from the “respiratory” to the “phonatory” position has three components: (1) an inward rocking action around the longitudinal CA joint; (2) a forward sliding movement along the longitudinal axis of the CA joint; and (3) an inward rotation around a virtual axis that runs perpendicular to the CA joint axis.Conclusions: Superimposing 3D images of the larynx with the help of the software package MIMICS allows us to visualize and to analyze mathematically the trajectory of the arytenoid cartilage. The arytenoid cartilages rock inward, slide forward, and rotate inward when they move from the “respiratory” to the “phonatory” position.

Categorizing Normal and Pathological Voices: Automated and Perceptual Categorization - Corrected Proof

2010-06-25

Summary: Objectives: The aims of the present study were to evaluate the accuracy of an elaborated automated voice categorization system that classified voice signal samples into healthy and pathological classes and to compare it with classification accuracy that was attained by human experts.Material and Methods: We investigated the effectiveness of 10 different feature sets in the classification of voice recordings of the sustained phonation of the vowel sound /a/ into the healthy and two pathological voice classes, and proposed a new approach to building a sequential committee of support vector machines (SVMs) for the classification. By applying “genetic search” (a search technique used to find solutions to optimization problems), we determined the optimal values of hyper-parameters of the committee and the feature sets that provided the best performance. Four experienced clinical voice specialists who evaluated the same voice recordings served as experts. The “gold standard” for classification was clinically and histologically proven diagnosis.Results: A considerable improvement in the classification accuracy was obtained from the committee when compared with the single feature type-based classifiers. In the experimental investigations that were performed using 444 voice recordings coming from 148 subjects, three recordings from each subject, we obtained the correct classification rate (CCR) of over 92% when classifying into the healthy-pathological voice classes, and over 90% when classifying into three classes (healthy voice and two nodular or diffuse lesion voice classes). The CCR obtained from human experts was about 74% and 60%, respectively.Conclusion: When operating under the same experimental conditions, the automated voice discrimination technique based on sequential committee of SVM was considerably more effective than the human experts.

Vocal Changes in Patients With Polycystic Ovary Syndrome - Corrected Proof

2010-05-31

Summary: Purpose: The purpose of this study is to look at the prevalence of vocal symptoms and acoustic changes in patients with polycystic ovary syndrome (PCOS).Materials and Method: A total of 17 patients with PCOS diagnosed on the basis of three criteria: the presence of irregular menstrual cycles, hirsutism, and polycystic ovaries were included in the study. Twenty-one normal females' frequencies matched on age with the cases were used as controls. The following vocal symptoms were investigated: throat clearing, deepening of the voice, loss of voice, lump in the throat, and difficulty being heard. Acoustic analysis and laryngeal videostroboscopy were performed.Results: The age range was between 19 and 38 years with a mean age of 26 years. The most common prevailing symptom was throat clearing present in 76.5% versus 4.8% in the controls, followed by loss of voice (47.6%), lump in the throat (41.2%), and deepening of voice (35.3%). The differences in the prevalence of throat clearing, deepening of voice, lump in the throat, and difficulty being heard were statistically significant compared with controls (P value<0.05). There was no statistically significant difference in the acoustic parameters except for an increase in the relative average perturbation (P value=0.035) and a decrease in maximum phonation time (P value=0.001) in patients with PCOS. In the PCOS group, three patients had evidence of mild vocal fold edema and one patient had vocal fold nodules. In the control group, one subject had vocal fold edema and one subject had vocal fold nodules.Conclusion: Patients with PCOS seem to have more vocal symptoms compared with controls. Physicians should be aware of vocal changes in hirsute subjects with PCOS.

Boot Camp: A Novel Intensive Approach to Voice Therapy - Corrected Proof

Rita R. Patel, Diane M. Bless, Susan L. Thibeault — 2010-05-31

Summary: It is well known in the disciplines of neurobiology, exercise physiology, motor learning, and psychotherapy that desirable learning and behavior changes occur primarily from practice that involves high-intensity overload, variability, and specificity of training. We propose a novel treatment approach called intensive short-term voice therapy that uses these practice parameters for recalcitrant dysphonia. Intensive short-term voice therapy involves multiple sessions with a variety of clinicians, incorporating multiple simultaneous therapeutic approaches. The intensive short-term voice therapy approach is characterized by voice therapy for 1–4 successive days each with an average of 5 hours of therapy and five clinicians. This form of intensive voice therapy provides rigorous practice, involving not only overload but also opportunities for specificity and individuality thereby facilitating better transfer of learned skills. This article discusses the conceptual, theoretical, and practical foundations of this novel therapy approach.

Laryngeal Dynamics of Pedagogical Taan Gestures in Indian Classical Singing - Corrected Proof

Nandhakumar Radhakrishnan, Ronald C. Scherer, Santanu Bandyopadhyay — 2010-05-31

Summary: Objectives: Vocal modulations characterize many styles of singing. Vibrato, trill, and trillo are some of the ornaments that Western classical singers use. Likewise, taan is one of the basic frequency modulations demonstrated by Hindustani Indian classical singers. The objective of this descriptive study was to discover the F0 contour of taan; establish selected acoustic, aerodynamic, and glottographic characteristics of the taan gesture; and explore the pedagogical taan utterances demonstrated by a well-known singer and teacher.Study Design: Exploratory.Methods: Fundamental frequency, alternating current (AC) glottal flow, and electroglottographic width measures were obtained for taan productions by the classical Indian singer and teacher who demonstrated taan rate variations based on his pedagogical approach.Results: The structure of the taan gesture was found to be an F0 lowering and rising (the “taan dip”) followed by a relatively flat portion (the “taan superior surface”). Rate of the F0 structure of the taan gestures ranged from approximately 1.65 to 3.41Hz, and the F0 extent ranged from 1.87 to 2.21semitone (ST). As the rate of the taan gesture increased, the superior surface shortened, whereas the taan dip stayed relatively constant (ranging from 170 to 230 ms). AC flow was greater for the lowest frequencies of the dip and faster rates.Conclusions: The pedagogical taan gesture has a specific structure of an F0 dip followed by a relatively flat F0 portion that shortens as taan rate increases. The F0 dip and extent are relatively robust across rate. The taan productions are voluntarily controlled, in contrast to vibrato productions.

Friedrich Berthold Reinke (1862–1919): Anatomist of the Vocal Fold - Corrected Proof

Désirée Louise Dräger, Ryan C. Branski, Andreas Wree, Lucian Sulica — 2010-05-21

Summary: Although Reinke's space, or layer, is a critical laryngeal structure, and the eponym is in current use in both clinical and research milieus, little is known about the life of the eponymist, German anatomist Friedrich Berthold Reinke. Extensive investigation of the archives at the University of Rostock and other sources, as well as multinational collaboration, has yielded unique insight into the personal and professional life of this pioneer who, among other things, identified and characterized the subepithelial space of the vocal fold and structures in the Leydig cells of the testicles and ovaries. This breadth of investigation reflects Reinke's intellectual curiosity and broad-ranging interest as well as his scientific environment. Without question, Reinke's observations of the human vocal fold are substantive contributions, without which modern laryngology could not have evolved. In 2009, at the 90th anniversary of Reinke's death, we summarize his achievements to express our appreciation for his singular brilliance and fundamental contribution to laryngology.

Perturbation Measurements in Untrained Male Voices' Transitions From Modal to Falsetto Register - Corrected Proof

Matthias Echternach, Johan Sundberg, Mark F. Zander, Bernhard Richter — 2010-05-21

Summary: Purpose: Voice periodicity during transitions from modal to falsetto register still remains an unclarified question.Method: We examined the acoustic and electroglottographic signals of 20 healthy untrained male voices' transitions from modal to falsetto register on the vowels /a, e, i, o, u, and æ/.Results: In addition to discontinuities in fundamental frequency (F0), an independent increase of jitter, relative average perturbation, and shimmer was observed during and apparently caused by the register transition. In falsetto, the jitter was higher than in the modal register. The contact quotient derived from the electroglottographic signal tended to be lower for higher than for lower F0.Conclusion: Register transitions are associated with increase of perturbation.

Perturbation and Nonlinear Dynamic Analysis of Adult Male Smokers - Corrected Proof

2010-05-18

Summary: Objective: Smoking results in a voice change, and the perception by smokers of an abnormal voice may encourage quitting behavior. Moreover, a disordered voice is often the first sign of vocal pathology. Efforts to evaluate voice have focused on classical acoustic analysis; however, nonlinear dynamic analysis has been shown to be a reliable objective method for the evaluation of voice. We compare the discriminatory ability of these two methods when applied to normal and smokers' voices.Study Design: Prospective study.Methods: The study included 73 subjects, 36 nonsmokers and 37 smokers. A segment of sustained vowel production was obtained from each subject. Acoustic dimension and correlation dimension (D2) analyses were applied to the data. Results were compared with a Mann-Whitney rank sum test, logistic regression, and receiver operating characteristics (ROC) analysis.Results: D2 values for smokers were significantly higher than D2 values for nonsmokers (P<0.001). Jitter and shimmer analysis showed higher values for these parameters among smokers. Logistic regression indicated a higher predictive power with D2, and ROC analysis found no significant difference between the analysis methods.Discussion: This study indicated that D2 is highly sensitive to changes associated with smoking and has the potential to be implemented clinically as an indicator of abnormal voice. Further research could focus on using nonlinear dynamic analysis to create a normative database, producing standards for monitoring voice changes caused by cigarette smoking.

A Case of Bilateral Vocal Fold Mucosal Bridges, Bilateral Trans-Vocal Fold Type III Sulci Vocales, and an Intracordal Polyp - Corrected Proof

Melin Tan, Michael J. Pitman — 2010-05-17

Summary: Introduction: We present a patient with a novel finding of bilateral mucosal bridges, bilateral type III trans-vocal fold sulci vocales, and a vocal fold polyp. Although sulci and mucosal bridges occur in the vocal folds, it is rare to find multiples of these lesions in a single patient, and it is even more uncommon when they occur in conjunction with a vocal fold polyp. To our knowledge, this is the first description of a vocal fold polyp in combination with multiple vocal fold bridges and multiple type III sulci vocales in a single patient.Objective: To describe and visually present the diagnosis and treatment of a patient with an intracordal polyp, bilateral mucosal bridges, as well as bilateral type III trans-vocal fold sulci vocales.Methods: Presentation of a set of high definition intraoperative photos displaying the extent of the vocal fold lesions and the resection of the intracordal polyp.Results: This patient presented with only 6 months of significant dysphonia. It was felt that the recent change in voice was because of the polyp and not the bridges or sulci vocales. Considering the patient's presentation and the possible morbidity of resection of mucosal bridges and sulci, only the polyp was excised. Postoperatively, the patient's voice returned to his acceptable mild baseline dysphonia, and the benefit has persisted 6 months postoperatively.Conclusion: The combination of bilateral mucosal bridges, bilateral type III sulcus vocalis, and an intracordal polyp in one patient is rare if not novel. Treatment of the polyp alone returned the patient's voice to his lifelong baseline of mild dysphonia.

Toward Dynamic Magnetic Resonance Imaging of the Vocal Tract During Speech Production - Corrected Proof

Sandra M. Rua Ventura, Diamantino Rui S. Freitas, João Manuel R.S. Tavares — 2010-05-17

Summary: Objectives/Hypothesis: The most recent and significant magnetic resonance imaging (MRI) improvements allow for the visualization of the vocal tract during speech production, which has been revealed to be a powerful tool in dynamic speech research. However, a synchronization technique with enhanced temporal resolution is still required.Study Design and Methods: The study design was transversal in nature. Throughout this work, a technique for the dynamic study of the vocal tract with MRI by using the heart's signal to synchronize and trigger the imaging-acquisition process is presented and described. The technique in question is then used in the measurement of four speech articulatory parameters to assess three different syllables (articulatory gestures) of European Portuguese Language.Results: The acquired MR images are automatically reconstructed so as to result in a variable sequence of images (slices) of different vocal tract shapes in articulatory positions associated with Portuguese speech sounds.Conclusions: The knowledge obtained as a result of the proposed technique represents a direct contribution to the improvement of speech synthesis algorithms, thereby allowing for novel perceptions in coarticulation studies, in addition to providing further efficient clinical guidelines in the pursuit of more proficient speech rehabilitation processes.

Mucosal Wave Measurement and Visualization Techniques - Corrected Proof

2010-05-17

Summary: Organized vibration of the vocal folds is critical for high-quality voice production. When the vocal folds oscillate, the superficial tissue of the vocal fold is displaced in a wave-like fashion, creating the so-called “mucosal wave.” Because the mucosal wave is dependent on vocal fold structure, physical alterations of that structure cause mucosal wave abnormalities. Visualization and quantification of mucosal wave properties have become useful parameters in diagnosing and managing vocal fold pathology. Mucosal wave measurement provides information about vocal fold characteristics that cannot be determined with other assessment techniques. Here, we discuss the benefits, disadvantages, and clinical applicability of the different mucosal wave measurement techniques, such as electroglottography, photoglottography, and ultrasound and visualization techniques that include videokymography, stroboscopy, and high-speed digital imaging. The various techniques and their specific uses are reviewed with the intention of helping researchers and clinicians choose a method for a given situation and understand its limitations and its potential applications. Recent applications of these techniques for quantitative assessment demonstrate that additional research must be conducted to realize the full potential of these tools. Evaluations of existing research and recommendations for future research are given to promote both the quantitative study of the mucosal wave through accurate and standardized measurement of mucosal wave parameters and the development of reliable methods with which physicians can diagnose vocal disorders.

Intonation and Emotion: Influence of Pitch Levels and Contour Type on Creating Emotions - Corrected Proof

Emma Rodero — 2010-05-17

Summary: Intonation is a vehicle for communication, which sometimes contributes greater meaning than the semantic content of speech itself. This prosodic element lends the message linguistic and paralinguistic meaning, which carries a highly significant communicative value when conveying emotional states. For this reason, this article analyses the use of intonation as an instrument for arousing various sensations in the listener. The aim was to verify which elements of intonation are more decisive to generate a specific sensation. Experimental research is conducted, in which certain pitch patterns (pitch levels and contour type) are assigned different emotions (joy, anxiety, sadness, and calmness) and are then listened to and assessed using a questionnaire with a bipolar scale of opposed pairs, by a sample audience comprising 100 individuals. The main conclusion drawn is that, although both the variables analyzed—pitch level and contour type—are representative of expressing emotions, contour type is more decisive. In all the models analyzed, contour type has been highly significant and constitutes the variable that has been determined as the final component for recognizing various emotions.

Acoustical Analysis of Speech in Progressive Supranuclear Palsy - Corrected Proof

Sabine Skodda, Wenke Visser, Uwe Schlegel — 2010-05-11

Summary: Background: Dysarthria often is an early and prominent clinical feature of progressive supranuclear palsy (PSP). Based on perceptual analyses, speech impairment in PSP reportedly consists of prominent hypokinetic and spastic components with occasional ataxic features.Objective: To measure objectively and quantitatively different speech parameters in PSP as compared with Parkinson's disease (PD) by acoustical analysis and to correlate these parameters with disease duration, global motor, and speech impairment and with the subtype of disease (Richardson's syndrome [RS] vs parkinsonian type of PSP [PSP-P]).Patients and Methods: Twenty-six patients with clinical diagnosis of PSP (n=14 classified as RS and n=12 classified as PSP-P) and 30 age- and gender-matched patients with clinical diagnosis of PD were tested. Speech examination was based on the acoustical analysis of a standardized four-sentence reading task. Several speech variables were measured to assess phonation, intonation variability, speech velocity, and articulatory precision. All participants were tested according to Unified Parkinson's Disease Rating Scale/Motor Score (UPDRS-III) and staged according to Hoehn and Yahr stages. Global speech intelligibility was evaluated on the basis of the UPDRS-III speech item.Results: In the PSP group, speech velocity, intonation variability, and the fraction of intraword pauses as a measure of articulatory precision were significantly reduced, whereas the percentage of speech pauses was prolonged as compared with the PD group. Only in the male PSP patients, vowel articulation was found to be impaired. Global speech performance was worse in the PSP group in comparison with the PD group and showed a correlation to some distinct speech dimensions. No differences of speech variables were seen between RS and PSP-P patients.Conclusions: PSP patients feature a mixed type of dysarthria with hypokinetic and spastic components that differ significantly from the speech performance of PD speakers. This probably reflects the widespread neuropathological changes in PSP comprising basal ganglia as well as pontine and further brainstem regions.

Cross-Cultural Adaptation and Validation of the Voice Handicap Index Into Brazilian Portuguese - Corrected Proof

Mara Behlau, Luciana de Moraes Alves dos Santos, Gisele Oliveira — 2010-05-03

Summary: The purpose of the present study was to culturally adapt and validate the Voice Handicap Index (VHI) to Brazilian Portuguese. Psychometric analyses were performed on the translated version as described by the Scientific Advisory Committee of the Medical Outcomes Trust. The translated version was completed by 52 individuals with vocal complaints and by a control group of 64 subjects. Validation, reliability, reproducibility, and responsiveness were evaluated. All participants also completed a self-rating vocal quality scale. Statistical analyses demonstrated high internal consistency and high test-retest reliability both for the overall VHI score and for the functional, physical, and emotional domains of the VHI. A positive correlation was found between the VHI and the self-rating vocal quality scale. The subjects in the control group had lower scores compared with the subjects with voice disorders for the overall VHI score and for the three domains. Based on these data, the Brazilian Portuguese version of VHI is a valid and reliable measure for use in the Brazilian population.

Effects of Soft Palate Implants on Acoustic Characteristics of Voice and Articulation - Corrected Proof

Meltem Esen Akpinar, Ismail Kocak, Berk Gurpinar, Halil Erturk Esen — 2010-05-03

Summary: Objective: To evaluate the effects of soft palate implants on voice and articulation.Study Design: Prospective case series.Methods: Male subjects (n=23) diagnosed with mild obstructive sleep apnea and/or habitual snoring underwent acoustic analysis with the Multidimensional Voice Program (Kay Multi-Speech Model 3700 Advanced Version; Kay Elemetrics [KayPentax], Lincoln Park, NJ) before and 8 weeks after insertion of palatal implants to determine the effects of soft palate implants on voice and articulation. Sustained vowels (/a/e/u/o/i/) and phonetically balanced carrier sentences were used for acoustic analyses. Parameters measured were fundamental frequency (F0), jitter, shimmer, noise-to-harmonics ratio, Voice Turbulence Index, Soft Phonation Index, degree of voiceless, degree of voice breaks and peak amplitude variation, first formant (F1) and second formant (F2) frequencies, and voice onset time (VOT). F1 and F2 for each vowel were determined using linear predictive analysis on a spectrogram. VOT was measured for the palatal consonant /k/ and the dental consonant /t/ on a wideband spectrogram from a carrier sentence segment that contained a syllable with a stop consonant.Results: No statistically significant difference was detected in F0, F1, F2, or other MDVP parameters before and after implantation. Average VOT values measured for /t/ were not significantly different. On the other hand, average VOT values of /k/ were found to be significantly shorter.Conclusions: Implant insertion had no significant effect on MDVP parameters, F0, F1, or F2. On the other hand, articulation as a function of velar region seemed to be affected because VOT values of velar /k/ were changed.

Vowel Articulation in Parkinson's disease - Corrected Proof

Sabine Skodda, Wenke Visser, Uwe Schlegel — 2010-05-03

Summary: Objective: The aim of the study was to analyze vowel articulation in Parkinson's disease (PD) speakers suffering from mild hypokinetic dysarthria as compared with healthy controls in correlation to net speech rate (NSR) and intonation variability (F0SD). Furthermore, we intended to reveal possible correlations among vowel articulation, global motor performance, and stage of disease.Patients and Methods: We examined 68 PD patients (34 male) with mild dysarthria (1 point according to the “speech” item 18 of the Unified Parkinson's Disease Rating Scale/UPDRS-III) and 32 age-matched control persons (16 male) using a reading task with subsequent acoustical analysis. F1 and F2 frequency values of the vowels /a/, /i/, and /u/ were extracted from defined words within the text. Description of vowel articulation was based on measures of triangular vowel space area (tVSA) and Vowel Articulation Index (VAI). PD patients were scored according to UPDRS-III and Hoehn and Yahr stages.Results: VAI values were significantly reduced in male and female PD patients as compared with the accordant control group, whereas tVSA was only reduced in the male PD speakers. NSR was negatively correlated to tVSA and VAI only in female PD speakers. No correlations were seen between vowel articulation and UPDRS-III and stage of disease.Conclusions: VAI seem to be superior to tVSA in the description of impaired vowel articulation in PD. Reduced VAI could be detected in male and female parkinsonian speakers suffering only from mild dysarthria with preserved speech intelligibility and therefore might be applicable to identify subclinical changes of vowel articulation. Moreover, some aspects of altered speech performance in PD seem to feature some gender-specific patterns, which justify further investigation.

Clinical Versus Laboratory Ratings of Voice Using the CAPE-V - Corrected Proof

Nancy Pearl Solomon, Leah B. Helou, Alexander Stojadinovic — 2010-04-30

Summary: Objectives: Procedures used for auditory-perceptual assessment of voice in the clinical setting often differ from those used in research settings. This study examined whether ratings made with the knowledge of a patient's identity and clinical status are consistent with those made under randomized and blinded laboratory conditions.Study Design: Data derived from a prospective observational clinical trial were used in this mixed laboratory (blinded, randomized, anchored) and field (clinical) correlational study.Methods: Ninety-nine adults scheduled for thyroidectomy were evaluated by one of two speech-language pathologists (SLPs) using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) before and up to three times after surgery over a 6-month period. Subsequently, voice recordings were played over headphones in randomized order within speaker to three experienced SLPs, including the two who conducted clinical ratings. Listeners were blinded to speaker identity and recording session, and were provided with auditory anchors for “moderate” dysphonia.Results: Each of the two SLPs who rated the speakers' voices clinically demonstrated moderately strong correlations with ratings of the same voices under laboratory conditions (r=0.807 and 0.708 for overall severity), but clinical ratings tended to be higher (more severe) than laboratory ratings particularly when dysphonia was moderate to severe. Intraclass correlations across the three SLPs for laboratory ratings were moderate (r=0.645 for overall severity). Correlations between clinical and the median of the three laboratory ratings across all sessions were moderate (r=0.526–0.792), with the strongest correlation for overall severity.Conclusions: Clinical bias may play a role in observed discrepancies between clinical and laboratory ratings of dysphonia. Additionally, auditory anchors available during laboratory procedures may contribute to these discrepancies. These findings highlight the need to standardize procedures for clinical voice assessment.

Laryngocele: A Rare Long-Term Complication Following Neck Surgery? - Corrected Proof

Tal Marom, Yehudah Roth, Udi Cinamon — 2010-04-30

Summary: Introduction: Laryngocele is an abnormal dilatation of the laryngeal saccule. Suggested etiologies include congenital enlargement of the saccule, weakness of laryngeal tissues, and increased intralaryngeal pressure. Only a few reports have described the late evolution of laryngocele following neck surgery.Case Presentation: Two heavy smoking patients presented with hoarseness in voice because of laryngocele, which has evolved many years following ipsilateral neck surgery: hemithyroidectomy 20 years earlier and frontolateral hemilaringectomy 12 years earlier. Both patients were treated similarly by an endoscopic laser-assisted resection of the laryngocele. No other risk factor could have been attributed to its development. Follow-up was unremarkable.Discussion: Laryngeal locus minoris violation may result in the development of laryngocele in the long run following neck surgery and may be considered as a late rare surgical complication. In addition, heavy smoking or its sequelae may predispose this condition.

Incidence and Predisposing Factors of Common Upper Respiratory Tract Infections in Vocal Students During Their Professional Training - Corrected Proof

Joanna Zimmer-Nowicka, Henryka Januszewska-Stańczyk — 2010-04-30

Summary: Objective: Upper respiratory tract infections (URTI) are among the major causes of dysphonia. There are only scarce data available on the incidence and predisposing factors of URTI in young singers, in particular, during a period of intense voice training.Patients and Methods: The data were obtained from medical records and a 43-item questionnaire distributed among 94 students of the vocal faculty (66 females and 28 males—age: 23.5±3.7 years) at all levels of their studies. The questions were divided into several categories, that is, personal, anthropometric, demographic, history of vocal education, and both general and singer-specific health risk factors.Results: The rate of URTI showed a steady decrease during vocal studies. The strongest factor predisposing to infections in the multivariate regression model was nonadherence to vocal hygiene. There was also a weak protective effect of a regular holiday rest and negative effect of allergy. The prevalence of several recognized risk factors of URTI was exceptionally high in the group of vocal students, for example, passive smoking (42.5%), poor dental status (39.4%), frequent gastric complaints (44.7%), and allergy (50%).Conclusion: Despite the persistence of many risk factors throughout the vocal studies, the frequency of URTI significantly decreases most likely because of vocal hygiene education and growing professional experience.

Effects of Practice Variability on Learning of Relaxed Phonation in Vocally Hyperfunctional Speakers - Corrected Proof

Amy Y.-H. Wong, Estella P.-M. Ma, Edwin M.-L. Yiu — 2010-04-26

Summary: The present study investigated the effects of practice variability on the learning of relaxed phonation using a motor learning perspective. Twenty-one individuals with hyperfunctional voice problems were evenly and randomly assigned to three groups of practice conditions: constant, blocked, and random practice conditions. During training, participants in the constant practice condition were asked to read aloud sentence stimuli with four Chinese characters. Participants in the blocked practice condition were asked to read aloud sentence stimuli with increasing sentence length, starting from sets of two characters to five characters. Participants in the random practice condition were asked to practice reading sentence stimuli of variable length from two to five characters presented in a random fashion. Surface electromyographic feedback (sEMG) from the thyrohyoid muscle site was given to each participant after reading every two sentence stimuli. Results demonstrated that for all the participants, voice motor learning was evidenced by the decreased sEMG levels in delayed retention test. Generalization to untrained passage was shown as well. However, results did not reveal any difference in the learning among the three practice conditions. The findings from the present study did not support the hypothesis of contextual interference, which states that practice using variable items presented in a random mode is more beneficial to learning than practice using constant items.

Formation of the Actor's/Speaker's Formant: A Study Applying Spectrum Analysis and Computer Modeling - Corrected Proof

Timo Leino, Anne-Maria Laukkanen, Vojtěch Radolf — 2010-04-26

Summary: Hypothesis: A strong peak between 3 and 4 kHz in the long-term average spectrum (LTAS) of speech has been found to be one correlate of a good male speaking voice, for example, among actors. The actor's or speaker's formant (resembling the singer's formant) can be established by certain vocal training. This study investigates the origin of the speaker's formant.Study Design and Setting: The immediate effects of a vocal exercise series on speaking voice were studied in a Finnish male actor, who is an experienced teacher of the exercises. They consist of nasal vowel syllable strings and words containing nasals. Before and after a 30-minute exercising, the subject (1) read aloud at three loudness levels and (2) phonated the Finnish vowels at habitual level.Methods: Formant frequencies were estimated from spectra of the vowel samples. LTAS was made and equivalent sound level (Leq) was measured for the text samples. Formant frequencies were used as the input for a one-dimensional (1D) mathematical model.Results: After the exercise, the peak at 3.5 kHz in the LTAS of the reading samples was stronger, although Leq was the same as before, suggesting a level-independent resonance change. Reading samples after exercising were evaluated to sound better in voice quality than before exercising. The strong peak at 3.5 kHz was present in all vowels, and it was mainly formed by clustering of F4 and F5.Conclusions: A 1D model-based optimization suggested that this kind of a formant cluster could be best established by simultaneously narrowing the epilaryngeal tube, widening the pharynx and narrowing the front of the oral cavity.

In Vivo Engineering of the Vocal Fold ECM With Injectable HA Hydrogels—Late Effects on Tissue Repair and Biomechanics in a Rabbit Model - Corrected Proof

Susan L. Thibeault, Sarah A. Klemuk, Xia Chen, Beatriz H. Quinchia Johnson — 2010-04-26

Summary: Objectives: To determine if the utilization of injectable chemically modified hyaluronan (HA) derivative at the time of intentional vocal fold resection may facilitate wound repair and preserve the unique viscoelastic properties of the extracellular matrix (ECM) and lamina propria 6 months after treatment.Study Design: Prospective, controlled animal study.Methods: Twelve rabbit vocal folds were biopsied bilaterally, and the left side of vocal fold was treated with Extracel, an injectable, chemically modified HA derivative, and the right side of vocal fold was injected with saline as control at the time of resection. Animals were sacrificed 6 months after biopsy and injection. Outcomes measured include transcription levels for procollagen, fibronectin, fibromodulin, transforming growth factor beta one (TGF-β1), HA synthase, and hyaluronidase, and tissue biomechanics—viscosity and elasticity.Results: Extracel-treated vocal folds were found to have significantly less fibrosis than saline-treated controls. Extracel-treated vocal folds had significantly improved biomechanical properties of elasticity and viscosity. Significantly decreased levels of fibronectin, fibromodulin, TGF-β1, procollagen I, and HA synthase were measured.Conclusions: Prophylactic in vivo manipulation of the ECM with an injectable HA hydrogel appears to induce vocal fold tissue regeneration to yield improved tissue composition and biomechanical properties at 6 months.

Listener Perception of the Effect of Abdominal Kinematic Directives on Respiratory Behavior in Female Classical Singing - Corrected Proof

Sally Collyer, Dianna T. Kenny, Michaele Archer — 2010-04-26

Summary: Breath management training in classical singing is becoming increasingly physiologically focused, despite evidence that directives focusing on chest-wall kinematic (ribcage and abdominal) behavior effect minimal change in acoustical measures of singing. A direct and proportionate relationship between breathing behavior and vocal quality is important in singing training because singing teachers rely primarily on changes in sound quality to assess the efficacy of breath management modification. Pedagogical opinion is also strongly divided over whether the strategy of retarding the reduction in abdominal dimension during singing has a negative effect on vocal quality. This study investigated whether changes in abdominal kinematic strategy were perceptible and whether listeners preferred a particular strategy. Fourteen experienced singing teachers and vocal coaches assessed audio samples of five female classical singers whose respiratory kinematic patterns during singing had been recorded habitually and under two simple, dichotomous directives: Gradually drawing the abdomen inward and gradually expanding the abdomen, during each phrase. Listeners rated the singers on standard of singing and of breath management. Ratings analysis took into consideration changes in kinematic behavior under each directive determined from the respiratory recordings. Listener ratings for two singers were unaffected by directive. For three singers, ratings were lower when the directive opposed habitual kinematic behavior. The results did not support the pedagogical assumption of a direct and proportional link between respiratory behavior and standard of singing or that the abdomen-outward strategy was deleterious to vocal quality. The findings demonstrate the importance of considering habitual breathing behavior in both research and pedagogical contexts.

Pitch-Matching Accuracy in Trained Singers and Untrained Individuals: The Impact of Musical Interference and Noise - Corrected Proof

Julie M. Estis, Ashli Dean-Claytor, Robert E. Moore, Thomas L. Rowell — 2010-04-26

Summary: The effects of musical interference and noise on pitch-matching accuracy were examined. Vocal training was explored as a factor influencing pitch-matching accuracy, and the relationship between pitch matching and pitch discrimination was examined. Twenty trained singers (TS) and 20 untrained individuals (UT) vocally matched tones in six conditions (immediate, four types of chords, noise). Fundamental frequencies were calculated, compared with the frequency of the target tone, and converted to semitone difference scores. A pitch discrimination task was also completed. TS showed significantly better pitch matching than UT across all conditions. Individual performances for UT were highly variable. Therefore, untrained participants were divided into two groups: 10 untrained accurate and 10 untrained inaccurate. Comparison of TS with untrained accurate individuals revealed significant differences between groups and across conditions. Compared with immediate vocal matching of target tones, pitch-matching accuracy was significantly reduced, given musical chord and noise interference unless the target tone was presented in the musical chord. A direct relationship between pitch matching and pitch discrimination was revealed. Across pitch-matching conditions, TS were consistently more accurate than UT. Pitch-matching accuracy diminished when auditory interference consisted of chords that did not contain the target tone and noise.

Voice Quality in Relation to Voice Complaints and Vocal Fold Condition During the Screening of Female Student Teachers - Corrected Proof

Leo F.P. Meulenbroek, Felix I.C.R.S. de Jong — 2010-04-26

Summary: Objectives: The purpose of this study was to compare the perceptual examination of voice quality with the condition of the vocal folds and voice complaints during voice screening in female student teachers.Methods: This research was a cross-sectional study in 214 starting student teachers using the four-point grade scale of the GRBAS and laryngostroboscopic assessment of the vocal folds. The voice quality was assessed by speech pathologists using the ordinal 4-point G-scale (overall dysphonia) of the GRBAS method in a running speech sample. Glottal closure and vocal fold lesions were recorded. A questionnaire was used for assessing voice complaints.Results: More students with an insufficient glottal closure (89%) were rated dysphonic compared with students with sufficient glottal closure (80%). Students with sufficient glottal closure had a significantly lower mean G-score (1.21) compared with the group with insufficient glottal closure (1.52) (P=0.038). This study showed a larger percentage of students with vocal fold lesions (96%) labeled a dysphonic voice compared to students with no vocal fold problems (81%). Students with no vocal fold lesions had a significantly lower mean G-score (1.20) compared with the group with vocal fold lesions (2.05) (P=0.002). A dysphonic voice (G≥1) was rated in 76% of the students without voice complaints compared with 86% of the students with voice complaints. Students with no voice complaints had a lower mean G-score (1.07) compared with the group with voice complaints (1.41) (P=0.090).Conclusion: The present study showed that perceptual assessment of the voice and voice complaints is not sufficient to check if the future professional is at risk. Therefore, preventive measures are needed to detect students at risk early in their education and this depends on broader assessment: on the one hand, assessing voice quality and voice complaints and on the other hand, examination of the vocal folds of all starting students.

Pathophysiology and Treatment of Muscle Tension Dysphonia: A Review of the Current Knowledge - Corrected Proof

Evelyne Van Houtte, Kristiane Van Lierde, Sofie Claeys — 2010-04-20

Summary: Objective: Muscle tension dysphonia (MTD) is a clinical and diagnostic term describing a spectrum of disturbed vocal fold behavior caused by increased tension of the (para)laryngeal musculature. Recent knowledge introduced MTD as a bridge between functional and organic disorders. This review addresses the causal and contributing factors of MTD and evaluates the different treatment options.Methods: We searched MEDLINE (Pubmed, 1950–2009) and CENTRAL (The Cochrane Library, Issue 2, 2009). Studies were included if they reviewed the classification of functional dysphonia or the pathophysiology of MTD. Etiology and pathophysiology of MTD and circumlaryngeal manual therapy (CMT) were obligatory based on reviews and prospective cohort studies because randomized controlled trials (RCTs) are nonexisting. Concerning the treatment options of voice therapy and vocal hygiene, selection was based on RCTs and systematic reviews.Results: Etiological factors can be categorized into three new subgroups: (1) psychological and/or personality factors, (2) vocal misuse and abuse, and (3) compensation for underlying disease. The effective treatment options for MTD are (1) indirect therapy: vocal hygiene and patient education; (2) direct therapy: voice therapy and CMT; (3) medical treatment; and (4) surgery for secondary organic lesions.Conclusions: MTD is the pathological condition in which an excessive tension of the (para)laryngeal musculature, caused by a diverse number of etiological factors, leads to a disturbed voice. Etiological factors range from psychological/personality disorders and vocal misuse/abuse to compensatory vocal habits in case of laryngopharyngeal reflux, upper airway infections, and organic lesions. MTD needs to be approached in a multidisciplinary setting where close cooperation between a laryngologist and a speech language pathologist is possible.

Patient Factors Related to Voice Therapy Attendance and Outcomes - Corrected Proof

Bonnie E. Smith, Gail B. Kempster, H. Steven Sims — 2010-04-12

Summary: Limited information is available concerning factors that may be associated with attendance and outcomes among patients referred for voice therapy. The purpose of this study was to determine whether patient-related factors could be identified which distinguished patients who attended voice therapy and had positive voice change from those who did not. This retrospective study included medical record information for 100 patients seen at a major urban, academic medical center. The attendance/outcomes of voice therapy resulted in patient division into five groups, those who (1) were successfully discharged from therapy, (2) attended a few sessions, had voices that improved to normal or were near normal and then stopped attending therapy, (3) attended many sessions with some voice gain, (4) failed to improve despite attending voice therapy, or (5) failed to attend voice therapy as recommended. Outcomes for groups 1–3 (53% of patients) were considered successful (positive voice change), whereas outcomes for groups 4 and 5 (47% of patients) were considered unsuccessful. A high percentage of patients (44%) essentially did not attend therapy. Patients having successful outcomes were more likely to be female, younger, employed, with fewer laryngeal diagnoses and medical problems, a less severe voice disorder and lower Voice Handicap Index (VHI) scores at the start of therapy. Patients with more complex laryngeal diagnoses, more perceived vocal severity, occupational issues, more health issues, and higher VHI scores at the time of the initial voice evaluation may be at greater risk for failing to attend voice therapy sessions.

Formant Characteristics of Human Laughter - Corrected Proof

2010-04-12

Summary: Although laughter is an important aspect of nonverbal vocalization, its acoustic properties are still not fully understood. Extreme articulation during laughter production, such as wide jaw opening, suggests that laughter can have very high first formant (F1) frequencies. We measured fundamental frequency and formant frequencies of the vowels produced in the vocalic segments of laughter. Vocalic segments showed higher average F1 frequencies than those previously reported and individual values could be as high as 1100Hz for male speakers and 1500Hz for female speakers. To our knowledge, these are the highest F1 frequencies reported to date for human vocalizations, exceeding even the F1 frequencies reported for trained soprano singers. These exceptionally high F1 values are likely to be based on the extreme positions adopted by the vocal tract during laughter in combination with physiological constraints accompanying the production of a “pressed” voice.

Reliable Jitter and Shimmer Measurements in Voice Clinics: The Relevance of Vowel, Gender, Vocal Intensity, and Fundamental Frequency Effects in a Typical Clinical Task - Corrected Proof

Meike Brockmann, Michael J. Drinnan, Claudio Storck, Paul N. Carding — 2010-04-12

Summary: The aims of this study were to examine vowel and gender effects on jitter and shimmer in a typical clinical voice task while correcting for the confounding effects of voice sound pressure level (SPL) and fundamental frequency (F0). Furthermore the relative effect sizes of vowel, gender, voice SPL, and F0 were assessed, and recommendations for clinical measurements were derived. With this cross-sectional single cohort study, 57 healthy adults (28 women, 29 men) aged 20–40 years were investigated. Three phonations of /a/, /o/, and /i/ at “normal” voice loudness were analyzed using Praat (software). The effects of vowel, gender, voice SPL, and F0 on jitter and shimmer were assessed using descriptive and inferential (analysis of covariance) statistics. The effect sizes were determined with the eta-squared statistic. Vowels, gender, voice SPL, and F0, each had significant effects either on jitter or on shimmer, or both. Voice SPL was the most important factor, whereas vowel, gender, and F0 effects were comparatively small. Because men had systematically higher voice SPL, the gender effects on jitter and shimmer were smaller when correcting for SPL and F0. Surprisingly, in clinical assessments, voice SPL has the single biggest impact on jitter and shimmer. Vowel and gender effects were clinically important, whereas fundamental frequency had a relatively small influence. Phonations at a predefined voice SPL (80 dB minimum) and vowel (/a/) would enhance measurement reliability. Furthermore, gender-specific thresholds applying these guidelines should be established. However, the efficiency of these measures should be verified and tested with patients.

Gender-Related Patterns of Dysprosody in Parkinson Disease and Correlation Between Speech Variables and Motor Symptoms - Corrected Proof

Sabine Skodda, Wenke Visser, Uwe Schlegel — 2010-04-12

Summary: Explorative analysis of prosodic parameters in patients with Parkinson disease (PD) and in healthy controls in correlation to gender, disease-specific parameters, and motor symptoms. Acoustical analysis was performed on 169 patients with PD and 64 age-matched healthy controls based on a four sentence-reading task. Assessment of motor impairment was performed on the basis of Unified Parkinson's Disease Rating Scale/Motor Score III and further symptom-related subscores. F0 variability was reduced in male and female PD patients, whereas meanF0 was found to be elevated in male patients with PD only. No significant difference in overall articulatory rate was found between PD patients and controls, but patients showed a reduction of percentual pause time within polysyllabic words (Pinw%). Female PD patients showed an additional reduction of percentual pause ratio (PR%). Variables of intonation and articulatory rate were not correlated to each other. Strong correlations were seen between some distinct prosodic variables and the axial and akinesia parkinsonian symptoms with some gender-related particularities. Reduction of F0 variability and Pinw% are the most conspicuous features of parkinsonian dysprosody with some further gender-related characteristics. Changes of intonation variability and speech velocity seem to be controlled by different pathophysiological conditions. In consideration of some gender differences, several distinct aspects of dysprosody can be interpreted as axial and akinesia symptoms of PD.

The Putative Involvement of the Transabdominal Muscles in Dysphonia: A Preliminary Study and Thoughts - Corrected Proof

J.S. Rubin, I. Macdonald, E. Blake — 2010-04-12

Summary: Objectives/Hypothesis: Real-time ultrasound was used as an adjunct to assess patterns of periabdominal musculature in 14 individual with dysphonia and muscle tension dysphonia.Materials: Fourteen individuals with muscle tension dysphonia were evaluated with real-time ultrasound as a part of their initial evaluation and management.Results: In 13 of 14 individuals, there was an imbalance found during phonation between the transversus abdominis muscles (TAs) and internal oblique muscles (IOs), whereby the IOs were found to be overactive and the TAs underactive. After physiotherapy, this pattern was reversed.Conclusion: The abdominal muscle pattern of overactivity of the internal oblique and underactivity of the TA during phonation was found to be present in the large majority of patients in this pilot sample who had presented with muscle tension dysphonia. The significance of this is unclear but deserves further review.

The Impact of Extended Voice Use on the Acoustic Characteristics of Phonation After Training and Performance of Actors from the La MaMa Experimental Theater Club - Corrected Proof

Carol Ferrone, Jessica Galgano, Lorraine Olson Ramig — 2010-04-12

Summary: Purposes: To test the hypothesis that extensive use of La MaMa vocal technique may result in symptoms of vocal abuse, an evaluation of the acoustic and perceptual characteristics of voice for eight performers from the Great Jones Repertory Company of the La MaMa Experimental Theater was conducted. This vocal technique includes wide ranges of frequency from 46 to 2003Hz and vocal intensity that is sustained at 90–108dB sound pressure level with a mouth-to-microphone distance of 30cm for 3–4 hours per performance.Methods: The actors rehearsed for 4 hours per day, 5 days per week for 14 weeks before the series of performances. Thirty-nine performances were presented in 6 weeks. Three pretraining, three posttraining, and two postperformance series data collection sessions were carried out for each performer. Speech samples were gathered using the CSL 4500 and analyzed using Real-Time Pitch program and Multidimensional Voice Program. Acoustic analysis was performed on 48 tokens of sustained vowel phonation for each subject. Statistical analysis was performed using the Friedman test of related samples. Perceptual analysis included professional listeners rating voice quality in pretraining, posttraining, and postperformance samples of the Rainbow Passage and sample lines from the plays.Results: The majority of professional listeners (11/12) judged that this technique would result in symptoms of vocal abuse; however, acoustic data revealed statistically stable or improved measurements for all subjects in most dependent acoustic variables when compared with both posttraining and postperformance trials.Conclusion: These findings add support to the notion that a technique that may be perceived as vocally abusive, generating 90–100dB sound pressure level and sustained over 6 weeks of performances, actually resulted in improved vocal strength and flexibility.

A Meta-Analysis of Outcomes of Hydration Intervention on Phonation Threshold Pressure - Corrected Proof

Ciara Leydon, Marcin Wroblewski, Naomi Eichorn, Mahalakshmi Sivasankar — 2010-04-02

Objectives: Vocal fold hydration is purported to promote optimal biomechanical characteristics of vocal fold mucosa, increase efficiency of vocal fold oscillation, and enhance voice quality. The purpose of this work was to determine the magnitude and consistency of the effect of vocal fold hydration on vocal fold function across published clinical studies.Methods: We completed a comprehensive meta-analysis of the effects of superficial and systemic vocal fold hydration on phonation threshold pressure (PTP), a measure of efficiency of voice production.Results: We identified 34 studies that examined the effects of hydration on vocal function. Of these studies, 14 examined the effects of hydration on PTP. Nine of these articles met the criteria for inclusion in this analysis. We observed an average effect size of 0.33, indicating that, overall, hydration treatment demonstrated a tendency to reduce PTP. However, this decrease in phonatory effort did not reach significance at the 95% confidence level. The effects of hydration intervention varied considerably across studies (−0.19 to 3.96). We considered that two factors, pitch level of the task and vocal health of participants, may have contributed to this variability in findings. However, our analysis found that these factors could not account for differences in effect size.Conclusion: To understand the variability in outcomes across studies, the role of factors that may impact the effects of hydration, such as the amount, type, and duration of intervention, must be determined. Only then can we obtain data to guide best clinical practice for protecting and rehabilitating vocal function.

Comparison of Voice-Use Profiles between Elementary Classroom and Music Teachers - Corrected Proof

Sharon L. Morrow, Nadine P. Connor — 2010-04-02

Summary: Among teachers, music teachers are roughly four times more likely than classroom teachers to develop voice-related problems. Although it has been established that music teachers use their voices at high intensities and durations in the course of their workday, voice-use profiles concerning the amount and intensity of vocal use and vocal load have neither been quantified nor has vocal load for music teachers been compared with classroom teachers using these same voice-use parameters. In this study, total phonation time, fundamental frequency (F0), and vocal intensity (dB SPL [sound pressure level]) were measured or estimated directly using a KayPENTAX Ambulatory Phonation Monitor (KayPENTAX, Lincoln Park, NJ). Vocal load was calculated as cycle and distance dose, as defined by Švec et al (2003), which integrates total phonation time, F0, and vocal intensity. Twelve participants (n = 7 elementary music teachers and n = 5 elementary classroom teachers) were monitored during five full teaching days of one workweek to determine average vocal load for these two groups of teachers. Statistically significant differences in all measures were found between the two groups (P < 0.05) with large effect sizes for all parameters. These results suggest that typical vocal loads for music teachers are substantially higher than those experienced by classroom teachers (P < 0.01). This study suggests that reducing vocal load may have immediate clinical and educational benefits in vocal health in music teachers.

Voice-Related Complaints in the Pediatric Population - Corrected Proof

2010-04-02

Summary: Subjective evaluation of the voice by the patient is routinely assessed in the adult dysphonic population; this is, however, not the case in the pediatric population. There were three objectives of this study: the first goal was to study the ability of children aged 5–13 years to express themselves about physical, emotional, and sociofunctional aspects of their voice. The second goal was to explore if specific voice-related complaints were expressed by dysphonic children as compared with normophonic children. The third goal was to compare the dysphonic children's voice-related complaints with those of their mothers. The overall objective was to set the grounds for the elaboration of a standardized questionnaire in French concerning subjective evaluation of voice in children. Twenty-five dysphonic children with vocal complaint (15 nodules, one polyp, one microweb, eight unspecified) and 55 normophonic children aged 5–13 years were interviewed. The interviews were semistructured based on a canvas of voice-related questions. The dysphonic children's mothers were interviewed with the mean of a written questionnaire and were invited to discuss their answers orally with the examiner. The results were analyzed qualitatively and statistically. A Chi-square test and the Fisher's test were used to analyze the differences between the complaints expressed by the dysphonic and the normophonic children, and a binomial test was used to compare the children's answers with their mothers' answers. The qualitative analysis of the interviews suggests that children are capable of reflecting over their own voice and of giving autonomous information about different aspects of their voice. It also appeared that voice is a complex phenomenon and that it needs to be clearly and cautiously defined to the children. We identified 27 different complaints related to the voice, out of which 17 were significantly more expressed by dysphonic than by normophonic children (P<0.05). Three of the 27 identified complaints show significant discordances between the mothers and the dysphonic children. The results suggest that children are capable of making a subjective and autonomous evaluation of their voice and that dysphonic children experience significantly more voice-related discomfort than nondysphonic children. The complaints expressed by the dysphonic children and their mothers are not all in concordance. The main conclusion is that a standardized subjective evaluation of the voice, not only by the parents but also by the child him/herself, would be relevant in the assessment of pediatric dysphonia.

Experimental Analysis of the Characteristics of Artificial Vocal Folds - Corrected Proof

Vojtech Misun, Pavel Svancara, Martin Vasek — 2010-04-02

Summary: Specialized literature presents a number of models describing the function of the vocal folds. In most of those models, an emphasis is placed on the air flowing through the glottis and, further, on the effect of the parameters of the air alone (its mass, speed, and so forth). The article focuses on the constructional definition of artificial vocal folds and their experimental analysis. The analysis is conducted for voiced source voice phonation and for the changing mean value of the subglottal pressure. The article further deals with the analysis of the pressure of the airflow through the vocal folds, which is cut (separated) into individual pulses by the vibrating vocal folds. The analysis results show that air pulse characteristics are relevant to voice generation, as they are produced by the flowing air and vibrating vocal folds. A number of artificial vocal folds have been constructed to date, and the aforementioned view of their phonation is confirmed by their analysis. The experiments have confirmed that man is able to consciously affect only two parameters of the source voice, that is, its fundamental frequency and voice intensity. The main forces acting on the vocal folds during phonation are as follows: subglottal air pressure and elastic and inertia forces of the vocal folds' structure. The correctness of the function of the artificial vocal folds is documented by the experimental verification of the spectra of several types of artificial vocal folds.

Comparison of neck tension palpation rating systems with surface electromyographic and acoustic measures in vocal hyperfunction - Corrected Proof

2010-03-29

Summary: The purpose of this study was to evaluate current neck tension palpation rating systems to determine interrater reliability and possible correlation with necksurface electromyography (sEMG, collected from three electrode recording locations) and to measure the third formant for /a/ during various vocal behaviors. This prospective study examined the neck muscle tension of 16 participants before and after a single session of voice therapy. Interrater reliability and relationships between palpation ratings and objective measures of sEMG (anterior neck) and the third formant for /a/ were assessed using Pearson's correlations (r). Interrater reliability was relatively low as measured by Pearson's correlations, although Wilcoxon signed-rank test results were similar as those in a previous study. Correlations between palpation ratings and sEMG and between ratings of laryngeal height and the third formant for /a/ were generally low. Correlations increased between anterior neck sEMG and ratings of suprahyoid muscle tension when examined in a reduced set of individuals with higher interrater reliability. Palpation rating scales do not reliably capture changes that may occur in neck muscle tension of typical voice therapy patients over one session. Consequently, little can be concluded from correlations between sEMG and palpation ratings.

Voice Characteristics of Female Physical Education Student Teachers - Corrected Proof

Elizabeth U. Grillo, Justine Fugowski — 2010-03-29

Summary: In this study, the subjective and objective voice measures of seven female physical education student teachers during a semester of student teaching were investigated. The participants completed the voice measures at three data collection time points: baseline, middle, and end of the semester. The voice measures included acoustic and aerodynamic data, perceptual rating scales of vocal quality and vocal fatigue, an end-of-semester questionnaire, and the Voice Handicap Index. Results demonstrated that the subjective and objective voice measures changed at the middle and the end of the semester as compared with those at baseline. The change in the voice measures may suggest that the vocal mechanism was adapting to the increased vocal demands of teaching physical education.