Journal of Voice - Articles in Press

Pathological Likelihood Index as a Measurement of the Degree of Voice Normality and Perceived Hoarseness - Corrected Proof

2010-03-08

Summary: A new index is introduced in this article to measure the degree of normality in the speech. The proposed parameter has demonstrated to be correlated with the perceived hoarseness, giving an indication of the degree of normality. The calculation of such a parameter is based on a statistical model developed to represent normal and pathological voices. The modeling is built around Gaussian mixture models and Mel frequency cepstral coefficients. The proposed index has been named pathological likelihood index (PLI). PLI is compared with other aperiodicity features (such as jitter and shimmer), and measurements sensitive to additive noise (such as harmonics-to-noise ratio (HNR), cepstrum-based HNR, normalized noise energy, and glottal-to-noise excitation ratio). The proposed parameter is revealed to be a good estimator of the presence of pathology, showing lower correlation with noise, frequency, and amplitude perturbation parameters than these classical features among them.

Physical Therapy as a Means to Optimize Posture and Voice Parameters in Student Classical Singers: A Case Report - Corrected Proof

2010-03-08

Summary: Objectives/Hypothesis: This study aimed at reporting on an intervention for optimizing postural alignment and voice parameters.Study Design: Case report.Methods: A clinical examination, including an evaluation of postural alignment, was performed and several voice parameters were investigated before, during, and after an individual rehabilitation program aimed at optimizing joint mobility, muscular stability, and posture. This program was given to a 26-year-old female classical singing student.Results: After a nine-session intervention (4 months), postural alignment was improved. The patient showed a good breath support and was able to maintain the lateral dimensions of the thorax, except for the high tones. Furthermore, she had a normalized cervical and scapulothoracic stability. At the last session, she had a lack of relaxation of the masseter muscle while singing. The vocal dynamic and pitch range were extended with smoother curves connecting the measuring points of the maximal and minimal vocal intensity, measured by means of the voice range profile.Conclusions: Results show that, in this student singer, postural alignment could be changed within 4 months and that it could influence some voice parameters. Further research in larger samples is necessary to see whether these findings can be generalized to other singers.

Quality of Life, Self-Perceived Dysphonia, and Diagnosed Dysphonia Through Clinical Tests in Teachers - Corrected Proof

2010-03-04

Summary: Objectives: To examine the impact of voice on the quality of life of teachers and to assess whether the degree of dysphonia and otorhinolaryngologists' (ORL) diagnostics are correlated with the quality of life.Methods: Eighty-eight female teachers from the municipal schools of Belo Horizonte who were in speech therapy at the Speech Therapy Clinic of the Hospital das Clínicas of Minas Gerais participated in the study. The variables studied were age, ORL diagnosis, perceptual-hearing assessment of voice through GRBAS scale, and vocal activities and participation profile (VAPP) protocol. Statistical analysis was performed through the descriptive analysis of the data and the Spearman coefficient of correlation.Results: The average age of the participants was 38 years. Vocal deviation: degree 1—56 teachers (63.6%); degree 2—27 teachers (30.6%); and without vocal deviation—five teachers (5.6%). It was found that 57.9% of the teachers presented combined ORL diagnosis. No statistically significant relationship was observed among the ORL diagnosis, the degree of dysphonia, and the parameter values of quality of life assessed by VAPP.Conclusions: The examined participants of this study presented light degree of vocal deviation and ORL combined diagnosis. According to the figures obtained by VAPP, there was negative impact of voice on the quality of life of female teachers, but these impacts were not correlated with ORL diagnosis and grade of dysphonia.

Voice- and Health-Related Quality of Life in the Elderly - Corrected Proof

2010-03-04

Summary: Objective: Restrictions of verbal communication and high prevalence of voice disorders in the elderly are suspected to influence the quality of life. For assessment, both voice-specific and unspecific methods are already established and fundamental components of clinical diagnostics, but the question of correlation between voice-related and general health-related quality of life is still open in this subpopulation.Methods: One hundred and seven socially active persons aged 65+ years were recruited and asked to complete Voice-Related Quality of Life (V-RQOL) and Short Form (SF)-36 questionnaires.Results: There was a mild correlation between V-RQOL score and both of the SF-36 subscores (rs=0.28 for the physical subscore and rs=0.27 for the mental subscore).Conclusion: As correlation of voice- and health-related quality of life in elderly persons is only mild, both voice-specific and unspecific assessment methods are required for clinical diagnostics.

A Comparison of Rating Scales Used in the Diagnosis of Extraesophageal Reflux - Corrected Proof

Joy Musser, Lisa Kelchner, Jean Neils-Strunjas, Marshall Montrose — 2010-03-04

Summary: Objective: To evaluate the level of agreement between reflux area index scores, the reflux symptom index (RSI), and the reflux finding score (RFS). Inter- and intrarater reliability of the RFS was assessed. A criterion of pH 5 was used to evaluate its effects on agreement.Study Design: Adult participants were enrolled in this prospective study.Methods: Eighty-two participants (72 patients and 10 controls) completed the RSI, videoendoscopy, and 24-hour pH probe monitoring. The reflux area index for extraesophageal reflux (EER) events was calculated at pH 4 and 5. Two speech-language pathologists and one otolaryngologist independently rated 36 endoscopic examinations using the RFS through a web-based system. A repeated rating of six examinations was completed.Results: Chi-square revealed poor agreement between the diagnostic tools, regardless of which pH criterion was used. Intraclass correlation coefficients revealed fair interrater reliability of the RFS and moderate intrarater reliability. Independent-sample t tests for the RFS and reflux area index (RAI) scores failed to identify patients from normal controls.Conclusions: The results of this study highlight the lack of agreement among the current available diagnostic tools for EER. Raters were not in agreement regarding the presence and severity of physical findings of EER. Results support the need for greater consensus among the clinical tools used in the diagnosis of EER. Physical rating scales may overidentify patients and would benefit from uniform scales and training. Assessing EER occurring at pH 5 may also yield important diagnostic information. Further research is needed to verify normative RAI cutpoints.

Arytenoid Asymmetry in Relation to Vocal Symptoms in Singers - Corrected Proof

Abdul-Latif Hamdan, Sami Tambouzi Husseini, Akaber Halawi, Abla Sibai — 2010-03-02

Summary: Objective: (1) To look at the prevalence of arytenoid asymmetry in singers with or without vocal symptoms and (2) to examine the correlation between arytenoid asymmetry and vocal symptoms.Patients and Methods: A total of 110 medical records and video recordings of singers were evaluated for the presence or absence of arytenoid asymmetry, in relation to the position of the corniculate cartilages, cuneiform cartilages, and the aryepiglottic angle.Results: The male to female ratio was 2:1. The age range varied between 15 and 39 years with a mean of 23.4+4.21 years. Almost 17% had history of smoking. The prevalence of arytenoid asymmetry during adduction in the overall sample was 53.6%. It was more common in males (74.6%) and on the right side (76.2%). The most common asymmetry was the cuneiform asymmetry accounting for 49.1% of the total sample and 91.6% of the total asymmetries. This was followed by aryepiglottic angle asymmetry in 31.9% and corniculate asymmetry in 27.3% of the total sample. Almost 25% of the total sample had vocal symptoms. The most common vocal symptom was vocal fatigue occurring in 22.7%, followed by hoarseness in 19% and contracted range in 10.9% of the cases. There was no correlation between any of the vocal symptoms and arytenoid asymmetry. All the P values were greater than 0.05.Conclusion: Arytenoid asymmetry during adduction is common in singers. There seem to be no correlation between arytenoid asymmetry and vocal symptoms.

Structures Constituting the Sound Source After the Treatment of Early Glottic Cancer - Corrected Proof

2010-03-02

Summary: Introduction: We indicate the exclusive radiation therapy as initial approach for T1a glottic tumors, and the frontolateral laryngectomy for the tumors staged as T1b and selected T2 glottic tumors. The videolaryngostroboscopy is a useful tool to analyze the laryngeal structural changes and compensatory motion after the therapeutic approach.Objectives: To evaluate the endolaryngeal structures of patients who participate in the vibratory sound source after the early glottic cancer treatment through the videolaryngostroboscopy.Methods: It was a retrospective transversal study in which 20 patients who underwent exclusive radiation therapy and 25 patients who underwent frontolateral laryngectomy were analyzed by means of videolaryngostroboscopy. The radiation doses ranged from 5000 to 7020cGy in the radiation therapy group. The mucosal wave and the vibratory source components were evaluated.Results: All of the irradiated patients presented vibratory behavior, and hyperfunction was occasionally observed in four cases. The mucosal wave source was glottic in 18 cases and mixed in two cases. In the laryngectomy group, 10 supraglottic sources, 10 glottic sources, and five mixed sources were identified. Among the 10 cases of supraglottic source, eight patients presented global constriction and two patients presented medial constriction. Among the five cases of mixed source, two patients presented global constriction, one patient presented medial constriction, and one patient presented anteroposterior constriction. Regarding the number of anatomical structures presenting vibratory pattern, five patients had two structures, four patients had three structures, and one patient had four structures.Conclusion: Patients who underwent radiation therapy recruit less supraglottic structures as vibratory source than the patients undergoing vertical laryngectomy.

Effects of Neck Dissection and Radiotherapy on Short-Term Speech Success in Voice Prosthesis Restoration Patients - Corrected Proof

2010-03-02

Summary: Objective: To compare the short-term speech success of voice prosthesis (VP) among patients who underwent total laryngectomy or total laryngectomy in combination with neck dissection and those who received postoperative radiotherapy.Materials and Methods: Thirty-two male patients treated for laryngeal squamous cell carcinoma were included. Nine patients underwent total laryngectomy and 23 underwent total laryngectomy combined with neck dissection, and 17 of the 23 with neck dissection were managed with postoperative radiotherapy (45–75Gy). All of the patients had indwelling intraoperative placement of the Provox VP (Atos Medical AB, Horby, Sweden; and Entermed BV, Woerden, The Netherlands) at the time of the primary tracheoesophageal puncture (TEP) completed in conjunction with total laryngectomy. Patients with pharyngoesophageal myotomy and pharyngeal plexus neurectomy were excluded. Patients' speech success was perceptually evaluated 3–4 weeks after the surgery and 3–4 weeks after the cessation of radiotherapy, using a 1–3 scale (1=failure to develop speech (aphonia); 2=communicate with short phrases only; and 3=communicate with fluency and long sentences).Results: No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Eighteen of 32 patients (56%) demonstrated successful speech (rating of 3). Nine patients (28%) demonstrated less successful speech (rating of 2). Five patients (16%) were found to be aphonic (P>0.05). Of the nine patients who underwent total laryngectomy only, six were found to have successful speech (66.6%), one (11.1%) was found to have less successful speech quality, and two (22.2%) patients were aphonic (P>0.05). Of the six patients who underwent total laryngectomy in combination with neck dissection, three had successful speech (50%), one (16.6%) had less successful speech, and two (33.3%) were aphonic (P>0.05). Of the 17 patients who received postoperative radiotherapy, nine (52.9%) had successful speech, three (17.6%) had less successful speech, and five (29.4%) were aphonic (P>0.05).Conclusion: Neck dissection and postoperative radiotherapy have no significant influence on short-term speech success in VP restoration patients. Primary TEP should be preferred in patients who have laryngectomy in combination with neck dissection and/or will have postoperative radiation therapy, as it provides early and successful voice restoration without interfering with radiation treatment and avoids a second surgical intervention.

Vocal Characteristics of Middle-Aged Premenopausal Women - Corrected Proof

2010-03-02

Summary: Aging influences the laryngeal anatomy and physiology, leading to altered vocal quality. In middle-aged women, the voice is affected by a combination of aging and menopausal transition. However, in many studies about vocal aging, the menopausal transition is not taken into account. The purpose of this study was to measure and describe the effect of aging on the vocal characteristics by comparing young women (between 20 and 28 years) and middle-aged premenopausal women (between 45 and 52 years). To determine the vocal characteristics in both groups, objective (aerodynamic measurements, vocal performance measurements, acoustic analysis, and a determination of the Dysphonia Severity Index) and subjective assessment techniques (perceptual evaluation, videostroboscopic evaluation, and Voice Handicap Index) were used. The middle-aged premenopausal women showed a smaller frequency and intensity range, a lower habitual fundamental frequency, and a higher soft phonation index compared with the young women. The results of this study are important when studying the voices of middle-aged women. Vocal characteristics of middle-aged women differ from young women, and these changes cannot only be because of hormonal changes during the menopause.

Rare Laryngeal Anomaly or Spontaneously Drained Bilateral Saccular Cyst? - Corrected Proof

Münir Demir Bajin, Taner Yilmaz — 2010-03-02

Summary: Laryngeal malformations are usually present at birth. Common anomalies include laryngomalacia, vocal fold paralysis, and subglottic stenosis; less common are congenital saccular cysts, laryngeal webs and atresias, and laryngeal lymphangiomas. Symptoms may range from stridor and hoarseness to respiratory distress. In some cases, patients are asymptomatic. Here, we present a case with abnormal laryngeal ventricles.

A Novel Model for Examining Recovery of Phonation After Vocal Nerve Damage - Corrected Proof

Prabhat K. Bhama, Allen D. Hillel, Albert L. Merati, David J. Perkel — 2010-03-02

Summary: Objectives/Hypothesis: Recurrent laryngeal nerve injury remains a dominant clinical issue in laryngology. To date, no animal model of laryngeal reinnervation has offered an outcome measure that can reflect the degree of recovery based on vocal function. We present an avian model system for studying recovery of learned vocalizations after nerve injury.Study Design: Prospective animal study.Methods: Digital recordings of bird song were made from 11 adult male zebra finches; nine birds underwent bilateral crushing of the nerve supplying the vocal organ, and two birds underwent sham surgery. Songs from all the birds were then recorded regularly and analyzed based on temporal and spectral characteristics using computer software. Indices were calculated to indicate the degree of similarity between preoperative and postoperative song.Results: Nerve crush caused audible differences in song quality and significant drops (P<0.05) in measured spectral and, to a lesser degree, temporal indices. Spectral indices recovered significantly (mean=43.0%; standard deviation [SD]=40.7; P<0.02), and there was an insignificant trend toward recovery of temporal index (mean=28.0%; SD=41.4; P=0.0771). In five of the nine (56%) birds, there was a greater than 50% recovery of spectral indices within a 4-week period. Two birds exhibited substantially less recovery of spectral indices and two birds had a persistent decline in spectral indices. Recovery of temporal index was highly variable as well, ranging from persistent further declines of 45.1% to recovery of 87%. Neither sham bird exhibited significant (P>0.05) differences in song after nerve crush.Conclusion: The songbird model system allows functional analysis of learned vocalization after surgical damage to vocal nerves.

Comparison of Labial and Mechanical Interruption for Measurement of Aerodynamic Parameters - Corrected Proof

William J. Chapin, Matthew R. Hoffman, Adam L. Rieves, Jack J. Jiang — 2010-03-02

Summary: Objectives/Hypothesis: To directly compare the mechanical and labial interruption techniques of measuring subglottal pressure (Ps), mean flow rate (MFR), and laryngeal resistance (RL).Methods: Thirty-four subjects performed 10 trials with both mechanical and labial interruption. Ps and MFR were recorded, whereas RL was calculated by dividing Ps by MFR. Coefficients of variation were calculated to compare intrasubject precision. A subset of 10 subjects performed the tasks twice with 30 minutes between sessions. Bland-Altman plots were used to determine intrasubject repeatability for each of the methods.Results: Mechanical interruption produced coefficients of variation for Ps, MFR, and RL of 0.0995, 0.127, and 0.129, respectively. Labial interruption produced coefficients of variation of 0.102, 0.147, and 0.169, respectively. P values were 0.824 for Ps, 0.159 for MFR, and 0.043 for RL. The Bland-Altman plots revealed comparable repeatability between the two methods. The 95% confidence intervals of the Bland-Altman plots for mechanical interruption were (−0.050, 0.072), (−0.543, 1.832), and (−2.498, 10.528) for MFR, Ps, and RL. Confidence intervals for labial interruption were (−0.018, 0.031), (0.057, 2.442), and (−3.267, 10.595) for MFR, Ps, and RL.Conclusions: Mechanical interruption produced higher precision when measuring RL because of more reliable airflow measurements. Mechanical and labial interruption showed comparable repeatability. Further research into using mechanical interruption clinically is warranted.

First Report of Intralaminar Tumorlike Lipomatous Lesions of the Thyroid Cartilage - Corrected Proof

Karl Kiesler, Gerhard Friedrich, Alfred Beham, Franz Ebner, Markus Gugatschka — 2010-03-02

Summary: Introduction: We present two cases of tumorlike lipomatous lesions in the thyroid cartilage. Both presented as circumscribed tumors by ultrasonography and were identified accidentally.Methods: Two tumorlike lesions were identified in two different patients. Additionally, computed tomography and magnetic resonance imaging scans of the laryngeal skeleton were performed. Surgery was performed in one patient, and the lesion was excised. Histopathology revealed fatty tissue with several foci of hematopoietic cells.Conclusion: This is the first report of intralaminar tumorlike lipomatous lesions in the thyroid cartilage. These should be included in the differential diagnoses of primary cartilaginous lesions of the laryngeal skeleton.

Vocal Cysts: Clinical, Endoscopic, and Surgical Aspects - Corrected Proof

2010-02-22

Summary: Vocal cysts are benign laryngeal lesions, which affect children and adults. They can be classified as epidermic or mucous-retention cyst.Objective: The objective was to study the clinical, endoscopic, and surgical aspects of vocal cysts.Methods: We reviewed the medical charts of 72 patients with vocal cysts, considering age, gender, occupation, time of vocal symptoms, nasosinusal and gastroesophageal symptoms, vocal abuse, tabagism, alcoholism, associated lesions, treatment, and histological details.Results: Of the 72 cases, 46 were adults (36 females and 10 male) and 26 were children (eight girls and 18 boys). As far as occupation is concerned, there was a higher incidence of students and teachers. All the patients had symptoms of chronic hoarseness. Nasosinusal (27.77%) and gastroesophageal (32%) symptoms were not relevant. Vocal abuse was reported by 45.83%, smoking by 18%, and alcoholism by 8.4% of the patients. Unilateral cysts were seen in 93% of the cases, 22 patients had associated lesions, such as bridge, sulcus vocalis, and microweb. Surgical treatment was performed in 46 cases. Histological analysis of the epidermic cysts revealed a cavity with caseous content, covered by stratified squamous epithelium, often keratinized. Mucous cysts presented mucous content, and the walls were coated by a cylindrical ciliated epithelium.Conclusion: Vocal cysts are benign vocal fold lesions that affect children and adults, being often associated with vocal overuse, which frequently affects people who use their voices professionally. Vocal symptoms are chronic in course, often times since childhood, and the treatment of choice is surgical removal. A careful examination of the vocal folds is necessary during surgery, because other laryngeal lesions may be associated with vocal cysts.

Clinical Outcome of Window Partial Laryngectomy for Stage T2-3 Glottic Laryngeal Carcinoma - Corrected Proof

2010-02-22

Summary: Objective: To investigate the operative impact and therapeutic value of window partial laryngectomy for the treatment of stage T2-3 glottic laryngeal carcinoma.Methods: From October 2000 to December 2006, window partial laryngectomy and laryngeal reconstruction were performed on 48 appropriately selected patients with stage T2-3 glottic laryngeal carcinomas. Twenty-nine males and 19 females were included. Before the operation and in the sixth month after the operation, degree of hoarseness, vocal cord mobility and symmetry, glottal width during quiet breathing, degree of glottal closure during phonating, respiratory function, and swallowing function were surveyed. In addition, tumor recurrence and metastasis and patient survival time were monitored.Results: With the exception of vocal cord mobility (P=0.343), there were significant differences between the two treatment groups in all areas that were investigated, including degree of hoarseness (all P<0.01), vocal cord symmetry (P=0.000), glottal width during quiet breathing (P=0.001), degree of glottal closure during phonating (P=0.001), and respiratory function (P=0.001). Swallowing function was not influenced (P=0.310). There was recurrence in one case (2.1%), cervical lymph node metastasis in one case, and hepatic metastasis in one case. The 3- and 5-year overall survival rates were 96.9% and 88.9%, respectively.Conclusions: This study showed that window partial laryngectomy was successful for treating properly selected stage T2-3 glottic laryngeal carcinoma. This operation was effective for reducing surgical invasion and facilitated the resumption of respiratory and vocal function.

Glottoplasty for Male-to-Female Transsexualism: Voice Results - Corrected Proof

Marc Remacle, Nayla Matar, Dominique Morsomme, Ingrid Veduyckt, Georges Lawson — 2010-02-22

Summary: Objectives: The aim of this study was to evaluate the objective voice results of Wendler's glottoplasty in male-to-female transsexuals.Method: We retrospectively reviewed our patients treated with Wendler's technique with minor modifications. Glottoplasty consisted in CO2-laser epithelial ablation of the anterior commissure and the two vocal folds in anterior third, suturing of the two vocal folds with two stitches of 3.0 resorbable thread, and application of fibrin sealant to strengthen the suture. Voice assessment was based mainly on fundamental frequency (F0), frequency range, jitter, maximum phonation time, phonation quotient, estimated subglottic pressure (ESGP) grade of dysphonia (G), and voice handicap index (VHI). These measures were taken before surgery and on the last follow-up visit.Results: Our series included 15 patients with a mean age of 36 years. The mean follow-up period was 7.2 months. We did not observe any early complications related to the technique. The comparison between the preoperative and the postoperative measurements, using Wilcoxon signed rank test, showed a significant improvement of median F0 from 139 to 191Hz (P=0.006) with an increase in the grade of dysphonia (Gpre=0.2, Gpost=1, P=0.013) and ESGP (ESGPpre=8.1±3.2, ESGPpost=12.0±3.8, P=0.002). Other measurements, including VHI, did not show any significant differences pre- and postoperatively.Conclusion: Wendler's glottoplasty can contribute to feminize the voice.

Cepstral Analysis of Voice in Persons With Vocal Nodules - Corrected Proof

B. Radish Kumar, Jayashree S. Bhat, Neitica Prasad — 2010-02-22

Summary: Objectives: Traditional measures of dysphonia were reported to be unreliable, and the measurements of cepstral peak prominence (CPP) have been shown to correlate well with perceptions of breathiness. Hence, the present study was hypothesized that there would be abnormal reduction of the cepstral peak in the speakers with vocal nodules relative to the normal controls as they are characterized by hoarse and breathy voice due to inadequate closure of vocal folds.Method: Phonation of sustained vowel /a/ was subjected to acoustic analysis using Computerized Speech Lab (CSL model 4150) software. The vowels were analyzed acoustically with the measurement of CPP.Results: Independent t test was employed to compare the significant differences between the clinical and the control groups in both males and females. The results revealed significant differences across the two groups at P<0.05. The obtained results were discussed with respect to the underlying pathophysiology.Conclusion: The present study investigated the CPP in subjects with vocal nodules. Cepstral deviations in the clinical group are explained due to the presence of laryngeal pathology leading to the lower values of CPP.

Reliability, Stability, and Sensitivity to Change and Impairment in Acoustic Measures of Timing and Frequency - Corrected Proof

Adam P. Vogel, Janet Fletcher, Peter J. Snyder, Amy Fredrickson, Paul Maruff — 2010-02-22

Summary: Assessment of the voice for supporting classifications of central nervous system (CNS) impairment requires a different practical, methodological, and statistical framework compared with assessment of the voice to guide decisions about change in the CNS. In experimental terms, an understanding of the stability and sensitivity to change of an assessment protocol is required to guide decisions about CNS change. Five experiments (N=70) were conducted using a set of commonly used stimuli (eg, sustained vowel, reading, extemporaneous speech) and easily acquired measures (eg, f0–f4, percent pause). Stability of these measures was examined through their repeated application in healthy adults over brief and intermediate retest intervals (ie, 30 seconds, 2 hours, and 1 week). Those measures found to be stable were then challenged using an experimental model that reliably changes voice acoustic properties (ie, the Lombard effect). Finally, adults with an established CNS-related motor speech disorder (dysarthria) were compared with healthy controls. Of the 61 acoustic variables studied, 36 showed good stability over all three stability experiments (eg, number of pauses, total speech time, speech rate, f0–f4). Of the measures with good stability, a number of frequency measures showed a change in response to increased vocal effort resulting from the Lombard effect challenge. Furthermore, several timing measures significantly separated the control and motor speech impairment groups. Measures with high levels of stability within healthy adults, and those that show sensitivity to change and impairment may prove effective for monitoring changes in CNS functioning.

Risk and Protective Factors for Spasmodic Dysphonia: A Case-Control Investigation - Corrected Proof

2010-02-22

Summary: Objectives: Spasmodic dysphonia (SD) is a chronic, incurable, and often disabling voice disorder of unknown pathogenesis. The purpose of this study was to identify possible endogenous and exogenous risk and protective factors uniquely associated with SD.Study Design: Prospective, exploratory, case-control investigation.Methods: One hundred fifty patients with SD and 150 medical controls (MCs) were interviewed regarding their personal and family histories, environmental exposures, illnesses, injuries, voice use patterns, and general health using a previously vetted and validated epidemiologic questionnaire.Results: Odds ratios and multiple logistic regression analyses (α<0.15) identified several factors that significantly increased the likelihood of having SD. These factors included (1) a personal history of mumps, blepharospasm, tremor, intense occupational and avocational voice use, and a family history of voice disorders; (2) an immediate family history of meningitis, tremor, tics, cancer, and compulsive behaviors; and (3) an extended family history of tremor and cancer.Conclusions: SD is likely multifactorial in etiology, involving both genetic and environmental factors. Viral infections/exposures, along with intense voice use, may trigger the onset of SD in genetically predisposed individuals. Future studies should examine the interaction among genetic and environmental factors to determine the pathogenesis of SD.

Measurement of Young's Modulus of Vocal Folds by Indentation - Corrected Proof

Dinesh K. Chhetri, Zhaoyan Zhang, Juergen Neubauer — 2010-02-22

Summary: Objectives: To assess the accuracy of the indentation method for stiffness measurements and to estimate the Young's modulus of the vocal fold using this technique.Study Design: Basic science.Methods: Indentation tests were performed using a range of indenter diameters and indentation depths on single- and double-layer silicone rubber models with various cover-layer thicknesses with known geometry and Young's moduli. Measurements were repeated on intact vocal folds and isolated muscle and cover-layer samples from three cadaveric human larynges.Results: Indentation on single-layer rubber models yielded Young's moduli with acceptable accuracy when the indentation depth was equal to or smaller than the indenter diameter, and both were smaller than the physical dimensions of the material sample. On two-layer models, the stiffness estimation was similarly influenced by indenter diameter and indentation depth, and acceptable accuracy was reached when indentation depth was much smaller than the height of the top cover layer. Measurements on midmembranous vocal fold tissue revealed location-dependent Young's moduli (in kPa) as follows: intact hemilarynx, 8.6 (range=5.3–13.1); isolated inferior medial surface cover, 7.5 (range=7–7.9); isolated medial surface cover, 4.8 (range=3.9–5.7); isolated superior surface cover, 2.9 (range=2.7–3.2); and isolated thyroarytenoid muscle, 2.0 (range=1.3–2.7).Conclusions: Indenter diameter, indentation depth, and material thickness are important parameters in the measurement of vocal fold stiffness using the indentation technique. Measurements on human larynges showed location-dependent differences in stiffness. The stiffness of the vocal folds was also found to be higher when the vocal fold structure was still attached to the laryngeal framework compared with that when the vocal fold was separated from the framework.

Morphological Properties of Collagen Fibers in Porcine Lamina Propria - Corrected Proof

Iecun Johanes, Elaine Mihelc, Mahalakshmi Sivasankar, Albena Ivanisevic — 2010-02-22

Summary: Objectives: Collagen influences the biomechanical properties of vocal folds. Altered collagen morphology has been implicated in dysphonia associated with aging and scarring. Documenting the morphological properties of native collagen in healthy vocal folds is essential to understand the structural and functional alterations to collagen with aging and disease. Our primary objective was to quantify the morphological properties of collagen in the vocal fold lamina propria. Our secondary exploratory objective was to investigate the effects of pepsin exposure on the morphological properties of collagen in the lamina propria.Study Design: Experimental, in vitro study with porcine model.Methods: Lamina propria was dissected from 26 vocal folds and imaged with atomic force microscopy (AFM). Morphological data on d-periodicity, diameter, and roughness of collagen fibers were obtained. To investigate the effects of pepsin exposure on collagen morphology, vocal fold surface was exposed to pepsin or sham challenge before lamina propria dissection and AFM imaging.Results: The d-periodicity, diameter, and roughness values for native vocal fold collagen are consistent with literature reports of collagen fibers in other body tissues. Pepsin exposure on vocal fold surface did not appear to change the morphological properties of collagen fibers in the lamina propria.Conclusions: Quantitative data on collagen morphology were obtained at nanoscale resolution. Documenting collagen morphology in healthy vocal folds is critical for understanding the physiological changes to collagen with aging and scarring and for designing biomaterials that match the native topography of lamina propria.

Prolonged Ulcerative Laryngitis: A New Disease Entity - Corrected Proof

Tzu-Yu Hsiao — 2010-02-22

Summary: Over the last decade, a new disease entity, prolonged ulcerative laryngitis (PUL), with unique clinical presentation and prolonged disease course, has been recognized. Until now, very few studies dealing with this disease have been reported in the literature. From 1999 to 2008, we analyzed clinical data from a series of 39 PUL patients who were treated with an observational approach without implementing specific treatments. This disease affects adults, predominantly females. The age of patients in our series ranged from 26 to 76 years with a median of 49.5 years. This disease is characterized by ulcers and signs of acute inflammation on the membranous portion of the vocal folds with a prolonged clinical course. The recovery times of patients ranged from 4 to 20 weeks with an average of 9.4 weeks. The data in this study may reflect a natural history of this disease. PUL seems to be a self-limited disease, but the etiology of this disease is unknown. Specific infections or systemic inflammatory processes involving the larynx must be ruled out before diagnosis, and conservative treatments are suggested.

Observations of the Relationship Between Noise Exposure and Preschool Teacher Voice Usage in Day-Care Center Environments - Corrected Proof

2010-02-22

Summary: Although the relationship between noise exposure and vocal behavior (the Lombard effect) is well established, actual vocal behavior in the workplace is still relatively unexamined. The first purpose of this study was to investigate correlations between noise level and both voice level and voice average fundamental frequency (F0) for a population of preschool teachers in their normal workplace. The second purpose was to study the vocal behavior of each teacher to investigate whether individual vocal behaviors or certain patterns could be identified. Voice and noise data were obtained for female preschool teachers (n=13) in their workplace, using wearable measurement equipment. Correlations between noise level and voice level, and between voice level and F0, were calculated for each participant and ranged from 0.07 to 0.87 for voice level and from 0.11 to 0.78 for F0. The large spread of the correlation coefficients indicates that the teachers react individually to the noise exposure. For example, some teachers increase their voice-to-noise level ratio when the noise is reduced, whereas others do not.

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

Raymond D. Kent — 2010-02-08

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2010-02-08

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

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

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

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

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

2010-02-08

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

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

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

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

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

2010-01-25

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

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

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

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

What is “Twang”? - Corrected Proof

Johan Sundberg, Margareta Thalén — 2010-01-18

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

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

2010-01-18

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

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

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

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

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

2010-01-18

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

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

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

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

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

2010-01-18

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

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

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

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

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

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

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

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

2010-01-18

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

Histological Asymmetry of the Human Recurrent Laryngeal Nerve - Corrected Proof

2010-01-18

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

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

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

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

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

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

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

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

2009-11-09

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

Perceptual Findings on the Broadway Belt Voice - Corrected Proof

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

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

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

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

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