Voice Disorders Research Papers - Academia.edu (original) (raw)

Singing voice is a special subgroup within the field of voice. In addition to the differences in physiology between singing and speaking voice, singer patients are often regarded as a challenge for the otolaryngologist. The reason for... more

Singing voice is a special subgroup within the field of voice. In addition to the differences in physiology between singing and speaking voice, singer patients are often regarded as a challenge for the otolaryngologist. The reason for this is probably that the field of voice has not received as much attention as others in our speciality. Moreover, in the case of singers, empathy is vital in the doctor-patient relationship, and, as in many other cases, it forms part of the therapeutic effect. In order to achieve this, the physician has to know what singers are and which are the main pathologies they suffer, how they are formed and how they are expressed. This review offers an overlook of the pathological-physiology of singing voice from a double point of view, scientific and artistic, which in the case of singing are inevitably linked.

The objective was to develop an abbreviated voice handicap assessment instrument and compare it with the Voice Handicap Index (VHI). Item analysis of the VHI in individuals without voice disorders and patients with voice disorders and... more

The objective was to develop an abbreviated voice handicap assessment instrument and compare it with the Voice Handicap Index (VHI). Item analysis of the VHI in individuals without voice disorders and patients with voice disorders and creation and validation of the abbreviated VHI. Clinical consensus review of the VHI items was held to prioritize the clinical value of each of the VHI items (30 items in all). Item analysis of the VHI was performed using the VHI responses of 100 patients with voice problems and 159 control subjects. The 10 most robust VHI items were selected using the item analysis and clinical consensus results to form the Voice Handicap Index-10 (VHI-10). Statistical analysis comparing the validity of the VHI-10 with the VHI was performed with 819 patients representing a wide spectrum of voice disorders. Statistical analysis of the VHI and VHI-10 scores from the study group showed no statistically significant differences between the VHI and the VHI-10. Irrespective of diagnosis, the correlation between the VHI and the VHI-10 was greater than .90 (P = .01). The ratios of the VHI-10 to VHI scores for a variety of voice disorder categories were analyzed and found to be consistently greater than the expected value (33%). This suggests that the VHI-10 may be a more robust instrument than the VHI. The VHI-10 is a powerful representation of the VHI that takes less time for the patient to complete without loss of validity. Thus, the VHI-10 can replace the VHI as an instrument to quantify patients' perception of their voice handicap.

Substitution voicing cannot be evaluated accurately by the GRBAS perceptual rating scale, and there is a need for a valuable alternative. Therefore, we developed and tried out a perceptual rating scale, consisting of five new parameters:... more

Substitution voicing cannot be evaluated accurately by the GRBAS perceptual rating scale, and there is a need for a valuable alternative. Therefore, we developed and tried out a perceptual rating scale, consisting of five new parameters: impression, intelligibility, noise, fluency and voicing, each to be scored between 0 (very bad score) to 10 (very good score for a substitution voice). In analogy to the GRBAS scale, they are then converted to deviance scores ranging from 0 (similar to good substitution voicing) to 3 (very deviant from good substitution voicing). Inter-individual agreement measured in a set of 24 semi-professional jury members seemed to be moderate for all parameters. Mean figures of 0.52, 0.51, 0.46, 0.53 and 0.46 are obtained for the parameters impression, intelligibility, noise, fluency and voicing, respectively. Because a high correlation exists between the first two parameters (0.917) and relying on the correlation figures between the two ''I''s and the other parameters (correlation values for ''impression'' vary from 0.79-0.86; values for ''intelligibility'' range from 0.74-0.83), we suggest to discard the parameter impression, which turns the actual IINFVo scale into INFVo. The proposed (I)INFVo perceptual rating scale seems promising for the assessment of substitution voicing. Eventual improvements and practical proposals are discussed.

We quantified the recovery of voice following a 2-hour vocal loading exercise (oral reading). Eighty-six adult participants tracked their voice recovery using short vocal tasks and perceptual ratings after an initial vocal loading... more

We quantified the recovery of voice following a 2-hour vocal loading exercise (oral reading). Eighty-six adult participants tracked their voice recovery using short vocal tasks and perceptual ratings after an initial vocal loading exercise and for the following 2 days. Short-term recovery was apparent, with 90% recovery within 4 to 6 hours and full recovery at 12 to 18 hours. Recovery was shown to be similar to a dermal wound healing trajectory. The new recovery trajectory highlighted by the vocal loading exercise in the current study is called a vocal recovery trajectory. By comparing vocal fatigue to dermal wound healing, this trajectory is parallel to a chronic wound healing trajectory (as opposed to an acute wound healing trajectory). This parallel suggests that vocal fatigue from the daily use of the voice could be treated as a chronic wound, with the healing and repair mechanisms in a state of constant repair. In addition, there is likely a vocal fatigue threshold at which poi...

The motor control of bimanual coordination and motor speech was compared between first degree relatives from families with at least 2 dyslexic family members, and families where probands were the only affected family members. Half of... more

The motor control of bimanual coordination and motor speech was compared between first degree relatives from families with at least 2 dyslexic family members, and families where probands were the only affected family members. Half of affected relatives had motor coordination deficits; and they came from families in which probands also showed impaired motor coordination. By contrast, affected relatives without motor deficits came from dyslexia families where probands did not have motor deficits. Motor coordination deficits were more common and more severe among affected offspring in families where both parents were affected than among affected offspring in families where only one parent was affected. However, motor coordination deficits were also more common and more severe in affected parents when both parents were affected than among affected parents in families where only one parent was affected.

The introduction, in the late 70s, of the first digital spectrograph (DSP Sonograph) by Kay Elemetrics has improved the possibilities of spectroacoustic voice analysis in the clinical field. Thanks to the marketing, in 1993, of the Multi... more

The introduction, in the late 70s, of the first digital spectrograph (DSP Sonograph) by Kay Elemetrics has improved the possibilities of spectroacoustic voice analysis in the clinical field. Thanks to the marketing, in 1993, of the Multi Dimensional Voice Program (MDVP) advanced system, it is now possible to analyse 33 quantitative voice parameters which, in turn, allow evaluation of fundamental frequency, amplitude and spectral energy balance and the presence of any sonority gap and diplophony. Despite its potentials, the above-mentioned system is not widely used yet, partly on account of the lack of a standard procedure. Indeed, there are still only a few case reports in the literature taking into consideration prescriptive aspects related both to procedure and analysis. This study aims to provide the results of amplitude perturbation parameter analysis in euphonic adult patients. In our opinion, these are the most significant parameters in determining the severity of a phonation ...

Several studies have reported prevalence rates for voice disorders in school-aged children. Less is known, however, about such prevalence in preschoolers, and whether racial, ethnic, or cultural diversity may influence it. The presence of... more

Several studies have reported prevalence rates for voice disorders in school-aged children. Less is known, however, about such prevalence in preschoolers, and whether racial, ethnic, or cultural diversity may influence it. The presence of voice disorders in a total of 2445 African-American and European-American preschool children, 1246 males and 1199 females, from 2 to 6 years of age is reported here. Presence of a voice disorder characterized by hoarseness was identified by a three-prong approach including teacher identification, investigator screening, and parent identification. Speechlanguage pathologists listened individually to each child's speech as they engaged each child in play-conversation activities. A voice disorder was identified on the basis of the judgment of two speech-language pathologists. Voice disorders characterized by hoarseness were identified in 95 children or 3.9% of the total sample by the investigators. Statistical analysis revealed no significant differences for age, gender, or race.

Purpose To determine what research evidence exists to support the use of voice measures in the clinical assessment of patients with voice disorders. Method The American Speech-Language-Hearing Association (ASHA) National Center for... more

Purpose To determine what research evidence exists to support the use of voice measures in the clinical assessment of patients with voice disorders. Method The American Speech-Language-Hearing Association (ASHA) National Center for Evidence-Based Practice in Communication Disorders staff searched 29 databases for peer-reviewed English-language articles between January 1930 and April 2009 that included key words pertaining to objective and subjective voice measures, voice disorders, and diagnostic accuracy. The identified articles were systematically assessed by an ASHA-appointed committee employing a modification of the critical appraisal of diagnostic evidence rating system. Results One hundred articles met the search criteria. The majority of studies investigated acoustic measures (60%) and focused on how well a test method identified the presence or absence of a voice disorder (78%). Only 17 of the 100 articles were judged to contain adequate evidence for the measures studied to ...

Introduction: Vocal hygiene sensitization programs help in propagating the information about conservation of voice in a swift manner to a target population. Nurses being bridge between patients and doctors help patients understand or... more

Introduction: Vocal hygiene sensitization programs help in propagating the information about conservation of voice in a swift manner to a target population. Nurses being bridge between patients and doctors help patients understand or convey important information. Hence, nursing trainees formed the target group for the sensitization program on voice conservation and care. Materials and Methods: Ninety‑two nursing trainees and their faculty participated in a one‑day sensitization program on vocal hygiene. The program consisted of two lectures on the anatomy and physiology of voice and vocal hygiene for voice conservation and voice care. Participants’ familiarity of the topic was assessed using a questionnaire before and after the lectures. Results: There was a significant increase in percent correct response from 77.41% to 91.46% after the program. Out of 10 questions, eight had increase in scores, one had decreased score, and one question remained the same. Conclusion: Improved percent correct response scores of the participants in the post test implied better awareness about the voice production mechanism and conservation of voice and its care. The results could imply that such programs could improve dissemination of information pertaining to voice use, conservation of voice, and helping in reducing the occurrence of voice problems in different groups of professional voice users.

Pitch and intensity range of 60 children were recorded and plotted in voice range profiles (VRPs). Different aspects were investigated: minimum phonation threshold, pitch range, and maximum dynamic range. Vocal fold status was determined... more

Pitch and intensity range of 60 children were recorded and plotted in voice range profiles (VRPs). Different aspects were investigated: minimum phonation threshold, pitch range, and maximum dynamic range. Vocal fold status was determined via laryngoscopic examination. Ten percent of the children had vocal nodules, 23% glottal chinks. Seven voice experts listened to the voices recorded on two separate occasions and rated their properties along 16 parameters including hoarseness. Fourteen percent were rated as hoarse on both recordings and were thus classified as being chronically hoarse. Departures from normal in VRP characteristics were found for children suffering from chronic hoarseness, nodules, and glottal chinks. Children in general seem to have somewhat compressed VRP contours compared with adults, reflecting restricted dynamic vocal capabilities; however, children with mutational voices exhibited an approximation to adult upper VRP contours.

A review of the records of the Voice, Swallowing and Sinus Center of St. Luke’s Medical Center—Quezon City had produced data on the population of patients referred both for assessment and intervention, particularly those with dysphagia.... more

A review of the records of the Voice, Swallowing and Sinus Center of St. Luke’s Medical Center—Quezon City had produced data on the population of patients referred both for assessment and intervention, particularly those with dysphagia. These data will be presented in a concise manner followed by a discussion of the possible factors that influenced the changes in the referral flow and patient followup. The recommendations that will conclude this study may serve as reference for similar centers that may be set up in various institutions in the future.

Psychogenic voice disorders are not infrequently encountered in the busy voice clinic. A clinician-friendly psychodynamic model and a multidisciplinary management approach are presented which have proven helpful for our voice team and our... more

Psychogenic voice disorders are not infrequently encountered in the busy voice clinic. A clinician-friendly psychodynamic model and a multidisciplinary management approach are presented which have proven helpful for our voice team and our patients. In essence the formulation revolves around an "event" occurring, which may be either organic or psychological in nature. The ensuing dysphonia then leads to emotional consequences which in turn have physical consequences on the vocal tract. The situation can become reinforcing and illness behaviors develop. Elucidating this event/process to the patient improves the likelihood of a successful long-term outcome. The diagnostic and management roles of the various team members are discussed.

The role of the speech-language pathologist (SLP) has developed considerably over the past 20 years given the medical and technological advances in life-sustaining procedures. Children born with congenital, surgical, or "medically... more

The role of the speech-language pathologist (SLP) has developed considerably over the past 20 years given the medical and technological advances in life-sustaining procedures. Children born with congenital, surgical, or "medically fragile" conditions become mainstreamed into regular school-based settings, thus extending the traditional role of the treating SLP and multidisciplinary team. Understanding the impact of associated voice disorders on educational performance requires dissemination of additional and important information, as eligibility decisions for students in school-based settings must be made within the framework of the federal legislation and regulations governing the provision of services for students with disabilities. This article discusses how to identify children with voice disorders under the Individuals with Disabilities Education Improvement Act (IDEA), the role of the SLP in various triaging scenarios, and how models of voice therapy can be integrated in a school-based setting.

Some vocal disorders in teachers are associated with occupational factors, but there are few studies that analyze the influence of vocal habits, fluid intake, mastication, and sleep on these disorders. The objective was to analyze the... more

Some vocal disorders in teachers are associated with occupational factors, but there are few studies that analyze the influence of vocal habits, fluid intake, mastication, and sleep on these disorders. The objective was to analyze the occurrence of vocal fatigue, hoarseness, and dry throat in elementary and high school teachers and their association with vocal habits, fluid intake, mastication, and sleep. A sample of 422 elementary and secondary school teachers was studied using a specific questionnaire. The multiple regression analysis showed that hoarseness was associated with absence of water intake (odds ratio (OR) ¼ 1.7; P ¼ 0.047), yelling/speaking loudly (OR ¼ 1.6; P ¼ 0.058), jaw-opening limitations (OR ¼ 3.8; P ¼ 0.003), average of 6 hours of sleep/night (OR ¼ 1.7; P ¼ 0.039), and wakingup feeling replenished (OR ¼ 2.0; P ¼ 0.020). The presence of vocal fatigue was significantly associated with yelling/ speaking loudly (OR ¼ 2.2; P ¼ 0.013), speaking excessively (OR ¼ 2.4; P ¼ 0.023), difficulty to open the mouth to masticate (OR ¼ 6.6; P ¼ 0.003), less than 6 hours of sleep (OR ¼ 4.0; P ¼ 0.008), and waking-up feeling replenished (sometimes OR ¼ 2.8; P ¼ 0.003; or never OR ¼ 3.3; P ¼ 0.002). The presence of dry throat was associated with being a former smoker (OR ¼ 3.3; P ¼ 0.011) and having jaw-opening limitations (OR ¼ 3.9; P ¼ 0.021). In recent years, speech and hearing interventions with teachers have focused on health-care promotion actions and prevention of vocal disorders, prioritizing issues related with hydration and healthy vocal use habits. However, the findings in the present study show the need to further focus on lifestyle habits related to sleep and eating habits.

Acoustical measures of vocal function are routinely used in the assessments of disordered voice, and for monitoring the patient's progress over the course of voice therapy. Typically, acoustic measures are extracted from sustained vowel... more

Acoustical measures of vocal function are routinely used in the assessments of disordered voice, and for monitoring the patient's progress over the course of voice therapy. Typically, acoustic measures are extracted from sustained vowel stimuli where short-term and long-term perturbations in fundamental frequency and intensity, and the level of "glottal noise" are used to characterize the vocal function. However, acoustic measures extracted from continuous speech samples may well be required for accurate prediction of abnormal voice quality that is relevant to the client's "real world" experience. In contrast with sustained vowel research, there is relatively sparse literature on the effectiveness of acoustic measures extracted from continuous speech samples. This is partially due to the challenge of segmenting the speech signal into voiced, unvoiced, and silence periods before features can be extracted for vocal function characterization. In this paper we propose a joint time-frequency approach for classifying pathological voices using continuous speech signals that obviates the need for such segmentation. The speech signals were decomposed using an adaptive time-frequency transform algorithm, and several features such as the octave max, octave mean, energy ratio, length ratio, and frequency ratio were extracted from the decomposition parameters and analyzed using statistical pattern classification techniques. Experiments with a database consisting of continuous speech samples from 51 normal and 161 pathological talkers yielded a classification accuracy of 93.4%.

This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin. This is a retrospective analysis of patients with adductor spasmodic dysphonia (strain-strangled... more

This paper reviews a 12-year experience in more than 900 patients with spasmodic dysphonia who have been treated with botulinum toxin. This is a retrospective analysis of patients with adductor spasmodic dysphonia (strain-strangled voice), abductor spasmodic dysphonia (whispering voice), and adductor breathing dystonia (paradoxical vocal fold motion), all of whom have been treated with botulinum toxin injections for relief of symptom. All of the patients were studied with a complete head and neck and neurologic examination; fiberoptic laryngostroboscopy; acoustic and aerodynamic measures; and a speech evaluation including the Universal spasmodic dysphonia rating scale. Some were given electromyography. All patients received botulinum toxin injections into the affected muscles under electromyographic guidance. The adductor patients had an average benefit of 90% of normal function lasting an average of 15.1 weeks. The abductor patients had an average benefit of 66.7% of normal function lasting an average of 10.5 weeks. Adverse effects included mild breathiness and coughing on fluids in the adductor patients, and mild stridor in a few of the abductor patients. Botulinum toxin A injection of the laryngeal hyperfunctional muscles has been found over the past 12 years to be the treatment of choice to control the dystonic symptoms in most patients with spasmodic dysphonia.

Purpose: This study investigated which acoustic features of the voices of transgender (trans) women correlate with self- and listener ratings of voice femininity and with listener perceptions of gender. Differences between trans- and... more

Purpose: This study investigated which acoustic features of the voices of transgender (trans) women correlate with self- and listener ratings of voice femininity and with listener perceptions of gender. Differences between trans- and cisgender (cis) voices on these acoustic variables were also explored.
Methods: Speech samples were collected from 12 trans women and 10 cis control subjects. The acoustic variables of speaking fundamental frequency (SFF), SFF variation, intensity, vowel formants, and correlates of breathiness were collected for each speaker. Speakers completed a self-evaluation of voice femininity on a five-point scale drawn from the Transsexual Voice Questionnaire for Male-to-Female Transsexuals. Excerpts of these speech samples were presented to blind listeners, who also evaluated the femininity of each voice and classified each speaker within a binary gender system. Correlations between the acoustic variables and self- and listener ratings of voice femininity and listener perceptions of gender were measured using Spearman’s rank-order coefficient.
Results: Moderate-to-strong correlations were found between ratings of voice femininity and mean and maximum SFF, SFF variation, and mean intensity. These same four acoustic variables were moderately correlated with listener perceptions of gender. There were no consistent or significant correlations between voice femininity ratings or gender perceptions and minimum SFF, vowel formants, and breathiness measures. The analysis of differences between trans and cis speakers was limited by sample size. Results suggest SFF, SFF variation, and intensity—or pitch, intonation, and loudness—are appropriate targets for evidence-based voice training of trans women.

Determining and classifying pathological human sounds are still an interesting area of research in the field of speech processing. This paper explores different methods of voice features extraction, namely: Mel frequency cepstral... more

Determining and classifying pathological human sounds are still an interesting area of research in the field of speech processing. This paper explores different methods of voice features extraction, namely: Mel frequency cepstral coefficients (MFCCs), zero-crossing rate (ZCR) and discrete wavelet transform (DWT). A comparison is made between these methods in order to identify their ability in classifying any input sound as a normal or pathological voices using support vector machine (SVM). Firstly, the voice signal is processed and filtered, then vocal features are extracted using the proposed methods and finally six groups of features are used to classify the voice data as healthy, hyperkinetic dysphonia, hypokinetic dysphonia, or reflux laryngitis using separate classification processes. The classification results reach 100% accuracy using the MFCC and kurtosis feature group. While the other classification accuracies range between~60% to~97%. The Wavelet features provide very good classification results in comparison with other common voice features like MFCC and ZCR features. This paper aims to improve the diagnosis of voice disorders without the need for surgical interventions and endoscopic procedures which consumes time and burden the patients. Also, the comparison between the proposed feature extraction methods offers a good reference for further researches in the voice classification area.

Introduction. The hallmark characteristic of adductor spasmodic dysphonia (ADSD) is irregular and uncontrollable spasms within the intrinsic laryngeal muscles, resulting in erratic disruption of normal voicing. Methods. Using a random... more

Introduction. The hallmark characteristic of adductor spasmodic dysphonia (ADSD) is irregular and uncontrollable spasms within the intrinsic laryngeal muscles, resulting in erratic disruption of normal voicing. Methods. Using a random assignment and the inclusion of a behavioral sham to determine the effect of voice therapy after initial botulinum toxin type A (BTX-A) injections for ADSD, this study examined duration of injection benefit, perceived vocal quality of life from the Voice-Related Quality of Life (V-RQOL) scale, acoustic measures of vocal instability, and perceptual ratings of voice quality. Measures of these variables were collected before initial injection; 3, 7, and 12 weeks postinjection; and immediately before reinjection. Thirty-one individuals with ADSD participated in this study. One-third received no further intervention after BTX-A injection, one-third received a standard 5-week course of voice therapy after BTX-A injection, and one-third received a 5-week course of sham voice therapy after BTX-A injection. Results and Conclusions. Significant effects were observed on perceived quality of life and acoustic variables for all participants, over time. Participants who received voice therapy after BTX-A injection did not experience longer injection effect duration or significantly greater improvements in V-RQOL or acoustic variables than participants in BTX-A only or BTX-A plus sham therapy groups. Additionally, perceptual ratings of voice quality improved for all participants in response to BTX-A injection. For participants in this investigation, undertaking voice therapy did not appear to exert significant beneficial effects on the variables of interest.

This study examined the regulation of speech volume in hypophonic subjects with Parkinson's disease (PD) and age-and gender-matched controls. The ®rst two experiments investigated the ability of subjects with PD to automatically regulate... more

This study examined the regulation of speech volume in hypophonic subjects with Parkinson's disease (PD) and age-and gender-matched controls. The ®rst two experiments investigated the ability of subjects with PD to automatically regulate speech volume in response to two types of implicit cue: (i) background noise (BGN) and (ii) instantaneous auditory feedback (IAF). Control subjects demonstrated the Lombard eect by automatically speaking louder when competing against increasing levels of background noise. They also showed the reverse eect, decreasing speech volume when increasing levels of facilitative instantaneous auditory feedback were provided. Subjects with PD demonstrated decreased overall speech volume; they were less able than controls to appropriately increase volume as background noise increased, and to decrease volume as IAF increased. Thus, subjects with PD demonstrated over-constancy of speech volume and failed to respond to the implicit cues integral to volumetric scaling. A further experiment (3) was carried out to contrast the regulation of volume in response to implicit cue with an explicit attention-driven cue (i.e. instructions regarding volume level). As in Experiments 1 and 2, subjects with PD exhibited reduced speech volume. Under explicit volume instructions, the ability of subjects with PD to regulate volume was normalised. These ®ndings suggest that subjects with PD have the capacity to speak with normal volume provided they consciously attend to speaking loudly. In subjects with PD, overall speech volume was always lower than for control subjects, suggesting a reduction of cortical motor set in the articulatory system similar to that demonstrated by the reduced amplitude of limb movements (hypokinesia) in the motor system. #

A questionnaire investigating the levels of interest in and knowledge of vocal function and dysfunction was completed by 129 singers. Those with professional singing experience indicated significantly greater interest and higher perceived... more

A questionnaire investigating the levels of interest in and knowledge of vocal function and dysfunction was completed by 129 singers. Those with professional singing experience indicated significantly greater interest and higher perceived knowledge levels than amateurs in areas of vocal anatomy and physiology, vocal hygiene, and functional vocal pathologies. Greater interest levels, but not higher perceived knowledge levels were reported by professional singers (PSs) in the area of the role of the speech-language pathologist (SLP) and the voice. Professionals answered significantly more knowledge-based questions correctly than amateurs in all areas except the role of the SLP and the voice. However, findings indicated wide variability in knowledge levels of both groups. Singing teachers (STs) within the group significantly outperformed the remainder of the group in areas of vocal anatomy and physiology, vocal hygiene, and functional vocal pathologies. Scores of the choir directors (CDs) within the group were not significantly superior to the remainder of the group except in the area of functional vocal pathologies. Implications for a preventative approach to vocal health are discussed.

The Voice Handicap Index (VHI) was developed to assess patients' perception of the severity of their voice disorder. The purpose of this study was to determine the degree of handicap expressed by professional and recreational presenters... more

The Voice Handicap Index (VHI) was developed to assess patients' perception of the severity of their voice disorder. The purpose of this study was to determine the degree of handicap expressed by professional and recreational presenters with a voice complaint. Singers (n = 106) and nonsingers (n = 369) with voice symptoms were studied. The results of the VHI for singers indicate that singers score significantly lower (less severe) on the VHI compared to nonsingers. Singers with vocal fold nodules had a lower mean VHI than singers with vocal fold cysts or polyps. Singers who perform classical music had the lowest mean VHI of all types of singers studied. A low VHI in singers may represent a significant handicap and should not be ignored when considering the severity of a singer's voice problem. Key Words: Voice handicap index--Vocal fold nodules--Nonsingers.

The primary purpose of this study was to compare patient's and communication partner's perceptions of handicap secondary to dysphonia. A secondary purpose was to compare patient health-related quality of life (HRQOL) to that of speakers... more

The primary purpose of this study was to compare patient's and communication partner's perceptions of handicap secondary to dysphonia. A secondary purpose was to compare patient health-related quality of life (HRQOL) to that of speakers with normal voice. Participants were 20 adults (mean age 5 69.15 years) with dysphonia and their communication partners. Patients completed the Voice Handicap Index (VHI), a questionnaire of selfperceived voice handicap, and the Short-Form 36 (SF-36), a general health questionnaire. Partners completed the Voice Handicap Index-Partner (VHI-P), a questionnaire derived from the VHI for this pilot study, to gauge partner perception of voice handicap. Patients in this study viewed themselves as only moderately handicapped by their dysphonia and their partners were in close agreement. Patients and their partners were also in close agreement on each of three VHI subscales (physical, functional, and emotional), and in all cases the physical domain was perceived by both patients and their partners to be most handicapped. Patients had lower SF-36 mean scores than those of persons with normal voice from the general U.S. population on scales assessing physical functioning, physical role, general health, vitality, social functioning, emotional role, and mental health. The results of this study are consistent with previous studies examining patient-partner agreement, which consider proxy ratings to be a useful alternative or collaborative source of patient's self-perception. Further research regarding the reliability of patient and partner agreement is necessary to most effectively assess and manage patients with dysphonia.

In the past several years, a number of scales have been developed that elicit a patient's self-assessment of the severity of his or her voice problem. The Voice Related Quality of Life Measure (V-RQOL) assesses a patient's perception of... more

In the past several years, a number of scales have been developed that elicit a patient's self-assessment of the severity of his or her voice problem. The Voice Related Quality of Life Measure (V-RQOL) assesses a patient's perception of the impact of the voice problem on quality of life. Although this tool assesses the patient's perception of the voice disorder, it may not reflect the severity of dysphonia as perceived by a clinician. The GRBAS is an auditory-perceptual scale developed in Japan and used by clinicians to categorize the voice using five descriptive perceptual parameters: overall grade or severity (G), roughness of the voice (R), breathiness (B), asthenia (A), and strain (S). The purpose of this research is to determine the relationship between the patient's perception of voice related quality of life using the V-RQOL and the clinician's perception of voice severity using the GRBAS scale. Fifty patients with a complaint of a voice disorder completed the V-RQOL prior to their examination. In addition, 45 patients without voice complaints (controls) also completed the V-RQOL. All patients and control subjects were assessed by one of the voice clinicians using the GRBAS. For 25 of the subjects, both clinicians provided GRBAS perceptual ratings. Each of the two groups, were subsequently divided into subgroups consisting of those age 66 years and under and those over 66 years of age. The results indicate that the two clinicians were highly reliable in rating severity in the normal and voice disordered groups using the GRBAS scale. The results also indicate that perceived voice severity and voice-related quality of life are related; however, the relationship is a moderate one, which suggests that factors other than those directly related to voice quality may contribute to responses on voice assessment scales completed by patients. The relationship was stronger for the subgroup under 66 years old compared with the subgroup 66 years and older.

The role of the speech-language pathologist (SLP) has developed considerably over the last 10 years given the medical and technological advances in life-sustaining procedures. Over time, children born with congenital, surgical, or... more

The role of the speech-language pathologist (SLP) has developed considerably over the last 10 years given the medical and technological advances in life-sustaining procedures. Over time, children born with congenital, surgical, or "medically fragile" conditions have become mainstreamed into regular school-based settings, thus extending the traditional role of the SLP and multidisciplinary team. Understanding the impact of these voice disorders on the child’s educational performance has been a struggle for many clinicians because the eligibility decisions for students in school-based settings must be made within the framework of federal legislation and regulations governing the provision of services for students with disabilities. This article discusses how to identify children with voice disorders under the Individuals With Disabilities Education Act (IDEA) definition, the role of the SLP in assigning priority in various voice management scenarios, and how models of therap...

Purpose: The purpose of this study was to investigate current practices of speech-language pathologists (SLPs) in the management of pediatric vocal health, with specific analysis of the influence of clinical specialty and workplace... more

Purpose: The purpose of this study was to investigate current practices of speech-language pathologists (SLPs)
in the management of pediatric vocal health, with specific analysis of the influence of clinical specialty and workplace setting on management approaches.
Method: American Speech-Language-Hearing Association– certified clinicians providing services within the United States (1%–100% voice caseload) completed an anonymous online survey detailing clinician demographics; employment location and service delivery models; approaches to continuing professional development; and specifics of case management, including assessment, treatment, and discharge procedures.
Results: Current practice patterns were analyzed for
100 SLPs (0–42 years of experience; 77 self-identifying as voice specialists) providing services in 34 U.S. states across a range of metropolitan and nonmetropolitan workplace settings. In general, SLPs favored a multidisciplinary approachto management; included perceptual, instrumental, and quality of life measures during evaluation; and tailored intervention to the individual using a combination of therapy approaches. In contrast with current practice guidelines, only half reported requiring an otolaryngology evaluation prior to initiating treatment. Both clinical specialty and workplace setting were found to affect practice patterns. SLPs in school settings were significantly less likely to consider themselves voice specialists compared with all other work environments. Those SLPs who considered themselves voice specialists were significantly more likely to utilize voice-specific assessment and treatment approaches.
Conclusion: SLP practice largely mirrors current professional practice guidelines; however, potential exists to further enhance client care. To ensure that SLPs are best able to support children in successful communication, further research, education, and advocacy are required.

This study compared acoustic and electroglottographic ͑EGG͒ jitter from ͓a͔ vowels of 103 dysphonic speakers. The EGG recordings were chosen according to their intensity, signal-to-noise ratio, and percentage of unvoiced intervals, while... more

This study compared acoustic and electroglottographic ͑EGG͒ jitter from ͓a͔ vowels of 103 dysphonic speakers. The EGG recordings were chosen according to their intensity, signal-to-noise ratio, and percentage of unvoiced intervals, while acoustic signals were selected based on voicing detection and the reliability of jitter extraction. The agreement between jitter measures was expressed numerically as a normalized difference. In 63.1% ͑65/103͒ of the cases the differences fell within Ϯ22.5%. Positive differences above ϩ22.5% were associated with increased acoustic jitter and occurred in 12.6% ͑13/103͒ of the speakers. These were, typically, cases of small nodular lesions without problems in the posterior larynx. On the other hand, substantial rises in EGG jitter leading to differences below Ϫ22.5% took place in 24.3% ͑25/103͒ of the speakers and were related to hyperfunctional voices, creaky-like voices, small laryngeal asymmetries affecting the arytenoids, or small-to-moderate glottal chinks. A clinically relevant outcome of the study was the possibility of detecting gentle laryngeal asymmetries among cases of large unilateral increase in EGG jitter. These asymmetries can be linked with vocal problems that are often overlooked in endoscopic examinations.

Eosinophilic esophagitis (EE) is a chronic inflammatory disorder of the esophagus that is rapidly emerging as a distinct clinical disease entity of importance. It is characterized by an isolated, dense eosinophilic epithelial infiltration... more

Eosinophilic esophagitis (EE) is a chronic inflammatory disorder of the esophagus that is rapidly emerging as a distinct clinical disease entity of importance. It is characterized by an isolated, dense eosinophilic epithelial infiltration of the esophagus with unusual structural alterations that are often overlooked by radiologists and endoscopists. The disease affects patients of all ages, but traditionally, it is appreciated mainly in the pediatric literature. The presenting symptoms are usually gastrointestinal in nature. Epigastric pain, chest pain, dysphagia, and food impaction are common in adults and children. Vomiting, regurgitation, feeding disorders, and failure to thrive are additional findings in children with EE. Recent reports highlight the upper airway and respiratory symptoms of rhinitis, sinusitis, pneumonia, wheezing, globus, hoarseness, dysphonia, and cough in children . Additionally, EE has been attributed as a causative factor in airway findings of subglottic stenosis and chronic laryngeal edema refractory to traditional reflux therapy in a case report of a child . With the crossover of upper airway symptoms and findings along with the expanding role of otolaryngologist in the treatment and management of esophageal disorders and dysphagia, it is important for otolaryngologist to recognize and appropriately treat or refer patients who have EE for further management.

The objective of this study was to compare the psychometric properties of voice disordered quality of life (VQOL) instruments. Nine VQOL instruments were identified through a comprehensive literature search. Based on specific criteria,... more

The objective of this study was to compare the psychometric properties of voice disordered quality of life (VQOL) instruments. Nine VQOL instruments were identified through a comprehensive literature search. Based on specific criteria, four were selected for comprehensive review: Voice Handicap Index (VHI), Voice Activity and Participation Profile (VAPP), Voice-Related Quality of Life (V-RQOL) and Voice Outcome Survey (VOS). Selected instruments were evaluated based on 11 measurement standards related to item information, versatility, practicality, breadth and depth of health measure, reliability, validity, and responsiveness. VHI and V-RQOL each met 7 of 11 criteria, with VHI showing additional preferable item information, practicality, and reliability over V-RQOL and V-RQOL showing preferable responsiveness properties over VHI. These study results do not support the Social Security Administration's recent conclusion that the VHI meets reliability and validity standards for individual decision making. Nevertheless, the present results do support the use of VHI total scores for clinical use with individual patients, and the use of V-RQOL total scores or individual dimension scores for use with groups of patients.

Background. Teachers constitute a profession with a high occurrence of voice disorders due to the occupation's intense vocal demands and unfavorable work environment. Purpose. To identify the association between voice disorders and work... more

Background. Teachers constitute a profession with a high occurrence of voice disorders due to the occupation's intense vocal demands and unfavorable work environment. Purpose. To identify the association between voice disorders and work ability among teachers from public schools in São Paulo, Brazil.

To develop and validate a score that can serve as a screening index for voice disorders in teachers. The subjects of this study were 252 female teachers, with and without voice disorders (WVD and WOVD) from the public school system of São... more

To develop and validate a score that can serve as a screening index for voice disorders in teachers. The subjects of this study were 252 female teachers, with and without voice disorders (WVD and WOVD) from the public school system of São Paulo, Brazil. All subjects underwent medical and vocal evaluations and completed a questionnaire about experienced vocal symptoms. They were then randomly divided into samples A and B. Sample A was used to develop and sample B to validate a screening index for voice disorder (SIVD). The development was done using a factorial analysis, and a cutoff point to predict the risk of having a voice disorder was defined using a receiver operating characteristic curve. The validation was done by calculating sensitivity and specificity values for the cutoff, comparing mean scores of subjects WVD and WOVD, calculating correlation between SIVD and Voice Handicap Index (VHI), and the association between the risk and presence of voice disorder. The SIVD comprise...

The voice handicap index (VHI) is one of the most widely used instruments for measuring a patient's self-assessment of voice severity. In some ways, it reflects the patient's quality of life. Although it has been recognized and widely... more

The voice handicap index (VHI) is one of the most widely used instruments for measuring a patient's self-assessment of voice severity. In some ways, it reflects the patient's quality of life. Although it has been recognized and widely applied to populations in European countries and to English speaking populations, it has not been used in its present forms in the Arabic speaking countries due to the specific language constraints of Euro-American terminology. The purposes of this study were to generate an Arabic version of VHI, to assess its reliability, and to apply it to a wide variety of normal and dysphonic individuals of Arabic descent. The Arabic version of VHI was derived in the standard way for test translation. The translated version was then administered to 65 patients with voice disorders and 65 control subjects. Participants' responses were statistically analyzed to assess the validity, and to compare the pathological group with the control group. The Arabic VHI showed a significant high internal consistency and reliability (Cronbach's a = 0.97 and r = 0.89, respectively), high item-domain and domaintotal correlation (r = 0.73-0.94). There was a statistically significant difference between the control and the voicedisordered groups (P \ 0.001). The results of this study demonstrated strong internal consistency of the Arabic VHI. Thus, the Arabic version of VHI is considered to be a valid and reliable self-assessment tool for the severity of voice disorders in Arabic language speaking patients.

Manual circumlaryngeal therapy (manual laryngeal musculoskeletal tension reduction) was used to treat 25 consecutive functional dysphonia patients. Pre-and post-treatment audio recordings of connected speech and sustained vowel samples... more

Manual circumlaryngeal therapy (manual laryngeal musculoskeletal tension reduction) was used to treat 25 consecutive functional dysphonia patients. Pre-and post-treatment audio recordings of connected speech and sustained vowel samples were submitted to auditory-perceptual and acoustical analysis to assess the immediate and long-term effects of a single treatment session. To complement audio recordings, subjects were interviewed in follow-up regarding the stability of treatment effects. Pre-and post-treatment comparisons demonstrated significant voice improvements. No significant differences were observed between post-treatment measures, suggesting that vocal gains were maintained. Interviews revealed 68% of subjects reported occasional partial recurrences, typically less than 4 days in duration, which resolved spontaneously. These results replicate and extend previous research suggesting the utility of manual circumlaryngeal therapy for functional voice disorders.

The objective of this study is to report the vocal characteristics of patients with type 2 diabetes mellitus in relation to disease duration, glycemic control, and neuropathy. This is a prospective study. The setting is institutional... more

The objective of this study is to report the vocal characteristics of patients with type 2 diabetes mellitus in relation to disease duration, glycemic control, and neuropathy. This is a prospective study. The setting is institutional setting. A total of 82 patients were recruited for this study, and a healthy control group matched according to age and gender was recruited. Subjects underwent acoustic analysis and perceptual evaluation using the GRABS classification where G stands for grading, R for roughness, A for asthenia, B for breathiness, and S for straining using a scale of 0-3 where o stands for normal and three for severe deviation from normal. There was no significant difference in any of the acoustic variables between diabetic patients and control. There was no significant difference in the mean score of any of the perceptual evaluation parameters between diabetic patients and control, despite the fact that the mean scores were all higher in the diseased group except for roughness. When looking at subgroups, we see that diabetic patients with poor glycemic control and with neuropathy had significantly higher mean score for the G overall grade of the voice compared to controls with P values of 0.005 and 0.009, respectively. What is also worth noting is that diabetic patients with poor glycemic control had more straining compared to controls, P value 0.043. Patients with type 2 diabetes mellitus and poor glycemic control or neuropathy have a significant difference in the grade of their voice compared to controls.

ENT/phoniatrics specialists are frequently the primary reference persons for patients who have problems with the professional use of their voice. Singers show the highest risk factors for voice disorders among all professional voice... more

ENT/phoniatrics specialists are frequently the primary reference persons for patients who have problems with the professional use of their voice. Singers show the highest risk factors for voice disorders among all professional voice users. The treatment and care of singers requires specific knowledge and competence of the physician, as well as a treatment setting adapted to the needs of this special group of patients, whose existence depends on the use of their voice. To some extent, evidence based concepts can be taken into account when treating professional singers. In cases for which no concepts have yet been developed and evaluated, recourse to clinical experience is necessary. In the present paper, current concepts for the treatment of singers are discussed on the basis of scientific publications and on long-standing experience of consultations in musician's medicine and ENT, under the aspects of diagnosis, therapy as well as prevention, taking into account the most frequen...

Unilateral vocal fold paralysis (UVFP) is associated with changes in acoustic and aerodynamic voice measurements and can have a significant impact on a patient's quality of life. Few objective data regarding the efficacy of voice therapy... more

Unilateral vocal fold paralysis (UVFP) is associated with changes in acoustic and aerodynamic voice measurements and can have a significant impact on a patient's quality of life. Few objective data regarding the efficacy of voice therapy for UVFP exist. The aim of this study was to retrospectively analyze voice modifications in a group of patients with UVFP before and after voice therapy. Forty patients with UVFP of different etiology were included in the study. Each subject had voice therapy with an experienced speech/language pathologist twice a week; the mean number of sessions was 12.6. A multidimensional assessment protocol was used; it included videoendoscopy, the maximum phonation time (MPT), the GIRBAS scale, spectrograms and a perturbation analysis, and the Voice Handicap Index (VHI). Pre-and posttreatment data were compared by means of the Wilcoxon and Student's t tests. A complete glottal closure was seen in 8 patients before voice therapy and in 14 afterward. Mean MPT increased significantly. In the perceptual assessment, the difference was significant for five out of six parameters. A significant improvement was found on spectrographic analysis; as for perturbation analysis, the differences in jitter, shimmer, and noise-to-harmonic ratio values were significant. VHI values showed a clear and significant improvement. A significant improvement of voice quality and quality of life after voice therapy is an often reached and reasonable goal in patients with UVFP.

A hypophonic voice, characterized perceptually as weak and breathy, is associated with voice disorders such as vocal fold atrophy and unilateral vocal fold paralysis. Although voice therapy programs for hypophonia typically address the... more

A hypophonic voice, characterized perceptually as weak and breathy, is associated with voice disorders such as vocal fold atrophy and unilateral vocal fold paralysis. Although voice therapy programs for hypophonia typically address the vocal folds or the sound source, twang voice quality was examined in this study as an alternative technique for increasing vocal power by altering the epilarynx or the sound filter. Objective: This study investigated the effect of twang production on physiologic, acoustic, and perceived voice handicap measures in speakers with hypophonia. Design/Methods: This prospective pilot study compared the vocal outcomes of six participants with hypophonia at pre-and posttreatment time points. Outcome measures included mean airflow rate, intensity in dB sound pressure level (SPL), maximum phonation time, and self-report of voice handicap. Results: All subjects improved in at least three of the four vocal outcome measures. Wilcoxon signed-rank test of paired differences revealed significant differences between pre-and posttherapy group means for airflow rate, SPL, and Voice Handicap Index scores. Conclusion: The twang voice quality as a manipulation of the sound filter offers a clinical complement to traditional voice therapies that primarily address the sound source.

The objective was to culturally adapt and validate the Voice Handicap Index (VHI) to the Greek language. The study design used was a psychometric analysis. The VHI was translated into Greek with cultural adaptations to accommodate certain... more

The objective was to culturally adapt and validate the Voice Handicap Index (VHI) to the Greek language. The study design used was a psychometric analysis. The VHI was translated into Greek with cultural adaptations to accommodate certain words. The translated version was then completed by 67 subjects with various voice disorders and by a control group of 79 subjects. All the participants also completed a self-rating scale regarding the severity of their voice disorder. 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 moderate correlation was found between the VHI and the self-rating severity scale. The subjects in the control group had lower scores compared to the subjects with voice disorders for the overall VHI score and for the three domains. Based on the internal consistency values and the test-retest reliability, the Greek version of VHI is a valid and reliable measure for use by Greek subjects with voice disorders.

Presbylaryngis, or aging of the larynx, can adversely affect vocal function and quality of life in the elderly. This preliminary investigation examined the effects of vocal function exercises, a physiologic voice therapy approach, as a... more

Presbylaryngis, or aging of the larynx, can adversely affect vocal function and quality of life in the elderly. This preliminary investigation examined the effects of vocal function exercises, a physiologic voice therapy approach, as a primary treatment for presbylaryngis. Nine consecutive elderly patients with presbylaryngis (2 female, 7 male) underwent a 6-week course of voice therapy employing vocal function exercises. Pretherapy-versus-posttherapy comparisons were made of self-ratings of voice handicap and phonatory effort level, as well as auditory-perceptual voice assessments, acoustic analyses, and visual-perceptual evaluations of laryngeal images. After treatment, patients reported significant reductions on Voice Handicap Index scores, phonatory effort levels, and voice disorder severity. Blinded listeners rated the posttreatment voices as significantly less breathy and strained. However, comparison of pretreatment and posttreatment maximum phonation times, acoustic measures...

To evaluate the clinical performance of an autocrosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus... more

To evaluate the clinical performance of an autocrosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short-and long-term follow-up. STUDY DESIGN: This was a prospective multicenter trial conducted between 2007 and 2009. SETTING: Academic center. SUBJECTS AND METHODS: Inclusion criteria were patients with glottic gap due to previous endoscopic phonosurgery, VF scars, vocal cord atrophy, and sulcus vocalis. Forty patients who underwent endoscopic injection of hyaluronic acid under general anesthesia were enrolled. Two different injections sites were used: the thyroarytenoid muscle in cases of glottic gap for augmentative purposes, and the lamina propria for treatment of scars and sulcus vocalis. A voiceevaluation protocol was performed before surgery, at the first follow-up visit (3 mo), and at the final follow-up (12 mo). RESULTS: Follow-up data at three months were available for 38 patients, while data at 12 months follow-up were available for 27 patients. No side effects, hematoma, or infection and allergic reactions were reported in either the perioperative or postoperative period. Patients had statistically significant improvement in voice parameters compared with the baseline data at the first follow-up visit and at the 12-month follow-up. CONCLUSION: ACP-based gel seems to be a new tool in the challenging treatment of VF scarring, functioning as both an antiadhesive product and an augmentation agent. Improvements in all glottal parameters and in both objective and subjective evaluation of voice performance were observed.

Occupational voice disorders are characterized by rich symptomatology, which is dominated by symptoms by the vocal tract discomfort. Therefore, in the management it is important to consider these subjective complaints. The aim of the... more

Occupational voice disorders are characterized by rich symptomatology, which is dominated by symptoms by the vocal tract discomfort. Therefore, in the management it is important to consider these subjective complaints. The aim of the study was to assess the usefulness of using the vocal tract discomfort scale (VTD) in evaluating the effects of rehabilitation concerning occupational dysphonia. The study included 55 teachers (mean age: 47.2) with occupational dysphonia diagnosed by means of videostroboscopy. The test battery covered also: voice self-assessment according to voice handicap index (VHI), perceptual GRBAS scale and the new VTD scale. Each subject underwent intensive rehabilitation, including voice training and voice hygiene education. The post-therapy examination was conducted using the above-mentioned methods. Comparing the results obtained in the preliminary and the control test a significant post-therapy improvement (p = 0.000) was discovered in relation to the general ...