Objective and Subjective Evaluation of Voice Quality in Multiple Sclerosis

The aim of this comparative, controlled, cross-sectional study is to evaluate the voice quality in patients with multiple sclerosis (MS) by subjective and objective methods. Female patients with MS (n=27) and age- and sex-matched healthy controls (n=27) were included in this study. Vocal functions were evaluated by a multidimensional set composed of videolaryngostroboscopic examination, acoustic analysis, and subjective measurements (GRBAS and "Voice Handicap Index"). Jitter percent, shimmer percent, and soft phonation index (SPI) values were higher in MS patients compared to controls (Jitt, P=0.001; Shim, P=0.033; SPI P<0.0001). Maximum phonation time was significantly shorter for MS patients compared to controls (P<0.0001). Stroboscopic examination revealed that 16 out of 27 MS patients have a "posterior chink" as glottic closure pattern with higher SPI values (40%). Noise to harmonic ratio (NHR) and mean fundamental frequency (F0) values were similar for MS and control groups (NHR, P=0.737; F0, P=0.976). In this study, most of the MS patients had dysphonia due to weakness of voice. MS tends to worsen acoustic parameters including fundamental frequency, SPI, and jitter values. These results are consistent with the more asthenic voice quality observed in MS group.     

Multiparametric Evaluation of Dysphonic Severity

SUMMARY: In recent years, the multiparametric approach for evaluating perceptual rating of voice quality has been advocated. This study evaluates the accuracy of predicting perceived overall severity of voice quality with a minimal set of aerodynamic, voice range profile (phonetogram), and acoustic perturbation measures. One hundred and twelve dysphonic persons (93 women and 19 men) with laryngeal pathologies and 41 normal controls (35 women and six men) with normal voices participated in this study. Perceptual severity judgement was carried out by four listeners rating the G (overall grade) parameter of the GRBAS scale. The minimal set of instrumental measures was selected based on the ability of the measure to discriminate between dysphonic and normal voices, and to attain at least a moderate correlation with perceived overall severity. Results indicated that perceived overall severity was best described by maximum phonation time of sustained /a/, peak intraoral pressure of the consonant-vowel /pi/ strings production, voice range profile area, and acoustic jitter. Direct-entry discriminant function analysis revealed that these four voice measures in combination correctly predicted 67.3% of perceived overall severity levels.     

Vocal stability in functional dysphonic versus healthy voices at different times of voice loading

Functional (nonorganic) dysphonia is often characterized by vocal instability. The purpose of the prospective study was to examine whether there is a difference in vocal instability of functional dysphonic voices compared with healthy ones, this means whether electroglottographic perturbation values differ (1) between healthy and dysphonic voices and (2) between two subgroups of the dysphponic voices (hpertonic and hypotonic dysphonic voices). Twenty-three patients with hypertonic functional dysphonia, 9 with hypotonic functional dysphonia and 31 healthy nonsmokers, were each examined electroglottographically before (Ex 1), immediately after (Ex 2), and 1 hour after (Ex 3) voice loading. Perturbations of frequency, amplitude, quasi-open-quotient, and contact-index were calculated from the EGG signal. At all three times of examination, hypertonic dysphonic voices showed higher perturbations than healthy voices, and they had higher perturbations than hypotonic dysphonic voices before and 1 hour after voice loading. Hypotonic dysphonic voices showed higher perturbations than healthy voices only 1 hour after voice loading. Voice loading induced different reactions in dysphonic voices: Some voices showed increased perturbations, and others exhibited normal or even decreased perturbation immediately after voice loading. Examination of electroglottographic-derived perturbations immediately after voice loading seems not to be useful. Differentiation of hypertonic and hypotonic dysphonic voices was possible with an estimated sensitivity of 88.9% and a specificity of 87.0% by using the sum of the amplitude-perturbation and the quasi-open-quotient-perturbation measured before voice loading.     

Quality of Life in Dysphonic Patients

Voice disorders can affect social life. Dysphonic patients report symptoms of psychological distress as a direct consequence of their dysphonia. It is assumed that their health-related quality of life (HRQL) is reduced. The purpose of this study was to find out whether changes of HRQL depend on the kind of voice disorder (organic or functional) and on the sex of the person affected. A total of 108 adult patients took part in the study, and patients with malignancies were excluded. Test persons were asked to complete the SF-36 questionnaire on their health-related quality of life without prior information about their individual diagnosis. The results of this study show that voice disorders significantly influence patients' HRQL. There are no statistically significant differences between patients suffering from organic and functional voice disorders or between dysphonic women and men. When comparing the results obtained in this study with those in the literature, surprisingly, it seems that the manner in which a person experiences a voice disorder depends on the individual cultural background. Patients with functional voice disorders have similar reduction in HRQL as those with organic voice disorders. HRQL in dysphonic women does not differ from the one in dysphonic men. The results allow for the conclusion that changes of HRQL do not depend on the kind of voice disorder and not on the sex of the person affected.     

Voice problems among teachers: Differences by gender and teaching characteristics

This study describes the effects of teaching activities on voice problems in male (n = 274) and female teachers (n = 280). Over 38% of the teachers studied complained that teaching had an adverse impact on their voice and 39% of those had cut back teaching activities as a result. Compared to males, female teachers more frequently reported a voice problem (38% vs. 26%, p <.05), acute (p <.05), and chronic (p <.05) voice problems, six specific voice symptoms, and five symptoms of physical discomfort. However, there were no gender differences in the perception that a voice problem adversely affected their current or future teaching career. For every type of course taught, women had a higher probability of reporting voice problems compared to men: odds ratio (OR) = 1.7–2.l. Compared with other courses, the teaching of physical education also was associated with an increased risk of developing a voice problem (OR = 3.7, 95% CI: 1.4–9.4) independent of gender, age, hours/day, or years taught. This is the first study to show that in the same occupation, females report a higher frequency of vocal symptoms than males even when teaching characteristics and years employment are similar.     

Reliability of Speaking and Maximum Voice Range Measures in Screening for Dysphonia

Speech range profile (SRP) is a graphical display of frequency-intensity occurring interactions during functional speech activity. Few studies have suggested the potential clinical applications of SRP. However, these studies are limited to qualitative case comparisons and vocally healthy participants. The present study aimed to examine the effects of voice disorders on speaking and maximum voice ranges in a group of vocally untrained women. It also aimed to examine whether voice limit measures derived from SRP were as sensitive as those derived from voice range profile (VRP) in distinguishing dysphonic from healthy voices. Ninety dysphonic women with laryngeal pathologies and 35 women with normal voices, who served as controls, participated in this study. Each subject recorded a VRP for her physiological vocal limits. In addition, each subject read aloud the "North Wind and the Sun" passage to record SRP. All the recordings were captured and analyzed by Soundswell's computerized real-time phonetogram Phog 1.0 (Hitech Development AB, T?by, Sweden). The SRPs and the VRPs were compared between the two groups of subjects. Univariate analysis results demonstrated that individual SRP measures were less sensitive than the corresponding VRP measures in discriminating dysphonic from normal voices. However, stepwise logistic regression analyses revealed that the combination of only two SRP measures was almost as effective as a combination of three VRP measures in predicting the presence of dysphonia (overall prediction accuracy: 93.6% for SRP vs 96.0% for VRP). These results suggest that in a busy clinic where quick voice screening results are desirable, SRP can be an acceptable alternate procedure to VRP.     

Objective Voice Measures in Nonsinging Patients With Unilateral Superior Laryngeal Nerve Paresis

The clinical value of objective voice measures in nonsinging patients with superior laryngeal nerve dysfunction is unknown. In this study, patients with symptomatic unilateral superior nerve paresis were evaluated for maximum phonation time, frequency range of phonation, and mean flow rate. Patients with coexisting pathology, bilateral superior nerve paresis, and those with recurrent laryngeal nerve paresis were excluded from this analysis. A total of 35 nonsinging patients, 14 men and 21 women, with unilateral superior laryngeal nerve paresis were examined between 1999 and 2002. The severity of superior laryngeal nerve paresis ranged from 25% to 85% of normal recruitment with a mean of 70% superior laryngeal nerve recruitment in men and 65% in women by electromyography. In both men and women with superior laryngeal nerve paresis, the maximum phonation time and frequency range of phonation were decreased and the mean air flow rate was increased when compared with normal population values. The jitter percent, shimmer percent, and noise-to-harmonic ratio were also increased in patients when compared with normative data. Selected objective voice measures are abnormal in voice patients with superior laryngeal nerve paresis, which suggests that the measures may be useful as outcomes measures after therapy. More research is encouraged.     

Voice of Postradiotherapy Nasopharyngeal Carcinoma Patients: Evidence of Vocal Tract Effect

This study was aimed at identifying acoustic and physiological measures useful for monitoring voice changes in postnasopharyngeal patients with nonlaryngeal malignancies, and providing evidences of vocal tract effect on voice through comparisons between individuals with and without intact vocal tract. Simultaneous acoustic-electroglottographic signals recorded during phonation of vowels /i/ and /a/ sustained at habitual, high, and low pitch levels were compared among 10 postradiotherapy patients with nasopharyngeal carcinoma (NPC), 10 voice patients (VPs) with intact vocal tract, and 10 healthy individuals with normal voice (NORM). Results from a series of discriminant analyses revealed that the NPC group generally exhibited lower signal-to-noise (SNR) and open quotient (OQ) and higher Formant 1 frequency (F(1)) and speed quotient (SQ) than the NORM group. Unlike both VP and NORM groups, the NPC group failed to show a pitch effect on all voice measures, including OQ, SQ, percent jitter, percent shimmer, and SNR, suggesting an effect of radiotherapy and/or vocal tract on laryngeal behaviors. For the vowel /i/, on the other hand, only the NPC and NORM groups showed a pattern of pitch-dependent F(1) raising, a reflection of increased pharyngeal narrowing. These findings suggested that the pitch effect on laryngeal behaviors differed not only between individuals with intact vocal tract and those without but also between those with structural and dynamic changes of vocal tract.     

Acoustic voice analysis in patients with Parkinson''s disease treated with dopaminergic drugs

To quantify several acoustic features of the voice in patients withParkinson's disease (PD), 41 patients and 28 age and sex-matched controls were studied. PD severity was assessed with the Unified PD Rating Scale (UPDRS) and the Hoehn and Yahr staging. The Computerized Speech Lab 4300 program (Kay Elemetrics) was used. Two seconds of a sustained /a/ and a sentence were captured with a microphone and laryngograph equipment. Measures included fundamental frequency (FO), frequency perturbation (fitter), intensity perturbation (shimmer), and harmonic/noise ratio (H/N) of the vowel /a/, and frequency and intensity variability of a sentence, phonational range, dynamic range at the natural frequency, maximum phonational time and s/z ratio. All subjects underwent indirect laryngoscopy and/or laryngeal fibroscopy. When compared with controls, PD patients showed higher jitter, lower H/N ratio, lower frequency and intensity variability of the sentence, and lower phonational range and reported a higher frequency of the presence of low voice-intensity, monopitch, voice arrests, and struggle. These features seem to be unaffected by the duration and severity of the disease.     

Validity and Reliability of the Reflux Symptom Index (RSI)

Laryngopharyngeal reflux (LPR) is present in up to 50% of patients with voice disorders. Currently, there is no validated instrument that documents symptom severity in LPR. We developed the reflux symptom index (RSI), a self-administered nine-item outcomes instrument for LPR. The purpose of this investigation was to evaluate the psychometric properties of the RSI. For validity assessment, 25 patients with LPR were evaluated prospectively before and six months after b.i.d. treatment with proton pump inhibitors (PPI). Each patient completed the RSI as well as the 30-item voice handicap index (VHI). For reliability assessment, the study patients were given the RSI on two separate occasions before the initiation of treatment. Normative RSI data were derived from 25 age-matched and gender-matched controls taken from an existing database of asymptomatic individuals without any evidence of LPR. The mean RSI (+/- standard deviation) of patients with LPR improved from 21.2 (+/- 10.7) to 12.8 (+/- 10.0), and the mean VHI improved from 52.2 (+/- 24.7) to 41.5 (+/- 25.0) after 6 months of therapy (p = 0.001 and 0.065, respectively). Of the three VHI subscales (emotional, physical, functional), only the functional subscale improved significantly (p = 0.037). Patients who experienced a five point or better improvement in RSI were 11 times more likely to experience a five-point improvement in VHI (95% confidence interval = 1.7, 76.8). For reliability assessment, the first and second pretreatment RSIs were 19.9 (+/- 11.1) and 20.9 (+/- 9.6), respectively (correlation coefficient = 0.81, p < 0.001). The single-item correlation coefficients ranged from 0.41 to 0.91 (p < 0.05 for all items). The mean pretreatment RSI in patients with LPR was significantly higher than controls (21.2 versus 11.6; p < 0.001). The mean RSI of patients with LPR after 6 months of PPI therapy approached that of asymptomatic controls (p > 0.05). The RSI is easily administered, highly reproducible, and exhibits excellent construct and criterion-based validity.     

Cross-cultural Adaptation and Validation of the Greek Voice Handicap Index-10 (GVHI-10) With Additional Receiver Operating Characteristic Analysis

Objective(s)The use of subjective evaluation tools are proven useful and of high clinical value in the case of voice disordered population. For that type of evaluation, self-assessment questionnaires about the severity of the voice like Voice Handicap Index-30 (VHI-30) have been developed. The VHI-30 is the most studied tool which includes psychometrically robustness while guiding physician's therapeutic decision making. Additionally, a valid abbreviated version of VHI-30 was developed for the first time in the Greek Language which is named as Greek Voice Handicap Index-10 (GVHI-10). Consequently, the aim of our study was to validate the proposed version of the VHI-10.MethodsNinety nondysphonic individuals and 90 dysphonic patients were classified by Otolaryngologists and Speech Language Pathologists. The study's subjects were evaluated with endoscopy and stroboscopy. Also, they were administrated the GVHI-30 and the translated version of the Voice Evaluation Template (VEF). The GVHI-10 was extracted by the Greek version of VHI-30.ResultsThe group with voice disorders exhibited higher statistical significance in all GVHI-10 scores compared to those of the control group. The GVHI-10 showed a high internal consistency (Cronbach's a = 0.915 and split-half reliability coefficient equal to 0.86), good sensitivity compared to Greek VHI-30 (r = 0.764, P = 0.000) and intraclass correlation. A total cut-off point equal to 6.50 (AUC: 0.964; P < 0.001) was also calculated.ConclusionsThe proposed version of GVHI-10 distinguished the perceived levels of voice between dysphonic and nondysphonic groups and between different voice disordered populations. The GVHI-10 is shown to be clinically valid and sensitive exhibiting high reliability.     

MRI Anatomical and Morphological Differences in the Vocal Tract Between Dysphonic and Normal Adult Women

Objective

To analyze the vocal tract morphometry of women with vocal nodules (VN) compared with normal subjects by means of magnetic resonance imaging (MRI) at rest position.

Study Design

Prospective study.

Methods

The present research included 20 young adult women, aged 18–40 years: 10 dysphonic patients with VN and 10 normal subjects. All participants were tested using MRI; 12 measurements of the vocal tract were performed: nine in median sagittal section and three in axial section.

Results

The 12 measurements were smaller in the dysphonic group; statistical significance was obtained for three parameters: in the sagittal plane, the laryngeal vestibule area was significantly smaller in the dysphonic group, with P = 0.012∗ (∗ = statistical significance); in the axial section, the distance between the right and left vocal processes of the arytenoids’ cartilages and the distance between the anterior commissure of the glottis and the laryngeal posterior wall were also significantly lower in the dysphonic group, with P = 0.036∗ and 0.010∗, respectively. Significant differences in the vocal tract morphometry of individuals with VN were observed compared with normal subjects, at rest position.

Conclusions

Results obtained from this study suggest that patients with VN may present a constantly increased tension of the laryngeal muscles, even at rest; moreover, reduced anterior-posterior dimension of the larynx may be a morphological characteristic of patients with VN.     

An investigation of the Voice Handicap Index with Speakers of Portuguese: Preliminary data

Although the Voice Handicap Index (VHI) has been recognized as a useful tool for quantifying American English speakers' perceived consequences of voice disorder, it has not yet been widely applied in the clinic to study dysphonic patient populations, or tested with a normally speaking population. The purpose of this investigation was to obtain information about the VHI in a group of Portuguese speakers with voice complaints compared with an age- and gender-matched group of speakers without voice complaints. The results demonstrate that speakers with voice complaints have overall VHI total scores significantly higher than speakers without voice complaints (p < 0.001). This is also true for all VHI subscores in the emotional (p < 0.001), functional (p < 0.05), and physical (p < 0.001) domains. So, the assumption that a group with voice complaints has higher voice handicap impact than the matched control comparison group is justified for Portuguese speakers.     

Cervical spinal cord MTR histogram analysis in multiple sclerosis using a 3D acquisition and a B-spline active surface segmentation technique

The application of a three-dimensional magnetization transfer (MT) sequence and B-spline active surface segmentation method to produce MT histograms of the cervical spinal cord in a pilot study of controls and multiple sclerosis (MS) patients is presented. Subjects' cervical spinal cords were imaged with (a) a volume-acquired inversion-prepared fast spoiled gradient echo sequence and (b) a volume-acquired noninversion-prepared fast spoiled gradient echo MT sequence. The images were segmented using the B spline active surface technique and MT histograms were produced from the MT images. The method was sensitive enough to detect differences between seven MS patients and 10 controls in mean MT ratio (42.4 pu versus 44.0 pu, p = 0.03) and peak location (45.2 versus 46.8, p = 0.03). The spinal cord volumes obtained from the two sequences were associated with each other (parameter estimate 0.972, 95% confidence intervals 0.742, 1.202, p < 0.001).     

A longitudinal study of MR diffusion changes in normal appearing white matter of patients with early multiple sclerosis

BACKGROUND AND PURPOSE: The stage at which normal appearing white matter (NAWM) abnormalities first appear in multiple sclerosis (MS) is not clear. The aim of our study was to monitor water diffusion changes over time in NAWM of patients with early MS.METHODS: Out of a consecutive series of patients enrolled in a MR study on clinically isolated syndrome (CIS), we selected 19 subjects who had completed a one year follow-up. The MR scans obtained at baseline and at 12 months were reviewed according to the new criteria on the diagnosis of MS. Lesion load on T2 and T1 weighted images and the trace of the apparent diffusion coefficient in NAWM were measured both at baseline and at 12 months in patients and in 12 healthy controls.RESULTS: In three patients the diagnosis of MS was done at baseline based on MR. Thirteen patients developed MS during the study and in three patients the diagnosis remained "possible MS." TADC in NAWM in patients was significantly higher than in controls at the 12 months' follow-up but not at baseline (controls mean tADC +/- sd = 0.745 +/- 0.02 mm(2)/sec x 10(-3); patients mean tADC(12) +/- sd = 0.767 +/- 0.02 mm(2)/sec x 10(-3); p < 0.02). TADC and T2 lesion load at 12 months were significantly correlated (p < 0.01). Patients exhibiting tADC(12) above a confidence interval had a significantly greater EDSS score at the same time period (EDSS(12) +/- sd = 1.9 +/- 0.5 and = 1.1 +/- 0.4 respectively; p < 0.01).CONCLUSIONS: This study suggests that diffusion MR cannot detect alterations in NAWM of patients with a CIS suggestive of MS. After one year, when most patients develop MS, diffusion MR abnormalities in NAWM become apparent. These abnormalities are correlated with T2 lesion load and may contribute to neurological impairment.     

Effects of voice therapy on the voice range profiles of dysphonic patients

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.     

Problems and pitfalls of electroglottography

The popularity and usefulness of the electroglottograph (EGG) has increased remarkably since its introduction over a decade ago. It has been used to measure fundamental frequency of phonation, fundamental frequency perturbation, details of the vocal fold vibratory cycle, as well as to provide an indication of laryngeal vertical movement. It has also been used with a variety of speech and voice disorders. The EGG is not without its limitations and problems. Some of these are found in the electronic designs of specific instruments, whereas other problems are related to subject characteristics, the placement of the electrodes, electrode symmetry, and subject/instrument interaction. This article explores some of these concerns, primarily from the perspective of two individuals who have used the EGG extensively with children, men and women, voice patients, stutterers, and neurologically impaired persons. Some of the concerns to consider and pitfalls to avoid in the interpretation and measurement of EGG signal are discussed.     

Acoustic Measures of Symptoms in Abductor Spasmodic Dysphonia

Speech of patients with abductor spasmodic dysphonia (ABSD) was analyzed using acoustic analyses to determine: (1) which acoustic measures differed from controls and were independent factors representing patients' voice control difficulties, and (2) whether acoustic measures related to blinded perceptual counts of the symptom frequency in the same patients. Patients' voice onset time for voiceless consonants in speech were significantly longer than the controls (p = 0.015). A principle components analysis identified three factors that accounted for 95% of the variance: the first factor included sentence and word duration, frequency shifts, and aperiodic instances; the second was phonatory breaks; and the third was voice onset time. Significant relationships with perceptual counts of symptoms were found for the measures of acoustic disruptions in sentences and sentence duration. Finally, a multiple regression demonstrated that the acoustic measures related well with the perceptual counts (r² = 0.84) with word duration most highly related and none of the other measures contributing once the effect of word duration was partialed out. The results indicate that some of the voice motor control deficits, namely aperiodicity, phonatory breaks, and frequency shifts, which occur in patients with ABSD, are similar to those previously found in adductor spasmodic dysphonia. Results also indicate that acoustic measures of intermittent disruptions in speech, voice onset time, and speech duration are closely related to the perception of symptom frequency in the disorder.     

Voice Care Knowledge Among Clinicians and People With Healthy Voices or Dysphonia

An important clinical component in the prevention and treatment of voice disorders is voice care and hygiene. Research in voice care knowledge has mainly focussed on specific groups of professional voice users with limited reporting on the tool and evidence base used. In this study, a questionnaire to measure voice care knowledge was developed based on "best evidence." The questionnaire was validated by measuring specialist voice clinicians' agreement. Preliminary data are then presented using the voice care knowledge questionnaire with 17 subjects with nonorganic dysphonia and 17 with healthy voices. There was high (89%) agreement among the clinicians. There was a highly significant difference between the dysphonic and the healthy group scores (P = 0.00005). Furthermore, the dysphonic subjects (63% agreement) presented with less voice care knowledge than the subjects with healthy voices (72% agreement). The questionnaire provides a useful and valid tool to investigate voice care knowledge. The findings have implications for clinical intervention, voice therapy, and health prevention.     

Adductor spasmodic dysphonia: case reports withacoustic analysis following botulinum toxin injection and acupuncture

We analyzed frequency and duration parameters of voice and speech in two men with adductor spasmodic dysphonia (SD). One was treated with botulinum toxin injection; the other received acupuncture therapy. Im provement after acupuncture therapy in terms of standard deviation of fundamental frequency, acoustic perturbation measurements, durational measurements of voice and speech, and spectrographic analysis was comparable to the results achieved with botulinum toxin injection. Voice and speech parameters were stable I year after acupuncture therapy.