Chronic Refractory Cough as a Sensory Neuropathy: Evidence From a Reinterpretation of Cough Triggers

Objectives/Hypothesis

The aims of this study were to examine cough triggers in individuals with chronic cough (CC), identify sensory symptoms consistent with central reflex sensitization (paresthesia and allotussia), and interpret this information in relation to sensory laryngeal neuropathy.

Study Design

Prospective observational study.

Methods

Patients (n = 53) with CC that was refractory to medical management based on the anatomic diagnostic protocol completed questionnaires regarding cough triggers, anxiety and depression, and factors contributing to laryngeal irritation such as vocal hygiene and laryngopharyngeal reflux.

Results

An abnormal sensation in the laryngeal area (laryngeal paresthesia) was present in 94% of people with refractory CC. Nontussive stimuli including phonation were frequent triggers for cough (allotussia), occurring in 71% of participants. Although tussive stimuli were significantly more potent than nontussive stimuli (P = 0.005), the relative clinical importance was not statistically different (P = 0.072). Most participants with refractory cough had poor vocal hygiene.

Conclusion

The sensory symptom changes that accompany CC suggest central reflex sensitization and include laryngeal paresthesia and allotussia. The results are consistent with cough as a sensory neuropathic disorder.     

Voice Analysis of Postlingually Deaf Adults Pre- and Postcochlear Implantation

Objectives

To ascertain whether cochlear implantation (CI), without specific vocal rehabilitation, is associated with changes in perceptual and acoustic vocal parameters in adults with severe to profound postlingual deafness.

Hypothesis

Merely restoring auditory feedback could allow the individual to make necessary adjustments in vocal pattern.

Study Design

Prospective and longitudinal.

Methods

The experimental group composed of 40 postlingually deaf adults (20 males and 20 females) with no previous laryngeal or voice disorders. Participants’ voices were recorded before CI and 6–9 months after CI. To check for chance modifications between two evaluations, a control group of 12 postlingually deaf adults, six male and six female, without CI was also evaluated. All sessions composed of the recording of read sentences from Consensus Auditory-Perceptual Evaluation of Voice and sustained vowel /a/. Auditory and acoustic analyses were then conducted.

Results

We found a statistically significant reduction in overall severity, strain, loudness, and instability in auditory analysis. In vocal acoustic analysis, we found statistically significant reduction fundamental frequency (F0) values (in male participants) and F0 variability (in both genders). The control group showed no statistically significant changes in most vocal parameters assessed, apart from pitch and F0 (in female participants only). On comparing the interval of variation of results between the experimental and control groups, we found no statistically significant difference in vocal parameters between CI recipients and nonrecipients, with the exception of F0 variability in male participants.

Conclusions

The patients in our sample showed changes in overall severity, strain, loudness, and instability values, and reductions in F0 and its variability. On comparing the variation of results between the groups, we were able to prove in our study that implant recipients postlingually deaf adults (experimental group), without specific vocal rehabilitation, differed from nonrecipients (control group) in loudness and F0 variability sustained vowel /a/ in male participants.     

Differences Between Flexible and Rigid Endoscopy in Assessing the Posterior Glottic Chink

Objective

To determine whether different modalities of laryngeal examination produce differences in the assessment of the posterior glottic chink (PGC), and whether the prevalence of PGC differs by gender.

Introduction

The PGC has been described as a triangular laryngeal space between the posterior laryngeal wall and the vocal processes during glottic closure found commonly in human females, but less often in males. The purpose of this study was not only to identify whether there are gender differences in prevalence of posterior glottic but also to determine whether there is a difference in detection of this configuration dependent on the modality of laryngeal imaging, specifically flexible nasopharyngolaryngoscopy (FNPL) versus rigid laryngoscopy (RL).

Methods

A review of 104 consecutive initial laryngeal examinations was performed. All patients underwent both flexible laryngoscopy (FL) and RL performed under stroboscopic light. Patients with immobile vocal folds, masses causing glottic gaps, atrophy, or severe muscle tension dysphonia causing an inability to fully visualize the entire length of the vocal fold were excluded. In the remaining patients, the posterior glottic configuration showing a posterior chink in relation to the vocal process was graded on a 0–4 scale (called the Posterior Glottic Closure Score [PGCS]); 0 was used to indicate a closed glottis and 4 the most open configuration without creating a complete glottic gap. PGCSs for males were compared with those of females, and the PGCSs obtained by flexible nasopharyngolaryngoscopy was compared with RL.

Results

Fifty-two patients were included in the study. Twenty-four of the patients were male, and 28 were female. The average age of the patients was 48.4 years (SD ± 17.35), and the range was 15–81 years. On RL, eight males had a PGCS 1–4, that is, evidence of PGC, and 23 females had a PGCS 1–4. On flexible nasopharyngolaryngoscopy, only four males had a PGCS 1–4 and 24 females had PGCS 1–4. Twenty-two females had a PGC detected by both modalities, and the PGCS was significantly higher using RL (2.73 ± 0.70 vs 2.14 ± 0.834) than FL. For the four males in which PGC was detected by both modalities, there was no statistical significance when comparing the PGCS between RL and FL (1.75 ± 0.96 vs 1.75 ± 0.5, P < 0.05). When comparing only males and females who had a PGC (PGCS 1–4), females had a higher PGCS (2.65 ± 0.78) than males (1.75 ± 0.71, P < 0.05) on RL, indicating a more open posterior glottis in females. On flexible examination, there was no difference detected in the average PGCS, 2.08 ± 0.83 for females and males 1.75 ± 0.50. PGCs were more common in younger (age 43 years) than older (age 54–56 years) subjects for both laryngoscopic modalities.

Conclusion

From this pilot study, we determined that there is a difference in male and female PGC prevalence and size. PGC is more common in females than males. Prevalence (or the detection rate) is about the same with RL and FL in females, but higher with RL than FL in males. The average score of the glottic opening, when present, was statistically significantly different between RL and FL in females but not in males. Furthermore, females had a larger PGCS on both modalities when compared with males, although this difference was only found to be statistically significant on RL; and complete glottic closure was more common in older than in younger subjects.     

Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

Bacterial Cellulose as Laryngeal Medialization Material: An Experimental Study

Hypothesis

The use of a material made of bacterial cellulose with the aim of obtaining vocal fold medialization has not hitherto been fully investigated. Although the material has been tested in other animal models, the evaluation did not include the larynx; hence, situations, such as tissue reaction, material absorption, and extrusion, need to be addressed to evaluate its usefulness as a material for laryngeal reconstruction.

Objective

To evaluate the medialization, tissue response, and healing of rabbit vocal folds, after the implantation of a membrane of bacterial cellulose.

Study Design

Experimental study.

Methods

A total of 32 rabbits were used, two of which were used to check out the adequacy of the implant location. The animals were followed for 4 months and grouped according to follow-up times of 2, 4, and 16 weeks. All test animals received an implant of bacterial cellulose in one vocal fold and the injection of distilled water in the other, both performed by videoendoscopic cervicotomy. At the end of the follow-up, the presence of inflammatory and medial displacement was evaluated.

Results

No statistically significant difference in the inflammatory parameters between the study and control vocal folds or among follow-up times was found. All animals receiving cellulose presented medial displacement of vocal folds, and all retained this material at the implant site up to study endpoint.

Conclusion

Bacterial cellulose is a useful material for laryngeal medialization, showing no signs of rejection or absorption.     

Investigating the Effects of Caffeine on Phonation

Objective

A core component of vocal hygiene programs is the avoidance of agents that may dry the vocal folds. Clinicians commonly recommend that individuals reduce caffeine intake because of its presumed dehydrating effects on the voice. However, there is little evidence that ingestion of caffeine is detrimental to voice production. The first objective of this study was to evaluate whether caffeine adversely affects voice production. The second objective was to evaluate if caffeine exacerbates the adverse phonatory effects of vocal loading.

Study Design

Prospective, double-blinded, sham-controlled study.

Methods

Sixteen healthy adults participated in two sessions where they consumed caffeine (caffeine concentration = 480 mg) or sham (caffeine concentration = 24 mg) beverages. Voice measures (phonation threshold pressure and perceived phonatory effort) were collected. Subjects then completed a vocal loading challenge and voice measures were obtained again.

Results

There were no significant differences in voice measures between the caffeine and sham conditions. Ingestion of caffeine did not adversely affect voice production (P > 0.05) or exacerbate the detrimental phonatory effects of vocal loading (P > 0.05).

Conclusions

Our findings contribute to emerging knowledge on the effects of caffeine on voice production. Recommendations to completely eliminate caffeine from the diet, as a component of a vocal hygiene program, should be evaluated on an individual basis.     

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

Objectives

Teachers are at increased risk for developing voice disorders. Occupational risk factors have been extensively examined; however, little attention has been paid to the consequences of the vocal complaints. The objective of this study was to investigate the knowledge that teachers have about vocal care, treatment-seeking behavior, and voice-related absenteeism.

Methods

The study group comprised 994 teachers and 290 controls whose jobs did not involve vocal effort. All participants completed a questionnaire inquiring about vocal complaints, treatment-seeking behavior, voice-related absenteeism, and knowledge about vocal care. Comparisons were made between teachers with and without vocal complaints and with the control group.

Results

Teachers reported significantly more voice problems than the control population (51.2% vs 27.4%) (χ² = 50.45, df = 1, P < 0.001). Female teachers reported significantly higher levels of voice disorders than their male colleagues (38% vs 13.2%, χ² = 22.34, df = 1, P < 0.001). Teachers (25.4%) sought medical care and eventually 20.6% had missed at least 1 day of work because of voice problems. Female teachers were significantly more likely to seek medical help (χ² = 7.24, df = 1, P = 0.007) and to stay at home (χ² = 7.10, df = 1, P = 0.008) in comparison with their male colleagues. Only 13.5% of all teachers received information during their education.

Conclusions

Voice disorders have an impact on teachers' personal and professional life and imply a major financial burden for society. A substantial number of teachers needed medical help and was obligated to stay at home because of voice problems. This study strongly recommends the implementation of vocal education during the training of teacher students to prepare the vocal professional user.     

Vowel Harmonic Amplitude Differences in Persons With Vocal Nodules

Background

Spectrum is a fast Fourier transform-generated power spectrum extracted from the speech sample. It is reported to provide a quantitative acoustic index of the degree of glottal abduction and adduction in voices perceived to be breathy or pressed. In the present study, it was hypothesized that there would be abnormal reduction of higher harmonic amplitudes relative to the amplitude of the first harmonics in the subjects with vocal nodules and hence the present study was carried out.

Method

One hundred twenty participants were divided into clinical group and control group. They were instructed to phonate /a/ at their most comfortable pitch and loudness. Fourier transformation of the recorded acoustic signal was first performed to create a spectrum. Amplitudes were measured for the first and second harmonics (H1 and H2) as well as the harmonics at the first, second, and third formants (A1, A2, and A3) using the Computerized Speech Science Lab (Kay Pentax, Lincoln, NJ).

Results

There was a significant difference between the means of two groups for all the parameters, such as H1-H2, H1-A1, H1-A2, and H1-A3 at P < 0.05. The obtained results are discussed with respect to the underlying pathophysiology.

Conclusions

The present study investigated the vowel harmonic amplitude differences in persons with vocal nodules. The results revealed a significant difference between the two groups for the vowel harmonic amplitude differences. This particular measure could be used to track the changes following the vocal treatment.     

Vocal Tract Configurations in Male Alto Register Functions

Purpose

Professional male altos (countertenors) mostly use a register function, which is considered to be derived from falsetto. However, the sound produced differs in professional altos compared with the modal register or falsetto of untrained voices. The aim of this study was to analyze differences of the vocal tract shapes in male alto register functions.

Material and Methods

Dynamic real-time magnetic resonance imaging of eight frames per second was used to analyze the vocal tract profile in seven professional male altos who sang on the vowel /a/, an ascending and descending scale from G3 (196 Hz) to E4 (330 Hz). The scale included their register transition from modal register to stage (counter) falsetto and naïve falsetto.

Results

Register transitions from modal register to stage falsetto were associated with increased lip opening, jaw retraction, elevation and back positioning of the tongue, pharynx narrowing, uvula elevation, drop of larynx height, and tilting of the larynx. Differences between stage and naïve falsetto were found mostly with regard to lip opening and pharynx width.

Conclusions

The differences between the vocal tract configurations might have an impact on the acoustic characteristics observed in professional male alto register functions.     

Vocal Fold Vibration and Phonation Start in Aspirated, Unaspirated, and Staccato Onset

Objectives/Hypotheses

Singers learn to produce well-controlled tone onsets by accurate synchronization of glottal adduction and buildup of subglottal pressure. Spectrographic analyses have shown that the higher spectrum partials are present also at the vowel onset in classically trained singers’ performances. Such partials are produced by a sharp discontinuity in the waveform of the transglottal airflow, presumably produced by vocal fold collision.

Study Design

After hearing a prompt series of a triad pattern, six singer subjects sang the same triad pattern on the vowel /i/ (1) preceded by an aspirated /p/, (2) preceded by an unaspirated /p/, and (3) without any preceding consonant in staccato.

Methods

Using high-speed imaging we examined the initiation of vocal fold vibration in aspirated and unaspirated productions of the consonant /p/ as well as in the staccato tones.

Results

The number vibrations failing to produce vocal fold collision were significantly higher in the aspirated /p/ than in the unaspirated /p/ and in the staccato tones. High frequency ripple in the audio waveform was significantly delayed in the aspirated /p/.

Conclusions

Initiation of vocal fold collision and the appearance of high-frequency ripple in the vowel /i/ are slightly delayed in aspirated productions of a preceding consonant /p/.     

The Role of the Cricothyroid Joint Anatomy in Cricothyroid Approximation Surgery

Objectives/Hypothesis

Cricothyroid approximation (CTA) surgery aims at raising the voice pitch in male-to-female transsexuals. However, 30% of the patients are not satisfied with the result. The purpose of our study was to examine the cricothyroid joint (CTJ) biomechanics and to analyze if (and how) the CTJ anatomy influences the movement of the cricoid and, consequently, the elongation of the vocal fold and the voice pitch after CTA.

Methods

Twenty-four cadaver larynges were examined with high-resolution computerized tomography and MIMICS three-dimensional imaging software (Materialise Interactive Medical Image Control System, Leuven, Belgium). After superimposing the two scans taken in “neutral” and in “CTA” positions, vector geometrical analysis was used to determine the effective rotation axis of the CTJ and to calculate the elongation of the vocal folds after CTA.

Results

Our results showed that the cricoid rotates around an axis, the position of which depends on the anatomical structure of the CTJ. Based on the location of this effective rotation axis, we could distinguish three groups. In group I (N = 13), the rotation axis was located in the lower third; in group II (N = 5), it was located in the middle third; and in group III (N = 6), it was located in the upper third of the cricoid. The elongations of the vocal fold were 12%, 8%, and 3%, in groups I, II, and III, respectively.

Conclusions

The anatomical structure of the CTJ influences directly (1) the position of the effective rotation axis and (2) the elongation of the vocal folds.     

Voice Training and Changing Weight—Are They Reflected in Speaking Fundamental Frequency, Voice Range, and Pitch Breaks of 13-Year-Old Girls? A Longitudinal Study

Objective

Assessment of the voice-change progress of 20 girls (12–13 years) over 1 year by observing changes in speaking fundamental frequency (SFo), voice range, and register pitch breaks in the context of weight, height, voice training, and self-perception.

Study Design

One-year longitudinal collective case study.

Method

Twenty girls were recorded at the beginning and end of a year; nine girls were recorded another three times. SFo, vocal range, and characteristics were analyzed and interactions between these data assessed against weight and height to indicate pubertal development, and to test the hypothesis that changes in weight, height, SFo, and pitch breaks were related. Effects of training and the girls' self-perception of their voice use were also assessed.

Results

Vocal characteristics changed as the girls passed through different weight ranges. During 47.5–52.4 kg (called band 2) and 52.4–57.5 kg (band 3), there was progressive contraction of vocal range and in some girls a slight rise in SFo between recording times 1 and 5. Both high- and low-pitch breaks were present in 45% of girls' voices. Girls in band 4 (<57.5 kg) had an increased vocal range, and pitch breaks in vocal-range areas that indicated the development of adult vocal registers. In this study, voice-trained girls were heavier, had higher SFo, used wider speech-range inflection, had a higher vocal range, and greater voice-use confidence; all girls lost confidence in their voice use over the year.

Conclusions

In this longitudinal study of twenty 13-year-old girls, voice changes in SFo, vocal range, and pitch-break frequency were synchronous with certain weight ranges. Girls with training registered higher maximum phonational frequency and were more confident in their voice use than girls without training.     

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

Objectives

The purpose of this study was to determine the objective vocal quality in 36 prelingually deaf children using cochlear implant (CI) with a mean age of 9 years. An additional purpose was to compare the objective vocal quality of these 36 CI users with 25 age-matched children with prelingual severe hearing loss using conventional hearing aids (HAs) and 25 normal hearing (NH) children.

Study Design

The design for this cross-sectional study was a multigroup posttest-only design.

Methods

The objective vocal quality was measured by means of the dysphonia severity index (DSI). Moreover, perceptual voice assessment using the GRBASI scale was performed.

Results

CI children have a vocal quality by means of the DSI of +1.8, corresponding with a DSI% of 68%, indicating a borderline vocal quality situated 2% above the limit of normality. The voice was perceptually characterized by the presence of a very slight grade of hoarseness, roughness, strained phonation, and higher pitch and intensity levels. No significant objective vocal quality differences were measured between the voices of the CI children, HA users, and NH children.

Conclusions

According to the results, one aspect of the vocal approach in children with CI and using HAs must be focused on the improvement of the strained vocal characteristic and the use of a lower pitch and intensity level.     

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

Objectives

The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI).

Study Design and Methods

Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000 Hz (256 × 256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values.

Results

HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis).

Conclusion

Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.     

Aspects of two-photon physics at lineare + e − colliders

We discuss various reactions at futuree ⁺ e ^– and colliders involving real (beamstrahlung or backscattered laser) or quasi-real (bremsstrahlung) photons in the initial state and hadrons in the final state. The production of two central jets with large transverse momentump _T is described in some detail; we give distributions for the rapidity andp _T of the jets as well as the di-jet invariant mass, and discuss the relative importance of various initial state configurations and the uncertainties that arise from the at present rather poor knowledge of the parton content of the photon. We also present results for mono-jet production where one jet goes down a beam pipe, for the production of charm, bottom and top quarks, and for single production ofW andZ bosons. Where appropriate, the two-photon processes are compared with annihilation reactions leading to similar final states. We also argue that the behaviour of the total inelastic cross section at high energies will probably have little impact on the severity of background problems caused by soft and semi-hard (minijet) two-photon reactions. We find very large differences in cross sections for all two-photon processes between existing desings for futuree ⁺ e ^– colliders, due to the different beamstrahlung spectra; in particular, both designs with 1 and 1 events per bunch crossing exist. The number of hadronic two-photon events is expected to rise quickly with the beam energy. Hadronic backgrounds will be even worse if thee ⁺ e ^– collider is converted into a collider.     

Allograft (Alloderm) and Autograft (Temporalis Fascia) Implantation for Glottic Insufficiency: A Novel Approach

Objective

Traditionally, glottic insufficiency because of scar, atrophy, and sulcus has been treated by injection or medialization laryngoplasty. These procedures do not reestablish the vertical height of the vocal fold margin. We propose soft tissue augmentation laryngoplasty with allograft (sheet Alloderm; LifeCell Corporation, Branchburg, NJ) or autograft (temporalis fascia) via a minithyrotomy or a transoral approach.

Study Design

A retrospective case series analysis of 21 patients treated by sheet Alloderm or temporalis fascia for correction of glottic insufficiency.

Methods

Twenty-one patients with glottic insufficiency secondary to scar, atrophy, or sulcus were treated. Ten failed prior techniques. Seventeen had minithyrotomy by a small fenestration in the thyroid cartilage. Exploration of scar or lamina propria through the fenestration allowed for the creation of a pocket for Alloderm implantation within the intermediate layer of the lamina propria. Four patients underwent a transoral approach by cordotomy with either Alloderm or temporalis fascia implantation, which also allowed for exploration of scar but required repair using sutures. These implantation approaches allowed for both restoration of the layered structure and augmentation of the middle third of the musculomembranous vocal fold. Preoperative and postoperative videostroboscopic examinations were reviewed with review of clinical outcome.

Results

With a median follow-up time of 12 months, patients demonstrated excellent long-term vocal fold augmentation and minimal absorption of the implant in 19 out of 21 patients. There is improved pliability of the vocal fold with good oscillation in scar patients.

Conclusion

Minithyrotomy with soft tissue augmentation is a novel approach for soft tissue augmentation of glottic insufficiency. It has the advantage of augmentation of the medial edge of the vocal fold with a soft tissue implant that has long-term viability. Its role should be explored further in patients with atrophy and scar.     

Augmentation of the Porcine Vocal Fold Using Autologous Composite Cervical Fascia and Fat Graft. Comparison Between the Transmuscular and Submuscular Approaches

Objectives

To assess the integration of an autologous composite fascia and fat graft implanted into the lamina propria of a porcine vocal fold using two different approaches.

Study Design

An experimental prospective study on the porcine larynx was conducted at a tertiary research institution.

Methods

An external cervical approach was used to expose the thyroid cartilage of 24 healthy minipigs under general anesthesia. The composite fascia/fat graft was implanted through two distinct approaches, transmuscular and submuscular. Animals were sacrificed at 7, 30, 90, and 180 days for macroscopic and histological study of the larynx. Graft integration and local inflammatory response were studied.

Results

The survival rate of the experimental model was 100% and all animals had local inflammatory response to the surgical procedure. Only 41.7% of the grafts placed inside the thyroarytenoid (TA) muscle fibers were identified postmortem, whereas 83.3% of the submuscular grafts remained intact.

Conclusions

Graft incorporation was better and there was less inflammation when the architecture of the TA muscle fibers was preserved. Graft extrusion was observed in the most of the cases where it was placed inside the muscle.     

Characteristics of Phonatory Function in Singers and Nonsingers With Vocal Fold Nodules

Purpose

The goals of this study were to determine if there were significant differences between singers and nonsingers in the morphology of vocal nodules and the associated impact on vocal function.

Method

Participants were 10 professionally trained singers with nodules, eight nonsingers with nodules, and 10 individuals with healthy normal voice (controls). Surface electromyography (sEMG) from three anterior neck locations and acoustic rise times for vowels /a/ and /i/ were measured in all the participants. In individuals with nodules, dB SPL/cm H₂O, glottal airflow, and nodule location and size were also measured.

Results

There were no significant differences between singers and nonsingers with nodules in terms of airflow, dB SPL/cm H₂O, nodule size, or nodule location. In nonsingers with nodules, airflow and nodule size were significantly correlated, but were not significantly correlated in singers. Vowel rise times and sEMG during vocal tasks did not differentiate among nodule and control groups. Sternocleidomastoid sEMG during initiation of the vowel /a/ was statistically significantly stronger in nonsingers with nodules relative to singers with nodules and controls.

Conclusions

Nodule morphology did not differ between singers and nonsingers, although some behavioral aspects of phonation differed between the groups.     

Differences in Self-Rated, Perceived, and Acoustic Voice Qualities Between High- and Low-Fatigue Groups

Objectives

The present study was performed to examine which factors among self-rated scales, perceptual evaluations, and acoustic parameters, calculated from sustained vowels, are reliable indicators of physical and mental fatigues.

Methods

A total of 73 volunteers (male:female, 52:21), aged 19–24 years, were enrolled in this study. We defined the high- and low-fatigue groups using the Chalder Fatigue Scale score. For assessment of self-rated symptoms, each subject was asked to complete Voice Handicap Index (VHI) and Voice Rating Scale (VRS). For perceptual evaluations, three clinicians assessed each subject’s vocal quality on the Grade, Roughness, Breathiness, Asthenia, Strain Scale. For acoustic analysis, each subject was asked to produce sustained vowels /a/, /e/, /i/, /o/, and /u/ for 3 seconds. Then, the habitual fundamental frequency (F₀), jitter, shimmer, F₀ tremor, mean F₀, standard deviation of F₀, maximum F₀, minimum F₀, normalized noise energy, harmonic-to-noise ratio (HNR), signal-to-noise ratio (SNR), amplitude tremor, and ratio within 2–4 kHz were calculated using Dr. Speech software.

Results

In men, VHI, VRS, F₀ tremor, shimmer, HNR, SNR, and amplitude tremor were related to mental fatigue. In women, only VHI was related to physical fatigue, and none of the acoustic parameters was related to the fatigue score. Perceptual evaluations were not related to fatigue in men or women.

Conclusions

These findings suggest that self-rated symptoms and acoustic parameters related to voice quality are indicative of mental fatigue, and these features are prominent in men.     

Categorizing Normal and Pathological Voices: Automated and Perceptual Categorization

Objectives

The aims of the present study were to evaluate the accuracy of an elaborated automated voice categorization system that classified voice signal samples into healthy and pathological classes and to compare it with classification accuracy that was attained by human experts.

Material and Methods

We investigated the effectiveness of 10 different feature sets in the classification of voice recordings of the sustained phonation of the vowel sound /a/ into the healthy and two pathological voice classes, and proposed a new approach to building a sequential committee of support vector machines (SVMs) for the classification. By applying “genetic search” (a search technique used to find solutions to optimization problems), we determined the optimal values of hyper-parameters of the committee and the feature sets that provided the best performance. Four experienced clinical voice specialists who evaluated the same voice recordings served as experts. The “gold standard” for classification was clinically and histologically proven diagnosis.

Results

A considerable improvement in the classification accuracy was obtained from the committee when compared with the single feature type-based classifiers. In the experimental investigations that were performed using 444 voice recordings coming from 148 subjects, three recordings from each subject, we obtained the correct classification rate (CCR) of over 92% when classifying into the healthy-pathological voice classes, and over 90% when classifying into three classes (healthy voice and two nodular or diffuse lesion voice classes). The CCR obtained from human experts was about 74% and 60%, respectively.

Conclusion

When operating under the same experimental conditions, the automated voice discrimination technique based on sequential committee of SVM was considerably more effective than the human experts.