Voice disorders in patients with suspected laryngo-pharyngeal reflux disease

Many symptoms have been recognized in association with laryngo-pharyngealreflux disease (LPRD), but reports of perceptual voice disorders in this condition have been lacking to date. Forty-nine patients with suspected LPRD were studied for five specific perceptual voice characteristics, and these characteristics were compared to the same characteristics in individuals who had never seen an Otolaryngologist for a voice disorder or throat problem (controls). Sixteen of the suspected LPRD patients also underwent 24-hour pH probe studies. All patients with suspected LPRD had significantly increased abnormal perceptual voice characteristics (musculoskeletal tension, hard glottal attack, glottal fry, restricted tone placement, and hoarseness) compared to the controls. Statistical objective differences between the two groups was demonstrated by the presence of increased shimmer in patients with suspected LPRD compared to controls. The differential diagnosis between functional voice disorders and LPRD may be complex, and perceptual parameters may overlap. Interdisciplinary evaluation is advocated.     

Prevalence of voice disorders among future teachers

An epidemiological study was conducted in order to find out the prevalence of voice disorders among students studying to be teachers. Vocal symptoms were inquired of 226 students. Their voices were assessed perceptually by a speech therapist and those who had abnormal voice quality or reported several vocal symptoms were referred to a clinical examination by a laryngologist. The results showed that 20% of this population reported two or more vocal symptoms during the previous year and that 19% had an organic voice disorder. This reinforces the need for clinical evaluation of students with vocal symptoms and more vocal training in the teacher education programs.     

A Pilot Survey of Vocal Health in Young Singers

The objective of this study was to determine the incidence of vocal problems in young choir singers and to correlate vocal problems with demographic and behavioral information. A questionnaire addressing vocal habits and hygiene was offered to 571 young choir singers, up to 25 years of age, who sing at least weekly; 129 (22.6%) responded. More than one-half of the respondents had experienced vocal difficulty, particularly older adolescents. Detrimental behaviors and circumstances surveyed were not reflective of the incidence of vocal difficulty, except for morning hoarseness, chronic fatigue, insomnia, and female gender after puberty. Voice care professionals should be aware that self-reported voice difficulties are common among young choral singers, especially postpubescent girls, and children with symptoms consistent with reflux (morning hoarseness) and emotional stress (insomnia). Laryngologists should communicate with choral conductors and singing teachers to enhance early identification and treatment of children with voice complaints, and to develop choral educational strategies that help decrease their incidence.     

The Prevalence of Childhood Dysphonia: A Cross-Sectional Study

There is only very limited information on the prevalence of voice disorders, particularly for the pediatric population. This study examined the prevalence of dysphonia in a large cohort of children (n = 7389) at 8 years of age. Data were collected within a large prospective epidemiological study and included a formal assessment by one of five research speech and language therapists as well as a parental report of their child's voice. Common risk factors that were also analyzed included sex, sibling numbers, asthma, regular conductive hearing loss, and frequent upper respiratory infection. The research clinicians identified a dysphonia prevalence of 6% compared with a parental report of 11%. Both measures suggested a significant risk of dysphonia for children with older siblings. Other measures were not in agreement between clinician and parental reports. The clinician judgments also suggested significant risk factors for sex (male) but not for any common respiratory or otolaryngological conditions that were analyzed. Parental report suggested significant risk factors with respect to asthma and tonsillectomy. These results are discussed in detail.     

Aerodynamic and Acoustic Characteristics of Voice in Prader-Willi Syndrome

Prader-Willi syndrome (PWS) is a multisystem disorder caused by DNA abnormalities involving chromosome 15. Major characteristics are infant hypotonia, hypogonadism, mental retardation, a short stature, atypical facial appearance, and the onset of obesity due to insatiable hunger in early childhood. Also, speech and language abnormalities have been reported including voice disorders. These have seldom been studied in detail, however. This paper reports the results of an acoustic and aerodynamic investigation of the voice in 22 individuals with PWS. Two age groups were distinguished, a group of children [chronological age (CA) 6 years, 7 months through 11 years, 7 months; total intelligence quotient (TIQ) 40-88] and a group of adolescents and adults (CA 17 years, 1 month through 29 years, 5 months; TIQ 41-94). Both aerodynamic and acoustic parameters were obtained and compared with normative data from the Belgian Study Group on Voice Disorders. It was found that voice difficulties do commonly occur in individuals with PWS including impairment of frequency levels, voice quality, and poor aerodynamic capabilities.     

Attitudes of Children With Dysphonia

SUMMARY: Because voice disorders in childhood may have a negative impact on communicative effectiveness, social development, and self-esteem, the objective was to determine the impact of voice disorders on lives of children from the perspective of chronically dysphonic children and their parents. This study consisted of focused interviews with chronically dysphonic children and their caregivers. Focused interviews were conducted with 10 children in each of the following age groups: Toddler (2-4 years old), Young Child (5-7 years old), School-Aged Child (8-12 years old), and Adolescent (13-18 years old). Interview questions were formulated to elicit attitudes in the following conceptual domains: emotional, social/functional, and physical. Interviews were transcribed and subjected to systematic qualitative analyses that identified common themes within each age group for each conceptual domain. For Toddlers, interviews relied heavily on parents and the biggest concerns were found in the physical and functional domains. Young Children expressed that their biggest issues related to voice were physical ("run out of air," "sometimes voice does not work"). Ninety percent of Young Children were repeatedly asked to use a quieter voice. Emotional factors and physical factors were prominent in the interviews of School-Aged Children and Adolescents. Children and Adolescents often felt that their dysphonic voice received undue attention and also limited their participation in important events. Anger, sadness, and frustration were also expressed. Chronic dysphonia negatively affects the lives of children. This work will serve as the basis for development of a valid, reliable, and age-appropriate measure of voice-related quality of life in children.     

A comparison of the prevalence of vocal symptoms among teacher students and other university students

Studies focusing on different groups of students show that the prevalence of vocal symptoms and voice disorder vary depending on the study populations. A previous study of vocal symptoms and voice disorders among teacher students has shown that 20% of the students studying to become teachers in comprehensive schools and upper secondary schools reported frequently occurring vocal symptoms, ie, two symptoms or more occurring weekly or more often during the past year, and that most of these students had an organic voice disorder. This raised the question of whether other university students would also report similar, frequently occurring vocal symptoms. A questionnaire was distributed to 220 students of several faculties at the University of Turku, Finland. The results were compared with the results of a study of vocal symptoms reported by 175 students studying to become teachers. This comparison showed that students in general reported frequently occurring vocal symptoms, whereas the students studying to become teachers reported a greater number of frequently occurring symptoms than did other students at the university.     

Voice Therapy Outcome—A Randomized Clinical Trial Comparing Individual Voice Therapy,Therapy in Group,and Controls Without Therapy

ObjectiveA stumbling-block in voice therapy is how the patient will be able to apply the new voice technique in everyday life. Possibly this generalization process could be facilitated by giving voice therapy in group because of the natural forum for training voice-to-speech early in communication between the patients in a group setting. The aim of the study was to compare treatment results from individual voice therapy and voice therapy in group, at several time points and in comparison to patients with no voice therapy.MethodsA randomized treatment study was performed with 77 consecutive patients diagnosed with a functional voice disorder. Thirty-one patients were randomized to individual and group therapy, respectively, and 15 patients to no therapy. The assessments included standardized voice recording and registration of voice range profile (VRP), answering Voice handicap index (VHI) and visual analogue scales for self-hoarseness and self-vocal fatigue, and perceptual voice evaluation by speech-language pathologist. The assessments were performed before, direct after therapy, and three months later in all groups. The 2 therapy groups were also assessed 12 months after therapy.ResultsAll VHI scores as well as the self-ratings of hoarseness and vocal fatigue, and the perceptual evaluation of voice quality and maximum VRP improved significantly in both therapy groups 3 months after treatment and at 12 months follow-up. There were no significant changes in the control group, with the exception of decreased self-rated hoarseness and increased maximum VRP. Comparisons between treatment groups showed significant larger improvement after group therapy for VHI physical subscale at 12 months, as well as significant lower VHI total score at all measurement sessions and lower subscale scores at 12 months. There were no differences between treatment groups in self-hoarseness or self-vocal fatigue and no difference in perceptual voice quality or VRP. Comparison between controls and treatment groups showed significant larger change in treatment groups from baseline to three months in VHI total and to end of therapy in functional subscale. Treatment groups also showed significant lower scores than controls at each measurement session, for VHI total and physical subscale as well as lower degree of perceptual aberration of voice quality and vocal fatigue, at three months follow-up.ConclusionsThis study shows long-term improvement from behavioral voice therapy, particularly in a group setting. The results indicate the importance of early transfer-to-speech and late posttherapy test to capture whether the goal of voice therapy was fulfilled or not for the patients.     

Spasmodic dysphonia and vocal fold paralysis:Outcomes of voice problems on work-related functioning

Patients at a university voice disorder clinic diagnosed with spasmodicdysphonia (SD, n = 68) or vocal fold paralysis (VFP, n = 57) reported vocal symptoms and adverse work outcomes in contrast to a nondisordered group (ND, n = 68). Patients with SD most frequently cited symptoms of effortfulness (57%) and weakness (54%), VFP cited hoarseness (70%) and weakness (60%), while the nondisordered reported hoarseness (28%). SD and VFP produced greater (p<.05) adverse work outcomes than the nondisordered in the past (SD: 65%, VFP: 41%, ND: 3%), potential future (SD: 78%, VFP: 65%, ND: 19%), and current job performance (SD: 64%, VFP: 46%, ND: 2%). These disorders significantly disrupt socioeconomic outcomes and research is needed to improve functional ability and quality of life.     

Instrumental and Perceptual Evaluations of Two Related Singers

The primary goal of this study was to characterize a performer's singing and speaking voice. One woman was not admitted to a premier choral group, but her sister, who was comparable in physical characteristics and background, was admitted and provided a valuable control subject. The perceptual judgment of a vocal coach who conducted the group's auditions was decisive in discriminating these 2 singers. The singer not admitted to the group described a history of voice pathology, lacked a functional head register, and spoke with a voice characterized by hoarseness. Multiple listener judgments and acoustic and aerodynamic evaluations of both singers provided a more systematic basis for determining: 1) the phonatory basis for this judgment; 2) whether similar judgments would be made by groups of vocal coaches and speech-language pathologists; and 3) whether the type of tasks (e.g., sung vs. spoken) would influence these judgments. Statistically significant differences were observed between the ratings of vocal health provided by two different groups of listeners. Significant interactions were also observed as a function of the types of voice samples heard by these listeners. Instrumental analyses provided evidence that, in comparison to her sister, the rejected singer had a compromised vocal range, glottal insufficiencies as assessed aerodynamically and electroglottographically, and impaired acoustic quality, especially in her speaking voice.     

Voice problems as side effects of inhaled corticosteroids in asthma patients—a prevalence study

Voice disturbances in asthma patients may be caused by inhaled corticosteroids. In order to study the prevalence of such voice disturbances, a questionnaire was delivered to asthma patients at three asthma and allergy departments in Stockholm. The questionnaire consisted of 25 questions concerning the asthma disease symptoms, medication, voice function, and voice disturbances. A total of 350 questionnaires were delivered. Response frequency was 80%. There was a significant positive correlation between inhalation of cortison and voice disturbances. Most of the patients complained about hoarseness, followed by throat clearing, a lump in the throat, loss of voice, and less frequently, throat pain. There were no significantly differences between men and women. Elderly had more voice problems than young persons. Patients with voice-demanding professions had more problems than patients who used their voice to a lesser extent during the working day. There was a significant positive correlation between high cortison doses and voice problems as well as between voice problems and acid regurgitation.     

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.     

Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review

The modern theory of hoarseness is that there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. METHODS: This project is a retrospective chart review of all patients seen in the Voice Speech and Language Service and Swallowing Center at our institution with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period. A literature search and review is also performed regarding current and emerging concepts of muscle tension dysphonia. RESULTS: One hundred fifty subjects were identified (60% female, 40% male, with a mean age of 42.3 years). Significant factors in patient history believed to contribute to abnormal voice production were gastroesophageal reflux in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. Otolaryngologic evaluation was performed in 82% of patients, in whom lesions, significant vocal fold edema, or paralysis/paresis was identified in 52.3%. Speech pathology assessment revealed poor breath support, inappropriately low pitch, and visible cervical neck tension in the majority of patients. Inappropriate intensity was observed in 23.3% of patients. This set of multiple contributing factors is discussed in the context of current and emerging understanding of muscle tension dysphonia. CONCLUSIONS: Results confirm multifactorial etiologies contributing to hoarseness in the patients identified with muscle tension dysphonia. An interdisciplinary approach to treating all contributing factors portends the best prognosis.     

Acid reflux and hoarseness

The aim of this study was to investigate the prevalence of acid reflux in patients complaining of hoarseness where no organic disease or functional dysphonia could be found. We also aimed to determine whether anti-reflux treatment improved their symptoms. Patients were not selected on the basis of symptoms of reflux. Fifty patients with hoarseness took part in a prospective study that sought to establish objectively whether acid reflux was present. All patients were given a 6-week course of ranitidine and Gaviscon. Patients were asked to score their voice quality before and after treatment. Although 72% of patients complained of heartburn more than once a week, only 40% proved to have acid reflux. Although subjective improvement after anti-reflux treatment was found in a larger proportion of those with than without proven reflux, the conclusions that can be drawn are limited as there were no satisfactory objective measurements of voice or controls.     

Voice Problems of Future Speech-Language Pathologists

Students training to be educators frequently exhibit voice disorders prior to employment. To date, there exist no similar studies of future speech-language pathologists (SLPs). The study is designed as a prospective, nonrandomized survey. The objective of this study is to determine the voice problems of first year graduate students training to be SLPs. Participants were 104 first year graduate students majoring in speech-language pathology at two universities. The Quick Screen for Voice was administered. Participants who failed completed a questionnaire regarding voice problems, medical history, daily habits, and voice use. When responses further indicated voice-related problems, endoscopic examination was completed. Fourteen percent (N=15) of the participants failed the screening by demonstrating two or more abnormal voice characteristics. These included persistent glottal fry (present in all who failed), low habitual pitch, juvenile resonance, hoarse, breathy, or strained phonation, abnormally low pitch on sustained vowels, and voice breaks during the frequency range. Twelve percent (N=12) failed both the screening and follow-up questionnaire. Responses included self-reported dysphonia, medical history with voice-related side effects, difficulty with excessive voice use, and voice problems occurring daily or weekly. Endoscopic evaluation showed one participant with bilateral vocal nodules. The results suggest that voice problems among future SLPs (12%) are more common than the 3-9% reported in the general population and similar to the 11% previously reported for teachers. However, future SLP voice problems are less frequent than those reported among education majors (21%) and all college students (17%). Faculty should identify students with voice problems and emphasize optimal voice use in classroom and clinical settings.     

Werner's Syndrome: A Rare Cause of Hoarseness

Werner's syndrome (WS) is a rare hereditary disorder which is characterized by clinical signs of premature aging. A 31-year-old man presented with a 12-year history of hoarseness. Also noted were diabetes mellitus, cataracts, scleroderma-like skin atrophy, osteoporosis, and hypogonadism. A clinical diagnosis of WS was made. Laryngoscopy revealed bowed vocal folds resulting in a spindle-shaped closure with glottal incompetence during phonation. We used Gortex for medialization of the middle part of vocal fold to correct the glottal gap in this patient. Despite correction of glottal incompetence in patients with WS, quality of voice could not be improved to that of age-matched normal individuals.     

Effects of sound-field frequency modulation amplification on reducing teachers'' sound pressure level in the classroom

Voice problems are a frequent difficulty that teachers experience. Common complaints by teachers include vocal fatigue and hoarseness. One possible explanation for these symptoms is prolonged elevations in vocal loudness within the classroom. This investigation examined the effectiveness of sound-field frequency modulation (FM) amplification on reducing the sound pressure level (SPL) of the teacher's voice during classroom instruction. Specifically, SPL was examined during speech produced in a classroom lecture by 10 teachers with and without the use of sound-field amplification. Results indicated a significant 2.42-dB decrease in SPL with the use of sound-field FM amplification. These data support the use of sound-field amplification in the vocal hygiene regimen recommended to teachers by speech-language pathologists.     

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.     

Voice problems and risk factors among aerobics instructors

Fifty female and four male aerobics instructors completed a questionnairepertaining to vocal problems and variables that could indicate an increased risk for developing problems. The questions concerned teaching experience, physical data regarding instructional facilities, method of voice projection, music volume, history of illness, allergies, voice loss, hoarseness, smoking habits, and knowledge of vocal hygiene. The results showed that a significant number of instructors experienced partial or complete voice loss (44%) during and after instructing, as well as increased episodes of voice loss, hoarseness, and sore throat unrelated to illness since they began instructing. Significant variables associated with voice problems included sore throat and hoarseness following instruction, and shouting to cue the participants. It was also found that very few instructors in this study had any knowledge of vocal hygiene techniques.