Electroglottographic tracking of phonatory response to Botox.

Botox injection into the thyroarytenoid muscle is thought to alter the glottal competence and laryngeal adduction of patients with adductor spasmodic dysphonia (ADSD). Hypofunctional responses to treatment have been rated subjectively and inferred from postinjection breathy voice, aphonia, midline glottal gap, or subclinical aspiration. Clinical experience suggests that temporary hypofunction varies in duration and severity among patients. This study used electroglottographic measures to examine changes over time in glottal competence during the relatively stable phonation produced by 5 patients with ADSD. Hierarchical linear modeling was used to test 3 hypotheses: (a) that reduced laryngeal adduction would occur during the first 3 weeks postinjection, followed by a reversal; (b) that patients' hypofunctional response curves would differ one from another; and (c) that changes in adduction, if present, would be related to changes in severity ratings of ADSD symptoms. For 3 participants, significant hypoadduction occurred after injection and reversed toward preinjection level over an 8-week period. Two participants demonstrated a flat or increasing vocal fold contact response curve during the early postinjection period. Observations were consistent with the previously reported differences and possibly complex relation between the resolution of breathy hypofunction and ultimate return of ADSD symptoms.     

Japanese version of voice handicap index for subjective evaluation of voice disorder

Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient's perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient's disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient's psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.     

Electroglottographic tracking of phonatory response to botox™

Botox injection into the thyroarytenoid muscle is thought to alter the glottal competence and laryngeal adduction of patients with adductor spasmodic dysphonia (ADSD). Hypofunctional responses to treatment have been rated subjectively and inferred from postinjection breathy voice, aphonia, midline glottal gap, or subclinical aspiration. Clinical experience suggests that temporary hypofunction varies in duration and severity among patients. This study used electroglottographic measures to examine changes over time in glottal competence during the relatively stable phonation produced by 5 patients with ADSD. Hierarchical linear modeling was used to test 3 hypotheses: (a) that reduced laryngeal adduction would occur during the first 3 weeks postinjection, followed by a reversal; (b) that patients' hypofunctional response curves would differ one from another; and (c) that changes in adduction, if present, would be related to changes in severity ratings of ADSD symptoms. For 3 participants, significant hypoadduction occurred after injection and reversed toward preinjection level over an 8-week period. Two participants demonstrated a flat or increasing vocal fold contact response curve during the early postinjection period. Observations were consistent with the previously reported differences and possibly complex relation between the resolution of breathy hypofunction and ultimate return of ADSD symptoms.     

Correlation of the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL)

The purpose of this study was to investigate the correlation between the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL), and to test conversion of scores between the two instruments. Understanding the relationship between instruments will facilitate comparison of voice outcome studies using different measures. A retrospective medical chart review of 140 consecutive patients with a chief complaint related to their voice presenting for speech pathology voice evaluation following laryngology evaluation and diagnosis was adopted. Each patient who filled out the VHI and V-RQOL within a 2-week period with no intervening treatment was included in the study. Correlation analysis for total scores was performed for the patients meeting inclusion criteria (n=132). Correlations were also performed as a function of diagnosis. Calculated VHI score based on measured V-RQOL score was compared to measured VHI score. Pearson correlation between scores on the VHI and V-RQOL was -0.82. There was no significant difference between the mean measured and mean calculated VHI scores. For individual scores, however, regression analysis did reveal a significant difference between calculated and measured VHI. The VHI and V-RQOL are highly correlated; however, this study suggests that the two instruments are not interchangeable for individuals.     

Voice Handicap Index in singers

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.     

Voice handicap index change following treatment of voice disorders

Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patient's perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patient's perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.     

The effect of patient factors on response outcomes toBotox treatment of spasmodic dysphonia

Injection of botulinum toxin (Botox) into the laryngeal muscleshas become the treatment of choice for controlling the symptoms of spasmodic dysphonia (SD). Currently, no specific battery of objective tests to assess the outcome is universally accepted. The purpose of this study was to investigate demographic, clinical, and treatment factors with voice outcome following Botox injection. Sixty-eight patients with adductor SD who underwent at least one Botox injection during a 5-year period were studied. Voice outcome measures were made from patient self-reporting scales and included overall vocal quality, length of response, and duration of breathiness. Vocal quality was significantly correlated with the underlying severity of vocal symptoms prior to treatment, incidence of breathiness and unilateral versus bilateral injection. The length of response was greater in males and following bilateral injections. An increased period of breathiness significantly correlated with bilateral injections.     

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.     

Voice-related Quality of Life in Laryngectomees: Assessment Using the VHI and V-RQOL Symptom Scales

The primary purpose of this study was to investigate the effect of the voice impairment across the physical, emotional, and functional domains in patients using valved speech following total laryngectomy with the help of two symptom specific scales. The study design used was a cross-sectional cohort. The setting was the Head and Neck Oncology Unit of a tertiary referral centre. Subjects were 54 patients who had undergone total laryngectomy. Two voice-specific questionnaires, the Voice-Related Quality of Life (V-RQOL-short form) Measure, and the Voice Handicap Index (VHI-long form) were used. The main outcome measure was patient perception of the voice following total laryngectomy in response to specific questions correlated with sociodemographic/treatment factors. Responses were received from 40 males and 14 females (response rate of 85.7%) with a median age of 63.4 years (range: 37-84). The V-RQOL overall analysis showed that 3 patients (5.6%) scored "excellent," 29 patients (53.7%) "fair to good," 14 patients (25.9%) "poor to fair," and 8 patients (14.8%) "poor." Analysis of the VHI revealed that 20 patients (37.0%) had a minimal handicap, 20 patients (37.0%) a moderate handicap, and 14 patients (25.9%) had a serious voice handicap. The individual domain or subscale scores for the VHI revealed a mean (SD) functional score of 15.8 (7.7), a physical score of 13.6 (7.2), and finally an emotional score of 11.6 (8.9). Functional aspects of the voice were significantly affected by age, radiotherapy, and chemotherapy (Spearman rho, P=0.01; Mann-Whitney, P=0.04 and P=0.01). The physical aspects of the voice were significantly affected by age and chemotherapy (Spearman rho, P=0.004; Mann-Whitney, P=0.04). Only age significantly affected the emotional aspects of the voice (Spearman rho, P=0.002). We found a strong correlation (Spearman rho, P<0.001) between the V-RQOL and VHI questionnaires. Our study revealed that the V-RQOL and VHI scores in our series of patients following voice restoration in laryngectomees were consistent with that reported in the literature. Only age, radiation, and chemotherapy were seen to influence the voice handicap scores. In addition, both symptom scales had good correlation between them and either one could be used with reliability in laryngectomees with a few modifications.     

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.     

The Voice Handicap of Student-Teachers and Risk Factors Perceived to Have a Negative Influence on the Voice

A cross-sectional questionnaire survey was performed. The objectives of the study were to assess the psychosocial impact of current voice complaints as perceived by student-teachers with voice complaints in comparison with student-teachers without voice complaints, and to observe the pattern of risk factors in relation to their voice handicap. Subjects in the general population without a voice-demanding profession were selected as a reference group for limited comparison with the total group of student-teachers (future professional voice users). The respondents to the questionnaires were anonymous. Among the student-teachers, 17.2% reported current voice complaints in comparison with 9.7% of the reference group, and the odds ratio was 1.94, which showed the relative risk. Student-teachers had significantly greater total Voice Handicap Index (VHI) scores than the reference group (P = 0.034). The VHI subscale scores were not significantly different (P > 0.05). Student-teachers who reported current voice complaints had a significantly higher total VHI and subscale scores than student teachers without voice complaints (P < 0.001). Of the student-teachers without voice complaints, 17.0% had VHI scores greater than the 75th percentile. These persons may be neglecting their voice handicap and probably represent the false-negative cases in the estimation of voice complaints. Logistic regression analysis of each of the given risk factors with the VHI as the independent variable showed that the perceived negative influence of the given risk factors on their voices was significantly greater with increasing VHI scores across the VHI range. A significant correlation was observed between the number of perceived risk factors and increasing VHI scores across the VHI range. An increased awareness of risk factors in relation to their voice handicap would serve to motivate student-teachers to change factors that contributed to their voice problem. Attention to all risk factors, which the subjects perceive to be a risk, would aid in effective management of their voice handicap.     

Patient Versus Partner Perception of Voice Handicap

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=69.15 years) with dysphonia and their communication partners. Patients completed the Voice Handicap Index (VHI), a questionnaire of self-perceived 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.     

Poor Voice Quality in Future Elite Vocal Performers and Professional Voice Users

The voice quality of 86 occupational voice users, i.e., students of a high school for audiovisual communication, was assessed by means of a multidimensional test battery containing: the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, dysphonia severity index (DSI), and voice handicap index (VHI). In a questionnaire on daily habits the prevalence of smoking, eating habits, and vocal abuse were recorded. A comparison of the voice characteristics of the future occupational voice users with a control group revealed significant differences. The results of the VHI and the DSI of these students revealed significantly worse scores than the score of a control group characterized by no vocal complaints. Moreover, the questionnaire on daily habits showed that the future elite vocal performers and professional voice users take less precautions for the care of their voices. These findings support the importance of a good balanced vocal coaching.     

Validation of the Voice Handicap Index Using Rasch Analysis

BACKGROUND: The Voice Handicap Index is a tool for measuring the psychosocial consequences of voice disorders and consists of three dimensions. Previous psychometric evaluation of the VHI focused on the classic evaluation of reliability and validity, which is sample dependent. The authors used Rasch analysis to re-examine the dimensionality of the VHI and to produce item and scale statistics that are less sample dependent. In addition, they provide estimates of VHI item and person severities that are reported on the same logit unit scale, allowing a more straightforward interpretation of a VHI test score. PATIENTS: Dysphonic patients (N = 530), who were referred for phoniatric examination, filled out the VHI. RESULTS: Rasch analysis revealed two truly uni-dimensional constructs: the 20-item psychosocial scale and the 9-item physical-functional scale. Logit item severity measures ranged from -2.1 to +2.7. Person severity scores ranged from -4.4 to + 4.4 logits. The internal consistency of the reduced scales was similar to that of the original total VHI (0.95 and 0.84). The VHI consisted of two uni-dimensional constructs. Raw test scores can be transformed into logit unit severity measures, making the VHI more suitable for evaluating the effectiveness of voice-related therapy.     

The Voice Handicap Index: Correlation Between Subjective Patient Response and Quantitative Assessment of Voice

The aim of this prospective study is to elucidate the relationship between the Voice Handicap Index (VHI) and several voice laboratory measurements in the network of the multidimensional voice assessment. Fifty-eight patients were included. Each patient replies to the questionnaire and performs a voice assessment during the same time. The following parameters were measured: minimum frequency, maximum frequency, range, minimum intensity, subglottic pressure, mean flow, maximum phonation time, jitter, and dysphonia severity index. Regarding the relationship with the scores of the VHI, poor correlations with the minimal frequency for all the scores except the emotional one (total and subscales) and with the range for only the physical one are found. Seventeen questions correlate with the voice laboratory measurements we performed, with a decreased distribution between physical, functional, and emotional subscales. We observe that acoustic parameter is correlated with the emotional subscale, the parameters of the profile range are more often involved in the emotional subscale, as is the minimal frequency, but never with the physical subscale, and all the subscales are interesting despite the smaller number of differences with the emotional one. The VHI and the laboratory measurements give independent informations in practice.     

Spectral Amplitude Measures of Adductor Spasmodic Dysphonic Speech

Spectral amplitude measures are sensitive to varying degrees of vocal fold adduction in normal speakers. This study examined the applicability of harmonic amplitude differences to adductor spasmodic dysphonia (ADSD) in comparison with normal controls. Amplitudes of the first and second harmonics (H1, H2) and of harmonics affiliated with the first, second, and third formants (A1, A2, A3) were obtained from spectra of vowels and /i/ excerpted from connected speech. Results indicated that these measures could be made reliably in ADSD. With the exception of H1(*)-H2(*), harmonic amplitude differences (H1(*)-A1, H1(*)-A2, and H1(*)-A3(*)) exhibited significant negative linear relationships (P < 0.05) with clinical judgments of overall severity. The four harmonic amplitude differences significantly differentiated between pre-BT and post-BT productions (P < 0.05). After treatment, measurements from detected significant differences between ADSD and normal controls (P < 0.05), but measurements from /i/ did not. LTAS analysis of ADSD patients' speech samples proved a good fit with harmonic amplitude difference measures. Harmonic amplitude differences also significantly correlated with perceptual judgments of breathiness and roughness (P < 0.05). These findings demonstrate high clinical applicability for harmonic amplitude differences for characterizing phonation in the speech of persons with ADSD, as well as normal speakers, and they suggest promise for future application to other voice pathologies.     

Does botulinum toxin alter laryngeal secretionsand mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmissionand has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox® injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

Validation of the Dysphonia Severity Index in the Dr. Speech Program

PurposeThe Dysphonia Severity Index (DSI) is an objective multiparameter index of voice quality that measures and describes overall voice quality. Some studies have suggested that the reliability of devices for DSI measurement should be examined. We explored the feasibility of DSI measurements using the Dr. Speech (DRS) device, verified its effectiveness for clinical voice measurements and intradevice reliability, and examined the correlation between the DSI and self-evaluations of voice problems.MethodsSeventy adult participants (including individuals with voice problems and healthy adults) underwent objective and subjective voice assessments. These data were then used to establish a DSI_DRS model and test the intradevice (DRS device and Praat software) reliability. The clinical validation of the DSI_DRS was conducted by measuring the DSI of six other participants and comparing the observed and predicted perceived voice quality as expressed by the G score (of the GRBAS scale). Moreover, the relationship between the DSI measurements and participants’ self-evaluations of voice problems was investigated by analyzing the correlation between the DSI and the Voice Handicap Index (VHI).ResultsThe DSI_DRS discriminated 80% of participants’ voice quality ratings. There were strong correlations between the DSI and variables measured by the DRS device and Praat software. Furthermore, there was no significant correlation between the DSI_DRS and VHI.ConclusionThe DRS device can perform DSI measurements. Objective voice measurements and perceptual voice ratings reflected different aspects of vocal function and its effects. These factors should be considered in clinical practice settings.     

Variations in adductor spasmodic dysphonia:Acoustic evidence

Acoustic analysis was used to gain information about the normal, aswell as the abnormal acoustic events associated with adductor spasmodic dysphonia (ADSD). This analysis was completed to determine whether specific acoustic events could be used to differentiate the voice of individuals with ADSD from those with normal voice. A group comparison between 14 women diagnosed with ADSD and 14 women (age-matched) with no evidence of vocal pathology or vocal dysfunction was completed. Phonatory breaks, aperiodicity, and frequency shifts, acoustic parameters previously identified in ADSD, were found throughout sustained vowel productions. The duration of the phonatory breaks and aperiodic segments was calculated and the amount of frequency shift was determined. The location of each acoustic event was marked relative to the onset of the vowel production. The subjects with ADSD presented with normal phonation and various amounts of each of the three acoustic parameters. Aperiodic segments primarily characterized the phonation of ADSD, followed by frequency shifts and phonatory breaks. The location of each of these acoustic events was within the midportion of the vowel production. The advantages of segmenting the acoustic waveform into these measures and separating the spasmodic events from normal phonation when examining laryngeal motor control of spasmodic dysphonics is discussed     

Treatment Outcomes for Professional Voice Users

Professional voice users comprise 25% to 35% of the U.S. working population. Their voice problems may interfere with job performance and impact costs for both employers and employees. The purpose of this study was to examine treatment outcomes of two specific rehabilitation programs for a group of professional voice users. Eighteen professional voice users participated in this study; half had complaints of throat pain or vocal fatigue (Dysphonia Group), and half were found to have benign vocal fold lesions (Lesion Group). One group received 5 weeks of expiratory muscle strength training followed by six sessions of traditional voice therapy. Treatment order was reversed for the second group. The study was designed as a repeated measures study with independent variables of treatment order, laryngeal diagnosis (lesion vs non-lesion), gender, and time. Dependent variables included maximum expiratory pressure (MEP), Voice Handicap Index (VHI) score, Vocal Rating Scale (VRS) score, Voice Effort Scale score, phonetogram measures, subglottal pressures, and acoustic and perceptual measures. Results showed significant improvements in MEP, VHI scores, and VRS scores, subglottal pressure for loud intensity, phonetogram area, and dynamic range. No significant difference was found between laryngeal diagnosis groups. A significant difference was not observed for treatment order. It was concluded that the combined treatment was responsible for the improvements observed. The results indicate that a combined modality treatment may be successful in the remediation of vocal problems for professional voice users.