Outcome of laryngeal manual therapy in four Dutch adults with persistent moderate-to-severe vocal hyperfunction: a pilot study

A relatively new management strategy for the treatment of voice disorders is the use of laryngeal manual therapy. The main purpose of the present pilot study is to document the outcome of vocal quality after a well-defined laryngeal manual therapy (LMT) program. Four Dutch professional voice users with a persistent moderate or severe muscle tension dysphonia were studied pretreatment (1 week before LMT) and posttreatment (1 week) after completion of manual therapy (25 sessions). These subjects had received several months of traditional voice therapy, without any success. To measure and compare, the effect of LMT objective and subjective assessment techniques were used. Perceptual voice assessment included a perceptual rating of the voice using the GRBAS scale. Furthermore, the vocal quality in this population was modeled by means of the Dysphonia Severity Index (DSI). All of the subjects selected for LMT showed improvement in perceptual vocal quality and DSI values. As the DSI is a weighted variable including aerodynamic and acoustic measures, small improvements (closer to 5) are very indicative of vocal quality improvement.¹ The use of LMT in professional voice users with persistent moderate-to-severe muscle tension dysphonia, especially in some subjects who have not responded to traditional voice therapy, is supported by this pilot study.     

Genetics of Vocal Quality Characteristics in Monozygotic Twins: A Multiparameter Approach

The main purpose of this study was to determine the vocal quality characteristics among the 45 monozygotic cotwins (MT). As the performance of the voice is related to several genetically determined anatomical and physiological factors, the authors hypothesized that the vocal characteristics and the overall vocal quality by means of the Dysphonia Severity Index (DSI) will be identical in MT. An additional objective of this study was to determine whether sex and age influence vocal similarities in MT and to compare the voice characteristics of MT with the normative data of unrelated peers. As more environmental factors influence the aging of the voice, age-related differences were expected. No sex-related differences were expected. Subjective and objective assessment techniques determined the vocal quality. No significant differences were obtained, and most comparisons resulted in significant correlation coefficients. For the acoustic parameters jitter and shimmer only, no significant correlation coefficients could be obtained. It is clear that the perceptual voice characteristics, the laryngeal aerodynamic measurements of maximum phonation time (MPT), the vocal performances, and the overall vocal quality by means of the DSI are similar in MT. These vocal characteristics are not influenced either by the subjects' age or sex and are situated within the normative range of unrelated peers. To what extent other aspects (environment, anxiety, tension, etc) might play a role in the acoustical dimensions regarding frequency and amplitude perturbation, which were in the normal range, is a subject of further research.     

Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis

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

Movement of the velum during speech and singing in classically trained singers

The present study addresses two questions: (a) Is the action and/orposture of the velopharyngeal valve conducive to allow significant resonance during Western tradition classical singing? (b) How do the actions of the velo-pharyngeal valve observed in this style of singing compare with normal speech? A photodetector system was used to observe the area function of the velopharyngeal port during speech and classical style singing. Identical speech samples were produced by each subject in a normal speaking voice and then in the low, medium, and high singing ranges. Results indicate that in these four singers the velopharyngeal port was closed significantly longer in singing than in speaking samples. The amount of time the velopharyngeal port was opened was greatest in speech and diminished as the singer ascended in pitch. In the high voice condition, little or no opening of the velopharyngeal port was measured.     

Acoustical Aspects of Vocal Function Following Radiotherapy for Early T1a Laryngeal Cancer

We evaluated acoustic voice characteristics of 18 male patients undergoing radiotherapy. The subjects were seen for voice assessment preradiotherapy and at 1 month, 3 months, 6 months, and 1 year following radiotherapy. A multidimensional voice analysis computer program (IVANS, Avaaz Innovations, 1998) was employed to evaluate measures of traditional frequency and amplitude perturbation as well as time-based and linear prediction (LP) modeled "noise" parameters of the acoustic output in conjunction with perceptual judgments of overall vocal quality. The results indicate vocal deterioration of vocal function immediately following radiotherapy with gradual and significant improvement in acoustic and perceptual features over 9 to 12 months following the radiation treatment. Measures of glottal noise demonstrated higher sensitivity than frequency-based measures of voice perturbation, and with more consistent, less variable changes in acoustical voice output from the preradiation to the 12 month postradiation periods. Future research evaluating vowel type and acoustic perturbation measures with a larger sample of subjects over a longer time period seems warranted.     

Vocal quality characteristics in children with cleft palate: a multiparameter approach

The main purpose of the present study was to examine the vocal quality and to investigate the effects of gender on vocal quality in 28 children with a unilateral or bilateral cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and dysphonia severity index (DSI) measurements. The DSI is based on the weighted combination of four voice measurements and ranges from +5 to -5 for, respectively, normal and severely dysphonic voices. Additional objectives were to compare the vocal quality characteristics of children with cleft palate with the available normative data and to investigate the impact of the cleft type on vocal quality. Gender-related vocal quality differences were found. The male cleft palate children showed an overall vocal quality of +0.62 with the presence of a perceptual slight grade of hoarseness and roughness. The female vocal quality had a DSI value of +2.4 reflecting a perceptually normal voice. Irrespective of the type of cleft, all subjects demonstrated a significantly lower DSI-value in comparison with the available normative data. The results of the present study have provided valuable insights into the vocal quality characteristics of cleft palate children.     

Outcome of Resonant Voice Therapy for Female Teachers With Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements

Teachers have a high percentage of voice problems. For voice disordered teachers, resonant voice therapy is hypothesized to reduce voice problems. No research has been done on the physiological, acoustic, and aerodynamic effects of resonant voice therapy for school teachers. The purpose of this study is to investigate resonant voice therapy outcome from perceptual, physiological, acoustic, aerodynamic, and functional aspects for female teachers with voice disorders. A prospective study was designed for this research. The research subjects were 24 female teachers in Taipei. All subjects received resonant voice therapy in groups of 4 subjects, 90 minutes per session, and 1 session per week for 8 weeks. The outcome of resonant voice therapy was assessed from auditory perceptual judgment, videostroboscopic examination, acoustic measurements, aerodynamic measurements, and functional measurements before and after therapy. After therapy the severity of roughness, strain, monotone, resonance, hard attack, and glottal fry in auditory perceptual judgments, the severity of vocal fold pathology, mucosal wave, amplitude, and vocal fold closure in videostroboscopic examinations, phonation threshold pressure, and the score of physical scale in the Voice Handicap Index were significantly reduced. The speaking Fo, maximum range of speaking Fo, and maximum range of speaking intensity were significantly increased after therapy. No significant change was found in perturbation and breathiness measurements after therapy. Resonant voice therapy is effective for school teachers and is suggested as one of the therapy approaches in clinics for this population.     

Vocal Evaluation in Teachers With or Without Symptoms

The aim of this study was to perform voice evaluation in teachers with and without vocal symptoms, identifying etiologic factors of dysphonia, voice symptoms, vocal qualities, and laryngeal lesions. Eighty teachers were divided into two groups: GI (without or sporadic symptoms, 40) and GII (with frequent vocal symptoms, 40). They answered a specific questionnaire, and were subject to a perceptual vocal assessment (maximum phonation time, glottal attack, resonance, coordination of breathing and voicing, pitch, and loudness), GIRBAS scale, and to videolaryngoscopy. Females were predominant in both groups, and the age range was from 36 to 50 years. Elementary teachers predominated, working in classes with 31-40 students. Voice symptoms and alterations in the perceptual vocal analysis and in the GIRBAS scale were more frequent in GII. In 46 teachers (GI-16; GII-30), videolaryngoscopy exams were abnormal with the vocal nodules being the most frequent lesions. These results indicate that a teacher's voice is compromised, and requires more attention including control of environmental factors and associated diseases, preventive vocal hygiene, periodic laryngeal examinations, and access to adequate specialist treatment.     

Voice changes in women treated for endometriosis and related conditions: The need for comprehensive vocal assessment

Hormonal treatments which have an androgenic effect have the potential to cause vocal changes. The changes in vocal fold structure and voice quality are considered to be irreversible. To date, studies have documented subjective vocal changes or documented single cases without detailed, baseline voice assessments. The impact on laryngeal function of women taking these androgenic treatments requires further detailed, objective assessment. The need for increased awareness of the actions of androgenic hormones on womns' voices, and the benefits of a thorough voice assessment are discussed.     

A Randomized Treatment-Placebo Study of the Effectiveness of Acupuncture for Benign Vocal Pathologies

Acupuncture is a widely accepted treatment option for many medical ailments in China. Some reports claim that acupuncture is effective for treating dysphonia associated with benign pathological tissue changes. However, many of these reports are based on anecdotal evidence that lacks a scientific experimental design. The objective of this study was to investigate the effectiveness of intensive acupuncture therapy for dysphonias associated with benign pathological changes with a randomized, control design. Twenty-four subjects aged between 19 and 51 years were randomly assigned to either an experimental group or a placebo group. The experimental group received acupuncture on acupoints Renyin (Stomach Channel 9), Lieque (Lung Channel 7), and Zhaohai (Kidney Channel 6), which are all related to improving throat problems and vocal function, whereas the placebo group received acupuncture on acupoints Houxi (Small Intestine Channel 3) and Kunlun (Bladder Channel 60), which are not related to voicing. All subjects received 10 intensive acupuncture sessions within a 20-day period. Acoustic analysis of voice range profile, perceptual analysis of voice quality, and self-perceptions of quality-of-life (QOL) measurement by patients were the outcome measures for determining treatment efficacy. Results revealed significant improvement in the treatment group in all three aspects when compared with the placebo group. The acupuncture effect was maintained into the second week after the completion of acupuncture treatment.     

The effects of preventive vocal hygiene education on the vocal hygiene habits and perceptual vocal characteristics of training singers

The purpose of the present study was to determine the effects of vocal hygiene education on the vocal hygiene behaviors and perceptual vocal characteristics of untrained singers. Eleven adult untrained singers served as subjects. They attended four 1-hour class sessions on vocal hygiene, including anatomy and physiology of the phonatory mechanism, vocally abusive behaviors, voice disorders commonly seen in singers, and measures to prevent voice disorders. Pre- and postinstruction surveys were used to record subjects' vocal abuses and their perceptions of their speaking and singing voice. They also rated their perceived value of vocal hygiene education. Results revealed minimal changes in vocal hygiene behaviors and perceptual voice characteristics. The subjects did report a high degree of benefit and learning, however.     

Changes in Objective Acoustic Measurements and Subjective Voice Complaints in Call Center Customer-Service Advisors During One Working Day

SUMMARY: The aim of this study was to investigate how different acoustic parameters, extracted both from speech pressure waveforms and glottal flows, can be used in measuring vocal loading in modern working environments and how these parameters reflect the possible changes in the vocal function during a working day. In addition, correlations between objective acoustic parameters and subjective voice symptoms were addressed. The subjects were 24 female and 8 male customer-service advisors, who mainly use telephone during their working hours. Speech samples were recorded from continuous speech four times during a working day and voice symptom questionnaires were completed simultaneously. Among the various objective parameters, only F0 resulted in a statistically significant increase for both genders. No correlations between the changes in objective and subjective parameters appeared. However, the results encourage researchers within the field of occupational voice use to apply versatile measurement techniques in studying occupational voice loading.     

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.     

Evaluation of Voice Quality in Patients With Vocal Fold Polyps: The Size of a Polyp Matters or Does it?

ObjectiveThis study aimed to investigate the correlation between morphological features of vocal fold polyps (VFPs) and subjective/objective voice parameters.MethodsPerceptual evaluations, aerodynamic and acoustic tests were performed on 47 patients with VFPs. Still images were captured from video and the morphological features associated with the size of VFP were quantified. To reveal the correlation between size-related morphological features (length of polyp base, the ratio of polyp base to vocal fold length, glottal gap area) and objective/subjective parameters of voice, Pearson's and Spearman's tests were carried out.ResultsThis cohort was composed of 30 (63.8 %) male and 17 (36.2%) female patients with the mean age of 45.2 years and 41.3 years, respectively. No correlation was found between the morphological features of VFPs and any of perceptual, aerodynamic and acoustic voice parameters.ConclusionsOur findings indicated that controversies still exist regarding the role of vocal fold polyp morphology in clinical decision making.     

Acute and Subacute Awake Injection Laryngoplasty for Thoracic Surgery Patients

SUMMARY: The rehabilitation of glottic incompetence by injection laryngoplasty is important in the management of thoracic surgery patients with vocal cord paralysis. This group of patients presents special considerations that favor injection under local anesthesia. The objective of this study is to characterize our experience with this minimally invasive approach in both the acute and subacute settings. The study was conducted using a retrospective chart review. From a database of 108 patients who received awake percutaneous injection laryngoplasty over a 3-year period, 15 cases were identified that underwent augmentation shortly following thoracic surgery. These records were reviewed for patient demographics, clinical characteristics, complications, and short-term outcomes. Fifteen patients were identified (12 male, 3 female); the age range for the group was 18-91 years (median=55 years). All the patients reported vocal improvement following injection; all 15 also were improved by perceptual assessment. Five of six dysphagic patients improved following injection. One patient's injection was aborted due to vocal fold edema; no significant bleeding or airway embarrassment was observed. No procedures were terminated because of patient discomfort. Awake percutaneous injection laryngoplasty for vocal paralysis can be performed safely in the postoperative thoracic surgery patient. Swallowing and voice complaints were almost universally improved following treatment. For patients who cannot tolerate or choose not to have open thyroplasty or vocal fold injection under general anesthesia, this procedure may offer a safe and effective alternative.     

The Towne-Heuer reading passage—A reliable aid to the evaluation of voice

The science of voice evaluation and assessment has profited from technological advancement and objective measurement of voice parameters has become an integral part of the voice examination, however, subjective voice evaluation remains a vital component of any voice examination. The Towne-Heuer Reading Passage was developed in 1970 to provide a reading sample that would facilitate subjective voice evaluation. The reliability of the passage was established using three judges listening to 15 normal Philadelphia speakers and 15 vocal abuse-misuse clients with verified vocal nodules. The frequency of hard glottal attack (HGA) was determined for the two groups and high interjudge and intrajudge correlation was found. A difference in the frequency of HGA was found between the two groups.     

The Towne-Heuer Reading Passage--a reliable aid to the evaluation of voice.

The science of voice evaluation and assessment has profited from technological advancement and objective measurement of voice parameters has become an integral part of the voice examination, however, subjective voice evaluation remains a vital component of any voice examination. The Towne-Heuer Reading Passage was developed in 1970 to provide a reading sample that would facilitate subjective voice evaluation. The reliability of the passage was established using three judges listening to 15 normal Philadelphia speakers and 15 vocal abuse-misuse clients with verified vocal nodules. The frequency of hard glottal attack (HGA) was determined for the two groups and high interjudge and intrajudge correlation was found. A difference in the frequency of HGA was found between the two groups.     

Average speaking fundamental frequency in soprano singers with and without symptoms of vocal attrition

Nineteen trained soprano singers aged 18–30 years vocalized tasks designed to assess average speaking fundamental frequency (SFF) during spontaneous speaking and reading. Vocal range and perceptual characteristics while singing with low intensity and high frequency were also assessed, and subjects completed a survey of vocal habits/symptoms. Recorded signals were digitized prior to being analyzed for SFF using the Kay Computerized Speech Lab program. Subjects were assigned to a normal voice or impaired voice group based on ratings of perceptual tasks and survey results. Data analysis showed group differences in mean SFF, no differences in vocal range, higher mean SFF values for reading than speaking, and 58% ability to perceive speaking in low pitch. The role of speaking in too low pitch as causal for vocal symptoms and need for voice classification differentiation in vocal performance studies are discussed.     

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.