Short-Term Effects of Endotracheal Intubation on Voice

The objective of this study was to examine the vocal symptoms and acoustic changes perceived in the short period after endotracheal intubation, and to find the association between these changes and the endotracheal tube parameters. A total of 35 subjects were included. They were examined preoperatively, and 2 and 24 hours postoperatively. The vocal symptoms of hoarseness, vocal fatigue, loss of voice, throat clearing, globus pharyngeus, throat pain, and the acoustic variables mainly average fundamental frequency, relative average perturbation, shimmer, noise to harmony ratio, voice turbulence index, habitual pitch, and maximum phonation time (MPT) were assessed as such and in relation to the following endotracheal tube parameters: duration of anesthesia, number of intubation attempts, size of the tube, cuff volume, cuff mean pressure, and the emergence. The association between anesthesia parameters with incidence of vocal complaints and changes in acoustic parameters were examined using logistic and linear regression. Vocal fatigue was associated significantly with the increase in cuff volume and the number of intubation attempts. Throat clearing was associated significantly with the increase in cuff mean pressure. Only the increase in habitual pitch was associated significantly with the increase in cuff volume. The acute short-term effect of endotracheal intubation on voice is significant. The most important endotracheal tube parameters that affect the vocal changes are the cuff mean pressure and volume. The laryngeal contribution to these vocal changes seems to be minimal. All vocal symptoms increased significantly except for globus pharyngeus at 2 hours postoperatively. The acoustic parameters did not change significantly except for a decrease in MPT. At 24 hours postoperatively, all vocal symptoms subsided with no significant difference to baseline value. The habitual pitch increased significantly, and the rest of the parameters remained comparable to baseline value.     

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.     

Vocal Fatigue—Do Young Speech-Language Pathologists Practice What They Preach?

PurposeSpeech-Language Pathologists can be categorized as Level II professional voice users who play the roles of voice therapist or vocal coach to treat voice problems. SLPs may be at the risk of experiencing vocal fatigue due to vocal loading and other contributing factors. The present study was undertaken to find the percentage of SLPs reporting vocal fatigue, the probable factors resulting in vocal fatigue, the measures that are taken to avoid/reduce the occurrence of vocal fatigue, its effect on their professional and personal life and the measures taken to tackle it.ResultsThe results of this study are based on data collected from 142 SLPs and 50 controls using a questionnaire. 71.13% SLPs reported that they experience vocal fatigue. Some of the contributing factors that are mainly reported are long durations of voice use, voice use for recreational purposes, speaking loudly, frequent throat clearing, lack of adequate hydration and working in noisy or air-conditioned environments. The major symptoms reported were dryness in throat, tightness in neck and shoulder, choking sensation, effortful speech and pain in the throat. 59% SLPs reported that vocal fatigue affected their professional life while 44% SLPs reported that it affects their personal life also to varying degrees. Measures taken to avoid/ reduce the occurrence of vocal fatigue included vocal warm up, break in between sessions, and play activities. Only a few SLPs took intervention measures like ENT consultation, voice therapy, and home remedies.ConclusionSLPs are inevitably at high risk of experiencing vocal fatigue which, if left untreated, will lead to organic voice problems. However, many young SLPs who experience vocal fatigue reported vocal abuse, do not follow vocal hygiene program and do not follow evidence-based preventive or intervention practices to treat vocal fatigue.     

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.     

Vocal Parameters of Aerobic Instructors with and without Voice Problems

Aerobic instructors frequently experience vocal fatigue and are at risk for the development of vocal fold pathology. Six female aerobic instructors, three with self-reported voice problems and three without, served as subjects. Measures of vocal function (perturbation and EGG) were obtained before and after a 30-minute exercise session. Results showed that the group with self-reported voice problems had greater amounts of jitter, lower harmonic-to-noise ratios, and less periodicity in sustained vowels overall, but no significant differences in measures of perturbation and EGG were found before and immediately after instruction. Measures of vocal parameters showed that subjects with self-reported voice problems projected with relatively greater vocal intensity and phonated for a greater percentage of time across beginning, middle, and ending periods of aerobic instruction than subjects with no reported voice problems.     

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.     

Work-Related Communicative Profile of Voice Teachers: Effects of Classroom Noise on Voice and Hearing Abilities

PurposeVocal instructors during their normal workday are exposed to high noise levels that can affect their voice and hearing health. The goal of this study was to evaluate the voice and hearing status of voice instructors before and after lessons and relate these evaluations with voice and noise dosimetry taken during lessons.MethodsEight voice instructors volunteered to participate in the study. The protocol included (1) questionnaires, (2) pre/post assessment of voice quality and hearing status, and (3) voice and noise dosimetry during lessons. Acoustic measurements were taken of the unoccupied classrooms.ResultsIn six of eight classrooms, the measured noise level was higher than the safety recommendations set by National Institute for Occupational Safety and Health. The background noise level and the reverberation time in the classrooms were in compliance with the national standard recommendations. We did not find a clear pattern comparing pre- and post-measurements of voice quality consistent among genders. In all subjects, the Sound Pressure Levels mean increased, and the standard deviation of fundamental frequency decreased indicating association to vocal fatigue. Previous studies link these changes to increasing vocal fatigue. The audiometric results revealed seven out of eight instructors have sensorineural hearing loss.ConclusionsThe interaction of the acoustic space and noise levels can contribute to the development of hearing and voice disorders for voice instructors. If supported by larger sample size, the results of this pilot study could justify the need for a hearing and voice conservation program for music faculty.     

Acoustic Measures and Self-reports of Vocal Fatigue by Female Teachers

This study investigated the relation of symptoms of vocal fatigue to acoustic variables reflecting type of voice production and the effects of vocal loading. Seventy-nine female primary school teachers volunteered as subjects. Before and after a working day, (1) a 1-minute text reading sample was recorded at habitual loudness and loudly (as in large classroom), (2) a prolonged phonation on [a:] was recorded at habitual speaking pitch and loudness, and (3) a questionnaire about voice quality, ease, or difficulty of phonation and tiredness of throat was completed. The samples were analyzed for average fundamental frequency (F0), sound pressure level (SPL), and phonation type reflecting alpha ratio (SPL [1-5 kHz]-SPL [50 Hz-1 kHz]). The vowel samples were additionally analyzed for perturbation (jitter and shimmer). After a working day, F0, SPL, and alpha ratio were higher, jitter and shimmer values were lower, and more tiredness of throat was reported. The average levels of the acoustic parameters did not correlate with the symptoms. Increase in jitter and mean F0 in loud reading correlated with tiredness of throat. The results seem to suggest that, at least among experienced vocal professionals, voice production type had little relevance from the point of view of vocal fatigue reported. Differences in the acoustic parameters after a vocally loading working day mainly seem to reflect increased muscle activity as a consequence of vocal loading.     

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.     

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.     

The Voice and Its Care: Survey Findings From Actors'' Perspectives

There is a need for research that would determine how the speech-language-voice pathologist could best be of service to actors who are experiencing vocal dysfunction or in furnishing preventive educational information. A questionnaire investigating interest and knowledge levels of vocal function and dysfunction was distributed to 543 subjects from the Pacific Northwest and British Columbia. A total of 345 questionnaires, including those completed by 79 professional actors, 73 amateur actors, 124 acting students, and 69 controls, were analyzed. Professional actors and amateur actors indicated the highest levels of interest in gaining further knowledge regarding the role of the speech-language pathologist (SLP) and the voice and vocal hygiene. Professional actors and amateur actors also reported higher perceived knowledge levels than the other groups in these areas, although very few claimed to have a thorough knowledge in the areas under investigation. Professional actors answered more knowledge-based questions correctly than amateur actors, acting students, and controls in the areas regarding the role of the SLP and voice and vocal hygiene. However, the professional actors' scores were not significantly higher than amateur actors in either area and were only significantly higher than acting students on the vocal hygiene items. Implications for a preventive approach to vocal health are discussed.     

The Effectiveness of a Voice Treatment Approach for Teachers With Self-Reported Voice Problems

SUMMARY: Teachers are considered the professional group most at risk of developing voice-problems, but limited treatment effectiveness evidence exists. We studied prospectively the effectiveness of a 6-week combined treatment approach using vocal function exercises (VFEs) and vocal hygiene (VH) education with 20 teachers with self-reported voice problems. Twenty subjects were randomly assigned to a no-treatment control (n = 11) and a treatment group (n = 9). Fibreoptic endoscopic evaluation was carried out on all subjects before randomization. Two self-report voice outcome measures were used: the Voice-Related Quality of Life (VRQOL) and the Voice Symptom Severity Scale (VoiSS). A Voice Care Knowledge Visual Analogue Scale (VAS), developed specifically for the study, was also used to evaluate change in selected voice knowledge areas. A Student unpaired t test revealed a statistically significant (P < 0.05) improvement in the treatment group as measured by the VoiSS. There was not a significant improvement in the treatment group as measured by the V-RQOL. The difference in voice care knowledge areas was also significant for the treatment group (P < 0.05). This study suggests that a voice treatment approach of VFEs and VH education improved self-reported voice symptoms and voice care knowledge in a group of teachers.     

Vocal Problems Among Teachers: Evaluation of a Preventive Voice Program

Vocal education programs for teachers may prevent the emergence of vocal disorders; however, only a few studies have tried to evaluate the effectiveness of these preventive programs, particularly in the long term. Two hundred and sixty-four subjects, mostly kindergarten and primary school female teachers, participated in a course on voice care, including a theoretical seminar (120 minutes) and a short voice group therapy (180 minutes, small groups of 20 subjects). For 3 months, they had to either attend the vocal ergonomics norms and, as psychological reinforcement, they had to make out a daily report of vocal abuse, or to follow the given exercises for a more efficient vocal technique, reporting on whether the time scheduled was respected or not. The effectiveness of the course was assessed in a group of 21 female teachers through a randomized controlled study. Evaluation comprehended stroboscopy, perceptual and electro-acoustical voice analysis, Voice Handicap Index, and a course benefit questionnaire. A group of 20 teachers matched for age, working years, hoarseness grade, and vocal demand served as a control group. At 3 months evaluation, participants demonstrated amelioration in the global dysphonia rates (P=0.0003), jitter (P=0.0001), shimmer (P=0.0001), MPT (P=0.0001), and VHI (P=0.0001). Twelve months after the course, the positive effects remained, although they were slightly reduced. In conclusion, a course inclusive of two lectures, a short group voice therapy, home-controlled voice exercises, and hygiene, represents a feasible and cost-effective primary prevention of voice disorders in a homogeneous and well-motivated population of teachers.     

Prevalence of voice symptoms and risk factors in teacher students

Teacher students seem to have low awareness of the vocal demands in their future professions, and students with vocal symptoms are at risk for developing voice disorders during their professional careers. The purpose of the present study was to determine the prevalence of voice problems in teacher students at the very beginning of their education at the university. Of 1636 students approached in the first couple of days, 1250 (76%) answered two questionnaires about voice symptoms, Screen6 and Swedish Voice Handicap Index (Sw-VHI), and one questionnaire about potential risk factors. A majority of the students were women, and their mean age was 23 years (range, 18-52 years). The results showed that 208 of 1250 students (17%) had voice problems, defined as at least two symptoms weekly or more often in Screen6. The proportion of women was larger in the group with voice problems than in the group without voice problems. Significant risk factors for voice problems were vocal fold problems in childhood and adulthood, frequent throat infections, airborne allergy, smoking, hearing problems, previous work as teacher or leader, voice demanding hobbies, and previous speech therapy or voice training. There was a clear association between the number of potential vocal risk factors and the number of voice symptoms. There was also a strong association between the scores of the two questionnaires, the Sw-VHI and the Screen6. Students with voice problems according to Screen6 scored 23.1 (mean Sw-VHI) compared with 7.8 for students without voice problems.     

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.     

Voice source characteristics in Mongolian "throat singing" studied with high-speed imaging technique, acoustic spectra, and inverse filtering.

Mongolian "throat singing" can be performed in different modes. In Mongolia, the bass-type is called Kargyraa. The voice source in bass-type throat singing was studied in one male singer. The subject alternated between modal voice and the throat singing mode. Vocal fold vibrations were observed with high-speed photography, using a computerized recording system. The spectral characteristics of the sound signal were analyzed. Kymographic image data were compared to the sound signal and flow inverse filtering data from the same singer were obtained on a separate occasion. It was found that the vocal folds vibrated at the same frequency throughout both modes of singing. During throat singing the ventricular folds vibrated with complete but short closures at half the frequency of the true vocal folds, covering every second vocal fold closure. Kymographic data confirmed the findings. The spectrum contained added subharmonics compared to modal voice. In the inverse filtered signal the amplitude of every second airflow pulse was considerably lowered. The ventricular folds appeared to modulate the sound by reducing the glottal flow of every other vocal fold vibratory cycle.     

Voice Source Characteristics in Mongolian “Throat Singing” Studied with High-Speed Imaging Technique, Acoustic Spectra, and Inverse Filtering

Mongolian “throat singing” can be performed in different modes. In Mongolia, the bass-type is called Kargyraa. The voice source in bass-type throat singing was studied in one male singer. The subject alternated between modal voice and the throat singing mode. Vocal fold vibrations were observed with high-speed photography, using a computerized recording system. The spectral characteristics of the sound signal were analyzed. Kymographic image data were compared to the sound signal and flow inverse filtering data from the same singer were obtained on a separate occasion. It was found that the vocal folds vibrated at the same frequency throughout both modes of singing. During throat singing the ventricular folds vibrated with complete but short closures at half the frequency of the true vocal folds, covering every second vocal fold closure. Kymographic data confirmed the findings. The spectrum contained added subharmonics compared to modal voice. In the inverse filtered signal the amplitude of every second airflow pulse was considerably lowered. The ventricular folds appeared to modulate the sound by reducing the glottal flow of every other vocal fold vibratory cycle.     

Acoustic Analysis in Asthmatics and the Influence of Inhaled Corticosteroid Therapy

The impact of sustained inhaled corticosteroid (ICS) therapy on the larynx and pharynx was assessed using a prospective, cross-sectional, and investigator-blinded study conducted at the University Hospital Aintree, Liverpool, UK. Forty-six adults recruited from two local general practices and from general ENT clinics at our University hospital were investigated for the study. Patients were allocated to three groups according to ICS use. Laryngeal effects were measured by correlating the results of a vocal performance questionnaire, a respiratory symptom questionnaire, and measurements obtained by computerized speech analysis. Sustained vowels and connected speech were analyzed in normal and asthmatic subjects. Acoustic analysis was correlated with cellular markers of inflammation after biopsy. Regular ICS users had significantly more pharyngeal inflammation and throat discomfort (P < 0.0001). Vocal performance was also worse in this group (P < 0.0001). They were more likely to have hoarseness, weakness of voice, aphonia, sore throat, throat irritation, and cough (P < 0.0001). All these variables were directly related to one another (P < 0.0001). Multiple linear regression analysis showed that jitter was a good objective measure of hoarseness (P < 0.05). Regular ICS users were significantly more likely to have abnormal jitter, shimmer, and closed-phase quotient scores (P < 0.0001). There was no difference between the groups in the observed parameters of inflammation (P > 0.01). A higher pharyngitis score did not correlate with any of the histological markers of inflammation (P > 0.01). Local side effects are more common in asthmatics that use ICS regularly. Measures of laryngeal function are significantly worse in regular ICS users. However, histological markers and oropharyngeal redness are not reliable measures of inflammation.     

Autologous fat implantation for vocal fold scar: A preliminary report

New insights into the anatomy and physiology of phonation, along with technological advances in voice assessment and quantification, have led to dramatic improvements in medical voice care. Techniques to prevent vocal fold scar have been among the most important, especially scarring and hoarseness associated with voice surgery. Nevertheless, dysphonia due to vocal fold scar is still encountered all too frequently. Although it is not generally possible to restore such injured voices to normal, patients with scar-induced dysphonia can usually be helped. Voice improvement is optimized through a team approach. Treatment may include sophisticated voice therapy and vocal fold surgery. Although experience with collagen injection has been encouraging in selected cases (particularly in those involving limited areas of vocal fold scar), there is no consistently successful surgical technique. Attempts to treat massive vocal fold scar, such as may be seen following vocal fold stripping, have been particularly unsuccessful. This paper reports preliminary experience with the implantation of autologous fat into the vibratory margin of the vocal fold of patients with severe, extensive scarring. Using this technique, it appears possible to recreate a mucosal wave and improve voice quality. Additional research is needed.