Vocal intensity in speakers and singers.

Vocal intensity is studied as a function of fundamental frequency and lung pressure. A combination of analytical and empirical models is used to predict sound pressure levels from glottal waveforms of five professional tenors and twenty five normal control subjects. The glottal waveforms were obtained by inverse filtering the mouth flow. Empirical models describe features of the glottal flow waveform (peak flow, peak flow derivative, open quotient, and speed quotient) in terms of lung pressure and phonation threshold pressure, a key variable that incorporates the Fo dependence of many of the features of the glottal flow. The analytical model describes the contributions to sound pressure levels SPL by the vocal tract. Results show that SPL increases with Fo at a rate of 8-9 dB/octave provided that lung pressure is raised proportional to phonation threshold pressure. The SPL also increases at a rate of 8-9 dB per doubling of excess pressure over threshold, a new quantity that assumes considerable importance in vocal intensity calculations. For the same excess pressure over threshold, the professional tenors produced 10-12 dB greater intensity than the male nonsingers, primarily because their peak airflow was much higher for the same pressure. A simple set of rules is devised for predicting SPL from source waveforms.     

Phonotrauma associated with crying

Vocal fold hemorrhage often results in a sudden change in voice quality. Traumatic use of the voice (phonation or singing) is generally thought to be the cause of the vocal fold hemorrhage. The current report reviews three cases in which the traumatic event was crying. In one case, the patient's voice was only used for crying. All three patients were female and all were professional singers. The treatment of these individuals consisted of voice rest and subsequent phonomicrosurgery for lesions associated with the vocal fold hemorrhage. These case studies suggest that crying as a traumatic vocal behavior may result in vocal fold hemorrhage.     

Stroboscopic and acoustic measures of inspiratory phonation

Inspiratory phonation (IP) is the production of voice as air is taken into the lungs. Although IP is promoted as a laryngeal assessment and voice treatment technique, it has been described quantitatively in very few speakers. This study quantified changes in laryngeal adduction, fundamental frequency, and intensity during IP relative to expiratory phonation (EP). We hypothesized that IP would increase laryngeal abduction and fundamental frequency. The experiment was a within-subjects, repeated measures design with each subject serving as her own control. Participants were 10 females (ages 19-50 years) who underwent simultaneous transoral videostrobolaryngoscopy and acoustic voice recording. We found that membranous vocal fold contact decreased significantly during IP relative to EP, while the trends for change of ventricular fold squeeze during IP varied across individuals. Vocal fundamental frequency increased significantly during IP relative to EP, but intensity did not vary consistently across conditions. Without teaching or coaching, changes that occurred during IP did not carry over to EP produced immediately following IP within the same respiratory cycle.     

Use of injectable autologous collagen for correcting glottic gaps: Initial results

We report our results pertaining to the use of injectable autologous collagen for the correction of dysphonia resulting from a glottic gap. To date 20 cases have been treated, 13 of which were for unilateral vocal fold immobility and 7 for sulcus vergeture and/or scar. Collagen is extracted from the skin. Approximately 5 cm2 is necessary to yield 2 ml. Injection must take place in the deep layer of Reinke's space. No patient suffered from any local or general intolerance. The phonatory glottic gap was totally or partially closed. In the paralysis group, the improvements were the following: the median maximum phonation time improved from 5.8 seconds to 11 seconds, the median mean flow rate from 0.13 ml/s to 0.09 ml/s, the median glottic gap from 8.4 to 4.5 ml/dB per s, the median intensity range from 21 to 29 dB, and the median frequency range from 141 to 195 Hz. The spectral analysis layout classification improved from 2 to 3.     

Vocal Warm-up Increases Phonation Threshold Pressure in Soprano Singers at High Pitch

Vocal warm-up is thought to optimize singing performance. We compared effects of short-term, submaximal, vocal warm-up exercise with those of vocal rest on the soprano voice (n = 10, ages 19-21 years). Dependent variables were the minimum subglottic air pressure required for vocal fold oscillation to occur (phonation threshold pressure, Pth), and the maximum and minimum phonation fundamental frequency. Warm-up increased Pth for high pitch phonation (p = 0.033), but not for comfortable (p = 0.297) or low (p = 0.087) pitch phonation. No significant difference in the maximum phonation frequency (p = 0.193) or minimum frequency (p = 0.222) was observed. An elevated Pth at controlled high pitch, but an unchanging maximum and minimum frequency production suggests that short-term vocal exercise may increase the viscosity of the vocal fold and thus serve to stabilize the high voice.     

Phonation Threshold Power in Ex Vivo Laryngeal Models

This study hypothesized that phonation threshold power is measureable and sensitive to changes in the biomechanical properties of the vocal folds. Phonation threshold power was measured in three sample populations of 10 excised canine larynges treated with variable posterior glottal gap, variable bilateral vocal fold elongation, and variable vocal fold lesioning. Posterior glottal gap varied from 0 to 4 mm in 0.5 mm intervals. Bilateral vocal fold elongation varied from 0% to 20% in 5% intervals. Vocal fold lesion treatments included unilateral and bilateral vocal fold lesion groups. Each treatment was investigated independently in a sample population of 10 excised canine larynges. Linear regression analysis indicated that phonation threshold power was sensitive to posterior glottal gap (R² = 0.298, P < 0.001) and weakly to vocal fold elongation (R² = 0.052, P = 0.003). A one-way repeated measures analysis of variance indicated that phonation threshold power was sensitive to the presence of lesions (P < 0.001). Theoretical and experimental evidence presented here suggests that phonation threshold power could be used as a broad screening parameter sensitive to certain changes in the biomechanical properties of the larynx. It has not yet been measured in humans, but because it has the potential to represent the airflow-tissue energy transfer more completely than the phonation threshold pressure or flow alone, it may be a more useful parameter than these and could be used to indicate that laryngeal health is likely abnormal.     

Phonatory control in male singing: A study of the effects of subglottal pressure, fundamental frequency, and mode of phonation on the voice source

This article describes experiments carried out in order to gain a deeper understanding of the mechanisms underlying variation of vocal loudness in singers. Ten singers, two of whom are famous professional opera tenor soloists, phonated at different pitches and different loudnesses. Their voice source characteristics were analyzed by inverse filtering the oral airflow signal. It was found that the main physiological variable underlying loudness variation is subglottal pressure (Ps). The voice source property determining most of the loudness variation is the amplitude of the negative peak of the differentiated flow signal, as predicted by previous research. Increases in this amplitude are achieved by (a) increasing the pulse amplitude of the flow waveform; (b) moving the moment of vocal fold contact earlier in time, closer to the center of the pulse; and (c) skewing the pulses. The last mentioned alternative seems dependent on both Ps and the ratio between the fundamental frequency and the first formant. On the average, the singers doubled Ps when they increased fundamental frequency by one octave, and a doubling of the excess Ps over threshold caused the sound pressure level (SPL) to increase by 8–9 dB for neutral phonation, less if mode of phonation was changed to pressed. A shift of mode of phonation from flow over neutral to pressed was associated with a reduction of the peak glottal permittance i.e., the ratio between peak transglottal airflow to Ps. Flow phonation had the most favorable relationship between Ps and SPL.     

Effect of Fasting on Voice in Women

OBJECTIVE/HYPOTHESIS: To study the effect of fasting on voice in women: abstinence from food and water intake between 14 and 18 hours. STUDY DESIGN: A prospective study on female subjects. MATERIAL AND METHOD: A total of 28 female subjects were included in this study. Their age ranged between 21 and 45 years. Subjects with vocal symptoms or vocal fold lesions were excluded. The subjects were tested when they were not fasting and while fasting after the first week of intermittent fasting during Ramadan. Each subject was first asked about her vocal symptoms and the ease of phonation or phonatory effort. Then each underwent acoustic analysis and laryngeal video-endostroboscopy. RESULTS: Vocal fatigue was the most common reported complaint (53.6%) followed by deepening of the voice (21.4%) and harshness (10.2%). Self-reported phonatory effort was significantly affected by fasting (P value < 0.001). Out of the 28 subjects, 23 had an increase in their phonatory effort. Vocal acoustic parameters did not change markedly except for the maximum phonation time, which decreased significantly. Laryngeal video-endostroboscopy did not reveal any significant changes during fasting. All stroboscopic parameters were the same except for a decrease in the amplitude of the mucosal waves in one subject and the presence of a posterior chink in three subjects. CONCLUSION: Fasting affects voice. There is an increase in the phonatory effort, and vocal fatigue is the most common symptom.     

Effects of laryngeal endoscopy on the vocal performanceof young adult females with normal voices

This study investigated changes in maximum phonation time andacoustic and perceptual measures of voice following topical anesthesia and laryngeal endoscopy with the flexible endoscope. Forty-four females, aged 18–33 years and with normal voices, performed four vocal tasks: (a) 3-second /i/ prolongation, (b) maximum phonation time on /i/, (c) stepwise scale-singing, and (d) reading a standard passage. Subjects performed these tasks prior to anesthesia, after anesthesia, and again during laryngeal endoscopy. Voice samples were analyzed for jitter, shimmer, harmonic-to-noise ratio, speaking fundamental frequency, maximum phonational frequency range, maximum phonation time, harshness, and breathiness. Results demonstrated significant reductions in maximum phonational frequency range following anesthesia and, during laryngeal endoscopy, reductions in maximum phonation time and increases in speaking fundamental frequency, minimum fundamental frequency on scale-singing, and breathiness. Clinicians using laryngeal endoscopy for evaluation and management of vocal dysfunction should, therefore, consider the possible effects of these procedures on vocal functioning.     

Effects of lung volume on the glottal voice source

According to experience in voice therapy and singing pedagogy, breathing habits can be used to modify phonation, although this relationship has never been experimentally demonstrated. In the present investigation we examine if lung volume affects phonation. Twenty-four untrained subjects phonated at different pitches and degrees of vocal loudness at different lung volumes. Mean subglottal pressure was measured and voice source characteristics were analyzed by inverse filtering. The main results were that with decreasing lung volume, the closed quotient increased, while subglottal pressure, peak-to-peak flow amplitude, and glottal leakage tended to decrease. In addition, some estimates of the amount of the glottal adduction force component were examined. Possible explanations of the findings are discussed.     

Characteristics of vocal fold adduction related to voice onset

This study examined whether vocal fold kinematics prior to phonation differed between hard (glottal), normal, or breathy onsets in men and women. Glottal landmarks were identified and digitized from videotape recorded with a rigid laryngoscope during different voice onset types. Significant linear relationships (p 0.0055) were found among onset types on measures of (a) gesture duration when moving from 80% to 20% of maximum distance during adduction, (b) maximum velocity, (c) duration between the completion of adduction and phonation onset, and (d) ratios of maximum velocity to maximum distance between the vocal processes, an estimate of stiffness. The gesture duration was greatest for breathy onsets and least for hard onsets, while the maximum velocity, latency between adduction and phonation onset, and estimated stiffness were greatest for hard onsets and least for breathy onsets. The results suggest that one trajectory seems to be used with increases in gesture duration being accompanied by decreases in articulator stiffness when moving from hard to normal to breathy voice onset types.     

Pressure-flow relationships during phonation as afunction of adduction

Pressure-flow relationships were obtained for five excised caninelarynges. Simultaneous recordings were made of average subglottal pressure, average air flow, and the electroglottograph at various levels of adduction and vocal fold lengths. The level of adduction was controlled by positioning the arytenoid cartilages via laterally imbedded three-prong attachments and by the use of intra-arytenoid shims. Adduction was quantified by measuring the vocal process gap. Results indicated a linear pressure-flow relationship within the experimental range of phonation for each level of adduction. Differential glottal resistance increased as the vocal process gap was reduced. A model is presented for the differential resistance as a hyperbolic function of vocal process gap. The pressure-flow relationship and the model can be used in computer simulations of speech production and for clinical insight into the aerodynamic function of the human larynx.     

A comparison of type I thyroplasty and arytenoid adduction

Glottal incompetence is a common laryngeal disorder causing impaired swallowing and phonation. The resultant voice has been characterized as weak and breathy with a restricted pitch range. Currently, medialization thyroplasty and arytenoid adduction are two of the surgical treatments for patients with glottal incompetence. However, few studies have evaluated the changes in objective measures of speech with type I thyroplasty and arytenoid adduction. In this study, 59 patients with glottal incompetence underwent either type I thyroplasty or arytenoid adduction. Acoustic (jitter, shimmer, and harmonics-to-noise ratio) and aerodynamic (airflow, subglottic pressure, and glottal resistance) measures were obtained both pre- and postoperatively. No significant differences were found among acoustic or aerodynamic measures for operation type. However, a significant pre/postsurgery effect was observed for translaryngeal airflow. In addition, no significant differences were found among the measures for patients with traditional compared with nontraditional operative indications. Patients who developed glottal insufficiency due to previous laryngeal surgery (e.g., vocal fold stripping) demonstrated no statistically significant improvement in acoustic or aerodynamic measures following thyroplasty or arytenoid adduction.     

Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results.

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.     

Objective Analysis of Vocal Warm-Up with Special Reference to Ergonomic Factors

Vocal warm-up was studied in terms of changes in voice parameters during a 45-minute vocal loading session in the morning. The voices of a randomly chosen group of 40 female and 40 male young students were loaded by having them read a novel aloud. The exposure groups (5 females and 5 males per cell) consisted of eight combinations of the following factors: (1) low (25 +/- 5%) or high (65 +/- 5%) relative humidity of ambient air; (2) low [< 65 dB(SPL)] or high [> 65 dB(SPL)] speech output level during vocal loading; (3) sitting or standing posture during vocal loading. Two sets of voice samples were recorded: a resting sample before the loading session and a loading sample after the loading session. The material recorded consisted of /pa:ppa/ words produced normally, as softly and as loudly as possible in this order by all subjects. The long /a/ vowel of the test word was inverse-filtered to obtain the glottal flow waveform. Time domain parameters of the glottal flow [open quotient (OQ), closing quotient (CQ), speed quotient (SQ), fundamental frequency (F0)], amplitude domain parameters of the glottal flow [glottal flow (fAC) and its logarithm, minimum of the first derivative of the glottal flow (dpeak) and its logarithm, amplitude quotient (AQ), and a new parameter, CQAQ], intraoral pressure (p), and sound pressure level (SPL) values of the phonations were analyzed. Voice range profiles (VRP) and the singer's formant (g/G, a/A, cl/c, e1/e, g1/g for females/males) of the loud phonation were also measured. Statistically significant differences between the preloading and postloading samples could be seen in many parameters, but the differences depended on gender and the type of phonation. In females the values of CQ, AQ, and CQAQ decreased and the values of SQ and p increased in normal phonations; the values of fAC, dpeak, and SPL increased in soft phonations; the values of AQ and CQAQ decreased in loud phonations; the harmonic energy in the singer's formant region increased significantly at every pitch. In males the values of OQ and AQ decreased and the values of dpeak, F0, p, and SPL increased in normal phonations; the values of fAC and p increased in soft phonations. The changes could be interpreted as signs of a shift toward hyperfunctional voice production. Low humidity was associated with more hyperfunctional changes than high humidity. High output was associated with more hyperfunctional changes than low output. Sitting position was associated with an increasing trend at both margins of male VRP, whereas the case was the opposite for standing position.     

Objective Voice Quality Analysis Before and After Onset of Unilateral Vocal Fold Paralysis

This study was designed to investigate objective voice quality measurements in unilateral vocal fold paralysis (UVFP) by eliminating intersubject variability. To our knowledge this is the first report objectively analyzing paralytic dysphonia as compared to the same voice before onset of UVFP. The voices of two male subjects were prospectively recorded before and after the onset of iatrogenic UVFP (thoracic surgery).The following acoustic measurements of the vowel /a/ were performed using the CSL and MDVP (Kay Elemetrics): jitter, shimmer, harmonics-to-noise ratio, cepstral peak prominence, the relative energy levels of the first harmonic, the first formant and the third formant, the spectral slope in the low-frequency zone (0-1 kHz and 0-2 kHz), and the relative level of energy above 6 kHz. Distribution of spectral energy was analyzed from a long-term average spectrum of 40 seconds of text. Laryngeal aerodynamic measurements were obtained for one patient before and after onset of paralysis using the Aerophone II (Kay Elemetrics). Pitch and amplitude perturbation increased secondary to UVFP, while the harmonics-to-noise ratio and the cepstral peak prominence decreased. A relative increase in the mid-frequency and high-frequency ranges and a decrease in the low-frequency spectral slope were observed. Mean airflow rate and intraoral pressure increased, and glottal resistance and vocal efficiency decreased secondary to UVFP. The findings of this self-paired study confirm some but not all the results of previous studies. Measures involving the fundamental and the formants did not corroborate previous findings. Further investigation with vocal tract modeling is warranted.     

Sarcoidosis Presenting as Bilateral Vocal Fold Paralysis

Sarcoidosis with cranial polyneuritis and mediastinal granulomatous compression as a cause of unilateral left vocal fold paralysis has been reported infrequently. No case of sarcoidosis causing bilateral vocal fold paralysis in the abducted position has been reported in the Otolaryngology/Voice literature. Vocal fold function can be impacted in sarcoidosis by direct laryngeal involvement or by neural pathways. In the patient described in this case, sarcoid cranial polyneuritis coupled with bilateral paratracheal and mediastinal adenopathy resulted in bilateral vocal fold paralysis. This patient had a dramatic response to treatment with steroids. Sarcoidosis should be included in the differential diagnosis of unilateral or bilateral vocal fold paralysis.     

The effect of head position on glottic closure in patients with unilateral vocal fold paralysis

The present study was designed to assess the effect of head position on glottic closure as reflected in airflow rates (open quotient and maximum flow declination rate), in patients with unilateral vocal fold paralysis. Ten patients, 2 males and 8 females ranging in age from 40 to 75, with a mean age of 57.3, served as subjects. Airflow measures were taken during sustained phonation of two vowels (/i/ and /a/) in 3 head positions (center, right, left). Vowels /i/ and /a/ were produced at subject's comfortable pitch and loudness, with random ordering of both vowel order and head orientation. Subjects were trained to focus eye gaze on right and left markers (70-degree angle) and a central marker at eye level directly in front of the subject. Theoretically, if turning the head during phonation alters the laryngeal anatomic relationship by bringing the vocal folds in closer proximity to one another, then airflow rate should lessen. Our results indicate that head position does not improve glottic closure in these patients, which is in contrast to previously published research.(1) Our results question the utility and underlying theoretical construct for the use of head turning as a therapeutic technique for improvement of voice in patients with unilateral vocal fold paralysis.     

Investigation of Anti-Hyaluronidase Treatment on Vocal Fold Wound Healing

SUMMARY: Phytochemical constituents of medicinal plants demonstrate inhibition of tissue and bacterial hyaluronidase. Echinacoside is a caffeoyl conjugate of Echinacea with known anti-hyaluronidase properties. The purpose of this study was to investigate the wound healing effects of Echinacea on vocal fold wound healing and functional voice outcomes. Pig animal model. Methods: Vocal fold injury was induced in 18 pigs by unilateral vocal fold stripping. The uninjured vocal fold served as control. Three groups of six pigs randomly received a topical application of 300, 600, or 1,200 mg of standardized Echinacea on the injured side. Animals were euthanized after 3, 10, and 15 days of wound healing. Phonation threshold pressure and vocal economy measurements were obtained from excised larynges. Treatment outcomes were examined by comparing the animals receiving treatment with a set of 19 untreated and 5 historical controls. Treatment effects on wound healing were evaluated by histologic staining for hyaluronan and collagen. Treated larynges revealed improved vocal economy and phonation threshold pressure compared with untreated larynges. Histologically, treated vocal folds revealed stable hyaluronan content and no significant accumulation of collagen compared with control. Findings provide a favorable outcome of anti-hyaluronidase treatment on acute vocal fold wound healing and functional measures of voice.