Laryngeal image biofeedback for voice disorder patients

Laryngeal image biofeedback (LIB) is a new therapeutic technique for selected patients with abnormal vocal production. In particular, patients with false vocal fold phonation or psychogenic aphonia/dysphonia who have failed traditional voice therapy have been found to respond to LIB. The apparatus and procedure used for this technique are presented along with suggested criteria for patient selection.     

Effects of voice therapy on the voice range profiles of dysphonic patients

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.     

Documentation of progress in voice therapy: perceptual, acoustic, and laryngostroboscopic findings pretherapy and posttherapy

The effect of voice therapy in a group of chronically dysphonic patients with diverse diagnoses was studied according to the normal clinical procedure. The results were evaluated by perceptual rating, acoustic analysis, and the assessment of laryngostroboscopic recordings. Although the group effects for the differences between posttherapy and pretherapy data were clearly significant, the effects of voice therapy for the individual patients were divergent. For each of the three evaluation methods, a significant improvement was found for about 40% to 50% of the patients. The diversity of the therapy outcome among the patients could not be explained by the pretherapy status nor by age, gender, or diagnosis groups. In general, the perceptual ratings and the acoustic parameters from the baseline data were clearly correlated. However, these characterizations of the voice were only moderately correlated with the visual evaluation of the vocal fold vibrations. Relations among the three evaluation tools for the changes caused by voice therapy were very weak. The low correlation among the three methods suggests that a multidimensional evaluation of the voice is necessary to give a complete picture of the therapy outcome.     

Longitudinal voice changes: Facts and interpretation

To study intraindividual vocal changes over time, a longitudinal research design is preferred. However, this procedure reveals many restrictions concerning methodology and interpretation, especially in cases of (semi)retrospective studies. This is illustrated by an investigation of the voices of 20 male Dutch-speaking reporters of the Belgian Radio Broadcasting service. These men read the same text they did 30 years previously for a digital registration. After having copied the high-quality archival recordings digitally, the results of the acoustical analysis of both recordings (recent and archival) were compared. This was done to search for the contribution of aging. In this article we report on the results of the speaking fundamental frequency (SFF) and the standard deviation of the SFF (SFFsd) as a measure of intraindividual variability, and the voice onset time (VOT). Results indicate that, in connected speech, SFF decreased, SFFsd became more restricted, and the VOT increased strongly. The interpretation of the results compels us to conclude that it is extremely difficult to define the specific effect of aging alone, since it is only one element among many others, including methodological concerns.     

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.     

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery

Laryngeal framework surgery can change the position and tensionof the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias. Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx . Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.     

Relationship Between Weight, Speaking Fundamental Frequency, and the Appearance of Phonational Gaps in the Adolescent Male Changing Voice

This 12-month prospective longitudinal study used acoustic analysis to identify phonational gaps in the vocal range of adolescent boys undergoing voice change and to investigate the relationship between the appearance of phonational gaps, weight gain, and changes in speaking fundamental frequency (SF0). Eighteen pubescent boys were recorded producing three descending and three ascending glides over their physiological voice range using the vowel "ah." Recordings were digitized over the range 0-16 kHz and then analyzed to determine both the frequency range and appearance and frequency characteristics of the phonational gaps. Data were plotted against changes in weight and SF0 both as an indicator of pubertal development and to test the hypothesis that changes in weight and SF0 were related to the appearance of phonational gaps. Results indicated that minimum F0 decreased significantly over the time period and phonational gaps increased significantly, but there were no significant changes in maximum F0 or range. Individual data indicated the initial appearance of a lower-frequency gap followed by a higher-frequency gap before the long-term establishment of a midrange gap. At time 5, all boys in the weight range 42.7-44.9 kg had either low- or high-range gaps. The SF0 for this group varied from 117 to 216 Hz. All boys heavier than 54.8 kg had highly variable phonational gaps. SF0 range for this group was 99.5-151 Hz. Transitory low- then high-frequency phonational gaps appeared before the establishment of a midrange phonational gap. In this study, these phonational gaps were associated with certain weight ranges and rapid weight gain, with changes to boys' speaking voices, and with loss of ability to use the mid- and falsetto vocal range.     

The treatment of essential voice tremor with botulinum toxin A: A longitudinal case report

The purpose of this study was to evaluate the effects of bilateral botulinum toxin injection into the thyroarytenoid (TA) muscles of a patient with essential voice tremor. Acoustic and aerodynamic data were collected weekly over a 16-week period. Flexible nasolaryngoscopy was performed prior to injection and 2, 6, 10, and 16 weeks postinjection. Perceptual analyses of the acoustic and nasolaryngoscopic data were performed. A reduction in frequency tremor and, to a lesser extent, amplitude tremor was observed during the 1-10 week period. Estimated laryngeal resistance decreased after injection and was accompanied in perceptual measures by a reduction in vocal effort, laryngeal tremor, and supraglottic hyperfunction. Essential voice tremor can be successfully attenuated with bilateral percutaneous injection of botulinum toxin A into the vocalis muscle.     

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.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Management of Vocal Fold Scar with Autologous Fat Implantation: Perceptual Results

Vocal fold scar disrupts the mucosal wave and interferes with glottic closure. Treatment involves a multidisciplinary approach that includes voice therapy, medical management, and sometimes surgery. We reviewed the records of the first eight patients who underwent autologous fat implantation for vocal fold scar. Information on the etiology of scar, physical findings, and prior interventions were collected. Videotapes of videostroboscopic findings and perceptual voice ratings [Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS)] were randomized and analyzed independently by four blinded observers. Etiology of scar included mass excision (7), vocal fold stripping (3), congenital sulcus (2), and hemorrhage (1). Prior surgical procedures performed included thyroplasty (1), autologous fat injection (9), excision of scar (2), and lysis of adhesions (2). Strobovideolaryngoscopy: Statistically significant improvement was found in glottic closure, mucosal wave, and stiffness (P = 0.05). Perceptual ratings (GRBAS): Statistically significant improvement was found in all five parameters, including overall Grade, Roughness, Breathiness, Asthenia, and Strain (P = 0.05). Patients appear to have improved vocal fold function and quality of voice after autologous fat implantation in the vocal fold. Autologous fat implantation is an important adjunctive procedure in the management of vocal fold scar, and a useful addition to the armamentarium of the experienced phonomicrosurgeon.     

Use of acupuncture for the treatment of adductor spasmodic dysphonia: a preliminary investigation

Ten subjects with adductor spasmodic dysphonia participated in a study examining the effects of an acupuncture treatment protocol on their voice disorder. Treatment consisted of eight sessions, and it was designed and performed by two physicians certified in acupuncture. Voice characteristics were evaluated pretreatment and posttreatment using the CSL Motor Speech Profile (MSP), Unified Spasmodic Dysphonia Rating Scale, and Voice Handicap Index (VHI). Subjects also answered a posttreatment questionnaire regarding their experience. Significant pretreatment and posttreatment differences occurred for some MSP measures. Significant differences were found on all three subtests of the VHI, and the average total scores pretreatment and posttreatment differed by 17 points (considered significant according to VHI standardization). Seven of 10 subjects reported improvements in voice production, although expert raters did not detect perceptual changes in voice quality. Possible reasons for the discrepancies between objective measures and self ratings, and implications for further research, are discussed.     

Resonance strategies for the belting style: Results of a single female subject study

This study explores resonance strategies used for the belting style and associated vocal fold vibratory patterns, for the vowels /e/, /a/, /i/, and /u/ on G4 and B4-flat. Acoustic spectra of belted vowels and their unoptimized, "speech-like" equivalents were compared. Vocal fold vibratory patterns were quantified using electroglottography. Results show that /a/ is inherently suitable for belting and requires no adjustment. For /e/, F2-H5 tuning was observed. For /i/, F1 was detuned from H1, enhancing also H2. For /u/, both F1 and F2 were raised to accomplish F2-H3 tuning. These results show that the loud, bright sound of the belting style is achieved by the implementation of resonance strategies that enhance higher harmonics. Electroglottography revealed that resonance strategies also result in raising the closed quotient (CQ) above 52%, an apparent threshold value for belting.     

Disrupted functional connectivity in social anxiety disorder: a resting-state fMRI study

Dysfunction of the corticolimbic circuitry has been highlighted in social anxiety disorder (SAD) during social stimuli. However, few studies have investigated functional connectivity in SAD during the resting state, which may improve our understanding of SAD pathophysiology. The aim of this study was to investigate whether whole-brain functional connectivity might be aberrant in SAD patients, and if so, whether these changes are related to the measured clinical severity. Seventeen SAD patients and 19 healthy controls participated in resting-state functional magnetic resonance imaging. The brain was first divided into 90 paired brain regions and functional connectivity was then estimated by temporal correlation between each of these regions. Furthermore, connections that were significantly disrupted in SAD patients were correlated with clinical severity measured using the Liebowitz Social Anxiety Scale. Compared with healthy controls, SAD patients showed decreased positive connections within the frontal lobe and decreased negative connections between the frontal and occipital lobes. In particular, the weaker negative connections between the frontal lobe, which mainly involved the right median prefrontal cortex, and the occipital lobe had a significant positive correlation with the severity of SAD symptoms. The results support the hypothesis that some abnormalities of functional connectivity exist in SAD patients, which relate to the frontal cortex and occipital cortex. In addition, decreased functional connectivity between the frontal and occipital lobes and within the frontal lobe might be related to abnormal information processing and reflect disturbed neural organization resulting in defective social cognition, which could represent an early imaging biomarker for SAD.     

Qualitative and quantitative analysis of voice onset by means of a multidimensional voice analysis system (MVAS) using high-speed imaging

High-speed filming is one of the most informative methods for assessing voice physiology data. Tracing high-speed images of the glottis provides quantitative parameters such as the glottal area and the glottal width function. By way of example, a number of studies are discussed which extract quantitative data from high-speed images showing voice onsets. Furthermore, a new computer system (MVAS; multi-dimensional voice analysis system) is presented that synchronously displays a laryngoscopic high-speed film, the electroglottographical signal, and several acoustic analyses of the recorded voice sample. The automatic measurement of glottal width and glottal area from the laryngoscopic images is also provided. Looking at former studies and our analyses of voice onsets reveals a tremendous intersubject and even intrasubject variability (different prephonatory closure, different time span until full amplitude is reached, different open quotient).