Assessing outcomes for dysphonic patients

This study was designed to evaluate a disease-specific outcome measure for patients with selected voice disorders and to relate this instrument to a standardized quality of life measurement. In addition, the study attempts to document the degree of handicap for dysphonia patients globally, between different vocal pathologies, and in comparison to other chronic diseases. In this prospective, observational study, 260 adult patients evaluated for alterations of voice completed a general quality of life measure (the Medical Outcomes Trust Short Form 36-Item[SF-36]) and a voice-specific instrument (Voice Handicap Index [VHI]) pretreatment.

The highest correlation was between the social functioning score of the SF-36and the total score of the VHI and the physical, emotional, and functional subscales (p < 0.001) of the VHI. Significant correlation was also obtained for the SF-36 domains mental health (p < 0.01), general health (p < 0.01), and role functioning emotional (p < 0.017) with the three VHI domains and the total VHI score. Patients had significantly lower scores than the general U.S. population in five of the eight domains of SF-36. Patients with vocal fold paralysis had the highest level of pretreatment disability as measured on both the VHI and SF-36 among voice patients. The patients with dysphonia had a lower level of physical functioning than the patients with chronic sinusitis (p < 0.01), reflecting a greater handicap. In addition, the dysphonia group had lower levels of social functioning than the angina (p < 0.01) and sciatica (p < 0.01) groups and a lower score for mental health than the angina group (p < 0.01).

The SF-36 correlates with the VHI in the domains of social functioning,mental health, and role functioning emotional. The baseline handicap for voice disorders represents a significant disability even in comparison to conditions such as angina pectoris, sciatica, and chronic sinusitis.     

Variations in adductor spasmodic dysphonia:Acoustic evidence

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

Control of Fundamental Frequency in Dysphonic Patients During Phonation and Speech

PurposeThe pitch-shift reflex (PSR) is the adaptation of the fundamental frequency during phonation and speech and describes the auditory feedback control. Speakers without voice and speech disorders mostly show a compensation of the pitch change in the auditory feedback and adapt their fundamental frequency to the opposite direction. Dysphonic patients often display problems with the auditory perception and control of their voice during therapy. Our study focuses on the auditory and kinesthetic control mechanisms of patients with muscle tension dysphonia (MTD) and speakers without voice and speech problems. Main purpose of the study is the analysis of the functionality of the control mechanisms within phonation and speech between patients with MTD and normal speakers.MethodSixty-one healthy subjects (17 male, 44 female) and 22 patients with MTD (7 male, 15 female) participated following two paradigms including a sustained phonation (vowel /a/) and speech ([‘mama]). Within both paradigms the fundamental frequency of the auditory feedback was increased synthetically. For the analysis of the PSR the electroencephalogram, electroglottography, the voice signal, and the high-speed endoscopy data were recorded simultaneously. The PSR in the electroencephalogram was detected via the N100 and the mismatch negativity. Statistical tests were applied for the detection of the PSR in the physiological response within the electroglottography, voice, and high-speed endoscopy signals. The results were compared between both groups.ResultsNo differences were found between the controls and patients with MTD regarding latency and magnitude of the perception of the pitch shift in both paradigms, but for the magnitude of the behavioral response. Differences also could be found for both groups between the “no pitch” and “pitch” condition of the two paradigms regarding vocal fold dynamics and voice quality. Patients with MTD showed more vibrational irregularities during the PSR than the controls, especially regarding the symmetry of vocal fold dynamics.ConclusionPatients with MTD seem to have a disturbed interaction between the auditory and kinesthetic feedback inducing the execution of an overriding behavioral response.     

The Relationship Between Perceptual Evaluation and Objective Multiparametric Evaluation of Dysphonia Severity

SUMMARY: The purpose of this study was to investigate the usefulness of the Dysphonia Severity Index (DSI) as an objective multiparametric measurement in assessing dysphonia. The DSI was compared with the score on Grade of the GRBAS scale. Investigated was also whether the DSI is related to severity of dysphonia, which was represented by different diagnosis groups. Furthermore, it was investigated whether the DSI can differentiate between a group of patients and a control group. A total of 294 patients with different voice pathologies were included. A control group consisted of 118 volunteers without any voice complaints. The voices of all participants were perceptually evaluated on Grade, and the DSI was measured. The groups of patients with voice complaints have a lower DSI and higher scores on Grade than the control group. The DSI was significantly lower when the score on Grade was higher. The DSI discriminates between patients with nonorganic voice disorders, vocal fold mass lesions, and vocal fold paresis/paralysis. To determine whether the DSI discriminates between patients and controls, the sensitivity and specificity for different DSI cutoff points were calculated. With a DSI cutoff of 3.0, maximum sensitivity (0.72) and specificity (0.75) were found. We conclude that the DSI is a useful instrument to objectively measure the severity of dysphonia.     

Cochlear Implant Users’ Vocal Control CorrelatesAcross Tasks

Cochlear implants (CIs) provide access to auditory information that can affect vocal control. For example, previous research shows that, when producing a sustained vowel, CI users will alter the pitch of their voice when the feedback of their own voice is perceived to shift. Although these results can be informative as to how perception and production are linked for CI users, the artificial nature of the task raises questions as to the applicability of the results to real-world vocal productions. To examine how vocal control, when producing sustained vowels, relates to vocal control for more ecologically valid tasks, 10 CI users’ vocal control was measured across two tasks: (1) sustained vowel production, and (2) singing. The results found that vocal control, as measured by the variability of the participants’ fundamental frequency, was significantly correlated when producing sustained vowels and when singing, although variability was significantly greater when singing. This suggests that, despite the artificial nature of sustained vowel production, vocal control on such tasks is related to vocal control for more ecologically valid tasks. However, the results also suggest that vocal control may be overestimated with sustained vowel production tasks.     

Comfortable effort level revisited

The purpose of this study was to measure the variability of frequency and intensity of speech, using multiple voice samples obtained over a period of time at a speaker's “comfortable effort level.” Variability in vocal output within and across several experimental sessions was assessed from measures of speaking fundamental frequency (SFF) and vocal intensity for utterances repeated three times a day over a 3-day period. Three distinct age groups of men and women—young, middle-aged and elderly—repeated the vowel /a/, read a standard passage, and spoke extemporaneously during each experimental session. Results indicated that variability in SFF and intensity were present across experimental sessions, age groups, gender, and speaking samples. Generally, group means indicated that ±1 semitone of variability for SFF and 2 db sound pressure level (SPL) variation in vocal intensity from any one experimental session to the next could be expected; individual variations within any group may reach two semitones and 6 db SPL.     

Voice Analysis of Postlingually Deaf Adults Pre- and Postcochlear Implantation

Objectives

To ascertain whether cochlear implantation (CI), without specific vocal rehabilitation, is associated with changes in perceptual and acoustic vocal parameters in adults with severe to profound postlingual deafness.

Hypothesis

Merely restoring auditory feedback could allow the individual to make necessary adjustments in vocal pattern.

Study Design

Prospective and longitudinal.

Methods

The experimental group composed of 40 postlingually deaf adults (20 males and 20 females) with no previous laryngeal or voice disorders. Participants’ voices were recorded before CI and 6–9 months after CI. To check for chance modifications between two evaluations, a control group of 12 postlingually deaf adults, six male and six female, without CI was also evaluated. All sessions composed of the recording of read sentences from Consensus Auditory-Perceptual Evaluation of Voice and sustained vowel /a/. Auditory and acoustic analyses were then conducted.

Results

We found a statistically significant reduction in overall severity, strain, loudness, and instability in auditory analysis. In vocal acoustic analysis, we found statistically significant reduction fundamental frequency (F0) values (in male participants) and F0 variability (in both genders). The control group showed no statistically significant changes in most vocal parameters assessed, apart from pitch and F0 (in female participants only). On comparing the interval of variation of results between the experimental and control groups, we found no statistically significant difference in vocal parameters between CI recipients and nonrecipients, with the exception of F0 variability in male participants.

Conclusions

The patients in our sample showed changes in overall severity, strain, loudness, and instability values, and reductions in F0 and its variability. On comparing the variation of results between the groups, we were able to prove in our study that implant recipients postlingually deaf adults (experimental group), without specific vocal rehabilitation, differed from nonrecipients (control group) in loudness and F0 variability sustained vowel /a/ in male participants.     

The effect of superior auditory skills on vocal accuracy

The relationship between auditory perception and vocal production has been typically investigated by evaluating the effect of either altered or degraded auditory feedback on speech production in either normal hearing or hearing-impaired individuals. Our goal in the present study was to examine this relationship in individuals with superior auditory abilities. Thirteen professional musicians and thirteen nonmusicians, with no vocal or singing training, participated in this study. For vocal production accuracy, subjects were presented with three tones. They were asked to reproduce the pitch using the vowel /a/. This procedure was repeated three times. The fundamental frequency of each production was measured using an autocorrelation pitch detection algorithm designed for this study. The musicians' superior auditory abilities (compared to the nonmusicians) were established in a frequency discrimination task reported elsewhere. Results indicate that (a) musicians had better vocal production accuracy than nonmusicians (production errors of 1/2 a semitone compared to 1.3 semitones, respectively); (b) frequency discrimination thresholds explain 43% of the variance of the production data, and (c) all subjects with superior frequency discrimination thresholds showed accurate vocal production; the reverse relationship, however, does not hold true. In this study we provide empirical evidence to the importance of auditory feedback on vocal production in listeners with superior auditory skills.     

The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign masses

Hard or abrupt glottal attack (HGA) is one of the vocal behaviors often associated with benign lesion of the vocal folds. This study was designed to determine whether the frequency of HGA was different in hyperfunctional voice patients with and without vocal fold masses. One hundred and forty-seven subjects were studied. All subjects received a complete otolaryngological evaluation including strobovideolaryngoscopy, objective voice measures, and evaluation by a speech-language pathologist. Thirty-two patients were diagnosed with muscle tension dysphonia (19 male, 13 female) without vocal fold masses. Fifty-seven patients were diagnosed with unilateral vocal fold masses (29 male, 28 female), most of which were cysts. Fifty-eight patients were diagnosed with bilateral vocal fold masses (13 male, 45 female). Of the 45 females with bilateral vocal fold masses. 26 had a vocal cyst and reactive nodule and 19 had bilateral vocal fold nodules. The control group was balanced and matched based on sex and on percentage of singers and nonsingers. It consisted of 49 subjects with no vocal fold pathology (20 male, 29 female). The group was composed of professional speakers, singers, and nonprofessional speakers. All voice disordered groups demonstrated higher frequencies of HGA than the control group. Differences were found between the male and female subjects in this study. No differences were found between the various disorders. Differences were also found between the subgroups of bilateral masses, where the bilateral nodules group presented a higher frequency of HGA than the cyst and contralateral reactive nodule.     

Aerodynamic Analysis of Male-to-Female Transgender Voice

The attainment of a feminine-sounding voice is a highly desirable goal among male-to-female transgender (MFT) persons, but this goal may be difficult for many to accomplish. The characteristics associated with a feminine vocal quality include increases in fundamental frequency and in vocal breathiness. In this study, we used inverse-filtering of the airflow signal to indirectly assess vocal fold function in 13 MFT persons. Each participant was asked to sustain the vowel /a/ first in her biological male voice and then again in her female voice. In addition, these vowel productions were compared with vowels produced by age-matched biologic women and men. The results of the study revealed a significant increase in maximum flow declination rate during female voice production. Perceptual ratings of a feminine voice were associated with a fundamental frequency (F0) of 180 Hz or greater, although F0 did not differ significantly between male and female voice production. These results are discussed relative to the mechanisms that obtained a feminine-sounding voice.     

Reliability of single sample experimental designs: Comfortable effort level

This study was designed to ascertain the intrasubject variabilityacross multiple recording sessions-most often disregarded in reporting group mean data or unavailable because of single sample experimental designs. Intrasubject variability was assessed within and across several experimental sessions from measures of speaking fundamental frequency, vocal intensity, and reading rate. Three age groups of men and women-young, middle-aged, and elderly—repeated the vowel /a/, read a standard passage, and spoke extemporaneously during each experimental session. Statistical analyses were performed to assess each speaker's variability from his or her own mean, and that which consistently varied for any one speaking sample type, both within or across days. Results indicated that intrasubject variability was minimal, with approximately 4% of the data exhibiting significant variation across experimental sessions.     

The impact of preventive voice care programs for training teachers: A longitudinal study

The teaching profession puts vocal health at a higher risk than other professions, causing what is referred to as "occupational dysphonia." There is a need for primary prevention of "occupational dysphonia" among the teaching profession, where good vocal health is promoted before a problem occurs. To investigate the primary prevention of occupational dysphonia among teachers, this study uses a sample population of 55 training teachers, in the postgraduate certificate of education (PGCE) course at the University of Ulster, Northern Ireland, who were randomly assigned to three training groups: control, indirect, and direct. The vocal performance of the three groups was measured at two points over the year of the PGCE course: first before any teaching or training began, and again after the first teaching practice. The training for the indirect and direct groups was provided before the teaching practices. Acoustic and self-perceptual measurements were used to assess the multidimensional outcomes. The results demonstrate interesting trends, that although not found to be significant, are approaching significance. Their voices will be reevaluated at a third point of measurement. The acoustic measurement reflects deterioration from time 1 to time 2 for the control group, improvement for the direct group, and no change for the indirect group, indicating that the training has proved beneficial. The self-rating scores vary in agreement with the acoustic results, presenting interesting findings. The findings of this study will be of benefit to teachers, their educators, voice therapists, health promoters, and human resource personnel.     

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.     

Aerodynamic and acoustic characteristics of the adult AfricanAmerican voice

Laryngeal aerodynamic and acoustic characteristics of African American voice production were examined from vowel samples produced by ten adult female and ten adult male speakers. The data were compared with that for a control group consisting of ten adult female and ten adult male White speakers, matched for age, height, and weight. All measures were analyzed using Cspeech 4.0. Aerodynamic measurements, extracted from a glottal airflow waveform, included maximum flow declination rate, alternating glottal airflow, minimum glottal airflow, and airflow open quotient. Acoustic measures included fundamental frequency and sound pressure level. No significant mean differences between the African American and White speakers were found, except for maximum-flow declination rate. The White speakers produced significantly higher declination rates than the African American speakers. The factor of sex for the African American speakers was statistically significant for the measures of maximum-flow declination rate, alternating glottal airflow, open quotient, and fundamental frequency, consistent with the functioning of the White speakers. The results suggest that during vowel production, where the vocal tract is in a fairly static position, acoustic and aerodynamic characteristics for African American and White Speakers are comparable.     

Fragments of a Greek Trilogy: impact on phonation

This study documents the vocal characteristics of an actor before and after a series of eight performances involving extended voice use. The hypothesis was that this type of extended voice use would result in symptoms of vocal abuse and that damage to the actor's voice would be evident in measures made after the performance series. Three pre-performance and three post-performance speech samples were gathered and analyzed using the CSL and Visipitch II. Measurements taken included maximum phonational range; maximum sustained phonation; fundamental frequency during reading; maximum intensity levels; sound pressure levels for soft, moderate, and loud productions of sustained /a/; and perturbation including jitter, shimmer, harmonics-to-noise ratio, and an s/z ratio. Pre- and post-performance samples of the “Rainbow passage” and sustained vowel phonation were rated by a group of blinded listeners that included professional voice trainers and speech pathologists. In addition, sample lines from the performance were played for the listeners to judge whether this technique would result in symptoms of vocal abuse. Eleven out of 12 professional voice trainers rated that this technique would result in symptoms of vocal abuse. The data revealed post-performance improvement in phonational range, maximum intensity levels, perturbation measures, and s/z ratio. Measures of maximum sustained phonation, fundamental frequency, and sound pressure levels remained stable. Videoendoscopy revealed normal function of the larynx and vocal folds.     

Vocal Intensity Characteristics inNormal and Elderly Speakers

The relationship of lung pressure, fundamental frequency, peak airflow, open quotient, and maximal flow declination rate to vocal intensity for a normal speaking, young male control group and an elderly male group was investigated. The control group consisted of 17 healthy male subjects with a mean age of 30 years and the elderly group consisted of 11 healthy male subjects with a mean age of 77 years. Data were collected at three levels of vocal intensity: soft, comfortable, and loud, corresponding to 25%, 50%, and 75% of dynamic range, respectively. Phonational threshold pressure and lung pressure were obtained using the intraoral technique. The oral airflow waveform was inverse filtered to provide an approximation to the glottal airflow waveform from which measures of fundamental frequency, peak airflow, open quotient, and maximal flow declination rate were determined. Excess lung pressure was calculated as lung pressure minus estimated phonational threshold pressure. The results show for both groups an increase in sound pressure level across the conditions, with corresponding increases in lung pressure, excess lung pressure, fundamental frequency, peak airflow, and maximal flow declination rate. Open quotient decreased with increasing vocal intensity. Lung pressure, sound pressure level, and peak airflow were all found to be significantly greater for the control group than for the elderly group at each condition. Open quotient was found to be significantly lower in the control group than in the elderly group at each condition. No significant difference was observed for excess lung pressure, phonational threshold pressure, fundamental frequency, or maximal flow declination rate between the two groups. These results show that a difference in vocal intensity does exist between young and elderly voices and that this difference is the result of differences in lung pressure, peak airflow, and open quotient.     

A report on alterations to the speaking and singing voices of four women following hormonal therapy with virilizing agents

Four women aged between 27 and 58 years sought otolaryngological examination due to significant alterations to their voices, the primary concerns being hoarseness in vocal quality, lowering of habitual pitch, difficulty projecting their speaking voices, and loss of control over their singing voices. Otolaryngological examination with a mirror or flexible laryngoscope revealed no apparent abnormality of vocal fold structure or function, and the women were referred for speech pathology with diagnoses of functional dysphonia. Objective acoustic measures using the Kay Visipitch indicated significant lowering of the mean fundamental frequency for each woman, and perceptual analysis of the patients' voices during quiet speaking, projected voice use, and comprehensive singing activities revealed a constellation of features typically noted in the pubescent male. The original diagnoses of a functional dysphonia were queried, prompting further exploration of each woman's medical history, revealing in each case onset of vocal symptoms shortly after commencing treatment for conditions with medications containing virilizing agents (eg, Danocrine (danazol), Deca-Durabolin (nandrolene decanoate), and testosterone). Although some of the vocal symptoms decreased in severity with the influences from 6 months voice therapy and after withdrawal from the drugs, a number of symptoms remained permanent, suggesting each subject had suffered significant alterations in vocal physiology, including muscle tissue changes, muscle coordination dysfunction, and propioceptive dysfunction. This retrospective study is presented in order to illustrate that it was both the projected speaking voice and the singing voice that proved so highly sensitive to the virilization effects. The implications for future prospective research studies and responsible clinical practice are discussed.     

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.