Respiratory and glottal efficiency measures in normal classically trained singers

Respiratory and glottal efficiency measures were collected from a pool of 40 classically trained singers with normal larynges. All singers had ?3 years of formal classical voice training and were active professional solo classical singers. Mean flow rates were obtained from all subjects to assess glottal efficiency. Additionally, maximum phonation times and phonation quotients were obtained from a subset of the singers. Pulmonary function test data on forced expiratory volume, forced vital capacity, and forced expiratory flow were obtained for all subjects. Results were compared with published normal values, not specifically derived from trained singers, used commonly in voice laboratoires. Differences were found, suggesting the need for separate normative data to be used for evaluation of the vocal athlete.     

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.     

Voice Handicap Index in singers

The Voice Handicap Index (VHI) was developed to assess patients' perception of the severity of their voice disorder. The purpose of this study was to determine the degree of handicap expressed by professional and recreational presenters with a voice complaint. Singers (n = 106) and nonsingers (n = 369) with voice symptoms were studied. The results of the VHI for singers indicate that singers score significantly lower (less severe) on the VHI compared to nonsingers. Singers with vocal fold nodules had a lower mean VHI than singers with vocal fold cysts or polyps. Singers who perform classical music had the lowest mean VHI of all types of singers studied. A low VHI in singers may represent a significant handicap and should not be ignored when considering the severity of a singer's voice problem.     

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

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

Predicted Singers' Vocal Fold Lengths and Voice Classification—A Study of X-Ray Morphological Measures

Students admitted to the solo singing education at the University of Music Dresden, Germany have been submitted to a detailed physical examination of a variety of factors with relevance to voice function since 1959. In the years 1959–1991, this scheme of examinations included X-ray profiles of the singers' vocal tracts. This material of 132 X-rays of voice professionals was used to investigate different laryngeal morphological measures and their relation to vocal fold length. Further, the study aimed to investigate if there are consistent anatomical differences between singers of different voice classifications. The study design used was a retrospective analysis. Vocal fold length could be measured in 29 of these singer subjects directly. These data showed a strong correlation with the anterior-posterior diameter of the subglottis and the trachea as well as with the distance from the anterior contour of the thyroid cartilage to the anterior contour of the spine. These relations were used in an attempt to predict the 132 singers' vocal fold lengths. The results revealed a clear covariation between predicted vocal fold length and voice classification. Anterior-posterior subglottic-tracheal diameter yielded mean vocal fold lengths of 14.9, 16.0, 16.6, 18.4, 19.5, and 20.9 mm for sopranos, mezzo-sopranos, altos, tenors, baritones, and basses, respectively. The data support the assumption that there are consistent anatomical laryngeal differences between singers of different voice classifications, which are of relevance to pitch range and timbre of the voice.     

Vocal fold microsurgery in singers

Some singers with benign vocal fold mucosal lesions remain unacceptably impaired vocally in spite of compliance with a regimen of medical treatment and voice therapy lasting several months—or even years. I present here my experience with 62 singers who, because of this predicament, chose to undergo vocal fold microsurgery. This series is the second largest reported to date in English literature. Procedures are presented which were used for patient selection, education, and vocal retraining, as well as for surgery itself and postoperative care. Results reported here include (a) comparison of my auditory-perceptual ratings of singing voice impairment before and after surgery, (b) preoperative versus postoperative videostroboscopic findings, (c) postoperative rate of return to public singing, and (d) postoperative patient questionnaires which sought to uncover patient/singer perceptions of the results of vocal fold surgery. Excellent results were achieved overall with a very low incidence of untoward results, and no complications were encountered.     

Vocal fold hemorrhage associated with coumadin therapy in an opera singer

Vocal fold hemorrhage can represent a disastrous and potentially career ending injury to a singer or professional voice user. The risk factors of vocal fold hemorrhage, including laryngeal trauma, phonotrauma, aspirin and nonsteroidal antiinflammatories, and hormonal imbalances are well known. We present a case of an opera singer who developed recurrent vocal fold hemorrhage associated with coumadin anticoagulation therapy. This case highlights the importance of the risk of vocal fold hemorrhage to professional singers and professional voice users and offers an alternative to long-term coumadin therapy in this select population.     

Strobovideolaryngoscopic Findings in Singing Teachers

Professional voice users often present to otolaryngologists and laryngologists with specific voice complaints. The contributions of pathologic lesions to the patients' vocal complaints are not always clear on examination, and often, premorbid examinations of the larynx are not available for review. This study examines the incidence of laryngeal pathology among singing teachers. At a national convention of singing teachers, volunteers were recruited for a "free strobovideolaryngoscopic examination." All volunteers completed a detailed questionnaire of their vocal and medical history and underwent strobovideolaryngoscopic examination. Strobovideolaryngoscopic examinations were completed in 20 volunteers, 7 of whom had voice complaints and 13 of whom perceived their voices to be normal. Vocal fold masses were common among the asymptomatic singing teachers. Evidence of reflux laryngitis was a common finding among both symptomatic and asymptomatic singing teachers. Asymmetries in vocal fold hypomobility were more common among those with voice complaints than was the presence of vocal fold masses in the population studied.     

Vocal Nodules and Laryngeal Morphology

Our purpose was to study the occurrence of vocal fold nodules under conditions of habitual vocal abuse associated with increased laryngeal muscle tension, to identify the existence of a relationship between vocal nodules and laryngeal morphology. We studied one group of 30 subjects with vocal nodules, 18 to 50 years old, who were compared with two control groups, one of females and one of males, consisting of 30 subjects each. The parameters evaluated were: type of vocal folds coaptation, glottic proportion (GP) and abduction angle (AA), obtained by videotelelaryngoscopy. In the nodules group, the larynges presented a mean value of GP similar to that of the female group, both of which were lower than the mean GP value of the male group. On the other hand, the mean AA was lower than the one in the female group, and closer to the one in the male group. We concluded that vocal nodules were present only in larynges with a predominantly young female morphology, with functional limitations of abduction.     

Measurement of Characteristic Leap Interval Between Chest and Falsetto Registers

A markedly smaller time constant distinguishes a chest-falsetto leap from the more usual execution of a sung interval by muscular adjustments in the length and tension of the vocal folds. The features of such a chest-falsetto leap are examined in detail with respect to F0, peak-to-peak amplitude of the vocal-fold contact area signal (EGG), and the closed quotient. A method is proposed to standardize and quantify this chest-falsetto leap in the characteristic leap interval (CLI), a measure of the separation between the natural registers in a given singing voice. The measure is applied to a varied group of experienced singers. Preliminary results include a suggested dimorphic pattern with respect to sex, with female voices exhibiting smaller CLIs and less individual diversity than male voices.     

Vocal fold nodules in adult singers: Regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing

This study was undertaken to better understand current regional opinions regarding vocal fold nodules in adult singers. A questionnaire was sent to 298 persons representing the 3 professional groups most involved with the care of singers with vocal nodules: otolaryngologists, speech pathologists, and teachers of singing. The questionnaire queried respondents about their level of experience with this problem, and their beliefs about causative factors, career impact, and optimum treatment. Responses within and between groups were similar, with differences between groups primarily in the magnitude of positive or negative responses, rather than in the polarity of the responses. Prevailing opinions included: recognition of causative factors in both singing and speaking voice practices, optimism about responsiveness to appropriate treatment, enthusiasm for coordinated voice therapy and voice training as first-line treatment, and acceptance of microsurgical management as appropriate treatment if behavioral management fails.     

Vocal Fold Mucosal Tears: Maintaining a High Clinical Index of Suspicion

Vocal fold mucosal tears have been discussed in the literature rarely, although they are not uncommon clinically. Disruptions in the epithelium usually follow trauma that may result from voice abuse and/or misuse, coughing, and other causes. A high index of suspicion is necessary to avoid missing vocal fold mucosal tears, and strobovideolaryngoscopy is indispensable in making the diagnosis. A brief period of complete voice rest is the standard of care and appears to be helpful in avoiding adverse sequelae and advancing the healing process, but there are no scientific studies to confirm its efficacy. Mucosal tears may heal completely or may be followed by the development of vocal fold masses, scar, and permanent dysphonia.     

Characteristics of Phonatory Function in Singers and Nonsingers With Vocal Fold Nodules

Purpose

The goals of this study were to determine if there were significant differences between singers and nonsingers in the morphology of vocal nodules and the associated impact on vocal function.

Method

Participants were 10 professionally trained singers with nodules, eight nonsingers with nodules, and 10 individuals with healthy normal voice (controls). Surface electromyography (sEMG) from three anterior neck locations and acoustic rise times for vowels /a/ and /i/ were measured in all the participants. In individuals with nodules, dB SPL/cm H₂O, glottal airflow, and nodule location and size were also measured.

Results

There were no significant differences between singers and nonsingers with nodules in terms of airflow, dB SPL/cm H₂O, nodule size, or nodule location. In nonsingers with nodules, airflow and nodule size were significantly correlated, but were not significantly correlated in singers. Vowel rise times and sEMG during vocal tasks did not differentiate among nodule and control groups. Sternocleidomastoid sEMG during initiation of the vowel /a/ was statistically significantly stronger in nonsingers with nodules relative to singers with nodules and controls.

Conclusions

Nodule morphology did not differ between singers and nonsingers, although some behavioral aspects of phonation differed between the groups.     

Evolution of Vocal Fold Nodules from Childhood to Adolescence

SUMMARY: Bilateral (quasi) symmetrical lesions of the anterior third of the vocal folds, commonly called vocal fold nodules (VFNs) are the most frequent vocal fold lesions in childhood caused by vocal abuse and hyperfunction. This study evaluates their long-term genesis with or without surgery and voice therapy. A group of 91 postmutational adolescents (mean age, 16 years), in whom VFNs were diagnosed in childhood, were questioned to analyze the evolution of their complaints. Thirty four of them could be clinically reexamined by means of the European Laryngological Society-protocol, including a complete laryngological investigation and voice assessment. A total of 21% of the questioned group (n=91) had voice complaints persisting into postpubescence with a statistically significant difference (P 相似文献   

Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

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.     

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.     

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.     

Vocal Fold Polyp in a Professional Brass/Wind Instrumentalist and Singer

Wind instrumentalists, especially brass players, and singers share common factors, including vocal tract shape, function and pressure, vocal fold opening and closure, breath vector of force and air flow rates. To understand the mechanism and function of the vocal folds with a pathological lesion, it is necessary to visualize the differing interactions of the vocal tract during wind and brass instrument playing and in singing. A school band director, singer, wind and brass instrumentalist, was referred by musician colleagues with intermittent dysphonia, aphonia, and inability to sing high notes. Simultaneous videolaryngoscopy, with and without stroboscopy, and external video examination were documented. An hourglass glottis with a sessile, cystic polyp of the left vocal fold were recorded and studied during phonation and the playing of 3 instruments. The techniques of glottic opening, closure, configuration and function varied with the type of instrument and phonatory function. Singing was adversely affected by the vocal fold polyp but no harmful interaction occurred during wind/brass instrument playing. Down-stream loading in singers is at the laryngeal level and in wind/brass instrumentalists is at the embouchure. Preoperative voice therapy, phonomicrosurgery, and postoperative voice rest followed by voice therapy, succeeded in restoring her combined wind/brass instrumental and singing career.     

Multiparametric Analysis of Vocal Fold Vibrations in Healthy and Disordered Voices in High-Speed Imaging

Objectives

The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI).

Study Design and Methods

Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000 Hz (256 × 256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values.

Results

HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis).

Conclusion

Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.