Voice characteristics, effects of voice therapy, and long-term follow-up of contact granuloma patients

This study evaluates the laryngoscopic findings and voice characteristics of male contact granuloma patients before and after voice therapy and at a follow-up about 9 years later. Pre- and posttherapy recordings as well as follow-up recordings were made for 19 granuloma patients. Pretherapy revealed the most salient perceptual voice characteristics were low pitch, monotony, and a high degree of vocal fry and hyperfunction. Interjudge reliability for these traits was high. Immediately following therapy the healed patients (n = 10) had a decrease in hyperfunction, vocal fry, and monotony, while the unhealed patients (n = 9) had an increase in hyperfunction and vocal fry decreased only marginally. Monotony decreased significantly in this group. As regards the acoustic analyses, no significant differences were found in mean fundamental frequency (F₀) or perturbation. At the follow-up assessment 4 patients had granuloma while 15 had normal laryngeal status. Perceptually their voice characteristics resembled those pretherapy independently of the laryngeal findings. The results suggest that reduced hyperfunction and decreased vocal fry may create better circumstances for the healing process at the posterior glottis.     

Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules

The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules. Perceptual and physiological progressive changes were examined during a strictly structured, behaviorally based voice therapy protocol in which 11 women with vocal nodules participated. Randomized audio recordings from pretherapy and from each of the therapy approaches (vocal hygiene, respiration, direct facilitation, carryover) were used for perceptual evaluations. Six speech-language pathologists rated ten voice quality parameters. Two evaluation procedures were performed and compared. Interlistener reliability was sufficiently high in both tests. Significant effects of therapy were found for decreased overall dysphonia, press, instability, gratings, roughness, vocal fry, and "scrape." Nonsignificant group effects were found for breathiness, aphonic instances, and lack of sonority. No significant parameter changes occurred between baseline assessment and the completion of the initial (vocal hygiene) phase of therapy. Significant changes were found following the direct facilitation and respiration phases of therapy. Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved. However, the nodules had decreased in size and edema was reduced after therapy for all clients, but one. Combined results suggest: (1) Alterations in vocal function were reflected in perceptual parameters, and (2) the voice therapy had a positive effect on voice quality, vocal status, and vocal function for the majority of the vocal nodule clients.     

The Effectiveness of Group Therapy for Students With Mild Voice Disorders: A Controlled Clinical Trial

Previous studies of students studying to be teachers have indicated that these students commonly have voice disorders. Ideally, voice disorders should be treated before students start their work as teachers, but the resources for this treatment are often limited. This study examines whether group voice therapy is effective for teacher students. Accordingly, 20 teacher students with mild voice disorders received group voice therapy (in three small groups), whereas 20 students with similar voice disorders served as a control group and consequently did not receive voice therapy. Two out of three outcome measures (perceptual evaluation of voice quality and a questionnaire on the occurrence of vocal symptoms) indicated significant changes in the treatment group compared with the control group. No differences between groups were noted in the laryngeal status. The results suggest that group voice therapy seems to be an effective method to treat students with mild voice disorders.     

Communicative Suitability of Voice Following Radiotherapy for T1 Glottic Carcinoma: Testing the Reliability of a Rating Instrument

The objective of the study was to determine whether a communicative suitability rating instrument could be used in a meaningful way to assess functionality of voice following radiotherapy for T1 glottic cancer. Seventeen naive listeners judged the suitability of voice of a patient group with T1 glottic carcinoma (n = 20) just before treatment, a group of patients (n = 40) after radiotherapy, and a matched control group (n = 20) of normal speakers. Listeners rated suitability on a 10-point scale for 10 speaking situations, which supposedly make different demands. In order to validate scores on communicative suitability, ratings were related to perceptual voice quality evaluations and videolaryngostroboscopic evaluations. Results indicate that the concept of measuring listener judgments of communicative suitability of voice is basically sound. Raters are reliable and can discriminate between groups of normal and pathological voices. Patients with T1 glottic carcinoma (assessed before the start of treatment) have on average the least suitable voices. Following radiotherapy suitability is, on average, improved, but does not approach the suitability of normal voices. Ratings on communicative suitability were clearly related to perceptual voice quality aspects and videolaryngostroboscopic evaluations. A subset of three communicative suitability rating scales is recommended as part of the protocol for evaluating voice outcome after radiotherapy for early glottic cancer, besides perceptual evaluation of voice quality by trained and naive raters, videolaryngostroboscopy, acoustical analyses, and self-ratings of vocal performance.     

Outcome of Resonant Voice Therapy for Female Teachers With Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements

Teachers have a high percentage of voice problems. For voice disordered teachers, resonant voice therapy is hypothesized to reduce voice problems. No research has been done on the physiological, acoustic, and aerodynamic effects of resonant voice therapy for school teachers. The purpose of this study is to investigate resonant voice therapy outcome from perceptual, physiological, acoustic, aerodynamic, and functional aspects for female teachers with voice disorders. A prospective study was designed for this research. The research subjects were 24 female teachers in Taipei. All subjects received resonant voice therapy in groups of 4 subjects, 90 minutes per session, and 1 session per week for 8 weeks. The outcome of resonant voice therapy was assessed from auditory perceptual judgment, videostroboscopic examination, acoustic measurements, aerodynamic measurements, and functional measurements before and after therapy. After therapy the severity of roughness, strain, monotone, resonance, hard attack, and glottal fry in auditory perceptual judgments, the severity of vocal fold pathology, mucosal wave, amplitude, and vocal fold closure in videostroboscopic examinations, phonation threshold pressure, and the score of physical scale in the Voice Handicap Index were significantly reduced. The speaking Fo, maximum range of speaking Fo, and maximum range of speaking intensity were significantly increased after therapy. No significant change was found in perturbation and breathiness measurements after therapy. Resonant voice therapy is effective for school teachers and is suggested as one of the therapy approaches in clinics for this population.     

Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial

Transnasal flexible laryngoscopy (TFL) is an examination of laryngeal anatomy and physiology using continuous light. TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it. The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool. The study used a prospective randomized controlled trial. Fifty dysphonic subjects were recruited and randomly assigned to either a traditional treatment group or a TFL-assisted treatment group. The effectiveness of voice therapy in both treatment groups was measured with a package of voice outcome measures. Subjects in both treatment groups demonstrated statistically significant improvements after voice therapy (perceptual auditory rating of voice quality measurement p < 0.01; instrumental electroglottographic measurement p < 0.01; patient questionnaire measurement p < 0.01). The time taken to complete treatment in both groups was recorded. The average (median) time taken to complete voice therapy in the TFL-assisted treatment group was 2 hours less than in the traditional treatment group (p < 0.01). Voice therapy with TFL as a therapy tool was effective and more efficient than traditional voice therapy.     

Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy.

An important clinical issue concerns the efficacy of current voice therapy approaches in treating voice disorders, such as vocal nodules. Much research focuses on finding reliable methods for documentation of treatment results. In this second treatment study of ten patients with vocal nodules, who participated in a behaviorally based voice therapy program, 11 aerodynamic (transglottal air pressure and glottal waveform) and acoustic (spl, f0, and spectrum slope) measures were used. Three pretherapy baseline assessments were carried out, followed by one assessment after each of five therapy phases. Measurements were made of two types of speech materials: Strings of repeated /pae/ syllables and sustained /ae/ phonations in two loudness conditions: comfortable loudness and loud voice. The data were normalized using z-scores, which were based on data from 22 normal subjects. The results showed that the aerodynamic measures reflected the presence of vocal pathology to a higher degree than did the acoustic spectral measures, and they should be useful in studies comparing nodule and normal voice production. Large individual session-to-session variation was found for all measures across pretherapy baseline recordings, which contributed to nonsignificant differences between baseline and therapy data.     

Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) is associated with changes in acoustic and aerodynamic voice measurements and can have a significant impact on a patient's quality of life. Few objective data regarding the efficacy of voice therapy for UVFP exist. The aim of this study was to retrospectively analyze voice modifications in a group of patients with UVFP before and after voice therapy. Forty patients with UVFP of different etiology were included in the study. Each subject had voice therapy with an experienced speech/language pathologist twice a week; the mean number of sessions was 12.6. A multidimensional assessment protocol was used; it included videoendoscopy, the maximum phonation time (MPT), the GIRBAS scale, spectrograms and a perturbation analysis, and the Voice Handicap Index (VHI). Pre- and posttreatment data were compared by means of the Wilcoxon and Student's t tests. A complete glottal closure was seen in 8 patients before voice therapy and in 14 afterward. Mean MPT increased significantly. In the perceptual assessment, the difference was significant for five out of six parameters. A significant improvement was found on spectrographic analysis; as for perturbation analysis, the differences in jitter, shimmer, and noise-to-harmonic ratio values were significant. VHI values showed a clear and significant improvement. A significant improvement of voice quality and quality of life after voice therapy is an often reached and reasonable goal in patients with UVFP.     

The use of an auditory model in predicting perceptual ratings of breathy voice quality

Despite much research, the relationship between vocal acoustic signals and perceived voice quality is not well understood. The present study used an auditory model proposed by Moore et al¹⁰ to study how changes in the acoustic spectrum may relate to changes in perceptual ratings of breathiness. Perceptual ratings of breathiness were obtained using a multidimensional scaling (MDS) design. The stimulus distances on the dominant MDS dimension were correlated with several commonly used acoustic measures for voice quality. These distances were also compared with measures obtained from the output of the auditory model. Results show that the partial loudness of the harmonic energy obtained with the aspiration noise acting as a masker was the most important predictor of perceptual ratings of breathiness. Results also demonstrate that measures obtained from the auditory spectrum were better predictors of perceptual ratings of breathiness than were commonly used acoustic spectral measures.     

Perceptual evaluation of voice quality and its correlation with acoustic measurements

To determine whether a correlation exists between the Grade, Roughness, Breathiness, Aesthenia, Strain (GRBAS) scale (a subjective measure of voice) and the Multi-Dimensional Voice Program (MDVP) scale (an objective measure of voice). A retrospective review of 37 voice patients (12 male/25 female) was conducted. Each voice was perceptually evaluated using the GRBAS scale by an experienced speech pathologist and acoustically analyzed using the MDVP scale. Statistical analysis using a multivariate regression model identified a significant correlation between the noise-related parameters of MDVP and the components of the GRBAS scale. Grade correlated with voice turbulence index (VTI), noise harmonic ratio (NHR), and soft phonation index (SPI). Roughness correlated with NHR only. Breathiness correlated with SPI only. Aesthenia also correlated with SPI only. Of the 19 acoustic variables measured by the MDVP system, only three noise parameters significantly correlated with the GRBAS perceptual voice analysis. Perhaps "noise" is the perceived acoustical quality of the dysphonic voice. A voice quantifying measure such as a "voice index score" could be proposed using the GRBAS scoring and the three clinically relevant MDVP values following further studies.     

Acoustic Measures of Symptoms in Abductor Spasmodic Dysphonia

Speech of patients with abductor spasmodic dysphonia (ABSD) was analyzed using acoustic analyses to determine: (1) which acoustic measures differed from controls and were independent factors representing patients' voice control difficulties, and (2) whether acoustic measures related to blinded perceptual counts of the symptom frequency in the same patients. Patients' voice onset time for voiceless consonants in speech were significantly longer than the controls (p = 0.015). A principle components analysis identified three factors that accounted for 95% of the variance: the first factor included sentence and word duration, frequency shifts, and aperiodic instances; the second was phonatory breaks; and the third was voice onset time. Significant relationships with perceptual counts of symptoms were found for the measures of acoustic disruptions in sentences and sentence duration. Finally, a multiple regression demonstrated that the acoustic measures related well with the perceptual counts (r² = 0.84) with word duration most highly related and none of the other measures contributing once the effect of word duration was partialed out. The results indicate that some of the voice motor control deficits, namely aperiodicity, phonatory breaks, and frequency shifts, which occur in patients with ABSD, are similar to those previously found in adductor spasmodic dysphonia. Results also indicate that acoustic measures of intermittent disruptions in speech, voice onset time, and speech duration are closely related to the perception of symptom frequency in the disorder.     

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.     

Voice Therapy Outcome—A Randomized Clinical Trial Comparing Individual Voice Therapy,Therapy in Group,and Controls Without Therapy

ObjectiveA stumbling-block in voice therapy is how the patient will be able to apply the new voice technique in everyday life. Possibly this generalization process could be facilitated by giving voice therapy in group because of the natural forum for training voice-to-speech early in communication between the patients in a group setting. The aim of the study was to compare treatment results from individual voice therapy and voice therapy in group, at several time points and in comparison to patients with no voice therapy.MethodsA randomized treatment study was performed with 77 consecutive patients diagnosed with a functional voice disorder. Thirty-one patients were randomized to individual and group therapy, respectively, and 15 patients to no therapy. The assessments included standardized voice recording and registration of voice range profile (VRP), answering Voice handicap index (VHI) and visual analogue scales for self-hoarseness and self-vocal fatigue, and perceptual voice evaluation by speech-language pathologist. The assessments were performed before, direct after therapy, and three months later in all groups. The 2 therapy groups were also assessed 12 months after therapy.ResultsAll VHI scores as well as the self-ratings of hoarseness and vocal fatigue, and the perceptual evaluation of voice quality and maximum VRP improved significantly in both therapy groups 3 months after treatment and at 12 months follow-up. There were no significant changes in the control group, with the exception of decreased self-rated hoarseness and increased maximum VRP. Comparisons between treatment groups showed significant larger improvement after group therapy for VHI physical subscale at 12 months, as well as significant lower VHI total score at all measurement sessions and lower subscale scores at 12 months. There were no differences between treatment groups in self-hoarseness or self-vocal fatigue and no difference in perceptual voice quality or VRP. Comparison between controls and treatment groups showed significant larger change in treatment groups from baseline to three months in VHI total and to end of therapy in functional subscale. Treatment groups also showed significant lower scores than controls at each measurement session, for VHI total and physical subscale as well as lower degree of perceptual aberration of voice quality and vocal fatigue, at three months follow-up.ConclusionsThis study shows long-term improvement from behavioral voice therapy, particularly in a group setting. The results indicate the importance of early transfer-to-speech and late posttherapy test to capture whether the goal of voice therapy was fulfilled or not for the patients.     

Clinical Analysis of Voice Change as a Parameter of Premenstrual Syndrome

We have evaluated the relationship between voice change and premenstrual syndrome (PMS) by comparing acoustic measurements made during the follicular phase and the premenstrual phase. Twenty-eight women were followed for 2 months for this study. Each participant was asked to produce an /a/ sound for 5 seconds at the midfollicular phase of the menstrual cycle and then 2-3 days before menstruation. Each voice sample was stored and analyzed by the Dr. Speech Science program. The voice data collected from all subjects during the two phases were compared. After that, the subjects were divided into a PMS-positive and PMS-negative group according to the criteria cited in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); the voice data from each group were compared separately between the two phases. There was no significant difference in the acoustic parameters between the two phases in all subjects (N = 28). In the PMS-positive group (N = 16), jitter was significantly increased during the premenstrual phase compared to the follicular phase (p = 0.048). The patient's PMS score was not correlated with the severity of voice change. We conclude that the change of voice parameter was objectively identified in the PMS-positive group, therefore more careful voice habituation is required during the premenstrual phase in that group.     

Voice disorders in patients with suspected laryngo-pharyngeal reflux disease

Many symptoms have been recognized in association with laryngo-pharyngealreflux disease (LPRD), but reports of perceptual voice disorders in this condition have been lacking to date. Forty-nine patients with suspected LPRD were studied for five specific perceptual voice characteristics, and these characteristics were compared to the same characteristics in individuals who had never seen an Otolaryngologist for a voice disorder or throat problem (controls). Sixteen of the suspected LPRD patients also underwent 24-hour pH probe studies. All patients with suspected LPRD had significantly increased abnormal perceptual voice characteristics (musculoskeletal tension, hard glottal attack, glottal fry, restricted tone placement, and hoarseness) compared to the controls. Statistical objective differences between the two groups was demonstrated by the presence of increased shimmer in patients with suspected LPRD compared to controls. The differential diagnosis between functional voice disorders and LPRD may be complex, and perceptual parameters may overlap. Interdisciplinary evaluation is advocated.     

Voice Quality in Laryngeal Cancer Patients: A Randomized Controlled Study of the Effect of Voice Rehabilitation

ObjectivesThe study aimed to investigate the short-term and long-term effects of voice rehabilitation in patients treated with radiotherapy for laryngeal cancer as measured by both the acoustic measure smoothed cepstral peak prominence (CPPS) and perceptual measures. A secondary aim was to investigate the relationship between acoustic and perceptual measures.MethodsIn total, 37 patients received voice rehabilitation post-radiotherapy and 37 patients constituted the irradiated control group. Outcome measures were mean CPPS for connected speech and ratings with the auditory-perceptual Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale. Outcome measures were analyzed 1 (baseline), 6, 12, and 24 months post-radiotherapy, where voice rehabilitation was conducted between the first two time-points. Additional recordings were acquired from vocally healthy participants for comparison.ResultsCPPS values of the voice rehabilitation group and vocally healthy group were not significantly different at 24 months post-radiotherapy. Ten out of 19 patients who received voice rehabilitation yielded a CPPS value above the threshold for normal voice 24 months post-radiotherapy, compared to 11 out of 26 in the irradiated control group. No statistically significant correlations were found between CPPS and perceptual parameters of GRBAS.ConclusionVoice rehabilitation for irradiated laryngeal cancer patients may have positive effects on voice quality up to 24 months post-radiotherapy. The relationship between CPPS and GRBAS as well as the applicability of CPPS for evaluation over several points of measurement needs to be studied further.     

Perceptual and Acoustic Characteristics of Voice Changes in Reflux Laryngitis Patients

The aim of the study was to outline the multidimensional perceptual, subjective, and instrumental acoustic voice changes in the group of reflux laryngitis (RL) patients. Data of multidimensional voice assessment of 108 RL patients and 90 healthy persons of the control group were subjected to comparative analysis. A slight hoarseness according to the GRB (G-grade, R- rough, B-breathy) scale was prevailing in the RL patients group. Statistically significant difference (P < 0.001) between RL patients group and the control group was found of all voice parameters measured, with the patients having worse results--increased mean jitter, shimmer, normalized noise energy, voice handicap index (VHI), and decreased parameters of phonetogram. The results of the study demonstrated that multidimensional voice assessment documented deteriorated voice quality and restricted phonation capabilities in the tested group of RL patients.