The clinical voice laboratory: Clinical application of voice research

In the past decade the number of voice laboratories has increased dramatically. Their primary mission is to enhance patient care by the application of knowledge gained from basic research. They also are dedicated to further improvement of diagnostic and therapeutic resources. The strength of the voice laboratory lies in collaboration between the clinician and the scientist.     

G. Paul Moore lecture: Rational thought: The impact of voice science upon voice care

Recent evolution in scientific knowledge and technology has led to monumental improvement in the standard of care for patients with voice disorders. New concepts in anatomy, physiology, measurement, and analysis have provided voice care professionals with not merely better understanding, but moreover an extensive vocabulary with which to think about voice function and dysfunction. Previously, we had to depend too much upon anecdote and “the art of medicine.” Thanks to scientific advances, we now have the tools we need for rational thought about the human voice. This is the fundamental change responsible for recent great advances in voice care.     

The relationship among voice onset, voice quality, and fundamental frequency: a dynamical perspective

In dynamical motor theory, skill acquisition occurs as a modification of preexisting coordination patterns or attractor states. The purpose of this study was to assess how different levels of voice onset, voice quality, and fundamental frequency (F₀) combine to form the attractor states common to voice motor control. Three levels of voice onset (glottal, simultaneous, and breathy), voice quality (modal speech, mixed, and falsetto), and fundamental frequency (low, mid, and high) were manipulated by vocally untrained, female subjects. Percent correct of acquisition trials and self-report of effort were used as measures of stable phonations indicative of an attractor state. Using intensity as a covariate, the results provided support for two of the three predicted triads representing attractor states in female speakers: (1) glottal onset/modal speech quality/low F₀; and (2) breathy onset/falsetto quality/high F₀. The results of this study suggest that certain parameters of voice motor control, such as onset, quality, and F₀, exist as part of a dynamical system that can be identified and manipulated in voice motor acquisition and learning.     

Allergic, dietary, chemical, stress, and hormonal influences in voice abnormalities

Allergic, dietary, chemical, biochemical, stress, and hormonal abnormalities have long been recognized as important factors in both abnormalities of the voice and in the general health of the professional vocalist. In recent years objective methods have become available to evaluate and treat allergic, dietary, and chemical abnormalities and to better understand the effects of stress and hormonal variations. Assessment of allergic disease is efficient and cost effective through the use of in vitro testing techniques combined with skin end point titration. This provides highly specific and objective results and leads to accurate planning of desensitization treatment. This form of treatment can be especially beneficial in the prevention of recurrent laryngitis. An accurate nutritional history provides evidence of food sensitivities that can lead to cyclical allergic-like vocal symptoms that can be prevented with the use of elimination diets and the judicious use of desensitization therapy. An adequate knowledge of the potential effects of chemical sensitivities will assist the patient in the avoidance of provocative chemical exposures. An in depth evaluation of biochemical abnormalities and a specific assessment of the nutritional status must be considered to evaluate the underlying causes of long-standing general health problems that can affect the voice. Likewise, hormonal variations are not only important in their direct effects on the vocal mechanism but in their cyclical effects on the patient's basic biochemical balance. Lastly, stress, which has long been related to problems in professional performance, is only now being fully studied to determine its actual biologic influences and these must be related to the causes of voice disturbances. Understanding all these influences and planning a rational and efficient evaluation of these potential problem areas are imperative in the complete care of the patient with voice abnormalities.     

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.     

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 field measurements—a new method of examination: the influence of hearing on the human voice

There are various methods to evaluate voice parameters. Original software was used to assess the voice quality by the staff of AUDIO-Fon centr Brno, Czech Republic. A group of hereditary deaf persons was examined. Deaf persons have all of the biological conditions to make voice except for the possibility of acoustic feedback. We examined the voices of 35 persons (20 men and 15 women) with hereditary profound hearing impairments, and we compared voice parameters with the voice of intact persons. To measure we used special software called voice field measurements (VFMs). The program graphically records voice frequency and intensity. VFM is an objective method that enables the assessment of basic physical voice characteristics. It is suitable for the examination of both intact and disturbed voice. The voice of the deaf has a higher basic voice frequency in men as well as in women. This type of voice production, ie, childlike voice, which is fixed only by a motor stereotype, is much more demanding for a mature larynx. Hearing influences both the voice development and speech production. The voice of persons with hearing impairments has a higher basic voice frequency regardless of their sex. This type of voice production, which is fixed only by a motor stereotype, ie, child voice, is much more demanding for a larynx of an adult. Thus, phonation of deaf people is more demanding and their voice production needs greater effort. Deaf people, despite an intact phonic apparatus, cannot produce more than one type of voice. They cannot modulate their voices concerning the frequency and dynamics. They cannot change their voices continually. The voice is limited in both of these parameters (frequency and dynamics). If a deaf person wants to change a voice characteristic, it is possible only by discontinuous changes-"skipping."     

On the terminology of voice research

This article reviews problems associated with establishment of a scientifically accurate, internationally recognized, multilingual terminology to describe voice. Two strategies for developing terminology are discussed: consensus and dictation. Ontological decisions are considered an integral part of developing terminology. We conclude that terminological problems should be solved by a terminological committee—as yet to be established—as they average from problems in interpreting the literature and the results of voice research. A comprehensive bibliography and audio tape of the multilingual terminology describing voice would help facilitate adaptation and understanding of the terms defined.     

Expanding perspectives in care of the speaking voice

The effective voice clinician has always had to borrow from various disciplines: voice science, otolaryngology, psychology, and speech-language pathology. Such eclecticism requires, however, that the clinician integrate the perspectives of these various disciplines into some kind of theoretical clinical bias. One bias might be that with greater use of instrumentation in voice therapy, the voice clinician must not substitute data collection for attending to the feelings of the patient. By using the clinical input from various disciplines, for example, voice clinicians might develop a useful clinical perspective that vocal hyperfunction is one of the primary causes of many voice disorders. Consequently, from such a clinical view might come a treatment perspective that can clearly define the problem (too much effort while speaking) and offer a rationale for voice remediation.     

Preparing the singing voice specialist revisited

In review of singing voice specialist preparation, discussion can be chronicled prior to the establishment of Arts Medicine in 1987. Although discussion began in 1984 (and earlier), no formal academic program currently exists to train the singing voice specialist. The need now is greater than ever for a formal program of study to prepare a person who seeks to be a singing voice specialist. The question of adequate preparation continues to be in need of an appropriate answer because no formal training programs or fellowships are available. It is essential to first define the role of singing voice specialists and the populations that they will encounter. To meet the needs of a diverse population, care of the professional voice demands cross-disciplinary training. Knowledge from the fields of music, science, medicine and communication disorders and experience/observation, clinical preparation, and research would provide for optimal preparation. To meet this need, development of a Masters degree program seems highly desirable. The structure of such a program is proposed, along with specific requirements outlined from the music and singing voice pathology components for a Masters Degree in Arts Medicine with a concentration in voice.     

Frequency and effects of teachers'' voice problems

This study compared the frequency and effects of voice symptomsin teachers to a group of individuals employed in other occupations. Teachers were more likely to report having a voice problem (15 vs. 6%), having 10 specific voice symptoms, and having 5 symptoms of physical discomfort. They averaged almost 2 symptoms compared with none for nonteachers. Likewise, teachers were more likely to perceive that a voice problem would adversely affect their future career options, had done so in the past, and was limiting their current job performance. Over 20% of teachers but none of the nonteachers had missed any days of work due to a voice problem. These findings suggest that teaching is a high-risk occupation for voice disorders and that this health problem may have significant work-related and economic effects.     

The young adult voice

Young adulthood is notable for rapid physical changes and psychosocial instability. Care of the young adult professional voice requires knowledge of the specific anatomic and physiologic changes associated with the mutational voice, as well as the effects of general growth and maturation on the vocal mechanism. The effects of psychological stresses common to young adulthood, such as educational commitments and early career choices, must also be understood. Upper respiratory infection and allergies are common in this age group. Treatment of these conditions must be tailored in the professional voice user because of the potential side effects of some medications and the performance imperatives of the patient. Surgical indications for tonsillectomy in the young voice patient are discussed. There are no special considerations in the evaluation and treatment of laryngeal pathology in the young adult, with the exception of limiting the use of sedative anesthesia. However, conservatism in surgical decision-making is advised. The development of a stable, efficient vocal technique and a mature professional background requires time, patience, and hard work.     

Feedback from spectrum analysis applied to the singing voice

Despite the general availability in the past two decades of the spectrum analyzer and prominent pedagogical theories concerning the conscious tuning of vowel formants to enhance the singing voice, there has been little reported use of spectrum analysis to track formant frequencies in singing. An important exception is Sundberg's work (1) on the soprano voice. The reasons for this neglect are considered: in the singing range where information on formant tuning would be most helpful, the wide spacing of the harmonics renders the formants difficult to locate by spectrum analysis. Methods are described for obtaining continuous spectrograms with the vocal tract in the varied articulations of singing by using sweep tones and nonharmonic voice sources, and thus locating quickly and accurately the frequencies of the first five formants.     

Some physical characteristics of the male falsetto voice

Previous research indicated that, as groups, male (bass/baritone) and female (soprano) professional singers tend to exhibit differing vocal tract and voice source behaviours. The use of an objective measure of voice [xeroradiographic-electrolaryngographic analysis (XEL)] revealed differences between the two voice types, especially at the highest sample pitches (e, 330 Hz for bass/baritones, and e″, 1,320 Hz for sopranos). XEL analysis combines two known techniques, i.e., soft-tissue radiographic imaging (xeroradiography), and an analysis of voice-source vibratory patterning (electrolaryngography). Subsequent to this investigation, interest centered on the male professional falsetto voice over a two-octave range (E 165 Hz to e′ 660 Hz) using a sample (n=9) of professional countertenors. Results suggest that there are characteristic trends in the patterning of the male professional falsetto register, but there is also evidence of within-group variability. The subjects significantly increased the size of the pharyngeal tube area during phonation. ANOVA and Trend Analysis revealed ventricular space as the only measure to expand systematically and consistently as sung pitch increases.     

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.     

The role of pitch in the discrimination of voice quality

Pitch is an important attribute of a musical sound. With it the melody of a song is established. With it the beauty of a voice is showcased. But how does pitch affect the perception of voice? Is it used to help to distinguish among voices or does it merely exist in the background, affecting the fine details of a voice but not radically altering the voice? The purpose of this paper is to review some of the evidence on the role of pitch in the perception of voice quality; specifically for the discrimination of one voice quality from another. The objective of the discussion is to understand how pitch affects our perception of voice quality and its importance to the perception of musical sound.     

Time-of-day effects on voice range profile performance in young, vocally untrained adult females

Time-of-day effects on voice range profile performance were investigated in 20 vocally healthy untrained women between the ages of 18 and 35 years. Each subject produced two complete voice range profiles: one in the morning and one in the evening, about 36 hours apart. The order of morning and evening trials was counterbalanced across subjects. Dependent variables were (1) average minimum and average maximum intensity, (2) Voice range profile area and (3) center of gravity (median semitone pitch and median intensity). In this study, the results failed to reveal any clear evidence of time-of-day effects on voice range profile performance, for any of the dependent variables. However, a reliable interaction of time-of-day and trial order was obtained for average minimum intensity. Investigation of other subject populations, in particular trained vocalists or those with laryngeal lesions, is required for any generalization of the results.     

Coping strategies, personality, and voice quality in patients with vocal fold nodules and polyps

Emotional state affects the physiological mechanism involved inphonation. Differences in acoustical parameters of the voice under stress have been attributed to the coping mechanism used, which is based on the individual's perception of the situation. This study examines the relationship between coping strategies, personality, and voice in female subjects, ranging in age from 19.3–55.7 years, diagnosed with vocal nodules or polyps. The differences between coping strategies and personality are examined and compared with another group with no history of voice pathology. The relationship of personality and coping strategies to voice quality variables is reported. Results show that patients use emotional coping strategies more and cognitive coping strategies less than the comparison group. Type of voice pathology was found to be related to dominance, and a number of coping and personality variables were found to correlate significantly with voice quality.