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.     

G. Paul Moore Lecture—1993: New voices for old

Otolaryngology and voice science have entered the era of “phonosurgery.” Several techniques allow voice professionals to intervene to restore or modify the voice in patients with immobile vocal folds and other problems related to voice production. It is necessary and appropriate that physicians and speech and language pathologists critically examine what has been accomplished and what may yet be possible for further voice improvement.     

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.     

The professional voice: Part III. Common diagnoses and treatments

Common problems that are of little consequence to other patients may be disabling to professional singers. Laryngologists must recognize even subtle manifestation of these ailments and be familiar with techniques to treat them without creating undesirable side effects. It is not usually necessary to restrict the trained professional from performing, and absolute voice rest is rarely necessary. Laryngeal surgery should be avoided whenever possible.     

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.     

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

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

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.     

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."     

Preparation of the Speech-LanguagePathologist Specializing in Voice: An Educational Survey

This study investigates the academic and clinical preparation a speech-language pathologist receives in the area of voice. The purpose is to determine how to structure continuing education and specialty training in vocology, defined as the science and practice of voice habilitation. Surveys were sent to the graduate programs in speech-language pathology accredited by the American Speech-Language-Hearing Association (ASHA) in 1994, and again in 1999. Results from the 1994 survey indicated that students received limited information and clinical experience in handling typical voice cases. Although most programs required a voice disorders course, fewer mandated coursework in normal voice production or clinical experience with voice patients. The follow-up survey showed that the educational environment in 1999 is similar to that in 1994. It is evident that the programs are in compliance with the Educational Training Board model developed by ASHA for basic clinical competence, but no structure for specialty training has yet emerged.     

Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report

The United States Bureau of Labor Statistics and other sources wereconsulted about the percentages of the working population that we identified as professional voice users. The largest percentage may be in sales and sales related occupations (13%), but the exact breakdown of those who approach their clients vocally rather than by mail is still uncertain. The second largest population is teachers, who comprise 4.2% percent of the U.S. workforce (1994 statistic). Teachers have been identified as having the greatest incidence of voice disorders. Population data are also given for professional voice users who could present a significant hazard to public safety if their vocal communication skills were severely impaired.     

Performance Anxiety: Loss of the Spoken Edge

The study aimed to assess whether a specific training program in vocal and physical skills could reduce the level of perceived performance anxiety. Eighteen undergraduate performing arts students were divided into two even groups. The experimental group experienced 10 two-hour sessions in a specialized vocal and physical skills training program. The control group received the same number of sessions in text analysis by the same teacher. Ten weeks after the training period, both groups were videotaped delivering a short speech of general interest. The videotaped material was assessed by four judges, using a visual analog scale (VAS). Perceptual variables considered were eight vocal and physical features: physical ease, physical presence, effective gesture use, effective eye contact, correct breath use, suitable pace, vocal variety, speech clarity, and one performance feature: perceived performance anxiety. Results indicated that the particular vocal and physical skills training program used showed positive results in effectively reducing the level of perceived performance anxiety. The experimental group scored significantly higher on each of the eight vocal and physical features and significantly lower on the perceived anxiety feature than the control group. This research has implications for those affected by performance anxiety in vocal presentation.     

Test-retest study of the GRBAS scale: Influence of experience and professional background on perceptual rating of voice quality

Perceptual evaluation was performed by means of the GRBAS scalefor a series of nine pathological voice samples that were presented twice to a group of 23 judges, consisting of experienced and inexperienced otolaryngologists (ENTs) and speech-language pathologists (S/LPs). The time interval between ratings was 14 days. Test-retest reliability was moderate. The best agreement between the observers was obtained for the G (grade) parameter and the worst for the S (strained) parameter. Considering the medians of the GRBAS ratings, no significant influence was measured for level of experience or professional background. Yet, based on means, the results show that professional background has a greater impact on perceptual rating than experience.     

Comparing Outcomes of Voice Therapy: A Benchmarking Study Using the Therapy Outcome Measure

The quality cycle requires clinicians to assess the outcomes of interventions. Benchmarking is an approach that has been advocated to compare current performance across different services to identify commonalities and significant differences. This article gives the results of a study of outcomes in speech and language therapy (SLT) using the therapy outcome measure (TOM) for patients with voice disorder (dysphonia) comparing outcomes of seven separate speech and language therapy services. The study aimed to identify the similarities and differences in outcomes of care provided by different services. Two hundred and forty patients with dysphonia (age range 3-87.5 years, average 51.9 years) were treated. The results indicated that although there was no significant difference in the profile of the severity of symptomology of patients referred to speech and language therapy in different geographical areas, there was a significant difference in the treatment outcomes across the services and in the stated reason for discharge from treatment. Nevertheless, most patients with dysphonia had a good outcome and this was associated with completion of the course of treatment. There were significant differences in the number of treatment contacts provided by the different services and in the duration (between admission and discharge) of treatment across the services. Benchmarking can provide useful information through use of routinely collected clinical data.     

Hearing myself with others: Sound levels in choral performance measured with separation of one's own voice from the rest of the choir

The choir singer has two acoustic signals to attend to: the sound of his or her own voice (feedback), and the sound of the rest of the choir (reference). The balance in loudness between feedback and reference is governed mainly by the room acoustics. Although earlier experiments have shown that singers have a fairly large tolerance for imbalance, with references ranging from −23 to +5 dB, experience suggests that, when singers are given control over this parameter, their preferences are much narrower. A quantification of the optimum balance would be useful in the design of concert stages and rehearsal halls. A method is described for measuring the feedback and reference levels as experienced by singers under live performance conditions. Recordings were made using binaural microphones worn by choir singer subjects. With the given combination of choir and room, it was possible to achieve adequate separation of the feedback and reference signals with simple signal processing. The feedback-to-reference ratio averaged over the 12 singers was found to be +3.9 dB, with extremes of +1.5 and +7.3 dB.     

Phonatory control in male singing: A study of the effects of subglottal pressure, fundamental frequency, and mode of phonation on the voice source

This article describes experiments carried out in order to gain a deeper understanding of the mechanisms underlying variation of vocal loudness in singers. Ten singers, two of whom are famous professional opera tenor soloists, phonated at different pitches and different loudnesses. Their voice source characteristics were analyzed by inverse filtering the oral airflow signal. It was found that the main physiological variable underlying loudness variation is subglottal pressure (Ps). The voice source property determining most of the loudness variation is the amplitude of the negative peak of the differentiated flow signal, as predicted by previous research. Increases in this amplitude are achieved by (a) increasing the pulse amplitude of the flow waveform; (b) moving the moment of vocal fold contact earlier in time, closer to the center of the pulse; and (c) skewing the pulses. The last mentioned alternative seems dependent on both Ps and the ratio between the fundamental frequency and the first formant. On the average, the singers doubled Ps when they increased fundamental frequency by one octave, and a doubling of the excess Ps over threshold caused the sound pressure level (SPL) to increase by 8–9 dB for neutral phonation, less if mode of phonation was changed to pressed. A shift of mode of phonation from flow over neutral to pressed was associated with a reduction of the peak glottal permittance i.e., the ratio between peak transglottal airflow to Ps. Flow phonation had the most favorable relationship between Ps and SPL.     

Differences in voice quality between men and women: Use of the long-term average spectrum (LTAS)

The goal of this study was to determine if there are acoustical differences between male and female voices, and if there are, where exactly do these differences lie. Extended speech samples were used. The recorded readings of a text by 31 women and by 24 men were analyzed by means of the Long-term Spectrum (LTAS), extracting the amplitude values (in decibels) at intervals of 160 Hz over a range of 8 kHz. The results showed a significant difference between genders, as well as an interaction of gender and frequency level. The female voice showed greater levels of aspiration noise, located in the spectral regions corresponding to the third formant, which causes the female voice to have a more “breathy” quality than the male voice. The lower spectral tilt in the women's voices is another consequence of this presence of greater aspiration noise.