Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects

PURPOSE

This epidemiological study compared the frequency and adverse effects of voice disorders in Brazilian teachers and nonteachers.

METHODS

A standardized interview/questionnaire was administered to 3,265 participants; 1,651 teachers; and 1,614 nonteachers recruited from all 27 Brazilian states.

RESULTS

Prevalence of reporting a current voice disorder was 11.6% for teachers and 7.5% for nonteachers, respectively (χ2(1)=16.1, P<0.001). Sixty-three percent of teachers and 35.8% of nonteachers reported having experienced a voice problem at some point during their lifetime (χ2(1)=246.6, P<0.001). Teachers reported a higher number of current (3.7) and past (3.6) voice symptoms as compared with nonteachers (1.7 current, 2.3 past) and more often attributed these symptoms to their occupation (P<0.001). Teachers, as compared with nonteachers (1) more frequently reported that their voice limited their ability to do certain tasks within their current occupation (29.9% of teachers vs 5.4% of nonteachers; P<0.001); (2) experienced more voice-related absenteeism over the past year (12.1% of teachers missed 5 or more days of work vs 2.4% of nonteachers; P<0.001); and (3) more often considered changing occupations in the future because of voice problems (16.7% of teachers vs 0.9% of nonteachers; P<0.001). The magnitude of voice-related dysfunction among teachers was similar across Brazilian states, and regional characteristics did not appear to significantly influence the results.

CONCLUSION

This large epidemiological study comparing teachers and nonteachers confirms that teaching at school is a high-risk occupation for developing voice disorders. These voice disorders contribute to reduced job performance, attendance, and force many Brazilian teachers to consider changing occupations in the future because of their voice.

Sustained vowels and continuous speech in the auditory-perceptual evaluation of dysphonia severity

PURPOSE: Auditory-perceptual evaluation of dysphonia may be influenced by the type of speech/voice task used to render judgements during the clinical evaluation, i.e., sustained vowels versus continuous speech. This study explored (a) differences in listener dysphonia severity ratings on the basis of speech/voice tasks, (b) the influence of speech/voice task on dysphonia severity ratings of stimuli that combined sustained vowels and continuous speech, and (c) the differences in inter-rater reliability of dysphonia severity ratings between both speech tasks. METHODS: Five experienced listeners rated overall dysphonia severity in sustained vowels, continuous speech and concatenated speech samples elicited by 39 subjects with various voice disorders and degrees of hoarseness. RESULTS: Data confirmed that sustained vowels are rated significantly more dysphonic than continuous speech. Furthermore, dysphonia severity in concatenated speech samples is least determined by the sustained vowel. Finally, no significant difference was found in inter-rater reliability between dysphonia severity ratings of sustained vowels versus continuous speech. CONCLUSION: Based upon the results, both types of speech/voice tasks (i.e., sustained vowel and continuous speech) should be elicited and judged by clinicians in the auditory-perceptual rating of dysphonia severity.

High spatial and temporal resolution breast DCE-MRI: A feasibility study

74

Background: The typical 1-2 min low temporal resolution (tRes) of conventional gradient-echo (GRE) breast dynamic contrast-enhanced (DCE) MRI precludes accurate quantitative pharmacokinetic (PK) analysis. The commercially available GRE-based TWIST (time-resolved angiography with stochastic trajectories) sequence employs an alternative k-space sampling scheme to provide high spatial and temporal resolution for dynamic imaging, originally intended for time-resolved MR angiography. Here we sought to evaluate the feasibility of breast DCE-MRI with the TWIST sequence, using both tumor morphology and quantitative PK analyses.

Methods: 22 patients with 25 mammography-detected suspicious lesions underwent TWIST DCE-MRI on a 3T Siemens system prior to biopsy. The axial bilateral images were acquired with 20 s tRes and 1.0x1.0x1.4 mm3 spatial resolution (sRes). Immediately after TWIST DCE-MRI, a single DCE image set was acquired in 68 s using a conventional GRE sequence with the same sRes. Blinded to pathology, 3 radiologists compared lesion morphology assessments from the last TWIST DCE and the conventional images, and gave MRI BIRADS scores based on morphology and qualitative kinetic curve analyses. The TWIST DCE lesion signal time-courses were also subjected to Shutter-Speed Model PK analysis.

Results: Normal parenchyma S/N ratios were not statistically different between TWIST and conventional GRE images. All readers indicated 88% [95% CI: (68%, 97%)] agreement in morphology evaluation between the TWIST and conventional DCE images. The degree of inter-reader agreement was substantial (κ = 0.75), as was the agreement in BIRADS scores (κ = 0.76). Pathology revealed 8 malignant and 17 benign lesions. Based on MRI BIRADS scores, all 3 readers attained 100% sensitivity and 82% specificity. With PK analysis, a Ktrans (contrast agent plasma/interstitium transfer rate constant) cut-off value of 0.1 min-1 further improved specificity to 94%.

Conclusions: TWIST breast DCE-MRI provides both high tRes and sRes for accurate quantitative PK analysis and morphology evaluation, respectively. Utilizing TWIST for clinical breast DCE-MRI with quantitative PK analysis is feasible and may improve MRI interpretation.

Spasmodic dysphonia: onset, course, socioemotional effects, and treatment response

OBJECTIVES

This investigation explored the onset, progression, socioemotional effects, and treatment outcomes of spasmodic dysphonia (SD).

METHODS

A cross-sectional epidemiological approach was used to examine questionnaire responses from 150 individuals with SD.

RESULTS

Symptoms of SD (mean age at onset, 46 years) began gradually in 76% of cases and were progressive (ie, failed to plateau) in 34% of cases. Botulinum toxin A (Botox) helped to attenuate voice symptoms in 91% of cases; however, the scores on the Voice-Related Quality of Life questionnaire (V-RQOL) were not associated with this effect. The V-RQOL scores improved with time since symptom onset, independent of age and treatment. The patients with only SD experienced onset, course, and progression of symptoms similar to those of the patients with SD and coexisting vocal tremor.

CONCLUSIONS

The symptoms of SD begin gradually and worsen over time. New evidence indicates that SD symptoms may continue to progress without plateau in at least a subset of patients. Individuals with SD and coexisting vocal tremor experience symptom trajectories similar to those of patients with SD only. Although Botox may attenuate voice symptoms, these effects do not appear to be strongly related to the V-RQOL scores. These results provide new and valuable insights regarding the onset, course, progression, and treatment of SD.

Voice Disorders in Teachers

Voice disorders are a common occupational hazard of teaching school. This article provides an overview of recent epidemiological research surrounding this high-risk occupation, identifies possible mechanisms contributing to voice disorder development including vibration overdose, summarizes recent clinical trials research evaluating treatments for teachers with voice disorders, and discusses primary prevention and the relative inadequacy of “education only” approaches.

Efficient Planning under Uncertainty with Macro-actions

Deciding how to act in partially observable environments remains an active area of research. Identifying good sequences of decisions is particularly challenging when good control performance requires planning multiple steps into the future in domains with many states. Towards addressing this challenge, we present an online, forward-search algorithm called the Posterior Belief Distribution (PBD). PBD leverages a novel method for calculating the posterior distribution over beliefs that result after a sequence of actions is taken, given the set of observation sequences that could be received during this process. This method allows us to efficiently evaluate the expected reward of a sequence of primitive actions, which we refer to as macro-actions. We present a formal analysis of our approach, and examine its performance on two very large simulation experiments: scientific exploration and a target monitoring domain. We also demonstrate our algorithm being used to control a real robotic helicopter in a target monitoring experiment, which suggests that our approach has practical potential for planning in real-world, large partially observable domains where a multi-step lookahead is required to achieve good performance.

Laryngeal Features of External Superior Laryngeal Nerve Denervation: Revisiting a Century-Old Controversy

A long-standing controversy exists regarding the laryngoscopic features associated with unilateral denervation of the external superior laryngeal nerve (ESLN). Recently, we modeled acute unilateral cricothyroid muscle paralysis by blocking the ipsilateral ESLN with lidocaine hydrochloride, and identified epiglottic petiole deviation to the side of paralysis during high-pitched voice production as a possible diagnostic sign. This study provides preliminary clinical evidence supporting the presence of petiole deviation in cases of ESLN denervation. Epiglottic petiole deviation to the side of weakness was present in electromyographically confirmed cases of unilateral partial or complete ESLN denervation, in isolation or in combination with denervation of other branches of the vagus nerve. In addition, a case of complete ESLN and recurrent laryngeal nerve (RLN) denervation showed return of the petiole to the midline 6 months after surgical reinnervation of the ESLN and RLN. Finally, petiole deviation was not present in isolated RLN paralysis — A finding suggesting that the diagnostic sign is uniquely associated with ESLN denervation. We concluded that deviation of the petiole to the side of cricothyroid muscle weakness during high-pitched voice production represents a potential diagnostic sign of unilateral ESLN denervation. Further research is necessary to determine factors that influence the expression and detection of this sign, as well as its diagnostic precision.

Nebulized isotonic saline versus water following a laryngeal desiccation challenge in classically trained sopranos

PURPOSE

To examine the effects of nebulized isotonic saline (IS) versus sterile water (SW) on self-perceived phonatory effort (PPE) and phonation threshold pressure (PTP) following a surface laryngeal dehydration challenge in classically trained sopranos.

METHOD

In a double-blind, within-subject crossover design, 34 sopranos breathed dry air (relative humidity < 1%) transorally for 15 min and then nebulized 3 mL of IS or SW, or experienced a no-treatment control condition over 3 consecutive weeks. PPE and PTP were measured every 15 min from baseline through 2 hr postdesiccation.

RESULTS

PPE increased significantly following the laryngeal desiccation challenge in all 3 treatment conditions (p < .01). After nebulization, PPE returned to baseline for the IS condition only. For the SW and control conditions, PPE remained above baseline during the 2 hr after desiccation. No statistically significant changes in PTP following laryngeal desiccation were observed, although values for the IS condition remained below baseline for nearly 2 hr after nebulization. PPE and PTP were not significantly correlated.

CONCLUSIONS

Following a laryngeal surface dehydration challenge, classically trained sopranos reported increased vocal effort that persisted for at least 2 hr. Compared with SW, nebulized IS showed promise as an effective way to remediate the adverse, self-perceived effects of laryngeal desiccation.

Quantifying dysphonia severity using a spectral/cepstral-based acoustic index: Comparisons with auditory-perceptual judgements from the CAPE-V

This study investigated the relationship between acoustic spectral/cepstral measures and listener severity ratings in normal and disordered voice samples. CAPE-V sentence samples and the vowel /a/were elicited from eight normal speakers and 24 patients with varying degrees of dysphonia severity. Samples were analysed for measures of the cepstral peak prominence (CPP), the ratio of low-to-high spectral energy, and their respective standard deviations. Perceptual ratings of overall severity were also obtained for all samples. Results showed that all acoustic variables combined in a four-factor model which correlated with perceived severity with R = 0.81 (R(2) = 0.65). For the vowel /a/, a five-factor model incorporating all acoustic variables and gender correlated with perceived severity with R = 0.96 (R(2) = 0.91). Results indicate that a strong relationship between perceptual and acoustic estimates of dysphonia severity can be achieved in both continuous speech and vowel contexts using a model incorporating spectral/cepstral measures.

Vocal Function Exercises for Presbylaryngis: A Multidimensional Assessment of Treatment Outcomes

Objectives

Presbylaryngis, or aging of the larynx, can adversely affect vocal function and quality of life in the elderly. This preliminary investigation examined the effects of vocal function exercises, a physiologic voice therapy approach, as a primary treatment for presbylaryngis.

Methods

Nine consecutive elderly patients with presbylaryngis (2 female, 7 male) underwent a 6-week course of voice therapy employing vocal function exercises. Pretherapy-versus-posttherapy comparisons were made of self-ratings of voice handicap and phonatory effort level, as well as auditory-perceptual voice assessments, acoustic analyses, and visual-perceptual evaluations of laryngeal images.

Results

After treatment, patients reported significant reductions on Voice Handicap Index scores, phonatory effort levels, and voice disorder severity. Blinded listeners rated the posttreatment voices as significantly less breathy and strained. However, comparison of pretreatment and posttreatment maximum phonation times, acoustic measures, and laryngeal images did not reveal significant changes.

Conclusions

These preliminary data suggest that vocal function exercises produce significant functional and perceptual improvements in voice, and deserve further attention as a treatment for elderly patients with presbylaryngis.

Differential diagnosis of muscle tension dysphonia and adductor spasmodic dysphonia using spectral moments of the long-term average spectrum

OBJECTIVES/HYPOTHESIS

Adductor spasmodic dysphonia (ADSD) can mimic the voice characteristics of muscle tension dysphonia (MTD) contributing to diagnostic confusion and inappropriate management. Elevated spectral noise has been reported in MTD, which may aid in differential diagnosis. The long-term average spectrum (LTAS) can be compared to a Gaussian bell curve using spectral moments analysis. Four moments describe features of the LTAS: spectral mean (moment 1), standard deviation (moment 2), skewness (moment 3), and kurtosis (moment 4). This investigation evaluated spectral moments analysis of the LTAS as an objective test to distinguish ADSD from MTD.

STUDY DESIGN

Case-control comparison.

METHODS

Pretreatment voice samples from 59 subjects with MTD (10 males and 49 females) and 41 subjects with ADSD (19 males and 22 females) were analyzed. Groups were separated by gender, adjusted for age, and results from the analysis were compared across different analyzing bandwidths. Diagnostic precision estimates were calculated including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios.

RESULTS

No significant spectral differences were found between men in both groups. However, significant between-group differences were identified for all spectral moments for women. Logistic stepwise regression identified that spectral standard deviation (moment 2) uniquely distinguished women with MTD and ADSD. No other spectral moments contributed significant discriminatory information.

CONCLUSIONS

The results suggest that moment 2 of the LTAS provides respectable diagnostic precision by highlighting spectral noise differences between females with MTD and ADSD. Automated spectral moments analysis deserves further attention as a possible test for differential diagnosis.

The Acoustic Voice Quality Index: toward improved treatment outcomes assessment in voice disorders

Voice practitioners require an objective index of dysphonia severity as a means to reliably track treatment outcomes. To ensure ecological validity however, such a measure should survey both sustained vowels and continuous speech. In an earlier study, a multivariate acoustic model referred to as the Acoustic Voice Quality Index (AVQI), consisting of a weighted combination of 6 time-, frequency- and quefrency-domain metrics, was developed to measure dysphonia severity in both speaking tasks. In the current investigation, the generalizability and clinical utility of the AVQI are evaluated by first assessing its external cross-validity and then determining its sensitivity to change in dysphonia severity following surgical and/or behavioral voice treatment. The results, based upon a new set of normal and disordered voices compared favorably with outcomes reported earlier, indicating acceptable external validity. Furthermore, the AVQI was sensitive to treatment-related changes, validating its role as a potentially robust and objective voice treatment outcomes measure.

LEARNING OUTCOMES

Readers will be able to: (1) explain methodological issues surrounding the development of voice treatment outcomes measures (such as external cross-validity and responsiveness to change), (2) appreciate the relevance of measuring dysphonia severity in both sustained vowels and connected speech, (3) describe the method of obtaining the Acoustic Voice Quality Index (AVQI), (4) appreciate differences among a variety of estimates of diagnostic accuracy, and (5) discuss the AVQI as a clinically valid treatment outcomes measure.

Risk and protective factors for spasmodic dysphonia: a case-control investigation

OBJECTIVES

Spasmodic dysphonia (SD) is a chronic, incurable, and often disabling voice disorder of unknown pathogenesis. The purpose of this study was to identify possible endogenous and exogenous risk and protective factors uniquely associated with SD.

STUDY DESIGN

Prospective, exploratory, case-control investigation.

METHODS

One hundred fifty patients with SD and 150 medical controls (MCs) were interviewed regarding their personal and family histories, environmental exposures, illnesses, injuries, voice use patterns, and general health using a previously vetted and validated epidemiologic questionnaire.

RESULTS

Odds ratios and multiple logistic regression analyses (α<0.15) identified several factors that significantly increased the likelihood of having SD. These factors included (1) a personal history of mumps, blepharospasm, tremor, intense occupational and avocational voice use, and a family history of voice disorders; (2) an immediate family history of meningitis, tremor, tics, cancer, and compulsive behaviors; and (3) an extended family history of tremor and cancer.

CONCLUSIONS

SD is likely multifactorial in etiology, involving both genetic and environmental factors. Viral infections/exposures, along with intense voice use, may trigger the onset of SD in genetically predisposed individuals. Future studies should examine the interaction among genetic and environmental factors to determine the pathogenesis of SD.

Acoustic measurement of overall voice quality: a meta-analysis

Over the past several decades, many acoustic markers have been proposed to be sensitive to and measure overall voice quality. This meta-analysis presents a retrospective appraisal of scientific reports, which evaluated the relation between perceived overall voice quality and several acoustic-phonetic correlates. Twenty-five studies met the inclusion criteria and were evaluated using meta-analytic techniques. Correlation coefficients between perceptual judgments and acoustic measures were computed. Where more than one correlation coefficient for a specific acoustic marker was available, a weighted average correlation coefficient was calculated. This was the case in 36 acoustic measures on sustained vowels and in 3 measures on continuous speech. Acoustic measures were ranked according to the strength of the correlation with perceptual voice quality ratings. Acoustic markers with more than one correlation value available in literature and yielding a homogeneous weighted r of 0.60 or above were considered to be superior. The meta-analysis identified four measures that met these criteria in sustained vowels and three measures in continuous speech. Although acoustic measures are routinely utilized in clinical voice examinations, the results of this meta-analysis suggest that caution is warranted regarding the concurrent validity and thus the clinical utility of many of these measures.

Estimating dysphonia severity in continuous speech: application of a multi-parameter spectral/cepstral model

The purpose of the study was to identify a sub-set of spectral/cepstral-based analysis methods that would most effectively predict dysphonia severity (as estimated via auditory-perceptual analysis) in samples of continuous speech. Acoustic estimates of dysphonia severity were used as an objective treatment outcomes measure in a set of pre- vs post-treatment speech samples. Pre- and post-treatment continuous speech samples from 104 females with primary muscle tension dysphonia (MTD) were rated by listeners using a 100 point visual analogue scale (VAS) and analysed acoustically with spectral/cepstral-based measures. Stepwise linear regression produced a three-factor model consisting of the cepstral peak prominence (CPP); the mean ratio of low-to-high frequency spectral energy; and the standard deviation of the ratio of low-to-high frequency spectral energy that was strongly correlated with perceived dysphonia severity ratings (R = .85; R2 = .73). Mean differences between predicted vs perceptual ratings for pre- and post-treatment speech samples were < 6 points on the 100 point VAS; mean absolute differences between predicted and perceived ratings were < 16 points on the 100 point VAS (equivalent to within one scale value on commonly used 7-point equal-appearing interval rating scales). A multi-parameter acoustic model consisting of spectral/cepstral-based measures shows considerable promise as an objective measure of dysphonia severity in continuous speech, even across the diverse voice types and severities observed in pre- and post-treatment MTD speech samples.

Outcomes measurement in voice disorders: application of an acoustic index of dysphonia severity

PURPOSE

The purpose of this experiment was to assess the ability of an acoustic model composed of both time-based and spectral-based measures to track change following voice disorder treatment and to serve as a possible treatment outcomes measure.

METHOD

A weighted, four-factor acoustic algorithm consisting of shimmer, pitch sigma, the ratio of low-to-high frequency spectral energy, and a measure of the cepstral peak was used to predict dysphonia severity in pre- and post-treatment vowel samples from 88 women with primary muscle tension dysphonia treated by manual circumlaryngeal therapy. Predicted severity ratings were also compared to mean perceived severity ratings determined by a group of judges.

RESULTS

Predicted severity scores were strongly associated with perceived dysphonia severity ratings for pretreatment, posttreatment, and change in dysphonia severity. Analyses of the agreement between predicted and perceptual severity ratings indicated that the majority of differences were within +/- 1 standard deviation from the mean difference. Acoustic predictions of perceived severity were observed to be most accurate for the midportion of the 7-point equal-appearing interval severity scale.

CONCLUSION

The acoustic model and predicted dysphonia severity scores show promise as a sensitive and objective outcomes measure, even with extremely perturbed pre-treatment voice samples that would be difficult to analyze using traditional time-based perturbation measures.

Articulatory changes in muscle tension dysphonia: evidence of vowel space expansion following manual circumlaryngeal therapy

In a preliminary study, we documented significant changes in formant transitions associated with successful manual circumlaryngeal treatment (MCT) of muscle tension dysphonia (MTD), suggesting improvement in speech articulation. The present study explores further the effects of MTD on vowel articulation by means of additional vowel acoustic measures. Pre- and post-treatment audio recordings of 111 women with MTD were analyzed acoustically using two measures: vowel space area (VSA) and vowel articulation index (VAI), constructed using the first (F1) and second (F2) formants of 4 point vowels/ a, i, ae, u/, extracted from eight words within a standard reading passage. Pairwise t-tests revealed significant increases in both VSA and VAI, confirming that successful treatment of MTD is associated with vowel space expansion. Although MTD is considered a voice disorder, its treatment with MCT appears to positively affect vocal tract dynamics. While the precise mechanism underlying vowel space expansion remains unknown, improvements may be related to lowering of the larynx, expanding oropharyngeal space, and improving articulatory movements.

LEARNING OUTCOMES

The reader will be able to: (1) describe possible articulatory changes associated with successful treatment of muscle tension dysphonia; (2) describe two acoustic methods to assess vowel centralization and decentralization, and; (3) understand the basis for viewing muscle tension dysphonia as a disorder not solely confined to the larynx.

Sensitive biomarker of polycyclic aromatic hydrocarbons (PAHs): urinary 1-hydroxyprene glucuronide in relation to smoking and low ambient levels of exposure

The study was conducted in a Chinese population with occupational or environmental exposures to polycyclic aromatic hydrocarbons (PAHs). A total of 106 subjects were recruited from coke-oven workers (workers), residents in a metropolitan area (residents) and suburban gardeners (gardeners). All subjects were monitored twice for their personal exposures to PAHs. The biological samples were collected for measurements of 1-hydroxypyrene (1-OHP) and cotinine in urine. The geometric means of personal exposure levels of pyrene, benz(a)anthracene (BaA) and benzo(a)pyrene (BaP) in workers were 1.470, 0.978 and 0.805 microg m-3, respectively. The corresponding levels in residents were 0.050, 0.034 and 0.025 microg m-3; and those in gardeners were 0.011, 0.020 and 0.008 microg m-3, respectively. The conjugate of 1-OHP with glucuronide (1-OHP-G) is the predominant form of pyrene metabolite in urine and it showed strong associations with exposures not only to pyrene, but also to BaA, BaP and total PAHs. Most importantly, a significant difference in 1-OHP-G was even detected between the subgroups with exposures to BaP at < 0.010 and > 0.010 but < 0.020 microg m-3, suggesting that 1-OHP-G is a good marker that can be used for the risk assessment of BaP exposure at levels currently encountered in ambient air. Furthermore, multiple regression analyses of 1-OHP-G on PAHs exposure indicated that cigarette smoke was a major confounding factor and should be considered and adjusted for while using 1-OHP to estimate PAHs exposure.

Sustained release nanoparticulate formulation containing antioxidant-ellagic acid as potential prophylaxis system for oral administration

The aim of the present work was to develop ellagic acid (EA) loaded poly(d,l-lactide-co-glycolide) (PLGA) nanoparticles for oral administration. PLGA nanoparticles were prepared by a method based on the concept of emulsion-diffusion-evaporation by using polyethylene glycol (PEG) 400 as a cosolvent for solubilizing the drug. While developing this method, didodecyldimethylammomium bromide (DMAB) and polyvinyl alcohol (PVA), alone and in combination with chitosan (CS) were employed. DMAB stabilized particles were the smallest of all the formulations with a particle size of 148.5 nm. PVA alone gave particles of 269.7 nm but a blend with CS (80:20) resulted in an increase in particle size (359.6 +/- 23.6 nm). Initial release of EA from nanoparticles in pH 7.4 phosphate buffer was rapid, followed by a slower sustained release. Release rates followed the order PVA > PVA-CS > DMAB. Release rate from the PLGA-DMAB particles was slowest, which is attributed to higher hydrophobicity of DMAB as compared to PVA, preventing diffusion of drug out of polymeric matrix. Insolubility of CS at alkaline pH could have retarded the release in case of PVA-CS system. In situ intestinal permeability study of pure drug and the drug encapsulated in nanoparticles prepared using PVA, PVA-CS blend and DMAB as stabilizer in rats showed 66, 75, 73 and 87% permeation, respectively. EA showed good free radical scavenging effect in a yeast cell culture model as well as in a cell free system.

Ansa-RLN reinnervation for unilateral vocal fold paralysis in adolescents and young adults

OBJECTIVE/HYPOTHESIS

To assess the outcomes of management of unilateral vocal fold paralysis by ansa-RLN reinnervation in a series of patients ages 12-21.

STUDY DESIGN

Clinical outcomes study.

METHODS

Six consecutive adolescents and young adults (ages 12-21 years) seeking treatment for unilateral vocal fold paralysis and glottal incompetence underwent ansa-RLN neurorraphy. Pre- and post-operative voice recordings acquired at least 1 year following surgery were submitted to acoustic and perceptual analysis. Patient-based measures were also taken.

RESULTS

Mean perceptual visual analogue scale rating of dysphonia severity (0mm=profoundly abnormal voice, 100mm=completely normal voice) improved from 50mm pre-operatively to 82mm post-operatively. Mean maximum phonation time improved from 6.5s to 13.2s. Pitch and dynamic range were also observed to improve. Global self-ratings of voice function (0-100%) increased from 31.2% to 81.6% of normal.

CONCLUSIONS

Ansa-RLN reinnervation is an effective treatment option for adolescents and young adults with unilateral vocal fold paralysis. The procedure has the potential to improve vocal function substantially, especially in those with isolated paralysis of the recurrent laryngeal nerve. The procedure alleviates the disadvantages associated with other surgical options for this age group.

How does cricotracheal resection affect the female voice?

OBJECTIVES

We measured the effects of cricotracheal resection on the adult female voice.

METHODS

Voice recordings of 14 women (mean age, 53 years; range, 35 to 69 years) who underwent cricotracheal resection for chronic airway obstruction associated with idiopathic laryngotracheal stenosis were acquired before and after surgery. The recordings were analyzed with voice analysis software. The measures included the mean fundamental frequency of a sustained vowel at a comfortable pitch and loudness (F0), the mean F0 of connected speech (ie, speaking F0), the pitch range (F0 range), and the maximum phonation time. Self-assessment measures of the Voice Handicap Index were taken.

RESULTS

The mean speaking F0 lowered significantly, by 21 Hz, from 186 Hz to 165 Hz (p = .04). In 7 patients, the speaking F0 was below 160 Hz after the operation. The mean sustained vowel frequency also dropped by 32 Hz (p = .03). The F0 range was reduced by an average of 5.9 semitones, from 21.5 to 15.6 (p = .05). The maximum phonation time did not change significantly. The postoperative mean Voice Handicap Index score was 21.9.

CONCLUSIONS

Cricotracheal resection can significantly impact the adult female voice. It often lowers the pitch of the speaking voice into the male range and reduces the pitch range of the voice. The change in voice that potentially accompanies this procedure should be discussed with patients in preoperative counseling.

Articulatory changes following treatment of muscle tension dysphonia: preliminary acoustic evidence

PURPOSE

Primary muscle tension dysphonia (MTD), a voice disturbance that occurs in the absence of structural or neurological pathology, may respond to manual circumlaryngeal techniques, which ostensibly alter the posture of the larynx and/or the configuration of the vocal folds without directly targeting supralaryngeal articulatory structures. Although the phonatory benefits of these techniques have been documented previously, this investigation examined whether acoustic evidence exists for articulatory changes accompanying successful management.

METHOD

In this retrospective study of a clinical database, pre- and post-treatment speech samples from 111 women with MTD were analyzed for acoustic evidence of supraglottal vocal tract changes associated with voice improvement, which was confirmed by perceptual ratings of dysphonia severity. The slopes of the first and second formants in diphthongs, as well as global measures of speech timing were acquired. Twenty younger females with normal voices were recorded twice, across a similar time-span to the disordered speakers, to allow comparisons in performance.

RESULTS

Repeated measures analysis of variance was used to evaluate changes accompanying treatment. Significant time by group interactions for /I/ F2 slope, /eI/ F2 slope, sample duration, and speaking time ratio were observed. As compared to the controls, diphthong second formant transitions increased in slope, and timing measures showed increases in speech continuity for the speakers with MTD.

CONCLUSIONS

Collectively, these preliminary findings suggest that individuals with MTD experience changes in both articulatory and phonatory behavior following successful treatment that targets the larynx.

Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects

OBJECTIVES

Epidemiological studies of dysphagia in the elderly are rare. A non-treatment-seeking, elderly cohort was surveyed to provide preliminary evidence regarding the prevalence, risks, and socioemotional effects of swallowing disorders.

METHODS

Using a prospective, cross-sectional survey design, we interviewed 117 seniors living independently in Utah and Kentucky (39 men and 78 women; mean age, 76.1 years; SD, 8.5 years; range, 65 to 94 years) regarding 4 primary areas related to swallowing disorders: lifetime and current prevalence, symptoms and signs, risk and protective factors, and socioemotional consequences.

RESULTS

The lifetime prevalence of a swallowing disorder was 38%, and 33% of the participants reported a current problem. Most seniors with dysphagia described a sudden onset with chronic problems that had persisted for at least 4 weeks. Stepwise logistic regression identified 3 primary symptoms uniquely associated with a history of swallowing disorders: taking a longer time to eat (odds ratio [OR], 9.5; 95% confidence interval [CI], 2.3 to 40.2); coughing, throat clearing, or choking before, during, or after eating (OR, 3.4; 95% CI, 1.1 to 10.2); and a sensation of food stuck in the throat (OR, 5.2; 95% CI, 1.8 to 10.0). Stroke (p = .02), esophageal reflux (p = .003), chronic obstructive pulmonary disease (p = .05), and chronic pain (p = .03) were medical conditions associated with a history of dysphagia. Furthermore, dysphagia produced numerous adverse socioemotional effects.

CONCLUSIONS

This study provides preliminary evidence to suggest that chronic swallowing disorders are common among the elderly, and highlights the need for larger epidemiological studies of these disorders.

Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders

Poorly regulated activity of the perilaryngeal muscles affects phonatory function and contributes to a class of disorders known as hyperfunctional or musculoskeletal tension voice disorders. Recognizing the signs and symptoms of excess or dysregulated laryngeal muscle activity is critical to proper diagnosis and selection of appropriate treatment(s). Although numerous approaches exist to manage such hyperfunctional syndromes, manual circumlaryngeal techniques have recently received attention as valuable tools in both assessment and treatment. Therefore, the purpose of this article is to: (1) describe common phenomenological features of dysregulated laryngeal muscle tension, thereby facilitating its recognition, (2) highlight the role of manual circumlaryngeal techniques in assessment and management, (3) survey additional treatment approaches for laryngeal hyperfunction, and explore the evidence to support their effectiveness, and (4) identify unresolved issues and controversies surrounding tension-based voice disorders. A series of pre- and post-treatment audio examples are provided on the journal website at www.informaworld.com/ijslp .

Portability of tag SNPs across isolated population groups: an example from India

Isolated population groups are useful in conducting association studies of complex diseases to avoid various pitfalls, including those arising from population stratification. Since DNA resequencing is expensive, it is recommended that genotyping be carried out at tagSNP (tSNP) loci. For this, tSNPs identified in one isolated population need to be used in another. Unless tSNPs are highly portable across populations this strategy may result in loss of information in association studies. We examined the issue of tSNP portability by sampling individuals from 10 isolated ethnic groups from India. We generated DNA resequencing data pertaining to 3 genomic regions and identified tSNPs in each population. We defined an index of tSNP portability and showed that portability is low across isolated Indian ethnic groups. The extent of portability did not significantly correlate with genetic similarity among the populations studied here. We also analyzed our data with sequence data from individuals of African and European descent. Our results indicated that it may be necessary to carry out resequencing in a small number of individuals to discover SNPs and identify tSNPs in the specific isolated population in which a disease association study is to be conducted.

The effects of three nebulized osmotic agents in the dry larynx

PURPOSE

This investigation examined the effects of nebulized hypertonic saline, isotonic saline (IS), and sterile (hypotonic) water on phonation threshold pressure (PTP) and self-perceived phonatory effort (PPE) following a surface laryngeal dehydration challenge.

METHOD

In a double-blind, randomized experimental trial, 60 vocally healthy women (n = 15 per group) underwent a laryngeal desiccation challenge involving oral breathing for 15 min using medical-grade dry air (RH<1%). Three of the four groups then received nebulized isotonic saline (0.9% NaCl), hypertonic saline (7% NaCl), or sterile (hypotonic) water, respectively; the 4th group served as a nontreatment control. PTP and PPE were estimated for high-pitched productions at baseline, immediately postdesiccation, and at 5, 20, 35, and 50 min postnebulization.

RESULTS

PTP increased significantly for all groups following the desiccation challenge. PTP values were, on average, 0.5 cm H(2)O greater immediately postdesiccation versus baseline. In contrast, PTP values did not change significantly following the administration of nebulized treatments, although a temporary trend toward a reduction in PTP was observed for the IS group. Unexpectedly, PPE ratings decreased significantly after the desiccation challenge. In general, PPE ratings were poorly correlated with PTP measures.

CONCLUSION

A laryngeal desiccation challenge (i.e., temporary exposure to extremely low relative humidity while breathing transorally) significantly increased PTP. Although interesting trends emerged, none of the nebulized treatments significantly enhanced recovery from the negative effects of desiccation on PTP. In light of very low correlations between PTP and PPE, serious questions are raised regarding presumed associations between these measures.

Epidemiology of Voice Disorders in the Elderly: Preliminary Findings

OBJECTIVES

Epidemiologic studies of the prevalence and risk factors of voice disorders in the elderly, nontreatment seeking population are nonexistent. The purpose of this preliminary investigation was to 1) estimate the prevalence of voice disorders, 2) identify variables associated with increased risk of voice disorders, and 3) measure the socioemotional impact of voice disorders on the elderly who live independently.

STUDY DESIGN

Prospective, cross-sectional survey.

METHODS

One hundred seventeen seniors (39 males and 78 females; mean age, 76.1 yr; SD, 8.5 yr; range, 65-94 yr), residing in Utah and Kentucky, were interviewed using a questionnaire that addressed three areas related to voice disorders: prevalence, potential risk factors, and socioemotional consequences/effects.

RESULTS

The lifetime prevalence of a voice disorder was 47%, with 29.1% of participants reporting a current voice disorder. The majority of respondents (60%) reported chronic voice problems persisting for at least 4 weeks. Seniors who had experienced esophageal reflux, severe neck/back injury, and chronic pain were at increased risk. Voice-related effort and discomfort, combined with increased anxiety and frustration and the need to repeat oneself, were specific areas that adversely affected quality of life.

CONCLUSIONS

This preliminary epidemiologic study confirmed that voice disorders are common among the elderly, and further research is needed to identify additional risk factors contributing to voice disorder vulnerability.

Toward Improved Differential Diagnosis of Adductor Spasmodic Dysphonia and Muscle Tension Dysphonia

OBJECTIVE

Adductor spasmodic dysphonia (ADSD) is characterized by a strained-strangled voice quality, whose diagnosis relies exclusively on auditory-perceptual features. However, muscle tension dysphonia (MTD) -- a functional voice disorder -- can mimic ADSD thereby contributing to diagnostic confusion. Unlike MTD, ADSD has been described as 'task-specific', implying that certain vocal tasks such as sentences loaded with predominantly voiced consonants will provoke greater sign expression. This investigation examined the diagnostic value of variable sign expression based upon phonetic loading as a means to disambiguate ADSD and MTD.

PATIENTS AND METHODS

Five listeners, who were blinded to the purpose of the study, used a 10-cm visual analog scale to rate the dysphonia severity of two sentences (one all-voiced and one containing primarily voiceless consonants) produced by participants with ADSD (n = 29) or MTD (n = 33).

RESULTS

A mixed-design ANOVA, with Group (ADSD vs. MTD) as the between-subjects variable and Sentence Type (all-voiced vs. voiceless) as the within-subjects variable, confirmed a significant Group-by-Sentence Type interaction effect (p = 0.0002). In ADSD, ratings of dysphonia severity for the all-voiced sentence were significantly more severe than for the voiceless sentence (p < 0.0001), whereas in MTD no significant difference was observed (p = 0.9981). The ROC curve confirmed that differences in dysphonia severity between voiced and voiceless sentences represented a highly specific (88-100%), but only 48% sensitive diagnostic marker.

CONCLUSIONS

Phonetic loading influences sign expression in ADSD, and assists in discriminating ADSD from MTD.

Behavioral Characteristics of Children With Vocal Fold Nodules

Vocal fold nodules (VNs) in children are benign, bilateral lesions occurring on the mid-membranous vocal folds. Repetitive phonotraumatic behavior leading to chronic vocal fold injury and repair is frequently cited as the primary etiology; however, specific behavioral characteristics may predispose some children toward intense and potentially phonotraumatic voice use, thereby contributing secondarily to VN formation. The purpose of this case-control study was to determine whether children with VNs possess unique behavioral characteristics that may predispose them to VN development. Parents of 26 children with VNs (20 boys, 6 girls, mean age=7.2 years, SD=2.5 years), and 29 vocally normal, medical controls (22 boys, 7 girls, mean age=6.7 years, SD=2.4), completed the Childhood Behavior Checklist (CBCL/4-18, Achenbach, 1991), a standardized parent-rating scale with strong psychometric properties. No significant between-group differences were detected on any of the behavior problem syndrome scales. Group differences approached significance for the individual items "screams a lot" and "teases a lot" (VN group > Controls). The VN group scored significantly higher than the controls on the "Social Scale," a compilation of positive ratings of the child's social activity, frequency of contacts with friends, behavior with others, and behavior by themselves. Observed outcomes were consistent with previous characterizations of children with VN as "outgoing" or "extroverted" but were not consistent with other claims that this population may be at risk for "aggressive," "attentional," or "impulsive" behavior problems.

Genetic variation of farrowing kinetics traits and their relationships with litter size and perinatal mortality in French Large White sows

Genetic parameters of litter traits and their relationships with farrowing kinetics traits were estimated in a Large White population to examine the impact of selection for litter size on perinatal mortality and one of its main determinants, farrowing kinetics. Data were collected on 2,947 farrowings from 1,267 sows between 1996 and 2004. Litter traits included the number born in total (NBT), number born alive (NBA), and the number (NSB) and proportion (PSB) of stillborn piglets. Four farrowing kinetics traits were considered: farrowing duration (FD), birth interval (BI = FD/NBT), heterogeneity of birth intervals (SDNB = SD of the number of piglets born each one-half hour), and birth assistance (BA) during the farrowing process. Genetic parameters were estimated using restricted maximum likelihood methodology. All traits were analyzed using a mixed linear animal model including year x month and parity as fixed effects; the additive genetic value of each animal and the sow permanent environment were treated as random effects. To normalize their distribution, kinetics traits were Box-Cox-transformed. Low heritability estimates were obtained for litter size and mortality traits, which was in agreement with literature results (i.e., 0.10 +/- 0.02, 0.08 +/- 0.02, 0.19 +/- 0.02, and 0.14 +/- 0.02 for NBT, NBA, NSB, and PSB, respectively). Heritability values were also low for kinetics traits: 0.10 +/- 0.02, 0.08 +/- 0.02, 0.01 +/- 0.01, and 0.05 +/- 0.03 for FD, BI, SDNB, and BA, respectively. The genetic correlation between NBT and NBA was strongly positive (ra = 0.90). On both phenotypic and genetic scales, NBT was positively associated with stillbirth (ra = 0.45 +/- 0.11, rp = 0.38 for NSB; ra = 0.46 +/- 0.13, rp = 0.17 for PSB). Conversely, NBA had low correlations with SB and PSB. Number born in total was moderately correlated to FD (ra = 0.34 +/- 0.15) and BI (ra = -0.37 +/- 0.15). A stronger relationship was found between NBA and BI (ra = -0.49 +/- 0.13), whereas the relationship with FD was lower (ra = 0.16 +/- 0.17). Moreover, FD was strongly correlated with stillbirth (ra = 0.42 +/- 0.12 with NSB), whereas BI was nearly independent of stillbirth. Contrary to selection on NBT, selection on NBA appears to be a good way to limit the negative side effects on stillbirth. Moreover, selection on NBA would lead to a small increase in FD and a faster and more regular birth process than would be obtained by selecting on NBT.

Lidocaine Block of the Recurrent Laryngeal Nerve in Adductor Spasmodic Dysphonia: A Multidimensional Assessment

OBJECTIVES/HYPOTHESIS

Lidocaine block of the recurrent laryngeal nerve (RLN) has been reported as a procedure for surgical selection of patients with adductor spasmodic dysphonia (ADSD). However, its effects on phonation have not been rigorously assessed in a prospective fashion using strict entry criteria and multiple measures of phonatory function. This investigation assessed the phonatory effects of RLN lidocaine block in ADSD to explore its potential as a diagnostic tool.

STUDY DESIGN

Single group, pre/postexperimental trial.

METHODS

Twenty-one consecutive patients with suspected ADSD underwent unilateral RLN block, causing temporary ipsilateral vocal fold paralysis. Voices were recorded before and during the block. Patients completed self-ratings of overall level of dysphonia severity, vocal effort, and laryngeal tightness. Blinded listeners completed auditory-perceptual ratings, and the frequency of phonatory breaks was acoustically analyzed.

RESULTS

During the block, patients reported significant reductions on overall severity (P = .045), vocal effort (P < .001), and laryngeal tightness (P = .002). Listeners rated the voices during the block as significantly more breathy (P < .001), less strained (P < .001), and less severe (P = .059). Acoustic analysis confirmed significantly fewer phonatory breaks during the block (P < .001). Patient-based ratings of improvement were more consistent than listener ratings, and reduction in overall severity correlated with perceived breathiness.

CONCLUSIONS

Although individuals varied in their outcomes, group results suggest that response to RLN lidocaine block warrants further study as a possible diagnostic tool in ADSD.

Quantitative structure activity relationship of benzoxazinone derivatives as neuropeptide Y Y5 receptor antagonists

Quantitative structure activity relationship (QSAR) has been established for 30 benzoxazinone derivatives acting as neuropeptide Y Y5 receptor antagonists. The genetic algorithm and multiple linear regression were used to generate the relationship between biological activity and calculated descriptors. Model with good statistical qualities was developed using four descriptors from topological, thermodynamic, spatial and electrotopological class. The validation of the model was done by cross validation, randomization and external test set prediction.

Toward the development of an objective index of dysphonia severity: a four-factor acoustic model

During assessment and management of individuals with voice disorders, clinicians routinely attempt to describe or quantify the severity of a patient's dysphonia. This investigation used acoustic measures derived from sustained vowel samples to predict dysphonia severity (as determined by auditory-perceptual ratings), for a diverse set of voice samples obtained from 134 adult females, with and without voice disorders. Stepwise multiple regression analysis on all voice samples, followed by randomized and repeated cross-validation (random selection of 75% of the original 134 voice sample corpus; 100 iterations) indicated that a four-variable model comprised of time and spectral-based acoustic measures was able to strongly predict perceived severity of dysphonia (mean R = .880; mean R(2) = .775). A cepstral-based measure (CPP/EXP ratio) was determined to be the most significant contributor to the prediction of dysphonia severity, though it is clear that the addition of other acoustic measures (pitch sigma; shimmer (dB); and the Discrete Fourier Transformation ratio, a measure of low versus high frequency spectral energy) add substantially to the accurate prediction of severity. The results are interpreted and discussed with respect to the key acoustic characteristics that contributed to the prediction of severity, the value of identifying a subset of time and spectral-based acoustic measures which appear sensitive to a perceptually diverse set of voices, and the possible use of acoustic models in guiding auditory-perceptual ratings.