Prevalence and Voice Characteristics of Laryngeal Pathology in an Italian Voice Therapy-seeking Population

Validation of the Acoustic Breathiness Index in Speakers of Finnish Language

Breathiness (perception of turbulence noise in the voice) is one of the major components of hoarseness in dysphonic voices. This study aims to validate a multiparameter analysis tool, the Acoustic Breathiness Index (ABI), for quantification of breathiness in the speaking voice, including both sustained vowels and continuous speech. One hundred and eight speakers with dysphonia (28 M, 80 F, mean age 50, SD 15.4 years) and 87 non-dysphonic controls (18 M, 69 F, mean age 42, SD 14 years) volunteered as participants. They read a standard text and sustained vowel /a:/. Acoustic recordings were made using a head-mounted microphone. Acoustic samples were evaluated perceptually by nine voice experts of different backgrounds (speech therapists, vocologists and laryngologists). Breathiness (B) from the GRBAS scale was rated. Headphones were used in the perceptual analysis. The dysphonic and non-dysphonic speakers differed significantly from each other in the auditory perceptual evaluation of breathiness. A significant difference was also found for ABI, which had a mean value of 2.26 (SD 1.15) for non-dysphonic and 3.07 (SD 1.75) for dysphonic speakers. ABI correlated strongly with B (rs = 0.823, p = 0.01). ABI's power to distinguish the groups was high (88.6%). The highest sensitivity and specificity of ABI (80%) was obtained at threshold value 2.68. ABI is a valid tool for differentiating breathiness in non-dysphonic and dysphonic speakers of Finnish.

Prevalence of Benign Vocal Fold Lesions: Long-Term Results From a Single European Institution

OBJECTIVES/HYPOTHESIS

Hoarseness and limited voice capacity are often associated with benign vocal fold (VF) lesions. Despite their high clinical prevalence, epidemiological investigations focusing on these structural alterations are rare. The aim of the study was to present current European data on five typical lesion types (VF nodules, polyp, cyst, contact granuloma, Reinke´s edema).

STUDY DESIGN

Retrospective investigation.

METHODS

Video recordings of laryngoscopies from all patients with one of the above-mentioned VF pathologies were subjected to a review process. Data collected arose from a single institution over a period of 13 years. They were evaluated statistically with respect to lesion type, sex, age at first diagnosis, and affected side.

RESULTS

In a total of 535 patients, VF polyps occurred most frequently, followed by Reinke's edema and nodules. Each of the lesion types studied was significantly associated with sex and, except VF cysts, all diagnoses were also significantly related to age. Female sex was a risk factor for VF nodules, cysts, and Reinke's edema, whereas male sex was associated with polyps and contact granulomas. VF nodules occurred predominantly in young patients, VF polyps in middle-aged, Reinke's edema, and contact granulomas in later adulthood. The predominantly affected side (bilateral, right, or left VF) depended on sex.

CONCLUSIONS

Different prevalences from previous studies resulted from inconsistencies in terms of classification framework, terminology, and definition. In addition to endoscopic findings, socio-cultural backgrounds must also be considered when studying benign VF lesions. Prophylactic voice care education for all populations and concomitant efficacy studies are required. Further research is needed to verify possible correlations between sex and the affected side. A non-binary view could broaden the spectrum of phoniatric research issues.

Prevalence of Laryngopharyngeal Reflux Symptoms, Dysphonia, and Vocal Tract Discomfort in Amateur Choir Singers

INTRODUCTION

Vocal tract discomfort (VTD), dysphonia, and laryngopharyngeal reflux (LPR) symptoms are complaints frequently reported by amateur singers. There are two aims of this study. The first is to evaluate the prevalence of these symptoms using validated questionnaires. The second is to correlate singing-related variables with the questionnaire responses.

METHODS

A total of 392 amateur choir singers (ACS) and 514 control subjects completed an online survey divided into four parts: (1) clinical and demographic characteristics, (2) training in singing and singing experience, (3) history of gastroesophageal reflux disease and LPR symptoms, (4) validated questionnaires. Specifically, the reflux symptom index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) were included to analyze the actual burden related to LPR symptoms, VTD, and dysphonia.

RESULTS

ACS demonstrated a healthier lifestyle and a lower prevalence of gastroesophageal reflux disease symptoms in comparison with control subjects. ACS scored significantly higher in VTDS and VoiSS than control subjects, while no differences in the RSI results were found. Significant correlations among the questionnaires' results were demonstrated. Occasional professional singing was the variable influencing VTDS and VoiSS results the most.

CONCLUSION

ACS do not evidently manifest a higher impairment connected to LPR (RSI score), while they do report higher levels of voice (VoiSS score) and vocal tract (VTDS score) impairments, in comparison with control subjects. The relevant correlations among the PRO measures suggest that LPR symptoms, VTD, and dysphonia are related to each other. Given the relevant repercussion on the severity of VTD and dysphonia, providers should specifically ask about occasional professional singing when treating amateur singers.

The Occurrence of Laryngeal Pathologies in a Treatment-Seeking Pediatric Population

OBJECTIVES

The purpose of this study was to 1) describe the age- and sex-specific occurrence of laryngeal pathologies in a treatment-seeking pediatric population in the voice unit of Ghent University Hospital, Belgium, and 2) describe this population in terms of vocal parameters, vocal complaints, influencing factors, and treatment history and recommendation.

STUDY DESIGN

Retrospective, observational study.

METHODS

All patient records were analyzed for children (0-18 years) who consulted the ear, nose, and throat department of Ghent University Hospital for the first time between July 2015 and June 2021 with complaints of dysphonia. In total, 103 children (66 males, 37 females) with a mean age of 10.01 years (SD: 3.4, range 3.93-17.96) were included in this study. Laryngeal pathology was diagnosed using a flexible videolaryngo(strobo)scopy. The influence of age and sex on laryngeal etiology (organic/functional voice disorder) was examined using a Welch-modified t test and a Fisher's exact test, respectively.

RESULTS

Organic lesions were observed in 77.7% of the participants, with vocal fold nodules (VFNs) being the most common diagnosis (66.0%). A functional voice disorder was diagnosed in 22.3% of the children. Children with a functional voice disorder are significantly older than children with an organic voice disorder. There was no statistically significant difference between males and females in laryngeal etiology. Mean dysphonia severity index was -2.7 (SD: 3.2, range -9.3 to +3.7), the mean acoustic voice quality index 4.70 (SD: 1.5, range 2.35-8.27), and the mean pediatric voice handicap index 29.8 (SD: 13.6, range 5-60). The occurrence of vocal misuse was mentioned in 80.6% of the patient records.

CONCLUSION

Organic voice disorders, especially VFNs, are predominant in treatment-seeking children with dysphonia. Functional voice disorders become more common with increasing age during childhood. A disordered vocal quality, reduced vocal capabilities and reduced voice-related quality of life were found.

Effects of Adenotonsillectomy on Vocal Function

INTRODUCTION

Correct breathing is a fundamental condition for adequate vocal production. Respiratory dynamics are able to modify the growth of facial mass and lingual posture, i.e., of the skull, the mandibular one. For this reason, infant mouth breathing can cause hoarseness.

MATERIALS AND METHODS

We evaluated the actual changes in the characteristics of the voice and articulation of language in a group of subjects affected by adenotonsillar hypertrophy (grade 3-4), with frequent episodes of pharyngo-tonsillitis who underwent adenotonsillectomy. Our study included 20 children-10 boys and 10 girls-aged 4 to 11 years who had adenotonsillar hypertrophy and pharyngotonsillitis episodes exceeding 5-6 per year in the previous 2 years. The control group (Group B) included 20 children-10 boys and 10 girls-aged 4 to 11 years (average age of 6.4 years) who had not undergone surgery and shared the same degree of adenotonsillar hypertrophy as those in Group A but who did not experience recurrent pharyngotonsillitis episodes.

DISCUSSION

The hypertrophy of adenoids and tonsils significantly impacted breathing, vocal function, and speech articulation. All this is responsible for a state of tension in the neck muscles, which at the level of the vocal tract causes hoarseness. The changes objectively observed in our study in the pre- and post-operative phase demonstrate how adenotonsillar hypertrophy is responsible for an increase in resistance to the passage of air at the glottic level.

CONCLUSIONS

For this reason, adenotonsillectomy has an impact on recurrent infections and can also lead to an improvement in speech, breathing, and posture.

Treatment of relapsing functional and organic dysphonia: a narrative literature review

Information about failure and relapses is critical in deciding whether and how to treat a given condition, as well as during patient counselling before therapy. This paper aims to perform a non-systematic review of relapses and failure of dysphonia treatment in the adult population. Studies on failure and relapses after treatment of benign vocal fold lesions, functional dysphonia and neurogenic dysphonia were analysed. The frequency and the duration of follow-up were heterogeneous, and the management of relapses was reported in only a portion of the studies. Relapses after surgical treatment of benign vocal fold lesions ranged between 1% and 58% of cases, and their management was mainly surgical. Rates of relapse after voice therapy for functional dysphonia and spasmodic dysphonia were 12%-88% and 8%-63%, respectively. Rates of relapse after surgical treatment for unilateral and bilateral vocal fold paralysis were 10%-39% and 6%-25%, respectively; treatment was mainly represented by surgical revision. In conclusion, failure and relapses of functional and organic dysphonias after therapy are not rare, but treatment modalities are seldomly reported. The data from this non-systematic review stresses the need for further research in this area.

[Vocal fatigue as an indicator of complex voice disorders-a diagnostic and therapeutic challenge]

Vocal fatigue is increasingly observed among professional voice users (e.g., teachers). This pathologic state is associated with restrictions in everyday life and is considered to be an indicator of complex voice disorders. Since there are few systematic studies on the phenomenon, there is currently no uniform definition or diagnostic workup. Based on the case study of a professional speaker, possibilities for a structured vocal fatigue assessment are presented. These are discussed with regard to their laryngoscopic, instrumental acoustic ("performance fatigue") and subjective symptom-related characteristics ("perceived fatigue"). In addition, a differentiation from the vocal effort, vocal demand, and vocal demand response models according to Hunter et al. (2020) is made.

Gender-related differences in the prevalence of voice disorders and awareness of dysphonia

Objective

Considering the impact of dysphonia on public health and the increasing attention to patient-centred care, we evaluated sex-related differences in the prevalence of benign voice disorders, awareness of dysphonia and voice therapy (VT) results.

Methods

One hundred and seventy-one patients, 129 females and 42 males, with functional or organic benign dysphonia underwent Voice Handicap Index (VHI), auditory-perceptual dysphonia severity scoring (GRBAS) and acoustic analysis (Jitter%, Shimmer%, NHR) before and after VT.

Results

Prevalence of each voice disorder was significantly higher among females. Mean time-to-diagnosis (time elapsed until medical consultation) was not different between males and females. The refusal of therapy and VT adherence (mean number of absences and premature dropout) were similar in the two groups. Pre-VT VHI and "G" parameter were worse in women. The percentage of women with abnormal acoustic analysis was significantly higher. Post-VT VHI gain was higher in women, whereas "G" parameter improvement did not differ by sex.

Conclusions

Our study showed a higher prevalence of voice disorders in females. Awareness of dysphonia was not gender related. Females started with worse voice subjective perception and acoustic analysis, but they perceived greater improvement after therapy.

Sex-and Age-Based Etiological Analysis of 2901 Patients With Dysphonia in a Japanese Tertiary Medical Institute

OBJECTIVES

Societal aging is a grave concern in Japan, and its impact on voice clinics has not been investigated. This study aimed to clarify recent demographic features of geriatric dysphonia at a tertiary medical institute in Japan.

STUDY DESIGN

Retrospective study.

METHODS

The medical records of 2901 patients newly referred to the Voice Outpatient Clinic of the University of Tokyo Hospital between 2003 and 2020 were analyzed for age, sex, and etiology.

RESULTS

The mean ± standard deviation age of all patients was 53.2 ± 20.7 (median, 58; range, 0-95) years. The aging rate (ratio of patients aged ≥65 years) increased continuously during the study period, and the recent aging rate was the highest in the world (43%). However, its rate of increase has slowed over the past 10 years. The etiologies of dysphonia associated with the largest number of older patients were vocal fold immobility (32%), vocal fold atrophy (23%), and benign vocal fold lesions (11%). The highest aging rate was detected in patients with laryngeal cancer/leukoplakia, vocal tremor, vocal fold atrophy, sulcus vocalis, and vocal fold immobility.

CONCLUSIONS

Societal aging substantially increased the aging rate of patients with dysphonia in a Japanese voice clinic. The incidence of vocal fold immobility and atrophy is expected to continue to increase, whereas that of benign vocal fold lesions is expected to decrease.

Voice disorders in children starting school education

<b>Introduction: </b>Voice disorders in children especially in the school-age period comprise a major and challenging medical, social and educational issue. There is a lack of epidemiological data regarding children's voice in Poland which limits the development of preventive and medical pediatric procedures in our country. <br><b>Objective:</b> The aim of study was to determine the prevalence of voice disorders in children starting school education in Mazovia. <br><b>Material and method:</b> The study was a retrospective analysis of survey data from parents of children attending the first grade of primary school. The survey consists of five questions describing the voice. A statistical analysis of 7891 questionnaires was carried out. <br><b>Results:</b> Analysis of the survey showed a prevalence of dysphonia in 12.8% children aged 7 starting primary school. In this study, voice disorders were observed more often in boys (14.6%) than girls (10.8%). The authors presented the correlation between voice disorders and the expression of emotions. <br><b>Conclusions:</b> Studies have shown that the percentage of children with voice disorders is significant in our country. The survey regarding voice in school children in Mazovia shows preliminary results of voice disorders in the pediatric population in Poland.

Clinical characteristics of singers attending a phoniatric outpatient clinic

Purpose: Studies suggest that singers are over-represented in voice clinics and present a high risk of developing voice disorders. This retrospective study aims to describe the characteristics of 78 singers consulting a phoniatrician.Methods: In their medical files, data related to age, gender, occupational status, singing training, musical style, voice complaint, diagnosis, voice-quality grading (GRBAS) and treatment were gathered.Results: The patients were mostly female singers (87%). Non-professional singers (semi-professional included) represented 64%, professional singers 25% and students of singing 11%. The majority of singers were choristers (27%) and 22% were classical-style/oratorio-style singers. Two-thirds of the population had intensive vocal activity in speech or singing. Vocal endurance, somatosensory signs and difficulties with high pitches were the most frequent symptoms. Among the patients, 79% presented with singing-voice disorders with 85% of these having vocal fold lesions. Generally, their speaking voices were preserved. Vocal-folds nodules were the most prevalent pathology (37%) followed by sulcus (26%) and voice therapy was the main treatment.Conclusions: This study emphasizes the fact that singers have specific voice complaints related to their voice usage. The high occurrence of sulcus and other congenital-lesion suspicions, unusual in the general population consulting an ENT phoniatrician, seems to be rather specific for singers in agreement with the literature.

Singing voice range profile: New objective evaluation methods for voice change after thyroidectomy

BACKGROUND

After surgery in the thyroid region, patients may present with phonation or singing difficulty, even within their vocal range. We designed a novel voice evaluation method that reflects subjective and objective voice complications of the surgery.

METHODS

This tool recorded patients' voice ranges while singing, which was named the singing voice range profile (singing VRP). Patients were asked to sing "Happy Birthday," which has a one-octave scale, at a comfortable tone and intensity. The singing VRP, standard VRP and voice handicap index-10 (VHI-10) results were recorded before thyroidectomy and 1 and 3 months after thyroidectomy for 128 patients. For subgroup analysis, a group where the maximum F₀ of standard VRP in 1 month postoperatively was lower than the highest singing F₀ of the preoperative singing VRP was defined as "Collapsed group" and the other group was "Preserved group."

RESULTS

The changes in the highest, lowest and range of singing fundamental frequency (F₀ ) had decreased at 1 month postoperatively. Subsequently, they had improved significantly at 3 months postoperatively but were lower than those preoperatively (all P < .05, except for the change in the lowest singing F₀ between 1 and 3 months postoperatively, P = .274). In the subgroup analysis, the singing range of the collapsed group (n = 65) showed significantly lower VHI-10 scores, range of vocal F₀ and singing F₀ than those of the preserved group (n = 63) at 1 and 3 months postoperatively (all P < .001). At 3 months postoperatively, the singing F₀ range in the preserved group had recovered to the range before surgery (13.0 ± 1.3 vs. 13.1 ± 1.4, P = .746 for the preserved group, and 13.0 ± 1.3 vs 11.5 ± 2.4, P < .001 for the collapsed group).

CONCLUSIONS

Parameters measured by singing VRP showed a trend similar to the change in VHI-10 and the maximum F₀ of standard VRP. In addition, singing VRP allowed a qualitative classification of the postoperative voice function when combined with standard VRP. Therefore, it can be used as a supplementary voice evaluation tool to reflect the physiologic and functional aspects of voice.

Voice Component Relationships with High Reflux Symptom Index Scores in Muscle Tension Dysphonia

OBJECTIVE

To analyze the Reflux Symptom Index (RSI) and the Voice-Related Quality of Life (V-RQOL) scores based on the perceptual and analytical parameters in primary MTD patients with no reflux.

STUDY DESIGN

Cross-sectional study.

METHODS

One hundred and eighteen participants, that is, sixty patients with normal voices and fifty-eight patients with primary MTD were recruited in this study. The diagnosis of primary MTD was made by perceptual voice analysis, neck palpation, video-laryngoscopic examination, and exclusion of other etiologies. Acoustic analysis and the GRBAS (Grade, Roughness, Breathiness, Asthenia, and Strain) scale were evaluated for all participants. The V-RQOL and RSI questionnaires were then given to all participants.

RESULTS

This study included 118 participants of 29 males (48.3%) and 31 females (51.7%) in the normal group. MTD group also included 27 males (46.6%) and 31 (53.4%) female patients. Mean (SD) RSI and V-RQOL scores were 12.35 (3.84) and 11.09 (2.20) for the normal group, and 22.87 (6.97) and 22.89 (7.94) for the MTD group (P = .000). In the MTD group, V-RQOL had a positive correlation with jitter for /i/ and /u/, Noise to Harmonic Ratio (NHR) for /i/, /a/, and /u/, and Grade, Roughness, and Strain of GRBAS scale (P < .05). In addition, RSI had a positive correlation with Strain in the MTD group (P < .05).

CONCLUSION

MTD patients in the absence of laryngopharyngeal reflux findings may have high RSI scores. Hence, patients with high RSI scores and disproportionate acoustic and perceptual analysis would require a thorough evaluation of MTD.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1573-E1579, 2021.

Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic

OBJECTIVES

Voice therapy is administered by speech-language pathologists in multiple practice settings, including private practice community voice clinics. However, the evidence for diagnosis patterns and voice treatment outcomes in community voice clinics is very limited. The purpose of this study was to extend knowledge from a previous investigation by assessing the epidemiological patterns of patient referrals to a private practice community voice clinic across a 4-year period (50 months) and to measure the effectiveness of treatment outcomes for patients who were followed up with voice therapy in the same setting.

STUDY DESIGN

Retrospective case series.

METHODS

Consecutive patient records from November 2014 through January 2019 were reviewed. Patients were grouped into seven categories of distinctive diagnoses. Descriptive data for each group were extracted to determine epidemiological patterns of disorder diagnosis, voice handicap, voice quality severity, age, and gender. For patients who completed at least three treatment sessions, pre- and posttreatment measurements of two assessments, the Voice Handicap Index (VHI) and the Acoustic Voice Quality Index (AVQI), were extracted and compared using a multivariate analysis of variance.

RESULTS

Records from 454 consecutive patient referrals over a 50-month time period were reviewed. The most frequent diagnoses were multifactorial etiologies or those with only a few cases, categorized collectively as an "other" diagnosis category. Diagnoses of nonspecific dysphonia and mid-membranous lesions were also common. Consensus Auditory Perceptual Evaluation of Voice-scale scores were not different among disorders; however, group differences were found for VHI and AVQI. Treatment data were available for 292 patients, with 47 of those patients completing at least three treatment sessions and with data for pre- and posttreatment VHI and AVQI. A mixed multivariate analysis of variance showed a significant effect of treatment (Wilks' Lambda = 0.42, F[2] = 27.58, P < 0.001, ƞ_p² = 0.58), where both AVQI and VHI improved significantly across the pre- to posttreatment measurements.

CONCLUSIONS

Patient characteristics and diagnosis patterns across a 50-month period were similar when compared to a previous study that investigated epidemiological patterns in this clinic across 28 months. Voice therapy administered in this community voice clinic to patients with varied diagnoses was found to be effective based on changes in VHI and AVQI measurements.

Demographics and coexisting tremor, cervical dystonia and vocal fold disorders in a group of patients with spasmodic dysphonia

The primary aim of this study is to describe the demographic and clinical characteristics of a group of patients with spasmodic dysphonia (SD). As a secondary aim, we examined associations of age at SD diagnosis and sex with co-existing cervical dystonia and nonvocal tremor; as well as association of vocal tremor with sex and nonvocal tremor. Seventy-four consecutive patients who were treated for SD at the Mayo Clinic in Jacksonville, Florida between October 1, 2015 and March 31, 2018 were included in this retrospective study. Information was collected regarding sex, age at SD diagnosis, BMI, SD diagnosis type, recent history of major stress/depression, recent history of upper respiratory tract infection (URTI), co-existing neurological diseases, and co-existing vocal disorders. The majority of patients were female (75.7%) and median age at SD diagnosis was 61 years (range: 17 – 80 years). The median BMI was 25.7 (range: 16.9 – 63.7). The most common diagnostic combinations were adductor dysphonia only (52.7%), adductor dysphonia and MTD (18.9%), and adductor dysphonia and tremor (17.6%). Co-existing tremor was present in 36.6% of patients and cervical dystonia was present in 15.5%. Co-existing vocal disorders were observed as follows: paresis/paralysis (3.1%), cyst (3.1%), mass (4.7%), polyp (1.6%), and anterior glottis web (1.6%). Sex was not notably associated with either cervical dystonia or nonvocal tremor (all P ≥ 0.30). Older age at SD diagnosis was significantly associated with cervical dystonia (P = 0.049), but not nonvocal tremor (P = .22). Other than co-existing tremor, most patients had no co-existing neurological diseases or vocal disorders. Additionally, patients who were older at SD diagnosis were significantly more likely to have co-existing cervical dystonia.

Voice Disorder Identification by using Hilbert-Huang Transform (HHT) and K Nearest Neighbor (KNN)

OBJECTIVES

Clinical evaluation of dysphonic voices involves a multidimensional approach, including a variety of instrumental and noninstrumental measures. Acoustic analyses provide an objective, noninvasive and intelligent measures of voice quality. Based on sound recordings, this paper proposes a new classification method of voice disorders with HHT and KNN.

METHODS

In this research, 12 features of each sample is calculated by HHT. Based on the algorithm of Linear Prediction Coefficient (LPCC), a sample can be characterized by 9 features. After each sample is expressed by 21 features, the classifier is constructed based on KNN. In addition, classifier based on KNN was further compared with random forest and extra trees classifiers in relation to their classification performance of voice disorder.

RESULTS

The experiment results revel that classifier based on KNN showed better performance than other two classifiers with accuracy rate of 93.3%, precision of 93%, recall rate of 95%, F1-score of 94% and the area of receiver operating characteristic curve is 0.976.

CONCLUSIONS

The method put forward in this paper can be effectively used to classify voice disorders.

Efficacy of Conversation Training Therapy for Patients With Benign Vocal Fold Lesions and Muscle Tension Dysphonia Compared to Historical Matched Control Patients

Purpose Conversation training therapy (CTT) is the 1st voice therapy approach to eliminate the traditional therapeutic hierarchy and use patient-driven conversation as the sole therapeutic stimulus. The purpose of this investigation was to determine the efficacy of CTT compared to standard-of-care voice therapy approaches for the treatment of patients with voice disorders. Method A prospective study of CTT treatment outcomes in adults with dysphonia due to primary muscle tension dysphonia or benign vocal fold lesions compared to age, gender, and diagnosis historical matched control (HMC) patients was used. The primary outcome was change in Voice Handicap Index-10 (VHI-10); secondary outcomes included acoustic, aerodynamic, and auditory-perceptual outcomes. Data were collected before treatment (baseline), at the start of each therapy session, 1 week after the final therapy session (short-term follow-up), and 3 months after the final therapy session (long-term follow-up). Results For the CTT group, statistically significant improvements were observed for VHI-10. Though statistically significant improvements were observed for the VHI-10 for the HMC group, the CTT group saw significantly greater improvement in VHI-10. Furthermore, equivalent gains were observed following only 2 sessions of CTT compared to 4-8 sessions of traditional therapy. Significant improvements in the CTT group were observed for cepstral peak prominence in a vowel, fundamental frequency, Cepstral Spectral Index of Dysphonia in a vowel and connected speech, vocal intensity, average airflow in speech in a reading passage, number of breaths and duration of reading passage, and auditory-perceptual measurement of overall voice severity. Conclusions Results support the hypothesis that training voice techniques in the context of spontaneous conversational speech improves patient perception of voice handicap and acoustic, aerodynamic, and auditory-perceptual voice outcomes both immediately following treatment and at long-term follow-up. CTT participants also demonstrated significantly larger decreases in VHI-10 compared to HMC participants who received standard-of-care, nonconversational, hierarchical-based voice therapy.

Indirect vs Direct Voice Therapy for Children With Vocal Nodules: A Randomized Clinical Trial

Importance

Benign vocal fold nodules affect 12% to 22% of the pediatric population, and 95% of otolaryngologists recommend voice therapy as treatment. However, no randomized clinical trials that we are aware of have shown its benefits.

Objective

To determine the impact of voice therapy in children with vocal fold nodules according to pretherapy and posttherapy scores on the Pediatric Voice-Related Quality of Life (PVRQOL) survey; secondary objectives included changes in phonatory parameters.

Design, Setting, and Participants

For this multicenter randomized clinical trial, 114 children ages 6 to 10 years with vocal fold nodules, PVRQOL scores less than 87.5, and dysphonia for longer than 12 weeks were recruited from outpatient voice and speech clinics. This age range was identified because these patients have not experienced pubertal changes of the larynx, tolerate stroboscopy, and cooperate with voice therapy. Participants were blinded to treatment arm.

Interventions

Participants received either indirect or direct therapy for 8 to 12 weeks. Indirect therapy focused on education and discussion of voice principles, while direct treatment used the stimulus, response, antecedent paradigm.

Main Outcomes and Measures

The primary outcome measure was PVRQOL score change before and after treatment. Secondary phonatory measures were also compared.

Results

Overall, 114 children were recruited for study (mean [SD] age, 8 [1.4] years; 83 males [73%]); with 57 randomized to receive either indirect or direct therapy. Both direct and indirect therapy approaches showed significant differences in PVRQOL scores pretherapy to posttherapy. The mean increase in PVRQOL score for direct therapy was 19.2, and 14.7 for indirect therapy (difference, 4.5; 95.3% CI, -10.8 to 19.8). Of 44 participants in the direct therapy group, 27 (61%) achieved a clinically meaningful PVRQOL improvement, compared with 26 of 49 (53%) for indirect therapy (difference, 8%; 95% CI, -12 to 28). Post hoc stratification showed robust effects in the direct therapy group for older children (Cohen d = 0.50) and the latter two-thirds of participants (Cohen d = 0.46). Vocal fold nodules reduced in size in 31% (22 of 70) and completely resolved in 11% (8 of 70) of participants who consented to a second set of images after going through the recruitment process.

Conclusions and Relevance

Both direct and indirect voice therapy improved voice-related quality of life in children with vocal fold nodules, although there was no significant difference between approaches. Future studies may focus upon which voice therapy approaches are effective in treating age-defined populations.

Trial Registration

clinicaltrials.gov Identifier: NCT01255735.

CoQ10 and Vitamin A Supplementation Support Voice Rehabilitation. A Double-Blind, Randomized, Controlled, Three-Period Cross-Over Pilot Study

Objectives: To evaluate the effectiveness of an adjuvant therapy (CoQ10 in its water-soluble form and vitamin A) in supporting voice rehabilitation in a large group of patients with muscle tension dysphonia (MTD).

Study Design: Twelve-week, double-blind, randomized, controlled, three-period cross-over pilot study. The primary endpoint was the change in the Dysphonia Severity Index (DSI) over the 12-week study period. Secondary endpoints were the changes in the subcomponents of DSI, including MPT, F0-high, I-low, and jitter. Exploratory endpoints were the changes in the Shimmer and in Voice Handicap Index (VHI).

Methods: Patients were randomly assigned in a 1:1 ratio to two counter-balanced arms. Group A (ADJ-PLA) patients were administered QTer 300 mg and Vit A acetate 500.000 Ul/g 1 mg twice daily for a 4-week intervention period, followed by a 4-week period of wash-out, and then were submitted to a last 4-week period of placebo. Patients in Group B (PLB-ADJ) were given the treatment period in reverse order. Both groups received a 45-min voice therapy in a group format once a day for 4 weeks during the first and the second active periods. The therapy was held during the wash-out period.

Results: The analysis of main time effect indicated a trend toward recovery of vocal function regardless of group assignment. A significant time by group effect was found on DSI [F = 3.4 (2.5, 80.5), p = 0.03], F0-high [F = 4.5 (2.6, 82.9), p = 0.008] and Shimmer [F = 3.6 (1.5, 46.9), p = 0.048], under CoQ10 and Vit A treatment, with a small effect size. There was no significant time by group effect on the other study measures, namely MPT, I-low, VHI.

Conclusions: A trend toward recovery of vocal function was observed in all the patients, likely due to voice rehabilitation. The improvement of DSI was greater under CoQ10 and Vitamin treatment, indicating a more pronounced improvement of vocal quality under adjuvant therapy. The study protocol was reviewed and approved by the Ethics Committee of Policlinico Umberto I Hospital, Rome, Italy Rif. 3069/13.02.2014.

Effect of Age, Sex, Bolus Volume, and Bolus Consistency on Whiteout Duration in Healthy Subjects During FEES

One of the major limitations of the fiberoptic endoscopic evaluation of swallowing (FEES) is related to the challenging application of temporal measures. Among them, Whiteout (WO) is due to pharyngeal and tongue base contraction and might be used as an estimation of the pharyngeal phase duration. The aims of this study were to evaluate the inter- and intrarater reliability of WO duration and to appraise the effects of age, sex, volume, and texture of the boluses on this temporal measurement. A total of 30 healthy volunteers were recruited. According to their age, the subjects were grouped into three different age groups. Each of them underwent FEES examination with different textures (liquid, semisolid, and solid) and volumes. FEES examinations were video recorded, processed with the software Daisy Viewer 2.0, which allowed the acquisition of 25 frames per second (s) and analyzed by three different raters in order to collect data on WO duration. A total of 863 swallowing acts were video recorded. Intra- and interrater reliability of WO duration were excellent. Both volume and bolus's texture significantly affected WO duration. In particular, WO duration was significantly shorter for the liquid texture than for the semisolid and solids ones. In addition, male subjects scored significantly higher values of WO duration. Finally, WO duration was significantly higher in seniors. WO duration seems to be a reliable temporal measure during FEES examination. WO duration seems to be affected by several factors such as age, sex, volume, and consistency.

Treatment Effectiveness of Novafon Local Vibration Voice Therapy for Dysphonia Treatment

BACKGROUND

The objective of this study was to explore the effectiveness of the five-week Novafon local vibration voice therapy (NLVVT) program with and without Novafon local vibration for dysphonia treatment.

METHODS

Twenty-two voice-disordered subjects were divided into two groups. The intervention group (IG) performed the NLVVT program and the control group (CG) had the same voice exercises of this program without local vibration.

RESULTS

After NLVVT, the IG showed significantly high results in all parameters of acoustics, multiparametric indices, and self-evaluation (all P values < 0.01). The CG revealed mostly much significantly lower results (P values < 0.05) or nonsignificant results for these parameters after the treatment. The intergroup comparison under consideration before and after NLVVT showed a large and significant treatment effect in voice quality (ie, narrowband spectrograms, and Acoustic Voice Quality Index), in which the IG had better treatment results. The aerodynamic measurement showed no significant changes for both groups after NLVVT (P value > 0.05).

CONCLUSION

After the NLVVT program both groups showed significant improvements of various voice measurements, in which the IG revealed better treatment results than the CG. However, next to voice exercises an extra benefit for local vibration with the Novafon appliance was assessed in voice quality.

The Importance of The Occupational Vocal Load for The Occurence and Treatment of Organic Voice Disorders

Introduction

The voice represents a basic working tool for carrying out certain occupations. Hoarseness, as a consequence of vocal fold lesions, presents an important cause of work-related absences for voice professionals.

Methods

Our study was designed as a retrospective cohort one. Data on gender, workplace, vocal load and exposure to risk factors for voice disorders of the patients who had surgery in the 2014-2015 period at the tertiary centre due to benign vocal fold lesions were collected from their clinical records. We compared professional voice users (PVU) to subjects with no vocal load at work (NPVU). The SPSS programme, version 22.0, was used for statistical analysis.

Results

From 2014 to 2015, 103 PVU and 132 NPVU were surgically treated for benign vocal fold lesions. In comparison to the second group, loud speech use was reported significantly more often by PVU (40.8% vs. 14.4%), as was a fast speaking rate (22.3% vs. 9.8%) and additional vocal load outside of the workplace (23.3% vs. 12.9%). The time that had passed between the occurrence of the hoarseness and the surgical treatment did not differ between the groups. The majority of patients were satisfied with the outcome of the operation.

Conclusions

Nearly a half of the operated patients had a considerable vocal load at work. An ENT assessment prior to starting a job as well as priority phoniatric treatment of voice disorders for PVU would significantly reduce the costs of work absences and contribute to a speedier recovery and return to the workplace.