Gender differences affecting vocal health of women in vocally demanding careers

Endoscopic-Guided Suture Lateralization for Bilateral Vocal Fold Paralysis: Surgical Tips for Better Outcome

OBJECTIVE

This study aims to describe a precise description of suture lateralization (SL) technique and evaluate its effectiveness and safety in management of bilateral vocal fold paralysis (BVFP).

METHOD

A preclinical cadaveric study followed by application on a case series of BVFP patients. After the preliminary study executed to precisely localize the optimal sites for needle insertion, a prospective interventional study was conducted on 19 subjects presenting with respiratory distress due to BVFP. Data collection included their clinical presentation and a detailed assessment including auditory perceptual assessment, laryngoscopy (rigid or flexible), and video fluoroscopic swallowing study.

RESULTS

Widening of the inter-glottic distance at the site of the sutures was statistically significant (P < 0.001). Decannulation was achieved in three out of four tracheotomized patients. The suturing led to a significant difference in loudness, jitter, and harmonic-to-noise ratio (P = 0.042, 0.004, and ≤0.001, respectively).

CONCLUSION

This study suggests that SL is a feasible and effective technique with low incidence of adverse events and the potential of reversibility. Optimal localization of the suture insertion points translated into less intraoperative manipulation of the cords and shorter operative time.

Prevalence of Occupational Voice Disorder Among Teachers of Kathmandu District, Nepal

The objective of this research was to identify the prevalence of voice disorders among teachers in the Kathmandu District of Nepal, with an emphasis on identifying possible risk factors that may be associated with these disorders. A cross-sectional study design was used, with both quantitative and qualitative data-gathering techniques using a mixed-methods approach. Data were collected from 95 non-teachers and 194 participating teachers from different schools in Kathmandu Valley. The analysis covered self-reported voice problem prevalence, job details, and demographic data. We examined the relationships between several variables and voice issues, including gender, class size, length of instruction, and tobacco usage. Findings: Compared with nonteachers (33.7%), teachers had a considerably greater prevalence of voice issues (69.1%). Greater class size and more than ten years of teaching experience were shown to be risk factors, while female instructors reported a greater prevalence of voice issues. Additionally, it was shown that instructors' voice issues are also linked to tobacco usage. The results of this study highlight how critical it is to provide voice therapy to educators employed in the Kathmandu District, particularly those in at-risk categories such as female instructors, more experienced educators, and educators with larger class sizes. The outcomes demonstrated important impacts on teacher well-being, job satisfaction, and academic achievement. More research and intervention strategies are needed to minimize the effects of voice problems and promote a positive teaching and learning environment.

Influence of Curved Video Laryngoscope Blade Sizes and Patient Heights on Video Laryngoscopic Views: A Randomized Controlled Trial

This study aimed to compare the video laryngoscope views facilitated by curved blades 3 and 4 with an exploration of the relationship between these views and patient height. Conducted as a randomized controlled trial, this study enrolled adults scheduled for surgery under general anesthesia. Intubation procedures were recorded, and the percentage of glottic opening was measured before tube insertion. Multivariate analysis validated the impact of various factors, including blade size and patient height, on the percentage of glottic opening scores. A total of 192 patients were included. The median percentage of glottic opening scores for curved blades 3 and 4 were 100 and 83, respectively (p < 0.001). The unstandardized coefficient indicated a significant negative impact of blade 4 on the percentage of glottic opening scores (-13, p < 0.001). In the locally estimated scatterplot smoothing analysis, blade 3 exhibited a steady rise in glottic opening scores with increasing height, whereas blade 4 showed a peak followed by a decline around 185 cm. The unstandardized coefficient of height showed no significant association (0, p = 0.819). The study observed superior laryngoscopic views with blade 3 compared to blade 4. However, no significant association was found between laryngoscopic views and patient height.

The Effects of Reading Speed on Acoustic Voice Parameters and Self-reported Vocal Fatigue in Students

INTRODUCTION

Vocal loading tasks (VLTs) help researchers gather acoustic measurements and understand how a healthy speaker adjusts their voice in response to challenges. There is a dearth of evidence measuring the impact of speaking rate in VLTs on acoustic voice parameters and vocal fatigue.

OBJECTIVES

In the present study, the relationships between acoustic voice parameters and self-reported vocal fatigue were examined through an experimental VLT.

METHODS

38 students completed a 45-minute VLT which involved the recording of three randomized reading tasks. The tasks varied by the speed in which the words were presented (slow, medium, fast) on a computer monitor. Vocal fatigue ratings were measured subjectively using a Borg scale and negative adaptations to vocal loading were measured objectively using Sound Pressure Level (SPL, in dBA), fundamental frequency (fo, in semitones), and phonation time (Dt %).

RESULTS

Analysis indicated that vocal fatigue increases with time, and the slope of this relationship is affected by the speaking rate. SPL and fo increased with speaking rate and the standard deviation of SPL and fo decreased with speaking rate. On average, the male participants' phonation time values were 7.8% lower than the female participants. The rate of increase of vocal fatigue with time during the experiment was higher in the fast speaking style compared to the slow and medium ones.

CONCLUSION

The results provide support that the novel VLT altered multiple vocal parameters to induce measurable changes in vocal fatigue.

Self-Perceived Voice Handicap During COVID19 Compulsory Facemask Use: A Comparative Study Between Portuguese and Spanish Speakers

This study investigates self-perceptions of voice-related handicap as a function of facemask use in the general working population during the COVID19 outbreak, using the Voice Handicap Index (VHI). Each VHI item was answered twice in a row; the first answer referred to the condition of not wearing a facemask (henceforth, the Without condition) and the second to the condition of using a facemask (henceforth, the With condition). VHI scores were collected via Google Forms (Google, Mountain View, California), targeting 2 groups of speakers of different nationalities, Portuguese (n = 261) and Spanish (n = 297). A Wilcoxon test was carried out to compare VHI scores between With and Without conditions for each group of speakers; a Mann-Whitney U test was used to compare groups within each condition. Results suggested that VHI overall scores and scores for all dimensions were higher for the With condition, for both Portuguese and Spanish speakers. When comparing groups of speakers, Spanish speakers presented higher scores for functional and emotional dimensions, for both With and Without conditions. In addition, the overall score for the Without condition was higher for Spanish speakers. No differences between groups were found for the total VHI score for the With condition. When comparing overall VHIdiff between speakers, that is, the difference in the VHI total score between With and Without conditions, no significant differences could be found. Thus, a multiple regression analysis was carried out between the VHIdiff and the independent variables of interest: age, sex, smoking habits, professional occupation, nationality, facemask type and its hours of use. The resulting model providing the highest association suggested that 2.5% of the variation in overall VHIdiff total score could be associated with sex, smoking habits, and professional level. Female smokers who use their voices during prolonged hours at work (e.g., teachers, lawyers, sales people) presented a higher VHI total score when wearing a mask. Future voice-related health interventions should address preventive strategies towards speaking behaviors leading to vocal fatigue and vocal effort as a consequence of compulsory facemask use, especially with respect to female professional voice users who smoke.

Prevalence of Self-Reported Voice Concerns and Associated Risk Markers in a Nonclinical Sample of Military Service Members

INTRODUCTION

Difficult communication environments are common in military settings, and effective voice use can be critical to mission success. This study aimed to estimate the prevalence of self-reported voice disorders among U.S. military service members and to identify factors that contribute to their voice concerns.

METHOD

A nonclinical sample of 4,123 active-duty service members was recruited across Department of Defense hearing conservation clinics. During their required annual hearing evaluation, volunteers provided responses to voice-related questions including a slightly adapted version of the Voice Handicap Index-10 (VHI-10) as part of a larger survey about communication issues. Changepoint detection was applied to age and years of service to explore cohort effects in the reporting of voice concerns. Logistic regression analyses examined multiple available factors related to communication to identify factors associated with abnormal results on the VHI-10.

RESULTS

Among the respondents, 41% reported experiencing vocal hoarseness or fatigue at least several times per year, and 8.2% (n = 336) scored above the recommended abnormal cut-point value of 11 on the VHI-10. Factors independently associated with the greatest risk for self-reported voice concerns were sex (female), cadmium exposure, vocal demands (the need for a strong, clear voice), and auditory health measures (frequency of experiencing temporary threshold shifts; self-reported hearing difficulties).

CONCLUSIONS

Based on self-reported voice concerns and false negative rates reported in the literature, the prevalence of dysphonia in a large sample of active-duty service members is estimated to be 11.7%, which is higher than that in the general population. Certain predictors for voice concerns were expected based on previous literature, like female sex and voice use, but frequency of temporary threshold shifts and exposure to cadmium were surprising. The strong link between voice and auditory problems has particular implications regarding the need for effective communication in high-noise military and other occupational environments.

Hoarseness among nurses

While many occupations are at risk for vocal health issues much of the current research has focused on teachers. The prevalence of hoarseness among nurses has not received much attention. The aim of this study was to determine the current prevalence of hoarseness among nurses and also to identify potential environmental risk factors from their working environment. The health data was collected from Finnish healthcare workers. Our findings are based on 13,560 health questionnaires which were statistically analyzed. Our results suggest that the one-year period prevalence of hoarseness was 30% and all the environmental problems which we evaluated (draft, room temperature too high, variable room temperature, room temperature too low, dry air, stuffy indoor air, moist air/ high humidity, inadequate ventilation, smell of mold or cellar, sewer odor, other unpleasant odors, tobacco smoke, noise and detectable dust or dirt) had an increasing effect on hoarseness. In conclusion, clear associations were found between environmental problems and hoarseness in nurses. Furthermore, efforts should be made to repair defective ventilation systems, remediate indoor air problems due to moisture damage and improve overall maintenance to protect the vocal health of nurses.

Normative data for certain vocal fold biomarkers among young normophonic adults using ultrasonography

PURPOSE

The current study aimed to profile vocal fold morphology, vocal fold symmetry, gender and task-specific data for vocal fold length (VFL) and vocal fold displacement velocity (VFDV) in young normophonic adults in the age range of 18-30 years using ultrasonography (USG).

METHODS

Participants underwent USG across quiet breathing, /a/ phonation and /i/ phonation tasks, and acoustic analysis was conducted to explore the relationship between USG and acoustic measures.

RESULTS

The study found that males have longer vocal folds than females, and overall greater velocities were observed in /a/ phonation, followed by /i/ phonation, with the lowest velocity observed in the quiet breathing task.

CONCLUSIONS

The obtained norms can be used as a quantitative benchmark for analyzing the vocal fold behavior in young adults.

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.

A Survey of Vocal Health in Carnatic Singing Students

OBJECTIVE

Vocal health and hygiene are well addressed for professional singers, but less attention has been paid to singing trainees/students whose vocal demands vary significantly from trained singers. Studies conducted in the literature on singing trainees have reported a higher prevalence of voice problems in them; however, no such information is available from Indian classical singing trainees. Hence, the present study explored the frequency and nature of voice problems, self-reported vocal health and awareness of vocal hygiene and its practices in Carnatic singing trainees.

METHOD

This cross-sectional study was conducted using a purposive sampling method. The data were gathered from 135 Carnatic classical singing trainees. The participants completed a self-reported questionnaire addressing demographic and singing-related details, vocal symptoms, variables associated with increased risk reporting voice problems and knowledge about factors influencing vocal health.

RESULTS

The experience of past and point prevalence of voice problems in Carnatic singing students were found to be 29% and 15%, respectively. Difficulty singing higher notes, hoarseness, tired voice, loss of ability to sing/speak loudly, and breathiness in higher pitch range were the most prevalent vocal symptom reported by Carnatic singing trainees. Nasal allergies, dry mouth/throat, and excessive stress in daily routine activities raising voice many times a day, dry mouth/throat and excessive talking in social situations was found to have a significant association with singing trainees reporting voice problems. However, availing medical assistance for voice problems was found to be poor in this group of singing students.

CONCLUSION

Similar to trainees of other form of singing, Carnatic singing trainees also found to have a higher frequency of voice problems. Most of the singing trainees were found to be in their adolescent age period, and they face instability in their voice and are more vulnerable to develop voice problems. This indicates the need for in-depth understanding of voice problems experienced by Carnatic singing trainees aiming to promote their vocal health and prevent injury and be successful in their singing career.

Patient Profiling: Determining the Effects of Patient Factors on Vocal Fatigue

OBJECTIVES

The phenomenon of vocal fatigue and the types of patients that are at greatest risk for vocal fatigue are not fully understood. The goal was to investigate patient profiles such as voice disorder type, demographics (age and gender), singing identity, interoceptive awareness, and psychosocial impacts on the severity of vocal fatigue.

STUDY DESIGN

Prospective cohort study.

METHODS

Ninety-five subjects with voice disorders were asked to complete Part 1 of the Vocal Fatigue Index (VFI-Part1), the Voice Handicap Index-10 (VHI-10), and the Multidimensional Assessment of Interoceptive Awareness, version 2 (MAIA-2). The effects of voice disorder type (structural, neurological, functional), psychosocial impact, age, gender, self-reported singing identity, and interoceptive awareness on self-perceived vocal fatigue (VFI-Part1) were determined using multivariate linear regression.

RESULTS

Vocal fatigue had a significant psychosocial impact on patients with voice disorders, as measured by the VHI-10 (P < 0.001). However, there were no significant effects of vocal fatigue across any of the three voice disorder types (P's >0.05). Age (P = 0.220), gender (P = 0.430), and self-identified singing experience (P = 0.360) also did not have significant effects on vocal fatigue. Additionally, there were no significant relationships between interoceptive awareness MAIA-2 sum scores (P = 0.056) or any of the MAIA-2 sub-scores (P's > 0.05) and vocal fatigue severity (VFI-Part1).

CONCLUSION

Vocal fatigue has a significant psychosocial impact on patients with voice disorders. However, patient profiles, including voice disorder type, patient age, gender, singing identity, and level of interoceptive awareness do not appear to play a major role in vocal fatigue symptom reporting. These findings suggest caution should be exercised when attributing patient profiles to vocal fatigue presentation and severity. Studying pathophysiological mechanisms underlying vocal fatigue may help better distinguish unconscious bias in patient profiling from the etiology and severity of vocal fatigue.

Predicting glycemic control status and high blood glucose levels through voice characteristic analysis in patients with cystic fibrosis-related diabetes (CFRD)

Cystic fibrosis-related diabetes (CFRD) is associated with reduced life expectancy in adults with cystic fibrosis (CF). Voice analysis may be a convenient method for diagnosing and monitoring CFRD. This study aims to determine the relationship between voice characteristics and markers of glucose and glycemic control and to identify if voice analysis can predict high blood glucose levels and glycemic control in adults with CFRD. We conducted a prospective cross-sectional study in adults with CF from March to December 2021. We recorded 3-second voice samples of a sustained /a/ vowel and analyzed voice characteristic using the Computerized Speech Lab with the Multi-Dimensional Voice Program. In female participants with CFRD, the noise-to-harmonic ratio was significantly lower in those with HbA1c ≥ 7. Furthermore, fundamental frequency variation was significantly lower in both male and female participants with CFRD who had a glucose level of 200 mg/dL or higher at the time of collection. This finding was also associated with a high level of point-of-care glucose. The human voice has potential as a non-invasive tool for measuring glucose levels and glycemic control status in CFRD patients in the future.

Self-perception of Voice Handicap in COVID 19 Patients

Voice abnormalities were reported in patients during the course of COVID-19 infection. This study aims to evaluate the effect of COVID 19 infection on the self-perception of voice handicap in positive COVID 19 patients in addition to investigating the factors that might correlate with voice handicap if present. Voice handicap index-10 was filled in by 200 patients that were confirmed to be COVID 19 positive based on the RT-qPCR and symptomatology of the disease. The result showed that about 65.5% had mild degree of COVID 19 and 27.5% had moderate degree. Dysphonia was reported by 19% of the patients when questioned about voice symptoms. Dysphonia was detected in 35% of them by auditory perceptual assessment. Symptoms of Dyspnea, dysphonia, headache were significantly correlated with total and subtotal scores of Voice handicap index. COVID 19 infection has a negative impact on some of the patients? self- perception of voice handicap on the functional, physical and emotional domains. Age and degree of COVID 19 severity were correlating with the patients? self -perception of voice handicap.

Modification of Wendler Glottoplasty for Male to Female Gender Transition

INTRODUCTION

Transgenderism is a condition regarding the gender identity of an individual where their psychological gender is discordant with their anatomic gender. For patients transitioning from Male to Female, voice changes are created predominantly with voice therapy, with vocal surgery as an adjunct if the patient desires it. A common surgical technique is the Wendler Glottoplasty. A CO₂ laser is used to de-epithelialize the anterior third of the vocal folds and the anterior one-third of the folds are sutured together. This shortens the vibratory folds and increases the fundamental frequency (F₀) of the voice. We present a novel modification that incorporates use of injectable aqueous carboxy-methyl-cellulose gel (Prolaryn) to medialize the anterior aspect of the vocal folds and apply fibrin glue sealant (Tisseal) in lieu of sutures, simplifying the operative technique and a thyroarytenoid myectomy for debulking of the cords in select cases.

METHOD

We present ten patients treated with our modified Wendler Glottoplasty technique. Voice assessment was based on F₀ and frequency range pre and post-operatively measured via MDVP and Real-Time Pitch on the Computerized Speech Lab.

RESULTS

The 10 patients had an average age of 34.0 years (range 22.2-64.3 years). The average preoperative F₀ was 136.1 Hz, with an average frequency range of 108.3-282.4 Hz. Postoperatively, the average F₀ was 245.9 Hz, with an average frequency range of 197.3-300.7 Hz. This led to an average F₀ increase of 106.3 Hz.

CONCLUSION

Our modification to the Wendler Glottoplasty successfully resulted in a significant increase in the postoperative F₀. In addition, there was improved satisfaction in vocal character after the procedure, compared to their preoperative vocal character.

Vocal Fatigue Index in Teachers Using Mokken Analysis

PURPOSE

Vocal fatigue (VF) is a primary vocal symptom experienced by professional voice users, such as teachers, whose voice is an occupational tool. The study determines the utilization of the Vocal Fatigue Index (VFI), a 19-item scale in identifying symptoms of VF and its severity in teachers.

METHODS

Using responses of 695 teachers who completed the VFI, Mokken scaling was conducted on the items to identify the experiences of VF and its associated hierarchical nature of VF symptoms in teachers. Mokken scaling was completed on a total of four groups: (a) Total teachers group, (b) No VF group, (c) Low VF group, and (d) High VF group.

RESULTS

Results revealed differences in item hierarchies between total teachers and across the separate groups of VF severity. Item hierarchy for teachers highlighted items from physical discomfort at the mild end of the hierarchy to items from symptom improvement with rest at the severe end of the hierarchy. Items related to avoidance presented as a separate scale for teachers presenting with high VF.

DISCUSSION

Mokken scaling in teachers provides insight into the underlying complexity of the experience of VF symptoms and reliance on differential behavioral strategies in its management, suggesting the heterogenous nature of latent trait for VF in this specific population.

Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female School Teachers With Voice Problems

BACKGROUND

Teachers suffer greater impacts of voice problems due inappropriate voice use and other contributing factors such as physiological, environmental, and individual & work related issues. Structured vocal hygiene programs (VHP) prevent/reduce the risk of vocal trauma and promote vocal health in teachers. This study aimed to estimate the outcome of instituting a sociocultural relevant vocal hygiene program in facilitating vocal health among female school teachers using a comprehensive voice assessment protocol.

METHOD

VHP was developed emphasizing adequate hydration, healthy vocal diet, posture and alignment, vocal practices while teaching, and ideal speaking environment. This was administered via a face to face session to seventeen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objective, and self-perceptual vocal measures) before and four weeks after the VHP. Inter-rater reliability for perceptual and visual examination was estimated using Intra-Class Coefficient. Wilcoxon signed ranks test was used to compare the pre- and post-treatment measures of continuous variables (acoustic, Maximum phonation time, s/z ratio, Vocal Fatigue Index [VFI] & Voice Disorder Outcome Profile [V-DOP]), and McNemar test was used for categorical variables (vocal health questionnaire, visual examination of larynx and perceptual evaluation of voice).

RESULTS

Teachers reported reduction of unhealthy vocal & nonvocal practices after VHP. Improvements in vocal and related symptoms such as sensation of heart burn (P = 0.031), discomfort around the throat (P = 0.008), inadequate breath control while speaking (P = 0.016) were noticed. Perceptually, minimal improvement was seen in voice quality (overall grade). However, MPT & s/z ratio showed no significant difference. Improvement was observed in frequency range (P = 0.004), low I₀ (P = 0.044), shimmer (P = 0.017), and DSI (P = 0.013). Changes were evident in all parameters of stroboscopic evaluation (except nonvibratory portion & ventricular fold hyper-adduction). V-DOP scores indicated positive change in the overall severity (P = 0.002), physical (P = 0.003) and functional domain (P = 0.034). VFI indicated improvement in teachers voice after a period of voice rest (P = 0.048).

CONCLUSION

Though VHP facilitated in improving the teachers' awareness of at risk phono-traumatic behaviors and vocal health, its efficiency was limited in producing physiological improvement in teachers' voice. The comparison of vocal metrics before & after the treatment provides information on changes that can be expected in teachers after guiding them through a systematic VHP.

The Effects of Collegiate Sports Coaching on the Male Voice: Pilot Data

PURPOSE

This research gathered pilot data on the effects of a typical collegiate athletic season on the male coach's voice.

MATERIALS AND METHODS

Ten male coaches and ten age- and sex-matched controls participated. Qualitative and quantitative analyses were performed to assess group differences in: 1) written self-reports obtained during one session, 2) acoustic and aerodynamic variables obtained during regular season and during off-season for the coaches and only once for the controls, and 3) auditory-perceptual data provided by three speech-language pathologists using the Consensus Auditory-Perceptual Evaluation of Voice during one listening session. Data pertaining to the coaches' regular season, to the coaches' off-season, and to the control participants were designated as in-season, off-season, and control, respectively.

RESULTS

Significant self-reported findings included more phonotraumatic behaviors in the coaches than in the controls and higher in-season than off-season and control vocal demand. The coaches' history of voice problems was unrelated and the controls' was related to respiratory illness and addressing a large audience. A significant acoustic finding was lower off-season than control low fundamental frequency. Finally, trained listeners perceived control loudness as more aberrant than off-season loudness and they noted vocal fry twice as many times in in-season and off-season than in control voices.

CONCLUSIONS

This study exposed traces of adverse voice reactions to coaching and confirmed that coaches harbor a job-based proclivity to voice overuse. Self-reported measures appeared to be the least and aerodynamic the most immune to phonatory exertion that pervades daily coaching tasks. Future studies are warranted to further delineate how athletic coaching interferes with voice production.

Menopausal Voice-Related Work Limitation Scale (MenoVWL): Development and Validation

OBJECTIVES

Menopause has been reported to affect the voice of female professional voice users (FPVUs). The present study aims at the development and validation of a scale to measure self-perceived menopausal voice-related limitation to work in FPVUs, henceforth the Menopausal Voice-Related Work Limitation Scale (MenoVWL).

METHODS

Items were drawn from previous studies on impacts of sex steroid hormones on voice, available validated scales, and in-depth interviews with post-menopausal FPVUs. A preliminary version with 16 items was evaluated by a panel of 15 voice experts. The resulting revised version was filled in online, together with questions on current endocrinological reproductive status and related symptoms, history of amenorrhea, professional occupation, and demographic information. Responses concerning only professional voice users were selected and inclusive and exclusive criteria were applied for correct allocation of participants into pre- and post-menopausal stages within a restrict age range;192 responses were subject to factorial analysis for MenoVWL validation. Cronbach's alpha measured internal reliability. The scale was tested by comparing MenoVWL scores between pre- and post-menopausal FPVUs (98 and 94, respectively).

RESULTS

Thirteen items were retained from the expert panel evaluation. Items presented a high Content Validity Index (.94 out of 1) and high Item Acceptance Ratio (86.25 %). Both exploratory and confirmatory factorial analysis rendered one dimension scale with an excellent internal consistency (Cronbach's alpha = .9). The results of a Mann-Whitney test showed a higher MenoVWL score for post- as compared to pre-menopausal FPVUs (Z = - 2.818; P = .005).

CONCLUSIONS

MenoVWL is a comprehensive and validated scale with a known factor structure. It constitutes a health care and safety outcome self-perceived measure of value to the early detection of voice-related limitations to work in FPVUs during menopause.

The acoustic voice quality index, version 2.06 and 3.01, for the Persian-speaking population

INTRODUCTION

Dysphonia assessment includes approaches like acoustic analysis, which is non-invasive and easy to use and provides an understandable numerical output. The Acoustic Voice Quality Index (AVQI) is an acoustic model that can detect dysphonia. The Persian language is spoken by around 70,000,000 native speakers. Since AVQI versions 2.06 and 3.01 have not been validated for the Persian yet, this study investigated their concurrent validity and diagnostic accuracy among the Persian-speaking population.

METHODS

This scale development study was conducted from 2020 to 2021 on 180 normophonic and dysphonic native Persian-speaking residents of Mashhad, Iran. Five raters rated the samples by auditory-perceptual-judgments, including Grade from the Grade-Rough-Breathy-Asthenic-Strained (an ordinal scale) and the overall dysphonia severity from the Persian version Consensus Auditory Perceptual Evaluation of Voice (a continuous scale) to investigate both versions' concurrent validity. The intra- and inter-rater reliability and concurrent validity were evaluated for both scales. Both versions' diagnostic accuracy was assessed by the receiver operating characteristic, and the optimal thresholds were determined.

RESULTS

AVQI-version-2-Persian thresholds of 3.47 and 4.04 provided sensitivity of 88.30% and 85.53% and specificity of 79.07% and 85.58% by the ordinal and continuous scales, respectively. AVQI-version-3-Persian thresholds of 3.07 and 3.03 also rendered sensitivity of 74.47% and 85.53%, and specificity of 97.67% and 91.35% by the ordinal and continuous scales sequentially.

CONCLUSION

The significant values of concurrent validities and diagnostic accuracies of both versions of AVQI-Persian confirmed that it can discriminate between normal and pathological voices among the Persian-speaking population. Hence, it can be used for screening or diagnosis purposes.

Voice Problems Among School Teachers employing the Tele-teaching Modality

OBJECTIVES

To assess the prevalence of voice problems among teachers in Riyadh during tele-teaching and examine the relationship between the Voice Handicap Index 10 (VHI10) scores and a variety of risk factors believed to be related to voice problems. We also assessed awareness of voice hygiene and therapy among teachers.

STUDY DESIGN

An observational cross-sectional study conducted using a multistage random sampling method among Riyadh school teachers who taught by tele-teaching for a minimum of one year.

METHODS

A self-assessment questionnaire which included demographic information about teachers, factors related to their teaching backgrounds, tele-teaching settings, effects of tele-teaching on the voice, medical and social histories, reports of voice and reflux symptoms, VHI10, and general knowledge about voice hygiene. This was distributed to school teachers using an SMS link through the Ministry of Education's IT department.

RESULTS

A total 495 were included in the study after exclusions. The prevalence of teachers who had significant voice problems during tele-teaching (VHI10>11) was 21.6%. Multiple risk factors significantly increased the risk of voice problems during tele-teaching. These factors included being female, teacher age, the presence of background noise from both teachers and students, loud voices, using an open camera during the teaching, stress and anxiety, allergies, respiratory disease, reflux, hearing problems, and a family history of voice problems. Only 4.6% of respondents were familiar with voice hygiene and voice therapy, but 65% believe that it is important for teachers to be knowledgeable about them.

CONCLUSIONS

Due to the lower prevalence of voice disorders among tele-teaching compared to traditional teaching methods, tele-teaching may be a viable option for teachers who have voice problems. There are still several factors influencing voice problems among tele-teachers. To attenuate potential risks, it is crucial that teachers are aware of the concepts of voice hygiene and voice therapy.

Occupational diseases among call center operators needing vocal rehabilitation

BACKGROUND

Work related diseases (WRDs) and occupational diseases (ODs) greatly affect call center operators (CCOs) who experience demanding work expectations and adverse working conditions in their workplace. The aim of this study was to evaluate the sociodemographic and job characteristics of CCOs diagnosed with OD, and to describe the changes in employment status after diagnosis.

METHODS

This descriptive study is based on the electronic data records of Istanbul Occupational Diseases Hospital available from February 2007 to March 2018.

RESULTS

According to the health board reports, 122 of the 173 (70.5%) CCOs had a confirmed OD diagnosis, 85.2% were females and the mean age was 27.5 years. Vocal cord disorders were the most frequent ODs (64.8%), followed by hearing loss (12.5%), dysphonia (10.2%) and temporomandibular disorders (4.7%). Vocal cord nodules (VCN) were found to be more frequent among females compared to males (92.9% vs 62.4%, p<0.001). Although not statistically significant, the frequency of VCN was also higher in subjects working overtime (14.6% vs 6.3%), having gastroesophageal reflux disease (82.3% vs 73.9%) or thyroid nodules (100% vs 73.7%) and being current smokers (41.7% vs 13.3%). Following the OD diagnosis, 43.8% of the cases were dismissed, 18.7% quit their job, and 9.4% still held the same job position. Only 28.1% changed unit within the workplace.

CONCLUSION

Including the CCOs who were diagnosed with an OD at a very young age and at an early stage of their working life into vocational rehabilitation programs and employing them under appropriate conditions is essential to proper health and safety protocol.

Comparison of Client-Led Asynchronous and Clinician-Led Synchronous Online Methods for Evaluation of Subjective Vocal Measures in Teachers: A Feasibility Study

BACKGROUND

COVID-19 has transformed face to face teaching in classrooms to online and hybrid modes. Increased vocal intensity/ pitch to call attention of students and transact in the online class, inappropriate posture (head, neck & upper trunk) while using the laptop and other online tools cause vocal loading leading to voice related concerns in teachers. Tele voice assessment is a feasible alternative means to seek professional help in the current situation and possibly in the future too. Client-led asynchronous and clinician-led synchronous voice recordings for clinical vocal measures among school teachers were compared in this study.

METHOD

Twenty-five school teachers (21 females & four males) from Chennai consented to the study. Information of voice use, its impact on the day-to-day situations, self-perception of vocal fatigue, and their recorded voice sample (phonation & speaking) were obtained online (asynchronous mode). Within a period of ten days, the clinician-led synchronous session was planned on a mutually convenient time for obtaining voice samples through zoom call. The voice samples obtained were compared for clinical measures and perceptual voice evaluation.

RESULTS

Participants reported of vocal symptoms and increased vocal fatigue scores. The maximum phonation time values obtained through synchronous mode were lesser when compared to asynchronous mode. Also, variability was noted in the perceptual vocal measures of voice samples obtained through synchronous mode. During synchronous voice recording & evaluation, the background noise, internet stability, audio enhancement feature, and microphone placement & quality could be monitored, and immediate feedback was provided. Additionally, the asynchronous recording can be supplemented for synchronous recording, with clear instructions & demonstration.

CONCLUSION

This study explored the feasibility of using synchronous and asynchronous voice recording for voice analysis in school teachers. The findings could serve as a base to understand the advantages and challenges of using client-led asynchronous and clinician-led synchronous methods for estimating vocal measures.

Systems Approaches to Occupational Vocal Health: Considerations for Community Faith Leaders

Systems thinking approaches can benefit the occupational vocal health of vocally reliant workers. This paper explores community faith leaders as an example of a highly vocally reliant occupation, who may benefit from systems thinking being used to support their vocal occupational health and safety. A scoping review of the current literature regarding faith leaders' occupational voice use and vocal health is detailed, including recognised occupational hazards. This article then discusses the unique and potential use of systems thinking for facilitating faith leaders' vocal occupational health and safety. Rather than using a solely clinical perspective, the sociotechnical systems approach and the biopsychosocial-spiritual approach are noted as particularly pertinent for this occupational group.

Effect of Nebulization on Laryngeal Parameters: Analysis Using High-Speed Digital Videolaryngoscopy

INTRODUCTION

Superficial laryngeal hydration, obtained through nebulization, is related to the moisture level on the epithelial surfaces of the vocal folds, modifying their biomechanical and aerodynamic properties. Through high-speed videolaryngoscopy it is possible to obtain objective data for laryngeal analysis after nebulization and a better understanding of this phenomenon OBJECTIVE: To verify the effects of nebulization with saline solution on laryngeal parameters of digital videokymography obtained by high-speed videolaryngoscopy examination in women and men with and without laryngeal alterations METHOD: This is a clinical, comparative intra-subject study. Fifty-nine adults were selected, with and without laryngeal alterations, 30 females and 29 males. Digital videokymographs in the anterior, middle and posterior thirds of the vocal folds of the participants were analyzed before and after nebulization with 0.9% saline solution.

RESULTS

Women without laryngeal alterations showed more parameters changes after nebulization, in which there was a decrease in maximum and medium opening, amplitude of opening of the left and right vocal fold in the anterior glottal third, and an increase of the percentage of closure of the vocal folds. These results indicate a minor extent of lateral excursion of the vocal folds during phonation. In women with laryngeal alterations, the parameters that changed after nebulization were the increased frequency of opening of the left and right vocal folds in the topography of the posterior third. In men, nebulization did not change the variables studied, except for the amplitude of the right vocal fold in men with laryngeal alterations, in the analysis of the posterior glottic third.

CONCLUSION

The results suggest that surface hydration modifies laryngeal dynamics differently between genders. After nebulization with saline solution, women without laryngeal alterations showed a decrease in the lateralization of the vocal folds during phonation, suggesting a better phonatory efficiency.

The Effect of Upper Airway Ailments on Teachers' Experience of Vocal Fatigue

BACKGROUND

Teachers have been found to have a higher than normal risk to develop voice disorders. One common symptom of voice problems among teachers is the report and occurrence of vocal fatigue, often associated with different individual, physical, environmental, and professional factors.

AIM

The aim of this study was to provide insight into the potential effect of sinus infections, laryngitis, colds, seasonal allergies, and reflux on reported vocal fatigue, as quantified by the Vocal Fatigue Index (VFI).

METHOD

An exploratory cross-sectional design was implemented via an online survey sent by email to teachers of kindergarten through 12th-grade in 31 states throughout the USA.

RESULT

The main result of this study was that teachers with self-reported reflux and seasonal allergies had statistically significant higher scores on VFI Factor 1 (performance), VFI Factor 2 (pain), and VFI Factor 3 (recovery) when compared to those without self-reported reflux and seasonal allergies.

CONCLUSIONS

It may be likely that an individuals' change in reported vocal fatigue over time may be also associated with health-related factors, such as reflux and seasonal allergies rather than just changes in voice production. These associated factors should be considered and potentially controlled for in future research and clinical practice surrounding teachers' experience of vocal fatigue.

Incidence of Voice Disorders among Private School Teachers in Taiwan: A Nationwide Longitudinal Study

Background: Teachers are more likely to use a loud voice at work than the general working population, but few longitudinal studies have been conducted on their risk of voice disorders. The occurrence of voice disorders in private school teachers was assessed by using the Longitudinal Health Insurance Database 2000 of Taiwan, which contains information on a random sample of 1 million beneficiaries of National Health Insurance. Methods: This study included private school teachers who were under 35 years old and newly employed between 2000 and 2010, and used workers with other occupations as the comparison cohort. Patients with voice disorders were identified using diagnostic codes on insurance claims. Cox proportional hazards regressions were applied to obtain relative risk estimates. Results: After adjusting for age, sex, income, and comorbidities of sinusitis and laryngitis, private school teachers had a higher risk of developing voice disorders (hazard ratio [HR] = 1.58; 95% confidence intervals: 1.43-1.75). In addition, the finding that elementary and high-school teachers had a higher risk than college teachers (HR: 2.56 vs. 1.44) and the pattern of increases in cumulative incidence over time supported a dose-response relationship between teaching and voice disorders. Conclusions: Private school teachers had higher risks of voice disorders. The results support the causality between occupation and voice disorders in teachers.

Comparación de parámetros de la carga vocal mediante dosimetría en profesoras

La carga vocal es definida como la cantidad de trabajo realizado por el mecanismo laríngeo a lo largo del tiempo. No se encontraron estudios de su valoración diferenciada en la sala de clases y en el espacio de simulación clínica. Es necesario diferenciar los resultados de los parámetros: frecuencia fundamental, intensidad vocal y ruido ambiental en ambos contextos para promover una perspectiva ecológica de la salud vocal de las docentes. El objetivo de esta investigación es determinar las diferencias en la carga vocal de un grupo de profesoras de tres establecimientos educacionales de la Región Metropolitana de Chile, en espacios de simulación clínica y laboral. Estudio comparativo transversal de 26 profesoras de educación preescolar y básica sin antecedentes de patologías vocales. La evaluación de los parámetros vocales se realizó a través de un dosímetro. El ruido ambiente fue evaluado por medio de un sonómetro. Los resultados arrojaron diferencias significativas de las tres variables entre la sala de clases y el espacio clínico simulado. También hubo diferencias significativas de intensidad y ruido ambiente entre niveles de enseñanza y cantidad de alumnos por sala, siendo mayor la intensidad y ruido en las salas de nivel básico, en comparación al nivel preescolar. Como conclusión existe una carga vocal mayor en la sala de clases, definida por un aumento en la frecuencia fundamental e intensidad, en comparación al espacio clínico simulado. Lo anterior podría estar determinado por el ruido ambiente. Se sugiere realizar intervención fonoaudiológica en el contexto laboral.

Diseño y validación de una escala vocal multidimensional para la detección del riesgo vocal en docentes

En el colectivo docente es frecuente el mal uso de la voz, para preservar su salud vocal es necesario un diagnóstico precoz. El objetivo del estudio fue diseñar, según criterios de especificidad y sencillez, una escala vocal multidimensional y fiable que contribuya a detectar situaciones de riesgo vocal del docente en el contexto escolar (EVM-D). Participaron 299 docentes, de 18 centros educativos de A Coruña seleccionados aleatoriamente, se dividieron en dos submuestras, una (n =143) para la realización del análisis factorial exploratorio, tanto con Análisis Paralelo como con factorización de ejes principales y rotación oblimin, y otra (n = 156) para el análisis factorial confirmatorio utilizando el método de mínimos cuadrados no ponderados. Una vez analizados los modelos, se optó por uno de tres factores de primer orden (Síntomas vocales, Hábitos de habla y Abusos vocales) y uno de segundo orden (Riesgo vocal). Los índices de bondad de ajuste fueron GFI = ,98, AGFI = ,97, SRMR = ,05; la fiabilidad compuesta (FC) en los tres factores de ,80; ,70 y ,73 y la varianza media extraída (AVE) de ,44; ,43 y ,47 respectivamente; la FC del factor de primer orden fue de ,83 y la AVE ,63. Se obtuvieron valores de corte según el sexo para los percentiles P90, P75 y P60 de riesgo vocal: alto, medio, bajo y muy bajo. La escala EVM-D fiable y consistente podría ser útil para detectar factores etiológicos o síntomas y aplicar la higiene vocal de forma precoz y autónoma por el docente.

Contribution of laryngeal size to differences between male and female voice production

In this study we investigated the effect of sex- and age-related differences in vocal fold length, thickness, and depth on voice production in a three-dimensional vocal fold model. The results showed that the cause-effect relationships between vocal fold physiology and voice production previously identified in an adult male-like vocal fold geometry remained qualitatively the same in vocal folds with geometry representative of adult females and children. We further showed that the often-observed differences in voice production between adult males, adult females, and children can be explained by differences in length and thickness. The lower F0, higher flow rate, larger vocal fold vibration amplitude, and higher sound pressure level (SPL) in adult males as compared to adult females and children can be explained by differences in vocal fold length. In contrast, the thickness effect dominated and contributed to the larger closed quotient of vocal fold vibration, larger normalized maximum flow declination rate, and lower H1-H2 in adult males as compared to adult females and children. The effect of differences in vocal fold depth was generally small. When targeting a specific SPL, adult males experienced a lower peak vocal fold contact pressure during phonation than adult females and children.

Relationships Across Clinical Measures of Vocal Quality and Functioning and Their Relationship With Patient Perception

Purpose The purpose of this study was to investigate the relationships among subjective auditory-perceptual ratings of vocal quality, objective acoustic and aerodynamic measures of vocal function, and patient-perceived severity of their vocal complaint. Method This study was a retrospective chart review of adult patients evaluated at a single outpatient center over a 1.5-year time period. Twenty-two clinical objective and subjective measures of voice were extracted from 676 charts (310 males, 366 females). To identify the underlying concepts addressed in an initial voice assessment, principal component analyses were conducted for males and females to account for sex differences. Linear regression models were conducted to examine the relationship between the principal components and patient perceived severity. Results Seven principal components were identified for both sexes and accounted for 75% and 71% of the variance in the clinical measures, respectively. Of these seven principal components, only two predicted male patient perceived severity, which accounted for 22% of the variance. In contrast, four principal components predicted female patient perceived severity of their voice disorder and accounted for 19% of the variance. Conclusions The results highlight the underlying aspects of vocal quality and functioning that are evaluated during an initial assessment. Male and female patients differ in which of these components may contribute self-perceived severity of a voice disorder. Identifying these underlying components may support clinical decision making when developing a clinical protocol and highlights the overlap between patient concerns and clinical measures. Supplemental Material https://doi.org/10.23641/asha.16879603.

Replication-based regularization approaches to diagnose Reinke's edema by using voice recordings

Reinke's edema is one of the most prevalent laryngeal pathologies. Its detection can be addressed by using computer-aided diagnosis systems based on features extracted from speech recordings. When extracting acoustic features from different voice recordings of a particular subject at a concrete moment, imperfections in technology and the very biological variability result in values that are close, but they are not identical. This suggests that the within-subject variability must be properly addressed in the statistical methodology. Regularization-based regression approaches can be used to reduce the classification errors by favoring the best predictors and penalizing the worst ones. Three replication-based regularization approaches for variable selection and classification have been specifically designed and implemented to take into account the underlying within-subject variability. In order to illustrate the applicability of these approaches, an experiment has been specifically conducted to discriminate Reinke's edema patients (30 subjects) from healthy people (30 subjects) in a hospital environment. The features have been extracted from four phonations of the sustained vowel /a/ recorded for each subject, leading to a database that has fed the proposed machine learning approaches. The proposed replication-based approaches have been proved to be reliable in terms of selected features and predictive ability, leading to a stable accuracy rate of 0.89 under a cross-validation framework. Also, a comparison with traditional independence-based regularization methods reports a great variability of the latter in terms of selected features and accuracy metrics. Therefore, the proposed approaches contribute to fill a gap in the scientific literature on statistical approaches considering within-subject variability and can be used to build a robust expert system.

Gender differences in hematotoxicity of benzene-exposed workers, three cross-sectional studies on 218,061 subjects

Our aim was to analyze the effects of benzene exposure on hematotoxicity in workers, with a focus on gender differences. The study was divided into three parts, and the survey included 218,061 workers. Since 2017, some workers are selected from the total workers each year to explore the possible influencing factors (age, duration of benzene exposure, TWA (8-h time-weighted average) of benzene, SPMA (S-phenylmercapturic acid), MDA (malondialdehyde), 8-OHdG (8-hydroxy-2'-deoxyguanosine) of different hematotoxicity of different genders). The abnormal rate of WBC (white blood cell), ANC (absolute neutrophil count), and platelets of female workers in the benzene exposure group was higher than that of males in the benzene exposure group and also higher than that of the female workers in the control group. Research results in 2019 showed increased SPMA as well as increases their DNA damage including 8-OHdG and MDA in benzene-exposed female workers compared to those in the control female group (all p < 0.05. SPMA, 8-OHdG, and MDA in benzene exposure female workers increased 555%, 183%, and 33.3%, respectively). Female workers are at significantly higher risk for blood system effects of benzene exposure. Therefore, more stringent standards and guidelines may be needed to protect the changing professional population, especially for females.

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.

Relationship Between Tasked Vocal Effort Levels and Measures of Vocal Intensity

Purpose Patients with voice problems commonly report increased vocal effort, regardless of the underlying pathophysiology. Previous studies investigating vocal effort and voice production have used a range of methods to quantify vocal effort. The goals of the current study were to use the Borg CR100 effort scale to (a) demonstrate the relation between vocal intensity or vocal level (dB) and tasked vocal effort goals and (b) investigate the repeated measure reliability of vocal level at tasked effort level goals. Method Three types of speech (automatic, read, and structured spontaneous) were elicited at four vocal effort level goals on the Borg CR100 scale (2, 13, 25, and 50) from 20 participants (10 females and 10 males). Results Participants' vocal level reliably changed approximately 5 dB between the elicited effort level goals; this difference was statistically significant and repeatable. Biological females produced a voice with consistently less intensity for a vocal effort level goal compared to biological males. Conclusions The results indicate the utility of the Borg CR100 in tracking effort in voice production that is repeatable with respect to vocal level (dB). Future research will investigate other metrics of voice production with the goal of understanding the mechanisms underlying vocal effort and the external environmental influences on the perception of vocal effort.

Do Professionals Who Use the Voice in a Journalistic Context Benefit from Humming as a Semi-occluded Vocal Tract Exercise?

INTRODUCTION

Many vocal enhancement and rehabilitation programs for voice professionals define vocal exercises without analyzing their effects on that specific population in which they will be applied, in the established dose and often without considering the presence and absence of vocal alteration. Journalists have sought the voice clinic due to new professional vocal demands and a vocal program is being elaborated.

OBJECTIVE

To determine the immediate effect of humming in professionals with and without voice disorders who work under high vocal demand in a journalistic context.

METHOD

Thirty-six individuals who completed the Dysphonia Risk Screening Protocol and underwent voice recording participated in the study. Three speech therapists defined the presence and/or absence of vocal changes by consensus. Subsequently, five repetitions of humming were proposed; the exercises lasted five seconds each and were separated by five seconds of complete silence, and recordings were made before and after the exercise (vowel and phrase). For the pre and post comparison between the groups with and without vocal changes, acoustic measurements and spectrogram, including the classification of the signal type, were performed.

RESULTS

The sample had a similar distribution of men and women and a mean age of 39.9 years. Most of the professionals were journalists or reporters. The risk of dysphonia was high for half of the sample, and the presence of vocal changes, predominantly mild ones, was identified in 56%. After the exercise, a decrease in noise at low frequencies and an improvement in the series of harmonics and the signal type were observed in both groups; a decrease in irregularity was observed only in the participants without vocal changes.

CONCLUSION

The proposed humming exercise had an immediate positive effect on the voice of professionals working in a journalistic context, and the changes were particularly evident in aspects of the voice that were initially altered.

Which teachers are most at risk for voice disorders? Individual factors predicting vocal acoustic parameters monitored in situ during a workweek

PURPOSE

To identify the factors affecting teachers' vocal acoustic parameters, with the aim of detecting individuals at risk of phonotrauma.

METHOD

The voicing time, voice sound pressure level [SPL] and fundamental frequency [f_o] of 87 teachers were measured during one workweek using a voice dosimeter. We retrospectively investigated the impact of 10 factors (gender, age, teaching experience, teaching level, tobacco, gastro-esophageal problems, nonoccupational voice activity, voice education, past voice problems, and biopsychosocial impact of voice problems measured using the Voice Handicap Index [VHI]) on each voice parameter.

RESULTS

None of the above factors affected voicing time or SPL. f_o depended significantly on gender, teaching level, nonoccupational voice activity and VHI score. Specifically, f_o was higher in women (Δ = 69 Hz), in individuals without nonoccupational voice activities (Δ = 11 Hz), and in individuals with a lower VHI score (increase of 0.7 Hz for each additional point). For females, post hoc comparisons revealed a substantial impact of teaching level on f_o: university instructors had deeper voices than kindergarten (Δ = 66 Hz), elementary (Δ = 52 Hz), or secondary teachers (Δ = 41 Hz).

CONCLUSIONS

Since higher f_o increases the mechanical stress related to vocal fold vibration, the screening and prevention of phonotrauma should focus primarily on women, particularly those who teach at lower levels, and teachers with more self-rated voice problems. The lower f_o of teachers who engage in nonprofessional voice activities may suggest acute inflammation or muscle fatigue due to voice overload.

The German Restructured Vocal Fatigue Index and Characteristics of Dysphonic and Vocally Healthy Populations

OBJECTIVE

The Vocal Fatigue Index (VFI), a 19-item psychometric self-report questionnaire, enables individuals with vocal fatigue (VF) to be identified and their complaints to be characterized. The purpose of this study was to improve the German-language version (VFI-G) and to evaluate further vocal fatigue-related characteristics of dysphonic and control populations.

METHODS

The VFI-G was restructured by replacing the three factors that structured the original: (1) tiredness of voice and voice avoidance; (2) physical discomfort; and (3) improvement of symptoms with rest, with two clusters developed on the basis of the results of a factor analysis by Nanjundeswaran et al. (2019). The two new clusters are: (1) tiredness and avoidance plus physical discomfort; and (2) symptom improvement through rest. One hundred one (101) individuals with voice disorders and 100 vocally healthy controls from a previous study that cross-validated the VFI-G participated in this study. In order to assess the validity of our newly adjusted VFI-G, independent samples t test, receiver operating characteristic curve, likelihood ratios and the Youden Index were calculated. The association of the two VF clusters with subject characteristics such as age, sex, type of voice disorder, and level of vocal usage was also analyzed using either a Pearson correlation or a one-way ANOVA for each of the two populations.

RESULTS

Significantly higher scores were obtained in voice-disordered subjects in both clusters (all P values < 0.001) than in healthy-voice subjects. The threshold for cluster 1 of the VFI-G was determined as ≥17.5 (74.3% sensitivity and 88.0% specificity). The results of cluster 2 are identical to that of factor 3 of the previous cross-validation study of the VFI-G. Most subject characteristics show no significant association with cluster 1 of the VFI-G, but cluster 2 seems to be moderately associated with age, type of voice disorder and level of vocal usage in the dysphonic population.

CONCLUSIONS

The restructured VFI-G showed improved validity and can be recommended for use in the assessment of VF. Cluster 2 is also moderately associated with several vocal fatigue-related subject characteristics of the dysphonic population.

Phonogenic Voice Problems among Speech-Language Pathologists in Synchronous Telepractice: An Overview and Recommendations

Many speech-language pathologists (SLPs) recently adopted a live, synchronous online distribution of clinical services due to physical distancing measures aimed at bringing the coronavirus disease 2019 (COVID-19) outbreak under control. Few SLPs had received training in telepractice to prepare them for changes from an in-person service delivery model to synchronous telepractice. The new telepractice environment may alter vocal behaviors and communication interactions in such a way that negatively impacts voice production. Thus, delivering synchronous online clinical services may require that SLPs adopt novel prevention strategies for avoiding phonogenic voice problems. Guided by two complementary injury frameworks, the Haddon Matrix and the Haddon Countermeasures, this article provides an overview of potential factors associated with phonogenic voice problems among SLPs in telepractice and proposes possible prevention strategies to maintain optimal vocal health and function with synchronous modes of online clinical practice.

The Effects of Menopause on Neuromuscular Parameters of the Rat Vocal Folds

OBJECTIVES/HYPOTHESIS

Menopause adversely affecs power and endurance of the limb muscles. However, despite clinical observations that menopause corresponds to negative changes of the voice, the direct effects of estrogen deprivation on the thyroarytenoid muscles are unknown. The purpose of this study was to investigate the effects of estrogen deprivation via ovariectomy on three neuromuscular parameters of the thyroarytenoid muscles using a rat model.

STUDY DESIGN

Animal model.

METHODS

Cryosections of vocal folds of 20 (10 control and 10 ovariectomized) female rats were stained to label neuromuscular junctions, fiber size, or parvalbumin levels using immunohistochemical techniques and compared between experimental groups.

RESULTS

The neuromuscular junctions, thyroarytenoid fiber sizes, and parvalbumin levels of the vocal folds were similar between experimental groups.

CONCLUSIONS

The loss of estrogen did not change neuromuscular parameters of the vocal folds of adult female rats; therefore, vocal changes within the outer vibratory layers of the vocal folds may primarily be responsible for clinically observed menopausal vocal changes.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1343-1348, 2021.

Identifying Type III Sulcus: Patient Characteristics and Endoscopic Findings

OBJECTIVE

Type III sulcus is a pathologic structural deformity of the vocal folds that is challenging to accurately diagnose without endoscopic examination under anesthesia. This study aims to further define the clinical presentation and examination features shared among a patient cohort intraoperatively diagnosed with type III sulcus.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary laryngology practice.

SUBJECTS AND METHODS

All patients diagnosed intraoperatively with type III sulcus from 2002 to 2014 at a tertiary laryngology practice were included. Clinical history of presenting symptoms, videostroboscopy, and intraoperative and histologic findings were reviewed.

RESULTS

Twenty-two patients were included in the study. A majority were female (77%) and had a mean age of 32.4 years. All patients endorsed hoarseness, and 86% were defined as professional voice users. Endoscopic examination revealed bilateral type III sulcus in 23% of patients. The most common preoperative stroboscopic findings included decreased mucosal wave (100%), dilated vessel (95%), phase asymmetry (91%), additional benign lesion (91%), and cyst (82%). Histology revealed epithelial changes of atypia and keratosis.

CONCLUSION

Both the severity of dysphonia and the difficulty observing structural malformations of the vocal folds make type III sulcus challenging to preoperatively diagnose. This study reports the clinical and endoscopic features seen within a cohort of patients with type III sulcus.

Age-Related Changes in Speech and Voice: Spectral and Cepstral Measures

Purpose This study examined differences in selected acoustic measures of speech and voice according to age and sex and across families. Method Participants included 169 individuals, 79 men and 90 women, from 18 families, ranging in age from 17 to 87 years. Participants reported no history of articulation disorders, stroke or active neurologic disease, or severe-to-profound hearing loss. They read aloud two passages to facilitate examination of the following speech and voice acoustic parameters: fricative spectral moments (center of gravity, standard deviation, skewness, and kurtosis), the proportion of time spent speaking, mean speaking fundamental frequency, semitone standard deviation (STSD), and cepstral peak prominence smoothed. Results The results indicated a significant age effect for fricative spectral center of gravity, spectral skewness, and speaking STSD. There was a significant sex effect for spectral center of gravity, spectral kurtosis, and mean fundamental frequency. Familial relationship was significant for spectral skewness, STSD, and cepstral peak prominence smoothed. Conclusions These findings revealed that certain speech and voice features change with age and some change differently for men and women. Additionally, speakers from the same family units may demonstrate similar patterns for prosody, voicing, and articulatory behavior. The results also demonstrated normal differences in speech and voice variation across age, sex, and family unit. Understanding patterns and differences across these demographic variables in healthy speakers is important to distinguishing more confidently between normal and disordered speech and voice patterns clinically.

Evidence of Possible Irritable Larynx Syndrome in Obstructive Sleep Apnea: An Epidemiologic Approach

OBJECTIVE

"Irritable larynx syndrome" (ILS) often refers to a constellation of laryngeal-based symptoms including chronic cough (CC), diurnal dyspnea, and dysphonia. In patients with OSA, we examined: (1) the frequency, severity, comorbidity, risks and triggers of each problem, (2) whether these symptoms were compatible with stereotypic ILS and (3) the role of CPAP in their expression.

STUDY DESIGN

Cross-sectional, descriptive epidemiology study.

SETTING

Sleep-Wake Center at University of Utah Health Care, Salt Lake City, UT.

SUBJECTS AND METHODS

Ninety-four individuals with OSA (53 men, 41 women; mean age 54.7 ± 12.8 yrs.) underwent an extensive telephone interview that addressed study objectives.

RESULTS

Long-term CC, daytime breathing and voice problems were common, especially among women despite less severe OSA. Women, more than men, reported all three chronic conditions alone or in combination: CC (44% vs 11.3%), diurnal dyspnea (41.5% vs 13.2%) and voice disorders (41.5% vs 13.2%). Symptoms were not associated with age, BMI or Apnea Hypopnea Index after adjusting for sex. Although evidence supporting stereotypic ILS symptomatology was inconsistent, those participants with a voice disorder were 3.3 (95% CI = 1.8-6.0) times more likely to report CC and 2.4 (95% CI = 1.3-4.4) times more likely to experience diurnal dyspnea. Esophageal reflux, post-nasal drip, and frequent sinus infections were significantly associated with all three conditions. Triggers that provoked or made symptoms worse varied by condition and sex. Nightly, humidified CPAP use was associated with fewer symptoms overall and improved quality of life.

CONCLUSIONS

Symptoms suggestive of possible ILS are common in OSA, especially among women, and lessened by nightly CPAP use.

Investigation of Vocal Fatigue Using a Dose-Based Vocal Loading Task

Vocal loading tasks are often used to investigate the relationship between voice use and vocal fatigue in laboratory settings. The present study investigated the concept of a novel quantitative dose-based vocal loading task for vocal fatigue evaluation. Ten female subjects participated in the study. Voice use was monitored and quantified using an online vocal distance dose calculator during six consecutive 30-min long sessions. Voice quality was evaluated subjectively using the CAPE-V and SAVRa before, between, and after each vocal loading task session. Fatigue-indicative symptoms, such as cough, swallowing, and voice clearance, were recorded. Statistical analysis of the results showed that the overall severity, the roughness, and the strain ratings obtained from CAPE-V obeyed similar trends as the three ratings from the SAVRa. These metrics increased over the first two thirds of the sessions to reach a maximum, and then decreased slightly near the session end. Quantitative metrics obtained from surface neck accelerometer signals were found to obey similar trends. The results consistently showed that an initial adjustment of voice quality was followed by vocal saturation, supporting the effectiveness of the proposed loading task.

Effects of Humidification of the Vocal Tract and Respiratory Muscle Training in Women With Voice Symptoms-A Pilot Study

OBJECTIVE

The aim of this study was to determine the efficacy of a 4-week breathing exercise intervention in participants with voice symptoms.

METHODS

Six nonsmoking women (mean age 49) experiencing voice symptoms used a novel device WellO₂ for respiratory exercises that provides counter pressure during both inspiration and expiration and warms and humidifies the breathing air. Speech samples were acoustically (Acoustic Voice Quality Index) and perceptually (grade, roughness, breathiness, asthenia, and strain scale) analyzed, and perceived voice symptoms and self-reported effort in breathing and phonation were obtained. Respiratory measurements included breathing frequency and pattern, peak expiratory flow, forced vital capacity, and forced expiratory volume in 1 minute.

RESULTS

The total scores of Acoustic Voice Quality Index and some of its subcomponents (shimmer and harmonic-to-noise ratio), and the grade, roughness, and strain of the GRBAS scale indicated significantly improved voice quality. However, neither the nature or frequency of the experienced voice symptoms nor the perceived phonatory effort changed as the function of intervention. According to the participants, their breathing was significantly less effortful after the intervention, although no significant changes were observed in the objective respiratory measurements with a spirometer.

CONCLUSION

Training with the WellO₂ device has the potential to improve voice quality. The combination of inspiratory and expiratory training and warmed, humidified air is a multifaceted entity influencing several parts in the physiology of voice production. The effects of using WellO₂ need to be confirmed by further studies with a larger number of participants.

Phonation Demonstrates Goal Dependence Under Unique Vocal Intensity and Aerobic Workload Conditions

Purpose This study investigated whether metabolic respiratory requirements (treadmill workload) affected glottal valving in phonation, based on aerodynamic measures, when a sound pressure level (vocal SPL) is dictated as a target goal. Consistent with a theory of action, we hypothesized that adjustments in glottal valving as measured by laryngeal airway resistance would be dependent upon vocal SPL level, even as workload increased, and loud vocal SPL would interfere more with respiratory homeostasis than spontaneous vocal SPL. Method Thirty-two women enrolled who were ages 18-35 years. A repeated-measures design was used with random assignment of workload and vocal SPL conditions. Aerodynamic and acoustic data were collected during phonation, as were gas volume and concentration data. Analyses were performed with generalized estimating equations. Results Laryngeal airway resistance at a low workload significantly increased when vocal SPL changed from spontaneous to loud. At a loud vocal SPL, laryngeal airway resistance decreased when workload changed from rest to either low or high. Regarding the respiratory system response, minute ventilation increased at a loud vocal SPL when workload changed from rest to either low or high. End-tidal CO₂ increased under low and high workloads relative to rest at loud and spontaneous vocal SPLs. Conclusions Mostly consistent with a theory of action, in which motor control is goal dependent (i.e., vocal SPL targets), speakers can achieve a loud vocal SPL despite increases in workload requirements. In contrast, laryngeal airway resistance stays relatively low when vocal SPL occurs spontaneously, suggesting glottal adjustments are made to improve gas exchange as metabolic respiratory requirements become prioritized. Metabolic respiratory requirements appear to be overcome by the overlay of motor control for voicing when a loud vocal SPL is targeted. The implication of goal-dependent phonation for clinicians is that real-world conditions (i.e., loud vocal SPL) matter in vocal testing and voice therapy.

Carbon nanotube composite hydrogels for vocal fold tissue engineering: Biocompatibility, rheology, and porosity

Porous composite hydrogels were prepared using glycol chitosan as the matrix, glyoxal as the chemical crosslinker, and carbon nanotubes (CNTs) as the fibers. Both carboxylic and hydroxylic functionalized CNTs were used. The homogeneity of CNTs dispersion was evaluated using scanning electron microscopy. Human vocal fold fibroblasts were cultured and encapsulated in the composite hydrogels with different CNT concentrations to quantify cell viability. Rheological tests were performed to determine the gelation time and the storage modulus as a function of CNT concentration. The gelation time tended to decrease for low concentrations and increase at higher concentrations, reaching a local minimum value. The storage modulus obeyed different trends depending on the functional group. The porosity of the hydrogels was found to increase by 120% when higher concentrations of carboxylic CNTs were used. A high porosity may promote cell adhesion, migration, and recruitment from the surrounding native tissue, which will be investigated in a future work aiming at applying this injectable biomaterial for vocal fold tissue regeneration.

The Effect of Pulmonary Function on the Incidence of Vocal Fatigue Among Teachers

INTRODUCTION

Females face a significantly higher risk of presenting with voice problems than males. This discrepancy has been associated with a number of differences in respiratory behavior and the physiology of the laryngeal and endocrine systems.

METHODS

In conjunction with established spirometry measures, the Vocal Fatigue Index (VFI) was used to determine (1) if there is a relationship between base pulmonary function and vocal fatigue among teachers; and (2) if that relationship is different in females from males. One hundred and twenty-two elementary and middle school teachers (96 females and 26 males) from the Jordan School District in Northern Utah participated in the study.

RESULTS

VFI factors were predictors of the outcomes of several raw spirometry measures for female participants, but the same predictive relationship was not found for male participants. Additionally, there appeared to be no relationship between VFI and spirometry measures in females when using normalized, rather than raw, spirometry metrics.

CONCLUSIONS

The results suggest that the pulmonary physiology that would result in reduced raw pulmonary function, in combination with other differences associated with gender, may lead to a greater incidence of vocal fatigue among female teachers than their male counterparts.