Voice use of nurses working in the intensive care unit during the COVID-19 pandemic

OBJECTIVE

This study aimed to investigate the voice use of nurses working in intensive care units (ICUs) and their perception of acoustic environments.

SETTING AND SAMPLE

The research was conducted in four different hospitals in China during the COVID-19 pandemic. A total of 60 ICU nurses were recruited for their voice use monitoring and 100 nurses participated in the survey.

RESEARCH METHODOLOGY

Firstly, voice-related parameters such as voice level (SPL, dB), fundamental frequency (F0, Hz), and voicing time percentage (Dt, %) were measured using a vocal monitor. To collect data, a non-invasive accelerometer was attached to the participants' necks during their working hours. Secondly, the perception of the ICU acoustic environment was assessed using semantic differential.

RESULTS

The results showed that nurses spoke approximately 0.9-4 dB louder to patients and colleagues in ICUs compared to quiet rooms, and their fundamental frequency (F0) significantly increased during work. The voice levels of nurses were influenced by background noise levels, with a significant correlation coefficient of 0.44 (p < 0.01). Furthermore, the background noise levels ranged from 58.1 to 73.9 dBA, exceeding the guideline values set by the World Health Organisation (WHO). The semantic differential analysis identified 'Stress' and 'Irritation' as the two main components, indicating the prevalence of negative experiences within ICUs.

IMPLICATIONS FOR CLINICAL PRACTICE

This study highlights the potential risk of voice disorders among ICU nurses. The findings also underscore the importance of implementing strategies to reduce noise levels in ICUs to reduce voice disorders among nurses.

Protocol for a Prospective Observational Study of Revision Palatoplasty Versus Pharyngoplasty for Treatment of Velopharyngeal Insufficiency Following Cleft Palate Repair

OBJECTIVE

To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI).

DESIGN

Prospective observational multicenter study.

SETTING

Twelve hospitals across the United States and Canada.

PARTICIPANTS

Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants.

INTERVENTIONS

Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team.

MAIN OUTCOME MEASURE(S)

The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings.

RESULTS

Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter.

CONCLUSIONS

Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date.

Conducting high-quality and reliable acoustic analysis: A tutorial focused on training research assistants

Open science practices have led to an increase in available speech datasets for researchers interested in acoustic analysis. Accurate evaluation of these databases frequently requires manual or semi-automated analysis. The time-intensive nature of these analyses makes them ideally suited for research assistants in laboratories focused on speech and voice production. However, the completion of high-quality, consistent, and reliable analyses requires clear rules and guidelines for all research assistants to follow. This tutorial will provide information on training and mentoring research assistants to complete these analyses, covering areas including RA training, ongoing data analysis monitoring, and documentation needed for reliable and re-creatable findings.

Speaking without vocal folds using a machine-learning-assisted wearable sensing-actuation system

Voice disorders resulting from various pathological vocal fold conditions or postoperative recovery of laryngeal cancer surgeries, are common causes of dysphonia. Here, we present a self-powered wearable sensing-actuation system based on soft magnetoelasticity that enables assisted speaking without relying on the vocal folds. It holds a lightweighted mass of approximately 7.2 g, skin-alike modulus of 7.83 × 105 Pa, stability against skin perspiration, and a maximum stretchability of 164%. The wearable sensing component can effectively capture extrinsic laryngeal muscle movement and convert them into high-fidelity and analyzable electrical signals, which can be translated into speech signals with the assistance of machine learning algorithms with an accuracy of 94.68%. Then, with the wearable actuation component, the speech could be expressed as voice signals while circumventing vocal fold vibration. We expect this approach could facilitate the restoration of normal voice function and significantly enhance the quality of life for patients with dysfunctional vocal folds.

Laryngeal Taping as a Supportive Tool to Relieve Phonasthenia in Singers: A Preliminary Report

AIM

This report aims to perform a preliminary evaluation of the role of taping in the improvement of phonasthenia among professional voice users. The larynx is a vital organ but also a work instrument for many people. Prevention of erroneous use of the vocal mechanism is essential for an optimal voice performance.

METHODS

Nineteen singers complaining voice fatigue underwent taping application in peri-laryngeal areas of the anterior neck for 10 days. Taping effects were estimated by the evaluation of voice analysis parameters (jitter, shimmer, noise to harmonic ratio and singing power ratio) performed in M1 and M2 mechanisms with PRAAT software before and after treatment. In addition, a subjective assessment of phonasthenia was performed using a self-administrated questionnaire.

RESULTS

Statistically significant reduction of Jitter% in M1 (P = 0.021) was reported at the end of treatment; also, an improvement of NHR in M2 was found immediately after the application (P = 0.012) and after 10 days (P = 0.002). These outcomes suggest possible beneficial effects of laryngeal taping on relieving voice fatigue, and therefore improving voice quality. Self-assessment results are consistent with this finding.

CONCLUSION

Since the application of muscular taping in phoniatrics is still in its early stage, further studies and in particular a standardized protocol of application, could facilitate the spread of this technique, also offering help in comparing results.

Comparison of the efficacy and adverse effects of unilateral or bilateral botulinum toxin injections for adductor spasmodic dysphonia: a systematic review and meta-analysis

PURPOSE

This study aims to aggregate and analyze existing clinical evidence to compare the efficacy and adverse effects of unilateral or bilateral botulinum toxin injections for the treatment of adductor spasmodic dysphonia (ADSD).

METHODS

Reports from non-randomized controlled trials and cohort studies pertaining to the efficacy and adverse effects of unilateral and bilateral botulinum toxin injections for ADSD were identified and retrieved from four electronic databases from inception to July 2023. The meta-analysis employed fixed or random effects models to assess pooled relative risks (RR), mean differences (MDs), and standard mean differences (SMDs) with their corresponding 95% confidence intervals (CIs).

RESULTS

We included two non-randomized controlled trials and seven cohort studies comprising 854 total patients. Meta-analysis of the included studies showed that bilateral botulinum toxin injections associated with a longer duration of vocal improvement (MD =  - 2.89, 95% CI - 3.13 to - 2.65, I2 = 0%, P < 0.00001). However, bilateral botulinum toxin injections associated with an increase in adverse effects, including a longer duration of breathy voice quality (SMD =  - 0.51, 95% CI - 0.79 to - 0.22, I2 = 35%, P = 0.0005) and a higher occurrence of swallowing difficulties (RR = 0.46, 95% CI 0.35 to 0.11, I2 = 0%, P < 0.00001).

CONCLUSION

Bilateral botulinum toxin injections for ADSD showed a longer duration of vocal improvement, a longer breathy voice duration and a higher dysphagia occurrence and duration than unilateral injections.

Unpacking the black box of voice therapy: A clinical application and revision of the Motor Learning Classification Framework (MLCF)

PURPOSE

Voice therapy is a complex behavioural intervention. Understanding its components is integral for continued advancement of voice therapy research, translation of evidence into the clinical setting and improved client care. The Motor Learning Classification Framework (MLCF) offers an excellent opportunity for increasing such knowledge, specifically in relation to identifying variables that affect motor learning (ML), an important mechanism hypothesised to bring about voice change during voice therapy. The MLCF has shown promising results in identifying speech-language pathologists' (SLPs) use of ML variables during experimentally controlled voice therapy contexts. The purpose of this study was to test the feasibility of applying the framework in the clinical context of everyday voice therapy practice.

METHOD

Data consisted of two video-recorded voice therapy sessions representing usual voice therapy care. Classification of ML variables used by SLPs during the recorded sessions was attempted based on the MLCF.

RESULT

Several problematic features of the framework were identified. Based on deliberations between the authors of the current paper, the MLCF was revised using an iterative process. This resulted in the construction of an updated version of the framework (MLCF-V2). The MLCF-V2 organises ML strategies into two broad categories: directly observable behaviours and learning processes. The framework incorporates greater consideration of theory and empirical evidence supporting motivational, attentional focus and subjective error estimation influences on ML. Several examples of each ML variable are included as well as an attempt to provide clearer classification instruction.

CONCLUSION

It is anticipated that the MLCF-V2 will provide a more useful and reliable classification for use in future investigations of SLPs' use of ML variables during usual voice therapy practice.

Do Adult Naïve Listeners Perceive Differences in Speech Before and After Therapy for Cleft Palate Speech Disorders? A Reliability Study of Perceptual Speech Ratings

PURPOSE

This study compared the interrater reliability of adult naïve listeners' perceptual assessments of different speech variables in children with a cleft palate with or without a cleft lip (CP ± L). In addition, the study investigated whether the listeners were able to perceive differences in these speech variables before and after speech therapy for cleft palate speech disorders.

METHOD

Thirty-four speech samples of 14 children with a CP ± L (14 samples collected immediately before 10 hr of speech intervention, 14 samples collected immediately after speech intervention, and six randomly selected samples that were duplicated to assess intrarater reliability) were perceptually assessed by 26 adult naïve listeners. The listening panel consisted of nine men and 17 women (age range: 18-51 years). The speech variables included speech understandability, speech acceptability, hypernasality, hyponasality, nasal airflow, and articulation, which were assessed on a visual analog scale. Furthermore, the need for speech therapy was assessed.

RESULTS

Good to very good interrater reliability was observed for the naïve listeners' ratings of all speech variables. A significant time effect was found for the pre- and postevolution of the speech variables "speech understandability," "speech acceptability," "nasal airflow," and "articulation." This time effect indicates an improvement of these variables postintervention. According to the naïve listeners, children were less in need of additional speech therapy after the 10-hr intervention period compared to assessments before this intervention period.

CONCLUSIONS

Adult naïve listeners perceptually identified an improvement in different speech variables after 10 hr of cleft palate speech therapy. These findings confirm previous assessments of expert speech-language pathologists and suggest that speech improvements after cleft palate speech therapy can also be perceived by communication partners outside the therapy room. Perceptual ratings of naïve listeners can, thus, be used to add life-situation significance to the assessments of experts. Future research could include both expert raters and caregivers or relatives of children with a CP ± L in listening panels, as previous knowledge on craniofacial anomalies may lead to different results.

The Effects of Classroom Acoustic Conditions on Teachers' Health and Well-Being: A Scoping Review

PURPOSE

Teachers spend a significant amount of time in classrooms, which can be noisy environments. The aim of this scoping review was to determine what is known from the literature about the effect of classroom acoustic conditions on teachers' health and well-being.

METHOD

This scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) protocol. Four bibliographic databases were searched: ERIC, PubMed, Scopus, and Web of Science.

RESULTS

Thirty-three articles were deemed relevant for the review. The most studied health aspect was teachers' vocal health. The majority of results showed higher noise levels or a higher number of students have a negative effect on teachers' health and well-being (61% and 60%, respectively), while 39% showed a negative effect of longer reverberation times. Most other results showed no effect.

CONCLUSIONS

These results show that poor classroom acoustic conditions can have a negative effect on teachers' health and well-being. Therefore, creating classrooms with good acoustic conditions and controlling noise is vital. Limitations are discussed, and future research to better understand the relationship between classroom acoustic conditions and teachers' health and well-being is proposed. This future research will help in understanding the acoustic conditions that are needed to optimize teachers' health and well-being in the classroom.

Can Resident Auditory-Perceptual Voice Assessments Predict Medical Urgency of Voice Disorders?

BACKGROUND/OBJECTIVES

Growing reliance on telemedicine has created new triaging challenges. This study investigated how effectively otolaryngology resident auditory-perceptual voice assessments performed via telemedicine determined the need for urgent in-person clinic visits.

METHODS

Twelve otolaryngology resident physicians (PGY1-PGY5) performed auditory-perceptual assessments on 25 voice samples recorded during initial voice evaluations. Voice samples were balanced in severity and taken in equal numbers from patients with the following diagnoses: benign laryngeal lesions, laryngeal cancer, functional voice disorders, laryngeal edema (associated with LPR), and laryngeal paralysis/paresis. Urgent diagnoses were defined as laryngeal cancer and severe unilateral laryngeal paralysis. For each voice sample, residents were initially blinded to patient medical history. Residents rated severity of voice disorder, predicted patient diagnosis, and determined the urgency of seeing the patient in clinic. Residents then reviewed information from the patient's medical history and again rated urgency of voice disorder.

RESULTS

On average, residents identified urgent voice disorders in 56% of cases. After reviewing medical history, this number significantly increased to 77% (P = 0.001). Voice severity, smoking history, time since onset, and course of symptoms were considered most influential when determining medical urgency of voice patients. Year in residency program had no effect on rating accuracy. As expected, diagnostic accuracy of auditory-perceptual assessments was low, ranging from 40% for laryngeal paralysis/paresis to 5% for laryngeal edema.

CONCLUSION

Auditory-perceptual voice assessment, combined with medical history, predicted most medically urgent voice disorders. Further work should investigate if task-specific training might improve these results and which medical history items are most critical. Until accuracy of auditory-perceptual assessment of medical urgency is improved, these data underscore the importance of laryngeal examination in identifying medical urgency and etiology of dysphonia.

A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021

OBJECTIVE

The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades.

METHODS

This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization.

RESULTS

Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate.

CONCLUSION

Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:247-256, 2024.

Observations and Considerations for Implementing Remote Acoustic Voice Recording and Analysis in Clinical Practice

OBJECTIVES/HYPOTHESIS

Remote voice recording and acoustic analysis allow for comprehensive voice assessment and outcome tracking without the requirements of travel to the clinic, in-person visit, or expensive equipment. This paper delineates the process and considerations for implementing remote voice recording and acoustic analysis in a high-volume university voice clinic.

STUDY DESIGN

Clinical Focus.

METHODS

Acoustic voice recordings were attempted on 108 unique patients over a 6-month period using a remote voice recording phone application. Development of the clinical process including determining normative data in which to compare acoustic results, clinician training, and clinical application is described. The treating Speech Language Pathologists (SLPs) were surveyed 2 months after implementation to assess ease of application, identify challenges and assess implementation of potential solutions.

RESULTS

Of 108 unique patients, 83 patients were successful in completing the process of synchronous remote acoustic voice recording in conjunction with their SLP clinician. The process of downloading the application, setting up, and obtaining voice recordings was most commonly 10-20 minutes according to the 8 SLPs surveyed. Challenges and helpful techniques were identified.

CONCLUSIONS

Remote acoustic voice recordings have allowed SLPs to continue to complete a comprehensive voice evaluation in a telepractice model. Given emerging knowledge about the viability of remote voice recordings, the success in obtaining acoustic data remotely, and the accessibility of a low-cost app for SLPs makes remote voice recordings a viable option to facilitate remote clinical care and research investigation.

Evaluation of quality and readability of internet information on voice disorders

OBJECTIVES

The purpose of this study is to evaluate the readability and quality of Internet information related to vocal health, voice disorders and voice therapy.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Eighty-two websites were included. Websites were then analyzed; their origin (clinic/hospital, non-profit, government), quality (Health On the Net [HON] certification and DISCERN scores) and readability (Ateşman readability formula and Bezirci-Yılmaz new readability formula) were assessed. Statistical analysis was used to examine differences between website origin and quality and readability scores and correlations between readability instruments.

RESULTS

Of the 82 websites, 93% were of private clinic/hospital, 6% were of non-profit organisation and 1% were of government. None of the 82 websites were HON certification, and the mean score of the item determining the general quality measure in DISCERN was 1.83 in a five-point scale. The mean of Ateşman readability formula value was calculated as 50.46 (±8.16). This value is defined as 'moderately hard' according to the readability scale. The average of Bezirci-Yılmaz new readability formula value is 13.85 (±3.48). This value is defined as 13th and 14th grade.

CONCLUSIONS

The quality of Internet-based health information about the voice is generally inadequate, and the sites examined in this study may be limited due to high readability levels. This may be a problem in people with poor literacy skills. For this reason, it is very important for speech and language therapists and other health professionals to evaluate and monitor the quality and readability of Internet-based information.

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.

Knowledge, Attitude and Practices Towards Vocal Health Care Amongst Indian Carnatic Singers

OBJECTIVE

The knowledge, attitudes and practices of Indian Carnatic singers is a dimension that yet to be explored in detail. The aim of the current study was to explore these knowledge, attitudes, and practices amongst Indian Carnatic singers towards vocal health care.

STUDY DESIGN

  Cross-sectional online questionnaire-based study.

METHOD

A cross-sectional online questionnaire-based study design was used to explore the knowledge, attitudes, and practices of Indian Carnatic singers towards vocal health care. The study was conducted in two phases, phase I involved questionnaire development and validation while phase II involved collection of data and further analysis.

RESULTS

One hundred trained self-identified Indian Carnatic singers participated in this study. These singers displayed good knowledge and positive attitudes towards vocal health care. A preference (73%) towards home remedies was noted as compared to seeking medical attention. The measures reported by the singers for maintaining good vocal health revealed use of several home remedies, vocal as well as non-vocal measures.

CONCLUSION

The findings of the present study reveal the knowledge and attitude of Indian Carnatic singers towards vocal health care as well as highlight several interesting practices.

Upper Airway-Related Symptoms According to Mental Illness and Sleep Disorders among Workers Employed by a Large Non-Profit Organization in the Mountain West Region of the United States

The relationships between selected upper airway-related symptoms (speech disturbances, voice disorders, cough, and breathing abnormalities) and mental illness and sleep disorders have been previously demonstrated. However, these relationships have not been compared in a single study with consideration of potential confounding variables. The current research incorporates a descriptive study design of medical claims data for employees (~21,362 per year 2017-2021) with corporate insurance to evaluate the strength of these relationships, adjusting for demographic variables and other important confounders. The upper airway-related symptoms are each significantly and positively associated with several mental illnesses and sleep disorders, after adjusting for demographic and other potential confounders. The rate of any mental illness is 138% (95% CI 93-195%) higher for speech disturbances, 55% (95% CI 28-88%) higher for voice disorders, 28% (95% CI 22-34%) higher for cough, and 58% (95% CI 50-66%) higher for breathing abnormalities, after adjustment for the confounding variables. Confounding had significant effects on the rate ratios involving cough and breathing abnormalities. The rate of any sleep disorder is 78% (95% CI 34-136%) higher for speech disturbances, 52% (95% CI 21-89%) higher for voice disorders, 34% (95% CI 27-41%) higher for cough, and 172% (95% CI 161-184%) higher for breathing abnormalities, after adjustment for the confounding variables. Confounding had significant effects on each of the upper airway-related symptoms. Rates of mental illness and sleep disorders are positively associated with the number of claims filed for each of the upper airway-related symptoms. The comorbid nature of these conditions should guide clinicians in providing more effective treatment plans that ultimately yield the best outcome for patients.

Immediate effects of the incentive spirometer in women with healthy voice

PURPOSE

To evaluate the immediate effect of the incentive spirometer on acoustic measures, aerodynamic measures and on the auditory-perceptual assessment of vocal quality in vocally healthy women.

METHODS

This is an experimental intra-subject comparison study with the participation of 22 women without vocal complaints. Acoustic measures, aerodynamic measures and auditory-perceptual assessment of vocal quality were obtained before and immediately after using the incentive spirometer by the participants. The device was used in the orthostatic position and the participants performed three sets of ten repetitions with a one-minute interval between sets.

RESULTS

After using the incentive spirometer, there was a significant reduction in jitter, shimmer and PPQ (period perturbation quotient) measurements and an increase in maximum expiratory volume, while the other acoustic and aerodynamic measurements were not significantly impacted. In addition, there was improvement in vocal quality in eight (36.4%) participants and 11 (50.0%) participants showed no changes in the auditory perceptual assessment of voice quality after using the incentive spirometer.

CONCLUSION

The use of the incentive spirometer is safe and, in its immediate effect, positively impacts the acoustic measures of short-term aperiodicity of frequency and intensity and increases the maximum expiratory volume in women with healthy voices.

Reducing Vocal Fatigue With Bone Conduction Devices: Comparing Forbrain and Sidetone Amplification

PURPOSE

Altered auditory feedback research aims to identify methods to strengthen speakers' awareness of their own voicing behaviors, diminish their perception of vocal fatigue, and improve their voice production. This study aims to compare the effects of two bone conduction devices that provide altered auditory feedback.

METHOD

Twenty participants (19-33 years old, age: M [SD] = 25.5 [3.85] years) participated in a vocal loading task using a standard Forbrain device that provides filtered auditory feedback via bone conduction and a modified Forbrain device that provides only sidetone amplification, and a control condition with no device was also included. They rated their vocal fatigue on a visual analog scale every 2 min during the vocal loading task. Additionally, pre- and postloading voice samples were analyzed for acoustic voice parameters.

RESULTS

Across all participants, the use of bone conduction-altered auditory feedback devices resulted in a lower vocal fatigue when compared to the condition with no feedback. During the pre- and postvoice samples, the sound pressure level decreased significantly during feedback conditions. During feedback conditions, spectral mean and standard deviation significantly decreased, and spectral skew significantly increased.

CONCLUSION

The results promote bone conduction as a possible preventative tool that may reduce self-reported vocal fatigue and compensatory voice production for healthy individuals without voice disorders.

Detecting Mild Phonotrauma in Daily Life

OBJECTIVE

The aim of this study was to gain quantitative insights into the role of daily voice use associated with mild phonotrauma via the Daily Phonotrauma Index (DPI), a measure derived from neck-surface acceleration magnitude (NSAM) and difference between the first two harmonic magnitudes (H1 - H2).

METHODS

An ambulatory voice monitor recorded weeklong voice use for 151 female patients with phonotraumatic vocal hyperfunction (PVH) and 181 female vocally healthy controls. Three laryngologists rated phonotrauma severity from each patient's laryngoscopy. Mixed generalized linear models evaluated the accuracy, sensitivity, and specificity of the original DPI trained on all patients versus a mild DPI version trained on only patients rated with mild phonotrauma. Individual contribution of NSAM and H1 - H2 to each DPI model was also evaluated.

RESULTS

Reliability across the laryngologists' phonotrauma ratings was moderate (Fleiss κ = 0.41). There were 70, 69, and 12 patients with mild, moderate, and severe phonotrauma, respectively. The mild DPI, compared to the original DPI, correctly classified more patients with mild phonotrauma (Cohen's d = 0.9) and less controls (d = -0.9) and did not change in overall accuracy. H1 - H2 contributed less to mild phonotrauma classification than NSAM for mild DPI.

CONCLUSIONS

Compared with the original DPI, the mild DPI exhibited higher sensitivity to mild phonotrauma and lower specificity to controls, but the same overall classification accuracy. These results support the mild DPI as a promising detector of early phonotrauma and that NSAM may be associated with early phonotrauma, and H1 - H2 may be a biomarker associated with vocal fold vibration in the presence of lesions.

LEVEL OF EVIDENCE

Level 4, case-control study Laryngoscope, 133:3094-3099, 2023.

An Euler-Bernoulli-type beam model of the vocal folds for describing curved and incomplete glottal closure patterns

Incomplete glottal closure is a laryngeal configuration wherein the glottis is not fully obstructed prior to phonation. It has been linked to inefficient voice production and voice disorders. Various incomplete glottal closure patterns can arise and the mechanisms driving them are not well understood. In this work, we introduce an Euler-Bernoulli composite beam vocal fold (VF) model that produces qualitatively similar incomplete glottal closure patterns as those observed in experimental and high-fidelity numerical studies, thus offering insights into the potential underlying physical mechanisms. Refined physiological insights are pursued by incorporating the beam model into a VF posturing model that embeds the five intrinsic laryngeal muscles. Analysis of the combined model shows that co-activating the lateral cricoarytenoid (LCA) and interarytenoid (IA) muscles without activating the thyroarytenoid (TA) muscle results in a bowed (convex) VF geometry with closure at the posterior margin only; this is primarily attributed to the reactive moments at the anterior VF margin. This bowed pattern can also arise during VF compression (due to extrinsic laryngeal muscle activation for example), wherein the internal moment induced passively by the TA muscle tissue is the predominant mechanism. On the other hand, activating the TA muscle without incorporating other adductory muscles results in anterior and mid-membranous glottal closure, a concave VF geometry, and a posterior glottal opening driven by internal moments induced by TA muscle activation. In the case of initial full glottal closure, the posterior cricoarytenoid (PCA) muscle activation cancels the adductory effects of the LCA and IA muscles, resulting in a concave VF geometry and posterior glottal opening. Furthermore, certain maneuvers involving co-activation of all adductory muscles result in an hourglass glottal shape due to a reactive moment at the anterior VF margin and moderate internal moment induced by TA muscle activation. These findings have implications regarding potential laryngeal maneuvers in patients with voice disorders involving imbalances or excessive tension in the laryngeal muscles such as muscle tension dysphonia.

The effects of vocal tract constrictions on aerodynamic measures in a synthetic vocal fold model

According to nonlinear source-filter theory, as the strength of the coupling between the source and filter increases, typically by a decrease in the vocal tract cross-sectional area, the resultant increase in the inertance of the vocal tract yields an increase in the interactions between acoustic pressures within the vocal tract and the changing glottal airflow and/or the vibratory pattern of the vocal folds as noted in Titze [(2008). J. Acoust. Soc. Am. 123(4), 1902-1915]. The purpose of the current research was to examine the effects of parametric vocal tract constrictions mimicking epilaryngeal tube and lip narrowing on aerodynamic measures in a dynamic self-oscillating physical model of the vocal folds and vocal tract. Multilayered silicone vocal fold models were created based on Murray and Thomson [(2011). J. Visualized Exp. 58, e3498] and Murray and Thomson [(2012). J. Acoust. Soc. Am. 132(5), 3428-3438] and mounted to a simple synthetic trachea and supraglottal vocal tract model. Four constriction cross-sectional areas were examined at two locations (i.e., at the epilarynx and lip regions). Phonation threshold pressure and flow were measured at phonation onset and offset using four M5-CONV vocal fold models. Results indicated that both constriction magnitude and location are relevant factors in determining glottal aerodynamics. In general, a narrow epilarynx tube or lip constriction resulted in the lowest onset pressures and airflows while the no vocal tract condition resulted in the highest onset pressures and airflows.

Are Children with Cleft Palate at Increased Risk for Laryngeal Pathology?

To determine the prevalence of laryngeal pathology in children presenting with cleft palate with or without cleft lip (CP ± L) who underwent nasoendoscopy to assess palatal function. A secondary aim was to determine the relationship between patient demographics, resonance, articulation, and prevalence of laryngeal pathology in this population.

Retrospective, observational cohort study.

Outpatient pediatric cranio-facial anomalies clinic.

Children ≤18 years of age presenting with CP ± L (N = 215) who underwent nasoendoscopy, speech language pathology, plastic surgery, and otolaryngological evaluations between 2009 and 2020.

Laryngeal diagnosis by pediatric otolaryngologists.

21.9% of children presented with laryngeal pathology. Diagnoses included benign vocal fold lesions and laryngeal edema sufficiently severe to alter vocal fold edge contour. Likelihood of laryngeal pathology increased by approximately 12% with every increase of 1 year in age (P = .001, OR = 1.12). Children with laryngeal pathology were 50% more likely to have undergone palatal repair (P < .001, OR = 1.50). In addition, children with severely hypernasal resonance were 78% less likely to present with laryngeal pathology (P =.046, OR = 0.22).

This population is at increased risk for laryngeal pathologies as determined by nasoendoscopy. This finding underscores the importance of careful laryngeal imaging in assessing these children. Additional research is warranted to identify the mechanisms underlying the increased risk for morphological vocal fold changes.

Nasal Breathing Through a Damp Gauze Enhances Surface Hydration of the Vocal Folds and Optimizes Vocal Function

OBJECTIVE

The present study proposes a direct surface hydration system based on nasal breathing through a damp gauze. The goal is to observe whether such direct hydration procedure positively modifies vocal fold functionality by improving voice quality and enhancing the mobility and pliability of the vocal fold mucosa.

METHODS

Sixty-one young adults without voice problems were enrolled and were randomly divided into three double-blinded treatment groups. In the first group (the gauze group), participants breathed through the nose wrapped in a damp gauze for 10 minutes while doing vocal warm-up exercises to facilitate water penetration into the mucosal layers of the vocal folds. The second group (the exercise group) performed the same warm-up exercises as the gauze group for 10 minutes without hydration procedures. The third group (the control group) talked using their normal speaking voice for 10 minutes. The participants were evaluated before and after the treatment tasks with three tests: a laryngostroboscopic examination (ie, the glottic closure, the amplitude of the mucosal wave, and the maximum opening of the glottic space); voice acoustic analysis (multidimensional voice program); and a perceptual voice evaluation (GRBAS scale).

RESULTS

Results showed that after the use of a damp gauze, glottic closure, the amplitude of the mucosal wave, the maximum opening of the glottic space, the shimmer, and the B of GRBAS all improved.

CONCLUSION

Findings showed significantly better vocal results for the participants of the gauze group, suggesting the damp gauze procedure to be an effective, fast, and economical procedure to improve and optimize vocal fold functionality. It can be hypothesized that the obtained results are related to an improvement in vocal folds surface hydration and viscoelasticity.

Corticosteroid-LABA inhalers increase phonation threshold pressure (PTP) and flow (PTF) in rabbits

OBJECTIVES

This study examined the effects of a combination corticosteroid plus long-acting beta2 -adrenergic agonist inhaler (IC) on rabbit phonation.

METHODS

White New Zealand male rabbits were assigned randomly to experimental and control groups (n = 11 per group). The experimental group received twice-daily doses of Advair HFA™ (fluticasone propionate 45 mcg and salmeterol 21 mcg) via a veterinary facemask with 1-way valve and spacer; the control group received aerosolized saline. After 8 weeks, animals were euthanized, larynges excised, frozen, and subsequently thawed and mounted on a standard bench apparatus. Phonation was elicited during 15 successive trials, and phonation threshold pressure (PTP; cmH2 O) and flow (PTF; L/min) were quantified.

RESULTS

Repeated measures analysis of variance indicated significant differences between the experimental and control groups (p < 0.05). Mean PTP and PTF values were higher (worse) for rabbits that received Advair HFA™.

CONCLUSION

Following 8-week exposure to ICs, rabbit larynges required greater air pressure and flow to initiate phonation. Because even modest phonation onset differences can have a meaningful clinical impact on voice function, these findings suggest that LABA ICs may put patients at risk for voice disorders. Furthermore, these voice disorders may occur within a relatively short timeframe. The results from this study have important clinical implications for voice care in those who use ICs.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2680-2686, 2023.

Study on relationship between self-recognition of voice disorder and mental health status: Korea National Health and Nutrition Examination Survey

BACKGROUND

The voice has been thought to be associated with emotions, but conducting large-scale research on this relationship has some limitations. To overcome these limitations, questionnaires have been utilized as a research tool.

METHODS

A population-based cross-sectional study was done. A total of 15,977 participants completed questionnaires regarding self-recognition of voice disorder (SRVD), and mental health status.

RESULTS

1053(6.6 %) participants answered that they had SRVD. In the multivariate Cox proportional hazard model, psychological stress (Hazard ratio (HR) = 1.371, 95 % confidence interval (CI) = 1.154-1.629), depressive symptoms (HR = 1.626, 95 % CI = 1.323-1.997), suicidal ideation (HR = 1.739, 95 % CI = 1.418-2.133), and suicide attempt (HR =2.206, 95 % CI = 1.067-4.56) were all associated with SRVD. In SRVD lasting over three weeks, psychological stress (HR = 1.604, 95 % CI = 1.278-2.014), depressive symptoms (HR = 1.807, 95 % CI = 1.384-2.36), and suicidal ideation (HR = 2.073, 95 % CI = 1.587-2.709) were also significant factors. As the number of mental health problems increased, the odds ratio of both SRVD (OR = 2.49, 95 % CI = 1.839-3.37) and SRVD lasting over three weeks (OR = 3.254, 95 % CI = 2.242-4.725) increased, respectively.

LIMITATIONS

SRVD and mental health status were judged only by simple questionnaires. Cross-sectional design and retrospective data could not draw causal relationships.

CONCLUSIONS

SRVD and SRVD lasting over three weeks had a significant relationship with mental health status, including psychological stress, depressive symptoms, and suicidal ideation. There is a need to consider psychiatric treatment for individuals who visit hospitals with voice disorders.

The influence of source-filter interaction on the voice source in a three-dimensional computational model of voice production

The goal of this computational study is to quantify global effects of vocal tract constriction at various locations (false vocal folds, aryepiglottic folds, pharynx, oral cavity, and lips) on the voice source across a large range of vocal fold conditions. The results showed that while inclusion of a uniform vocal tract had notable effects on the voice source, further constricting the vocal tract only had small effects except for conditions of extreme constriction, at which constrictions at any location along the vocal tract decreased the mean and peak-to-peak amplitude of the glottal flow waveform. Although narrowing in the epilarynx increased the normalized maximum flow declination rate, vocal tract constriction in general slightly reduced the source strength and high-frequency harmonic production at the glottis, except for a limited set of vocal fold conditions (e.g., soft, long vocal folds subject to relatively high pressure). This suggests that simultaneous laryngeal and vocal tract adjustments are required to maximize source-filter interaction. While vocal tract adjustments are often assumed to improve voice production, our results indicate that such improvements are mainly due to changes in vocal tract acoustic response rather than improved voice production at the glottis.

Effect of perceptive-auditory training on the classification of speech hypernasality

PURPOSE

To analyze the effect of auditory-perceptual training by inexperienced speech-language pathologists in the classification of hypernasality in individuals with cleft lip and palate and compare their classification of hypernasality individually, with the gold standard evaluation, before and after this training.

METHODS

Three inexperienced speech-language pathologists used a four-point scale to assess 24 high-pressure speech samples from individuals with cleft lip and palate, before and after auditory-perceptual training. The speech samples corresponded to six samples of each degree of hypernasality. The speech-language pathologists received auditory-perceptual training during the assessments. They had access to anchor samples and immediate feedback of correct answers regarding the degree of hypernasality in training.

RESULTS

There was no significant difference in the overall percentage of correct answers when comparing before and after the auditory-perceptual training. There was a significant association and agreement of the three evaluators with a gold standard evaluation after training, with an increase in agreement for a single evaluator for absent and mild degrees of hypernasality. The dichotomous analysis of the data showed an increase in the Kappa Index of Agreement of this evaluator. Although there was an increase in the Index of Agreement between evaluators for absent, mild, and severe hypernasality, this increase did not reach statistical significance.

CONCLUSION

The auditory-perceptual training provided did not result in a significant improvement in the hypernasality classification for the inexperienced speech-language pathologists, even though the individual data analysis showed that the training favored one of the evaluators. Further studies involving gradual and more extensive auditory-perceptual training may favor the classification of hypernasality by inexperienced SLPs.

Pediatric Voice Handicap Index (pVHI): Validation in European Portuguese Children

OBJECTIVES

To determine reliability and validity of the European Portuguese pVHI version (pVHI-EP).

STUDY DESIGN

Cross-sectional design.

METHODS

The pVHI-EP and the talkative and global voice assessment scales were administered to the caregivers of children aged from 3 to 16 years old with and without dysphonia. Reliability (internal consistency and test-retest) was analyzed. The validity analyses performed were: (1) content validity by analyzing the percentage of missing data; (2) construct validity with intraclass correlation coefficients among pVHI-EP domains and overall score; (3) concurrent validity was conducted between pVHI-EP, the caregivers' judgment of the child's voice severity on a visual analog scale and the Speech-Language Pathologist perceptual voice assessment; (4) known-groups validity between children with and without dysphonia, and (5) predictive validity by calculating receiver operating characteristics, sensitivity and specificity and determining cut-off points.

RESULTS

A total of 283 children (61.5% boys, mean age 8.3 years) participated in the study. The pVHI-EP showed an excellent internal consistency for the pVHI-EP total data. Strong to moderate test-retest reliability confirms pVHI-EP reproducibility. Excellent to good intraclass correlation coefficients between the pVHI-EP overall and the domains confirms its construct validity. Weak to moderate concurrent validity with visual analog scale and Speech-Language Pathologist perceptual voice assessment was confirmed. The pVHI-EP significantly distinguished two groups of different voice conditions. A cut-off point of 10.5 with 95.9% sensitivity and 92.5% specificity was determined for the overall score of the pVHI-EP.

CONCLUSIONS

The pVHI-EP is a reliable and valid caregiver voice outcome tool for EP children with dysphonia.

Systematic Review of Literature on Vocal Demand Response: Understanding Physiology, Measurements, and Associated Factors

PURPOSE

Considering the conceptual migration from vocal load and vocal loading to vocal demand and vocal demand response, this review of literature aimed to identify physiological explanations, reported measurements, and associated factors (vocal demands) reported in the literature when considering the phonatory response to a vocal demand.

METHODS

A systematic review of literature, following the PRISMA Statement, was conducted using Web of Science, PubMed, Scopus, and ScienceDirect. Data were analyzed and presented in two parts. First, a bibliometric analysis, co-occurrence analysis, and content analysis were performed. Three criteria that got article inclusion were defined: (1) written in English, Spanish, and Portuguese; (2) published between 2009 and 2021; and (3) focused on vocal load and loading, vocal demand response, and voice assessment parameters. A total of 54 publications met the criteria and were included in this review. The second part included a conceptual framework based on the content analysis of three aspects of vocal demand response: (1) physiological explanations, (2) reported measurements, and (3) vocal demands.

RESULTS AND CONCLUSION

As would be expected since vocal demand response is a relatively new term and not yet commonly used in literature when discussing way that the speakers respond to communicative scenarios, most of the studies reviewed (both historical and recent) still use the term of vocal load and vocal loading. Although there is a broad variety of literature discussing a wide range of vocal demands and voice parameters used to characterize the vocal demand response, results show that there is consistency across the studies. While vocal demand response is unique and intrinsic to the talker, associated factors that contribute to this response include both internal talker and external talker factors. Internal factors include muscle stiffness, viscosity in the phonatory system, vocal fold tissue damage, elevated sound pressure levels during occupational voice demands, extended periods of voice use, suboptimal body posture, difficulties in breathing technique, and sleep disturbances. Associated external factors include the working environment (noise, acoustics, temperature, humidity). In conclusion, although vocal demand response is intrinsic to the speaker, the speaker's response is affected by external vocal demands. However, due to the wide methods to evaluate vocal demand response, it has been difficult to establish its contribution to voice disorders in the general population and, specifically, among occupational voice users. This literature review identified commonly reported parameters and factors that may help clinicians and researchers define vocal demand response.

Mapping of the characteristics in the CoDAS journal publications in the voice area: a scoping review

PURPOSE

To map and describe the characteristics present in the publications of the CoDAS journal in the voice segment.

RESEARCH STRATEGIES

The research was carried on the Scielo database using the descriptor voice.

SELECTION CRITERIA

CoDAS publications in the field of voice.

DATA ANALYSIS

Specific data collected according to delineation, summarized by descriptive analysis and analyzed in narrative format.

RESULTS

Studies published in 2019 and with cross-sectional delineation were more frequent. The most frequent result in the cross-sectional studies was the vocal self-assessment. Most intervention studies were of immediate single-session-only effect. The most frequent procedures in the validation studies were translation and transcultural adaptation.

CONCLUSION

There was a gradual increase in the number of publications of voice studies, though these had heterogeneous characteristics.

Association of Visit Volume and Sociodemographic Characteristics With Vocal Improvement Among Older US Adults With a Self-reported Voice Problem

This cross-sectional study evaluates the association of sociodemographic characteristics and care utilization with improved voice function among a large sample of older US adults.

Identifying Clinical Behaviors Using the Motor Learning Classification Framework: A Pilot Study

CONTEXT

Although differences in clinical interactions with patients between students and experienced clinicians are well described, differences in therapeutic training behaviors have not been explored, especially in relation to motor learning principles.

AIMS

This pilot study compared clinical behaviors between speech language pathology (SLP) students and experienced SLPs in a voice therapy task, using prepractice variables in the Motor Learning Classification Framework (MLCF).

METHODS

Using a quasi-experimental design, five final-year undergraduate SLP students and four experienced SLPs with a voice therapy caseload taught a standardized patient to produce a vocal siren. Two trained raters categorized the clinicians' behaviors using the MLCF.

RESULTS

High intrarater reliability (91.9%, 92.3%) and interrater reliability (89.6%, 82.1%) were shown across both raters. Both clinician groups used the same percentage of behaviors classified as verbal information but differed in the subtypes of these behaviors. Experienced clinicians used behaviors categorized as problem-solving and only experienced clinicians used repeated behavior sequences that included perceptual training. Both groups used significantly more talking behaviors than doing behaviors.

CONCLUSIONS

The MLCF can be reliably used to identify prepractice behaviors during client interactions in voice therapy. Students and experienced clinicians showed similarities in behaviors, but experienced clinicians used more problem solving and perceptual training behaviors than students. These differences have implications for student training. The greater use of talking behaviors than doing behaviors warrants further investigation into whether this impacts the subsequent quality of practice engaged by the client and ultimately treatment effectiveness.

Effects of intensive speech treatment on Mandarin speakers with Parkinson's Disease: A review

BACKGROUND

Benefits of intensive speech treatment have been documented for a range of speech signs in English speakers with Parkinson's Disease (PD). However, the answer to a critical question that whether the same treatment benefits speech variables including intelligibility in Mandarin speakers is still unclear. In order to develop a targeted speech treatment for Mandarin speakers with PD, we reviewed the efficacy of intensive speech treatment to improve vocal loudness and functional communication and discuss possible explanations for efficacy on Mandarin speakers with PD.

METHODS

Literatures about intensive speech treatment for Mandarin speakers with PD were retrieved from PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), Wanfang and Weipu Database for Chinese Technical Periodicals (VIP) Database. Search strategy was (voice therapy OR speech therapy OR voice treatment OR speech treatment OR voice training OR speech training OR voice rehabilitation OR speech rehabilitation OR Lee Silverman voice treatment OR intensive speech treatment) and (Parkinson's disease) and (Mandarin speakers OR Chinese OR Chinese people).

RESULTS

Five randomized controlled trials were selected and possible explanations for efficacy on individuals with PD are discussed. Further research directions are suggested.

CONCLUSION

The existing evidence from treatment efficacy studies of intensive speech treatment provides support for improving vocal loudness, speech intelligibility, pitch and rate in Mandarin speakers with PD. Our future research will continue to work to conduct a large sample multicenter randomized controlled trial to provide high quality evidence and understand the basic mechanisms accompanying treatment-related change.

Social Vulnerability of Brazilian Metropolitan Schools and Teachers' Absence from Work Due to Vocal and Psychological Symptoms: A Multilevel Analysis

Teachers' voices and psychological symptoms are the main reasons for absence from work. The objectives of this study were: (i) to spatially represent, through a webGIS, the standardized rates of teachers' absences due to voice (outcome 1) and psychological symptoms (outcome 2) in each Brazilian Federative Unit (FU = 26 states plus Federal District) and (ii) to analyze the relationship between each national outcome rate and the Social Vulnerability Index (SVI) of the municipality where urban schools are located, adjusted for sex, age, and working conditions. This cross-sectional study comprised 4979 randomly sampled teachers working in basic education urban schools, of which 83.3% are women. The national absence rates were 17.25% for voice symptoms and 14.93% for psychological symptoms. The rates, SVI, and school locations in the 27 FUs are dynamically visualized in webGIS. The multilevel multivariate logistic regression model showed a positive association between voice outcome and high/very high SVI (OR = 1.05 [1.03; 1.07]), whereas psychological symptoms were negatively associated with high/very high SVI (OR = 0.86 [0.85 0.88]) and positively associated with intermediate SVI (OR = 1.15 [1.13; 1.16]), in contrast with low/very low SVI. Being a woman (voice: OR = 1.36 [1.35; 1.38]; psychological: 1.22 [1.21; 1.24]) and working in schools with various precarious conditions (17 variables) increased the odds of being absent due to voice and psychological symptoms. The results confirm the need for investments to improve working conditions in schools.

Longitudinal Vocal Outcomes and Voice-Related Quality of Life After Selective Bilateral Laryngeal Reinnervation: A Case Study

PURPOSE

Bilateral vocal fold paralysis (BVFP) is a severe disorder that can result in respiratory, swallowing, and voice-related problems. Most surgical treatments do not restore laryngeal function and often need to compromise voice quality to preserve respiratory function. Laryngeal reinnervation (LR) may offer a solution to this problem, but literature on longitudinal outcomes of this procedure is scarce. This study aims to report the longitudinal vocal outcomes of BVFP after LR and subsequent voice therapy.

METHOD

The case of a 23-year-old man with BVFP after a traumatic dissection of both recurrent laryngeal nerves is described. Selective bilateral LR of both adductors and abductors was performed 5 months after the onset of BVFP. Voice therapy was provided after the LR procedure. Multidimensional voice assessments, including acoustic, perceptual, and patient-reported outcome measures (PROMs), were conducted 2, 5, 6.5, 8, and 31 months after LR.

RESULTS

An improvement of vocal capabilities and voice quality was noticed 6.5 months after LR, after 4.5 months of voice therapy, with normative values after 2.5 years. PROMs showed an improvement of voice-related quality of life, but some limitations to activities of daily living were still present. Inspiratory arytenoid abduction was not observed on laryngeal videostroboscopic findings in this patient, but tracheostomy was not required.

CONCLUSIONS

Voice therapy after LR helps establish healthy and efficient voice use without increasing compensatory hyperfunctional behavior. More research is needed to examine potential merits of voice therapy in the rehabilitation of vocal and respiratory functions after LR.

Fatigue-Related Change in Surface Electromyographic Activities of the Perilaryngeal Muscles

PURPOSE

This study set out to quantify the fatigue-related changes in surface electromyographic (sEMG) activities of the perilaryngeal muscles following a vocal loading task.

METHOD

Thirty-six young healthy participants (M _age = 22.4 years) with normal voice performed karaoke singing for at least 100 min. Before the singing task, all participants underwent the sEMG measure and completed a Perceived Vocal Fatigue Score (P-VFS) questionnaire. After the singing task, all participants were immediately measured with the P-VFS again. Half of the participants were then measured for their sEMG immediately after their karaoke singing task, and the other half were given 20 min of rest before undertaking the sEMG measure. The P-VFS and the median frequency (MDF) of the sEMG signals collected from the suprahyoid, infrahyoid, and sternocleidomastoid muscles before and after the singing task were compared using a linear mixed-effects model.

RESULTS

All participants reported a perceived vocal fatigue after singing, with a significantly increased P-VFS. Compared with the presinging baseline, the MDF of the sEMG signals in perilaryngeal muscles was significantly lower immediately after the singing task. Such a significant difference was also found after 20 min following the singing task.

CONCLUSIONS

The MDF analysis of the sEMG signals could identify and quantify the performance vocal fatigue contributed by perilaryngeal muscles following a vocal loading task. The findings also showed that such fatigue in perilaryngeal muscles, as far as sEMG activities are concerned, can last for at least 20 min.

[Voice disorders associated with novel coronavirus infection]

OBJECTIVE

To evaluate the features of voice disorders associated with novel coronavirus infection and to develop the clinical algorithm for diagnostic and treatment these patients.

MATERIAL AND METHODS

A prospective observational study was conducted in patients with dysphonia after COVID-19 (n=60). All patients underwent a comprehensive voice assessment before and after the proposed treatment. The follow-up period was 1 month.

RESULTS

Functional dysphonia or aphonia with a stable (refractory) or recurrent course was diagnosed in 58 (97%) patients. A tendency to an increase in the value of the latent period of the P300 and MMN in patients with voice disorder was revealed. There was a significant decrease in supraglottic constriction and glottal insufficiency before and after the treatment. The mean VHI-10 decreased from 25.4 before treatment to 15.3 after treatment. The DSI which is based on the set of voice measurements, statistically significant improved from -5.2 to 2.6 in patients as a result of treatment. The average value of MFI-20 improved from 65.4 (8.7) at the beginning of the study to 20.3 (5.3) after treatment.

CONCLUSION

In patients with dysphonia or aphonia associated with COVID-19 are indicated a refractory type of dysphonia. This was indicated by the study of AEPs of the brain. The clinical algorithm for treatment and diagnostic patients with voice disorders after COVID-19 has been developed. The treatment of this group of patients should be adjunct by the drug therapy, kinesiotaping method and psychotherapy.

Detection of Major Depressive Disorder Based on a Combination of Voice Features: An Exploratory Approach

In general, it is common knowledge that people's feelings are reflected in their voice and facial expressions. This research work focuses on developing techniques for diagnosing depression based on acoustic properties of the voice. In this study, we developed a composite index of vocal acoustic properties that can be used for depression detection. Voice recordings were collected from patients undergoing outpatient treatment for major depressive disorder at a hospital or clinic following a physician's diagnosis. Numerous features were extracted from the collected audio data using openSMILE software. Furthermore, qualitatively similar features were combined using principal component analysis. The resulting components were incorporated as parameters in a logistic regression based classifier, which achieved a diagnostic accuracy of ~90% on the training set and ~80% on the test set. Lastly, the proposed metric could serve as a new measure for evaluation of major depressive disorder.

Predictions for Three-Month Postoperative Vocal Recovery after Thyroid Surgery from Spectrograms with Deep Neural Network

Despite the lack of findings in laryngeal endoscopy, it is common for patients to undergo vocal problems after thyroid surgery. This study aimed to predict the recovery of the patient's voice after 3 months from preoperative and postoperative voice spectrograms. We retrospectively collected voice and the GRBAS score from 114 patients undergoing surgery with thyroid cancer. The data for each patient were taken from three points in time: preoperative, and 2 weeks and 3 months postoperative. Using the pretrained model to predict GRBAS as the backbone, the preoperative and 2-weeks-postoperative voice spectrogram were trained for the EfficientNet architecture deep-learning model with long short-term memory (LSTM) to predict the voice at 3 months postoperation. The correlation analysis of the predicted results for the grade, breathiness, and asthenia scores were 0.741, 0.766, and 0.433, respectively. Based on the scaled prediction results, the area under the receiver operating characteristic curve for the binarized grade, breathiness, and asthenia were 0.894, 0.918, and 0.735, respectively. In the follow-up test results for 12 patients after 6 months, the average of the AUC values for the five scores was 0.822. This study showed the feasibility of predicting vocal recovery after 3 months using the spectrogram. We expect this model could be used to relieve patients' psychological anxiety and encourage them to actively participate in speech rehabilitation.

Perspectives and Experiences of College-Aged Singers Regarding Voice Injury and Visiting the ENT: A Phenomenological Approach

Among singers, stigma surrounding voice injury can affect self-esteem, self-efficacy, and self-worth and can lead to hesitancy to disclose vocal injuries for fear of damaging their career. In addition, stressors in the singer-physician relationship can work against positive interactions with physicians. To date, no study has documented the perspectives of singers about voice injury and their interactions with physicians through a qualitative approach. The purpose of this study was to a) examine the perspectives and experiences of college-aged singers regarding voice injury and visiting an ear, nose, and throat physician (ENT), and b) identify behaviors of singers and ENT physicians that establish a functional and healthy relationship with the other. Following an interpretive phenomenological design, 6 collegiate singers were interviewed using a semi-structured guide, and from the results of these interviews three emergent themes were generated: a) the emotional connection of a singer and their voice, b) the presence of stigma surrounding voice injury, and c) the barriers to effective relationships between a singer and an ENT physician.

The effects of a simulated fMRI environment on voice intensity in individuals with Parkinson's disease hypophonia and older healthy adults

PURPOSE

Functional magnetic resonance imaging (fMRI) has promise for understanding neural mechanisms of neurogenic speech and voice disorders. However, performing vocal tasks within the fMRI environment may not always be analogous to performance outside of the scanner. Using a mock MRI scanner, this study examines the effects of a simulated scanning environment on vowel intensity in individuals with Parkinson's disease (PD) and hypophonia and older healthy control (OHC) participants.

METHOD

Thirty participants (15 PD, 15 OHC) performed a sustained /ɑ/ vowel production task in three conditions: 1) Upright, 2) Mock Scanner + No Noise, and 3) Mock Scanner + MRI noise. We used a linear mixed-effects (multi-level) model to evaluate the contributions of group and recording environment to vowel intensity. A second linear mixed-effects model was also used to evaluate the contributions of PD medication state (On vs. Off) to voice intensity.

RESULTS

Vowel intensity was significantly lower for PD compared to the OHC group. The intensity of vowels produced in the Upright condition was significantly lower compared to the Mock Scanner + No Noise condition, while vowel intensity in the Mock Scanner + MRI Noise condition was significantly higher compared to the Mock Scanner + No Noise condition. A group by condition interaction also indicated that the addition of scanner noise had a greater impact on the PD group. A second analysis conducted within the PD group showed no effects of medication state on vowel intensity.

CONCLUSION

Our findings demonstrate that performance on voice production tasks is altered for PD and OHC groups when translated into the fMRI environment, even in the absence of acoustic scanner noise. For fMRI studies of voice in PD hypophonia, careful thought should be given to how the presence of acoustic noise may differentially affect PD and OHC, for both group and task comparisons.

A Deep Learning Algorithm for Objective Assessment of Hypernasality in Children With Cleft Palate

OBJECTIVES

Evaluation of hypernasality requires extensive perceptual training by clinicians and extending this training on a large scale internationally is untenable; this compounds the health disparities that already exist among children with cleft. In this work, we present the objective hypernasality measure (OHM), a speech-based algorithm that automatically measures hypernasality in speech, and validate it relative to a group of trained clinicians.

METHODS

We trained a deep neural network (DNN) on approximately 100 hours of a publicly-available healthy speech corpus to detect the presence of nasal acoustic cues generated through the production of nasal consonants and nasalized phonemes in speech. Importantly, this model does not require any clinical data for training. The posterior probabilities of the deep learning model were aggregated at the sentence and speaker-levels to compute the OHM.

RESULTS

The results showed that the OHM was significantly correlated with perceptual hypernasality ratings from the Americleft database (r = 0.797, p < 0.001) and the New Mexico Cleft Palate Center (NMCPC) database (r = 0.713, p < 0.001). In addition, we evaluated the relationship between the OHM and articulation errors; the sensitivity of the OHM in detecting the presence of very mild hypernasality; and established the internal reliability of the metric. Further, the performance of the OHM was compared with a DNN regression algorithm directly trained on the hypernasal speech samples.

SIGNIFICANCE

The results indicate that the OHM is able to measure the severity of hypernasality on par with Americleft-trained clinicians on thisdataset.

A simple qualitative scale for diagnosis of laryngopharyngeal reflux: high correlations with pH measurements and disease severity. The usefulness of the Warsaw Scale in LPR diagnostics compared to other diagnostic tools

Purpose

Diagnosis and monitoring of laryngopharyngeal reflux (LPR) is a constant challenge in otolaryngological practice, chiefly because there are no specific symptoms characteristic of the disease. In this paper, we present the validation of a simple, 6-level qualitative scale to gauge the clinical findings of LPR. It has been previously published in Polish as the Warsaw Scale.

Methods

In the study, we enrolled 100 patients with voice problems who had registered in our clinic, and we performed an extended battery of diagnostic tests for LPR, together with 24-h pH monitoring.

Results

The Warsaw Scale significantly outperformed other instruments in both predicting LPR status and correlating with pH measurements. Moreover, the rating provided by the scale showed a strong association with patient-reported symptoms.

Conclusion

The data indicate that the Warsaw Scale could be used as an affordable, consistent, and effective diagnostic and monitoring tool for LPR.

Neck complaints before and after uncomplicated thyroidectomy: prevalence, postoperative outcome and relationships with thyroid weight and reflux like symptoms

PURPOSE

The surgical thyroid disease includes upper aerodigestive complaints with not homogenous prevalence and specific features. The purpose was to analyze before and after total thyroidectomy (TT) the prevalence and severity of voice, swallowing, respiratory, and reflux airway symptoms in relation with thyroid weight.

METHODS

A total of 98 consenting patients undergoing TT were enrolled. Preoperatively, 1 and 3 months after TT, patients underwent videolaryngoscopy, subjective evaluation of voice (VIS), swallowing (SIS and EAT-10), respiratory (mMRC), and reflux symptoms (RSI, Gerd-Q). The scores were analyzed based on thyroid weight (<25 gr, 26-50 gr, 51-75 gr, >75 gr) and post-operative score gain was calculated from the score before TT and the follow-up examination.

RESULTS

In total, 40/98 selected cases of uncomplicated TT completed the postoperative evaluation. Endoscopic signs suggestive of reflux disease were observed in 1/40 (2.5%) and 0/19 cases before and after TT respectively. The prevalence of cases with abnormal reflux symptom index decreased significantly after surgery (8/40 vs 1/40) (p < 0.05), similarly occurred for the Gerd-Q (4/40 vs 1/40) (p < 0.05). Three months after TT the voice, swallowing and respiratory scores were significantly lower than the preoperative ones (p < 0.05). The SIS correlated positively with EAT-10 and RSI. After 3 months the postoperative score gain of voice, swallowing, respiratory, and reflux symptoms (Gerd-Q) was statistically higher (p < 0.05) in the cases with heaviest gland.

CONCLUSIONS

The surgical thyroid disease is associated to mild aerodigestive preoperative compressive symptoms, that include respiratory abnormalities and reflux like symptoms, regardless of the gland weight. In absence of endoscopic signs of airway reflux the presence of reflux symptoms suggests an overlapping with thyroid neck complaints. The patients undergoing uncomplicated TT had improvement in compressive symptoms and the greatest improvement is seen in larger goiters.

Computational simulations of respiratory-laryngeal interactions and their effects on lung volume termination during phonation: Considerations for hyperfunctional voice disorders

Glottal resistance plays an important role in airflow conservation, especially in the context of high vocal demands. However, it remains unclear if laryngeal strategies most effective in controlling airflow during phonation are consistent with clinical manifestations of vocal hyperfunction. This study used a previously validated three-dimensional computational model of the vocal folds coupled with a respiratory model to investigate which laryngeal strategies were the best predictors of lung volume termination (LVT) and how these strategies' effects were modulated by respiratory parameters. Results indicated that the initial glottal angle and vertical thickness of the vocal folds were the best predictors of LVT regardless of subglottal pressure, lung volume initiation, and breath group duration. The effect of vertical thickness on LVT increased with the subglottal pressure-highlighting the importance of monitoring loudness during voice therapy to avoid laryngeal compensation-and decreased with increasing vocal fold stiffness. A positive initial glottal angle required an increase in vertical thickness to complete a target utterance, especially when the respiratory system was taxed. Overall, findings support the hypothesis that laryngeal strategies consistent with hyperfunctional voice disorders are effective in increasing LVT, and that conservation of airflow and respiratory effort may represent underlying mechanisms in those disorders.

A Mandarin Chinese Reading Passage for Eliciting Significant Vocal Range Variations

Purpose There is a lack of standardized Mandarin reading text material that could potentially elicit significant variations in fundamental frequency (F0) and in vocal intensity for clinical voice evaluation. In this study, a phonetically balanced "Three Bears Passage" was developed based on the classical "Goldilocks" story for this purpose. The hypothesis was that the vocal range (F0 range and Intensity range) elicited while reading aloud the passage could be similar to that of the voice range profile (VRP) obtained with sustained vowel production and significantly different from that while reading an existing standard Mandarin passage. Method One hundred twenty young adults (60 men and 60 women, aged 25.22 ± 3.74 years) without vocal pathologies and vocal training participated in the study. Vocal range data, including F0-related measures and intensity-related measures, were obtained with Praat in order to construct VRPs for the sustained /a/ and to construct speech range profiles for passage reading. Results F0 range and intensity range for the new passage were significantly larger than those for the existing Mandarin passage for both male and female participants. In particular, the F0 range for the passage was not significantly different from that of the VRP for male participants. Conclusions These findings suggested that the new passage could allow individuals without vocal training to demonstrate a large vocal range in both F0 and vocal intensity, in a passage reading setting in a relatively short time. Further studies should be pursued with the passage to investigate the vocal range and vocal potential of individuals with voice disorders.

Kampo Medicine for Essential Voice Tremor

Voice tremor is a common symptom in the elderly, as well as in patients who have had Parkinson's disease and related disorders, and other neurologic conditions. In this study, we analyzed 26 patients whose essential tremor symptoms involved phonation alone and were treated in our clinic alone as essential voice tremor. Kampo medicine yokukansan was found to be effective in the treatment of essential voice tremor compared with clonazepam. We suggest that yokukansan may be one of the best choices for first-line treatment of essential voice tremor.