Medicine by Alexandros G. Sfakianakis: Voice

Prevalence, Characteristics and Impact of Dysphonia in US Marine Corps Drill Instructors
Prior studies have evaluated various populations at increased risk of voice impairment. However, minimal data is available for military Drill Instructors, a population known to have significant vocal demands.

Adaptation and Validation of Vocal Fatigue Index (VFI) to Malayalam Language
The purpose of the present study was to translate and validate the English version of the Vocal Fatigue Index (VFI) in to Malayalam language.

Perceptual Judgment of Voice Quality in Nondysphonic French Speakers: Effect of Task-, Speaker- and Listener-Related Variables
Several perceptual scales have been developed to assess voice quality in dysphonic voices, among which the Grade Roughness Breathiness Asthenia Strain and a Rate of Dysphonia scale is probably the most frequently used. However, this clinical tool has not been properly validated with a normophonic population yet. The aim of the present study was to provide a first set of reference data gathered from a normal population, to serve as a basis of comparison for vocologists and laryngologists working with French-speaking patients.

Detection of Muscle Tension Dysphonia Using Eulerian Video Magnification: A Pilot Study
To determine whether Eulerian Video Magnification software is useful in diagnosis of muscle tension dysphonia (MTD).

A Comparison of the s/z Ratio to Instrumental Aerodynamic Measures of Phonation
The purpose of this study was to examine how the s/z ratio and instrumental measures of laryngeal valving and voicing efficiency.

Auditory-Perceptual Evaluation of Deep Brain Stimulation on Voice and Speech in Patients With Dystonia
To determine the effects of globus pallidus interna (GPi) deep brain stimulation (DBS) on speech and voice quality of patients with primary, medically refractory dystonia.

Laryngeal and Pharyngeal Movements During Inner Singing: A Cross-Sectional Study
Laryngeal and pharyngeal activity during inner singing is discussed in the context of vocal hygiene. Inner singing is defined as imagined singing, reading music silently, and listening to vocal music. When vocal rest is prescribed, doctors, speech therapists, and voice pedagogues recommend avoiding listening to music or reading music silently, since it is suggested that inner singing unconsciously influences the glottis, and thus moves the vocal folds involuntarily. The aim of this study was to compare the degree to which involuntary laryngeal and/or pharyngeal activity occur during inner singing, inner speech, and at rest, and to evaluate if current recommendations concerning vocal hygiene are still reasonable.

Electroglottography – An Update
Electroglottography (EGG) is a low-cost, noninvasive technology for measuring changes of relative vocal fold contact area during laryngeal voice production. EGG was introduced about 60 years ago and has gone through a "golden era" of increased scientific attention in the late 1980s and early 90s. During that period, four eminent review papers were written. Here, an update to these reviews is given, recapitulating some earlier landmark contributions and documenting noteworthy developments during the past 25 years.

Effect of Functional Endoscopic Sinus Surgery on Voice and Speech Recognition
Functional Endoscopic Sinus Surgery (FESS) is the surgery of choice for nasal polyposis and chronic rhinosinusitis. The aim of our study is to assess the influence of this surgery in the acoustic parameters of voice, and their implications in the systems of identification or verification of the speaker through the speech.

Pediatric Voice Handicap Index Profiles in Patients With Benign Vocal Fold Lesions
Benign vocal fold lesions (BVFL), including nodules, polyps, and cysts, are the most common etiology of dysphonia in the pediatric population. Voice surveys, such as the Pediatric Voice Handicap Index (PVHI), have become instrumental in the evaluation and monitoring of pediatric patients with dysphonia; however the symptom profiles reported in surveys have not yet been well correlated to specific etiologies for dysphonia. In a retrospective chart review of 95 patients with PVHI surveys and laryngoscopic exams, we sought to correlate the PVHI results with findings of BVFL.

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Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/S0892-1997(19)30046-3

Editorial Board

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Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/S0892-1997(19)30047-5

Calendar Listings

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Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/S0892-1997(19)30048-7

Calendar

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Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/S0892-1997(19)30071-2

Impact Factor and the Journal of Voice

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Robert T. Sataloff*,†,‡,§,*,Correspondence information about the author Robert T. Sataloff Email the author Robert T. Sataloff

Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/j.jvoice.2019.02.003
In late June of 2018, Clarivate Analytics, formerly Thomson Reuters, notified us that they had decided to "suppress" the Journal of Voice (JOV) from the 2017 Journal Citation Reports (JCR), hence disqualifying the journal from having its 2017 Journal Impact Factor (JIF) (https://clarivate.com/essays/impact-factor/) calculated and published as usual. Clarivate claimed they had calculated Journal of Voice's journal-level self-citations made in the 2017 JIF calculation window at 47%, which apparently resulted in a "distortion" of its ranking in the Otorhinolaryngology journal category.

Acoustic Analysis of Soccer Fans in Acute Phonotrauma After the Match

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Mehmet Ozgur Pinarbasli*,*,Correspondence information about the author Mehmet Ozgur Pinarbasli Email the author Mehmet Ozgur Pinarbasli
,
Ercan Kaya*
,
Erkan Ozudogru*
,
Melek Kezban Gurbuz*
,
Ertugrul Colak†
,
Mehmet Akif Aksoy*
,
Leman Birdane‡
,
Fatma Ozgur Guney*

Journal of Voice, Volume 33, Issue 2

Accepted: October 4, 2017; Published online: November 13, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.004

Summary

Objectives

Acute phonotrauma is the result of sound production by shouting or straining one's voice. In this study, we aimed to investigate the acute changes in the vocal folds and voices of soccer fans who voluntarily applied to our clinic after the soccer match where they engaged in acute phonotrauma. There are no other studies in the literature conducted on a similar sample group.

Study design

This is a case-control study.

Methods

Videolaryngostroboscopic (VLS) examination, acoustic voice analysis, and Voice Handicap Index (VHI) questionnaire were performed on 29 voluntary soccer fans included to the study before the match and at the first hour after the match. The values obtained were compared statistically with each other and with 29 control groups without voice pathology.

Results

The jitter, shimmer, and normalized noise energy values measured after the match increased significantly statistically compared with the pre-match level, but harmonic noise ratio value decreased significantly (P < 0.05). VHI scores increased significantly after the match according to the pre-match scores (P < 0.05). In the VLS examinations, there was no difference in the images before and after the match.

Conclusions

It has been concluded that people who are using their voices loudly and intensely by shouting during the match are exposed to sound changes after the match, and if this situation becomes persistent, it may cause permanent voice pathologies. It is thought that VHI and acoustic voice analysis should be done together with VLS for diagnosis and follow-up of voice changes for which the VLS examination alone is not sufficient.

Endoscopic and Phoniatric Evaluation in Singing Students

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Andrea Nacci*,*,Correspondence information about the author Andrea Nacci Email the author Andrea Nacci
,
Giovanna Baracca†
,
Salvatore Osvaldo Romeo*
,
Maria Denise Cavaliere*
,
Maria Rosaria Barillari‡
,
Stefano Berrettini*,§
,
Francesco Ursino¶
,
Bruno Fattori*

Journal of Voice, Volume 33, Issue 2

Accepted: October 5, 2017; Published online: December 11, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.006

Summary

Objectives

In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing.

Methods

56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS).

Results

At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P = 0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students.

Conclusions

Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition.

Comparing Videostroboscopy and Direct Microlaryngoscopy: An Argument for Flexible Consent and Operative Plan

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William Greg Young*,†
,
Liat Shama*,‡
,
Brian Petty*,§
,
Matthew R. Hoffman*
,
Seth H. Dailey*,*,Correspondence information about the author Seth H. Dailey Email the author Seth H. Dailey

Journal of Voice, Volume 33, Issue 2

Accepted: October 5, 2017; Published online: November 27, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.005

Summary

Introduction

Office-based evaluation of glottic lesions has progressed significantly, but there can still be discrepancies compared with direct microlaryngoscopy (DML) in the operating room. We performed a prospective evaluation comparing diagnosis of epithelial and lamina propria glottic lesions on rigid telescopic strobovideolaryngoscopy (RTS) with DML.

Methods

Fifty subjects were enrolled and underwent RTS followed by DML. We compared presence and extent (unilateral or bilateral) of lamina propria and epithelial lesions. Primary (diagnoses motivating an operation) and secondary (diagnoses not requiring an operation) were considered. Changes in diagnosis and operative plan based on DML findings were evaluated.

Results

Sixty-eight lesions were identified on RTS, including 53 primary (15 epithelial, 38 lamina propria) and 15 secondary diagnoses. RTS was accurate in only 36% of subjects. Ten subjects had a different primary pathology identified on DML. A change in surgical management occurred in 16% of subjects.

Conclusions

This is the first prospective study evaluating how both diagnosis and operative plan for epithelial and lamina propria glottic lesions differ based on RTS and DML. Despite significant advances in office-based diagnosis of glottic lesions, there are still notable limitations. Clinicians should consider these findings when counseling patients on interpretation and plan for findings based on RTS. Obtaining a flexible surgical consent and counseling patients on the potential for new diagnoses and interventions based on DML is warranted.

Association Between Pepsin in the Saliva and the Subjective Symptoms in Patients With Laryngopharyngeal Reflux

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Ah Ra Jung*
,
Oh Eun Kwon*
,
Jung Min Park†
,
Sung Hwa Dong*
,
Su Young Jung†
,
Young Chan Lee*,†
,
Young-Gyu Eun*,†,*,Correspondence information about the author Young-Gyu Eun Email the author Young-Gyu Eun

Journal of Voice, Volume 33, Issue 2

Accepted: October 18, 2017; Published online: November 24, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.015

Summary

Objectives

Our study was designed to further evaluate the relationships between the saliva pepsin level and the symptoms and quality of life of patients with laryngopharyngeal reflux (LPR).

Study design

A prospective cohort study without controls.

Setting

Tertiary teaching hospital.

Subjects and methods

We analyzed 50 patients diagnosed with LPR by 24-hour multichannel intraluminal impedance pH monitoring. All subjects were instructed to collect saliva samples upon waking in the morning. The saliva pepsin levels were analyzed using enzyme-linked immunosorbent assay. The Reflux Symptom Index, Reflux Finding Score, Laryngopharyngeal Reflux-Health-Related Quality of Life, and Short Form 36 survey were administered.

Results

The pepsin was detected in the saliva of 41 patients with LPR (17.15 ± 20.42 ng/mL). Nine patients did not have pepsin in the saliva. There were no significant associations between the pepsin level in the saliva and Reflux Symptom Index, Laryngopharyngeal Reflux-Health-Related Quality of Life, or Short Form 36 of patients with LPR.

Conclusion

The saliva pepsin level is not significantly correlated with LPR symptoms or quality of life in LPR patients. It may be true that there is no association between pepsin levels and LPR symptoms, but this lack of association does not prove the lack of pathophysiological effect.

Lipoid Proteinosis: A Rare Cause of Hoarseness

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Elke Loos*,†
,
Liliane Kerkhofs‡
,
Griet Laureyns*,*,Correspondence information about the author Griet Laureyns Email the author Griet Laureyns

Journal of Voice, Volume 33, Issue 2

Accepted: May 26, 2017; Published online: October 29, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.05.024

Summary

Lipoid proteinosis is a rare cause of voice problems. Hoarseness is often the first clinical manifestation of this disorder and can present years before any other symptom. Therefore, it is very important as an otorhinolaryngologist to be familiar with the main characteristics of this disease. We present a case report and a review of current literature to provide a concise overview of this frequently missed diagnosis.

Multidose Botulinum Toxin A for Intralaryngeal Injection: A Cost Analysis

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Mark R. Gilbert
,
VyVy N. Young
,
Libby J. Smith
,
Clark A. Rosen*,Correspondence information about the author Clark A. Rosen Email the author Clark A. Rosen

University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

Journal of Voice, Volume 33, Issue 2

Accepted: November 6, 2017; Published online: January 04, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.11.004

Summary

Objectives

Botulinum toxin A (BtxA) injection is the mainstay treatment for laryngeal dystonias. BtxA product labeling states that reconstituted toxin should be used within 4 hours on a single patient despite several studies that have demonstrated multidose BtxA to be safe and effective. Many insurance carriers mandate the use of an outside pharmacy which necessitates a single-use approach. This study compares the cost savings of multidose BtxA for laryngeal dystonia compared to single-use.

Study Design

This is a retrospective review and projected cost savings analysis.

Methods

Records and billing information were reviewed for patients receiving BtxA for intralaryngeal injection at a single laryngology division in 2015. Inclusion criteria included CPT 64617 or J0585; exclusion criteria included CPT 64616. The price of BtxA 100 unit vial for calculation was $670.

Results

A total of 142 patients were seen for intralaryngeal BtxA injection resulting in 337 visits over 1 year. The average BtxA dose per visit was 2.86 units with an average of 3.06 procedure visits per year. The calculated cost of BtxA treatment using a single vial approach was found to be $2,050 per patient per year. If billed instead for $7/unit with 5 units wastage charge per visit, the yearly per patient charge is $168. Single vial-use of BtxA injection thus represents a 1,118% price increase versus multidose use. When estimated for yearly prevalence of spasmodic dysphonia, multidose BtxA use would save almost $100 million annually.

Conclusions

Multidose botulinum toxin A application utilizing per unit billing is significantly less expensive than per single-use vial billing and would save the health-care system significant amount of money without any sacrifice in safety or effectiveness.

Pin-up Glottoplasty: Feasibility Study of a Novel Approach Medializing or Lateralizing Immobile Vocal Folds

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Christina Pflug*
,
Almut Niessen*,*,Correspondence information about the author Almut Niessen Email the author Almut Niessen
,
Frank Müller*,†
,
Clarissa Precht‡
,
Julie C. Nienstedt*
,
Markus Hess*,†

Journal of Voice, Volume 33, Issue 2

Accepted: October 11, 2017; Published online: November 24, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.010

Summary

Principles in medializing and lateralizing vocal folds have not changed a lot within the last decades (Isshiki et al, 1974; Bruenings, 1911). We present a feasibility study for a completely new approach to perform medialization and lateralization of immobile vocal folds.

The method was tested on 20 human larynges by inserting a 21G needle into the vocal fold, medializing (or, in other cases, lateralizing) the vocal cord and fixing the needle at the cricoid cartilage posteriorly. The anterior and posterior fixation points of the needle allow for a stable positioning of the needle, which we consider necessary in both cases of medialization or lateralization. The needle position was examined visually as well as three-dimensionally via cone beam computed tomography.

Evaluation of a Shorter Follow-up Time to Capture Benefit of a Trial Vocal Fold Augmentation

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Thomas L. Carroll, MD *,Correspondence information about the author MD Thomas L. Carroll Email the author MD Thomas L. Carroll
,
Elizabeth Faudoa
,
Maxine Van Doren, MS, CCC-SLIP

Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts

Journal of Voice, Volume 33, Issue 2

Accepted: October 19, 2017; Published online: January 18, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.10.017

Summary

Objective

Trial vocal fold injection (TVFI) is employed diagnostically for patients with subtle glottic insufficiency to explore potential for improvement. Clinical experience demonstrates the time to and length of peak benefit of the TVFI is variable. Previous studies collected data 4 weeks or more after TVFI. The aim of this study was to compare subjectively successful and unsuccessful TVFI patient groups. It is hypothesized that patients with subjectively reported success will also have significant improvements in Voice Handicap Index-10 (VHI-10), phase closure percentage, and aerodynamic measures 2 weeks after trial augmentation.

Methods/Design

Subjects with glottic insufficiency were included in this retrospective review if they underwent office-based, per-oral vocal fold injection augmentation specifically for trial purposes. Patients were divided into "successful" and "unsuccessful" groups based on their subjective experience during the 2-week post-TVFI period. VHI-10, subjective report, phase closure evaluation using frame-by-frame analysis, and aerodynamic data were collected pre- and 2 weeks post-TVFI.

Results

Of the subjects, 15 of 23 (65%) reported a successful subjective improvement of their symptom, whereas 8 (35%) were unsuccessful (only partial improvement or no improvement). The number of subjects with an improvement in VHI-10 by 5 or more points was not significantly different between groups. The number of subjects that demonstrated complete, long phase closure was significantly higher in the successful group (P = 0.021).

Conclusions

The understanding of how to more precisely determine the success of TVFI remains incomplete. Subjective improvement of successful TVFI was captured with basic clinical questioning, yet the VHI-10 was unable to confidently demonstrate this reported success 2 weeks after TVFI.

Long-term Voice Outcome Following Radiation Versus Laser Microsurgery in Early Glottic Cancer

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Yue Ma*
,
Rebecca Green†
,
Stephanie Pan*
,
Daniel McCabe*
,
Leanne Goldberg*
,
Peak Woo*,*,Correspondence information about the author Peak Woo Email the author Peak Woo

Journal of Voice, Volume 33, Issue 2

Accepted: October 25, 2017; Published online: December 08, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.018

Summary

Objectives

Long-term voice outcome (LTVO) after radiation (XRT) or trans-oral laser microsurgery (TLM) is unclear. This study is a multi-modality analysis of LTVO following XRT or TLM in patients with early glottic cancer. We hypothesize that as compared with TLM, LTVO is worse in the XRT group because of progressive fibrosis in the glottic tissue

Material and Methods

One hundred and two patients with early glottic carcinoma (carcinoma in situ, T1, T2) were included. Multi-modality voice analyses were performed with self-perception using Voice Handicap Index-10, objective analysis using Analysis of Dysphonia in Speech and Voice Software (Cepstral Spectral Index of Dysphonia score for Consensus Auditory-Perceptual Evaluation of Voice sentences), and perceptual rating by two blinded speech language pathologists (GRBAS scale).

Results

Fifty-five patients received TLM (mean follow-up = 52 months) and 47 patients had XRT (mean follow-up = 65 months). There is no difference between the two groups in sex, age, stage, and follow-up time. Intraclass correlation coefficient between raters was high at 0.94. Controlling for age and stage, XRT increases total GRBAS score by 1.38 points (P = 0.006) and increases Cepstral Spectral Index of Dysphonia score by 13.7 points (P < 0.001) when compared with the TLM group. No significant differences were found in the Voice Handicap Index score between the XRT and the TLM groups.

Conclusions

This is the first multi-modality voice analysis to suggest TLM results in better LTVO than XRT in GRBAS score and objective voice analysis but not in self-perception. These differences may reflect the progressive effects of XRT on glottic tissue. A randomized controlled study is required to confirm our findings.

Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging

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Nelson Roy*,*,Correspondence information about the author Nelson Roy Email the author Nelson Roy
,
Maria Dietrich†
,
Michael Blomgren*
,
Amanda Heller*
,
Daniel R. Houtz‡
,
James Lee§

Journal of Voice, Volume 33, Issue 2

Accepted: November 16, 2017; Published online: December 19, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.11.009

Summary

Primary muscle tension dysphonia (pMTD) is a voice disorder that occurs in the absence of laryngeal pathology. Dysregulated activity of the paralaryngeal muscles is considered the proximal cause; however, the central origin of this aberrant laryngeal muscle activation is unclear. The Trait Theory (Roy and Bless, 2000a,b) proposed that specific personality traits can predispose one to laryngeal motor inhibition and pMTD, and this inhibition is mediated by a hyperactive "behavioral inhibition system (BIS)" composed of limbic system structures (and associated prefrontal connections). This case study used functional magnetic resonance imaging to detect brain activation changes associated with successful management of pMTD, thereby evaluating possible neural correlates of this poorly understood disorder.

Method

A 61-year-old woman with moderate-to-severe pMTD underwent functional magnetic resonance imaging scans before and immediately after successful treatment using manual circumlaryngeal techniques. Experimental stimuli were blocks of repeated vowel production and overt sentence reading.

Results

Significantly greater activation was observed pre- versus posttreatment in all regions of interest during sentence production, that is, periaqueductal gray, amygdala, hypothalamus, anterior cingulate cortex, hippocampus, dorsolateral prefrontal cortex, Brodmann area 10, and premotor and inferior sensorimotor cortex.

Conclusions

Our findings are compatible with overactivation of neural regions associated with the BIS (cingulate cortex, amygdala, hypothalamus, periaqueductal gray) and motor inhibition networks (eg, [pre-]supplementary motor area) along with the dorsolateral prefrontal cortex and medial prefrontal cortex. Heightened input from limbic regions combined with dysfunctional prefrontal regulation may interfere with laryngeal motor preparation, initiation, and execution thereby contributing to disordered voice in pMTD.

Voice Acoustic Analysis of Pediatric Vocal Nodule Patients Using Ratios Calculated With Biomedical Image Segmentation

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Nagihan Bilal*,*,Correspondence information about the author Nagihan Bilal Email the author Nagihan Bilal
,
Turab Selcuk†
,
Selman Sarica*
,
Ahmet Alkan†
,
İsrafil Orhan*
,
Adem Doganer‡
,
Saime Sagiroglu*
,
Mehmet Akif Kılıc§

Journal of Voice, Volume 33, Issue 2

Accepted: November 16, 2017; Published online: December 19, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.11.010

Summary

Objective

The aim of this study was to determine nodules using newly developed software with a computer-assisted visual process technique for the calculation of size. The effects of the ratios of nodule base and width were evaluated with voice acoustic analysis.

Methods

A total of 72 patients with pediatric vocal nodule were evaluated. Nodules were marked with the ImageJ News program on photographs obtained from the video recordings in the videostroboscopic examination and classified according to the Shah et al scale. Segmentation was applied automatically. The ratios were taken as base of nodule/width and base of nodule/vocal cord. In the voice acoustic analysis, basic frequencies (mean F0), jitter (local %), shimmer (local %), and harmonicity (mean harmonics-to-noise [mean HNR]) were evaluated.

Results

A statistically significant negative correlation was determined between the mean F0 value and the nodule base/width ratio (P = 0.042, r = −0.240). A negative statistically significant relationship was determined between jitter (%) and vocal nodule base/width (P = 0.009, r = −0.305). A statistically significant positive correlation was determined between mean HNR and vocal nodule base/width (P = 0.034, r = 0.324). In discriminant analysis, correct classification of the Shah et al scale degrees of the classifying variables was 73.6%.

Conclusion

Through collaboration with the biomedical engineering department, the results of this study determined new ratios in patients with pediatric vocal nodule. In voice acoustic analysis, the mean F0 was more affected by the width of the nodule, mean HNR was affected by the length of the base of the nodule, and jitter (%) was affected by the width of the nodule.

The Perception of Breathiness in the Voices of Pediatric Speakers

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Lisa M. Kopf*
,
Mark D. Skowronski†
,
Supraja Anand‡
,
David A. Eddins‡,*,Correspondence information about the author David A. Eddins Email the author David A. Eddins
,
Rahul Shrivastav§

Journal of Voice, Volume 33, Issue 2

Accepted: September 28, 2017; Published online: November 20, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.09.024

Summary

Background

The perception of pediatric voice quality has been investigated using clinical protocols developed for adult voices and acoustic analyses designed to identify important physical parameters associated with normal and dysphonic pediatric voices. Laboratory investigations of adult dysphonia have included sophisticated methods, including a psychoacoustic approach that involves a single-variable matching task (SVMT), characterized by high inter- and intra-listener reliability, and analyses that include bio-inspired models of auditory perception that have provided valuable information regarding adult voice quality.

Objectives

To establish the utility of a psychoacoustic approach to the investigation of voice quality perception in the context of pediatric voices?

Methods

Six listeners judged the breathiness of 20 synthetic vowel stimuli using an SVMT. To support comparisons with previous data, stimuli were modeled after four pediatric speakers and synthesized using Klatt with five parameter settings that influence the perception of breathiness. The population average breathiness judgments were modeled with acoustic measures of loudness ratio, pitch strength, and cepstral peak.

Results

Listeners reliably judged the perceived breathiness of pediatric voices, as with previous investigations of breathiness in adult dysphonic voices. Breathiness judgments were accurately modeled by loudness ratio (r2 = 0.93), pitch strength (r2 = 0.91), and cepstral peak (r2 = 0.82). Model accuracy was not affected significantly by including stimulus fundamental frequency and was slightly higher for pediatric than for adult voices.

Conclusions

The SVMT proved robust for pediatric voices spanning a wide range of breathiness. The data indicate that this is a promising approach for future investigation of pediatric voice quality.

The Influence of Noise on the Vocal Dose in Women

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Alessandra Terra Vasconcelos Rabelo*
,
Juliana Nunes Santos†
,
Bárbara Oliveira Souza‡
,
Ana Cristina Côrtes Gama‡,1,*,Correspondence information about the author Ana Cristina Côrtes Gama Email the author Ana Cristina Côrtes Gama
,
Max de Castro Magalhães*

Journal of Voice, Volume 33, Issue 2

Accepted: October 31, 2017; Published online: December 28, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.025

Summary

Objective

The objective of this study was to evaluate if noise interferes with the vocal dose in women without vocal complaints.

Study design

This is an experimental and comparative study.

Methods

Data were collected on 27 women between 22 and 50 years of age without vocal complaints in a university classroom. Speech-language pathology evaluation was performed employing auditory-perceptual analysis and a vocal symptom questionnaire. The acoustics of the classroom were evaluated via both observation of the characteristics of the room and the quantification of background noise and reverberation time. Two distinctive acoustic conditions were created for evaluations: condition 1, a room without acoustic treatment and without noise reproduction, and condition 2, a room without acoustic treatment with noise reproduction. Each participant was evaluated individually in both acoustic conditions. To obtain vocal dose data, a vocal dosimeter was used. Subjects were asked to perform two 10-minute readings, one in each acoustic condition. The order of conditions was randomized between subjects. Subjects were instructed to complete the reading tasks at the vocal intensity deemed appropriate to be heard by a listener in the back of the room. t Tests and the Wilcoxon test were employed to compare parameters across subjects and conditions.

Results

Fundamental frequency, vocal intensity, percentage of phonation, and cycle dose significantly increased in the background noise condition.

Conclusion

A positive relation between vocal dose and the presence of excessive noise in the environment was observed.

Effect of Auditory-Perceptual Training With Natural Voice Anchors on Vocal Quality Evaluation

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Priscila Campos Martins dos Santos*,*,Correspondence information about the author Priscila Campos Martins dos Santos Email the author Priscila Campos Martins dos Santos
,
Maurílio Nunes Vieira†
,
João Pedro Hallack Sansão‡
,
Ana Cristina Côrtes Gama*

Journal of Voice, Volume 33, Issue 2

Accepted: October 26, 2017; Published online: January 10, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.10.020

Summary

Purpose

To analyze the effects of auditory-perceptual training with anchor stimuli of natural voices on inter-rater agreement during the assessment of vocal quality.

Study design

This is a quantitative nature study.

Methods

An auditory-perceptual training site was developed consisting of Programming Interface A, an auditory training activity, and Programming Interface B, a control activity. Each interface had three stages: pre-training/pre-interval evaluation, training/interval, and post-training/post-interval evaluation. Two experienced evaluators classified 381 voices according to the GRBASI scale (G-grade, R-roughness, B-breathiness, A-asthenia, S-strain, I-instability). Voices were selected that received the same evaluation by both evaluators: 57 voices for evaluation and 56 for training were selected, with varying degrees of deviation across parameters. Fifteen inexperienced evaluators were then selected. In the pre-, post-training, pre-, and postinterval stages, evaluators listened to the voices and classified them via the GRBASI scale. In the stage interval evaluators read a text. In the stage training each parameter was trained separately. Evaluators analyzed the degrees of deviation of the GRBASI parameters based on anchor stimuli, and could only advance after correctly classifying the voices. To quantify inter-rater agreement and provide statistical analyses, the AC1 coefficient, confidence intervals, and percentage variation of agreement were employed.

Results

Except for the asthenia parameter, decreased agreement was observed in the control condition. Improved agreement was observed with auditory training, but this improvement did not achieve statistical significance.

Conclusion

Training with natural voice anchors suggest an increased inter-rater agreement during perceptual voice analysis, potentially indicating that new internal references were established.

The Design and Assessment of a Multiparametric Model for the Dysphonia Severity Index for Persian-speaking Populations

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Akbar Darouie*
,
Mahshid Aghajanzadeh*,†,*,Correspondence information about the author Mahshid Aghajanzadeh Email the author Mahshid Aghajanzadeh
,
Payman Dabirmoghaddam‡
,
Abolfazl Salehi*
,
Mehdi Rahgozar§

Journal of Voice, Volume 33, Issue 2

Accepted: November 13, 2017; Published online: December 18, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.11.007

Summary

Objectives

In instrumental voice assessment, multiparametric models reflect the multidimensional nature of voice and are therefore better than models that reflect only a single dimension of voice. The Dysphonia Severity Index (DSI) is one of the most common multiparametric models. In voice assessment, race, language, and structural and physiological features affect the acoustic, aerodynamic, and voice range profile measures. Given these differences, this study was conducted to design and evaluate a multiparametric and objective model for assessing the severity of dysphonia in Persian-speaking populations.

Material and Methods

This study examined 300 participants with several types of dysphonia (104 women and 196 men) and 100 healthy individuals (63 women and 37 men). Five acoustic parameters, three aerodynamic parameters, and seven voice range profile parameters were measured for designing the model. Perceptual evaluation was performed using the grade, roughness, breathiness, asthenia, strain scale. The logistic regression analysis was used to determine the factors affecting the DSI and each component's coefficient.

Results

Of the 15 parameters assessed, shimmer, vital capacity, semitone range, and voice onset time of /pa/ remained in the model with their coefficients. This section presents the DSI model for the examined population. The discriminant analysis showed that this combination corresponds to 47.8 of the perceptual assessment: DSI = 0.289 (shimmer) + 0.0001 (VC) − 0.059 (STR) − 13.278 (VOT_Pa).

Conclusion

In this study, the DSI corresponded to the physiological, linguistic, and racial characteristics of the Persian-speaking population with or without voice disorder.

Development and Validation of the Voice Catastrophization Index

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Hagit Shoffel-Havakuk*
,
Steven Chau†
,
Edie R. Hapner*
,
Madeleine Pethan‡
,
Michael M. Johns III*,*,Correspondence information about the author Michael M. Johns Email the author Michael M. Johns

Journal of Voice, Volume 33, Issue 2

Accepted: September 29, 2017; Published online: November 10, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.09.026

Summary

Introduction

Catastrophization is a cognitive distortion that has been studied in pain patients and found to be a significant factor in their disability and response to treatment. Dysphonia patients may demonstrate a similar behavior, suggesting the existence of voice catastrophization.

Objective

To establish the validity of the Voice Catastrophization Index (VCI), a new instrument estimating voice symptoms catastrophization.

Methods

A prospective study. Patients with and without voice conditions were administered with the VCI, Voice-Related Quality of Life (V-RQOL), and the Generalized Anxiety Disorder-7 (GAD-7)questionnaires. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) rating was determined for patients with voice conditions.

Results

Ninety-one patients participated, 65 with voice conditions and 26 without. 61.5% were females; mean age was 49.8 ± 15.7 years. The VCI score for patients with voice conditions was significantly higher, 22.46 ± 16.56, compared with 3.96 ± 10.79, respectively (P value < 0.0001). The VCI demonstrated moderate correlation with both V-RQOL and GAD-7 scores: −0.562 and 0.560, respectively (P value < 0.000001); however, it showed no correlation with the CAPE-V. The VCI's internal consistency with each of its three dimensions and 13 items was acceptable to strong. The reproducibility and stability was demonstrated in a subgroup of 26 patients; 81% of these patients had a difference of 10 or less points between the two evaluations.

Conclusions

The VCI accomplished the requirements of a scale's validity for estimation of voice symptoms catastrophization in voice patients. The potential role of voice catastrophization as a predictor of treatment response and tailoring can now be investigated using the VCI.

Show and Tell: Video Modeling and Instruction Without Feedback Improves Performance but Is Not Sufficient for Retention of a Complex Voice Motor Skill

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Clarisse Look
,
Patricia McCabe
,
Robert Heard
,
Catherine J. Madill*,Correspondence information about the author Catherine J. Madill Email the author Catherine J. Madill

University of Sydney, Lidcombe, New South Wales, Australia

Journal of Voice, Volume 33, Issue 2

Accepted: September 27, 2017; Published online: February 02, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.09.023

Summary

Purpose

Modeling and instruction are frequent components of both traditional and technology-assisted voice therapy. This study investigated the value of video modeling and instruction in the early acquisition and short-term retention of a complex voice task without external feedback.

Method

Thirty participants were randomized to two conditions and trained to produce a vocal siren over 40 trials. One group received a model and verbal instructions, the other group received a model only. Sirens were analyzed for phonation time, vocal intensity, cepstral peak prominence, peak-to-peak time, and root-mean-square error at five time points.

Results

The model and instruction group showed significant improvement on more outcome measures than the model-only group. There was an interaction effect for vocal intensity, which showed that instructions facilitated greater improvement when they were first introduced. However, neither group reproduced the model's siren performance across all parameters or retained the skill 1 day later.

Conclusions

Providing verbal instruction with a model appears more beneficial than providing a model only in the prepractice phase of acquiring a complex voice skill. Improved performance was observed; however, the higher level of performance was not retained after 40 trials in both conditions. Other prepractice variables may need to be considered. Findings have implications for traditional and technology-assisted voice therapy.

Clinical Features of Psychogenic Voice Disorder and the Efficiency of Voice Therapy and Psychological Evaluation

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Zahide Çiler Tezcaner*,Correspondence information about the author Zahide Çiler Tezcaner Email the author Zahide Çiler Tezcaner
,
Muhammed Fatih Gökmen
,
Sibel Yıldırım
,
Gürsel Dursun

Department of Otorhinolaryngology, Medical School, Ankara University, Ankara, Turkey

Journal of Voice, Volume 33, Issue 2

Accepted: September 26, 2017; Published online: November 06, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.09.022

Summary

Objectives

The aim of this study was to define the clinical features of psychogenic voice disorder (PVD) and explore the treatment efficiency of voice therapy and psychological evaluation.

Method

Fifty-eight patients who received treatment following the PVD diagnosis and had no organic or other functional voice disorders were assessed retrospectively based on laryngoscopic examinations and subjective and objective assessments. Epidemiological characteristics, accompanying organic and psychological disorders, preferred methods of treatment, and previous treatment outcomes were examined for each patient. A comparison was made based on voice disorders and responses to treatment between patients who received psychotherapy and patients who did not.

Results

Participants in this study comprised 58 patients, 10 male and 48 female. Voice therapy was applied in all patients, 54 (93.1%) of whom had improvement in their voice. Although all patients were advised to undergo psychological assessment, only 60.3% (35/58) of them underwent psychological assessment. No statistically significant difference was found between patients who did receive psychological support concerning their treatment responses and patients who did not. Relapse occurred in 14.7% (5/34) of the patients who applied for psychological assessment and in 50% (10/20) of those who did not. There was a statistically significant difference in relapse rates, which was higher among patients who did not receive psychological support (P < 0.005).

Conclusion

Voice therapy is an efficient treatment method for PVD. However, in the long-term follow-up, relapse of the disease is observed to be higher among patients who failed to follow up on the recommendation for psychological assessment.

Evaluation of the Supraglottic and Subglottic Activities Including Acoustic Assessment of the Opera-Chant Singers

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Emine Petekkaya*,*,Correspondence information about the author Emine Petekkaya Email the author Emine Petekkaya Email the author Emine Petekkaya
,
Ahmet Hilmi Yücel†
,
Özgür Sürmelioğlu‡

Journal of Voice, Volume 33, Issue 2

Accepted: October 30, 2017; Published online: December 28, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.023

Summary

Opera and chant singers learn to effectively use aerodynamic components by breathing exercises during their education. Aerodynamic components, including subglottic air pressure and airflow, deteriorate in voice disorders. This study aimed to evaluate the changes in aerodynamic parameters and supraglottic structures of men and women with different vocal registers who are in an opera and chant education program. Vocal acoustic characteristics, aerodynamic components, and supraglottic structures were evaluated in 40 opera and chant art branch students. The majority of female students were sopranos, and the male students were baritone or tenor vocalists. The acoustic analyses revealed that the mean fundamental frequency was 152.33 Hz in the males and 218.77 Hz in the females. The estimated mean subglottal pressures were similar in females (14.99 cmH2O) and in males (14.48 cmH2O). Estimated mean airflow rates were also similar in both groups. The supraglottic structure compression analyses revealed partial anterior-posterior compressions in 2 tenors and 2 sopranos, and false vocal fold compression in 2 sopranos. Opera music is sung in high-pitched sounds. Attempts to sing high-pitched notes and frequently using register transitions overstrain the vocal structures. This intense muscular effort eventually traumatizes the vocal structures and causes supraglottic activity.

F0 Characteristics of Newsreaders on Varied Emotional Texts in Tamil Language

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Nishanthi Gunasekaran*
,
Prakash Boominathan†,*,Correspondence information about the author Prakash Boominathan Email the author Prakash Boominathan
,
Jayashree Seethapathy†

Journal of Voice, Volume 33, Issue 2

Accepted: November 9, 2017; Published online: December 26, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.11.005

Summary

Objective

The objective of this study was to profile speaking F0 and its variations in newsreaders on varied emotional texts.

Study design

This study has a prospective, case-control study design.

Methods

Fifteen professional newsreaders and 15 non-newsreaders were the participants. The participants read the news bulletin that conveyed different emotions (shock, neutral, happy, and sad) in a habitual and "newsreading" voice. Speaking fundamental frequency (SFF) and F0 variations were extracted from 1620 tokens using Praat software (version 5.2.32) on the opening lines, headlines, news stories, and closing lines of each news item. Paired t test, independent t test, and Friedman test were used for statistical analysis.

Results

Both male and female newsreaders had significantly (P ≤ 0.05) higher SFFs and standard deviations (SDs) of SFF in newsreading voice than speaking voice. Female non-newsreaders demonstrated significantly higher SFF and SD of SFF in newsreading voice, whereas no significant differences were noticed in the frequency parameters for male non-newsreaders. No significant difference was noted in the frequency parameters of speaking and newsreading voice between male newsreaders and male non-newsreaders. A significant difference in the SD of SFF was noticed between female newsreaders and female non-newsreaders in newsreading voice. Female newsreaders had a higher frequency range in both speaking voice and newsreading voice when compared with non-newsreaders.

Conclusions

F0 characteristics and frequency range determine the amount of frequency changes exercised by newsreaders while reading bulletins. This information is highly pedagogic for training voices in this profession.

Long-term Average Speech Spectra of Postlingual Cochlear Implant Users

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Mustafa Yüksel*,Correspondence information about the author Mustafa Yüksel Email the author Mustafa Yüksel
,
Bülent Gündüz

Audiology, Marmara University, Fevzi Cakmak Mah., Pendik, Turkey

Journal of Voice, Volume 33, Issue 2

Accepted: October 18, 2017; Published online: January 09, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.10.013

Summary

Long term average speech spectra (LTASS) is a commonly used voice analysis method for different purposes. This method offers an acoustic representation of the language in daily conservations. Results of that method can be altered by the deteriorations in the auditory feedback loop. Hearing losses occurred in the post lingual stage of life have some serious negative effects on the auditory feedback loop. Cochlear implantation may help these patients with regards to auditory feedback loop. Therefore, we aimed to evaluate the LTASS of cochlear implant users whose have a post lingual hearing loss. We assessed the LTASS of 24 cochlear implant users and compared our findings with normal hearing subjects. Our findings revealed that cochlear implant users have similar LTASS findings with normal hearing subjects. We conclude that cochlear implantation helps to the recovery of auditory feedback loop in patients with post lingual hearing losses.

Popular and Classical Female Singers: Acoustic Comparison of Voice Use in the Song Melodia Sentimental (Sentimental Melody) by Heitor Villa-Lobos

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Natalia Eugenia Sanchez Escamez
,
Ana Paula Guimarães Silva*,Correspondence information about the author Ana Paula Guimarães Silva Email the author Ana Paula Guimarães Silva
,
Marta Assumpção de Andrada e Silva

Pontifical Catholic University of São Paulo, São Paulo, Brazil

Journal of Voice, Volume 33, Issue 2

Accepted: November 9, 2017; Published online: December 29, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.11.006

Summary

Objective

This study aims to compare acoustic characteristics of classical and popular female singers' vocal performances in Heitor Villa-Lobos' Melodia Sentimental (Sentimental Melody).

Method

Long-term average spectrum acoustic analysis and long-term voice onset time (VOT) were performed for two consonants /d/ in the first six verses of Melodia Sentimental sang by 10 professional singers: five classical (GC) and five popular (GP).

Results

Classical singers presented prominence in the region of the frequencies between 2.5 and 3.5 kHz, not observed in the majority of the popular singers' group. The GC group showed lighter spectral decline curves and the numerical value of decline was also lower. Classical singers presented lower long-term voice onset time values, which indicates a longer period of glottic closure.

Conclusion

Acoustic analysis revealed that classical singers have more energy in glottic closure associated with a shorter duration of glottic coaptation.

The Effect of a Voice Therapy Program Based on the Taxonomy of Vocal Therapy in Women with Behavioral Dysphonia

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Vanessa Veis Ribeiro*
,
Amanda Gabriela de Oliveira*
,
Jhonatan da Silva Vitor*
,
Larissa Thais Donalonso Siqueira†
,
Pamela Aparecida Medeiros Moreira*
,
Alcione Ghedini Brasolotto*
,
Kelly Cristina Alves Silverio*,*,Correspondence information about the author Kelly Cristina Alves Silverio Email the author Kelly Cristina Alves Silverio

Journal of Voice, Volume 33, Issue 2

Accepted: October 26, 2017; Published online: January 18, 2018

DOI: https://doi.org/10.1016/j.jvoice.2017.10.019

Summary

Objective

This study aims to propose and analyze the effect of a voice therapy program (VTP) in women with behavioral dysphonia.

Materials and Methods

This is a controlled, blinded, and nonrandomized cohort study. Participants of this study were 22 women with behavioral dysphonia divided into two groups: G1, 11 women with behavioral dysphonia who received the VTP, and G2, 11 women with behavioral dysphonia who did not receive any intervention. Before and after 6 weeks, the outcome variables evaluated in both groups were auditory-perceptual evaluation of the global degree of vocal quality (vowel /a/ and counting), instrumental acoustic parameters, Voice-Related Quality of Life, vocal and larynx symptoms, and musculoskeletal pain. The statistical analysis used the Wilcoxon, chi-square, and Mann-Whitney tests (P < 0.05).

Results

After 6 weeks, we observed a significantly higher improvement in the general degree of vocal deviation in vowels, a reduced F0 and symptom of "fatigue while talking" in G1, and an increased "shoulder" pain intensity in G2. Both groups showed improvement in the socioemotional domain of Voice-Related Quality of Life. In addition, the comparison between the groups showed a significantly greater reduction in fundamental frequency and the "voice loss" symptom in G1 compared with G2.

Conclusions

The VTP using semioccluded vocal tract exercises obtained a positive effect on voice quality, symptoms, and musculoskeletal pain in women with behavioral dysphonia. The proposal, based on the taxonomy of voice therapy, seems to have promoted a phonatory balance, muscle relaxation, and improvement in the vocal resistance of this population.

On Exploring Vocal Ornamentation in Byzantine Chant

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Dimitrios S. Delviniotis*,Correspondence information about the author Dimitrios S. Delviniotis Email the author Dimitrios S. Delviniotis
,
Sergios Theodoridis

Department of Informatics and Telecommunications, University of Athens, Ilisia, Athens, Greece

Journal of Voice, Volume 33, Issue 2

Accepted: October 18, 2017; Published online: December 05, 2017

DOI: https://doi.org/10.1016/j.jvoice.2017.10.016

Summary

Objectives

A special vocal ornament in Byzantine chant (BC), the single cycle ornamentation structure (SCOS), is defined and compared with the vibrato with respect to its time (rate, extent) and spectral (slope [SS], relative speaker's formant [SPF] level, formant frequencies [Fi] and bandwidths [Bi], and noise-to-harmonics ratio [NHR]) characteristics.

Study Design

This is a comparative study between the vocal ornaments of SCOS and vibrato, of which time and spectral acoustic parameters were measured, statistically analyzed, and compared.

Methods

From the same hymn recordings chanted by four chanters, the SS, SPF level, FFi, FBi, and NHR difference values between the vocal ornament and its neighbor steady note, and the rate and extent, were compared with those of vibrato.

Results

The mean extent values for SCOS were found to be almost double the corresponding values for vibrato, and the rate of SCOS tends to be different from the rate of vibrato. The difference values of: 1) the NHR, 2) the spectral slope, and 3) the SPF level, between the vocal ornament and its neighbor steady note were found to be: 1) higher for SCOS, 2) mainly lower for SCOS, and 3) lower for SCOS, respectively. No significant differences were detected for the FFi and FBi. The FF1 differences tend to be negative in both ornaments indicating a formant tuning effect.

Conclusions

A new vocal ornament (SCOS) in BC is studied, of which the extent, NHR (HNR), the spectral slope, and the SPF level are different compared to those of vibrato.

Instructions for Contributors

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Journal of Voice, Volume 33, Issue 2

DOI: https://doi.org/10.1016/S0892-1997(19)30049-9

Alexandros G .Sfakianakis,ENT,Anapafeos 5 Agios Nikolaos Crete 72100 Greece,00302841026182

Δευτέρα 1 Απριλίου 2019

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