Δευτέρα, 15 Απριλίου 2019

Voice https://www.jvoice.org/



Association Between Subglottic Pressure and Pulmonary Function in Individuals With Parkinson's Disease
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Adrián Castillo*, Javiera Castillo†, Alvaro Reyes‡,a,'Correspondence information about the author Alvaro ReyesEmail the author Alvaro Reyes
Journal of Voice

Accepted: March 5, 2019; Published online: April 15, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
In individuals with Parkinson's disease (PD), pulmonary complication such as weakness and rigidity of respiratory muscles and reduced cough airflow may be associated with reduced voice production due to limited pulmonary capacity and reduced airflow needed to vibrate the vocal folds. It is not clear, however, which pulmonary function parameter is determinant in the association with peak subglottic pressure (SGP). Therefore, the purpose of this study was to determine the association between peak SGP and pulmonary function parameters in individuals with PD.

Methods
Forty-two individuals with diagnosis of idiopathic PD of both genders were recruited in the study. Mean and peak SGP, spirometric indices, maximum inspiratory pressure, maximum expiratory pressure (MEP), and peak cough flow (PCF) during reflex and voluntary cough were measured on all participants.

Results
The analysis revealed that peak SGP had a moderate but significant linear association with MEP (r = 0.38; P = 0.013), voluntary (r = 0.31; P = 0.051), and reflex PCF (r = 0.40; P = 0.012), but not with maximum inspiratory pressure (r = 0.23; P = 0.145). Higher values in peak SGP were associated with higher values in MEP, voluntary PCF, and reflex PCF. No linear association was detected between peak SGP and spirometric indices.

Conclusions
Peak SGP has a direct association with voluntary and reflex PCF, and expiratory muscle strength, but not with inspiratory muscle strength. The association with peak SGP is higher for reflex PCF than for voluntary PCF.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Longitudinal Case Study of Transgender Voice Changes Under Testosterone Hormone Therapy
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Gabriel J. Cler*,†,low asterisklow asterisk,'Correspondence information about the author Gabriel J. ClerEmail the author Gabriel J. Cler, Victoria S. McKenna†, Kimberly L. Dahl†, Cara E. Stepp*,†,‡,║
Journal of Voice

Accepted: March 14, 2019; Published online: April 13, 2019
Publication stage: In Press Corrected Proof
Abstract
The purpose of this study was to comprehensively evaluate voice and speech changes in one healthy 30-year-old transgender male undergoing testosterone therapy for transition. Testing occurred at three timepoints before cross-sex hormone therapy and every 2 weeks thereafter for 1 year. Data collected included measures of acoustics, aerodynamics, and laryngeal structure and function via flexible laryngoscopy. Analysis included acoustic correlates of pitch, loudness, voice quality, and vocal tract length, as well as perceptual measures of voice quality and gender. Speaking fundamental frequency (fo) lowered from 183 Hz to 134 Hz. Phonatory frequency range (ie, minimum and maximum singing range) shifted from a range of D#3–E6 to a range of A2–A5. Perceptual measures of voice quality indicated no negative changes. Naïve listeners reliably rated the participant's speech samples as male after 37 weeks on testosterone. Few studies document in detail the variety of voice changes that occur during cross-sex hormone therapy, focusing instead on fo alone. This study adds to the literature a comprehensive case study of speech and voice changes experienced by one transmasculine participant undergoing testosterone therapy.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Air Injection and Transillumination in Phonosurgery: A Novel Technique
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Ismail Kocak*, Zeynep Alkan†,low asterisklow asterisk,'Correspondence information about the author Zeynep AlkanEmail the author Zeynep Alkan, Okan Ovunc‡
Journal of Voice

Accepted: March 20, 2019; Published online: April 12, 2019
Publication stage: In Press Corrected Proof
Abstract
Objectives/Hypothesis
The goal of this study was to introduce two novel techniques in phonomicrosurgery, air injection (AIR), and transillumination (TI), to improve the diagnosis and surgical excision of pathological tissue in vocal folds during suspension laryngoscopy while preserving the healthy tissue as much as possible.

Study design
Prospective clinical case series.

Methods
Thirty-four patients with benign vocal cord lesions who underwent phonomicrosurgery between January 2016 and May 2017 were evaluated. Pre- and intraoperative recordings were evaluated by three experienced laryngologists. Stroboscopic video images taken during the preoperative diagnosis and interoperative video recordings made before and after AIR and TI were performed were reviewed and compared. During the preoperative evaluation, the surgeons declared their surgical plans and noted changes while observing the intraoperative evaluation during AIR and TI.

Results
Sixty-eight vocal folds were evaluated. The initial diagnosis was found to be consistent with the final diagnosis in only 10 patients (29.4%). The diagnoses of 29 vocal folds (42.6%) and the surgical plans changed after AIR and TI. In six cases, submucosal bands, additional morphological structures in the vicinity of the primary pathology, were observed; these could only be visualized with AIR and TI. AIR and TI revealed new pathologies in four vocal folds that were noted to be normal in the preoperative evaluation.

Conclusion
AIR and TI are useful and promising techniques to identify undiagnosed lesions in vocal folds and to increase the success of minimally invasive phonosurgery.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
The Prevalence of Dysphonia and Dysphagia in Patients with Vitamin D Deficiency
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Abdul-Latif Hamdan*, Elie Khalifee*, Nader Al Souky*, Bakr Saridar*, Pierre Richard Abi Akl*, Anthony Ghanem*, Sami Azar†,low asterisklow asterisk,'Correspondence information about the author Sami AzarEmail the author Sami Azar
Journal of Voice

Accepted: March 14, 2019; Published online: April 12, 2019
Publication stage: In Press Corrected Proof
Abstract
Objective
To investigate the prevalence of phonatory and swallowing symptoms in patients with hypovitaminosis D.

Methods/Design
All patients presenting to the endocrinology clinic and investigated for vitamin D deficiency between January 2018 and April 2018 were asked to participate in this study. Demographic data included age, gender, allergy, and history of smoking. Patients filled Voice handicap Index (VHI-10) and Eating Assessment Tool (EAT-10).

Results
A total of 136 consecutive subjects presenting to the endocrinology clinic for vitamin D testing were included: 60 with hypovitaminosis D and 76 with no hypovitaminosis D. The mean vitamin D level in the study group and controls was 13.25 ng/mL and 31.91 ng/mL, respectively. There was no significant difference in the mean score of VHI-10, nor in the mean score of EAT-10 in patients with hypovitaminosis D versus those with no hypovitaminosis D (P value >0.05).

Conclusion
There was no significant difference in the prevalence of phonatory and dysphagia symptoms using VHI-10 and EAT-10 questionnaires between subjects with hypovitaminosis D and those with normal serum vitamin D levels.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Strap Muscle Type I Thyroplasty After Gore‐Tex Implant Extrusion: Case Report and Literature Review
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Rishabh Sethia*,†, Ryan J. Ivancic†, Winslo K. Idicula‡, Brad W. deSilva*,†,1,'Correspondence information about the author Brad W. deSilvaEmail the author Brad W. deSilva
Journal of Voice

Accepted: March 19, 2019; Published online: April 10, 2019
Publication stage: In Press Corrected Proof
ABSTRACT
Objectives
To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal.

Methods
We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation.

Results
A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0.

Conclusions
Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Group Voice Therapy Reduces Anxiety in Patients With Dysphonia
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Flávia Maiele Pedroza Trajano*,†, Larissa Nadjara Alves Almeida†, Sauana Alves Leite de Alencar†, João Euclides Fernandes Braga‡, Anna Alice Almeida§,low asterisklow asterisk,'Correspondence information about the author Anna Alice AlmeidaEmail the author Anna Alice Almeida
Journal of Voice

Accepted: March 12, 2019; Published online: April 09, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
To evaluate the impact of group therapy in patients with dysphonia, as well as to verify the correlation between vocal symptoms and levels of anxiety.

Methods
The study was composed of 52 patients subdivided into two groups, named the Experimental Group (EG) with 28 volunteers and the Control Group (CG) with 24 volunteers. Anxiety and voice protocols were used for data collection. The State-Trait Anxiety Inventory (STAI) was used to measure trait levels of anxiety that after collection were categorized according to the variation in scores value: low anxiety (20-40 points); average anxiety (40-60 points); high anxiety (60-80 points). In addition, the Voice Symptom Scale (VoiSS) was used for voice assessment. Inferential statistical analysis from the Student's t test for paired and independent data, in order to compare the average scores of STAI trait levels and VoiSS domains of the pre- and postmoments, intra- and intergroups, EG and CG, respectively. For that purpose, the program Statistical Package for Social Sciences (SPSS) was used.

Results
Half of the patients in the survey presented an average trait level of anxiety. Regarding the EG, there was a significant reduction of state anxiety when comparing the moments before and after group therapy. There was also a significant reduction in the values of the VoiSS-Total and VoiSS-Physical domains when compared to the pre- and postgroup therapy moments. It was verified the existence of a positive correlation between the levels of anxiety after group therapy and VoiSS-Total, VoiSS-Limitation, and VoiSS-Physical domains. As for the CG, there was an increase in anxiety levels as well as in all domains of the VoiSS scale when compared to the pre- and postmoments.

Conclusions
Group voice therapy was effective for a significant reduction of vocal symptoms and anxiety – common conditions in patients with dysphonia. It was possible to perceive the positive correlation between anxiety levels and vocal symptoms.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Is There a Relationship Between Vocal Effort and VHI?
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Brienne Ruel*,low asterisklow asterisk,'Correspondence information about the author Brienne RuelEmail the author Brienne Ruel, Susan Thibeault†
Journal of Voice

Accepted: March 14, 2019; Published online: April 08, 2019
Publication stage: In Press Corrected Proof
Summary
Objectives
Vocal effort is often a symptom reported when a patient experiences a voice disorder. The aim of this investigation was to compare Voice Handicap Index (VHI) scores among patients with primary complaints of vocal effort (VE) versus vocal quality (VQ) and both vocal effort and quality (VQ+VE). A secondary aim was to compare Glottal Function Index (GFI), and glottic closure pattern between patients with the aforementioned primary presenting complaints and laryngeal pathology diagnosis.

Study Design
Prospective outcomes database design

Methods
Patients were identified with presenting complaints of VQ, VE, or VQ+VE who completed the VHI. Seven hundred and thirteen subjects who met criteria were categorized across three complaint groups and five laryngeal pathologies. Variables selected included age, gender, diagnosis, VHI, GFI, and 12-Item Short Form Health Survey. VHI and GFI scores were compared between the three presenting complaints. Relationships between the categorical variables and glottic closure were also assessed.

Results
Significant differences in total VHI were measured among all three presenting-complaint categories (P < 0.0001). Patients with VE only complaints had significantly greater VHI scores than those patients who report VQ only complaints. VHI scores were significantly higher for patients with combined complaints of VQ+VE as compared to VQ only or VE only. Significant differences in GFI were measured across all three complaints, and GFI was significantly higher in VE only as compared to VQ only (P < 0.001). Glottic closure pattern was not statistically significant in the variables examined. VHI scores were significantly different within pathology subgroups (P < 0.03).

Conclusion
VE only complaints affect quality of life with and without concomitant VQ complaints. Patients with VE complaints perceive a higher level of glottic dysfunction. An underlying mechanism for increased VE could be altered glottic function, however, we were unable to suggest a correlation between glottic closure and GFI.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Prevalence, Characteristics and Impact of Dysphonia in US Marine Corps Drill Instructors
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Joseph Spellman*,†, Michael Coulter*, Carole Roth*, Christopher Johnson*,#,'Correspondence information about the author Christopher JohnsonEmail the author Christopher Johnson
Journal of Voice

Accepted: February 27, 2019; Published online: March 26, 2019
Publication stage: In Press Corrected Proof
Abstract
Importance
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.

Objective
The purpose of this study was to determine the prevalence of subjective, perceptual, and objective dysphonia in this population and to evaluate contributing factors and impact on job performance.

Design
Cross-sectional analysis.

Setting
United States Marine Corps base (Marine Corps Recruit Depot, San Diego, California).

Participants
Active US Marine Corps Drill Instructors.

Interventions
A survey was administered investigating subjective measures of dysphonia and its impact on occupational function. Standardized voice samples were recorded for objective and perceptual voice analysis.

Main Outcomes and Measures
Prevalence of subjective (Voice Handicap Index-10 and Glottal Function Index scores), perceptual (CAPE-V score), and acoustic (Cepstral-spectral index of dysphonia) measures of dysphonia.

Results
Subjective dysphonia was present in 47.7% by the Voice Handicap Index-10 and 70.2% by the Glottal Function Index. 51% of subjects reported periods of aphonia, while 47% reported voice problems limiting job function in the month prior to being surveyed. The Cepstral-Spectral Index of Dysphonia Mean was abnormal in 95.3% and CAPE-V overall severity score was abnormal in 94%. There was significant improvement in subjective, perceptual, and acoustic voice outcomes as the amount of time since last training cycle (ie, relative voice rest) and as experience as a Drill Instructor increased, however the VHI-10 was the only measure that normalized.

Conclusion and Relevance
There is a very high prevalence of self-reported dysphonia in Drill Instructors, with near-universal prevalence of some degree of objectively and perceptually-rated dysphonia. Nearly half of those surveyed reported that dysphonia limited their job performance. Relative voice rest and experience seem to mitigate severity, but normal ratings were rare. While objective and perceptually-rated dysphonia are persistent and highly prevalent, it does not necessarily translate into a perceived impairment in this population. For these reasons and considering the importance of extraordinary vocal function in this occupation, Drill Instructors appear to be in dire need of proper voice care to both maximize job performance and mitigate long-term voice-related problems.

Published by Elsevier Inc.
Article in Press
Adaptation and Validation of Vocal Fatigue Index (VFI) to Malayalam Language
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Usha Rajan Athira, Usha Devadaslow asterisk,'Correspondence information about the author Usha DevadasEmail the author Usha Devadas
Department of Speech and Hearing, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, India
Journal of Voice

Accepted: March 7, 2019; Published online: March 26, 2019
Publication stage: In Press Corrected Proof
Abstract
Objective
The purpose of the present study was to translate and validate the English version of the Vocal Fatigue Index (VFI) in to Malayalam language.

Methods
The English version of the VFI was translated into Malayalam language using parallel back translation. The translated version was content validated by three qualified Speech Language Pathologists. The final Malayalam version of the VFI was administered on 528 primary school teachers with and without self-reporting of voice problems. The internal consistency and test-retest reliability were determined using Cronbach's alpha and intraclass correlation coefficients. Independent sample t test was used to assess the difference in means. Receiver operating characteristic curves with sensitivity and specificity were calculated to set cut-off scores for three domains of Malayalam VFI.

Results
The results revealed that the Malayalam version of VFI has an excellent internal consistency across all the three factors of VFI; tiredness of voice and avoidance of voice use (α = 0.922), physical discomfort symptoms (α = 0.923), and improvement of symptoms with voice rest (α = 0.925). Independent sample t test revealed a significant difference (P ≤ 0.001) for total scores of three domains [tiredness and avoidance of voice use (factor 1), physical discomfort symptoms (factor 2), improvement in symptoms with voice rest (factor 3)] between teachers reporting voice problems and teachers not reporting voice problems. Cut-off scores for three different domains of the Malayalam VFI were set at ≥ 16.5 (80% sensitivity and 71.4% specificity) for factor 1, ≥ 6.5 (71.1% sensitivity and 70.1% specificity) for factor 2 and ≤ 7.5 (71.1% sensitivity and 69.9% specificity) for factor 3.

Conclusion
The Malayalam VFI was found to have good internal consistency and reliability. Hence, it can be considered as a valid and reliable tool for identifying vocal fatigue symptoms and its severity among the Malayalam speaking community who report voice disorders.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Perceptual Judgment of Voice Quality in Nondysphonic French Speakers: Effect of Task-, Speaker- and Listener-Related Variables
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Véronique Delvaux*,low asterisklow asterisk,'Correspondence information about the author Véronique DelvauxEmail the author Véronique Delvaux, Claire Pillot-Loiseau†
Journal of Voice

Accepted: February 25, 2019; Published online: March 25, 2019
Publication stage: In Press Corrected Proof
Abstract
Purpose
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. A second goal was to investigate the influence on this normal voice dataset, of variables known to affect perceptual judgments of pathological voice.

Material and methods
Sustained vowels and sentences produced by 80 healthy, normophonic French native speakers were perceptually assessed by a panel of 18 raters (nine students, nine experts) using the Grade Roughness Breathiness Asthenia Strain and a Rate of Dysphonia scale.

Results
The average overall grade was close to 1 on the (0 to 3) scale, questioning the notion of "normal" voice as opposed to dysphonic voice. Rating reliability as well as perceptual scores were affected by task-, speaker-, and listener-related factors: speech stimuli led to better rating reliability and were judged less severely than voice stimuli; experts were slightly more reliable and less severe than students; older speakers were unanimously considered as more dysphonic. Multiple interactions between these factors were observed, confirming the multidimensional nature of voice quality.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Detection of Muscle Tension Dysphonia Using Eulerian Video Magnification: A Pilot Study
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Jason Adleberg*, Ashley P. O'Connell Ferster†, Daniel A. Benito‡, Robert T. Sataloff§,low asterisklow asterisk,'Correspondence information about the author Robert T. SataloffEmail the author Robert T. Sataloff
Journal of Voice

Accepted: February 13, 2019; Published online: March 25, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
To determine whether Eulerian Video Magnification software is useful in diagnosis of muscle tension dysphonia (MTD).

Study Design
Prospective.

Methods
Adult patients scheduled in a tertiary care laryngology practice for evaluation of dysphonia were recruited between November 2016 and March 2017. Demographic and clinical data were extracted from patient charts. Diagnosis of MTD was confirmed with videostroboscopic and physical exam and by a speech-language pathologist. Eighteen MTD patients were video recorded while at rest and with phonation. Five patients without MTD also were analyzed as controls. Videos were analyzed using Eulerian Video Magnification software (Massachusetts Institute of Technology) to assess change in blood flow at the forehead, infrahyoid muscles, and sternocleidomastoid muscles, while using the values of the background wall as a control value.

Results
Patients with MTD demonstrated little change in perfusion to the infrahyoid muscles of the neck while phonating (+1% ± 55%). Control subjects demonstrated an increase in perfusion to the infrahyoid muscles while phonating (+102% ± 164%), with this change being significant when comparing the two groups (P = 0.04, t = 2.189, df = 21). A change in perfusion of 0% or less to infrahyoid muscles was 75% sensitive and 70% specific for diagnosis of MTD. No differences in perfusion were found between other regions assessed. Patient age and gender did not correlate with any change in perfusion between rest and phonation.

Conclusion
Our data suggest that Eulerian Video Magnification can be used in the diagnosis of MTD by focusing on the difference in perfusion to the infrahyoid muscles between rest and phonation.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
A Comparison of the s/z Ratio to Instrumental Aerodynamic Measures of Phonation
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Ashwini Joshilow asterisk,'Correspondence information about the author Ashwini JoshiEmail the author Ashwini Joshi
University of Houston, Houston, Texas
Journal of Voice

Accepted: February 27, 2019; Published online: March 20, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
The purpose of this study was to examine how the s/z ratio and instrumental measures of laryngeal valving and voicing efficiency.

Study Design
Prospective, cohort design.

Methods
Fifteen adult males (mean age 28.3 years) and 15 adult females (mean age 29.2 years) with normal voice quality were recruited and compared on productions of the s/z ratio and instrumental aerodynamic measures. The aerodynamic measures included vital capacity, maximum phonation time, airflow rate during sustained and sentence production, subglottal pressure, and laryngeal airway resistance. These measures were obtained on the Phonatory Aerodynamic System Model 6600. Statistical analyses included a univariate analysis of variance to examine for differences between sexes for all the variables, and between the s/z ratios for each of the three trials. Pearson's Product Moment Correlations were performed to identify the strength and nature of any significant relationships between the s/z ratio and instrumental aerodynamics.

Results
There were significant differences in the mean values between males and females only for the measures of vital capacity and maximum phonation time. There were no significant differences between the three trials for the s/z ratio. There was a significant moderate negative correlation between the s/z ratio and laryngeal airway resistance in females and between the s/z ratio and sentence airflow rate in males.

Conclusions
The s/z ratio demonstrated only a moderate correlation with limited instrumental measures of laryngeal valving. In the absence of clear evidence of its ability to accurately assess laryngeal valving, the s/z ratio should be used in combination with other instrumental measures of laryngeal aerodynamics for a better representation of aerodynamic functioning.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Auditory-Perceptual Evaluation of Deep Brain Stimulation on Voice and Speech in Patients With Dystonia
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Mary E. Finger*,†, Mustafa S. Siddiqui*, Amy K. Morris†, Kathryn W. Ruckart†, S. Carter Wright†, Ihtsham U. Haq*, Lyndsay L. Madden†,1,'Correspondence information about the author Lyndsay L. MaddenEmail the author Lyndsay L. Madden
Journal of Voice

Accepted: February 19, 2019; Published online: March 14, 2019
Publication stage: In Press Corrected Proof
ABSTRACT
Objective
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.

Methods
Voices of 14 patients aged ≥18years (males = 7 and females = 7) with primary dystonia (DYT1 gene mutation dystonia = 4, cervical dystonia = 6, and generalized dystonia = 4) with bilateral GPi DBS were assessed. Five blinded raters (two fellowship-trained laryngologists and three speech/language pathologists) evaluated audio recordings of each patient pre- and post-DBS. Perceptual voice quality was rated using the Grade, Roughness, Breathiness, Asthenia, and Strain scale and changes in speech intelligibility were assessed with the Clinical Global Impression scale of Severity instrument. Inter-rater and intrarater reliability rates for perceptual voice ratings were assessed using the kappa coefficient.

Results
Voice quality parameters showed mean improvements in Grade (P < 0.0001), Roughness (P = 0.0043), and Strain (P < 0.0001) 12 months post-DBS. Asthenia increased from baseline to 6 months (P = 0.0022) and declined significantly from 6 to 12 months (P = 0.0170). Breathiness did not change significantly over time. Speech intelligibility also improved from 6 to 12 months (P = 0.0202) and from pre-DBS to 12 months post-DBS (P = 0.0022). Grade and Strain ratings had nearly perfect and substantial inter-rater agreement (0.84 and 0.71, respectively).

Conclusions
Voice and speech intelligibility improved after bilateral GPi DBS for dystonia. GPi DBS may emerge as a potential treatment option for patients with medically refractory laryngeal dystonia.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Laryngeal and Pharyngeal Movements During Inner Singing: A Cross-Sectional Study
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Carmen Unterhofer*,low asterisklow asterisk,'Correspondence information about the author Carmen Unterhofer†,Email the author Carmen Unterhofer, Anna Maria Stefanie Buchberger*,†, Olivia Jeleff-Wölfler†, Naglaa Mansour‡, Simone Graf†
Journal of Voice

Accepted: February 19, 2019; Published online: March 12, 2019
Publication stage: In Press Corrected Proof
SUMMARY
Introduction
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.

Material and method
Thirty vocally healthy participants were examined transnasally with a flexible videoendoscope. The sample consisted of 10 nonsingers, 10 lay singers, and 10 professional singers. Participants were examined during five tasks including rest, silent reading, imagining a melody, listening to music, and reading music. Two medical doctors specializing in phoniatrics analyzed the videos both qualitatively and quantitatively.

Results
During the endoscopic examination, the raters identified movements at the base of the tongue, the posterior and lateral pharynx wall, the arytenoid cartilage, and the vocal folds. The inner singing tasks showed significantly more laryngeal movements as well as significantly more glottal closures than the control tasks (at rest, silent reading). Pharyngeal structures did not show an increase in activity during inner singing. These findings were independent of the level of proficiency in singing.

Conclusion
When total vocal rest is prescribed, patients should also be advised to avoid music imagination. Still, further research is needed to survey in detail the actual effects of these involuntary movements during inner singing on the regeneration process of vocal fold healing.

© 2019 Published by Elsevier Inc.
Article in Press
Electroglottography – An Update
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Christian T. Herbstlow asterisk,'Correspondence information about the author Christian T. HerbstEmail the author Christian T. Herbst
Bioacoustics Laboratory, Department of Cognitive Biology, Faculty of Life Sciences, University of Vienna, Wien, Austria
Journal of Voice

Accepted: December 28, 2018; Published online: March 11, 2019
Publication stage: In Press Corrected Proof
Abstract
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 60years 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.

After presenting an algorithmic bibliographic analysis, some methodological aspects pertaining to measurement technology, qualitative and quantitative analysis, and respective interpretation are discussed. In particular, the interpretation of landmarks in the (first derivative of the) EGG waveform is critically examined. It is argued that because of inferior-superior and anterior-posterior phase differences of vocal fold vibration, vocal fold (de)contacting does not occur instantaneously, but over an interval of time. For this reason, instants of vocal fold closing and opening cannot be resolved exactly from the EGG signal. Consequently, any quantitative analysis parameter relying on the determination of (de)contacting events (such as the EGG contact quotient) should be interpreted with care.

Finally, recent developments are reviewed for the various fields of application of EGG, including basic voice science and voice production physiology, speech signal processing and classification, clinical practice including swallowing, phonetics, hearing sciences, psychology, singing, trumpet playing, and mammalian and avian bioacoustics. Overall, EGG has over the past six decades developed into a mature technology with a wide range of applications. However, due to current limitations, the full potential of the methodology has as yet not been fully exploited. Future development may occur on three levels: (a) rigorous validation of existent measurement approaches; (b) introduction and rigorous validation of novel quantitative and interpretative approaches; and (c) advancement of the measurement technology itself.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Effect of Functional Endoscopic Sinus Surgery on Voice and Speech Recognition
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Estefanía Hernández-García*,low asterisklow asterisk,'Correspondence information about the author Estefanía Hernández-GarcíaEmail the author Estefanía Hernández-García, Laureano Moro-Velázquez†,‡, Ramón González-Herranz*, Juan Ignacio Godino-Llorente†, Guillermo Plaza*
Journal of Voice

Accepted: February 20, 2019; Published online: March 07, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
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.

Material and methods
A prospective study was performed between January 2017 and June 2017 including two groups of patients: those undergoing FESS, and a control group. Demographic data and GRBAS assessment were statistically analyzed. In addition, a recording of patients' voices was made with a subsequent acoustic analysis and automatic identification of the speaker through machine learning systems, establishing the equal error rate. Samples were taken before surgery, 2 weeks after surgery and 3 months later.

Results
After FESS, a significant difference was observed in Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS). Besides, acoustic analysis showed a significance decrease in fundamental frequency (F0), when compared with the control group. For the automatic identification of the speaker through computer systems, we found that the equal error rate is higher in the FESS group.

Conclusions
Results suggest that FESS produce a decrease of F0 and changes in the vocal tract that derive in an increase in the error of recognition of the speaker in FESS patients.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Pediatric Voice Handicap Index Profiles in Patients With Benign Vocal Fold Lesions
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Thomas Townes*,low asterisklow asterisk,'Correspondence information about the author Thomas TownesEmail the author Thomas Townes, Carolyn Noelke†, Jonathan Lively†, Pamela Mudd†
Journal of Voice

Accepted: February 14, 2019; Published online: March 04, 2019
Publication stage: In Press Corrected Proof
Summary
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. Forty-five patients in our study had BVFL. We found that the physical portion of the PVHI survey (PVHI-p) and the overall severity visual analog scale correlated significantly to the presence of BVFL, while the functional and emotional portions (PVHI-f and PVHI-e), the overall PVHI score, and the talkativeness scale did not. This supports the idea that the PVHI is a useful tool for pediatric dysphonia evaluation, and that paying particular attention to the distribution of symptoms within specific portions of the PVHI may be useful for predicting a patient's etiology of dysphonia.

Published by Elsevier Inc.
Article in Press
The Impact of Respiratory Exercises on Voice Outcomes: A Systematic Review of the Literature
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Maude Desjardins*, Heather Shaw Bonilha*,†,low asterisklow asterisk,'Correspondence information about the author Heather Shaw BonilhaEmail the author Heather Shaw Bonilha
Journal of Voice

Accepted: January 24, 2019; Published online: February 25, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
The role of respiratory exercises in voice therapy remains unclear as many patients do not need extensive breath support to meet their voice demands. However, since these exercises are commonly used in clinical practice and ubiquitous in voice therapy textbooks, there is a need to determine the evidence for using respiratory exercises to improve vocal function.

Objective
The goal of the present review is to determine the state of the evidence regarding the effectiveness of respiratory interventions to improve respiratory and voice outcomes.

Methods
A review of the literature was conducted using three electronic databases: Pubmed, Scopus, and CINAHL. A search strategy was developed to highlight two main concepts: (1) voice and (2) respiratory exercises.

Results
Out of 650 articles identified through the search, 23 articles met the inclusion criteria, spanning nine types of respiratory exercises: (1) expiratory muscle strength training; (2) inspiratory muscle strength training; (3) incentive spirometry; (4) isocapnic hyperpnea; (5) respiratory effort treatment; (6) abdominal directives; (7) "easy breathing"; (8) stimulation training; and (9) vocalization with abdominal breath support. Respiratory improvements were reported in 12 articles. Nine of 12 articles also reported some voice improvements, although these were limited to subsets of participants.

Conclusions
The results of this review suggest that the evidence to support using respiratory exercises to improve vocal function is specific to a patient's respiratory and vocal needs. That is, current evidence does not support using respiratory exercises for all patients with voice disorders. Emerging evidence also indicates the importance of generalizing the outcomes of respiratory exercises to voice tasks. It is critical that the mechanism of action through which respiratory exercises can impact voice outcomes be thoroughly understood, and it is hoped that future research will help provide more information in this regard.

© 2019 Published by Elsevier Inc.
Article in Press
Ex Vivo Porcine Larynx Model for Microlaryngoscopy Laryngeal Surgery: Proposal for a Structured Surgical Training
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Michael Ghirelli, MD *,low asterisklow asterisk,'Correspondence information about the author MD Michael GhirelliEmail the author MD Michael Ghirelli, Francesco Mattioli, MD *, Gaia Federici, MD *, Gaetano Ferri, MD *, Andrea Malagoli, PhD, MD†, Marco Trebbi, MD *, Livio Presutti, MD *
Journal of Voice

Accepted: February 13, 2019; Published online: February 25, 2019
Publication stage: In Press Corrected Proof
Summary
Purpose
Microlaryngoscopy laryngeal surgery (MLS) is a highly specialized and delicate surgical procedure performed by a single operator. The aim of this study is to report the initial development of a validated and codified training program on ex vivo porcine larynx, allowing residents to obtain the basic skills of the MLS.

Methods
Two residents without previous MLS experience were tested with four different exercises on 10 larynxes, one side at a time. The time needed for each exercise was noted. A skilled surgeon performed the same procedure, and this was considered to be the gold standard. Videos of the training exercise were evaluated by the two expert surgeons in a random, blinded sequence, using a modified global rating scale (GRS) to evaluate specific surgical skills.

Results
The median execution times and GRS scores were calculated for both residents. Execution times and surgical skill scores were subsequently analyzed. For each exercise, a Spearman test between observations and time was performed to evaluate a significative increasing or decreasing trend in time execution. Execution times and surgical skills were also compared between the two subjects. Wilcoxon rank-sum test was used to evaluate any significant differences between them. A P value ≤0.05 was considered statistically significant. The results showed a significant improvement of the execution times for each resident (P value < 0.01). While the GRS scores for the exercises have remained between 3.0 and 5.0 from the first to the last procedure.

Conclusion
MLS training on a porcine ex vivo model is useful, repeatable, and low cost. The work showed that, after only 10 training sessions, two residents without experience in MLS could quickly improve their execution times without statistically significant decrease of the visual analysis of surgical skills.

© 2019 Published by Elsevier Inc.
Article in Press
Voice Disorders in Islamic Religious Officials: Is It Any Different Than Those of the Teachers, Another Well-Known Professional Voice Users?
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Zahide Ciler Büyükatalaylow asterisk'Correspondence information about the author Zahide Ciler Büyükatalay, Muhammed Fatih Gökmen, Sibel Yıldırım, Gürsel Dursun
Department of Otorhinolaryngology, Head and Neck Surgery, Ibni Sina Hospital, Ankara University School of Medicine, Ankara, Turkey
Journal of Voice

Accepted: February 6, 2019; Published online: February 21, 2019
Publication stage: In Press Corrected Proof
Summary
Objectives
This study explores Islamic religious officials' voice use, disorders, and treatment methods by comparing the officials with teachers, the largest group of voice professionals.

Study Design
This is a nonrandomized retrospective study.

Methods
This study included 85 patients with voice disorder complaints; 42 were religious officials and 43 were teachers. We compared the two groups of patients in terms of demographic information, job descriptions, years in their professions, smoking histories, alcohol consumption, allergies and other systemic disorders, average weekly vocal loads, voice training, vocal abuse–misuse, reflux symptom index and voice handicap index scores, and voice disorder diagnosis and treatment methods.

Results
The study compared 39 male (92.85%) and three female (7.14%) religious officials with five male (11.62%) and 38 female (88.37%) teachers. The alcohol use, systemic diseases, and vocal loads were found to be statistically higher in the teachers than the religious officials (P < 0.05), while the vocal abuse–misuse, vocal hygiene knowledge, and voice handicap indices were determined to be statistically higher in the religious officials than the teachers (P < 0.05). A statistically significant difference in the distribution of the diagnoses exists between the two groups (P < 0.005). Voice therapy is the most common treatment method in both groups.

Conclusions
Like teachers, Islamic religious officials appear to be at high risk of developing voice disorders. Because of the lack of research on the frequency of voice disorders among Islamic religious officials, it is important to raise awareness of the prevalence of voice disorders.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Voice Outcomes Following Multiple Surgeries for Recurrent Respiratory Papillomatosis
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Lindsey A. Parker*,‡, Melda Kunduk*,‡,§,low asterisklow asterisk,'Correspondence information about the author Melda KundukEmail the author Melda Kunduk, David Blouin†, Lacey Adkins‡,§, Andrew J. McWhorter‡,§
Journal of Voice

Published online: February 19, 2019
Publication stage: In Press Corrected Proof
Summary
Objectives
Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus that presents as warty, exophytic growths in the upper airway. RRP in the larynx can lead to severe airway obstruction and voice changes. It is clinically known that patients with RRP frequently experience dysphonia. The purpose of this study was to assess the impact of multiple surgical treatments on RRP patients' voice outcomes, and to determine whether a higher number of repeated surgeries lead to decreased voice quality.

Methods
A retrospective cohort study was conducted of adult RRP patients (n = 23) who underwent multiple surgeries. Group 1 included patients (n = 11) who had <5 surgeries (range 2–4 surgeries) and Group 2 included patients (n = 12) who had ≥5 surgeries (range 5–50+ surgeries). Voice recordings were selected from the following clinic visits: initial office visit (initial presurgery), first postsurgery, and the last clinic encounter(s) with no immediate planned surgery. Blinded auditory-perceptual ratings along with cepstral and spectral acoustic measures assessed voice severity.

Results
There was significant improvement from the initial presurgery visit compared to each postoperative visit over time for all voice outcome measures for both Group 1 and Group 2. The results of the study indicated that the number of surgeries did not significantly affect mean postoperative voice outcomes, and there were no significant differences between patient groups for voice quality over time.

Conclusions
The results of this study suggest that RRP patients' voice quality may not suffer cumulative negative effects when using modern tissue-sparing surgical techniques.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Measurement Reliability of Laryngeal Resistance and Mean Flow Rate in Pediatric Subjects
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Austin J. Scholp, Calvin D. Hedberg, Jim R. Lamb, Matthew R. Hoffman, Maia N. Braden, J. Scott McMurray, Jack J. Jianglow asterisk,'Correspondence information about the author Jack J. JiangEmail the author Jack J. Jiang
University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Madison, Wisconsin
Journal of Voice

Accepted: February 11, 2019; Published online: February 19, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
Mean flow rate (MFR) and laryngeal resistance (RL) are sensitive to changes in glottal configuration and biomechanics. There is little reported on aerodynamic parameters in children. We conducted a pilot study to evaluate MFR and RL measurement reliability in a pediatric population using labial and mechanical interruption methods.

Method
Thirty-nine subjects aged 4–17 performed 10 trials per method. For labial interruptions, subjects produced five labial plosives at a comfortable amplitude. For mechanical interruptions, subjects maintained a steady /α/ while a balloon valve interrupted their airflow five times for 250 milliseconds each. MFR was measured as the flow through the interruption device between interruptions. RL was calculated by dividing subglottal pressure (Ps) by MFR. The primary outcome measures of this study were the coefficients of variation of MFR and RL. Paired t tests were used to compare each variable between the two methods. Pearson's correlation was used to analyze the relationship between each parameter and subject age.

Results
Mean PS (t(38) = 2.966, P < 0.01) and RL (t(38)=3.563, P < 0.01) were higher for labial interruptions while mean MFR (t(38) = −2.036, P < 0.05) was lower. Intrasubject coefficients of variation were higher for the labial technique for both MFR (t(38) = 4.939, P < 0.001) and RL (t(38) = 3.439, P < 0.01) while there was no difference in PS variability (P = 0.260). Mean MFR and RL were related to age for both the labial (MFR: r = 0.588, P < 0.001; RL: r = −0.468, p = 0.003) and mechanical trials (MFR: r = 0.534, P < 0.001; RL: r = −0.496, P = 0.001). The coefficients of variation for RL were negatively correlated with age for both labial (r = −0.415, P = 0.009) and mechanical trials (r = −0.471, P = 0.002). MFR was only correlated in the labial trials (r = −0.514, P = 0.001) and PS was only correlated in the mechanical trials (r = −0.519, P = 0.001).

Conclusions
Differences in means and intrasubject variation are likely due to differences in task and measurement timing. Precision of MFR and RL measurement in pediatric subjects was higher for mechanical interruption; further exploration of this method and its clinical utility is warranted. Measurement of aerodynamic parameters may be a useful addition to pediatric voice assessment.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Phonotherapeutic Intervention in Patients With Mucosal Leishmaniasis Sequelae
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Famiely Colman Machado de Machado*,low asterisklow asterisk,'Correspondence information about the author Famiely Colman Machado de MachadoEmail the author Famiely Colman Machado de Machado, Marcus Miranda Lessa†, Carla Aparecida Cielo‡, Tássia Milenna de Oliveira Souza§, Fernanda Ventin Prates de Souza§, Camila Sampaio Ribeiro§, Juliana Almeida Silva§, Edgar Marcelino de Carvalho Filhoǁ, Paulo Roberto Lima Machado¶, Thaynara Montagner**, Mailane Mota Muniz#, Thalita Nunes Barbosa##, Daniela Da Silva Gonçalves**, Carolina Cincurá†
Journal of Voice

Accepted: December 26, 2018; Published online: February 19, 2019
Publication stage: In Press Corrected Proof
ABSTRACT
Purpose
To characterize the voice before and after speech-language intervention, with Humming nasal sound in patients with sequelae Mucosal Leishmaniasis (ML) and Cutaneous Leishmaniasis (CL).

Methods
Collection of phonation /a:/ from 44 patients with ML and CL for perceptual voice analysis and computed acoustic. The Wilcoxon nonparametric test and Fisher's exact test were used, with significance level of 5%.

Results
It was observed, prespeech therapy, that 27.7% of participants with ML presented asthenic vocal quality, and for the acoustics characteristics there was a statistically significant result for measures of frequency, frequency disturbance, noise, and subharmonic measurements, indicating phonatory instability, weakness, and noise emission giving the emission a feeling of vocal weakness. After therapy, the subharmonic segment measurements for the group with ML, showing reduction noise emission. Patients with CL had more grade 1 instability (36.4%), indicating tremor in vocal tract structures. After speech therapy, this group presented a reduction in the degree of roughness and reduction of the frequency disturbance measures, indicating a decrease in tension in the larynx and pharynx.

Conclusion
Even after completing treatment for LM, patients may experience vocal changes due to the sequelae of the disease, like vocal alterations due to nasal lesions or in other locations that interfere in the correct vocal emission. As for participants with CL, no vocal changes would be expected, since these patients present thorax, leg and arm lesions that would not cause problems for the voice. Nevertheless, the two groups of participants presented vocal changes to different degrees before vocal therapy. However, it was observed that patients with ML present vocal alterations with more severe degrees. After the speech-language intervention, the participants of both groups showed vocal improvement, but the group with CL presented more vocal benefits, possibly due to the previous vocal alterations not being so severe.

© 2019 Published by Elsevier Inc.
Article in Press
Correlating Undiagnosed Hearing Impairment with Hyperfunctional Dysphonia
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Ahmed Nagy*,†,low asterisklow asterisk,'Correspondence information about the author Ahmed NagyEmail the author Ahmed NagyEmail the author Ahmed Nagy, Reham Elshafei†, Somaya Mahmoud†
Journal of Voice

Accepted: February 6, 2019; Published online: February 18, 2019
Publication stage: In Press Corrected Proof
Abstract
Purpose
This study initially investigated the co-occurrence of hearing impairment that had not been previously diagnosed in a group of patients with hyperfunctional dysphonia. Subsequently, it explored whether any correlations exist between quantitative dysphonia severity assessment parameters and distinctive acoustic features of hearing impairment.

Method
The age-stratified participants were 36 patients presenting with hyperfunctional dysphonia to the voice clinic. For each subject, the following measurements were collected: grade of dysphonia severity rating by the clinician, a Voice Handicap Index (VHI) Patient Questionnaire, and an acoustic analysis of a standardized voice sample. Subsequently, the participants were referred to the audiology clinic for pure tone audiometry testing.

Results
The co-occurrence of hyperfunctional dysphonia and coincidentally discovered hearing impairment showed a percentage of 33% in the study subjects. There were no significant differences in the acoustic profiles of patients with and without hearing impairment. Mean frequency and jitter % were positively correlated in all investigated cohorts, except in subjects with simultaneous occurrence of hearing impairment and dysphonia. Mean intensity and shimmer % were not correlated in any of the groups investigated.

Conclusion
The physiological mechanism for regulating pitch perturbation is altered in individuals with hearing impairment compared to normal hearing subjects. Pitch and amplitude perturbation have different regulatory mechanisms.

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Article in Press
The Relationship Between Vocal Fatigue Index and Voice Handicap Index in University Professors With and Without Voice Complaint
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Maedeh Moghtader1, Majid Soltani2, Mohammad Mehravar1, Mohammad JafarShaterzadehYazdi1, Maryam Dastoorpoor3,4, Negin Moradi2,low asterisk,'Correspondence information about the author Negin MoradiEmail the author Negin Moradi
Journal of Voice

Accepted: January 24, 2019; Published online: February 13, 2019
Publication stage: In Press Corrected Proof
Abstract
Introduction
University professors, just like teachers, are considered as professional voice users, who are subject to voice disorders and complaints due to their field of work. The present study aims to investigate the relationship between vocal fatigue index and voice handicap index in university professors with and without voice complaint.

Methods
This is a cross-sectional descriptive-analytic study that was conducted on 84 university professors with an average age of 38.27 ± 9.95. University professors were divided into two groups with and without voice complaints based on the opinion of the professors about the existence or absence of voice complaint. Data obtained from this study was analyzed using SPSS 22 software at a significant level of less than 0.05.

Results
There was a significant correlation between vocal fatigue index and voice handicap index in university professors (P <0.05). In the university professors without voice complaints, only the third factor of the vocal fatigue index was not significant (P > 0.05). However, in this group, there was a significant correlation between the first and the second factor of vocal fatigue index and voice handicap index (P < 0.05).

Conclusion
The results of this study indicate the effect of vocal fatigue on the quality of life of university professors. University professors, like teachers, are exposed to voice disorders and, thus, complaints which leave impacts on their career and should be addressed as a group of professional voice users to prevent voice disorder among them.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Repetitive Voice Evaluation in Dysphonic Teachers: Office Versus Home
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Batoul Jaber*,1,'Correspondence information about the author Batoul JaberEmail the author Batoul Jaber, Reina Remman*, Nayla Matar†
Journal of Voice

Accepted: January 25, 2019; Published online: February 11, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
A patient's voice can vary from one moment to another, and these variations cannot be captured by a one-time assessment. Multiple assessments may give a more holistic idea of the severity of the patient's dysphonia and by asking the patient to do the recordings he becomes involved in his therapeutic plan from the beginning.

Aim
This study aims to evaluate the added value of a repetitive assessment outside the speech therapist's (SLP) clinic, to have a broader vision of the voice disorder and identify parameters that change after working hours to be able to explain this disorder and find solutions for it.

Methodology
Twelve dysphonic Lebanese teachers, aged between 20 and 60 years, recorded their voices once at the SLP's office, and five other times at home every day after working hours. The recordings included a standardized text and a sustained /ɑ/. For perceptive evaluation of voice quality, six SLPs (three experts and three naïve) analyzed the recordings using the GRBAS scale. For self-assessment, patients filled two self-assessment grids at the office: (SSVS: subjective assessment for vocal overwork) and the Lebanese Voice Handicap Index (VHI-10lb) questionnaire. They responded orally to a third scale ranging from 0 to 100 assessing the severity of dysphonia every day after completing the repetitive home recordings. For objective evaluation of the acoustic parameters, PRAAT software was used.

Results
Results reveal significant difference between the scores of the voices recorded in the office compared to the home repetitive assessment for the G and R of the perceptual evaluation with P < 0.01, as well as for the Jitter, the fundamental frequency, and the harmonic-to-noise ratio with P < 0.05. The recordings made at home revealed a more severe dysphonia. The self-evaluation scales 1 and 2 (VHI-10Ib, SSVS) did not correlate with the results of the objective and perceptual analysis, whereas the results of the oral self-assessment 3 seem to be in agreement with the results of Jitter (P < 0.05), and Grade of dysphonia (P < 0.05).

Conclusions
In teachers, the severity of dysphonia is more pronounced when the voice is recorded after working hours. Daily self-evaluation allows the patient to be more aware of his vocal disorder and voice fluctuations and might improve participation and compliance with therapy. It may also be used to monitor the response to speech therapy.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Pitch-Synchronous Analysis of Human Voice
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C. Julian Chen*,1,'Correspondence information about the author C. Julian ChenEmail the author C. Julian Chen, Donald A. Miller†
Journal of Voice

Accepted: January 16, 2019; Published online: February 07, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
Based on simultaneous voice and electroglottograph (EGG) signals, to gain a better understanding of human voice production process, to make pitch-synchronous segmentation of voice signals, and to make visual representations of pitch marks and timbre spectra with high resolution.

Methods/Design
The traditional spectrogram segments the voice signals with a process window of fixed size and fixed shift, then performs fast Fourier transformation after multiplied with a window function, typically a Hamming window. Then display power spectrum in both frequency and time. Pitch information and timbre information are mixed. The new design segments the signals into pitch periods, either using the derivatives of the EGG signals or based on the voice signals, then performs Fourier analysis to the segment of signals in each pitch period without using a window function. The pitch information and the timbre information are cleanly separated. The graphical representations of both pitch marks and timbre spectra exhibit high resolution and high accuracy.

Results
Detailed analysis of simultaneously acquired voice and EGG signals provides a more precise understanding of human-voice production process. The transient theory of voice production, proposed by Leonhard Euler in early 18th century, is substantiated with modern data. Based on the transient theory of voice production, a pitch-synchronous spectrogram software is developed, which makes a visual representation of pitch marks and timbre spectra. In addition, the timbre spectrum and the power evolution pattern in each pitch period can be displayed individually.

Conclusions
Simultaneously acquired voice and EGG signals indicates that each glottal closing triggers a decaying elementary wave in the vocal tract. A superposition of those elementary waves constitutes voice. Based on that concept and using EGG data, a pitch-synchronous voice signal processing method is developed. The voice signal is first segmented into pitch periods, then the two ends are equalized. Fourier analysis is applied to obtain the timbre spectrum of each pitch period. High resolution display of timbre spectrum is generated. The power evolution pattern in each pitch period is also displayed.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
The Voice Performance After Septoplasty With Surgical Efficacy Demonstrated Through Acoustic Rhinometry and Rhinomanometry
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Emre Apaydın*,#,'Correspondence information about the author Emre ApaydınEmail the author Emre Apaydın, Aykut İkincioğulları†, Mustafa Çolak†, Doğan Atanǂ, Serdar Ensari†, Hacı Hüseyin Dere†
Journal of Voice

Accepted: January 16, 2019; Published online: February 07, 2019
Publication stage: In Press Corrected Proof
Abstract
Objective
To demonstrate the surgical efficacy of septoplasty using acoustic rhinometry (AR) and anterior rhinomanometry (ARM) and to evaluate the effect of septoplasty on voice performance through subjective voice analysis methods.

Materials and Methods
This prospective study enrolled a total of 62 patients who underwent septoplasty with the diagnosis of deviated nasal septum. Thirteen patients with no postoperative improvement versus preoperative period as shown by AR and/or ARM tests and three patients with postoperative complications and four patients who were lost to follow-up were excluded. As a result, a total of 42 patients were included in the study. Objective tests including AR, ARM, acoustic voice analysis and spectrographic analysis were performed before the surgery and at 1 month and 3 months after the surgery. Subjective measures included the Nasal Obstruction Symptom Evaluation questionnaire to evaluate surgical success and Voice Handicap Index-30 tool for assessment of voice performance postoperatively, both completed by all study patients.

Results
Among acoustic voice analysis parameters, F0, jitter, Harmonics-to-Noise Ratio values as well as formant frequency (F1-F2-F3-F4) values did not show significant differences postoperatively in comparison to the preoperative period (P > 0.05). Only the shimmer value was statistically significantly reduced at 1 month (P < 0.05) and 3 months postoperatively (P < 0.05) versus baseline. Statistically significant reductions in Voice Handicap Index-30 scores were observed at postoperative 1 month (P < 0.001) and 3 months (P < 0.001) compared to the preoperative period and between postoperative 1 month and 3 months (P < 0.05).

Conclusion
In this study, first operative success of septoplasty was demonstrated through objective tests and then objective voice analyses were performed to better evaluate the overall effect of septoplasty on voice performance. Shimmer value was found to be improved in the early and late postoperative periods.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Variation on Vocal Economy After Different Semioccluded Vocal Tract Exercises in Subjects With Normal Voice and Dysphonia
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Carlos Calvache*,low asterisklow asterisk,'Correspondence information about the author Carlos CalvacheEmail the author Carlos Calvache, Marco Guzman†, Marcelo Bobadilla‡, Cori Bortnem*
Journal of Voice

Accepted: January 3, 2019; Published online: February 06, 2019
Publication stage: In Press Corrected Proof
SUMMARY
Purpose
The present study aimed at observing the possible differential effects of eight semioccluded vocal tract exercises (SOVTE) on vocal economy measured by the Quasi Output Cost Ratio (QOCR).

Methods
Thirty-six participants were included in this study. They were divided into two groups: an experimental group of subjects diagnosed with mild hyperfunctional dysphonia (n = 17) and a control group of vocally healthy subjects (n = 19). Participants were required to randomly select and produce a series of three SOVTE from a list of eight exercises. The electroglottographic based measure QOCR was used to calculate the vocal economy before and after each voice exercise.

Results
Significant differences were found when comparing pre and poststages regardless of the vocal condition (normal voice or dysphonia) or the specific SOVTE used. Moreover, when individually comparing the effect of each SOVTE, only tube in water (10 cm) showed significant differences between pre and postconditions (QOCR values were higher after exercises).

Conclusion
In general, semioccluded vocal tract exercises tend to increase vocal economy regardless the vocal condition (normal voice or dysphonia) or the specific SOVTE used. Phonation into a tube submerged deep into water promoted the highest increase in vocal economy. An increased acoustic output, nonproportional increase in vocal folds adduction and an effortless voice production would cause this increase in vocal economy after water resistance therapy.

© 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
Article in Press
An Acoustic Examination of Pitch Variation in Soprano Singing
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Glaucia Verena Sampaio de Souza*, João Marcos Trindade Duarte*, Flávia Viegas†, Marcia Simões-Zenari*,low asterisklow asterisk,'Correspondence information about the author Marcia Simões-ZenariEmail the author Marcia Simões-Zenari, Kátia Nemr*
Journal of Voice

Accepted: December 10, 2018; Published online: February 01, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
The ability to perform acoustic inspection of data and to correlate the results with perceptual and physiological aspects facilitates vocal behavior analysis. The singing voice has specific characteristics and parameters that are involved during the phonation mechanism, which may be analyzed acoustically.

Objective
To describe and analyze the fundamental frequency and formants in pitch variation in the /a/ vowel in sopranos.

Methods
The sample consisted of 30 female participants between the ages of 20 to 45 years without vocal complaints. All sustained vowel sounds were recorded with the /a/ vowel sustained for 5 seconds, with three replications at low (C4–261 Hz), medium (Eb4–622 Hz), and high (Bb4–932 Hz) frequencies that were comfortable for the voice classification. In total, 90 samples were analyzed with digital extraction of the fundamental frequency (f0) and the first five formants (F1, F2, F3, F4, and F5) and manual confirmation. The middle segment was considered for analysis, whereas the onset and offset segments were not considered. Subsequently, FFT (fast Fourier transform) plots, LPC (linear predictive coding) graphs, and tube diagrams were created. The Shapiro-Wilks test was applied for adherence and the Friedman test was applied for comparison of paired samples.

Results
For vocalizations at low and medium pitches, higher values were observed for the first five formant frequencies than for the f0 value. Overlaying the LPC and FFT graphs revealed a similarity between F1 and F2 at the two pitches, with clustered harmonics in the F3, F4, and F5 region in the low pitch. At the medium pitch, there was similarity between F3 and F4, an F5 peak, and tuned harmonics. However, in the high-pitch vocalizations, there was an increase in the F2, F3, F4, and F5 values in relation to f0, and there was similarity between them along with synchrony between f0 and F1, H2 and F2, H3 and F3, H4 and F4, and H5 and F5.

Conclusions
Pitch changes indicate differences in the behavior of the fundamental frequency and sound formants in sopranos. The comparison of the sustained vowels sounds in f0 at the three pitches revealed specific vocal tract changes on the LPC curve and FFT harmonics, with an extra gain range at 261 Hz, synchrony between peaks of formants and harmonics at 622 Hz, and equivalence of f0 and F1 at 932 Hz.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Principles of Motor Learning in Classical Singing Teaching
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Laura Crocco, Patricia McCabe, Catherine Madilllow asterisk,'Correspondence information about the author Catherine MadillEmail the author Catherine Madill
The University of Sydney, Sydney, Australia
Journal of Voice

Accepted: December 26, 2018; Published online: February 01, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
Classical singing is a complex and multifaceted skill that requires the amalgamation of multiple cognitive, perceptual and motor functions. The teaching of classical singing is consequently a unique skill that holds further complexity. The singer is required to achieve and maintain consistently high performance development of a specific motor activity, much like the sports athlete. This pilot study examines a method of using the principles of motor learning to more objectively and reliably investigate the teaching behaviors of classical singing teachers. Such a method may establish a nexus between empirical research, teaching quality and learning outcomes in music performance education.

Method
A total of 12 participants were recruited from two Australian conservatoria of music. All participants were fluent in English at tertiary level. Participants included four classical singing teachers and eight classical singing students over the age of 18 years. Eight one-to-one singing lessons between the teacher and student were audio-visually recorded. Content analysis was conducted on the observational data. The principles of motor learning were used as a behavioral framework protocol to allow for the systematic identification of teaching behavior.

Results
Results presented various findings regarding teaching behaviors in one-to-one classical singing lessons in higher music education. Key findings included (a) common use of instruction, feedback, modeling, and other behaviors (b) uncommon use of motivation, explanation, and perceptual training behaviors, (c) higher use of knowledge of results than knowledge of performance feedback behaviors, (d) high routine use of instruction, modeling, and feedback behaviors each time a student attempted a task, (e) common use of other suggested teachers use behaviors unidentifiable by the behavioral protocol, and (f) the principles of motor learning appear to be a reliable framework for the identification of teaching behaviors in this field.

Conclusion
This study may have implications for how teachers administer and govern their behaviors in one-to-one classical singing lessons. The principles of motor learning may encourage a nexus between empirical research, teaching quality, and learning outcomes. Furthermore, this study provides recommendations for future research on systematically improving teaching and learning in this field.

© 2019 Published by Elsevier Inc.
Article in Press
Lorazepam-Assisted Interview in a Resistant Case of Functional Dysphonia
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Tamonud Modak*,low asterisklow asterisk,'Correspondence information about the author Tamonud ModakEmail the author Tamonud Modak, Saurabh Singh*, Senthil Kumaran†, Koushik Sinha Deb*, Rakesh K Chadda*
Journal of Voice

Accepted: January 3, 2019; Published online: January 28, 2019
Publication stage: In Press Corrected Proof
Summary
Background
Functional neurological symptom disorder presents with varied neurological signs often as a result of stress. It is usually treated with supportive psychotherapy and occasionally antidepressants. Literature regarding treatment for resistant cases is scarce. We describe on such presentation.

Case presentation
A 40-year-old man who presented with a history of sudden onset dysphonia for 5 days. There were no immediate stressors. Physical examination revealed that he was unable to make movements of the tongue while speaking although power and range of movement were normal. Magnetic resonance imaging and computed tomography of brain and endoscopic examination of oral cavity and larynx did not reveal any organic cause. Functional magnetic resonance imaging imaging was conducted under a language protocol to determine neurophysiological circuits involved in this unique presentation. The patient failed conventional pharmacotherapy and supportive psychotherapy. Thereafter, he underwent lorazepam-assisted interviews where he would be asked to made purposive movements of the tongue and attempt to pronounce basic phonemes. He would converse normally during the lorazepam interviews and made gradual improvements after each session. The patient was able speak clearly after 12 such sessions and continues to maintain well since.

Conclusions
We describe a resistant case of functional dysphonia. The patient presented without any stressor and failed conventional treatments. The case demonstrates that Lorazepam can be used effectively in drug-assisted interviews for functional dysphonia. It also provides information regarding functional activity of the brain during a dissociative state.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Relationship Between Laryngeal Signs and Symptoms, Acoustic Measures, and Quality of Life in Finnish Primary and Kindergarten School Teachers
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Caitriona Munier*,1,'Correspondence information about the author Caitriona MunierEmail the author Caitriona Munier, Meike Brockmann-Bauser†, Anne-Maria Laukkanen‡, Irma Ilomäki‡, Elina Kankare§, Ahmed Geneid*
Journal of Voice

Accepted: December 10, 2018; Published online: January 25, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
This study investigated the relationship between the acoustic measure smoothed cepstral peak prominence (CPPS), teacher's quality of life as measured by the voice activity and participation profile (VAPP), laryngeal signs and symptoms, voice related health problems and laryngoscopic findings in Finnish teachers. The relationship between CPPS and sound pressure level (SPL) was also assessed.

Methods
Vowel and text samples from 183 healthy Finnish teachers (99 kindergarten teachers [KT] and 84 primary school teachers [PST]) were analyzed for CPPS. Text reading was recorded in conversational loudness by PST, and KT were recorded wearing headphones, while listening to a masking noise of children talking to simulate their classroom voice and environment. CPPS values were correlated with the VAPP, self-reported laryngeal signs and symptoms, voice related health variables, and laryngoscopic findings.

Results
There was a significant difference between the two groups for CPPS text, PST showed significantly lower CPPS values (10.44) than KT (11.52). There was no difference between the two groups for CPPS vowel phonation. There was a significant correlation between SPL text and CPPS text for KT (P < 0.001, r = 0.43) but not for PST (P < 0.10, r = 0.16). There was a significant correlation between SPL vowel and CPPS vowel for both PST (P < 0.001, r = 0.47) and KT (P < 0.001, r = 0.45). CPPS did not correlate with the VAPP, laryngeal signs and symptoms, health variables or laryngeal findings.

Factorial analysis of variance resulted in a significant relationship between the VAPP, laryngeal signs and symptoms, and teacher type. Teacher type and symptoms had a significant effect on VAPP scores.

Conclusions
In the present work CPPS does not correlate with vocal health indicators of functionally healthy teachers. CPPS was significantly influenced by differences in speaking voice SPL, emphasizing the impact of recording conditions and technique. There was a significant relationship between laryngeal signs and symptoms, teacher type and the VAPP. Laryngeal signs and symptoms and teacher type are important variables and should be included in the clinical evaluation of occupational voice users, and voice problems.

© 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
The Effect of Supraclavicular Radiotherapy on Acoustic Voice Quality Index (AVQI), Spectral Amplitude and Perturbation Values
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Saime Sagiroglu*,low asterisklow asterisk,'Correspondence information about the author Saime SagirogluEmail the author Saime Sagiroglu, Neslihan Kurtul†
Journal of Voice

Accepted: January 3, 2019; Published online: January 24, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
The Acoustic Voice Quality Index (AVQI), spectral amplitude, and voice perturbation parameters are objective assessment methods that are used in clinical settings and for research purposes. The aim of this study was to demonstrate the effect of supraclavicular RT on the physiology and function of the vocal fold.

Methods
A total of 29 female patients were included in the study. The voices of the patients, who were diagnosed with breast cancer and underwent supraclavicular RT, were recorded before and after the treatment (1 and 6 months). AVQI, spectral amplitude (H1-H2, H1-A1, H1-A2, H1-A3) and acoustic analyses of the voice perturbation parameters were performed.

Results
AVQI was significantly higher in the first month (P < 0.05). Of the voice perturbation parameters, shimmer was found to be significantly high in the first month (P < 0.05). However, not all spectral amplitude values showed a significant change (P > 0.05).

Conclusion
In this study, AVQI and shimmer values were found to be higher following the application of supraclavicular RT. These results showed that nonlaryngeal RT might cause changes in the acoustic values of the voice in the early stage.

© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
The Effect of Pulmonary Function on the Incidence of Vocal Fatigue Among Teachers
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Eric J. Hunter*,a,'Correspondence information about the author Eric J. HunterEmail the author Eric J. Hunter, Lynn Maxfield†, Simone Graetzer‡
Journal of Voice

Accepted: December 20, 2018; Published online: January 24, 2019
Publication stage: In Press Corrected Proof
Summary
Introduction
Females face a significantly higher risk of presenting with voice problems than males. This discrepancy has been associated with a number of differences in respiratory behavior and the physiology of the laryngeal and endocrine systems.

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

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

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

© 2019 Published by Elsevier Inc.
Article in Press
What Makes the Cepstral Peak Prominence Different to Other Acoustic Correlates of Vocal Quality?
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Carlos A. Ferrer Riesgo*,†,low asterisklow asterisk,'Correspondence information about the author Carlos A. Ferrer RiesgoEmail the author Carlos A. Ferrer Riesgo
Elmar Nöth†
Journal of Voice

Accepted: January 3, 2019; Published online: January 22, 2019
Publication stage: In Press Corrected Proof
Cepstral peak prominence (CPP) has become the most successful individual acoustic measure for the objective measurement of vocal quality. It is also the strongest contributor to multidimensional available measures like Acoustic Voice Quality Index1 and Cepstral and Spectral Index of Dysphonia.2 However, a clear understanding of what CPP actually measures and where it can (and where it cannot) be expected to outperform other measures are issues which are still not clearly understood. Given the popularity and relevance that CPP has attained, these topics are of major interest, as the latest literature reveals.
© 2019 Published by Elsevier Inc.
Article in Press
Immediate Effect of a Resonance Tube on the Vocal Range Profile of Choristers
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Nathália Suellen Valeriano Cardoso, Jonia Alves Lucena, Adriana de Oliveira Camargo Gomeslow asterisk,'Correspondence information about the author Adriana de Oliveira Camargo GomesEmail the author Adriana de Oliveira Camargo Gomes
Departamento de Fonoaudiologia, Programa de Pós-Graduação em Saúde da Comunicação Humana da Universidade Federal de Pernambuco, Centro de Ciências da Saúde, Recife, Pernambuco, Brazil
Journal of Voice

Accepted: January 4, 2019; Published online: January 22, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
The aim of this study was to determine the immediate effect of the resonance tube technique associated with ascending and descending glissando on the vocal range profile (VRP) of amateur choristers.

Method
The sample consisted of 40 choristers aged between 18 and 57 years (average of 26.28 ± 7.51 years) with the following voice types: soprano, contralto, tenor and bass, with no vocal symptoms. Recordings of the VRP of the choristers were made before and after performing the resonance tube technique executed in ascending and descending glissando for 3 minutes in each modality. The recordings were made in the VRP of specific software.

Results
The VRP of the choristers increased after application of the ascending and descending technique. Stratifying by voice types showed an increase in contralto, tenor and bass after the ascending glissando technique and in tenor and bass after the descending technique.

Conclusion
The resonance tube technique associated with ascending and descending glissando increased the VRP in contralto, tenor and bass voice types, as well as the maximum frequency and range in hertz and semitones, in all the voice types of the choristers under study, justifying its application in the vocal warm-up of this population.

© 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
Article in Press
Application of a Landmark-Based Method for Acoustic Analysis of Dysphonic Speech
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Keiko Ishikawalow asterisk,low asterisklow asterisk,'Correspondence information about the author Keiko IshikawaEmail the author Keiko Ishikawa, Marepalli B. Rao†, Joel MacAuslan‡, Suzanne Boyce§
Journal of Voice

Accepted: December 26, 2018; Published online: January 22, 2019
Publication stage: In Press Corrected Proof
Summary
Aim
Speakers with dysphonia often report difficulty with maintaining intelligibility in noisy environments; however, there is no objective method for characterizing this difficulty. Landmark-based analysis is a linguistically-motived, knowledge-based speech analysis technique, which may serve as the basis of acoustic tool for describing the intelligibility deficit. As the first step toward development of such a tool, this study examined whether Landmark-based analysis could describe acoustic differences between normal and dysphonic speech.

Method
The recordings subjected to the Landmark-based analysis were the first sentence of the Rainbow Passage from 33 speakers with normal voice and 36 speakers with dysphonia. These recordings were selected from the Kay Elemetrics Database of Disordered Voice. The between-group difference was evaluated based on counts of certain Landmarks (LM).

Results
The average counts of all LMs were significantly greater in normal speech, t(66.85) = 2.36, P = 0.02. When the group-difference was examined for each LM, dysphonic speech had more [g] and [b] LMs and fewer [s] LMs than normal speech (P < 0.01 for all cases). A classification tree model identified [+s] and [+b] LMs are the primary predictors for the dysphonic speech. The model's misclassification rate was 7.24%.

Conclusions
This preliminary investigation demonstrates that LM-based analysis is capable of differentiating dysphonic speech from normal speech. This encouraging result rationalizes future examinations of LM analysis in other areas of interest. For example, LM-based measures could conceivably be used as to quantify general intelligibility, and/or provide insight into underlying mechanisms of intelligibility deficits.

© 2019 Published by Elsevier Inc.
Article in Press
Accuracy of Thyroid Cartilage Fenestration During Montgomery Medialization Thyroplasty
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Gauthier Desuter*,†,a,'Correspondence information about the author Gauthier DesuterEmail the author Gauthier DesuterEmail the author Gauthier Desuter, Olivier Cartiaux‡, Jonathan Pierard‡, Séverine Henrard§, Julie van Lith-Bijl*,‖, Peter Paul van Benthem†, Elisabeth Sjögren†
Journal of Voice

Accepted: January 3, 2019; Published online: January 16, 2019
Publication stage: In Press Corrected Proof
ABSTRACT
Introduction
Accuracy of thyroid cartilage fenestration during Montgomery thyroplasty (MTIS) is considered a key success factor.

The primary aim of the study was to retrospectively evaluate the accuracy of fenestration.

Furthermore, recent publications indicate a possible discrepancy in MTIS voice outcomes related to gender.

The secondary aim of the study was to investigate whether the fenestration accuracy could explain this discrepancy.

Material and Method
Study was performed by virtually drawing the fenestration on a 3D CT scan as proposed by the MTIS's instructions for use (the "expected window" (EW)), and comparing it to the actually realized fenestration (the "realized window "(RW)). Four position variables, (a) surface overlap (%), (b) the distances between RW and EW centers (mm), (c) the angle between RW and EW (°), and (d) the orientation of RW's center, were studied and compared to MPT (seconds) and VHI-30 scores outcomes.

A descriptive statistical analysis and comparison between males and females were performed using a Mann-Whitney U test. Linear regression and multivariate analysis were also performed.

Results
The median overlapping surface was 58.8 % [34.6; 75.4]. The median radius was 3.2 mm [1.7; 4.1]. The median angle was 16° [6.8; 21.2].

Results show no significant differences of overlapping surface percentage, distance, or angle by gender. Data show no correlation between voice outcome and percentage overlap, distance, or angle. However, data show better outcomes when fenestration was located in the infero-anterior orientation. All patients of this orientation were males.

Conclusions
Data provided by this study advocate a maximal infero-anterior positioning of the window during MTIS. This position is more difficult to obtain in female patients.

© 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
Article in Press
Factors Affecting Initiation of Voice Therapy for Paradoxical Vocal Fold Motion Disorder
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Kevin Pasternak*,a,'Correspondence information about the author Kevin PasternakEmail the author Kevin Pasternak, Susan L. Thibeault†
Journal of Voice

Accepted: December 20, 2018; Published online: January 16, 2019
Publication stage: In Press Corrected Proof
Summary
Objective
To investigate patient-level predictors of initiation of voice therapy for paradoxical vocal fold motion disorder (PVFM).

Study Design
Prospective outcomes database study.

Methods
Patients consented to the University of Wisconsin Voice and Swallow Clinics Outcomes Database between March 2010 and November 2016 who were diagnosed with PVFM and recommended for voice therapy were eligible. Patients who attended at least one voice therapy session were considered to have initiated therapy. Analyzed variables included age, gender, distance to the clinic, insurance status, socioeconomic factors, comorbidity score, spirometry results, presence of asthma and/or dysphonia diagnoses, length of evaluation and evaluation model, and patient scores on the Voice Handicap Index and Generalized Anxiety Disorder 7-item scale.

Results
One-hundred seventy-eight patients met inclusion criteria. Of these, 118 initiated voice therapy as recommended (66.29%). The majority of patients were female (n = 127; 71.35%). Age was the only factor significantly associated with therapy initiation in both univariate (P = 0.0359) and multivariable (P = 0.0295) analyses, with patients aged 30–39 least likely to attend compared with other age groups. Multivariable analysis also showed that patients evaluated by a speech-language pathologist alone were an estimated three times as likely to initiate therapy compared to patients evaluated by speech-language pathologist and otolaryngologist (ENT) together (P = 0.0407). Other variables were not statistically significant for prediction of therapy initiation.

Conclusions
This study suggests that age group and evaluation model are associated with initiation of voice therapy for PVFM. Further study is needed to investigate social-cognitive and quality-of-life factors in predicting therapy initiation.

© 2019 Published by Elsevier Inc.
Article in Press
From Voice Clinic to Operating Room: Are We Out of Tune?
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Rehab Awad*,‡,low asterisklow asterisk,'Correspondence information about the author Rehab AwadEmail the author Rehab Awad, Eamon Shamil†, Nicholas Gibbins†, Anthony Aymat†, Sara Harris*
Journal of Voice

Accepted: December 26, 2018; Published online: January 16, 2019
Publication stage: In Press Corrected Proof
Abstract
Introduction: To determine the consistency and accuracy of preoperative diagnosis in the voice clinic with intraoperative diagnosis and to suggest a standardized laryngeal examination protocol in the UK that is supported by evidence-based findings.

Method: From January 2011-September 2014, 164 patients were referred to the Multidisciplinary Team voice clinic and diagnosed with laryngeal pathology that required phonosurgery. The visualization (videostrobolaryngoscopy) in clinic was performed using either rigid laryngoscope or a video-naso-laryngoscope. Intraoperatively, laryngeal visualization and surgical procedure was conducted using Storz Aida HD system, 10-mm rigid laryngoscope 0° or 5-mm rigid laryngoscope 0°/30° and a Zeiss S7 microscope.

Results: Of the 164 patients seen in the multidisciplinary voice clinic, 86 clinic diagnoses were confirmed intraoperatively (52.4%), 15 patients had the diagnosis confirmed intraoperatively with additional lesion found (9.1%). The clinic diagnosis changed intraoperatively in 63 cases (38.4%). 61 (37.2%) patients seen in the voice clinic were diagnosed with cyst, in 39.3% the diagnosis was confirmed intraoperatively with 5 cases (8.2%) having an additional diagnosis. Twenty (12.2%) patients were diagnosed with polyps, with 80% confirmation intraoperatively; 3 patients (10%) had an additional diagnosis.

Conclusion: Videolaryngostroboscopy imaging of the larynx provides an outpatient tool for accurately diagnosing more than 50% of laryngeal pathologies when interpreted by multidisciplinary voice clinicians. However direct laryngeal examination under general anesthesia remains the gold standard when obtaining accurate diagnoses of laryngeal pathology. Patients diagnosed with nonorganic voice disorders should be considered for direct laryngoscopy under general anesthetic should they fail to respond to conservative management.

© 2019 Published by Elsevier Inc.
Article in Press
In Vivo Quantification of the Intraglottal Pressure: Modal Phonation and Voice Onset
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Philippe H. DeJonckere*,1,'Correspondence information about the author Philippe H. DeJonckereEmail the author Philippe H. DeJonckere, Jean Lebacq†
Journal of Voice

Accepted: January 2, 2019; Published online: January 16, 2019
Publication stage: In Press Corrected Proof
Abstract
Intraglottal pressure is the driving force of vocal fold vibration. Its time course during the open phase of the vibratory cycle is essential in the mechanics of phonation, but measuring it directly is difficult and may hinder spontaneous voicing. However, it can be computed from the in vivo measured transglottal flow and glottal area (hence the air particle velocity) on the basis of the Bernoulli energy law and the interaction with the inertance of the vocal tract. As to sustained modal phonation, calculations are presented for the two possible shapes of glottal duct: convergent and divergent, including absolute calibration in order to obtain quantitative physical values. Whatever the glottal duct configuration, the calculations based on measured values of glottal area and air flow show that the integrated intraglottal pressure during the opening phase systematically exceeds that during the closing phase, which is the basic condition for sustaining vocal fold oscillation. The key point is that the airflow curve is skewed to the right relative to the glottal area curve. The skewing results from air compressibility and vocal tract inertance. The intraglottal pressure becomes negative during the closing phase. As to the soft (or physiological) voice onset, a similar approach shows that the integrated pressure differences (opening phase − closing phase) actually increase as the onset progresses, and this applies to the results based on Bernoulli's energy law as well as to those based on the interaction with the inertance of the vocal tract. Furthermore and similarly, the phase lead of the pressure wave with respect to the glottal opening progressively increases. The underlying explanation lies in the progressively increasing skewing of the airflow curve to the right with respect to the glottal area curve.

© 2019 Published by Elsevier Inc.
Article in Press
The Current State and Future Possibilities of Mobile Phone "Voice Analyser" Applications, in Relation to Otorhinolaryngology
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Amberley Jade Munningslow asterisk,'Correspondence information about the author Amberley Jade MunningsEmail the author Amberley Jade MunningsEmail the author Amberley Jade Munnings
Christchurch Canterbury University, Medway Campus, Kent, United Kingdom
Journal of Voice

Published online: January 14, 2019
Publication stage: In Press Corrected Proof
SUMMARY
Background
A large proportion of the population suffers from voice disorders. The use of mobile phone technology in healthcare is increasing, and this includes applications that can analyze voice.

Objective
This study aimed to review the potential for voice analyzer applications to aid the management of voice disorders.

Methods
A literature search was conducted yielding eight studies which were further analyzed.

Results
Seven out of the eight studies concluded that smartphone assessments were comparable to current techniques. Nevertheless there remained some common issues with using applications such as; voice parameters used; voice pathology tested; smartphone software consistency and microphone specifications.

Conclusions
It is clear that further developments are required before a mobile application can be used widely in voice analysis. However, promising results have been obtained thus far, and the benefits of mobile technology in this field, particularly in voice rehabilitation, warrant further research into its widespread implementation.

© 2019 Published by Elsevier Inc.
Article in Press
The Low Mandible Maneuver: Preliminary Study of Its Effects on Aerodynamic and Acoustic Measures
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Eve Mercer, Soren Y. Lowelllow asterisk,'Correspondence information about the author Soren Y. LowellEmail the author Soren Y. Lowell
Department of Communication Sciences and Disorders, Syracuse University, Syracuse, New York
Journal of Voice

Accepted: December 7, 2018; Published online: January 10, 2019
Publication stage: In Press Corrected Proof
Summary
Objectives
The purpose of this preliminary study was to determine the aerodynamic and acoustic effects of the low mandible maneuver (LMM) as compared to normal voice production.

Methods
Ten participants with normal voice characteristics who were nonsingers produced sustained vowel and repeated syllable utterances during two different speaking conditions: using the LMM and using normal phonation posture. The LMM involves a wider vocal tract configuration with a lowered and relaxed jaw position. Acoustic recordings and analyses were performed to determine formants 1 and 2 (F1 and F2) and sound pressure level. Aerodynamic data were collected and analyzed to investigate the effects of the LMM on mean peak pressure, mean airflow, aerodynamic power, aerodynamic efficiency, and aerodynamic resistance.

Results
Participants showed greater aerodynamic efficiency, mean peak pressure, and sound pressure level during the LMM condition as compared to normal phonation. The LMM vocal tract configuration changes were also associated with a lowering of F1 and F2 relative to normal voice production.

Conclusions
The lowering of the mandible and increased oral area that occurred during the LMM increased vocal efficiency and sound output without significant change to parameters that can be associated with increased vocal effort. These changes in filter configuration were associated with changes in vocal tract resonances. The LMM was readily learned and implemented by healthy participants in this study, and may have utility for singers in training as well as people with hyperfunctional voice disorders.

© 2018 Published by Elsevier Inc.
Article in Press
Speech Pathology Intervention for Chronic Refractory Cough: A Pilot Study Examining the Benefit of Using Prerecorded Videos as an Adjunct to Therapy
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Sarah L. Kapela*,low asterisklow asterisk,'Correspondence information about the author Sarah L. KapelaEmail the author Sarah L. Kapela, Anne E. Vertigan†, Peter G. Gibson†
Journal of Voice

Accepted: December 4, 2018; Published online: January 10, 2019
Publication stage: In Press Corrected Proof
Abstract
Speech pathology intervention is effective for chronic refractory cough (CRC). Speech pathology treatment for CRC includes therapy exercises to teach cough suppression and reduce laryngeal closure during respiration.

Aim
The aim of this study was to evaluate the benefit of providing patients with supplemental pre-recorded videos of speech pathology exercises for chronic refractory cough (CRC) to assist with patients' independent practice. These videos were pre-made recordings of the treating speech pathologist demonstrating specific exercises for chronic cough suppression.

Method
This study was a prospective randomized controlled trial design. Participants included 18 adult patients attending a speech pathology outpatient clinic in a tertiary referral hospital for treatment of CRC. Participants were randomized to receive either standard speech pathology intervention (SPI) for CRC combined with supplemental pre-recorded videos for home practice or standard SPI alone. The primary outcome measure was a rating of accuracy during demonstration of the speech pathology exercises for cough suppression. This rating was assigned by the treating speech pathologist from session 2 onwards. The treating speech pathologist asked the patient to demonstrate the exercises they had been practising since the last speech pathology session. Secondary outcome measures included the Symptom Frequency and Severity Rating Scale, Leicester Cough Questionnaire, and Consensus Auditory Perceptual Evaluation of Voice.

Results
There was a significant pre- to post-treatment improvement in both groups however the degree of improvement was not significantly different between the two groups.

Conclusion
The addition of supplemental pre-recorded videos of SPI for CRC did not lead to greater accuracy of therapy exercise practice or superior treatment outcomes than standard SPI alone.

Declaration of interest
There are no interests to declare.

© 2018 Published by Elsevier Inc.
Article in Press
Characteristics of the Voice Handicap Index for Patients With Unilateral Vocal Fold Paralysis Who Underwent Arytenoid Adduction
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Kenichi Watanabelow asterisk,'Correspondence information about the author Kenichi WatanabeEmail the author Kenichi Watanabe, Takeshi Sato, Yohei Honkura, Ai Kawamoto-Hirano, Kazutaka Kashima, Yukio Katori
Department of Otolaryngology – Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi 980-8574, Japan
Journal of Voice

Accepted: December 20, 2018; Published online: January 05, 2019
Publication stage: In Press Corrected Proof
Summary
Purpose
This study was performed to evaluate the characteristics of the Voice Handicap Index (VHI), a self-assessment measure, for patients with unilateral vocal fold paralysis (UVFP) who underwent arytenoid adduction (AA), in comparison with postoperative vocal function examinations.

Methods
A retrospective chart review was conducted for patients who underwent AA at Tohoku University Hospital during the period between 2014 and 2017. VHI was compared before and after surgery; moreover, correlations were assessed between the VHI and other voice measurements, including perceptual assessment of voice, as well as aerodynamic and acoustic measures. Factors involved in the VHI score were explored by multivariate analysis.

Results
Forty-three UVFP patients (28 males, age 32–81 years; 15 females, age 34–80 years) were enrolled in the study; the average age of all patients was 61.5 years (32–81 years). Among the enrolled patients, 33 (76.7%) left and 10 (23.3%) right vocal folds were impaired. After surgery, nearly all of the patients exhibited significantly improved VHI score; each of the three subscales (functional, physical, and emotional) was also improved. The postoperative VHI correlated mildly with several values of the other voice measurements, with the exception of the mean flow rate. Multivariate analysis showed that the sole variable associated with postoperative VHI score was preoperative VHI.

Conclusions
The postoperative VHI likely reflects improvement in the voices of the patients with UVFP. Although there were weak correlations with other voice measures, postoperative VHI is a relatively independent measurement parameter for patients with UVFP who underwent AA.

© 2018 Published by Elsevier Inc.
Article in Press
Vocal Fatigue—Do Young Speech-Language Pathologists Practice What They Preach?
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Bennet Elsa Josephlow asterisk,'Correspondence information about the author Bennet Elsa JosephEmail the author Bennet Elsa Joseph, Ashna Mariya Joseph, Theres Mariya Jacob
Nitte Institute of Speech and Hearing, Mangaluru, Karnataka, India
Journal of Voice

Accepted: November 28, 2018; Published online: January 04, 2019
Publication stage: In Press Corrected Proof
Abstract
Purpose
Speech-Language Pathologists can be categorized as Level II professional voice users who play the roles of voice therapist or vocal coach to treat voice problems. SLPs may be at the risk of experiencing vocal fatigue due to vocal loading and other contributing factors. The present study was undertaken to find the percentage of SLPs reporting vocal fatigue, the probable factors resulting in vocal fatigue, the measures that are taken to avoid/reduce the occurrence of vocal fatigue, its effect on their professional and personal life and the measures taken to tackle it.

Results
The results of this study are based on data collected from 142 SLPs and 50 controls using a questionnaire. 71.13% SLPs reported that they experience vocal fatigue. Some of the contributing factors that are mainly reported are long durations of voice use, voice use for recreational purposes, speaking loudly, frequent throat clearing, lack of adequate hydration and working in noisy or air-conditioned environments. The major symptoms reported were dryness in throat, tightness in neck and shoulder, choking sensation, effortful speech and pain in the throat. 59% SLPs reported that vocal fatigue affected their professional life while 44% SLPs reported that it affects their personal life also to varying degrees. Measures taken to avoid/ reduce the occurrence of vocal fatigue included vocal warm up, break in between sessions, and play activities. Only a few SLPs took intervention measures like ENT consultation, voice therapy, and home remedies.

Conclusion
SLPs are inevitably at high risk of experiencing vocal fatigue which, if left untreated, will lead to organic voice problems. However, many young SLPs who experience vocal fatigue reported vocal abuse, do not follow vocal hygiene program and do not follow evidence-based preventive or intervention practices to treat vocal fatigue.

© 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
Article in Press
Selective Laryngeal Examination: Sensitivity of Endocrine Surgeons in Screening Voice Abnormality
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Syarifah N. Al-Yahya*, Rohaizak Muhammad†, Shahrun N.A. Suhaimi†, Mawaddah Azman*, Abdullah S. Mohamed*, Marina M. Baki*,low asterisklow asterisk,'Correspondence information about the author Marina M. BakiEmail the author Marina M. Baki
Journal of Voice

Accepted: December 4, 2018; Published online: January 03, 2019
Publication stage: In Press Corrected Proof
ABSTRACT
Objectives
Selective laryngeal examination for patients undergoing thyroidectomy is recommended for patients with voice alterations, history of prior cervical or chest surgery, and patients with proven or suspected thyroid malignancy. The study objective is to measure the sensitivity of surgeons in detecting voice abnormalities in patients undergoing thyroidectomy, parathyroidectomy complicated with laryngeal nerve paralysis, or patients with known vocal cords palsy (VCP) due to other neck surgeries.

Design and Setting
Descriptive cross-sectional study in a tertiary center.

Participants and Methods
The subjects are 274 audio files of voices of patients undergoing thyroid, parathyroid surgeries, and known VCP due to other neck surgeries. Voice assessments were done by three endocrine surgeons (A, B, and C) with 20, 12, and 4 years of surgical experience.

Main outcome measures
Sensitivity and specificity of surgeon documented voice assessment in patients with underlying VCP. Subjects' acoustic analysis and Voice Handicap Index (VHI-10) were analyzed.

Results
Raters A, B, and C have sensitivity of 63.6%, 78.8%, and 66.7%, respectively. Inter-rater reliability shows substantial agreement (ƙ = 0.67). VHI-10 has sensitivity of 75.8% and strong correlation of 0.707 (p value <0.001) to VCP. Subjects with VCP have notably higher jitter, shimmer, and noise-to-harmonic ratio compared to normal subjects with sensitivity of 74.2%, 71.2%, and 72.7%, respectively.

Conclusions
The results for surgeons documented voice assessment did not reach the desired sensitivity for a screening tool for patients with underlying VCP. Other tools such as VHI-10 and acoustic analysis may not be used as standalone tools in screening patients with underlying VCP. Routine preoperative laryngeal examination may be recommended for all patients undergoing thyroid, parathyroid, or other surgeries that places the laryngeal nerves at risk.

© 2018 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
Article in Press
Voice Outcomes After Radiation for Early-Stage Laryngeal Cancer
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Matthew R. Naunheim‡,low asterisklow asterisk,'Correspondence information about the author Matthew R. NaunheimEmail the author Matthew R. Naunheim, Jonathan Garneau*, Chris Park*, Linda Carroll†, Leanne Goldberg*, Peak Woo*
Journal of Voice

Accepted: November 14, 2018; Published online: January 02, 2019
Publication stage: In Press Corrected Proof
Summary
Objectives
Radiation treatment for laryngeal cancer has been shown to cause tissue changes to the vocal folds, which can result in degradation of voice. Our objective in this study was to investigate changes in perceptual, acoustic, and patient-reported outcomes over an extended period of follow-up after radiation.

Design
Retrospective review.

Methods
All patients treated with radiation for early-stage laryngeal carcinoma (in situ, T1, or T2) by a single surgeon from 2011–2018 were reviewed. Demographics and treatment information were recorded. Only patients with at least two dates of follow-up with acoustic data (cepstral spectral index of dysphonia [CSID]) and patient-reported surveys (voice handicap index-10 [VHI-10]) were included. Voice samples were rated by two senior speech-language pathologists on the grade, roughness, breathiness, asthenia, and strain scale.

Results
Of 115 patients with early-stage laryngeal cancer, 31 patients met inclusion criteria. The average follow-up from time of treatment was 9.6 years (range 3.0–20.3 years), and the average time in between the first and last voice recordings was 2.6 years (range 0.3–5.5 years). The lesions represented were carcinoma in situ (n = 4), T1 (n = 22), and T2 (n = 5). The VHI-10 scores worsened slightly (mean increase +0.27, median +1) from first to last measurements as did the CSID score (median increase +7.0, median +7.4), though neither reached statistical significance when correlated with time since radiation (P = 0.269 and P = 0.0850). Perceptual analysis as rated by two speech-language pathologists raters showed excellent inter-rater reliability (Cronbach's alpha = 0.84), with no significant change over time (mean +0.39, median, with P = 0.347). Grade, roughness, breathiness, asthenia, and strain, VHI-10, and CSID were all correlated (all pairwise comparisons P < 0.001).

Conclusion
Perceptual, acoustic, and patient-reported outcomes years after radiation for early-stage laryngeal cancer do not show voice degradation over time in this preliminary analysis. Further research with a larger cohort may elucidate voice changes in this population.

© 2018 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
Article in Press
Vibratory Onset of Adductor Spasmodic Dysphonia and Muscle Tension Dysphonia: A High-Speed Video Study✰
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Wenli Chen*,low asterisklow asterisk,'Correspondence information about the author Wenli ChenEmail the author Wenli Chen, Peak Woo†, Thomas Murry‡
Journal of Voice

Accepted: December 18, 2018; Published online: December 28, 2018
Publication stage: In Press Corrected Proof
Summary
Objective
Adductor spasmodic dysphonia (AdSD) is a challenging voice disorder to diagnose, often erroneously diagnosed as muscle tension dysphonia (MTD) or vocal tremor, due to its similarity in auditory and perceptual presentation. Assessments using laryngoscopy or strobolaryngoscopy procedures have demonstrated limited utility in the diagnosis of spasmodic dysphonia. High-speed videoendoscopy (HSV) provides visualization of the precise vibratory pattern of phonatory onset and thus, offers an alternative to previous diagnostic strategies for visual diagnosis of AdSD. The purpose of this study was to examine vibratory onset of patients with AdSD and patients with MTD using HSV methodology.

Methods
HSV of six adults with AdSD and five adults with MTD were captured during sustained phonation. Digital kymography was used to obtain precise vibrogram data at the mid-membranous region of the vocal fold prior to and at the onset of phonation. Voice onset delay was examined by (1) quantifying timing of prephonatory delay and steady state delay and (2) describing vocal fold onset movements qualitatively in each diagnosis.

Results
HSV adequately captured the phonatory onset of the vocal folds. Voice onset delay was not significantly different between AdSD and MTD. However, there were distinct differences in voice onset gestures. Both AdSD and MTD patients presented with vocal hyperfunction during the onset of phonation. In a subset of AdSD patients, a rapid sustained adduction occurred following the initial vibratory motion. Vocal fold vibration then continued until steady phonation was achieved. This oscillatory break pattern was not observed in patients with MTD. Therefore, there appears to be differences in vocal fold vibratory onset motion between MTD and AdSD.

Conclusion
HSV captures the precise vibratory onset in patients with MTD and AdSD. Differences were most notable after vibratory onset as opposed to vibratory delay measurements. Examination of voice onset gesture may offer an additional laryngeal parameter to assist in the differential diagnosis of spasmodic dysphonia.

© 2018 Published by Elsevier Inc.

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