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Objectives: To explore the characteristics of functional dysphonia (FD) using multimodal methods., Methods: A total of 47 FD patients and a group of 22 normal controls were enrolled. Subjective auditory-perceptual assessment of the voice, Voice Handicap Index (VHI) 30, acoustic analysis, psychological scales assessment, surface electromyography (sEMG), nasal airflow and thoracoabdominal studies were performed., Results: FD was mostly triggered by mood changes. Patient self-evaluation was more serious than auditory-perceptual evaluation and objective acoustic analysis. There was no obvious organic disorder observed under laryngoscope in patients with FD, but there were cases of glottic insufficiency and supraglottic compensation. With regards to sEMG, nasal airflow, chest, and abdomen examination results: (1) sEMG in the normal control group was symmetrical and stable on both sides during rest and phonation, and nasal airflow as well as the chest and abdomen were symmetrical and regular; (2) sEMG in the FD group showed increased recruitment of the sternocleidomastoid muscles, the infra- and suprahyoid muscles, and the cricothyroid muscle, accompanied by prephonation recruitment and postphonation persistence, mainly involving the infra- and suprahyoid muscles; (3) In the FD group, there was shortened inspiratory time, increased chest breathing amplitude, and reduced abdominal breathing, with predominantly chest breathing, and a "breath-holding" phenomenon was observed in some patients, with a significant increase in the number of breaths during the short text task., Conclusions: FD occurs mainly in middle-aged women, and there are many triggers. The Hamilton Anxiety/Depression Rating Scale scores were higher, and subjective symptoms were more serious than objective evaluation. No obvious organic changes were seen under laryngoscope, and features such as supraglottic compensation and glottic insufficiency were observed; muscle tension was significantly higher than that of the normal control group, and prephonation recruitment and postphonatory persistence were seen in some patients; the breathing pattern was mainly chest breathing, and the times of breaths during the short text task significantly increased. With identification of the characteristics of FD, the therapy could be focused them., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The Nyquist plot provides a graphical representation of the glottal cycles as elliptical trajectories in a 2D plane. This study proposes a methodology to parameterize the Nyquist plot with application to support the quantitative analysis of voice disorders., Methods: We considered high-speed videoendoscopy recordings of 33 functional dysphonia (FD) patients and 33 normophonic controls (NC). Quantitative analysis was performed by computing four shape-based parameters from the Nyquist plot: Variability, Size (Perimeter and Area), and Consistency. Additionally, we performed automatic classification using a linear support vector machine and feature importance analysis by combining the proposed features with state-of-the-art glottal area waveform (GAW) parameters., Results: We found that the inter-cycle variability was significantly higher in FD patients compared to NC. We achieved a classification accuracy of 83% when the top 30 most important features were used. Furthermore, the proposed Nyquist plot features were ranked in the top 12 most important features., Conclusions: The Nyquist plot provides complementary information for subjective and objective assessment of voice disorders. On the one hand, with visual inspection it is possible to observe intra- and inter-glottal cycle irregularities during sustained phonation. On the other hand, shaped-based parameters allow quantifying such irregularities and provide complementary information to state-of-the-art GAW parameters., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Practitioners in the field of voice are often faced with patients who are 'dysphonic', but who do not have identifiable abnormalities of the vocal tract structures or any neural or hormonal alteration affecting the phonatory function. For lack of better nomenclature describing the origin of the disorder, this group of patients has been labeled as having 'non-organic' or 'functional' dysphonia. 'Non-organic' only states what the dysphonia is not, and 'functional' does not have any etiological implication. Hence 'functional disorder' as a determination of the origin is at best vague, imprecise and often misleading. In truth, the terms "functional" and 'non-organic' are by now so muddled and confused in everyday clinical usage and parlance that it is unclear what they mean in any given clinical setting or for any particular clinical case. Thus, the UEP Voice Committee (VC) has come to the conclusion that it is best to adopt a new term that is clearly defined, universally agreed to, and indicative of a different and more useful perspective. We have reviewed the literature relating to terminology of these phonatory disorders. We now propose replacement of the phrase 'functional dysphonia' with 'malregulative dysphonia', since the indication of faulty regulation represents an etiological connotation. We also propose a restructuring of the etiological terminology of phonation disorders. We believe this to be a biologically clearer framework for the labeling of 'non-organic' phonatory disorders, and hope that its routine use will allow for more clarity of presentation and discussion in the future., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Functional dysphonia refers to a voice disorder without organic laryngeal disease. In this article, the clinical features and therapeutic strategies of functional dysphonia in children were investigated., Method: Retrospective analysis of 595 cases of children with dysphonia 3-18 years of age, including 42 patients diagnosed with functional dysphonia. The patients were distributed by age into four groups:3-6, 7-10, 11-14, 15-18 years. The clinical features, laryngeal signs, voice characteristics, pediatric voice handicap index, and therapeutic effects were analyzed., Result: In this study, 7.1% of the patients were struck with functional dysphonia. 7 (16.7%) patients aged 7-10 years, 16 (38.1%) aged 11-14 years, and 19 (45.3%) patients aged 15-18 years, and there were 23 males and 19 females. Thirteen (31.0%) patients had no cause identified, while some were triggered by upper respiratory tract infection (16 cases, 38.1%), voice overuse (9 cases, 21.4%), or other factors (4 cases, 9.5%). Thirty-four (80.9%) patients had prominent hoarseness, with aphonia in 25 (73.5%) patients, and other 7 (16.7%) patients (15-18 years) showed vocal breaks or vocal effort (4 patients), and high pitch or pitch instability (3 patients). Some patients were accompanied by reduced mucosal waves, supraglottic compensations, and glottal insufficiency. Twelve patients received voice therapy, and their voice was improved after treatment., Conclusion: In our study, functional dysphonia characterized 7.1% of the patients with voice disorders in children. All patients were 7-18 years of age, particularly 11-18 years. The main triggers of the disorder were upper respiratory tract infection, unknown and voice overuse. Other than apparent hoarseness, some 15-18 years patients experienced vocal breaks, vocal effort, or abnormal pitch. Supraglottic compensations and glottal insufficiency were observed in more than half of the patients. Symptomatic voice therapy obtained significant effects., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Muscle tension dysphonia (MTD) is generally diagnosed through clinical history and physical examination. Several diagnostic or classification systems exist, such as those of Van Lawrence, Morrison-Rammage, and Koufman, that delineate MTD and distinguish subtypes on the basis of laryngoscopic features. The aim of this study is to determine which of the clinical features included in these classifications are most related to the aerodynamic profile of MTD., Study Design: This is an analytic retrospective study., Material and Methods: This study evaluates a series of 30 consecutive patients, all over 18 years old, who attended the voice clinic consult of our department and were diagnosed with MTD. All subjects underwent fiberoptic nasal endoscopy, acoustic voice assessment, and aerodynamic voice assessment. The study only includes patients with a pathological aerodynamic profile. Presence or absence of each laryngoscopic feature in the full range of features in the Van Lawrence, Morrison-Rammage, and Koufman classification systems was evaluated independently by three experts. Cohen's kappa coefficient was calculated to indicate the degree of concordance between the experts. The chi-squared test was used to determine the degree of association between clinical features and mean value of the subglottic pressure peak (mmH 2 O)., Results: Clinical parameters that were found to have a statistically significant association (P < 0.05) with an alteration in mean subglottic pressure peak were those related to anteroposterior and lateral compression of the larynx in Van Lawrence, Morrison-Rammage, and Koufman classification systems., Conclusions: While several studies have sought to clarify the laryngoscopic features of MTD, the current study is the first to evaluate these features in subjects who have been objectively diagnosed by means of aerodynamic voice assessment. The laryngoscopic features most strongly related to an aerodynamic profile of MTD were anteroposterior compression of the larynx, lateral compression of the larynx, and vestibular fold contribution to phonation., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The validity and sensitivity to change of instrumental acoustic measurements in patients with functional dysphonia have been controversially discussed. This work examines combined voice therapy effects on standard acoustic measurements, and if these agree with perceptual and subjective voice outcomes., Study Design: Retrospective study., Methods: Thirty-nine patients (26 women, 13 men) aged 20-70 years (mean: 46.3, standard deviation 12.8) with functional dysphonia were investigated before and after combined voice therapy. Instrumental parameters included mean and range of speaking fundamental frequency (f o ) and intensity (SPL (dBA)); maximum SPL and mean f o of calling voice; minimum, maximum, range of singing voice f o and SPL, jitter (%), and the Dysphonia Severity Index. Voice Handicap Index-9 international was used for subjective and Grading-Roughness-Breathiness-Asthenia-Strain scale for perceptual assessment. Differences were investigated by Wilcoxon signed ranks test and coherences by Spearman rank correlation coefficient., Results: After treatment, the speaking voice f o range (7-8.13 semitones) and SPL range (12.9-14.85 dB(A)) were significantly larger (P < 0.05). Both parameters were highly correlated (P < 0.001). Subjective symptoms were significantly reduced from a mean Voice Handicap Index-9 international of 15.6-8.6, and all perceptual Grading-Roughness-Breathiness-Asthenia-Strain scale parameters were significantly improved (G: 1.05-0.51) after therapy (P < 0.05). These findings were not associated with any acoustic parameter (P > 0.05)., Conclusions: Significantly improved subjective and perceptual findings verify positive combined voice therapy effects in patients with functional dysphonia. The larger f o and SPL speaking voice range after treatment indicate an altered voice technique. These instrumental measures may be clinical indicators of therapy success and transfer effects., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

The objective of the study was to analyze the outcome of the proprioceptive-elastic (PROEL) voice therapy method in patients with functional dysphonia (FD). Fifty-two patients with FD were involved in the study; they were composed of three subgroups of patients with (1) FD without glottal insufficiency (n = 28), (2) FD and glottal insufficiency (n = 9), and (3) FD, glottal insufficiency, and vocal nodules (n = 15). A multidimensional assessment protocol including videolaryngostroboscopy; maximum phonation time; perceptual evaluation of dysphonia with the Grade, Instability, Roughness, Breathiness, Asthenia, and Strain (GIRBAS) scale; and 10-item version of the Voice Handicap Index was conducted before and after 15 sessions of voice therapy. All voice therapy sessions were conducted by the same speech-language pathologist. The comparison between voice assessment before and after voice therapy with the PROEL method in patients with FD, in all the three subgroups, revealed a statistically significant improvement in periodicity and the mucosal wave in the laryngostroboscopy, maximum phonation time, GIRBAS scale scores, and VHI-10. Voice of patients with FD improved after treatment with the PROEL method. Further studies are needed to analyze the efficacy of the PROEL method with randomized double-blind clinical trials using different methods for voice therapy. At present, the PROEL method represents an alternative tool for the speech pathologist to improve voice in patients with FD., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Type of Study: This is a longitudinal, case-control clinical trial., Objectives: This study aims to track recovery time following a vocal loading task (VLT) imposing vocal fatigue and to explore if patients with functional dysphonia (FD) are worse affected by vocal loading, and if these patients take longer than others to recover., Methods: Fifty (n = 50) female participants in four vocal subgroups on a spectrum of everyday vocal loading and functional voice complaints, including n = 20 patients with FD, took part in a clinical VLT, inflicting vocal fatigue through loud speech in ambient noise. Short-term recovery was explored through self-assessment of unspecified voice problems every 15 minutes for 2 hours following loading. Long-term recovery was tracked through self-assessments of specific voice symptoms during 3 days following vocal loading. Effects of heavy vocal loading were evaluated through voice recordings, long-time-average spectrum, perceptual assessments, and assessments of digital imaging performed pre- and post vocal loading., Results: Patients with FD did not return to baseline for unspecified voice problems within 2 hours of vocal loading and were worse affected by vocal loading than other groups. Women with high everyday vocal loading with no voice complaints identified vocal loading more evidently than other groups. Long-term recovery took 7-20 hours for all groups., Conclusions: Short-term recovery is slower for patients with FD and these patients are worse affected by a VLT than others., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The study aimed to examine the vocal behavior and self-assessed vocal health in women with varying everyday vocal load and functional voice problems, including patients with functional dysphonia, in three conditions: work, leisure, and a vocal loading task (VLT)., Study Design: This is a longitudinal controlled, clinical trial., Methods: Fifty (n = 50) female subjects were tracked during 7 days' voice accumulation accompanied by a voice health questionnaire, containing general assessments with visual analogue scale and specific voice health questions. Subjects were divided into four vocal subgroups according to everyday vocal load and functional vocal complaints. Accumulation time was divided into three conditions: a VLT, work, and leisure. The following behavioral parameters were measured: (1) relative phonation time (%), (2) phonatory sound pressure/voice level (dB sound pressure level), (3) ambient noise level (dB sound pressure level), and (4) phonatory fundamental frequency (Hz)., Results: Patients with functional dysphonia reported significantly higher specific voice problems across conditions and worse general voice problems during work and leisure than other groups. Women with high everyday vocal load and voice complaints showed higher phonation times and fundamental frequency during work than voice healthy controls. They also reported the highest incidence of general voice problems in the VLT., Conclusions: Vocal loading relates to prolonged phonation time at high fundamental frequencies. Patients with functional dysphonia experience general and specific voice problems permanently, whereas women with everyday vocal load and voice complaints recover during leisure. This may explain why the latter group does not seek voice therapy., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Clinicians believe that psychosocial factors play a causal role in the etiology of many forms of functional dysphonia (FD). But for decades, all attempts to confirm such causation have failed. This paper aims to show the logic of this failure, to discuss the possibilities of employing psychology in therapy nonetheless, and to encourage clinicians to use their psychosocial knowledge and skills. The failure to confirm psychic and social factors as causal in the etiology of FD is basically a consequence of a principal shortcoming of evidence-based medicine (EBM). As the gold standard for validity, reliability, and objectivity in medical research, EBM is based on calculability and hence the processing of quantitative data. But life paths and life situations are best or sometimes only expressible in qualitative, experiential, and idiographic terms. Thus EBM-guided evaluation undervalues most psychosocial studies. This report of an experienced multidisciplinary voice team proposes alternative pathways for integrating psychosocial knowledge into the diagnosis and the treatment of FD. The difference between the fields of activity of psychotherapists and speech-language pathologists is discussed, and the latter group is shown the potential benefits of using more of their psychosocial knowledge and skills., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The present study aimed to observe the effect of two types of tubes on vocal tract bidimensional and tridimensional images., Methods: Ten participants with hyperfunctional dysphonia were included. Computerized tomography was performed during production of sustained [a:], followed by sustained phonation into a drinking straw, and then repetition of sustained [a:]. A similar procedure was performed with a stirring straw after 15 minutes of vocal rest. Anatomic distances and area measures were obtained from computerized tomography midsagittal and transversal images. Vocal tract total volume was also calculated., Results: During tube phonation, increases were measured in the vertical length of the vocal tract, oropharyngeal area, hypopharyngeal area, outlet of the epilaryngeal tube, and inlet to the lower pharynx. Also, the larynx was lower, and more closure was noted between the velum and the nasal passage., Conclusion: Tube phonation causes an increased total vocal tract volume, mostly because of the increased cross-sectional areas in the pharyngeal region. This change is more prominent when the tube offers more airflow resistance (stirring straw) compared with less airflow resistance (drinking straw). Based on our data and previous studies, it seems that vocal tract changes are not dependent on the voice condition (vocally trained, untrained, or disordered voices), but on the exercise itself and the type of instructions given to subjects. Tube phonation is a good option to reach therapeutic goals (eg, wide pharynx and low larynx) without giving biomechanical instructions, but only asking patients to feel easy voice and vibratory sensations., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to investigate the effect of phonation into tubes in air and tubes submerged in water on air pressure variables and vocal fold adduction in subjects with different voice conditions., Methods: Forty-five participants representing four vocal conditions were included: (1) subjects diagnosed with normal voice and without voice training, (2) subjects with normal voice with voice training, (3) subjects with muscle tension dysphonia, and (4) subjects with unilateral vocal fold paralysis. Participants phonated into different kinds of tubes (drinking straw, 5 mm in inner diameter; stirring straw, 2.7 mm in inner diameter; silicon tube, 10 mm in inner diameter) with the free end in air and in water. Aerodynamic, acoustic, and electroglottographic signals were captured simultaneously. Mean values of the following variables were considered: glottal contact quotient (CQ) measured by electroglottograph, fundamental frequency, subglottic pressure (Psub), oral pressure (Poral), and transglottal pressure., Results: All exercises had a significant effect on Psub, Poral, transglottal pressure, and CQ (P < 0.05). Phonation into a 55-cm silicon tube submerged 10 cm in water and phonation into a stirring straw resulted in the highest values for CQ, Psub, and Poral compared with baseline (repetition of syllable [pa:]) for all vocal status. Poral and Psub correlated positively., Conclusion: During semioccluded exercises, most variables behaved in a similar way (same trend with a quite large individual variation) regardless of the vocal status of the participants., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: This crossover study compared the effects of two osteopathic treatments specific laryngeal manipulation (SLM) and postural manual therapy (PMT) on voice quality and pitch., Methods: Twelve asymptomatic singers were measured acoustically immediately before and immediately after each intervention using a laryngograph. Fundamental frequency and the glottal closing quotient were used to determine any differences between groups before and after., Results: Fundamental frequency showed a statistically significant change following both interventions (combined [P = 0.007] and PMT and SLM individually (P = 0.0143, P = 0.018, respectively). Although the benefit demonstrated using SLM was greater than that with PMT (2.4, 2.02, respectively), following Bonferroni correction there was no statistical significance demonstrated between the two groups. There was no statistically significant change with glottal closing time for any intervention or at any time (P = 0.52)., Conclusion: This pilot study provides evidence of the benefit for both SLM and PMT in singers. A significant difference was found in the voice quality of the participants involved in both PMT and SLM. These results set the way for further larger scale studies to evaluate group interactions and potential benefits in symptomatic patients., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Functional dysphonias are commonly associated with reduced treatment attendance leading to variable treatment outcomes. Preliminary research has proposed that intensive treatment may improve client adherence and outcomes; however, further research into the application of intensive models in functional dysphonia in comparison with standard intensity models is warranted., Aims: The present study evaluated the impact of intensive and standard treatments on functional, well-being, and service outcome measures in clients with functional dysphonia., Methods: Participants with a functional dysphonia were randomly allocated to one of two treatment groups: (1) intensive treatment (n = 7) or (2) standard treatment (n = 9). Participants completed the voice handicap index (VHI) and the Australian therapy outcome measures voice assessment (conducted by a blinded assessor) before and after treatment and 4 weeks after treatment. Satisfaction questionnaires were completed after treatment and data pertaining to attendance and duration of intervention were collected throughout treatment. In addition to a vocal hygiene education session, all participants received a total of 8 hours of treatment; intensive treatment consisted of four 1-hour treatment sessions per week over 2 weeks, whereas the standard group received one 1-hour treatment session per week over 8 weeks., Results: High satisfaction and statistically significant improvements on the VHI ratings were found after treatment in the intensive group. Significantly greater attendance rates were found in the intensive group. Intensive treatment is a potentially viable service delivery option for functional dysphonia and warrants further larger scale investigation., (Copyright © 2014 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Clinical research in the field of voice disorders, in particular functional dysphonia, has suggested abnormal laryngeal posture due to muscle adaptive changes, although specific evidence regarding body posture has been lacking. The aim of our study was to verify if there were significant differences in sagittal spine alignment between normal (41 subjects) and dysphonic speakers (33 subjects)., Study Design: Cross-sectional study., Methods: Seventy-four adults, 35 males and 39 females, were submitted to sagittal plane photographs so that spine alignment could be analyzed through the Digimizer-MedCalc Software Ltd program. Perceptual and acoustic evaluation and nasoendoscopy were used for dysphonic judgments: normal and dysphonic speakers., Results: For thoracic length curvature (TL) and for the kyphosis index (KI), a significant effect of dysphonia was observed with mean TL and KI significantly higher for the dysphonic speakers than for the normal speakers. Concerning the TL variable, a significant effect of sex was found, in which the mean of the TL was higher for males than females. The interaction between dysphonia and sex did not have a significant effect on TL and KI variables. For the lumbar length curvature variable, a significant main effect of sex was demonstrated; there was no significant main effect of dysphonia or significant sex×dysphonia interaction., Conclusions: Findings indicated significant differences in some sagittal spine posture measures between normal and dysphonic speakers. Postural measures can add useful information to voice assessment protocols and should be taken into account when considering particular treatment strategies., (Copyright © 2014 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)